Sydney Running Physio: How To Manage The 6 Most Common Causes Of Foot Pain When Running

One of the more common complaints we hear from runners is foot pain when running. There are a few common causes, and diagnosing them early so you can manage them correctly is effective in getting you back into training quickly. From blisters and plantar fasciopathy (fasciitis), to more serious problems like stress fractures, knowing what to look out for can help you manage pain, recover quickly and prevent any further injury or damage..

Proper treatment and injury minimisation strategies are essential for long-term relief from foot pain with running. Often targeted strength exercises, following the right training program which includes adequate recovery time, and choosing the correct running shoes, make a big difference. Being aware of the early warning signs of more significant injuries, such as bone stress reactions or stress fractures, can help you avoid extended disruption to your training program and help you get back on your feet faster and stronger.

Understanding Foot Anatomy and Function

Your feet are strong and complex structures comprising bones, muscles, tendons, joints, nerves, and blood vessels. All of these elements play important roles in how your feet move, absorb shock, keep you balanced, and help you push off the ground when running or walking.

Bone Structure and Joints

The human foot contains 26 bones. It is divided into three sections: the forefoot, midfoot, and hindfoot.

The forefoot consists of the phalanges and metatarsals. The midfoot has the arch, supported by five bones called tarsals. The hindfoot includes the talus and calcaneus bones, which form your heel and connect to your ankle.

Joints in the foot, like the subtalar and tarsometatarsal joints, allow for the foot’s flexibility and strength. These joints enable various movements such as running and walking.

Muscles and Tendons

Your foot has about 20 muscles, essential for movement and stability. Key muscles include the flexor and extensor muscles, which help you lift and flex your toes, and arch your foot. Intrinsic foot muscles support the arch and assist in balance.

Tendons are like strong ropes that attach muscles to bones, for example the Achilles tendon attaches your calf muscle to your heel bone (Calcaneus). They are what allows the muscles to produce and control movements like running and walking. Tendinopathy, where the tendon becomes irritated or inflamed (tendonitis) is a common problem for runners and can cause significant pain and restriction in movement, for example Achilles tendinopathy.

Foot Nerves and Blood Supply

Nerves in your foot are responsible for sensation (sensory nerves) and movement (motor nerves). The tibial nerve and the common peroneal nerve are the most significant foot nerves. These nerves transmit signals to and from the foot, influencing pain and motor control/movement.

Blood is supplied to the foot via arteries like the dorsalis pedis and posterior tibial arteries. A good blood supply ensures that your muscles and tissues receive oxygen and nutrients, which is vital for healing and performance.

6 Common Causes of Foot Pain When Running

Running can lead to several foot injuries, largely due to overload and repetitive stress. Understanding these injuries, their causes and symptoms, can help you reduce your risk of having them interrupting your running.

Plantar Fasciopathy / Fasciitis

Plantar fasciopathy, also known as plantar fasciitis, affects the plantar fascia, which is the band of tissue that runs along the bottom of your foot. The main symptom is heel pain, especially first thing in the morning or after long periods of rest. Read more about plantar fasciopathy / fasciitis.

Causes:

• Overload from running
• Poor footwear
• Tight calf muscles

Prevention and Treatment:

• Load management, i.e. adjusting running volume and/or intensity
• Physiotherapy focusing on lower limb strength exercises
• Taping and orthotics (in some cases)
• Stretching exercises
• Proper footwear with good arch support
• Running gait assessment and correction

Achilles Tendinopathy (previously called Achilles tendonitis)

Achilles tendinopathy involves irritation or inflammation of the Achilles tendon, which connects the calf muscles to the heel bone. It is characterised by pain and stiffness along the back of the heel.

