Should a Runner Have Morton's Neuroma Surgery?

Hello Running Doc!

I am a life-long time runner who has done many marathons. About a year and a half ago I started developing tingling and pain in the ball of my foot about. The pain gradually got worse. I saw a podiatrist and learned that I had a Morton’s neuroma.  I was given some neuroma pads to try to take the pressure off it, but it still continued to bother me after I would run. Eventually I went to the doctor again and I was told that I would have to stop running.

I really don't want to stop running. For this reason I went and got a second opinion from an orthopedic surgeon. He recommended that I have surgery on my foot to remove the Morton's neuroma. I'm still not sure if this is the right approach because I am concerned that surgery can alter my foot in someway that might change my running biomechanics. Is that something I should really be concerned about?

Thanks!
Henry B.
San Jose, CA

A painful Morton's neuroma certainly can disrupt your ability to run. The swollen nerve on the bottom of the foot can cause tingling and burning pain. But in addition this pain can get worse. In the initial stages of the development of then neuroma, many patients will say that they have tingling foot pain that is intermittent and only happens following long runs.

But over time, the continual irritation of the neuroma makes the nerve swell and the pain becomes more frequent. The nerve endings in the painful neuroma become over active. Then you start to have pain when you're simply sitting in a chair, driving your car, or even while relaxing reading a book.

Surgery can be an effective treatment for a Morton's neuroma that is keeping a runner from running. Basically the nerve is removed and you get numbness in the area where you previously had pain. That is the biggest concern is explained by surgeons before you have surgery.

But there are other risks to surgery. The one that is particularly relevant to your concerns is that in order to remove the neuroma the most common surgical approach involves cutting of the intermetatarsal ligament that stabilizes the forefoot. This ligament is not sewn back together once the nerve has been removed.

Because you have essentially removed a ligament in the ball of the foot, you can have a small amount of foot instability that was not present prior to surgery. This is not a “surgical complication” but is just a consequence of the surgery as it is normally performed. The only other alternative is to place a surgical incision on the bottom of the foot. However a painful surgical scar on the bottom of the foot can be even more disruptive to your capacity to run than the Morton’s neuroma.

If you are really considering having surgery in order to surgically remove the Morton’s neuroma, you have to make sure that you discuss your running activity in great detail with your sports medicine surgeon. You have to make sure that your surgeon understands how much you run, which surfaces you prefer to run on and, for what distances. As long as you understand the biomechanical implications of the surgery and you and your surgeon agree that it is the best option for you, it may be appropriate to proceed with surgery to remove the neuroma. If you're not convinced that neuroma surgery is right for you then you should try all of the other alternatives to surgery to make sure that you have tried the less invasive options that can better preserve your ability to run.

Dr. Christopher Segler is a sports medicine surgeon and runner. He is 14-time Ironman triathlon finisher. His practice focuses on the rapid treatment of running injuries, and a rapid return to running for his patients in the San Francisco Bay Area.  If you have a question about a painful neuroma that it is affecting your ability to run, you can reach him directly at 415–308-0833. You can also learn more about Morton’s neuroma at AnkleCenter.com and alternatives to neuroma surgery at DocOnTheRun.com 

Popping, Clicking Ankle Pain. What, Why and How!

Hi My Running Doc!

My daughter has sprained her ankles a number of times. She keeps turning her ankles and they swell up. She also seems to have this popping and clicking sound from the ankle when she walks and it's really bothering her.

     Questions:

          Why does that happen?

          How do we fix it?

          What's the surgery that she needs 
          to cure the snapping and pain?

Thanks!

S.B., Berkeley, CA

Answer: Ankle sprains are the most common musculoskeletal injury. In fact, there is no sports injury that shows up in the emergency department more often in a twisted ankle. Fortunately ankle sprains heal just fine most of the time. But in some cases there can be a significant injury to the ankle that prevents them from healing properly and causes problems down the road.

There are 3 primary potential causes of popping and clicking in the ankle that might be associated with persistent ankle sprains and chronic ankle instability.

1. Torn Peroneal Retinaculum

2. Lateral Process Fracture of the Talus Bone

3. Osteochondral Lesion of the Talar Dome

One common cause of popping and clicking in the ankle is from dislocating or subluxing peroneal tendons. The peroneal tendons run down the back to leg behind the fibula. They turn around the end of the fibula as they curve down toward the outside of the foot. 

