Introduction
Running is one of the most popular forms of exercise. It is simple, easy, inexpensive, and does not take much organization. However, the incidence of running injuries is between 20% and 79% annually depending on what study you look at.1 Most of these injuries are not serious, but they can be painful and derail a training and workout program. They can sometimes require medical treatment and time away from exercise. Some risk factors can be controlled and reduced, and some cannot. The goal of this article is to identify some of the risk factors and educate you to know how to recognize and treat injuries early on, or better yet prevent injury by reducing the risk factors that we can control. The most common injuries are “runner’s knee” (patellofemoral pain syndrome), “IT Band Syndrome“ (iliotibial band syndrome), “kneecap pain” (patellar tendinopathy), shin splints, achilles tendonitis, and plantar fasciitis. Several common risk factors include training load, history of previous injury, body mass index (BMI), and biomechanical factors. Another risk factor is the amount of time you spend running. The more hours that someone spends running the more likely they are to have a running injury, especially for novice runners. For every 1,000 hours of running about 18% of novice runners have an injury, and 8% of recreational runners have an injury.2
Runner’s Knee (Patellofemoral Pain Syndrome) Injury and Treatment
Runner’s knee, or patellofemoral pain syndrome (PFPS) is pain behind the kneecap. It is caused by friction of the kneecap rubbing on the thigh bone. The kneecap is supposed to sit in a groove where it can move as the knee bends but PFPS is when the kneecap is pulled towards the side of the knee where it rubs on the bone and becomes irritated. PFPS was the most common reported running injury, which gives it the nickname “runner’s knee.”
Risk factors for runner’s knee are being shorter, running less frequently, and having knee alignment issues. The alignment issues are typically that the kneecap sits more to the outside or too far up on the thigh bone, or that the knee moves towards the center from the hip. The risk factors that we can control are running frequency, so be sure to build up slowly. We can also impact some alignment issues through strength and neuromuscular control.
Treatment for runner’s knees is typically aimed at improving the biomechanical factors. There are two main theories of why the knee would collapse inward: a top down approach and a bottom up approach. The top down approach is that weakness in the hip allows the thigh bone to turn inward because it is not strong enough to keep it in the right position. There is a strength imbalance where people are much stronger in the front to back direction than the side to side direction. Typically people with runner’s knee are quite weak in the muscles that control side to side strength in comparison to the muscles which move front to back. Strengthening the gluteus medius is one of the best ways to fix runner’s knee. In addition, people with patellofemoral pain syndrome generally over emphasize their quad muscles with running and squatting, and do not use the muscles on the back of their legs enough. Strengthening the gluteus maximus and hamstrings will also help reduce runner’s knee pain. If you have pain behind your kneecap when you run or exercise, try the strength program that I have created here to start doing the best evidence based exercises to reduce your patellofemoral pain.
Iliotibial Band Syndrome Risk Factors and Treatment
Your Iliotibial band (IT band) is a dense band of connective tissue that runs along the outer part of your thigh. It goes from your hip to your knee where the seam of your pants would be. Sometimes this tissue can get irritated and become painful. Although it could be anywhere along the IT band, the most common place for IT band pain is closest to the knee joint. The IT band gets irritated from repetitive motions such as running or biking. Oftentimes people can run or bike a certain distance, and then the pain becomes worse and worse until it is no longer tolerable. The pain then diminishes if activity level is reduced.
The biggest risk factor for developing IT band syndrome is weakness in the hip. Specifically the gluteus medius which is muscle that prevents the knees from drifting inward when moving. If the knee starts to drift inward with running or walking then you will cause tension in the IT band which can allow for a mechanical irritation as the IT band rubs along the side of the knee. As you do repetitive activity, the IT band gets very irritated and painful.
Treatment of Iliotibial band syndrome should include hip strengthening. I have created a 6 week IT band Home Exercise Program that can be a great starting point. Since this is a mechanical irritation of the IT band, the key is going to be to get the gluteus medius to learn to kick in and prevent the knee from drifting inward. Typically people can exercise for a certain amount of time before the onset of pain, so building strength and endurance is important. Another good tip is to do one or two gluteus medius exercises just before going for a run to make sure your brain is talking to your hip muscles before your run. Foam rolling can be helpful in reducing pain when done following activity. It also does not need to be done for an extensive amount of time, typically 30-60 seconds on each muscle group (IT band, quads, hamstrings, calf) is all that is needed.
Patellar Tendonopathy Risk Factors and Treatment
Patellar tendon issues are also common running injuries. These include patellar tendonitis, which is more acute, and patellar tendinopathy which is more chronic. Both are an irritation of the patellar tendon from putting more load through the tendon from your kneecap to your shin than your body can safely handle.
A big risk factor for patellar tendinopathies is an imbalance of strength in the front of your leg compared to the back. Having a higher body mass index and running more frequently also are risk factors for patellar tendinopathy. Most people are used to loading the quads on the front of your thigh, and not as good at loading the muscles on the back of your leg like your gluteals and hamstrings.
