Overview of burning pain on top of the foot
There are many alternative causes including local skin compression causing focal symptoms, tendonitis related to inflammatory arthritis, or stress fracture of the bones around the front of the ankle. A less common but important cause of burning pain on top of foot is nerve root compression in the lower back; the deep peroneal nerve is formed from the L4 nerve root so people with symptoms from this level will also feel pain around the front of the leg and have associated back pain.
Burning pain on the top of foot is a distressing symptom that is the result of a relatively small number of conditions, each with their own differential diagnoses and treatments. The most important factors in determining the cause of the pain are the method and the circumstances in which it started, the exact site and the nature of the pain, and associated symptoms. The most common cause is compression of the deep peroneal nerve as it passes around the front of the ankle, usually by an acute injury to the ankle such as a sprain or blow to the front of the ankle. The symptoms are typically of sudden onset, sharp or stabbing pain on the top of the foot. It may be associated with weakness of ankle or big toe movement as the nerve also supplies the muscles around the front of the ankle.
Common causes of foot ankle pain
The ankle joint is a hinged joint formed by the articulation of the lower leg bones with the heel. The joint is held together by several strong ligaments and supported by the surrounding muscles. The main bony prominences of the ankle are the medial and lateral malleolus, and the joint is somewhat protected by the anterior and posterior talofibular ligaments. The joint is subjected to great force and stress during walking, running, and jumping, and is also quite vulnerable to injury because of its position between the ground and the bones of the leg. A 2009 study in the American Journal of Sports Medicine showed that foot and ankle injuries have increased 85% over the past 17 years due to an increase in participation and intensity of sports and recreational activities. With the increase in foot and ankle pain due to injuries, it is even more important to understand and be aware of the specific causes of pain.
The causes of foot and ankle pain are quite vast and can be a result of direct trauma or as an overuse/repetitive stress injury. A particular type of injury known as a high-ankle sprain has been increasing in frequency but is often misdiagnosed or mistreated. This type of sprain is a tear to the syndesmotic ligaments that connect the tibia and fibula in the lower leg. Symptoms include persistent pain above the ankle and also difficulty in walking, and a recent article published in the British Journal of Sports Medicine describes the best techniques to evaluate and diagnose this injury. Overuse type injuries can be seen in recreational athletes, when doing too much too soon, can lead to various painful conditions such as Achilles tendinitis or plantar fasciitis. Lastly, chronic pain or insidious onset of pain can be a result of degenerative changes in the joint or post-traumatic arthritis. With so many different types of injuries and conditions of the foot and ankle, the reader/patient will have to understand that an accurate diagnosis of the cause of pain is the most important step in management and treatment.
Symptoms and Diagnosis
Diagnosis and recognizing the symptoms are crucial. This is important for exclusion of any other sources of pain within or around the foot which might have a similar presentation. A very common cause of pain on the top of the foot is extensor tendinopathy. This has a similar presentation to that of Sural nerve irritation with pain on the top and around the ankle, usually following an injury or increase in activity. Pain caused by dorsal nerve compression is generally localized to the center of the foot around the 2nd metatarsal phalangeal joint and does not radiate widely. Determining the etiology and pathophysiology of the patient’s pain is important. Isolated injury to the Sural nerve is rare and the presence of further neurological symptoms such as a sensation of giving way, reduced power, or altered sensation may indicate alternative pathology. Pain caused by radiculopathy may have similar symptoms to Sural and or Peroneal nerve pain and symptoms such as reduced power or altered sensation can indicate upper motor neuron lesion. An EMG/NCV can be useful to diagnose neural pathology and can help to pinpoint the lesion.
Recognizing the symptoms of burning pain on top of the foot
Symptoms of burning pain on top of the foot are localized to a small region. The pain is often extreme, leaving many patients to describe it as similar to walking on a hot coal. Many patients with burning pain on top of the foot may also experience numbness and tingling in the same area. Usually, the symptoms will begin spontaneously, but are often related to a minor trauma, nerve impingement, or compression. In some cases, no precipitating event can be identified. The symptoms may be intermittent or continuous, and will often worsen at night. Sometimes there may be relief with rest. Patients with burning pain on top of the foot will often complain that their shoes are uncomfortable because it feels like the sock is bunched up in the shoe. This is due to the fact that the pain is often generated by a problem with the nerve. In the early stages of nerve symptom onset, there may be no signs of atrophy (muscle wasting). As the condition becomes chronic, muscle atrophy may become more visible.
