Common Running Injuries

Running is a repetitive movement by nature and with ground reaction forces of 2-3 times the runners body weight there is a high level of stress placed upon the body. The majority of injuries experienced by distance runners are overuse injuries resulting from continued degeneration as a result of repetitive load. Acute injuries are also possible due to inadequate warm ups, poor footwear of just unavoidable circumstances.

The knee is the most commonly injured area of the body followed by the foot and ankle, the lower leg, the hips and the lower back. Below is a list of common running injuries with tips on how to identify your injury and some possible solutions to prevent reoccurrence  

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome is the most common knee complaint in young runners. The condition is a result of muscle and connective tissue imbalances around the knee joint. Most commonly the lateral quadriceps muscle, the vastus lateralis, creates a lateral pulling force stronger then the oblique fibres of the medial quadriceps, the vastus medius (VMO). Gender differences in the incidence of patellofemoral pain exist with women being around 2 times more likely to experience the condition (Boling et al, 2010)

Symptoms

Patellofemoral pain syndrome produce pain in and behind the patella (knee cap). The pain is usually experienced when climbing and descending stairs, squatting or during the running gait, particular during hill climbs. A tell tail sign is pain as the knee is flexed through 30-45 degress, there may also be pain during periods of prolonged sitting. There usually is minimal swelling and activity usually aggravates the injury further though you can most likely run through the pain

Causes

Weakness of the hip muscles (Ireland et al, 2003, Robinson et al, 2007), particularly the external hip rotators is thought to position the upper thigh such that the lateral quadriceps becomes more active. Strengthening of these hip rotator muscles along with other rehabilitation exercises reduces symptoms (Dolak et al, 2011). Women have higher incidences due to wider hips resulting in increased Q angles, this increased Q angle increases the force requirement of the hip muscles to maintain upper leg and knee in alignment

Solutions

• Strengthening of the gluteus medius and maximus muscles as well as the deep hip rotators with specific movements to control hip adduction and internal rotation (see article on the Importance of the Gluteus muscles in runners)
• Orthotics have been used as part of the treatment program with some success (Timm et al, 1998, Collins et al, 2008). It’s thought orthotics help to control the internal rotation of the upper leg, leading to reduced symptoms.
• Motion control shoes - A review by Cheung and Gabriel, 2007 suggested motion control shoes do decrease patellofemoral pain incidence in those with excessive pronation

Can you run on?

Patellofemoral pain can be quite debilitating and rehabilitation will be more effective if you take a break from running so the injured area is less irritated. In saying that there are minimal ramifications from pushing through the pain if you have an event you’d like to see completed

Iliotibial Band (ITB) Syndrome

The ITB is a connective tissue band running from the tensor fasciae latae (muscle on the outside of the hip) down to the knee, it is involved in stability and extension of the knee and leg abduction. Irritation of the band commonly occurs in long distance runner and cyclists

Symptoms

A dull ache over the lateral aspect of the knee which is exasperated by repetitive exercise in particularly running on uneven surfaces. The pain will most likely appear during the later stages of the run. There may be incidences of swelling and localized tenderness on the outside of the knee

Causes

Friction of the Iliotibial band is most common when the knee is bent at 25-30 degrees. Decreases in hip abductor strength are thought to lead to pelvic drop, increasing the tension on the ITB, similarly decreases in external hip rotator strength are thought to increase internal rotation of the femur during gait, also increasing tension and friction on the ITB (Fredericson et al, 2000, Ferber et al, 2010, Noehren et al, 2007). In cyclists seat height and cleat positioning are possible contributors

Solutions

• Strengthening of the external hip and adductor muscles using specific exercises
• Possible pronation control through orthotics or supportive footwear
• Rest
• Connective tissue massage and release techniques
• Anti-inflammatories therapies

Can you run on?