Causes:

• Overload, often due to increasing running volume too quickly
• Weak calf muscles
• Excessive foot pronation, i.e. flat feet, can increase your risk

Prevention and Treatment:

• Load management, i.e. adjusting your running volume to let the pain settle
• Calf strengthening exercises
• Proper footwear
• Gradual progression back into running activities, or more gradual increase in running volume to avoid overloading the Achilles

Metatarsalgia

Metatarsalgia is pain underneath the ball of the foot. It is really an umbrella diagnosis, meaning that it doesn’t really describe a specific pathology, but instead it includes a range of pathologies that cause pain underneath the ball of the foot. It can feel like a sharp or aching pain which worsens with activity and running.

Causes:

• Overloading the forefoot during running, including increasing running volume too quickly
• Forefoot running gait
• Poor footwear can be a factor

Prevention and Treatment:

• Load management (i.e. reduced running volume) or rest,
• Ice application can be helpful initially
• Wearing appropriate shoes with good support
• Metatarsal pads or orthotics
• Some forefoot runners may need running gait coaching to reduce forefoot load

Blisters and Skin Issues

Blisters are common among runners and are caused by friction. While we often think of blisters as just minor issues, they can be very painful and may open up, leading to possible infections.

Causes:

• Friction from shoes or socks
• Moisture
• Ill-fitting footwear

Prevention and Treatment:

• Choosing well-fitted shoes and moisture-wicking socks
• Using blister prevention products like tapes or pads
• Keeping feet dry
• Cleaning and covering blisters to prevent infection

Bunions and Hallux Rigidus

Bunions are bony bumps that form on the joint at the base of your big toe. Hallux rigidus is a form of arthritis affecting the big toe joint that leads to stiffness and pain. This is important because a reduction in range of motion of the big toe joint can impact your running gait and cause significant pain.

Causes:

• Genetic predisposition and foot posture are common factors, for example flat feet (excess pronation)
• Ill-fitting footwear
• Repetitive stress and overloading

Prevention and Treatment:

• Wearing shoes with wide toe boxes and appropriate arch support
• Using orthotic devices or taping
• Physiotherapy for range of motion and strengthening
• In severe cases, surgery may be required

Risk Factors for Foot Injuries in Runners

As you can see from the list above, increasing your running volume too quickly is a common cause of many foot injuries in runners. Other factors, such as the type of footwear you use, your running gait, the intensity of your runs, the surfaces you run on, and your biomechanics can affect the likelihood of foot injuries. Understanding these can help in minimising the risks.

Overtraining – Increasing Running Volume and/or Intensity Too Quickly

Overtraining is probably the most common cause of foot injuries that we see in runners. Increasing your running volume too quickly can place too much stress on your feet and legs, leading to overload injuries like tendinopathy and stress fractures. It’s important to follow a gradual training plan that builds both endurance and strength.

A common guide that is used is to only increase running volume by a maximum of 10% per week. While this can be a useful idea, there are lots of factors to consider so you need to listen to your body and adjust your program accordingly. Incorporate rest days and cross-training to give your body time to recover from your runs. Pay close attention to any signs of discomfort, as they can indicate the need to adjust your training intensity.

Not Enough Strength In Key Running Muscles

Strength training has been proven to be very protective against many running injuries (read the full post about strength training for marathon runners). In fact, research shows that strength training can reduce overuse injuries by almost 50%! This meta-analysis included the results of over 26,000 athletes from beginner to elite. So, working in reverse, if increasing strength protects against injury, then not enough strength is a significant risk factor for running injuries. This is one reason why runners of all abilities will benefit from strength training, and another is that it will significantly improve your running performance.

Footwear and Running Shoes

Choosing the right footwear is important for preventing foot injuries in runners. However, which is the “right” footwear will vary greatly for each runner, so working out which is the right shoe for you sometimes takes some time and experimentation. There are many factors that influence which is the best shoe for you, for example your foot type, running gait and injury history. Because many factors are involved, even 2 runners with similar foot types will often feel more comfortable in different shoes. Going to a running shoe shop to be professionally fitted and trying a few different running shoe models is a great idea.

Shoes with proper arch support can help manage the pressure on your feet, and by improving your biomechanics it can distribute the load correctly and reduce your risk of foot pain. A well-designed toe box offers enough space to prevent blisters and other issues. If you have very flat feet or very high arches then using a shoes that is specifically designed for that type of foot is important, or using orthotics may be helpful.

Running Gait and Foot Strike

How you run can significantly impact your risk of injury. Foot strike refers to the part of the foot that first makes contact with the ground. Heel striking can lead to excessive pressure on your lower legs and hips, while forefoot striking may overload your forefoot, calves and Achilles tendon. However, we also need to remember that our running gait is influenced by many factors such as genetics, running experience and injury history, so there is no single running gait that is best for everyone. For example, if a runner who has been running for 10 years using a forefoot gait suddenly tries to switch to a mid- or rear-foot gait, the sudden change in loading patterns are likely to cause an injury.

Having a professional running gait assessment is very beneficial. Adjustments to your running form, stride and foot placement can help improve your running economy and efficiency, which can help you run faster for longer with less chance of injury.

Running Surfaces and Environment

The surface you run on may also affect your risk of foot injuries, although the evidence around this is incomplete. Hard surfaces like concrete can increase the impact and pressure on your feet, leading to stress injuries. Softer surfaces such as grass or dirt trails can provide more cushioning but may pose a risk of uneven terrain causing ankle sprains. Softer surfaces may also increase the amount of force required as you push off the ground, potentially increasing the risk of tendon overload injuries such as Achilles tendinopathy. Consider varying your running routes to avoid the repetitive stress associated with a single type of surface.

Biomechanics and Anatomical Variations

Your body’s biomechanics also play a role in your risk of foot injuries with running. Variations in your anatomy, such as the shape of your feet and legs, can affect how stress is distributed while running. Issues like flat feet or high arches can lead to overloading of some structures, increasing your injury risk.

Working with a running physio can help identify any anatomical variations that may be relevant. Then, depending on the results of your assessment, you will be guided through a program of strength exercises to target key muscles, such as the calf, glutes, hamstrings and quads muscles. Mobility and stretching may also be appropriate in some cases. This targeted approach can improve your overall biomechanics and improve your running economy, reducing your injury risk while also allowing you to improve your running performance.

Treatment For Foot Pain When Running

Treating foot injuries from running involves several components such as load management, specific exercises for strength and mobility, pain relieving strategies such as icing or rolling, discussing shoe choice, and in some cases, running gait adjustment. The vast majority of running-related foot injuries resolve well with physio, but in some cases, immobilisation in a boot may be required. Very rarely, surgery is required, for example in navicular stress fractures. Understanding and applying these strategies effectively can help speed up recovery and prevent further injuries.

Load Management – Balancing Running, Rest and Recovery

Allowing adequate rest and recovery is crucial in managing foot injuries. However, that doesn’t always mean you have to stop running completely as you recover. Whenever possible we keep runners doing some level of running as part of their rehab, and if a complete break from running is required we try to make this as short as possible.

Importantly, once you have a clear diagnosis, it is sometimes ok to continue running through some level of discomfort, for example in chronic Achilles tendinopathy working through some discomfort is fine. However, you need to get a diagnosis before running through pain because some injuries, for example bone stress injuries, can be made significantly worse if you continue to overload them.

Part of load management also includes cross-training. If you have to reduce or pause your running training, that doesn’t mean you just reduce or stop your overall exercise routine. Cross-training on a bike, or swimming, helps you maintain your strength and fitness while your running program is limited. This is a crucial part of load management and effective rehab, because if you lose overall strength during your recovery period then you are more likely to pick up another injury when you return to running.

Strength Exercises for Foot Pain with Running

Strengthening exercises are vital for injury recovery and prevention. Targeting key running muscles including your calf muscles, glutes, quads and hamstrings is effective. In some cases specific exercises for the intrinsic foot muscles is beneficial, for example toe curls and arch lifts. Consistent strength training including whole-leg and whole-body exercises (sometimes called kinetic chain strengthening) can improve your overall biomechanics, reducing your risk of future injuries as well as improving your running performance.

