Possible pre dislocation of 3rd MTJ -- rroof, help!

Triathlon Forum
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Sept 2010 I was coming on the end of marathon training when my foot became swollen and very, very painful. The pain was under my 3rd metatarsal and felt like I was walking on a marble. I have severe bunions, so having pain was not surprising, but the severity of it was. However, I continued my 50 mile per week regimen (I have been running for 20 years, doing marathons for 11 years and maintaining a somewhat consistent 45-50 miles per week average for 4 years.) I went to several doctors, the first admonishing me not to run my 10-10-10 marathon. I wanted a second opinion, thinking it might be a neuroma with the pain being under my 3rd toe. This doctor did a Morton’s neuroma test (the pinch test – it was positive), gave me a shot and told me I could run. I ran the marathon, with the last 4 miles feeling like a knife was coming through the bottom of my foot.

Since then, I continued to run, but cut back dramatically on the miles. The first week of Dec 2010 I quit running and all other forms of exercise that might put pressure on my foot to see if that would help. It did not. It continued to be swollen and the feeling of walking on a marble persisted. Also, somewhere along the way, my 3rd metatarsal has drifted over, leaning against the 2nd MT and during exercise or any kind of continual pressure from the bottom of my foot, the 3rd MTJ “raises” up onto the 2nd MT. (I also have not been able to walk barefoot since Sept 2010.) I have gone back to my orthopedic doctor who diagnosed me as having metatarsalitis and sent me to PT, hoping to see if the pain will subside by strengthening the muscles in the bottom of my foot. I also have adjusted my orthodics with an addition of a metatarsal pad. This doctor mentioned that if my symptoms plateau or worsen, we might need to talk surgery. Since mid-January, I have resumed some excercise, including running, but it is minimal. I can run, but not without some pain during the run, and post-run it is quite painful, and sometimes the 3rd “toe column” as I call it can become numb.

I am losing hope that PT will help, and am becoming worried that running will not be an option in my future. I am very leery of surgery, but have always known bunion surgery might be in my future with my genetic history. After looking on this site, I have researched pre dislocation, and from what I can tell, this might be a probable diagnosis (although I had an x-ray done and no doctors have said as much?). I’m not sure if it’s the collateral ligament that has stretched out of shape, or the joint itself has “fallen” thus causing it to lie on a nerve. I also had a bone scan performed to eliminate a stress fracture.

I’m hoping to attach pictures, and that might help. But, do you think there is anything I can do without surgery for this? And if surgery is a must, can my foot be restructured in such a way where I can resume my active lifestyle?

Also, if there are specific questions I can ask my doctor that would be helpful to know. Of course I’m being a fatalist here and have looked into different surgery procedures: Weil, flexor tendon transfer (which I’ve heard doesn’t allow for much activity post-surgery).

Thank you for any help you can offer.

Katherine
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Bump to see what Rod has to say about this one…

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Have you tried a chiropractor? I landed in NZ about 15 months ago and went for a run the first morning that I woke up there. On the waterfront in Wellington, loving life… when suddenly a woman with a stroller comes around a blind corner and I had to make an aggressive lateral move that resulted in my foot landing on the ridge of the pavement. I spent the next three weeks ambling around in constant pain. When I got back to the states I saw my chiro and he popped everything back into place and I’ve been right as rain since. Most people wouldn’t think of seeing a chiropractor for a foot problem, but mine straightens me out from head to toe about once a month and it makes all the difference to me. Also, it’s something that will probably take a few visits to sort out in any sort of enduring way…

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Interesting. No, I have not thought of a chiropractor, but right now I’d even consider voo-doo if I knew it would work! I wonder in what ways your condition differs from those who have pre dislocation? It seems if you have a stretched ligament, you have a stretched ligament… But I will certainly entertain the notion. Thanks for responding.

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Onlynone person hasnuglier feet than that!! Think he posted a picture once also.

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Ha, ha. Yes, my feet draw looks of horror from passers-by when I wear sandals, believe me!

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i had a morton’s neuroma…they can be tough to treat! mine actually just went away…it just waxed and waned for years, aggravated by surfing, and then finally went away and never came back. options are injections (steroids may shrink the sucker) or excision…your pain sounds like a neuroma to me.

