The 5 Commonest Running Injuries I See As A Foot And Ankle Surgeon

1. Plantar Fasciitis

Plantar fasciitis is the single most common cause of heel pain in runners, accounting for around 10% of all running-related injuries. It involves inflammation of the plantar fascia — the thick band of connective tissue running along the sole of the foot from the heel bone to the base of the toes.

**What it feels like:** A sharp, stabbing pain at the base of the heel, classically worst with the first steps in the morning or after prolonged sitting. The pain often eases as you warm up but returns after rest.

**What causes it:** A combination of training load errors (increasing mileage too quickly), reduced ankle dorsiflexion, tight calf muscles, and foot biomechanics all contribute. It is more common in those with a high arch or flat foot.

**What the evidence says:** The current evidence strongly supports a structured physiotherapy programme as first-line treatment, centred on progressive loading of the plantar fascia through specific stretching and strengthening exercises. A 2021 systematic review in the *British Journal of Sports Medicine* confirmed that load management combined with calf and intrinsic foot strengthening produces the best outcomes. Most cases resolve within 6-12 months with conservative management. Shockwave therapy has good evidence for persistent cases. Surgery is rarely required.

2. Achilles Tendinopathy

The Achilles tendon is the strongest tendon in the body, but it is also one of the most commonly injured in runners. Achilles tendinopathy — a degenerative rather than purely inflammatory process — typically presents in two forms: mid-portion (2-6cm above the heel bone) and insertional (at the point where the tendon meets the heel bone).

**What it feels like:** A gradual onset of pain and stiffness along the back of the ankle, often worse first thing in the morning and at the start of a run, easing with warm-up before returning after activity. There may be localised thickening or a visible nodule in mid-portion tendinopathy.

**What causes it:** Rapid increases in training load, inadequate recovery, reduced ankle mobility, and calf weakness are the main contributors. Age-related tendon changes also play a role.

**What the evidence says:** The Alfredson heavy-load eccentric programme, and more recently the heavy slow resistance protocol described by Beyer and colleagues, have the strongest evidence base for mid-portion Achilles tendinopathy. A structured 12-week progressive loading programme should be the cornerstone of treatment. Insertional tendinopathy requires a modified approach that avoids end-range compression. Platelet-rich plasma (PRP) injection has emerging evidence in certain cases, though indications are very specific. Surgical intervention is a last resort — typically a tendon debridement — it can be effective when 6 months of structured rehabilitation has failed.

3. Stress Fractures

Stress fractures in runners most commonly affect the metatarsals (particularly the second and third), the navicular, and the calcaneus (heel bone). They represent a failure of bone to remodel at a rate sufficient to cope with repetitive loading.

**What it feels like:** A gradually worsening, well-localised pain that is reliably reproduced by weight-bearing and direct pressure over the affected bone. Unlike soft tissue injuries, the pain typically does not ease with warm-up and worsens progressively through a run.

**What causes it:** A sudden increase in training volume or intensity, transition to harder surfaces, inadequate nutrition (particularly low bone density or relative energy deficiency in sport — RED-S), and biomechanical factors all contribute.

**What the evidence says:** Early diagnosis is critical, particularly for high-risk stress fractures of the navicular, fifth metatarsal base, and anterior tibial cortex, which carry a significant risk of non-union if managed incorrectly. MRI is the gold standard investigation — plain X-ray frequently misses early stress fractures. Management ranges from relative rest and load modification for low-risk fractures to surgical fixation for high-risk sites or displaced fractures. Return to running is guided by symptom resolution and imaging, typically 6-12 weeks for low-risk sites.

4. Ankle Sprains and Chronic Ankle Instability

Lateral ankle sprains are the most common acute sporting injury overall, accounting for up to 25% of all sports injuries. What is less well appreciated is that a significant proportion of runners who sustain an ankle sprain go on to develop chronic ankle instability — recurrent giving way, persistent pain, and difficulty on uneven ground.

**What it feels like:** Acute sprains present with pain, swelling, and bruising over the outer ankle. Chronic instability presents with a sense of the ankle giving way, persistent aching, and reduced confidence on uneven terrain.

**What causes it:** Incomplete rehabilitation of the initial sprain — particularly failure to address proprioceptive deficits and peroneal muscle weakness — is the primary driver of progression to chronic instability.

**What the evidence says:** Current evidence, including the 2023 International Ankle Consortium guidelines, emphasises early functional rehabilitation over immobilisation for acute sprains, with progressive proprioceptive and strength training central to recovery. For chronic instability that has failed 3-6 months of structured physiotherapy, surgical reconstruction (Broström-Gould procedure) has excellent outcomes with high rates of return to sport.

5. Peroneal Tendon Pathology

Peroneal tendon problems are frequently overlooked in runners presenting with lateral ankle pain and are often misdiagnosed as a recurrent ankle sprain. The peroneal tendons run behind the outer ankle bone and are responsible for eversion and dynamic ankle stability.

**What it feels like:** Pain and swelling behind and below the outer ankle bone, aggravated by running (particularly on cambered roads or trails), and sometimes a snapping or clicking sensation around the ankle.

**What causes it:** Overuse, ankle instability, and acute inversion injuries can all precipitate peroneal pathology, which ranges from tendinopathy to partial tears and subluxation.

**What the evidence says:** MRI or ultrasound is required for accurate diagnosis. Conservative management with physiotherapy is appropriate for tendinopathy and minor partial tears. Peroneal subluxation and significant tears typically require surgical management, with good published outcomes for both peroneal groove deepening procedures and direct tendon repair.

When Should a Runner See a Consultant?

As a general rule, any running-related pain that has not responded to 6-8 weeks of appropriate conservative management, any injury associated with significant swelling, deformity, or inability to weight-bear, or any pain that is worsening despite rest warrants specialist assessment.

Early specialist input avoids the common pattern I see in clinic — months of inappropriate management, progressive structural damage, and a much more difficult treatment pathway than would have been needed with earlier intervention.