Ankle pain is one of the most common problems people experience with running. There is a high level of demand placed on the ankle joint during running, including the need to withstand high ground reaction forces, the need to react quickly to a change in position or terrain, and the ability to hold up for potentially thousands of steps, all occurring within a single run.
This article is intended to describe some of the most common sources of ankle pain in running, the related anatomy and physiology of the ankle, as well as some general treatment strategies that are often recommended to help treat these injuries.
What causes ankle pain when running?
Aside from acute ankle injuries that are difficult to prevent, such as falling on an undetected slippery surface, ankle pain can commonly arises when:
- Our current lifestyles distract from proper care required to prevent and recover from ankle injuries
- If there is a sudden change in activity levels
- The amount of activity pushes the body’s capacity, such as marathon running
The best way to avoid ankle pain in running is to focus on 3 things: 1) Maintaining adequate strength and stability in the ankle joint, 2) Maintaining proper flexibility around the ankle joint, 3) Wearing proper footwear.
Common Ankle Injuries in Running
The most common ankle injuries in runners are ankle sprains, tendinopathies (especially Achilles tendinopathy), plantar fasciitis, stress fractures, and the eventual development of osteoarthritis.
While these are not the only injuries that may cause a runner may experience ankle pain, they represent the most common ankle injuries in running that are directly associated with dysfunction in and around the ankle. We will describe these ankle injuries in more detail below.
Ankle Sprains in Running
Ankle sprains, whether acute or chronic, are some of the most running ankle injuries, especially those who run on uneven terrain or in winter conditions.
Lateral ankle sprains are the most common type of ankle sprain in runners, and even when they are mild sprains, continued running without proper treatment can create nagging pain in the ankle, especially with sprinting or long distance running.
An ankle sprain happens when you damage a ligament that helps support the ankle joint. The anterior talofibular ligament , or ATFL for short, is the most commonly injured ligament in the ankle. The ATFL is susceptible to damage when rolling the ankle joint (inversion +/- plantarflexion).
The deltoid ligament, which sits on the inside of the ankle, is another commonly injured structure, just not as common as the ATFL. The deltoid ligament’s primary mechanism of injury is forced eversion, or stretching out the inside of the ankle, and this is more likely to occur on very uneven terrain.
When considering these ligaments on the whole across the entire ankle, it’s important to keep in mind that they provide a high level of stability or support for the ankle. Therefore, damage to an ankle ligament can lead to ankle instability and increase the risk of future injury.
Also, the muscles and tendons are also crucial in this regard, so they act in tandem with the ligaments in terms of providing ankle stability. This is important to keep in mind when treating or working to prevent ankle sprains when running (more on that below).
Tendinopathy in Running
Tendinopathies are overuse conditions that involve degeneration to the collagen fibers that make up the tendon, and these also represent a very common ankle injury in running.
Pain will be local to the tendon or its insertion point and may potentially radiate through the muscle/tendon’s pain referral pattern.
Contrary to popular belief, while chronic inflammation can certainly play a role, it’s not always present in these conditions, and a general breakdown and/or disorganization of collagen fibers is typically more prevalent.
The most common form of tendinopathy in running is Achilles tendinopathy, followed next by tibialis posterior tendinopathy.
Other forms of tendinopathy, such as peroneus longus and/or brevis tendinopathy, tibialis anterior tendinopathy, and the flexor hallucis longus tendinopathy, can also occur from running.
One of the reasons Achilles tendinopathy is the most common tendinopathy in running is because of the pure demand on the Achilles tendon during both propulsion and landing phases of running, especially with uphill running.
If the calf muscle is relatively weak, or you have a stiff Achilles tendon and calf muscle, and this is combined with a sudden increase in running volume or lack of recovery between runs, then you are more susceptible to developing Achilles tendinopathy.
Tibialis posterior tendinopathy is also very common in running due to the assistance it provides to the calf muscle and Achilles tendon, as well as its additional role in supporting the medial arch of the foot. Other tendinopathies listed above are usually associated with a previous injury or specific style of running and are generally less common.
Plantar Fasciitis in Running
Plantar fasciitis occurs when there is inflammation and dysfunction of the plantar fascia located on the bottom of the foot. While the ‘itis’ in the name of this condition denotes inflammation, the fascia can become structurally damaged as well, for example tearing to a micro and/or macro degree.
While technically located on the sole of the foot, its origin is located on the calcaneus (heel bone), which is part of the ankle joint complex. Additionally, it’s highly intimate with the Achille’s tendon and peroneus longus tendon, and as such, dysfunction in these other structures can lead to the development of plantar fasciitis in running.
The reason plantar fasciitis is common in runners is multi-factorial. First, the plantar fascia acts as the primary passive restraint to prevent medial arch collapse when you are on your feet.
With running, ground reaction forces are much higher than they are with walking, which will stress the plantar fascia more. Combine this with a high number of steps and running will increase the chances of developing plantar fasciitis.
