Runners!  Have you ever experienced foot pain?  Are you frustrated that you are receiving poor advice about your foot pain and your foot pain is not going away?  I know I’ve been there.  I was ignored and wasn’t taken seriously.  I was told I shouldn’t be a runner!

Well, that resulted in a total of 48 road races including 20 half marathons and 1 full marathon!

Finishing half marathon #19

In this article we’re going to be discussing 3 tips to handle your foot and ankle pain! I’ve been hearing a lot of stories from runners that I’ve been working with lately and it’s been the same story over and over.   This is why I wanted to talk about this topic.

To hear the live training I did in our Free Healthy Runner CT Facebook group just click the video below!

When I started running, I was 32 years old and I was in the gym.  I’d run on the treadmill for some cardio during my workouts.  During this time, I started to experience foot pain.  I went to see an orthopedic surgeon, an orthopedic specialist!  He takes x-rays and we look at the x-rays.  I have a fifth toe that bends in.  We call that a bunionette deformity. Here is a picture of what it looks like on x-ray!

Bunionette Deformity of the 5th toe

It’s the same thing as anyone who’s had a bunion before where the first toe dips in.   It can be very painful in runners!  But I, have a bunionette deformity.  The orthopedic specialist said  “oh your feet are the worst… you definitely shouldn’t be running.” I was frustrated.  He really wasn’t listening to anything I had to say.  Obviously, I was a physical therapist, going to the gym working out five days a week, and suddenly I’m being told that I can’t run. I  was not very happy to hear that.  I didn’t listen to the advice, I kept running.  I was having a little “metatarsalgia”, which is just pain between the metatarsals (bones) in my foot.  The surgeon even brought up surgery!

The face I made when he said I need surgery!

Luckily, I’m in the medical field and I know a little something. So, being a physical therapist, I’ve encountered a lot of runners with foot pain who decide that they need to see a specialist, so they go see an orthopedic surgeon.  Orthopedic surgeons tend to see things through their surgical lens.  The majority of musculoskeletal injuries you’re going to get  as a runner will be handled through conservative treatment, meaning you do not need surgery.  It’s always good to receive a second opinion and to see a physical therapist who works specifically with runners.  In the state of Connecticut, you can see a physical therapist without a referral from a doctor.  A physical therapist is a movement specialist and they will be able to evaluate you and properly diagnose your pain.  If there’s a red flag or something very serious going on, we’re also trained to refer out to the proper specialist to get you the best care!

If my story doesn’t resonate with you…my wife over the weekend was running 11 miles for the first time in preparation for the Disney Half Marathon that we’ll be running in 2 weeks on marathon weekend in Disney!  While she was running this first 11 miler of her life, she started to experience pain on the inside of her ankle.  The reason she was getting pain on the inside of her ankle is because of a little something we call Posterior Tibial Tendonitis.  The posterior tibial tendon runs along the inside of your ankle.

Anatomy of posterior tibial tendon

If you are a runner who has flat feet, meaning “fallen arches”, which we call over-pronation, that causes over stretching and bowstringing of the posterior tibial tendon.  This means with every step you take while you’re running, the tendon has to over-work to slow your body down even more, meaning your tendon will be overused and you will develop tendonitis.  This was something she was very nervous about! It’s normal to get nervous and fearful.  You’re not alone in those feelings if you get them too!

Position of your foot when it overpronates during running

Tendonitis is a repetitive overuse injury.  If it’s chronic and it’s been going for a while, then it’s not really tendonitis anymore.  “ -itis” means inflammation, so if it’s been going on for months, you don’t have inflammation anymore.  What you start to have is something we call degeneration.  The tendon morphology, so the structure of the actual tendon is starting to change, and it’s become degenerative.  Your treatment should be totally different at this point.  In the chronic phase, treatments should stimulate healing in the tendon, load the tendon with exercises that are going to aid the tendon in healing.  This is very different from that acute tendonitis where you need to protect it, rest it and use NSAIDS (non-steroidal anti-inflammatory drugs).  You can ice it and back off your training a little bit for that time period to let it rest. However, if it’s a true chronic tendon pathology that you’ve been battling for months, there are other specific exercises you need to be doing in order to allow that tendon to heal.

