5 weeks ago, I started experiencing burning pain in the insertion to the 5th metatarsal midway through my long run (I was at 10 miles at that point). I ran twice more before I realized this was a serious problem that needed rest. It is clearly my peroneal tendons. I've been resting for 4 full weeks, except for a lot of swimming and weights, some yoga, bike and elliptical and day-to-day activiites. X-rays clear for fracture. Alieve twice a day, massage for tight peroneous muscles, stretching and rolling, tennis ball cross friction, icing, etc. I've had three ART treatments and 4 visits to my regular chiro to work on what is likely a hip issue. I limped the first two weeks, stopped limping and was walking normally aside from occasional clicking, did a 10 minute walk/2:30 minute test run and the pain came back. It is still now today better than it was the first week. There was no pop, never any swelling or discoloration. I don't think it is subluxing, based on my own physical examination and comparison during motion to the other foot. I think it is a case of a tiny, tiny bit of TMTS coupled with all of my long runs being on incredibly snowy roads with YakTrax with supination and a leg that turns out more than the other. I have a MRI tomorrow to hopefully rule out a tear or subluxation and an appointment with an ortho later this week. I imagine that after 5 weeks of this, immobilization will be recommended, as well as PT. Is there anything I'm not doing or not thinking of? Thank you.
I don't have any major thoughts to offer - however a couple of things popped in my mind as I read your story:
* If you have a hip issue going on (I'm assuming it's the same side as the foot issue) I would pursue that thoroughly. Many lower extremety issues are rooted in the hips. I had chronic heel pain and did all sorts of things - with the guidance of doctors and PTs. I found a PT, though, that found a speicific hip issue and when that got addressed the heel pain went away.
* I doubt you're that close to immobilization. Immobilization is not a desirable thing to do. I would only do so if there is a clear line-of-sight as to what the issue is and an understanding of why immobilization is the right course of action. My docs and PTs (who I love) are very clear that "active rest" is the desirable healing mode. Depending on the situation you want to enable whatever level of movement doesn't aggravate the condition. Complete immobilization introduces a variety of other issues that then must be dealt with.
"Kick off your high heel sneakers, it's party time."
-- From the song FM by Steely Dan
Thank you! My chiro tells me that the problem leg turns out more than the other from the hip. I have also had IT band issues in this leg, but rolling and stretching alleviated it and it has been gone since the fall. She has not suggested any hip exercises, however - I need to ask about that.
Second, thanks for your comments on immobilization. My concern is that after 4 full weeks of non-running rest, something is still aggravating it. Walking is the only thing that can be. And I have to walk, obviously. I have a 2 year old.
Perhaps what I am missing most is patience.
In my experience peoneal muscle tendon problems are frequently related to habitual sitting postures. Often we sit with the foot tucked underneath the chair resting in a maximum supinated posture laying the base of the 5th metatatarsal directly on the ground, sometimes with the opposite foot resting on top of the injured foot. Ladies with short legs will often tuck one foot under the opposite thigh, again with the foot in a maximum supinated position and the base of the 5th metatarsal is compressed into the chair. This is sub-concious habitual asymmetrical sitting patterns. The peroneal muscles are chronically stretched resulting in "stretch weakness". A smart Physical Therapist should be able to clinically determine if there is a length associated muscle weakness of the peroneal muscles and design a remedial strengthening exercises to strengthen the muscles at thier shortest length.
Bilateral pain at the base of the 5th metatarsal is often related to wearing shoes that are too narrow. Ladies running shoes common in B width, and mends come in D width. Ask to have you foot measured to see if you are in correct size shoes. Make sure you measure both feet do not assume the feet are symmetrical size.
Damien Howell PT, DPT, OCS
The fact that your foot was turned to the outside changes everything about the differential diagnosis due to frequency of occurrence. The usual rules may no longer apply, so forget about what it looks like, feels like, or the vast majority of internet hits. Most of those problems and solutions will apply to runners with a normal stride, and you are faced with a highly unique set of possibilities, primarily because your foot is forced to roll differently on contact with the ground, causing potential problems, for example, with interosseous friction and resulting neuropathy. The "occasional clicking" you noted is an important clue to this.
You asked about what you may have overlooked, and because of reasons stated above, what might be missed by your healthcare providers. One thing you may be missing is often hard to diagnose, is regularly misdiagnosed, yet amazingly common. The pain is frequently described as a burning sensation (usually "unilateral," in only one foot), often occurs (at onset in runners) many miles into a run, and with greater regularity thereafter when training continues. It is sometimes accompanied by clicking ("Mulder's Click"). It can mysteriously disappear after prolonged rest, remaining dormant until repetitive motion, such as long runs during marathon competition or training, bring the pain back with a vengeance.
