My foot hurts!
Causes and prevention of foot & ankle conditions associated with running
By Tracy D. Harper PT, DPT, ATC
Guest Writer for Running Illustrated
Recreational and competitive runners are used to pain. We often train through chronic, overuse conditions such as sesamoiditis or metatarsalgia (injuries associated with a pain in the ball of the foot or toes), stress fractures, plantar fasciitis, Achilles tendonitis, and painful bunions. Those nagging pains can eventually become severe enough, however, that we must alter or even cease training. Some injuries, if not treated properly, can come right back when we resume running. And sometimes runners sustain traumatic injuries such as sudden sprains and strains of the foot and/or ankle during training can curb training all together.
The general causative factors of foot and ankle injuries can usually be blamed on a combination of things ranging from fatigue, poorly-fitted shoes, old shoes, and over training to body make up, weight and other factors which are listed below.
Common Factors Contributing to Foot/Ankle Conditions
Other more familiar factors contributing to foot/ankle conditions include:
- training errors
- excess training on hills
- ramping up your pace or distance too quickly
- insufficient rest
- improper footwear
- running in other than running shoes
- trying to get too much mileage out of a single pair
- too much or too little shock absorption for your foot or body type
- too much or too little pronation control features for your tendencies
- shortened calf (Achilles) and/or hamstring length
- perhaps congenital, perhaps as a result of training
- possible weakness of muscles that reinforce the arch
- may relate back to training errors that overly fatigue the posterior tibialis muscle
- incomplete rehabilitation after a traumatic injury
- excessive body weight
- eating disorders that have lead to bone density loss
- See: http://www.femaleathletetriad.org
Runners Are Predisposed to Certain Conditions
Some runners have a genetic predisposition to loose ligaments and tendons – allowing excessive joint mobility. Depending upon the work load placed upon these tissues, this tendency can lead to tendonitis, fasciitis, or even progressive alteration of joint structure – such as in (acquired) flat foot. Tendonitis may occur in the loose jointed runner since the tendons are working overtime to stabilize the foot/ankle while also trying to propel you forward. The demands upon the tendon may be too great for it to handle, so breakdown (and eventually pain) occurs. The loose jointed (or hypermobile) individual usually needs more time to ramp up their training, more support from a running shoe, and can take longer than usual to heal if they do sustain an injury. See: http://www.hypermobility.org/
Structural or bony alignment issues
Similarly, you can be born with certain structural features affecting the bony alignment of the foot such as a 2nd toe lengthier than the 1st, an “equinus foot” that restricts the degree your ankle bends, a high rigid arch, or a relatively flattened arch. You may also be born with a bone/joint structure that gives you the tendency to over- or under-pronate when you run. Your bone/joint structure can even change as you age, usually in response to the stresses placed upon it, but also due to injury or disease processes. These bone/joint aberrations change how your foot accepts weight when it strikes the ground and propels you forward during your stride.
Common Foot/Ankle Region Conditions
Sesamoiditis: Sesamoid bones are small pea-shaped bones located under the joint at the ball of your foot and are important attachment sites for many soft tissues of the foot. They help to maintain the right alignment of tendons as well as to absorb pressures as you push off. This region can become inflamed due to various compensatory foot motions that occur as a result of structural problems with the foot, including hypermobility of the forefoot especially. Sometimes the sesamoids can be subjected to extra pressure in those who have thinning of the usual fat pads that help cushion bony prominences of the sole of the foot. Continued stress without treatment can sometimes lead to stress fracture of a sesamoid bone. Source: http://www.foot.com/info/cond_sesamoiditis.jsp.
Stress fractures: As mentioned above, sesamoid bones can fracture with repeated, unmanaged stress. However you may be more familiar with the more common type of stress fractures in runners which occur to the long bones of the forefoot called the metatarsals. Usually the second or third metatarsals are involved, and sometimes the 5th. Stress fractures may result due to a combination of factors including structural (bone density, excess weight, structural foot abnormalities, tight Achilles) and those such as poor shoe wear and/or poor training habits. Pain is usually on the top of the forefoot. It can be quite dull at first, and then become sharp each time you try to push off.
Plantar fasciitis: The plantar fascia is a rather dense tissue – sort of like your ligaments – that begins at the heel and spans most of the bottom of your foot. It helps to absorb shock and to add structural stability to your foot. Many of the same factors responsible for stress fractures can create inflammation and pain of this tissue. With plantar fasciitis, you often have pain that is worse in the morning when you try to take that first step after getting out of bed. As you warm up and stretch a bit you may have less pain. The longer you stand or the longer you run, the pain begins to intensify. Some people describe it as an ache while others experience a burning sensation. Some have more pain in the heel area while others have pain more so in the arch, or even the whole length of the underside of the foot. Even when diagnosed with plantar fasciitis, other tissues may be involved such as nerve tissue – hence the variability of symptoms.
