Top of foot pain: Causes and solution

Dr. Conway McLean, Journal columnist

Medical problems can have a high degree of visibility in our culture, depending on the flavor of the day. Part of this phenomenon is to encourage fund raising efforts, which certainly benefit research efforts. But some common health problems end up getting ignored without the marketing. When it comes to foot problems, heel pain gets all the “pub”. Appropriate, since there is practically an epidemic of heel pain, but other problems occur with regularity.

I will present to you a common scenario, one experienced by many. The prototypical sufferer is middle-aged, female, and is shorter of stature. Because of her height, or lack thereof, she has tended to wear wedged shoes. Upon reading that, some will no doubt assume I am referring to Achilles tendon problems or possibly ankle sprains. But not so fast!

Perhaps the lack of notoriety for this problem is the absence of a cute, little catch phrase, like heel pain. (Short, sweet and to the point, that one.)

This article concerns a part of the body from which many have pain, although there are many different causes, each having their own treatments. One might simply call it “pain from the top of the foot”, but that isn’t very catchy. Others would refer to it, technically-speaking, as dorsal midfoot pain. This would be pain emanating from the top of the foot, the area midway between the ankle and where the toes start.

Biomechanically speaking, this is the top of the arch of the foot, so it experiences tremendous compressive forces in the course of a day. Thus, one of the conditions that can cause pain from this area is poor mechanical function of the foot and leg, such as with a tight Achilles tendon. At last, we have returned to our subject and her use of wedged or higher heeled shoes. Recurrent excessive compression on the joints in this region will tend to lead to inflammation and pain, such as when the tendon is tight. With time and sufficient jamming of the joint, degeneration of the cartilage will occur.

Cartilage degeneration is a hallmark of osteoarthritis, itself the result of these abnormal forces. As has been noted previously in these very pages, this type of arthritis is quite often not the result of some generalized disease process. Perhaps a more accurate way to think of this situation is as a mechanical arthritis, with the stiffness and pain the result of the degradative changes to the cartilage, the bone, and the soft tissue structures around the joint.

Another sort of problem leading to pain from this area is not due to joint problems, but nerve problems. Nerves are funny structures, averse to any kind of compression or pinching, and will lead to pain when these situations are present. The top of the foot is one of the most common sites where nerve compression develops. Spurring in this region can irritate this sensitive nerve running over the top of the foot. This pain often feels like a stinging or burning sensation. Numbness can also develop. As one can imagine, shoe gear is a big issue when this nerve impingement syndrome develops. Those afflicted will tend to wear more open or casual shoes since these often have no material over the painful area. Men will rarely use this approach but, instead, will attempt different lacing patterns.

The previously mentioned joint jamming condition can have various repercussions. Chronic physical force on a joint can lead to bone spurs. This produces an entirely new set of problems. Spurs can lead to inflammation of the soft tissue on the top of the joints in the midfoot, in a manner similar to traditional arthritis. The pain produced is often aching in nature, worsened after standing for some time, but may also be experienced as a sharp, stabbing pain. These bony masses can irritate various neighboring structures like the capsule (the covering of the joint), as well as the nerve that runs over this area.

Foot architecture has much to do with midfoot pain. The low arched foot type, will have more compressive forces and so a greater tendency to have pain here. An unstable arch, one that lowers too much in gait, will also result in joint compression. The top of a high arched foot will experience tremendous pressure from shoes over the years. The midfoot has a critical function in enabling humans to adapt to uneven surfaces while standing and walking. The structure and relationship among midfoot bones allows both rotation and stability, essential for human locomotion and stance.

What to do if you have recurrent or chronic pain from the top of your foot? Naturally, the treatment should be determined by the cause. If your pain is due to a bone spur, removal is not always necessary. Many conservative measures can provide relief. As mentioned, experimenting with various shoe types or different lacing patterns is an approach most will attempt. Padding of the area is a simple idea, but can simply cause more pressure than without it if not properly configured.

The common steroid injection is frequently used in this scenario, often with great effect. Injections in this location can be repeatedly periodically if sufficient time has passed. Thus, the duration of relief is important to this discussion. Another type of injection, termed a sclerosing technique, requires a series of injections but often helps for significantly longer. The downside is the numbness that often results. Sometimes it comes down to a question of numbness or pain.

If a tight Achilles tendon is increasing the jamming forces on this joint, stretching this largest tendon can provide relief. A difficult task, it takes time and effort. Consistency is also a necessity. Working with a physical therapist can help in achieving this healthy goal. The excessive forces can also be reduced with some type of arch support, with a well-prescribed prescription device, termed a foot orthotic, the most effective way to do that. Again, everyone is different, meaning that not everyone needs a custom support, but, understandably, when someone is living with pain, they generally want the best.

Removal of the spur is certainly an option, although recurrence is a concern if the spur developed because of foot and leg mechanics. The surgeon must be extremely careful when performing resection of this bony prominence since the nerve courses right over this area, as does a good sized artery. Although complications are possible, this can be a rewarding procedure, as long as a thorough evaluation is performed pre-operatively.

A very different option is the application of a regenerative medicine technique called shockwave therapy (technically referred to as ESWT, extracorporeal shockwave therapy). It has been utilized for decades on all manner of musculoskeletal problems. Many studies have been performed with it, and shockwave continues to be popular with patients and health care providers alike, especially because of the absence of complications and lack of recovery time.

If you are suffering from dorsal midfoot pain, do not despair. No, there is no catchy term referring to your problem, but that’s okay, it is still a painful condition. Just be certain the problem is correctly diagnosed, and all the appropriate treatments are “on the table.” There are so many options available. Once again, the message of the day remains the same: don’t live with pain. That’s no fun!

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 atdrcmclean@outlook.com.


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