Common Running Injuries

Hello and welcome back to the ThreeSpires Physiotherapy blog where we take a look at all things physiotherapy and health related. This blog forms part of our ongoing series of blogs aimed at giving people information about exercising safely and staying injury free during the Corona Virus lockdown. As the Corona Virus lockdown continues and large numbers of people are doing a lot of running I thought it would be good to have a look at common running injuries.

Running an Injury Risky Sport

Although running is a fantastic sport for improving cardiovascular fitness and general health it also has a fairly high injury rate, especially amongst those who have recently taken up running and are trying to build up their distance and speed of running. As such I thought it would be a good idea to have a look over common running injuries and go into detail about what causes them and some of the underlying anatomy. Before reading this article if you have just started running recently then I would highly recommend that you have a read of our recent article about starting running.

Who is Most at Risk of Running Injuries?

Okay, before looking over the most common running injuries it is probably a good idea to first have a think about who is most at risk of picking up a running injury and why.

1. New Runners: as mentioned if you are a new runner or have come back to running recently then you should definitely read our article about how to start running. Anyone who is new to running is generally going to be prone to running injuries as often they will be trying to get back into shape and will be pushing the mileage and speed.

2. Overweight Runners: even though running is a great way to burn calories, it can be quite hard on the joints and ligaments if you are overweight and as such anyone who is overweight is at risk of injury from running. If this is the case it is important that you take a slow and steady approach to building up your running and I would very much recommend that you read our article on how to start running.

3. Runners training for a marathon: anyone training for a big event such as a marathon or just trying to push their distance a significant amount is generally going to be at a risk of picking up an injury. This is mostly due to the increased load on small structures such as ligaments and tendons and not giving these structures time enough to adapt.

4. Runners Increasing Speed: as with anyone trying to build up their running distance anyone trying to run faster is also at a high risk of injury.  

Okay, so now we have had a look at who is at risk of running injuries, I think it is probably best that we move onto looking at the most common areas that are injured and the injuries that we see there.

Knees

Runners due to the high load (landing and pushing off generate large loads) and the repetition are especially prone to injuries at the knee and pain in this area. Problems at the knee have many causes and origins and we will try briefly to cover them all. Firstly though I would recommend that you have a brief look over the anatomy of the knee so that you have a good understanding of some of the likely anatomical structures involved: we have an excellent article about knee anatomy here. Okay, so now that you have a decent understanding of knee anatomy I think it is worth moving on and having a look at some specific and fairly common running injuries.

Runner’s Knee/Anterior Knee Pain

This is in general the bane of many runners’ lives and is an extremely difficult condition to treat. It has quite a few names such as anterior knee pain or patella-femoral pain or often in the running community it is simply called runner’s knee. The symptoms are fairly easy to recognise and pain is in general located at the front of the knee over and around the knee-cap (patella). Pain is in general intermittent and mostly doesn’t bother the patient when they are not running and also often takes a while to come on during the run. For example patients will describe feeling fine initially but then after 20-30mins the front of their knee slowly gets more painful until eventually they have to stop. After that a few days rest allows most symptoms to settle and they can then go out and run again. This is extremely frustrating for anyone trying to build up their distances and speeds. It has a large range of causes which makes it one of the most difficult conditions to get resolved. Below are some quick discussion points about causes but for a more in depth look at patella-femoral pain (runner’s knee) I would recommend our article on the subject here.

Potential Causes of Runner’s Knee:

1. Going too Fast or too Far: Undoubtedly the single most common cause of runner’s knee (this is especially common in those new to running) is increasing the distance or speed too quickly. If you have been building up the distance that you run or have been trying to run quicker and have found that one of your knees is getting sore then I would advise that you back things off and have a look at our in depth article about starting running. This is useful for all runners as we cover how to build up the distance and speed of your runs. The article can be found here.  

2. Hip Weakness: Okay, so you haven’t changed your run speed or the general distance but you have found that every time you run further than 40 minutes or when you run off road on uneven ground you get knee pain. So what could be causing this? Well one of the most common causes of runner’s knee in regular runners is a weakness in the hips or glutes on one side. Your hips and glutes are vital for controlling the position of your leg and knee through your running gait and any weakness here can lead to loss of control at the knee and subsequently developing runner’s knee.

