Return of Top of Foot Pain

[Sid]

I've been getting back into running, after a over a year off, when I was swimming. I had been doing okay. Even making progressing rehabbing my forefoot, straightening a bunion, improving my technique. Great progress.

I notice some TOFP last night. Oh no, too much too soon! So, I did some stretching and used some ice. Also, decided to go swimming today, instead of running.

 

[Sid]

I found this information on Top of Foot Pain. Very interesting stuff!

Dorsal Interosseus Midfoot Compression Syndrome by Kevin A. Kirby, DPM from Podiatry Arena

patients with DMICS point to the area of the metatarsal-cuneiform joints, navicular-cuneiform joints, and sometimes to the area of the metatarsal-cuboid joint as the source of most of their pain.

Managing ‘Top of Foot Pain’ in Forefoot Strikers by Craig Payne

‘Top of Foot Pain’ (ToFP) or Dorsal Interosseus Midfoot Compression Syndrome (DMICS) is a very common problem in forefoot strikers or minimalist runners. Its actually really easy to treat when you understand it...

The typical symptoms of ToFP or DMICS is pain over the dorsal midfoot, usually more toward the medial side. The cause of this condition is when the dorsiflexion moments of the forefoot on the rearfoot increase the loads in the dorsal midfoot tissues beyond what the tissues can tolerate. This creates a dorsal jamming of those midfoot joints producing the symptoms.

The management of this top of foot pain is going to be like any other overuse injury – initially with activity modification, ICE, NSAIDs, etc. Primarily, like any other overuse injury, the key is to reduce the load causing the problem (ie those dorsiflexion moments of the forefoot on the rearfoot) and increase the ability of the tissue to take the load.
...
How do you increase the ability of the tissues to take the load:
There is only one way to do this in this ‘top of foot pain’ problem; you need to cut back on the running to a level which reduces the symptoms and then progressively overloads the tissues at a slower rate than what was done previously (ie allow for a more slower progressive adaptation to the loads).

"Top of Foot Pain" from Barefoot Running from Podiatry Arena

Why does someone get DICS? They get it because the forefoot dorsiflexory moment is higher than the plantarflexion moment, combined with higher activity levels.... ie its an issue of decreased forefoot dorsiflexion stiffness. If the compressive forces are great enough --> DICS.
Craig Payne
...
The most logical method for a barefoot runner to heal from Dorsal Midfoot Interosseous Compression Syndrome (DMICS) if they want to continue running with nothing covering their feet is as follows:

1. lose weight
2. run slower with higher stride frequency
3. run on softer surfaces
4. ice the foot 20 minutes twice daily
5. work on strengthening the deep flexors, peroneus longus and plantar intrinsic muscles
6. use calcium supplements to help increase bone density
7. reduce training mileage and intensity for 3-12 months to allow the structural components of the foot to become stronger and more resistant to the stress injuries inherent in barefoot running.

Of course, they could just get some good running shoes and custom foot orthoses and be cured from DMICS in 2-3 weeks...
Kevin A. Kirby, DPM

 

[Sid]

So at work today, it dawned upon me, what the most likely caused the return of my TOFP was: dorsiflexion of the forefoot.

I run in the morning, then basically sit at a desk all day. So, I've tried sitting in different positions to stretch out a bit. Lately, my hip flexors have been feeling a bit tight, and I found that I was able to stretch them a bit by sitting at the edge of my chair, with my legs tucked under me, with my toes dorsiflexed and touching the ground. This position also helps me stretch out the bunions on my big toes.

Ouch, that position made my TOFP worse today! After reviewing the information above, it makes sense. It's funny, how things that we do the rest of the day, affects our running.
http://www.thebarefootrunners.org/index.php?posts/153439

 

[NickW]

Sid, also try using a roller on the lower legs, specifically on the muscles close to the shin on both sides. Works like magic almost every time for me if I get tofp. I believe Lee is the one who normally suggests that, but I thought I would beat him to it this time. Hope that helps.

 

[migangelo]

don't you know Craig Payne is mr anti-bf? don't listen to him. nsaids to cure your pain? no. like Nick said roll the muscles to the side of your shin and do back off the mileage a little. once your roll out the pain strengthen those muscles.

 

[Bare Lee]

Sid, also try using a roller on the lower legs, specifically on the muscles close to the shin on both sides. Works like magic almost every time for me if I get tofp. I believe Lee is the one who normally suggests that, but I thought I would beat him to it this time. Hope that helps.

