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Foot injuries caused by running is most common around the heel bone and the forefoot.

Imbalance in the foot may also be a reason for developing running related injuries in the leg bone, knee, hip and back (see the following articles: lower leg injuries, knee injuries, hip injuries).

The foot is the platform and the foundation for the whole body, and is constructed in a genious way, consisting of knuckles, ligaments, muscles, tendons, nerves and cushioning fat pads. Although the foot contains 26 knuckles and is subject to very high loads, these parts only weigh around 100 grams all together.

The foot’s ability to resist such high loads is primarily due to the foot’s archs. There are four archs in the foot; one longitudinal at the outside (lateral arch), one longitudinal at the inside (medial arch), and two transverse archs, one at the toeballs (metatarsal arch) and one at middle of the foot (anterior transverse arch). These archs can absorb high loads and are the basis in a unique form of spring system, which is working together with more than 20 muscles to coordinate the foot’s movements.

Underneath the foot there is a strong fascia – tendon –  which has a major impact on the foot movement. It’s most important task is to tighten up all the archs in the foot and by that tighten up the foot to get ready for the toe-off, which is the kick-off at the start of each stride.

During walking, the whole foot movement from the touch down of the heel (heel strike) to the toe-off, is performed in only half a second. During running, the contact phase with the surface is even less – only 1/5 of a second. It is this movement speed that gives huge demands on the steering and coordination of the foot. If one or more units inside the foot do not function correctly, even a small positioning error, this may cause running related injuries in the foot itself or in the lower leg, knee, hip or back.

Running related pain in the forefoot

Hallux Valgus is the term for a bigtoe that is skewed towards the next toe inside. The angle formed by this occurs in the basic joint of the toe and leads to an inflammation condition and a thickened skin around the joint, and a lowered transverse arch. Hallux Valgus is most common among women and occurs due to a genetical disposition. It may lead to a less stable foot. This insufficient stability may spread to other joints higher up in the body.

The bigtoe is important during walking and running in order to have sufficient power during the toe-off. A skewed bigtoe may lead to a weakened toe-off. A skewed bigtoe cannot be corrected in any other way than a surgery. There are however certain measures that can reduce the further development and pain, such as correct shoes for the foot, adapted soles and different strengthening execercises. One of this exercises – toe-lift with a roll, is demonstrated in the video below:

Lowered forefoot:

The front transverse arch in the forefoot may be low in itself, or has been lowered due to loose ligaments in the forefoot, hormon level changes during pregnancy, weight increase and increased load on the forefoot. When the transverse arch is lowered, the load on the fat pads under the toeballs increases. A lowered tranverse arch may also lead to squeeze on nerves and blood veins/arteries between the long tubular knuckles in the forefoot. Most often this happens in the three toes in the middle. A lowered transverse arch will not get back it’s original arch, however by training the muscles at the underside of the foot, pain can be released and agility in the arch can be restored. An adapted sole that gives correction of the front transverse arch may also reduce the pain.

The longitudinal and transverse archs of the foot are of great importance for the release of energy in the toe-off part of the stride. This means that collapsed archs reduce the energy economy of the running.

Stone bruise – metatarsalgia:

Pain under the forefoot / toe balls, soreness when pressing the toe balls and pain between the toe joints, are often symptoms of stone bruise – metatarsalgia. This is a common notion for pain that occurs in a part of the foot known as the metatarsal (ball of foot). It often occurs in the metatarsal heads – where the three middle toes meet the ball of the foot. It is a common problem which can affect all the bones and joints of the metatarsals. Go to this article to see details of this: Stone bruise -metarsalgia.

Running related pain in the midfoot

Plantar fasciitis:

Inflammation and soreness in the strong tendon band under the foot may be painful, and it can be difficult to reduce the load on the tendon. The tendon, which is stretching from the heel to the forefoot, is loaded at every step. It is being stretched during landing and contracted during toe-off. By repeatedly being overloaded, small ruptures may appear in the tendon, in particular when running in uneven terrain and when running uphill in the terrain.  These are typically symptoms and effects of plantar fasciitis. Plantar fasciitis is an inflammatory condition in the tendon. Pain is often located just on the inside of the heel and somewhat towards the toes. Such pain is often felt in the mornings when starting to walk, but is then reduced during the day.

Plantar fasciitis may be difficult to treat, but some strengthening exercises like e.g. toe lift on a roll – see video above, are recommended. Use of adapteds soles and good cushioning shoes may also reduce the pain. Go to this article to see details of this: Plantar fasciitis.

Stress fractures:

Stress fractures in the long tubular knuckles may occur due to too much training and if pain in the foot is ignored. This typically happens when the training  load is increased frequently in an already heavy training period towards marathon.

Stress fractures are small ruptures in the bone tissue due to overload. The symptom is typically increasing pain during a running session, meaning that the pain does not disappear when getting warm. The reason for this is increased bleeding in the knuckle, which leads to “striking” pain.

Go to this article to see details of this: How to deal with stress fractures

Outside of the midfoot:

Pain may occur at the outside of the midfoot when running in uneven terrain. A tendon from one of the outside leg muscles (peroneus longus) crosses under the midfoot. The stretch from the tendon may, due to repeated twists in the midfoot, shift the position of the knuckle which the tendon is passing – the cuboideum – and the knuckle may lock or cause a stiffness in the midfoot that after a while may cause pain.

Running related pain in the heel

The heel bone – calcaneus – is protected by a unique fat pad which may absorbe huge pressures. Even so, it is quite common that the heel may become irritated and sore due to overload. Long lasting pain may in particular occur if the foot is overpronating, combined with weight increase and high load on hard surfaces.   In such situations, the fat pad is shifted to the side, normally to the outside, and the load is then put directly on the heel bone, without the normal protection of the fat pad. This may also lead to  squeezing of some of the nerves in the area. This condition may be difficult to treat, but a correction of the heel bone by the use of an adapted sole may help. Use of a heel pillow and taping may also contribute to reduction of the load and by that also reduction of the pain.

Heel spur:

Heel spur is a calcification at the point where the plantar fascia is fastened to the heel bone. The calcification may be caused by repeated stress to the plantar fascia – traction periostitis. Pain from heel spur is located straight under the heel, a little bit on the inside, at the point where the surface hits the heel at every single step, and by that causing the pain. The pain is not increased when the toes are bent. In many cases it turns out that heel spur is present and is  detected in X-ray or ultrasound scanning, but without causing any pain. In such cases it is not considered to be a problem.

Foot anatomy

See detailed descriptions of the bones and the archs of the foot at these pages from TeachMeAnatomy.info:

3D pictures (at teachmeanatomy.info):

See more about running injuries, preventive exercises and videos here:

Author: Hege Erichsen

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