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When two bones rub together, it often causes the outer coating of a nerve in your foot to swell. This swelling is most commonly referred to as Morton’s neuroma. It usually presents between the metatarsal heads of the third and fourth toe, but can occur elsewhere in the foot.

Causes

The exact etiology of Morton’s neuroma is still somewhat unclear. There are, however, a number of precipitating factors that can cause a localized irritation of the nerve which may contribute to the development of a neuroma. These factors are:

Footwear

Any shoe that is constricting in the forefoot can place excessive pressure on the nerves in the front of the foot. Morton’s neuroma is commonly seen in women who have worn high-heeled shoes for many years, or in men whose occupation puts excessive stress on the forefoot such as jobs involving prolonged kneeling, climbing ladders or which require constricting shoe-gear (e.g. construction boots, soccer cleats, etc).

Biomechanical Abnormalities

Instability (pronation) can predispose the foot to the development of a neuroma. The excessive pulling on the common digital nerve against the deep transverse intermetatarsal ligament results in irritation and eventually the development of the neuroma.

Treatments

Footwear
Modification of footwear can reduce the pain. This may include avoiding high-heeled shoes.

Orthotics
Custom shoe inserts adjust the structural support of your foot, helping to prevent irritation and remove the pressure from the nerve, thus allowing it to heal. Early treatment is critical as, once the neuroma has become permanently scarred, orthotics become less effective.

Injection
Anti-inflammatory medications can reduce the swelling in the nerve and offer temporary relief. These are recommended when other, more conservative therapies are insufficient on their own to heal the neuroma.

Sclerosing Injection
Sclerosing injections are a new therapy consisting of an injection which neutralizes pain fibers in the neuroma. A single weekly injection is given for four to seven weeks. This therapy has been very successful in helping patients resolve long-term neuroma pain and avoid surgery.

Physical Therapy
Ultrasound can be used in conjunction with other treatments to help the healing process.

Surgery
If the neuroma pain persists after the patient has undergone the above tretments, the nerve is likely permanently scarred or damaged and must be surgically removed. The surgery is done under local anesthetic and is often performed in the doctor’s office. Full recovery is expected in a few weeks. If surgery is an option, the doctor should discuss it with you thoroughly.

Neuroma pain is a very common problem and in most cases, is treated quickly and easily without requiring removal of the nerve. If you have any further questions or concerns, please ask the doctor during your appointment.

Fall is a beautiful time to get onto the trails, improve your cardiovascular fitness and clear your mind. Make sure to keep these do’s and dont’s in mind when training for a Fall race or simply running for pleasure and fitness.

• Dr. Roy Mathews DPM and Dr. Victor Quintoro DPM

1. Do wear socks made of synthetic fibres that wick moisture away from your skin to help prevent blisters and athlete’s foot.
2. Do fit your running shoes or other sports shoes with the type of sock you intend to wear them with. Also get fit at the end of the day when your feet are more swollen to ensure proper width sizing and avoid excessive foot compression.
3. Do replace your running shoes often. Replace them at least every 350 – 450 miles run.
4. Don’t wear new shoes in a race. Do make sure you have at least 75 – 100 miles of running use of your shoes before wearing them in a marathon.
5. Do wear sport-specific shoes. Running shoes do not have the lateral support needed for court sports. Help yourself avoid ankle sprains and other injuries.
6. Do warm up slowly and gently before your runs and especially before doing speed work.
7. Do be careful about building up their mileage too quickly after a low mileage summer.
8. Do break in new sport shoes before racing or using them for a long run or workout.
9. Do use sunscreen to prevent solar injury to your skin in all seasons, including the Fall.
10. Do make certain that you taper properly before your fall race. Most recommendations are for a 3 or 4 week taper before the marathon.

The foot and ankle contain 28 bones, 33 joints and over 100 muscles, tendons and ligaments. At least 20 of these muscles act to hold the foot bones in place and create movement throughout the joints of the foot.

An over-emphasis on extra-supportive footwear and orthotics can lead to foot musculature becoming incapable of supporting body weight during movement, which contributes to endless alignment issues and painful problems. During this phase it is essential to further decrease pain and inflammation, maintain/increase flexibility of injured (and surrounding) tissue, and strengthen the soft tissue connection to the bone. Physiotherapy, with the use of modalities, is very helpful during rehabilitation. Modalities include ultrasound, phonophoresis, contrast baths, transverse friction/deep tissue massage, and augmented soft tissue mobilization.

