The Anatomy, Biomechanics and Psychology of An Ankle Injury.

If you read my previous blog on my barefoot-not-running experiment, you will have learned that my right foot and ankle have caused me persistent trouble. 

This blog writes about injury, foot and ankle anatomy, a new injury, a trip to Wales and some reflections on mindset, strewn across the page as a straggle of separate threads of story and information. It ends with some stuff that might help you if you have a buggered ankle. 

Firstly, as the primary update to that previous post – 

Rest really does work. 

Within one week of not running, the pain and stiffness in the big toe joint had settled down to almost nothing.  I had no discomfort when walking, which was a great relief (having a nagging stiffness when doing simple activity such as walking really bores into the mind). 

After two weeks, the residual inflammation seemed to have settled to an extent where I could flex my big toe joint without a feeling of any added tension or swelling across the dorsal aspect (the top) of the foot. 

The anterior ankle pain took a bit longer to get better – but after one month of not running, the pain, stiffness and feeling of thickness and impingement at the front of my ankle had improved. Success!

Recovery, continued..

My continued recovery should have been a gentle, gradual process at this point. For many reasons, I did not comply with the plans I had previously written about. Actually I did not make any plans at all.

I just started running. Why?

My friend Frazer (who previously challenged me to a half Ironman, which was the most recent in the series of assaults against my ankle) challenged ‘invited’ me to join a 30km fell race in North Wales. The course was across mountainous terrain, running up and down and traversing steep inclines.

My mind was very excited. My ankles trembled in fear. 

As often happens, the will of my mind exceeded that of my body. I decided that running for short amounts of time, gradually increasing in duration and intensity, would not be the sensible way to build fitness and robustness. Instead, I thought that I should run for 10 kilometres, albeit slowly, to test to see if and when my body would break. If my body broke, it would be a clear sign to rest. To me, this was clearly the most effective way to make a body fit to run 30km…

It worked well at first – I managed about three weeks of occasional slow 10km runs. No significant pain, might I add. Not the leaps and bounds of progress I had envisioned but at least I was running. 

And then the new injury..

3 weeks before the race I decided to join a Parkrun (A free initiative that provides a 5km run in various parks internationally, that is timed yet not a race). My mind was eager to join the non-competitive competition. My body hesitantly shuffled around, preparing to hand in its resignation. 

The Ashton Court Parkrun in Bristol is a simple course. You start at the bottom of a long hill. You run 2.5km up the hill. You turn around at the top and fly down the hill, before finishing where you started. 

The first part of the climb is on hard, smooth tarmac that is perfect for just setting a pace and running. The latter part of the climb is on a path of ‘hard-pack’ coarse gravel and rocks; perfect terrain for challenging (and overwhelming) the limits of maintaining good running form, especially when I was panting up the hill, my legs and arms burning and vision failing because my heart was almost fibrillating.

The First Ankle Anatomy Lesson – Mortise Joints

It turns out that my ankle is fine when running up hill on a regular surface. Perhaps because when the ankle is being pushed into dorsiflexion, the large bone of the ankle (the talus) is wedged in between the mortise joint formed by the tibia and fibula malleoli.

The talus is wider at the front than at the back (like a chunk of Brie), so when it rotates under the ankle mortice to allow dorsiflexion, the wedge creates more stability.

Image result for talus mortice
The ‘Mortise’ joint of the ankle. From here

When running uphill, while the ground slopes upwards in front of the runner, the position of the ankle in its range of movement is biased towards dorsiflexion, hence more stable.

The subsequent range of lateral movement that the ankle can undergo is reduced, possibly reducing strain on the tendons and ligaments that control pronation and supination of the foot.

The foot lands on its forefoot, dissipating load through the entire foot and ankle and allowing a more nimble gait that avoids obstacles that may roll an ankle.

The Achilles tendon takes the load, stretching and recoiling in a vertical plane with every foot strike up the hill.

Furthermore, running uphill is hard enough without trying to run uphill fast. The reduced speeds will reduce the load on the ankle. 

running uphill male athlete runner
Uphill terrain is more comfortable for me, which I think is due to the reduced range of movement encountered by the ankle when landing on an upwards sloping surface. Picture originates here.

Downhill running has the opposite effect.

Instead of having a small, compact range of movement with a stable joint, dealing with lower loads, you might see runners flying down the hill with legs outstretched in front of them, feet flying forwards.

They might have a rapid cadence, their legs trying to smoothen out the impacts as they surf both gravity and the ground. 

The leading leg outstretched, the ankle plantarflexed and the mortise joint in its weaker position. I think this makes downhill running more tricky than going uphill. From Salomon.com

Anatomically, the ankle is weaker when running downhill.

When the foot and leg is outstretched to receive the ground, the ankle is plantarflexed causing the talus to sit more loosely in the mortise of the bones of the leg. The Achilles tendon is shortened, slackened and is not positioned to absorb the load of the foot strike.

