Pain on the top of my foot

by Kathleen
(Wichita KS USA)

My right foot has hurt off and on for the last two years on the top of the foot. This pain hurts when I take a step and the foot bends. However this time it has not stopped hurting the last four weeks. I do have planter fasciitis (not active right now) in that foot and I have sprained that ankle many years ago. There is no pain when touching in this area. There is also no swelling. I have had it x-rayed and I do have a bone spur on the bottom of my foot. Nothing else was evident on x-ray. The doctor that X-rayed it said the bone spur would not be the cause of the pain. it should be noted that I have Poly Malaysia rheumatica therefore I am on prednisone. However this pain in my foot began about one and half years before the PMR was diagnosed. I do have an appointment to see an orthopedic doctor but would like to hear your opinion as it will be a while before I will see him.

RESPONSE

Hi Kathleen,

After reading your narrative, the first thing that comes to mind is the possibility of a midtarsal fault. This may not be a condition that an orthopedist is aware of.

The fact that there is no swelling on the top of the foot and the fact that it does not hurt to touch the area, leads me to believe that you do not have extensor tendonitis, which is a tendonitis of the tendons that allow you to bend your toes upward. A tendonitis is probably the most common cause of pain on the top of the foot.

When you walk, if you are getting pain without other symptoms such as burning or tingling in your foot, then I would venture to guess that you do not have a nerve entrapment between the top of your foot and your shoe.

So what is a midtarsal fault?

It is essentially a jamming of the bones on the top of your foot when you walk. As you ambulate, most feet will flatten out to some degree. As the foot flattens, the highest portion of your arch collapses and the bones jam into each other causing pain. If this occurs frequently enough, the foot will then begin to hurt all the time.

To someone not intimately familiar with foot x-rays, they may not pick this up on x-ray. Generally, the x-ray will reveal a jagged appearance on the top of the bones that make up the mid portion of your foot (where you are probably experiencing pain).

Look at the enclosed picture. In a midtarsal fault, the bones in the yellow area will be jagged on their top, instead of smooth as seen in the picture.

The fact that you have a history of plantar fasciitis leads me to believe there is a chance your foot flattens out too much when you walk, as excessive flattening of a foot is a primary cause (but not only cause) of plantar fasciitis.

Here is a couple of things to consider.

Does the foot hurt more when barefoot, or in flimsy type shoes like flip flops, Uggs, dress flats and feel somewhat better in a good sneaker? If that is the case then midtarsal fault has to be considered.

Now take a look at your foot. Notice the height of the arch when you are non-weightbearing. Now stand up on the foot and note the arch, or perhaps flattening of the foot.

If there is a big difference between the arch when non-weightbearing vs. bearing weight, then once again a midtarsal fault has to be considered.

I do not know how much prednisone you are presently taking, but I would have thought that might have reduced your symptoms.

As I tell every one, without actually having the luxury of examining you and seeing x-rays, I am actually just guessing what your actual problem is. However, based on the facts presented, a midtarsal fault would be the first thing I would be looking at.

I have a section of midtarsal fault on my site. Check it out.

Marc Mitnick DPM
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