Additionally, other ankle injuries that are common in running can also predispose one to developing plantar fasciitis. For example, a weak or injured tibialis posterior muscle/tendon, which helps support the medial arch of the foot, can place more demand on the plantar fascia.
Weak intrinsic muscles of the foot, ankle instability, dysfunction in the Achilles tendon or weak calf muscles, and other problems up the chain at the knee and hip can also increase the risk of developing plantar fasciitis, particularly when combined with a running training regime.
Stress Fractures in Running
Stress fractures are very small fractures in the bone that occur from repetitive impact, such as running or jumping. The most common stress fractures in runners are located in the tibia (primary shin bone), metatarsals, calcaneus, femur, and fibula.
A stress fracture will develop from overuse in the sense that the bone cannot deposit, remodel, and mineralize bone at the same rate of incurring damage, and therefore, are more often seen in long distance runners and marathon runners. In other words, the bone doesn’t have enough time to repair itself between bouts of running.
In many cases, stress fractures can lead to leg, foot, and ankle pain in runners before showing up on a standard x-ray. Additional risk factors that could lead to the development of a stress fracture includes concurrent conditions (e.g. osteoporosis), medication use, nutrition, and footwear.
Given a stress fracture can sometimes be difficult to formally diagnose in the early stages, it’s important to keep in mind a general pattern of symptoms. For runners, stress fractures typically involve sharp pain local to a specific bone that gets increasingly worse throughout a run and is eventually relieved with rest. When pronounced enough, there will be severe pain elicited on palpation of the injured bone.
Ankle Osteoarthritis in Running
Ankle osteoarthritis refers to the progressive breakdown of cartilage that lines that bones of the ankle joint. While much less common than the other ankle injuries described above, osteoarthritis can be a source of chronic pain while running especially if there is a longstanding history of ankle instability.
For ankle pain due to ankle osteoarthritis to occur during running, the condition has to already be present. Standard recreational and competitive running training, especially with proper footwear, does not pose a significant risk to the development of ankle osteoarthritis.
Moreover, running with ankle osteoarthritis is typically safe, so long as pain is mild and can be self-managed confidently, both during running and between runs.
How to treat ankle pain from running
Treating Ankle Sprains in Runners
Most treatment plans for ankle sprains in running will focus on initial protection, followed by specific range of motion and ankle strengthening exercises, and finally more advanced “return-to-sport” stability and range of motion exercises for the ankle joint.
Given that physical therapy for a sprained ankle from running will vary depending on the person and severity of ankle injury, it’s important to seek care from a physiotherapist to determine the extent of injury, specific diagnosis, and proposed treatment plan.
The initial focus for the injured ankle will be allowing the ligament to heal properly will ensure that the ankle can progress through the inflammatory phase while providing an optimal environment for healing, which ultimately allows for the torn ligament to heal in a good position.
Then, work can begin to strengthen the surrounding ankle muscles that reinforce the torn ligament while avoiding excessive stretch to the torn ligament. This may include resistance band exercises among other types of exercise.
The more advanced phase of rehab for an ankle sprain from running will focus on dynamic stability, meaning there is a bigger focus on challenging the ankle joint while moving. This may come in the form of advanced balance activities, advanced lower body strengthening exercises, jumping exercises, and ultimately a gradual return to running.
Generally speaking, ankle pain may come and go even in the middle to late stages of rehab, but you should notice your ankle stability and overall function improving with the same or less amount of ankle pain, and then eventually, the ankle pain should be largely abolished.
Treating Tendinopathy in Runners
If severe, physical therapy treatment for tendinopathies in runners may begin with a brief initial rest phase to allow the tendon to heal and progress through the inflammatory phase should there be any associated inflammation, much like a sprain.
However, the most important part of treatment for Achilles tendinopathy in runners, or any other tendinopathy, is a tendon loading program, which is essentially a program of specific strengthening exercises.
Most people have the instinct to stretch the tendon for treatment, which may provide some very short term pain relief; however, stretching is typically not recommended as an effective way to treat tendinopathies.
The reason strengthening is very important for treating tendinopathies is because we need to guide proper organization of the collagen fibers that are being deposited during the healing process, and to help build resiliency to the forces that are commonly placed on the tendon (i.e. running).
Given this loading should be very strategic, these injuries often require the assistance of a physiotherapist to develop an appropriate strengthening and stretching program, or at least a general evidence-based protocol for that type of injury, such as a heel drop program.
For example, with Achilles tendinopathy in runners, a heel drop program may start with basic calf raises under body weight, but over time will progress to increasing the amount of motion the ankle is working through, adding more weight or resistance, and eventually increasing the speed of the movements.
While strengthening programs for tendinopathies may be demanding and quite uncomfortable in the moment, they represent the best long term solution for getting rid of tendinopathies and proventing the onset of these tendon injuries in the future.
