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Ask the Running Doc: Running Injuries

Updated: Oct 19, 2018

It is no secret that runners get injured. In fact, depending on what study you look at, running injuries can affect 19-92% of runners [1-2]. Of the injured runners, 30-90% of them have to reduce or cease running because of their injuries [3]. Injuries take the fun and enjoyment out of running. So let’s dive in and examine what causes running injuries and what we can do to prevent them.

What causes running injuries?

Running injuries typically occur because people love to run so much! Eighty percent of running injuries are overuse injuries [5]. Runners have a bad habit of running too often, too much, too soon and don’t know when to get help! My suggestion is that if you are hurting for more than seven to 10 days, see a physical therapist to make sure it doesn’t turn into something that takes you away from running. The longer an injury is around, the longer it takes to get rid of it. 

It is not surprising that injury is so prevalent, since runners strike the ground between 800-2000 steps/mile, with forces as high as 1.5-5x their body weight. The faster a person runs, the fewer steps they take per mile.  For instance, someone running an eight-minute-mile pace will take 1,400 steps per mile, and if they are running a 12-minute-mile pace, they take approximately 1,951 steps per mile [4]. So why is step count important? Unfortunately, it means that slower runners tend to be exposed to an increased load over time [6]. However, no matter how fast you run, you are still striking the ground over and over in a repetitive motion. 

The exact cause of running injuries tends to be both diverse and multifactorial [5]; however, there are several factors that contribute to injury. Research has found the most common risks for running injuries were being a novice runner (running < 3 years), history of previous injury, use of orthotics or inserts, running on concrete surfaces, weekly running distance 30-39 miles, wearing running shoes for >4-6 months, participating in a marathons and age. Age was found to be a factor in primary hamstring and Achilles tendon injuries. Men and woman tend to have slightly different risk factor because of their different biology and physiology [5].  

Clinically, I see running injuries every day for many of the reasons above, but I also find that when injured runners come into the office they fit a pattern.  Many of them have not been consistent with their running program or have recently made a change that may not seem aggressive to them but is for their body. It is surprising how many people that “used to run a lot” and have taken several years off decide to start running five miles right off the bat. There are runners that don’t pay attention to their nutrition and become so fatigued during runs that they end up with an overuse injury.  I also see a lot of runners with poor postural control (especially women after they have had children), suboptimal running form, dysfunctional movement patterns (such as squatting), weakness in their hips, pelvic girdle and core, as well as tightness and stiffness in their muscles and joints.

Where do running injuries typically occur?

Several studies have pointed to the knee as the most injured area of the body in runners; nearly 50% of running injuries are at the knee. Other common injuries are in the lower leg, foot/ankle, hip/pelvis and lower back [5,7].

What are the typical injuries: what do they look like and what do we do?

This blog is already long, but it would be 10 or more pages long if I went into all of the common running injuries in detail, so I have highlighted the top four running injuries I treat in the clinic.

The knee may have a higher incidence for injury because it is trapped between the hip and the ankle. This makes it more susceptible to dysfunctional loading patterns if there is any weakness, tightness or dysfunction above or below it. Common knee injuries include Illiotibial band syndrome (IT band) and patellofemoral pain/chondramalacia.

1. ITB syndrome

What is it?

ITB is an irritation of the tissues at the outside of the hip, where the IT band originates, and at the outside of the knee where it inserts. ITB syndrome may also be irritation of the highly innervated fat deposit deep to the ITB itself.

How does it present?

Typically, there is pain and swelling at the knee, pain at the hip or outside of the knee, difficulty moving the knee from a straight to bend position, limping, sharp pain on the outside of the knee and pain that occurs with ground contact during running.

What are the risk factors?

Risk factors include overuse, training error, sudden increase in mileage or increased downhill running, repeated flexion/extension of the knee, pelvic obliquity and weakness or inhibition of the hip musculature.

What do you do?

There is controversy about foam rolling the ITB in popular literature, but there is no good research out there that discourages it. Gently or moderately rolling out the trigger points in the hip, thigh and knee can be very helpful in decreasing pain in the knee or hip.  Working with a massage therapist to decrease some of the soft tissue restriction may also be beneficial. Taping the ITB may help decrease the pain and load in the knee temporarily – say if you have to get through a race. However, the reason the ITB was injured in the first place is likely due to weakness in the pelvic girdle/hips. Glute exercises, single leg strength and possibly a running assessment would be ideal.  If you ignore the root cause, you will only be putting a band aid on it.

2. Patellofemoral pain syndrome (PFPS)/chondromalacia

What is it?

There is not a clear definition of what PFPS is; however, it may possibly be from increased contact of the patella on the femur or irritation of the infrapatellar fat pad or retinaculum.

How does it present?

It presents with pain and aching in the front of the knee, especially with prolonged sitting, and there may be clicking, pain with descending stairs, pain with bending or squatting, swelling and crepitus or noises in the knee.

