Foot and ankle injuries account for nearly one-third of running injuries. Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the most common types of injuries sustained during training. Other common injuries include other tendinopathies of the foot and ankle, bone stress injuries, nerve conditions including neuromas, and joint disease including osteoarthritis. This review provides an evidence-based framework for the evaluation and optimal management of these conditions to ensure safe return to running participation and reduce risk for future injury.
Key points
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Achilles tendinopathy is common and may require comprehensive assessment and management. A similar approach is required for most foot and ankle tendon-related diseases.
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Plantar fasciopathy is the most common cause of plantar foot pain in runners; interdigital neuromas, tarsal tunnel syndrome, and jogger’s foot should also be considered.
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Although lateral ankle sprains are a common cause of ligament injury and ankle dysfunction, other joint conditions must be considered in chronic cases with refractory pain and dysfunction.
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Most foot and ankle conditions respond favorably to conservative management, including activity modification along with corrective exercises to restore strength and function.
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Preventive measures may reduce the risk for injury and are an emerging area for future investigation and research.
Introduction
Foot and ankle injuries are estimated to compose 31% of total running injuries sustained. A systematic review of running injuries by Lopes in 2012 revealed that Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the top 5 most common running injuries. The complex anatomy and biomechanics of the foot and ankle underscore the importance of a careful and thorough history, examination, and workup to confirm a diagnosis and rule out concomitant conditions. The running athlete requires special consideration during rehabilitation and return to participation. This review encompasses common foot and ankle injuries in running athletes, including evaluation and management of these conditions. Although the majority of our focus is on the most common injuries, this comprehensive discussion covers the full spectrum of pathology from tendinopathies to bone, joint, and nerve disorders ( Table 1 ).
| Category | Diagnosis |
|---|---|
| Tendinopathies | Achilles tendinopathy Posterior tibial tendon dysfunction Peroneal tendinopathy Flexor hallucis longus tendinopathy Anterior tibial tendinopathy |
| Ligament and fascia conditions | Plantar fasciopathy Inversion ankle sprain High ankle sprain (syndesmosis injury) |
| Bone conditions | Bone stress injuries |
| Joint disorders | Hallux rigidus Osteochondral defect of the talus Osteoarthritis |
| Nerve disorders | Interdigital neuralgia/Morton’s neuroma Tarsal tunnel syndrome Superficial peroneal neuropathy Jogger’s foot |
Introduction
Foot and ankle injuries are estimated to compose 31% of total running injuries sustained. A systematic review of running injuries by Lopes in 2012 revealed that Achilles tendinopathy, plantar fasciopathy, and ankle sprains are 3 of the top 5 most common running injuries. The complex anatomy and biomechanics of the foot and ankle underscore the importance of a careful and thorough history, examination, and workup to confirm a diagnosis and rule out concomitant conditions. The running athlete requires special consideration during rehabilitation and return to participation. This review encompasses common foot and ankle injuries in running athletes, including evaluation and management of these conditions. Although the majority of our focus is on the most common injuries, this comprehensive discussion covers the full spectrum of pathology from tendinopathies to bone, joint, and nerve disorders ( Table 1 ).
| Category | Diagnosis |
|---|---|
| Tendinopathies | Achilles tendinopathy Posterior tibial tendon dysfunction Peroneal tendinopathy Flexor hallucis longus tendinopathy Anterior tibial tendinopathy |
| Ligament and fascia conditions | Plantar fasciopathy Inversion ankle sprain High ankle sprain (syndesmosis injury) |
| Bone conditions | Bone stress injuries |
| Joint disorders | Hallux rigidus Osteochondral defect of the talus Osteoarthritis |
| Nerve disorders | Interdigital neuralgia/Morton’s neuroma Tarsal tunnel syndrome Superficial peroneal neuropathy Jogger’s foot |
Achilles tendinopathy
The Achilles tendon is the largest tendon of the body and connects the soleus, and medial and lateral gastrocnemius muscles (collectively referred to as triceps surae) to the insertion on the calcaneus. Insertional fibers of the Achilles tendon are in continuity with the plantar aponeurosis. This musculotendinous group serves as the primary plantar flexor of the foot and ankle. The Achilles tendon is a common site of pain in runners and may be the second most common musculoskeletal injury, after medial tibial stress syndrome, with an incidence of 9.1% to 10.9%. The lifetime risk in former elite male distance runners is 52%. In addition to overuse from running, multiple intrinsic and extrinsic risk factors have been outlined that may contribute, including systemic disease, older age, sex, body composition, and biomechanics.
Terminology becomes important in the assessment and management of Achilles tendon disorders. In the acute phase, Achilles tendinitis refers to inflammatory changes at the tendon level and may include the paratenon that surrounds the tendon. In the chronic phase, Achilles tendinosis represents a more chronic and degenerative process. Achilles tendinopathy is our preferred term to use for Achilles tendon pain, with recent proposed definition for tendon pathology on a continuum of 3 stages: “reactive tendinopathy, tendon disrepair (failed healing), and degenerative tendinopathy.”
