Tuesday, February 9, 2016

The Metatarsalgia - Morton's Neuroma Saga

Most likely anyone who doesn't have or doesn't treat the foot problems of Morton's Neuroma or metatarsalgia is going to find this post boring. However, I wanted to put on record what I've done to treat my foot problem so that anyone else using "Google Doctor" searches might find my process helpful.
I did a LOT of Google Doctor searches on my foot problem. I also went to see two doctors, a podiatrist and an orthopedic doctor. And a physical therapist.
Podiatrist course of action:
  1.  One cortisone shot. Did not help.
  2. Started schlerosing alcohol injections every two weeks. Did 5 of them. I thought they might be minimally helping, but in the end, the doctor chose to stop the injections because I wasn't seeing significant improvements.
  3. Doctor did an MRI scan of my foot and concluded that I have a Morton's Neuroma, and also some edema in the 3rd metatarsal. However, google searches on this seem to confirm that MRIs are typically inconclusive.
  4. Doctor suggested neuroma surgery. Forums of those who have received the surgery had a lot of horror stories. I decided to get a second opinion.
  5. Gave me several pairs of metatarsal pads to use in my running shoes.
Physical Therapist course of action:
  1. Thought there wasn't much he could do about a MR in terms of physical therapy.
  2. Showed me some foot massage techniques to loosen up the area between 3rd and 4th toes.
  3. Showed me how to place metatarsal pads in my shoes.
Orthopedic doctor course of action:
  1. Did several manual tests on my foot.
  2.  Did not think it was a Morton's Neuroma. Suggested metatarsalgia or synovitis. Why? Because I found being barefoot the most painful over wearing shoes, and he says the symptom is the other way around for MR.
  3.  Wanted me to pick up marbles with my toes, 250 times per day. Sounds silly, but I started doing this. Not as much as he suggested and not every day, but I did this mostly at work at my desk with one shoe and sock removed. He said it would feel better after five weeks of this exercise, and he was correct.
  4. Suggested Powerstep Pinnacle Plus insoles in my shoes. At first I was against insoles in running shoes, being a proud minimalist. However, a month ago I finally hung up my stupid pride and tried some Powerstel Originals that I already had in my closet. Immediate pain improvement. So I bought the Powerstep Pulse insoles and tried those. Way better. Decreased discomfort 80%. Why? Because arch supports off load the pressure on your metatarsals and back onto your arches, where some of that pressure is supposed to falling anyway.
My own course of action:
  1.  Started a routine of at least one icing daily, a gel pack that folds so I get both top and bottom of my foot. Google searches often say icing is useless esp through a metatarsal pad, but my met pad is VERY thin and at the least, applying ice to an injury can't hurt it.
  2.  Ordered a home TENS unit from Amazon. Started applying at least 15 min daily of therapy to the top and bottom of my foot. Another Google search concludes this is also useless, but again it doesn't hurt.
  3. Then I started reading about the link between gastrocnemius tightness and plantar fascitis. Calf muscles being tight seems to be the foundation for most foot injuries from running. So, maybe tight calves are exacerbating my metatarsalgia? Started massaging my calves manually and with a lacrosse ball and foam roller. Going to try the TENS electrodes next.  One solution might be to go back to shoes that have a slight heel lift as this relieves some of the tension on the calves.
Running: I've been wearing Altra Olympus as recommended by the podiatrist as he said that I have some of the thinnest metatarsal pads and feet he's seen. He said "you need to add padding to your foot since naturally you don't have much". Also these shoes are wide and can handle the insoles and allow my toes to spread wide. But the Altra's disadvantages is that they offer no arch support and are zero drop. The Powerstep insoles resolve the arch support issue. And I think zero drop is great but possibly it is causing me issues. I'm not ready to give up on zero drop yet, but I have totally given up on shoes lacking a wide toe box. Currently the only brands out there offering the square toe box shape are Altra and Topo Athletic. I can't understand why other manufacturers dont at least add lines of shoes with this shape. People do not have arrow-shaped feet. Most of them don't. But most people also don't run many miles, so they can get by with shoes that cram their toes together and are the hottest designs and colors currently - features I do not value as someone who wants to put in a lot of miles without getting injured.
Casual/Work: I have had to give up on feminine shoes and heels. Here's what I finally figured out, me and my stubborn brain. Just ONE infraction causes at least one week of pain and suffering. The mindset you have to adopt is ZERO TOLERANCE for shoes that aren't geared towards alleviating your foot pain. That dinner at a fancy restaurant? Gotta wear the right shoes, not heels. End of story. What I found works for me: (a) flat boots that are a size too big with Powerstep insoles in them (b) Danskos (c) Chacos. I dont have to wear insoles in the Chacos or Danskos; they already have arch support.
Therapies I haven't tried:
Ultrasound - the effectiveness is inconclusive, but a home ultrasound unit is fairly affordable at this point and may be worth a shot.
Stuff that didn't seem to work:
  • Toe spreaders/yoga toes - Didn't do anything for me. Too static.
  • Advil - Not recommended for long term use. I do take some turmeric supplements daily but can't say if it helps.
If you want to see a PT for this condition, have them massage your foot and spread your toes out wide. Have them ice your foot and use TENS electrodes both top and bottom of your foot. Have them massage and stretch your gastrocnemius muscle. Try ultrasound as well.

