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The response to the question below was authored by Marc Mitnick DPM

Pain on top inside of foot

by Hannah
(Indiana)

I have been having sharp pain on the top inside aspect of my foot. This was gradual in onset with no injury or trigger. I also have popping on my great toe as well. I went to a podiatrist. Found to have a sesmoid fracture but did not relate that to my pain. I had a cortizone injection in a joint (b/w navicular and ?) they said I showed some arthritis in the xray. Pain was unbearable for 1 day then good for 1 week before the pain returned. I was placed in a walking boot for 6 weeks. No/minimal pain while in the boot but as soon as i took it off the pain returned immediately. I have tried new, expensive shoes that are stability controlled as I was told by PT my foot it hypermobile. I had orthotics made. It took me 2 days to get used to them then had NO pain for ~1 week before pain returned. Orthotics were "adjusted" but still having the pain though not as severe. It is a sharp pain down the top/middle of my foot (inline with my big toe), worse with no shoes, with more activity. I am on my feet all day as I work in a hospital. Sometime I will take a step and my foot just "gives out" I also can feel a "catch" at times on the inside of my ankle. Please help this has been going on for over 6 months. I switched podiatist to see if any new thoughts. He said to have a cortisone injection into the tendon (posterior tibials as this showed tendonitis in the MRI) or surgery to debride the tendon.

Any thoughts/suggestions would be greatly appreciated as this has been going on for over 6 months. I have stopped exercising other that some light weight lifting while seated as this is all I am able to tolerate

RESPONSE

Hi Hannah,

I think I have an idea of what is going on, but during your narrative a couple of different things popped into my head. Anyway, it would seem to me, based on your "story" that you have an irritation of the tibialis posterior tendon where it attaches into

the navicular bone.
Additionally, the physical therapist mentioned you have a hypermobile foot which means when you stand and walk your foot collapses a great deal and this collapsing puts tremendous pressure on the tibialis posterior tendon whose function is to maintain the congruity of the arch.
Furthermore you apparently have a tendonitis of the posterior tibialis tendon where it attaches into the navicular and thus I would suspect that is where your pain is coming from. It would not surprise me if perhaps you might also have a small tear where the tendon attaches into the navicular bone.
You make no mention of having an accessory bone in the area of the navicular and that is good.
So, what is going on is you irritated the attachment of tibialis posterior tendon where it attaches into the navicular bone either from exercise or walking the hard hospital floors.
Treatment typically is through the use of an orthotic to not allow the foot to collapse and thus not allow the tibialis posterior tendon to over work.
You mention you have orthotics, but I am wondering if they are supportive enough. Do you actually feel them supporting and lifting up your arch? I would suspect that you do not, because in my experience with this type of problem, a good supportive orthotic, along with some physical therapy will usually resolve this issue, keeping in mind that the orthotic will probably need to be worn even after the pain resolves.
Additionally, while trying to relieve the pain, the orthotic needs to be worn constantly, so no walking around the house barefoot at the end of the day, like most people do, as this will negate all that was accomplished by wearing the orthotics at work.
I would not recommend a cortisone injection as there is a good chance the injection could actually further weaken the tendon rather than help it. Oral anti-inflammatory medication would be a better option, if you can tolerate such medication.
So, I would suggest you go back to the podiatrist and make sure the orthotics are actually supporting your foot, because if they are not, they are useless and the foot will never get better.

Marc Mitnick DPM
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Pain on top inside of foot

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