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"Top of Foot Pain" from Barefoot Running

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Jul 14, 2010.

  1. Craig Payne

    Craig Payne Moderator


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    I just have had the opportunity to meet up with 3 'barefoot runners'. Only one of them is still doing some drills barefoot; the other two were disillusioned because of the injuries. One with stress fractures from his Vibrams; and the other could not shake “Top of Foot Pain” - it was not until he went back to his running shoes would it go away, only to return again when he tried to transition.

    It was the nature of the “Top of Foot Pain” in barefoot running that intrigued me, so I did some looking up and it is commonly reported by barefoot runners.

    I don’t want this thread to turn into a debate on barefoot running (we have some of those: Debate on Barefoot Running and The Effect of Running Shoes on Lower Extremity Joint Torques) and also on the stress fracture epidemic in Vibrams.

    From what I can glean, this top of foot pain is either a stress fracture or its actually the dorsal interosseous compression syndrome (DICS) - most of the reports I read and enough info was given, they appear to be DICS (the runner I mentioned above had DICS).

    The reason for this thread, apart from telling them to stop barefoot running and go back to shoes, how can we manage this clinically in barefoot runners?

    The simplistic approach on the barefoot running websites is to blame training errors and errors in the barefoot technique and not transition properly and you treat it by revisiting that (which is somewhat paradoxical that barefoot runners are happy to blame training errors for injury, but it is the running shoes are the problem when a runner gets an injury in a shoe and can’t be a training error ... don’t figure that logic).

    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. With foot orthotics and running shoes, it is easy to decrease that forefoot dorsiflexion moment.

    How would you treat DICS in a barefoot runner without resorting to the Church of Barefoot Running rhetoric? The only way this can be treated in someone who wants to continue running barefoot would be to find another way to reduce that forefoot dorsiflexion moment and increase the plantar flexion moment. The only way to do that without an external aid, is to strengthen the muscles that can provide a forefoot plantarflexion moment (and those options are limited). The only way that will work will depend on the magnitude of that moment. In some it will be too high for the muscles to overcome (sorry, but you have to give up barefoot running) and it others it will low enough to overcome (but you going to have to use an external aid in the short term). Some barefoot runners are going to be able to adapt and other will never be able too.

    What say you?
     
    Last edited: Jul 17, 2010
  2. 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........but that would mean that they wouldn't still be running "naturally"........:bash::bang::craig:
     
  3. What about looking at stride length, adjusting the foot striking position to a slightly more midfoot as well.


    Are we allowed to use tape ?

    if so look at ways to reduce to FF dorsiflexion moment. or are you not allowed to run with taped feet if your " barefoot" Running Zola used to tape, so I assume you can tape as well.
     
  4. Michael:

    By running slower with a higher stride frequency the runner will have a reduced stride length.
     
  5. Which should increase leg stiffness. Couple this with running on a softer surface and you have even more leg stiffness. Interesting, Irene Davis's work suggests bone injury is associated with increased leg stiffness....
     
  6. Bruce Williams

    Bruce Williams Well-Known Member

    Craig;

    heheheh, heheh, (in Beavis and Butthead voices) you said DICS!
    sorry couldn't resist!:dizzy:

    I think the primary problem for these runners is that they are used to a built in heel height in their running shoes and that they transitioned directly from shoes to barefoot.
    Stretching is mandatory, as is dialing down heel height over a period of time.

    I see it as both the DFion stiffness problem of 1-3 met bases, usually, along with AJE.
    It's easy enough to identify in athletes adn use an orthotic and AJ manipulation to treat.
    Definitely more difficult in barefooters, but not impossible if they are willing to understand the mechanics as you explain them and to take time to work on their AJ DFion ROM.
    Once the AJ can move again the midfoot and metatarsals will not have to DF for loss of AJ ROM and the problem should take care of itself over time.

    Decided on where you are staying in Seattle yet?
    Bruce
     
  7. Their ankle joints are fused?
     
  8. Bruce Williams

    Bruce Williams Well-Known Member

    I don't think I wrote that did I?

