The different types of running injuries
A patient will come into our office. They have spent the greater part of their life dedicated to running. This lifetime of running has accounted for several nagging and sometimes significant injuries which have put this patient into periods of intolerable inactivity. They sit on our examination table because they are looking for a reason for their pain and why surgery and years of physical therapy treatments have not helped them. They are in our office because they are looking at a regenerative medicine option.
This article is written for people who have tried to rest, ice, compress, elevate, taped, braced, sleeved, used orthotics, massage, chiropractors, acupuncturists, physical therapists and cortisone injections have have continuing pain related to their running.
When we sit with this patient, we obviously want to know about the injuries they have had in the past as we choose a treatment program to help them with the more significant current injuries they are suffering from now beyond those I have just listed above.
Typically, this is what we hear:
Meniscus tears, ankle sprains, Achilles tendon
- I had a couple of meniscus tears, only one needed the surgery I do feel my knee catching every once in a while. A lot of ankle sprains. The ankle sprains became chronic and I developed problems with my Achilles tendon, I have chronic Achilles tendonitis. I have had stress fractures or a talus fracture. The doctors also thought I had Tarsal Tunnel Syndrome or Morton’s Neuroma. I have had too many muscle pulls to remember them all except when I had to stop running because they were so bad.
- I am a runner, I am looking for alternatives to meniscus surgery. I want something that will repair the injured tissue, not keep cutting it out.
- I had a meniscectomy because of all the running I did. Before the surgery, I ran 50 miles a week in a good week. Since the surgery, I haven’t been able to run at all. Mu knee gives out and is painful.
Low back pain, IT Band, heel spurs
- I have a lot of back pain, I was diagnosed with SI joint dysfunction, low back pain / disc problems, a lot of knee problems, I have chondromalacia, Iliotibial band friction syndrome, plantar fasciitis, heel spurs, on and off problems with my toes.
- I have been running on an ankle that my doctors told me years ago I should have fused. Now I am limited to stationary bike. I am looking for options to run again if I am not too far gone.
ACL reconstruction, knee surgery again, low back and hip problems.
- I am a competitive runner, I had ACL reconstruction which built up scar tissue in that knee. I had a second knee surgery to release the scar tissue. Because of the knee pains I developed low back, pelvic and SI joint instability.
High hamstring tendonopathy
- I am a competitive runner. I pulled up hurt in a race and was diagnosed with high hamstring tendonopathy. Physical therapy is not working, I am being told to rest and rest so more. Rest is not helping either this has been going on and on.
- I have groin pain when I run. I am told this is uncommon. That is not reassuring because I have it. My doctors are unsure if it is iliopsoas injuries, sports hernias, muscle pulls.
We can list another 50 diagnosis and problems including ACL, PCL, MCL, tears in the knees, various problems with hip instability and hip osteoarthritis, knee osteoarthritis, ankle osteoarthritis, piriformis syndrome, abdominal tears, groin tears, pelvic instability, etc. What we would like to get across in this article is that single diagnosis – single treatment of chronic, nagging, wear and tear running injuries is usually not as effective as treatment guideline as one would hope for. Addressing biomechanics, instability in the hip, knee, ankle, foot, low back can be a more effective treatment.
Treatment: Compression Garments, Socks, tubes and sleeves
This is a March 2021 study in the BMC sports science, medicine and rehabilitation (3) which discusses why runners use compression garments and if they help. The summary learning points are below:
- The aim of this study was to describe which athletes use compression garments, why athletes use compression garments, and when athletes use compression garments.
- Of the total 512 participating athletes, 88.1% (451 people) were endurance athletes
- The most reported primary sport for the endurance athletes was running (84.7%, 382 people).
- The PRO sports compression socks (59.2% used by 303 people) and tubes (27.0%, used by 138 people) were the most-often used compression garments in our study.
- Almost half of the endurance athletes indicated that the most important primary reason to wear the compression garments is secondary injury prevention.
- About 15% reported that the second most reported primary reason was reducing symptoms of a current sport injury. These compression garments were mainly used during training and competitions and to a lesser extent directly after or the day after a competition.
- Athletes seem to get motivated to start using preventive measures after they have suffered from a sports injury. (This) study showed that athletes see compression garments as a preventive measure to reduce injuries.