Achilles tendonitis: Most runners are familiar with the Achilles tendon since, hopefully, you do spend at least some time trying to stretch it before a training session. The Achilles tendon is a rather dense tissue that attaches 2 major calf muscles (gastrocnemius and soleus) to the heel bone (calcaneus). When repeatedly overstressed, it can become inflamed and eventually even damaged with small tears. The tendon can be overstressed by excessive tension such as when the tendon is shortened (tight) but the demands for lengthening are high, or when there is compensatory motions at the ankle that cause a twisting of the tendon where it receives the least amount of circulation. Pain can be at the site where the tendon attaches to the heel bone or even a short distance above this site. Like plantar fasciitis, this condition can be most painful upon getting out of bed in the morning or any time you have been sitting a long period and then take that first step. Of course, this pain is also felt during running, often as you push off. It may cause you to shorten your stride such that you could continue running with less pain.
Metatarsalgia: This is a blanket terms for pain under the ball of your foot, usually in the area just before your 2nd and 3rd toes. It usually hurts there mostly when you are bearing weight over this area, and especially as you push off. Calluses may form as the body’s way of reducing stress here. Pain can originate from too much stress to the soft tissue forming the joints in the area, or even due to compression of the small nerves that run between the bones called you metatarsals. Pain may start in the foot and even radiate into the 2nd and 3rd toes. People with this condition often have a second toe that is longer than the 3rd, but other factors can lead to this condition as well.
Bunions: A bunion is actually a change in the bony alignment of the bones forming the inside part of the forefoot and big toe which occurs as tendon slide out of their desired alignment. The forefoot will actually appear wider over time than it once was, and may occur with both feet – but often unequally. This change in alignment due to abnormal stresses to the foot affects the structure and function of what is called your 1st metatarsal-phalangeal joint. The joint can become quite prominent in severe cases, often laying down extra bone material such that it projects even further inward (toward the other foot). Sometimes this prominence rubs against the shoe or sneakers – which are now too narrow – creating painful calluses. The change in the joint alignment can eventually lead to restricted motion of your big toe joint, which then changes how you walk or run. Pain can therefore occur at the affected joint or elsewhere.
Dr. Benjamin Overley, DPM of the Sports Medicine Institute (www.sportsmedinstitute.com) of Pottstown, PA reminds runners to honestly consider how their bodies’ are feeling before increasing training intensity and mileage.
“A reasonable training schedule plus the appropriate running sneaker type for the intended mileage are the best defenses against overuse injuries.”
An avid runner and foot/ankle specialist surgeon, Dr. Overely suggests to consider the time and training needed for to adequately prepare for a race, and that is perhaps lengthier than you are accustomed.
Preventing common foot injuries is easy – it just takes paying some time an attention to your feet.
- Address training errors! Perhaps you need a coach to design a training schedule that meets your goals yet minimizes the chance of injury. There are many resources available to assist the novice runner in judicious training for an event. When your training is too rigorous for your fitness level or even your joint structure (remember loose jointed people?), breakdown in the body’s tissues can occur – even before you begin to experience pain. All those endorphins that kick in during a long run tend to mask the pain that otherwise would occur with tissue breakdown. If experiencing pain when you run, you can try to modify the workout by changing the mileage, velocity, intensity, running surface, and incline as well as adding rest days or cross training.
- Go to a reputable running store for advice regarding which brand and style are best for you. Usually, a good running store will have someone watch you run and then offer suggestions. Runners training over 25 miles/wk usually need to replace their shoes every 3-4 months.
- Stretch those heel cords and hamstrings! Tight musculature alters how you run. When your ankle cannot bend easily due to tight heel cords, you tend to move excessively at joints not meant to do so. If you tend to position your toes pointing outward when you run, you may need advice as to whether this is due to tight muscle/tendon or caused by something structural you cannot change. Running with a toe-out gait also stresses joints improperly.
- Consult a physical therapist (with foot/ankle expertise) for advice regarding specific strengthening of foot/ankle muscles if you think weakness is an issue. If your foot tends to “wobble” a lot when balancing on one leg, you may have weakness that should be addressed.
