capulitis with orthotics & running shoes

by Robert
(Denville, NJ)

Your webpage is excellent, I commend you on sharing your knowledge to the public. I have a few questions for you regarding my recent foot pain (capsulitis) from starting a running routine.

History:
I’m an engineer with a fairly sedentary life style (desk job), 42 year old male, 5’-11”, 193 lbs. I wear and have been wearing RX custom orthotics (different pair) for running shoes and every day shoes for several years. The orthotics are approximately 3 years old and do NOT have any metatarsal “pad” or “cut out”. My left foot has an apparent arch when seated however when standing, the arch falls and is flat footed. My right foot appears normal and has a normal arch when both seated and when standing. Both shoes (L & R) show wear along the outside heels, along the outside of mid foot toward entire forefoot. I started a combination run/walk routine on a treadmill for 30 minutes every other day back in July 2014. This routine started as mostly walking with some running. After 1 month or so, I was able to gradually transition to running non-stop for the full 30 minutes on a treadmill (no pain). In Aug 2014 I then transitioned to running outside on asphalt for the full 30 minutes with new running shoes. After 2-3 weeks of running (30 min, every other day) outside on asphalt with new running shoes, I developed a pain in my right foot under the second metatarsal. I then went to see my podiatrist (Sep 11, 2014), after physical evaluation (no XRAY or MRI), he diagnosed me with capsulitis at second metatarsal joint, my second toes are longer. He then gave me a cortisone shot and told me to rest for 1 week, and to resume running after the 1 week rest period. I rested for 2 weeks, then did a light run, and the pain resurfaced, I have not ran since. I’m scheduled to see him in a week or so, and getting new orthotics with a metatarsal “cut out”. I’ve noticed my new running shoes (supportive NB1260) have a heel elevation of 12mm above the toe box.

Questions:
Q1- What do you recommend regarding metatarsal “pad” or “cut out” for my new orthotics?
Q2-Although I have a flat foot, am I a pronator?
Q3- Supportive/ motion control running shoes for over pronators have a higher heel elevation to toe box. If I wear RX orthotics, do I still need to wear supportive/motion control running shoes or can I wear normal running shoes with more cushioning and less elevated heel?

Thank you
Rob

RESPONSE

Hi Rob,

In regards to your questions I have a few points to mention.

Capsulitis is a fairly easy diagnosis for a podiatrist, and in most cases does not require an x-ray or MRI. However, since you had a cortisone shot and rested for two weeks, but the pain returned, I would not be too quick to have new orthotics made just yet.

I say that for the simple reason, you should be certain that capsulitis is what you have before you actually go out and have new orthotics made.

One other possibility is that you may actually have a stress fracture and yes, stress fractures can occur that far up in the metatarsal bone.

You have a couple of options here. You can have an x-ray which may or may not show a small crack in the bone. If the x-ray appears normal, then before being casted for new orthotics, ask your podiatrist to tape a metatarsal pad, or a cut-out pad on to your foot and have you try running to see if that alleviates the pain. If it does, then you should be comfortable going forward with a new pair of orthotics. If the taping does not relieve the pain, then an MRI or even a bone scan might be in order to get a better idea if there is a small fracture that is not showing up on x-ray.

On the subject of using a cut-out pad to treat capsulitis, I have never heard of using that type of padding. It is counter intuitive to what you are trying to accomplish.

In capsulitis, there is an over-strectching of the capsular ligament on the bottom of the second metatarsal-phalangeal joint (in your situation). By adding a metatarsal pad just behind the second metatarsal bone, you are slightly elevating the bone which in essence reduces the stretching of the ligament.

On the other hand, if you add a cut-out pad around the second metatarsal head, you are allowing the second metatarsal head to drop down further which essentially stretches the plantar capsular ligament and will actually exacerbate the problem.

The only time a cut-out pad would be helpful would be if you have a true metatarsalgia which is pain directly underneath the metatarsal bone. The cut-out pad would then take pressure off the metatarsal bone and you would experience relief.

If you have a flexible flat foot meaning off weight bearing you have an arch, but when you stand up your foot flattens out, that is pronation. (going from some sort of arch, to no arch). Pronation is a compensatory motion to counteract some other mis-alignment in your skeletal system.

As far as running shoes go, any decent running shoe is fine once you are in orthotics. A custom orthotic takes over control of your foot mechanics and does a much better job than any store bought running shoe could ever do, simply because a custom orthotic makes changes to your gait based on your specific foot structure. A standard running shoe could never do that.


Marc Mitnick DPM
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