‘Top of Foot Pain’ (ToFP) or Dorsal Interosseus Midfoot Compression Syndrome¹ (DMICS) is a very common problem in forefoot strikers or minimalist runners. Its actually really easy to treat when you understand it, yet so often it becomes an ongoing problem and on barefoot websites you often see it called, “the dreaded ToFP”!
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 reduce the dorsiflexion moments:
- Low dye strapping is very effective at this, but has to be applied to ensure the the forefoot is plantarflexed on the rearfoot as it is not going to be very effective if not done this way; usually this is only a short term measure.
- Heel striking. Get into running shoes that allow it. This does not have to be a medium to long term measure, but will reduce the dorsiflexion moments and allow the tissues to heal. You can worry about transitioning away from this later; depends how much priority you want to give to getting over the injury.
- Fibula mobilization may be necessary if this is inhibiting ankle joint mobility; this can load up the midfoot joints.
- Foot orthotics are the best way to lower the dorsiflexion moments, providing they have the design features that allow it to happen (most common foot orthotic designs do not have these). The required design features are to dorsiflex the calcaneus and have no or minimal support in the anterior half of the medial arch. You can worry about transitioning away from these later if necessary; depends how much priority you want to give to getting over the injury.
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). This can be done with or with out the strapping, heel striking and foot orthotics mentioned above. If they are used, then recovery will be considerably quicker than not using them. You can attempt to transition away from them over the medium to longer term at a rate that allows the tissue to adapt to the increasing load as you cut back on their use and increase activity levels.
My approach to the above is to go through the options with the runner. I know which options will probably give the better results, but it all depends on what they want and their views on the different interventions (and that will depend on how much weight they give to my advice compared to the nonsensical rants that read in the blogosphere!). Its their choice and depends on how quick they want to get over the problem.
When is heel striking and foot orthotics needed long term? (see: Short or Long Term Use of Foot Orthotics?):
If the tissues can not adapt to the load being placed on them, then heel striking and foot orthotics are the best long term option to reduce the dorsiflexion moments. The tissue will not adapt to the loads if the magnitude of the forces are too high for adaptation to take place. Invariably the magnitude of the forces vary substantially from individual to individual and is most likely related to variations in the position and orientation of joint axes of motion and the resultant variation in lever arms and vectors. The ability of the tissue to adapt will also depend on the health of those tissues. Staying as a heel striker or using foot orthotics long term is not a problem.
Despite all the rhetoric and propaganda, not one study has shown anything wrong with heel striking or long term use of foot orthotics (they do not weaken the muscles). It all depends if you want to get over the injury or not. It is easy to treat.
¹For more on dorsal midfoot interosseous compression syndrome, see this.