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As a runner, your feet are perhaps your most valuable asset, [or your best friends], so punishing them with blisters or plantar fasciitis can be a real drag. If you’ve incurred a foot ailment, you’re certainly not alone. Luckily, there’s a lot of research out there on how to keep your paws happy and operable.
According to research that evaluates the incidence of musculoskeletal injuries in runners, many runners are sidelined by foot injuries during their careers, and there’s nothing more annoying than having to miss a season when your legs feel great, but your foot isn’t cooperating.
While you may not face foot woes every day, we can attest to a blister, bunion, or plantar fasciitis throughout our time running, or perhaps we know someone who has experienced one or more of these foot ailments. It’s no doubt that our feet play a critical role in trail running as the basis for many other muscles and joints, even our running form. Here’s a rundown on what experts say about the most common foot injuries in runners.
Why Do My Feet Hurt When I’m Trail Running?
The Seven Most Common Foot Injuries, Defined:
A common injury involving bubbles on the skin containing fluid that are often caused by friction or moisture between the sock, shoe, and foot.
Bunions (a.k.a. Hallux Vagus)
These are bony bumps or protrusions that often form at the base of one’s big toe, often the result from genetics, tightly fitting shoes, foot stress, or poor foot mechanics.
This common and often hard-to-shake foot condition is characterized by inflammation and pain in the plantar fascia, a thick band of tissue that runs along the bottom of the foot. The plantar fascia connects the heel bone (calcaneus) to the toes and supports the arch of the foot. The most common symptom of plantar fasciitis is heel pain, particularly near the heel’s bottom or on the underside of the foot. The pain is usually worse in the morning when taking the first steps after waking up or after periods of inactivity. You might notice it getting out of bed each morning or lacing up your running shoes after a long work day. It may also worsen after long periods of standing, walking, or strenuous activity.
A condition characterized by inflammation or irritation of the peroneal tendons in the foot and ankle. The peroneal tendons are located on the outer side (lateral side) of the lower leg and pass behind the bony prominence on the outer ankle (lateral malleolus) before attaching to the bones in the foot. This is often caused by ankle instability, overuse, foot abnormalities, or inappropriate footwear.
A neuroma is a common foot condition characterized by numbness or tingling that involves the thickening of a nerve in the foot, usually between the third and fourth toes. A neuroma is a benign growth or enlargement of nerve tissue. Morton’s neuroma typically develops as a result of compression or irritation of the interdigital nerve, which runs between the metatarsal bones in the ball of the foot.
Posterior Tibial Tendonitis
Also known as “adult-acquired flatfoot,” this is a condition characterized by inflammation and irritation of the posterior tibial tendon, a long tendon that runs along the inside of the ankle and foot, playing a crucial role in supporting the arch and maintaining proper foot alignment. This typically occurs due to repetitive stress or overuse of the tendon.
These are some of the most extreme injuries to the foot typically caused by overuse, which involve small cracks or breaks in the bone. Common types of foot stress fractures include metatarsal, navicular, calcaneus (heel bone), tibial, and phalangeal.
As we look further into causes behind these foot injuries, it’s important to note that many of these can be interrelated, says Dr. Sarah Zimmer, PT, DPT, with Boulder Sports Physiotherapy in Boulder, Colorado.
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“There are many cases in which many of the above injuries are going on simultaneously and affecting the other,” Zimmer says. “For example, I see many runners with bunions (either full or due to hallux valgus) who also then struggle with plantar fasciitis or neuromas because of this malalignment of the big toe. It is important to address both.”
What Causes Foot Pain or Injuries?
There are many potential causes of foot and ankle pain, the main two being instability and weakness. When muscles are used beyond their functional strength, it can often result in tightness or soreness. Tightness is a way to form stability for your muscles to support each stride, although it’s not functional long-term and often correlates to pain. Decreased mobility in the foot and ankle can also cause pain and exacerbate foot injuries.
Katie Carbiener, DPT, PT, a physical therapist and avid trail runner from Golden, Colorado, says that especially on trails, having greater range of motion (ROM) is critical because your foot/ankle complex is forced into odd positions and stressed differently on inclines, declines and varying trail features.
“If you force a range of motion that isn’t there, the pressure on the joint can be painful,” she says, adding that if a runner repeats that over several hundreds of steps it will typically lead to inflammation. “The cool part is we can specifically train the feet to be stronger and there are many ways to improve mobility of both the foot and ankle”
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Pain from overuse can often be avoided with essential strength exercises, which are highlighted below..
Carbiener attributes many of the awkward movements that lead to ankle sprains to proprioceptive feel for the ground, or the body’s ability to know where it is in space. When your ankle begins to roll, the nerve fibers in your feet are stretched and signals are sent to the brain to contract muscles to react and correct to keep your ankle in the most advantageous position. But, because of the variable terrain of most trails, an optimal response can be tricky, depending on the specific elements on the trail surface, a runner’s shoes, and experience running technical trails.
