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Pain in the dorsal forefoot

by Ann
(Kentucky)

About 4 weeks ago, I began experiencing pain when walking on my left foot. It was not bad so as a nurse, I just kept walking. Two weeks ago the pain suddenly escalated to where I was in tears after walking barefoot in my house. It continued about 15 minutes after I went to bed. The following day, I was in clinical with students when it did the same thing again. I had the foot X-rayed. No fracture was seen, but after seeing a podiatrist, he put me in a cast boot and ordered a bone scan. My foot is better after a week of little activity (walking) on it. I am still wearing the cast boot. The pain is sharp, and almost burning achy just behind the great toe joint. It will radiate to the left and cover my entire forefoot. It also may radiate backwards to the midfoot or there is a tender place there which aches. It swells by night. I can hardly stand for anything to touch the dorsal forefoot. Any thoughts?

RESPONSE

Hi Ann,

You did not mention the results of the bone scan but I am assuming the doctor was looking for a stress fracture. Typically the first metatarsal is not the metatarsal that fractures for no apparent reason, but anything is possible.
So your pain seems to be in the neighborhood of the great toe joint.
One possibility would be an inflammatory problem in the joint. Have you had any blood work, to rule out gout or perhaps some of the other collagen diseases that could inflame the big toe joint? I do not know your age, so I do not know if gout is a viable option.
You mention you had an x-ray, I wonder if you have any excess bone spurring in the joint. This too, could set off a fair amount of pain.
That is two most common causes for pain in that area of the foot. If those possibilities do not pan out, you might want to consider an MRI to see if you inadvertently tore something just from simply walking.
The fact that you are in a cast boot and the foot feels somewhat better does not give me any indication as to what the problem may be. I would give the cast boot at least four weeks of regular wear before I would consider that treatment a failure.
You could and should certainly have blood work done now and if in a minimum of four weeks, the foot is not virtually healed, then I think the next step would be an MRI. Keep in mind that an MRI should also be able to pick up a small fracture if that is what the problem seems to be.

Marc Mitnick DPM
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