Stabbing pain on lateral bottom side of right foot

by Jason
(Illinois, USA)

I am a 41 year old male, 6'3" and 220 lbs. I have suffered from this stabbing pain on the lateral bottom side of my right foot for the past 1-2 years. I originally went to a podiatrist who made a donut to cushion the painful area of my foot. That only seemed to increase the pain. During an appointment at a chiropractic specialist I mentioned the foot pain. He took xrays and those did not reveal any abnormalities. I tried cold laser therapy hoping to eliminate the pain and that did nothing. I finally went to an orthopedic specialist who ordered an MRI. According to the specialist, the MRI shows the peroneal tendon was swollen and filled with fluid. She also determined that I have high arches, very poor flexibility in my calf muscles, hammer toes, and big toe that points upward. She sent me to an orthotics specialist to have custom orthotics made. After wearing the orthotics for several weeks, the pain in my right foot seemed to worsen and I began experiencing pain in my left foot. So in another appointment at chiropractor, it was determined that the bones on the lateral side of my foot were inverted. After some adjusting, he was able to get the bones back in proper alignment. I have returned to him several times to work on my foot. Initially it seemed as though the pain was getting better, but I am back to intense, knee-buckling pain. I went to another foot doctor, who came highly recommended, for a second opinion. He said he would have put me in an immobilizer boot, but did then took no further action. After suffering from this unbearable and chronic pain, my wife ordered an immobilizer boot to rest the foot, hoping to eliminate the swelling. I have worn the boot as much as I possible can over the past 4 weeks and the pain has not subsided. I am at a loss on what to do and who I go to for help. My wife has done a lot of reading on my various symptoms and questions a possibility of nerve entrapment. I cannot continue to live with this intense pain as it definitely prohibits any sort of physical activity. I am at a loss and feeling hopeless in resolving this crippling pain! Any suggestions/recommendations you can make would be greatly appreciated!

It might be helpful to know that I broke this same foot when I was 14. So question whether scar tissue could be a possibility and if it could perhaps be a cause to my current problem.

RESPONSE

Hi Jason,

Obviously I will not be able to give you a diagnosis but let me discuss the most common causes of pain in that portion of the foot.

You say your MRI revealed an inflammation of the peroneal tendon. I will assume it is the peroneal longus tendon as that is the only peroneal tendon that travels under the foot. The tendon starts out on the top of the foot and at the level of what is known as the cuboid groove it cuts down and under the foot. This tendon is very susceptible to injury if for no other reason just where it is located. The major cause of irritation to this tendon, other than trauma, is from shoes that are too narrow at the level of cuboid bone.

Most times the width of a shoe is determined at the level of the metatarsal heads, just behind the toes, but certain foot structures will also have width at the level of the cuboid/fifth metatarsal base that may exceed the width of the forefoot, thus every shoe you put on ends up being too narrow at the level of cuboid/fifth metatarsal base junction.

So what happens is this section of the foot "overhangs" the innersole of the shoe and the peroneal tendon is constantly being irritated. So as you keep having different treatments, they are all for naught because every time you put your shoes back on, you start irritating the tendon again and you never get better. This is particularly true if you wear dress shoes where the inner sole tends to be hard.

Keep in mind, that in people with high arched feet, in your normal gait cycle the foot tends to "lean" more to the outside of the foot, so that your foot structure increases pressure in the area of the foot where you are experiencing pain.

In this same vein, the cuboid groove needs to be examined via MRI or CAT scan to see if there is any bone prominence that may be irritating the tendon as it slides back and forth through the cuboid groove.

The next problem that may cause as much unremitting pain as you are experiencing is what is known as a subluxed cuboid. In this instance the cuboid bone itself has "moved" ever so slightly that is out of place and hurts when you walk on it.

This is a hard diagnosis to make by just looking at the foot or even an x-ray as the subluxation is so small that it will not show up on x-ray. Again, an MRI or CAT scan may be better at making this diagnosis.

Both conditions will probably not respond to a walking boot because once out of the boot, the shoes you may be wearing will aggravate the tendon again, or the cuboid will sublux once again.

My suggestions include, possibly repeating the MRI or have another radiologist read the one you already have had with emphasis on the position of the cuboid and any irregularity that might be in the cuboid groove.

Have an expert look at a few pairs of shoes that you wear regularly to determine if there is an "overhang" at that level of the foot. I should also mention that if there is no overhang of the foot, but, the leather of the shoe is very tight and has no "give" to it, that could also be an issue.

Marc Mitnick DPM
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