Pain on Top of Foot: Causes and Diagnostic Approach
Start with plain radiographs of the foot as your initial imaging study for dorsal foot pain of unknown etiology. 1
Primary Causes of Dorsal Foot Pain
The dorsal (top) surface of the foot can be affected by multiple distinct pathologies, each requiring specific diagnostic consideration:
Musculoskeletal Causes
Extensor tendon inflammation is a common cause, presenting with pain directly over the dorsum that worsens with active toe extension or resisted dorsiflexion, with point tenderness localizing along the extensor tendons running across the dorsal foot surface. 2
Stress fractures of the metatarsals are frequently missed initially because radiographs have poor sensitivity (only 12-56%) for detecting them early. 1, 2 Patients typically report increased walking activity before symptom onset, and pain occurs before fractures become radiographically visible. 1
Osteoarthritis of the tarsometatarsal or midtarsal joints causes dorsal foot pain that worsens with weight-bearing and dorsiflexion. 2
Tarsal coalitions (abnormal bony or fibrous connections between tarsal bones) can cause dorsal midfoot pain, with radiographs showing 80-100% sensitivity for calcaneonavicular coalitions and 100% sensitivity for talocalcaneal coalitions. 1
Neurologic Causes
Deep peroneal nerve entrapment on the dorsal foot can cause burning, tingling, or numbness rather than purely mechanical pain. 2 This requires different management than mechanical causes. 1
Traumatic Causes
Acute fractures from direct trauma present with focal tenderness at the fracture site and are confirmed with radiographs. 1
Diagnostic Algorithm
Step 1: Clinical Examination
Palpate systematically for point tenderness along:
- Extensor tendons across the dorsal foot 2
- Individual metatarsal shafts 2
- Navicular bone 2
- Deep peroneal nerve course on the dorsal foot 2
Assess pain with resisted dorsiflexion of the foot and toes to evaluate for tendonitis. 2
Perform calcaneal compression test (medial-to-lateral squeeze) if pain extends to the heel region to evaluate for stress fracture. 1, 3
Distinguish pain character: Mechanical pain worsens with activity, while neurologic pain presents as burning/tingling. 1, 2
Step 2: Initial Imaging
Obtain weight-bearing radiographs of the foot in all patients with dorsal foot pain as the first imaging study. 1, 2 Conventional radiography is useful to distinguish among different causes and has high sensitivity/specificity for tarsal coalitions, osteoarthritis, and established fractures. 1
Step 3: Advanced Imaging (If Needed)
If radiographs are negative but pain persists beyond 1 week, obtain either MRI without contrast or CT without contrast—these are equivalent alternatives for detecting stress fractures and soft tissue pathology. 2 MRI is particularly useful for diagnosing early stress fractures, tendon pathology, and bone marrow edema. 1
Technetium bone scanning can be used for suspected stress fractures with negative initial radiographs, as symptoms often occur before radiographic visibility. 1, 3
Critical Pitfalls to Avoid
Do not rely solely on initial radiographs to exclude stress fractures, as sensitivity ranges from only 12-56% early in the disease course. 1, 2 If clinical suspicion is high, proceed to advanced imaging even with negative X-rays.
Reexamine patients 3-5 days post-injury if the initial examination is limited by swelling, as excessive edema can obscure findings within the first 48 hours. 3
Consider neurologic causes when patients describe burning, tingling, or numbness rather than purely mechanical pain—these require subspecialist referral for nerve conduction studies and electromyography. 1, 2
Avoid corticosteroid injections near extensor tendons due to risk of tendon rupture. 2
When to Refer
Immediate subspecialist referral is indicated for: