Spring marathon season is upon us, and across the country, training plans are in full swing. Weekend long runs are getting longer, mileage is creeping up, and runners are beginning to feel both the excitement and the physical strain that marathon preparation brings.
Although I am a cyclist rather than a runner, I have enormous respect for the physical and mental demands of endurance sport.
The principles are the same whether you are on the bike or on the road; load, recovery, biomechanics and consistency determine performance and injury risk.
In my clinic, I see first-hand how marathon foot pain and ankle injuries in runners can derail months of careful preparation.
The good news? Most running injuries can be managed conservatively if identified early and treated appropriately.
Surgery is rarely the first step. However, when underlying structural problems or more significant pathology are present, specialist diagnostics and, occasionally, surgical intervention may be required.
In this article, I’ll explain how to protect your feet and ankles during marathon training, highlight the most common conditions I see, and outline when you should seek expert help.
The marathon places an extraordinary repetitive load on the lower limb. With every step, forces of two to three times body weight pass through the foot and ankle. Over 26.2 miles, that equates to tens of thousands of loading cycles.
Unlike cycling, where impact is minimal and load is more controlled, running involves ground reaction forces, balance demands, and constant micro-adjustments in foot mechanics.
As mileage increases, tissues must adapt. If they do not adapt quickly enough or if there is a biomechanical imbalance, injury develops.
Understanding how these conditions arise is central to effective running injury prevention.
Plantar fasciitis remains one of the most frequent causes of marathon foot pain. It typically presents as sharp pain under the heel, often worst with the first steps in the morning or after periods of rest.
The plantar fascia is a strong band of connective tissue supporting the arch of the foot. As training load increases, particularly with speed work or hill sessions, it can become overloaded.
Only a small proportion of patients require surgical intervention.
However, persistent pain beyond 9 -12 months, failure to improve despite a structured rehabilitation, or suspicion of alternative diagnoses (such as nerve entrapment or stress fracture) warrant specialist assessment.
In my practice, careful clinical examination combined with imaging, often ultrasound or MRI, helps clarify the diagnosis and guide treatment.
Tibialis posterior dysfunction is less widely discussed but potentially more significant.
The tibialis posterior muscle is a deep muscle that sits behind the calf muscle.
The tibialis posterior tendon supports the arch and stabilises the ankle during running. When overloaded, it can become inflamed, degenerate, or even rupture.
If caught early, this condition can often be managed conservatively with:
However, when progressive deformity develops or the tendon becomes irreparably damaged, surgical reconstruction may be necessary.
Runners sometimes push through medial ankle pain, assuming it is “just tendonitis.” Make sure you don’t ignore these symptoms, and get it checked out sooner rather than later.
The Achilles tendon absorbs enormous loads during running.
Symptoms include morning stiffness, pain during push-off, or swelling and tenderness along the tendon.
Treatment:
Conservative management is highly effective:
Surgery is rarely needed unless there is a full tear or chronic tendon degeneration that fails to respond to conservative management.
High mileage and repetitive impact can overload bones in the foot and ankle, leading to:
Signs to watch for:
Localised pain that worsens with training, swelling, and tenderness over the injured bone.
Pain often starts gradually, then becomes constant without rest.
The peroneal tendons run along the outside of the ankle, stabilising the foot. Injuries commonly occur due to:
Symptoms include lateral ankle pain, swelling, and occasional snapping sensations. Chronic injuries may lead to tendon tears.
Treatment:
Repeated sprains or ligament laxity can lead to chronic ankle instability.
Symptoms include:
Management:
Physiotherapy is the cornerstone of conservative treatment for all of these conditions.
I work with some of the best Physiotherapists in London, and will make sure that you receive high-quality, coordinated rehab.
This is likely to include:
The most effective strategy for avoiding ankle injuries in runners is intelligent load management.
The body adapts to stress, but only when given time to rest and recover. Rapid mileage increases, sudden introduction of speed work, or returning too quickly after illness or minor injury are common triggers for breakdown.
As a broad principle:
Cross-training can be particularly valuable.
As a cyclist, I often recommend incorporating low-impact aerobic work such as cycling or swimming to maintain cardiovascular fitness while reducing cumulative impact load.
Running shoes are not a cure-all, but they do matter.