    Decreased AJ DFion ROM will lead to a need for compensatory Forefoot / Midfoot increase in DFion. This is the root cause of DICS in my opinion.

    So, either accomodate the AJE with heel lifts, or a running shoe, or get the AJ to DF more in midstance.

    Is that clearer now Simon?

    Bruce

    PS: anyone have any references on DICS? I cannot find any online. Thanks
     
  9. You wrote:
    Assuming that aj means ankle joint, the inference being that it cannot move until you do whatever it is that you propose to do. Anyway...

    As mud Bruce, lighten up.

    I think:
    AJ = ankle joint
    DFion = dorsiflexion
    ROM = range of motion
    DICS = dorsal interosseous compression syndrome
    AJE = ankle joint equinus
    DF = dorsiflexion (again, but with a different acronym)

    Simples, particularly on this international website where English is not the first language of many of the members.

    So, the assumption being that these runners all have ankle equinus? As I've not examined them (nor have you) it's difficult to say. What's the average heel height differential of modern running shoes?
     
  10. Bruce Williams

    Bruce Williams Well-Known Member

    Gee Simon, maybe Craig can post the abbreviation bar you created!:rolleyes:

    Lighten up yourself Dr. knit picker!
    :drinks

    Bruce
     
  11. Light as a feather Dr Williams.....

    Lets think this through. Dorsal midfoot interosseous compression syndrome can be due to either a decrease in rearfoot plantarflexion stiffness or a decrease in forefoot dorsiflexion stiffness, or both- agreed>

    So one of the key structures resisting the rearfoot plantarflexion moments and the forefoot dorsiflexion moments is the plantarfascia- agreed? Tension in the plantarfascia is correlated with tension in the achilles tendon- Kogler, so if we decrease achilles tendon tension we decrease plantarfascial tension = decrease in resistance to "arch flattening", viz. rearfoot plantarflexion, forefoot dorsiflexion = increased chance of dorsal midfoot interosseous compression syndrome. So the key to therapy in these cases, should be to increase achilles tendon tension, but achilles tendon tension = increase in arch flattening moment = increase chance of dorsal interosseous compression syndrome= paradox. But we need to consider the position of the net ground reaction force vector- right, Bruce? And increasing ankle range of motion (decreasing ankle dorsiflexion stiffness) via manipulation should allow the centre of pressure to pass more distally along the bottom of the foot for a given achilles tension (reduced ankle dorsiflexion stiffness), which should present the foot with greater forefoot dorsiflexion moment to cope with, without the tension in the plantarfascia to deal with it.- Right, Bruce?

    If however, we could increase the activity of the plantar intrinsics, this might achieve the same aim, i.e. increase dorsiflexion stiffness of the forefoot etc. Interesting to note that activity of certain plantar intrinsics which span the medial longitudinal arch and could help to control these forces, increases as the foot pronates.

    Interesting also, that dorsal interosseous compression syndrome is, I guess, a bone pathology. According to Butler et al. Bone pathology is associated with increased leg stiffness as are higher arched feet. I think what is happening here is that the body can't make the leg stiffness compliant enough (low enough) to deal with the increased surface stiffness induced by getting rid of the cushioned trainers. So lets pretend for a moment that if we decreased leg stiffness and allowed more pronation (decreased foot stiffness), by decreasing step frequency and increasing stride length and moreover, increasing knee flexion, what would be the effects on our pathology?? Radical thought, I know, but then who wants to be a sheep?

    Yeah, but if we increase knee flexion, we decrease achilles tension... Baaa. You see this circular argument I'm stuck in with myself.
     
  12. Bruce:

    I'm not sure that stretching the gastrocnemius-soleus-Achilles tendon (GSAT) complex would help in barefoot runners since these runners invariably self-select to foot strike on their midfoot or forefoot to avoid heel striking and possibly causing plantar heel injury. This midfoot-forefoot stiking pattern is also preferred by those who choose to run in Vibram FiveFingers also, presumably also to decrease risk of plantar heel contusions.

