Top of Foot Pain

author : AMSSM

comments : 1

My foot is now in a tremendous amount of pain, it is swollen, and I can barely walk on it at all, it hurts so much. I am still putting the gel on, taking anti inflammatories, and icing. Help!

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I have had pain on the top of my foot for the past month, right overtop of the area between my first and second toes. At first thought it was a metatarsal stress fracture so I didn't run for about four weeks. It wasn't really getting much better so I got an MRI and there was no stress fracture. I rested some more and it got a lot better, but there was definitely some pain still. I ran a ten miler much slower than my normal pace and it was ok. I then started back doing some speed work since I was two weeks out of a marathon I was training for. It felt ok for a while, there was definitely pain in the foot when running, but not nearly as bad as before, and I figured that since it wasn't a stress fracture, what more damage could I possibly do?

Then a week before the marathon it started hurting again so I went to see another doctor for a second opinion. He said I had "lace bite" or a neuroma/neuritis of the nerves in my foot. He gave me some anti inflammatory gel to put on my foot called Voltaren gel and a lidoderm patch to put on during the day of the race. I think it was due to getting new shoes maybe. I always wore Asics but they stopped making my model so I bought a pair of Mizunos. 

It was feeling pretty good before the race, so I wore my old Asics and tied them very loosely. I was completely fine for the first 15 miles, on pace for the 3:18 I wanted, and then my foot blew up. I was in so much pain that I could barely walk let alone jog. I hobbled to the finish line and finished about an hour later than my goal time. 

My foot is now in a tremendous amount of pain, it is swollen, and I can barely walk on it at all as it hurts so much. I am still putting the gel on, taking anti inflammatories, and icing. I still have pain in the same general area, but now also a bit on the ball of my foot (I don't know if that’s just soreness from the marathon or if it has to do with the neuroma).

What can I do to get better?

Answer from Shayne Fehr, MD and Travis Vande Berg, MPT
Members AMSSM 

Dear top of foot pain,

It sounds like you are in quite a predicament. Based on what you said, this problem has been going on for at least six weeks now. Some of the diagnoses you mentioned, such as stress fracture can cause pain in the region of the 1^st and 2^nd toes/metatarsals. The MRI should have shown stress reaction or a stress fracture by four weeks time, but you still have severe pain and now swelling two weeks later. There is a strong possibility of a new stress fracture. It would be helpful to know if current x-rays of the foot are normal to start any diagnosis.

If a stress fracture is not the cause of your pain, a condition of the toe/foot extensor tendons could be the problem. You mentioned lace bite, which is usually described as a tenosynovitis (inflammation of the tendon/tendon sheath) of the extensor hallucis/digitorum longus tendons or less likely the tibialis anterior tendon. Inflammation of a bursa fluid sac may also have developed in that region and could cause significant swelling. Impingement (pressure on) of the deep peroneal nerve could be complicating matters, as this supplies the region of foot you describe. Some people have a mildly increased prominence along the top of the foot that can create a pressure point.  

A less likely cause of pain would be a neuroma. The most common type in the foot is a Morton’s neuroma, which actually is not a true neuroma. These are present with pain in the webspaces of the 2^nd and 3^rd toes, not the 1^st as you describe. Depending on the type of swelling, a cyst could be present such as a ganglion cyst.  I would have expected the above soft tissue conditions to be noted on the MRI. The bottom of the foot pain may be from other causes such as sesamoiditis, inflammation of the floating bones at the ball of the foot, but it seems that the dorsal (top) pain is your main concern.

The 1^st and 2^nd metatarsals/toes bear a large percentage of the body’s weight and play important roles in absorbing shock with landing and generating force with push-off.  The repetitive forces in distance running make injuries in this region common. It is possible that you have asymmetry in your foot structure/position and/or gait that has caused this to happen on only one side. 

It would be wise to be reevaluated by your physician or a sports medicine specialist. If you have developed a stress fracture, most likely you will need a period of immobilization to allow healing.  At this point you need to be resting entirely from running. One way or another, you will need a course of physical therapy to evaluate and treat your feet and gait. Strengthening should also have a top-down approach to ensure there is no weakness in your hips and core. If gait retraining is needed, be patient because it takes time. A semi-custom orthotic may be a good option to provide you with extra support.

It is possible that the recent shoe change contributed to your injury. My understanding is that toe box width is usually about the same for the brands you describe, but there may be more depth with Mizunos than Asics. A wide toe box will likely be beneficial for you. Some models of Asics have a polymorphic material that may help conform to swelling. Mizunos can be more rigid with a longer foot plate, so if you are getting swelling, the Mizuno may get tighter. Remember that in general, it is important to avoid running with shoes that are worn-out.  Some runners choose to cycle shoes to help with this issue. Replacing everyday running shoes every 300-500 miles or every 3-6 months are some rules of thumb.

Sincerely, 

Shayne Fehr, MD

Travis Vande Berg, MPT

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date: September 21, 2012