What causes pain on the top of the foot?

Top of Foot Pain: Causes and Diagnostic Approach

Extensor tendon inflammation from overuse or repetitive dorsiflexion is the most common cause of dorsal foot pain, presenting with tenderness along the extensor tendons that worsens with active toe extension or resisted dorsiflexion. 1

Primary Causes of Dorsal Foot Pain

Musculotendinous Causes

• Extensor tendonitis produces pain directly over the dorsum of the foot that intensifies with active toe extension or resisted dorsiflexion, with point tenderness localizing along the extensor tendons running across the dorsal foot surface 1
• Pain from extensor tendon inflammation typically results from overuse or repetitive dorsiflexion activities 1

Osseous Causes

• Metatarsal stress fractures cause progressive dorsal foot pain following increased activity or changes to harder walking surfaces, though initial radiographs have poor sensitivity (12-56%) for detection 1
• Tarsometatarsal or midtarsal joint osteoarthritis produces dorsal foot pain that worsens with weight-bearing and dorsiflexion 1
• Avascular necrosis of the metatarsal head (Freiberg's disease) or navicular bone (Köhler's disease) can cause dorsal foot pain, though these are less common 2

Neurologic Causes

• Deep peroneal nerve compression on the dorsal foot presents with burning, tingling, or numbness rather than purely mechanical pain 1

Diagnostic Algorithm

Physical Examination Priorities

• Palpate for point tenderness along extensor tendons, metatarsal shafts, navicular bone, and over the deep peroneal nerve course on the dorsal foot 1
• Assess pain with resisted dorsiflexion of the foot and toes to evaluate for tendonitis 1
• Consider neurologic causes when patients describe burning, tingling, or numbness rather than mechanical pain 1

Imaging Sequence

• Weight-bearing radiographs of the foot should be obtained initially for all patients with dorsal foot pain 1
• If radiographs are negative but pain persists beyond 1 week, MRI without contrast or CT without contrast are equivalent alternatives for detecting stress fractures 1
• Do not rely solely on initial radiographs to exclude stress fractures, as sensitivity ranges from only 12-56% 1

Critical Pitfalls to Avoid

• Never exclude stress fractures based on negative initial X-rays alone—radiographs have poor sensitivity (12-56%) and symptoms often precede radiographic findings 1
• Reexamine patients 3-5 days post-injury if initial examination is limited by swelling, as excessive edema can obscure findings 1
• Avoid corticosteroid injections near extensor tendons due to risk of tendon rupture 1
• Consider systemic causes (rheumatoid arthritis, spondyloarthropathies, gout) when symptoms are bilateral or involve other joints, as these frequently affect the foot as a first presentation 3

Additional Considerations

• Foot pain is very common, especially in women, often owing to inappropriate footwear 3
• Overuse, repetitive strain, and minor injuries may result in chronic foot pain 3
• Prompt diagnosis and treatment, particularly focusing on offloading, lifestyle modifications, and footwear adjustments, can prevent development of chronic musculoskeletal pain 4