HealthRunning

The Ultimate Guide to Foot and Lower-Leg Pain

From plantar fasciitis to blisters, these are the top causes of foot pain for runners

Feet hurt? Here’s why. (Photo: sportpoint/iStock)
feet

At least 50 percent of runners are injured annually, according to a 2010 review published in Current Sports Medicine Reports, and feet are one of the main culprits. But foot pain can be hard to manage. Is it a serious injury? Just an ache? Can you push through, or will you make it worse

We asked two podiatrists to give us a rundown on the most common foot injuries for runners. Stephen M. Pribut, former president of the American Academy of Podiatric Sports Medicine, is a runner himself and has treated Olympic athletes. Lisa M. Schoene is a sports-medicine podiatrist and a certified athletic trainer who has been in practice for over 28 years.

Both Pribut and Schoene explained that most running-related foot injuries are a result of overuse, the wrong shoes, or an abrupt transition between different types of shoes. Natural foot shape and biomechanics also play a role. Here’s a helpful guide to figuring out why your feet hurt and how to jump-start your recovery. But of course, this doesn’t replace a visit to your doctor. If you’re dealing with serious or persistent pain, make an appointment with a physician.

Plantar Fasciitis 

What it is:

The most common foot injury among runners is plantar fasciitis, an inflammation of a web of thick ligaments (the plantar fascia) that runs along the bottom of the foot and connects the heel bone to the bones of the forefoot. The plantar fascia support the arch of the foot and act as a spring for forward propulsion. The usual signs and symptoms include pain on the bottom of the heel, which could present as dull, sharp, or a burning ache, either directly below the calcaneus (heel bone) or toward the front of it. The pain typically comes on slowly and builds over multiple days or weeks. It can be strongest when you wake up in the morning or during a run.

Why you get it:

  • Overuse from an increase in training volume or intensity
  • Switching to a zero-drop shoe or a pair of shoes with less arch support
  • Tight Achilles tendons or calf muscles
  • Weight gain, which adds unaccustomed stress to the plantar fascia

How to fix it:

Reduce your training volume and intensity or, better yet, lay off running altogether for a few weeks. “If you keep running through your plantar fasciitis, it will inevitably get worse,” Schoene says, “but you can definitely cross-train.” In your day-to-day life, wear shoes with ample cushioning, arch support, and elevated heels. Seriously—whether they’re 12-millimeter drop running shoes, clogs, or kitten heels, they’ll alleviate the pressure on your plantar fascia. Avoid going barefoot. 

When you return to running, ease back into it. If you had switched to different running shoes in the weeks before your pain started, it might be wise to switch back to something like what you had before. You’ll want a shoe with ample cushioning, a high drop, and good arch support. If the heel pain returns, go see a professional, because you might benefit from orthotics.

As for physical therapy, do 20 reps of towel crunches once or twice per day: place a towel on the floor, put your foot on top, and curl your toes to squeeze a fold of fabric. Stretch your calves from a step. Roll out your arches with a soft massage ball or a tennis ball (as opposed to a firmer lacrosse ball), and be extremely gentle around your heel. Roll out your lower legs with a foam roller or a massage stick to release tension in your calves and Achilles.

Achilles Tendonitis

What it is:

The Achilles tendon connects the calf muscle to the heel bone and is subject to repetitive stress. When the calf contracts, it pulls the heel up, and this movement allows us to push off our toes when we run, walk, or jump. Over time this can lead to inflammation, micro tears, and tendonitis. The tendonitis can be located at the insertion point where the Achilles connects to the heel bone, in the middle of the tendon, or higher up where the tendon attaches to the calf muscle. Achilles tendonitis typically involves pain or a dull ache behind the ankle, anywhere between the heel bone and the start of the calf muscle. This area can also swell and become red.

Why you get it:

  • Overuse from an increase in training volume or intensity
  • Hill workouts (running uphill puts more strain on the Achilles)
  • Change in running stride (heel strike to midfoot strike, or vice versa)
  • Worn-out shoes or switching to a flatter or less supportive shoe
  • Tight calf muscles
  • Hip and core weakness

How to fix it:

Take a break from running. “It’s unwise to push through Achilles tendonitis for probably 95 percent of the people who have it,” says Schoene. “There could be microscopic tears, and you just don’t want to mess with the Achilles.” Low-impact cross-training is still OK. Wear heels, heel lifts, or high-drop shoes to take strain off the tendon. Resist the urge to walk barefoot, even at home.  “Don’t overstretch,” says Pribut. “That’s very important. If you have tendonitis at the insertion point, you can yank the tendon right off the bone.” Avoid eccentric calf stretching (dropping your heel off a step) for a few weeks. Try toe crunches (see above) for this as well. Roll out your lower legs once or twice daily. Once the initial pain, swelling, and inflammation have subsided, begin a strength-training routine to target the calves, the core, and the hips.

