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Processed foods, cigarettes, and metatarsal pads

There are things we know which are bad for us, but still we use them. Among these are processed foods, cigarettes and “metatarsal pads”, bumps often found on custom orthotics which are ostensibly given to elevate the metatarsal heads at the ball of the foot to reduce pain and irritation there from ground contact. Unfortunately, some prescribers order metatarsal pads on all their orthotics, even if there is no “indication” for them.

I try to avoid metatarsal pads unless there is no other option. Why? It has been published that braces and appliances which cross or fortify a joint weaken the muscles which cross that joint. I strongly believe metatarsal pads weaken the toe muscles, because they do the work of the toes muscles by forcing the toes down, as described by the orthopedist Kelikian many years ago. Our toe muscles weaken naturally as we age, due primarily to diminished small vessel arterial supply, which often occurs in the feet before anywhere else in the body. Also, for metatarsal pads to “function”, one has to keep one’s weight back and engaged on the pad, thus not robustly stride forward. This further weakens the toes due to abbreviated stride. Abbreviated stride also weakens the calves and the peroneal muscles, particularly the peroneus longus which stabilizes the ankle against sprains while on tip-toe. This disuse of the calf group causes overuse of the hip muscles, which have to work harder to pick the heel off the ground when striding because the calf becomes lazy. Eventually these hip muscles fatigue, increasing leg impact at heel contact and resultant likelihood to bruise the frame.

I was visited by a still-practicing attorney who’d kept in excellent physical condition his whole life by walking everywhere he had to go in New York City. He’d never taken surface or underground transport except to commute back and forth to his home in Bronxville. A remarkable status for an 80 year old, no? Tragically, he’d ceased this habit 6 weeks prior to seeing me, mainly due to by now near-unbearable pain at the tips of his toes whenever he’d walk. 8 months prior he’d visited his general practitioner, who sent him to a neurologist. The neurologist, a neuropathy (abnormality of the nerves which can cause burning, tingling or pain not provoked by activity) specialist, said a neuropathy was present, but did not think the neuropathy was the cause of his complaint. His GP then sent him to a podiatrist, who made orthotics for him 6 months prior to his seeing me. Unfortunately, subsequent to receiving the orthotics, his symptoms worsened logarithmically, eventually causing him to stop walking and resort to mass transit when in NYC.

First thing I noticed were tiny “seed corns” at the tips of his toes. As we age our fat buffer thins in our skin, especially in our feet. This allows the bones to press from within and create these little hard corns. Having been in great shape his whole life (160 pounds, 6 feet tall), this octogenarian was double-whammy thin. His podiatrist had not trimmed the corns, only prescribed orthotics.

Second thing I noticed were huge metatarsal pads on the orthotics, even thicker in height than the arch support region of the orthotic. When I pushed my finger into the sole of his foot at the same spot the orthotics had their met pads, his toes pushed stubbornly towards and even beyond what would be the level of the ground. Thank you, Dr. Kelikian. Try it on yourself and see.

I decided he’d most likely accumulated these seed corns during his lifetime walking, accompanied by his diminishing subcutaneous fat, and his problems likely would have been short-circuited 8 months prior if he’d had the corns (painlessly, btw) trimmed upon his initial podiatry visit. In fairness to his GP, the corns were relatively small at the time of our visit, and likely even slighter when he’d visited this MD. I have trouble applying the same degree of forgiveness to the podiatrist. If a podiatrist does not debride your painful corns, daddy, who else is there? Additionally, the custom orthotics did nothing but force his toe tips more vehemently into the ground, exacerbating the situation.

I checked his toe strength, ankle strength, and calf tone. Fortunately, they were all adequate. To give caution its due, I had to assume that he’d lost adaptation to the constancy regime he’d habituated as far as walking is concerned, especially with regard to likely subtle loss of bone density at this age. I promptly advised him to return to his walking rather gradually, fearing his instant liberation from pain (which he exclaimed joyously as soon as he stood up after trimming his corns), might result in a kid in the candy store phenomenon and result in a stress fracture.

Thus, my approach to this gentleman’s issue was first to debride his corns. I also asked him to discontinue his orthotics, and to very gradually return to his walking in cushy-insole shoes. I suggested he might want to return to me on an as-needed basis for debridement of his corns, though I also mentioned I knew a good podiatrist in Bronxville near where he lived, who could also perform this task. I was delighted to receive his gratitude-filled e-mail six months after his visit. He is happily back to his beloved ad-lib walking, and a semi-regular patient of my colleague in Westchester county.

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