Diagnostic tests for foot ankle pain
When doctors diagnose the cause of foot pain and ankle pain, they usually try to find the mechanism that is causing the pain to occur. This is important because it is the underlying mechanism that points to the best treatment for the pain. In order to determine the mechanism of your foot pain or ankle pain, your doctor may order x-rays or an MRI. If the primary problem is related to arthritis, an x-ray is the easiest way for your doctor to make a diagnosis. An MRI is best for soft tissue problems and it is the test that most clearly shows the cause of the pain. Other forms of diagnostic imaging are not usually necessary. Special diagnostic tests are rarely required to determine the mechanism of foot pain or ankle pain. An injection of local anesthetic into a specific joint will sometimes help to determine whether that joint is the cause of the pain. This is called a diagnostic block. If the pain is coming from a specific muscle or tendon, sometimes an EMG or muscle testing will be performed. This is usually only necessary in cases of significant chronic muscle pain in the foot or chronic muscle pain in the ankle where the diagnosis is unclear.
Throughout the process of diagnosis for your foot or ankle pain, it is important to be an informed patient and to ask questions. The key things to find out from your doctor are the cause of the pain, the prognosis, and the best treatment options. With that information, you and your doctor can develop a treatment plan that will allow you to return to the activities that you enjoy.
Treatment and Management
Non-surgical approaches for relieving burning pain
Non-surgical methods to alleviate the pain tend to use a more holistic approach to treating the body as a whole and do not only focus on the source of pain. Changing the footwear that is worn can often relieve the pain on the top of the foot. High heels and shoes that are too tight in the toe box can cause compression and entrapment of the nerve, increasing symptoms of burning pain. Wearing shoes with a lower heel and wider toe box can help to relieve these symptoms. Orthotic insoles/pads can help to offload the pressure on the front of the foot, and taping can help to splint and support the foot. Although these methods may not provide immediate pain relief, they can provide sufficient long-term pain control.
Phonophoresis involving the use of enzymes and ultrasound is a novel treatment not commonly offered in Singapore. Studies performed on patients have shown that this method is effective at reducing symptoms of burning pain. Acupuncture is another method that can be used to treat burning top of foot pain. The basis of acupuncture is to improve the flow of energy around the body to its internal organs and to its external structures of the body such as the skin, muscles, and joints. Acupuncture would aim to trigger the body’s natural self-healing mechanisms and is commonly used to treat chronic pain.
Surgical options for foot ankle pain
This can be considered when pain is severe and non-responsive to other measures and there is no functional deformity. The aim is to diagnose and treat the primary lesion. This may prevent more major reconstructive surgery. Arthroscopy is keyhole surgery which can be used to treat many conditions affecting the foot and ankle, avoiding the need for large incisions. Fusion of joints can be used to treat severely damaged joints with a poor prognosis. The joint is cleaned of all cartilage and arthritic bone, and then held in position until it heals, usually with screws and/or a plate. This is being superseded by joint replacement for some joints, and is usually only performed on the big toe. If one of the tendons around the ankle becomes pathological, it can be transferred. If this occurs in a patient with a neurological disorder, AFOs and walking boots can be modified to enable walking.
Rehabilitation and physical therapy
Physical therapy is instrumental in helping patients with posterior tibial tendon dysfunction return to normal activity. Physical therapists are trained to evaluate muscle strength, range of motion of joints, and gait (the way a person walks). The therapist may provide an exercise program to improve the strength of the muscles that support the arch. An exercise program to improve flexibility or strength of the hip, knee or ankle muscles may be prescribed. This will be done in a controlled manner to avoid stressing the posterior tibial tendon. In advanced cases, motorized treadmills in the physical therapy facility with a harness support may be used to help the patient learn the coordination of the new muscles they are recruiting to stabilize the foot and ankle. These are the muscles that were previously supported by the damaged tendon. The therapist may fabricate a custom-made orthotic to position the foot for maximization of healing of the posterior tibial tendon and to prevent further damage. A foot and ankle surgeon may refer patients to a physical therapist to start this treatment. Implementing an exercise program is an effective way to prevent further damage, and avoid pain and dysfunction in the foot and ankle. Randomized clinical studies are showing improved outcomes and are validating the functional effectiveness of physical therapy and orthotic devices for the treatment of adult acquired flatfoot.
