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Returning to Running after Injury

Author: Shane Brown, Director & Physiotherapist at The Physio Movement

Foot pain is the bearer of all evil when running. With so many bones, tendons, ligaments and more in the foot, it can sometimes be difficult to self-diagnose your pain while running, and to know if it is damaging or not. Here is a brief guide to foot pain while running, and some warning signs to look out for.


Tendon problems can be characterised mainly into tendinopathies and tenosynovitis. Tendinopathies are usually more common, and can be seen in the period after quick spikes in training load, or changes in surface, terrain or even footwear. The most common tendinopathy areas in the foot are the Achilles, the tibialis posterior, and the flexor hallucis brevis. The best part about most tendinopathies is you can usually train through them to a degree, it’s just a question of how much. This is dependent on a case-by-case basis, and should be discussed with your allied health practitioner. Tendinopathies usually present as pain first thing in the morning, or after a run; pain which warms up throughout a run; and thickening and tenderness over the site of the tendon.

The key difference between this and a tenosynovitis is inflammation. Tendons themselves don’t inflame, but the sheath which they are surrounded by can inflame and cause pain. The pain coming from a tenosynovitis is often more severe but also more short-lived. Being an inflammatory issue, these are usually treated with relative rest and anti-inflammatories, rather than modifying load, as they can usually resolve much quicker. Avoid stretching these tenosynovitis issues and don’t try to run through them. 


There are many ligaments throughout the foot, but often these don’t actually cause us issues during long-distance running, and also often aren’t injured with distance running, although present more frequently in trail running communities. Ligaments don’t like sudden changes in force or sudden changes of direction. Take your ankle ligaments, for example. These are often injured by rolling your ankle, which can occur when running on uneven ground e.g. over tree roots, rocks and undulating surfaces associated with trail running. During rehabilitation, we often promote straight line activity for ligament injuries as early as possible, as this doesn’t tend to flare these injuries too much if done in moderation.


A distance runner’s worst nightmare. Bony injuries are usually responsible for the most time missed by endurance athletes due to the difficulty associated with healing. The bones of the foot can be even more complex with healing times, due to the variability in blood supply. Stress injuries to the 5th metatarsal and navicular for example, take much longer to heal and should be treated with much more care due to their lack of blood supply. In contrast, calcaneal stress fractures have much lower associated risk, because of the improved blood supply. Bony stress injuries are usually characterised by ongoing pain which worsens with running or weightbearing, localised pain area and a dull, aching nature at rest, which sharpens with activity. If you suspect that you may have a bony stress injury, consult your allied health professional immediately, who may also involve a sports physician or orthopaedic surgeon if more severe. The rehabilitation process for a bony stress injury is multi-faceted, often involving a number of different professionals, including Dietitians, S&C coaches, Sports Physicians and your own coach.


The biggest take away point for runners here is that if you have pain – see your allied health professional. We won’t always tell you to rest (which we know you are all afraid of!). In fact, we usually do quite the opposite, facilitating ways you may be able to run with more comfort while you rehabilitate your injury. We look at many area’s in the rehabilitation process including technique, diet, sleep, strength and your periodisation plan to help you get the best possible outcomes out of your body and keep you running.

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