Addendum:

Preface:  I am not a doctor, and I do not claim that this article can diagnose or treat tendon injuries.  This is a collection of information based on my personal experiences, research, and talks with doctors.  This is an informative article meant to assist someone in understanding a possible injury and offer information on how to treat said injuries.  With that said I get a lot of questions about injuries which is why I started my Injuries posts in the first place.  Well not I’m getting a lot of questions about recovery time and tricks so here is what I have for TOFP.

The biggest question in terms of recovery for TOFP is how long it will take to recover.  However, this question cannot be answered without first asking other questions.  It helps to determine if there are inflammatory cells present on the tendon (tendonitis).  If there are no inflammatory cells present then the injury will be tendonosis.  This is important because it determines the length and severity of the injury.  The problem is that inflammatory cells can usually only be seen with a microscope, and that can only be done with surgery.  Since the average person with tendon pain is not going to go under the knife to find out exactly what is causing the pain, diagnosing the injury can be a difficult task.

The majority of recent studies have shown that most injuries do not have an inflammatory process present, which means that TOFP is caused by tendonosis.  However, it is still not common practice to just assume there are no inflammatory cells present and a general prognosis will be tendonitis.

If it is tendonitis (inflammation present) then the injury should respond quickly to anti-inflammatory meds and rest.  A true case of tendonitis should and can be resolved within a few days to two weeks.

If the issue is tendonosis (no inflammation present) then what you are dealing with is a degeneration of tissue that must be rebuilt.  The majority of barefoot runners with this injury will likely fall in this category because they are now putting strain on tissue that has not felt that strain in many years.  The tendons of the foot have degenerated, and the sudden switch in loading has caused an injury.  If this is the case then the affected person must avoid loading the muscles and tendons involved in the painful area.  This can be done with bracing, taping, supportive shoes, and avoidance of exercise/stress.  It takes time for tissue to heal and regenerate, and it is especially true for tendons so the recovery time will be much longer.  The time it takes to recover from an uncomplicated form of tendonosis is 6 to 8 weeks, while chronic complicated tendonosis could take 3 to 6 months. The only way to determine which of these time frames applies is to rest and see.

You may be able to rest for 4-6 weeks with a tendonosis injury and then test the area with a short bout of exercise that will put stress on it.  If the response is pain or an unusual amount of discomfort then continue resting.  If there is no pain present then you may restart your normal routine with a few things in mind.

First you should consider all possible causes for the injury in the first place.  This will mostly include form and level of exertion prior to the injury.  Analyzing your footfall and making any necessary changes will be vital in the avoidance of a re-injury scenario.  Second you should start extremely slow as you work your way back into a safe routine that will allow you to progress from the injury and not from the point where you left off in your training.  Once you’ve suffered an injury, your new starting point will typically be far behind the last point you were training at, and that adjustment must be made in order to avoid future setbacks.

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29 responses »

  1. Nancy Allen says:

    I am not a barefoot runner but I am pretty sure I injured my entensor tendon by wearing a new pair of shoes that had an insert that made my foot lift too high in the middle part of the arch.
    It has been four weeks now and ibuprofen helps a lot. But you say to do calf stretching exercise and I would like to know how to do that.

    • Nothing wrong with not running barefoot 🙂 The best stretch I’ve found for the area is to use a step or stairs. Stand so that the edge of the stair is just behind the ball of your foot and then let the heel drop as far as comfortable. Once you are at the end range of your drop, bend your knee slightly and you should feel a good stretch of the calf and foot as well. Do this stretch barefoot to get the most out of it. I’ve also found that night splints for plantar fasciitis help a lot with top of foot pain as well.

  2. Hyl says:

    How can i tell the difference between this TOPTF pain and a stress fracture? I have read descriptions of both on the web that seem to fit what I have.

    Background: I started running about 6 months ago in shoes designed to support my flat feat and deal with overpronation. After a while I began to feel muscle pain in my thigh. I saw an ortho who sent me for orthotics. I have some mild scoliosis, and the thought was that one leg is slightly longer than the other, causing pain in the shorter one. The orthotics were supposed to help with that and the flat feet. I got the orthotics. The pain didn’t stop. Then I read born to run and bought the new merrell minimalist shoes. I had the calf pain, which went away. I now have pain in my left foot. When I strike and flex my foot bearing weight, I feel pain along my big toe along the top and up to the ankle.

