Predictable and always recurring pain between 2nd and 3rd toe

Discussion in 'Ask the Docs' started by jlubkoll, Jun 20, 2011.

  1. jlubkoll Barefooters

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    I've transitioned from all-shoe wo 1/3 BF and 2/3 shoe milage over the course of a little more than a year, in between with a little VFF running and from mostly VFF wear to an all BF lifestyle (except when running longer distances) since 1st of March this year.



    However I do have a constant problem with my left foot that after a certain time (and it is really time not only distance) of either walking, running or even just standing barefoot my left foot on/below the 2nd and 3rd toe starts hurting pretty badly. Pain increases when movement/standing is not stopped. Once I do stop the action (or sit down) pain goes away pretty quickly (it completly vanishes after around 30 minutes). Pain takes much longer to come in once I do move/stand on soft surfaces (even light gravel) but comes quickly on concrete or asphalt.

    I have no idea what it is, since it also happens when I just stand around for longer periods of time it can not really be created by running form or moving form. Pain happens when BF or in VFF, always some spot. Sometimes when stretching my toes in that situation i have sort of a snapping feeling below the 2nd/3rd toe as if something was being hindered in its motion. Fascinating is that the worst painful part is any pressure (especially on an uneven surface then) on the foot from below on/between 2nd and 3rd toe. Oh, toe counting wise, the big toe would be number 5, small toe number 1.

    It currently keeps me from running anything above roughly 10k on asphalt. Pain sets in after approx 8-9k or 45m of walking steadily, even approx. 45m standing start the pain (but less than walking/running). It does not get any better by training, it has not changed in a year.





    Anyone got any idea what that can be and what could be done to get rid of it ?

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  2. Barefoot TJ Administrator
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    Sounds like what I have,

    Sounds like what I have, Morton's Neuroma, but I have four of them, two in each foot. MN is something that is caused by the types of shoes we wear, specifically shoes with a tight or too narrow toe box and shoes that force the weight of your body over your forefoot, such as those with heels, a.k.a., traditional running shoes, ladies' high heels.

    Seems like you developed this back in your shod days, just as I did. I find that running barefoot, truly barefoot, allows me to run much farther (miles farther) than in shoes, even VFFs. VFFs become painful to me after 20 minutes of running in them or 30 minutes of walking in them. I've managed to put off having traditional surgery (where they cut the neuroma out) for 2-1/2 years, but I'm getting to the point where I will either be having surgery later next month or see if I can wait and have it during the winter; January would be best for me, since I won't be running much during that time anyway, and it takes about six weeks to heal from the surgery, so I should be ready by spring next year.

    I've had every other conceivable treatment for MN. Now, please keep in mind that some of these procedures work for other people, but not one of them worked for me. Are you ready? Here goes:

    Orthotics, which made the pain worse AND gave me knee pain, which I didn't have before;

    1 cortisone shot that the good doc stuck ALL THE WAY THROUGH my foot, yes, to the outside. He hit a nerve. I won't go into details beyond that, but it wasn't pretty;

    16 alcohol scerlosing injections (four sessions x four neuromas);

    5 sessions of shockwave therapy with 8 more needles; and

    Cryosurgery where they cut between the fine webbing of the toes, insert a cryoproble and freeze the neuroma, after numbing the areas with 12 more needles! Not to mention, I developed a bad case of plantar fasciitis in both feet from walking around on my heels for three plus months because I couldn't put any weight on the balls of my feet. Nice, huh?

    For those not couting, that's 37 needles in all, in my feet, no less. I've had lots of needles over the course of my life for varying surgeries and problems, and they never bother me in my arms or wrists, but put a needle near my feet, at this point, and I will freak out. If I had known then what I know now, I would have just had the traditional surgery and had them removed back when. They're just gonna have to knock me out first to do it. ;-)

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  3. Barefoot TJ Administrator
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    Oh, BTW, the big toe is

    Oh, BTW, the big toe is number one, so when you are counting and talking about where the pain is, it's best to start from the big toe and go outwards.

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  4. jlubkoll Barefooters

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    Tj, that does sound horrible.

    Tj, that does sound horrible. 37 needles and then surgery.

    If I understand it correctly, it is "just" pain. Nothing gets broken from the pain except the auto-form-change the body will dictate once the pain sets in or is there any other physiological piece that gets broken?

    It may increase in intensitiy. I do not have the pain when I wear not too minimalist shoes while running (I usually use Asics Hyperspeet GT 4, they're not that much padded) and even through marathon distance the pain does not hit me (yet).

