Takeaway: What happens with bones during a trauma is only one part of the picture. Sadly, the rest is often overlooked because you can’t see it on a diagnostic image.

My new client was a college student who injured his foot playing club soccer. At one point, he was about to kick the ball and misjudged the trajectory, hitting the ground first, putting his toe into hyperflexion and immediate pain. He sat out for the next few minutes but was able to resume his participation and played the remainder of the match. The real trouble started later. 

“Later that evening, my big toe really started to hurt,” he said. “Walking became difficult, and I got more concerned I might have broken something. After visiting the campus medical center, the doctor sent me to get an X-ray to see if everything was OK. The doctor said the X-ray looked negative. If it was OK, why the heck does my foot hurt so much? It’s more than just my toe now; I can feel it higher up my leg, which I didn’t feel earlier. That’s kind of scary.”

“Let me take a look and perhaps I can give you some answers,” I said. 

Having him lie supine on my treatment table, I noted no obvious swelling at the metatarsophalangeal joint. The range of motion was good in terms of total movement, but the quality of movement drew my attention. Taking the toe into flexion, I could feel his extensor muscles slightly engage, making the movement somewhat hesitant.

“Want to see a picture?” he asked, somewhat out of the blue.

“Sure,” I said. 

He found a picture on his phone of the metatarsophalangeal joint two days after the injury. The bruising was impressive. As I was about to ask another question, he added another wrinkle. 

“You know, it’s strange, but when I did this, pain wasn’t the first thing I felt,” he said.

“What was?” I asked.

“I felt like my whole toe went numb,” he said. “That was concerning to me; I expected it to hurt like crazy. Instead, it was a numbness from my toe to the top of my foot. It is still kind of weird feeling.”

“Let’s try something,” I said. Using a paper clip, I pulled it lightly across the skin on the dorsal side of his foot. He experienced hypersensitivity to touch in the area of the superficial fibular nerve relative to other areas. 

“That’s weird,” he said. “Why would that be?” 

“Let’s think about the greater context of your injury,” I said. “You must have really stretched your toe when you hit the ground, with enough force to make you wonder if you broke something. You didn’t, but other tissues in that area were massively affected. Clearly, the ligaments around the joint and the large muscle that extends your great toe were overstretched. On top of that, there is a superficial nerve in this area that was also taken far beyond its normal length. The ligament, muscle, and nerve overstretching could easily account for the pain you have now.”

“Wouldn’t any of that show up on an X-ray?” he asked. 

“Nope, none of it,” I said. “What happens with bones during a trauma is only one part of the picture. Sadly, the rest is often overlooked because you can’t see it on a diagnostic image.”

“Wouldn’t it just get better on its own?” he asked. 

“Would you ask that if it was an injury to the bone?” I asked. “When any one of these aspects of injury are affected, there are ways to accelerate and facilitate the healing process. Hands-on treatments can play a big role in that process.”

Having made the case for the work, I began by addressing soft-tissue influences for branches of the fibular nerve that might explain his symptoms. Finding some fascial restrictions near the superior aspect of the fibularis brevis, I gently followed the nerve all the way to the toe, being careful not to recreate symptoms and further irritate the nerve. Switching gears, I focused on muscular influences, especially the extensor hallucis longus. It was quite sensitive, especially the superior aspect of the muscle. This restriction was about the same height of the neural issue, just more medial. 

“I’m surprised how far up my leg this goes,” he said. 

“The muscles and nerves over the joint originate much higher on the leg,” I said. “Let’s see if we are making some difference.” 

Putting pressure on the metatarsophalangeal joint itself, it was far less tender than initially. Dragging the paper clip across the skin, the nerve was also much less sensitive. 

“Looks like progress,” I said. 

“Feels like progress,” he agreed. “You didn’t spend as much time with the toe joint as I expected. Yet it is clearly better.” 

“If the effects of overstretching the joint go to distant areas, it also means we can use that to our advantage. You don’t have to touch something to affect it,” I said. 

I was feeling good about all this until his last question, which was gut-wrenching. 

“Is this kind of a dying art?” he asked.

I certainly hope not. It is up to all of us to make sure we can make a difference for generations to come.