"Crush injury" with inflammation - second opinion? PT?

BFnLBC

BFnLBC

Barefooters
Jul 9, 2013
33
28
18
Long Beach
#1
Hi Docs,
I'm hoping I can get an opinion (or two) on a diagnosis I received today that I have a soft tissue "crush injury" - with related inflammation - from stepping on a rock a few weeks ago. I was given a post-op shoe (or the option of a boot) and told not to even walk my dogs or walk from the train station to my office! I was also told I should start PT right away - which will involve, as I understand, myofascial release to break up the scar tissue that has formed.

Here's some background:

I successfully ran barefoot for about 2+ years, and ultimately ran a full marathon. Never had any injuries. Due to a new commute and new puppy, I took about 18 months off (with a couple half marathons and irregular running in between).

I recently started running barefoot again (starting from scratch, it feels like), primarily on my treadmill. On my first outdoor run November 14, I stepped on a sharp rock while running - right under the ball of my foot - and it hurt! I cursed but ran another block home, favoring the foot. I've stepped on sharp rocks before, and this pain was similar - like a bad bruise - only it has not completely gone away and can be re-aggravated by pressure on that spot.

The day after, it hurt when walking and I favored it enough to walk on the outside of my foot. But I put on my Uggs, didn't run for a week and a half, and the pain seemed to go away for the most part. It returned intermittently if walking barefoot on a hard surface, although if I shifted into a slow jog, the pain would subside because the ball of my foot was hitting the ground in a different spot.

Over the past three weeks, I felt like I was taking it easy though I did run run six times for a total of 22 miles - mix of concrete, beach and trail. A few twinges of pain would come back in the bruised spot (usually while barefoot walking), so I'd take a few days off.

Today, my foot felt fine - until the doc pressed around my feet and was able to isolate the painful spot - and ouch, he woke it up and its angry! He also made something in there click. Took X-rays and there is nothing wrong with the bone, and said it's not a neuroma (I don't have any tingling or anything). But he said that when I landed on the rock (about the size of a big marble only pointier), I crushed the soft tissue containing capillaries, lymphatic system, ligaments, etc., and scar tissue has now formed and is hardened.

He recommended 1) regular massage with a PT to break up scar tissue, and said he is not worried about the massage aggravating the inflammation further; 2) as little walking as possible. In a "few weeks" I'll check in to see if further steps need to be taken (MRI or possible "herbal injections" - I figured going the holistic route was better to start with, but please weigh in!).

My questions for the docs:

- Does this seem like something that can be diagnosed without an MRI? If not, what should I request with respect to an MRI? (certain views, contrasts, other buzzwords?)

- What are your thoughts on myofscial release massage on a now-painful, currently inflamed area with apparent scar tissue? Is there a danger that the massage could aggravate the inflammation futher? If I simply rest it religiously, will it subside on its own? (I practically got carpal tunnel - or some type of major, month long nerve irritation - from a really forceful, badly done thai massage, so I'm spooked by the prospect of any type of deep tissue massage).

- Should I get a second opinion? If so, anything I'm missing that I should mention?

Thanks so much in advance for reading this dissertation. I'm really bummed. Here I was thinking I was being conservative and it was just a standard barefoot bruise, until I started to realize it wasn't.
 
#2
Sorry to hear about your problem. It sounds like sesamoiditis, from your symptoms. It is likely there is scar tissue but looking at just the foot is short sighted, and if that is what your therapy perscription says to do, it will be a frustrating experience. Some therapists will go the extra mile and call the doc and ask for additional authorization, but most in my experience will just follow the script and use protocols. You are not a protocol.

Most likely ,since this was feeling better, there is involvement up the kinetic chain into the tibialis posterior, flexor hallicus (you can look them up) and I wouldnt be surprised if the calf and even the hips are involved, since usually foot pain has a domino effect.

A good sports chiropractor may be a good second opinion, because they will also evaluate the motion of these joints, the stability of the core and the entire lower kinetic chain. Look for someone certified in sports injuries with knowledge of myofascial release, graston or instrument assisted soft tissue and most importantly runners. Your local running society may have a good referral for you since they probably have chiropractors they use.

I hope that helps :)
 
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#3
Since a doc has weighed in first, as is the rule, I would like to share what I know about injections. Injections of any kind will create new scar tissue, and if you are already dealing with damaging, painful scar tissue, then why add more? Just because something is called herbal or holistic doesn't mean it's good for you, especially considering the method used to deliver it.
 
#4
A belated thank you for weighing in, Backfixer and Barefoot TJ.

Well, I got a second opinion from another podiatrist today, and it almost could not be more different than the first doc's opinion. The second doc is a runner and open minded about limited barefoot running per his blog. He did not take X-rays like the first doc, but he palpated both feet to feel for potential plantar plate issues, sesamoiditis, and metatarsal head issues - none found (sesamoiditis would happen in an area remote from my pain spot). He isolated the pain and basically said it's likely inflammation from the bruise caused by the rock, and that he expects it to go away in another 3-4 weeks. He recommended taking it easy and wearing some type of shoe to offer some protection, but did not proscribe my dog walks or my train commute, nor did he recommend PT or a ortho-boot like the other doc. He was very relaxed and pretty confident that it should heal on its own. Without mentioning the second opinion, I asked about all the injuries I've read about, including the crush injury, but he patiently answered my questions about why it was not any of those problems.