Here is ONE EXERCISE you can do to stimulate healing in your tendon if you have chronic pain

Thinking about my wife’s case, she’s dealing with some tendonitis because she’s ramping up her miles for the first time in her life and she really hasn’t built up that foundational foot strength and ankle strength before running.  This brings me to my next point – I am all for everyone being active.  Obviously, that’s what we support here at SPARK.  However, I do want to caution, especially for the full marathon distance.  After training for a full marathon, myself (which I only did after 6 consecutive years of running – meaning I was running all year round with different training cycles, doing all of my running prehab exercises, increasing my half marathon time, adding in speed work and doing it the right way).  I do get a little nervous when I meet the novice runner training for a full marathon.  I don’t get nervous because I don’t believe that you can do it, but I caution because I’ve encountered many runners who get injured along the way.

The full marathon distance, in my full, true medical opinion – for the most part, for 90% of us out there, it will take time for our bodies to adapt to the demands of running.  This means you should run consistently all year round and that you should run many half marathons before running your first full marathon.  You should also follow my 5 Healthy Tips For Running to be sure you are healthy to train for the full marathon distance!

So, don’t get frustrated and give up on running.  Running is a journey, it’s a process.  You need to really work your way up to where you want to be and be patient with yourself.  I hope to be running my whole life and I hope you want that too.  I hope to be placing in the 70 to 80 age group at the those 5k’s.  Running should be life long – so be patient and trust the process.

Let’s jump into those 3 tips! This is going to the MSA method (shout out to Multisports Academy in Hamden!)

Tip 1: M- Mobility!

In this case we’re talking about ankle mobility.  This is the most common impairment that I see.  Meaning the most common positive examination finding during an evaluation.  When I examine a runner, who has foot and ankle pain, they are 9 times out of 10 limited in their ankle mobility.

There are 2 ways we can assess this. We can do this by looking at your joint mechanics. The ankle is made up of 2 bony surfaces. The true ankle joint is the talus bone and it articulates with your lower leg bones – your tibia and fibula. Your ankle joint flexes and extends, known as dorsi-flexion and plantarflexion. In many of the runners we see, the ability to dorsiflex is limited. You can see this by simply bringing your toes and foot up towards the ceiling and seeing if it goes as far as the other side. The other thing we like to do is to have the runner stand up against the wall and go into a lunge into the wall. From here, we can measure and see how much flexion we have at the ankle in comparison to the other leg.

Test to assess ankle mobility against a wall

Remember, 9 times out of 10 when we compare, the side with the pain is usually going to be limited in range of motion. What does that require? Well that’s a quick fix. There are great manual therapy techniques that a good manually trained therapist can provide. They’ll do a little joint manipulation technique to free up the joint and we’ll also mobilize the joint. We can also do a joint mobilization technique with movement to help get that ankle moving.

Ankle mobility in the joint as well as the soft tissue is super important. The soft tissue includes the calf muscle and the Achilles tendon. The calf muscle includes the gastrocnemius and the soleus muscle. If these muscles are tight, they will restrict your ankle in flexing forward. This would require soft tissue techniques to this muscle! There are things that can be done in the clinic such as dry needling or instrumented assisted soft tissue mobilization or soft tissue work with our hands, or foam rolling, or stretching… there are SO many options!

Bottom line is that ankle mobility is the first thing we want to assess!

Tip 2: S- Foot Stability!

Foot stability is going to be the most important thing you can do as a runner. Let’s talk about the muscles of the foot!

There’s a fascia on the bottom of your foot which is connective tissue and underneath that fascia are a bunch of tiny little muscles. These muscles help to stabilize the structure of your foot! Going to back to that idea of flat foot or an over pronator, that type of foot really needs food stability. Your bottom foot muscles help to build up your arch. If you can activate those muscles under your arch, they can act to stabilize your foot a little bit better. This means that when you’re running and having those repetitive contacts, those muscles will be able to better stabilize that arch.