Probably the best thing is to stop running. I haven't stopped (but have cut down to 15-20 miles per week on trails), and am reserving this course of action for the last straw.

My ortho doctor said he does not recommend MR surgery as it has lower than a 90% success rate and too many complications. Besides, removing a neuroma doesn't address the cause of the problem which is why so many people get a recurrence. Your feet are so delicate - don't cut into them unless your problem is very debilitating.


Thursday, September 3, 2015

Manning Park, British Columbia

The justification behind the Appalachian Trail training runs was to pace my boyfriend at the Fat Dog 120 mile trail race in Manning Park, BC, on August 15th. The week before the trip, I came down with some kind of awful crud. I can think of many reasons why I got sick; I was completely run down, having symptoms of adrenal fatigue, and cheating myself of adequate sleep. I went to the doctor in desperation for a steroid shot - something I'd rather not do, but a lot of time and money had been invested in this trip. I was on the mend when the race began, but still feeling fairly exhausted and not sure how I was going to manage 42 miles with an estimated time on foot around 14 hours.

The area is usually dry, but they had some storms pass through during the race and the participants had a rather wet two days. My boyfriend became hypothermic in a hail storm, spent an hour in a car with the heat on, and could not warm his extremities, so he decided to drop. A lot of participants dropped due to the cold temperatures. His warm clothes were at the next major aid station; he didn't  have a buff or warm hat and gloves with him.

So, my duties as pacer were not needed. I was relieved he didn't make himself ill by staying cold for an extended period of time. I wish things went differently for him, and had no regrets that we didn't utilize our training because the process in itself was enjoyable.

Once the sun came back out a few days later, we did a hike on the Skyline Trail which is the last portion of the race course.

Manning Park is lovely and peaceful; I enjoyed 5 days of respite there. We found Canadians to be much quieter than Americans and appreciated the lack of loud screaming and music played from car and/or portable speakers at top volume. 

More Manning Park beauty:

We did some trail running & hiking & walking in Vancouver and Garibaldi Provincial Park during the remainder of the trip, and the neuroma in my foot acted up a bit. It became clear to me that I needed to take a break from running (a few weeks to a month) to see if my foot will heal without the continual aggravation of running. This also provides the opportunity for my adrenals to recover. To assist with recovery I have added some new supplementation and dietary changes (reduced caffeine, fermented fish oil, no gluten/wheat) as well as an earlier bedtime. I am feeling much more rested already.