Shin Splints

What it is:

Shin splints is a catchall term for pain in the front of the shins, also known as medial tibial stress syndrome. The tibia, your shin bone, is the larger of the two bones in your lower leg, and this stress occurs in the midline of the bone and the surrounding tissue. This overuse injury is characterized by inflammation and possible micro tears in the posterior tibialis muscle (the key stabilizing muscle of the lower leg), as well as inflammation in the surrounding tissue and shinbone. Shin splints usually present as a throbbing, aching pain or soreness in the front or inside of the lower leg between the ankle and knee. Pain can last all day but is usually sharpest during each foot strike and right after exercise.

Why you get it:

  • Overuse from an increase in training volume or intensity
  • Poor foot mechanics, including overpronation (foot rolls inward), which puts repetitive tension and stress on the tibialis posterior muscle and tendon, which hold up the arch
  • Worn-out or unsupportive shoes that allow overpronation
  • Frequent running on hard surfaces, such as pavement or a track

How to fix it:

If your pain isn’t increasing, you can keep running, but you’ll recover much faster if you switch to low-impact cross-training until the pain and inflammation have subsided. If you continue to push through, it’s best to cut back on mileage and intensity, avoid hills, and stick to softer surfaces like trails. After runs, ice for 20 minutes on, 45 minutes off, repeating this sequence three times.

Have a coach or trained medical professional assess your foot mechanics. If you are mildly overpronating, you’ll likely benefit from shoes with motion control and better arch support. Severe overpronators should talk to a podiatrist about custom orthotics. Fixing overpronation removes the source of stress from the tibialis posterior muscle and tendon, which helps you recover faster and prevents the injury from reoccurring. Stretch your calves, and roll out your lower legs (be cautious around your shins, though, and avoid rolling over the shin bone altogether). Once the initial pain has subsided, begin a strength-training routine to target the calves, the core, and the hips.

Posterior Tibial Tendonitis

What it is:

Posterior tibial tendonitis and shin splints are both inflammation injuries in the same muscle-tendon structure. While shin splints occur in the posterior tibialis muscle (the shin), posterior tibial tendonitis can occur in the tendon that wraps around the inside of the ankle and connects the muscle to the navicular bone at the midfoot. They can usually be traced to similar causes. If you’re dealing with tendonitis, you’ll feel pain, tenderness, and swelling around the inside of the ankle and sometimes down to the navicular bone.

Why you get it:

  • Overuse from an increase in training volume or intensity
  • Overpronation (foot rolls inward), which puts repetitive tension and stress on the posterior tibialis muscle and tendon
  • Worn-out or unsupportive shoes that allow overpronation

How to fix it:

See the above steps for shin splints. Wearing an ankle-compression sleeve can also help alleviate pain and prevent further injury when you return to running.

Peroneal Tendonitis

What it is:

Peroneal tendonitis is posterior tibial tendonitis’s evil twin—it’s an inflammatory injury of the peroneal tendons (there are two) on the outside of the ankle. The main function of these tendons is to stabilize the foot and the ankle and prevent them from rolling outward. Unlike the majority of the other injuries listed here, peroneal tendonitis can be acute (from a single injury, like rolling your ankle) or result from overuse. The usual signs and symptoms are pain, tenderness, and swelling around the outside of the ankle and possibly down to the outside of the midfoot. Pain can sometimes occur on the bottom of the foot, where it is often mistaken for plantar fasciitis.

Why you get it:

  • Overuse from an increase in training volume or intensity
  • Supination
  • Unsupportive or too soft shoes that allow supination
  • Chronic ankle instability
  • Inversion ankle sprain (foot inverts and ankle rolls to the outside)
  • Running on uneven terrain with roots, rocks, and other obstacles that stress the ankles
  • Lateral sports that involve quick changes of direction
  • Always running around a track in the same direction

How to fix it:

Reduce your training volume and intensity, and wear an ankle-compression sleeve for support when you run. Switch to shoes with firmer stability to prevent supination. Orthotics might help severe supination, and heel lifts can help relieve tension on the tendon. After runs, ice for 20 minutes on, 45 minutes off, and repeat this sequence three times. While you recover, avoid knobby trails and technical terrain where you risk rolling or straining the ankle.

Spend some time on a wobble board to improve your balance and ankle strength. Start with one to two minutes, going side to side, front to back, and in circles, to improve your balance and ankle strength. Build up to longer sessions of up to ten minutes. Stretch your calves and roll out your lower legs (avoid rolling over the ankle bone). Once the pain is gone, begin a strength-training routine to target the calves, the core, and the hips.