    Any thoughts/advice?

    • TOFP and Stress Fractures present in a very similar manner which can make it difficult to determine which you have. It sounds like you need to rest. My advice for TOFP is always rest and see what happens. Rest will alleviate the pains if it is TOFP but not really help much when it’s a fracture of any kind unless you rest for more than six weeks. With regards to the scoliosis and leg length discrepancy I say you’re doing the right thing about getting into a more natural shoe. Getting closer to the ground and allowing your form to become more natural you should be able to find ways for your form to work around those issues. I’ve worked with and know many people that have the same issues and they all enjoy fruitful running lives. Some are even highly competitive.

  3. Frank says:

    Just did a little extra searching on Wikipedia and was pleased to see that one of the newer approaches to tendonosis treatment is eccentric loading. Easy way to do this is a toe raise that starts with you already up on your toes and dropping to flat on the floor (or lower if you do this on a step). Do not push back up from the flat position as that would be a concentric contraction. I just knocked off 3 sets of 10 with no pain.

  4. […] Gobarefooting have their own recipe for TOFP. Rode Rick Russel hase his own story (which more or less same as me). […]

  5. kevinp says:

    ive just had chrondroplasty and cheilectomy surgery on my ankle 10 weeks ago. Am weighty bearin on it, but having severe pain all up my EDL includin the tendon, worse on dorsiflexion. Was wondering if the two could be linked and what is the time frame for recovery. I am 29 and sporty so this is not ideal. Thank you.

    • Your procedure is directly related to dorsiflexion so it would make sense that you are having pains during that motion. Being only 10 weeks out from surgery it’s hard to say what’s what. The best advice I can give is stay the course with your recovery plan and physical therapy. If it doesn’t improve then you need follow up with your ortho. It does make sense for those pains to be there given the manipulation of the tissue during surgery and the ankle is a complex region that can take a long time to fully recover. I would say yes it’s probably not uncommon to be feeling what you’re feeling but if you have any real concerns you need to see your doctor. I know injuries and am certified in recovery training for them but I’m not a doctor so I can only answer so much. Good luck with it

  6. Ok now I haveread this one too. I just posted a comment and question on your other page. So apparently I am going to have o hit the gym and do weight lifting instead of cardio? I was thinking that I could just run through it but it doesn’t seem to be what is going to happen. What can I do in the meantime while my foot is healing? Could I ride a stationary bike? eliptical? all of course with shoes since I have to go to my gym. Could I run in shoes or would that be going the wrong direction? If you could give me some tips and direction I would love it. Thanks so much for all your info here too. You hit it right on the nose for me as far as calves to tofp. Crazy smart you are and I thank you.

    • I would avoid running when dealing with TOFP and issues like it. That would be like having soreness in your elbow and still doing bicep curls. If you’re going to supplement and do a different type of cardio training you want to ride the bike or maybe swim. I wouldn’t do things like the eliptical because those all keep you on your feet which can keep the issue aggrivated. Running in shoes uses your feet less stress but you will still be forcing your feet to carry your body’s weight and the issue will take longer to heal. When it’s an injury I never recommend running through it because you have to give your body time to heal. Hopefully you are feeling better already and getting back into the swing of things. If you ever have questions feel free to contact me.

      • Tara Stemper says:

        I will start at the gym with the bikes this week and see how it goes. I can walk fine now but if I flex my foot hard, I can still feel the muscle. I do have a question for once I can start running again: what can I do to avoid the pain coming back? Is there a certain form I should concentrate on when I run or specific pre stretching or post stretching? Should I maybe run 2.5 miles in the am and 2.5 in the pm so not to have too much strain at once? Again I thank you for your experience.

      • All of those are good questions. The warm up of the feet can be very important. You want to do some calf raises up onto the toes, jog and hop around, and stretch them. To avoid the pain and problems coming back you have to make sure you take care of your feet the way you take care of everything else. Include them in the strength training during the week by doing exercises that work them specifically as well as making sure they get good stretching. When you do start running again make sure you take it slow and keep it short. Build up a good base ability before you do anything else.