So, I guess the good thing about two opinions is that I get to choose which doctor's orders I abide by! Since the foot is not at all painful unless there is fairly strong pressure applied directly to the rock-hit area (not the surrounding tissues or joints), and I don't feel like I'm compensating, I'm going to wear shoes but not that ortho-boot, which was already giving me muscle imbalances from walking in two different shoes. I'll probably avoid running for a while, although maybe I'll test out some Altras on the treadmill in a week or two. Haven't run in sneakers for years...

I'll come back and update this though. I found it incredibly helpful to read about other people's experiences with foot issues - especially stepping on rocks, since we barefooters are bound to do that now and then. It's just strange because while I've stepped on plenty of rocks that have caused me to wince, this is the first time a rock has been more than a passing annoyance. We shall see.
 
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#6
In my experience, this kind of injury (painful spot after stepping on sharp stone, with or without visible bruise under the skin) will resolve itself in 3-6 weeks, without extended rest or medication. Probably there is an internal capsule of coagulated blood or scar tissue that needs to be absorbed/broken down. If you don't have constant pain, I would continue walking or maybe even running. If you have constant pain, rest. If it gets better with running (= increased blood flow helps), massage.

I would really avoid all kinds of injections or surgery if there is no proven structural condition (e.g., broken bone, tendon dislocation, cyst) visible in some kind of imaging. In serious cases of doubt about structural damage, I would pay for an MRI, it is simply the best imaging method available.

Wish you all the best ... Christian
 
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#7
Might wish to consider putting the 2nd doc's information on the Barefoot Friendly map.
https://www.thebarefootrunners.org/threads/barefoot-friendly-doctors-specialists-map.5791/

In my personal experience and from reading other people's stories on BRS, it seems that any injury that would sideline an experienced barefooter, is going to take a while to heal.

My worst barefoot injury occurred when I was cleaning the shower, and stepped on an upside-down drain cover. (I know, I know, I should have been wearing shoes!) It took about 6 weeks to feel normal again.

uploadfromtaptalk1418822953499-jpg.5205
 
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#8
Thanks for your additional thoughts, all - particularly with respect to injections. I agree that the herbal injections sound like quackery too! I had originally gone to the first doc because of the "holistic medicine" aspect, thinking that would equate to open-mindedness, whole-body, natural healing etc. But it was not quite like that!

Christian, thanks for your thoughts - that was basically the feeling of the second doc. It should resolve itself, and there is a bit of a lump one can feel right in the area where I stepped on the stone.

Sid, that drain looks painful! But at least you did not hurt your foot while barefoot running, so no need to sheepishly explain....

Well, after the happy high of my second opinion, I got overly optimistic and decided I could wear heels to a big holiday party after all (plus, then I wouldn't need to wear a boot and explain the barefoot running injury). I wore the heels below, which do not have the BRS stomp of approval, and, it was about 3 hours of standing/wandering with an hour of sitting. At the time, my foot's angry protests were muffled by the free-flowing wine; however, the foot later woke me up in the middle of the night screaming "not happy! ice me! or something!" The ball of my left foot, radiating from the rock impact point out through the arch, just felt irritated, hot and cold and swollen (though it was not actually swollen) and achey - not stabbing or sharp but just really weird and buzzy. So Saturday and Sunday was a definite setback and I decided to ask the second doc for some Rx anti-inflammatories that he had mentioned in response to my questions. It's five days later and I'd say I'm back to where I was before The Heels - no real pain unless under direct, localized, hard pressure, and an occasional dull feeling that "something's still not quite right." So I'll just exercise more patience and not run for another week or so - and put these shoes away until next year's holiday parties...
e1811e12250e0fdfe79d35325fa0637d.jpg
 
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#9
Those Valentinos definitely do _NOT_ have the BRS stomp of approval! :(

When I had my drain injury, it was a bit challenging, because the drain prong jabbed me between my 4th and 5th mets. It was definitely more comfortable when my toes were able to splay, and even my runamocs were a bit uncomfortable. In my case, using yogatoes was helpful when resting.

Hope you heal up soon!
 
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#12
Well, yesterday was the two month anniversary of stepping on that #$%*! rock and I continue to have issues with the foot and am unable to run. No Surf City half marathon for me :( This is such a drag and I'm pretty upset - especially because it is such a stupid injury, and especially because it still seems so mysterious and persistent. I've probably stepped on hundreds of rocks that made me wince - why was this one so different? It didn't feel different at the time.

I continue to have weird intermittent nerve-related sensations (not really pain per se), and the pain can still be triggered with direct pressure on the injury point. I returned to the second, more laid back doctor last week, who taped my foot with a metatarsal pad just below the rock impact point. I wore it all week, and it seemed to help some, with the nerve feelings diminishing. Got taped up with the pad again yesterday (doc is still able to trigger pain on direct pressure), so we'll see. I did pilates this morning, as I've been doing twice a week, and although I have been modifying to protect the foot, something today made it act up again - possibly just activating the muscles for the balancing I was doing.