At-home maintenance of flexibility and range of motion in the foot and ankle (as well as stretching of the posterior muscle group) should be done daily. Strengthening of the fascial/bone interface is achieved through isometric exercises (muscular contraction against resistance, in which the length of the muscle remains the same), followed by isotonic (constant tension during joint motion) exercises, and finishing up with isokinetic exercises (constant speed with variable workload or accommodating resistance to maintain that speed). When the exercises can be performed without pain in the leg, the functional phase can then begin.

Even the elite athletes that I’ve worked with are subject to this condition. One 300-pound professional football player, who is obviously very powerful, saw how his performance and physical health were compromised, in part, because his feet were dysfunctional. His foot musculature was so weak that he was unable to transition the power from his hips and legs to the ground, resulting in changes in his sport-specific technique.

Recently, he’s been using a product known as the AFX, which has been shown to produce impressive results for high-performance athletes.

The AFX (Ankle Foot MaXimizer) is one of my favourite training tools because it’s the first product that can be used to specifically strengthen the intrinsic muscles of the feet through movement patterns and ranges of motion that are safe and effective. This allows for rapid progression of strength and function.

–Dr. Roy Mathews DPM and Dr. Victor Quintoro DPM, Vancouver Podiatrists.

 

Check out this article published on BestHealthMag.ca about the dangers of flip flops to your feet. In the article Dr. Roy Mathews, DPM of Vancouver Podiatry explains why he recommends staying far away from flip flops when choosing summer footwear.

–Dr. Roy Mathews DPM and Dr. Victor Quintoro DPM, Vancouver Podiatrists.

 

The summer wouldn’t feel complete without a pair of strappy sandals or colourful flip-flops. According to Dr. Roy Mathews, a Vancouver Podiatrist, his clinic sees an increase in patients complaining of foot pain during the warm summer months.‘During the winter, women wear better, more supportive shoes,’ he says. Once the snow has melted and patio season is back in vogue, we’re desperate to don footwear that’s airy, less constrained’and less supportive. While flip-flops, flats and sandals accessorize the perfect summer outfit, did you know that they can also do serious damage to the bones and joints in your feet?

The problem with flip-flops

They’re cute; they scream summer’but they’re also really tough on your feet. ‘With flip-flops, you’re walking on something that’s just a flat piece of rubber with no support,’ says Mathews. Flip-flop fans may forget that their favourite footwear was created to be worn at the beach or pool. They weren’t designed for hours spent walking in the city. It’s the flip-flop’s no-frills design that contributes to summer’s most common foot injury, metatarsalgia. An extremely painful condition, metatarsalgia is inflammation of the ball of the foot. ‘To walk in flip-flops, you must grip the toe piece with your toes. While flexing your toes down, you’re driving the ball of your foot into the ground,’ says Mathews. ‘You’re using muscles out of sequence and with no support, you get pain across the ball of the foot and in its joints’the metatarsal joints.’ Left untreated, metatarsalgia can result in stress fractures of the metatarsal joints and several weeks in a cast’or worse, a complete bone fracture that requires surgery.

If you’re not experiencing foot pain and refuse to part with your flip-flops, Mathews suggests that you invest in a pair that has a stiffer sole, a bit of an arch and a rocker bottom such as the Fit Flop brand. And don’t keep wearing the same pair year after year. ‘The worst thing [for your feet] is to wear a pair that’s completely beaten up,’ says Mathews. If you’re going to wear flip-flops and flexible shoes in the summer, buy new ones every year.’

Think flats are better? Think again.

Many women who steer clear of flip-flops believe that flats are a better, healthier option for their feet. They couldn’t be more wrong. ‘I don’t think there’s anything positive about flats,’ says Mathews. Like flip-flops, flats are floppy and unsupportive of your feet. Frequent wearers often suffer from metatarsalgia as the ball of the foot and its adjacent joints receive a pounding with each step. And if you have foot problems already, you could be in line for even more discomfort. ‘People who need arch support in their shoe such as flat-footed people can get strains like plantar fasciitis or heel spur syndrome,’ says Mathews.

Still love your flats despite your aching feet? Mathews says that there are options available to help support your foot in a bad shoe. The days of bulky or awkward orthotics stuffed into a shoe are long gone. ‘Orthotics can be made from graphite and fiberglass’they’re as thin as a credit card, so you hardly notice them. They’ll create a little more support and that’s better than wearing nothing inside these shoes,’ he says.

The case for sandals

In the battle for summer footwear supremacy, sandals are actually the best bets for your feet. ‘They’re typically more supportive than a flip-flop. Sandals like Birkenstock and Mephistos have built-in arch support and a little bit of cupping to the heel, so they have more support,’ says Mathews.

Look for sandals with a sole that doesn’t bend too much. A stiffer sole as well as straps that cross the foot will help distribute the pressure on your foot more evenly. The heel and arch will take some of the weight, so that the ball of your foot and its sensitive joints don’t receive the full impact of each step.

