Preventing Foot and Ankle Overuse Injuries

By Steve Elton

As triathletes, we put our bodies through a lot of stress on a daily basis. Running, in particular puts the most stress on the foot, ankle and lower leg. The most common running injuries we see in the therapy clinic are plantar fascitis and shin splints. The good news is that these overuse injuries can be treated, and to a large extent avoided with preventive measures.

The plantar fascia is connective tissue that runs under the base of the foot from the heel to the toes. It helps to maintain the arch of the foot along with the bones and tendons in the ankle and foot. Although it can be seen in athletes with a high arched foot, it is most commonly seen in athletes with a flat foot.

During the gait cycle a foot normally flattens out to accept shock when the foot strikes the ground. This is called pronation. Then, in order to push off the foot has to supinate, or roll out, to from a rigid lever for propulsion. If the foot has excess pronation during foot strike, or if it does not supinate during push off, too much stress is placed on the fascia and it gets inflamed. Also if an athlete has decreased flexibility in the calf muscles, the foot and ankle compensates for this lack of flexibility by turning out. We call this a positive toe sign. The body then compensates by allowing the foot to roll in too much and again puts too much stress on the fascia.

In each case, one not only has to treat the inflammation but also the cause. Typical treatments for inflammation are rest, ice; non-steroidal anti-inflammatory drugs and in some cases a cortisone injection. Physical therapists also use ultrasound, deep tissue massage and electrical stimulation to the fascia to decrease the pain. But, all these forms of treatment focus on the symptoms and not the cause. In the case of the athlete who has problems with pronation, an orthotic is placed in the running shoe to help support the arch. If flexibility is a problem, and it usually is in both cases, a calf stretch is performed with a book underneath the ball of the foot and the heel kept on the ground. Unlike most stretches that are typically held for 30 seconds to one minute, plantar fascitis seems to respond best when holding a the stretch for a time of 3-5 minutes that is preformed 2-3 times per day. Commercial splints are also available that keep the foot cocked up at a 90 degree angle when sleeping. This keeps the fascia and calf muscles in an elongated position during sleep when most of the healing is occurring in the tissues. In my opinion, these splints are a must for anyone suffering from fascitis.

Additionally, the muscles and tendons in the foot and ankle develop poor habits while the athlete is suffering from this condition. So, they need to be strengthened in order to attain normal gait. This is done using strengthening bands for the ankle, toe curls using a towel for the foot muscles, and single leg balance exercises. Balance exercises usually start in a static position and progress to the athlete performing dynamic movements on one leg. A favorite of mine is to have the athlete perform single leg balance on a Bosu ball while alternately touching the toes with the left and right hands.

Shin splints are a condition caused by inflammation of the posterior tibialis muscle where it inserts on the inside border of the tibia. There are varying degrees of this condition, the simplest being a mild inflammation at the muscle bone interface and the most severe being a stress fracture. The most common variables that cause this condition are excessive pronation and training errors. The posterior tibial muscle inserts at a bone in the arch called the navicular. When the arch flattens during pronation this bone drops towards the ground and puts stress on the posterior tibial tendon and muscle. This constant stress leads to inflammation and shin splints. Training errors such as wearing the wrong type of shoe, too much of an increase in distance, too much of an increase in intensity, or too much hill running can all cause excessive stress in the posterior tibial muscle as well.

First line treatments again focus on treating the symptoms with rest, ice, anti- inflammatories and physical therapy modalities. Supporting the arch with an orthotic must be done in those with pronation problems. Calf stretching, since the posterior tibial muscle is part of this muscle group, is employed as well as strengthening with elastic bands and heel raises. Round wobble boards area also great to strengthen the muscles of the lower leg. Place one foot in the middle of the board and perform repetitions forward, backward, sideways, clockwise and counter clockwise. Progress from sitting to standing to make the exercise more difficult. As with plantar fasicitis a program of toe curls with a towel and single leg balance exercises are performed to strengthen the entire foot and ankle.

By far the best way to avoid these painful conditions of the foot and ankle is through a few simple preventative measures. Number one, make sure a trained professional fits you in the proper shoe for your foot type. Next, anyone running over 20 miles per week should have orthotics in their running shoes. These don't have to be fancy $300 dollar insoles, although some severe pronators may need these, but at least have an over the counter brand place inside the shoe. Superfeet orthotics, www.superfeet.com, is a brand I have used with great success over the years. Incorporate stretching in to your daily routine. It doesn't have to be immediately after or before exercise. In fact, most sources now advocate a ‘dynamic warm up' or ‘movement preparation' before exercise and stretching afterward. I have my athletes set aside 20-30 minutes every night to address general flexibility. If certain muscles are prone to being tight I have them focus here for a few extra minutes. Lastly, Have a plan. One sure way to get injured is by training randomly. If you don't know how to set up an appropriate training program seek a coach or experienced athlete to help you in this area.

Steve Elton is a physical therapist, strength and conditioning specialist and triathlete. He received his MS from the University of South Carolina and holds certifications through the NSCA, NASM. Steve is a former elite triathlete with racing experience from sprint to Ironman distance.