Pain in the ball of foot accompanied by swelling on top of foot

by Audrey
(Santa Cruz, CA)

I recently saw a podiatrist about this problem, and she was unable to diagnose it, so I'm hoping someone else out there can give me some guidance.

I've been suffering from pain in the ball of my left foot off and on for approximately three years. The pain seems to be centered in the joints behind my second and third toes and, at its mildest, feels as though there were something like a small rock between those joints (to clarify, if I'm standing, it feels like I might have a small rock in my shoe in that location. There's nothing to see or to palpate, however.) At its worse, there's a dull, throbbing ache. It seems to get worse at night when I'm sleeping, or when I have to stand for a long period of time. Walking doesn't seem to aggravate it unless I'm wearing the wrong shoes (see below)

Putting ice on it causes severe pain. Heat, on the other hand, is soothing.

The odd thing is that this pain is accompanied by (or perhaps aggravated by)swelling on the top of my foot, usually starting near the base of my little toe and gradually expanding to the entire top of the foot. I say "accompanied by or aggravated by" because I don't know if one is caused by the other...I just know that once the swelling starts, the pain will soon follow.

Both problems seem to be aggravated by shoes that allow my foot to move around a lot, such as Birkenstock-style sandals. Wearing shoes that don't allow the foot much movement, such as my hiking boots, or an old pair of Clarke's sandals I have that slightly compress the foot from just behind the toes almost to the ankle, is helpful, especially with the swelling. The pain is also aggravated by anything with any kind of heel (not surprisingly!)...even a very moderate wedge. Wearing flats doesn't seem to help much, however: I can't wear ballet-style flats at all, as the swelling starts as soon as I put them on.

On the podiatrist's advice I've started wearing mild to moderate compression socks, but they don't seem to make much of a difference. They're good for keeping the ankles from swelling on long car trips, but they don't do a thing for the swelling on the top of my foot. I've tried wrapping the foot with an Ace bandage, but it's not possible to get it tight enough near the base of the toes to make much difference.

I'm a moderately active female (I do lots of walking, when I'm not in pain, and Jazzercise), 51 years of age, moderately overweight (working on that!). Other than the extra weight, I'm generally pretty healthy: I don't smoke, I drink only in moderation, I eat a low-fat vegetarian diet rich in vegetables and whole grains, etc. I don't wear high heels (haven't for 20 years!) or shoes with a narrow toe box. My usual day-to-day shoes are running shoes, or the aforementioned hiking boots when the pain and swelling are especially bad. For dress, I wear Earth shoes (I also have a pair of Earth sandals but, unfortunately, they aggravate the swelling, whereas the Mary Jane type Earth shoes I wear for dress do not).

When I saw the podiatrist, she took an X-ray, which revealed "a normal left foot." She didn't mention any other possible causes, and the only advice she gave me was to wear the compression socks. I'm getting very frustrated and discouraged. I hope you can give me some insight.


RESPONSE

Hi Audrey,

Obviously, if this problem is still bothering you then it will have to be investigated further. Based on your narrative it sounds like there may be two issues going on; the pain on the bottom of your foot in the area of the second and third toes plus the pain that starts on your little toe and runs across the top of your foot.
I view sneakers/running shoes as probably the most neutral shoe one can wear. So, assuming there is no pain in sneakers, which I assume "hold" your foot, one thing you or your doctor could do, is see what kind of motion in your foot is occurring in your other shoes, the shoes that make your foot hurt. On the surface, based on your comments, it seems there may excessive motion in the joints just behind your toes which could lead to a condition known as capsulitis (read article to the left). This is caused by an overstretching of the ligaments that bind the metatarsal bone to the toes. A worsening of this condition is known as a plantar plate tear where the ligaments actually tear, so again, based on your narrative, a shoe that "holds" your foot, would tend to limit motion at these joints, while a shoe, such as a ballerina shoe would exacerbate the pain.
Your symptoms do not sound like Morton's neuroma (see article to the left) as generally speaking, a tight shoe will exacerbate the problem.
Another condition to consider would be what is known as an intermetatarsal bursitis, which is a bursitis that is in between the metatarsal bones, but again, a tight shoe would probably worsen the symptoms while a loose shoe might lessen the pain.
I am not so sure that a compression stocking is going to do much at all, other than try to keep the swelling down, but in reality, that will not solve your problem.
If you were to walk into my office at this point in time, having a normal x-ray, but pain and swelling that has been going on for some time, I would first start you on a round of anti-inflammatory medication (assuming you can tolerate them), probably for two to three weeks, have you stay in rigid shoes exclusively for this period of time. I would then have you back. If your symptoms were much improved, but possibly not completely gone, I might continue this regimen for another two weeks. If your symptoms at this point had not improved substantially, then I would order an MRI of your foot, to get a better look at what might be going on "inside" your foot.
Because your pain is only occurring in one foot and I assume that you are not having joint pain anywhere else in your body, I do not think conditions like rheumatoid arthritis are part of the problem, but certainly a blood test to rule that out along with some other inflammatory conditions, would certainly be worth the effort.
A follow up visit to your podiatrist is indicated.

Marc Mitnick DPM
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