3. Foot and Ankle Weakness: weakness at either the foot itself or in the muscles controlling the ankle can lead to overloading one of your knees and a lack of control on this side. This can sometimes be seen with overpronation on one foot causing the knee on that side to move inwards and this pull the patella out of line and overload the structures in the area. Often orthotics can be helpful in these cases.

4. Quads Weakness: in some cases the quads (muscles at the front of the thigh) can be weak or can be pulling the patella out of line causing overload of the structures around the knee and patella and pain.

Commonly runner’s knee (anterior knee pain or patella-femoral pain) is caused by a combination of all of the above factors and determining which is the primary driver of the problems is quite a challenge. As such it is advisable to have an assessment by a physio experienced at dealing with running injuries in order to find out the best way to manage your knee pain.

Patella Tendinopathy

At the front of your knee and just below the patella (kneecap) is a tendon called the patella tendon. Actually it is part of the quadriceps tendon which encloses the patella itself and joins the quads to the tibia (shin bone). It is an important tendon as it transmits the load from the quads to the tibia and is vital in moving the knee into extension. As such it takes a huge amount of load and stress when running and can become overloaded. It is easy to confuse a problem with the patella tendon itself with anterior knee pain (as described earlier) as many of the symptoms will be the same. For a more in depth look at patella tendinopathy please read our complete article on the subject here.

Common Symptoms of Patella Tendinopathy:

Pain will generally be located specifically at the patella tendon itself just below the kneecap, rather than with anterior knee pain where runner’s will describe a general feeling of pain around and at the front of the knee. Specific actions will trigger the pain such as squats or resisted knee extension and commonly the patient will describe either a very recent sharp increase in training load or a change in their training such as hill work.

Causes of Patella Tendinopathy

As with runner’s knee and patella-femoral pain there can be a few causes but in general the cause tends to be much clearer and easier to define.

1. Recent Increase in Speed Work: sprinting or simply running much quicker than you are used to tends to load up the patella tendon significantly. Tendons take time to adapt to increases in load and if this speed work is done either too regularly or too vigorously then this can overload the patella tendon and cause patella tendinopathy.
2. Recent Increase in Hill Work: again as with sprinting a lot of hill work or taking up something new like fell running can place a large amount of strain through the patella tendon. If you have not done any physical preparation or have just done a bit too much of the fell running or hill work then you will often overload the patella tendon and cause patella tendinopathy.

The above are not the only potential causes of patella tendinopathy but they are in my experience as a physiotherapist fairly common causes. As mentioned it is easy to confuse with anterior knee pain and it also requires quite a different treatment approach and as such if you think you might have patella tendinopathy then I would recommend getting an assessment with a physio.

Meniscal Tears

These are not often a direct consequence of running rather they can start to become more problematic if you have recently started running or potentially they happen when you have a slip during running. The menisci (as mentioned in our anatomy section here) are anatomical wonders that provide extra cushioning and improve the fit of the femur and tibia onto each other. They are semi-circular bits of fibro-cartilage deep inside the actual joint of the knee and they come under a lot of load during any weight bearing activity. As we age though as with any cartilage they can become worn and start to cause swelling and pain or if you are younger and land on your knee and twist at the same time they can get torn again causing swelling and pain.

Symptoms of Meniscal Tears

Mensical problems in general will cause swelling, stiffness and discomfort that is felt deep inside the knee itself rather than on the outside. Sometimes there will be audible clunking inside the knee and some people will have the “classical” symptoms of a meniscal tear of locking of the knee. Often meniscal problems will resolve over time and given a bit of rest.

Causes of Mensical Tears:

Although there are many categories of meniscal tears such as bucket handle tears basically there are 2 mechanisms of usual damage to the menisci:

1. Trauma: these patients are generally younger (under 40) and will have been playing sport and felt a quite distinct and memorable event in their knee. Often they will have jumped, landed and twisted at the same time and will have felt an immediate pain and been unable to walk. This is a traumatic tear of a meniscus and is different in nature (and possibly treatment options) to the next type of meniscal damage.
2. Degeneration: in this situation the patient will be older (most likely over 50) and will not easily be able to think of a particular cause of their knee pain. They will have in general just randomly starting getting a very painful, stiff and swollen knee. Here the meniscus has slowly worn down over time and has eventually torn and the bit that is torn occasionally gets pinched and irritated. As mentioned these two types of meniscal issues are quite different and need a different approach to treatment.

