When she first came to me, this previously-athletic young mom had had 12 years' pain in the ball of her foot. She was given orthotics back then which helped the problem somewhat, yet the pain persisted. Soon after getting the orthotics she developed pain in the middle of her foot at the tendon which pulls her foot up. She was then prescribed physical therapy. The physical therapists prescribed strengthening of the tendon. Her tendon pain worsened. She stopped the therapy, and decided to change her lifestyle and take athletics out of her life. Her tendon pain lessened, but persisted minimally, as did the pain at the ball of her foot, for the remainder of the twelve years before she first visited my office. She was referred by her husband, a tennis player who was a long-time patient of mine. He hoped I could get her well enough so they could play tennis together again.
She brought her MRI in, which had been done recently. I wouldn't have been surprised to see a chronic fracture or other serious injury at the ball of her foot, considering the problem had lasted at the same site for over a decade. Curiously, there was only a speck of inflammation at the site, nothing severe enough to make a problem so chronic. There was also some tendon inflammation at that foot puller-upper tendon (the anterior tibial tendon).
Looking at her feet, they didn't have the shape which usually causes problems at this part of the ball. Her circulation and strength were fine. Then I watched her walk. We humans are supposed to walk heel, foot-flat, and then heel-off, when we suspend our weight on the ball of our foot for the final moment before our foot leaves the ground. She didn't. She didn't put any weight on the ball of her foot. She was overusing her foot puller-upper tendon, which explained the tendinitis. But this gait pattern, and the calm MRI, did not explain the persistence of the problem for so many years at the ball of her foot.
Whenever something doesn't make sense, I've trained myself to check the footgear. I looked at her sneakers--not too tight, not too stiff, not too old, not too flimsy, fit her feet, insides nice and devoid of bumps. OK, they were perfect for her. Then I looked at her orthotics. Very suspicious. They had a 1" thick hill just behind the ball of her foot where the pain was. This hill is called a metatarsal pad, or simply "met" pad. I figured the pad had originally helped the ball of her foot by elevating it from behind, but at a price. In order for it to work, she had to learn to keep her weight back, and engaged on the pad. As soon as she took her heel off the ground and put the weight on the ball of her foot, she'd disengage from the met pad and have her weight smack on the painful ball.
But having to keep her weight back began her long odyssey of not pushing-off with her calf, which is what's supposed to happen when your foot leaves the ground. Instead, she was pulling up with that pesky midfoot tendon, putting it on triple overtime and starting its chronic tendinitis.
OK, tendinitis explained. But why the main booboo, the pain at the ball of her foot? I did a little experiment I often do in such a situation. I put her orthotics back in her sneakers. Then I took out a skin marking pen and marked, exactly and only the tiny site of her chronic pain at the ball of her foot. Then I asked her to quickly put her bare foot into her sneaker and stand up, so the ink would transfer to the orthotics before it dried. When I took the orthotics out of her shoe, I saw what I expected: the mark representing the place on her foot where her pain was had transferred to a place high up on the huge met pad. In other words, the pad was perpetuating her bruise! The orthotics helped only because they fostered the abnormal gait pattern, but they were actually perpetuating the problem.
The treatment? The orthotics were fortunately made of a solid enough material that allowed me to adjust them on the spot in my shop. I ground off the blasted met pad. Then we put the orthotics back in her sneaker for another skin pen transfer mark. I then saw the spot on her now flattened orthotic where her pain was, and ran back into my shop and ground a raisin-sized cavity in the orthotics exactly where her pain was. This provided instant relief (and joy).
I asked her to return in a month, barring unforeseen problems. If she was not able to relearn how to walk by herself, now that she could push-off and regain her strength and muscle balance and yet be protected by the little cavity, I was going to send her to some excellent physical therapists who work well with such situations.
She did not return in a month, in fact I didn't hear from her for a long time. But that Christmas, I received a lovely fruit basket via messenger. Taped to the top was a signed photo of my patient and her husband, on tennis holiday in Hawaii.