Caring Medical - Where the world comes for ProlotherapyAlternative treatments for foot pain

Danielle.Steilen.ProlotherapistDanielle R. Steilen-Matias, MMS, PA-C

In this article we will discuss various problems of the feet and non-surgical alternatives.

Please see our companion article for questions on Morton’s Neuroma .

Writing in the The Journal of Orthopaedic and Sports Physical Therapy doctors reported on a case where Prolotherapy injections successfully treated a dancer who had suffered from foot instability due to the excessive force she was placing on her metatarsophalangeal joints (the foot area formed by the metatarsal and phalangeal bones of the toes).

In their case presentation the doctors reported on a 33-year-old dancer with insidious onset (meaning slow without symptoms) of medial arch and second and third metatarsophalangeal joint pain. Functional problems included severe limitations of foot function.

Imaging studies revealed osteoarthritis of the first metatarsophalangeal joint, second metatarsophalangeal joint calcification, capsulitis (ligament inflammation), and plantar plate rupture (ligament tear) , leading to a diagnosis of instability.

The dancer underwent a treatment program that included taping, padding, physical therapy, a series of prolotherapy injections, and activity modification.

One year after discharge, the dancer reported pain-free dancing with no taping or padding.1


Ligaments of the toes and feet – the cause of foot pain and instability


In 2012, Ross Hauser, MD and Wayne A. Feister, DO published findings in the Foot and Ankle Online Journal from the International Foot and Ankle Foundation.

In this research the doctors examined the foot for hallux valgus, a precursor to bunions, and hallux rigidus, stiffness in the big toe and associated ligament laxity known to cause these problems.

In this study, twelve patients were treated with a series of Prolotherapy injections to stimulate the regeneration of tendons and ligaments and to promote the repair of articular cartilage. Upon completion of three-to-six therapy sessions, eleven of twelve patients had a favorable outcome—the relief of symptoms—with an average of four treatments.2

One year earlier in 2011, health professionals here at Caring Medical published their findings on alternative treatments for foot pain. The main treatment tested was Prolotherapy. Here is what Ross Hauser, MD and colleagues published:

The goal of the observation study was to test the effectiveness in patients using comprehensive dextrose Prolotherapy treatments on foot and toe pain. Patients were chosen who were given a varied diagnoses as to the cause of their foot pain. Some of the most common are hallux rigidus (stiff big toe) and hammer toes. Prolotherapy is an injection treatment used to initiate a healing response in injured connective tissues such as tendons and ligaments, common in painful foot and toe conditions.

Study highlights:

Results:

Prolotherapy helped the patients make large improvements in walking and exercise ability, as well as produced decreased levels of anxiety and depression.


Prolotherapy for Metatarsalgia and Tarsal Tunnel Syndrome


“The traditional open surgical options for the treatment of metatarsalgia and lesser toe deformities are limited and often result in unintentional stiffness.”4

Metatarsalgia is an umbrella term and not the name of an actual injury. It can be pain in the ball of the foot with or without inflammation. Sometimes the diagnosis is isolated down to Tarsal Tunnel Syndrome.

Tarsal Tunnel Syndrome is very similar to Carpal Tunnel Syndrome. The tibial nerve runs in a canal on the inside of the foot called the tarsal tunnel. When the tibial nerve gets pinched here, it is called Tarsal Tunnel Syndrome. The symptoms described for this syndrome include pain in the ankle, arch, toes, or heel.

Recently doctors found that one of the many reasons Tarsal Tunnel Syndrome treatment fails is lack of an accurate diagnosis or lack of understanding or appreciation of the actual anatomy involved.5

The problem of understanding Tarsal Tunnel is chronic burning arch, toe, or heel pain is most often due to ligament weakness at the ball of the foot or soft tissue weakness in the arch of the foot, rather than pinching of a nerve.

Since these structures bear the bulk of the body weight when a person stands, walks, or runs, it is no wonder that these are generally the first structures to weaken.

Metatarsal ligament weakness is manifested by pain at the ball of the feet which often radiates into the toes. This is  metatarsalgia. 