There is a thin band of tissue called the peroneal retinaculum that holds the peroneal tendons in place behind the fibula. In some cases involving ankle sprains, the peroneal tendons actually fire so hard to try to keep the foot under the leg when you roll the ankle that the perineal retinaculum actually gets torn off of the fibula bone. Because it is torn, the peroneal tendons are not held firmly in place behind the fibula.

When this occurs, the peroneal tendons are free to slide forward over the leading edge of the fibula bone. As the tendons snap back and forth across the fibula, they cause a popping and clicking sound and/or sensation as you walk. When this occurs it is not always painful but it certainly can be painful. It is more worrisome if it is painful simply because this might signify a tear or a split in one of the peroneal tendons.

If one of the peroneal tendons is torn or split it might need a platelet rich plasma injection (also known as a PRP injection) to help stimulate healing. If the torn peroneal tendon cannot heal on its own, it might require surgery to sew it back together. In any event pain in this area should not be ignored.

Another cause of popping and clicking in the ankle can be a misdiagnosed or undiagnosed lateral process fracture of the talus bone. The talus bone is the bone that connects the top of the foot to the bottom of the ankle. Lateral process fractures are sometimes referred to as snowboarders fractures.

We used to think that lateral process fractures were a rare occurrence. However Dr. Segler led a team of investigators through the largest study ever completed on lateral process fractures of the talus. He and his team won an award from the American College of Foot and Ankle Surgeons for this research. What his team found was that these fractures are about 10 times more common than previously thought. They just get missed all the time.Is

Lateral process fractures are frequently misdiagnosed as ankle sprains. Yet a broken bone does not generally heal the same way as a torn ligament. If not treated correctly, the broken bone can develop into a nonunion where the bone actually never heals. When this occurs, there can be continued pain and swelling in the ankle. Sometimes there can be a popping and clicking sensation as well.

The third potential cause of popping and clicking in the ankle after an ankle sprain is an osteochondral lesion of the talus. An osteochondral fracture is a crack in the bone underneath the cartilage. Basically what happens is the ankle rolls and the talus bone can tilt so far that the corner of the talar dome smacks into the tibia bone or fibular bone. If the talus has a hard enough impact as it twists, it can crack the bone and damage the cartilage. 

Sometimes the cartilage and the fractured piece of bone (known as an osteochondral fragment) can become loose. If not treated correctly this may not heal. If the cartilage is loose and has a flap of tissue that flips back and forth it can cause a clicking or popping sensation. This is often associated with swelling and pain in the ankle.

If there is popping and clicking from the ankle, but no history of a serious ankle sprain, the shape of the fibula can potentially lead to subluxing peroneal tendons. The retinaculum might actually still be intact but because there is not a very deep groove in the back of the fibula the peroneal tendon still slide back and forth causing a popping and clicking sensation at the side of the ankle. This can cause peroneal tendinitis.

If this is the case, it is possible to perform surgery to deepen the groove at the back of the fibula in order to help the peroneal tendons stay in place. This will stop the popping and clicking and prevent chronic irritation of the tendon that can lead to tears in the peroneal tendons.

Another related issue with chronic ankle instability and persistently weak ankles is that the ankles can get sprained over and over. If you often find yourself rolling your ankles when walking on uneven surfaces or running on trails, the first step would be physical therapy or a home rehabilitation self-treatment program to try to strengthen the ankles and restore stability.

In some cases of chronic ankle instability the ankles are so weak that the ligaments on the outside of the ankle need to be surgically repaired or rebuilt. 

In any case, if you have popping and clicking, especially associated with pain and swelling of the ankle, it shouldn't be ignored. Get it checked out right away.

Dr. Christopher Segler, D.P.M. is board certified, American Board of Podiatric Medicine. His practice is limited to  runners, triathletes and active young adults who want to stay active. He travels often to accommodate patients with complicated injuries in San Francisco, Houston, and Hawaii. He also provides remote consultations via Skype for injured expat patients living abroad who need expert advice, but cannot readily access a true foot and ankle expert while overseas. If you have a question about a complicated foot or ankle injury that just isn't getting better, you can reach him directly at 415-308-0833. 

When is Surgery Needed for a Ganglion Cyst in the Foot by San Francisco Running Foot Surgeon

A runner with a ganglion cyst called from San Francisco and had the simple question. "When should a runner consider ganglion surgery?" Here is the answer....

