Category Archives: Foot Pain


I have had several runners and one roller derby player come to the office recently having sesamoiditis. The sesamoids are two small bones which are embedded in the tendon directly underneath the big toe joint. They act as a stabilizer of the big toe, keeping the toe moving up and down as opposed to side to side.

Sesamoids can occasionally fracture or be bipartate. Bipartate means that an individual sesamoid which normally starts out as two pieces and fuses together doesn’t fuse, leaving the two pieces separate, which the image below shows.


High-arched feet have a greater tendency to develop sesamoiditis than flat feet. Excessively worn, poor fitting or improperly designed shoes can also cause sesamoiditis.

Medical treatment depends on the severity of pain include icing, anti-inflammatory medications (Advil/Aleve), cortisone injections into the joint, immobilization and orthotics.

Shoe treatments include wearing a shoe that doesn’t flex at the forefoot or have a thin, non-shock absorptive sole. In a running shoe, this means no flex groove directly under the big toe joint where the sesamoid is inflammed.

Going barefoot is also not a good idea until the area heals.

Since the sesamoids bear weight with every step, this condition can take several weeks to months to improve. If however, the pain remains unchanged in spite of the treatment, then MRI should be used to make sure there’s no fracture. Fractured sesamoids require non-weight bearing immobilization with cast and crutches and occasionally surgical removal of the sesamoid.

If you have pain under the big toe joint that doesn’t improve with reduced activity and rest then you may have a fracture. Whether or not you have big toe discomfort of pain, it’s important to see a podiatrist for evaluation. Waiting to seek treatment can make this condition worse.

Flex Grooves and Forefoot Pain

Horizontal grooves in the forefoot of running shoe outsoles are called flex grooves. As the name implies, flex grooves are designed to promote forefoot flexion across the ball of the foot.

In many cases of forefoot pain, however, this is exactly where you don’t want the shoe to bend. You actually want the shoe to be as inflexible as possible in this area if you have the following forefoot conditions: hallux limitus, sesamoiditis and metatarsalgia.

If you have forefoot pain, deep flex grooves located directly beneath the affected joint will cause an increase in forefoot flexion as well as reduced shock absorption due to a lack of an overlying outsole in the area of a groove.

The shoe on the left side of the image has flex grooves adjacent to where the forefoot bends, which can alleviate forefoot pain. The shoe on the right side of the image has a flex groove where the forefoot bends, leading to more pressure in this area.

If you experience pain in the forefoot, check the flex groove placement in your shoes. Flex grooves in the wrong place can contribute to forefoot pain.

Blood Blisters Under Toenails

DG came in today with subungual hematoma, or blood blisters, underneath the toenails from playing soccer in shoes that were too short.

Soccer cleats are designed to be worn snugly, but if they are too short, pressure will build up against the nail, causing a subungual hematoma to form. In this case DG had been wearing size 10 1/2, but measured size 12 1/2 heel to ball and 11 1/2 heel to toe. Additionally, his current soccer cleats were too shallow in the toe box, as well as too short as this image shows.

If you routinely lose toenails from playing sports, you will probably need to go into a bigger size shoe. The best place to have your foot professionally measured is at a specialty running shoe store and then use that information to size your cleats accordingly.

If you experience a subungual hematoma, you will want to visit a podiatrist and have your nails trimmed and thinned down.

Here’s an additional post on runners thickened toenails

Shoe Review – Adidas AdiPower Predator TRX FG Soccer Cleats

Just had my first look at these sleek, well-made and expensive cleats.

All I can say is Adidas, what did you do? The concept is great (lightweight, yet rigid), the style is great (cool colors, streamlined look) but the back cleats are manufactured to sit uneven which will be a major problem for a lot of Soccer players out there.

The above image shows a new-out-of-the-box pair placed on a flat surface. New cleats should NEVER do this. In fact when cleats wear this way, they should be immediately replaced. Adidas Product Defect Department assured me that their cleats are designed level, however a trip to the Adidas Sport Performance Store in San Francisco, confirmed that every new pair of AdiPower Predator’s was manufactured in this way.

Here’s an image of a pair of Adidas F50 AdiZero TRX FG which rest level on a flat surface. This is what you want to look for when shopping for shoes.

If you are excessively pronated or experience problems due to pronation (instep pain, arch pain or inner knee pain) then you will want to steer clear of AdiPower Predator TRX FG . For this reason, I can’t endorse this soccer shoe.

Neuroma Pain

Reader Doug writes “I have been having trouble maintaining a level of consistency in my training due a Morton’s Neuroma in my left foot. Over the past two years, I have had 2 cortisone shots, switched shoes multiple times to different sizes, widths, and makes. The first time I had a neuroma, I was running in the Brooks Adrenaline GTS 8 in a size 9 regular width. Then I switched to the Asics GT-2150 size 8.5 2E width.”

Doug is not alone in his frustration of not being able to solve his neuroma pain by changing his shoes. Unfortunately, even with shoe changes or orthotics, neuroma pain can continue to worsen.

A neuroma is an inflamed nerve in the forefoot. Symptoms include burning and tingling in the toes, or feelings of walking on a bunched-up sock. For some people, the discomfort is more noticeable while wearing shoes, for others the discomfort is more pronounced when barefoot. For everyone, however, the more frequent and the longer the symptoms persist, the worse the prognosis.

When this happens, treatment recommendations include cortisone injections and medical grade alcohol, or sclerosing injections infiltrated into and around the nerve.

When a neuroma doesn’t respond to cortisone or sclerosing injections, surgery is the next likely step. To locate a qualified foot and ankle surgeon see

If The Custom Orthotic Isn’t Perfect, The Shoe Doesn’t Matter

My area of expertise, aside from shoes of course, is biomechanics. I received specialized training in podiatric orthopedics and in orthotic evaluation and treatment. If you are considering custom orthotics, or if they have been recommended to you, you will want to make sure a thorough evaluation is done.

This video, although longer than my earlier videos, provides comprehensive information about how the custom orthotic process works in my sports medicine clinic. Understanding this process will make you a more informed consumer, and hopefully guide you to someone who is equally qualified to do this most important rehabilitation step.

Although many specialists make orthotics (chiropractors, physical therapists, and pedorthists, to name a few) they just don’t have the knowledge or training to be able to do this as well as a qualified sports medicine podiatrist – see for more. So it’s worth your time to not only find the best shoes, but to also to find the best provider of custom orthotics if they are prescribed for you.

Hallux Limitus and Hallux Rigidus or Turf Toe

Hallux limitus and hallux rigidus or turf toe are painful conditions of the big toe joint. Recently, my associate and FDFAC surgeon Dr. Sandi Pollard did a video about these injuries that I wanted to share.

Here are my other blog posts about hallux limitus, hallux rigidus and turf toe.

Rocktape For Injury Prevention and Rehabilitation

Rocktape is a company that makes a comfortable, long lasting, easy-to-use sport tape which can enhance athletic performance as well as help recover from injury. I am a huge fan of Rocktape and prescribe it for many of my patients. Rocktape has extensive how to use instructions on their website. The following videos show taping methods I developed using Rocktape for plantar fasciitis and posterior tibial tendonitis.

Plantar Fasciitis Question

Reader Mark writes “I had no idea that plantar fasciitis and achilles tendonitis were related. I’ve also been told that rolling your foot on a tennis ball while seated is good for stretching the plantar fascia. Is this a good idea, or is it doing damage? I’ve found it really relieves the pain for a while. Also I am wondering if shoes that are too loose or tight might be a factor.”

Mark asks great questions and ones I get every day. First lets talk about rolling your arch over a tennis ball…I’m not a fan. I know that many physical therapists and other sports medicine specialists will recommend this but in my experience agressive stretching of the plantar fascia can lead to tearing or even rupture of the plantar fascia. Athletes in general do things in a big way and stretching with a tennis ball is no different. In this case, experiencing a stretch so good it hurts, can actually be doing harm. Better off to make an appointment with your local sports medicine podiatrist for evaluation and treatment.

In general, shoes that are too loose are worse than too tight and shoes that are too short are worse than too long. The more loose your shoe, the more your foot will pronate which can cause plantar fasciitis. If your shoe is too is too short, particularly heel-to-ball, your plantar fascia won’t be properly supported as this image shows.

Lacing for Heel Slippage, Top of the Foot Bump and Bunions

Modified shoe lacing can help with a variety of shoe fit problems. Today’s video tutorial shows you how to do this for the following problems:
1. Heel slippage
2. Bumps on top of the foot
3. Bunions or a wide forefoot

Here are my related posts on top of the foot bumps,

Sizing Superfeet – Easy How To

Superfeet are my favorite non-custom insoles. They come in a wide variety of styles for many different shoes. What most people don’t realize is that even though Superfeet are pre-sized A,B,C,D etc. your foot may not fall exactly within the corresponding numbered size. This video shows you how to properly size Superfeet so that you get optimum support. My other posts about Superfeet follow the video.

Plantar Fasciitis & Achilles Tendonitis – Stretches Make A Difference

Wearing the wrong shoes can directly cause or contribute to plantar fasciitis and Achilles tendonitis. Especially shoes that are excessively worn or are the wrong size.

