Transcription
[Music] Hi guys, this video is about metatarsalgia, or pain kind of in the ball of your foot in this area. Now, I recently managed to give myself this condition, so I thought I'll share with you how I managed to get rid of it as well.
So, what we're going to look at is what causes the pain in that area, what's the injury process, and the biomechanical factors and stuff that can predispose you to getting that. We're going to look at how it feels, how you can tell if you've got it, other conditions that can feel very similar, recovery times you can expect, and then, of course, the treatment regime—how do you actually get rid of it?
For those of you who don't know me, my name is Marika. I'm one of the physios from Sports Injury Physio at Comley. You can get online physiotherapy assessment as well as treatment of your injuries. Have a look at the description of this video if you want a link to our website.
Okay, so metatarsalgia. Let me get an x-ray of the foot up, and you'll understand a little bit better. So, that foot you can see is one that's predisposed to this condition, actually, because you can see the toes dip into the floor. The metatarsal heads make contact with the floor more. But if you look at the reason I've got it, it's just to give you an idea of the bones. Your toes are the first bones you see there, and then where it dips to the floor—that's the ball of the foot. Those are the metatarsal heads making contact with the floor there, and then you've got your metatarsal bones in this area.
When we walk, the foot naturally rolls over onto the front of the foot, and the leg comes off. This condition is caused when the metatarsal heads take too much strain on the floor when you're walking, and then they become injured. It's most often a change in the shape of your foot or something to do with the biomechanics of your foot that causes that part to overload.
Now, there are a few reasons why this condition can develop. You can get it if you've got certain arthritic-type conditions like rheumatoid arthritis or any inflammatory joint disease that can predispose you to this. But also, the thing with arthritis is it changes the shape of your foot and your bones, often in your joints, so then you can make that part of the foot take more pressure when you're walking.
This video is not about that; this video is about somebody with a regular foot like mine. Well, regular—I’ve got a few issues in it; that's why I got it. But you're just a healthy individual, and it's the shape of your foot that's caused it to overload through activities you did.
So, one of the big things that can cause it to overload is, like in my case, I've got lax ligaments in my feet. My ligaments just go, "Yeah, we'll collapse." It has caused me no end of trouble through the years with different things, but these and stuff like that. You can improve the condition a little bit through strengthening, but there's only so much you can do. So, orthotics can be useful for people like me.
Now, if I show you the shape of my foot, can you see that my toes are riding up? They're quite high, and I'm not pulling them up. It looks as if I'm pulling them up; I'm not. My foot is relaxed, but look at what happens if I press on that—how that changes the shape of my foot. It's because of my lax ligaments; my metatarsal heads have dropped down lower than what they should be. The ligaments haven't just allowed them to drop to the floor, so now it changes the way my toes sit and where I take the pressure when I walk.
So, this area takes a lot more pressure when I'm walking than any other part, and specifically, my second and third metatarsal heads are the ones that take the strain. Now, I've had this foot issue for as long as I can remember. I can remember at school already having discomfort in that area whenever I walked on hard surfaces for a long time.
It's not that I wasn't used to being barefoot. I mean, I grew up in a farming community in the middle of nowhere in South Africa. We didn't wear shoes going to school until the age of 13 or older, really, because it was just too hot in the summertime. So, it wasn't the issue of being used to shoes and then taking your shoes off. No, I grew up barefoot, and that still caused knee issues. I'm on the hypermobile spectrum of the population. I don't have hypermobility syndrome, but I've definitely got my ligaments moving a little bit more than what they should in certain areas, and my feet have always taken strain from that.
Now, your feet can be taking strain in that area due to the length of your toes. Some people have a really long second toe or a very short first toe; that can cause the metatarsal heads to take more strain. Sometimes, if your big toe moves over a bit more, that can change where your foot strains. So, there are loads of different reasons why the foot shape can be causing that to overstrain.
