Author(s): Sera Yoo, MD, MPH, Schan Lartigue, MD, Eric K. Holder, MD
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Disease/Diagnosis

Overuse ankle and foot disorders involve chronic microtrauma to tendons or soft tissues, leading to pain, impaired function, and tissue degeneration.1 This section focuses on tendinopathies, impingement syndromes, and plantar fasciitis. Other common overuse disorders involve osseous injuries, such as stress fractures. Please see Ankle and Foot Overuse Disorders: Bony Injuries.

Etiology

Overuse injuries result from repetitive mechanical stress applied to muscles, tendons, bones, or neural structures without adequate time for recovery.1 The causes of such stress are varied, with common contributors including sports activities and occupational demands.1

Epidemiology including risk factors and primary prevention

The most frequently reported diagnoses in sports related ankle and foot overuse injuries are tendinopathy, with the Achilles tendon to be most commonly reported.2 Overuse injuries are prevalent among athletes and individuals in occupations requiring prolonged standing.2,3 Risk factors include improper footwear, biomechanical abnormalities (pes planus, pes cavus, or calcaneal bone spurs), or systemic conditions that predispose to an inflammatory state, such as diabetes or obesity.4,5 Primary prevention strategies therefore focus on proper exercise form, proper footwear, and managing comorbidities.

Patho-anatomy/physiology

As “overuse disorders” is an umbrella term for many different diagnoses, the pathophysiology differs for different injuries. Listed below are some common overuse injuries. Notably, some diagnoses already have detailed PM&R KnowledgeNOW articles. The links to these articles are included in this review for further information.

Tendinopathy is an overarching term, and the spectrum of tendon disorders may include tendinosis, tenosynovitis, partial tear or complete rupture. Mechanical instability of the tendon (subluxations) as a result of tendon injury and/or disruption of the supportive retinaculum are also common sequelae of overuse ankle/foot tendon injuries. Three common tendinopathies are Achilles tendinopathy, tibialis posterior tendinopathy, and peroneal tendinopathy.

Achilles tendon connects the gastrocnemius and soleus muscles to the calcaneus and is critical for plantarflexion; its overuse can lead to Achilles Tendinopathy.7 The posterior tibial tendon is the primary muscle providing dynamic stability of the medial longitudinal arch. Less common than Achilles tendinopathy, tibialis posterior tendinopathy is posteromedial pain with overuse of plantar flexion and foot inversion.10 Lastly, tendinopathy of the peroneal tendons—specifically the peroneus longus and brevis—can result from repetitive ankle inversion, as these tendons function to evert and stabilize the ankle.10

Neuropathy in the setting of overuse is typically linked to mechanical overload, with common overuse conditions including tarsal tunnel syndrome, interdigital (Morton’s) neuroma, and superficial peroneal nerve entrapment. Tarsal Tunnel Syndrome is caused by compression of the posterior tibial nerve behind the flexor retinaculum at the tarsal tunnel.7 Morton’s neuroma is due to repetitive irritation, resulting in thickening of the interdigital nerve, commonly between the 3rd and 4th metatarsals.7 Superficial peroneal nerve entrapment is compression of the superficial peroneal nerve at the lateral component of the leg.7

Plantar Fasciitis is commonly degenerative, leading to collagen fiber stretching and tears, leading to thickening and heterogeneity of the plantar fascia.7

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

Overuse injuries of the ankle and foot typically progress from acute localized tenderness and mild stiffness to subacute pain with daily activity and worsening post-exercise symptoms.8 Molecularly, it is suggested that acute overload leads to non-inflammatory proliferative cell and matrix response, before it leads to fibrillar disorganization and increased vascularization.9 Chronic stages may involve tendon or fascia thickening, persistent pain, and gait changes, with some cases leading to tendon rupture or chronic instability requiring surgical intervention.8

Specific secondary or associated conditions and complications

Untreated conditions may lead to tendon rupture, chronic pain, and altered gait mechanics (e.g., contralateral knee or hip issues), which can contribute to secondary joint degeneration, muscle imbalances, and long-term functional limitations.10 It is important to note that overuse injuries often involve multiple anatomical sites, and patients may present with overlapping or concurrent diagnoses.