Well, just figured I would update this in case there are any other similarly afflicted barefoot runners googling "stepped on a rock" like I was doing. Any ideas for next steps? Doc said maybe an MRI because I'm so bothered with not knowing what is going on, and he mentioned cortisone shots but I don't want to go there yet.
 
#13
I had nerve-related sensations similar to hitting "the funny bone" on the elbow, when I was landing on my fifth met and hitting the lateral plantar nerve that runs underneath it.
Your situation sounds different?

An MRI is non-invasive, and you can take the images to a different doc if you want a second opinion.
 
#14
I am sorry to read that you won't be able to run the Surf City 1/2, I was looking forward to seeing (with any luck) you there. I am more sorry of your set back and I hope you heal completely so you can continue your progress back to running.
 
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#15
Well, just to check back in (and maybe give other injured rock steppers hope of healing), I do feel like the injury is sloooowly going away, though it's not completely resolved.

I finally went back to the first doctor to get another opinion. This time (late January), no real pain triggered upon direct pressure to the injury spot. The irritation came a day later though. He again recommended physical therapy, so after expressing concerns about generic protocols, and causing (further) inflammation, and how would we know whether that inflammation was bad or good, I decided to try it. Better than the "traumeel" shot the doctor proposed, but didn't push.

Anyway, the PT pointed out that I still have a lump at the impact point which is visible when stretching my foot back (see photo he took). The doc has directed the PT to "go to town" on this area (using TENS, ultrasound, and massage - feel free to debate the merits of any of these in general or for this issue if you have opinions!)

In the last couple weeks, the nerve issues have significantly diminished, though I'm not sure if it was simply a result of time/rest or possibly the two PT sessions I've done (two weeks apart...). The feeling had been similar to the "funny bone" feeling you mention, Sid - not painful, but annoying and a constant reminder that something was up with my foot. Activating muscles (like in pilates) made it worse. However, there are many times during the day where the sensations disappear and I suddenly realize that I forgot about my foot for while, which is a good thing!

My foot often has a tightness that reminds me it has issues right now, and sometimes the tingling returns, but I really hope I have turned a corner on this...I'm very slowly and cautiously increasing the pilates footwork, and I've started to do itty bitty slow runs with the dog, just a couple miles plus or minus, including walking breaks (trying a Maffetone-type of heart rate training since I'm starting from scratch again). I'm wearing Altras, which seem to be fine so far. Still walking in my huaraches, including some easy trail and rocky beach walks. I'm pretty paranoid about aggravating it by stepping just wrong on another rock, so I may not be barefooting for a while yet, although I miss it.
 

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#17
Well, I thought the massage aspect of PT was helping, but it's now clear something is still very wrong with the foot.

I started running a bit while getting the PT, because the foot felt mostly better aside from intermittent arch stiffness. And by running, I mean super easy walk/running 18 minute miles to keep my heartrate low. And I've been wearing Altras as an experiment (though still wearing Shammas to walk around town, and a bit of barefoot on my treadmill - no rocks). Foot felt pretty good for 2-3 weeks, then a couple weeks ago on a gorgeous Sunday I think I was just out too long (2.5 hours/8 miles), and/or for too many days in a row (4), and bam - swelling at the bottom of my arch, pain from ball of foot to middle of arch, mostly on the outside edge, sensitive to the touch, limping. After icing for a few days, there's no more swelling, but it's been generally irritated and, again, stiff feeling. I'm getting an MRI on Sunday (yes, Easter Sunday! Hooray for big city services) so maybe that will be enlightening.

I went back to the more laid back doc and he thought maybe it was tendinitis from TMTS, but also possibly because of the forcibly slow pace and shoes(!). I jokingly said, "So what you're telling me is to run faster and run barefoot?!" To which he smiled and said "But you didn't hear it from me!"

I had written to the AngryOrthropod, who thinks I may have MTP synovitis based on my writeup. But who knows at this point. Anyway, I'm very frustrated. I hope the MRI will show something definitive - the uncertainty, and feeling like it's better but then causing a setback - is so incredibly frustrating. And I just found out Matt Damon ran Surf City, which I had to sit out - gah!! Hahaha. Oh well. Thanks for letting me vent. I miss barefoot running.
 
#18
BFnLBC said:
I wore the heels below, which do not have the BRS stomp of approval, and, it was about 3 hours of standing/wandering with an hour of sitting.
e1811e12250e0fdfe79d35325fa0637d.jpg
Click to expand...

You have just committed a mortal sin. ^^^^^^^^^ :D

On a serious note I am sorry for your trouble and I hope you will be able to eventually heal yourself.
Had a "landing hard on a sharp rock barefoot" incident a couple years ago too (my third metatarsal head got the hit), it took about four weeks for the foot to fully recover but it has been fine since then. Good luck :nurse:
 
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