Yep, that's what does it for me. I also think rolling or massaging the bottoms of the feet is really helpful, if not for ToFP, then just for general foot health. I also love to stretch out the hammes, ITB, and piri formis. It's all related, but definitely, the shin muscles are key for ToFP. You can actually feel immediate relief in your foot tendons as you massage the tightness away. Like Mike says, Kirby doesn't know what the f*ck he's talking about.

 

[Sid]

Sid, also try using a roller on the lower legs

roll the muscles to the side of your shin and do back off the mileage a little. once your roll out the pain strengthen those muscles.

Yep, that's what does it for me. I also think rolling or massaging the bottoms of the feet is really helpful, if not for ToFP, then just for general foot health. I also love to stretch out the hammes, ITB, and piri formis.

Thanks for the suggestions. I really do appreciate each of you trying to be helpful. I iced my foot last night and wore a compression sleeve for a bit, and it helped immensely. I was 90% better this morning and was back to jogging. Still feels good, this evening.

As for the cause, I'm certain that it was due to how I managed to wedge my foot in a dorsiflexed position while sitting at work, in order to try to stretch my hip flexors. Once, I changed that, it got better. (I also figured out a better way to stretch my hip flexors!) In addition, I found that in my specific case that plantarflexing helped, and their articles were quite beneficial in helping me understand why it helped.

don't you know Craig Payne is mr anti-bf? don't listen to him.

Like Mike says, Kirby doesn't know what the f*ck he's talking about.

I'm a bit concerned about both of your statements. I understand that both of you are very well-educated professionals. As per my first link above, Dr. Kirby first described DMICS in 1997, and was studying it as early as 11 years before that. His description in 1997 is a solid contribution to human knowledge and showed little antipathy towards barefooters.

I can appreciate that both Doctors Payne and Kirby have expressed less than favorable opinions of barefooting in more recent times, particularly as they've treated those injured from the minshoe fad. It seems that in general, their disdain is towards those who might treat minimalist footwear as magical cure-all shoes and those who think barefooting is a panacea. All of us probably share some similar opinions of novices who lack patience, seek quick fixes, and attempt too much too soon, only to injure themselves.

History shows that brilliant people can have less than brilliant opinions. Often years later, future generations learn to separate those invaluable scientific contributions from discriminatory prejudices. I sincerely believe that value can be extracted from their work. I'd like to do that now, rather than years later.

I suppose that this would apply to each of us as well. I, for one, would prefer to focus on the good, rather than the bad.

 

[NickW]

Part of my problem with these drs Sid, is that they think of the human condition as flawed and needing protection such as a shoe just to do its daily activities. Because of the way they view how the foot works (as a shoddie would use it) their understanding of how the foot affects everything else in the chain is flawed. This includes how tight shin muscles can cause tofp (some drs even diagnose this as a stress reaction or stress fracture). Just my two cents. If you like theor suggestions and they work for you, more power to you. We only say something because we have collectively found their beliefs, statements, and treatments to be incorrect when it comes to barefooters and minimalists.

 

[Sid]

Because of the way they view how the foot works (as a shoddie would use it) their understanding of how the foot affects everything else in the chain is flawed.

I'm not sure that I understand. When you say "they", do you mean Drs. Kirby and Payne, or barefoot-unfriendly docs in general?

Dr. Kirby's suggestions 1-7 are typical of what many folks on BRS suggest to novice barefooters. His eighth suggestion reflects his personal, as well as his professional opinion. It would appear that he has a fair understanding of the shod and unshod foot. Now, this certainly may not be true of all doctors.

My foot doesn't care about someone's beliefs or opinions; my foot is a biomechanical structure. My foot doesn't care whether or not it is in a shoe, on concrete or grass, or whether other people, doctors, or members of BRS think that it should be shod or unshod. All that matters to my foot, is that when it is able to function properly, it works pain-free.

 

[Bare Lee]

I'm not sure that I understand. When you say "they", do you mean Drs. Kirby and Payne, or barefoot-unfriendly docs in general?

Dr. Kirby's suggestions 1-7 are typical of what many folks on BRS suggest to novice barefooters. His eighth suggestion reflects his personal, as well as his professional opinion. It would appear that he has a fair understanding of the shod and unshod foot. Now, this certainly may not be true of all doctors.

My foot doesn't care about someone's beliefs or opinions; my foot is a biomechanical structure. My foot doesn't care whether or not it is in a shoe, on concrete or grass, or whether other people, doctors, or members of BRS think that it should be shod or unshod. All that matters to my foot, is that when it is able to function properly, it works pain-free.

Last year, or was it the year before, I watched Jason enter the scary world of blogging podiatrists. Their attitude was quite smug and hostile, and like Nick says, they start with the assumption that the foot is flawed and needs correction, as evinced in Kirby's statement "Of course, they could just get some good running shoes and custom foot orthoses and be cured from DMICS in 2-3 weeks..."