- Hypothetically wearing compression garments might prevent (recurring) sports injuries.
The injury prevention aspect
- This study also reports on the perceived benefits of compression garments.
- Of the athletes who aimed to use compression garments for secondary injury prevention (80.5%), almost 90% reported that they perceived that using compression garments strongly or partly contributed to this purpose.
- The athletes who aimed to use compression garments for recovery, over 80% perceived faster recovery.
- Over 70% of those indicating that they use compression garments for improvement of sports performance, actually perceived sports performance improvement.
- A psychological or placebo could not be ruled out.
The general summary is, if the athlete thinks compression garments are helpful, that’s okay.
The problem of looking for a single diagnosis when the problem may be multi-joint instability
Why do these people still have problems? Because maybe the knee pain that they experienced and had treated is being caused by other factors. Look at the image below.
The caption reads: The progression of joint instability. If you have untreated joint instability in the left knee, your left hip, left ankle, and right knee will eventually become unstable as well.
It is easy to understand why people with joint instability, perhaps hip instability, knee instability, ankle instability, have lower extremity pain with walking that increases with stair climbing and running. Since pain occurs when the force on a ligament or tendon exceeds that tissues strength, it would make sense that someone with joint instability would have more pain with running and thus would stop running.
After all, those with joint instability rarely have pain at rest and as such would continue to rest more and more to avoid pain. While this can certainly decrease the pain, it does not address the underlying tissue weakness. Additionally, eliminating activity due to pain without actively treating the cause of pain is a slippery slope to becoming more and more sedentary.
Movement typically means joint health, whereas immobility typically means poor joint health and increased pain You could say that less joint pain from the correct treatment leads to more movement, healthier soft tissues, and improved mobility and function when one has right treatment. The wrong treatment could lead to less movement, constricted and weakened soft tissues, less mobility and more pain.
Runners intuitively know that that their knee problem is probably more complex than just knee pain.
Runners intuitively know that that their knee problem is probably more complex than just knee pain. Their chronic ankle pain is probably more complex that managing the occasion sprain. They know that there are connections between their knee, their back, and their hips and pelvis. But when they get to their doctors office an MRI will reveal some type of damage and that in many cases a singular focus on treating an injury in isolation will be made.
Above we presented some of the things we hear from people when they describe their running injuries. Some people related a single problem like a meniscus tear, a hamstring problem, and other describe many problems related to their running. Typically when someone has a running injury, even if it is an acute tear of a specific ligament or meniscus, there is a likely other components that are weak in the joints and spine. Fixing one problem may not fix chronic injuries and wear and tear running related problems.
Doctors from Balgrist University in Zurich writing in the German language Zeitschrift für Rheumatologie (Journal of Rheumatology) (1) provide us with a summary of the problems of overuse injuries in runners. Many in this list of injuries are overlapping. Some people can have many of them.
- Up to 50% of regular runners report having more than one injury each year.
- Some injuries are caused by an accident but most are caused by overuse.
- The most frequent diagnoses are:
- patellofemoral pain syndrome,
- tibial stress syndrome (shin splint),
- Achilles tendinopathy,
- iliotibial band friction syndrome (runner’s knee),
- plantar fasciitis and
- stress fractures of the metatarsals and tibia.
- Hamstring injuries are typically acute resulting in a sudden, sharp pain in the posterior thigh.
- Foot and ankle injuries are the most common injuries reported by long distance and marathon runners.
- Excess body weight and the number of kilometers run per week are high risk factors for injuries.
- The roles of other factors, such as shoes, stretching and biomechanics are less clear.
Joint instability is easy to understand if you have it.
Joint instability is easy to understand if you have it. This is a wobbly or loose joint that causes pain, suddenly giving way of the joint, and loss of balance. In runners, this could affect the hip, the sacroiliac joint, the knee, the ankle, the shank rear foot joint complex (heel), and the foot.
The joint is vulnerable to damage because of the unnatural movement, degenerative grinding, and unnatural load forces joint instability causes. Here are a quick review and learning points of new research that indicates how fast a runner’s running can end because of joint instability.
The caption reads: The kinetic chain joint instability connection. Joints are interconnected and helps explain why instability in one part of the body can follow the kinetic chain and affect other parts far removed from it.
