Ankle injuries are, unfortunately, a common problem for runners. And yet despite their prevalence, ankles are an oft-neglected body part until something quite obviously goes wrong with them – such as a sprain while trail running or a persistent ache after a race.
Our view? Your ankles deserve better. From your first mile to your last, every single step weighs heavy on this important joint. Since you can reasonably expect to take an average of 1,500 steps per mile, it’s easy to see how, over time, this could result in injury and pain.
While certain factors make ankle injuries more likely – from overtraining to bad mechanics – it’s possible to side-step ankle issues with a little know-how. Read on to discover the most common ankle injuries for runners and the crucial steps to take to keep them at bay:
How does the ankle move when running?
Your ankle both drives you forward and minimises impact forces. ‘When your foot hits the ground, the ankle’s dorsiflexion – when your toes move closer to the shin – acts as a kind of shock-deferral device,’ says physiotherapist Paul Hobrough of Physio and Therapy. ‘Along with your knees and hips, the ankle allows the body to absorb multiple times your body weight. Then, stabilising muscles and the elastic recoil of your Achilles tendon enable the ankle’s next phase, known as plantar flexion, in which your toes move away from your body, to propel you forward and upward again.’
The ankle also works in tandem with your foot to allow impact-absorbing pronation (inward roll of the foot). ‘A locking mechanism within the tarsal bones in the foot creates a stiff foot and ankle for maximum drive forward,’ says Hobrough. ‘Pronation takes place when this mechanism unlocks, allowing the foot to absorb the ground force with the least possible impact.’
What are the most common ankle injuries for runners and how can you prevent them?
The joint’s complex, delicate biomechanics mean ankle injuries are common in runners. Here’s how to ensure they don’t keep you sidelined:
‘These injuries tend to damage lateral or external ligaments,’ says Alessandro Marconato, rehabilitation physiotherapist at the Isokinetic clinic. ‘Grade-one injuries just overstretch the ligament, with no actual tear; grade twos are partial tears and a grade three is a complete rupture.’
Treatment: ‘It’s vital in the first 24 hours to control pain, swelling and inflammation,’ says Marconato. This is achieved through rest, ice, compression and elevation (or RICE, every runner’s favourite acronym). ‘Depending on the damage, it may be beneficial to wear a brace to protect the ligament. Pain permitting, early mobilisation in extension and flexion of the foot from the ankle is important to maintain a good range of motion. Do this by pointing your toes, then flexing them. If it’s possible without pain, weight bearing is recommended, working towards normal walking technique. Seek expert advice when you reach this point so you don’t cause further damage through improper walking form.’
Prevention: ‘Strength, balance and neuromuscular control are central to rehabilitation,’ says Marconato. ‘The gluteal muscles and the peroneal muscles (connecting the tibia and fibula in the lower leg) are particularly important. It’s essential to work on muscle activation and neuromuscularcontrol exercises so you’re able to switch on these muscles.’
2. Achilles Tendinopathy
‘This overuse injury is the most common cause of posterior ankle pain,’ says Marconato. As well as pain, this kind of ankle injury can cause swelling and stiffness. Overpronation, weak calf muscles and a reduced range of upward flexion are among the most common causes, says Marconato.
Treatment: ‘Rehabilitation starts with symptom control, which means reducing activity and controlling pain through RICE,’ says Marconato. ‘It’s also essential to recover the range of movement, and you can do this by stretching the calf muscles – both the soleus and gastrocnemius muscles.’ How? Stand with your heels hanging over a step. Drop one heel, hold for 30 seconds, switch sides and repeat three times to stretch the gastrocnemii. Then repeat the exercise, but this time with a bend in your knee to stretch the soleus. ‘The calf muscles will be weaker than they are on the non-affected limb, so it’s vital to regain strength,’ says Marconato.
Prevention: You can begin building strength (to prevent injury or as part of your treatment) by using a resistance band. Sitting on a chair, loop a resistance band around your foot. Keeping hold of the other end, point and flex the foot 20 times. Rest, then repeat three times. ‘Progression is key,’ says Marconato, ‘so move on to bodyweight exercises such as calf raises.’