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get the book Why you Really Hurt: it all starts fwith the foot by Dr. Schuler…should give insights

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Just now seeing this - how are you doing?

Lesser MPJ pre-dislocation syndrome is most definitely a possibility for you (sorry there isn’t a better name for this condition - the guy who coined the term was a great man who died much too young BTW, Dr. Gerard Yu).

I have only rarely seen it in the 3rd MPJ, usually the 2nd. You seemed to have read up quite a bit. It is often misdiagnosed as simple metatarsalgia or Morton’s neuroma (although the treatment can be similar initially). I don’t like flexor tendon transfers much and prefer a Weil type (named for Dr. Lowel Scott Weil who I’m not near as fond of) procedure that I find more effective for runners for the long term (i.e. you can still run after!), but you don’t get as much correction of the digit (but the plantar joint pain/swelling resolves).

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RRoof, thank you for responding! My foot is not doing too much better, although I have seen the swelling go down slightly. The pain, however, has remained.

What causes you to think it is pre-dislocation and not sub-luxed? (I have read aritcles by Yu, and when I discovered he passed away contemplated contacting Molly Judge, another author of the articles.)

This might be an offline conversation, but I would like to have a doctor who has seen this type of foot injury on athletes. I have been to 3 doctors thus far and only one has indicated having seen something like this, but not the exact thing. Do you have knowledge of any doctors in Texas? I am really desiring one who understands the lifestyle of marathoning I want to return to, and one who routinely works with athletes. Might be too tall an order.

Thank you again,
katherine

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Dr. Judge trained under Dr. Yu and is still in the Cleveland area I think.

This is NOT that uncommon an issue. I routinely see several per month, it is just often misdiagnosed.

As for your question: that is the entire point of Dr. Yu’s work. There is no difference between “subluxed” and “pre-dislocation”. The reason he coined the pre-dislocation term is the typical progressive nature of this pathology (leading to eventual dislocation, and general dorsal and medial dislocation of the toe). “Subluxation” is not a very good term and has no real definition.

PM me - I do know a few good docs in TX (but that is a HUGE area!)

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i think i have the same thing going on in my root foot, but 2nd toe. first dx was neuroma, second was capsulitis, havent run really in 2 months, but have been dealing with swelling since october. ive been in a boot since jan 1, 2012. going crazy!!
have you found any resolution?
i have no pain anymore, but definite toe drift. reading things online is making me paranoid and i am looking for answers regarding running and predislocation syndrome- also in texas and wondering if you found a doctor down here familiar with it regarding athletes and return to sport.

going to get prolotheraphy on it and wondering if anyone has tried that for this issue?

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Would you be up for talking offline about this? I’ve been dealing with it for over a year now. Not sure what encouragement I can give, but would be curious to see how your injury began and what you have been doing. I’d be happy to share articles I have found and conversations with doctors I’ve had. Email me at: khill359@gmail.com.

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Hi! I’m dealing with this in my second toe as well. Has yours resolved? I don’t think my toe has drifted. Did any of your doctors tell you to wear the boot? I’m wondering if I should just start wearing a boot. Is the boot what took the pain away? How long did it take for the pain to resolve? Did you go to PT?

Thanks!!

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It resolved! the toe has permanently moved slightly towards the the big toe so I affectionately call it my star trek toe. I am not sure what finally worked treatment wise but ill outline what I did.

  1. stopped running-i substituted biking but only inside on a trainer and for less than 1.5 hours at any time. i also did not aqua jog until the boot came off.
  2. wore a boot for 6 weeks EVERY DAY. i probably could’ve gotten away with wearing it for only 4 if i had worn the boot all the time instead of only when it was convenient (which was any time i wasn’t needing to get in my car to drive anywhere, which was, of course, rare!)
  3. iced and elevated (my foot was super swollen on the top of it and no one could tell me why)–figured it wouldn’t hurt
  4. used arnica cream (traumeel) and took celebrex (even though i am anti-anti-inflammatories)
  5. once the boot came off, i aqua jogged for a few weeks.
  6. I received 3 prolotherapy injections from dr fullerton at proloaustin.com

i began a “return to running” program approx 3 months after the MRI showed a partial tear of the plantar plate (but it took a few radiologists and a foot surgeon to figure it out) but was pain free at the start of that. it was a VERY VERY conservative build. in fact, its been nearly a year since I got the boot off and my longest run to date has been 14 miles…

i was completely paranoid about the shoe situation once i started running again. i thought i had my shoe situation nailed down but it was clear i didn’t. i worked with a great orthotic maker and went through numerous iterations before i decided to chuck them and went with the advice of my coach at the time (ironically an orthopedic surgeon as well) to try the Sketchers GORuns. I thought he was joking when he told me to get a pair.

