Runner Therapy: Foot Pain, Stress Fracture or Tendonitis?

Question via Twitter: What advice do you have for top of foot pain? Podiatrist says either stress fracture (not present on x-ray, yet) or tendonitis.

Runner Therapy Says: There are many things that may cause pain on the top of the foot. In general, we have to decide between soft tissue and bone injury.

More often than not, we use a patients’ subjective history to decide which.
For instance, if there is evidence of trauma, we may be looking for more symptoms of a frank tear, a bone break or significant injury.

In the case of repetitive injury, where there is not trauma, we look for signs of overuse. Generally, this is how distance runners present. A lot of mileage over a short period of time…possibly marathon training or other race training where the runner increases his or her mileage. This can easily cause damage. We will immediately think not of tears and bone breaks, but strains, sprains and stress fractures…symptoms of overuse.

And ’tis the season for stress fractures, so its good to get it checked!

Stress fractures are generally point tender and involve pain on weight bearing. However, so do soft tissue injuries. Fortunately, most stress fractures occur on the under surface of the foot and heel because they develop from the constant weight bearing pressure of running.

On the top of the foot, several soft tissue injuries can occur. The most common in runners? You will laugh when I tell you…

The most common foot issue I see on the top of the foot involves swelling on the dorsal surface mostly where the upper three sets of laces would hit the foot.

The reason? Shoelaces tied too tight. Sometimes on a humid day. Really!

The solution? Unlace afew and leave the top lace intact. Wear loafers, crocs, birkenstocks or other shoe that does not compress the top of the foot. Massage and ice the area. The pain will be gone in no time!

Of course there are other things that can cause pain in this location, but remember, its a numbers game. First look at what’s the most common before jumping to conclusions.

And for the record, an MRI will show a stress fracture that is not seen yet on X-ray…if you really want to rule it out, that’s the way to go!

Have you had a stress fracture? How long have you waited to get it checked out? Do you tie your shoelaces too tight? What other foot issues have you dealt with?


(Marisa, a MS PT SCS ATC, is a member of  iRunnerBlog’s team and writes the Runner Therapy column, she is a physical therapist in private practice in midtown NYC called Dash Physical Therapy.  She one of only a dozen or so physical therapists  in the state of NY to be board certified in sports.)

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