Foot pain is not always what it seems!

The small digital nerves of the Anterior and Medial foot are often something that comes up within the unexplained foot pains that I see.

Injuries or prangs to these nerves happen for all sorts of reasons….

Good example… my sister! She tells me she has terrible burning in her big toe, its very sensitive and she can hardly touch it, she has had it for months. She has not banged it, fell, or down anything traumatic, it came on gradually.

When I look at her foot she has hypersensitivity to touch along the course of her Medial Dorsal Cutaneous nerve from the middle of her foot to her toe. When I look at her foot, she has a red mark where her shoes have been tied and some swelling around the redness but not much. When I did a Tinel’s tap test on the course of the nerve she had a shooting pain into her toe. She also had pain on a SLR and inversion, with plantar flexion.

She had been having the pain for months, sleeping with her foot out of the sheets and it had been gradually getting worse. Yes she had irritated the small nerve from where the seam of the new shoes she had bought a few months ago was rubbing on the superficial nerve. She loved the shoes, wore then nearly every day and did not think that they were what was causing her problem, after all she had no blisters (typical girl I hear you cry!). The pain was worse at night, and she could not put two and two together! Shoes in the bin, pins and needles gone in a few days, and the nerve settled down in a few weeks.

The other nerves of the foot can be irritated by lots of sources ( not just shoes)…

• Direct trauma ( I have heard some great stories… letter opener dropped on the foot whilst wearing flip-flops… ochhh thats got the hurt!) 
• Kicking a ball.
• Kicking someone… I saw someone who had been kick boxing (badly) and hit something hard giving himself a neuroma of the inter medial dorsal cutaneous nerve. This gave him terrible pins and needles and pain on the outside boarder of the foot- he had had it for 10 months with out a diagnosis!)
• Surgery-Irration of the nerve as it passes near the site of a portal for arthroscopy…. patients wake up with or develop a different type of pain post surgery.
• Scars that then wind the nerve into their makeup as they contract and heal- pain comes on gradually as the nerve is tethered.
• Compression- such as Morton’s neuroma, as the nerve passes between the toes around the level of the MTP joint.
• Tying up laces or boots to tightly ( I have seen this one lots of times!)
• Positional- I had a child once who had it from sitting on her feet and compressing the nerve whilst watching telly!
• High Arch supports-the medial plantar nerve can be irritated by high arch supports worn in shoes, or if it gets trapped in the Abductor Hallucis. Pain is always in the medial arch.
• One patient had a Plaster of Paris which gave him nerve pain!

Remember the nerve can be irritated anywhere along the course, it can be one part of one branch or the whole  of the nerve. I always get the anatomy books out and trace the nerve along its course, ask the questions about when it started, and further back than that too.

Change of foot wear, habits, trauma- even if it was only small and  bruising that the patent may have had.

Put the nerve under stretch- use your ANDs tests-pointing the toes and inverting the foot whilst doing a SLR can bring the pain or sensation on.

Use a Tinel’s tap test.

Look properly where the nerve runs- you can often see them as fine threads when under stretch.

Little nerves can recover well with the right guidance and advice…. like stop kicking hard objects!