Metatarsalgia usually occurs at the metatarsal heads (the areas just before the second, third and fourth toes), or it may be more isolated, in the area near the big toe. Besides pain in the ball of the foot, sharp and intense pains in the toes may be present, and pain in the toes and/or ball of the foot may increase when the toes are flexed. Accompanying symptoms may include tingling or numbness in the toes.6

So the causes of many incidents of metatarsalgia are mechanical structure of the foot, poorly fitting shoes and improper foot mechanics with walking or running. Most research however points to simple wear and tear as the main culprit, and to demonstrate this in the extreme doctors looking at female professional flamenco dancers and found that the evidence for high heels or other shoe problems as cause of their chronic foot pain were not as common as chronic repetitive trauma suffered during the practice of footwork dancing.7

Advanced metatarsalgia can lead to conditions of Avascular necrosis (bone death) of the second metatarsal head. Conservative treatment includes nonsteroidal anti-inflammatory medication, reduced activity, padding, orthotics, and immobilization. When conservative treatments fail, a wide variety of surgical procedures exist; however, the optimal procedure is unknown.8


 


Foot Arches – Fallen arches and Flat Feet


A weakened arch causes the foot to feel weak and tired especially after a day of standing or walking. It can also radiate pain into the big toe side of the foot. Chronic metatarsal ligament weakness and arch weakness (also known as plantar fasciitis).

Fasciitis can cause numbness in the foot and toes in the same areas of pain. Pain and numbness in the foot can also be caused by ligament and tendon laxity in the knee. The lateral collateral ligament can refer pain and numbness down the lateral side of the leg and foot and the medial collateral ligament down the medial side. Thus anyone with foot pain or numbness needs to have their knees looked at to see if there is any evidence of ligament weakness there.

Fallen arches, or flatfoot, is a condition in which the arch on the inside of the foot is flat and the entire sole of the foot rests on the ground. Although flat feet in and of themselves are not usually problematic, they can create problems in the feet, hips, ankles and knees. Pain may be experienced in the lower legs if there are alignment problems and if the individual is engaged in a lot of heavy, high-impact activities that put stress on the bones and muscles of the lower legs.

To understand why other injuries occur in the feet, it is important to consider the three arches of the foot. The medial longitudinal, lateral longitudinal, and transverse arches of the foot. The talus, cuboid, and intermediate cuneiform bones function as keystones to these arches. These bones have joint surfaces that form a wedge to provide support. Interlocking joint surfaces also provide support.

The typical treatment for pain from fallen arches is an arch insert. While many people experience dramatic pain relief from this, others continue to suffer from chronic achy feet despite the arch support. The long-term problem with this approach is that it does not strengthen the weak arch ligaments that may be at the root of the problem.

Another standard practice is to use steroids or to prescribe anti-inflammatory medications. However, in the long run, these treatments do more damage than good. Cortisone shots and anti-inflammatory drugs have been shown to produce short-term pain benefit, but both result in long-term loss of function and even more chronic pain by actually inhibiting the healing process of soft tissues and accelerating cartilage degeneration.

As discussed below Prolotherapy strengthens the weakened ligaments.  In simple terms, Prolotherapy stimulates the body to repair the foot ligaments. It does so by inducing a mild inflammatory reaction in the weakened ligaments and cartilage.

Although skeletal structure is important to arch support, without the ligaments, the arches would collapse. The plantar ligaments (ligaments on the bottom of the foot), which are stronger and larger than dorsal ligaments (ligaments on top of the foot), tie the inferior edges of the bones together. The most important ligament in the maintenance of the medial longitudinal arch is the plantar calcaneonavicular, or spring ligament.


Plantar Fasciitis


The pain associated with plantar fasciitis is usually described as pinpoint or knife-like pain in the heel pad. Pain is usually worse in the morning, when the plantar fascia is stiff, cold, or tensed. The pain is caused when the damaged tissue is stretched, so when the person begins to bear weight on the foot, the pain level is very high, but lessens as he/she continues to walk/run, presumably as the plantar fascia becomes more flexible. The pain typically originates very gradually; starting only with pain at the beginning of exercise. However, without appropriate treatment; even walking becomes too painful.

Plantar fasciitis can occur for any number of reasons, most having their root in simple overuse. The pain is a result of the weakness of the plantar fascia, which then inflames. Please see our article on Plantar fasciitis and Plantar Fasciopathy for a more detailed discussion on these problems.


Heel Spurs


A heel spur forms because the plantar fascia is barely connected. Thus, the heel spur is not the cause of the pain, but rather the result of plantar fasciitis. By administering Prolotherapy, the spur-producing process stops. This idea is applicable to any osteoarthritis process in the body. Prolotherapy stops every arthritis-producing processes because it corrects the root of the problem, which is tendon, ligament, and fascia weakness. Prolotherapy has corrected many a foot problem that would otherwise have had to have surgery that is often unsuccessful.