Monday, July 13, 2015

Appalachian Trail Training Weekend #2

The guys doing Fat Dog 120 wanted another AT training weekend to get in some elevation so we headed to Cosby Campground a month after the first training weekend with a plan for the guys to trek 60 miles and a 40 mile route for myself. I always look forward to unplugged weekends in the woods, this one no exception.

We woke up at 5 am with time for coffee and started from Cosby at 5:30 am in the dark. We hiked the 5 miles up Mt. Cammerer at an ~19 minute per mile pace while occasional rain showers kept us from overheating. The 5 miles downhill allowed me to recover for the next climb, 6 miles to the top of Mt. Sterling on the Baxter Creek trail.

Big Creek
Baxter Creek is so far the most beautiful trail I have seen in the GSMNP and in the top 5 I've ever traversed. We started out going uphill at a mild grade next to the creek and then above it; the forest floor was covered with fern groves, trilliums, and other shade loving plants.

Selfie at the bottom of Baxter Creek Trail

As we continued up the mountain, the temperature dropped significantly and the air became very breezy, like fall. We climbed through tunnels of rhododendrons and our footsteps trampled carpets of fallen white and pink rhododendron blooms. We scurried past rotting timber that was creaking in the wind; we stared in awe at virgin timber towering above us.

Ferns! Rhododendrons!

Daniel quoted lines from The Chronicles of Narnia as the woods looked like a scene from a fairy tale. The air was misty and the forest covered in green except for the brown ribbon of trail snaking through it. Since we couldn't see the scenic vistas due to the rainy weather, I plan on returning to this trail again on a sunnier day.

Dark, misty fantasy forest land

Snail drinking water out of a mushroom

During the descent of Mt. Sterling I snacked on salty popcorn chips to satisfy my salt craving. Also after last month's AT run, I added thermotabs to my nutrition regimen and they seem to have a beneficial effect in reducing salt cravings.

My Morton's neuroma has been better lately, but climbing Mt. Sterling caused it to start talking again. The descent started painfully, but after a couple of miles, the pain had mostly subsided again. Another example of the ultrarunning rule of thumb "If it starts hurting, wait a few miles and the pain will probably go away".

We started descending Long Bunk and Little Cataloochie trails. Neither one of us felt fond of these trails as they were muddy and covered in briars. The terrain was marred by horse traffic - which does quite a bit of damage to trails in comparison to running shoes and bicycle tires.

Around mile 23, Daniel accidentally stubs his little toe on a stick or stump and experiences some severe pain. He removes his shoe and sock, and it looks like the toe is broken as it is very displaced. He hobbles around and it's obvious that he needs to stop running and go back to the campground. We debate if an ER visit is required. We decide to head to the closest FS road because the mileage back to Cosby is around 15-plus. We debate if I should run the distance back to camp and get my car to pick him up. We decide to stick together.  We hike about 2 miles slowly, and fortunately Daniel can lean on his hiking poles. A truck approaches, and it looks like a National Park Service sticker on the side. The driver stops, and it's a maintenance crew, but they allow us to hop in the back for what turns out to be a very long (15 mile ride) on FS roads to the park boundary where the NPS Ranger arrives to pick us up and take us a long 28 miles on I-40 back to the Cosby area, drops us off with another ranger who takes us the remaining 8 miles. All events in the sequence are due to amazingly good luck. We could have never seen a soul; we might have been out there until nightfall.

Back at camp, we packed up our tent and drove back to Chattanooga that evening. Decided ER visit wasn't necessary; he was in pain, but they wouldn't have done much for him aside from pain mitigation, and he made an appointment with a friend who is a podiatrist first thing Monday morning.

Daniel's broken toe via x-ray

The x-ray revealed the fifth toe phalange right above the metatarsal head is broken. Doctor adjusted toe due to joint dislocation and put toe in a splint.

