Even though you work your whole body when running (including your arms, hips, and core), your feet bear a lot of the burden. So it’s particularly scary when you start to feel a flash of pain every time you take a step – and confusing when you can’t pinpoint the cause. That’s especially true for top-of-foot pain, which, unlike more well-known conditions such as plantar fasciitis and shin splints, can be difficult to self-diagnose.
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The good news is: You’d know it if you had a full-on fracture. “If you recently increased your training volume or frequency, and feel a gradual onset of pain, it’s unlikely that you’re looking at a fracture or the rupture of a ligament, tendon, or muscle,” says Cameron Yuen, senior physical therapist at Bespoke Treatments in New York City.

The bad news? You could have one of a few problems, including a stress fracture that could turn into a full fracture if you aren’t careful. “The underlying cause is almost always the rule of toos: too much, too soon, too often, too long,” Yuen says. “But if the pain still persists after a week of rest, always see a medical professional.”

In the meantime, here’s what could be causing your top-of-foot pain in particular, plus what you can do about it.

1. You have tendonitis.

Lots of people associate tendonitis (a.k.a. an inflamed tendon) with knee pain, but it’s also a common cause of top-of-foot pain. “You can develop tendonitis of the tibialis anterior tendons, which run from the middle of your leg down to the middle of your foot,” says Jacob Wynes, DPM, assistant professor of orthopaedics at the University of Maryland School of Medicine.

How you know you have it: “The pain will be concentrated in the middle of your foot and off to the instep, close to your big toe,” he says. “You might also have shin splints since the tendon starts near your shins.” (Two for one!)
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What to do: In addition to icing and taking an anti-inflammatory, you’ll also want to do some toe grip exercises to take the stress off the tendon, along with dorsiflexion (flexing your foot up towards your shin), which Wynes says helps this type of tendonitis. “This type of foot pain is often found with high-arch foot types, so custom orthotics can also be helpful,” he says.

2. You have a metatarsal stress fracture.

There are five metatarsal bones in the centre of your foot, and you can develop a metatarsal stress fracture if you go too hard, too fast (this is most common in the second through fourth metatarsal bones). “I’ve seen this in runners who had long periods of rest due to an injury, then abruptly went into marathon mode,” Wynes says. Look out for tell-tale swelling and pain concentrated on the top of your foot over the bones. “The swelling could be so bad, you can’t see your veins anymore.”

What to do: See your doctor. “Stress fractures require a more aggressive treatment plan, like a boot, and time off until they heal,” Wynes says. Otherwise, you risk creating a full-on fracture or another stress fracture.

3. You have ”vamp disease.”

Vamp disease is a colloquial term for irritation over the top of the foot, and it sometimes happens when runners wear shoes that are too tight. “You can trace the pain exactly to where the tongue of your shoes touches the top of your feet,” Wynes says.

What to do: Thankfully, you can easily solve this problem by loosening your laces or buying better fitting sneakers (here’s how to buy the right running shoes). “The pain should go away within two to four weeks as the inflammation subsides,” Wynes says.

4. You have a neuroma.

“Neuromas of the forefoot are inflamed and swollen nerves that travel near the metatarsals and feel like a burning sensation,” Yuen says. It can also feel like a sharp pain that shoots up through your foot into your toes. “There isn’t much space between the metatarsals, so an inflamed and swollen nerve can become aggravated quickly.” The cause of that aggravation? “Shoes that are too small or too tight around the forefoot.”

What to do: “Look for a shoe with more room in the forefoot (we like Altra running shoes for this reason), then ice and take an anti-inflammatory to reduce the inflammation,” Yuen says. “Sensation changes in the foot can also be caused by vascular diseases, metabolic diseases, and from irritated nerve roots at the level of the spine, so you should still see a doctor just in case.” You will likely need to get an MRI or an ultrasound to see a neuroma.

This article originally appeared on runnersworld.com.

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