Foot pain in runners - A quick guide

Foot pain in runners can present in two ways. It can develop suddenly, e.g. you go over on your ankle or you feel a sudden sharp pain while running – also known as traumatic injuries. It can also develop slowly over time, and the cause of this type of injury is often not that clear. In this article, we're going to focus on the second group of foot injuries – the ones that seem to develop for no apparent reason. We'll also share the top three treatments that we find work best for treating each of these foot injuries. Remember, if you need more help with an injury you're welcome to consult our team of sports physios via video call.

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In this article:

1. Pain on the outside of your foot

2. Pain on the inside of your foot

3. Pain over the front of your ankle

4. Pain under your heel

5. Pain in the front of your foot

6. Getting any tingling in your ankle or foot?

7. Stress fractures

We've also discussed this topic in this video:

Pain on the outside of the foot

Sinus tarsi syndrome

Despite its impressive name this condition is more painful than harmful. It is caused by chronic inflammation in the soft lining of the ankle joint.

The pain is usually located  just in front of the lateral malleolus (ankle bone), in a very similar place to where your ankle ligaments run and it often gets mistaken for a ligament sprain.

Here's a video where we discuss Sinus Tarsi Syndrome in a lot more detail:

Causes:

It often develops after you’ve sprained your ankle. Ankle ligaments usually take about 8 to 12 weeks to heal so if your pain continues for longer than 12 weeks, sinus tarsi syndrome may be to blame.

Another common cause is if your foot rolls in excessively (over-pronation) when you walk or run. When this happens you tend to squash the outside of the ankle joint which can cause it to flare up. Some of the most common things that can cause your foot to roll in too much include muscle weakness around your ankle or hips, wearing trainers that are too soft or running on a camber.

Our top 3 fixes:

The main goal with treatment is to improve the foot’s position and stop it from rolling in excessively while walking and running. You can achieve this through:

1. Wearing supportive shoes ALL DAY LONG. This injury may have been caused by running, but if you want it to recover you’ll have to look after it throughout the day.

2. We usually also prescribe supportive insoles for our patients (see examples below). In severe cases they may even benefit from wearing an ankle brace for 4 to 6 weeks while we strengthen up the muscles. Again, the aim of this is to stop the foot from rolling in.

3. Foot arch strengthening exercises as well as strengthening the stability muscles around the hips are important to prevent this from recurring.

You can find a more detailed discussion about the treatment of sinus tarsi syndrome here.

Peroneal Tendinopathy

Your peroneal muscles run along the outside of your lower leg. Their main function is to turn your foot out. Their tendons wrap around the back of the bone on the outside of your ankle. If these guys are to blame for your foot pain, you’ll often feel the pain over the outside of the foot – below the ankle bone or towards the outside border of the foot.

Here's a video where we discuss Peroneal Tendinopathy in a lot more detail:

Causes:

The main cause for this type of injury is usually something that makes your foot roll out more (excessive supination) while running.

Our top 3 fixes:

1. Check your running shoes – is it time to lay them to rest and get a new pair?

2. How tight are your calves? Tight calves (especially soleus) can make your peroneal muscles take more strain.

3. Have you been running on cambers that made your foot roll out more? Change your running route so that you run on the flat.

You can find more information about the treatment of peroneal tendinopathy here.

5th Metatarsal stress fracture

Your 5th metatarsal is the little bone that runs along the outside of your forefoot. The little bump that you can feel on the outside of your foot is the head of the 5th metatarsal bone. This is by far the most common area for stress fractures, but it can develop in any part of the bone. The pain is located on the outside of the foot and can sometimes be mistaken for peroneal tendonitis. It's also possible to have both conditions at the same time.

I discuss the diagnosis and treatment in detail in this video:

Causes:

Stress fractures are overuse injuries that develop when your bones can't recover quickly enough after exercise, either because you are training too hard, or not eating enough, or sometimes due to other conditions or deficiencies. Find out more about the causes of stress fractures here.

Our top 3 fixes:

1. Have it assessed by a sports doctor or a medical professional who is experienced in dealing with stress fractures. If you don't follow the correct treatment regime, it can delay healing and even mean that you may require surgery.

2. You will have to take your weight off your foot to allow the bone to heal. Depending on how bad your case is, your doctor may still allow you to walk around on it, but you'll likely be required to wear a boot and not place much weight through it.

3. Make sure that you eat a healthy diet and that your Vitamin D levels are adequate. Your bones can only repair if you provide them with the tools to do so.

Pain on the inside of the foot

Tibialis posterior tendinopathy

Your tibialis posterior muscles (tib post) is one of the main muscles that support your arch and stop your foot from rolling in or pronating excessively. Tib post tendinopathy causes pain on the inside of the heel and along the inside of your foot’s arch. The muscle belly of the tib post lies in your calf and it can sometimes even produce pain along the inside of your shin bone.

