March 7, 2019

Overuse Injuries of the Foot and Ankle

By Aaron M. O’Brien, MD

Orthopaedic Surgeon, Foot and Ankle Fellowship Trained Specialist


We all want to be healthy. We are told to stay active and exercise regularly, which can help us feel better, have more energy, lose weight, and even live longer. The benefits of exercise are numerous, but too much of a good thing can also be bad for you. Foot and ankle pain is a common problem occurring with high impact exercises that involve running and jumping. With the weather starting to warm up and bringing with it the opportunity to exercise outdoors, overuse injuries are frequently seen in the doctor’s office.

Overuse injuries occur when tissues in the body are unable to adapt to the stresses placed on them. Mechanical fatigue within bones, tendons, ligaments, and nerves leads to changes in their structure. For example, when stress is placed on a bone, its density increases over time and becomes stronger. However, without appropriate time to heal between stress intervals, the tissues become injured, and pain ensues. Overuse injuries are the result of going too hard, too fast, too frequent, or too soon.

Common foot and ankle overuse injuries include stress fractures, tendinitis, fasciitis, and neuromas.

Figure 1

Stress Fractures

Stress fractures are usually seen in the metatarsals, calcaneus (heel bone), and sesamoids (small bones under the foot near the big toe). Anatomic variations can lead to certain bones being placed under higher stress than others. High-arched feet experience more stress on the outside of the foot, resulting in fifth metatarsal fractures, also known as Jones fractures (A in Fig 1), (Fig 2). Flat feet may distribute more weight on the inside of the foot, leading to sesamoiditis (inflammation around the sesamoid bones) or a stress fracture (B in Fig 1). When the second metatarsal is significantly longer than the first, it can be fractured under the ball of the foot (C in Fig 1). Inadequate cushioning in shoes can lead to calcaneal (heel) stress fractures (D in Fig 1).

Figure 2


The Achilles tendon and plantar fascia are some of the most common areas for inflammation to occur with overuse. The Achilles tendon has a poor blood supply and struggles to repair itself quickly. Pain and swelling are usually felt a couple of inches above its insertion on the heel (E in Fig 1).

On the bottom of the heel, many athletes experience pain that is often worse in the morning after getting out of bed. This condition is likely plantar fasciitis, which is inflammation of the tough fascia that runs along the bottom of the foot (F in Fig 1). This accounts for 10 percent of running-related injuries. Tendinitis also commonly occurs on the inside (posterior tibial tendon) and outside (peroneal tendons) of the ankle.


Nerve tissue is usually well protected and less likely to be injured, with a couple of exceptions. Near the ball of the foot between the ends of the metatarsal bones (usually between the third and fourth metatarsal) the nerve is more susceptible to injury. This condition is named Morton’s neuroma (G in Fig 1). It’s at this point—right before the nerve splits and heads toward the toes—where it becomes compressed. The symptoms are usually described as burning, pins and needles, and electric shock type of pain.

Most all overuse injuries in the foot and ankle will heal with the right treatment, which usually includes rest, cross training, ice, anti-inflammatory medications, and proper foot wear with orthotics (inserts). Correcting any vitamin and mineral deficiencies (such as calcium and vitamin D) and working with a physical therapist are sometimes needed to enhance the healing process. Occasionally, when these other modalities have failed, surgery may be needed in order for the injury to get better.

Staying active and engaging in regular exercise improves our health and makes life more enjoyable, especially when injuries can be avoided. Protect your feet with good shoes and orthotics and consider switching your activities up with cross-training to allow adequate time for healing.


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