Whenever a patient has a big squishy lump on the top of the foot, big toe joint or the ankle joint, they want to know what will make it go away. The most common soft tissue mass in the foot is a ganglion cyst. Sometimes ganglion cysts will go away on their own. Sometimes the ganglion cyst needs to be drained. But sometimes a ganglion cyst in the foot needs surgery.

There are really 3 reasons that a ganglion cyst in the foot or ankle will need surgery

1. The ganglion cyst is painful.

2. The ganglion cyst is pushing directly on a nerve and can cause nerve damage.

3. The ganglion cyst is so big that it makes it difficult to wear shoes.

Unfortunately, many times ganglion cyst happen to develop in locations that are positioned close to nerves. This is really the best reason for a runner to think about ganglion surgery.

The tingling and burning pain that is often associated with a ganglion cyst is usually because the soft tissue mass is pushing against a nerve and causing the nerve to become irritated. If this continues for a long period of time, you can develop chronic pain or permanent nerve damage. The skin on the top of the foot is very thin and when a soft tissue mass develops the mass gets squished between the shoe and the bones that are close to the skin. The nerves that are located in that area can then get caught in the middle and cause pain. For this reason midfoot ganglion cysts often have to be removed surgically.

Dr. Christopher Segler is a runner, 6-Time Ironman finisher and a nationally recognized foot surgeon and sports medicine podiatrist who focuses on rapid recovery from running injuries. He is an internationally recognized expert in the treatment soft tissue masses that may appear to be ganglion cysts. His research and theories on PVNS (a dangerous soft tissue mass that is often mis-daignosed as a ganglion in young adults) have been published in the medically journals and were used as the basis for new treatment methods of these soft tissue masses. He practices podiatry, sports medicine and surgery in San Francisco.

You can learn more about the best treatment for ganglion cysts in the foot at www.AnkleCenter.com and www.DocOnTheRun.com. If you live out-of-state or abroad, you can arrange a remote consultation with a true running expert through www.RunnerSecondOpinion.com

San Francisco Podiatrist on Difference Between Heel Pain and a Heel Spur

Heel pain is the most common form of foot pain that causes people in San Francisco to make an appointment with a podiatry clinic. In fact, nationwide, about 40% of all visits to podiatrists are due to heel pain diagnosed as plantar fasciitis. As a podiatrist in San Francisco myself, the thing that I find interesting is that most people with plantar fascitis think they must have a heel spur to have heel pain. But that’s not always true.

So what is the difference between plantar fasciitis and a heel spur?

To begin with, let’s explain how to tell if you have plantar fasciitis. Anyone with plantar fasciits will have pain in the bottom of the heel or in the arch. In most cases this pain is worse when you get up and step out of bed in the morning. The heel may also hurt when you get up from your desk after working at a computer for a couple of hours.

As you start to walk, the first step is usually a sharp pain or sudden ache in the bottom of the heel. After a few steps, the heel pain starts to subside and feels better. In many cases, it may not even hurt at all while you are walking around or even running. But when you sit still and get back up again to start walking, that’s when the heel pain returns.

If you have this kind of morning heel pain and simply push on the bottom of the heel (and it hurts) you most likely have plantar fasciitis.

Many people in the San Francisco Bay Area seem to believe that heel pain is due to a sharp heel spur poking down and causing pain. But in fact about half of all people who have this kind of heel pain don’t have a heel spur at all. And about half of people with no heel pain, happen to have a heel spur that will show up on x-ray. So the two problems aren’t necessarily related.

The most common cause of heel pain is plantar fasciitis, which is simply inflammation of the plantar fascia. The plantar fascia is a big ligament attaching to the bottom of the heel and extending out to the toes. If you put too much stress on the plantar fascia, it can become inflamed where it attached to the heel bone.



With improper biomechanics, such as excessive pronation (flat feet that roll inward as the arch collapses) the plantar fascia ligament may tug away at the heel bone. With tension applied to the plantar fascia, the attachment may cause the heel spur to form.

The way this happens is that the ligament pulls the covering (called the periosteum) of the heel bone away. A small blood clot forms and then becomes calcified as it heals. If this happens again and again, the heel spur gradually grows. Because the heel spur is caused by the pulling on this big ligament, you can understand why a heel spur points out toward the toes and not down toward the ground.