How you run and how you make things hurt
Forward movement, such as running, depends on repetitive performances of the lower limbs in precise, consecutive motions that simultaneously propel the body in its desired direction while also maintaining a stable weight bearing posture. The effectiveness of the motion depends on the stability and mobility of the hip, knee, ankle and toe joints and the action of particular muscles or muscle sets that are selective in timing and intensity.
Initial Contact Subphase of running: Initial contact occurs when the lead foot hits the ground and marks the beginning of the stance phase (heel hits ground and you propel off your toe to the next stride). Unlike the heel strike phase of walking, during the initial contact of the running gait cycle, the part of the foot that strikes the ground can be the heel, midfoot, or forefoot. Initial contact phase impacts heel, foot, and toe. It is interesting to note that most research surrounding the toe discusses stress fractures or eventual patella pain syndrome. The initial contact is causing knee pain.
Braking Subphase (Absorption): As soon as the lead foot makes contact with the ground in front the body, the body begins to decelerate in order to control the landing and placement of the foot. The knee and ankle of the lead leg flex and the lead foot rolls in (pronates) to absorb the impact of the force as it hits the ground. During this process of absorption, the tendons and connective tissue within the muscles absorb elastic energy to use when the lead leg propels the body forward. Pain and instability occurs when the ligaments and tendons are already hurt and weak.
Midstance: The braking phase continues until the lead leg is directly under the hips, taking maximum load as the body’s weight passes over it. The lead ankle and knee are at maximum flexion angle in this phase. At this moment, the entire weight bearing load is on the lead foot.
What are we seeing in this image? The ligaments of the ankle.
The ligaments of the ankle. Lateral ankle sprain is among the most common of injuries seen in runners. Chronic ankle sprain is the accumulative result of weakening ankle ligaments.
Propulsion: Once the lead leg has made a controlled landing and absorbed as much energy as possible, it starts to propel the body forward. Propulsion is achieved when the lead ankle, knee and hip all extend to push the body up and forwards, using the elastic energy stored during the braking phase. The propulsion phase ends when the toe of lead foot, now behind the body, leaves the ground during toe-off.
What are we seeing in this image? Plantar aponeurosis – the thick structure that protects the sole of the foot.
In this image we see the toe collateral ligaments, metatarsal joint capsule and ligaments, abductor hallucis muscle. These are things that can be hurt while running.
Float phase: After toe-off occurs, both of feet are off the ground and the body is airborne. Float phase ends when the non-lead foot hits the ground.
The problems chronic ankle instability was causing in the knees and hips
June 2018, in the journal Sports biomechanics: (5) This study from doctors at the University of Virginia and Weber State University examined the relationship between the problems chronic ankle instability was causing in the knees and hips.
- Four joint-coupling pairs were analyzed:
- knee sagittal-ankle sagittal, (the knee and ankle remain straight on the side to side vertical plane (s)
- knee sagittal-ankle frontal, (the knee remains straight on the side to side vertical plane and the ankle remain straight on the frontal (f) back and forth plane.
- hip frontal-ankle sagittal and
- hip frontal-ankle frontal.
Here are some very fascinating findings.
- During walking the researchers found chronic ankle instability patients demonstrated HIGHER joint-coupling variability (destructive movement) occurring across various intervals of gait.
- During jogging, the researchers found chronic ankle instability patients demonstrated LOWER joint-coupling variability (destructive movement) occurring across various intervals of gait.
What does this mean and why is it so bad for runners?
The increased knee sagittal-ankle frontal joint-coupling variability (destructive movement) in chronic ankle instability patients during walking may indicate an adaptation to help alleviate pain.
The decreased ankle-knee and ankle-hip joint-coupling variability during jogging shows that the body tries not to allow itself to stray from the natural movement at a faster pace. This forcing the body to “stay straight,” in cases of joint instability creates unnatural stress, shear forces, and strain on the joint structures.
Variations in gait and posture create unnatural stress, shear forces, and strain on the joint structures. Instability leads to chronic injury
In the above research, we examined the body’s response to instability which in turn leads to unnatural stress, shear forces, and strain on the joint structures. It must be remembered that the body’s response to joint instability is really a short-term solution with the goal of helping the body heal. When the body does not heal, the short-term solution, which includes swelling and inflammation, becomes a long-term problem of chronic inflammation.
