Pain is never normal.  As you go about your day, if you experience pain on the outside of the foot, it is not comfortable and if not treated, the pain can get worse over time. This is why it is important to understand what the pain could possibly mean.

What Could Pain On the Outside Of My Foot Possibly Be?

Pain on the outside of the foot could be a tendinitis, peroneal tendinitis, to be exact.  Peroneal tendinitis is inflammation of the peroneal tendon.  This muscle belly starts on the outside (lateral aspect) of the lower leg and the tendon inserts on the outside of the foot at the base of the 5th metatarsal, which is the long bone of the foot that attaches to the base of the 5th toe.  The peroneal tendon derives from the muscle and it courses behind the ankle bone and inserts on the base of the metatarsal.  The peroneal tendon is made up of the peroneus longus and peroneus brevis.  The peroneal tendon is responsible for dorsiflexion (pulling the foot upwards at the ankle) and eversion and pronation (outside of the foot pulling upward) and inside or medial part of the foot moving towards the ground. Tendinitis can be due to overuse of this tendon or repetitive motion. An overuse injury could be due to over training if you are in a sport, or if not in a sport, due to wearing new shoes, different shoes, or a new activity that affects your gait and puts stress on that tendon over time. Sometimes you may not know why the inflammation of the tendon is occurring, but the important thing is to receive a proper diagnosis in order to start a treatment program. 

How Is Peroneal Tendinitis Diagnosed?

At the first visit, a thorough history and lower extremity physical is conducted along with radiographs (Xrays) to rule out a fracture or other bony abnormality or bony explanation for the pain. 

A physical exam is essential, and key characteristics include pain along the tendon as it courses behind the lateral malleolus (ankle bone) and at the base of the 5th metatarsal bone.  Sometimes the pain will radiate upwards towards the muscle belly.  If there is pinpoint pain, then it is considered an insertional tendinitis and the inflammation is focused on where the tendon inserts on the bone.  The important thing is to get a proper diagnosis in order to start a treatment plan. 

How Is Peroneal Tendinitis Treated?

In order to to treat tendinitis and inflammation, it is important to decrease inflammation by compression and immobilization.  Our doctors may recommend a temporary soft cast, called an unnas wrap, in order to jump start this.  It is applied in the office and it is not removed until advised by your doctor and this can be done at home.  After the edema and swelling has subsided with the unnas wrap, then our doctors may dispense a special ankle brace.  What makes this brace specialized is the specific strapping that comes along with it.  By customizing the application of the strapping, this will alleviate the pain on the outside of the foot.  This makes the ankle brace far superior than anything that can be obtained over the counter.  In addition, your doctor may give you icing instructions and recommendations on how to decrease the edema and swelling.  Our doctors recommend the MLS laser which is a non invasive treatment that is painless and has virtually no side effects.

It turns photo energy into biomechanical energy and increases circulation to the area and decreases edema.  The treatments are 1-2 days apart, so you would have 2-3 treatments a week for a minimum of 6 treatments to obtain the best results. This is a great alternative to an oral NSAID, or non-steroidal anti inflammatory drug, as NSAIDs have many side effects.  The best part about the MLS pain laser as a treatment is that it can be used with other modalities, for example in conjunction with physical therapy.  As the pain improves, your doctor will transition you out of the brace and may prescribe physical therapy to help strengthen the muscle and tendon and teach you exercises to prevent recurrence. In addition, your doctor will suggest a custom orthotic as a way to support the foot and prevent recurrence. 

Your doctor will take a mold of your foot and send this to the lab where a custom orthotic is made. It is placed in your shoe and holds your foot in a biomechanically neutral position to decrease abnormal pressures on the tendons, joint, and ligaments and prevent recurrence of this tendinitis. 

If It Is Not A Tendinitis, What Else Can Pain On The Outside Of My Foot Possibly Be?

You may or may not recall any trauma to the area, but it is possible that pain on the outside of your foot can be a stress fracture. If the pain is on the outside of the foot, the most common affected bone is the 5th metatarsal, the long bone that attaches to the base of the 5th digit on the outside of your foot.  A stress fracture occurs due to repetitive trauma to the bone,  often not direct trauma or injury.  After direct trauma, there is most of the time a clear fracture, or crack, in the bone.  In repetitive trauma there may not be a clear fracture but instead there may be bone marrow edema or swelling to the bone itself.  Often times the stress fracture may not even show up on the Xray.  Stress fractures in general may not show up for up to 2 weeks on Xray.  A few weeks later, the radiograph may show new bone formation in the area that was injured and this confirms the stress fracture occurred in the first place.  Sometimes a radiograph may never show signs of the stress fracture, and advanced imaging such as an MRI is used to visualize the internal swelling of the bone.  The pain along this 5th metatarsal bone on the outside of the foot could also be a bony bruise, or a contusion. This diagnosis is confirmed with physical exam would confirm this diagnosis. 

 

If you do remember trauma to the outside of the foot, such as twisting the foot, landing on it wrong during sports activities, or even something falling on the bone, then you may have a 5th metatarsal fracture or a fracture of the cuboid bone, which is the bone immediately behind the 5th metatarsal.  This diagnosis is confirmed by radiograph and physical exam.  If the 5th metatarsal is fractured, then it is treated with compression and immobilization.  Depending on the size, location, and position of the 5th metatarsal fracture, you may be in a removable CAM boot or your physician may place you in a fiberglass below knee cast. 

Example of a CAM (controlled ankle motion) boot

In addition, she may recommend that you remain non-weightbearing with crutches or a knee scooter in order to allow the area to heal.  If the bone position is not ideal (it may be a displaced fracture) or if it is in an area known to have decreased blood flow, then your physician may recommend surgical correction in order to have the bone on its way to healing.  

Example of a fiberglass non-weightbearing cast

If you have pain in your foot or ankle, it is important to have it examined as pain is never normal.  The sooner you have your foot examined, the sooner you can receive a proper diagnosis and start a treatment plan.  Call our office to make an appointment. Better not delay!