ITB can become easily exasperated to the point where exercise need to be ceased. In the incidence of swelling and prolonged tenderness running will need to be reduced until a solution can be found. Reducing your training load may allow you to finish your event in question, complete rest though is always a better option until the initial irritation subsides

Anterior lateral shin splints (stress fractures)

Stress fractures of the shin bone are the most common form of stress fracture in athletes with fractures to the tarsal bones of the foot being the second most common (Matheson et al, 1987, Bennell et al, 1996). Stress fractures are more common in the feet of track athlete and in the lower leg of distance runners (Bennell, 1996)

Symptoms

Stress fractures result in localized areas of sharp pain that can be felt during impact or with palpation. Pain usually increases with exercise duration

Causes

Stress fractures are a result of the failure of bone tissue to adapt to the repetitive loads being presented. The formation of shin splints is most likely multifactorial incorporated bone health, footwear, foot structure and running biomechanics. Anterior Shin splints differ from Medial Tibial Stress Syndrome in they are likely a result of increased impact loading due to hard surfaces and ridged footwear. Tarsal stress fractures are more likely a result of minimalist footwear as worn by track athletes. Nutrition may play a role in stress fractures, with calcium intake and lower bone density being linked with stress fractures (Marx et al, 2001, Nieves et al, 2010). Dietary restriction and amenorrhea have also been linked to increased stress fractures in women (Bennell et al, 1995, Barrow et al, 1988)

Solutions

• Footwear - Unlike Medial Tibial Stress Syndrome, Shin Splints may benefit from more cushioned and less supportive footwear. A ridged shoe along with heal striking increases tibial loading forces which may contribute to the formation of shin splints. This could explain the high rates of shin splints found in military personal training in ridged boots. Introducing padded slightly more flexible footwear may shift loads to different areas of the body
• Foot strike – Shifting to a slightly more forefoot strike and reducing shoe heel drop may reduce peak landing loads decreasing the incidence of shin splints (Edwards et al, 2009, Hobara et al, 2012).
• Rest
• Grass running and low impact cross training, particularly cycling

Can you run on?

I’m sorry to say it, but no, stress fractures of tibia require usually 6-8 weeks to heal this can vary based on the severity. Similarly stress fractures of the feet also require complete rest in order for recover, pushing through this pain may only result in further complications

Medial Tibial stress syndrome (MTSS)

Medial tibial stress syndrome is a condition of the shin bone of the lower leg.  MTSS is commonly grouped under shin splints along with anterior tibial stress fractures and compartment syndrome. It’s important to separate these conditions as causes and treatments are different. MTSS is thought to arise from irritation of the periosteum, the connective tissue junction of the lower leg muscles with the tibia. Stress fractures and bone remodeling of the tibia have also been found at this point.

Symptoms

MTSS causes pain and possible swelling along the medial side of the shin bone. Isolated areas of severe pain warrants further investigations and imaging scans will most likely be ordered to diagnose the severity

Causes

Higher incidences of MTSS have been found in those with increased pronation (Bennett et al, 2001, Yates et al, 2004). Pronation during gait may increase the force output of the medial soleus muscle and tibialis posterior increasing injury risk. Increased training loads and body weight are also contributing factors as may be tight calf muscles particularly the soleus (deep calf muscle)

Solutions

• Proceeding your warm up always stretch your soleus muscle - soleus stretch, heel taps
• Look into a medial arch support to help control pronation or choose cushioned footwear with some medial posting
• Perform hip muscle strengthening to help control pronation
• Rest

Can you run on?

Provided your pain hasn’t reached the point of where you can find isolated points of severe pain you should be ok to run but at reduced distances. You must though either correct your gait or attempt new footwear, as continued training is unlikely to produce a differing result

Plantar fasciitis

The plantar fascia is a layer of fascia on the base of the foot which helps maintain stability of the longitudinal arch of the foot. The plantar fascia is active throughout the gait and injury is usually a result of repetitive stress

Symptoms

Plantar fasciitis produces pain on the under side of the foot just on the toe side of the heel. Pain is, usually worse in the morning and subsides as activity begins. There may be tenderness when palpating the medial underside of the heel

Causes

Conflicting data exists in regards to the causes of plantar fasciitis, over pronation, increased body weight and decrease calf muscle flexibility (Riddle et al, 2003, Irving et al, 2007) have all been reported more often than they have not in patients with plantar fasciitis. Theoretically decreases in flexibility in the soleus (deep calf) brings about early pronation, pronation causes increased forces on the plantar fascia. With plantar fasciitis being more common in runners, those with jobs involving prolonged standing and the overweight it can be assumed repetitive load is a contributing factor. It’s not yet understood whether this load becomes too great for the intrinsic foot muscles to handle resulting in the forces being shifted to the plantar fascia resulting in injury

Solutions

Evidence on the methods of treatment for planta fasciitis is inconclusive

• Orthotics have been used as part of treatment but evidence is still inconclusive. Theoretically repositioning the foot and improving arch height should help
• Body weight reduction will decrease load on the plantar fascia
• Ankle flexibility and calf stretches will increase range of motion and delay pronation lessening the stretch on the plantar fascia. Studies have been conducted with outcome success equal to that of orthotic intervention
• Intrinsic foot muscle strengthening should decrease the contribution of the plantar fascia in maintaining the longitudinal arch of the foot, no known research
• More supportive shoes and less speed work may in the short term allow you to continue running. When the problem subsides returning to flatter more flexible shoes may be ok
• Rest

Can I run on?