    Also, Simon's point of first spelling out your acronyms and abbreviations is a good one since I believe we would all be able to understand each other better on this forum if we didn't assume that everyone knows what we mean when we use such confusing terms in these discussions. I am much more "nitpicky" than Simon, probably because he is still nearly a decade away from becoming a half-century old and isn't nearly as crotchety as I have become, now with three grandchildren (and our first grand daughter)!!
     
  13. Congratulations on adding another female to the "Kirby tree". At least Pam is less out numbered now. The next point I was going to make was on strike pattern... let's see how it runs though...

    P.S. regarding acronyms and abbreviations, I had a nit-picking teacher.
     
  14. Bruce Williams

    Bruce Williams Well-Known Member

    interesting argument. I don't recall the correlation of the plantar fascia tension and achilles tension in Kogler, I suppose I'll have to look at it again to see what you mean.

    I took away from Kogler what I did from Eric's paper on the plantar Fascia, PF, that elongated tension in the fasia during midstance, or prolonged elongated tension as I see it, is usually a bad thing in regards to causing pain.

    It is easy enough to shorten this prolonged elongated period (maybe I should say pronlongated? :rolleyes:) tension via manipulating the ankle joint allowing for the AJ to DF further which then as you alluded often leads to an elimination of the increased force within the fascia.

    Once the ankle joint motion is restored then often the tension within the PF will decrease I think, until the mpj's have dorsiflexed for proper windlass function.

    Fascia and tendon are distinctly different tissues in their capabilities to return energy, muscle / tendon, and in their positional functional abilities, both fascia and tendons. The PF will not function appropriately on its own without proper timing and positioning of the mpj's and the ankle joint as well I thnk.

    If the ankle joint is allowed to have an increased DFion rom, then the energy return from the achilles should more than equal out the possible tension lost as you state.

    DICS is not necessarily a boney pathology but I think tension within the dorsal ligamentous structures of the metatarso-cuneiform joints, usually 1-3 in my experience. It can lead to a "dorsal boss", an exostosis at the 1st metatarso-cuneiform joint. Usual cause is attributed to hypermobility at the 1st ray, decreased DFion stiffness for those on the list. I assume any boney pathology results from prolonged tension of the ligamentous structures on the local bone, much as achilles spurring and plantar fascia spurring come about.

    Interesting thread. I am not currently treating any barefooters so it is not a problem for me at this time. I still think stretching is a must to decrease achilles tension but I couple it with manipultion of course.

    I do not disagree with the running technique changes suggested, I am utilzing them myself currently in my training.

    I do think that there feet that will never do well without shoes, or are very likely to not do well. Example would be feet with an anterior/Forefoot equinus and low DFion stiffness / hypermobility within the 1st ray, ie Functional Hallux Limitus, FnHL. Interesting that Kevin coined that abbreviation and used(s) it regularly despite his aversion to abbreviations! :dizzy:

    Still waiting for any references on DICS.

    :drinks
    Bruce
     
  15. Griff

    Griff Administrator

    Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997, pp 165-168.

    Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, Arizona, 2009, pp 117-118.
     
  16. Bruce:

    The correct acronym, not abbreviation, for dorsal midfoot interosseous compression syndrome is DMICS.

    I fully support and recommend the use of proper acronyms and abbreviations as long as they are initially fully spelled out on their first initial use in a posting or paper. It's just when certain individuals use their own pet acronyms and abbreviations in postings here on Podiatry Arena without spelling them out initially that problems arise. These individuals tend to assume that all podiatrists around the world know what their pet acronyms and abbreviations mean, which couldn't be further from the truth.

    I prefer for people to understand what I mean when I have taken the time to write on these forums. I don't want my international podiatry colleagues to feel like they are reading a message written in some sort of secret code that can't be completely understood without an official Podiatry Arena decoder ring.

