What is foot pain? This is an important question to ask since some of the most common running complaints are related to an overuse injury within the foot or lower leg. Taunton et al (2002) reported that 12.8% and 16.9% of running-related injuries occur within the lower leg, foot and ankle, respectively.13 More importantly, there are several options for how to treat foot pain but a proper assessment and diagnosis is the critical first step. For example, foot orthotics have been shown to be an effective treatment method to reduce excessive foot pronation and collapsing of the medial longitudinal arch, which is a common source of foot and ankle pain.9 However, there are several other reasons for why your foot might hurt. Thus, the purpose of this paper is to discuss some of the most common foot, ankle, and lower leg injuries and to provide information related to potential methods of treatment.


Hallux rigidus (big toe pain) is characterized by reduced dorsiflexion (toes pointing upward) and stiffness within the first metatarsalphalangeal joint (MTPJ: the ball of the foot).3, 5 This common injury becomes more problematic with age and is more prevalent in females than in males.3 Limited range of motion and stiffness in the big toe and ball of the foot can be caused by a number of issues including a tight plantar fascia,3 a low medial longitudinal arch, prolonged or excessive pronation,3 and a tight or weak flexor hallucis longus muscle.5 Stiffness within the big toe often causes a lateral or outward shift in the center of pressure, transferring the stress to the outside aspect of the ball of the foot.3 As well, alterations to gait patterns and restricted propulsion from reduced dorsiflexion can increase the force on the medial metatarsals which can lead to other types of foot pain including metatarsalgia.3

Metatarsalgia is a progressive overuse injury that creates pain and inflammation under the metatarsal heads of the foot. Specifically the second to fourth MTPJs.14 Pain under the ball of the foot is a common complaint14 with symptoms that include callus formation, inflammation, and pain upon palpation or while weight bearing.14 Beyond the compensation as a result of hallux rigidus, other factors related to metatarsalgia include arthritis, entrapped nerves between the long metatarsal bones,8 a reduction in the size of the fat pad under the ball of the foot, and irritation of the joint capsules.8,14 Similarly, a chronic or developing pes planus (low arch) and associated excessive pronation can also cause this type of foot pain.8

The medial longitudinal arch (the long inside arch of the foot) is dynamically supported by the posterior tibialis muscle which originates deep in the posterior compartment of the leg.1 The tendon extends behind the inside of the ankle bone to attach to the base of the first metatarsal as well as other bones that comprise the arch of the foot.1 This muscle is mainly responsible for maintaining the arch of the foot during activity and through strong muscular contractions.2 If this muscle is weak, or if it is overworked because of other associated muscle weakness, a condition called posterior tibial tendon dysfunction (PTTD) can occur.1 PTTD is characterized as overuse of the tibialis posterior muscle causing gradual fatigue and decreased dynamic arch support during running and other weight bearing activites.1,2 PTTD is one of the most common running injuries,13 and is a progressive condition widely recognized as a contributor to adult acquired flat foot disorder.1 The pain is generally located immediately behind the inside ankle bone (medial malleolus) and occurs when running for long periods of time, on unstable surfaces,4 or during high impact activities such as jumping-based sports.2,4 When the dynamic support of the arch is compromised due to a weak or overworked posterior tibialis muscle, the plantar fascia experiences greater tissue stress as it also functions to maintain the medial longitudinal arch.9

Heel pain, or plantar fasciitis, is one of the most frequent complaints of foot discomfort in athletes12 and is among the top five most common running injuries.13 The plantar fascia is a band of connective tissue which fans out from the medial calcaneal tuberosity (heel bone) to the far end of each metatarsal bone and is constantly under a tremendous amount of stress to statically support the longitudinal arch.9 Strain on the arch from excessive and repetitive loading (as in long distance running) can create inflammation along this fascia and pain near the medial aspect of the calcaneus.12 Pain is generally located directly under the calcaneus and is most painful when the tissue is allowed to shorten such as after long periods of rest or, first thing in the morning.12 The first few steps thus result in rapid lengthening or tissue which is inflamed and painful.11,9

Medial tibial stress syndrome (MTSS) or pain along the inside of the shin bone (tibia), is a complex injury that also has an association with posterior tibialis muscle weakness.7,15 It has been suggested that MTSS is the beginning stages of a stress fracture and is caused by increased loading to the tibia bone and often occurs because of muscle weakness or overuse.7 The initial stages are characterized by periostitis, or the outer covering of the bone being pulled away by the posterior tibialis muscle.15 As the injury progresses, the pain becomes more localized, increases in intensity and, if proper steps are not taken to treat the cause of MTSS, a stress fracture can occur.7,15 Other factors associated with MTSS include imbalances of the ankle stabilizer muscles, inflexibility of the calf muscles, increased or rapid increases in training volume, or training on hard surfaces.15


