I ran my first Sunburst in 1999 as a visiting fourth year medical student. In the years to follow, I’ve enjoyed running this event with friends, engaged many happy patients at the finish line, and even finished one race carrying my shoe that became untied just outside of the stadium. One particular race however stands out among the rest. It was the first year that the Sunburst was going to include a Half Marathon. It had been a while since I’d run that distance, and this inaugural launch was just the right motivator to get back to it.
As always, I picked the training program that suited my work schedule and began strategic implementation of the shorter distances, with great anticipation of a smooth long run on the weekends. I really tried to play it smart this time and not let my enthusiasm get the best of me. I built a solid mileage base and cross-trained with the elliptical trainer and recumbent bike. I also incorporated hills once a week and even a little speed work every other week. For some reason however, I managed to ignore a strange numbness in my third toe. As my mileage progressed, the numbness subtly transformed to a dull ache between the second and third toes—which I also managed to ignore due to my commitment to stay on schedule. With the race just weeks away, I had time to not only hit my mileage goal, but shoot for a personal best time. With just a few weeks left before the race, I set out on my next scheduled long-run—5 miles out and 5 miles back. With the turnaround distance in site, the dull ache between my toes turned to a sharp stabbing pain that shot up my ankle. All of a sudden, (personal) record setting times were gone and survival mode kicked in….
Interdigital Neuromas:
Neuromas occur as a benign thickening of a nerve from pressure/trauma. Most neuromas in the feet exist between the toes, can occur in any web-space, and are the result of chronic trauma such as walking, running or impact aerobics.
Symptoms: There is usually a pattern of gradual, progressive symptoms similar to the following:
It may begin as a subtle numbness in the toes or feel like a rolled up sock in your shoe. Some report a “full feeling” in the ball of their foot. Over time, this numbness can progress to dull ache in the forefoot. At some point you may notice a distinct spreading of the toes at the symptomatic web space. With further progression, the dull ache can become a sharp stabbing sensation—intermittent at first, then continuous. The symptoms are aggravated with walking/running and are alleviated by rest. As the symptoms progress, some many find a desire to remove their shoes to rub the forefoot and flex their toes. In time, the pain progresses from a dull ache, to a sharp stabbing pain with weight bearing, and many times is aggravated by wearing tight shoes.
Biomechanics, (why does this happen?)
A normal gait cycle relies on several movements for normal ambulation. As your heel strikes the ground with each step, your foot will pronate (roll inward) to conform to the surface on which you’re walking. As your body passes over your foot, it supinates (externally rotates) locking your bones into a rigid lever, and propels you forward as your heel lifts from the ground. If you hyperpronate, (roll your feet in too far), the metatarsals tend to place abnormal pressure against the interdigital nerves; trapping them between the each other and the ground, resulting in a benign thickening—much like a guitar player would develop callouses on his/her fingers with repeated pressure against the strings. A tight Achilles tendon tends to aggravate the process further.
Treatment: What you can do;
- Rest. Your body is responding to chronic trauma and needs to recover. If you have a little more than half of your mileage, you’ll probably be able to complete your race. Target completion, not speed. Supplement efforts with swimming, elliptical training or the recumbent bicycle. When bicycling be sure to place the pedal away from the area of pain and more towards the arch. Slowing down speed or distance can also serve your overall goal. As much as I hate to say this, you may do well to call off plans for a current race, for the sake of retaining your ability to run throughout the rest of the year.
- NSAIDs. Non-steroidal Anti-inflammatories such as Ibuprofen and Aleve can not only reduce the pain, but reduce the inflammation contributing to your symptoms. As many drugs interact with NSAIDs, be sure to check any existing medications you’re taking against potentially harmful interactions. You may need to consult your family doctor or pharmacist if you’re unsure.
- The runner’s stretch is your greatest defense against any forefoot pain. Be sure to hold it for a minute and do it with each leg, three times a day.
- Over-the-counter arch supports with stretching may be sufficient to offload the painful area.
What else could it be?
Pain in the forefoot can be from several different causes; Bone bruising in the metatarsals, a stress fracture, or injury to other soft tissue. If your symptoms continue to persist in spite of the above efforts, it’s time to see your physician.
Treatment: What your doctor can do. A good history and physical, combined with in-office x-rays can narrow the diagnosis, and hone the treatment toward a productive outcome.
- Rest. Rest unfortunately is key to many chronic injuries. Your physician may incorporate immobilization in a walking boot for several weeks.
- Physical Therapy. If you’ve not been able to relieve biomechanical pressure with home stretching, the next step may be physical therapy. They can not only reduce localized inflammation around the forefoot, but produce greater flexibility in the Achilles complex.
- Prescription NSAIDs. There are many NSAID’s on the market that aren’t available without a prescription. Many of these are designed to specifically target musculoskeletal symptoms and reduce unwanted side effects, such as stomach upset or gastric reflux.
- Orthotics, (combined with flexibility) are the mainstay of treating neuromas. At least 80% of patients recover from neuroma symptoms with these two modalities. Once flexibility is gained however, an athlete should seek to maintain it or the symptoms could return.
- Steroid injection. Nobody like shots. However, injecting a steroid into the site of pain can not only reduce the physical size of the neuroma but also treat the surrounding inflammation. This treatment has to be used with discretion as too much steroid in a single layer can also reduce the integrity of the surrounding intrinsic structures of the foot.
- Surgery. If conservative efforts have been unsuccessful, it may be time to consider surgery. There are several surgical options available, each with potential benefits and consequences. Your podiatrist will be able to describe these in detail.
…In spite of discovering a neuroma just several weeks before the race, I was able to complete the 2003 Sunburst Half-Marathon as hoped. Even though it took a bit more strategy and rest than anticipated, the experience had a happy ending. We’ve all had some degree of success in powering through discomfort while training, however this particular injury would be best treated early. May the rest of your year be blessed with good health. I hope to see you at the Sunburst Races!
Dr. Randall Kline is a board-certified podiatrist specializing in injury, wound and diseases of the foot and lower leg. Contact Allied Bone and Joint at (574) 247-4667 or visit AlliedBoneandJoint.com for more information.
This article was originally published in RacePlayMichiana. RacePlayMichiana is the premier local source for all news regarding sports and fitness in the Michiana area. RPM is produced in print and online on a bi-monthly basis.