3. Other tendinopathies
These include peroneal tendinopathy, tibialis posterior tendinopathy and tibialis anterior tendinopathy. ‘They are a common set of overuse injuries that affect the ankle’, says Marconato, affecting, respectively, the outside, inside and front of the ankle. ‘They tend to arise from bad mechanics, such as overpronation, or from running up and down hills. The affected tendon maybe tender or painful to the touch, and painful while the muscle is tested.’
Treatment: ‘As with an Achilles injury, first control symptoms with RICE, then work to increase range of movement, correct biomechanics and strengthen your muscles. And add some balance or proprioception training,’ says Marconato.
Prevention: ‘When you’re working on gluteal strength, coordination and balance are key,’ says Marconato. ‘Use wobble boards and unstable surfaces and progress to squatting exercises.’ To build the gluteal strength that will prepare your body for wobble-board squatting, start with deep standing squats, focusing on engaging the glutes as you drive upwards. Start with three sets of 10-15 squats.
5 things all runners should know about ankle injuries:
We spoke to Ant Brightwell, physiotherapist at Ten Health & Fitness, to uncover the most important things runners need to know about their ankle health to avoid risking time on the sidelines.
1. There’s more to ankle injuries than just sprains
While sprains are common ankle injuries, usually from a trip or fall, there are also problems runners can acquire through overuse. ‘What I see most are tendon problems, such as in the Achilles or tibialis posterior tendons,’ says Brightwell.
The tibialis posterior, or tib post, is a stabilising muscle in the lower leg, which wraps behind the ankle bone and supports the arch of the foot – if its tendon is inflamed, this area may feel tender or achy before becoming painful. Left untreated, an injured tib post tendon can become unable to support the arch of the foot and lead to fallen arches – not good.
The Achilles tendon, which you may be more familiar with, is the thick tendon that runs from your heel, over your soleus (the long, deep calf muscle) up to the gastrocnemius (the upper, rounded calf muscle). Tendon problems in the Achilles can present as tenderness or thickening, with a notable physical symptom according to Brightwell: “Typically, you have a tendinopathy then you get this sort of egg formation, like a Cadbury’s mini egg – the tendon will be nice and thin and then there’ll be a hard lump, and then it goes back down to normal size.”
2. Certain people are at greater risk of ankle injuries
Runners who’ve had ankle injuries in the past may be all too aware that they can be prone to further injuries: “If you’ve had an ankle injury before and it’s not been rehabbed to 100% then it would be a predisposing factor,” explains Brightwell. “A common mistake that many people make is to stop rehab too soon. They assume that just because they’ve got back to the stage where they’re pain-free, that this means that the injury is now 100% recovered – when in fact, it isn’t.”
Additionally, office workers can be in trouble: “If you’ve got a very busy but sedentary work life with long hours but at a desk, that ends up switching off a lot of postural muscles, which has a huge influence on your leg alignment.”
Luckily, there are a few ways you can tell whether you have ankle instability or weakness so you can prehab before you hit an injury-related roadblock. “Look at the wear pattern on your shoe – if there’s a discrepancy on where the shoe is wearing down on the left and right then it shows you’re running slightly differently on each side which could be a sign that you’re unstable,” Brightwell says. “Also, if you have lots of mini twists – where you’re walking down the street and find you almost twist your ankle but not quite, that’s definitely a sign that the muscles on the inside and/or outside are slightly too weak and you’re leaning on your ligaments a bit more.”
Try comparing calf raises on each side when at home or at the gym. “See how high can you go on one leg, then do double leg calf raises and see if there’s a tendency to lean on one leg more. Does one hurt, feel weak or feel tight? Can you do the same amount on each leg?”
Additionally, put your single leg balances to the test and see if you’re wobblier on one side. “Sometimes you might not see a difference instantly but if you look at your endurance through that exercise you’ll notice a difference. So you might find you can hold your balance a minute and a half balancing on one leg, but on the other leg you’re not stable for more than 10 seconds – a great indicator of an inherent weakness or instability.
3. Running with an ankle injury can cause you to develop more injuries elsewhere
Taking a break from training while injured can be a struggle, so dashing back to your runs after an ankle injury is totally understandable. However, continuing to train before your ankle muscles and ligaments have been rehabbed can lead to more injuries down the line. “Something I find people often overlook in the picture of ankle instability is something like IT band syndrome – feeling something higher up because again you’re trying to compensate for the ankle,” explains Brightwell. That means that if you’ve got a persistent overuse injury in your knee or hip joint and prescribed glute activation exercises aren’t helping, the cause could be further down.
