The foot and ankle combined is the most common area for both acute injury and chronic pain for trail runners and ultrarunners.
Injuries to the Achilles tendon, ankle, and foot are by far the most common issues — accounting for up to two-thirds of all injuries that trail runners and ultrarunners encounter (1).
This is likely because of the demands of both distance and terrain — widely varied inclination, angulation, and composition of the surface underfoot — place a huge demand on the foot and ankle to efficiently flex, extend, and tilt with each step.
Ankle joint front view, with talus (middle), tibia (larger) and fibula (smaller) bones circled. All photos iRunFar/Joe Uhan unless otherwise noted.
Whether acute demands or chronic overload, parts of the foot and ankle may move too much or too little to adapt to the terrain, resulting in over-stretch, strain, and potential tissue injury. Commonly injured tissues include the ankle ligaments, connecting bones of the lower leg and the foot, and tendons — such as the Achilles tendon in the back of the ankle, the posterior tibialis tendon on the inside, the peroneal tendon on the outside, and the plantar fascia on the bottom, to name a few.
Ankle joint lateral view: fibula and talus circled (red) with lateral ankle ligaments (yellow).
Note that strains refer to overstretched, partially, or fully torn soft tissues like muscles, tendons, and fascia; sprains involve specific injury to tissue connecting two bones in a joint, usually ligaments.
Ankle joint rear view, showing lateral ankle ligaments and inversion sprain mechanism.
Acute Injuries and Chronic Problems With the Ankle and Foot
Even if you don’t acutely injure your foot or ankle on the trails, that doesn’t guarantee you freedom from future pain.
Rugged trail running can cause other foot and ankle issues that, initially, may be more subtle, but over time can cause — and perpetuate — pain and dysfunction. Steep, technical terrain can also cause joint misalignment. This occurs when various bones in a system lose their efficiency, balanced articulation, and fluid movement.
This often happens at times of a severe sprain, when the foot and ankle system moves beyond its healthy range. For example, landing only halfway onto a narrow rock with the medial foot may allow the lateral foot to fall farther, causing a tissue-straining drop of the lateral foot. This is the most common cause of lateral ankle sprains.
But in the course of that sprain event, bones might also be pulled out of alignment. And unfortunately, while sprained soft tissues often heal on their own, bones that have lost their efficient position and movement seldom regain that efficiency without help.
Joint misalignment can also happen with non-injurious but repetitive loading in an asymmetrical way. For example, running for a prolonged period on a side hill may place an unbalanced load onto the foot and ankle that, over time, may not only strain tissue, but cause subtle-but-significant bone shifts that later result in the loss of efficient movement once you return to the flat.
Again, like an acute injury, once bones have lost alignment, they often require additional and targeted efforts to restore normal position and movement.
Ankle and Foot Anatomy and Function
The ankle is the articulation of the lower leg, comprised of two bones, the tibia and fibula, and the foot, containing 36 bones. The talus bone is the go-between for the lower leg and the rest of the foot.
Functional movement at the ankle occurs largely between the talus and the lower leg. The two primary running movements are dorsiflexion — the foot and toe in the up position — and plantarflexion — with the foot and toe in the down position.
Functionally, the foot dorsiflexes after we land on it and the body passes over it, and then again when we swing through, to shorten the whole limb for efficient forward motion.
The foot plantarflexes as the final aspect of the leg push-off, and then slightly plantarflexes again, just before initial contact.
Ankle joint lateral view, showing dorsiflexion.
Ankle joint lateral views, showing plantar flexion.
Side-to-side ankle motions are also important. Inversion is when the top of the foot angles outward, and weight is mostly on the outer edge. Eversion is when the bottom angles outward, and the weight is mostly on the inner edge. These frontal plane motions are key for impact — and variable terrain — attenuation. The foot naturally lands slightly lateral (in an inverted position), before lightly rolling inward toward eversion. This outward-to-inward motion is also known as pronation (where an inward to outward motion is supination.)
