'Top of Foot Pain' Management in Barefoot Runners

Despite all the propaganda that barefoot or minimalist running is better due to less injuries occurring, it is now becoming increasingly clear that it is not the way to get less running overuse injuries. Just check any barefoot/minimalist website and look at all those looking for advice on their injuries! Just ask any of the health professionals who treat a lot of running injuries. Most will tell you of the barefoot running injury epidemic that they are seeing. There is no doubt that there are some who have successfully transitioned to barefoot or minimalist running who now claim to get less injuries, but there are also those who are getting more!

One of the more common injuries being seen is what has become known as ‘top of foot pain’, which probably is dorsal midfoot interosseous compression syndrome (DICS). The pain of this is usually over the dorsal midfoot area. The cause of this is when the dorsiflexion moments of the forefoot on the rearfoot are higher than the plantarflexion moments, resulting in the dorsal jamming. Forefoot striking has greater forefoot dorsiflexion moments of the forefoot on the rearfoot than does heel striking. I have been involved in the management of a lot of ‘top of foot pain’ now in forefoot strikers or minimalist runners and here is my approach to it:

1. Firstly you really need to understand the runners views on barefoot/minimalist running and just what they are prepared to do. By this I mean how acceptable of different interventions are they to be; are they training for a specific event (to get an indication of the ‘urgency’ to get over the problem); what sort of time frame they have; etc

2. Of course we use the RICE principle with this injury like any others in the short term and make modification to the training regime to manage it.

3. The best way to manage ‘top of foot pain’ in the short term and long term is to decrease that dorsiflexion moment. How can you do that?

• a. If you follow some of the advice on the barefoot sites, you need to change your running form or gait somewhat and try to ‘retract’ the toes. As this will put a plantarflexory load on the metatarsals which will reduce the forefoot dorsiflexion moment. Most runners find this difficult and often it does not reduce the load enough for healing to occur (it may work better in the long term once the problem is treated).

• b. Low dye strapping, correctly applied to plantarflex the forefoot in such a way that it decreases the dorsiflexion moment will work brilliantly in the short term, but is not a good long term option. Correctly applying the low dye tape is crucial.

• c. Foot orthotics are easily the best way to reduce that dorsiflexion moment, however they have to have the right design features to do that or they are not going to work. All foot orthotic failure I have seen in those with ‘top of foot pain’, either did not decrease that forefoot dorsiflexion moment or even increased it!

• d. Depending on where they are at, they are also probably better off getting back to heel striking if they can to help reduce those forefoot dorsiflexion moments that are higher in forefoot striking.

• e. Ankle joint dorsiflexion also need to be checked and often a fibula mobilisation is needed to get that going properly.

• f. Increasing muscles strength may be a longer term option to reduce the dorsiflexion moment. However, as the joint moments are high, the muscles are already having to work hard because of that and are probably already really strong. The problem is the lever arm that the muscles have to the joint axes of rotation.

• g. A windlass dysfunction can also be an issue in creating higher forefoot dorsiflexion moments, so some sort of intervention to preload the hallux to get the windlass active sooner can be helpful (this can easily fit in minimalist running shoes)
  

4. However, depending on some of the answers to the discussion in (1) above, as too how acceptable some of these interventions are, for example:

• a. If they are more ‘purist’ in their views on barefoot/minimal, then they are not going to want to use foot orthotics or transition back to rearfoot striking (even in the short term). In this case, the running has to be cut back to level that is tolerable and a slow and gradual build up to allow the tissues to adapt to the load (ie adapt to those higher forefoot dorsiflexion moments). I happy to work with them on this, but they have to realise that in some people the moments are so high, that the tissues may never be able to adapt to the load and changes to the running form or gait. In this case other interventions will be needed if they want to get over it. I also point out that it will be harder and take longer to get better without the use of heel striking and/or foot orthotics.

• b. If they not so ‘purist’ then I will get them into foot orthotics and, if they, can get them back to heel striking in the short term. Once they are better and back to their normal training routine we then decide what to do in the longer term. Ideally they will transition back to forefoot striking (if that is there wish) and away from the foot orthotics. This has got to be a planned process and done incredibly carefully (as the previously injured tissues are very prone to re-injury) and gradually. In some, that forefoot dorsiflexion moment is so high, there is no way that it can be lowered with a gait change and so high that the tissues can adapt to that load. In which case the heel striking and/or foot orthoses are going to have to be a long term option

Just why are the joint moments causing this problem so high? I think the most likely reason is the variations that occur in joint exes positions and the lever arms the bones and tendons have to that joint axis.

‘Top of foot pain’ is common in forefoot strikers (barefoot/minimalist runners). Understanding the role that the higher joint moments play in it guides the short and long term management, as well as the attitudes to forefoot vs rearfoot striking and the role of foot orthoses as a short or long term option and the issue of the magnitude of the moments and if the tissues can adapt to those moments or not.

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