Clinical Evaluation
The 2 most common sites of injury in runners include midportion Achilles tendinopathy (2–6 cm distal to the calcaneal insertion, a region of reduced vascularity ) and insertional Achilles tendinopathy (injury localized to the insertion of the Achilles tendon with calcaneus), although injuries to other regions including the myotendinous junction can occur.
Developing a systemic clinical evaluation is recommended to evaluate this injury and differentiate from other causes of heel pain. First, the runner should be asked to localize the site of maximal pain. Examination should include inspection of the tendon for differences in the general appearance of the Achilles tendon, including thickening or overlying erythema. The calcaneus should be evaluated for difference in size or prominence of the posterior aspect that may suggest presence of Haglund’s deformity. On palpation, patients with unilateral Achilles tendinopathy may have differences in the quality of the tendon, such as thickening. Presence of crepitus, swelling, and tenderness localized to a fixed position with ankle range of motion (ROM) suggests active inflammation in the paratenon surrounding the Achilles tendon. Dorsiflexion ROM may be limited on the affected side. Dorsiflexion ROM assessment should include evaluation of ROM with knee in full extension and 90° of knee flexion to determine differences in ROM (the Silfverskiold test), with decreased ROM with full knee extension suggesting the presence of gastrocnemius tightness or contracture that may place the Achilles tendon in increased tension. Evaluation of strength should include requesting the patient perform a series of single leg calf raises and evaluating for pain during this maneuver, differences in heel height from side-to-side, and fatigue.
If there is concern for Achilles tendon rupture (based on patient history or presence of palpable gap of the tendon), the Thompson’s test should be performed. To perform this maneuver, the patient lies prone and examiner squeezes the triceps surae distal to the knee. Passive foot plantar flexion suggests that the Achilles tendon is contiguous with the calcaneus and unlikely to have a full-thickness tear. If there is no foot plantarflexion with calf squeeze (be sure to compare with the contralateral side), there is concern for Achilles rupture. Extensor lag and a palpable gap at the rupture site are also signs of rupture. The calcaneal squeeze test is helpful to exclude the presence of a calcaneal BSI. This test is performed with the clinician pressing both medially and laterally onto the calcaneus and evaluates for pain localized to the calcaneus.
With regard to imaging, weight-bearing radiographs (lateral and axial views of the heel), may be helpful to evaluate for Haglund’s deformity, calcific tendinopathy, or if the diagnosis is unclear. MRI is indicated primarily if there is concern for significant tear or rupture of the Achilles tendon or to evaluate for a BSI. Ultrasonography is a useful modality that can be helpful to qualify Achilles tendon injury.
Differential Diagnosis
The differential diagnosis for heel pain in a runner includes Achilles tendinopathy, posterior ankle impingement, retrocalcaneal bursitis, symptomatic Haglund’s deformity, BSI to the distal tibia, fibula, or calcaneus, peroneal tendinopathy, and hindfoot arthrosis.
Management
In the acute phase, initial management includes rest, activity modification, trial of heel lifts, and stretching the triceps surae. If the patient has significant pain with weight bearing, a brief period of immobilization in a boot can help to alleviate this, but long periods of time in a boot should be avoided owing to the risk of increased muscle atrophy. Local modalities including ice, massage, and ultrasound may reduce pain. Iontophoresis may also be considered to reduce local inflammation for acute presentation. Nonsteroidal antiinflammatory medications (NSAIDs) are commonly prescribed for a short course of treatment, although the degree of true inflammation is questionable in more chronic conditions. Topical nitroglycerine does not have clear evidence to support its use.
After achieving pain control, treatment should focus on strengthening the integrity of the Achilles tendon and triceps surae. Alfredson and colleagues demonstrated efficacy of eccentric loading protocol for addressing pain and strength in patients with Achilles tendinopathy. In this landmark study, 15 subjects with unilateral midportion Achilles tendinopathy completed a 12-week session of single leg eccentric loading program with progressive weight loading. Subjects who completed this protocol of 3 sets of 15 repetitions with both knees bent and straight twice per day had normalization of strength, reduction of pain, and all returned to running over 12 weeks. A larger study using Alfredson’s protocol in athletes with a 5-year follow-up reported that most individuals experienced gains in function, although nearly one-half of subjects pursued other therapies and most reported mild pain. For insertional Achilles tendinopathy, the authors recommend a modified version of Alfredson’s protocol with eccentric load calf raises that do not include heel drop.
