How should foot pain in a long-distance runner be evaluated and managed?

Evaluation and Management of Foot Pain in Long-Distance Runners

Initial Evaluation

Begin with weight-bearing foot radiographs as your first imaging study, which have 85% sensitivity and 95% specificity for common running injuries like plantar fasciitis. 1

Key Clinical Findings to Elicit

• Pain location determines diagnosis: Plantar heel pain indicates plantar fasciitis; posterior heel pain suggests Achilles tendinopathy; lateral heel pain points to Haglund's deformity, calcaneofibular ligament injury, or calcaneal stress fracture; forefoot pain indicates metatarsal stress fracture, sesamoiditis, or Morton's neuroma 1, 2, 3

• Timing and onset: Insidious onset after sudden increases in mileage, frequency, or speed is classic for plantar fasciitis 4; progressively worsening pain following increased activity or change to harder surfaces suggests stress fracture 2

• Physical examination maneuvers:

  • Calcaneal compression test (medial-to-lateral squeeze) detects stress fractures 1, 2
  • Palpate Achilles insertion, lateral malleolus, posterior-superior calcaneus, and lateral calcaneal wall 1, 2
  • Pain at inferior pole of patella with resisted leg extension indicates patellar tendinopathy 5
  • Thickening and tender nodules along Achilles tendon confirm Achilles tendinopathy 5

Critical Pitfall

Do not rule out stress fractures based solely on negative initial radiographs—sensitivity is only 12-56% early on, and clinical symptoms precede radiographic changes by weeks. 5, 1, 2

First-Line Conservative Management

Implement all conservative measures simultaneously from day one: stretching of plantar fascia and Achilles tendon, activity modification with relative rest, NSAIDs for pain/inflammation, cryotherapy, orthotic devices (arch supports, heel pads), weight loss when indicated, and appropriate footwear. 1

Specific Treatment by Diagnosis

• Plantar fasciitis: Heel cushions, arch supports, Achilles stretching exercises, NSAIDs, activity modification 1, 4, 6

• Achilles tendinopathy: Eccentric strength training (most effective), stretching and deep friction massage of gastrocnemius-soleus complex, heel lift orthotics to unload the tendon, shoe orthotics to correct overpronation or pes planus 5

• Patellar tendinopathy: Eccentric exercise to reduce symptoms and promote healing, deep transverse friction massage for pain reduction 5

• Metatarsal stress fractures: Protect and immobilize the foot with cast or fixed-ankle walker device 2

Advanced Imaging When Radiographs Are Non-Diagnostic

For persistent pain beyond 1 week with negative or equivocal radiographs, order MRI foot without contrast or diagnostic ultrasound as your next step. 5, 1, 2

• MRI provides higher sensitivity for early stress fractures, particularly in the navicular and metatarsals 5, 1, 3
• Bone scintigraphy with technetium is an alternative when stress fracture is suspected despite negative radiographs 1, 2
• CT without contrast is appropriate for suspected occult fractures or painful accessory ossicles 5

Navicular and Sesamoid Stress Fractures Require Urgent Attention

These fractures may cause significant long-term consequences, so clinical suspicion warrants immediate definitive diagnosis with MRI or bone scan. 3

When to Refer to Foot-and-Ankle Specialist

Refer if any of the following criteria are met: 1, 2

• No improvement after 6-8 weeks of appropriate conservative therapy
• Advanced imaging or further diagnostics required
• Surgical intervention being considered
• Red-flag signs present: constant rest pain, numbness, increasing edema/erythema, complete sensory loss, or motor paralysis

Critical Safety Warning

Never inject corticosteroids near the Achilles tendon due to significant risk of tendon rupture. 1, 2, 7 Corticosteroid injections for lateral epicondylopathy are effective in acute phases but don't change long-term pain outcomes 5, and should be used judiciously only in appropriate anatomic locations 1.

Re-examination Protocol

Always re-examine the patient 3-5 days after initial injury if swelling limited your first examination. 1, 2 Excessive swelling and pain within the first 48 hours can obscure findings.

Common Predisposing Factors to Address

Identify and correct: excessive pronation, flat or cavus foot, tight Achilles tendon, improper footwear, anatomic misalignment (forefoot/heel varus), and training errors (sudden increases in mileage, frequency, or speed) 5, 6, 8. Excess body weight and kilometers run per week are high-risk factors 8.