Overuse Foot Injuries in Runners

One of the fun things about running is that it gives one the opportunity to learn, and it seems as if this never stops. No matter how experienced you are there is always something more to learn. This observation is made relevant by several investigations into overuse injuries in runners. These studies show that experienced runners have about the same rate of overuse injuries as beginners. It is not that experienced runners never learn. Certainly some do not and constantly run, and rerun, into the same injury pattern. However, it is likely that a larger percentage cure one injury then develop and improve until they stumble into the next. This is probably because as one area gets stronger the stress load is subsequently re-applied elsewhere. Injuries, thus, tend to march along what is referred to as the “kinetic chain”. Each runner, however, tends to march to the beat of a different drummer. The specific location for an overuse injury is determined by a multitude of factors (e.g., genetics, previous injuries, training factors, etc.). This means that there is not an etched-in-stone-overuse-injury-sequence through which all runners progress (Feet first, then ankles, then shins, then knees, then … ). Thus, it is a good idea for runners to become aware of regions of the body that may become affected and learn a little about the specifics in each region. Knowledge and early warning are a runner’s best friends. In this column I periodically highlight either a specific injury or a region of the body in which overuse injuries occur or originate. This month it is, “de feet”.

Conceptually it is easy to think of the feet as an area that may become overused and injured in runners. They are, after all, the first part of the body that hits the ground. One must consider that injuries elsewhere may have their roots in the feet. Similarly, it must be pointed out that nagging foot injuries may have their cause higher up the kinetic chain.

When searching for factors that may have contributed to any running injury (i.e., not just those limited to the foot) a good starting point is the foot. The details of advanced biomechanics are beyond the scope of this article, but a discussion of a few basics is warranted. As a simplification there are three types of ‘arches’, neutral (normal), high (and/or rigid), and low (“flat feet”). In a normal running gait at footstrike the foot is in a relatively supinated position and then progresses, or rolls, through pronation during the mid-stance phase. To visualize this, open a paperback book at the midpoint and place it face down on a table. It tends to tent up with the spine elevated, supported on two “wings”. Each wing is in a supinated position relative to the spine. Now press down on the spine to flatten the book. Each wing has now moved towards a more pronated (less supinated) position. The action, from supinated to pronated, is called pronation -- and going the opposite direction is called supination. Of course when we run this happens to each foot alternatively, and obviously involves different mechanics and angles. The foot hits the ground in a relatively supinated position and then ‘rolls’ into a more pronated position by the mid-stance phase, which is the point when the foot is directly under the body and is bearing full weight.

In returning to examine different foot types it is now easier to understand why runners with high arches are referred to as “supinators” or “under pronators”. In their running gait they have decreased mobility such that there is inadequate pronation during running. These runners have a foot that doesn’t absorb shock well. This shock is transmitted to lateral (outside) structures in the foot, lower leg, and knee. An injury example is anterior (lateral) shin splints. “Overpronators” have the opposite problem. There is too much mobility and, thus, excess pronation during running. These runners end up transmitting excess force to the medial (inside) structures of the leg. An injury example here is posterior (medial) shin splints.

The right shoe for underpronators (supinators) are ones that provide extra cushioning and shock absorbing capacity. Overpronators need shoes that provide extra stability, or “motion control”. A quick and dirty method for determining individual needs is the wet footprint test. Start by placing a wet towel on concrete. Simply step onto the towel with each foot (one-two) then step forward (one-two) onto dry concrete and then step forward again. Now look at your footprints. If the only wet spots are the ball, the heel, and a sliver of the outside edge of the foot you are likely an underpronator. Conversely, if the entire footprint is filled in then you fall into the overpronator camp. There are several running shoe guides (e.g., www.roadrunnersports.com) to help you determine what shoe is right for you. Finally some runners need the extra help provided by orthotics. These customized shoe inserts may be designed to provide extra support and motion control for overpronators, or extra cushioning for underpronators.
A few other tips about running shoes. After about 250 miles shoes lose about 30 – 50% of their shock absorbing capacity. The same is true for wet shoes, which – depending upon how wet -- may take 48hrs to dry out. If you run daily you may want to consider buying two pairs and using them on alternate days. This will help prolong effective shoe life-span.

Foot injuries in runners.

Not listed in any particular order, nor is this list all-inclusive.

1. Plantar fasciitis - heel pain caused by inflammation of the tough fascia on the bottom of the foot, usually right where the fascia attaches into the heel.
2. Calcaneal stress fracture – an overuse fracture of the “heel bone”
3. Achilles tendon bursitis – inflammation of the bursa located at the attachment of the Achilles tendon to the heel. (NOTE: Although not defined as a foot injury there is also a separate condition involving inflammation of the Achilles tendon itself, higher up the ankle, referred to as Achilles tendinitis.
4. Extensor tendinitis – inflammation of the tendons on the top of the foot, usually midway along the foot.
5. Sesamoiditis -- inflammation of those tiny little free-floating “sesame seed” bones, which are located in the ball of the foot near the base of the big toe.
6. Metatarsal stress fracture – an overuse fracture of one of the metarsals. These are the long bones that start at the midway point of the foot and run right up to the base of the toes. There are 5 in each foot.
7. Morton’s neuroma – a condition caused by the chronic irritation of the interdigital nerve, usually between the 3rd and 4th metatarsals, near the toes. Runners often experience a “pins-and-needles” or “electric shock” pain.
8. Posterior tibialis tendonitis – this tendon passes underneath the medial malleolus (the inside “ankle bone”) and attaches into the medial aspect of the foot (navicular bone). Runners usually experience pain below the inside of ankle or slightly further along the inside of the foot.
9. Peroneal tendonitis – this tendon passes underneath the lateral malleolus (the outside “ankle bone”) and attaches on the lateral aspect of the foot (cuboid and base of 5th metatarsal). Runners usually experience pain on the outside part of the ankle or lateral edge of the foot up to the base of the 5th metatarsal.

10. Subungal hematoma -- bleeding underneath the nail from the chronically jamming the toe(s) into the shoe. Also may happen acutely if you drop something heavy on your toes(s). NOTE: This is just one type of toe condition – there are many others (e.g., ingrown nail). I just wanted to mention one so that the toes didn’t feel left out in the foot discussion.

Common point of tenderness in plantar fasciitis
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