The simplest exercise you can do to help activate these muscles is called the short foot exercise or foot doming.  This is really the first step in activating those foot muscles. This exercise may be challenging at first! When I first started doing this exercise, I couldn’t do it on my left foot. There’s a big motor control aspect to this exercise. What does that mean? This means that signals from the brain are sent down to the muscles where we learn how to activate those muscles. That takes a little bit of training so don’t feel frustrated if you don’t feel it initially. What you need to do is keep working at is so that you can feel those muscles activate.

Tip 3: A- Above!

For this tip, we want to be looking above. What does that mean? It means looking above the foot and ankle.

Usually, foot and ankle problems are not caused only by the foot and ankle region, there are caused from “above” … looking specifically at the hip! Because the hip rotates in all six planes of movement! If you’re a “toe-in” runner or a “toe-out” runner, that comes from your hips! If your muscles in your hip are weak, or you were born with your bone structure a certain way, or you were a “W sitter” when you were a kid and you’re a toe in runner, that’s going to cause more of that over pronation. It’s going to put you more at risk for posterior tibial tendonitis. It’s going to put you more at risk for plantar fasciitis heel pain and it’s going to put you more at risk for a bunion because it’s going cause your toe to go inwards and you’re going to think that it’s just because you wore ill-fitting shoes or because you were a dancer as a kid. Nope! Your bunion is caused from the mechanics of your running and the mechanics of your walking. Therefore, we need to consider the hip! We want to think about where the problem is stemming from. We want to look to see if it’s a muscle issue or a structural issue. You NEED to be strengthening your hip muscles as a runner and if you’re not doing that – STOP HERE and head over to our YouTube channel and watch those hip strengthening exercises! Start with clamshells, those are going to immediately fire up your external rotator muscles. The external rotators are your anti-pronation muscles. Most foot and ankle problems are caused by too much pronation. You want to strengthen the foot stability muscles, but you also want to strengthen the anti-pronation muscles up at the hip!

CLICK HERE for the standing progression of exercises for these muscles especially important for runners because we run with our feet on the ground!

Here was the live Q &A we had during the Facebook Live stream!   If you want to be a part of our Q & A TUNE IN every Monday Night at 8pm EST to have your question answered.  Join the Healthy Runner CT group by CLICKING HERE

Q: What are your thoughts about ankle weights? Will they help to strengthen and stabilize? 

A: Not for your ankle. Ankle weights are used to add resistance to the leg if you’re doing thigh strengthening, such as straight leg raises. If you’re walking around or running with ankle weights, that does nothing for you except add more load down into your leg. That’s not going to add any resistance to your muscles. The load is pulling downwards and sitting on your foot and ankle. It may make it a little more difficult to lift your leg, so perhaps you’re strengthening your hip flexor but that’s really the only thing you’re going to be able to. Exercises with ankle weights are going to be for more open kinetic chain exercises!

Q: I never knew that it came from hips. My feet tend to go inwards when I run, and I get pain under my feet! 

A: Yes! 9 times out of 10 it’s coming from your hips! It’s all what we’ve talked about. The arch collapsing, causing your toe to go in! That means you need to be doing your short arc exercises and strengthen those muscles in your foot!

Q: Would a lot of balancing work in yoga strengthening your hips, legs, feet and ankles be beneficial? 

A: Yes, ABSOLUTELY! However, it is important to make sure you’re activating those muscles when doing that balancing work. Whenever I’m balancing on one leg, I’m making sure my hips are level, using those side abductors muscles to make sure one hip isn’t dropped. Then you’re going to want to make sure that you’re able to activate those foot doming muscles. Once you can dome the foot, stand on one foot! Working the hip flexors on one leg and then the foot stabilizers on the other leg.

Let’s wrap up!

We talked about three tips to combat foot and ankle pain! The MSA Method!

Three steps

1. Ankle mobility – assessing it, treating it, taking care of it!

2. Ankle stability! Foot and ankle stability together. Strengthening the foot muscles and working towards gaining that stability.

3. Look Above! – Check out that hip and see if there’s any structural issues or muscle weaknesses up there that may be affecting your foot and ankle!

Until next time, guys! Happy Holidays!