A recent patient had an interesting chief complain that I have not come across before in my practice.
History of Present Illness: 21 y/o female runner who complained of muscular cramping in her left foot between 2nd and 3rd rays at approximately 4 minutes of jogging that caused her enough discomfort to keep her from continuing to run. Pt reports being a runner and soccer player throughout high school with no issue. Pt symptoms began when training for her 2nd half marathon and occurred typically at about 45 minutes of running and pain generally increased over the next several minutes to the point where she had to refrain from running. The discomfort would even return with running after resting for a few minutes. Over the next month of training symptoms began occurring earlier and earlier into her run to the point she was limited to 4 minutes of running prior to pain. Throughout this time the patient was able to playing full length soccer matches without symptoms.
Upon evaluation the Pt was found to have equinus forefoot bilaterally, normal mobility in midtarsal and hallux, plantar flexed first ray bilaterally, navicular drop of 5mm bilateral, and 15 right ankle dorsiflexion in long sitting compared to 10 degrees left dorsiflexion. Pt did not have running shoes at initial appointment and was unsure of shoe type. Walking/running assessment showed bilateral heel whips, otherwise normal with no execessive pronation. Pt was issued calf stretching to address ROM deficit and trial metatarsal bias for patient to trial in running shoes to allow additional space for plantar flexed first rays.
1st follow up: Pt reports being able to run 10 minutes longer than previous run with metatarsal pad in. A slight improvement from recent session but pain continued to limit running time. Pt brought running shoes to 2nd visit and she reports being on her 3rd pair of Brooks adrenaline. The Brooks adrenaline is in the stability category. Pt was issued these shoes by a local running store who specialized in analysis of gait patterns and matching shoes to those gait pattern.
Upon video gait analysis pt was noted to have very limited pronation to hallux and therefore limited push-off from great toe. The majority of push-off pressure was coming through digits 2 through 5. Simply put the stability shoe was limiting the patient already minimal amount of pronation. Remember she only has 5mm of navicular drop (the normal is 6-8 mm).
It was recommended that the patient switch to a neutral shoe to allow patient to pronate so she is able to use the hallux during push off. We also recommend to continue use of metatarsal wedge to allow the hallux to have room to plantar flex.
Pt called the office back a few days later to inform me that she was able to run for 45 minutes without any discomfort or symptoms. Only fatigue since she had not been able to run that far in months.
There is no replacement for a true bio mechanical assessment. Most running stores base shoe selection on watching clients walk and occasionally run on treadmill with even fewer using video analysis. An incorrect shoe prescription might not have an immediate impact on a runner but at some point it will catch up to them. This goes the other way for minimal shoes for those who have over-pronation. In this patients case it took several years for the bio mechanical change to cause pain. The good news is a quality foot bio mechanical evaluation helped lead me to correct shoe prescription which abolished patients symptoms in less than a week and allowed her to return to her training.
Shoe technology is improving every year but it can only help us when it is applied appropriately.