Let’s return to unnatural stress, shear forces, and strain on the joint structures.
During running the ground comes up fast and impacts hard
A study from doctors at Oregon State University, Ohio University, University of Evansville, and Indiana University, suggests that individuals with chronic ankle instability had increased peak forces and loading rates and a shorter time to active peak force than the group without the ankle problems.(6)
What does this mean? It means that a vulnerable ankle joint suffers greater force and stress loading upon ground impact during running. Further, it does not recover well between ground strikes. As we have seen in the research above, this destructive force not only impacts the ankle but is shared in the knee and the hip. The ankle instability is making the knee and hip vulnerable.
Iliotibial band friction syndrome
We have a more extensive article on Iliotibial band friction syndrome. It is summarized here:
Recently you may have received a diagnosis of Iliotibial band syndrome. It is the explanation for your chronic knee pain that you and your doctor will follow in your treatment guidelines moving forward. If you do a lot of running your doctor may have called it “runner’s knee,” if you are involved in a sport where you do a lot of jumping your doctor may have said you have “jumper’s knee.”
A lot of the people we see are at our center are in a chronic situation. Their knee pain is accompanied by ankle instability and hip instability. There is really nothing on their MRIs or ultrasounds to suggest they need surgery but they have pain, focused in the knee, and it is making their hip and ankle joints problems as well. One more factor to consider: Possibly the reverse is happening, their ankle and hip instability are the cause of their knee pain. Finally, eventually, for some of these people, the Achilles tendon has become involved as well as problems in the feet.
There are a few theories of how Iliotibial Band Syndrome develops, but most are in agreement that there is a component of high or irregular compression forces between the iliotibial band and the lateral femoral condyle (the lower bony part of the thigh bone that connects to the shin bone) which causes the irritation and inflammation of the tissue. It is this location that also gives IT Band Syndrome, and it may be easier to understand the name “Runner’s Knee.” There are two distinct problems labeled “runner’s knee.” For problems that relate to Chondromalacia Patella – Patellofemoral Pain Syndrome please see that article.
We have a more extensive article on Achilles tendinopathy, we have summarized here:
A patient will come into our clinics and tell a story we have heard many times before and one that may sound very familiar to you. It goes something like this . . .
One day, out of nowhere, I developed a tightness in the back of my ankle. I did some stretches, the tightness went away. I thought it was just one of those spasms I get occasionally and thought I had taken care of it. The next day the tightness in the back of my ankle returned and it stayed. I thought I could run through it but my problem was getting worse and worse. I went to my doctor, we did an MRI, it showed Achilles tendon damage.
- I was put on REST, no running for the next few months or until my situation improved greatly.
- I got heel supports and shoe inserts.
- I was given a lot of anti-inflammatories.
- I went to Physical Therapy and did heel drops and other exercises.
After a few months, my walking improved to the point I could jog again.
Then the tightness came back.
Injury to the Achilles tendon increases with age and overuse. That has been clearly and well documented in the medical literature. While age and overuse make athletes and active people predisposed to injury, many patients will come into our office and describe an onset of pain that can be traced to a new and sudden burst in activity (a new exercise program). In many cases this acute injury has occurred from chronic wear and tear – the tendon has finally torn sufficiently enough to be considered an acute injury.
Treatment: Exercise therapy
When many runners start having wear and tear pain and or soreness they usually rely on information and demonstration videos found in web searches. Here they get get varying opinions and options on the types of exercises and braces that will help them. For some people these general exercise guidelines may help. It is likely that if you are reading this article you may not have found that help yet.
An April 2018 paper in the journal American family physician (2) offers guidance to the types of exercise recommended to specific running injuries.
Eccentric exercises can be simply explained as “lowering exercise.” The downward motion of a pushup is eccentric, the downward movement during squat is eccentric.
The paper recommendations for exercises is as follows:
- Eccentric exercises are primary therapy for patellar and Achilles tendinopathies.
- Exercise therapy for patellofemoral pain should consist of core and leg strengthening as well as leg flexibility exercises.
- Exercise therapy for iliotibial band syndrome should consist of hip abductor strengthening and hamstring and iliotibial band stretching.
