Runner’s ask: Why do I have so many 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.

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.

Typically, this is what we hear:

  • 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.

Another patient may come in and offer this history:

  • 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.

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.


Doctors from Balgrist University in Zurich writing in the German language Zeitschrift für Rheumatologie (Journal of Rheumatology) provide us with a summary of the problems of overuse injuries in runners.

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:

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.(2)

What Dr. Felson wrote is something we call whole joint disease caused by joint instability

Joint instability

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.

Adjacent joint instability

  • June 2018, in the journal Sports biomechanics:

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.(3)

  • 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

Long-term joint instability

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.(4)

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.

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.(5)


If you have questions about Running overuse injuries and non-surgical treatments, 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 Felson DT. Risk factors for osteoarthritis: understanding joint vulnerability. Clinical orthopaedics and related research. 2004 Oct 1;427:S16-21. [Google Scholar]

3 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]

4. 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]

5. 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]


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