But despite my foot shape, I've had years and years and years where I haven't had issues with it. So, why now? The reason for that is partly the shoes I chose. If we think of it as being that part of the foot taking more strain, if I'm going to wear shoes that are not soft enough for them, and it's a really hard surface or doesn't give me enough cushioning when I walk on hard surfaces, that's going to increase the pressure on that area and predispose it to overstrain as well.
The second thing that I also did, or the third thing I did, was I've always been, for the last ten years, in the UK, where I've been pretty much living in trainers because my job was as a hands-on physio. I was running around the whole day, so I had lots of cushioning in there. Then, I was also used to, if I walked indoors, it was either carpeted flooring or springwood-type flooring—so really soft surfaces.
In the last six months, I moved to a warmer climate where all the floors are tiles because it's cooler, but it means it's rock-solid hard. At the same time, I changed over to wearing sandals—Birkenstocks—which are very comfortable because they've got arch support and a bit of a metatarsal dome, which my feet prefer. But they're much harder than what I'm used to, and of course, I walked miles and miles and miles—over ten kilometers on Sundays—and I didn't quite understand what was happening. I just didn't look because my feet had always been uncomfortable, and I didn't realize until the last moment that I was really pushing them too far.
So, the combination of things that causes it is your foot shape causing more pressure there, but then the shoes you wear and the surfaces you walk on are very big contributing factors.
So, what does it feel like when you're starting to get metatarsalgia? It feels as if you've got a pebble in your shoe, as if there's something underneath it when you're walking. It literally feels as if you want to cut a hole in the shoe in that area, and it'll take care of everything. It's because the bone and the ligaments and the tendons in that area have thickened and are a bit swollen, and there's just more fluid and stuff in there. That's why it feels as if you're walking on a pebble. You can get sharp pains from it as well, and even electric shock-type sensations if it's affecting the little nerves next to those bones.
But there are other conditions that can feel similar. You can get referred pain from the lower back that can cause pain or discomfort in that area. You can get tarsal tunnel syndrome that can cause pain in that area. You can get stress fractures in that area that can feel very similar, and depending on how advanced yours is and how bad it is, the pain you experience can be different as well.
For mine, because I didn't realize early enough what was happening, I had a period where I really increased the walking in those hard shoes, plus then spent two to three days walking around the house barefoot all day long—cleaning the house, cooking, and stuff. By the second or third day, I realized, "Now I'm in trouble," and I pushed it over the edge. For me, I had a lot of pain first thing in the morning when I woke up. Those first few steps, or if I wanted to get up in the middle of the night to go to the loo—oh my soul! I wanted to walk on my heels at that point; it was really horrendous.
It was slightly better if I put my trainers on, but they were just not soft enough. I couldn't walk more than 200 meters; then I became really uncomfortable. I could feel I was changing my gait, and then I would feel worse afterward. So, whereas at the beginning, when I should have been paying attention to it, it was just a bit uncomfortable while I walked, I kind of made a mental note that I should wear my trainers when we walk long distances. Then, when it's hot, it's not that bad, and then I wear my sandals again.
So, it can be quite a different spectrum of discomfort that you feel in there.
What else with that? If we think of recovery times for this, if you've got a very mild case and you catch it early, it can be as little as six weeks that you feel really comfortable. For myself, because I neglected it for a long time and got to the point where it was super painful first thing in the morning getting out of bed and just walking short distances, it took me three months before I saw a significant improvement in my symptoms. I didn't dread going for a walk in my trainers anymore, and then I would say it's taken me another month on top of that to become comfortable with jogging and having my normal running style come back.
I still wouldn't sprint up a hill with them, but I can definitely feel that I was starting to get back to my normal gait. If I have to think of how long bone stress injuries and tendinopathy-type injuries usually last, I think mine's going to take six to nine months to fully go away. I do feel if I had access to the right type of orthotic at certain points, I would have shortened my recovery period, but I'll talk about that a little bit more in detail in a minute.
