What are the differentials for pain on the dorsum of the foot?

Differential Diagnoses for Dorsal Foot Pain

The most common causes of dorsal foot pain include extensor tendonitis, stress fractures (particularly metatarsals and navicular), osteoarthritis of midfoot joints, ganglion cysts, and deep peroneal nerve entrapment. 1

Primary Musculoskeletal Differentials

Tendon Pathology

• Extensor tendonitis causes 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 surface 1
• Pain from overuse or repetitive dorsiflexion activities is the typical mechanism 1

Osseous Pathology

• Stress fractures of the metatarsals (especially 2nd and 3rd), navicular, cuboid, or cuneiform bones are common in runners and athletes 2, 3
• Initial radiographs detect only 12-56% of stress fractures, so negative X-rays do not exclude the diagnosis 1, 4
• Tarsal coalitions (calcaneonavicular or talocalcaneal) cause chronic midfoot pain, with radiographs showing 80-100% sensitivity for calcaneonavicular and 100% sensitivity for talocalcaneal coalitions 4, 2

Articular Pathology

• Osteoarthritis of the tarsometatarsal or midtarsal joints causes dorsal foot pain that worsens with weight-bearing and dorsiflexion 1
• Freiberg's infraction (osteochondrosis of the metatarsal head, typically second metatarsal) presents with localized dorsal forefoot pain 4, 2

Soft Tissue Masses

• Ganglion cysts on the dorsal foot are typically painful due to the thin subcutaneous tissue over foot bones and proximity to the dorsalis pedis artery and medial branch of the deep peroneal nerve 5
• Deeper lesions beneath the fascia are more likely to require resection and cause persistent symptoms 5

Neurologic Differentials

• Deep peroneal nerve entrapment causes burning, tingling, or numbness rather than purely mechanical pain 1
• Palpate along the deep peroneal nerve course on the dorsal foot to assess for point tenderness 1

Systemic and Inflammatory Causes

• Inflammatory arthropathies (rheumatoid arthritis, spondyloarthropathies, gout) frequently affect the foot as a first presentation 6
• Consider when bilateral symptoms or pain in other joints is present 2

Diagnostic Algorithm

Initial Evaluation

• Obtain weight-bearing radiographs (anteroposterior, oblique, lateral views) as the first imaging study for all patients with dorsal foot pain 4, 1, 3
• Palpate for point tenderness along extensor tendons, metatarsal shafts, navicular bone, and over the deep peroneal nerve course 1
• Assess pain with resisted dorsiflexion of the foot and toes to evaluate for tendonitis 1

Advanced Imaging (if radiographs negative but pain persists >1 week)

• MRI without contrast or CT without contrast are equivalent alternatives for detecting stress fractures 1, 3
• MRI is preferred for soft tissue pathology including ganglion cysts, nerve entrapment, and tendon pathology 3
• Three-phase bone scan has 100% sensitivity and negative predictive value for ruling out stress fractures when radiographs are negative 4, 3

Critical Pitfalls to Avoid

• Do not rely solely on initial radiographs to exclude stress fractures given the 12-56% sensitivity 1, 2
• Reexamine patients 3-5 days post-injury if initial examination is limited by swelling, as excessive edema can obscure findings 1, 3
• Avoid corticosteroid injections near extensor tendons due to risk of tendon rupture 1
• Consider neurologic causes when patients describe burning, tingling, or numbness rather than purely mechanical pain 1
• For ganglion cysts, anatomical knowledge is prerequisite to any puncturing procedure to avoid nerve injury to the dorsalis pedis artery and deep peroneal nerve 5