The focus of this paper was to discuss some of the most prevalent injuries related to foot, ankle and lower leg pain and their sources. Based on the research, weakness of the posterior tibialis muscle is a common variable between most running injuries which can often overlap into other related problems. There are also a number of progressive connections between the various injuries linking them to one another. Foe example, stiffness in the big toe (hallux rigidus) can lead to alterations in gait pattern (metatarsalgia), increased stress on the medial longitudinal arch (plantar faciitis), and muscle weakness (PTTD) which can thus result in increased torsion in the lower leg and stress on the medial tibial bone (stress fracture and MTSS). A wide range of prevention protocols and treatment plans exist to reduce foot and leg pain .


One of the most commonly used, and well-accepted methods to treat the aforementioned injuries is orthotics. Several research studies have provided credible evidence that some type of supportive foot bed will significantly reduce the pain associated with these, and other, overuse foot and ankle problems.9,11 However, when the underlying problem is muscle weakness, an orthotic device should only be considered a temporary fix to relieve pain and discomfort until sufficient gains in muscle strength can be achieved through appropriate therapeutic exercise.


  1. Arangio GA, Salathe EP. A biomechanical analysis of posterior tibial tendon dysfunction, medial displacement calcaneal osteotomy and flexor digitorum longus transfer in adult acquired flat foot. Clinical Biomechanics. 2009; 24: 385-390.
  2. Bennazo F, Mosconi M, Maffulli N. Hindfoot Tendionpathies in Athletes. Tendon Injuries. Springer London. 2005: 178-186
  3. Canseco K, Long J, Marks R, Khazzam M, Harris G. Quantitiative characterization of gait kinematics in patients with hallux rigidus using the Milwaukee foot model. J Orthopaedic Research. 2008; 26: 419-427.
  4. Edwards MR, Jack C, Singh SK. Tibialis posterior dysfunction. Current Orthopaedics. 2008; 22: 185-192.
  5. Flavin R, Halpin T, O’Sullivan R, FitzPatrick D, Ivankovic A, Stephens MM. A finite- element analysis study of the metatarsophalangeal joint of the hallux rigidus. J. Bone and Joint Surgery. 2008; 90-B: 1334-1340.
  6. Hreljac A. Impact and overuse injuries in runners. Med. Sci. Sports Exerc. 2004; 36 (5): 845-849.
  7. Hubbard TJ, Carpenter EM, Cordova ML. Contributing factors in medial tibial stress syndrome: a prospective investigation. Med. Sci. Sports Exerc.2009; 41(3): 490-496.
  8. Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskeletal Disorders. 2006; 7 (95) 1-8.
  9. Landorf KB, Keenan A, Herbert RD. Effectivness of foot orthoses to treat plantar faciitis. Arch Intern Med. 2006; 166: 1305-1310.
  10. Romani WA, Gieck JH, Perrin DH, Salibat EN, Kahler DM. Mechanisms and management of stress fractures in physically active persons. J Athletic Training. 2002; 37 (3) 306-314.
  11. Ryan MB, Wong AD, Gillies JH, Wong J, Taunton JE. Sonographically guided intratendinous injections of hypersmolar dextrose/lidocaine; a pilot study for the treatment of chronic plantar fasciitis. Br. J. Sports Med. 2009; 43: 303-306.
  12. Schepsis AA, Leach RE, Gorzyca J. Plantar Fasciitis. Clinical Orthopaedics and Related Research. 1991; 266: 185-196.
  13. Taunton JE, Ryan MB, Clement DB, Mckenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case control analysis of 2002 running injuries. Br. J. Sports Med. 2002; 36: 95-101.
  14. Thomas JL, Blitch EL, Chaney DM, Dinucci KA, Eickmeier K, Rubin LG, Stapp MD, Vanore JV. Diagnosis and treatment of forefoot disorder. Section 2. Central Metatarsalgia. J. Foot and Ankle Surgery. 2009;48(2): 239-250.
  15. Tweed JL, Campbell JA, Avil SJ. Biomechanical risk factors in the development of medial tibial stress syndrome in distance runners. Journal of the American Podiatric Medical Association. 2008; 96(6): 436-444.

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