Running Injuries

Running Injuries

Running is one of the most common forms of exercise. It is a convenient and efficient workout that can be an escape from the noise and stress of the outside world; it can be a great way to get your day started off on a good foot, or to decrease stress after a long day of work.  Many runners use running as their primary, and sometimes only source of physical activity.  Running places a lot of stress on our body and just like with any sport there are inherent injury risks.  When compared to other types of aerobic exercise such as biking, swimming, or walking, running has a higher risk of injury.  This is tied to the amount of impact that our body undergoes during running and the need to dissipate those forces between muscles and joints.  In this blog we will discuss some common running injuries, some potential causes, and some potential management strategies.

Common running injuries

According to Francis et al. the knee is the most common location on injury among runners, followed by the foot and ankle then shin area.  The most common injury is patellofemoral pain followed by: achilles tendon pathology, medial tibial stress syndrome, or "shin splints"; plantar fasciitis; and IT Band syndrome.  The common trend among all of these injuries is that they are all "overuse injuries."  Overuse injuries occur when the demand that we place on our body tissue exceeds that tissue's capacity for load.  So what are these common injuries? What causes them?

Patellofemoral pain: 

• Our patellofemoral joint is the articulation between our knee cap, or patella, and our femur.  As we run, that joint is subject to compression and shear forces.  Those forces are not inherently bad, but if our body is not ready for those forces, it can result in pain that commonly feels like it is right behind, or around your patella. This condition is commonly referred to as "runners knee" and accounts for 17% of all injuries in runners.  For more information on patellofemoral syndrome, you can view my blog post here.

Achilles Tendon Pathology:

• Before talking about tendon injury, it is important to know what a tendon is.  The tendon serves a non-contractile continuation between the muscle and bone. The muscle contracts, those forces are transmitted through the tendon, and the bone is moved.  The achilles tendon is the continuation of our calf muscles which serve to point our toes (plantar flex), or to slow the descent of our heel when running on our toes.  They also help to control the amount of knee bending.  If our tendon has not been trained to handle the level of stress that it undergoes with running, the tissue can be damaged and result in pain.  Some of the common pain sites for achilles tendon pathology are at the base of the calf at the "musculotendinous junction," the "midportion" of the achilles, a couple inches above the heel, and at the insertion of the achilles onto the heel.

Medial Tibial Stress Syndrome:

• Medial Tibial Stress Syndrome is commonly referred to as shin splints.  Shin splints is a "catch all" term for pain in the anterior shin area.  The diagnosis of shin splints does nothing to help with management as the pain can be from a few different things.  The main causes that I have seen are:
• True "medial tibial stress syndrome:" where the bone itself is beginning to be overworked and may be progressing toward a stress fracture if not handled properly. 
• Tibialis anterior shin splints: Our tibialis anterior muscle sits just lateral to our big shin bone (tibia) and actually inserts along the bone.  As we run, our tibialis anterior pulls our toes toward our face and slows the descent of our foot after our heel hits the ground. Slowing this descent requires a lot of work which can potentially result in an overload presenting as shin pain at the interface between the muscle and the bone.
• Medial musculature shin splints: When I have seen this type of shin splints it is often from an overload of the soleus muscle (one of our 2 calf muscles) at its insertion onto the medial side of the tibia, similar to the tibialis anterior overload that can happen on the lateral side.

Plantar Fasciitis:

• The plantar fascia, also called the plantar ligament, is a non-contractile piece of tissue that serves to help support the arch of our foot.  We also have some musculature that serve to help support our arch.  Running places a lot of stress on the muscles of our feet to absorb the force of hitting the ground.  As we run more, the repetitive stretching of our plantar fascia can potentially get worse as our foot musculature fatigues and is not able to help attenuate the forces of running as much as they were earlier in our run and the plantar fascia has to do a little more to resist arch collapse.  Over time, that can result in some pain on the bottom of the foot, commonly at the insertion of the plantar fascia onto the medial portion of our heel and can be very painful with walking after sleeping or prolonged sitting.

IT Band Syndrome:

• The iliotibial band (IT band) runs from some hip musculature, down the outside of the leg, overlies the lateral portion of our knee and inserts onto the top of our tibia just beneath the knee a bony landmark called "gerdy's tubercle."  As we run, that IT band is compressed against the lateral portion of our knee and also undergoes shear forces from the femur rotating underneath of the IT band.  This force can be made more stressful if the hip musculature does not do a good job controlling the "internal rotation" of our femur which places more stress on the IT band at the level of the knee and can potentially result in pain.

How Can These Injuries be Prevented?