Treating Plantar Fasciitis in Runners
Treatment for plantar fasciitis in runners will focus on targeted stretching of the plantar fascia, as well as strengthening for muscles that help support the plantar fascia. These muscles can include the calf muscles (gastrocnemius and soleus), tibialis posterior, peroneus longus, flexor hallucis lingues, the small intrinsic muscles of the foot, and even muscle higher up the chain, such as the glutes.
A Windlass stretch is often recommended for runners suffering from plantar fasciitis, which is basically a calf stretch, but the additional component of having the big toe in an extended position. For more information on the biomechanical changes to the plantar fascia during running, please refer to Welte et al, 2021, for a study that explores the Windlass mechanism in more detail.
Some massage techniques, such as rolling the sole of the foot on a ball or a frozen water bottle, or stripping the plantar fascia with your thumbs (foot massage), and also help improve the flexibility of the plantar fascia while reducing pain during walking or running.
The reason that strengthening muscles around the plantar fascia is so important is because the plantar fascia is a passive tissue, meaning it cannot be actively contracted, thus making it be at the mercy of the forces placed upon it. If other structures can take up more of these stressful forces that occur with high impact activities like running, then the plantar fascia will be able to cope with these forces and heal any damage in the process.
Additionally, given that running can be an aggravating factor for plantar fasciitis, there may be a reduction in running while working on treatment. Re-introduction of running needs to be gradual, which is often why runners seek advice from a physiotherapist to ensure a proper return to running program is established.
Taping the plantar fascia can add support and reduce pain during running, as well as other forms of apparel, such as plantar fasciitis socks and sleeves, but these should be used as an adjunct to activity-based treatment, the latter of which provides the best long term outcomes.
Treating Stress Fractures in Runners
The most important part of treatment for stress fractures in runners is rest, which can be immensely discouraging for runners who would prefer to write it off as leg or ankle pain they can run through. It’s extremely important to be diligent with rest, as appropriate rest will allow for a faster recovery and prevention of this turning into nagging pain.
However, that doesn’t mean no activity whatsoever. A physiotherapist can set up a runner with a program to maintain strength in specific muscles groups that support the lower extremity, specifically the ankle, during running. These will start out as non-impact exercises, and cardio may be replaced with another form of non-impact cardio to maintain fitness while the runner progresses through rehab.
Treating Ankle Osteoarthritis in Runners
Treatment for ankle osteoarthritis involves improving ankle joint range of motion and strengthening all the muscles that assist in supporting and stabilizing the ankle joint complex, as well as other lower extremity joints that need to function properly in order to not place too much demand on the ankle.
Cyclical activities, like riding a stationary bike, using an elliptical, or swimming, represent more comfortable activities that help maintain and improve ankle joint range of motion, ultimately promoting cartilage health.
In the most severe cases, an ankle joint replacement can be performed, but this is usually avoided as much as possible due to limitations and/or disability that occurs after the fact (the surgery is more for pain than it is function).
Summary
Ankle pain in runners can be a result of many different injuries or problems and may not be limited to one specific issue. If you read the entire article, you may have noticed a recurrence of activity-based treatment being suggested for treatment, specifically strengthening.
While ankle pain that occurs during running can be reduced by following a general strengthening protocol that is tolerable on the ankle, visiting a physiotherapist or sports medicine physician is an excellent way to optimize your recovery and maintain confidence along the way.
References
Angelo V Vasiliadis (2017). Common stress fractures in runners: An analysis. Saudi Journal of Sports Medicine. Volume 17. Pages 1-6. DOI: 10.4103/1319-6308.197457.
Nicolas Kakouris, Numan Yener, Daniel T.P. Fong (2021). A systematic review of running-related musculoskeletal injuries in runners. Journal of Sport and Health Science. Volume 10, Issue 5. Pages 513-522. ISSN 2095-2546. https://doi.org/10.1016/j.jshs.2021.04.001.
Seyed Hamed Mousavi, Juha M. Hijmans, Reza Rajabi, Ron Diercks, Johannes Zwerver, Henk van der Worp (2019). Kinematic risk factors for lower limb tendinopathy in distance runners: A systematic review and meta-analysis. Gait & Posture. Volume 69. Pages 13-24. ISSN 0966-6362. https://doi.org/10.1016/j.gaitpost.2019.01.011.
Tony Lin-Wei Chen, Duo Wai-Chi Wong, Yinghu Peng, Ming Zhang (2020). Prediction on the plantar fascia strain offload upon Fascia taping and Low-Dye taping during running. Journal of Orthopaedic Translation. Volume 20. Pages 113-121. ISSN 2214-031X. https://doi.org/10.1016/j.jot.2019.06.006
Welte, L., Kelly, L. A., Kessler, S. E., Lieberman, D. E., D’Andrea, S. E., Lichtwark, G. A., & Rainbow, M. J. (2021). The extensibility of the plantar fascia influences the windlass mechanism during human running. Proceedings of the Royal Society B, 288(1943), 20202095.
Disclaimer:
The content here is designed for information & education purposes only and is not intended for medical advice.
