Author: Chloe Wilson - BSc(Hons) Physiotherapy
Most runners will complain of ankle pain running at some point, it is an all too familiar problem. But no one wants to be on the side-lines, especially when they are training for an upcoming race. So why is it such a common problem and what can we do about it?
Most runners take around 160-180 steps per minute. Each step sees forces transmitting through the foot and ankle and up the leg, with the ankle taking the brunt of the force. Do this over and over again, and it’s no wonder that foot and ankle pain is such a common, ongoing and frequently recurring problem for runners.
So here we will look at the most common causes of ankle pain from running, how to tell them apart, how to treat them and also, how to prevent them.
Ankle pain from running is usually caused by a combination of these factors:
1) Muscle Imbalance
Weakness and/or tightness in the foot, ankle, calf, knee and hip muscles are a common cause of ankle pain running. Muscle imbalance can make subtle changes to the position of your foot when it hits the ground, which can place certain structures under more stress and lead to foot and ankle pain when running.
We’ve all done it. Had a sudden fitness burst, started training for a race, upped our game – for whatever reason.
When we suddenly ask our bodies to work harder than they are used to, particularly over a sustained period of time, rather than gradually working through a training programme, our body sometimes says no. It can’t handle the extra demands on it and we develop ankle pain running, walking, standing or even at rest.
How many people wait until they’ve fully recovered from an injury before returning to running? The temptation to get back out there is often just too great and people start training too much, too soon, and their body doesn’t have a chance to fully heal. Maybe it’s just some mild discomfort, maybe the ankle feels a bit weak and wobbly. But they’re fed up of doing the exercises and rehab, and just want to get back running. The niggles continue and we ignore them until one day, it’s too much, we reinjure ourselves and the ankle pain running returns.
A problem with the bone such as a break in one of the bones, stiffness or excessive bone growth in a certain area is another possible cause of ankle pain running. The foot needs to be flexible in order to move smoothly in the different phases of running, so anything that interferes with that can lead to pain.
Do you know how often you should change your running shoes? The advice on the block is approximately every 500 miles. Factors such as running surface and body weight have an impact but on average that means if you run 5 miles a day, three times a week, you should be getting new shoes approximately every 7-8 months. Shoes lose their cushioning, their shock absorption and some of their shape, all of which places more strain on the ankle.
Each of these factors, alone, or in combination can lead to ankle pain during or even after running. So let’s have a look at the most common conditions that cause ankle pain running. We’ve split them by the location of the pain to help you to quickly identify your problem. Choose from side ankle pain, front (anterior) ankle pain, pain behind the ankle and pain below the ankle.
There is a whole network of ligaments around the ankle joint that hold it together and keep it stable. Ligaments join bone to bone, and whilst they are very strong, they are not particularly flexible so get damaged if over-stretched. Most runners will experience it at some point – their foot suddenly catches and twists (most commonly inwards) and they roll over on their ankle. If an ankle sprain is not fully rehabbed, it will most likely cause ongoing instability and ankle pain running.
What Is It: When one of the ankle ligaments gets over stretched which may tear some or all of the fibres. Most commonly affects the lateral ligament on the outer side of the foot due to an inversion injury – going over on the foot and forcing it inwards at the ankle.
Symptoms: Sudden onset of pain at the time of injury. The level of pain and swelling will depend on the severity of the injury. There is often ongoing ankle pain running even when the initial injury seems to have settled if full strength and flexibility is not achieved
Treatment: Initially rest, ice, compression, elevation and exercises. In some cases a brace or support may be helpful. Longer term rehab should include physical therapy and balance exercises to ensure a full recovery.
Find out loads more about the causes, symptoms, diagnosis and treatment options in the Ankle Sprain section.
The two peroneal tendons are found on the outer side of the ankle and also help with ankle stability. They work hard during running during the push off phase (plantarflexion). Overuse leads to inflammation and small tears in the tendon resulting in ankle pain running
What is it: Inflammation and degeneration in the peroneal tendons
Symptoms: Gradual onset of pain around the outer side and back of the ankle, worse with activity, better with rest. There will most likely be ankle pain running and when you turn your foot inwards due to the strain on the tendons
Treatment: Rest, ice, exercises, orthotics, physical therapy.
Find out more about the causes, symptoms and treatment options in the Peroneal Tendonitis Section
The posterior tibial tendon is found on the inner side of the ankle, connecting the tibialis posterior muscle to the foot. Its main function is to stabilise the ankle joint – picture a suspension bridge, the posterior tibial tendon is the huge steel cable under tension to keep the whole bridge (i.e. foot) from collapsing.
What Is It: Damage to the posterior tibial tendon resulting in inflammation or degeneration. This means it can’t support the foot arches or transmit the forces from the foot to the calf properly. Overtime, the medial foot arch will slowly collapse.
Symptoms: Localised pain along the inner side of your foot and ankle. Ankle pain running (during or after) with minimal pain at rest. A simple test for posterior tibial tendonitis is to stand on one leg with your knee straight and try to push up onto your tiptoes. Difficulty or pain doing this indicates this condition.
Treatment Options: Rest, ice, exercises, orthotics, injection or in severe cases immobilisation in a cast/walking boot. If symptoms fail to settle, surgery may be indicated.
The posterior tibial nerve passes through a passage on the inner side of the ankle known as the tarsal tunnel.
