The BEST Way to Treat Running Injuries
Why do runners get injured?
People who run, LOVE to run. Running is an amazing way to manage body weight, improve aerobic capacity, relieve stress, be competitive, and find a community of like-minded people. Another trait that comes with running, is injuries. A Yale Medicine study showed that 50% of runners will get hurt at some point during a year of training. Some injuries are caused by trauma due to sprained ankles or falling, but the majority of injuries are caused by overuse. Running requires a lot of demand from our body and puts large forces through our muscles, tendons, ligaments, and bones. For comparison, walking puts forces around 2-3x our body weight on the knees. But while running, there is 6-8x the force of our body weight on our knees. Over time, these forces can lead to overuse injuries that keep runners from doing what they love, running.
Despite those forces, research has shown that running REDUCES the incidence of knee and hip arthritis. In addition, the more children run from age 6-23 the more cartilage they grow which is essential to maintaining healthy joints. A systematic review showed that 3.5% or runners had hip or knee arthritis compared to 10.2% of sedentary adults. So when dosed properly, running has a net positive effect on overall physical and mental health.
What are the most common running injuries?
Due to being outside and on uneven conditions, runner can cause traumatic injuries such as joint/ligament sprains, muscle strains or bone fractures from falling. More common, are overuse injuries. Overuse injuries can segmented into two different groups based on the tissue involved. The two types of overuse injuries are Bone Injuries and Soft Tissue Injuries.
Bone Injuries:
Some of the most complicated injuries for runners are bone stress responses or stress fractures. As you likely suspect, stress fractures happen due to excess force going through the bone during running. Common bones to develop stress fractures are the Tibia, Fibula, Metatarsal, Navicular, and Femur. Shin splints, while not a true stress fracture, is a stress response that can be very painful and debilitating and common among runners. If you’ve ever seen a runner wearing a walking boot, they likely are battling a stress response injury. In addition to the treatment strategies listed below, bone injuries are commonly related to nutrition, hydration, and micronutrient deficiency including Vitamin D, Magnesium, and Calcium.
Soft Tissue Injuries:
Soft tissue injuries are related to structures that are not bone including Muscles, Tendons, Ligaments, and Fascia. The most common running-related soft tissue injuries occur because have poor blood supply so they don’t have adequate blood to help them recover from the high force demand of running. This is why a muscle strain, which has a very good blood supply, typically will get better with a little rest. Ligaments, Tendons, and Fascia do not have as good of a blood supply and have a tendency to linger around for months and require professional help. Some examples are
Plantar Fasciitis
Achilles Tendonitis/Tendinopathy
Sciatica/Piriformis Syndrome
Hamstring Tendonitis/Tendinopathy
Low Back Pain
Is it OK to run with a running injury?
If you ask an Orthopedic Surgeon, they will tell you that running is bad for your knees and you should stop and instead pick up swimming or biking. We must consider that we are all a product of the environment we are in each day and Orthopedic Surgeons ONLY see runners with knee pain in their clinic, they’ve likely never met a runner who wasn’t injured so of course they never associate running with physical and mental health improvements. This exact situation happened to my client Kathy. She is a master’s athlete who is nearly the age of 60 with a history of hip and knee arthritis on her x-ray. She had an MRI which showed knee arthritis and her surgeon told her to do more biking and swimming. Kathy is a daily runner and she took over a month off but still no progress. She took her time, followed the strategy below and she returned to running 26.2 miles in the Boston Marathon.
So when it comes to running while overcoming an injury here are a few things to consider.
Bone Injuries like stress fractures need a period of complete rest to fully heal so running with a bone injury will only lead to more injury.
Soft Tissue Injuries- I tell my runners rehabbing from an injury
Don’t Rip Off the Scab- I want runners to run what they can mainly for the psychological benefits and they must not have a setback in pain 0-48 hrs after the run. Obviously, there isn’t a literal scab on our soft tissue injuries, but if we continue to “rip the scab off” and restart the inflammation process, you will never make progress back to running. Depending on the injury, taking a rest day between running days can help accelerate the rehab process of injuries as well.
Find the Running Floor- I want runners to find the floor of the most amount of distance/time they can run without “ripping the scab off.”
Rehabbing from an injury is not fun and while it may be easier to tell an injured runner “no runner for 4-6 weeks”, I try to make the injury rehab process more enjoyable by letting runners do what they love most, run. So while it may depend on the injury, changing duration, frequency, or intensity of runs make it OK to do while injured.
The Best Treatment for Injured Runners
So when it comes to the best treatment for running-related injuries, it isn’t one particular stretch or warm-up technique. Overuse running-related injuries are complicated and require a multimodal treatment strategy. Because running-related injuries are due to too much force putting stress on tissues, the best treatment approaches all work to decrease force on the body. While Instagram and TikTok are filled with tactics for how to run pain-free, it’s important to remember that the best strategy to treat a running-related injury is to decrease force through the injured tissue. So when I see a frustrated runner dealing with an injury, here are the Top 5 areas I look at to decrease stress on an injury.
1. Mobility
Mobility is your ability to move your joints through their full range of motion. While it’s important to look at each joint throughout the body, the ankle and hip are the most common limitations I find in injured runners. Limited ankle mobility leads to less force absorption through the ankle and more force going into the knee and hip. Limited hip mobility can lead to less hamstring and gluteal muscle use causing more stress on the knee, IT band, shins, or plantar fascia. Limited spine rotation mobility from sitting all day at work can contribute to low back pain.