Podiatrists would prefer that people wear more supportive footwear in the summer, but they know that for fashion-sake, patients won’t necessary listen. ‘Fashion is what fashion is,’ says Mathews, ‘but if you’re suffering in pain, you need to wear something more supportive, like a running shoe. If pain lasts for more than a few days, you should immediately seek help. Too many people with pain in their foot do nothing for weeks and [they end up with] a fracture.’ If you expect to be doing lots of walking or standing, put the health of your feet first’before fashion’and step out into a pain-free summer.

‘Shin splints’ is a commonly used term to describe pain in the anterior calf that occurs during physical activity such as running. It is commonly an overuse injury that can develop over a few months, but may arise following a single rigorous athletic activity. The pain worsens with activity and may initially respond to rest. However, without treatment, the pain may eventually become so severe as to prevent physical activity.

The proper term for the most common cause of shin splints is “medial tibial stress syndrome”, which is an inflammatory reaction involving the connective tissue of the leg (called the deep or crural fascia) at its insertion into the inside (medial) or front (anterior) aspect of the leg bone (tibia). It occurs when excessive running, insufficient conditioning or over-pronation cause stress to the medial leg resulting in micro-tears and inflammation to the muscle attachments to the tibia. Excessive strain over a long period of time can lead to microscopic stress fractures which can be detected on x-rays or bone scans. X-rays should be taken when conservative therapy fails to eliminate the pain, and if a stress fracture of the tibia is suspected.

1. In the inflammatory phase, think R.I.C.E

Initially, it is important to treat the pain and inflammation occurring in the soft tissues attached to the leg. The inflammatory phase must be controlled before healing can begin. When the shin area is no longer painful to the touch, the rehabilitation phase can be initiated.

R = Rest: The required rest can vary from absolute rest of the affected leg, including crutches, to simply reducing the frequency, intensity and time of physical activity. It is recommended that the patient decrease their physical activity by 50-90% and increase the rest time between workouts. If physical activity is continued, non-running exercises, including swimming, weight training and bike, are advised. If the acute phase healing does not occur, complete immobilization (cast or removable cast boot) is required for two to six weeks.
I = Ice: Ice- 15-20 minutes of icing following activity will help to reduce inflammation.
C = Compression: Athletic wraps of the leg before and after activity will reduce recovery time.
E = Elevation: Elevating the legs after activity helps to reduce blood flow and inflammation of the soft tissues.

2. Rehabilitation Phase

During this phase it is essential to further decrease pain and inflammation, maintain/increase flexibility of injured (and surrounding) tissue, and strengthen the soft tissue connection to the bone. Physiotherapy, with the use of modalities, is very helpful during rehabilitation. Modalities include ultrasound, phonophoresis, contrast baths, transverse friction/deep tissue massage, and augmented soft tissue mobilization.

At-home maintenance of flexibility and range of motion in the foot and ankle (as well as stretching of the posterior muscle group) should be done daily. Strengthening of the fascial/bone interface is achieved through isometric exercises (muscular contraction against resistance, in which the length of the muscle remains the same), followed by isotonic (constant tension during joint motion) exercises, and finishing up with isokinetic exercises (constant speed with variable workload or accommodating resistance to maintain that speed). When the exercises can be performed without pain in the leg, the functional phase can then begin.

3. Functional Phase

The functional phase focuses on strengthening the fascia/bone connection and correcting the biomechanical cause of the stress. Unless the biomechanical abnormalities are addressed, the symptoms will continue to occur and cause chronic problems. This is probably the most important phase because it prepares the patient for their return to activity. At this stage, the patient must make sure they moderate their activity and stay within their limits, as re-injury can easily occur.

Exercises include plantarflexion and dorsiflexion of the foot with resistance and weight, plyometics and jump training including rope skipping. Cross training to increase muscle strength is also incorporated at this stage. For runners, the safest method of regaining strength is by riding a stationary bike.

For some runners, proper running shoes that assist with problems such as over-pronation or ankle instability will help reduce symptoms.

It is at this stage that custom foot orthotics should be considered for treating poor biomechanics. A podiatrist that specializes in sports medicine, is best able to diagnose faulty biomechanics by assessing foot function and doing a proper gait analysis. The podiatrist can then conduct a simulation of orthotic use by taping and padding the foot for a short time . Molds of the feet should be taken using plaster, or a digitized computer scan of the foot while the physician holds the foot in correct position. Runners should wear their orthotics continuously during the healing phase to reduce stress from the muscles and decrease inflammation.

