Ankle Pain in Runners

author : AMSSM

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Mystery ankle pain afflicts triathlete upon return to running

Member Question:

"When I first started running years ago (starting totally from scratch), I had major issues with shin splints. Eventually I worked through all that and was able to run pain free. I took a pretty long hiatus from running for a variety of reasons but I'm getting back to it now. I'm not having any shin splint issues, but I'm getting horrible ankle pain. I usually don't notice it until after a workout, but sometimes I notice it while running ... especially if it already hurts when I start.

Is this a difference in my form causing me to feel it in my ankles now instead of my shins? If it is form related, does that mean I can somehow change my form to make it less painful? Or is it just that I'm older now so it's affecting my body differently? Also would it have something to do with the fact that before I was doing mostly long (for me) runs at a steady pace, and now I'm doing more sprint-like stuff (playing soccer, Crossfit, playing with kids at work, etc.) that involves a lot more varied movement? Is this something I can run through? I'm used to soreness but I don't want to end up causing injury. I did have one scare when I cut to the side during a soccer game and my ankle rolled. It hurt so bad I couldn't walk for most of the rest of the day ... but after icing it that night I was fine the next day besides a little soreness. Actually both ankles were equally sore the next day. My job requires me to run, so doing no running at all is nearly impossible for me ... although I do have some extra time off coming up soon so I can take it easy if that's the best course of action. Should I be investing in ankle braces of some sort? Are there stretches/exercises I should be doing to help work through this? It's hard to pinpoint where it hurts...seems to be more of just an "all over" thing. I've tried doing some range of motion type stuff (tracing the alphabet with my foot, but usually it hurts WAY more after that. Stretching seems to help, but I'm not sure if there' are specific stretches I should be doing. The weird part is that they generally feel good while I'm doing something active, but after I stop then it hurts. After sitting still for a while, when I try to stand up I feel like I can barely walk because they hurt and feel unstable. That makes it even harder to know what I should and shouldn't be doing, because the "stop if it hurts" thing doesn't really work. If I'm going by that I need to stop resting at all!

Sorry for the long list of questions, but this is totally new to me."

Answer from Jane T. Servi, M.D.
Member AMSSM

In order to answer your question, let’s start by discussing the ankle joint. A joint is an area in the body where two or more bones make a connection that allows motion. The ankle joint is made up of three bones, the tibia (shin bone), the fibula (the non-weightbearing bone on the outside of the tibia) and the talus (the highest bone of the foot). Ligaments attach from bone to bone to hold them in place, and tendons (which connect the muscles to the bones) act to move the ankle joint so that the toe end of the foot can be pulled up (dorsiflexion) and the toe end of the foot can be pointed downward (plantar flexion). Nerves carry the message from the brain to tell your muscles to move. The largest joint of the foot (subtalar joint) sits immediately below the talus and allows the foot to roll inward (inversion) and outward (eversion).

Ankle injuries can occur to any of these structures. Nerves can be injured by over stretching them during forced ankle movements such as twisting the ankle or when they become pinched by the structures around them. Ligaments are damaged by over stretching them (sprain) when the ankle is twisted or they may simply thin over time and break with little excessive motion if there has been repetitive stretching over time. Similarly, tendons can be stretched (strained) with forced movement to the ankle or thinned over time leading to tears with repetitive injuries. Additionally, bones can be broken either from extreme force like a twist or repetitive impact over time like a stress fracture. Furthermore, the articular cartilage on the end of the bones, the smooth gliding surface where two bones meet can be damaged either from force or repetitive impact (osteochondral injury) or from genetics that result in arthritis (wear and tear of the articular cartilage).

Since one of the roles of the ankle is to transfer forces from the foot to the leg, another potential category of injury from the ankle results from biomechanics. Pain can result when the structures previously described are not in proper alignment. For instance, excessive pronation (foot rolling inward/flattening upon impact) or supination (foot rolling outwards upon impact) can result in abnormal forces being placed on the bones and their articular surfaces resulting in injury. Occasionally bones may strike each other with movement and result in ankle impingement.

While preventative exercises may be helpful they should not be a cause for pain and may indicate the need for further evaluation. Specific exercises can be directed at the calf muscle and tendon with an Achilles/runner’s stretch and calf strengthening which can be performed by raising and lowering the heels while standing on the end of a stair. A theraband or rubber tube can be looped around the foot and used to strengthen the muscles that point the foot down and also the muscles that move the foot inward and outward. Balancing (proprioception) exercises may also be helpful.

In terms of alignment; arch supports from a local sports store, orthotics which are custom designed for your individual foot and appropriate shoe wear can contribute to improving the biomechanics. Sport specific shoes, meaning soccer shoes for soccer and running shoes for sprinting may diminish the risk for injury.

Since your ankle pain affects both ankles and began before and persists after you rolled your ankle, it most likely falls into the biomechanics category and could certainly be evaluated and confirmed by a sports medicine physician. There are many missing pieces to your history of ankle pain, such as your age, presence or absence of swelling and the type of pain (dull, sharp or burning). Furthermore, an exam by a physician can provide answers to your foot’s biomechanics, strength and stability.   Persistent or worsening pain, especially if accompanied by swelling may warrant x-rays or CT scans to evaluate the bones or articular surfaces.

Jane T. Servi, M.D. is a physician with Northern Colorado Orthopedic Associates.

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date: November 28, 2015