    So the options are

    a) treatment which at the end is removal of nerves and therefore partial elimination of senses.

    or

    b) stop running barefoot and cut down on bf-lifestyle.

    And with (b) the MN may hit me later with shoes which only throws me into (a) then.

    Can I have more choices please ? :(

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  5. Barefoot TJ Administrator
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    I don't know what you mean by

    I don't know what you mean by broken.

    The nerve develops scar tissue around it; the more it gets damaged from being compressed between the metatarsals, the more scar tissue develops. This enlarges the nerve. The larger the nerve, the more pain. It starts with tingling, then numbness, then pain, then searing hot, burning pain that shoots like needles through your toes making you feel like you fractured them. Some people state they have pain in the ball of their foot, where the neuromas are, which makes sense, but not everyone has pain in the ball of their foot.

    Some people have stated they have the pain when running barefoot but not in shoes. Some state the opposite. I can't even get 1/4 of a mile in shoes now if I tried before I would have to stop from the horrible pain, but barefoot, I can get much farther (although after putting it off for 2-1/2 years, it is starting to progress to the point where I will be having it surgically removed soon enough). The bottom line is, at some point, regardless of the way you decide to run, you will have to treat it. Otherwise, it will continue to get worse.

    I just spoke to a woman who had one neuroma removed 20 years ago. She said she does not have any numbness or sense of void in her toes. That nerve has not caused her any problems since. She had another one removed 5 years ago on the other foot, but 1 year later, she feels the neuroma after 10 miles of running, but not so bad that she has to stop running. She also is a very fast runner and always places in her age group. I suggested that perhaps the nerve had grown back, which is called a stump neuroma.

    Is this correct Docs? Dr. Mike, do you know what percentage of patients experience a regrowth of the nerve as a stump neuroma after having it excised?

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  6. jlubkoll Barefooters

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    By broken I mean that since

    By broken I mean that since the surgery does nothing else but remove scar tissue and - depending on style and quality of surgery apparently - removal of parts of the nerve, ignorance of the pain will not lead to anything else breaking. The pain might get worse but nothing breaks fundamentally, just more scare tissues needs to be removed and the progression might be sped up comparing to not continuing the activity.

    Taking a more in-depth look here in Germany about the various doctors treating it and the outcome, the reviews vary greatly. Some experience after-numbness of the area (apparently a part of the nerve was removed), others experience worse pain than before and others (a minority from this rather quick scan) are pain free and happy.

    Certainly further evaluation in my case has to be performend and the next task is to find a suitable doctor to diagnose and afterwards a neusurgeon - if MN is the diagnosis - in order to cut away whatever needs to be cut away, if that decision is made.

    From what I read and depending on the situation surgery can be performed from the upper side as well as the lower side, what was recommended is using a zik-zak shaped cut in order to keep the scar from developing too much elevation from the area around, especially when the entry is made from below the foot (guess that is the plantar side).

    At the end of the day, it is something that can not be fixed by training or adjustment(*). This is bad news but not fatal, therefor can be worked around if necessary even if that means surgery. However that surgery has the risk of making things worse, that needs to be taken into consideration for a decision to either fix it now or wait and fix in case it is necessary.

    (*) one possible adjustment, to slow down progression, would be to loose a fair amount of weight. This is in my case possible to a certain extent but I have not found any quantified information about the extent this can help.

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  7. Barefoot TJ Administrator
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    Sure, if we sit around on our

    Sure, if we sit around on our butts and do nothing, the pain will most likely cease. But then once you get up and start getting active again, the pain will come back. The scar tissue doesn't go away on its own. The more the nerve is compressed, the more scar tissue develops, the thicker the nerve shaft becomes, the more pain you experience.

    They actually remove the neuroma along with a segment of the nerve depending on where the neuroma developed, so they aren't just removing scar tissue. Some will even move the nerve to another place on the foot, minus the neuroma. I will ask that they remove the nerve all the way up my foot before my ankle. The lady I was telling you about said she has had no problems with that foot since the neuroma was removed, but she doesn't know how much of the nerve was removed with it. That was 20 years ago. The one that came back a year after it was removed on the other foot causes her little trouble. That was five years ago she had it removed, so I'm sure if it gets worse, she can always have it removed again.

    I have put off having traditional surgery, putting all my hope in those other procedures that failed me, until I am at a point that I won't be able to put it off much longer. You may be able to do the same, but it's going to have to be taken care of eventually.