  7. Eric says:

    Hi, I’m not a barefoot runner but I did experience the exremely stiff calves which eventually transitioned to TOFP (it feels like my EDL has been aggravated/inflamed). I believe it was due to me shortening my stride (while running long distances in preparation for this year’s Boston Marathon) and therefore changing the impact position of my foot (closer to midfoot than your typical heel striker — I was wearing Brooks Defyance 5 shoes).
    The clock is ticking for me and I’m currently in PT after seeing a podiatrist. They’ve recommended biking for now which doesn’t appear to aggravate it and I keep a compression sleeve on it almost all day (along with the typical icing and ibuprofen daily regimen). Unfortunately, this injury has plagued me since early December. My question is: Do you think I could purposely attempt to heel strike with a shorter stride to protect my injury and therefore make a marathon doable? Since my legs were more accustomed to this motion maybe they’ll hold up better? Are there any particular shoes out there that might help me with this? I’ll be asking my PT and podiatrist these questions as well but I was interested in hearing your comments since you seem to be very well informed in regards to this specific type of injury. Thanks.

  8. 8. Hi there, just found your blog and it seems you have great knowledge here. I am a long time moderate jogger with many different “ailments”. I wear Nike sneakers, now completely worn out and should also ask advice for next pair of shoes, since I have your attention! Exactly five months ago I twisted my ankle and suffered and avulsion fracture of the fifth metatarsal. The healing was slow but complete (as I of course worked on my feet during the healing process) I then had much BOTTOM of the foot pain, when barefoot in Thailand on mid month three, very good massage and tiger balm and an amazing pair of healing hands diagnosed and treated a planter faciitis. The pain was completely gone by the time i returned home, with much walking in flip flops and gentle hikes. A final jog on the beach five months after the initial injury felt just fine on the foot. So, Once I got home I started jogging my usual 3 miles, three times a week, for five sessions it felt great. Then I got inspired by the Boston Marathon and ran two five mile loops with very mild tenderness ON THE TOP OF MY FOOT this time. I of course am not jogging, but am distressed as all joggers are to not be able to get out there. I did the eliptical for three or four days but think that is making it worse. With some reading I am worried this is either a stress fracture vs the tendonosis you describe here. I have no swelling, Minimal point tenderness over the lesser extensor tendon into the front of the ankle. The tenderness is clearly worse with pulling my toes back to my nose (extension??) So, my questions arise: does this sound like a tendonosis or a stress fracture? Is this related to my broken bone? Is brisk walking ok for exercise since eliptical doesn’t sound good? When do I start jogging again? And thoughts on moving to a minimalist shoe?? THANKS for your advice oh wise one!

    • I will start with shoes. I have fallen totally in love with a company called Altra and I highly recommend them them for people with nearly any running ailment. As for the pains. They could totally be related to the broken bone you had. The odds of injury in the months after an injury are extremely high. The body is weakened after an injury and when it gets thrown back into the stresses of training and exercise it can sometimes break back down. In your case it could be quite a few things. It could be a new break, tendonosis, sprain, strain, or even a tear. The problem is the diagnosing of these types of injuries requires scanning.

      I would like to say that brisk walking should be fine for you but if your foot is hurt then anything you do on it will upset it. You may be in a situation where you have to completely shut it down for a bit in order to fully heal. If the pain is over a few weeks old without any improvement then I’d say to stop doing all exertion on the foot and go see a doc. If it’s getting better continuously then I’d say maybe try taking a week off while trying to stay off the foot as much as possible during that time and see how it feels. Sadly I cannot offer much advice on this one as it’s just kind of a vague situation that is tough to get a feel when it’s not in person.

  9. rasmus says:

    Hey I am a barefoot runner. (or fivefingers) I have that top of the foot pain. I have run four marathons in classic running shooes. When I first shifted I felt ligther an after a while I felt faster (I use to run 10 k in 40 minutes). When I shiftede I startede out slow. The fist 6 mounths I never ran over 5 k. But the very fist time I was ready to time my self, at a 10 k run, I felt a small pain at the top of the foot. Stupid as I was I pushed though. I its four weaks ago. I still feel that pain. But it is worst in the morning. Is it to late to get rest an let it heal?

