An elegantly-dressed gentleman presented not long ago in mild distress/despair. Seven years before coming to my office, he visited a podiatrist, whom he likes very much, in California, where he used to live. He had considerable pain at the ball of his foot, which she diagnosed as a Morton's neuroma (a collection of scar tissue about a main nerve bundle which supplies the third and fourth toes, causing shooting pain into the toes). She gave him a cortisone shot, a pair of orthotics incorporating a neuroma "plug" on their top surface designed to spread the bones pinching the neuroma, and his pains went away for two years. She also advised him to stop wearing his tight pointy shoes, likely the cause of the neuroma. All good advice. He moved to New York City five years ago, shortly before the pains at the ball of the foot came back. He visited another podiatrist, who suspected the problem recurred due to the increased walking many patients report on moving to the Big Apple. As the orthotics had theretofore been successful, neither podiatrist nor patient thought there should be a change in the orthotics.
The podiatrist thought the best approach would be a temporary lessening of the amount my patient walked, and a cortisone shot to calm the situation down. This approach didn't work too well. By the time the gentleman had come to see me, he'd been given 21 cortisone shots into the site, so many that his skin and fat pad had severely thinned and discolored. He could barely walk a block before experiencing severe pain, only localized at the ball of his involved foot.
On examining his foot, it was curious that he had what I could palpate as only the tiniest of neuromas, not something huge, which I would expect after his history. In fact, I couldn't even get the neuroma to hurt by forcible palpation. I could get the ball of his foot about one inch away from the neuroma to hurt quite a bit with only gentle palpation. This also happened to be at his second toe joint, the spot the NY City podiatrist had injected 21 times. This was not a neuroma. It was a major weight-bearing site we all have on the balls of our feet.
To me, this totally didn't make sense. His foot looked OK shape-wise. There were no deformities, weaknesses, or deficiencies in range of motion or circulation to cause such focal debility. Surely such a normal looking foot should respond to a few cortisone shots, and not worsen after 21 shots given over five years into the same painful spot. I figured there must be a gremlin around, perpetuating his pain, which was not in his foot, but in his shoes or his orthotics.
Bingo.
I matched his orthotics up to his feet, using 7-year old pressure patterns on his orthotics that his toes had made to make sure I was aligning them accurately. The answer lit up like a 24-foot neon sign. The "neuroma plug" which had been affixed seven years previously, had not been fixed in the right spot. It was not situated to splay the bones of the 3rd and 4th metatarsals. Although it was made of a moderately soft foam covered with vinyl, it was situated smack under his second joint, his pain place. He'd been walking on a marble-sized piece of dense foam at his second ball joint for 7 years. It took two years to start to hurt, and became continually symptomatic when he increased his walking a little on moving to NY City. I often use this analogy with patients when I encounter such a situation: "If you hit your hand with a feather 42,000 times a year, it will start to hurt." In his case, he did that for seven years, with a chunk of foam, at full body-weight force, many thousands of times per year.
His treatment? Do you want to say so, or should I? If you had to close your eyes as you got further into the last paragraph, I'll fill in the obvious:
He called me. Pain gone. He never needed orthotics for his neuroma. When he switched from pointy to round toe shoes, he already gave himself all the treatment he should have needed.