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I saw a 35 year old gentleman in good health referred to me for orthoses, whose prime complaint was burning within his feet during and after running and walking. His alignment was very good through his feet, ankles and legs, very good ROM in all respects and generally loose jointed. He was treated 2 years ago with an oral antifungal which he found bothersome and had reservations about its continued use. The burning is smack in the middle of the foot. No plantar or doral pain whatsover, and even his burning is not so much pain but veryuncomfortable. He does not perspire very much at all in his hands or feet.

His father is Type 1 diabetic but his sugars and bloodwork show neither arthritis or diabetes.

His concerns are: will running "hurt" him? and what is this?

Any help is greatly appreciated,
Sincerely,

Freeman Churchill, C. Ped ( C ) Halifax, NS

HI Freeman,

just curious on any other testing you may have done. Despite his alignment being OK, what about dynamically --> LArge MTJ collapse, early heel off etc. Can you find any nervous pathology?? Entrapment of med calc nerve etc etc. IS the any post static dyskinesia maybe suggesting something inflammatory. Any imaging?

Sounds like an interesting case. Keen to hear more after further testing.

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My karma ran over my dogma .....

Dawsey, thanks for ytour reply. the only things out of whack areslight enlargment of 1st MTP jts, L-R, not deviated, no pain, he had both big toenails removed 10 years ago when they were ingrown, he had mild patello femoral pain, L=R and mild Achilles strain. His gait looks very good and his runnign technique for a beginner is exceptional. Quiet as a mouse and smooth as silk on the treadmill.

I did not do any neuroligical testing other than ask if he can feel very light sensastion with a monofilament. I do not have assess to MRI's etc but have great links to MD's who do.
Free

Why not put a met dome under him and see if altering the balance and distribution of mid/fore foot plantar forces alters how he feels?
What does the tension of his DTML feel like between each pair of met heads.?

PG,

He was quite loose jointed throughout...more hypermobile I would say. No real callusing under his mets.
Thanks,
Free

AS Pgcarter replied, altering distibution of forces oculd be a good method to trial. I guess my other thing from what i could read is that he has enlarged 1stMPP joints. DOes this lead to any funtional/dynamic blocks? There may be no pain here as he is compensting elsewhere.

Even if minor blocks in the sagittal plane are occuring, the midfoot may be trying to compenstate (intersting to read some of craigs sagittal plane theory stuff on this...). If this was part of the problem, despite his mechanics generally being good, even a minor mal-alignment can cause overuse at compensating joints.

Point of pain can often be the result of functional problems elsewhere.

Good luck!

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My karma ran over my dogma .....

Dawsey, thanks so much for your thoughts there. At one point in my mind I thought that had made good sesne when you added up all the complaints he had. I would say the "burning" threw me. I shall dispense the orthotics with met pad/dome and make sure sgital motion is not blocked and let you know how it went. Happy Labor Day. :)
Free

I think I see easily irritated plantar nerves....(neuroma type stuff) in feet with lax DTML...but early on maybe it is just vague burning sensations with a difficult to locate specific point of origin.....maybe?....see this generalized burning foot stuff in hormonal related change of life stuff too....but not this one.
Regards Phill

Dear Freeman,

I am a little confused, throughout your posted assessments you comment on how good his mechanics were/are
"His gait looks very good and his runnign technique for a beginner is exceptional. Quiet as a mouse and smooth as silk on the treadmill'.
Why then have you dispensed orthotics? and did you trial any temporary padding and strapping in an effort to change his CC?

Regards
Mark Egan

Dear Mark,
I did not dispense orthotics at all. Whereas my first thought was it was #1 neurological, I thougtht I should ask smarter folks than myself. I thought perhaps someone might say, "Oh goodness this is a classic case of............." But nobody did.
But then, #2. he did have some hints in his history of malalignment, enlarged 1st, calf/achilles, some shin and knee pain, I began to second guess myself.

He did have totally flexible orthotics which did relatively little to change his alignment and di not give him any sympotmatic relief of his burning.

I told him to go out run, gradually increase his mileage about 5% per week, loosen his shoes a bit, undo the bottom eyelet entirely to reduce any forefoot squeeze by the laces and get back to me in a couple weeks. By then, I had hoped to be able to impart some wisdom. And you know, I am getting some good ideas which I will try! I will still lean more towards conservative treatment at first and if there is improvment, I will lean towards a semirigid device.

