Conway McLean, DPM, Journal columnist

Robert, today’s protagonist, was an active fellow and enjoyed many local sports, from mountain biking to trail running. The latter was his primary passion, leading to entering and running several marathons some years back. But work demands had prevented this for too many years and Robert had longed for a return.

Robert was planning a half marathon in the future but as he increased his mileage and pace, he found a consistent and persistent discomfort developing. A significant ache was experienced from the outside edge of his foot midway between the ball of his foot and the heel. What was in that part of his foot and what was causing his pain was a mystery to him.

This was a new and distinct problem he hadn’t noticed before during his athletic pursuits. After each run, the pain was noted. Initially, it was a mild dull ache, and would be almost completely resolved the next morning. The pain began to be experienced earlier in his training and progressed to the point that he was having to stop his run.

He had always been careful about his running shoes and understood their importance in staying injury-free. This new symptom, experienced to some degree from the outside of both feet, perhaps could be resolved with a change in the type of shoe he was using. A visit to the local running shoe store resulted in a completely different shoe type, with a change to a cushioning-type shoe from the neutral shoe that had been his preference historically. He was excited to find that, indeed, simply changing shoes reduced the intensity of the pain.

Unfortunately, as he ramped up his training, his foot pain returned but now to nearly debilitating levels. Robert grew frustrated with his inability to be more active, his inability to train harder without this discomfort, and knew he needed to seek professional care. A visit to his primary care provider resulted in a prescription for an anti-inflammatory. The x-rays obtained were unremarkable, revealing no fracture or bony injury. And as soon as he discontinued use of the medicine, the pain returned to prior levels: it wasn’t fixing anything.

A referral to a specialist led to a steroid injection, which indeed provided great relief but, as is so often the case, the benefits were transient. Robert was able to run without pain for several weeks, but thereafter, a subsequent run saw the pain return unchanged. Several other opinions were sought with one suggestion being a reconstruction of Robert’s arch type. This seemed a radical suggestion since he had generally had no pain as long as he didn’t run. A prescription for physical therapy was produced and several visits did lead to some mild improvements in pain levels……but not enough.

Eventually consultation with a foot specialist revealed some surprising truths. Apparently, Robert’s higher arched foot type was generating excessive stress to the joint connecting the outer two metatarsal bones and the bone in front of the heel bone. With simple ambulation, the stress to this structure was inadequate to result in pain.

But running is a different animal. The impact and forces placed on a variety of structures is significantly greater with this activity. This joint in particular, in the middle part of the foot, becomes aggravated and inflamed with greater physical manipulation, which is exactly what occurs when running. For others, simply walking or standing for longer can produce pain from this region.

A detailed evaluation of Roberts gait, as well as his foot structure and biomechanics, resulted in the prescribing of a foot support placed inside his shoes. With these customized foot-body supports, a.k.a. foot orthotics, in place, Robert was able to train successfully without pain. He gradually (and comfortably) increased his training regimen and went on to complete his goal of running a marathon.

Robert’s experience with foot pain highlights that of many others. Some abnormality in foot shape or function causes no symptoms when the individual is flush with the vitality of youth. But the years take their toll, and that stress is greater to those specific joints in the higher arched foot. These recurrent symptoms, sometimes experienced as a sharp pain, more often as a dull, aching sensation, are a mystery to most healthcare providers. And have led many sufferers to abandon the activity or reduce their fitness level.

Many structures, such as joints, tendons, or ligaments, can be stressed by abnormal structure or function. And symptoms often develop over time, without an inciting injury. The pain simply appears. But normalizing gait mechanics can relieve the stress to the affected structures, leading to resolution of the problem.

It is a complex phenomenon, how the body moves, but a thorough and detailed study of human structure and function can lead to pain relief, allowing the pursuit of a variety of fitness and sporting activities. If you have recurrent pain from some region of your foot or leg, get an evaluation of your biomechanics. It may be the next step to keeping you running (or biking, swimming, walking, etc).

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.