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Ankle Pain When Running

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.


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.


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.


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


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.


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.


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.


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?

Achilles Tendonitis

Heel pain is one of those issues that can affect most of what you do in a day and can be disabling. A common cause of heel pain is the Achilles tendon. What is the Achilles tendon? What is Achilles tendonitis? What are the different injuries? Is stem cell therapy for Achilles tendonitis a viable option? Where & What Is the Achilles Tendon? A tendon is a thick fibrous band of connective tissue that connects a muscle to bone. There are more than 30 million tendon and ligament injuries annually. The Achilles tendon, which is the thickest tendon in the body connects the calf muscles to the heel bone. It consists of the gastrocnemius and soleus muscles that unite to form a thick band that is immediately above the heel tab on your shoe. It enables the downward movement of the foot and bending of the knee.

Read More About Achilles Tendonitis

Ankle Arthritis

Your ankle is located where the distal ends of the tibia and fibula bones (lower-leg bones) meet the talus bone at the foot. Between these bones are the ankle joints (e.g., tibiotalar, tibiofibular, subtalar, etc.). The ankle joint also consists of strong supporting tendons and ligaments. If you consistently experience ankle pain with walking or running or carrying a heavy load, this could be tendon inflammation, ligament instability, or arthritis in one of those joints.

Read More About Ankle Arthritis

Ankle Instability

The ankle is susceptible to injury. It is the most injured joint in sports and accounts for 10-30% of all sports injuries. A sprain (aka twisting the ankle) is when one or more of the ligaments is stretched or torn. Pain, swelling, and bruising are common. Sprains are classified into grades 1, 2, or 3 based upon the severity of the injury. Simple tasks like stepping off the curb or sports can lead to ankle sprains. Ligaments stabilize the ankle joint and when sprained can lead to ankle instability. When acute ankle sprains are not identified, treated, and allowed to heal chronic…

Read More About Ankle Instability

Ankle Tendon Tear

Have you been told you have an ankle tendon tear and need surgery? Do you really need this procedure or will less invasive injections do the trick? Let’s review ankle tendon surgery and who needs it and who doesn’t. The ankle has many tendons that come from leg muscles. They help stabilize the ankle and move the foot up, down, left, and right. The ankle tendons include: Peroneal FHL (Flexor Hallicus Longus) Tibialis Posterior FDL (Flexor Digitorum Longus) Tibialis Anterior Achilles These can be torn in trauma or due to wear and tear.

Read More About Ankle Tendon Tear

EDS in Children

Ehlers-Danlos Syndrome (EDS) refers to a group of disorders that affect the body’s connective tissue including skin, tendons, and ligaments. It is a hereditary disorder which means you are born with it. EDS has many different signs and symptoms which can vary significantly from patient to patient. It most commonly affects the skin, joints, and blood vessels. The estimated prevalence for all EDS varies between 1/10,000 and 1/25,000. The three most common types of EDS are: Hypermobile, Classic, and Vascular. We have used these skills and knowledge to treat the loose ligaments commonly found in EDS in children. Treatment options include bone marrow concentrate (BMC) and PRP.

Read More About EDS in Children

Ehlers-Danlos Syndrome (EDS)

Disorders that affect and weaken the connective tissues such as tendons and ligaments. It is a hereditary disorder which means you are born with it.  EDS has many different signs and symptoms which can vary significantly depending upon the type of EDS and its severity.   It most commonly affects the skin, joints, and blood vessels.  Joints are typically hypermobile with excessive joint range of motion because of a defect in collagen formation. In most cases Ehlers-Danlos syndrome is inherited. That is to say that you are born with it. The two main ways EDS is inherited are: autosomal dominant inheritance and autosomal recessive inheritance…

Read More About Ehlers-Danlos Syndrome (EDS)

Sprained Ankle

Your ankle is comprised of bones held together by a bunch of ligaments. These ligaments end up getting damaged when you sprain or roll your ankle. Common causes are trauma or injury related, such as twisting your ankle.

Read More About Sprained Ankle

Tarsal Tunnel Syndrome (TTS)

Carpal tunnel syndrome is compression of the median nerve at the level of the wrist with resultant hand and wrist pain. Tarsal tunnel syndrome (TTS) is the equivalent in the ankle. What is Tarsal Tunnel Syndrome (TTS)? Also called tibial neuralgia, TTS is compression of the tibial nerve as it passes through the tarsal tunnel at the ankle. The tarsal tunnel is located behind the medial malleolus, the bump on the inside of the ankle.

Read More About Tarsal Tunnel Syndrome (TTS)
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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.

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 fasciitis, 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.

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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.


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.

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