If you have already replaced your shoes, what else can you do? Achilles tendon stretches, that’s what. When the Achilles tendon is tight the foot compensates by pronating and pronation directly contributes to both Achilles tightness and plantar fasciitis.

Muscles attach tendons to bone and in this case, these two muscles join to form a common tendon, the Achilles. In this video, Whitney will show you how to stretch the Gastrocnemius and Soleus muscles. Performing these individual stretches daily in addition to wearing the right shoes, should get you back on track no time.

If the pain persists however, make an appointment with your nearest Sports Medicine Podiatrist for additional evaluation and treatment.

Miles Austin III – Get Some Better Fitting Nike’s

I was shocked last week when the July 26, 2010 Issue of Sports Illustrated arrived in my office. There on the cover is Dallas Cowboy wide receiver Miles Austin III, running down the field with holes in his Nike sponsored cleats where his big toes should be. Yikes…one of the faster ways to derail athletic talent is to wear shoes that don’t fit properly which is happening here.

Without seeing how the cleats fit when he is standing still it is difficult to determine whether there is too much volume and he’s sliding forward or whether the toe box is simply too short. One thing however is certain, having your toes exposed and unprotected is not a good thing, especially in a field sport. I think Mr. Austin’s trainers should give me a call.

Climbing Shoes

OD came in today with her climbing shoes. If you’re a rock climber then you already know how painfully short and tight these shoes are. Discussing the rationale behind this or the lack of a single scientific studies supporting this will be tabled to another blog posting on another day.

For now, I am going to return to the basics and remind you that a square peg is not designed to go into a round hole, especially if you have a bunion (wide forefoot) which OD has.

She has been wearing the Mad Rock shoes on the right for the past few years. Because they are starting to wear out, she purchased a new pair of Evolv shoes shown below on the left.

As you can see from the above image, these two shoes are not designed the same. The Evolv on the left is much narrower than the Mad Rock on the right, and the widest part of the shoe (forefoot) is not adjustable because it has straps instead of laces that don’t go as far down to the toes.

If you have a wide forefoot then you want the shoe to be adjustable at the widest point. Although laces are less popular than straps, this is a must-have design for a wide foot.

If you’re comparing two laced styles, check the width by turning the shoe over and comparing the width of the forefoot between the pairs. Again, in comparing the images below, with the Evolv on the left to the Mad Rock on the right, it’s easy to see independent of the upper, that the Mad Rock has a wider forefoot sole.

Now if you look at the side profile of both shoes, the rubber on the left Evolv comes up much higher on the foot, whereas the Mad Rock’s rubber is lower to the ground. This reduces forefoot compression, another plus for a wide forefoot

Finally, if you need even more forefoot room, you can always modify the lacing on your climbing shoes. This image shows what we did with OD’s shoes. Both feet are the same width, but the Evolv shoe on the left is essentially acting like a vice grip. You will not experience a loss of gripping ability with the modified lacing on the left, but an enormous improvement in overall comfort and fit.

Shoe Review – New Balance 1123 Excessive Forefoot Wear

I have reviewed New Balance 1123 in a previous post


This has been one of my favorite shoes for the wide, deep foot. It’s especially good for walkers due to it’s wide base and seemingly firm midsole. Or, so I thought.

Today, someone came in having worn this shoe while walking for the few past months with a recent onset of ball of the foot pain (metatarsalgia). When I turned the shoe over, I was shocked to find that the thin firm, rubber outsole had worn clear through, exposing a butter soft EVA midsole. The midsole was so soft in fact that it provided little in the way of forefoot shock absorption, causing the ball of the foot to be pounded with each step.


If you own this shoe, make sure to check the outsole monthly. If it has worn down like this shoe has, replace it immediately or you may do your feet severe harm. Otherwise, I still like this shoe.

Roller Derby – Outside of the Foot Swelling (bursae)

Lusty Malice ( came in today with increasing outside of the foot pain. She purchased new boots in January which alleviated her ankle pain but created outside of the foot pain and swelling otherwise known as a bursae. A bursae is a fluid-filled sac which develops in areas of  pressure. In this case, a wide forefoot and a tight new boot, caused pressure and friction resulting in bursae formation.


Fortunately, since this is a new problem, the solution is easy. First the skate needs to be spot stretched. I use a ball and ring stretcher for just such cases. You can also go to your local shoe repair store and have them do this as well. Be sure to tell them that it needs to be spot stretched as opposed to forefoot stretched, otherwise you won’t get the desired result.


Next, I showed LM how to re-lace her skates skipping the eyelets that correspond to the bursae location which will reduce pressure in this area.


Finally, if there is still some residual pain and swelling then a quick trip to the podiatrist for a cortisone injection into the burse should take care of things once and for all.