At the ankle, a runner may rely more on pronation and supination, loading the tendons of the muscles tibialis anterior and posterior in an intense, eccentric pattern as they disperse load laterally, to control the deceleration of the body. 

Wow. In retrospect it sounds obvious that running downhill with a weakened ankle is a dangerous idea. 

Anyway, I was neck and neck with another runner so I nailed it down that hill. 

A Painful Anatomy Lesson

I had to take two weeks out of running after that.

This time, the big toe and anterior ankle were not the culprit. Instead, the pain was on the inside of the arch of my right foot, with sharp pain when walking. 

The pain was during the transition of weight from my heel to the ball of my foot – at this point of the gait cycle, the load of the body is being transferred from a bone (the calcaneus or heel) to another bone (the head of the first metatarsal, or ball of the foot), via a series of smaller bones that form the bricks of the arch of the foot.

The arch of the foot is swaddled in a complex organisation of ligaments and muscles that span both short distances, between each brick/bone, and longer distances, e.g. from the heel to the heads of the metatarsals. 

The tendons creating the ‘stirrup’ around the ankle, with subsequent insertion into areas of the foot that allow supination and pronation. From this site which has many other good pictures describing foot and ankle anatomy.

Further to all of these small structures is a large wad of stretchy tissue called the ‘spring ligament‘ (which acts like a spring!). It operates with a ‘windlass mechanism’, akin to the string of a bow that stores elastic potential, the bow being the arch of the foot.

Finally, the sole of the foot is protected with soft fat and tough fascia that together allows our skin to be compliant yet grippy against the ground.

Fig 2 - Supporting structures of the foot arches.
Some of the ligaments in the sole of the foot that support the foot’s arches. A plantar view of some of the tendons illustrated in the image above. Many thanks to TeachMeAnatomy.

The ankle’s structural connective tissue components stretch above and beyond the joint itself.

It is supported on both sides by the tendons of the muscles that lie on the inside and outside of the lower leg (tibialis anterior, tibialis posterior and the peroneal/fibular muscles).

These tendons stretch across the ankle joint before binding into the bones of the foot, acting almost like stirrups to support the ankle on both sides. It is these muscles and tendons that allow the ankle to invert and evert.

The position of insertion of some of these tendons into the foot also allows the foot to twist along its arch. Complicated to describe so check out a YouTube video. 

Another image describing the tendons that surround the ankle, including those creating the stirrup-like function supporting the inside and outside of the ankle. From this site.

The foot and ankle complex is a masterpiece of engineering.

Its ability to adapt both passively and actively to a variety of terrain of different densities and of planes is incredible.

While walking on sand, the gait adapts to walk with flat, supple feet and with spread toes for maximum surface area, like an elephant.

Walking on soft grass? Claw the toes in for propulsion. Traversing a hill? The ankles invert and evert to a great level of movement, maintaining strength and stability, while the feet reciprocate with an orchestrated coordination of muscle, bone and tendons.

It is quite fun to watch your feet and toes behave when walking on soft natural surfaces, like watching a dog weave and leap through long grass. If you don’t want to watch your feet, watch a video on youtube (not sure which option is weirder). 

This time my pain originated from the stirrup-like tendons of the tibialis posterior – as described above, they act to supinate the foot and ankle when they contract concentrically, while acting to resist pronation (thus decelerating the body while running) when contracting eccentrically. They undergo high loads when trying to control speeds when running downhill, may become damaged under critically high loads or with pre-existing weakness, and herein is the mechanism of my ankle failure.

Lessons Learned: 

What a saga – I am grateful if you have made it this far because the above anatomy and biomechanics stuff goes deep. 

Despite appreciating the complexities of the ankle, I still failed to put this appreciation into practice.

Although it has been useful for me to think mechanistically about foot and ankle function, it has also provided a rich opportunity to think about the origins of injury.

It’s clear that I started my return to running too rapidly and too vigorously.

I did not identify or deal with the weaknesses that would contribute to further injury in the future. This probably stems from a long history of failed recovery from injury – when I broke the fibula of my right leg as a teenager, I was eager to continue training even with a plaster cast. When the cast came off, I did not follow any formal rehab programme and grabbed my rugby boots or running shoes. This seems to have set the tone for the management of subsequent injuries.

But what about the psychological side of things?

A determined and driven mindset is often praised in Western society as a positive characteristic that pushes an individual to achieve and contribute more. Pain and gain is a trait widely promoted by a wide range of success stories, from sports people to start-up venturers. 

Another concept is of delayed gratification – putting the pursuit of pleasure behind the pursuit of a virtuous action. In some cases, it might be going for a run instead of sitting on the sofa.  This definitely applies to me and many of my peers. This concept, however, can be applied paradoxically here; train now, succeed later is but one perspective and is one that focuses on mind over body. The other perspective, from a joint mind and body approach, would be to listen to the body’s cries for rest, to train smart with continued feedback, to avail later with consistent performance and success. 

