Dorsal Foot Pain on Flexion: Diagnostic Considerations

Primary Diagnostic Considerations

Extensor tendon inflammation from overuse or repetitive dorsiflexion causes pain directly over the dorsum of the foot that worsens with active toe extension or resisted dorsiflexion, according to the American College of Family Physicians guidelines 1
Point tenderness localizes along the extensor tendons running across the dorsal foot surface, as noted by the American Academy of Orthopaedic Surgeons 1
Initial radiographs have poor sensitivity (12-56%) for detecting stress fractures, so negative X-rays do not exclude the diagnosis, as stated by the American College of Radiology 2
Osteoarthritis of the tarsometatarsal or midtarsal joints causes dorsal foot pain that worsens with weight-bearing and dorsiflexion, according to the American College of Rheumatology 2

Palpate for point tenderness along extensor tendons, metatarsal shafts, navicular bone, and over the deep peroneal nerve course on the dorsal foot, as recommended by the American College of Family Physicians 1
Assess pain with resisted dorsiflexion of the foot and toes to evaluate for tendonitis, as suggested by the American Academy of Orthopaedic Surgeons 1
Weight-bearing radiographs of the foot should be obtained initially for all patients with dorsal foot pain, according to the American College of Radiology 2
If radiographs are negative but pain persists beyond 1 week, MRI without contrast or CT without contrast are equivalent alternatives for detecting stress fractures, as noted by the American College of Radiology 1

Do not rely solely on initial radiographs to exclude stress fractures, as sensitivity ranges from only 12-56%, as stated by the American College of Radiology 2
Reexamine patients 3-5 days post-injury if initial examination is limited by swelling, as excessive edema can obscure findings, according to the American College of Family Physicians 1
Consider neurologic causes when patients describe burning, tingling, or numbness rather than purely mechanical pain, as recommended by the American Academy of Neurology 4
Avoid corticosteroid injections near extensor tendons due to risk of tendon rupture, as warned by the American Academy of Orthopaedic Surgeons 3