    I have heard no correlation between weight and worsening of neuromas. That's a new one. I have read that losing weight will help people with plantar fasciitis though.

    From what I understand, it's not advisable to operate from the bottom of the foot. It's risky. Doc can clarify, but I'm told it's safer to go into the top.

    Dr. Mike will be along shortly to join our conversation here. I sent him a note, and he asked for the link. Dr. Mike, could you please share your expertise on this subject?

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  8. randicoot Barefooters

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    Hi TJ and Jörn,Does massage

    Hi TJ and Jörn,

    Does massage help or is that too painful? I have massaged away scar tissue from wounds. Every scar I haven't massaged is either still there or stayed a long time.

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  9. Barefoot TJ Administrator
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    I've not tried massaging my

    I've not tried massaging my scar tissue away, so I cant' answer to your question. I haven't even heard of this being a treatment for MN either.

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  10. randicoot Barefooters

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    Massage is a valid treatment

    Massage is a valid treatment for reducing scar tissue, from surgical or other wound, even if doctors never mention it.

    Hmm, the few sites I just researched don't exactly call MN scar tissue, so maybe it wouldn't work. Also, massage works better on younger scar tissue; less than 8-10 weeks. Older than that is considered permanent.

    Even so, could it make things worse?

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  11. Barefoot TJ Administrator
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    Thanks, Randi.  Perhaps the

    Thanks, Randi. Perhaps the Docs will be answering shortly and can comment on that as well.

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  12. Dr. Mark Barefooters

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    This is a tough one as most

    This is a tough one as most are by descriptions alone. Does the area hurt worse with local palpation, loading, or squeezing the foot together? this can help differentiate the tissue structure which is hurt....i.e bone, muscle/tendon, neuroma?

    sorry for delay...camping with my son and now hosting 3 day Running Medicine conference here.



    Dr. Mark

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  13. jlubkoll Barefooters

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    When squeezed from top and

    When squeezed from top and bottom after being "woken up" by usage, it hurts on the base of the 3rd toe. It does greatly hurt after an activity (for example after todays 10k it was hurting with every little step).

    Surprisingly enough a bit of taping around the 3rd toe seems to ease the pain and does stop the flipping below the foot. Will have another longer run this week (taping it before, maybe the flipping then never starts and maybe the hurting then does not start).

    Is there anything that can actually flip and make snapping sounds below/in the 3rd toe that gets triggered by heavier forefoot motion ?

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  14. Barefoot TJ Administrator
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    Jlubkoll , I was waiting for

    Jlubkoll , I was waiting for the docs to give their comments on this thread before I sprung this idea on you, but since you mentioned binding your toes together, here goes:

    Can you post a picture of your toes here? I'm wondering if there's some relationship between the way our metatarsals are that would cause the pincing of the nerve/s. See my picture below. Here's what I'm talking about. Toe #1 is the big toe. Notice how, on both feet, my #3 toes snuggle up with my #4 toes? That's where the worst neuromas are, between metties 3 & 4. The left foot is the very worst, and you will notice that left's #3 sits closer to #4 than my right foot's do.

    About a week or more ago, I (again) decided to try to wrap my toes together, to get the 3rd toe away from the 4th toe. I did this first on only my left foot, since it's the worse. I used an elastic waist band that you buy from the fabric store to sew into clothing. It's white and about an inch wide (any narrower won’t work and would cause pinching and perhaps move too much up or down the toes). I cut it so that it wouldn't be tight at all but be snug enough to wrap around with my 2nd toe (like a splint, splinting the 3rd toe to the 2nd toe). I sewed one end just slightly over the other and made sure to put the knots on the outside (one less thing to rub). Doing this moves the 3rd toe away from the 4th toe and frees up the nerve between them allowing the nerve some room, lessening the compression. I have run with it about four times now, and so far, SO GOOD! It seems to be working. Of course, I still have the pain, but not as much and not as soon into my runs. I know I will still need surgery, and this too is just buying time, but it's getting me through for this moment. I tried this on my right foot too, but I'm still trying to get the tightness just right on that band. Too tight messes with the bones and causes soreness and pinching, so I'm onto experimenting with the right foot a third time. Oh, and I wrote L for left and R for right on them, so I wouldn't get them confused, since I've got the left one perfect-fitting. (BTW, I have tried this experiment before, but apparently, I was using the wrong materials: too thin an elastic band that cut into my skin, since I tied it into a bow; a tiny hair scrunchie that was too loose or too tight if twisted twice, and medical tape that kept rolling up on my toe and coming undone with moisture.)