- Functional bracing while running should be continued for six to 12 months after an ankle sprain to improve stability and prevent recurrence.
- Foot orthoses are beneficial for plantar fasciopathy (plantar fasciitis).
- Eccentric exercises should be considered for treatment of hamstring tendinopathy.
What is joint vulnerability in runners?
In a heavily cited paper, Dr. David Felson of Boston University School of Medicine wrote in Clinical Orthopaedics and Related Research🙁4)
“Joint damage occurs when structures protecting the joint fail. Because osteoarthritis consists of end-stage joint damage, I propose that risk factors for disease can be best understood as either impairment of joint protectors, increasing joint vulnerability, or as factors that excessively load the joint, leading to injury.”
Dr. Felson separated separating joint vulnerability factors into those increasing joint vulnerability including malalignment (joint instability), muscle weakness, and aging, among others. Dr. Felson also separated those that cause excessive loading (obesity; certain physical activities).
Osteoarthritis and cartilage loss can occur without pain. Dr. Felson focused separately on factors associated with pain in those with osteoarthritis. Those with pain are more likely to have effusions, bone marrow lesions, synovial hypertrophy, and tendinitis and bursitis around the joint.
Prolotherapy as a treatment: The research
In 2014, our Caring Medical research team published: Structural Basis of Joint Instability as Cause for Chronic Musculoskeletal Pain and Its Successful Treatment with Regenerative Injection Therapy (Prolotherapy) in the Open Pain Journal. In this study we wrote:
- The most frequently reported chronic pain conditions are associated with musculoskeletal dysfunction and degeneration. One primary cause of this is joint instability from a ligament injury, which is hampered by standard therapeutics such as NSAIDs and corticosteroid injections.
- The degenerative process associated with weak and unstable joints can be slowed and potentially prevented by treatment with Prolotherapy.
- If treated in the early stages, the proliferation of new ligament tissue strengthens the joint and helps restore proper joint mechanics and smooth/frictionless joint motion.
- By decreasing laxity of the ligaments and instability of the joint, contact forces can be redistributed back onto the areas of thickest cartilage that are designed to handle high loads and reduce the stress at thinner, weaker points, preventing deleterious biochemical and biomechanical events in the joint and allow healing to take place. Even in later stages of degeneration and osteoarthritis, improvements in pain, instability and function are possible as amply described in the published literature.
- Prolotherapy is an old and respected technique of alternative musculoskeletal pain treatment that has its place in comprehensive musculoskeletal joint pain and joint instability management.(7)
Summary and contact us. Can we help you?
We hope you found this article informative and it helped answer many of the questions you may have surrounding your running related inuries. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
1 Tschopp M, Brunner F. Diseases and overuse injuries of the lower extremities in long distance runners. Zeitschrift fur Rheumatologie. 2017 Feb 24. [Google Scholar]
2 Arnold MJ, Moody AL. Common running injuries: evaluation and management. American family physician. 2018 Apr 15;97(8):510-6. [Google Scholar]
3 Franke TP, Backx FJ, Huisstede BM. Lower extremity compression garments use by athletes: why, how often, and perceived benefit. BMC Sports Science, Medicine and Rehabilitation. 2021 Dec;13(1):1-4. [Google Scholar]
4 Felson DT. Risk factors for osteoarthritis: understanding joint vulnerability. Clinical orthopaedics and related research. 2004 Oct 1;427:S16-21. [Google Scholar]
5 Lilley T, Herb CC, Hart J, Hertel J. Lower extremity joint coupling variability during gait in young adults with and without chronic ankle instability. Sports biomechanics. 2018 Apr 3;17(2):261-72. [Google Scholar]
6 Bigouette J, Simon J, Liu K, Docherty CL. Altered Vertical Ground Reaction Forces in Participants With Chronic Ankle Instability While Running. Journal of athletic training. 2016 Sep;51(9):682-7. [Google Scholar]
7 Hauser RA, Blakemore PJ, Wang J, Steilen D. Structural basis of joint instability as cause for chronic musculoskeletal pain and its successful treatment with regenerative injection therapy (prolotherapy). The Open Pain Journal. 2014 Sep 9;7(1). [Google Scholar]
This article was updated March 30, 2021