Top-of-foot pain: Here's hoping it's not a stress fracture

author : AMSSM

comments : 0

What could be causing the pain on the top of the foot at the toes? Here are some easy ways to find the cause and possibly end the pain.

Member Question from Coldbrew

"I have done some searching but don't really have a definite answer yet. I am having pains on the top side of my right foot when I run, and it's still there sometimes when I walk. The pain runs in between my big toe and my second toe. It is tender to the touch but not excruciating, which makes me think (hope, actually) that its not a stress fracture. It does not bother me when I am cycling (at least no more than it does just walking around) and when swimming I typically don't feel it at all. However, I did feel it a little at the end of my 2,000-yard swim yesterday.

Any ideas what it could be and recommendations for the quickest way to get it healed? I would rather not spend the money on going to the doctor if I don't have to."

Answer from Thad Barkdull, MAJ, MC, FAAFP, CAQSM
Member AMSSM

When I consider a diagnosis like this, I like to think about what is in the area of the pain that you're having.  Between the big toe and the second toe are mostly nerves, some small muscles, and soft tissue.  Because there is a larger space between the toes here, injuries to the nerves are much less common (unlike a painful condition called a neuroma which can happen in between the other toes), but it is possible. These neuromas are typically right between the joints that join the toe with the midfoot (metatarsophalangeal joint), and often respond to a steroid injection.

Sometimes the problem can be as simple as pressure from tight-fitting shoes causing a neuritis of the superficial nerves in this area.  Pressure from the top causes compression of these nerves, which then respond by sending pain signals to the brain.  The symptoms are alleviated by removing the cause of the pressure. Does the pain change depending what shoes you wear to train for triathlon?

It would be unusual to have an injury specifically to one of the small muscles in between the toes (called dorsal interosseous muscles), but it is conceivable that a strain or tear of one of them could cause the pain in the location you describe.  I would expect that you would recall a specific point in time when you injured the muscle, as there would have most likely been a very obvious trauma.

Referred Pain

Sometimes pain can be "referred," which means it does not come exactly from the location where you feel it.  The nerves that provide sensation to this area come from the deep peroneal nerve, which runs on the outside of the leg and becomes the common peroneal nerve at the knee (on the outside).  An injury to this nerve, or compression on it from tight muscles or soft tissue in the shin, could cause pain symptoms, but those would tend to come with more heavy exertion, and be associated with some pain/pressure in the shin.

There are also two small bones called sesamoid bones, one of which lies in this area, but on the bottom of your foot.  They are like "kneecaps" for the big toe, providing a greater force when flexing the big toe.  These sesamoids can become inflamed (sesamoiditis) usually from some chronic pressure/overuse or a direct blow/injury, and can be excruciatingly painful, especially when bearing weight.  However, you would have very localized pain on the bottom of your foot where the sesamoids are located.

Arthritis in the joint joining the big toe with the midfoot could potentially cause pain, more with weight bearing activities, and less with an activity like swimming, but would be more chronic and long lasting in nature.  Arthritis in this joint (the metatarsophalangeal joint) is often the result of developing hallux valgus, commonly referred to as a bunion, where the big toe begins to curve outward toward the other toes.  I see it frequently in women who wear tight fitting shoes, and in people with flat feet, because the associated forces push the big toe in that direction.  Arthritis in this area can also be the result of a Liz Franc dislocation, where ligaments in the midfoot are torn, causing excess movement in this area.

Stress Fracture

Finally, your pain could be the result of a stress fracture of the metatarsal bone, although usually the pain must be elicited with direct pressure on the bone itself, rather than pressure in the space between as you describe.

Based on all of these options, I would first try to alleviate any pressure that might be on the top of your foot in this area.  Small foam pads placed on either side of the tender area will act to lift the shoe away from the superficial nerves, and if it is a compression neuritis, this should gradually alleviate your pain.  You should notice within days.  Wearing loose fitting shoes may also alleviate some of the pain associated with a neuroma, though often the pain won't permanently go away once the neuroma develops. 

Rest

If this doesn't work, a period of two to three weeks of relative rest from activities that cause the pain will help you to determine if it is a muscle strain/sprain.  If the pain returns with resumption of running, one of the other conditions should be considered.  At that point, I would recommend seeing your physician, and start with some x-rays to rule out a fracture, Liz Franc dislocation, or arthritis.  He or she then might consider a steroid injection if a neuroma is suspected, or an MRI if something like a sesamoiditis is suspected.

Good luck, and I hope this is helpful in getting you back on the road quickly!

Director, Sports Medicine
Family Medicine Department, Tripler Army Medical Center
Honolulu, Hawaii

"He koa na 'alapa a pau" (Every Warrior an Athlete)

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date: March 23, 2011