In my case, the burning first occurred several miles into a long training run. I eased up and cut the run short, because it felt like a fracture or some other serious problem. It went away and returned during marathon competition, repeating in subsequent years in the latter phases of training, or during the marathon itself. For me, it felt like a hot nail being driven down into my foot. What I'm talking about is usually referred to as a Morton's Neuroma. In my case, it was between the 2nd and 3rd metatarsals, but has been found to occur less frequently between 3rd and 4th, and rarely, between 1st and 2nd, or 4th and 5th, as is possible in your case. A turned-out foot could precipitate one of the rare manifestations of MN, which is thought to be caused by compression of nerves between the metatarsals when the foot rolls in repetitive motion.
I am suspicious because it was not mentioned as being excluded during your otherwise detailed and fairly complete discussion.
Location of pain near insertion of the Peroneal tendons could be coincidental in this case. The main (Longus) Peroneal (sometimes called Fibularis) tendon actually inserts in several places, beginning on the lateral aspect of the foot and continuing underneath to the 1st metatarsal. It's action is not only to plantarflex, but to evert the foot - an action that would be more necessary when the foot is turned out - in order to augment the propulsive phase of your stride. While this action involves the Peroneal muscle and tendon as you suspect, it forces the abnormal movement between bones of the foot that can lead to further pathology, such as Neuroma, in that vicinity. Once again, a rare symptom, logically speaking, is more likely to come from an equally rare set of circumstances.
Damien noted that certain sitting postures can lead not only to pressure on the area noted, and a form of false metatarsalgia, but to failure of stretched Peroneals to perform. Sitting can also affect the tone of important core muscles governing your hip. A casual search of terms like "sitting is the new smoking" can show the growing awareness of potential problems related to sitting, that professionals like Damien have helped to pioneer. I am attempting to complement these observations with another point of view more anatomical than procedural in origin.
Though it is true that your hip is involved with the action of turning the foot outward, your foot is involved with the proprioceptive feedback that causes your central nervous system to orchestrate the rotation of the hip. In other words, chasing one symptom related to another may seem logical enough, until another cause for the secondary symptom is revealed. You could have a pain in your foot, related to the action of your hip, that is in turn caused by the structure of your foot. It would not be logical to assume that the foot is turned out for no reason at all, or that it simply needs to be retrained to point forward. It would be logical to surmise that your body is attempting to achieve stability due to a unilateral anatomical problem, not merely due to lack of sufficient training, when it is obvious you have been going out of your way to train, even in adverse conditions.
I have a unilateral MN that I have been able to control with modifications to my footwear to reduce excess motion. In my case it was due to a short 1st metatarsal (not toe, but metatarsal only), but your case could involve a combination of an abnormal arch and hypermobile 1st metatarsal, or various other combinations, even single factors, that are often considered "normal" by themselves in the sedentary population most practitioners treat, yet pose significant stability problems in a dedicated runner or other endurance athlete. Such stability issues would likely lead to the gradual rotation of the hip as a maladaptation in your stride.
It's one thing to chase a pathology, another to look for an immediate cause, and yet another to find the ultimate cause. It's not always simple, and can't be expected of the average practitioner. However, it is encouraging that at least, the position of your hip has been noted and implicated, and that your personal search has been relatively exhaustive. By no means can anyone diagnose over the internet based on a casual history, but such conversations can be useful in your search for clues to a thus far perplexing problem, and help to leave no stone unturned.
Thank you, James. That was a lot of information to digest and very wise words about the hip issue.
By way of an update, the peroneal pain went away but the clicking remained.
MRI showed a calcaneal stress fracture in the anterior aspect.
I've been NWB (airboot AND crutches) since March 20, 2014 with orders for zero biking, elliptical or swimming. After the first 2 weeks at 95% compliance, I'm now at about 75% compliant. No pain on weight bearing, just achiness after a day where I've walked at all on it.
Re-check for healing on 4/22. I am curious as to whether tendonitis can cause stress fractures? I was not really significantly overtraining.
Oh, and I would add that my peroneal tendons were unremarkable at MRI. Very strange. You would think they would have shown signs of inflammation, given the weeks of pain I had in that spot. This suggests maybe this was not tendonitis but something more akin to what James is discussing.
And one more comment - I'm going to bring James' comments to my ART practictioner and my ortho, as well as PT once I am ready. I really appreciate the throrough response.
Good luck with that. You've definitely got some complicating factors. There are other possibilities such as unusual tarsal bones not fitting together properly, etc. Sorry it took so long for me to respond, but my original post got wiped out when my battery died, and it took a couple weeks to find time to rewrite. The new chromebooks have some advantages, but 100% fault-tolerance is not one of them lol. Once again, best of luck in your healing, and thank you for the kind words.
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