Most common Ankle injuries in runners

​A runner is as susceptible to ankle pain as any other lower limb injury. The repetitive demands of continual load acceptance during the running gait can create a high level of stress through this joint. The result ranges from an increasingly uncomfortable run to a complete inability to weight bear. Either scenario can be catastrophic to a carefully planned training programme or even the disruption to a regular health and wellbeing activity.
The Ankle is made up of three bones, the Tibia and Fibular of the lower leg and the talus in the foot. These bones are held together by a series of ligaments most of which run along either side of the ankle joint. These ligaments offer stability to the ankle. There are also several tendons that cross the ankle attaching to muscles higher up the leg which create the movement of this joint. Each of these structures can become injured when running. The most common causes and types of injury are discussed in this article.
Sprains
What is it and what causes it?
An ankle sprain is a generic term for an injured ligament in the ankle. However, there are numerous ligaments that can become injured in the ankle, all of which may be caused by a different movement. A sprain is caused when a joint is stretched passed its natural available range. Ligaments are bands of connective tissue creating an attachment between bones, forming a joint. When the joint is over-stretched a ligament becomes stressed to the point it can tear.
The most common sprain is a lateral ankle sprain. It is often termed a ‘rolled ankle’ this affects the ligaments on the outside of the ankle. It is also possible to sprain the ligaments that support the inside (medial aspect) of the ankle too. Site of pain is usually a good indicator of which ligaments you have injured. The least common of ankle sprains is a high ankle sprain (Syndesmotic injury), this effects the connective tissue between the two lower leg bones (Tibia and Fibula) and commonly causes pain just above the front of the ankle joint as supposed to the outside of the joint as with a common lateral ankle sprain.
Just like Muscle strains, ligament sprains can be classified in the three categories, grade I, II or III.

​Runners may suffer an ankle sprain of any type by landing awkwardly into a stride, slipping off a curb, falling in a pothole, or tripping on uneven ground during a trail run.
Symptoms

• A sudden onset of a sharp pain directly following a trauma such as those described above will occur.
• Depending on the severity of the injury, an audible ‘Pop’ may occur.
• There will be degrees in significance of swelling and bruising depending on the grade of tear. A Grade I tear may leave you hobbling around, where as a grade III will likely leave you on the floor in immense pain completely unable to weight bear.
• Most sprains will cause restriction in range of movement of the ankle.
• Instability in the ankle can be experienced.

How to treat it?

• R.I.C.E (Rest, ice, compress and elevate) protocol is most beneficial in the first 24-48 hours of an acute flare up.
• Restricting pain eliciting activities such as running.
• If significantly painful the use of crutches may be beneficial.
• Maintaining full available joint range of movement.

• Appropriate strengthening and balance exercises.

• NSAIDs (anti-inflammatory drugs) may help manage pain.
• Application of specific taping techniques can support the joint.
• Ensure full recovery and rehabilitation is carried out to prevent the recurrence of secondary sprains which may lead to chronic ankle instability.

If it doesn’t settle seek medical advice. If concerns are raised about a more significant tear due to the inability to weight bear or high levels of pain and instability, then medical advice should be sort immediately. 

How to prevent it?

• Be aware of uneven, rough terrain particularly if training under fatigue.
• Introduce balance and proprioception training into a programme to challenge your bodies awareness in space.
• Wear appropriate footwear for the activity and biomechanics. 
• Introduce appropriate strengthening exercises.

 
Stress fractures
What is it and what causes it?
Stress fractures are common in runners and have been widely discussed in the guide to running injury series. The repetitive high impact forces created during the running gait cycle are absorbed by many bones in the lower limb. Over time these repetitive forces result in microscopic trauma to the bones. Through inappropriate training programmes, this microscopic trauma does not have chance to remodel and can progress to create fine cracks (stress fractures).
Most common stress fractures in the lower limb are found in the foot or shin. However, the Talus and Navicular bone are not immune to these stresses. They are located within the foot just below the ankle joint.
Stress fractures will present with pain on weightbearing. This is worse on impact and settles at rest. It is often a localised sharp pain pinpointed to the site of the fracture. In the case of the talus and Navicular this may be in the front of the ankle or deep within the ankle joint.

​How to treat it?