Essentials of Assessment

History

Key elements of the history include mechanism of injury, onset, location and character of pain, duration of symptoms, aggravating and alleviating factors.11 The context in which the current injury developed is important as well, as different sports can affect different areas.11 Questions about footwear, exercise frequency, medical history and occupational history should also be included.

Physical examination

A thorough exam includes inspection for asymmetry, deformity, edema, erythema, ecchymosis, or atrophy.12 Palpate for tendon thickening, crepitus, nodules, gaps, and point tenderness. Assess ankle dorsiflexion, subtalar mobility, and perform resisted muscle testing.12 Provocative tests such as the single-leg heel raise (posterior tibialis, Achilles tendon) and Thompson test (Achilles rupture) aid diagnosis.11 Gait analysis may reveal overpronation, asymmetry, or an antalgic pattern.9

Functional assessment

Functional assessment includes range of motion, strength tests, and gait analysis. Single-leg heel rise or hop tests may also be used to assess functional status.13

Laboratory studies

Laboratory findings are generally not useful for diagnosing overuse injuries, as these disorders are commonly clinical diagnoses. They may play a role in ruling out other conditions, such as infection, malignancy, or rheumatologic conditions.11 In this case, C-reactive protein, erythrocyte sedimentation rate, complete blood count, and metabolic panel may be ordered.17

Imaging

Imaging is not always required but can aid in diagnosis and management of overuse injuries. Ultrasound is the preferred, cost-effective tool for dynamic in-office assessment of soft tissues, including tendon thickening, tears, and guiding injections.11 X-rays may show heel spurs or soft tissue calcifications, while MRI offers detailed evaluation for complex cases or surgical planning; CT and bone scans are less commonly utilized for soft tissue evaluation.7,14

Supplemental assessment tools

Supplemental assessments may include nerve conduction studies/electromyography to evaluate neuropathic pain or nerve injury.7,15

Early predictions of outcomes

Early treatment leads to a favorable prognosis, but full recovery may take up to a year, with chronic pain, tendon degeneration, and comorbidities potentially worsen outcomes. Elite athletes often experience prolonged recovery, dependent on the demands of their respective sport.7

Environmental

Environmental factors such as worn-out shoes and hard surfaces increase stress on the body, while orthoses and shock-absorbing insoles can help prevent lower extremity overuse disorders.4

Social role and social support

Treatment outcomes depend on the cooperation of the patient, family, and support team, with education about the injury and recovery expectations crucial for adherence.

Professional issues

The professional implications of ankle and foot overuse disorders will vary, dependent on the type of injury and the specific demands of the patient’s profession.  The clinician should be prepared to discuss return to work/play considerations and chronic pain management options if symptoms persist.

Rehabilitation Management and Treatment

Current treatment guidelines

There are no universal treatment guidelines for management of ankle and foot overuse injuries, and grade of evidence is limited.11 Treatment is based on reviews of current scientific literature, clinical reports, and expert opinion.11

At different diseases stages

Conservative management options include rest, short term use of anti-inflammatory medications, and/or orthotics (heel lift, change of shoes, corrections of malalignments).11 In certain instances, short-term immobilization with a walking boot may be used.10 Second line therapy, such as corticosteroid injections, prolotherapy, platelet-rich plasma injections, needle tenotomy, extracorporeal shockwave therapy (ESWT) may be used as an adjunct to conservative measures.1,16 Notably, corticosteroid injections are performed for short-term benefit but used with caution, particularly about the weightbearing tendons such as the Achilles, due to concern for tendon rupture.19 Patients should also be referred to physical therapy to guide engagement in strengthening foot intrinsic muscles and frequently incorporate eccentric exercises.11 Operative treatment is recommended for patients who do not respond adequately to appropriate conservative treatment. Surgical intervention may be necessary, such as debridement, adhesion removal, neurectomy or fasciotomy.7,11

Coordination of care

Coordination of care includes clear communication between a multidisciplinary healthcare team which may include physiatrists, orthopedic surgeons, family physicians, and physical therapists. Dieticians or nutritionists may also be incorporated into the coordination of care if obesity is a risk factor.