TBD if he can run Fat Dog 120 in exactly one month and one day.  **Update: Likelihood is high he will be able to run in 1 to 2 weeks. :)

At mile 23 we both felt good; I was on target to complete 40 miles in fairly good spirits. I changed my nutrition strategy for this run anticipating 12 hours of activity by ingesting calories early and often.

When we got home I weighed our vests - each were at 7 lbs, which is a lot of weight to carry, but this run was fully self-supported so we had to carry all nutrition for the day, but were able to refill water in streams and used Sawyer filters installed in-line.

My Strava activity for this run
Distance 23.4 miles
Time 6:14
Total ascent 7,100 feet

Ultimate Direction SJ Ultra Vest with Camelbak bladder & Amphipod bottle
Altra Lone Peak 2.0
Swiftwick Vibe One socks
Generation UCAN plain
GU Lemon Lime
GU Chomps
GoPro Hero 3 with GoPole mount
Sea Salt Popcorn Indiana chips
Kind Bar Dark Chocolate Nuts & Sea Salt
Sawyer mini filter installed inline on Camelbak bladder
Hammer Heed drink mix
Leki hiking poles
Headsweats visor
Suunto Ambit3 watch

Wednesday, June 24, 2015

Picky feet

I have been told that I have an obsession with running shoes. I'm not into running shoes for making a fashion statement; I have problem feet. Specifically, my feet pronate quite a bit and over the past 15 years they have developed bunions. Large enough that my feet do not fit in most medium width shoes. This has become a very limiting factor, as I cannot wear certain brands that focus on narrow feet.

After having various small issues (peroneal tendinitis) resulting from wearing stability shoes, a physical therapist suggested that I go more minimal and reduce the shoe drop. My feet pronate, but my arches are not flat. The transition was gradual. I was running in Brooks Adrenaline (too much stability) and changed to Brooks Cascadias (10 mm drop, too high). I ran a road marathon in the Cascadias without difficulty, not caring that they were trail shoes. I transitioned to Brooks Launch, then a New Balance trail shoe with an 7-8 mm drop that made a hilariously annoying squeaking noise from an exterior plastic rock plate, and these shoes demonstrated the durability of a raspberry in a panini press. The next shoe in the transition was a Pearl Izumi N2 Trail. Excellent shoes, but too narrow because after 300 miles, my left foot (which is wider than the right foot) had developed a full blast Morton's Neuroma. A quick and desperate transition to the Altra Lone Peak 2.0s allowed me to keep running with the neuroma, and I added metatarsal pads to the insoles to help split apart the 3rd and 4th metatarsal heads.

One hundred miles of trail running in the Lone Peaks, and the front part of the soles was getting worn flat and several lugs had broken off. I emailed Altra with photos of the soles, mentioning that the durability of the shoes is cause for concern.

 Altra Lone Peak 2.0, with 100 trail miles

Thus, I'm going to try a pair of shoes from Topo Athletic next - the Runventures. Same wide forefoot as the Altras, but the soles look more rugged and the stack height is similar. I'd like to see how the Topos compare to the Altras with a real life test.

Transitioning to zero drop has resulted in some very sore calves, but I am optimistic that my legs and hips will eventually adjust. Running with a splayed toe/forefoot has been very comfortable. I hope other shoe manufacturers decide to capture this market.

Update: Topo Athletic sent me this useful site via Twitter to improve your stability and correct weaknesses: ACU-Running

Wednesday, June 10, 2015

How I ran a marathon on the Appalachian Trail with a Morton's Neuroma...

My foot developed a Morton's Neuroma in early April; I ignored it until it flared up in mid-May. I ran a trail marathon in late April (Scenic City Trail Marathon in Chattanooga, TN) with no issues, so I didn't think it was anything significant. Until it started hurting enough to make me walk when I went for a run. Immediately I changed running shoes from Pearl Izumi N2 Trail to Altra Lone Peak 2.0s. I went to an orthopedic doctor and had a cortisone shot, which provided a small amount of relief. And then I swallowed the bitter pill that I was going to have to cut back on running. I tried to console myself with, "Well, you can go outside and do more rock climbing in the interim!"