If you have previous ankle sprains and have not worked on strength or proprioception, you are more likely to re-sprain the ankle, Carbiener says A weak or rigid foot is also less reactive, which makes the ankle work harder on uneven surfaces like technical trails.
The good news in all of this? Proprioception, stability, and strength are skills that can be trained and improved upon.
Should You Run Through Foot Pain?
So the big question runners often wrestle with is whether or not to run through persistent foot pain. The answer depends on a lot of factors.
“Most of the time, a low level of discomfort—3 or less on a 1-10 scale—is safe and OK to run on,” Zimmer says. “Typically, we want to mitigate the post-run pain that lingers into the next morning, and we want the pain to diminish and/or subside during the run if possible (within the first 10-15 minutes).”
However, if your pain is sharp or accompanied by redness, swelling, and a limp, then it is not safe to push through and you should have it checked out by your primary care physician, who can then refer you to a specialist (likely a podiatrist or physical therapist, depending on the severity and location of injury). These can likely be symptoms of a stress fracture or worsening injury.
Cariener adds that more acute type injuries (blisters, fractures, wounds, etc.) shouldn’t be pushed through without treatment. These can result in infection or worsening symptoms that can lead to more time away from the trails than if you stopped or rested sooner.
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If you’re not sure about whether you should continue running, go through this checklist of considerations:
- First, determine whether you’re experiencing severe soreness or actual pain. Soreness is typically mild discomfort in your muscles experienced from overuse or fatigue (such as a long day out) and resolves with rest, whereas pain is typically recurring and could be centered on the heel, ball, arch, or entire foot.
- If your pain lasts throughout a run, it is likely something that needs to be addressed and won’t just “work itself out.”
- If your pain dissipates during a run, but comes back with vengeance the rest of the day while you are walking around, then you might need to back off or get treatment
- If you wake up the next morning with sharp pain getting out of bed, then you also may need to back off on your volume/intensity in order for things to heal faster.
There is a delicate art to pushing through foot injuries safely, Carbiener says, adding that if you are currently seeking interventions (both specific exercises for your condition and possibly hands-on interventions like massage, icing, needling, mobilizations) then you can sometimes work through it with reduced running volume and potentially more cross-training..
“Runners can get stuck in a cycle of rest, reintroduction of running, and reinjury,” she says. “Your body needs to be exposed to the impact of running to tolerate running. Your tissues need to be stressed to some capacity to be ready to progress.”
When in doubt, ask a running-specific professional (i.e. a physical therapist, sports chiropractor) who can provide individualized insight on the severity of your condition, possible long-term effects of pushing through, and a course of action to keep you moving, while prioritizing the necessary recovery time to improve your condition.
Essential Foot-Strengthening Exercises
While feet aren’t necessarily the first muscle group we think of when considering our strength training routine, giving the foot/ankle complex some love is key to preventing injury. Zimmer shares that there are many areas of the foot and ankle to strengthen for treating and preventing injuries. Some areas to focus on include:
- Big toe flexion, extension, and abduction. This is often referred to as “toe yoga,” designed to increase the amount of activation through the big toe and reduce excessive gripping with our other toes.
- The three arches of the foot can be strengthened by practicing “arch lifts” or “doming” in a seated and standing position.
- Tibialis anterior, which is a very important and forgotten muscle at times. This muscle assists in flexing the foot and ankle upwards (dorsiflexion) and is essential for optimal ankle mobility, foot clearance while running and stability.
- Hip strength is also important for foot health, as the rotational stability of our feet comes from our lower legs and hips. Zimmer states, “I usually give the example of a marionette puppet. The puppet is controlled by the strings/handle above. If you cut one of the strings or remove half of your handle, that side of the puppet will collapse and be hard to control. Strengthening your glutes and core muscles is important for foot strength, too.”
- Hopping and jumping—Carbiener recommends incorporating plyometrics into your strength routine, as they load the joints, muscles, and other tissues to prepare for the stress of running. Agility drills and even line jumps can train stability of the ankle and prepare your lower extremity for the loading it encounters in trail running. Carbiener shares that she has personally seen a significant decrease in shin splints and plantar fasciitis with athletes after implementing these drills in their off-season.
Now that we’ve covered many of the foot ailments you might encounter as a trail runner, including blisters, plantar fasciitis, and stress fractures, it’s important to consider how much we can do to prevent and address these conditions. Consider our physical therapist recommendations, including foot and ankle-specific strength training, balancing your training volume to prevent overuse and ensuring proper footwear. You better be making those feet a priority—after all, they are the force that keeps us going!