Early this year I had a call for an urgent appointment from a lady with pain on the top of her foot that had been there for two months.

Her pain level was 10/10 across the top of her left foot, some bruising was still present and swelling was clearly visible. Due to the pain she had begun to walk differently trying to avoid putting pressure on the foot, this led to knee and hip pain, known as referred pain due to compensatory gait. She also back and neck pain and all of these were affecting her mood and ability to perform normal daily activities. Pain killers and anti-inflammatories had not helped.

As part of a podiatrists job we take a full history of the patient and try to gain as much information as possible about the reported problem. The more information we have, the more we are able to put the whole story together and deliver the correct treatment.

The story, it was during winter, when most people where tighter and more supportive footwear around the ankle and the arch, that she went on holiday to a warm location. The shoes changed to flip flops for the week and one evening of strappy heels, the kind with a strap across the top of the foot near the leg. That night was the start of the pain and the next day she noticed swelling.

Due to the pain I was only able to perform a gentle musculoskeletal assessment of both feet. We always check both feet for comparison. The pain was found to start at the big toe, radiated up through the top of her foot and and up the outside of her leg. The muscle involved was the extensor hallucis longus which starts at the big toe and follows the line of pain reported. This muscle also passes under the retinaculum at the top of the foot, a tight sheath that keeps the muscles where they should be.

Extensor Hallucis Longus with retinaculum  

My plan was to reduce the movement of the muscle and allow it rest and reduce swelling and pain levels. I did this by providing an insole to reduce plantar flexion, pushing the foot down, as this was reported as the most painful movement. The following week the pain was reported as 8/10.

At this second appointment I sought help from another health professional, sports therapist РSteve, to assist on a more in-depth musculoskeletal assessment. I am always prepared to seek help if it benefits my patients and furthers my knowledge. Steve provided  her with strapping that would help reduce the muscle and tendon work and allow for more healing in conjunction with the insole. It was noted that her walking had improved, no visible limping or altered gait. We also provided her with gentle non-weight-bearing exercises to strengthen the knee and hip to allow her to return to a normal gait when the pain resided further. I also gave footwear advice to ensure that supportive footwear was being used, even in summer shoes.

Two weeks later we met up again and pain was reported as 2/10, improved walking and less back pain. She was able to perform her normal daily activities and was smiling.

This type of injury is more commonly seen in runners but as I now know a simple sandal strap can also be the cause. A good history of any injury, knowing the right questions to ask and having associated health professionals I can turn to ensures I can provide the best possible care for my patients. Foot pain must always be seen by a specialist.