Hola amigo -- below is excerpts from an article I wrote that may benefit your mom. Two overuse injuries of the lower extremities that hamper some athletes are conditions of the forefoot; Metatarsalgia and Morton’s Neuroma. Prevention and proper management of these conditions is paramount as they can be slow to resolve short of total rest.

Metatarsalgia is characterized by a bruised feeling in the "ball" of the foot where the long bones meet and join your toes. The capsule of the joint becomes inflamed as a result of repetitive trauma. You may also experience numbness and/or some nasty burning. Morton’s Neuroma presents as a burning pain in the bottom of the foot, which typically radiates into the 3rd and 4th toes. Symptoms may be as light as numbness or show up as a debilitating burning pain that makes simply walking difficult. A neuroma is a cyst, benign tumor, or a thickening of the nerve. In the case of Morton’s Neuroma, the nerve is the common digital just prior to the bifurcation. These two forefoot conditions may develop separately or at the same time. Once they have taken hold they can be a real problem to get rid of. Prevention and quick action at first signs are important.

In the early stages of aggravation to the forefoot, reducing swelling and inflammation with rest, ice, oral anti-inflammatories, ultra sound and other forms of PT may be enough to alleviate your symptoms. Treatment should always be accompanied by preventative measures. Change out your running shoes often. As a larger runner with foot problems I have found that anything over 250 miles on my shoes is a problem for me. Over pronators are more likely to develop injuries of the forefoot. Make sure you are in the correct shoe for your foot and gait. A shoe with ample forefoot padding is desirable if you are prone to foot problems. It is possible for an athlete to have a thinning of the fat pads of the foot. A thinning fat pad could make further forefoot padding necessary in your shoe. A custom orthotic fitted by a knowledgeable doc or health care provider may redistribute your weight over the foot and reduce trauma to these areas. Try to run more trails and on softer surfaces.

For some, the symptoms we are discussing come on the bike. Make sure that your cycling shoes have ample room in the toe box. Lateral compression can often impinge the nerves of the foot that travel between the metatarsal heads causing numbness and burning. Hot spots can result from cleat position fore and aft, or pedals that do not suit you.

Unfortunately, it is possible to find yourself with a chronic Metatarsalgia or Morton’s Neuroma, having to manage symptoms, even after taking the preventative and management steps discussed. If that is the case consider changing some of your training strategy. There are different ways to attain our sport specific fitness. While some athletes log huge running volumes, others gain a good deal of their running fitness on the bike.

At first glance this idea may seem a bit disconcerting to some and may even require a leap of faith for many runners. As a coach I have found that one of the hardest things to convince a "runner turned triathlete" is that their run splits may actually improve if they run a little less and bike more. If you are forced by injury to reduce running miles, you can take solace in the many examples of positive results had by some who have increased cycling volume while reducing running volume. This will promote healing as it reduces trauma to the feet.

These two conditions of the forefoot can be agonizingly painful. They often have to be managed rather than resolved, especially if one keeps training. Some cases become surgical. The keys to successful management include proper equipment, training on appropriate surfaces, appropriate training volumes and in some cases a change in running technique.

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Kevin Purcell, D.C., is a USAT Level 1 certified coach for Elite and Age Group triathletes who compete at both Ironman and short course distances. Coach KP has completed 14 Ironmans and qualified for the Hawaii Ironman Triathlon World Championships five times. Dr. Purcell practices Chiropractic with an emphasis on sports medicine.

Kevin, thanks!! who would perform ultrasound, a chiro?

Any number of practitioners could perform ultrasound. However, the key would be to get a proper differential diagnosis by an examiner who understood your mom's needs, could identify correct steps to healing as well as prevention. My first thoughts would be to search for a direct referal to a podiatrist who also does surgery and deals with local athletes.

Kevin P. -

At what point would you recommend something more intrusive, such as corticosteroid injections or removal of the neuroma? My neuroma appeared quite suddenly in mid-March, and while I have yet to skip a run in that time, almost every run has had some sort of symptom attached to it. These are a real "fun house", however, with the symptoms never preseting themselves the same way twice.

In mid-May I had a corticosteroid injection, and that seemed to help some. In fact, until two days ago the foot was largely unproblematic --- or at least I had learned how to manage it and the realted discomfort. I had asked my doctor back in June if he would recommend a second injection, and he was reticent, saying that one of the undesirable side-effects of the injections can be a diminishing of the metatarsal pad, thus creating the very unpleasant feeling that one is running on the metatarsals themselves!

Two days ago, during a very innocent 24-minute brick run, my toes felt more sore than usual, and since then I have had the same sensation as I did back in March and April; that is, that the pad is swollen, and that the third and fourth toes are somewhat sore. I have an iron coming up in 14 days, and I'm a bit nervous about whether or not the foot can be comfortable throughout the 26.2 mile run. I might be okay, as back in the spring when it was more acute the general tendency was for the discomfort to abate as a run progressed.....but you never know.

Finally, I ran into a guy at a race last month who had had his neuroma removed, and he regretted it, saying that much of his forefoot is now permanently numb; he figures too much was removed. I believe my doctor is also a bit hesitant to recommend this for me, choosing instead for me to learn to manage and worj though the discomfort. He says that neuromas are NOT similar to an overuse injury, wherein the more you stress it the worse it becomes. I guess my experience would support that, as I have had a very full season without the condition worsening - until the innocent run two days ago.

So ----- Injections and/or removal. Where do you see them as viable options? (If it matters, I'm 56.)

Many thanks!!

I don't think there is _one_ correct answer for these two injuries, They seem to react differently in different people. More invasive treatments usually is considered if an athlete suffers enough but will not stop training. I started with neuroma type symptoms and ended up having a shredded capsule at the base of my 2nd toe from genetic toe problems (medial deviation). My condition required surgery in March. All of my runs for the last five years were painful. I was injected a number of times and got partial, temporary relief. Some docs said the injection was no problem and that my fat pads were fine. Others said it was less advisable. Turns out the fat pads are good, but the capsule was gone. Go to a top guy or gal who is able to you answer Qs and make decisions. There are a few problems in the area that can overlay or confuse at first glance.

KP