Any podiatrist in San Francisco can simply take an x-ray of your heel to tell whether or not you have a heel spur. But the reality is, it doesn’t matter.

In the last 7 years, I have only surgically removed 2 heel spurs. Both of them were broken and wouldn’t heal. One was an young ironworker in San Francisco who fell off some scaffolding while working on the Golden Gate Bridge retrofit project. The other was a woman in her sixties who has some osteoporosis and broke the heel spur while doing high impact aerobics.

But most people with plantar fasciitis can get better on their own, even if they have a heel spur. In the vast majority of cases, spending a few minutes doing our San Francisco Podiatry Heel Pain Recovery Stretches will make the heel pain go away. The spur just simply doesn’t usually need to be removed in surgery.

Dr. Christopher Segler is a nationally recognized expert on conditions affecting the heel bone. In 2006 he was awarded 1st Place at the National Meeting of the American Podiatric Medical Association for his research on diagnosing heel bone infections with magnetic resonance imaging (MRI). He offers podiatry house calls in San Francisco for busy athletes and people who just think it is ridiculous to take half a day off work just to see a foot doctor. You can reach him through Doc On The Run: San Francisco Bay Area Podiatry House Calls.You can also learn more about the causes and available treatments for heel pain at AnkleCenter.com.

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San Francisco Marathon Runner and Bunion Surgeon Posts Video Explaining "What is a Bunion?"

Educational Video by San Francisco Bunion Surgeon "What is a Bunion?"

One day after a marathon, a runner came up to me and explained that he had stopped running because he had so much bunion pain. This guy was no novice runner. And no wimp. He was a multiple Ironman finisher, who had even qualified for the Ironman World Championships in Kona. He said he just wanted to know if he would be able to run again.

As a runner currently training to earn my own Kona slot, I know first hand the level of pain tolerance that has to exerceised to finish an Ironman in a respectable time. So when he told me that "pain" was what was stopping him from running, I knew he really had to be suffering from some serious bunions.

And he was. So after evaluating his feet, looking at the x-rays, etc., we decided to surgically correct his painful bunion. Interestingly to me, he still didn't really seem to understand how a bunion forms. In fact, I have had many bunion surgery patients who came to see me with bunions who have tried to research bunions on the internet, but still didn't fully understand how a bunion happens.

To help people understand what a bunion is, how a bunion forms, why it gets bigger, why bunions become more painful, etc, I created a short video and posted it. Click on the link above if you want to understand how a bunion develops.


Dr. Christopher Segler is a 4-time Ironman Finisher and foot surgeon in San Francisco. He is also the inventor of the Tarsal Joint Distractor, a surgical instrument designed to help bunion surgeons perform bunion correction surgery faster with a lower complication rate. You can learn more about bunion surgery at San Francisco's Best Foot Info Site. If you are a busy athlete who would rather have a doctor come to you for your evaluation see San Francisco's Podiatry House Call Site.

Can I Run After Ankle Ligament Surgery?

Question from Mike in Corte Madera:
For years I had unstable ankles and repeated ankle sprains. It seemed like every time I would walk on any sort of uneven ground, my ankle would roll under. Although it wasn't always painful, it was bothersome. My doctor said this unstable ankle (continually giving way) was porbably caused by a bad ankle sprain I had back when I was playing high school basketball. I had surgery about a year ago to repair the torn ankle ligaments. The ankle ligament surgery was called a Brostrum repair. Now the ankle seems fine, but I want to know if I can run in a marathon. Ultimately I would like to participate in a triathlon this year as well. Is this possible?

Answer from My Running Doc:
Ankle sprains are very common. Some estimates show that there are nearly 25,000 ankle injuries in the U.S. every day. The vast majority of these ankle injuries (about 85%) are ankle sprains. Many people try to treat ankle sprains at home with ice, rest, elevation, and maybe an over-the-counter brace or ACE wrap to keep the swelling down. But many more will seek treatment at the Emergency Room or from an ankle expert like a podiatrist.

When doctors try to determine how severe the sprain is, they base it on a grading system from 1 to 3. A grade 1 ankle sprain means that you have sort of stretched the ligaments a little. A grade 2 ankle sprain means that you have partially torn one of the ligaments supporting the ankle. Although this is more severe, the ankle ligaments are still mostly intact. A grade 3 ankle sprain means that you have completely torn at least one of the ankle ligaments.