    See you in Seattle.:drinks
     
  17. It may not have been in Kogler, I was working from memory of the reference, but it is here:
    Carlson RE, Fleming LL, Hutton WC: The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Intl., 21:18-25, 2000
    And here:
    Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA: Dynamic loading of the plantar aponeurosis in walking. JBJS, 86A:546-552, 2004
     
  18. Bruce Williams

    Bruce Williams Well-Known Member

    Thank you Simon, I will look those up when I can get
    them from my librarian.
    Bruce
     
  19. I prefer to describe dorsal midfoot interosseous compression syndrome (DMICS) as being due to increased external forefoot dorsiflexion moment which, in walking patients, is invariably due to a lack of adequate ankle joint dorsiflexion and/or increased ankle joint dorsiflexion stiffness.

    As you noted, the only references that I know of that have shown strong correlation between Achilles tendon tension and plantar fascial tension are as follows (Erdimir A, Hamel AJ, Fauth AR, Piazza SJ, Sharkey NA: Dynamic loading of the plantar aponeurosis in walking. JBJS, 86A:546-552, 2004;Carlson RE, Fleming LL, Hutton WC: The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Intl., 21:18-25, 2000). In fact, one of my main complaints about Kogler's studies where he measured plantar fascial tension in cadavers is that in his experimental setup, he loaded only the tibia, not the the Achilles tendon which, in my opinion, greatly weakens the validity of trying to measure physiological loads within the plantar fascia (Kogler, G.F., Veer, F.B., Solomonidis, S.E., and J.P. Paul: The influence of medial and lateral placement of orthotic wedges on loading of the plantar aponeurosis. JBJS (Am), 81(10): 1403-1413, 1999).

    The key to therapy for DMICS is as follows:

    1. Decrease external forefoot dorsiflexion moment. This can be often accomplished by reducing Achilles tendon tension with calf stretching exercises and using shoes with optimum heel height differential.

    2. Increase external forefoot plantarflexion moment/rearfoot dorsiflexion moment. Custom foot orthoses with excellent medial arch contour and also plantar arch strapping can effectively accomplish the goal of reducing the arch flattening moments on the foot.

    3. Increase internal forefoot plantarflexion moment. Even though I have never tried this on my patients, strengthening the plantar intrinsic muscles, the flexor hallucis longus, flexor digitorum longus, posterior tibial and peroneus longus muscles should theorectically help reduce the dorsal interosseous compression forces within the midfoot joints. However, this may be a uphill battle for most patients as long as their gastrocnemius-soleus-Achilles tendon complex has increased stiffness.
     
  20. Bruce:

    I first named and described the condition of dorsal midfoot interosseous compression syndrome (DMICS) over 13 years ago in my February and March 1997 Precision Intricast Newsletters (Kirby KA: Foot and Lower Extremity Biomechanics: A Ten Year Collection of Precision Intricast Newsletters. Precision Intricast, Inc., Payson, Arizona, 1997). I believe DMICS is a bony pathology since dorsal midfoot joint compression forces are huge when there is increased body weight and a tight Achilles tendon while nearly all patients who have DMICS have no biomechanical cause of increased tensile force on the dorsal midfoot ligamentous structures.

    One of the tests I use for DMICS is what I call the "forefoot plantarflexion test" where the forefoot is plantarflexed on the rearfoot to reproduce the pain of DMICS. This test is invaluable at diagnosing DMICS and is nearly always painful for the patient with DMICS. I believe the forefoot plantarflexion test is so painful because of the increased pulling of the dorsal ligaments on the injured and sensitve dorsal midfoot joint margins which occur due to the test. I would expect patients with significant DMICS to have MRI evidence of dorsal midfoot joint subchondral bone edema, even though I have never ordered an MRI on these patients. This would be an excellent research project and I predict will confirm my hypothesis as to the causative mechanism of this relatively common pathology.
     
  21. Bruce:

    I have been using these references in my "Ten Functions of the Plantar Fascia" lecture for quite a few years now. The study by Erdemir et al was done at Penn State Biomechanics Lab and is the only study I know of that directly measured the tension within the plantar fasia (done by fiber optic cable), not with a strain gauge as in the other papers that measured "plantar fascial tension".

    BTW, one of the coauthors of the Erdemir study, Steve Piazza, PhD, will be lecturing in Seattle. Steve and I have done a few papers together on subtalar joint axis location. Lots of smart engineers will be attending the meeting....can't wait!
     