So, it can take anything from six weeks to six to nine months, and then some people don't. Some people need to go on to have surgery and stuff, depending on their foot shape. But it's usually people with really bad or addicted feet. If you're a young person and an active person, and it just suddenly happened, your first port of call needs to be the podiatrist because they'll be the best investment for this type of condition for you, and I'll talk about that in a minute.
Okay, so let's talk about treatment. If you think about what causes this injury, it's overload and too much pressure on those joints and the tendons and stuff underneath there. The first line of treatment needs to be that you stop offloading that. Now, it doesn't mean you've got to sit with your feet up all day long. Yes, it does mean a reduction in how much you walk, how much you stand, especially on hard surfaces. But you can also offload it through the right shoes, the right orthotics, things like that—just being clever about it.
So, let me talk you through those. Yes, I had to definitely reduce the amount of walking I did, and I had to give up running for a while because I could feel that if I did go for a run or I did go for a walk longer than two to three hundred meters, my feet felt significantly worse after that. I was unfortunately stuck in a place where I couldn't get hold of the right type of orthotics and things that I knew I needed. But the one thing I could order was very soft Crocs, and these Crocs are amazing! I don't know if all Crocs are like that, but these ones feel like marshmallows inside, and they made the biggest difference to my life because immediately when I put them on my feet, I could walk indoors without pain.
That was massive because at that point, I was hobbling around waiting for these guys for two weeks to arrive in the mail inside the house, feeling really miserable and uncomfortable because I just couldn't walk inside the house without pain, especially getting up first thing in the morning, which was agony. As soon as I got these, I would just stick my feet into them first thing in the morning; I had no pain with my first few steps. If I forgot, then the first few steps were agony until I could find them.
So, definitely get the softest shoes you can and start wearing them; it will make a difference. Then, I knew from experience from previous years where I had this type of thing that if I could get my hands on my orthotic with a metatarsal dome—now, what I mean by that is that type of thing where it can lift the metatarsal heads off the floor so that they don't make contact with the floor, or as much contact with the floor when you walk—I would feel much more comfortable.
But unfortunately, I had stupidly ditched my old orthotics in the UK before we started traveling, so I didn't have access to them. I'm traveling in Southeast Asia, and the websites here—you don't have Amazon; you've got criminal ones—but they didn't have the type of orthotic that I needed. So, I have a feeling if I could find those, I would have been a lot more comfortable more quickly.
I want to show you how that works. If you can see my foot, let me show you my foot better. So, if you can see my foot and how my toes stick up, if I press, if I lift that, can you see how that changes the shape of my foot? It lifts the metatarsal heads just a bit off the floor.
So, what that dome does is it does not sit under the metatarsal heads; it doesn't sit on this bed. If it sits on that, it will make it worse because it's going to increase the pressure on it. Trust me, I even tried the little gel cushions you can get to put under there; it was horrendous. It really didn't work because it definitely makes it take more pressure on there. Even if it's gel, the metatarsal dome sits behind, so it fits in there. It's not pressing on their heads; it's pressing on the shaft of the bones, and by doing that, it lifts the heads up as well.
So, if you're going to do a DIY job of this, make sure you don't go and stick that metatarsal dome under your metatarsal heads because it will definitely make it feel worse. That's why it's useful to go through a podiatrist to make sure that actually fits in the right place.
Now, I couldn't find those. The only orthotics that I could get that helped me a bit in my trainers were these gel ones, and they literally just made the surface super soft because even in my trainers that were cushioned, it wasn't—it was still too much friction and too painful for me to just walk a little bit to get to a restaurant or café or something, and they made a big, big difference.
So then, once I found, once I offloaded it for a few weeks through really soft shoes, really soft orthotics, and also limiting the time on my feet—so not too much standing, not too much walking—I found that my feet started to calm down. I could tolerate a bit more walking and standing on them, but always with soft shoes.