    Anyway I thought you might want to try this out and let me know how it goes, but please do post a picture of both your feet first. (Do you have this problem in both feet? Regardless, I would like to see both feet.)

    Also, there’s a self-test you can do that Dr. Mark is talking about you can search for on the net that will tell you how to manipulate your metatarsals to see if you get pain between them. Sounds like you may have figured it out, but just in case you want to make sure you’re doing it just right, search for it on the net.

    Before having ANY treatment, I would advise you to first have ultrasound done to make sure you actually have a neuroma/s and exactly where it is/they are. I suspect I didn’t have neuromas between my 2nd and 3rd metties on either of my feet at all, but because the first two docs “thought” they were there, they went ahead and gave me all those needles anyway, which then (if I didn’t have neuromas there) caused me to develop neuromas there, since all those many injections created scar tissue to the areas.

    [IMG]

    [IMG]

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  15. Barefoot TJ Administrator
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    So the pain only affects one

    So the pain only affects one foot then.

    Your toes don't look crazy like mine. You don't even have Morton's Toe.

    I have that flipping/snapping you are talking about sometimes too. That started years and years ago, before I developed the neuromas. I equate it to a rubber band snapping under my toes. Makes me wonder if with me there could have been two issues going on, MN and tendon; regardless, MRIs show I now have neuromas.

    Keep me posted on how your taping works and if anything changes. I find out converstation very helpful. And I hope I was able to help you as well.

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  16. Barefoot TJ Administrator
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    Oh, could you shrink that

    Oh, could you shrink that photo please ;-) Thanks!

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  17. jlubkoll Barefooters

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    I'd just put kinesio-tape

    I'd just put kinesio-tape around the 3rd toe, apparently when the pain hits I also have that flipping below my 3rd toe which could be the flexor digitorum longus being a little instable below the foot. That tape yesterday after the 10k helped me quickly wind down the pain that started below Nr. 3. That is the thing I am going to try on my next longer BF run, maybe at the end it helps stabelizing that tendon that jumps around.

    Haven't been to a doctor yet as most times they just do the standard answer of, "no running for 6 weeks" or "orthotics needed". And I've been there and done yet a lot and it never helped. And I am sure that when I go there and tell the doctor that when running barefoot for 10k it starts to hurt he'll mumble something like - yeah, of course it does. Haven't seen a BF running aware doctor here yet.

    [IMG]

    You certainly have the nicer polish :)

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  18. jlubkoll Barefooters

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    On the Mortons Toe I am not

    On the Mortons Toe I am not so sure, it is without the toes bend approx on the same length as the large one. When bending the toes down it becomes visible that the metarsal head of the 2nd toe is futher in front than the big toe. Given their (nearly) same front ending that would mean that from corresponding metarsal head to the end of the 2nd toe that distance is longer than for the big toe. That would qualify as Mortons Toe even if not visible without the bending (Learned that in this forum somewhere).



    [IMG]

    The end-result of this would only be whether or not to qualify for entry into the order of the MT, no other benefits included :)

    However before digging into the whole Neuroma approach, my first area of attack is going to be that snapping.

    Hard on the diagnosis by any doctor on this would be that the pain only starts after several kilometers of walking or running barefoot (or in VFF, same problem btw.). I'd need to take an approx 10k run directly into the doctors practice with immediate attention in order to get the cat out of the box for the doc.

    Given that you have the same snapping issue, i'd wonder whether this is the pre-condition which maybe lead to the neuroma or helped its initial development?

    At this time I do not know whether in my case that condition is on both feet, maybe the 2nd one comes much after the first in terms of time/distance and giving the condition on the left I never get to trigger this for the right. Hopefully however it is only a one side issue and there is some way to fix.





    I definetly find this discussion very helpful!

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  19. Barefoot TJ Administrator
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    Well, keep me posted.  If you

    Well, keep me posted. If you do end up seeing a doctor about this, please remember to let me know what they diagnose, and remember, get an ultrasound or MRI to confirm.

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  20. Dr. Nirenberg Barefooters

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    It does sound like a neuroma,

    It does sound like a neuroma, though a stress fracture is a possibility. Neuromas can be tough and soaks in Epsom salts and stretching the toes apart can help, as can heat and massage. Depending how advanced the neuroma is, you may need a cortisone shot which for most people works well.

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