  22. How do we know it's increased external forefoot dorsiflexion moment and not decreased internal forefoot plantarflexion moment?
    And by reducing Achilles tendon tension we also reduce plantarfascial tension, so we also decrease internal forefoot plantarflexion moment. This is the point I was making.
     
  23. Simon:

    Of course, it could be either increased external forefoot dorsiflexion moment or decreased internal forefoot plantarflexion moment that causes dorsal midfoot interosseous compression syndrome (DMICS). Decreasing Achilles tendon tensile force will reduce external forefoot dorsiflexion moment due to decreased ground reaction force acting on the plantar forefoot and will also cause decreased internal forefoot plantarflexion moment due to decreased plantar fascial tensile force. However, the positive effect of reducing external forefoot dorsiflexion moment with Achilles tendon stretches and heel lifts seems to nearly always win out over the negative effect of reduced plantar fascial tensile force and decreased internal forefoot plantarflexion moment in the clinical treatment of DMICS.

    Complicated.....but good discussion, Simon!:drinks
     
  24. It is complicated, Kevin. It gets even more complicated when we consider the forward progresssion of the centre of mass ( COM) and centre of pressure (COP). In a foot with decreased Achilles tendon tensile forces, the progression of the COM and COP distally prior to heel lift should be greater than in a foot with higher tensile forces generated through the Achilles. The more distal migration of the COP / COM should increase external forefoot dorsiflexion moment. So, not only should reduced achilles tendon tensile forces result in reduced internal forefoot plantarflexion moment via the plantarfascia, we also have potential for the external forefoot dorsiflexion moment to be increased. Just an observation.
     
  25. Simon:

    A decrease in Achilles tendon tensile force would certainly allow the center of mass (CoM) of the body to progress further forward relative to the plantar foot before heel lift when compared to where there is an increase in Achilles tendon tensile force. However, a decrease in Achilles tendon tensile force should also slow the forward progression of the center of pressure (CoP) since the foot is not being plantarflexed into the ground as rapidly when compared to when there is increased Achilles tendon tensile force. Therefore, I can't agree that external forefoot dorsiflexion moment will be increased with a decrease in Achilles tendon tensile force.
     
  26. What is the relationship between the centre of pressure position and the position of the centre of mass?

    Some further thoughts, the timing of heel lift is important. Lets say that we get a slower distal migration of the centre of pressure with reduced achilles tension, but we also get a relatively delayed heel lift- so who's to say this timing difference doesn't result in the same or increased forefoot dorsiflexion moment?


    There is research which shows that achilles tension accounts for only about 10% of the variance observed in forefoot pressures- what accounts for the other 90%?

    One of the important factors here that we haven't yet discussed is the position of the net midfoot axis. What factors influence the angulation of the midtarsal joints net axis, given the relative lack of constraint at these joints? As I recall the Nester showed a net midtarsal joint axis that was longitudinal at strike, oblique through midstance and longitudinal again in propulsion.

    Also the relative lengths of the metatarsals might be important.
     
  27. I believe this subject of the relationship of the position, velocities and accelerations of the center of mass (CoM) of the body relative to the position, velocities and accelerations of the center of pressure (CoP) during walking and their relationship to such things as what causes a early, normal or late heel lift, what relationship it has to electromyographic (EMG) activity in the lower extremity and what relationship it may have to injury of the foot and lower extremity is a virtually untouched subject, research-wise. For that reason, I don't think that we have any solid research to hang our hats on at this point in time so we must, for now, use mechanical modelling methods to try to sort out what probably happens.

    First of all, the external forefoot dorsiflexion moment will be determined by the location of the CoP, and the direction and magnitude of the ground reaction force (GRF) vector, not necessarily by the location of the CoM, during walking. Since walking is a dynamic activity, the CoP and CoM are constantly changing relative to the plantar foot. [David Winter calls the plantar representation of the CoM the center of gravity (CoG)].

