“I get pain on the top of my foot whenever I wear shoes. What can I do?”

That’s a good question!  The most common reason for pain on the top of the foot (called the mid tarsal region) is bone spurs.  People with high arched feet are predisposed to this condition but it can also occur in patients whose feet flatten (pronation).

Abnormal motion (like pronation) causes friction on the bones and joints in this area resulting in bone spurs which can often be felt directly under the skin.  Joint damage can also occur and cause osteoarthritis.

Once the spurs become large enough, they begin to push the structures on top of them (tendons, blood vessels and nerves) up, while shoe pressure pushes these structures down.  A tiny nerve in this area (dorsal intermediate cutaneous nerve – for those of you who want to impress your friends) becomes trapped and compressed… in essence causing a nerve entrapment syndrome.

Because of this the symptoms may change from originally being achiness and soreness to signs of nerve irritation.  This may include burning, tingling and numbness as well as sharp electric type pain that can stay localized or radiate down towards the toes or up towards the ankle.  A bursa may also form from the constant friction and pressure in the area.  If this occurs, swelling may become evident on the top of the foot.

Because of the wide variety of symptoms that can develop with this condition, physicians who are unfamiliar with it may incorrectly make a diagnose of peripheral neuropathy…a far more significant problem often seen with Diabetes, vitamin deficiencies and other diseases.  I have even seen gout diagnosed because of the severity of symptoms that can occur.

Treatment is often simple, and rarely do the bone spurs need to be removed.  As mentioned, symptoms are due to the downward shoe pressure over this area.  The direct cause of the pain is actually the tightening of your shoe laces directly over the bone spurs which in turn compresses the nerves in this area. So wearing a shoe that doesn’t press on this spot is obviously preferred.

But since this is not always possible or practical, placing some adhesive foam under the tongue of your shoe will usually provide enough cushioning to eliminate the symptoms.  Remember the skin in this area is very thin and doesn’t offer much protection.

If this doesn’t work, padding the tongue of the shoe on either side of the most painful area will usually do the trick.  This will allow you to tie your shoes without any direct pressure on that tiny nerve or other sensitive structures.

At times an injection of cortisone directly under the skin may be necessary in conjunction with the foam padding.  But like most bone and joint problems in the feet, knees, hips and back, decreasing the stress on these joints can prevent the problem.  Fully custom foot inserts, if made precisely, can help do this. 

— A former reconstructive foot and ankle surgeon and past clinical instructor of Medicine at Emory, Dr. Pack practices at MCG in Greensboro.  He works with patients who have arthritis and wish to decrease joint symptoms and remain active without medication or surgery. Dr. Pack also treats athletes at all levels. In the 2004 Olympics he had a silver and gold medalist, and helped the UGA Golf Team (2005 NCAA national champions). For further information please see www.drloupack.com, drloupack.blogspot.com or contact him directly at (706) 454-0040.