Outside-to-inside rolling at foot strike adds a cushioning effect to our landing. The outer foot absorbs the ground first. Then, as the body passes over the foot, we roll onto the medial arch, the part of the foot used for the most powerful push-off.
The foot and ankle complex has additional mobility to handle uneven surfaces: extra inversion motion for a controlled landing on an angled surface; extra eversion helps the medial arch get to the ground for a strong push-off.
To a point, at least If the terrain is too extreme in angle, or too loose, and the landing forces too great, the foot and ankle may be forced to move beyond their given range. This is how tissue strains.
How the Ankle Loses Movement and Efficiency
Acute sprains or repetitive imbalanced loading can cause large-magnitude or small, repetitive forces that shift bones out of place. The most common area for this to occur is between the talus, tibia, and fibula.
Problems With the Fibula
This lateral shin bone, because it doesn’t technically bear weight, has remarkable mobility. This is good to allow both motion and athleticism, but it’s prone to getting out of alignment. It can shift forward or back, but more commonly, it can shift upward toward the knee or down.
With inversion ankle sprains, the force of a hard roll can actually pull the fibula down, closer to the heel. It gets stuck in this depressed position and, ironically, will keep forcing the entire foot and ankle into a lateral-loading, inverted position. It also keeps the lateral ligaments on slack. This is the most common reason for chronic ankle instability.
Problems With the Talus
The most common ankle dysfunctions occur when the talus gets out of alignment. It either becomes tilted to one side or the other, or rotated. When that happens, the dominant movements — dorsiflexion and plantarflexion — are lost. The most common motion lost is dorsiflexion.
Problems With the Tibia
As the main weight-bearing bone of the lower leg, the tibia doesn’t necessarily get into a bad position. Instead, it can do one of two things.
First, it commonly loses its fluid glide against the talus. Specifically, it must fold with the talus for dorsiflexion. If it can’t fold, it often rotates externally instead.
This achieves some ankle motion, but is bad news for the knee: a twisting tibia creates a rotational stress at the knee joint. Tibial and femoral torsion is the primary cause of knee pain, stiffness, and tissue damage.
Second, there is a joint between the tibia and fibula. A long spiderweb-like connective tissue, called the syndesmosis, runs between the two bones to help keep them connected. Then two tie-down ligaments connect the bones at the top and bottom, and front and back. Bad sprains or imbalanced loading can change the spacing of the tibia and fibula, causing movement problems.
Too much space between them? That is the mechanism of a high-ankle sprain.
Video Showing Efficient Alignment and Inefficiency Issues in the Talus, Fibula, and Tibia
Problems Caused by Stiff, Misaligned Ankles
The foot and ankle are where the “rubber” of our body meets the “road” of the world. For happy, healthy running, this “meeting” must be efficient — not only to prevent foot and ankle pain, but also to ensure efficient movement throughout the rest of the body.
When the ankle loses efficient movement, the following issues can occur at the foot and ankle:
- Lost dorsiflexion, plantarflexion, eversion, and inversion motions
- Imbalanced weight bearing via excessive load transmission — both static standing and dynamic landing and push-off — on the medial or lateral foot
- Inefficient motion of the tibia and fibula
When this happens, all sorts of problems can occur, throughout the body.
Chronic Ankle Pain
This is an obvious one. If the bones and surrounding tissues don’t move correctly, the ankle can hurt with impact and movement demands. This is often worse with uphill running which demands more dorsiflexion, or on uneven surfaces.
Chronic ankle pain can be made worse by uneven surfaces. Photo: Human Kinetics/Kirsten Kortebein
Chronic Ankle Instability and Repetitive Sprains
I’ve said for years, “An ankle that can’t move the right way will move the wrong way.” Once bones are out of alignment, there’s often a movement that is stiff or completely locked up, while the opposite movement is excessive. This often occurs after a forceful inversion sprain. It’s seldom that the lateral ligaments are permanently loose. Rather, that the bones are aligned in such a way that the ligaments are on slack.