Toe Pain


The toes of the feet are held together in part by capsular ligaments. These ligaments keep the toes pointed straight. Capsulitis is an inflammation of these ligaments.

Turf toe is a very common condition among football players, as well as other “turf” sports. Turf toe is, simply, a sprain of the ligament of the great toe.

Turf toe may cause severe and chronic pain. If there is an injury to the MPJ, it can lead to prolonged disability, because the MPJ joint is vital to walking. This is the joint involved in the push-off phase of walking and running. If untreated, turf toe can cause hallux rigidus, or an immobile joint in the great toe. Other long-term injuries include painful arthritis and bunions.

Surgical treatment of moderate hallux rigidus remains controversial and the optimal surgical technique has yet to be defined.

Slullitel G, López V, Seletti M et al. Joint Preserving Procedure for Moderate Hallux Rigidus: Does the Metatarsal Index Really Matter? J Foot Ankle Surg. 2016 Jul 27. pii: S1067-2516(16)30159-4. doi:

Bunions, also referred to as hallux valgus or hallux abducto valgus, and hammertoes (hallux malleus), are two common diagnoses for toe pain whose etiologies can be related to the structures of the forefoot. A multitude of diagnoses can be arrived at for foot/toe pain, though many times the underlying problem, a weakness or injury in the ligaments, tendons or cartilage, is the culprit. For a more detailed discussion on Bunion pain and Human Growth Hormone Injections research study.


Sesamoiditis

Runners and dancers are most likely to suffer from sesamoiditis, but really anyone can experience this type of pain in the big toe. It occurs in the ball of the foot as the sesamoid bones become irritated. Like the kneecap, the sesamoid bones act as a pulley. Unlike the kneecap, the sesamoid bones are tiny bones that run along the tendon to the big toe. As they become irritated, they can cause inflammation in the tendon in which they reside. Standard treatment for sesamoiditis include rest, ice and special shoe pads. Unresolved sesamoiditis pain involves removing the sesamoid bones.

Sesamoiditis Pain Treatment
Rest and ice are two treatments that can actually inhibit healing. What’s needed in this type of pain is regeneration of weakened structures. Rest and ice both inhibit blood flow, eliminating any chance of the body’s immune system repairing the weakened area. A better option is Prolotherapy, an injection technique that induces inflammation, ushering in healing factors to strengthen the weakened area.


1. Ojofeitimi S, Bronner S, Becica L. Conservative Management of Second Metatarsophalangeal Joint Instability in a Professional Dancer: A Case Report. J Orthop Sports Phys Ther. 2016 Feb;46(2):114-23.
2. Hauser RA, Feister WA, Dextrose Prolotherapy with Human Growth Hormone to Treat Chronic First Metatarsophalangeal Joint Pain. The Foot and Ankle Online Journal 5 (9): 1
3. Hauser RA, et al. A Retrospective Observational Study on Hackett-Hemwall Dextrose Prolotherapy for Unresolved Foot and Toe Pain at an Outpatient Charity Clinic in Rural Illinois Journal of Prolotherapy. 2011;3(1):543-551.
4. Redfern DJ, Vernois J. Percutaneous Surgery for Metatarsalgia and the Lesser Toes.
Foot Ankle Clin. 2016 Sep;21(3):527-50.
5. Gould JS.Recurrent tarsal tunnel syndrome. Foot Ankle Clin. 2014 Sep;19(3):451-67. doi: 10.1016/j.fcl.2014.06.015. Epub 2014 Jul 12.
6. The American College of Foot & Ankle Orthopedics & Medicine. Position paper on Metatarsalgia
7. Castillo-López JM, Vargas-Macías A, Domínguez-Maldonado G, Lafuente-Sotillos G, Ramos-Ortega J, Palomo-Toucedo IC, Reina-Bueno M, Munuera-Martínez PV. Metatarsal pain and plantar hyperkeratosis in the forefeet of female professional flamenco dancers. Med Probl Perform Art. 2014 Dec;29(4):193-7.2.
8. Schade VL. Surgical Management of Freiberg’s Infraction: A Systematic Review. Foot Ankle Spec. 2015 May 19. pii: 1938640015585966. [Epub ahead of print]

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