    The CoM will always be moving forward during walking, will never move backwards and these movements will be relatively smooth with low accelerations. However, it is possible to have the CoP move rapidly from posterior to anterior, then make a sudden acceleration backwards from anterior to posterior and even may stop in place for a few milliseconds, due to the peculiar muscle activity of the individual during walking.

    Imagine that the patient fired their gastrocnemius-soleus complex (GSC) very hard and very early during gait, before the CoM had reached the middle of midstance, with the CoM over the center of the foot. The CoM would still be moving forward, but the CoP would accelerate forward rapidy toward the metatarsal heads, then as the GSC relaxed, the CoM would continue to move forward, but the CoP may then reverse in a posterior direction. The changes in the plantar location of GRF, which is determined largely by muscle activity, will determine not only the plantar location of the CoP but also the externally generated moments acting across the joint axes of the foot and lower extremity (from the GRF vector).

    Maybe someone with access to a force plate or pressure mat could send in images to us of them trying to get odd movements of the CoP on their plantar foot using odd firing patterns of their lower extremity muscles during walking. I think this would be highly instructive for this excellent discussion that Simon has begun.
     
  28. http://www.univie.ac.at/cga/teach-in/grv/
     
  29. Bobba Booey

    Bobba Booey Active Member

    What is the optimum heel height differential?
     
  30. kzemach

    kzemach Welcome New Poster

    Hi,

    I'm not a podiatist (doctorate's in a different field), but stumbled upon this thread and, as a runner, do think I have some anecdotal information about my new top-of-foot pain to add to this. I'll try to be brief...

    Background

    *Long distance runner (some 50s, training for 100)
    *Recent runner (1.5 years, 41yo) and when I started was a running shoe heal striker with an average cadence of ~170-174.
    *Started using Vibram Five Fingers (VFF) as a cross training tool only, about 6 months ago. Would ONLY use them once every week or every other week to a) give me some variety and b) they make you quicken your pace and I can't count the number of distance running coaches who swear by the increased efficiency of both ~180 for cadence and mid/forefoot striking IN SHOES.
    *Again, perhaps one hour / 7 miles of VFF running every week or two, with another 50 or so miles per week in shoes (and not minimalist shoes).

    Recent Addition of Top Foot Pain

    I hadn't tried to force my cadence/foot striking too radically until after my last 50 miler (which was fine, no pain, no issues). Then I worked mainly on picking up cadence and mid-foot/forefoot striking in my regular running shoes. The good news is I've been pretty successful at moving to a 180+ cadence in my regular running shoes. The bad news is that I developed top foot pain, and I'm pretty sure it's not stress fractures, in my right foot. And it sounds exactly like the type of pain to which you're referring.

    My Subjective Analysis

    A. I moved too quickly to a different gait/stride type for my feet to properly adjust, and combined with the relatively long distances (say, 2 x 18 milers on a given weekend plus runs during the week), the pain crept up on me without any severe warning signs.
    B. I had noticed that in changing my foot strike, I was perhaps concentrating too much on the feet, and I was tensing my feet a bit (especially the right foot... oddly enough...)

    Thoughts for You All To Chew On

    *Assuming I have the same thing about which you're conversing, and I'm pretty sure I do, in my case at least it wasn't barefoot running that did it, as it developed entirely during a time period where I was using my regular shoes. But it was "barefoot-type technique" that probably contributed.
    *This may lend some credence to the barefoot fanatics' argument that new barefoot runners' topfoot injuries are due to either switching too rapidly or not "doing it right." Because, really, I think my top foot pain was in changing my technique a little too rapidly as well as probably not "doing it right" (tensing my foot up too much).

    I don't know if my conjecture is correct (we are talking about a self-diagnosis using a sample size of one), but since barefoot runners do generally transition from heel striking to mid/forefoot strikes, and that's the same thing I did in shoes and developed the same kind of pain, perhaps that helps shed some light on the issue? I think more to the point of Craig's original post: [...How would you treat DICS in a barefoot runner without resorting to the Church of Barefoot Running rhetoric?..], then simply switching back to shoes may not be enough to address the underlying issue for a top-of-foot-injured barefoot runner. It may (MAY) require some reversion of technique as well. Again, this is conjecture on my part, not a conclusion by any stretch of the imagination.