Stretches for Foot Pain with Running

While we (and the research) usually find that increasing strength is more of a priority than increasing length, stretching is beneficial in some cases. Calf stretches are the most common muscles we target, since tight calf muscles can contribute to some types of foot pain in runners. Perform stretches like the wall calf stretch, where you lean against a wall with one leg extended backwards while keeping the heel on the ground.

Pain-Relieving Modalities Like Taping and Ice

In acute injuries with higher pain levels, using treatments like tape to unload some structures, or ice to relieve pain, can be helpful. We also sometimes use tape to allow runners to resume running as quickly as possible, or to get through a big race, although we need to remember that we still need to fix the underlying problem once the race is done.

Medication and Injections

Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can reduce pain and inflammation. In more severe cases, corticosteroid injections or PRP injections may be necessary to manage pain and promote healing, for example in persistent cases of plantar fasciopathy. Always consult a healthcare provider before starting any medication to ensure it is appropriate for your specific case.

Imaging (X-Rays, MRI, Ultrasound…) for Foot Pain in Runners

Imaging techniques like X-rays and MRIs are not usually required for most foot pain in runners. However, in some cases they are important, for example in assessing bone stress injuries or potential stress fractures. MRIs are usually the gold-standard imaging technique because of their sensitivity of assessing bone as well as soft tissue pathology. If a bone stress injury or stress fracture is suspected then clarifying the diagnosis is crucial because it can determine if the runner needs to stop running completely for a period to allow recovery.

Surgery For Foot Pain When Running

Surgery is very rarely required and is the last resort, only used when other treatment strategies fail. Procedures vary depending on the injury but may involve repairing torn tissues, removing bone spurs or stabilising a fracture using a pin. Post-surgery, a structured physio rehabilitation program is crucial for regaining strength and mobility, and ensuring a safe and structured return to running.

Injury Minimisation and Long-term Care for Runners

Taking preventative measures and following a proper training routine can significantly reduce your risk of foot injuries while running. Strategies include training modifications, strength training, choosing the right footwear, and appropriate warm-up and cool-down routines.

Training Modifications and Load Management

Proper training modifications and load management are crucial to avoid overtraining and injury. Gradually increase your running intensity and distance. Avoid sudden spikes in your training program. Cross-training can be beneficial, allowing you to maintain and build fitness while giving your feet a break from the stresses of running. Include low-impact activities like swimming or cycling.

Working with a running coach or running physio to create a balanced training plan and manage any niggles is very helpful. They can provide you with a tailored training program that effectively balances load and recovery, minimising your risk of injury while effectively building your running performance.

Paying attention to your body is also important. Some general soreness is common with runners, especially following harder sessions or training blocks, but persistent pain is not normal and may signal that you are overloading some structures. Often managing these niggly types of pain early is very effective and they resolve much quicker than if left to progress and become worse.

Choose The Correct Running Shoes and Orthotics

Choosing the correct running shoes is important for any runner, to help minimise your injury risk as well as to help you recover if you do become injured. However, as mentioned above, choosing the right running shoe for you is not always simple. Different foot types, running styles, injury history and individual biomechanics all paly a role in determining which is the best and most comfortable shoe for you to run in. So, if you are planning on doing a decent volume of running consistently, we recommend going and getting fitted for your running shoes at a running shoe store where they can assess your foot position and biomechanics, and let you try on a few different pairs that may work for you. It’s also important to replace running shoes regularly. Worn-out shoes lose their cushioning and support, which may increase your injury risk.

Orthotics may be helpful in some cases of foot pain when running. Often choosing the correct running shoes provides enough support, but if you have very flat feet or high arches then the extra support available by using orthotics can be helpful. Orthotics can either be off-the-shelf, which are a lot cheaper but are not individually fitted to your foot and biomechanics, or custom, which are made specifically for you by a podiatrist. The choice as to which type you need will vary between people, and your running physio can advise you on this if necessary.

However, while orthotics can be very effective when appropriate, it’s important to remember that just because you get pain in your feet it doesn’t mean that your foot position is automatically the cause and needs to be “corrected”! We often find that simple interventions, like load management and strength exercises, effectively resolve foot pain without the need for long-term foot biomechanical correction using orthotics.

