This is going to be long so I hope that it is helpful. Many treatments are offered without knowing what the problem is. Treating the right problem with the right treatment is both a science and an art. Many long time runners know more about handling running injuries than most physicians. The folks at the local running shoe store have usually seen it all and can be a great source. They, along with sports physicians, sports chiropractors, and physical therapists are good resources to help handle your problem. The most important thing to know is whether or not you have a condition that is dangerous.
Pain along the outside of the foot comes from 3 main sources:
The first and most dangerous problem is stress fracture. Stress fractures often come on slowly so they don’t feel like a fracture. Since these are micro fractures they are sometimes not painful until you put the bone under excessive stress, such as running. The pain often intensifies as you run, becoming more and more painful until the bone breaks. The outside of the foot is the most common place for this to occur, along the mid shaft of the 5th metatarsal. Try this test: Find the long bone along the outside of the foot and try to bend it by holding on the the ends and pushing up from the center of it with your thumb. If you feel pain in the mid shaft of the bone then you are probably in trouble and you’ll need to rest it for the next 6 weeks. Keep exercising with a stress fracture, and you run the real risk of a broken bone and all of the troubles that ensue, including a cast and possible surgical pin. If you have pain while hopping on the foot, especially on the first hop, you may have a stress fracture.
The second is tendonitis at the insertion of the Peroneus tendon. This is the tendon that begins as muscle and narrows into a tendon along the outside of the calf and wraps around the back of the ankle bone known as the lateral maleolus. This tendon is attached to the outside of the foot at the wide point near the mid foot. The right foot often suffers from pain at this location because it is usually the foot on the low side of the road. This can be further complicated by a short right leg, thereby placing more stress on the outside of the foot. If you have this problem then there are several things that you can do to mitigate the problem but it will probably not go away anytime soon. You can usually run with peroneus tendonitis though if you make some changes to the stresses on the outside of the foot.
Take a look at your shoes and see if the wear pattern on the sole of the shoes are more oriented to the outside of the forefoot. If it is, then you are over supinating, meaning you are running on the outside of the foot. Supinators get about half of the normal life out of their shoes and have to replace them much more frequently.
Speed is the third major cause of forefoot stress because it causes you to run on your toes. If you add hills to speed you are putting maximum stress on the front of your foot. If this is the cause of your problem, then the fix is simple: Stop running fast up the hills. In fact, stop running fast altogether until the problem goes away. This is what we call rest, which is relative, meaning give the afflicted part some rest from the stresses that caused the problem.
The treatments are as follows:
Anti-inflamatories can be a help. There are a few approaches to anti-inflamatories. Use over the counter medicines called N.S.A.I.D. which mean, non steroid anti inflamatories. Advil, Ibuprofen, Motrin are all pretty much the same. I wouldn’t recommend taking these for extended periods of time, since they can have some deleterious effects on you kidneys and may cause gastric problems. Many runners use Naproxyn or Aleve which can be taken every 12 hours instead of every 6 hours. The idea is that since you have to take less of it, you pose less of a threat to you stomach. The gel caps seem to be easier to digest and are easier on your digestive system. (I welcome Dr. Lerner’s comments here) Since the affected area is close to the surface, you may derive benefit from a topical anti inflammatory such as Aspercreme. Applying folk remedies like Vaporub, Ben Gay, China Gel, etc. are of limited value. they feel good but have no medicinal value. in other words, they cause no physiological effect and contrary to popular opinion, do nothing to speed healing. I use them though, just because they feel good.
Ultrasound works very well for this problem. The effect of a single treatment can be dramatic for this problem because the tendon is close to the surface and accessible to the therapy. This therapy should be done in a PT clinic or chiropractic office since the application requires a license. Don’t have very many of these treatments though. If this treatment is going to work, you will know within 2 or 3 visits. Usually 3 weeks of ultrasound is sufficient.
Epsom Salt soaks do a great job at reducing swelling and inflammation. Fill a bucket with enough very warm water to submerge the affected area and then pour in Epsom salts until they will no longer dissolve. This is called a super saturated solution and will draw out any swelling. Do this for 20 minutes every day.
Ice is the most powerful anti inflammatory i know of. Use a good gel ice pack that has been kept in the refridgerator. If your ice pack has been in the freezer it may cause tissue damage. Make sure that you have a sock or some other fabric between the ice pack and your foot. A 10 minute treat time is sufficient, since the affected area is close to the surface. Another ice option is a frozen water bottle.
You can try using a foam roller along the side of you calf. This will only help if that particular area is painful though. If there is no pain there then you will not derive any benefit.
If you are wearing orthotics of any kind, this would be a good time to scrutinize them since many of these appliances are made with the assumption that almost everyone over pronates (rolls the foot excessively inward) during the gait cycle. This often results in improper biomechanics, loading huge stresses on the outside of the foot. Shoes that have too much pronation control can cause the same effect. Take a look at your shoes and see if there is a lot of plastic or other cushioning material along the instep area. If the shoe is nearly straight along the inside of the arch then you may have “Motion control shoes” and need to switch to another type of shoe. Other shoes that control motion known as “Stability shoes” can cause the same problem. In general, runners with high arches should not use either of these type of shoes. The best way to tell if your shoes are the right type is to go to a running specialty store. You can tell if it’s a running shoe store if all of the people who work there are runners, track coaches, winners of running events or well known runners. They are generally skinny runners with stringy muscular legs. They will know what type of foot you have and what type of shoe will work best. Fitting running shoes is not an exact science and it is possible to get it wrong. However, a good running store should be able to get it right at least nine out of ten times. The key to this is the return policy. Quality running shoe stores will always have very liberal return policies.
There are exercises that can help to strengthen the the muscles that attach to the tendon. Standing on a step and doing calf raises and slowly lowering can be helpful in developing strength and flexibility. The stretches that we use on Saturday mornings are a good way to stretch the outside of the foot. Start with the toes in contact with the floor and slowing rotate the foot in large circles. Do this for 20 seconds every hour of the day to develop flexibility.
There are some don’ts to consider. Do not get a cortisone injection in this area. Not only is it painful but it can weaken your tendon. Do not get orthotics as a first treatment. They often worsen the problem or caused it in the first place. Don’t get off the shelf orthotics either. I often recommend the off the shelf orthotics but this is one condition where they are only going to prolong or worsen the problem. Only in rare cases do they help.
There is another problem that can cause pain along the outside of the foot. If you have contact pressure along the outside of the shoe it can rub along the wide bony area of the foot, causing an irritation. The best way to handle this is by locating the laces nearest to the affected area and simple re-lacing the shoe to skip that area. Sometimes the shoes are fine during short runs but as your foot swells on the long runs there is more pressure and the area can get irritated. Sometimes it is just the fit and you need new shoes. The most troublesome shoes are new or very worn ones. Be wary of either. In general. runners are going to need 2 or 3 pairs of running shoes per year if you a Marathoner, less if you run less mileage. I always keep 2 pairs of shoes, new ones and worn ones. That way I always have a god pair to race on without having to run on brand new shoes. Besides that, I love the smell of a new pair of running shoes.
I hope this helps. Leave your questions or comments below.
Steve Smith D.C.