Training FAQ: How to relieve foot pain

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Dear Chris,
This year I ramped up my mileage and the amount of climbing I did after time off the bike, which led to some irritation under the ball of my foot (in the sesamoid bones). In terms of preventing injuries like this, what’s the story on cycling shoes where the sole is more flat versus those with a slight toe-up design? Does it make a difference?
— Tim

Dear Tim,
Many cyclists think that numbness and irritation in the feet and hands are just part of riding a bike. The truth is that if you’re experiencing numbness, something is wrong, and it can generally be solved. It sounds like you’re thinking ahead on how to prevent these types of issues from cropping up again in the future. That’s the best approach to making cycling more enjoyable.

The sesamoiditis you’re experiencing can often be relieved with proper shoe choice and/or orthoses of some kind. Sometimes people will refer to the sesamoids as the “ball bearings of the foot.” These two small bones found beneath the first metatarsal bones can inflame or rupture under the stress of cycling.

To better answer your specific question about how shoe design can help prevent this issue, I reached out to sports medicine consultant Dr. Andy Pruitt, who has more than 40 years of experience in cycling medicine and ergonomics. He has seen every cycling injury in the book and, because of that, has literally written the book on the subject. It’s called “Andy Pruitt’s Complete Medical Guide for Cyclists.”

Here’s what Dr. Pruitt had to say:

Tim, sorry to hear about your sesamoiditis. Let’s assume that it came purely from your cycling and not other activities of daily living, because there are a lot of other things that can cause pain in the sesamoids. These little bones are similar in function to your knee cap, except not only are they active fulcrums but they are under constant compression while standing, walking, and, of course, cycling. Personal foot design plays a role in one’s propensity for getting sesamoid pain.

You ask about addressing it for cycling and you ask about cycling shoes where the front sole plate is flat versus a shoe (like the Specialized shoe) that has 1.5 millimeters of varus canting (tilted up) built in. About 80-plus percent of all humans have a foot design that appreciates the varus cant, meaning that the big toe is lifted 1.5 millimeters relative to the little toe. If the varus forefoot support doesn’t fix it, I would start with adding a little extra support under and just behind your metatarsal heads. That might lift the rest of your forefoot enough to decompress your sesamoids. Also, we sometimes just cut an area of relief (like a donut hole) under the painful area, allowing those sesamoids to have a recession to sit in and, thus, diverting the pressure away. Finally, custom cycling footbeds are an expensive option but many times that is what it takes.

Dr. Pruitt is a wealth of knowledge when it comes to the most common over-use injuries seen in cyclists. We were lucky enough to discuss this subject with him for an episode of the Fast Talk podcast, including:

• Knee problems — why they are no longer the most common problem, and how it’s possible for most of us to go through the rest of our cycling careers without one.
• Back and neck problems — unfortunately, the cycling position is not kind to the lower back, but there are still things we can do to prevent pain.
• Saddle sores, numbness, and pressure issues, and how with the right saddle and fit most of these issues can be addressed.
• And much more