About a decade ago a 25-year-old runner visited me with pain in the inner sides of both feet just behind the big toe joints. She said her problems began four years previously when she got into competitive running and developed iliotibial band tendinitis on the outer sides of both hips and knees. She'd seen an orthopedist who diagnosed the iliotibial problem and gave her exercises to stretch the muscles they attach to, but she never did the exercises. She found it unnecessary to do the exercises, because the pain in her iliotibial bands began to clear up despite continuing to run.
Around that time, about three years before she came to visit me, she started to experience the pain about the insides of the arches of both feet. This pain worsened about the same time that her hip/knee pain went away. She saw three podiatrists for her foot pain, all diagnosing the problem as plantar fasciitis. Each made her a different pair of orthotics. None of the orthotics got rid of her foot pain. I checked each pair. Two of them looked very adequate in terms of arch contact and the wedges which were affixed to them per her foot mechanics.
Why weren't they helping?
First, her diagnosis was incorrect. It was not the dreaded plantar fasciitis. On careful examination I found that no aspect of her plantar fascia was tender, swollen, thickened, or otherwise involved. I asked her to point carefully to the places on her feet which hurt. She pointed to the muscles on the inside of her arches which control the big toe, the abductor hallucis muscles. I tested them by resisting her toe motion in a certain way. She yelped, but then she smiled. No previous doctor had been able to get her feet to hurt during the exam. She was happy when I announced her diagnosis. I was sort of happy, but would be a lot happier if I could figure out why this weird muscle decided to hurt her for three years in both feet. Time to watch her walk. The mystery was solved as soon as I watched her walk. With each step, she'd push-off with her foot turned way to the outside and make final contact with the inner edge of her big toes. I could actually see the chiseled abductor hallucis muscle stand out with each step, unusually defined like a weightlifter's muscles. That's why the orthotics weren't working. The problem in her foot was not occurring when her arch was in contact with the orthotic. The problem in her foot was happening when she pushed off in a vigorous tip-toe. The orthotics may as well have been in her back pack.
What would cause her to reach so with every step, to the point of overusing her big toe muscle? Go back to the beginning, her iliotibial band. These muscles attach to the tensor fasciae latae (TFL) muscles. A chief function of the TFL is to lift the opposite hip when the opposite foot pushes off. So we checked the strength of her TFL muscles. Really weak.
I figured her body decided the best way to make her iliotibial band problems go away four years previously was simply by not using their TFL muscles. But she had to find a way to keep her hips from crashing down with each step. So she started overusing her abductor hallucis muscles, going on as extreme a tip toe as one could possibly do with each step to keep her pelvis even.
The solution? I asked her to go to the gym three times a week and do the station which strengthens the TFL. Then she was to call me in a month. It was a happy phone call. Foot pain nearly gone, she'd begun Pilates training to strengthen the muscles about the hip. We discussed what approach she should take to gradually resume running. I've received five Christmas cards from her, and have seen her name in road runner's forums as a successful runner. She never needed orthotics for her arch pain.