"Please can you help with my foot pain. I have been running for years and after a recent skiing trip I tried to run and started with acute pain in the middle side of my right foot. This then progressed to pain at [...]]]> Question – foot pain and numbness in the 4th toe

"Please can you help with my foot pain. I have been running for years and after a recent skiing trip I tried to run and started with acute pain in the middle side of my right foot. This then progressed to pain at the top base of my fourth and fifth toes which is very painful if I try to turn my right foot to the left. the pain is also accompanied by numbness in my fourth toe on occasions. This pain has lasted for five weeks now and even after rest, ice, heat, and anti-inflammatory medication nothing has changed. The pain is worse at night but does not hurt me when I am weight bearing. It seems worse when my foot is off the ground. The foot can be moved around and there is no redness or swelling."

ANSWER

A diagnosis based on such limited information is difficult. I recommend you consult someone about your problem – GP, physio, podiatrist. Do not just rely on my help.

So what is going on? Difficult to say without examination/x-rays/MRI. It might be Morton’s Neuroma, which is irritation of the common digital nerve causing thickening of the nerve sheath. What else could it be? Stress fracture, arthritic/degenerative changes, capsulitis, bursitis … and more.

Morton’s Neuroma? However you say that rest, ice and anti-inflammatory meds have not helped. And strangest of all is that you have no pain when you are weight bearing, and you have no swelling or redness. But you do have numbness and your ski boots might have been too narrow for you and put pressure on the nerve. Morton’s Neuroma often produces sharp, stabbing, burning pain, and numbness which is often located around the 3rd/4th toes. The pain can radiate to the ends of the toes and even up the legs. The pain is often relieved by removing the shoe and is more common in women because of shoe choice (high heels/tight shoes across the front of the foot), and those with flat feet. Treatment: rest, ice, elevation, anti-inflammatory meds, taping, padding, supportive comfortable shoes, orthotics with a metatarsal pad to spread the metatarsal bones. I suggest an x-ray to rule out a stress fracture, orthotics/arch supports and most important of all a metatarsal pad to spread the metatarsals. Get some thick chiropody felt and stick it to your foot as below. It is better to stick it more towards the arch than putting it anywhere near the problem area. If you put the felt on top of the painful area it will make your pain worse. And lay off the running. If things don’t improve soon you should ask your doctor for an MRI scan.

Metatarsal pad

Online question – custom made orthotics

"I’ve just been to a podiatrist for the first time – he is a private podiatrist. I had an ankle injury which has also affected my instep ligaments – this has all just come about in the last 8 months after I went over on [...]]]>

Online question – custom made orthotics

"I’ve just been to a podiatrist for the first time – he is a private podiatrist. I had an ankle injury which has also affected my instep ligaments – this has all just come about in the last 8 months after I went over on my ankle … since then I have now gone over on my ankle three times. The podiatrist was very good and advised custom made orthotics for my feet as they have become more flat footed and slightly painful (and also affecting my knees, lower back and upper back). He has quoted £300 for this – I didn’t realise they would be so expensive. Can you tell me if I would be better to go to my doctor and be referred to the NHS for this instead as £300 is a lot of money."

Answer

Custom made orthotics/insoles are expensive … unfortunately. They are like prescription glasses, they are made to your specific prescription in the lab and anything which goes through a lab once only will be expensive. Anywhere between £250-£400 is about the norm for custom made orthotics. It depends which system the podiatrist uses and which lab they use. As a comparison my fees are £215 for the custom orthotics and £100 for a full biomechanical assessment and computerised gait analysis.

Custom made orthotics might well be the route you have to go down, however … you could try over the counter orthotics first and see how much of the pain and discomfort they remove and how comfortable they are. Unless there is a very specific reason I mostly suggest over the counter orthotics to my patients first to trial them out. Of course the downside is that they might not be supportive enough for you or they might not be functionally accurate enough for you and you will still have to go down the custom orthotic route. Over the counter orthotics suit many people, just not all.

By all means go to your doctor and ask for a referral. In some areas you can self refer. Sometimes you can wait months to see an NHS podiatrist and then even longer for the orthotics to arrive. Some trusts produce excellent custom made orthotics but unfortunately others produce what I would call a very poor attempt at a "custom" orthotic, something not much more than a floppy insole with bits of felt stuck on to it. It’s the luck of the draw really.

