Strange forefoot/2nd met pain

[kozz]

I will include as much technical detail as possible in hope of getting useful suggestions.

background: I've been running barefoot for over 4 years, have never worn minimalist shoes, weigh 180 pounds but am fast. I focus on short middle distance and never race above 5k. During summer training I've altered my form by adjusting my center of mass forward a bit.

onset: after a 3k run at lactate threshold, I felt a focused pain in my right foot centered under the 2nd and 1st metatarsal shafts, interfering with and weakening push-off. This subsided after about 5 minutes of walking and remained a dull but annoying ache during about 2k of cool-down jogging.

persistence: rested for 4 days. During this time, pain occurred when standing up, centered around the 2nd metatarsal. It was sharp at times but did not feel like a SF, more like an acute tear to soft tissue. It seemed to migrate around to the inter-metatarsal spaces, to the lower muscles and fascia (FDB and FHB), to ordinary TOFP, and forward to under the 2nd metatarsal head. I supposed that inflammation was occurring.

This pain was not severe but was annoying enough to affect my gait when initially standing and walking. It did not improve over the 4 days, however it was no hindrance at all to walking, jumping, or other athletic movements and tended to decrease rather than increase when bearing weight.

strangeness: So after 4 days, I decided to try a bit of jogging, found it completely painless, and proceeded with a light workout, including a few intervals at 800m race pace in spikes. The pain, when it existed, was a barely noticeable dull ache around the 2nd to 3rd metatarsals. When running it seemed focused under the 2nd metatarsal head and, near the end of the workout, in the distal 2nd phalange. I don't have Morton's toe, but my right 2nd phalanges have gotten sore before, often feeling like they've been stubbed after a fast run. My right ankle is relatively loose from a sprain about 20 years ago and may contribute to biomechanical issues. I've also got a bit of soreness and tightness in my hip flexors, medial glutes and the fascia around my right femur which preceded this by a few days.

Since it hurts only when I'm not running, I'm fairly convinced that I haven't got a MSF, but I'm still scratching my head over this. Other than a generic overuse injury, I have no idea what it might be.

 

[kozz]

3 days later, another workout. warmed up, did sprint form drills, preparing to run an interval series, this time barefoot on pavement which I do fairly often.

I've read that injuries like to move up and down kinetic chains. Today I got an aching, stubbed feeling in the distal 2nd phalange, right side, during form drills. Then in the first 100m repeat, pain and perceived weakness in pushing off with the hallux, and top of foot pain along the 2nd to 4th metatarsals from the heads upwards to beyond the tarsus. I observed this was causing a gimp in my stride that seemed related to the hip flexor trouble, as both were hindering full extension of my leg on takeoff. After the first repeat I cut the workout short and limped home.

An hour or two later, bearing weight causes pain on pronation above the 2nd to 4th metatarsal heads, but less TOFP farther up. The pain feels soft-tissue in nature and seems associated with the extensor digitorii. 2nd phalange is still sore. There is no visible swelling though I assume as I did a few days ago that some inflammation must be present. There is no pain under the 2nd or 1st metatarsals like before and it seems more diffuse than focused on one spot.

 

[Backfixer]

Without actually seeing you on a treadmill, or examining you, the most likely scenario is shin splints. While you are experiencing the problem on the top of the foot, the tendons will get sore is the fascia surrounding the shin muscles get very tight. It will also cause weakness if you try to pull the toes up against resistance as compared to the other side.

I would suggest using a foam roller gently in the shins using it to pin an area and flex downward slowly, working your way toward the knee. Then retest the toes and see it it is alot stronger. Then walk and see if the pain is markedly reduced. If it is, you have shin splints and the pain is tendonosis.

 

[kozz]

Nope, not shin splints.

Next workout was on the 5th, 4 days after last one. Felt ok warming up and did a series of 10 flying 100m sprints in middle-distance spikes. Felt good but a little tentative, and some pain during the last two.

As soon as I was done and had the spikes off, the pain hit, and I couldn't pronate on my right foot at all, and had to limp away and start resting. Scratched the race.

It's now been 9 days. I can fully pronate without pain and walk normally, but pain around the top of the 2nd metatarsal head, instead of the bottom, and referring along tendons and into intertarsal spaces and phalanges. My flexor halluci feel weak but it seems like that may be a side effect of reduced 2nd metatarsal/phalange function. Significant edema around the middle 3 metatarsal heads after walking or cycling. I haven't tried to run yet.

 

[kozz]

A month after onset I went to get x-rays and they showed no sign of any SF. Tendinopathy and achy bones continues all over the place.

What could cause these symptoms other than a SF?

edit - after diligently sorting through the wall of useless online information about foot injuries I've discovered the apparently very common plantar plate tear which matches my symptoms exactly.

 

[migangelo]

tight shin muscles will pull on your feet giving you tofp. that's why the doc said shin splints. you may weak/tight muscles there and not know it until you touch them. ankle sprain means weak calves. your calves are your external foot muscles. check them for tightness and tenderness. release that pain then build up strength. search up the kinetic chain as well as tightness above can lead to tightness below. it's lots of fun searching out your problems!

