By Rick Rosa, D.C.,D.A.A.P.M.
With the temperature reaching 105° this week in the Washington DC area, I was asked by il Pez himself, who had received an email about a reader who had been experiencing foot pain, which he soon came to learn, was a condition known as “Hot Foot.” He asked me about it and wanted my help to “cool off” the situation.
“Hot Foot” or Metatarslgia is caused by the compression and inflammation of nerves and joint tissue in the metarsal heads, which is the area right above a well placed pedal spindle. It is characterized by pain and a sensation of burning as well as numbness. Many cyclists believe that splashing water on the feet will help with the symptoms, but that is a symptomatic treatment that is not getting to the root of the problem, namely an inflammation in the nerve and surrounding tissues.
The Joys of New Stuff
Recently, I had a case of a young man who had classic symptoms of metatarsalgia that began after putting in some long miles on his bike on a hot day shortly after buying new shoes and pedals. He claimed that the pain kept returning when he climbed hills or during a long ride. In taking his history, I noted that the new shoes and pedals were made up of much stiffer carbon fiber. In addition, he was in the habit of using regular short socks that he would wear with his regular running shoes. There was no evidence that organic diseases, such as diabetes or degenerative joint disease, was present in his history.
Upon physical examination, I found that he had significant restricted movement in the joint tissue of the foot and ankle. He had an obvious fallen medial arch (foot was flat) and was pronating. In addition, he had very tight gastroc/soleus (calf), as well as Achilles tendon. His foot would swell up from the heat and this would only add to the pressure on the forefoot, excacerbated by the thicker socks he wore.
The treatment in his case worked out well. We began using ultrasound and manipulation of the foot and ankle as well as ice baths in order to restore proper biomechanics and reduce inflammation. I placed a small pad that was inserted into his shoes under the metatarsal heads in order to spread them out and reduce pressure in hopes that this would help him without the need to be fitted for orthotics. I also suggested that he get thin socks and asked him to loosen the lowest strap over the metatarsal heads to decrease the pressure that was building up during the long rides.
He was very diligent about performing the stretches I gave him for his calf muscles and Achilles’ tendon, which added to his recovery. In this case he was able to acclimate well with these minor adjustments, primarily because most of the injury was due to the sudden change in stiffness of the carbon pedals and shoes. In one study done by Jarboe and Quesada on the effects of shoe stiffness on the forefoot, they found that carbon shoes can be 42% to 550% stiffer, which translated to an average increase in the pressure of 18% over more traditional plastic shoes. (1)
Other Things to Consider
In other cases, casting for an orthotic that will support the metatarsal heads as well as the medial arch is needed. Orthotics correct and support proper biomechanics, which evenly distribute the pressure on the metarsal heads. In cases of extreme events like RAAM they place the cleat way back or cut open the toe box to help alleviate pressure on the forefoot but this is not ever necessary for the amateur cyclist. Lastly, moving the seat down 1 cm and shifting the cleat back 1 cm can also take some pressure off the metatarsal heads. However, I am not a big fan of this because I believe this can force other biomechanical issues to other joints, such as the knees to come about.
Also using pedals with a large platform is better for distribution of the pressure over the forefoot and will not pinpoint all your weight and force into a small area. Using cortisone injections and surgery is rare and is usually related to other issues, such as neuroma’s, seasamoid issues, or acute trauma to the foot.
As always remember to work with a qualified professional.
1. Jarboe NE, Quesada PM. “The effects of cycling shoe stiffness on forefoot pressure.” Foot Ankle Int. 2003 Oct;24(10): 784-8.
2. Cailliet R. Soft Tissue Pain and Disability. Philadelphia: F.A. Davis Company 1996 pg 442-445
Rick Rosa, DC, DAAPM, is a practising chiropractor based in Maryland. He is the owner of Rosa Rehab in the Washington, DC area, and has worked as a team doctor for a wide variety of champion boxers and cycling teams. He can be reached for comments at firstname.lastname@example.org
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