The Monday Shakeout: Common Runner's Problems at the Top (Dorsum) of Your Foot
By Matt Klein PT DPT PhD FAAOMPT
This week we talk about the anatomy of the top of the foot and how that relates to footwear. An area often forgotten but nonetheless important, Matt talks about what structures sit on the top of the foot, what happens when they get irritated and what components of the shoe can either be modified or may influence the development of certain irritations in this area.
While many people focus on the bottom and sides of the foot for pathologies like plantar fasciitis, bunions, metatarsalgia, neuromas and more, the top of the foot does not get as much attention. Regardless, this is still an important area that houses a complex set of anatomical structures that are important to take care of. All the major bones of the midfoot and forefoot, including the navicular, cuneiforms and metatarsals are all fairly exposed on the top of the foot. The ligaments that connect all these structures may be accessible in this area, although typically they are deeper than other superficial structures. The most prominent structures are the various toe and foot extensor tendons, including the extensor digitorum longus, extensor digitorum brevis, extensor hallucis longus, extensor digiti minimi and anterior tibialis. Further on top of the tendons lie the extensor aponeurosis expansion that keep the tendons secured.
What is Usually Impacted at the Top of the Foot?
The tissues that are most commonly irritated on the top of the foot are the bones and tendons. While most runners are familiar with stress fractures, bone bruising can also happen from either trauma or extended pressure into an area. A poorly fitting upper (top part of the shoe) or laces that are too tight are common pressure reasons. The tendons can also become compressed/irritated for the same reasons, with either the laces being too tight, creating too much pressure on the top of the foot, or the instep of the upper being too low and pushing down onto the tissues. This typically results in acute extensor tendinitis, although ongoing issues may result in chronic tendinopathys. Both of these can present as pain on the top of the foot and while the severity of each one will determine how long they take to heal, often the tendon compression resolves within a day or so after the pressure is removed.
Areas to Assess to Protect Top of Foot
The first thing to look at when assessing for irritations on the top of the foot are the laces. These are an easily modifiable part of the shoe that can be tightened, loosened or otherwise modified. Lydiard lacing is a common technique that removes the crisscrossing of the laces and instead has them come straight across, reducing pressure on the top of the foot and sometimes increasing volume in a shoe. The other option is to relace the shoes and simply skip the area where the irritation or excessive pressure is occurring, continuing the laces at the lace hole above.
The less modifiable things but those with these sensitivities should still pay attention to is the tongue volume, shoe volume and the instep/midfoot height. Thin tongues can sometimes make the pressure from the laces more apparent and those with these sensitivities may want shoes with thicker tongues. A low shoe volume or midfoot height can also put extra pressure on this area, although in the midfoot this can be modified to degree as discussed above.
While every part of the foot and shoe may be important, the top of the foot has some unique structures and shoe characteristics that certain people may want to pay attention to. The key takeaways from this including paying attention to the instep height and midfoot volume, seeing how thick the tongue is and understanding some additional lacing techniques that may reduce pressure on the top of the foot. While not everyone has issues here, it is still a great place to look as a great deal of a shoe's security comes from this area. If you want you have to really tighten down a shoe to the point it bothers the top of your foot, there may be too much volume in the shoe. If you can't wear a shoe for long without feeling like the top of your foot is being smashed, there may not be enough volume or instep height. This is all part of the continued journey of figuring out which shoes may and may not work for you. The more you know, the better you will get at finding the ones that will work.
Learn more about uppers in our recent podcast.
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NEXT: How Much Taller Can Shoes Get?