Brain and brawn are needed for sustainable performance – Sitting here in my injured state pondering over mindset, I realised I have suffered from having neither. 

How to make YOUR ankles less weak / (what I SHOULD have done (and should do)): 

If you have an acute injury:

  • What I’m about to write isn’t right for you. Contact your responsible health provider especially if you’re concerned about serious injury e.g. fracture. 
  • You may try to implement some initial management of rest, compression and elevation. Ice might be helpful for symptomatic control of pain and swelling. 


When appropriate and able, try some foot and ankle rehab exercises:

  • See your physiotherapist for a proper diagnosis and rehabilitation programme. 
  • Every day, once or twice a day, try to draw the alphabet with your big toe of each foot. Try to do an upper case and a lower case alphabet. I picked this up from TriForLes who have some other tips.
  • Put your feet together so that both the ball of the foot and the insides of the ankle are touching. Raise up onto your tiptoes and hold it in full extension. You could do this twice a day for 2 minutes. Try putting a post-it on your mirror to remind you when brushing your teeth. I got this from a book titled ‘Keep Your Joints Young’by Sarah Key, which has a 30 minute daily full body stretching programme too.
  • This blog recommends rocking from the inside to the outside edges of your foot. It looks interesting and I am keen to give it a try when I have a chance to stand idly…He is also selling something about a spring system which I have no affiliation to.
  • Giving your feet some tough love with a lacrosse ball was popularised by Dr Kelly Starrett. You can find him at MobilityWOD or via his book, ‘Becoming A Supple Leopard’.
  • Another good exercise is to walk on your heels and your toes. You could do three sets of each for 10 metres or so before you start a run. It isometrically loads the tendons and muscles in both full plantar- and dorsi-flexion. This was frequently included in the Power Speed Endurance programming I did to prepare for the St Polten Half-Ironman last year.

Try some upstream exercises: 

  • Being strong is important. Deadlifts, squats and variations of these can build good movement patterns and robust strength. 
  • Variations of these movement patterns using only one leg e.g. single-leg deadlifts can be a fun way to test proprioception and balance, while identifying asymmetries and weaknesses. I sure am not the expert on these – ask your physiotherapist or a strength and conditioning coach. 
  • Eccentric calf declines have been used and studied to recover Achilles tendinopathy. As part of a toolkit to build a robust running body, it might be worth building these in. 

Run better: 

  • Get a running coach (Something I am yet to do). 
  • Video yourself running, with a view to looking at your foot strike. 
  • Look at Prof Mark Cucuzzella’s running resources, designed for the US Air Force.
  • Consider a higher cadence and or a forefoot strike. Consider the pros and cons of footwear, be it maximalist, minimalist or somewhere in between.
  • Read more blogs about running and running downhill e.g. Salomon or Inov-8

Other stuff:

  • I used a collagen supplement with vitamin C as I was concerned I did not get enough collagen in my diet. Ligament and tendon injuries can take a long time to heal (mainly because they have a poor blood supply and struggle to get the building blocks to recover). I wanted to ensure that the tissue got what it needed to rebuild. My theory and practice was based on this blog about connective and soft tissue development
  • Wear appropriate day-time shoes. I love my Blundstone boots, but their heel and last really seem to aggravate my ankle. A soft running shoe is much more comfortable.
  • You aren’t sidelined. Row, swim and cycle to maintain aerobic capacity.

Most Importantly

Forget all the specific exercises, running techniques and supplements: the MVP in this game is the relationship between body and mind. 

  • A valuable take-away is to just appreciate that the body and the mind don’t always want the same thing, and that is OK. 
  • Just like two people in a relationship, there has to be some compromise somewhere. The secret is to open up communication channels between body and mind, to understand the agendas of each. 
  • You, like me, might think you know your mind. However, if your body has been politely and persistently asking your mind to give it a break, yet your mind is blind to it, in this or other aspects of your life… then don’t run, but sit on the couch and get comfortable with your mind. 
  • Employ some self-love sometimes. I can’t believe I just wrote that but it is true.
  • Running, mental health and life are all about the journey. There aren’t quick fixes in any of these. They all require a balanced approach of dedicated work, introspection and just letting it hang loose once in a while (like running down a hill with windmilling arms as you see at some fell races, how fun).

Addendum:

Frazer and I finished the ‘Sheeptracks’ fell race, which I wholly recommend. It was a long day of 33km and 1,900M of elevation. The winners ran less distance and less elevation in less time, which basically means we took the scenic (slow) route. We ran together, kept a gentle pace, talked a lot, scraped through the cut-off checkpoints with minimal extra time and came dead last out of the cohort who finished. We ate lemon drizzle cake and hot chilli at the finish line in an empty village hall because everyone else had washed, warmed up and gone home. It’s all about the journey!

87259746_506608073381636_345446130877726720_n.jpg
Freezing our butts off on a hill. The visibility was great at this point – 5 minutes earlier it had rained, hailed and blown high winds at us.

Thanks for reading. Please feel free to share and follow my blog!

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