Prepare:

• Preparation involves building up the load tolerance of our bones, joints, and musculature so that they are ready to handle the demands of running.  If your musculature and tendons are strong, they will be able to handle more of the demands of running. Stronger musculature also helps to improve running economy making each stride less tiring.  Our bones and joints also benefit from some preparation.  If you have been a couch potato for 10 years and decide to get into shape, your bones and joints have not undergone the repetitive impact loading that running will place on your body and it may be wise to start with a walking and elliptical program that progresses to a walk-jog-walk-jog program before doing any sort of longer runs.

Appropriate Progression:

• If you are looking to get into running, it is important to not overdo it early on.  As we perform physical activity our bodies release endorphins.  These endorphins help to decrease our perception of pain.  This is one the the many amazing effects of exercise, but can also allow us to push ourselves a little more than our bodies are prepared to handle.  An easy rule to follow is to not progress the distance of any individual run by more than 10% from your previous longest run and to not increase your total training mileage for the week by more than 10% of the previous week.  If you have never been a runner and are just looking to get started, see the table below for a simple progression to get you started.

Adams, D., Logerstedt, D., Hunter-Giordano, A., Axe, M. J., & Snyder-Mackler, L. (2012). Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. journal of orthopaedic & sports physical therapy, 42(7), 601-614.

Appropriate Rest and Training Variation:

• Everyone knows that runners love to run, but if running is your only form of exercise you will likely run into these overuse injuries.  If you have pushed your mileage one day, or feel like you got a little aggressive with your progression from the previous week, it can be wise to take a rest day and maybe just foam roll, stretch, or perform some yoga.  
• If you do not want to take a rest day, things such as high intensity interval training (HIIT) can be a great way to help increase your aerobic capacity by increasing your anaerobic threshold.  Your anaerobic threshold is the level of exertion that your body shifts from aerobic metabolism (which we can in theory maintain indefinitely as long as we continue to provide our body with the appropriate fuel) to anaerobic metabolism which is what people talk about when they discuss "lactic acid build-up."  If you are able to increase your anaerobic threshold, you will be able to run at a faster pace while remaining in an "aerobic state" and running at your previous pace will feel easier.  This is a great way to improve your pace if you have found that your speed has plateaued, and can be a great substitution for one or more of your running workouts throughout the week.  

What about running form?

Common running errors include:

• Over-striding
• This is when the runner attempts to increase their stride length by reaching their foot further in-front of them. It causes increased stress on joints, but also makes running less efficient and places more demand on our muscles to absorb force and then create more force than is ideal to generate the next stride and can decrease running economy.
• Crossover
• If you draw a line right down the middle of a treadmill you do not want one foot to cross over to the other side.  The faster your speed, the closer to that line your feet will hit with sprinting resulting in near mid-line striding.  With slower distance running paces, crossing mid-line can create a lot of stress on our hip, knee, shin, and foot/ankle.
• Backward Trunk Lean
• Running with a backward trunk lean decreases the ability of our big and gluteal muscles to help with propelling us forward.  It will increase the demand of our hamstrings, increase stress on the low back, and often results in over-striding.
• Excessive Pelvic Drop
• This is commonly a result of our lateral gluteal muscles not performing their job appropriately and can result in hip, back, or knee pain.
• Excessive Toe Out
• This creates "torsion" of our tibia and can potentially result in true medial tibial stress syndrome. It can also be a contributor to hip and knee pain.
• Excessive Vertical Oscillation
• You have probably seen people running that look like they are "bouncing" way more than it looks like they should be, and they probably are.  Too much vertical oscillation creates much more impact with each stride and a much higher muscular demand to attenuate those forces.

Should I change my stride?

• Maybe???? - It is hard to determine who will best benefit from changing their stride.  If you are a very active person, understand your body well, and/or have been running for a long time, some good cues to think of are:
• Run tall through your hips
• Kiss the ground and get off of the ground quick, don't "bash" it
• Run with a slight forward lean starting from your ankles
• These 3 simple cues will help to address many of the common running mistakes that were discussed above.
• If you are nervous about getting started back to running, or have never run before it may be wise to consult a physical therapist prior to getting started to find any significant strength or mobility deficits that may be present.  If you would like a running analysis, call ahead and see if they perform video running an gait analysis at their clinic.  
• It is important to remember that everyone's ideal running form is different and if you have been running one way for a long time your body has adapted to taking stress in that way. Changing your stride will change the forces that your body has to withstand during running and should be accompanied with a significant decrease in training volume.

I'm Injured, Now What?

Your best bet would be to get in with a physical therapist, ideally one that has some experience handling running injuries.  If you are not a competitive runner, this may not be as important; but if you have a race coming up, a qualified physical therapist will be able to help determine if that race is realistic and if so can help with determining safe strategies for training.

Citation

Francis, P., Whatman, C., Sheerin, K., Hume, P., & Johnson, M. I. (2019). The proportion of lower limb running injuries by gender, anatomical location and specific pathology: a systematic review. Journal of sports science & medicine, 18(1), 21.

 

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