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Tired of ankle pain when running?   What are the causes of ankle pain when running?   What are the treatment options?  Are there new, valuable diagnostic options available?   Let’s dig in.

Causes of Ankle Pain When Running

There are multiple causes of ankle pain while running (1). The six major causes are:

Stress Fracture

A stress fracture is a small crack in the bone due to overuse and repeated impact. They are a common cause of pain in runners, accounting for up to 16% of injuries (2).  The shin bone (tibia) is the most commonly affected bone accounting for approximately 40 % of stress fractures (3).  Pain is the most common symptom.

Plantar Fascititis

The plantar fascia is the thick connective tissue that extends from your heel to your toes.  Plantar fascititis is the inflammation of the plantar fascia and is the most common cause of heel pain in athletes. (4).   Pain is localized on the inside aspect of the heel, typically worse during the first several steps in the morning.

Arthritis

There are several different types of arthritis.  The two major types are osteoarthritis and rheumatoid arthritis.  Rheumatoid arthritis is an autoimmune disease in which your own immune system attacks the joints as opposed to osteoarthritis which is due to wear and tear.  The ankle and foot are composed of multiple bone and joints which are susceptible to injury and arthritis.

Tendinitis

A tendon is a thick band of connective tissue that connects muscle to bone.  Tendons are important as they transfer force from muscle to bone and provide stability to the joint (5).  Tendon injuries include:

  • Tendonitis:  acute inflammation
  • Acute tears:  can be partial-thickness or full-thickness
  • Tendinosis:  chronic degeneration with tears

There are five principal tendons in the ankle which include the tibialis anterior, tibialiis posterior, peroneal longus, peroneal brevis, and Achilles.  They are all susceptible to injury and can cause pain.  The peroneal tendons are located on the outside of the ankle whereas the tibialis posterior is on the inside.  The Achilles is the thick cord that is in the rear of the foot that connects your calf muscle to the heel.

Strain

A strain is a stretch or tears in the muscle or tendons (6).  Pain, swelling, and restriction in movement are common.

Sprains

A sprain is a stretch or a tear in the ligament.  Ligaments are thick bands of connective tissue that connect one bone to another.  Ligaments are critical as they provide stability for a given joint.  Ankle sprains are the most common injuries in sports, representing 40% of all injuries (7).  The majority of the injuries involve the ligaments on the outside of the ankle which include the ATF and CF ligaments (8).  Tear or stretching of the ankle ligaments can result in instability and pain.  Instability is similar to having loose lug nuts on your wheels as it jeopardizes the safe operation of the vehicle and results in premature wear and tear on the tire.   So too with instability in the ankle.  An unstable ankle results in excessive movement which puts the ankle cartilage, tendons, and ligaments at risk for additional injury.  Left undiagnosed and untreated, the worst-case scenario is severe ankle arthritis.

Treatment Options for Ankle Pain When Running

For clinical outcomes, it is always best to identify and treat the underlying cause. When appropriate physical therapy should always be the first line of treatment.  Below is a brief summary of each condition and its treatment options.  Other blog posts have discussed in detail each condition, their presentation, and treatment.

Stress Fracture

Rest, elevation and x-rays to document the injury.

Plantar Fascititis

Identify and treat ankle instability, treat inflamed fascia and dysfunctional muscles, stretch and evaluate probable low back nerve irritation. Treatment options include PRP or bone marrow concentrate depending upon severity.

Arthritis

Identify and treat ankle instability, MRI ankle to document areas of the extent of arthritis, and treat affected areas with PRP or bone marrow concentrate.

Tendonitis

Identify and treat ankle instability, treat injured tendon and possible dysfunctional muscle and evaluate possible low back nerve irritation. Treatment options include PRP or bone marrow concentrate depending upon severity.

Sprains

Ankle joint stability is critical to the health and longevity of the ankle joint.  Ligament injuries and tears can jeopardize the stability of the joint putting the cartilage, tendons, and ligaments at additional risk for injury.  At the Centeno Schultz Clinic , we are experts in the evaluation and treatment of ankle and ligament injuries. Treatment options include PRP and bone marrow concentrate.  Bone marrow concentrate can both orchestrate a repair response by bringing other cells into the area as well as turn into ligament cells (9).

Do you have ongoing ankle pain but no MRI? At the Centeno- Schultz Clinic we acknowledge the limitations of MRIs as they are typically performed lying down without any movement (Static).  Unfortunately, this does not resemble your posture when your ankle pain occurs.  Is there a diagnostic alternative?

Ultrasound Stress Test:  A New Technology

Ultrasound is a diagnostic imaging technique that uses high-frequency sound waves.  Most of us are familiar with maternal ultrasound exams where you see the developing baby.  Ultrasound is also extensively used in the evaluation and treatment of common orthopedic conditions.   Tendons, ligaments, and muscles are easily identified.  Unlike an MRI which is a static examination, an ultrasound scan can be used to evaluate ligaments under stress, similar to the forces the ligament sustains as you run.  To better understand this critical but often ignored examination please click on the video below.

 

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Ligaments are critical to ankle well being.  A ligament examined with a static MRI may look normal as it lacks the forces of running or walking.  Stress ultrasound is a dynamic examination that allows you to evaluate a given ligament under pressure.  This will afford a real-time picture of what may be a stretched or partially torn ligament. This ligament may be the very cause of your ankle pain while running.

In Conclusion

Ankle pain when running can be disabling.  The six major causes of ankle pain while running are stress fracture, plantar fascititis, arthritis, tendonitis, strain, and sprain.  Ligaments are thick bands of connective tissue that connect one bone to another.  They are responsible for the stability of a joint.   Sprains, a ligament stretch or tear can jeopardize the health and integrity of the ankle joint.   MRIs are static tests with limited biomechanical information.  An ultrasound stress test evaluates an ankle ligament under similar forces as those during activity.  It can easily identify ligament injuries not appreciated during a physical examination or static MRI. Targeted treatment into these areas will provide the best clinical outcomes.


1.Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. Br J Sports Med. 2002 Apr; 36(2):95-101.

2. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, MacIntyre JG
Am J Sports Med. 1987 Jan-Feb; 15(1):46-58.

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95-101.DOI: 10.1136/bjsm.36.2.95.

4. Pelletier-Galarneau M, Martineau P, Gaudreault M, Pham X. Review of running injuries of the foot and ankle: clinical presentation and SPECT-CT imaging patterns. Am J Nucl Med Mol Imaging. 2015;5(4):305-16.

5.Kirkendall DT, Garrett WE. Function and biomechanics of tendons. Scand J Med Sci Sports. 1997;7(2):62-6.

6. https://www.sciencedaily.com/releases/2017/02/170223144723.htm

7.DiGiovanni BF, Partal G, Baumhauer JF. Acute ankle injury and chronic lateral instability in the athlete. Clin Sports Med. 2004;23:1–19.

8.Ferran NA, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex. Foot Ankle Clin. 2006;11:659–62.

9. Ramdass B, Koka PS. Ligament and tendon repair through regeneration using mesenchymal stem cells. Curr Stem Cell Res Ther. 2015;10(1):84-8. https://www.ncbi.nlm.nih.gov/pubmed/25274564.

 

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