Proper Warm-up and Cool-down Practices

Proper warm-up and cool-down practices prepare your body for running and aid in recovery. For running, an adequate warm-up may be simply running slowly for 5 minutes or so, and then getting into your main session. For some runners, adding in dynamic mobility exercises like leg swings and walking lunges can be helpful. Muscle activation exercises can also be great to have in a warmup, for example doing glute activation exercises like crab walks. Some athletes also like to use a foam roller or trigger ball to loosen up muscles that feel tight.

After running, you can cool down with light jogging or walking. You can also do static stretches to relieve muscle tension and facilitate recovery, or use a roller. Target the main running muscles including your calves, hamstrings, quads and glutes. Some athletes feel that rolling their foot arches, including using a frozen soft-drink bottle for a combined icing and rolling effect, helps to relieve tightness and reduce any post-run pain.

A well-rounded warm-up and cool-down routine helps your body prepare for your runs, and recover as quickly as possible afterwards. However, for most runners, it doesn’t have to be overly complex or time consuming. If you feel that you need to do extended work to warm up or cool down for sessions, then this may indicate that there are some underlying niggly issues that you should get checked out.

When Can You Return to Running After Foot Pain?

The amount of time it takes you to return to running after a foot injury varies greatly depending on the type and severity of the injury. However, whatever the actual injury is, you should follow a structured return to run process as part of your overall rehab program. This takes the “guesswork” out of the process, as much as possible, meaning that your return to running is as rapid as possible while also being safe.

Exercises for Foot Strength and Mobility

Improving foot strength and control is important for many types of foot pain when running. Some examples of foot exercises we use for runners include;

• Calf raises: Make sure you push up hard from your big toe as you lift your heel
• Towel scrunches: Scrunch a towel with your toes.
• Toe yoga: This includes exercises to move and grip with your toes, helping to engage your foot and toe muscles.

These exercises help strengthen the muscles supporting the arch of your foot, your ankles and your toes, especially your big toe. Strengthening your big toe muscles is important because your big toe should be the power-house of your push-off, the driving force to propel you forward as you run. This is important for reducing your injury risk, as well as improving your running form.

Assessing Your Readiness To Start Running Again – The Return To Run Screen

Assessing your readiness to return to running includes tests of mobility, strength, control, and symptom response to impact and loading. Doing clinical tests helps take the guesswork out of determining if you are ready to start running again. There are many tests that we choose from to help us confirm that you are ok to start running again, and the choice of which tests to use will vary for each client. Some of the common test components that we use include;

• Is there any activity-related pain: with walking or other normal daily activity?
• Jumping and hopping: Jump on both feet, then hop on one foot. Try for height, then do some hops forward. Is there any pain?
• Test run in the clinic: we will get you to trial a light run in the clinic, on the floor or on a treadmill, to see if there is any pain
• Strength and control tests: we check your strength, control and stability, looking for relative symmetry with your other side, for example single-leg squats or triple-hops
• Clinical examination: sometimes using clinical tests is important, for example after bone stress injuries or stress fractures we feel for persisting pain on palpation (i.e. soreness to touch the affected bone). Significant bony soreness over the site usually indicates that the bone has not healed sufficiently to take the impact of running.

If you pass these tests with minimal or no pain, good strength and control, and can do a trial run without pain, then you are able to start your return to running program.

Running Gait Analysis

A running gait assessment can be very helpful, especially for recurrent or persistent foot pain with running. It looks at how you run and can identify inefficiencies or issues in your stride. It involves being filmed running on a treadmill, and then your running physio or run coach going through the footage with you to identify areas where your running form can be optimised. This can give us great information about how to get rid of your current pain, reduce your risk of future injuries, and improve your running economy leading to improved performance. Some key areas we focus on for foot pain include:

• Foot strike: How your foot lands and strike the ground?
• Stride length: Do you overstride, meaning does your foot land significantly out in front of your hip?
• Leg rotation or valgus: Does your knee roll inwards as you land, which is a risk factor for several leg and foot injuries when running?
• Foot rotation: Does your foot rotate outwards as you push off and swing your leg through?