Patient & family education

Patients and their support systems, including family, coaches, and trainers, should be involved in care. Education about the diagnosis, treatment options, expectations for recovery, and the return to play decision making process should be provided.

Management of treatment outcomes

Return-to-activity decisions should be guided by functional outcomes and injury prevention goals. Emerging evidence suggests that complete rest during the early phase of overuse injuries may not be necessary, and carefully monitored activity does not negatively impact recovery.16 Gradual return to sport or work is recommended, based on pain levels, range of motion, strength, and validated tools such as walking and hop tests.13 Ultimately, readiness depends on the patient’s comfort and ability to participate with minimal discomfort.

Translation into practice

Early identification and education concerning risk factors for overuse disorders of the ankle and foot are necessary to avoid chronic pain.8 Gathering a comprehensive history of presenting illness and understanding of the patient’s goals for treatment are essential to making the correct diagnosis and designing an effective treatment plan.11 Thorough physical examination including functional assessment and paying careful attention to any muscular imbalances can assist with guiding appropriate physical therapy regimen.12 The goal in the treatment of overuse injuries is to provide adequate pain control to allow for rehabilitation with exercise modification, orthotics, and eccentric exercises to prevent further injury and allow healing of damaged structures.11

Cutting Edge Concepts and Practice

Emerging therapies are exploring inflammatory pathways, cytokine regulation, and epigenetic modifications to develop targeted pharmacologic treatments.1 Regenerative medicine—such as platelet-rich plasma (PRP) and stem cell therapy—shows promise but is limited in current research.1 ESWT is non-invasive therapy using high-energy acoustic waves to improve plantar fasciitis.16 Cutting-edge approaches in overuse injury management include personalized 3D-printed orthotics and wearable sensors that provide real-time gait and load monitoring.18

Gaps in Evidence-Based Knowledge

Current research is advancing pharmacologic therapies, regenerative medicine, and tissue engineering, though translating these innovations into clinical practice remains a challenge. There is a need for high-quality RCTs comparing interventions like PRP and ESWT to standard rehabilitation, along with clearer post-procedural protocols.19 As new treatments emerge, a multidisciplinary approach remains essential for the effective management of foot and ankle overuse disorders.