I got to the point where it was driving me nuts because I really wanted to get back to running, and I felt a bit stuck. So then I experimented because usually when you get back to running from an injury, you want to do run-walks. But I actually found that walking was a lot more aggravating for this injury than running was. It's because when you try to walk, especially if you're trying to walk fast, you tend to push through the fronts of your feet to propel yourself forward, and that friction was just making things worse.
So, I found it better to have a bit of a shuffle run; that was less pressure because I didn't have to go through the whole dorsiflexion range of movement with that. So, that definitely made it better, and I could do little bits of running—just enough to keep my sanity.
Now, as time went on, because I've offloaded it longer and just kind of looked at my load management, I always use my discomfort that I feel first thing in the morning when I get out of bed. That's a good way for me to monitor my discomfort because at this point, my feet are now good enough that I can walk to the loo in the middle of the night without my shoes on; it doesn't really bother me.
Whereas if I go and overdo it, then I try to get up and go, "Oh, that's a bit sharp again today." I need to think about offloading, and I need to think about what I did yesterday that caused it to be more sensitive today because you want to limit that to an extent.
So, where I'm at now is I can run five days a week for about 23 minutes, and I'm back to pretty much my normal running style. I can't run up hills still because when you run uphill, you've really got to go on your toes, and that's too much. I can feel that if I do that—I've done it once or twice to test it, and then I pay for it the next day. I can now walk up hills, which even a month ago I couldn't really do.
So, it's slowly improving, and it's getting better with that. What I find is you've got to think of your total volume of load you put through that part of the foot in the day. If I go for a run in the mornings, then I have to make sure that I wear these guys all day in the house because otherwise, it's more sore the next morning. If I don't go for a run first thing in the morning, so I don't have that volume of pressure, then I can get away with not wearing these guys for most of the day, and I still feel fine the next morning.
So, just think of the volume of compression and pressure you put through your feet for the whole day, and try to see a cause and effect in how you can play with that. Because it's important to start loading the tissue again so that it can get used to it, but listen to your feet as to what they want.
Now, exercises for this condition—yes, you could do some stuff to strengthen different muscles and things, but in my experience, that's got a limited benefit to it. It is important to get them going, absolutely, and I do balance exercises and things as well because I always want to keep my arches strong. I'm predisposed to ankles and feet that give me trouble because I've got really relaxed ligaments, so I tend to always try to keep my feet strong.
But the most important part of the treatment for this is to offload it with the right orthotics if you can get your hands on them. So, a visit to the podiatrist and soft shoes. I know from my patients that I had in the UK in the past, there are two specifically that come to mind. One was a young girl who was wearing these ridiculous ballet pump things—that's just a piece of cardboard between you and the floor—and not understanding why her feet killed her. We fixed it through her just switching to trainers for most of the day at that period and then switching to normal regular shoes that had a bit more cushioning.
The other person was a male who used to walk to work in dress shoes and walk quite a long distance in his dress shoes on hard pavements. His were so bad that the surgeon said, "Well, the only thing we can do still is do a release on your calf muscles," which didn't make sense to me because his calf muscles weren't tight. I eventually convinced him to just start wearing trainers when he had to walk, and it took a while. He was also quite bad, like my foot; it took I had to keep on just really motivating him to stay with the process because you only see tiny little improvements at the beginning.
I think it was about eight weeks when he finally said to me, "You know what? It's getting better. It is getting better." So, an important takeaway from that is it's not an instant fix to switch to soft shoes. That pain will still linger. I'm four months in, and some days I get really annoyed with these feet because I can't do what I want to be doing. But if I'm good and honest with myself and I look at where I am now versus a month ago, there's a massive improvement. A month ago, I was struggling to run three times a week; I'm up to five times a week now, plus walking around in addition to that.
So, my load is much more, even though I've still got some pain. So, that's what you want to see. You want to see your load tolerance of your feet increasing despite the fact that you've still got something. The pain will eventually come down.
Excellent! Let me know if you've got any questions, and if you need more help with the injury, you're always welcome to consult one of us via video call. Link to our website in the description of this video. Take care. [Music]