    By the way, my plan is lots of icing, limited application of ibuprofen, backing off on mileage a bit, and elevation. Sort of an ibu+RICE approach without the R. If that doesn't work, then drop the running for a bit.

    Hopefully that helps the discussion.

    Ken
     
    Last edited: Aug 18, 2010
  31. You'd be better of dropping the running.:hammer:
     
  32. Dana Roueche

    Dana Roueche Well-Known Member

    Ken, I agree with Simon, back off on the running and give yourself a chance to recover.

    As an ultra runner, what is wrong with a cadence of 170-174? The 180 you see is an AVERAGE number coaches found when working with Elite runners in a marathon. The correct cadence for an individual runner is the rate that minimizes metabolic cost. Without getting on a tmill and measuring VO2 at various stride rates to find the optimum rate that minimizes oxygen uptake, you will not know what is optimum for you.

    What has been found though is that there is a good probability that your preferred stride rate of 170-174 is pretty close to your optimum. It's OK to work on picking it up a stride or two but I wouldn't go crazy because Jack Daniels measured elite athletes at 180. By forcing yourself to run at that rate, you may actually be losing efficiency.

    Dana
     
  33. Ken:

    Most distance running coaches don't a lot about foot and lower biomechanics and/or exercise physiology. There is no single best stride frequency for all runners since there are too many variables, most important probably being limb length and limb mass. Research has shown that experienced runners tend to properly self-select their optimum stride frequency-stride length, so don't go changing your running style just because some over-confident coach told you to or because you read it in a running magazine or on the internet.

    As for dorsal midfoot interosseous compression syndrome (DMICS) here are the newsletters I wrote on them from years ago. It may help you in understanding your injury.
     
  34. Dana, maybe you should put in your sign off that you are not a Podiatrist or have no medicial training - Your post sounds like your an ultra running Podiatrist giving out advice, which I´m not really sure is the way to go. If you say that you have no medical training but have run around the earth a couple of times and picked up a few wisdoms over the way no problems with that.
     
  35. Dana Roueche

    Dana Roueche Well-Known Member

    I'm just about on my 4th lap around the world but who is counting.

    I have been told more than once by members of this forum that they don't want to hear about my background, so I'm done repeating it.

    Where in the post did I give advice other than agree with Simon?

    Mike, what is the real point of your post?

    Dana
     
  36. LukerM

    LukerM Member

    I think that is important to remember that no experience runner will have a heel strike when running barefoot. A forefoot runner will make the gastronemius go through ecentric and concentric contration through forfoot/midfoot strike to forefoot toe off.
    for this reason surly posterior leg stretches are not going to help midfoot pain as the gastronemius is one of the main supports with this type of running. The development of an ankle equinus may develop through this type of running as posterior leg muscles strngthen and tighten as the foot is in a dorsiflexed position and so to prevent achillies issues then stretching may be beneficial. With the development of a ankle equinus then other issues may arise.
    With and incresed force through the midfoot in this type of running surely a stress fracture and some sort of midtarsal joint sprain would be a more common cause of pain in that area.
    This means that if the person chaning to forefoot running has previously had a heel raise in their trainner as most running shoes do. this would have previously helped the midtarsal area gain strength as a greater stress would have been placed through it previously.
    Also the fact that when plantarflexing the foot some degree of inversion is also experienced. This means that there is a slight lateral strike when toe running/ barefoot running. There weight will then move more medialy as the medial side of the foot comes into contact with the ground. This will then cause a twist within the midfoot causing a lot of stress as the foot trys to keep the forefoot from over everting.
    To prevent this happening maybe a forfoot medial wedge could be used to prevent this twist and excess stress upon the midtarsal joint. this would not exactly be barefoot running but if built into the sole of either a running spike, nike free or vibram, maybe it could reduce injury due to this.
    I dont think you can compare bearfoot running to running in shoes unless both times you are a forfoot/midfoot runner, as different types of landing bring their own problems.
    Also the fact that forefoot running is ment to reduce shock by up to 60% are shin splints common?? and if yes, are forefoot running pathologies as likly to occur as over pronatory pathologies e.g. shin splints.
     
