Repeated microtrauma from running or jumping

Anatomy and stress in running and jumping sports

The ankle joint connects the lower leg and foot and transfers the forces of the entire body to the ground. During running and jumping movements, joints, tendons, muscles and connective tissue work as a functional unit.

• Upper and lower ankle joint: movement control in dorsi/plantar flexion and inversion/eversion.
• Tendons: Achilles tendon, peroneal tendons, tibialis posterior, tibialis anterior tendon, flexor hallucis longus.
• Band apparatus: outer and inner bands stabilize against twisting.
• Bones: Tibia, fibula, talus, calcaneus and metatarsals transmit loads.
• Soft tissue: Plantar fascia and foot muscles support the longitudinal and transverse arches.

Significant forces are exerted at every step, which can be multiplied by poor technique, unfavorable ground or a lack of preparation. If suboptimal stress is repeated, micro-injuries occur - initially without acute trauma, but with increasing irritation.

What are microtraumas – and how do they occur?

Microtraumas are tiny tissue damages caused by repeated mechanical stress. Biologically normal is an alternation of stimulus and regeneration: the tissue adapts and becomes more resilient. However, if there is no recovery or the stimulus exceeds the current resilience, the balance tips.

• Tendons: Collagen fibers lose their order, resulting in tendinopathy with pain on exertion and morning stiffness.
• Muscles/Fascia: Micro-injuries lead to trigger points, tension and reduced strength development.
• Bone: Initially a stress reaction (edema), later possible: stress fracture.
• Cartilage/Joint: Repeated impingement or incorrect loading can cause irritation.

A gradual onset is typical: pain at the start, better after warming up, later pain during and after exercise. If training is not adjusted, there is a risk of chronic disease.

Causes and risk factors

Extrinsic (external) and intrinsic (body's own) factors usually work together.

• Training errors: increasing volume or intensity too quickly, monotonous stress, too little regeneration.
• Surface: hard ground, strong gradient/camber changes, unfamiliar trails.
• Footwear: worn cushioning, inadequate stability or drop.
• Technique: Overstriding, low cadence, collapsing arch.
• Misalignments: e.g. E.g. bending, fallen arches, hollow feet or leg axis deviation.
• Overpronation or supination with uneven load distribution.
• Strength and coordination deficits in the lower leg and torso.
• Previous stress: previous ligament stretches, instability, scars.
• Systemic factors: low energy balance, vitamin D deficiency, smoking.

The earlier risk factors are identified and addressed, the lower the risk of persistent symptoms. Our examination therefore combines functional analysis, running history and, if necessary, treadmill diagnostics.

Symptoms and warning signs

• Pain on exertion in the ankle joint, heel or along tendons.
• Morning stiffness, starting pain, improvement after running in, later also possible pain at rest.
• Pressure pain over tendon attachments or on the shinbone/metatarsus.
• Swelling, feeling of warmth, rubbing noises (irritation of the tendon sheath).

Warning signs that should be checked medically:

• Increasing pain despite reducing stress over 1-2 weeks.
• Local, stabbing bone pain, esp. a. under pressure or jump load (suspected stress reaction/stress fracture).
• Pain at night when resting, significant swelling or redness.
• New instability, accident-like event or sensation of clicking.

Diagnostics: structured and targeted

A structured clarification takes place in our practice in Hamburg. The aim is to identify structures relevant to stress, to recognize contributing factors and to align therapy accordingly.

• Anamnesis: course, amount of training, change of shoes, surfaces, previous illnesses.
• Clinical examination: palpation, functional and provocation tests, mobility of the ankle, arch and hip.
• Gait analysis/running analysis: step frequency, axis control, foot strike, push-off phase.
• Sonography: dynamic assessment of tendons and tendon sheaths.
• X-ray: if bony changes/stress fracture are suspected.
• MRI: if the findings are unclear, a stress reaction is suspected, cartilage/bone edema or complex tendon involvement.

Not every complaint needs imaging immediately. Indication and timing are decided individually and based on evidence.

Structures commonly affected when running and jumping

• Achilles tendon (midportion and insertion): tendinopathic irritation, possibly involving the bursa.
• Peroneal tendons: lateral pain, rubbing behind the lateral malleolus.
• Tibialis posterior tendon: medial ankle pain, arch collapse.
• Plantar fascia: Start-up pain on the plantar side of the heel.
• Shin splints (medial tibial splint syndrome): stress-dependent shin splints.
• Metatarsal/heel bone: Stress reactions up to stress fracture possible.
• Anterior/posterior impingement of the ankle joint due to repeated impact.

Conservative therapy: step-by-step plan instead of a forced break

The aim is not absolute protection, but rather clever control between stimulus and regeneration. The step-by-step plan is adapted to the structure, duration of the complaint and the training goal.

Special procedures can supplement in selected cases:

• Shock wave therapy: considered for chronic tendon and plantar fascia problems; Benefit individually.
• Ultrasound-assisted infiltrations: e.g. B. Platelet-rich plasma (PRP) in chronic tendinopathy can be discussed. The evidence is heterogeneous; Decision made individually after informed consent.
• Cortisone injections into the Achilles tendon and plantar fascia are critically examined and usually avoided due to the risk of complications.

Surgical measures are rarely necessary for microtraumas and are reserved for treatment-resistant special cases.

Safe return-to-run: criteria and progression

The return to running depends on symptoms, resilience and structure. A pain-adapted, gradual structure helps to prevent relapses.

• Criteria for starting: pain-free walking, pain-free hop tests on the spot, climbing stairs without gaining weight the following day.
• Rule: Pain is maximally mild during the session and decreases within 24-48 hours. No sustained increase.

Progress is individual and can happen faster or slower. Regular re-checks and adjustments are important.

Prevention: manage stress wisely

• Increase volume/intensity gradually, observe individual tolerance.
• Variable surface, shoe rotation with 2-3 models with different properties.
• Increase step frequency slightly, avoid overstriding.
• Regular strength and coordination sessions for calves, foot muscles, hip stabilizers.
• Warm-up and progressive transitions into new forms of training.
• Check sufficient regeneration, nutrition and, if necessary, vitamin D status.
• Take early warning signs seriously and make short-term adjustments instead of “biting through”.

Different surfaces are available in Hamburg - for example, switch between park paths and Alster paths to avoid monotonous stimuli.

When should you seek medical advice?

• Symptoms last longer than 10-14 days, despite reducing training.
• Stinging pain close to the bone or point pressure pain on the shinbone/metatarsal.
• Pain at night when resting, significant swelling or redness.
• Recurring “knocking events” or feeling of instability.

Early clarification helps to avoid longer training breaks and to treat them specifically.

Our approach in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we clarify microtraumas to the ankle joint in a structured manner. The focus is on conservative, evidence-based measures: individual stress management, physiotherapeutic programs, technology and shoe advice as well as accompanying measures. Regenerative procedures are only offered with clear indications and after transparent information. We will discuss together what makes medical sense and what you can actively contribute yourself.