I have created a program to help with overall running strength that will address the imbalance of the front and back of the leg. The goal is to get the big powerhouse muscles on the back of the leg and body to do more work, and allow the muscles on the front of the thigh to do less work. Additionally, the goal is to train the patellar tendon to accept and handle load better going forward. This will allow the normal strains of running to not be at an irritating level to your patellar tendon.
Posterior Shin Splints Risk Factors and Treatment
Posterior shin splints or “medial tibial stress syndrome” or “posterior tibialis tendonitis” are all the same thing. It means that there is damage to the muscle or tendon that lives on the back of the shin near the inside part of the leg. It is caused by doing too much activity too quickly. The posterior tibialis is a muscle on the back of the tibia (shin bone) which controls inward rotation of the foot and helps to keep the arch of the foot up.
Risk factors for shin splints are being overweight, having collapsing arches, and weakness of the posterior tibialis.
The best way to treat shin splints is to reduce activity level and build up the muscles of the foot and leg, which I have built out in this posterior tibialis tendonitis home exercise program. It will be important to improve your balance as well as increase the muscle strength as this muscle is one of our balance muscles. Ice can help reduce inflammation if the injury is acute. The long term fix is going to be strength and balance training of the foot and ankle. The goal is to increase your strength enough to not be stressed as you are running or exercising.
Achilles Tendonitis Risk Factors and Treatment
The Achilles tendon is the thick tendon connecting your calf muscles to your heel. Achilles tendonitis is an irritation of that tendon. The calf is made up of two muscles, the gastrocnemius and the soleus, which both attach into the Achilles tendon. This is a common area to injure when running because the calf helps us push forward off the toes when running or walking.
Some risk factors for Achilles tendonitis are easier to change than others. The amount of flexibility in your ankle and your gait or running mechanics will impact how you absorb load with your calf. If you are a forefoot runner the risk of injury to the Achilles tendon also increases. The strength and endurance of your calf muscles also are going to impact the ability of your body to absorb strain and stress.
Treatment for Achilles tendonitis needs to address strength, flexibility, and endurance like this Achilles tendonitis home exercise program. The goal is to gradually overload the system to make it adapt and not react to repetitive load like running. The literature shows that with this type of injury eccentric training is the best for remodeling the tissue to handle load better moving forward. This means that the muscles are being stretched while they are under tension. For example, focusing on the going down phase of a heel raise can be therapeutic, while the going up phase can be irritating. It will be important to train both the gastrocnemius and the soleus muscles in both strength and endurance as they both turn into the Achilles tendon.
Plantar Fasciitis Risk Factors and Treatment
The plantar fascia is dense connective tissue on the bottom of your feet. It runs from your heel all the way to the ball of your foot near the base of each toe. Its job is to help support the arch of the foot, and to store and release energy like a spring when you run or walk. The most common signs of plantar fasciitis is pain on the bottom of the foot with activity and painful first steps when getting out of bed.
Risk factors of plantar fasciitis increase if you are a forefoot runner, have a higher body mass index, have collapsing arches when standing or running, and if you have poor flexibility of your calf muscles.
Plantar fasciitis is a soft tissue injury that can be treated with mobilization of the plantar fascia, stretching both the gastrocnemius and soleus, and increasing your foot ankle strength like in this plantar fasciitis home exercise program. A useful trick is to freeze a water bottle and roll the bottom of the foot on it. That will give you the anti inflammatory effects of cold while you mobilize the tissue. The tissue that makes up your calf muscles will turn into the Achilles and then that turns into the plantar fasciitis. Stretching both the gastrocnemius and the soleus has been shown to reduce the overall tension on the plantar fascia and help resolve plantar fasciitis. You can focus the stretch even more by stretching your calf muscles while you have your big toe up on a towel or elevated surface.
Conclusion
While running injuries are common, they are typically not severe. Some risk factors can be reduced by gradually building your running tolerance so that your body has time to get stronger before increasing the load too much. Many biomechanical risk factors can be reduced with specific strength training. Many people are hurt by doing too much too fast. Take it slow at first and see how your body adapts. If you start to feel any of these common running injuries, back off on the running, and try some of the strength programs that I have created. These are programs that I have used to help train myself, my family, and hundreds of runners to prepare for running events ranging from 5k to ultramarathons and ironman triathlons. Focus on controlling the risk factors that you can impact and you will be a much safer runner to help keep running a sustainable and effective part of your exercise program.
1. van Gent, B.R.; Siem, D.D.; van Middelkoop, M.; van Os, T.A.; Bierma-Zeinstra, S.S.; Koes, B.B. Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br. J. Sports Med. 2007, 41, 469–480.
2. Benca, E., Listabarth, S., Flock, F. K. J., Pablik, E., Fischer, C., Walzer, S. M., . . . Ziai, P. (2020). Analysis of running-related injuries: The Vienna study. Journal of Clinical Medicine, 9(2), 438. doi:https://doi.org/10.3390/jcm9020438
3. Lopes AD, Hespanhol Júnior LC, Yeung SS, Costa LO. What are the main running-related musculoskeletal injuries? A Systematic Review. Sports Med. 2012 Oct 1;42(10):891-905. doi: 10.1007/BF03262301. PMID: 22827721; PMCID: PMC4269925.