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Monday, August 18, 2025

Pain in the top of the foot


Pain in the Top of the Foot (Dorsal Foot Pain)

Introduction

Pain on the dorsum (top) of the foot is a common clinical complaint, affecting people of all ages and activity levels. It may arise from:

  • Musculoskeletal structures (bones, joints, tendons, ligaments).

  • Nerve compression.

  • Vascular or dermatological conditions.

The top of the foot bears significant mechanical stress during walking, running, and footwear use. Causes of pain range from simple overuse injuries to fractures, arthritis, and nerve entrapments.

Anatomy of the Dorsal Foot

  • Bones: metatarsals, tarsals (navicular, cuboid, cuneiforms), talus.

  • Joints: midfoot (tarsometatarsal, intercuneiform), forefoot (metatarsophalangeal).

  • Tendons: extensor hallucis longus (EHL), extensor digitorum longus (EDL), tibialis anterior.

  • Nerves: deep and superficial peroneal nerves.

  • Vessels: dorsalis pedis artery and branches.

Pathology of any of these can produce pain.

Causes of Dorsal Foot Pain

1. Musculoskeletal and Overuse Injuries

  • Stress fractures (metatarsals, navicular):

    • Common in athletes, runners, military recruits.

    • Gradual onset, worsens with activity.

  • Extensor tendonitis:

    • Inflammation of EHL/EDL tendons due to overuse, ill-fitting shoes, or tight laces.

    • Pain worsens with resisted toe extension.

  • Midfoot arthritis (Lisfranc joint, tarsometatarsal arthritis):

    • Common in older adults or after trauma.

  • Gout or pseudogout:

    • Acute inflammatory arthritis affecting midfoot joints.

  • Ganglion cysts:

    • Soft, fluid-filled swellings on dorsal aspect.

2. Neurological Causes

  • Superficial peroneal nerve entrapment:

    • Produces burning pain or numbness on dorsum.

  • Deep peroneal nerve entrapment (“lace bite”):

    • Compression by tight footwear causes pain between first and second toes.

3. Traumatic Causes

  • Contusions: direct impact injuries.

  • Fractures/dislocations: acute trauma.

  • Lisfranc injury: disruption of midfoot ligaments, serious if missed.

4. Vascular Causes

  • Peripheral artery disease (PAD): cramping pain with exertion (claudication).

  • Dorsalis pedis artery aneurysm or thrombosis (rare).

5. Dermatological Causes

  • Cellulitis, abscess.

  • Ingrown toenails with referred dorsal pain.

  • Shingles (herpes zoster) affecting superficial nerves.

Clinical Presentation

  • Nature of pain: aching, sharp, burning, throbbing.

  • Onset: acute (trauma) vs gradual (stress, arthritis).

  • Aggravating factors: walking, running, footwear, resisted toe extension.

  • Associated features:

    • Swelling, redness, warmth (infection, gout, arthritis).

    • Numbness/tingling (nerve entrapment).

    • Bruising (fracture).

    • Visible lump (ganglion cyst).

Diagnostic Evaluation

1. History

  • Recent trauma or repetitive activity.

  • Footwear habits.

  • Systemic diseases (gout, diabetes, arthritis).

  • Vascular risk factors (smoking, diabetes, hypertension).

2. Examination

  • Inspection: swelling, erythema, deformity, skin lesions.

  • Palpation: tenderness over metatarsals (fracture), tendons (tendonitis).

  • Range of motion: limited with arthritis.

  • Neurological exam: sensory deficits over dorsal foot.

  • Vascular exam: dorsalis pedis pulse.

3. Investigations

  • X-ray: fractures, arthritis.

  • MRI: stress fractures, tendonitis, soft tissue masses.

  • Ultrasound: ganglion cysts, tendon inflammation.

  • Blood tests: uric acid (gout), ESR/CRP (inflammation).

  • Nerve conduction studies: peroneal nerve entrapment.

Management

Treatment depends on the cause, but follows principles of pain relief, rest, correction of underlying problem, and rehabilitation.

1. General and Supportive Measures

  • Rest, ice, compression, elevation (RICE) for acute injuries.