  10. Mike says:

    I just found your blog through my massage therapist – she is awesome. Anyway, I think that this is the pain that I too am suffering from, I can see some similarities between myself and rasmus. Like a lot of people I was curious about barefoot running and read Chris MacDougalls book – this certainly intensified my interest. As I knew I was getting surgery on a minuscal tear in Jan 2012 I decided to wait until afetr the surgery to incorporate a gradual phase-in of more minimalist shoes. I started slowly, after surgery I never ran more than a couplle of miles for the firts 2 months, alternating between my trusy Asics Kinsei and a pair of Inov8 Roclites. Then, thanks to an REI attic sale I picked up 2 pairs of Vibrams. After the initial calf stiffness I really enjoyed running in them, never quite as fast as I would have in my Asics, but my whole running style had changed – heel strike to ball and eventually forefoot. Over time I graduated to only running in Vibrams doing between 4 and 7 miles alternate days. No problems. The 2 days after my first longer run – 10 miles I felt a numbness in the ball of my foot. Itll be fine I thought, just warm up the stiffness – unfortunately no, the stiffness became pain on the top of my foot that intensified with weight . I had to hobble home. X-ray shows no breaks or soft tissue damage, diclofenac and other anti-inflammatories had no effect and two weeks later its still as sore. Thanks to your research I will be better informed when I see the specialist tomorrow. Hoping its not chronic and will heal fast.

    • I hope it’s no big deal as well. Hopefully the specialist can give you some good info. It sounds like you just over did it and then didn’t give it enough time to heal and I hope that is the case. Good luck

  11. Kathy love says:

    What a great site, especially for those of us transitioning to barefoot/minimal shoes and running style. Thank you!!

    I’ve had TOTF pain for 3 years or so. At one point it got so bad I was advised to try MBT shoes (for walking, of course, I was running Sauconys) and in them I could at least walk without pain, but it was like having my feet in a cast, couldn’t actually feel a thing. I didn’t want to live that way.

    I also wondered if it was partly caused by having to pull against my running shoes to flex my foot with every step, so barefoot sounded like an interesting idea. (I went barefoot a lot as a kid.)

    About 4 months ago I started going barefoot in the house, and immediately noticed a) how hard I was slamming my feet on the ground (common I believe for people used to cushioned shoes) and b) how light my feet were with nothing on them. After a month I got some Vivo Barefoot shoes, and quickly adapted to wearing them all the time. I can now walk 8-10 k with no problem, and am starting to mix in some running. I have also got some Merrell barefoot shoes, which I think I prefer as they have just a tad more structure. I love not having heavy, inflexible shoes to wrestle!

    But I still have TOTF pain although it seems to ease up after a mile or so. After a couple of miles I also get pain in the front of my shin, which would tie up with your explanation about over-flexing the foot and ankle. (Although my calves don’t seem to be tight.)

    While I was starting to transition to barefoot I got a lot of rest for several months (15 inches of snow outside helped ;-)), and I am transitioning slowly and cautiously.

    Is there anything else I can do? This TOTF pain has been a real pain for a long time, and it is starting to put me off running, or even walking, which is not what I want! Very grateful for any advice.

    • It sounds like you’re on the right track but just have to realize it’s can take a while to work your way out of the pain. You may also still be landing too hard on your feet when you’re walking. Is this a leisure walk or a power (training) walk? Leisure walking will allow you to change your landing rate but power/speed/fitness walking almost always puts you way out in front and heavy on the heels. This could be causing your shin issues. The TOFP could be caused by a lot of things so that’s more difficult. You had it when you wore more cushioned shoes so that tells me you probably have very weak feet. Sorry. I’d advise doing some foot strengthening exercises. I like barefoot calf raises, crunching and curling the toes into some carpet, and picking things up with the feet while standing balanced on the other foot. You also need to focus on stretching the arches, rolling your feet on a ball (I like tennis balls), and stretch your calves. Most people with overly tight calves have no idea that they have them. Get into a calf stretch and try to hold it for one minute. That will give you a good gauge on how tight your calves are.

  12. Taibi says:

    I ran a marathon in 3h20 with a pair invisible shoes (huarrache ) and had about 700 miles in them. I felt the typical calf tightening and overcame it with stretching. Then a few weeks into the spring I felt a discomfort at the base of my tibia whci led to harsh pain, mix of bruising and the dull tendinitis pain. Flexor hallucis longus, is what I believe has been the culprit. Only after 3 months have I been able to get back to running, 2 miles every other day, a change from a regular 50 mile week. Although pain has subsided, I can feel pockets of tenderness, but nothing bad when I ran. Your blog seems to have been the most coherent explanation to date. My question or rather, dilemma is whether I shoal continue resting, or on advice of my physio, carry on this light running I am currently enjoying. Still running in my sandals, unfortunately no Altra in the UK but have eyed up some vivos. Thank you very much for a great article…