That is not to say they don't know a lot about biomechanics in general and foot function in particular, and if you've found their suggestions apply to your case, that's great. But their assholic attitude and anti-evolutionary assumptions make engaging with their work impossible for me.

 

[Hobbit]

Hello,
when I was transitioning to barefoot, of course I did too much too soon and I suffered from TOFP. The explanations of Doctors Payne and Kirby have the merit of explaining what happens actually in the "the metatarsal-cuneiform joints, navicular-cuneiform joints, and sometimes to the area of the metatarsal-cuboid joint". This makes it easier to understand instead of just suffering from some kind of "TOFP".
So with my beginners' TOFP I went to an Osteopath, who was decidedly barefoot unfriendly and tried to convince me to stop it at once. (Usually Osteopaths are rather barefoot friendly, but this particular one used to be a shod runner in his youth, apparently even some kind of top athlete - I suppose this is one of the reasons why he could not admit the idea of barefoot running as a good thing) Any way, he did his special cranial osteopathy thing on me (some method he invented, apparently), and since then, I've never again suffered from TOFP!

 

[Sid]

Last year, or was it the year before, I watched Jason enter the scary world of blogging podiatrists. Their attitude was quite smug and hostile

Is this the dialogue that you are referring to? It does appear a bit brusque. Though, Dr. Kirby appeared somewhat conciliatory. It seems that the discussion just sort of petered out...
www.podiatry-arena.com/podiatry-forum/showthread.php?t=64746

In the past, I did come across a dialogue that involved Dr. Mark. I don't think that one ended so well.

 

[Sid]

The explanations of Doctors Payne and Kirby have the merit of explaining what happens actually in the "the metatarsal-cuneiform joints, navicular-cuneiform joints, and sometimes to the area of the metatarsal-cuboid joint". This makes it easier to understand instead of just suffering from some kind of "TOFP".

Exactly! With their explanation, I was able to figure out that it was the position of my foot while sitting that was putting pressure on those areas. It was not due to too much too soon, or tight anything. I didn't need to massage my shins, or back off on my running.

That is not to say they don't know a lot about biomechanics in general and foot function in particular, and if you've found their suggestions apply to your case, that's great.

There's a great deal of anecdotal knowledge on BRS. It would be nice to bridge that folk wisdom with biomechanics.

 

[Sid]

But their assholic attitude and anti-evolutionary assumptions make engaging with their work impossible for me.

It would appear from Podiatry Arena that many of them feel the same way about evangelistic barefooters!

I find it curious that several people (who were sincerely trying to help, which I do very much appreciate) responded to my post with the usual recommendations for TOFP, despite my statement that I had already determined the cause.
It's also curious how strong of an emotional reaction was generated, after I had already edited out most of the anti-barefoot statements from the doctors.
Perhaps, strong biases exist on both sides?

 

[Bare Lee]

Is this the dialogue that you are referring to? It does appear a bit brusque. Though, Dr. Kirby appeared somewhat conciliatory. It seems that the discussion just sort of petered out...
www.podiatry-arena.com/podiatry-forum/showthread.php?t=64746

In the past, I did come across a dialogue that involved Dr. Mark. I don't think that one ended so well.

Yah, I'm definitely not going to go back and read all that, but if I recall correctly, the problem is that Kirby/Payne et al confuse, just as the popular media does, acute injuries incurred while transitioning to barefoot/minimalist running, with chronic injuries from habitual use of overbuilt shoes and orthoses. And so they end up shrugging and saying, "you see, neither one is better or worse and there's no science to back any of it up."

The former kind of injury, of course, presupposes previous habitual shoe use that has led to the atrophy of the foot and lower leg muscles, tendons, and bones. It's like blaming strength training for an injury incurred by an obese, sedentary person who launches right into deadlifting their bodyweight. It's the previous lack of strength training, or barefoot activity, that is to blame. Kirby/Payne refuse to acknowledge this and so assume that feet are weak and in need of protection/support by nature. If there is greater subtlety to their argument, or if some of the contributors are more nuanced in their approach, I apologize, but that's how I remember the crux of their argument.

If they want proof that barefoot is healthier, all they have to do is look at habitually unshod populations, where foot maladies are much rarer. Again, it's the evolutionary perspective that is missing in their arguments. They assume the contemporary urban condition is normal/the default, rather than look at how a biology that has evolved under quite different selection pressures may become better adapted to the world we have built up over the last few centuries of industrial capitalism. Simply walking around barefoot more and strengthening the body through fitness activity is a pretty obvious solution to many of us. No orthoses or pills or supplements required. The only question is how best to deal with the period of transition necessary in the habitually shod or sedentary. That's where all the problems lie, it seems to me.