There are many types/makes of over the counter orthotics. What’s best? Depends what you want the orthotics to for and the type of shoes they are to go in – sport, general everyday, diabetic. If general orthotics for every day then I suggest 3/4 Superfeet for ladies
(and Superfeet 3/4 for Men)

The knee is a modified hinge joint which means it can flex (bend/swing backwards) and extend (straighten/swing forwards). It also can very slightly rotate. The hamstrings at the [...]]]> Runner’s knee can also be known as pain under the knee cap, anterior knee pain, chondromalacia patellae, and/or patellofemoral pain (PFP).

The knee is a modified hinge joint which means it can flex (bend/swing backwards) and extend (straighten/swing forwards). It also can very slightly rotate. The hamstrings at the back of the thigh control flexion of the knee, and the quadriceps at the front of the thigh control extension. The strength, size and position of the hamstrings and quadriceps muscles can affect the way the leg moves, and therefore the way that the patella (kneecap) moves.

The patella is a small triangular-shaped bone within the quadriceps tendon in front of the knee joint. There are tendons and muscles above and below the patella and if they all work properly the patella slides in a groove on the upper leg bone (femur; femoral groove) as the knee joint moves. However when the patella is pulled out of alignment (typically towards the outside (lateral) aspect of the knee joint) it fails to glide easily and centrally in the femoral groove and this is known as Runner’s knee. 

Causes

• Weakness of the vastus medialis (the inner of the quadricips) muscle relative to the other thigh muscles
• Knock knees (genu valgum)
• Excessive/abnormal rearfoot pronation
• Flat feet (can cause internal rotation of the tibia)
• Tightness in the iliotibial band

Symptoms

• dull aching pain under or around the front of the patella. Running down hill, walking up or down stairs, squats, leg extensions at the gym, sitting for a prolonged time with the knees bent can all make the problem worse
• sudden, stabbing pain in the knee while running – eases off with rest

Women

More women suffer from the problem than men because of the angle of their hips/knees

Diagnosis

Clarkes test/patella femoral grinding test to test the quality of the patella articulating surfaces. Lie supine/face up. Get someone to place their hand over your patella and push the patella down and distally i.e. towards the foot, and hold while you straighten your leg. This means you will contract your quadriceps and elevate your knee holding it in extension. The patella should glide easily and smoothly up the groove in the femur. If there is degenerative change on either side of the femur or the patella you will feel a grinding sensation, and sometimes extreme pain.

How to help Runner’s Knee

• Rest
• Wear orthotics in your shoes to control your foot movement 
• Buy new running shoes if your old ones are worn out
• Cross training to help muscle weakness/imbalance. Cycling good, Swimming good – crawl rather than breaststroke (the leg movement from swimming breaststroke can irritate the area)
• Stretching the quads and hamstrings after exercise (latest research suggests stretching before exercise can increase chance of injury)
• Exercises – straight-leg exercises are best (knee extensions on a machine might make your problem worse)
• Knee strap – can help for some people

And … avoid sudden changes in your exercise routine, if you run on roads be aware of the camber/try to run on a flat surface, run slowly and carefully downhill

Knee strap

Superfeet orthotics for running

"I have developed pains in my knee when I run for more than an hour and I think it might be the ‘runners knee’. I have read about the runners knee and it could be due to weak quadriceps or biomechanical error and i think it [...]]]> Online question – Runners Knee

"I have developed pains in my knee when I run for more than an hour and I think it might be the ‘runners knee’. I have read about the runners knee and it could be due to weak quadriceps or biomechanical error and i think it might be the latter for me since I do cycle and my quads should be fine. I am looking at getting off the shelf orthotics to see if it helps my situation before seeking professional help. Do you have any recommendations to orthotics, or is there anything I should look out for when buying a pair? Any other advice would be greatly appreciated. "

Answer

Orthotics come in various lengths, typically ¾ (from the heel to the fall of the foot) and full length (which are the full length of the foot). When running any sort of distance a full length orthotic is more comfortable however just make sure there is enough room in your running shoes to accommodate them. Best thing is to remove the insole that is currently in the running shoe and replace it with a full length orthotic.

Standard over the counter orthotics often have a 4 degree rearfoot control which will suit the majority of people except people who excessively supinate their feet (very few people are in this category), people who have very “bandy” legs and people who walk on the lateral side (outside) of their feet.

I recommend you try blue Superfeet over the counter orthotics for running. If you can’t decide which size to get go for the size higher. For instance if you are a size 10 buy size F (even though size E fits 8.5-10 and size F fits 10.5-12).

And make sure your running shoes are not old and broken down. If they are get some new ones. Best of luck.