What are the risk factors?

Risk factors include hip weakness, pelvic obliquity, inability to control your leg in single-leg stance or the stance phase of gait, excessive femoral internal rotation or adduction, knee valgus or collapsing in and being female.

What do we do?

Much like ITBS, hip strength and strength with single-leg activities are musts. Strengthening the glutes, adductors, core, quadriceps and hamstrings is important.  Single-leg balance and proprioception are also key to better running mechanics.  Rolling on a foam roller might be helpful if there are trigger points anywhere in the hips or thigh, ice on the front of the knee will help decrease swelling and tape may help unload the patella.

3. Plantar fasciosis

What is it?

Plantar fasciosis  refers to microtears in the plantar fascia and progressive collagen degradation at the medial calcaneal tubercle. Sometimes, there is a component of the lower back contributing to plantar fasciosis that is overlooked.

How does it present?

Plantar fasciosis presents with a sharp pain in the heel in the morning or after sitting down for awhile, pain in the heel during the first five to 10 minutes of running and increased calf tightness. Walking barefoot is more uncomfortable, and it hurts when you touch the heel.

What are the risk factors?

Risk factors include training error (too much, too soon), old shoes, lower longitudinal arch of the foot and increased ground reaction forces during running.

What do we do?

It will be important to remember that even though the pain is in the foot, the entire kinetic chain will have to be addressed to conquer this issue. First, start with improving the flexibility of the lower leg/calf muscles and foot. Increase hip and core strength to help decrease possible over pronation and movement at the foot. Work on strength of the foot/arch and single-leg balance. Again, massage and manual therapy will also help improve this condition.

4. Achilles tendonosis

What is it?

Achilles tendonosis  refers to the degradation of the tendon’s collagen in response to chronic overuse. Microtrauma occurs over time, and the tendon is unable to repair itself.

How does it present?

Swelling, weakness with heel raises and pain with the use of the calf muscles are all symptoms. There may be a bump on the Achilles, joint stiffness, pain with palpation of the tendon, crackling/popping and pain during the push-off phase of gait.

What are the risk factors?

Risk factors include age > 40, sudden increase in load on the tendon (running more, faster or on more hills), increased intensity of exercise, decreased flexibility of the calf muscles, over pronation, heel whip, running form, nutrition, certain antibiotics, like Cipro, and shoes that are too old.

What do we do?

Eccentric [SH8] strengthening of the tendon is the number one thing that research supports to improve Achilles tendon issues. Other things are strengthening the foot/ankle and supporting muscles around the calf muscles to help distribute the load and strengthening the core and glutes to help with landing mechanics. Improving the flexibility of the calf muscles and plantar fascia helps as well.

Take home message: if you have an injury take care of it!  The sooner you take care of it, the sooner you will be able to enjoy running again. If you are unable to achieve relief from your symptoms on your own, don’t wait too long to get help. Many people don’t know that in the state of Georgia you can see a physical therapist for eight visits or 21 days without seeing an MD for a script. Your physical therapist will evaluate you, and if he or she feels like you need to see an MD, he or she will refer you to one. I have heard that people are afraid to see a PT because they don’t want to stop running. 

I’m here to tell you that PTs who truly understand how to treat runners will not stop you from running unless it is absolutely necessary. They should do a running gait analysis to determine if there is anything you can adjust in your gait to help decrease pain and improve your recovery. They should do manual therapy if it is indicated and help you improve the dysfunctional movement patterns and strength you are lacking.

Good luck out there, and I hope you stay injury free


  1. Yamato TP, Saragiotto BT, Dias Lopez, A A Concensus Definition of Running-Related Injury in Recreational Runners: A Modified Delphi Approach. . J Orthop Sports Phys Ther. 2015;45:375-380.

  2. Van Gent RN, Siem D, van Middelkoop M, van Os AG, A Bierma-Zeinstra  SM, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic  review. Br J Sports Med 2007;41:469–480. doi: 10.1136/bjsm.2006.033548

  3. Magrum, E. (2014). Epidemiology of Running Injuries. In F. Connor & F. Wilder (Eds.), Textbook of running medicine (2nd ed., Vol. 1, pp. 15-27). Monterey, CA: Healthy Living.

  4. Hoeger, W. F. et al. 2008. One-mile step count at walking and running speeds. ACSM's Health and Fitness Journal 12(1): 14-19.

  5. van der Worp MP, ten Haaf DSM, van Cingel R, de Wijer A, Nijhuis-van der Sanden MWG, Staal JB (2015) Injuries in Runners; A Systematic Review on Risk Factors and Sex Differences. PLoS ONE 10(2): e0114937. doi:10.1371/journal.pone.0114937

  6. Hreljac A. Impact and overuse injuries in runners. Med Sci Sports Exerc 2004;36:845–9.

  7. Taunton JE et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36:95–101


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