Unfortunately, the fitness industry shies away from simple, evolutionarily sound solutions a good deal of the time. Instead of getting back to basics/nature, we're told we need more products to make our bodies function more naturally. Or instead of simply lifting heavy stuff to make our bodies strong, limber, and loose, we're told we need machines and stability balls and myriad different workout strategies.

It would appear from Podiatry Arena that many of them feel the same way about evangelistic barefooters!

I find it curious that several people (who were sincerely trying to help, which I do very much appreciate) responded to my post with the usual recommendations for TOFP, despite my statement that I had already determined the cause.
It's also curious how strong of an emotional reaction was generated, after I had already edited out most of the anti-barefoot statements from the doctors.
Perhaps, strong biases exist on both sides?

I'm not sure who these evangelistic barefooters are. Straw men perhaps? Everyone here at BRS seems pretty open-minded. It's simply reasonable to assume barefoot function as the default, given what we know about evolution. No evangelism or purism required.

As for responding stereotypically to your post, I guess the standard definition of ToFP is pain in the top of the foot above the metatarsals, and the standard treatment is massaging the shin and calf muscles (http://gobarefooting.wordpress.com/2010/05/01/injury-top-of-the-foot-pain-treatment-and-recovery/). It's too vague, you're right, and doesn't apply to more complicated cases like yours.

 

[Sid]

Okay, I think I'm beginning to appreciate your perspective. It seems unlikely that podiatrists will be the source of promoting such a change. Individual practitioners of Western medicine are too far removed from the larger picture to explore such things. A doctor may be great at prescribing pills, surgery, or making orthotics to address the individual patient's needs. That same doctor may be quite miserable in evaluating and designing interventions for prevention on a population level.

That belongs to the field of public health. Those advocates have their hands full with the usual alcohol, tobacco, child safety, vaccination, health insurance, heart disease, obesity, elder care. Foot care ranks pretty low on that list. Correction: it's not on the list at all.

 

[Bare Lee]

Okay, I think I'm beginning to appreciate your perspective. It seems unlikely that podiatrists will be the source of promoting such a change. Individual practitioners of Western medicine are too far removed from the larger picture to explore such things. A doctor may be great at prescribing pills, surgery, or making orthotics to address the individual patient's needs. That same doctor may be quite miserable in evaluating and designing interventions for prevention on a population level.

That belongs to the field of public health. Those advocates have their hands full with the usual alcohol, tobacco, child safety, vaccination, health insurance, heart disease, obesity, elder care. Foot care ranks pretty low on that list. Correction: it's not on the list at all.

I don't agree. Doctors treat individuals, and a population-level lifestyle (culture) affects individual anatomy and physiology on a continuous basis (again, the evolutionary perspective), and must therefore be taken into account. The organism doesn't exist in isolation, but rather in an environment. A mechanistic perspective is part of vulgar science of course, and that's what most doctors are exposed to I suppose.

When I returned Stateside, for example, I had high blood pressure, somewhere in the 140s I think. My doc, like a good mechanic, wanted to fix the malfunctioning machine and prescribed a pill that would bring the pressure down. I told him wait, give me a few months to start getting back into shape. And sure enough, my blood pressure returned to normal quickly. All I had to do was return my organism to a more normal, evolutionarily given, biological functioning--i.e., greater movement within its environment.

I don't know why podiatrists are so opposed to this kind of thinking. I think my doc recommended the pill because most patients are resistant to exercise. I dunno, but he certainly didn't oppose my exercise experiment. And dentists know that our modern diets have too much sugar and that's why we have so much tooth decay. Why do podiatrists think it's natural to walk around in heels that throw the whole gait and skeletal-musculature off? Or encase our feet in stiff, supportive shoes that allow them to atrophy?

 

[NickW]

I wouldn't say I am an evangelist at all. I wear shoes and sandals most of the time and rarely go barefoot outside the house anymore. I had just made a suggestion about rolling your shins. Mike and Lee had made the initial comments about the drs. I thought a free home solution might help. Kinda seemed like that was what you were looking for.

Yah, I'm definitely not going to go back and read all that, but if I recall correctly, the problem is that Kirby/Payne et al confuse, just as the popular media does, acute injuries incurred while transitioning to barefoot/minimalist running, with chronic injuries from habitual use of overbuilt shoes and orthoses. And so they end up shrugging and saying, "you see, neither one is better or worse and there's no science to back any of it up."

