Pain in inner side of foot and across top from ankle

by Deb
(Queens, NY)

I have had gradually worsening pain in both feet, right one worse, over many years while both arches have collapsed. My metatarsal arch is collapsed and I have severe bunions, worse on right ft. I've used various orthotics over the years, never wear narrow shoes or heels. Have worn only hiking boots since this spring for more support. A podiatrist had custom orthotics made for me and I wore them several months but the pain got worse. It became so bad I've been hobbling around at home on my knees and for the past few weeks I'm using a wheelchair at work. A physical therapist said I have tendinosis and gave me exercises to do 2 months ago. I've done them but no improvement yet.

The pain is worst on the inner side of my feet; it also stretches across the top of the foot from ankle to ankle. If I stay totally off my feet for days I feel much better. As soon as I start putting weight on them the pain starts up and gets bad quickly. I've had x-rays and an MRI, which show the severe bunions, arthritis in my big toe and inner side ankle, but no other problems. I'm getting nowhere and I don't have the money to keep going to doctors who give me no info. I was told the problem must be my back, but I don't have sciatica or back pain. As my feet have gotten worse I've developed numbness in parts of my foot, my shin, and one spot on right knee.
I don't know what to do! Feeling extremely frustrated and I so hope you can give me some direction. Wish I could send you my x-ray or a diagram but I've got nothing.

I am female, 61 yrs old, very thin with fairly narrow, thin feet. I lost about 25 lbs over a 2-3 yr period for no apparent reason. No major health problems.

Thank you again for your help.

RESPONSE

Hi Deb,

Don't know how much help I can be from the other side of the internet, but based on your narrative I get a picture of a scenario I have seen many times over my career.
You may have very "bony" feet that pronate (flatten out excessively), additionally you probably have very little fat on the ball of your feet.
Because of the excess pronation you may have musculo-skeletal pathology from the feet all the way up to the lower back. Stated another way, if you consider the feet to be the foundation of your skeletal system, then any malfunction in the feet can have an adverse effect all the way to your lower back.
Your flat feet is something you have probably had your whole life but you have reached a point in the aging process where it is becoming more symptomatic. As we age the musculo-skeletal system becomes less adaptable to the daily stresses placed on it and pain begins.
If it were just your bunions that hurt, the pain would be coming from them and you could have them surgically corrected. In your case it sounds like the bunions are just a manifestation of the excess pronation.
Of course, I am just guessing here, but I would think the pain on the inside of your foot is from excess strain on your tibialis posterior muscle where it attaches into your navicular bone. It would probably be the tendinosis that the physical therapist referred to.
As far as the numbness goes that you referred to, there are two areas that need to be explored. One is a possible tarsal tunnel which is the foot equivalent to carpal tunnel seen in the hands. Excess pronation creates pressure on the nerve that passes below the inside of the ankle and can cause numbness and muscle weakness in either or both feet.
Secondly, as you mentioned, your numbness may also be coming from your lower back.
I have no way of knowing which it is.
The most obvious way to treat this problem from a conservative standpoint is through the use of a custom orthotic, but I have been around long enough to know that just because an orthotic is custom made, it still might not be right for the patient.
I do not know what kind of orthotic you actually have, but if you were my patient I would have started out with an orthotic made of softer materials like cork and leather, instead of a hard plastic orthotic. Perhaps you have that kind, I do not know. My point is, I think an orthotic that "gently" corrects your pronation and cushions your gait might be helpful.
I would also suggest that the orthotic might have to be adjusted based on your response to it. Don't know if that has been done or not.
Basically what you are looking for here is a reduction in your excess pronation which would improve your symptoms.
There are also far more radical treatments out there to control excess pronation which all involve surgery.
If your ambulating around on your knees and using a wheelchair that tells me things have gotten pretty bad.
I understand it is expensive to go to doctors, but you cannot ignore this problem as you are too young to end up confined to a wheelchair.
I do not know if you have been there or not, but since you live in New York, why not make an appointment at The Hospital for Special Surgery in Manhattan and be evaluated by them.
They will be able to evaluate you from your feet all the way to your back.

Marc Mitnick DPM
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