Similarly, if you train too much with an injury higher up the leg, that can lead to ankle problems developing. “In trying to offload that injury because it’s too painful, such as by trying to keep the weight on the other leg or pushing through the foot of the injured leg in a compensatory way instead of bending the knee, people can load one foot too much.” This can cause overuse injuries in the ankle such as the Achilles and tib post mentioned above.
4. Don’t go overboard with taping
“This is where I get into lots of arguments with other physios!” says Brightwell. “I’m against taping long term.” Obviously, in some situations strapping tape is just what you need. “If someone comes in and they’re in a lot of pain then taping will obviously stabilise the ankle. Or if you’ve got a ligament strain or a muscle you need to take the pressure off, then again it’s exactly what you need.”
However, if you never run without taping up first, problems can arise. “If you do it for too long, you’re taking away the function of a lot of the tissue in that ankle – not even necessarily the injured tissue. If you’ve ever broken something and had it in a cast, when you take the cast off the muscles have wasted away because they’ve not been needed. That’s the same if you strap up the ankle for too long.”
5. Rehab ankle injuries thoroughly
On top of any specific exercises your physio has prescribed for your ankle injury, Brightwell says well-performed calf raises are excellent for strengthening the ankle joint. “Ideally your heel and ankle should be coming up in a straight line,” he advises. If you’re an over-pronator, you can be prone to your feet rolling in as you rise, so keep an eye on your technique in a mirror. In addition to calf raises, Brightwell recommends working on your technique for more global leg exercises like squats and lunges.
Remember, being able to complete a certain amount of exercises doesn’t necessarily mean you’re ready to run again. “You may be able to perform a very simple calf raise properly - but that’s very different from running, landing on one foot, absorbing pressure from the uneven ground or the gradient and pushing off again. It’s very different going from a controlled environment [with calf raises and other physio exercises] back to the habitual movement pattern [running].”
How to get stronger ankles for running
The tests: Balance on one leg in front of a mirror. Watch how much your foot and ankle wobble. Can you maintain balance easily? Then try balancing while moving the other leg forward and back, as if running; can you still maintain your balance?
Try the Y-balance test. Place a tape measure on the floor, angled 45 degrees backwards away from your standing foot (backwards and left from your right foot, or backwards and right from your left). While balancing on one leg, reach back with your toe and touch the farthest point on the measure you can without losing your balance. Repeat this measurement on the other side and compare. According to a recent study, runners with reach differences greater than four centimetres are two-and-a-half times more likely to sustain an injury.
Recommended moves: Work on balance whenever you can. Brush your teeth on one leg, eyes closed if you get good at it.
Single-leg cone touch: Set up two cones (ideally of different heights) in front of you, a foot apart. Standing on one leg, pivot forward at the hip to touch the top of one cone. Jump up, land and touch the other cone. Switch legs every two reps and rest every eight. Do 3-4 sets. Make it harder by doing it on an unstable surface such as a Bosu ball.
Bosu ball figure 8: Stand on a Bosu ball, feet apart. Hold a medium-weight medicine ball and squat. As you do, move the ball to the right of your legs, knees forward. Stand and slowly take the ball overhead. Squat again, taking the ball to the left. Repeat the right, overhead and left moves in a figure-of-eight motion. Do 1-3 sets of 12-16 reps.
Other exercises to help protect your ankles
Another way to reduce the chances of an ankle injury is to improve strength and flexibility in your calves, as tight soleus and gastrocnemius muscles limit ankle motion. The stretches and exercises here all target your lower leg and can be added to any workout.
Stand tall with your feet hip-width apart. Brace your core and hold it that way for the entire exercise. Step forward with your right leg and slowly lower your body until your front knee is bent at least 90 degrees and your rear knee nearly touches the floor. Pause, then push yourself to the starting position as quickly as you can. Complete the prescribed number of repetitions, then do the same number with your left leg.
Cross-legged foam roll
Place a foam roller under your right ankle, with your right leg straight. Cross your left leg over your right. Put your hands on the floor for support and keep your back naturally arched. Roll your body forward until the roller reaches the back of your right knee. Then roll back and forth. Repeat with the roller under your left calf. (If this is too hard, perform the movement with both legs on the roller.)
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