Diagnosis: Marbles In My Foot

Danh NgoUncategorized

Today I evaluated a patient with a diagnosis of neuroma, Morton’s neuroma to be specific.  My experience today is very fitting for my first clinical post.  It demonstrates the unfortunate, but all too common situation and downfall of today’s medical system.  Sue is a middle age minority who came to me with her husband as the translator.  She complained of pain to the ball of her left foot between the second and third toe.  “Burning” and “feels like she is walking on marbles”.  I can walk for only a few feet and it gets worse as I walk more.  What she is telling me are classic symptoms of Morton’s neuroma — a thickening of nerve tissue usually brought upon through compression.

Morton’s neuroma is easy for anyone to confirm.  The “squeeze test” can help you confirm suspicion by squeezing the sides of your forefoot together, like you are “squeezing” your toes together to fit a nice pair of pointy shoe/high heels.  I noticed that 90% of my morton’s neuroma patients tend to weight shift forward as a compensation from a weak “core” or tightness of their leg somewhere.  An anterior (forward) weightshift plays a role in adding to more forefoot pressure.

MortonYou will commonly see localized swelling at the bottom of the painful toes.  Pain is reproduced when you touch and put weight over the joints.  Makes sense, right?  You don’t have to be a science nerd to figure this out.  Push it.  Pain.  Poke it.  Pain.  The only thing I would add is that it is important to rule out suspecting fracture.  Radiographs or x-ray is the most accurate test out there, but a quick and easy test to ease your worries is done by grabbing the corresponding toe to the neuroma and push the toe towards your foot then pull the toe away from your foot.  This motion is called long axis (in the direction of the bone) compression and distraction test.  Fractures hates to be pushed on and feels good when the pressure is relieved.   http://www.apma.org/Learn/FootHealth.cfm?ItemNumber=987

In therapy, knowing is the easy part.  Managing the condition is the difficult part.  I rarely find a simple case, which means that there are many layers to everyone’s painful story.  This story reminds me of an onion.  An onion has many layers.  The smell of an onion is very distinct, some say it can be pungent.  The appearance of an onion is unique.  An onion makes you teary the more you peel it to uncover the hidden truth of her condition.

Sue revealed that she had left knee pain prior to the neuroma incident that the orthopedist told her she needed a knee replacement.  “It’s bone on bone” she said.  Upon further questioning, I found out that she is dealing with a left sided low back pain that bothers her just as much as her knee and toe pain.  Where do I begin?  Efficiency of movement begins at the pelvis and spine, so I always assess the mechanics there first.  She was able to bend forward and touch her toes.  Hooray!  My job is a bit easier to manage.  The ability to touch her toes is a big deal in that a whole subsystem called the posterior fascial sling is demonstrating optimal  movement.  Dysfunctional “aging” joints tends to effect the fascial system.  She has pain upon returning to standing.  Sue uses her arm to walk herself back up to a standing position.  This movement strategy can indicate a uncoordinated spinal stabilization system — nothing physical therapy cannot fix.  To keep this post short, her ability to bend backwards and knee mobility is limited.  Her ankle and foot complex was remarkably healthy, moved well and strong.  I ended her evaluation checking her ability to stand on one leg.  She stood 8 seconds on the left and 3 on the right leg.   Wait, hold up….3 seconds on the opposite leg, the “good” leg?  This is a common component that lots of people undervalue and provides huge insight on a theory to why Sue is in pain.

What does this all mean?  I mentioned earlier that knowing that she had a neuroma is easy and can take me minutes to figure out.  Let’s make our case simple to understand and say that she has pain in the front of the foot.  Sue’s odds are not in her favor because she has three compensatory factors that all results in more forefoot loading.  If you have pain in the knee, one would walk more on the ball of their foot.  Their gait (walking pattern) would tend to avoid the heel rocking and skip to forefoot loading.  Sue is relying more on her painful left leg to support her as one can deduce from the 3 seconds right single leg balance test.  Add the typical forward weight shift pattern to the mix, and one can easily understand that Sue has more than a morton’s neuroma.

I will have you guess where I started to help her…ankle, toes, knee, low back, or balance?  I addressed her beliefs. Why you might ask. Sue is a typical patient that comes to see me. She has been labeled. The sad part is that she believes in her label like she earned it. The doctor forecasting her future of having a total knee replacement has crushed her hopes of moving and exercising. The pain reinforces this beliefs. The doctor told her there is nothing she can do, and when she does try to exercise her way out of her knee pain, she gets back and foot pain as a result. The podiatrist did not touch her foot. As a Hispanic who doesn’t speak English well, she can be perceived as a burden to the medical system, because trying to bridge the communication gap is an extra load in a high paced day. Don’t do anything and you will be fine. When you hear this multiple times, one can start believing this. Where is the positive reinforcement? She complains to her husband so much that her husband is tuning her out, labeling her “stubborn” and “lazy”. It’s a lose lose situation so far. She is destined to fail.
I educated Sue and her husband that there are many ways of exercising with or around  pain so she can contain her knee and low back issues. Once we gain any physical rehab momentum we will transition towards all of her individual goals that brings her self worth, her desire to be a community ambulatory and be a part of society again…to prove to her husband that she is not lazy. If everything is painful, she can focus on regaining her balance of her unpainful leg. Studies have shown that periodic sessions with a rehab professional that provides manual therapy AND exercises over a extended period can provide great benefits to knee osteoarthritis. “But it is bone on bone and the doctor says I cannot do anything, and doing things will make it worse.” This is a common fallacy. “Motion is lotion” and joints needs to move to be healthy. Physical therapists are movement experts. I sat down with her and helped her to strategize in movement options (other ways of doing things that are joint friendly) until she gets stronger. “She won’t do this” says her husband, and this is important why I invited him to this discussion to nurture a supportive environment.

This is the beginning of her personal empowerment. She is still skeptical, but at least I planted the seed for her to be skeptical in a different light. Is she in control of her pain? What do you think?