Like many injuries a small problem can become a big problem. Take some time off, when the pain subsides take a further 5-10 days off. This is similar with muscle tears, just because the pain is gone, the injury is still present and the fascia is most likely still damaged  

Achilles Tendinitis

Tendinitis refers to the inflammation of a tendon usually due to overuse; tendinosis refers to the degenerative breakdown of the connective tissue of the tendon. Debate exists as to whether tendinosis is a progression of tendinitis

Symptoms

Pain and swelling in the effected tendon, the pain may be worse first thing in the morning and lessen with a gradual warm up

Causes

Tendinitis is linked to increased training volume and loads. Men are also more susceptible as are those with lower levels of flexibility. Pronation during gait may also contribute to increased load on the Achilles

Solutions

• Footwear – Minimalist and flat shoes have been shown to increase loads on the Achilles tendon. Typical supportive shoes with a higher heel drop and larger medial posting have been shown to decrease ankle dorsi-flexion and knee flexion during gait, shifting forces to the hip, lower back and tibial plateau as opposed to the Achilles tendon and anterior knee as with flatter running shoes. Although this is a progression away from what is the called the “natural gait” these changes will be beneficial in lowering Achilles and Patella tendon loads. Try a larger more supportive shoe with at least a positive 10mm heal drop
• Rest
• Anti-Inflammatories
• Warm up pre run and should include stretches for the soleus and gastrocnemius

Can I run on?

No, if you’ve had your tendonitis for a prolonged period you’re at increased risk of rupturing the Achilles tendon. So if you pain is quite unbearable rest and seek fixing this problem rather than reducing your training distance

Muscle strains and tears – The soleus and hamstring

Muscles strains or tears occur when the eccentric  loading of a muscle becomes too great for the muscle fibres. Tears can be minor or implicate large areas of the muscle body. Tears result from tight or weak muscles or both. The soleus (deep calf) muscle and the hamstring muscle are the most commonly torn muscles in runners

Symptoms

Muscle tears usually occur suddenly and are acute in nature, there is a localized area of pain that appears immediately causing running to cease. There may be swelling and some bruising. Alternatively some muscle tears especially close to the muscle tendon junction can occur slowly and become more and more exasperated with time

Causes

Causes can be a result of muscle tightness or weakness and rapid increases in training distance or training speed. Muscle tightness can be a biomechanical or postural issue, inactive gluteal muscles (Bum) may lead to increased hamstring tone in order to produce hip flexion, the same can be said of tight hip flexors and the abdominals. Muscle weakness can be included in the rapid increases in training speed and duration category as the muscle has yet to strengthen and remodel to cope with this new training load

Solutions

• Correcting biomechanical and postural problems
• Look at training methods and equipment that may have caused the injury
• Eccentrically strengthen and stretch the muscle in question

Hamstring Tears

Correct biomechanical postural problems

Decreasing hamstring tone through posture and biomechanical changes may prevent consistent hamstring strains. Posterior pelvic tilt is a sign of overactive hamstrings and stronger abdominals. Posterior pelvic tilt limits gluteus muscle activity and further increases hamstring load. Attempt to introduce lower back extension exercises and Glute strengthening exercises

Training methods and equipment

Reduce speed running and sprints on flat ground until a full recovery is complete. Replace flat intervals with hills or stairs. Lighter shoes may also reduce hamstring load

Eccentrically Strengthen and stretch the hamstring muscles

Perform light stretching, Bench hamstring stretch

Progress to eccentric strengthening late in recovery, leg swings (beginner), flat interval work (intermediate) single leg deadlift (advanced)

Soleus Tears (deep calf)

Training in shoes with a larger heel drop decreases load on the soleus. This can be beneficial if immediate tears are your concern. Long term training in a flatter shoe may be beneficial as it increases dorsi flexion range of motion which may have long term benefits for other injuries whilst providing possibly improvements in running economy

Perform soleus stretches and heel taps to strengthen and stretch the soleus (see strength session warm up for a description)

Perform Soleus strengthening exercises

Can I run on?