Shoe Review – Asics Gel-Stratus 2.1

This is a great shoe for the narrow foot. However, if you wear this shoe, you will want to pay particular attention to forefoot wear. BT came in today with this pair which were only 6 weeks old. When placed on a flat table, the heel counter is no longer upright, tilting to the outside, indicating excessive wear.


Looking at the forefoot sole on the bottom, excessive wear is also evident. This causes the shoe to pronate causing metatarsalgia (forefoot pain) and in this case worsening plantar fasciitis.


Surprisingly the rearfoot outsole wear is unaffected and is evenly worn.


In this case, the worn shoe can cause foot pain and problems so carefully evaluate your shoes monthly for excessive wear.

Shin Splints

Reader Jason asks “I was wondering if you had more information about shin pain during running.  what could be the cause, what could be the remedy, etc.? “

Shin splints also known as Anterior Tibial Tendonitis can occur for a variety of reasons.


Here are the most common causes I see in my office.

  • Shoes – A soft lateral midsole or simply excessive wear can cause shin splints. If you haven’t had shin splints before  and then you do, you probably need new shoes. If the wear looks like this (especially the left) when you set your shoes on a flat surface, then excessive wear is probably the cause.


  • Over-training or changing running surface or terrain. A change to concrete from trails or an increase in downhill running can also cause shin splints.


  • Alignment – A condition called tibial varum (bowed legs) can predispose a person to shin splints as this causes the pull of the muscle to be angled versus straight, resulting in the muscle pulling away from the lower leg bone (tibia). If a person’s tibial varum is significant, it can also cause Achilles tendonitis or even a stress fracture of the tibia which becomes a serious problems activity-wise.

Whenever I have a patient with shin splints, I do a thorough treadmill evaluation with shoes on and off and make specific recommendations if the problem is the shoe. I will also do a complete medical examination including xrays, ultrasound and MRI if indicated.

If the problem is biomechanical (alignment)I will make a custom orthotic, especially if the pain has been long standing. If the problem is acute I will try taping, icing and over the counter anti-inflammatory medications (Motrin, Aleve). If this doesn’t work and the pain is really severe, I will probably do a cortisone injection, which typically works very well.

If the problem is over-training I have the person back it up and if it’s a change in terrain, I’ll recommend softer trails and/or fewer hills until the pain lets up. Physical therapy can also help.

Arch or Heel Pain – Plantar Fasciitis

Many patient’s I see have arch or heel pain, otherwise known as plantar fasciitis. The plantar fascia is a structure on the bottom of the foot which extends from the heel to the ball of the foot. When it is tight (bow-strung) it can cause inflammation and pain.


Not surprisingly, shoes can cause plantar fasciitis, especially shoes that are excessively worn, too short in the arch or too flexible. If you have plantar fasciitis you will definitely want to evaluate your shoes. You should also try not going barefoot in the house.

If the pain persists, you will want to visit your podiatrist who may recommend calf stretches, anti-inflammatory medications (Motrin, Aleve) or give you a cortisone injection. Custom orthotics may also help. If you have morning pain, your podiatrist may want to fit you for a night splint which will keep your plantar fascia stretched out all night or show you how to tape if the pain persists.

Although plantar fasciitis is a common condition, the longer you wait to seek treatment, the harder it will be to resolve.

Hallux Limitus vs. Hallux Rigidus

Reader Mike writes“I was recently diagnosed with functional hallux limitus after developing a strong interest in hiking (and having never done any other long distance running, or walking type things before that) Do you have any recommendations for a good hiking boot/shoe? I’m currently using Montrail CTC.”

Hallux limitus is a condition whereby the big toe joint becomes restricted during weight bearing but is otherwise healthy, hence the name functional. In this condition you still have cartilage with little to no arthritis in the joint. Pain arises with excessive flexion of the great toe or while standing due to pronation and rolling onto the big toe joint, causing restricted motion.

In Hallux rigidus, the great toe joint becomes arthritic with associated cartilage loss, resulting in bone on bone motion which is very painful. This is a structural problem usually requiring surgery to correct.

In this video, my associate Dr. Sandi Pollard talks more about these conditions.

In hallux rigidus, you want to stop motion, in hallux limitus you want to improve motion. For both conditions an inflexible or stiff soled shoe is usually best which fortunately most hiking boots have. I have several patients with hallux rigidus, who I have wear only hiking boots becuase this eliminates the pain. For my hallux limitus patients I can usually stop the pain by getting them into shoes that are primarily inflexible in the forefoot. Montrail CTC is a classic example of this. Custom orthotics can also help since they improve big toe joint function.

For even more information about hallux limitus read my other post which talks about sole design.