  • Footwear modification: supportive shoes, avoid tight laces.

  • Orthotics: arch supports for flat feet or arthritis.

  • Weight management: reduces load on joints.

2. Pharmacological Treatment

a) Analgesics

  • Paracetamol (acetaminophen): 500–1000 mg orally every 6 hours as needed (max 4 g/day).

  • NSAIDs (for pain and inflammation):

    • Ibuprofen: 400 mg orally every 6–8 hours with food.

    • Naproxen: 250–500 mg orally twice daily.

    • Diclofenac sodium: 50 mg orally three times daily, or topical gel applied 3–4 times daily.

b) Gout/Pseudogout

  • Colchicine: 500 micrograms orally 2–3 times daily until resolution (max 6 mg per attack).

  • Indomethacin: 50 mg orally three times daily.

  • Allopurinol: 100–300 mg orally daily (long-term urate-lowering therapy).

c) Neuropathic Pain

  • Gabapentin: start 300 mg orally daily, titrate to 900–1800 mg/day in divided doses.

  • Pregabalin: 75 mg orally twice daily (max 600 mg/day).

  • Amitriptyline: 10–25 mg orally at night.

d) Infections

  • Flucloxacillin: 500 mg orally four times daily for 5–7 days (cellulitis).

  • Clindamycin: 300 mg orally four times daily (if penicillin allergy).

3. Specific Treatments

  • Stress fractures: rest 6–8 weeks, walking boot if needed.

  • Extensor tendonitis: NSAIDs, physiotherapy, footwear adjustment.

  • Ganglion cyst: aspiration or surgical excision if persistent.

  • Lisfranc injury: urgent orthopedic referral, often requires surgical fixation.

  • Nerve entrapment: footwear modification, physiotherapy, corticosteroid injections if persistent.

  • PAD: smoking cessation, statins, antiplatelets (Aspirin 75–150 mg daily), supervised exercise.

4. Non-Pharmacological Therapy

  • Physiotherapy: strengthening, stretching, gait correction.

  • Corticosteroid injections: for arthritis or persistent tendonitis (e.g., triamcinolone acetonide 10–40 mg intra-articular).

  • Surgery:

    • Fracture fixation.

    • Cyst excision.

    • Nerve decompression.

    • Arthrodesis for severe arthritis.

Complications

  • Untreated fractures: malunion, chronic pain.

  • Chronic tendonitis: rupture, functional impairment.

  • Recurrent gout: tophi, joint damage.

  • PAD: ulcers, gangrene, limb loss.

  • Neuropathy: persistent pain, sensory loss.

Prognosis

  • Mild overuse injuries: good prognosis with rest and conservative care.

  • Stress fractures: heal in 6–12 weeks, but recurrence possible.

  • Arthritis: progressive, but managed with medications and orthotics.

  • Neuropathic causes: chronic but manageable with therapy.

  • Vascular causes: prognosis depends on systemic risk factor control.

Preventive Measures

  • Wear supportive, properly fitted shoes.

  • Gradual increase in physical activity to prevent overuse injuries.

  • Maintain healthy body weight.

  • Manage systemic conditions (diabetes, gout, PAD).

  • Regular foot care and inspection, especially in diabetics.

Pharmacological Quick Reference

  • Pain relief:

    • Paracetamol 500–1000 mg q6h (max 4 g/day).

    • Ibuprofen 400 mg q6–8h.

    • Naproxen 250–500 mg BD.

    • Diclofenac 50 mg TDS (oral) or topical gel.

  • Gout:

    • Colchicine 500 mcg 2–3×/day.

    • Indomethacin 50 mg TDS.

    • Allopurinol 100–300 mg OD.

  • Neuropathic pain:

    • Gabapentin 300–900 mg/day (up to 1800 mg).

    • Pregabalin 75 mg BD (max 600 mg).

    • Amitriptyline 10–25 mg nocte.

  • Infections:

    • Flucloxacillin 500 mg QDS.

    • Clindamycin 300 mg QDS.

  • Vascular disease:

    • Aspirin 75–150 mg OD.

    • Statins (e.g., Atorvastatin 10–80 mg OD).



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