Ankle Pain Before and After Running: 3 Possible Causes

Ankle pain is a common problem for runners, and approximately one-third of injured runners will experience either a foot or ankle injury.[1] The repetitive and high-impact nature of running can cause a range of ankle conditions, starting from overuse to traumatic injuries.

According to a Scandinavian study, every stride taken during running requires the body to experience 2-2.9 fold of the body weight's impact.[2] Running factors, such as training experience and volume, can increase the impact on the ankle and cause pain.

The ankle has many structures, such as muscle, tendon, ligaments, and bone, which can be affected by stress, strain, and running. There are however some ankle injuries that runners will more commonly experience.

Common ankle conditions that runners experience

Given the complexity of the ankle joint, there are many types of injuries that are caused by running. Most of these are classified as overuse conditions and gradually occur over time with repetitive movements. According to research from Harvard University,[1] the most common ankle pain injuries, include:

• Tendinopathy

• Ligament injuries

• High Ankle Sprain

• Ankle Sprain

• Ankle bursitis

• Stress fractures

• Ankle joint disorders

1. Tendinopathy around the ankle

Tendinopathies are generally overuse injuries to the tendon. The tendon is a connective tissue that connects a muscle to a bone. Due to its elastic nature, the tendon readily stores and releases energy, comparable to a spring or rubber band. As a result, it transmits the forces when running into the muscle to create movement.

Although similar, tendinopathy is not identical to tendonitis (or tendinitis). Unlike tendonitis, significant inflammatory reactions are less likely to occur in tendinopathy. Currently, tendinopathy can be seen as a painful response from the tendon's cells and the surrounding nerves due to high impact movements (e.g., running, jumping). However, more research is needed to understand what occurs during tendinopathy.

Common tendinopathy conditions

Examples of common tendinopathy conditions that occur in runners include:

• Achilles tendinopathy

• Peroneal tendinopathy

• Posterior tibial tendon dysfunction

• Anterior tibial tendinopathy

• Flexor hallucis longus tendinopathy.

Common tendinopathy symptoms

Tendinopathy symptoms are generally quite consistent. They can occur in different locations, depending on which tendon(s) has been affected.

• Specific locations of pain (can be pinpointed with your finger)

• Swelling

• Reddening of the affected area (also known as erythema)

• Gradually worsening pain over time

Risk factors of tendinopathy

Several risk factors[3] increase the likelihood of developing tendinopathy in runners, these include:

• Training patterns (e.g., sudden increases in running distance and intensity)

• Footwear

• Being overweight or obese

• Running on hard surfaces

• Muscle imbalance

• Muscle weakness

• Asymmetrical leg lengths.

2. Stress fractures around the ankle

Fractures occur due to cracks or breaks of the bone. Unlike the typical fracture, which occurs during high impact activities, stress fractures occur gradually due to repetitive lower impact movements, such as running. Depending on the severity of the fracture, it can range from a partial to complete break of the bone.

Common ankle stress fracture locations

Stress fractures along the ankle joint gradually worsen over time with increased ankle loading (e.g., running, jumping). Typical symptoms to look out for include:

• Swelling

• Pain which increases with the amount of physical activity

• Pain which improves when resting

• Specific pain that can be located with your finger.

Stress fracture symptoms

Stress fractures along the ankle joint gradually worsen over time with increased loading of the ankle (e.g. running, jumping). Typical symptoms to look out for, include:

• Swelling

• Pain which increases with the amount of physical activity

• Pain which improves when resting

• Specific pain that can be located with your finger.

Risk factors for ankle stress injuries

Several risk factors[1] increase the likelihood of suffering from boney stress injuries along the ankle joint in runners, including:

• Female gender

• Training patterns (i.e., duration and frequency of training)

• Low calcium and vitamin D levels

• Suboptimal bone density (e.g., osteopenia, osteoporosis)

• Low body mass index.

3. Joint conditions around the ankle

The joints describe the connections between the bones found around the ankle and foot. The high impact and repetitive nature of running can cause constant compression between the joints around the ankle. Over time, this can lead to degenerative changes around the joints.