• R.I.C.E (Rest, ice, compress and elevate) protocol is most beneficial in the first 24-48 hours of an acute flare up.
• Prevent all impact activities such as running for the first 4-8 weeks. Specifically, whilst pain is present.
• Alternative non-impact activities such as swimming and cycling would be advocated.
• NSAIDs (anti-inflammatory drugs) may help manage pain and swelling.
• It is advisable to seek medical advice as it may be appropriate in certain cases to provide weightbearing aids such as crutches or an air boot.

 
How to prevent it?

• Introduce new activities such as running in a steady progressive programme.
• When increasing the intensity and volume of running ensure this is carried out as a gradual progression and there is adequate recovery time between training sessions to allow for the sufficient bone remodelling following the previous training session.
• Upon returning to running after a longer break period ensure that you commence your programme at a lower intensity than previous and build back up to the distance and frequency that you were last training at. 
• Consider cross training to vary the training load.
• Runners with osteoporosis or low levels of Vitamin D may consider a very gradual increase in duration and frequency of training to ensure the bones have optimal time to adapt to the impact load without causing too much stress.
• Ensure a healthy balanced diet to encourage Vitamin D absorption for improved bone health.
• Ensuring the use of appropriate footwear, which provides adequate shock absorbency.

 
Avulsion fractures
What is it and what causes it?
An avulsion fracture is when the forces stressed on a ligament or tendon are such that they create too much strain on the attachment causing a small piece of the bone to be pulled away with the ligament or tendon. The mechanism of these injuries is largely the same as a sprain and often presents in a similar way. Generally this is diagnosed by X-ray or CT scans. 

How is it treated?

• A period of immobilisation is often required, this may be by splint or air cast boot.
• The application of Ice and NSAID’s may be beneficial.
• As the injury recovers gradual return to mobility, balance/stability and strength exercises is advocated.
• Gradual return to running as pain allows.

How to prevent it?

• Considered in the same way as any ankle sprain:
• Be aware of uneven, rough terrain particularly if training under fatigue.
• Introduce balance and proprioception training into a programme to challenge your bodies awareness in space.
• Wear appropriate footwear for the activity and biomechanics. 
• Introduce appropriate strengthening exercises.

​
Tendinopathy
A tendinopathy is the degeneration of a tendon. Tendons attach a muscle to the bone.  A tendinopathy occurs when a tendon is overused and subjected to adverse stresses. The subsequent degeneration is displayed as thickening, splitting or even tearing of the tendon.
The repetitive nature of running and the high impact on the foot and ankle mean the numerous tendons around the ankle are vulnerable to tendinopathies if not managed sufficiently.
Common sites affected are:

• The Achilles Tendon where pain can be experienced in the back of the ankle or heel.  
• The Peroneal Tendons which wrap around the outside of the ankle (Lateral Malleolus).
• The Tibialis Posterior Tendon, which passes along the inside of the ankle attaching into the arch of the foot.

Symptoms
Symptoms associated with all these tendinopathies would be pain, swelling, weakness and even possible balance disturbances at the site of the respective tendon.
As with all tendon injuries the pain tends to be prominent at the start of activities settling as the activity progresses. It may completely disappear at rest. Tendinopathies rarely get better without intervention and should not be ignored. 

​Tibialis posterior tendinopathy

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​Peroneal tendinopathy

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​Achilles Tendinopathy

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​How to treat it?

• R.I.C.E (Rest, ice, compress and elevate) protocol is most beneficial in the first 24-48 hours of an acute flare up.
• Restricting pain eliciting activities such as running. Substitute activities such as cycling.
• Maintaining full available joint range of movement.

• Carry out appropriate balance and strengthening exercises. A progressive eccentric loading programme is often advocated after the initial inflammation has settled.
• Use of foam roller or massage ball to conduct myofascial release of connecting muscles.

• NSAIDs (anti-inflammatory drugs) may help manage pain.
• Application of specific taping techniques can support the effected tendon.
• If it doesn’t settle seek medical advice.

How to prevent it?

• Stretch daily throughout the lower limb, particularly as part of your training recovery programme.
• Ensure a progressive training load programme is carried out allowing for adequate stress and adaptation phases.
• Introduce appropriate balance and strengthening exercises to support the lower limb alignment.
• Use of foam roller or massage ball to conduct myofascial release.
• Ensure footwear is appropriate and supportive.

Many of these injuries discussed can occur in varying degrees of severity. It is helpful to understand when to seek further medical advice and when to simply rest from the offending activity to let the symptoms settle. Rarely do you find that ignoring the pain results in improvement or recovery.