Pain on top of the foot

The top of the foot has very little padding. Tendons, a nerve and an artery cross the front of the ankle under a band of tissue,^[9] then run over the midfoot joints and the long metatarsal bones, right where your laces press. We see patients with pain on the top of the foot at our offices in Lyndhurst, Paramus and Millburn, NJ. For other areas, see our guide to foot pain.

Where it hurts is the first clue

Where it hurts	Common causes
Front of the ankle, worse in tight laces	Irritated tendons, a pinched deep peroneal nerve
Middle of the top of the foot	Midfoot arthritis, a navicular stress fracture, a Lisfranc injury after a twist
Toward the toes, tender over one bone	A metatarsal stress fracture, irritated toe tendons
One joint, suddenly red, hot and swollen	Gout, or an infection
Burning, tingling or numbness	A pinched superficial or deep peroneal nerve; burning or numbness in both feet is more often neuropathy or a nerve problem in the back

This is a starting point, not a diagnosis; an examination sorts it out.

Extensor tendonitis: laces, shoes and overuse

The tibialis anterior, which lifts the foot, and the long extensor tendons of the toes cross the front of the ankle and run over the top of the foot.^[9] When they are overloaded or pressed on, they become sore, which is often called extensor tendonitis. It often follows a jump in walking or running mileage or adding hills,^[1] and new shoes or laces pulled tight can add pressure over the tendons. In a small study of 14 male runners, pressure under the shoe’s tongue was highest over the ankle bone (talus), the navicular and the first ray (the big toe’s long bone), and less pressure over these spots and the extensor tendons went with better comfort.^[8]

Tibialis anterior tendonitis hurts at the front of the ankle and the inner midfoot, often at night as well as with activity, and stretching the tendon by pointing the foot down and out brings on the pain.^[1]

What helps:

• Relative rest: cut back on what hurts rather than stopping everything, then rebuild with guided exercise and fix what overloaded the tendon.^[7]
• Lacing and shoes: loosen or skip the eyelets over the sore spot, or choose shoes that fit with more room over the instep.
• A boot or brace, then physical therapy, for tibialis anterior tendonitis, with surgery only if that fails.^[1]

A metatarsal stress fracture

A stress fracture is a small crack from repeated loading. The metatarsals are the usual site in the foot, especially the thinner second and third. The pain builds gradually, worsens with weight-bearing activity and eases with rest; the bone is tender to press, and the top of the foot may swell. The usual trigger is a sudden increase in activity; new shoes or weakened bone can contribute.^[2] Most stress fractures heal in 6 to 8 weeks with time off high-impact activity and a stiff-soled shoe or removable boot.^[2]

A stress fracture of the navicular, in the middle of the foot, causes pain that is hard to pinpoint and can be hard to see on X-rays, so a CT or MRI may be needed. Treatment needs a period without putting weight on the foot, sometimes in a cast, and surgery is recommended for it more often than for other stress fractures.^[2] Stress fractures are frequently missed, and a late diagnosis can mean prolonged pain and a bone that doesn’t heal.^[10] See foot and ankle fractures and stress fractures in runners.

Midfoot arthritis and bone spurs

Osteoarthritis is common in the midfoot, where it often follows an old injury, such as something heavy dropped on the foot, a sprain or a fracture. It causes pain, stiffness, swelling and difficulty walking, and a bone spur at the worn joint can hurt where the shoe presses.^[3]

Shoes with stiff, rocker-bottom soles and shoe inserts can reduce pressure and pain.^[11] A steroid injection into the painful joint can relieve pain and help show which joint is the source. If pain still limits walking, fusing the worn joints is the main operation.^[12] See arthritis of the foot and ankle.

Gout on top of the foot

A sudden, red, hot, swollen joint can be gout. It most often strikes the big toe but can affect any joint.^[4] The foot and ankle are common places for its crystals to collect.^[13] An infected joint can look the same and needs urgent treatment, so a hot, swollen joint with a fever should be seen the same day.^[14] The surest way to confirm gout is finding crystals in fluid drawn from the joint; a high uric acid level in the blood is not enough on its own.^[15] We can evaluate a hot, swollen foot; repeated attacks need long-term treatment with your primary care physician.^[4]

A Lisfranc (midfoot) injury

A Lisfranc injury is a break of the midfoot bones or a tear of the ligaments that hold them together, and a simple twist and fall can cause one. The top of the foot swells and hurts, pain gets worse with standing, walking or pushing off, and bruising on the sole strongly suggests it.^[6] A delay in diagnosis worsens the result, so we take X-rays standing up to check stability, with CT or MRI when they are unclear.^[16]

Burning or numbness: a pinched nerve

Two main nerves supply feeling to the top of the foot. The superficial peroneal nerve is most often trapped where it comes out from the muscles of the outer lower leg. The deep peroneal nerve is most often trapped under a band of tissue at the front of the ankle.^[5] The deep peroneal nerve supplies the web space between the big toe and second toe, so numbness there is a clue.^[9] Treatment starts with removing outside pressure, such as tight laces, and surgery to release the nerve is considered if symptoms persist.^[5] New weakness lifting the foot (foot drop) needs prompt evaluation, because a timely diagnosis helps avoid permanent nerve damage.^[5]

The Nerve Institute also covers superficial peroneal nerve entrapment (external site).

How we evaluate and treat it

We ask how the pain started and what shoes you wear, press along the tendons and bones, move each joint, and check sensation and circulation. X-rays at the practice are usually the first test. After an ankle or midfoot injury, a short set of checks, the Ottawa ankle rules (whether you can take four steps, and tenderness over specific spots such as the navicular or the base of the fifth metatarsal), shows who needs one.^[17]

Treatment matches the cause: protection, changes to shoes, lacing and inserts, guided exercise, and injections for an arthritic joint. Surgery is considered when needed, for example for an unstable midfoot injury, a fracture that won’t heal, or arthritis that still limits walking.^[16,2,12]

Common questions

Can you walk with extensor tendonitis?

Usually, yes, though you may need to walk less for a while. Tendon pain is treated with relative rest: cut back on what hurts rather than stopping all activity.^[7] Loosen your laces and keep walks shorter and flatter;^[1] a sore tibialis anterior tendon sometimes needs a boot or brace for a short time first.^[1] If one spot on the bone is tender and the pain builds as you walk, get checked for a stress fracture.^[2]

My X-ray was normal. Could it still be a stress fracture?

Yes. A stress fracture starts as a tiny crack and is often hard to see on X-rays at first. An MRI or bone scan can confirm it.^[2]

Is pain on top of my foot gout or arthritis?

A gout flare comes on suddenly, often overnight, with a red, warm, swollen joint.^[4] Midfoot arthritis causes pain and stiffness with walking, sometimes with a bony bump that hurts in shoes.^[3] The surest way to confirm gout is finding crystals in joint fluid.^[15]

When to seek care

Book an evaluation for pain that lasts more than a couple of weeks, keeps coming back, or changes how you walk. If you have diabetes or neuropathy and your foot turns warm, red and swollen, be seen right away: it can be Charcot foot.^[18]