No, Initially muscle tears require rest. Minor tears may heal in under a week whilst larger tears may take several weeks. It’s important once the pain from the tear has ceased to allow a further weeks rest prior to recommencing the training which caused the initial injury. Similar to a cut, an absence of bleeding doesn’t indicate the tissue has formed to its pre injury state

References

Barrow, Gray W., and Subrata Saha. "Menstrual irregularity and stress fractures in collegiate female distance runners." The American journal of sports medicine 16.3 (1988): 209-216.

Bennell, Kim L., et al. "The Incidence and Distribution of Stress Fractures in Competitive Track and Field Athletes A Twelve-Month Prospective Study." The American Journal of Sports Medicine 24.2 (1996): 211-217.

Bennell, Kim L., et al. "Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis." Clinical Journal of Sport Medicine 5.4 (1995): 229-235.

Bennett, Jason E., et al. "Factors contributing to the development of medial tibial stress syndrome in high school runners." Journal of Orthopaedic & Sports Physical Therapy 31.9 (2001): 504-510.

Boling, M., et al. "Gender differences in the incidence and prevalence of patellofemoral pain syndrome." Scandinavian journal of medicine & science in sports 20.5 (2010): 725-730.

Cheung, Roy TH, and Gabriel Y. Ng. "A systematic review of running shoes and lower leg biomechanics: a possible link with patellofemoral pain syndrome?: review article." International SportMed Journal: Foot and ankle injuries sport 8.3 (2007): 107-116.

Collins, Natalie, et al. "Foot orthoses and physiotherapy in the treatment of patellofemoral pain syndrome: randomised clinical trial." Bmj 337 (2008).

Dolak, Kimberly L., et al. "Hip strengthening prior to functional exercises reduces pain sooner than quadriceps strengthening in females with patellofemoral pain syndrome: a randomized clinical trial." journal of orthopaedic & sports physical therapy 41.8 (2011): 560-570.

Edwards, W. Brent, et al. "Effects of stride length and running mileage on a probabilistic stress fracture model." Medicine and science in sports and exercise 41.12 (2009): 2177-2184.

Ferber R, Noehren B, Hamill J, Davis IM. Competitive runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. J Orthop Sports Phys Ther. 2010;40:52–58

Fredericson, Michael, et al. "Hip abductor weakness in distance runners with iliotibial band syndrome." Clinical Journal of Sport Medicine 10.3 (2000): 169-175.

Giuliani, Jeffrey, et al. "Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners." Orthopedics 34.7 (2011): 550.

Ireland, Mary Lloyd, et al. "Hip strength in females with and without patellofemoral pain." Journal of orthopaedic & sports physical therapy 33.11 (2003): 671-676.

Irving, Damien B., et al. "Obesity and pronated foot type may increase the risk of chronic plantar heel pain: a matched case-control study." BMC musculoskeletal disorders 8.1 (2007): 41.

Nieves, Jeri W., et al. "Nutritional factors that influence change in bone density and stress fracture risk among young female cross-country runners." PM&R 2.8 (2010): 740-750.

Noehren B, Davis I, Hamill J. ASB clinical biomechanics award winner 2006 prospective study of the biomechanical factors associated with iliotibial band syndrome. Clin Biomech (Bristol, Avon). 2007;22:951–956

Marx, Robert G., et al. "Stress fracture sites related to underlying bone health in athletic females." Clinical Journal of Sport Medicine 11.2 (2001): 73-76.

Matheson, G. O., et al. "Stress fractures in athletes A study of 320 cases." The American Journal of Sports Medicine 15.1 (1987): 46-58

Riddle, Daniel L., et al. "Risk factors for plantar fasciitis: a matched case-control study." The Journal of Bone & Joint Surgery 85.5 (2003): 872-877.

Robinson, Ryan L., and Robert J. Nee. "Analysis of hip strength in females seeking physical therapy treatment for unilateral patellofemoral pain syndrome."journal of orthopaedic & sports physical therapy 37.5 (2007): 232-238.

Timm, KENT E. "Randomized controlled trial of Protonics on patellar pain, position, and function." Medicine and science in sports and exercise 30.5 (1998): 665-670.

Yates, Ben, and Shaun White. "The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits." The American journal of sports medicine 32.3 (2004): 772-780.