References

  1. Millar, N. L., Silbernagel, K. G., Thorborg, K., Kirwan, P. D., Galatz, L. M., Abrams, G. D., … & Murrell, G. A. C. (2021). Tendinopathy. Nature Reviews Disease Primers, 7(1), 1–20. https://doi.org/10.1038/s41572-020-00234-1
  2. Sobhani, S., Dekker, R., Postema, K., & Dijkstra, P. U. (2013). Epidemiology of ankle and foot overuse injuries in sports: A systematic review. Scandinavian Journal of Medicine & Science in Sports, 23(6), 669–686. https://doi.org/10.1111/sms.12055
  3. Coenen, P., Willenberg, L., Parry, S., Shi, J. W., Romero, L., Blackwood, D. M., … & Straker, L. M. (2018). Associations of occupational standing with musculoskeletal symptoms: A systematic review with meta-analysis. British Journal of Sports Medicine, 52(3), 176–183. https://doi.org/10.1136/bjsports-2016-096795
  4. Im Yi, T., Lee, G. E., Seo, I. S., Huh, W. S., Yoon, T. H., & Kim, B. R. (2011). Clinical characteristics of the causes of plantar heel pain. Annals of Rehabilitation Medicine, 35(4), 507–513. https://doi.org/10.5535/arm.2011.35.4.507
  5. Franceschi, F., Papalia, R., Paciotti, M., Franceschetti, E., Di Martino, A., Maffulli, N., & Denaro, V. (2014). Obesity as a risk factor for tendinopathy: A systematic review. International Journal of Endocrinology, 2014, 670262. https://doi.org/10.1155/2014/670262
  6. Cook, J. (2011). Tendinopathy: No longer a ‘one size fits all’ diagnosis. British Journal of Sports Medicine, 45(5), 385. https://doi.org/10.1136/bjsm.2010.081166
  7. Tenforde, A. S., Yin, A., & Hunt, K. J. (2016). Foot and ankle injuries in runners. Physical Medicine and Rehabilitation Clinics of North America, 27(1), 121–137. https://doi.org/10.1016/j.pmr.2015.08.006
  8. Charnoff, J., Ponnarasu, S., Sina, R. E., et al. (2025). Tendinosis. In StatPearls. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK448174/.
  9. Canosa-Carro, L., Bravo-Aguilar, M., Abuín-Porras, V., Almazán-Polo, J., García-Pérez-de-Sevilla, G., Rodríguez-Costa, I., & Romero-Morales, C. (2022). Current understanding of the diagnosis and management of the tendinopathy: An update from the lab to the clinical practice. Disease-a-Month, 68(10), 101314. https://pubmed.ncbi.nlm.nih.gov/34996610/
  10. Ferber, R., & Macdonald, S. (2014). Running mechanics and gait analysis (2nd ed.). Human Kinetics.
  11. Deu, R. S., Coslick, A. M., & Dreher, G. (2022). Tendinopathies of the foot and ankle. American Family Physician, 105(5), 479–486.
  12. Pillemer, R. (2023). Examination for specific conditions of the foot and ankle. In Handbook of Lumbar Spine and Lower Extremity Examination: A Practical Guide (pp. 217–260). Springer. https://doi.org/10.1007/978-3-031-30012-7_9
  13. Vallance, P., Hasani, F., Crowley, L., & Malliaras, P. (2021). Self-reported pain with single leg heel raise or single leg hop offer distinct information as measures of severity in men with midportion and insertional Achilles tendinopathy: An observational cross-sectional study. Physical Therapy in Sport, 47, 23–31. https://doi.org/10.1016/j.ptsp.2020.11.015
  14. Pereira, H., Amaral, M. F., & Longo, U. G. (2023). Foot and ankle tendinopathies. In U. G. Longo & V. Denaro (Eds.), Textbook of Musculoskeletal Disorders (pp. 945–959). Springer. https://doi.org/10.1007/978-3-031-20987-1_59
  15. Wasker, S. V. Z., Challoumas, D., Weng, W., Murrell, G. A. C., & Millar, N. L. (2023). Is neurogenic inflammation involved in tendinopathy? A systematic review. BMJ Open Sport & Exercise Medicine, 9(1), e001494. https://doi.org/10.1136/bmjsem-2022-001494
  16. Yusof, T. N. B. T., Seow, D., & Vig, K. S. (2022). Extracorporeal shockwave therapy for foot and ankle disorders: A systematic review and meta-analysis. Journal of the American Podiatric Medical Association, 112(3). https://doi.org/10.7547/21-094
  17. Grävare Silbernagel, K., & Crossley, K. M. (2015). A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and implementation. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 876–886. https://doi.org/10.2519/jospt.2015.5737
  18. Samarentsis, A. G., Makris, G., Spinthaki, S., Christodoulakis, G., Tsiknakis, M., & Pantazis, A. K. (2022). A 3D-printed capacitive smart insole for plantar pressure monitoring. Sensors, 22(24), 9725. https://doi.org/10.3390/s22249725
  19. Townsend, C., Von Rickenbach, K. J., Bailowitz, Z., & Gellhorn, A. C. (2020). Post‐procedure protocols following platelet‐rich plasma injections for tendinopathy: A systematic review. PM&R, 12(9), 904–915. https://doi.org/10.1002/pmrj.12317

Original Version of the Topic

Alexandra Rivera-Vega, MD, Stephanie P. Joseph, MD, William F. Micheo, MD. Ankle and foot overuse disorders. 9/20/2014

Previous Revision(s) of the Topic

William Micheo, MD, Brenda Castillo, MD, Alexandra Rivera, MD, Odrick Rosas, MD. Ankle and foot overuse disorders. 2/13/2018

Lindsay Burke, MD, Kristina Barber, MD, Malia Cali, MD, Adele Meron, MD. Overuse Ankle and Foot Disorders. 6/22/2022

Author Disclosure

Sera Yoo, MD, MPH
Nothing to Disclose

Schan Lartigue, MD
Nothing to Disclose

Eric K. Holder, MD
Nothing to Disclose