 

[kozz]

no, it's still not shin splints, and it's not weak or tight muscles, it's an injury.

 

[Sid]

Sounds unpleasant. What's the treatment for it?

 

[kozz]

I don't know what it is, hence this thread.

But I've been x-rayed and the radiologist saw something. I'm skeptical of it so it's not worth mention unless confirmed. I'll be seeing a DPM soon.

 

[migangelo]

ask barelee. trigger points in your shin can feel like a stress fracture in your foot. roll your shins to check.

 

[kozz]

I got copies of the x-rays and it looks like the radiologist was right: avascular necrosis of the 2nd metatarsal head, also called Freiberg's disease.

Now I'm in the process of deciding which podiatrist to see, if any. From what I've studied about the condition, the x-rays don't look very bad, and the treatment will likely be resting until it heals up.

Just to make you squirm, AVN is when there are fractures under the joint cartilage that interrupt the blood supply and lead to bone death. The bone recedes as the dead bone is absorbed, and the cartilage above it wears away leaving exposed bone which interferes with joint function. Scrape, scrape, scrape.

 

[migangelo]

eww. i know what necrotic is. that sucks. what the hell did you do? damn! kill your bone? shoes right?

 

[Sid]

Yowsers! Good luck!
http://www.wheelessonline.com/ortho/freibergs_disease

 

[Barefoot TJ]

This sounds exactly like a Morton's Toe discussion! Yikes! So much of us are affected by MT!

I hope you are able to manage this thing, Kozz. Good luck to you!



Freiberg's Disease


- Discussion:
- anterior metatarsalgia that involves head of second metatarsal;
- occurs during the growth spurt at puberty - most are female;
- caused by avascular necrosis of the metatarsal head;
- from repetitive stress with microfractures at the junction of the metaphysis and the growth plate
- these fractures deprive the epiphysis of adequate circulation;
- disease is more common in pts whose 1st metatarsal is shorter than 2nd metatarsal, which increases wt on 2nd metatarsal head;
- in adulthood, DJD may develop in MTP joint;

- Clinical Manifestations:
- pain in the forefoot, usually localized to head of the second metatarsal;
- wearing of high heeled shoes makes condition worse;
- localized swelling and limitation of motion in MP joint;
- Radiologic Findings:
- initially the epiphysis becomes sclerotic;
- early in disease, joint space is widened, much later, it narrows & irregular bony surfaces, sclerosis, & bone spurs at margins give the
appearance of osteoarthritis;
- epiphysis becomes fragmented followed by osteolysis & reconstitution of bony archetecture;
- fragmentation and osteolytic phases:
- metatarsal head becomes irregular, widened, and flattened at articular surface;
- Diff Dx:
- Ewing's Sarcoma
- Stress Fracture
- Osteosarcoma
- Treatment:
- initial management includes proper foot wear w/ metatarsal bar or pad placed beneath the involved bone;
- limit activity for four to six weeks;
- w/ severe symptoms consider immobilizing foot in short leg walking cast until symptoms subside, usually in 3-4 weeks;
- surgical indications: rare:
- failure of conservative treatment;
- surgery may be warrented to remove metatarsal heads


Freiberg Disease Complicating Unrelated Trauma.

Surgical Treatment of Freiberg's Infraction in Athletes.

Frieberg's disease: A suggested pattern of management.


Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, April 12, 2012 10:05 am

 

[kozz]

I don't think I have Morton's toe. More likely a weak hallux combined with barefoot speedwork on concrete which invoves extreme dorsiflexion on toe-off. In the past, that has made my 2nd toe sore before.

With spikes on the track, I'm protected from excess dorsiflexion by the spike plate. But that has its own pitfalls from all the left turns.

I think a 2MSF would have been worse. I've already got 3 weeks time off if it manages to heal in that 4 to 6 week time frame. Symptoms have regularly improved, no more swelling, doesn't hurt to walk.

 

[BarefootOakland]

kozz, how did this turn out? I've been having some pain at the end of my 2nd metatarsal myself, I hope it's not Frieberg's. My pain is weird. I was having some in training for a half marathon I ran on November 24th, so I took off a week before the half and had no problems during/after the race. I took a break for two weeks and ran an easy 3 miler today and the pain returned towards the end. I was thinking it might be plantar fasciitis until I saw this thread.

 

[kozz]

The symptoms have improved greatly, though not 100%.

I didn't see a podiatrist, and I'm glad I didn't. Most of the doctors in my area are ripoff artists. The place where I got the x-ray wants $330. I had an appointment with one podiatrist, but when I got there the x-rays weren't there yet. The first thing the guy said was "Freiberg's usually requires surgical intervention" which I knew was an outright lie, so I didn't reschedule. Phil McKinney was his name, and I don't mind mentioning what a jerk he was.

I'll get another x-ray in January when I've got better insurance, until then it seems to be healing up fine. I can do speedwork again up to around 800m race pace without fear of injury, and should safely be doing all-out sprints soon.

 

[Barefoot TJ]

That's great news, Kozz! Glad you are doing better. You should let that doctor know how wrong he was, and that you didn't need surgery after all.