Here's a video where we discuss tib post tendinopathy in a lot more detail:

Causes:

The main cause of tib post tendinopathy in runners is when your foot rolls in too much while running (over-pronates). As mentioned above, over-pronation can be caused by several different things including the wrong running shoes, lots of downhill running, muscles weakness around the ankle or higher up in the leg etc.

Our top 3 fixes:

1. Check your running shoes (starting to see a pattern here??) – are they too soft or are they worn out? Do they provide enough support?

2. Use supportive insoles or orthotics to take some of the strain off the tib post tendons. (See examples below)

3. Strengthen your muscles in your foot and ankle as well as the stability muscles around your hips.

Here are some examples of supportive insoles that we found on Amazon – similar to the ones we use in clinic:

You can find more information about the treatment for tibialis posterior tendinopathy here.

Navicular stress fractures

Navicular stress fractures produce pain over the inner part of the bridge of the foot, but it can also feel as if it is at the top of the foot.

We've discussed navicular stress fractures in this video:

Causes:

The most common causes are overtraining and not getting the nutrients or vitamins your need (often it's a combination of the two).

Treatment:

These stress fractures are slow to heal and may require surgery, so it is really important to get them seen to immediately. We've discussed how to treat navicular stress fractures in detail here, but it can be summarised in three steps:

1. Immobilisation in a boot.

2. Not placing any weight through your foot for 6 to 8 weeks.

3. Then, once the boot is removed, very slowly increasing the load and strength in your foot.

Pain over the front of the ankle

Tibialis Anterior tendinopathy

This tendon runs down the front of the ankle joint and wraps around the inside of the foot. It flexes your foot upward but also helps to stop your foot from rolling in too much. If the pain in your foot is coming from this tendon, you usually feel it in the area where your foot joins your ankle.

Causes:

The number one cause for Tib Ant tendinopathy that we see in clinic is when runners tie their laces too tight, causing the tendon to rub as they run. Running in shoes that are a lot heavier or doing a lot of downhill running can also cause the Tib Ant to flare up.

Our top 3 fixes:

1. Check if your shoelaces are a problem. You may have to tie them extremely loosely to help your tendon recover. I caused mine to flare up while hiking in Scotland a few months back and it took about 4 weeks of careful management before it settled down again.

2. If you’ve recently changed running shoes you may have to check that they’re not too heavy.

3. Check if it’s better if you run on flatter terrain for a while.

Pain under your heel

Plantar Fasciitis

We’ve previously written a whole series of blog posts on how to treat this pesky problem, but here are the highlights. The plantar fascia is a thick fibrous band of tissue that runs from your heel to your toes. Its main function is to support your foot’s arch and stop it from collapsing when you put weight on it. Plantar fasciitis is essentially an overuse injury that develops when you strain the plantar fascia where it attaches to the heel bone. It can be extremely painful and stop you from running and walking.

Here's a video where we discuss Plantar Fasciitis in a lot more detail:

Causes:

Anything that puts extra strain on the plantar fascia e.g. unsupportive shoes, gaining weight, upping your running distance or intensity too dramatically. We’ve explained the causes of plantar fasciitis in more detail before.

Our top 3 fixes:

1. Wear supportive shoes with arch support inserts ALL THE TIME. You may have developed this injury through running, but you will have to nurse it all day long if you want to make a quick recovery.

2. Identify what’s making it worse and try to avoid it while you strengthen your foot arch and other leg muscles.

3. Do not go back to running too soon. You should have at least 4 pain free weeks and be able to walk 10km pain free (and without pain the next day) before you go back to running.

These arch support insoles are made with NASA foam technology:

Read the complete guide to treating Plantar Fasciitis here.

Pain in the front of your foot

Metatarsalgia

This is pain under the ball of your foot. Our patients often also describe it as feeling as if they are walking on a pebble. It is caused by inflammation in the little joints where your toes attaches to your foot.

We discuss metatarsalgia in much more detail in this article.

Causes:

These little joints become painful and sore when they are put under too much pressure for too long. In our experience (unless you’re a dancer) the main cause for this condition is wearing the wrong shoes. And we're not necessarily talking about running shoes. Regular work shoes or leisure shoes are often the culprits. Examples include ballet pumps, men’s dress shoes, minimalist running shoes or old trainers.

Our top 3 fixes:

1. Switch to wearing soft trainers ALL DAY LONG until your foot has fully recovered. This may mean that you’ve got to commute in them as well.

2. If you’re running in minimalist shoes (with very thin soles) you may have to switch to more cushioned shoes. Minimalist shoes are often touted as being the key to injury prevention, but they can cause their own injuries and metatarsalgia as well as metatarsal stress fractures are 2 examples.