Plantar Foot Pain
A foot with imbalanced loading will put too much force on one side of the foot. This can cause excessive pronation, for example, or simply too much force through a small area of the foot. This is often responsible for common issues like plantar fasciitis and posterior tibialis strains.
Shin Pain
Medial or lateral shin pain can occur by the same mechanism as foot pain, or imbalanced loading in the side (frontal) plane putting excessive static or dynamic landing force onto either side of the lower leg.
Knee Pain
Chronic and often imperceptible ankle dysfunction is a major contributor to knee pain. Efficient knee motion requires the tibia to track in a mostly straight line as the knee flexes and extends. Knee flexion also occurs during running after we strike the ground and pass over the foot. If dorsiflexion is lost — or is inefficient — the tibia will often rotate, rather than efficiently flex. This rotation can cause torsional and/or shear forces that result in knee strain and pain.
Chronic ankle dysfunction is a major contributor to knee pain. Photo: Shutterstock
Hip Pain
Full hip extension requires full ankle dorsiflexion. When we land on one foot and pass over it, the ankle must continue to dorsiflex through its full range, in order for the hip to fully extend. Lost dorsiflexion will result in premature toe-off and deficient hip extension. If you try to run faster than dorsiflexion allows, this often results in…
Low Back Pain
Lost ankle dorsiflexion will cut off hip extension. Prolonged running or fast running may cause the body to achieve greater functional push-off by extending at the low back. Repetitive, forceful low back extension can be compressive and straining to the joints and tissues of the lumbar spine.
So many problems can arise from a stiff, dysfunctional ankle — and one that is often impervious to conventional stretching.
“Walk it Off and Stretch it Out:” Why Basic Mobility Often Fails at the Ankle Joint
One might think that such a crucial joint as the ankle wouldn’t so easily become stiff and dysfunctional. That, after a bad sprain or a long-and-crazy mountain run, the ankle would regain its full, efficient motion.
Unfortunately, that’s seldom the case. Why? Because while fluid and athletic mobility is useful, resilient strength and stability is far more important for survival and long-term health. Little wiggle room is built into the ankle complex. Thus, when bones in the ankle complex move even slightly off-axis, stability is maintained, but efficiency can be lost. In the end, stability always wins out.
As such, restoring joint efficiency often requires specific strategies to the bones, themselves, rather than general stretching.
Mobility of the ankle involves multiple tissue systems. Soft tissues must move. These include the muscles, tendons, and surrounding fascia and connective tissues — even blood vessels and nerves must move.
But truly at the core, for efficient ankle joint mobility, the bones must move. Bony joint movement requires more than the pulling of muscles. The surfaces of bones must slide and glide against each other to create movement. This requires two intrinsic things, the proper alignment — bony surfaces lying flush against one another — and a degree of friction-reducing joint lubrication between those surfaces. (That lubrication, hyaluronic acid, is discussed in this article about fascial mobility.)
Joint lubricant is present in all joints but requires full and efficient movement to hydrate, coat, and thus move all the surfaces of bones making up a joint. If a joint loses motion — either from basic stiffness or misalignment, that lubricant fails to coat those bony edges.
If either element — alignment or lubrication — is lost, the joint simply won’t move as far, or with ease.
At the same time, it’s possible, when performing a basic stretch, to mobilize the surrounding soft tissue without improving joint motion. This often occurs when performing a calf stretch. Bending at the ankle, leaning against a wall, will most certainly lengthen muscles, tendons, and fascia structures in the bottom of the foot and back of the ankle and lower leg. But doing so often does little to actively slide-and-glide the tibia and fibula on the talus, especially if those bones are out of alignment or stubbornly stiff.
Long periods of foam rolling and stretching may lengthen the calf, Achilles tendon, and plantar fascia, but eventually a wall is hit with a stiff ankle joint. Runners with this issue often will feel a pinch in the front or sides of the ankle when trying a conventional calf stretch. This sensation results from the bones failing to glide on one another.
No matter how much additional stretching is done, little will budge a rigid and often twisted talus, a translated fibula, and a frozen tibia.