Additionally, rehabilitation exercises that address function of the full kinetic chain are important given studies that suggest biomechanical factors may contribute to Achilles tendinopathy including reduced activity of tibialis anterior, rectus femoris, gluteus medius, and gluteus maximus. Foot intrinsic strengthening and restoring proprioception is important for this condition, as with any foot and ankle disorder.
Treatment for chronic refractory Achilles tendinopathy may include injection of platelet-rich plasma (PRP) at the affected site. PRP injection has shown benefit for Achilles tendinopathy in symptomatic patients based on published case series. However, 1 randomized control trial in chronic patients who were treated with eccentric exercise, a PRP compared with a saline injection did not result in improved management of this condition.
Operative management for this condition may include debridement of degenerative tendon and repair of remaining healthy tendon. In cases of recalcitrant insertional Achilles tendinopathy, removal of an associated Haglund’s deformity and retrocalcaneal bursectomy can be beneficial. In individuals over 50 years of age or with severe tendon degeneration, the augmenting the repair with ipsilateral flexor hallucis longus (FHL) transfer may provide additional benefit.
Plantar fasciopathy
The plantar fascia serves as both a static and dynamic stabilizer for the medial longitudinal arch of the foot and consists of lateral, medial, and central bands. The central band spans the medial tubercle of the calcaneus to the 5 toes of the foot. The term plantar fasciopathy reflects that this condition may include acute inflammation or chronic degenerative changes, both of which result in significant pain and limitations during running activity.
Clinical Evaluation
A runner typically reports a sensation of pain over the plantar aspect of the foot, typically worse with initial morning ambulation and improved during the course of a run, with worsening pain after discontinuation of activity. Duration of symptoms helps to classify the phase of injury and guide management.
The runner commonly exhibits tenderness to palpation over the medial calcaneal tubercle and along the plantar fascia. Thus, the plantar fascia should be palpated for presence of crepitus, thickening, or swelling. The Achilles tendon contributes fibers in continuity with the plantar fascia and should also be evaluated by palpation for presence of pain. Ankle ROM is important to assess, as described, using the Silfverskiold test. Passive extension of the toes places the plantar fascia and medial longitudinal arch on stretch and may elicit pain (Windlass test). Tinel’s sign, or shooting pains elicited by tapping over the tarsal tunnel, may help to identify tarsal tunnel syndrome as a contributor to pain. The calcaneal squeeze test should be performed to evaluate for signs of a calcaneal BSI. The calcaneal fat pad should be examined for evidence of atrophy or tenderness to palpation, because this may suggest fat pad atrophy. Weight-bearing radiograph of the foot and ankle is valuable to assess for presence of tension esophytes or calcifications, and can help exclude fracture or stress injury of the calcaneus. In a runner with acute onset of plantar foot pain with suspicion for significant tearing, MRI can be helpful to further evaluate for plantar fascia tear or rupture. New ultrasound techniques are emerging as a tool for dynamic evaluation of hindfoot structures including evaluating the plantar fascia.
Differential Diagnosis
Personal and family history of rheumatologic conditions, including seronegative spondyloarthropathies, should be queried, because enthesopathy of the foot may mimic plantar fasciopathy. Additionally, a history of low back pain or radicular symptoms is important to elicit and consider as lumbosacral referred pain patterns can result in plantar foot pain. Other conditions on the differential diagnosis for plantar foot pain include sesamoiditis (inflammation and irritation of the sesamoid bones that lie on the plantar aspect of the hallux) and metatarsalgia, or pain localized to the metatarsal heads. These conditions are usually differentiated from plantar fasciopathy by its more forefoot location. Further discussion is beyond the scope of this article, but can be found elsewhere in the literature.
Management
The vast majority of cases of plantar fasciopathy respond to conservative treatment. A passive plantar foot stretching program has been shown to improve pain compared with active Achilles tendon stretching exercises for chronic plantar fasciopathy with good long-term effects. In this stretching protocol, the runner should be instructed to use 1 hand to passively extend the toes toward the shin until a stretching sensation is achieved, with the other hand palpating the medial longitudinal arch to ensure the plantar fascia structure is being stretched, held for 10 seconds for 10 total repetitions and performed 3 times daily. A recent, randomized, controlled trial demonstrated high load strength training resulted in less pain at 3 months and similar outcomes at 1 year compared with the passive plantar foot stretching program. The high load strength training program consisted of performing single leg calf raises with the toes supported under a towel to aid in Windlass mechanism. The program started with 3 sets of 12 repetitions and advanced to added weight with 5 sets of 8 repetitions, performed every other day. The strength training program has added advantage of being performed less frequently than passive plantar stretching and may be reasonable initial therapy for most runners. Foot orthosis can also be beneficial.