4. Return to Activity

A gradual return to pain-free activity, including running, should result. Graduated running with periods of walking in-between is the most effective way of ensuring limited stress on the fascia. A proper warm-up is extremely important to allow the muscle and tendon to stretch, which puts less stress on the bone-fascia junction. Post-run stretching of the posterior calf muscles (gastrocnemius and soleus) will also decrease the chance of muscle imbalances.

Running on surfaces such as concrete and asphalt, which provide little shock absorption, are traumatic to the leg and should be avoided during this phase. Bark chips and grass are the best surfaces for returning to activity.

If appropriate rest and treatment have occurred and the symptoms persist, then medical intervention should be taken. Occasionally, shin splints left untreated can develop into tibial stress fractures.

Certain foot types including severely flexible flat feet and rigid high-arched feet are prone to shin splints. Biomechanical control (orthotics) should be able to control flexible flatfoot symptoms. Rigid, higher-arched feet are more problematic and people with this foot type are advised to avoid certain activities such as running up hills, if the shin splint pain does not resolve.

We hope this article helps you manage your pain and better understand this medical condition. Please contact us at the number below if we can be of assistance in measuring you for, designing and producing a custom foot orthotic to address your shin splints.

–Dr. Roy Mathews DPM and Dr. Victor Quintoro DPM, Vancouver Podiatrists.

Over our 20+ years of experience in podiatry, we have had the pleasure of lecturing to Sun Run InTraining Clinic Series runners. They always have great questions and their energy and excitement as they train towards this epic fitness goal is truly inspiring. Below is Tom Mayenknecht’s excellent Blog Post in the Vancouver Sun about Dr. Roy Mathews’ lecture on the latest research and trends on foot care in running, as part of the 13-week Sun Run InTraining clinic series.

–Dr. Roy Mathews DPM and Dr. Victor Quintoro DPM, Vancouver Podiatrists.

 

Going into our 13-week Sun Run InTraining clinic series leading to the event April 15th, I had a good sense of appreciation for the role played by the programs’ run leaders. That was easy to develop in the previous years I took the program and benefitted from the dynamics of the weekly group run and the encouragement from the run leaders themselves during the runs.

Yet it’s only this year that I’ve truly wrapped my head around how important a role is played in my mind set and preparations by the Sun Run InTraining support team.

That, of course, still includes the clinic coordinators and the run leaders; many of whom have been volunteering for multiple years in support of the Sun Run and SportMedBC, the provincial network of sport medicine, sport science and sport training practitioners which developed the SportMed RunWalk curriculum that is at the heart of InTraining. Yet it’s more than that.

Throughout the clinic series, we’re introduced to some of the best minds in the running sector, on everything from shoe selection and apparel to stretching tips from chiropractors and nutrition “intel” from dietitians. Thanks to SunRun InTraining and SportMedBC, the people presenting short talks on their respective areas of expertise are always best of class.

That was certainly the case this week when Dr. Roy Mathews of Vancouver Podiatry dropped by to bring us up to date on the latest research and trends on foot care in running. In the dictionary beside “this guy knows what he’s talking about”, there’s Dr. Mathews’ picture. He even made the recent proliferation in metatarsal injuries (to the balls of our feet) sound interesting and related it to the mantra of Sun Run InTraining: running and walking smartly and safely to avoid getting injured and to make the most of its inherent exercise and wellness benefits.

Now, I’m a guy who has been in the sports and media fields my entire career and I have had the privilege of working closely with some of the best sport medical practitioners in the world through my relationships with SportMedBC and the MultiSport Centre of Excellence Group; and before that in my years with Tennis Canada and in the NBA. So, I’m both spoiled by the level of expertise in my circle of life and not impressed easily. Yet when Dr. Mathews gave us his take on the new flex shoes that are all the craze, I learned something. I knew coming in that these minimalist shoes have been inspired by the running stars of the African continent, who often run barefoot. What I didn’t know was the reason they did so (to build strength in the smaller muscles in the foot) and how they incorporated it in their training (alternating with running in regular athletic shoe wear).

That was only one example. He talked about the best ways to get sized up for orthotics and the best practices in that field. He compared and contrasted the merits of heel-strike running and mid-sole strike running. He even weighed in on the pitfalls of wearing high heels for women.

I’m pleased to say that last part was beyond my scope of “need to know” information, but even on that front, he was informative and entertaining. It was yet another example of how solid the support network behind Sun Run InTraining is for me and, I’m sure, for the thousands of active living people who sign on to the program. For me, it was another reminder of how much I rely on the experts associated with the program, sometimes for new information and other times, simply for reinforcement of the tried-and-true principles of running and walking the smart way.