Instead, this stiff joint requires larger forces, targeting specific parts of the ankle. Enter the belt ankle stretch.
The author performing a belt ankle stretch.
Targeted Dorsiflexion Force With the Belt Ankle Stretch
Clinically, restoring ankle alignment and motion frequently requires hands-on manual treatment. First, specific force to re-align the bones — namely the tibia, fibula, and talus — into an efficient, neutral position. Then, since misaligned joints have often been deficient in lubrication for prolonged periods, even more force is required to restore those functional motions, most notably dorsiflexion.
Ankle joint mobilization is both nuanced and hard work. And, like a rusty hinge recently freed, it also requires ongoing doses of forceful motion to keep it moving. And since it’s very expensive to take a manual physiotherapist or other body worker home with you after hours, an alternative strategy was developed to deliver targeted force to the ankle joint in the belt ankle stretch.
Ankle dorsiflexion requires primarily two motions: a neutral talus to glide posteriorly (versus the foot below it), and the tibia and talus to fold (or posteriorly glide) on either side of the talus. Because both systems glide posteriorly, the talus motion is small, and the tibia-fibula motion is larger.
The belt ankle stretch is a simple way to apply an anterior-to-posterior force to both the talus and tibia-fibula complex. It facilitates those crucial glides with targeted force concentrated in the small area of a belt or strap.
To perform the belt ankle stretch:
- Obtain a long belt or strap. I prefer a yoga strap, used for supportive stretching. The strap should be between one and two inches wide, and made of material with minimal stretch. It should be long enough to create a three- to four-foot loop.
- Loop the band on an immovable object, low to the ground. The belt must be secured at ground level, and the level of the ankle. Then, the belt must be attached to an immovable structure, such as a post, piping, or an otherwise very heavy object. A substantial force is applied to the belt, which will move anything not secured.
- Loop the band around the front of the ankle. The front of the loop should be positioned at the base of the ankle, in front of and around the ankle bones.
- Step away from the post until the band is taut. To enhance the tension, lift the toes and shimmy the heel as far forward as possible.
- Rock forward onto the whole foot. This will maximally tension the band around the front of the ankle. Pressure should be fairly intense but not painful.
For maximal stretch, apply two different movements. Keeping the whole foot flat:
- Rock forward at the hips.
- Flex and extend the knee.
This creates dynamic (think lubricating) movement in the ankle complex, of the tibia and fibula on the talus, and the talus upon the foot bones below it.
Perform slow oscillations of each movement for 30 to 90 seconds, multiple times to the affected ankle. Retest dorsiflexion out of the strap.
For rigid ankles, this stretch should be performed twice a day, including immediately before running, until the ankle motion is consistently improved. After that, the belt stretch is useful for occasional check-ins, especially when running high mileage on uneven and heavy vertical gain and loss.
Video Demonstration of the Belt Ankle Stretch
Hold Onto That Motion!
To maintain newly gained dorsiflexion motion, we need to strengthen into it. This reminds both the joint and the brain that there’s more motion available.
Perform active dorsiflexion in sitting or standing, with a straight or bent knee. Raise slowly, and to end range as high as you can lift your foot and toes, and lower as many times as you can until fatigue. Perform this immediately after the belt ankle stretch for best range of motion maintenance.
Conclusion
The ankle may have the biggest impact of any joint on whole-body running efficiency, affecting the feet and ankles, as well as the knees, hips, and even spine. Dorsiflexion is among the most crucial running motions, yet it is the easiest to lose amidst the demands of ultra distances, terrain, and vertical.
Keep the ankle mobile, and help restore post-sprain mobility losses, using this belt technique. It may be the single most impactful mobility input for your running.
Call for Comments
- Has an ankle injury and its knock-on effects ever gotten in the way of your running?
- Did you find this advice helpful?
References/Notes
- “Injury and Illness Rates During Ultratrail Running.” G. Vernillo, A. Savoldelli, A. La Torre, S. Skafidas, L. Bortolan, F. Schena. “International Journal of Sports Medicine,” 2016.