3. Using orthotics with a metatarsal dome (see examples below) can often help to relieve some pressure on these painful joints. It fits just behind the metatarsal heads and lifts the little joints slightly.

Morton’s neuroma

You have little nerves that run between the bones in your forefoot. When these nerves get squashed they swell and become irritated causing pain in your forefoot that often also refers into your toes. Because it’s caused by irritated nerves, you may also feel tingling or numbness.

Causes

Wearing shoes that are too tight is an obvious cause for Morton’s neuroma. But anything that causes the bones to move and squash together excessively can contribute e.g. if you have very flexible feet or your feet roll excessively while you run (pronation or supination).

Our top 3 fixes:

1. Make sure that you avoid all tight shoes.

2. Wear supportive shoes that limit excessive movement.

3. Use insoles with a metatarsal dome that can help to spread the little bones in the forefoot, creating a bit more space for the nerves.

Here are some examples of orthotics that have arch support and metatarsal lifts. What we like about them is that they seem to have adjustable domes. Remember the dome has to sit BEHIND THE BALL OF YOUR FOOT – not on it.

Getting any tingling in your ankle or foot?

Tingling, numbness, a sensation of pins and needles or any strange sensations are usually a sign that your injury involves a nerve. Tingling etc. in the ankle and feet can be caused by injuries in the lower back or the leg or in the foot/ankle. It's best to consult a physio or other sports medicine professional if you’re experiencing these type of symptoms. They’re not necessarily more serious injuries, but they can be tricky to get better by yourself. This is also something that we can assess via video call.

Stress fractures

Stress fractures are rare, but they are a risk for anyone who does a lot of running. The most common areas where runners develop stress fractures are in the navicular bone, calcaneus (heel bone), and 5th metatarsal.

Bones normally first develop a stress reaction, during which time they’re very painful but nothing is broken. If you can catch this injury early and do the right things, it can settle down in as little as 4 to 6 weeks. If you neglect the signs and symptoms and continue to train, it may develop into a full-blown fracture, which can take months to heal.

Causes:

Very high training loads, usually combined with not enough recovery time, and often also a restricted diet. You can get a better understanding of how stress fractures develop in our previous blog post. Diagnosing stress fractures can be tricky, as they often don’t show up on regular X-rays. An experienced sports physio should be able to diagnose this for you.

Our top 3 fixes:

1. Immediately cut out all aggravating activities and rest the body part from all impact. This may include immobilising it in a boot for a few weeks. It is best to get guidance on how to best do this from a healthcare professional.

2. Analyse your training programme, including your diet and recovery to see where things have gone wrong.

3. Ask your GP to check your general bone density and Vitamin D levels.

Need more help?

Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.

We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.

About the Author

Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. You can read more about her here.

Follow her on LinkedIn or ResearchGate.

References:

1. Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education.

2. López-Valenciano, A., et al. (2016). "Impact of dynamic balance and hip abductor strength on chronic ankle instability." European Journal of Human Movement 36: 137-149.

3. Mansur, N. S. B., et al. (2019). "Subtar arthroscopic debridment for the treatment of sinus tarsi syndrome: case series." Revista da Associação Médica Brasileira 65(3): 370-374.

4. Tu, P. (2018). "Heel pain: diagnosis and management." American family physician 97.

5. Bowring B, Chockalingam N. Conservative treatment of tibialis posterior tendon dysfunction—A review. The Foot 2010;20(1):18-26.

6. Kulig K, Pomrantz AB, Burnfield JM, et al. Non-operative management of posterior tibialis tendon dysfunction: design of a randomized clinical trial [NCT00279630]. BMC musculoskeletal disorders 2006;7(1):1.

7. Ross MH, Smith MD, Mellor R, et al. Exercise for posterior tibial tendon dysfunction: a systematic review of randomised clinical trials and clinical guidelines. BMJ open sport & exercise medicine 2018;4(1):e000430.

8. McKeon, P. O., Hertel, J., Bramble, D., & Davis, I. (2015). The foot core system: a new paradigm for understanding intrinsic foot muscle function. British Journal of Sports Medicine, 49(5), 290.

9. Robroy L.M. et al., (2014). Heel Pain—Plantar Fasciitis: Revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), A1-A33.

10. Bentall, D. (2020). "RED-S: not just a female phenomenon." British Journal of Sports Medicine: bjsports-2019-101868.

11. Herbert, A. J., et al. (2019). "The interactions of physical activity, exercise and genetics and their associations with bone mineral density: implications for injury risk in elite athletes." European Journal of Applied Physiology 119(1): 29-47.

12. Mountjoy, M., et al. (2018). "IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update." British Journal of Sports Medicine.

13. Wright, A. A., et al. (2015). "Risk factors associated with lower extremity stress fractures in runners: a systematic review with meta-analysis." British Journal of Sports Medicine 49(23): 1517-1523.