Two days before the trip to run 42 miles of the SCAR route on the Appalachian Trail, my neuroma had a bad flare up. I had run 4 miles the prior day, and the only thing I did was bend down to pick something up, and it felt like someone had pulled the nerve and released it like an archery bow string. My hopes of running any of the AT at all were getting crushed. I decided to continue as planned and take two 600 mg rounds of Advil the next day , and then a not-recommended dose of Advil plus Aleve (folks, don't do this at home) on the day we were to run. (I should mention: I have an ironclad stomach lining.) I decided to use metatarsal pads plus a toe spacer between the third and fourth toe in my Altras.

On Saturday morning we woke up in our tents/hammocks at 3:30 am and drove up the road to Davenport Gap. I slept in my running clothes so I could save time when the alarm went off. The guys took off with headlamps and I drove the truck back to the campground and crawled in the backseat for a two hour nap.  Stopped for coffee at McDonald's through Gatlinburg. Parked the truck at Newfound Gap and got geared up and ready for my run. It's odd starting a run not knowing how far I'll end up going. I altered my plan the night before from running Newfound Gap to Fontana Dam (42 miles) to running towards Davenport Gap, turning around back to Newfound, then if my foot felt good, run 8 miles up to Clingman's Dome.

Two glorious hours into the run, my foot felt fine. But I was worried that I had somehow missed the guys coming in the opposite direction towards me. I decided to turn around and head back. Got back to the truck, no sign of them getting water refills. Turned back on the trail again, went about one mile before they appeared. Turned around again, ran the mile back to the truck.  At this point, I had logged 18 miles and was feeling good. I had eaten two GU gels during the first four hours, but due to cutting back on mileage to heal my foot, I was well rested and didn't feel like I needed extra calories. The guys had run 32 at this point, with 40-ish to go.

After the refueling stop, we started the uphill slog to Clingmans, which took around 2.5 hours and was barely runnable. The relentless uphill stepping drained my energy reserves and I started craving salt. I took a gel, a shot of Generation UCAN, and a single use packet of Peanut Butter & Co. By the time I reached Clingman's, I had logged 26.3 miles and 7000 feet of ascent. I felt like I could have gone further, but there is no exit point between Clingman's and Fontana Dam. I ended my run there, and was glad my foot allowed me to put weight on it for 7 hours.

I don't regret making a conservative choice not to stray too far from a ride (8 miles at my longest point). The 40 mile trek, mostly after dark, would not have been a good choice for someone with a foot injury and untested shoes (the longest run I had done in the Altras before this day was 10 miles).

The Lone Peaks have allowed me to keep running with this neuroma. Without Altras and their wide toe box advantage, I would not be running at all. I'm grateful.

This was my fourth 26 mile plus run in my life, and the marathon to 50K distance has become more joyous and fun each time I've done it. Of course, the slower the pace, the less I suffer.

Post run. Closed out the night with beers and a starry night sky. Set up the tents and feel asleep as the guys doing the whole SCAR route would not return for a few more hours. They arrived around 3-4 am and reported that the route is very challenging as a whole. It took them around 22-23 hours including breaks - an impressive effort for all three of them. I'd like to log a couple of 40-50 milers before I consider attempting the entire route.

My Strava activity for this run
26.3 miles
6,900 feet ascent
6:55 time

Altra Lone Peak 2.0
Headsweats visor
Suunto Ambit3 watch
North Face polyester t-shirt
Ultimate Direction SJ Ultra Vest with Camelbak 80 oz bladder & 20 oz Amphipod bottles
Pearl Izumi Infinity run short
Swiftwick Vibe One socks
GoPro Hero 3 with GoPole mount
Generation UCAN plain
Peanut Butter & Co chocolate peanut butter
GU Lemon Lime energy gels