Once you have had your running assessed, and identified key components to improve, working with a running coach can help you make the necessary adjustments to improve your running economy, efficiency and form. This is especially important for foot injuries which just seem to keep persisting, or keep coming back if you try to push your running more. In these cases, even with good strength and control, there can be things about your running form that keep overloading foot structures and causing injury.

Strategies to Avoid Re-injury

Preventing your foot pain from coming back is a crucial part of treatment. Good load management is essential, including only gradually increasing your running volume slowly, allowing adequate recovery between runs, and not increasing hill or speed work too quickly. Listen to your body, take note of niggles that seem to be getting worse or lasting longer after your runs, and get niggles diagnosed early to avoid significant issues. Other strategies include:

• Incorporate strength training: Well-structured strength training is one of the most effective ways to reduce your risk of running injuries, including foot pain.
• Wear proper footwear: Ensure your shoes provide adequate support.
• Warm-up and cool-down: This doesn’t have to be complex or time-consuming, but a well-structured warm-up and cool-down can help your body prepare for, and recover from, your runs
• Be aware of your general health and fatigue levels: We need to remember that running puts stress on our body, so if there are other things in our life that affect our ability to recover we may need to adjust our running training. For example if you’ve had a flu that stopped you running for a couple of weeks, just ease back into your runs. Or if work has been crazy so you’re a bit sleep deprived, you may want to schedule some easier or shorter sessions to avoid over-loading your body.

Foot Pain When Running – Frequently Asked Questions

This section answers common questions about treating and preventing foot injuries from running.

What are common treatments for foot pain resulting from running?

Common treatments include load management (adjusting your running volume), strength and control exercises and physio treatment. Running gait analysis and correction can also be important in some cases, and ice and anti-inflammatory medications can be helpful in some cases. Sometimes taping orthotics or getting into more appropriate running shoes might be necessary to resolve the pain.

How can a running physio treat foot pain from running?

A running physio can provide you with an accurate diagnosis, load management advice, targeted exercises, manual (hands-on) treatments, and taping techniques. They can also provide education on proper running form and footwear. If further investigation is required, for example t exclude a stress fracture, they can provide you with a referral for this.

Which exercises can prevent foot pain and injury from running?

Overall, strength exercises are the most protective exercises against running injuries. As well as all-round strengthening, for example squat and lunge variations, execises specifically for the foot and ankle muscles are effective in some cases. For example, toe curls involve scrunching a towel with your toes, while arch lifts involve raising the arch of your foot while keeping your heel and toes on the ground. Strengthening exercises for the calves and shins are also very important.

What symptoms indicate a foot injury related to running?

Common symptoms include sharp or dull pain, swelling, and bruising. Numbness or tingling can indicate nerve involvement. Persistent pain that stops you running, or persists for a significant time after running, can signal a more significant injury and is a signal you need to get it checked out.

How can I prevent foot injuries while running?

Gradually increase your running distance and intensity, as increasing your volume too quickly is one of the most common causes of foot pain when running. Incorporate strength training,control and flexibility exercises into your routine. Also, ensure you run in shoes that are matched to your foot type.

What is the typical recovery time for a foot injury sustained through running?

Recovery time varies depending on the severity of the injury. Minor injuries may heal in a few days to a week, while more serious conditions can take several weeks to months.

Can running lead to muscle strains in the foot, and how can they be identified?

Yes, running can cause muscle strains in the foot. Signs of a muscle strain include localised pain, swelling, and difficulty weight-bearing on the foot. Strains often occur from overloading, or improper footwear.

What are effective ways to relieve pain along the inner or outer edges of the foot after running?

Resting and icing the affected area can give short-term relief. Anti-inflammatory medications can sometimes be used to reduce swelling and pain. Stretching and massage can also provide short-term benefit. For persistent pain, consult a running physio.