Running Related Foot, Ankle, and Lower Leg Injuries


Foot, ankle and lower leg injuries are very common in runners and can be frustrating to overcome. Part of the difficulty in recovering from injury is knowing exactly what the injury is and what to do about it. Today, I am going to talk about three of the most common running injuries I see clinically and have high prevalence rates in runners. The intention of the blog is not meant for you to treat the conditions on your own and this is not medical advice. The purpose of the blog is to provide valuable information that could point to a diagnosis and some exercises that we use in physical therapy for these conditions that would also be good for prevention. If you are experiencing pain, I recommend consulting a physical therapist for specific guidance to your issue.

Plantar Fasciitis 
What is it?

Plantar fasciitis is the most commonly treated foot condition in health care settings.  More recent evidence suggests that thickening and structural changes are more common than inflammation, so “plantar fasciopathy” more accurately reflects the diagnosis. Plantar fasciopathy is an overuse injury from repetitive stress to the plantar fascia.

Common signs/symptoms
  • Sharp pain on the bottom of your heel (most commonly) or arch of the foot
  • Pain first thing in the morning or after a period of prolonged inactivity
  • Pain is worse with barefoot walking
  • Pain worse the weight-bearing activity such as walking or running
What causes it?

Plantar fasciopathy in runners is usually from overuse from a recent spike in training volume. Many patients report an increase in training volume prior to the injury. This is the “too much too soon” principle that I talked about in the Knee Running Related Injuries blog post.  If you did not have a recent spike in training volume, then the listed risk factors below may have contributed to developing the condition.

Risk Factors 
  • Increased BMI (body mass index) in non-athletes
  • Reduced ankle dorsiflexion range of motion (motion of brining foot up toward your shin)
  • Running
  • Work-related weight-bearing activities
  • Flat arch foot type
  • High arch foot type
  • Sedentary lifestyle

I have already reviewed some exercises for plantar fasciitis in a previous blog post, so I will not review them again today. ​

Achilles Tendonitis
What is it?

Degenerative or failed healing of the tendon that causes localized pain, swelling, and loss of function of the Achilles tendon (connects calf to heel). Similar to plantar fasciitis, more recent evidence supports that it is not a true inflammatory process, so Achilles tendinopathy is the more appropriate name. There are three types of Achilles tendinopathy: insertional (20-25%), mid-portion (55-65%), and higher up at the Achilles tendon/muscle junction (proximal musculotendinous junction (9-25%).

Common signs/symptoms
  • Localized, tender to touch pain and impaired function
  • Pain/stiffness in the morning or after prolonged sitting/inactivity
  • Warm up effect: pain worse at beginning of a run then gets better after the initial discomfort.
  • Even though the pain reduces after it ‘warms up,’ the pain can come back if you continue to run and/or the pain will be worse later after your run, sometimes for the rest of the day into the next day.
What causes it?

In the running or sport population, tendon overload without adequate rest is the main cause. Once again, the too much too soon principle applies here. Do you see the pattern yet? Overuse injuries are the main reason injured runners come to see physical therapists. Below are the risk factors for developing plantar fasciopathy.

Risk factors
  • Decreased calf strength
  • Hip strength/neuromuscular control deficits
  • Decreased ankle range of motion
  • Increased foot pronation
  • Increased body weight
  • Systemic disease

The mainstay of Achilles tendonitis rehab is to load the tendon appropriately. This may seem counter-intuitive to many people who have heard health care professionals tell them to “just rest it.” That is not the best approach. With more recent research, calf strengthening slowly is the most effective treatment option. Calf strengthening also loads the Achilles tendon, which causes it to adapt and heal. When I say to slowly strengthen the calf, I mean a 3 second up and 3 second down time period each rep for the exercises. Toward the later phases of rehab, faster movements will be incorporated but not early on because they tend to be more pain provoking. 

Calf Strengthening
Calf Strengthening – Soleus Focused
Shin Splints (Medial Tibial Stress Syndrome)
What is it?

Irritation and inflammation of the bone and muscle that attaches to the inside of the front of the shin.

Common signs/symptoms
  • Tenderness on the inside of your shin bone >5 cm with <5 cm area of tenderness indicative of stress fracture.
  • The pain location is often the bottom to middle of the shin.
  • Pain may be present at the beginning but progresses the longer you run. Often the pain relievers with rest but if it is very irritable, it can hurt at rest.
What causes it?

Shin splits are an overuse injury to the shin (tibia) from repeated stress, often from running or jumping. The risk factors listed below may predispose someone to shin splints, but without overuse, shin splits will likely never develop.

Risk factors
  • Flat feet and overpronation
  • High volume/sport involving running and/or jumping
  • Previous running injury
  • High body mass index (BMI)
  • Excessive hip mobility
  • Decreased bone mineral density

The first step to treating shin splints is activity modification. Yes, that means reducing running volume. There is less research supporting the best exercises for shin splints but strengthening and stretching the calf complex are where to start. Any calf stretching method you prefer is fine as long as it does not increase your pain. I reviewed ways to stretch the calves in the plantar fasciitis blog. In addition to the strengthening exercises above, the exercises in the videos below also strengthen the calf complex. 

Wall Squat Heel Raise
Bridge with Heel Raise

In addition to strengthening and stretching the calf complex, hip strengthening is important for managing lower leg injuries. The stronger your hip musculature is, specifically the gluteals, the better they absorb forces going through your leg with each step of running. Reduced force each step will lead to reduced chance of an overuse injury. In the video below, I added a heel raise to a traditional side-stepping exercise to kick in the calf complex, but for most people, it still fatigues the gluteals more than the calf complex. 

Side-Stepping with Heel Raise
Final Thoughts

All three of the injuries discussed in the blog are overuse injuries. Load management is essential with overuse injuries. Load management for the runner involves specific dosing of exercise, safe return to running from injury, and safe progression in running volume. The best exercise program is not going to work if load is not managed correctly. The good news is that these injuries can be conservatively managed for most people. If pain is persistent, it may be time to have specific guidance on your injury. Contact a physical therapist for medical advice pertaining to your specific condition. 

Disclaimer: This content is designed for information and education purposes only and is not intended for medical advice.

  1. Martin RL, Davenport TE, Reischl SF, McPoil TG, Matheson JW, Wukich DK, McDonough CM; American Physical Therapy Association. Heel pain-plantar fasciitis: revision 2014. J Orthop Sports Phys Ther. 2014 Nov;44(11):A1-33. doi: 10.2519/jospt.2014.0303. PMID: 25361863.
  2. Silbernagel KG, Hanlon S, Sprague A. Current Clinical Concepts: Conservative Management of Achilles Tendinopathy. J Athl Train. 2020 May;55(5):438-447. doi: 10.4085/1062-6050-356-19. Epub 2020 Apr 8.
  3. Newman P, Witchalls J, Waddington G, Adams R. Risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. Open Access J Sports Med. 2013;4:229–241
  4. Moen MH, Holtslag L, Bakker E, et al. The treatment of medial tibial stress syndrome in athletes: a randomized clinical trial. Sports Med Arthrosc Rehabil Ther Technol. 2012;4:12.
  5. Moen MH, Tol JL, Weir A, et al. Medial tibial stress syndrome: a critical review. Sports Med. 2009;39(7):523-546.

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