Developing A Plan To Treat Chronic Forefoot Nerve Pain

I recently received an email from a 57-year-old male, who was active and in good health. While recovering from bilateral quad tendon issues, he injured both forefeet in 2012 while hiking for two days in a an area with caves. To protect the quads, he went up many, many stairs using his feet and calves. Think of it as doing 4,000 calf raises.

The results were bilateral stinging pain on the balls of the feet, the metatarsal “marble” sensation and sharper pain with dorsiflexion of the second metatarsal and to a lesser extent third and fourth metatarsals. There is no issue with the great toes and he had no foot issues whatsoever prior to hiking. His primary physician had ruled out upper body issues.

Failed treatments over three years included cortisone shots, orthotics, a regrettable right foot bunionectomy and a metatarsal shortening osteotomy on the second metatarsal along with pinning of the third metatarsal. The patient did physical therapy and then went to a pain clinic. The next doctor the patient saw focused on the left foot and performed a 2/3 neurectomy, which provided no relief.  

The patient’s current status includes a broad stinging sensation on the ball of the foot that escalates with ambulation; a “marble” sensation on metatarsal heads (left second and fourth metatarsal heads and the right fourth metatarsal head); and some stiffness and numbness from the surgeries. There is no swelling and no toe drifting on the left foot. However, there is a slight pulling down of the third metatarsal head on the right foot. Aggressive stretching leads to stinging, sometimes on a delayed basis.

The patient has had three magnetic resonance images (MRIs), which were generally unremarkable. He had one diagnostic ultrasound, which identified microtears on the plantar plate.

“I have been wrestling this for three years and feel my condition is deteriorating while my activity level is very low,” the patient says.

The condition sounds more nerve-related than plantar plate-related. For nerve pain, clinicians can consider some combination of the following modalities.

• Have the patient perform “neural flossing” three times daily. Patients should find out if sitting or laying techniques are more productive.

• Have the patient take nerve pain supplements like B12 or vitamin C. Patients should gradually add one per month to check effectiveness. 

• Have the patient apply a topical nerve cream (NeuroEze or prescription) to the affected area four times daily.

• Encourage patients to favor heat over ice.

• Advise patients to refrain from sciatic nerve/calf stretching. Patients should find out everything posture-wise that is stressing the sciatic nerve, whether it is beds, sitting chairs, standing habits, workout techniques).

• Oral medications. Patients should start with evening doses only of pregabalin (Lyrica, Pfizer), gabapentin (Neurontin, Pfizer) or duloxetine (Cymbalta, Eli Lilly). 

• Consider referral for epidural injections into the L5 nerve root.

• Consider the use of soft orthotic devices like Hannaford.

• Sometimes transcutaneous electrical nerve stimulation (TENS) and capsaicin are helpful. (However, patients typically have increased pain for up to three weeks before the pain starts to reduce with those treatments.)