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380 Views 3 Replies Latest reply: Apr 21, 2014 7:52 AM by JamesJohnsonLMT
Leslie9797 Rookie 1 posts since
Aug 24, 2011
Currently Being Moderated

Apr 20, 2014 6:54 AM

Foot pain and Frieberg's disease

Hello,

I am a 44 year old female runner with pain in the ball and top of my foot for the last year and a half. First they told me it was a morton's neuroma, so I had a succession of cortisone shots that took away some of the pain, but not all of it. Finally the third doctor I saw gave me an MRI and said I had Friedberg's Infarction of the second metatarsal. My understanding is that the top of the metatarsal bone is wearing away due to repeated pounding on that part of the foot.

 

Has anyone had any experience with this? I've seen two foot/ankle specialists and they both recommend surgery, saying it will not heal on its own. One wants to just clean up the top of the bone, getting rid of the bone fragments and allowing blood to get back to the bone. The other wants to do that along with shortening my second toe so it is in line with the third (spreading out the area that takes the pounding) and a gastrocnemius release of the calf muscle. He says that my calf is so tight that it is not allowing my foot to flex like it should when I run, not allowing for full distribution of the pounding along my whole foot.

 

I'm not sure what to do....the second surgery seems like so much, however he tells me that just cleaning up the bone won't prevent it from happening again b/c of the length of my toe and tightness of the calf. He says it is too tight for just physical therapy.

 

I'd really appreciate anyone's thoughts on this! I have been active my whole life and want to make the right decision to continue to be able to run for many more years!

 

Leslie

  • lenzlaw Community Moderator 10,424 posts since
    Jan 18, 2008
    Currently Being Moderated
    1. Apr 20, 2014 7:52 AM (in response to Leslie9797)
    Foot pain and Frieberg's disease

    There is a ton of info online about this ("Freiberg's Infraction").  You may want to research it if you haven't already.  Mostly occurs in young girls active in sports.  Most suggest conservative/non-surgical treatment with surgery only if it becomes necessary.  (I personally would avoid surgery if possible.)  In any case it looks like no running for several weeks.  The first surgery seems typical and apparently usually works.  Hopefully JamesJohnson or Damien Howell will chime in and give their opinions.  Good luck.





    Len

  • Damien Howell Legend 312 posts since
    Feb 27, 2008
    Currently Being Moderated
    2. Apr 21, 2014 5:07 AM (in response to Leslie9797)
    Foot pain and Frieberg's disease

    You have had problem for year and half, of misdiagnosis and therefore mistreatment.  I would recommend 6 months of appropriate conservative treatment before escalating to surgery.  Unload the joint for a period of time to see if healing can occur.  Unloading joint may mean not running or biking for a period of time.  When you come back to running unloading means custom orthotic insert and appropriate shoe therapy.  I am not a fan of releasing Achilles tendon surgery, I have seen alot of problems develop as a result tendon lengthening. 

    Damien Howell PT, DPT, OCS

    www.damienhowellpt.com

  • JamesJohnsonLMT Legend 1,163 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Apr 21, 2014 7:52 AM (in response to Leslie9797)
    Re: Foot pain and Frieberg's disease

    I'm sorry for your healthcare experience so far. It's sad to see you have this kind of ride when there are so many alternatives to the old-school approaches you have been offered. I can't believe the suggestion to "release" a tight muscle in an athlete, but there is some truth to loading of the second metatarsal head due to bone length problems. I don't think shortening of the bones or lengthening muscles is the answer, even though it is based on simple logic.

     

    Usually the problem is not that the second metatarsal is too long, but that the 1st metatarsal is too short. This common anatomical arrangement was popularized by a Dr. Dudley Morton (no connection with Thomas Morton's neuroma) over a half-century ago, and blamed for a natural rolling of the foot away from the second metatarsal to increase stability and avoid pain. It doesn't matter how long your second toe is, it's about the stability of the metatarsal alignment when pressure moves to the forefoot in the gait cycle. I'm not surprised that medical attention gets diverted to the symptom away from the cause. It happens all the time.

     

    The classic solution for the Morton Toe was to add a thin pad beneath the 1st metatarsal, but this approach has been incorporated into some clever orthotics. The idea is to simulate a longer 1st metatarsal by raising it slightly, which alters the proprioception during footstrike and determines how your muscles are orchestrated in the gait cycle. This in turn changes the stress on your joints and muscles that results from avoiding the metatarsal length discrepancy.

     

    Since Morton, Dr. Brian Rothbart has made a lot of noise about another foot structure that involves a hypermobile first ray, again causing problems with pressure distribution in the foot and a cascade of other problems related to chronic pain throughout the body. You can read a description here. Another link from Medscape with x-ray pics of relevant foot structure and Frieberg's theory on the etiology, including a discussion of metatarsal length, is found here. You can clearly draw a line in this pic along the metatarsal heads and see how the 1st is set way back. It does not have to be this radical to have an effect. My 1st metatarsal is only slightly shorter, as in the second Medscape pic, but the resulting pain and dysfunction was quite dramatic.

    http://img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1236085-796tn.jpg

     

    The problem with most prescribed orthotics is that they mess with the biomechanics of your foot in ways that can be unhealthy. The idea is to compensate for an anatomical shortcoming in a way that is slightly prosthetic and proprioceptive, without resorting to a kind of crutch that slowly deconditions the muscles that maintain your arch, that move your foot from supination to pronation in a natural gait cycle.

     

    Unfortunately, your condition has advanced to the point that a simple change to your footwear now, may be too late to allow a return to the sport of your choice in the immediate future. However, if damage to the 1st metatarsal is not imminent, the pad approach may help. The change should not be abrupt, but gradual, to avoid further irritation of the ball of the foot. If the problem involves hypermobility, orthotic approaches are much more complex. See Rothbart on that.

     

    Meanwhile, one of your doctors may or may not have meant to disparage "just physical therapy" as a way to solve your problem, but I can assure you that retraining of the muscles will most definitely be at the core of any real solution. As Damien notes, snipping away at misbehaving musculature can backfire badly. Muscles become tight for many reasons that can include overtraining, but not all training leads to the general tightening of muscles. Sometimes overtraining (or in some cases lack of activity) can result in 24-hour spasms that prevent a muscle from releasing, but these problems can be very easy to solve. The enhanced circulation of exercise is often helpful, but there is more to know.

     

    As I often remind others, part of developing healthy muscle involves relaxing hypertonic tissue. This is not only to insure proper function, but to allow recovery and healing to take place. A muscle in a contracted state is not in a healing state. Just as your brain needs sleep to recover each day, your muscles need to be relaxed in order to allow the immune system to reconstruct them. This is one reason why inactivity after overtraining leads to muscle stiffness. It's not that the exercise softens them, so much that the repair process immobilizes them. A healthy lifestyle involves a balance between activity and rest. Muscles that are tight 24 hours a day do not get the benefits of rest, even during sleep. It is an important part of any effective training regimen to induce a relaxed state in hypertonic muscle tissue, and this is one of the benefits of massage therapy. In some cases, a focused type of massage known as trigger point therapy can accomplish the spontaneous release your doctor was looking for.

     

    I have no doubt your biomechanics are off, and some retraining is in order. Your doctor is right, however, to highlight anatomical causes for biomechanical compensation. I wish the entirety of this issue was studied more in med school, and that all practitioners were aware of the panoply of biomechanical etiologies, and the impressive array of non-invasive, non-surgical approaches to solving them that are well-studied and available, as many physical therapists, and some massage therapists are. There is too much to know about the human body for any one practitioner to know it all, but one thing for certain, is that there is life beyond the knife.

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