Common ankle joint conditions

Examples of common ankle joint conditions that occur in runners, include:

• Ankle osteoarthritis

• Cartilage damage (Osteochondral Dissecans)

• Big toe arthritis (Hallux Rigidus).

Common symptoms of ankle joint issues

Joint conditions are generally degenerative by nature. This means that the symptoms of ankle joint conditions occur over time and gradually worsen.

• Swelling around the joint

• Pain around the joint

• Limping

• Ankle and feet stiffness

Risk factors for ankle joint conditions

Several risk factors[3] increase the likelihood of runners suffering from ankle joint conditions, these include:

• Older age

• Being obese and overweight

• Previous injuries around the ankle (e.g. sprains and strains, fractures)

• An inactive lifestyle

• Misalignment of the joint.

Ankle pain treatments

There are several ways of managing ankle pain for runners in the short-term and long term. It is essential to seek the advice of a health professional, such as a physiotherapist, to ensure that the appropriate treatment is received.

RICE - Rest, Ice, Compression and Elevation

RICE stands for rest, ice, compression and elevation. These are some strategies that can help ease the pain and swelling around the ankle in the short term.

Especially during the initial stages of an ankle injury, keeping off the feet can help ease the inflammation and pain. Eliminating the load through the ankle allows the injury to recover.

Applying ice around the ankle can ease the pain, inflammation and swelling. This can be especially helpful during the first couple of days after an injury, such as a sprain or tendinopathy.

Wearing compression stockings around the ankle can help ease the swelling. Inflammation and swelling usually occur during the early phases of an ankle condition, and reducing the swelling can help reduce pain and stiffness.

Keeping the ankles elevated above hip height can also help decrease swelling. The direction of gravity helps drain the fluid away from the leg.

Assistive Devices

Assistive devices can be used or worn to protect the ankle. Reducing the impact through the leg allows for the structures to recover. Examples of assistive devices include:

• Crutches

• Camboots

• Wheelchairs

• Frames

• Knee scooters

• Walking stick

• Ankle braces.

These devices are typically used for a short period to prevent the ankle from becoming deconditioned and stiff. It is recommended to consult a physiotherapist to determine which assistive device might suit your ankle condition.

Pain Relief

Medications, such as ibuprofen (e.g., Voltaren, Neurofen) and paracetamol (e.g. Panadol) can be used to help ease pain and/or inflammation. Consult your doctor and/or physiotherapist to determine which medication is most beneficial for your ankle pain.

Physiotherapy for ankle pain

Physiotherapists are health professionals who specialise in assisting with physical injuries and conditions. They will provide a diagnosis, refer for investigations, find strategies to ease pain and help rehabilitate the painful ankle. Types of physiotherapy treatments that can help runners with their ankle injuries include:

• Exercise

• Lifestyle strategies (e.g. changing training patterns, rest)

• Running assessments

• Footwear recommendations

• Manual therapy (e.g. massage, mobilisations)

• Electrotherapy (e.g. TENs, ultrasound)

• Dry needling

• Specialist referrals (e.g. orthopaedic surgeons, sports physicians, podiatrists)

When to see a physiotherapist?

For most minor to mild running ankle injuries, seeing a physiotherapist is advised. They are generally the first-line health professionals that look after physical injuries. Every day, physiotherapists manage patients with these types of conditions. Additionally, they will perform physical assessments and specific tests to diagnose conditions and identify the root causes.

Runners who are experiencing ankle pain should see physiotherapy if:

• The pain is not resolved after 2-3 days

• Symptoms are worsening

• There is increased swelling

• Bruising appears

• Limping

• There are any persisting difficulties with running

• The ankle is stiffening.

Key Takeaways

There are many reasons for runner's ankle pain, including joint, tendon, ligament and nerve injuries. Fortunately, there are several ways of treating these conditions in both the short-term and long term. For the majority of these ankle conditions, it is advisable to see a physiotherapist for professional guidance. Other options include:

• RICE

• Assistive devices

• Pain relief and medications