Other treatment may include use of low-dye or calcaneal taping, accommodative foot orthosis, acupuncture, manual therapy, night splints, iontophoresis, and extracorporeal shockwave therapy. Treatment may also include injections, including corticosteroid medication, PRP, or botulinum toxin. Corticosteroid injections have been shown to provide pain relief for 1 month and may be more effective under ultrasound guidance. However, complications for corticosteroid injection include heel fat pad atrophy, nerve damage, and risk for rupture of the plantar fascia that result in biomechanical changes in the Windlass mechanism. Thus, corticosteroid injections should be used with caution, and the number limited. PRP and botulinum toxin injections may provide greater duration of benefits. PRP has been shown to provide durable benefits up to 24 months when compared with corticosteroids. Botulinum toxin has been shown to provide pain relief at 3 months after treatment. Because studies on management of plantar fasciopathy have been primarily performed in nonathlete populations, the effectiveness of these treatments in runners is unknown.
Ankle sprains
Acute ankle sprains are a common injury in runners, especially those who run on uneven terrain. One study found that nearly one-third of female and one-quarter of male high school-aged runners have a history of ankle sprain. Lateral (ie, inversion) ankle sprains are most common and result from damage a combination of the anterior talofibular ligament, calcaneofibular ligament, and posterior tibiofibular ligament. High ankle sprains (ie, eversion or external rotation) are less common and result in injury to the syndesmotic ligaments and/or deltoid.
Clinical Evaluation
A careful history should be obtained regarding injury mechanism, history of ankle sprain, or feelings of instability and prior rehabilitation completed. Physical findings from a comprehensive examination allow for grading of ankle sprain severity, and may be used to guide appropriate management and return to play ( Table 2 ).
| Grade | Signs and Symptoms |
|---|---|
| First degree (mild) | Ligament strain with or without some ligament fibers torn Mild tenderness and swelling No laxity or residual instability Full function Full strength |
| Second degree (moderate) | Incomplete ligament tear Moderate pain and swelling Mild laxity and instability Slight reduction in function Possible decrease in strength Potential loss of proprioception |
| Third degree (severe) | Complete ligament tear Severe pain and swelling Gross instability and laxity Potential complete loss of function Potential complete loss of strength Potential complete loss of proprioception |
The clinician should evaluate for the presence of swelling, discoloration, and pain with ambulation. The clinician should systematically palpate the full length of the tibia, fibula, and over the anterior inferior tibiofibular ligament to evaluate for evidence of syndesmotic injury or high ankle sprain. The anterior talofibular ligament, calcaneofibular ligament, and posterior tibiofibular ligament should each be palpated for tenderness. Additionally, the fifth metatarsal, and the cuboid and tarsal navicular should be assessed for bony tenderness. Single leg balance can be assessed for general proprioception and neuromuscular control of the lower extremity. The peroneal tendons should be evaluated for subluxation, tendinosis, and/or weakness. Anterior drawer test and talar tilt tests are compared with the asymptomatic side for differences in total translation and laxity to assess for the integrity of the anterior talofibular and calcaneofibular ligaments, respectively.
A weight-bearing radiograph of the ankle should be obtained based on the Ottawa Ankle Rules for acute presentation or based on concern for high ankle sprain, syndesmotic injury, or associated fracture.
Differential Diagnosis
Differential diagnosis for acute low lateral ankle sprain should include consideration for high ankle sprain involving the syndesmosis and associated fracture, such as a Maisonneuve fracture, because this would urgently change management decision making. There are 5 concomitant injuries that should be considered in patients who have not made expected progress during their course of injury rehabilitation after an inversion sprain. These include (1) peroneal tendinopathy or tear, (2) osteochondral lesion of the talar dome, (3) fracture of the anterior process of the calcaneus, (4) neuritis of the superficial peroneal nerve or sural nerve, and (5) lateral malleolar fracture.
Management
Initial management for inversion ankle sprain begins with PRICE: protection, rest, icing, compression, and elevation. This can be accomplished with use of a walking boot for runners with painful ambulation, or a stirrup ankle brace. The authors advocate a short period in a walking boot until pain free (usually 7–10 days) followed by transition to functional bracing. NSAIDs can be initiated 24 hours after the injury. Initial rehabilitation goals include resolution of edema and restoring painless ROM of the ankle. Postural control is impaired after both acute and chronic lateral ankle trauma, and balance exercises have been shown to help address this impairment. Additionally, reduced muscle activity of the hip, knee, and ankle has been observed in patients with chronic ankle instability. Therefore, advanced ankle rehabilitation protocols should include strengthening both intrinsic and extrinsic muscles of the foot and ankle along with addressing neuromuscular control and evaluation of the full kinetic chain. Although an optimal protocol for injury rehabilitation and prevention has not been defined, we recommend applying concepts of foot core paradigm for management of this injury. For patients with recurrent ankle sprains (≥3 total), or persistent anatomic and functional instability despite appropriate conservative care, referral to an orthopedist for evaluation and surgical reconstruction of the lateral ligaments may be considered.
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