- Consider Orthotics: If you think that you may be loose jointed you may benefit from orthotic shoe inserts, and definitely from a running shoe recommended by an expert. You may have the tendency to overpronate. See: http://www.youtube.com/watch?v=pODcT55_7zA
Runners With Injuries We Can Relate To
The following case studies describe three runners with common foot injuries.
CASE #1 – The 45-Year-Old Female 5K Competetor
A runner, lets call her “Karen,” is a health care worker who runs 30 miles a week. She has been doing this mileage for many years and while she runs on many different types of surface, mostly, she is running along the side of road facing traffic.
Karen was complaining about a dull achilles tendon pain just above the heels of both feet where her right foot experienced worse than her left. She felt a very sharp in the morning or trying to take a stride after her long commute to work. Before she went to a physical therapist, she used to have pain at the beginning of the run and would get better as she warmed up. Karen did notice that the pain she felt upon getting out of bed got better with stretching as well as taking small steps at first. After three months experiencing this pain, Karen realized the pain in her feet was getting worse; she experienced it walking and that the pain did not get better after her warm up.
Karen saw podiatrist who recommended consultation with physical therapist (PT).
The PT diagnosed Karen with plantar fasciitis in her right foot and suggested Karen use cold packs after every run. She shortened her training distance, avoided hill work, and changed her running shoe. As part of her therapy, Karen did the following:
- Modified Achilles’ stretch – wall push type stretch with foot straight ahead, although with weight more to the outside of the foot. Lean forward at the hips without allowing foot to “roll” inward (keep weight on outside of foot).
- Small heel lift added to both orthotic shoe inserts (Karen had to buy a running shoe with a deeper heel seat to accommodate for the extra height of the insert). Another alternative, since both feet were affected, would have been to add a lift to the heel aspect of the sneaker soles. This would usually be done at a shoe repair facility or by a pedorthotist (practitioner who specializes in shoe accommodations for foot problems).
- Saw a PT. Her physical therapist performed manual techniques to increase the mobility of both ankle joint and the potential scar region within the tendon, stretches for the hip to help correct the toe-out style running and walking that had developed, and strengthening of the muscles that bend the ankle (toes/forefoot move up).
- Continued use of cold packs after work, and stretching throughout the day (especially in the morning).
- Ceased running until walking was pain free. Using the advise of her PT, Karen could start training only when walking was pain free, and then she could begin a light jog of 1 – 2 miles, and then slowly increase mileage if she had no pain during, after, or in the morning. When she could jog 5 miles pain free, only then, could the she increase her speed.
- Karen’s PT advised her to run on level surfaces that do not create unequal footing since she agreed that she was running mostly on a road in which the slope caused her right leg to be slightly elevated versus the left.
- Corrected her running gait. Once appropriate heel lift was added, KBV was trained in correcting her toe-out gait.
After going through this program, Karen was able to return to running her usual mileage and running speed in 6 weeks.
CASE #2 – 40-Year-Old Male Attorney; Running for Fitness and Weight Loss
“Steve” had gained 20 pounds. His wife had kindly urged that he lose weight. Steve had adopted the traditional American diet of high fat foods. To loose the weight he took to running. He grabbed a pair of running shoes from the back of his closed and started to run on the wooded trails near his home.
Steve got up to running 10 miles per week but was experiencing heel and arch pain in his left foot. Steve’s symptoms were worse in the morning, after running, and if standing long periods.
Steve called an uncle, a physical therapist who lived 3 hours away. His uncle recommended he consult a known, reputable pedorthotist near Steve’s office and faxed him a series of Achilles stretches. Steve’s uncle also advised him to stop running until he saw the doctor.
Steve saw the podiatrist who quickly saw the problem, first of which was that Steve’s running shoes were two years old. Steve was diagnosed with “compensated forefoot varus” which begins as a structural alignment “deformity” in which the forefoot has to move excessively just to get the sole of the foot firmly onto the ground with each step. This appears as overpronation or prolonged pronation of the foot, often leading to excessive mobility of the forefoot. This places extra stress on the plantar fascia, and eventual pain and tissue breakdown. The same condition – combined with being overweight and/or overtraining – can cause painful bunion formation, metatarsalgia, stress fractures, Achilles’ strains, and even symptoms at the knee (predisposition to ACL injury).
Steve was told to stretch his Achilles’ at least two times a day and to buy new running shoes. The podiatrist fit Steve with custom made orthotic inserts, specifically constructed with what is termed medial posting. Once Steve started his treatment, we has able to get back into running after a three short weeks.