Conway McLean, DPM, Journal columnist

It’s a common but mysterious problem, the development of pain, seemingly out of nowhere. You’ve done nothing different, the same old routine. One day your foot is fine and the next, you’re almost hobbling. The normal reaction is to remove the shoe and inspect. Your evaluation reveals a tender, swollen area on the top of the arch. What could be responsible for this pain?

Many believe that bone spurs, those nefarious evil-doers, cause symptoms wherever they may lie. Devoted readers know better, of course. These osseous growths don’t have to produce pain, but they can, with the spur’s location being the key. One very common location for a spur is on the front of the bottom of the heel, your prototypical heel spur. But, in this location, the spur doesn’t bear weight and causes no pain.

Another very common location for a spur is on the top of the foot. This region is subjected to tremendous physical stresses. The bones in this area of the foot are compressed together, sometimes with great force. The amount of compression varies person-to-person, and occurs for a variety of reasons. Regardless of the cause, it typically leads to the development of inflammation of the joint structures. Initially, this is often experienced as an aching pain with localized warmth and swelling, hallmarks of the inflammatory process.

The aforementioned “pain out of nowhere” may begin after a day of normal activity. A traumatic event, even a slight misstep, is unnecessary for this pain to manifest. As is so often the case, genetics is a critical component. This is a problem some are set up to have. A person’s foot architecture, the type of arch, the shape of the heel, these and more are terribly important parts of how (and how well) the foot works.

But there are a multitude of factors at play in this equation. Numerous structures and functions have a role to play in how we walk. For example, a tight Achilles tendon may be the primary issue in the development of mid-foot pain. It’s the cause of many other problems as well, from the ball of the foot to chronic back pain. A tight Achilles pulls up too hard on the heel, resulting in greater compressive forces on the middle region of the foot. This is indeed a common area of pain.

Bone is an interesting tissue: when stressed, instead of wearing out, it overgrows. This is fortunate in many situations such as fracture repair, but when it comes to poor joint mechanics, spurs are often the by-product. When the joints in the middle of the foot are affected, the bony outgrowth created frequently cause problems, especially with shoe pressure.

The bony protrusion will impinge on whatever soft tissue structure is being trapped between the spur and the shoe. This might be the joint capsule, a tendon, or a nerve. This latter option frequently produces symptoms, from shooting pains to burning or tingling. Nerves don’t like being trapped or pinched and will reliably cause symptoms of some type. Think carpal tunnel of the top of the foot, although there is no tunnel. Regardless of the anatomy of the region, nerves don’t like physical stress and will generate pain when they are.

This can become a chronic condition. And prevention is possible, although the situation is often not identified early enough. This lack of recognition means effective treatment may not be instituted until some damage is done. If the origin of the abnormal joint mechanics is appropriately addressed, be it with an effective stretching regimen, properly prescribed foot orthotics, or whatever is needed to improve the biomechanics of the foot and leg, the bone overgrowth can be prevented.

Some might term this situation “osteoarthritis”, but this tends to minimize the biomechanical nature of the problem. This is not a systemic condition of joints but a local problem of one particular articulation. As is often the case, osteoarthritis is frequently a result of poor joint motion. Because this process does not always result in sufficient inflammation to elicit pain, there may be little warning. The increased compression may still result in cartilage wear, inflammation, and, in time, spurs.

So, you develop pain on the top of your foot when wearing some shoes. Then take your shoe off? Of course, that is not much of a solution. Walking without some support usually increases the compressive forces to the symptomatic region, leading eventually to pain. Many shoes produce some pressure to this region, especially a “tie shoe”. As a generalization, most other kinds of shoes don’t provide enough support, leading to more pain.

What’s a person to do? Buy one of those “customized” off the shelf arch supports? For some sufferers, something this simple does the trick. Maybe getting into a more stable shoe type, or performing a regular stretching regimen. In case you didn’t know, we are all different. What works for a few may not work for most.

Along with changing shoe types, altering the lacing pattern is commonly employed in an attempt to reduce the pain. Any technique which reduces soft tissue inflammatory changes is appropriate, from therapeutic ultrasound to cold compression. A physical therapy prescription can provide these treatments. Cannabinoids, the suddenly famous CBD products, have been found to have anti-inflammatory effects along with pain relief.

A steroid injection is one of the most frequently utilized methods of treatment. Steroids effectively reduce the biochemistry of inflammation, but do nothing for the biomechanics leading to said inflammation. And since that’s really the root of the problem, steroid injection therapy is of temporary benefit. A new technology, termed photobiomodulation (more commonly referred to as cold laser), has been found beneficial for this condition, providing some measure of both pain relief and healing.

Surgical removal of the spur is sometimes necessary. Because of the large number of nerves in this region of the foot, numbness is a frequent result of the surgery. Simply cutting away the spur obviously removes the problematic structure, but again, does not address the forces that led to the spur. Recurrence is a concern.

An extremely common scenario, pain from the top of the foot is a condition many deal with for far too long. Some of the therapeutic measures described are often employed, providing some measure of transient pain relief. But, until the root of the problem is addressed, this is too often a problem that returns repeatedly. Biomechanics is the culprit and must be addressed to find real, lasting relief. It may not be a topic addressed by your primary care provider, but you may need to find a physician attuned to this area of specialization to resolve your problem. Biomechanics, another example of the complexities of modern medicine.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments at drcmclean@outlook.com.