    • Bruising is almost never related to irritation. Bruising is usually a sign of much worse things like fractures and tears. I’m not saying that’s what you had but given the time it has taken to recover it is a possibility. I think you can probably keep running the short distances that you have been but be very mindful of the pains. If it starts to increase you should shut it down and rest. I would also recommend icing to help get rid of the irritations and pains you are still having. If you’re interested in trying something like Altra I recommend http://www.naturalrunningstore.com as they ship international. I hope your pain continues to get less and you can get back to your normal running schedule. I know what it’s like to be held back and it’s no fun.

  13. Enrico says:

    Hello Gobarefooting. I switched to A2 Adidas Adios from A4 Adidas Salvation, and while I was delighted by the huge improvements in terms of speed and running feeling I developed TOFP. My left (top of ) foot hurts for just 30 seconds – 1 minute when I wake up in the morning or after I stay in horizontal position. I never experience the pain while warming up or running. The pain appears 2 days after the running session. What is your opinion? Should I rest for the 6-8 weeks you suggest or can I try to continue to train? With the transition from A4 to A2 I reduced the length of my routine training session from about 12km to 5-7km, giving some rest to the feet at half path.
    Thanks a lot.

    • It doesn’t sound like you need to rest that long. It sounds like the new shoe is causing an issue in your foot by straining something. Think of your muscles after a hard workout. They are going to be the most sore around 48 hours after the workout which is what it sounds like your foot is going through. I would say you either need to take some rest (a week or so) and see how it feels, alternate the old shoes back into your routine until the issues stop, or get rid of the new shoes. Not all shoes are built on the same last and mold as other shoes, even within the same brand, so they don’t always fit the same. I think this might be the case here more than anything but you’ll have to test that out. It sounds like there is something to the shape of the new shoe that isn’t agreeing with your foot structure but that’s tough for me to confirm without seeing it in person. Feel the insides of both shoes with your hands and see if there’s a big difference in shape, heel/toe drop, etc and you might find your answer.

      • Enrico says:

        Thank you so much for your time and your detailed answer! I deeply appreciate it. I’ll keep you updated, for statistical purposes. Thanks! Enrico

  14. Stella says:

    Hey Gobarefooting. I’m a newish (enthusiastic) bare foot runner. I also play softball, so try to do some interval/speed training. I’ve had no trouble converting and adapting to barefoot running and have been running 5+ miles in five fingers for about 6 weeks. I am training for a half marathon, the first in my five fingers. Early into an 11 mile run I felt some discomfort during my strike, with referral pain along the top right hand side of my right foot. It doesn’t hurt until I put pressure on the ball of my foot, and the pain is then only along the top right side of the foot. I think it might be bruising, because if I now touch that top part of my foot it’s tender, whereas a couple of days ago I couldn’t pin point exactly where the pain was. Interestingly it eases as I use it. So when I first stand up and try to walk it’s incredibly painful, if I then force myself to walk normally it eases until it’s a dull ache. About two weeks ago I did some major damage to the toe (nail) of my right hand foot. I strapped the toe and ran. This injury only took a week to repair. Wondering whether I’ve caused another injury by sub-consciously favouring that side of my foot. My half marathon is in two weeks. Any help would be great. Stella

    • Sounds like a compensation issue and possibly an issue of over use at the same time. There are signs that can give that stuff away. The fact that it took a while to manifest into a pin point issue means it was building and the irritation hadn’t settled. That’s very common with over use injuries and also doing too much too soon. It getting better as you warm up is also a muscular inflammation sign as well as the fact that it only hurts when you put weight on the ball of your foot. The only real way to get something like that better is rest but you’ve got a race coming up so that’s hard. It sounds like you’re not a “shut it down” kind of person so if that’s the case my advice would be to back it off…way off and try to let it rest up some before the race. Maybe wear some sort of thin shoe and only do short runs till race time to see if that helps alleviate some of the pain. I don’t think you’re at any risk of major injury with this one but you could make it worse to the point that it could take a long time to recover. I’m not doctor and I can’t see your foot in person so this is all just guess work.

      • Stella says:

        Quick update: Have now rested my foot for two weeks. Hugely improved. I’m going to give it one more week off. Really grateful for your help. S

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