What Is It: Compression of the posterior tibial nerve as it passes through the tarsal tunnel, usually due to abnormal foot position (over-pronation) or following an injury.
Symptoms: Burning pain across the inner side of the ankle into the arch of the foot. There may also be pins and needles and/or numbness in the sole of the foot (which distinguishes it from plantar fasciitis). Increase in symptoms and ankle pain running or when standing for long periods
Treatment: Rest, strengthening and stretching exercises, orthotics to correct foot position, steroid injection and physical therapy. If there is continued ankle pain running or at rest, surgery may be advised.
The Achilles tendon is found on the back of the lower leg and connects the calf muscles to the heel. It is an extremely thick tendon and very strong – it can cope with forces up to twelve times body weight. But, it is not very flexible.
What Is It: Wear and tear on the Achilles tendon, either where it attaches to the back of the heel, or at its narrowest point, approximately 3cm above the heel
Symptoms: Ankle pain running (during and after) at the back of the ankle and around the heel. The pain is usually at is worst after periods of rest e.g. first thing in the morning or after strenuous activity. You may also feel a thickened area at the back of your heel. Symptoms tend to come on gradually over time rather than suddenly
Treatment Options: Rest, ice, exercises, injections, orthotics. It can take months for symptoms to full settle.
Visit the Achilles Tendonitis section to find out more about causes, symptoms, diagnosis and treatment.
Bursa are small fluid filled sacs that sit between bone and muscles/tendons to provide cushioning and prevent friction. The retrocalcaneal bursa is found on the back of the heel between the heel bone (calcaneus) and the Achilles tendon.
What Is It: Irritation and inflammation of the bursa, usually from excessive running, walking or jumping placing too much pressure on the bursa. It usually develops after a sudden increase in activity level or a particularly intense workout. In some cases, a bone spur may also develop, known as Haglunds Deformity
Symptoms: Heel and ankle pain running and walking or when standing on tiptoes. Heel may look slightly red and feel warm. Minor swelling may be present
Treatment: Rest from aggravating activities, ice, anti-inflammatories, shoe inserts and physical therapy. Symptoms usually settle within a few weeks.
The plantar fascia is a thick band that runs along the sole of your foot from the heel to the toes. It helps to support the foot arches and transmits forces through the foot when running and walking
What Is It: Small tears develop in the plantar fascia, usually from overuse, muscle tightness, unsupportive footwear and sudden changes in training schedules
Symptoms: Heel, foot arch and ankle pain running. Pain is often worse after resting (e.g. first thing in the morning), eases with movement but then gets worse with activity. There is often tenderness underneath the foot
Treatment: Early treatment is essential to ensure a quick recovery and includes
Find out more about the causes, symptoms and best treatment options in the plantar fasciitis section
A common problem for runners, shin splints affect the lower leg down to the front of the ankle.
What Is It: A combination of inflammation and/or small tears in the muscles and/or bone on the front of the lower leg. It is usually caused by a combination of abnormal foot biomechanics, muscle tightness and weakness, overtraining and running on hard, sloped surfaces. Usually affects both legs but more prevalent in a runners dominant leg. AKA Medial tibial stress syndrome
Symptoms: Generalized dull, achy shin and ankle pain running – may become a sharp pain as it gets progressively worse. Worse with activity, better with rest. Simple test – resist the movement of dorsiflexion (lifting your toes up) – pain with this indicates shin splints
Treatment: Rest, ice, anti-inflammatories, stretches, changing footwear. Usually takes a few weeks to settle.
The ankle joint is made up of two bones, the tibia (shin bone) and talus (part of the foot) and is lined with thick layers of spongy cartilage which acts as a shock absorber. The bones glide and roll on each other as the ankle moves.
What is it: Repetitive force through the front of the ankle joint leads to inflammation and the formation of bone spurs at the front of the joint which leads to pain and stiffness in the ankle, particularly when dorsiflexing the foot. Usually develops due to muscles tightness, overtraining, poor balance, abnormal biomechanics, after ankle sprains or with repetitive activities involving end range dorsiflexion such as deep squats or landing jumps
Symptoms: Dull ache at the front of the ankle when resting, sharp anterior ankle pain running and walking (worse with increased activity), swelling, pain with deep squats, lunges or landing a jump
Treatment: RICE (rest, ice, compression and elevation), anti-inflammatories, physical therapy, balance exercises, and in persistent, severe cases surgery may be recommended.
Stress fractures can occur in any of the foot bones, but most commonly affect the metatarsals.
What Is It: Suddenly increasing your activity levels can lead to a stress fracture in the foot. The muscles don’t have the strength or endurance needed to support the foot and excessive force can go through the bones, causing a fracture (break in the bone)
Symptoms: Mild to moderate pain and swelling - location will depend on where the injury is. While it may be possible to run with a stress fracture, the foot and ankle pain running usually gets progressively worse – it comes on quicker, last longer and is more intense
Treatment: Rest, ice, ankle brace, crutches and occasionally surgery. Visit the stress fractures section to find out more
You can find out loads more about these causes of ankle pain running, including in-depth information on the causes, symptoms, diagnosis, treatment and prevention, by using the links above. Alternatively, if none of these are sounding quite like your problem, visit the foot pain diagnosis section for help working out what is wrong.