Friday, July 23, 2010

Foot Sleuth and Fancy Free

I hurt my foot running. A seemingly simple question to ask is "Why"? I ask this question because I don't want the same thing to happen again. I've been looking for answers. Most sources answer the question from the perspective of their area of expertise.

The ER doctor diagnosed the injury as "foot pain" because the Xray was negative for a break, although a stress fracture was suspected. The doctor at my regular clinic diagnosed it as "metatarsalgia", which suggests an issue with the metatarsal bones but in most literature it looks like the reference is to general pain in the ball of the foot. It could more specifically be capsulitis which is an irritated joint capsule at the end of, in my case, the second metatarsal. This capsule can even rupture. It could be a bone bruise at that same end of the metatarsal or both.

Most of what I read regarding descriptions of similar diagnoses do not sound like a similar injury. Most people seem to experience some relatively gradual build up to soreness or pain. I had a gradual build up over one day and then a sudden intensely painful event the following day. My interpretation of this is that there was some type of catastrophic failure, albeit rather localized. Much of the metatarsalgia accounts speak of the sensation of a stone in the shoe, not of a spear suddenly being jabbed through it. So I'm picturing either the ruptured capsule or some kind of fissuring of the end of the joint. Something that was definitely stressed gave out. Why?

Some might say overuse, or too much of an increase too soon, was the cause. OK, fair enough. I've had other overuse injuries and they've all gone away. Why was there this failure at this particular place in my body? Clearly there was too much repetitive pressure/stress on the same spot. In just a three week period, this particular point on this 52 year old foot struck the ground at a running gait approximately one quarter of a million times with a 180 pound cargo. Did I exceed the limit or was there some pathology that allowed this failure?

My impression is that if I ask the orthopedist I will be told that the bone rides lower than it should and could be shortened, if I ask a physical therapist I will be told that I need to strengthen certain muscles, if I ask the chiropractor I'll be told my hips are out of alignment and I need adjustments, the HappyFeet people will say I need their orthotics, the nutritionist will say I need calcium, the running shoe people will want to put me in a shoe that controls pronation which they've done for 20 years. (Analyzing the implications from the callouses on the bottom of my feet, particularly the right, I would say that my feet don't complete their pronation which should go all the way to the big toe side. Hmmm, this problem was already occurring before I kicked off the running shoes.)

I'd like to have all of the above knowledge in one person, but I think the only way to do this is for me to be that person. I need to look at some evidence: My left running shoe has always had much more significant tread wear than the right foot and since I've been running barefoot or minimalistically my right foot has become significantly more padded and calloused than the left. When I've had plantar faciitis or Achilles tendonitis they have always been worse on the right leg. I've always thought the muscles in my right leg looked bulkier than the left leg.

To me, much of this might suggest a longer left leg or maybe unlevel hips. It makes sense; shorter limbs often look more muscular. Wouldn't the foot on a longer leg scuff the ground more often than its shorter counterpart? Would the padding on the foot of a shorter leg thicken to balance things out? Hard to say. Would it thicken because the forces coming down on it were greater because it has farther to go to reach the ground? More conceivable. Tight calves supposedly contribute to plantar faciitis, which I had for a long time so presumably I've had tight calves. I read that tight calves can lead to the far end of the metatarsal riding lower which makes it take more of a load. If that takes more of a load, then a callous builds up under it. If a callous builds up under it, that callous becomes the point of propulsion instead of the big toes and the part of the pad that corresponds to it. Did wearing pronation control shoes for so long cause the middle of my foot to become the point of push off instead of allowing the big toe side of the foot to become involved? Once I took my shoes off to run and there was this big callous in the middle of my foot was now a part of my foot handling a job it wasn't designed for?

So how do I fix this? If my hips were not level, the chiropractor could adjust this and the adjustment would probably last as long as the car ride home. I could get routine adjustments, get physical therapy, and do exercises to support the adjustments, but I just don't picture all of that overriding 52 years of me being a little bit crooked, not to mention the cost nor the discipline required. How about lengthening or shortening a leg? For someone who's impatient waiting for a bone bruise to heal!?

My feet seem to be trying to correct the matter themselves by adapting. Maybe I should follow their lead. I can support them by continuing to not let the calves interfere by keeping them from tightening and pulling on foot parts. I'm picturing a little bit of orthotic padding under the termination of the first metatarsal; if that were in effect lower to the ground, when the foot pronated from its initial foot strike on the pad between the 5th and 4th metatarsal ends inward, it would roll to next point closest to the ground which would be the padding, taking the 2nd metatarsal out of the picture. The big toe and the corresponding metatarsal are significantly heftier and are intended to handle the push off. This padding would have to be tapered to nothing as it crosses the forefoot pad. This could be done inside a minimalist shoe or the Vibram FiveFinger. I could try to get my foot back to how it should be naturally without the big callous in the middle of it.

This is the state of my pondering to this point.

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