Prevention and Self-Care
Tips for preventing burning pain on top of the foot
Many individuals who have burning pain on top of the foot or foot ankle pain have a high likelihood of it to recur if preventive measures are not instituted. Preventive measures include wearing lace-up shoes as much as possible as this gives a good balance of foot support and ease of walking. Shoes with good midfoot support are better than sandals or clogs. Using an ankle brace if you have a history of repeated ankle sprains. Eccentric strengthening exercises for the peroneal muscles can also prevent recurring ankle sprains and pain on top of the foot. Maintaining a healthy body weight to avoid excess stress on the foot and ankle. Avoiding over stressing the foot and ankle with excessive amounts of sport or work activities if you have had recent pain in the area. Addressing postural or biomechanical problems which may have led to increased stress on the affected area a consultation with a physiotherapist or podiatrist will be beneficial for this. During the acute or inflamed phase of an ankle injury rest from aggravating activities and periods of ice application can be useful to minimise pain and swelling in the foot and ankle.
Self-care measures for managing foot ankle pain
One of the simplest and effective ways of decreasing pain and swelling in the foot and ankle is by reducing the time spent standing and walking. This can be achieved using elbow crutches to offload the affected limb. In more severe cases of foot ankle pain where the individual is having difficulty weightbearing due to pain, use of a single or double limb Aequilibrium Re-education Wobbly Board can facilitate balance and proprioceptive exercises while the patient remains non-weightbearing. This can help to prevent an excessive loss in lower limb strength and function and reduce the time taken for recovery back to full weightbearing activities. An appropriate period of rest from aggravating activities and foot ankle pain can also be useful to allow the affected tissues to heal. This should always be followed by a progressive return to normal activities. If no specific advice or treatment has been received, for persistent foot and ankle pain which is not settling, it is recommended that you see a physiotherapist or podiatrist to receive an accurate diagnosis and advice on treatment.
Tips for preventing burning pain on top of the foot
- Ensure that your shoes fit well and do not pinch the feet. Try to buy shoes at the end of the day or after a long walk when the feet are slightly swollen; this is the time when the feet are the largest. There should be at least one thumb’s breadth between the toes and end of the shoe. Too wide shoes may allow too much movement of the foot in the shoe and cause blistering to occur.
2. Ensure shoe laces are not too tight across the top of the foot; this may compress the superficial nerves and blood vessels in the foot/ankle.
3. Avoid walking barefoot on hard surfaces. This may increase the mechanical loading on the foot due to impact of the foot on the hard surface and cause inflammatory conditions to flare up.
4. Wear slippers or flip-flops with a sole to provide some cushioning effect to decrease mechanical loading and possibly reduce stress on the plantar intrinsic foot muscles.
5. When walking long distances, it is advisable to wear a more cushioned shoe to act as a shock absorber.
6. Use of an orthosis or customized insole may help improve foot function and reduce forces acting on the foot. This may decrease mechanical loading on the foot and thus reduce burning pain.
Self-care measures for managing foot ankle pain
Non-steroidal anti-inflammatory medication. Use of common medicine like aspirin, ibuprofen, naproxen or any other anti-inflammatory medicine can help decrease pain and swelling. Follow all label instructions and do not use this medication for people who have stomach ulcers, kidney failure, an allergy to that specific medication, or are children.
Elevation. At the end of your day or any time there is significant swelling present, try to elevate your ankle to a point level with or higher than your heart for 30 minutes.
Ice application. Use a cold pack, crushed ice in a plastic bag, or a bag of frozen peas over a moist towel to the area for 15-20 minutes three to four times a day.
Decrease your usual amount of weight bearing activity. Use a cane, crutch or brace. These may take some weight off of the ankle to allow for better ambulation and decreased pain.
For foot ankle pain that is not severe or life- or limb-threatening, you can still take certain steps initially over the first 48 hours following an injury or onset of pain to help manage the condition. All of these steps can be initiated without special equipment or prior knowledge and involve no expense. They are generally safe and should not worsen the condition.
Once the cause of your ankle pain has been diagnosed by your orthopaedic specialist, you’ll learn the most effective and safest forms of treatment. But it is important to consider the steps to manage foot ankle pain by yourself.
