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You are ready to improve your split times. Many hours of roadwork and a smart strength training program this winter and spring should result in your best ever year in triathlon. You have the equipment, the knowledge, support and desire. Mentally, you are focused. The only question remaining is whether your body will hold up. Many endurance athletes face this dilemma as they plan an ATP and ponder a long season. Chronic overuse injuries of the lower extremities may derail athletes during the pursuit of their goals. We need healthy "wheels" to run and cycle the long hours a successful season demands. I am going to explore a case study involving two of the many over use injuries that hamper some athletes. They are conditions of the forefoot; Metatarsalgia and Morton’s Neuroma. Prevention and proper management of these conditions is paramount as they can be slow to resolve short of total rest.

Metatarsalgia is characterized by a bruised feeling in the "ball" of the foot where the long bones meet and join your toes. Here, the capsule of the joint becomes inflamed as a result of repetitive trauma. You may also experience numbness and/or some nasty burning. Morton’s Neuroma presents as a burning pain in the bottom of the foot, which typically radiates into the 3rd and 4th toes. Symptoms may be as light as numbness or show up as a debilitating burning pain that makes simply walking difficult. A neuroma is a cyst, benign tumor, or a thickening of the nerve. In the case of Morton’s Neuroma, the nerve is the common digital just prior to the bifurcation. These two forefoot conditions may develop separately or at the same time. Once they have taken hold they can be a real problem to get rid of. Prevention and quick action at first signs are important.

In the early stages of aggravation to the forefoot, reducing swelling and inflammation with rest, ice, oral anti-inflammatories, ultra sound and other forms of PT may be enough to alleviate your symptoms. Treatment should always be accompanied by preventative measures. Change out your running shoes often. As a larger runner with foot problems I have found that anything over 250 miles on my shoes is a problem for me. Over pronators are more likely to develop injuries of the forefoot. Make sure you are in the correct shoe for your foot and gait. A shoe with ample forefoot padding is desirable if you are prone to foot problems. It is possible for an athlete to have a thinning of the fat pads of the foot, particularly if you are treated with cortical steroid injections in the area. A thinning fat pad could make further forefoot padding necessary in your shoe. A custom orthotic fitted by a knowledgeable doc or health care provider may redistribute your weight over the foot and reduce trauma to these areas. Try to run more trails and on softer surfaces.

For some athletes, another way to reduce trauma to the forefoot may be to alter your running technique. I have found that these injuries were more easily managed when the athlete changed from a heel striker to a mid or forefoot striker. As cadence quickened and strides softened, wear and tear of the foot was reduced. A quieter, more efficient gait resulted in less of a pounding being absorbed from the road. An added benefit may be more speed.

For some, the symptoms we are discussing come on the bike. Make sure that your cycling shoes have ample room in the toe box. Lateral compression can often impinge the nerves of the foot that travel between the metatarsal heads causing numbness and burning. Hot spots can result from cleat position fore and aft, or pedals that do not suit you.

Unfortunately, it is possible to find yourself with a chronic Metatarsalgia or Morton’s Neuroma, having to manage symptoms, even after taking the preventative and management steps discussed. If that is the case consider changing some of your training strategy. There are different ways to attain our sport specific fitness. While some athletes log huge running volumes, others gain a good deal of their running fitness on the bike.

At first glance this idea may seem a bit disconcerting to some and may even require a leap of faith for many runners. As a coach I have found that one of the hardest things to convince a "runner turned triathlete" is that their run splits may actually improve if they run a little less and bike more. If you are forced by injury to reduce running miles, you can take solace in the many examples of positive results had by some who have increased cycling volume while reducing running volume. This will promote healing as it reduces trauma to the feet.

These two conditions of the forefoot can be agonizingly painful. They often have to be managed rather than resolved, especially if one keeps training. Some cases become surgical. The keys to successful management include proper equipment, training on appropriate surfaces, appropriate training volumes and in some cases a change in running technique.


Kevin Purcell, D.C., is a USAT Level 1 certified coach for Elite and Age Group triathletes who compete at both Ironman and short course distances. Coach KP has completed 10 Ironmans and qualified for the 2003 Hawaii Ironman Triathlon World Championships. Dr. Purcell practices Chiropractic with an emphasis on sports medicine in San Diego, California and can be reached at kevprcll@aol.com.