  37. HansMassage

    HansMassage Active Member

    Like Ken I am not a podiatrist. My connection is prescriptions from a podiatrist when posture is contributing to foot pain.
    My top of fore foot pain is on the left. I attribute it to collar bone injury on the right [clavicle menubriam ligament laxity ] that causes me to swing my right arm further forward than my left. By keeping my right fore arm behind my low back when the pain flares up it subsides or goes away.
    I therefor agree with the position that center of momentum has an effect on the fore foot reflexes and resultant stress pain.
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
     
  38. kzemach

    kzemach Welcome New Poster

    Update:

    Luckily, contrary to fears, what I tried worked. I am now basically top of foot pain free while walking and running. The one thing I can do to induce a very small amount of pain still is to drive my big toe upwards (standing/sitting/running, doesn't matter). That seems to hit the same area on the top of the foot with some of residual soreness.

    To reiterate, what I did was:
    A. slightly reduce the amount that I was running. Didn't end up reducing it that much honestly, and am now back up to pretty high weekly mileage as of last week.

    B. ibuprofen (800mg every six hours for a day or two, then 600mg per dose for a few days, then nothing, all taken with copious water/food of course)

    C. ice. I did a lot of icing of the top of my foot

    D. really concentrated on relaxing the top of the foot while running

    E. did more mid foot and heel striking.

    All this seemed to work out just fine. Point taken that I was probably lucky in that; I'm not idly dismissing the input on this forum that stopping running could be well advised.

    This of course raises the question: was my injury of the same nature as that of barefoot runners who express concern about pain in the same area? Obviously I can't answer that, but it SEEMS to have been the same by the description. If it is, could one argue to a barefoot runner that a similar treatment (yeah, granted, probably with a lot less running than I was doing) but to use running shoes as a recovery crutch before building back into full barefoot; would that work? I don't know, but it would be an interesting experiment.

    -------------
    Side note / don't want to get too off topic here:

    Dana & Kevin: Thanks of the thoughts on questioning the need to increase cadence. The reason I've mostly bought into that argument is both due to the quantity of opinions on the matter coming from a relatively large number of quality sources, and probably moreover, that I buy the argument that with slower cadences you are (generally) heel striking in front of your CG, and thus there will be a force vector in the direction opposite to that of your travel, whereas faster cadence with a foot strike beneath your hips has (relatively) little to no force vector opposing your direction of travel. Thus, the argument that it is more efficient seems to make sense to me. However, your points are well taken and I think require me to do some additional reading on the issue.
    -------------

    Now, getting back on topic... I'm not sure if my issue, being a shod runner, and what looks like a fairly good recovery trajectory are any use to the question posed here. The key points being: I seem to have experienced a similar top of foot pain but am not really a barefoot runner; the technique I was switching to probably too rapidly emulated barefoot technique to a certain extent (as Kevin's link to the DMICS discussion, I'd have fallen into the " increased ground reaction force (GRF)" category); moderately switching back, with shoes, reduced mileage, ice, ibuprofen (for the swelling, not the pain), all seemed to have worked.

    I am curious to hear what podiatry specialists here do think about the original poster's question about how to treat this in a full barefoot runner. That's what attracted me to this post: the medical approach to the issue.

    Thanks all,

    Ken
     
    Last edited: Sep 9, 2010
  39. Ken:

    Thanks for the update.
     
  40. Craig Payne

    Craig Payne Moderator

    The point I was trying to get to in starting the thread was that there are only two ways to treat this (apart from the usual ice etc to manage the initial stages):
    1. Reduce the dorsiflexion moment of the forefoot (can't do that unless you are wearing shoes); or
    2. Find a way for the tissues to adapt to the magnitude of that dorsiflexion moment (this can be done, but if the moment is too high, its not going to be possible without doing (1)
     
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