Having full mobility of the spine, hip, knee, ankle, and foot is essential to absorbing force and treating running-related injuries.
If you are looking for more detail, I’ve written in the past on How to Improve Your Mobility and REV’s Youtube Channel showing mobility drills for each joint in the body.
2. Flexibility
Flexibility is the length or tightness of your muscles. For example, sitting for work can lead to tightness or tension in the quadriceps and hip flexor muscles and eventually that tension can lead to force going through the IT Band and Knee Cap. Tight and stiff calf muscles can lead to Achilles tendon or Plantar Fascia injuries. The most effective ways to improve muscle tightness is by doing Self Myofascial Release with a Foam Roller or Mobilizing the Muscles at end range. Notice I didn’t say stretching. Static stretching which includes holding the muscle at end range of motion for 30-60 seconds doesn’t really do much for flexibility. When it comes to running, muscles that need good flexibility include:
Quadriceps Self Release, Standing Quadriceps or 1/2 Kneel Quad Mobilization
3. Strength
When it comes to force demands and stress capacity that leads to injuries, strength training is the BEST way to build up the stress capacity of the tissue. So yes, resting or decreasing stress from running will help an injury rehab process but building up strength of the bone, muscles, tendons, ligaments, and fascia is ESSENTIAL and by far the biggest limitation I see in injured runners. To clarify, strength training isn’t just bands and bodyweight exercises. Strength training isn’t to build bigger muscles, it’s main effect is building up tolerance to your ligaments, tendons, and fascia. Running injury rehab should include heavy weights being help the body tolerate the 6-8x bodyweight force going through the body with each step.
If you are like most runners, strength training is not something you enjoy and is intimidating because you don’t know what to do and how to do it. I know runners love to run and not lift weights but my passion is teaching runners how to do the least amount of strength training to allow them to run the miles they want.
If you are looking for a place to start, here is a guide to the Best Strength Training for Runners
4. Volume
During every Running Analysis I perform, I gauge a runner’s total volume based on distance per week and intensity of running. Every athlete is different depending on the injury and tissue capacity, but if you run 60 miles every week, adding Flexibility and Mobility isn’t going to rehab your injury fully. I have seen runners build up the Strength and tissue capacity to tolerate 60 miles per week, but they also have dedicated rest days mixed with strength training days.
Assessing your running Volume is an essential part of the injury recovery process and I find “conventional treatment” is to tell runners not to run for 4-6 weeks and then go right back to running. Because runners love to run, I prefer to help runners “find their running floor” of running. Depending on the injury you may need to take a full rest, but many overuse soft tissue injuries can tolerate low volume of running during the rehab process.
5. Running Form
When it comes to injuries, how you run matters. When I do a Running Analysis I use a high-resolution camera at 240 frames per second from multiple angles to analyze how each joint and muscle moves during different phases. Running is a difficult skill where many things can go wrong but the 3 most common faults I see in runners are Low Cadence (< 162 steps per minute), Pelvic Drop, and Overstriding (Heel Striking).
Running Cadence
If you wear a Garmin, it does a pretty good job estimating running cadence or how many steps you take per minute. It may sound counterintuitive, but taking more steps more evenly distributes the ground reaction force going through your leg. Many runners aim to increase their cadence up to 180 but research shows that below 162 steps per minute is a significant risk of injury. If you have a low running cadence, I recommend using a running playlist that has a beat of 165-168 steps per minute and try to keep up.
Pelvic Drop
Pelvic drop occurs on the stance leg and can lead to significant injury risk. For every degree of pelvic drop, injury risk goes up significantly. Pelvic Drop is especially common in IT Band and Runner’s Knee. You can see in the runner below, her left hip had significant weakness which led to chronic IT band problems. To correct Pelvic Drop, you need to build up the strength of the Outer Gluteal Muscles and use running form cues to keep your knees from touching.
Initial Running Analysis showing a large angle of pelvic drop and knees nearly touching
Final Running Analysis showing a strong and stable hip and space between the knees
Overstriding (Heel Striking)
When it comes to Overstriding, everyone is a Heel Striker until they aren’t. Overstriding or reaching your leg in front of your body puts a significant amount of ground reaction force through the heel, Achilles, and lower leg. Don’t believe me? Try heel striking barefoot and see how long you make it before you change your running. To combat the high forces of heel striking, The Hoka shoe revolution has led each shoe brand to make a shoe with more and more cushion to tolerate the demands of heel striking.
Initial Running Analysis showing overstriding/heel striking
Final Running Analysis showing a midfoot strike with a vertical shin angle
When to get help for a Running Injury?
Some Running injuries are simple and go away with a little rest but unfortunately, many overuse soft tissue injuries linger for months and years and keep runners from doing what they love most, running. Many of the 50% of runners who get injured end up giving up their passion because of a running injury. Passive treatments like rest, ice, massage and chiropractor don’t train the body to tolerate the high force demands of running.
If aren’t able to run the miles you want for your mental health or aren’t able to train for the race you have coming up, you should get help. Don’t give up your love of running unless you address your Mobility, Flexibility, Strength, Volume, and Running Form.
If that sounds like you, set up a Free Strategy Call so we can talk about your injury and determine if I can help you resolve your issue for good and get back to what you love to do, which is running.
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Remember if you have a body, you are an athlete.
Dr. Ryan