In over 20 years, I have not seen anything like this.

Cheers
Freeman

Good to see your name on this list, Freeman. Hope all is well.

Burning pain in the midfoot may be a few things. First of all, consider a chronic exertional compartment syndrome (CECS) in one of the plantar compartments of the foot. Even though this is rare, it could possibly occur. See if the burning pain occurs at a certain distance during the run every run and whether a short rest relieves it. If it starts up sooner once running is started again after the short rest then it could possibly be CECS. This may be accompanied by transient numbness or a feeling of "tightness" in the plantar foot.


This could also be what I call plantar ligament stress sydrome, which is an aching sensation in the plantar ligaments of the midtarsal joint/midfoot joints (nearly always medial joints) in feet that have excessive longitudinal arch flattening during walking and/or running. Increased forefoot dorsiflexion moments will cause increased ligamentous tensile stress and possibly cause ligament damage and pain. This syndrome can be diagnosed by palpating for abnormal tenderness along the medial-plantar border of the medial midfoot joints, usually at the navicular-first cuneiform or first cuneiform-first metatarsal joints.

It could also be what I call plantar intrinsic fatigue syndrome where the plantar instrinsics are becoming fatigued and likely accumulating excess lactic acid from chronic overuse due to flatter arch height and increased forefoot dorsiflexion moments. This presents as a more generalized "achey" sensation in the plantar arch, with no tenderness and not a sharp or pulling sensation such as that from distal plantar fasciitis.

A fairly simply test to see if your patient's pain is mechanical in nature is to see if it improves considerably with a strong low-dye strapping with medial arch padding to effectively increase the forefoot plantarflexion moments during walking and running. You may want to apply the strapping in the office and then allow him to go out for a run to see if it helps. If it does help then it is most likely to be mechanical in nature.

Also, any history of trauma?

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks Kevin,
all is well in Nova Scotia as we watch 3 hurricanes keep us on edge out in the Atlantic.

Thanks so much for your response with very good suggestions. I will bring this gentlman back ASAP and try the taping. He does shut down, as it were, quite quickly in his runs as the burning comes on quickly. He has no history of trauma.

Thanks again, sincere best wishes
Freeman

Today I had the runner come back for a re-check. I made a polypro orthotic with 4 degrees rear foot postitng and full medial long arch correction and a met pad . He is totally painfree with running and walking. No burning at any time.

Thank you all for your comments, encouragement and suggestions!

Sincerely
Freeman Churchill

:) Hey Free Glad to see you resolved this. I was going to say that in your device prescription that you could incorporate a first metatarsal cut-out on the shell and a reverse morton's extension to help the foot windlass at propulsive phase. I have had cases that fall into the plantar intrinsic fatique category and have resonded well to this approach.

Bob

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Woodman

Hi Woodie,

He did not have a plantarflexed first or I would have done the first met cutout and the 2-5. I have to say I have not seen one quite like this before but it will certainly make me a better listener.

Best regards to the crew.
Free

Freeman:

Do you think your patient's pain was caused by plantar ligament or plantar intrinsic muscle pain as I had suggested? It would be helpful also for you to discuss why and how your orthosis helped the patient get better.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin ... what you doing here? Shouldn't you be getting ready for dinner --- see you in 45

Hi Kevin,
I am inclined to think it is the plantar intrinisc muscle pain. His pain was always almost immediate and lasted a long time afterwards even into activities of daily living, for a few days after running. He has no point tendeness but a very distict burning that ran lengthwise in his feet. No joints hurt and paplation at any spot did not regenerate specific pain.

I do not believe it was a compartment syndrome.

I believe the semi-rigid polypro helped reduce dorsiflexion of the forefoot, reducing the length of time and magnitude the foot acted a mobile adapter.

This gentleman found the devices a bit overwhelming at first, but not uncomfortable, so I am inclined to belive the support provided was very much helpful and that there might have been "collapsing" of the medial and lateral arches than I would have otherse supected. This may have hindered slowed down sagital plane motion.

Sincerely
Freeman

Having a wonderful time here in Melbourne with Craig and company who have been quite fantastic in making me and my wife feel right at home here in Oz. I also think we may be making progress in understanding orthosis function, from the comments I heard after our lectures today. Wish all the rest of you could be here....lots of good stuff being talked about here at the SMA conference in Melbourne. It is an exciting time for podiatry!

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************