The former kind of injury, of course, presupposes previous habitual shoe use that has led to the atrophy of the foot and lower leg muscles, tendons, and bones. It's like blaming strength training for an injury incurred by an obese, sedentary person who launches right into deadlifting their bodyweight. It's the previous lack of strength training, or barefoot activity, that is to blame. Kirby/Payne refuse to acknowledge this and so assume that feet are weak and in need of protection/support by nature. If there is greater subtlety to their argument, or if some of the contributors are more nuanced in their approach, I apologize, but that's how I remember the crux of their argument.

If they want proof that barefoot is healthier, all they have to do is look at habitually unshod populations, where foot maladies are much rarer. Again, it's the evolutionary perspective that is missing in their arguments. They assume the contemporary urban condition is normal/the default, rather than look at how a biology that has evolved under quite different selection pressures may become better adapted to the world we have built up over the last few centuries of industrial capitalism. Simply walking around barefoot more and strengthening the body through fitness activity is a pretty obvious solution to many of us. No orthoses or pills or supplements required. The only question is how best to deal with the period of transition necessary in the habitually shod or sedentary. That's where all the problems lie, it seems to me.

Unfortunately, the fitness industry shies away from simple, evolutionarily sound solutions a good deal of the time. Instead of getting back to basics/nature, we're told we need more products to make our bodies function more naturally. Or instead of simply lifting heavy stuff to make our bodies strong, limber, and loose, we're told we need machines and stability balls and myriad different workout strategies.

I'm not sure who these evangelistic barefooters are. Straw men perhaps? Everyone here at BRS seems pretty open-minded. It's simply reasonable to assume barefoot function as the default, given what we know about evolution. No evangelism or purism required.

As for responding stereotypically to your post, I guess the standard definition of ToFP is pain in the top of the foot above the metatarsals, and the standard treatment is massaging the shin and calf muscles (http://gobarefooting.wordpress.com/2010/05/01/injury-top-of-the-foot-pain-treatment-and-recovery/). It's too vague, you're right, and doesn't apply to more complicated cases like yours.

I do agree with Lee on a lot of this. I used to have the utmost faith in drs, it wasn't until I had numerous drs try to make me a frankenstein with unnecessary surgeries that I wised up. I believe they know a lot, but I don't believe they know everything and their view of how the foot works is incorrect since their starting platform is the shoe, a man made device. Shoes make people walk and run differently, not to mention disfigurement of the feet and atrophy of the muscles. If they don't understand that the foot is not supposed to be weak like that because they think the foot is flawed and they cam't understand the foot acts and moves differently when strengthened, how are they supposed to really fix the root cause of problems? In any case, I told you in my very first post that if their suggestions work for you then more power to you. I've often seen drs suggestions not work for people while the rolling of the shin muscles does. Thought it was good free advice for you to help...

 

[DNEchris]

I don't know why podiatrists are so opposed to this kind of thinking. I think my doc recommended the pill because most patients are resistant to exercise. I dunno, but he certainly didn't oppose my exercise experiment.

Your doctor may be wise as he could have felt that, with the suggestion coming from you, you would be likely to take your own advice - the doctor may well have already got tired of making recommendations to others knowing that the advice was not very likely to be followed
Your level of motivation could have been the deciding factor!

 

[Bare Lee]

Your doctor may be wise as he could have felt that, with the suggestion coming from you, you would be likely to take your own advice - the doctor may well have already got tired of making recommendations to others knowing that the advice was not very likely to be followed
Your level of motivation could have been the deciding factor!

Yah, that's what I suspect, like I said, I think my doc recommended the pill because most patients are resistant to exercise. Still, it was strange how he seemingly ruled out right from the start suggesting exercise to me as a possible cure. In any case, judging from Kirby and Payne, in the case of podiatrists, it is the doctor, not the patient, who appears resistant to more natural remedies for foot maladies. A big difference. Maybe they know few patients will be willing to go through the transitional period of slowly weaning their feet from support and orthoses through strengthening exercises and activity, much as my doc may know few patients at my age will be willing to exercise regularly, but judging by the hostility of Kirby/Payne to barefoot running, I suspect not.

Anyway, I never intended to get into a discussion about podiatry and barefoot running again. I'm glad Sid has found a solution and hope to see him reporting his mileage again soon. I only confirmed Nick's rec because it has worked well for me and, judging by the responses at go barefooting, well for a lot of other people as well. I don't presume to understand any of the fundamentals about biomechanics and foot structure. I like my solutions to be as mindless as possible. Massaging, stretching, and strengthening have kept me loose, limber and strong for more than a year now of trouble-free running.