Metatarsal Capsulitis and Morton’s Neuroma

What they are:

Metatarsalgia is a general term to describe pain, tenderness, and inflammation in the ball of the foot. Usually, that pain comes from metatarsal capsulitis: swelling in the capsule surrounding the joint where your toe meets your foot, typically at the second toe. Morton’s neuroma, the enlargement of the nerves between your foot bones, feels similar, though the pain is closer to the outside of the foot, at the third and fourth toes.

Sharp, aching, or radiating pain in the ball of the foot is a common symptom of both metatarsalgia and Morton’s neuroma. The pain typically worsens during exercise or when you wear a firm or tight shoe. Pain or a sensation of numbness can also extend into the toes. You might also get the feeling that there’s a bunch in your sock or a pebble in your shoe under the ball of your foot.

Why you get them:

  • Overuse from an increase in training volume or intensity
  • Shoes that are too narrow or tight (including climbing or cycling shoes)
  • Low-cushion or minimalist shoes
  • Bunions (the curvature of the big toe can put more pressure on the second toe, creating a greater risk of capsulitis)

How to fix them:

If you’re dealing with capsulitis, lay off running altogether for a few weeks and visit your doctor. “You want to jump on capsulitis as quickly as you can, because the capsule around the joint can tear, and if that happens, the second toe can pop up into what we call hammer toe, which is very unstable and painful,” says Shoene. In daily life, wear a wider, high-cushion shoe with a rockered sole to remove some of the impact and stress to the metatarsal bones and joints.

For Morton’s neuroma, switching to a wider, high-cushioned shoe often brings immediate pain relief, since that decreases pressure on the nerve. If the pain is manageable and begins to fade, you can usually continue running and training with a wider shoe.

Stress Fracture

What it is: 

A stress fracture is a hairline crack or group of cracks in a bone. These can happen in any bone, but for runners, they most commonly occur in the tibia (and are often associated with shin splints), metatarsals, and the calcaneus (heel bone). This is primarily an overuse injury but can also result from a single event, for example, if you’re used to running on softer trails and then complete a long road race in low-cushioned shoes. Typically, stress fractures present as an aching or burning pain, usually localized, anywhere along a bone.

Why you get it:  

  • Overuse from an increase in training volume or intensity
  • Running frequently on hard surfaces or a track in a single direction
  • Running in low-cushioned shoes, such as track spikes or minimalist shoes
  • Eating disorders or energy imbalances (burning more calories than you’re consuming)
  • The female-athlete triad: an eating disorder, amenorrhea (the absence of a period), and osteoporosis

“It often starts as a physiological change at the cellular level, where you’ll have decreased production of new bone, increased absorption of bone, and an inflammatory component that can cause pain,” says Pribut. “As bone density decreases and the stress of running continues, it can become a physical crack.”

How to fix it:

Reduce training volume and intensity, and visit your doctor. Switch to a high-cushioned, rockered shoe, such as those made by Hoka, to reduce impact forces. Eat a well-balanced diet with adequate calcium and vitamin D. Build consolidation weeks—during which you back off your mileage—into your training plan to give your body a chance to recover and put the calcium where it needs to be.

“Runners have good pain tolerance and often ignore the issue,” says Pribut. “Listen to your body for warning signs. If your bones are achy, back off the training immediately, assess, and get to work on recovery.”

Mild stress fractures can heal in approximately three to six weeks if you’re diligent about recovery, but serious stress fractures can take six weeks to three months to heal and might require a walking cast. If you’re prone to stress fractures, consult a medical professional and ask for a bone-density scan.

Blisters and Black Toenails

What they are:

You probably don’t need help identifying blisters and blackened toenails (which form when blood vessels rupture beneath the nail). They can sneak up on you anytime, and, if you’re lucky, you’ll only notice once you take off your shoes. That said, they can certainly derail a run or two, with burning pain or dull achiness.

Why you get them:

  • Blisters result from prolonged friction, pressure, and moisture, all of which can be exacerbated by your shoe and sock choice.
  • Black toenails come from repetitive trauma to the nail bed, usually from the toe hitting the front or top of the inside of a shoe, which can be exacerbated by ill-fitting shoes and long downhills.

How to fix them:

Both blisters and black toenails generally resolve on their own. In the case that a blister ruptures or a toenail falls off, do your best to keep it clean and otherwise leave it alone.

To avoid blisters, keep your feet dry with moisture-wicking socks and breathable shoes. During long training runs or races, periodically change into fresh socks, and even shoes, if you can. If you’re getting a hot spot, dry your feet and try to put padding around the area.

Buy shoes that fit well. Shoes that are too tight cause excessive pressure, which leads to blisters and jams your toes against the top or front of the shoe. Shoes that are too loose allow for too much movement within the shoe, which causes blisters and black toenails, especially on the downhill. If you just bought new shoes, break them in around the house, office, or on shorter runs before using them for a long run or race. 

Filed To: RunningRecoverySkinLegsSportsAthletes
Lead Photo: sportpoint/iStock
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