It is often difficult for a patient to tell the severity of the ankle sprain, but there are some indicators that it might be severe and needs to be treated by an ankle specialist. Bruising and swelling are clues that you have had some level of tissue damage. With severe bruising, your ankle doctor should also be suspicious of a fracture. But even if there is no fracture and the ankle isn't broken, that doesn't mean you don't still need serious treatment.

In your case it sounds like you had one of the classic ankle sprains that resulted in Grade 3 ankle injury. Because the ankle ligaments never healed, you were left with an unstable, wobbly ankle. By performing a Brostrum ankle ligament repair, your ankle surgeon has attempted to rebuild and repair the torn ankle ligaments. If the ankle surgery has been successful, you should gain full mobility and use of the ankle. If I were to have performed your ankle surgery, the goal would be to have a much stronger ankle after the surgery than before. This of course means that you should be better able to run and bike once the ankle surgery is all healed.

In short, anyone who has ankle surgery to repair the torn ligaments should be able to run or ride a bicycle without any trouble. Marathon training and triathlon training are reasonable goals, once you have healed. Having said all of that, you should check with your current treating ankle surgeon and make sure your ankle surgery has healed before you start running, cycling or any new training routine.

Best of luck in your 2010 season!

My Running Doc - Dr. Chistopher Segler is a San Francisco based foot & ankle surgeon with a unique perspective on foot and ankle injuries.  He is a rock climber, skier, marathon runner, and Ironman triathlete.  Because of this, he understands when someone has an injury, they want to get better, just to get back to activity.  He understands that the common doctor's notion of "just stop running" or "find another hobby," or "take up Scrabble" are all unacceptable to the athletically minded.  He believes that any active athlete can suffer an injury yet return to sport stronger than ever.

Posterior Tibial Tendonitis: a Pain in the Arch

When you run, your foot hits the ground, you pronate to absorb impact and then you supinate to push off again. All of this is possible because of a muscle in your leg call the tibialis posterior. This muscle deep in the back of your leg forms a tendon call the posterior tibial tendon that attaches to your foot. It attaches to the navicular bone in the instep of your foot, right at the top of your arch.

In the very simplest of terms, this tendon helps to hold up the arch. It is really much more complex than that, but we won’t bore you with the details. All you really need to know about this is that when you get posterior tibial tendinitis it can quickly progress and become a surgical problem.

The good news for runners is that it one of the things that least frequently affect us. It most often affects people who are middle-aged. It also is often associated with high blood pressure, obesity and diabetes. Not exactly the picture of a runner. Interestingly though, one study showed women get it four times more often than men.

This is one thing to watch out for if you have fleet feet. It seems many who get this problem are already flat-footed long before it starts. Excess pronation (common in people with flat feet) puts tremendous stress on the tendon. Running increases the stress and strain several fold. The result is repetitive overuse that can set the condition off.

When too much stress is placed on this tendon, it can become inflamed. Continued inflammation can weaken the tendon and cause it to stretch out. This can lead to a torn or ruptured tendon with a complete collapse of the arch. Not good.

So how do I know if have posterior tibial tendonitis? One clue that you might be getting this problem is pain from the ankle bone to the arch on the inside of your leg. If it is inflamed and you stand up on your toes on that foot, it will likely hurt much worse. If you stand only on one leg and do this, it will be even more painful. You might even have some swelling around the ankle or arch.

If you notice these symptoms you need to get it checked out by an foot and ankle expert. This is not one of the ice-it-and-will-go-away kind of problems. Neglecting it can (and often does) lead to surgery. It is preventable as well as easily treatable in its early stages. Orthotics can limit the force of pronation and help to decrease the risk of injury to the tendon, especially if you over-pronate or have flat feet. And as always, make sure you are wearing the right type of running shoes for your foot type.


Dr. Christopher Segler is an Ironman Finisher and award winning foot and ankle surgeon specializing in elite athletes. His Bay Area based podiatry practice is Doc On The Run Podiatry House Calls. To learn more about Achilles tendonitis, runner’s heel pain, stress fractures, bunions and other common causes of foot pain, you can register for a FREE membership and copy of his monthly newsletter “Finisher’s Circle” by visiting http://www.AnkleCenter.com .