What is the best course of action for chronic pain on the top of my right foot that has lasted for 2 years?

Chronic Right Foot Pain on Top of Foot for 2 Years

Start with plain radiographs (X-rays) of the foot as your initial diagnostic step, using standard three-view imaging (anteroposterior, oblique, and lateral), as this is the most cost-effective approach recommended by the American College of Radiology for any chronic foot pain of unknown etiology. 1, 2

Initial Diagnostic Approach

Obtain plain radiographs first because they identify the majority of structural causes of chronic dorsal foot pain with high sensitivity for many conditions:

• 80-100% sensitivity for tarsal coalitions 1, 2
• 80-100% sensitivity for toe fractures 3, 2
• Useful for detecting osteoarthritis, stress fractures, and other bony abnormalities 3

Important caveat: Radiographs have only 12-56% sensitivity for stress fractures, so negative X-rays don't rule them out if clinical suspicion is high 1, 2

Key Physical Examination Findings to Assess

Palpate systematically to localize the pain source:

• Point tenderness at metatarsal bases, metatarsophalangeal joints, and midfoot bones 2, 4
• Calcaneal squeeze test (medial-to-lateral compression) suggests stress fracture 2
• Assess for deformity, swelling location, and weight-bearing ability 3, 2
• Check for hammertoe deformity with nail changes or callus formation 4

Common Causes of Dorsal Foot Pain

Midfoot pathology is most likely given the "top of foot" location:

• Tarsal coalitions (calcaneonavicular or talocalcaneal) - detectable on radiographs with 80-100% sensitivity 1, 2
• Occult stress fractures of navicular, cuboid, or cuneiform bones - require high clinical suspicion 2
• Metatarsophalangeal joint osteoarthritis or capsulitis 1
• Extensor tendinopathy (though less commonly causes chronic pain)

Next Steps Based on Initial Radiograph Results

If radiographs are negative but pain persists, order MRI foot without IV contrast as the next diagnostic step:

• MRI is indicated for suspected stress fractures, soft tissue pathology, or when clinical suspicion remains high despite negative X-rays 1, 3, 2
• Technetium bone scanning is an equivalent alternative for suspected stress fractures 2, 4

If radiographs show specific pathology, treatment depends on findings but generally starts conservatively 1, 5

Conservative Treatment Protocol

Implement these measures while awaiting or following imaging:

• NSAIDs (ibuprofen, naproxen, or celecoxib) for pain control and inflammation reduction 4, 5
• Activity modification - reduce activities that provoke pain 5
• Appropriate footwear with adequate width and support 3, 6
• Orthotic devices to redistribute pressure 3, 6

When to Refer

Refer to a podiatric foot and ankle surgeon if:

• Pain persists despite 6-8 weeks of appropriate conservative treatment 3, 4
• Displaced fractures or deformities requiring surgical correction 3
• Suspicion of systemic disease causing foot pain 3
• Need for advanced diagnostic testing or interventional procedures 3

Critical Pitfalls to Avoid

Don't overlook these common errors:

• Missing small avulsion fractures on radiographs - requires systematic review 3, 2
• Failing to obtain weight-bearing views when indicated, which can miss subtle deformities 3, 2
• Assuming negative radiographs rule out stress fractures - they often appear normal initially 1, 2
• Underestimating the impact of proper footwear on symptom management 3, 2
• Using corticosteroid injections near tendons in the forefoot, which increases rupture risk 4

Red Flags Requiring Immediate Evaluation

Seek urgent evaluation if any of these are present:

• Neurologic symptoms (numbness, weakness, burning pain radiating to toes) 4, 5
• Constant pain at rest unrelieved by position changes 4
• Signs of infection (erythema, warmth, purulent drainage) 2, 4
• Suspected vascular compromise 4