Numb top of the foot? Tight laces and the nerves beneath

A numb top of the foot, with tingling or burning after a day in your shoes, often has a simple explanation: your laces. The nerves that run across the front of the ankle sit just under the skin, with little padding, and they can be irritated by pressure from above.

Two nerves, two patterns

The deep peroneal nerve travels down the front of the lower leg and passes under a band of tissue called the extensor retinaculum at the front of the ankle. Beyond that band, one branch serves the skin of the web space between the big toe and second toe, and another controls two small muscles on the top of the foot. Squeezing the nerve here is called anterior tarsal tunnel syndrome.^[1] It typically produces pain that radiates to the web space between the first two toes.^[6]

The superficial peroneal nerve exits the lateral compartment of the lower leg a few inches above the ankle and then runs under the skin over the top of the foot. It gives feeling to most of the top of the foot and the outer lower leg.^[2,3] The pattern of numbness varies from person to person, because the way this nerve supplies the top of the foot is not identical in everyone.^[7]

For details on each, see anterior tarsal tunnel syndrome and superficial peroneal nerve entrapment.

What can press on these nerves

• Footwear. Tight shoes and laces add pressure from outside, and the most common site of deep peroneal compression is under the extensor retinaculum at the front of the ankle.^[1,3]
• An old ankle injury. Symptoms that persist after an ankle sprain are common, and the superficial peroneal nerve is one possible reason. In a report of children with severe sprains, a few developed scarring around it.^[8]
• Positions that keep the foot pointed. In a study of 14 people with anterior tarsal tunnel syndrome, all had for years regularly prayed in a kneeling position with the feet pointed. The authors suggested that prolonged stretching of the nerve on the top of the foot was the cause.^[4]
• Growths or swelling, such as a cyst, a bone spur on the top of the midfoot, or a swollen tendon sheath, which are visible on ultrasound or MRI.^[9]

What you can try first

Reviews of these conditions agree on the starting point: remove what is pressing on the nerve.

• Change how you lace. Skip the eyelets over the sore spot, re-route the laces, or use a softer, padded tongue. Shoe modifications are one of the options listed for anterior tarsal tunnel syndrome.^[5]
• Choose shoes that leave room over the top of the foot and the front of the ankle.
• Support an unstable ankle, because repeatedly rolling the ankle can stretch the nerve.^[3]
• Take a break from positions or activities that keep your foot pointed for long periods.
• Give it time. Many peroneal nerve entrapments will resolve with observation and activity modification.^[3]

When it doesn’t settle

Other options include physical therapy and, in selected cases, a cortisone injection. If symptoms persist despite non-surgical measures, surgical release of the nerve can be performed.^[5] See nerve decompression surgery and non-surgical treatment for foot nerve pain.

Before anyone reaches that point, the diagnosis needs to be confident. The history and examination are the core of it, and ultrasound or MRI can show what is pressing on the nerve.^[9] Numbness on the top of the foot can also come from a pinched nerve in the lower back, particularly when it comes with pain from the back or buttock. See sciatica or a foot nerve problem?

When to see a specialist

Consider an evaluation if pain, burning or numbness on the top of your foot lasts more than a few weeks, gets worse when you wear your usual shoes, or keeps returning after an ankle sprain.