Poorly fitted or worn-out shoes can exacerbate biomechanical inefficiencies. That said, there is no universal “best shoe.” The ideal choice depends on your foot type, running style, and training goals.
Key considerations:
Above all, your trainers should feel really comfortable.
Orthotics may be helpful for some individuals, particularly those with significant pronation or arch collapse, but they should be prescribed thoughtfully rather than used indiscriminately.
One of the most common patterns I see is runners presenting very late, often just weeks before race day, after months of worsening symptoms.
Pain that:
should be assessed as soon as possible.
Early assessment allows us to distinguish between straightforward overuse injuries and more serious pathology such as stress fractures or tendon tears.
In many cases, early intervention allows continued training with minor modification, rather than complete rest or weeks of rehab – often prolonging recovery by months.
I always aim to provide my patients with clarity and an individualised treatment plan.
Most marathon-related foot and ankle problems do not require surgery. Conservative management is highly successful in the majority of cases.
However, surgical intervention may be appropriate when there is:
Modern surgical techniques in foot and ankle surgery allow precise correction with improved recovery protocols.
My focus is always on restoring function and allowing patients, whether runners, cyclists, or walkers, to return confidently to activity.
That said, surgery is considered only when non-operative strategies have been exhausted or when there is clear structural pathology that will not resolve otherwise.
Surgery is reserved for patients with:
Examples include:
As someone deeply familiar with the demands of endurance cycling, I understand the psychology of athletes. Training plans are carefully constructed. Goals are set months in advance. The thought of stepping back due to injury can feel devastating.
But pushing through significant pain rarely ends well.
Marathon preparation is not just about cardiovascular fitness, it is about tissue resilience. Respecting recovery, addressing niggles early, and seeking specialist advice when needed are signs of intelligent training, not weakness.
Spring marathon season is an exciting time. With thoughtful preparation, most runners will reach the start line strong and injury-free
Conservative strategies work remarkably well when applied consistently, and surgical options are available if required - but early intervention is always preferable.
Train smart and protect yourself from injury by listening to your body.
Marathon foot pain is usually caused by repetitive overload. As mileage increases, tissues such as the plantar fascia, Achilles tendon and tibialis posterior tendon are subjected to thousands of loading cycles.
If training progresses too quickly or recovery is insufficient, these structures can become irritated or damaged.
Biomechanical factors, footwear choices and underlying structural issues can also contribute.
Not always, but it depends on the severity and nature of the pain.
Mild discomfort that settles quickly and does not alter your gait can sometimes be managed with load reduction and a short course of rehabilitation.
However, if the pain causes limping, persists beyond several days, worsens with activity, or is associated with swelling, you should seek assessment.
Continuing to train through significant ankle pain can lead to more serious injury.
Plantar fasciitis typically presents as sharp pain under the heel, especially with the first steps in the morning or after sitting.
The pain often improves as you move but can return after longer runs.
A clinical examination is usually sufficient for diagnosis, though imaging may be helpful if symptoms persist or the presentation is atypical.
Most ankle injuries in runners are overuse-related tendon problems rather than acute ligament tears.
The majority respond well to conservative treatment, including load modification, strengthening and footwear adjustments.
However, persistent medial ankle pain may indicate tibialis posterior dysfunction, which requires early specialist input to prevent progression.
Surgery is rarely required for common overuse injuries such as plantar fasciitis or mild tendon irritation.
It may be considered when there is structural deformity, progressive tendon rupture, recurrent instability, or failure of well-managed conservative treatment.
Early assessment helps determine the most appropriate pathway and often prevents problems from escalating.
In many cases, yes, but often with some training modification.
Cross-training, temporary mileage reduction, and structured rehabilitation often allow athletes to maintain fitness while addressing the injury.
The key is tailoring the plan to the diagnosis rather than adopting a one-size-fits-all approach.
If you are unsure about persistent marathon foot pain or ankle symptoms, early assessment provides clarity and reassurance, and often keeps you on track for race day.
Mr Martin Klinke is one of London’s most trusted, and experienced foot specialists. He performs many bunion surgeries each year, and is a highly skilled surgeon.
He offers this surgical treatment to private self-funded and insured patients at the Cleveland Hospital and the Cleveland Clinic in London.
You can find all his patient reviews here.