BUT THEY ARE AWESOME. I had been wearing orthotics for years and had been told by people I would always need them. What BullS***. With the right program that addressed imbalances and was a VERY CONSERVATIVE build, i was able to wean off of them, no problem.

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Might try Hoka One One’s. Worked wonders for me. May be a more “technical” super cushioned shoe?

I was out 10 mos with a foot injury (2nd metatarsal head injury) until I switched to Hokas. Very frustrating.

Glad you’re better.

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Do you have high arches and a morton’s toe? I have both–just wondering how similar our feet are. You said it started to hurt in October and then you started the boot in Jan–did you notice the toe shifting before you started wearing the boot? Did the doctors tell you to use the boot? My podiatrist is having me tape it down for now, but it is still painful to walk on so I am using the boot so I don’t have to walk so awkwardly.

Also, did you use ultrasound therapy at all? My podiatrist wants me to get an injection, but I’m nervous about residual effects from it and am hoping that a physical therapist can help expedite healing.

Lastly, did it still hurt when you wore the boot, or not at all? I mostly feel fine in the boot, but occasionally feel the pain when I walk.

Thank you SOOO much for responding to me!!! Seriously, yours is the first post that has given me hope for real recovery!! Everything else that I’ve read or heard about the plantar plate has stressed me out!!

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Hey! I asked you about my plantar plate injury back in February and you told me that it would take forever to heal (and you’re right haha). At the time it was only a guess that I had a plantar plate injury or capsulitis. I was in a boot for 6 weeks and the pain went away, almost completely and then kinda snuck back in as I began to walk normally again. I just got an MRI last Thursday and saw my podiatrist today and he said the MRI showed that I did have a plantar plate tear, but that it’s mostly (if not completely) healed. It still hurts to walk, but is not as bad as it was when I first was injured. So my podiatrist prescribed me some steroids to take over the course of 5 days that taper off and he said that it would likely take all the pain away, but could come back, but not be as bad (am I making sense here?).

So I’m just wondering what your experience with this is. Have you used this approach? Does it work? He said that it could take it away completely if we can just break the cycle of inflammation. He said I may be able to run again in 3-4 months time. I just want to be realistic about it. I haven’t run in so long it’s killing me!! My second toe has only slightly lifted, no one would notice unless I stood and pointed it out, and it has begun to hammer slightly as well. Other than that there is no physical evidence of injury.

Please tell me this won’t require surgery! There’s no current tear in the plate (as far as he can tell) but it’s still bugging me. Is this normal?

Thanks for taking the time to read my worries! I just want to know that I’ll be able to walk normally again and eventually run.
Kayleen

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It is a reasonable approach, but as I mentioned earlier (actually 2 years ago!), these “injuries” tend to be progressive in nature. They aren’t too hard to calm down with time off, immobilization, anti-inflammatory modalities (local or systemic), only to return with various degrees of disability. Since the surgical approaches to “fixing” aren’t great either, you are sorta’ stuck I realize. Most people find several things that seem to help and do them (same goes for avoiding things that irritate, but that could be running :()

I’m not sure I understand your MRI reading that you had a tear but it is healing/healed? That doesn’t quite make sense.

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So are you saying plantar plates don’t heal ever? That can’t be the case, right? My podiatrist said it takes a really long time, but usually in 3-6 months it’s pretty much there.

He said the plantar plate looked like it was not quite as flat as it should, but there was no white in the MRI near there so it had healed (or something like that.) He said it looked like it had healed and there was minimal if any inflammation of the capsule. He initially thought it was the plantar plate and then thought it was capsulitis, but the MRI led him to believe that it was the plantar plate, but not a full rupture. Does this make sense or no?

So there’s nothing I can do to promote true, lasting healing? Should I be going to physical therapy? It’s not just running that I’d like to do at this point, I can’t even walk without a limp!