I think with meniscal tears and damage it is usually a good idea to get an early assessment with a physiotherapist as the two types require quite a different discussion about treatment options and for one exercises and strengthening may be appropriate and for another it may be that a surgical opinion is required.  

Collateral Ligament Strains

Along the outside and inside of your knee are two important ligaments: the medial collateral ligament and lateral collateral ligament. These have important stabilising roles for the knee and if injured can cause a large amount of pain and discomfort.

Symptoms of Collateral Ligament Strains:

In general with collateral ligament strains of the knee pain is quite sharp and often (not always though) patients will describe an event such as a trip or stumble. Pain is also in general located at the site of the ligament involved itself which will be at the side of the knee (either inside for the medial or outside for the lateral).

Causes of Collateral Ligament Strains:

Although some patients will struggle to describe a specific event most people will be able to describe a stumble, fall or trip and a very sharp pain and as such mostly collateral ligament strains involve some form of trauma. Occasionally they can be from simple overload and doing too much running but these are far less common.

So, although there are a few more potential sources of knee pain and difficulties such as ACL ruptures these injuries are not very common in running and are more related to other sports such as football or netball and as such I think it is best to leave thinsg as regards the knee here and move on.

Feet:

Clearly the foot and ankle in running come under enormous stress and as such it is no surprise that runners are especially prone to injuries around this area. Below I have highlighted some of the most common injuries that runners suffer in the foot and ankle area:

Plantar Fasciitis

The plantar fascia is an amazing structure underneath the foot that supports the arch of the foot, provides shock absorption and energy storage through gait. As such it comes under enormous stress and load when running. The plantar fascia itself runs right from the heel bone (calcaneus) along the underside of the foot all the way to the big toe. Sometimes it can become overloaded from too much weightbearing and it becomes painful.

Symptoms of Plantar Fasciitis

In general anyone with plantar fasciitis will experience pain around the base of the heel but it can spread along the base of the foot. The pain will often be quite intense and is worse in the morning with patients describing the first few steps in the morning as being like walking on glass. Although after these first few steps things improve, symptoms tend to worse the longer you are on your feet.

Common Causes of Plantar Fasciitis

As it is in general an overload injury the most common cause of plantar fasciitis is doing too much weightbearing activity but there are some specific issues to running:

1. Lack of Shoe Cushioning/ Support: now without getting into the whole barefoot running argument I think it is reasonable to say that if you have always run with supportive and well cushioned shoes if you simply swap over to barefoot running shoes without any form of preparation then you are very likely to overload your plantar fascia. Certainly if you have recently begun transitioning to barefoot running and have developed heel pain then you should consider that you may be developing plantar fasciitis.
2. Change of Running Style: by this I mean that you have decided recently to attempt to be more of a mid-foot or even forefoot striker when running. Again, there is nothing wrong with this per se but to make these kind of changes you need to give your feet time to adapt and if you do this too quickly you can overload the plantar fascia.
3. Change of Running Surface: varying the surface you run on makes sense in order to make your body adaptable and stronger, however if you have been doing the majority of your running off road and now start only road running there is likely to be a change in the load on the plantar fascia and this can cause plantar fasciitis.
4. Change of Running Terrain: I know this sounds exactly the same as the issue before but what I mean here is that you have changed the amount of up and down hill you are doing. For example if mostly you have been used to running on the flat but suddenly change to large amounts of hill running or even fell running then this is almost certainly going to put a large increase in load through your plantar fascia.
5. Large Increase in Speed or Distance: anyone reading this article or our previous article on how to start running safely will have noticed I have quite a thing about the dangers of going too far or too fast. This is the cause of most running injuries and it is no different with plantar fasciitis; if you build up your distance, speed or both too fast and without sufficient preparation then you are likely to develop plantar fasciitis.

As with the other common running injuries, it is very much worthwhile having an assessment by a physiotherapist to actually make a diagnosis of plantar fasciitis and then work out the best management strategy for you. For more information and a more detailed look at plantar fasciitis click here.

Ankle Ligament Strains

As with the rest of the foot the ankle takes an enormous load throughout gait and especially upon striking the floor. Now, although ankle ligament strains aren’t a problem particular to running they are something that can flare up when running or if you have a stumble when running. The main ligament that tends to be injured is the anterior tibio-fibular ligament (ATFL) which is located at the front outside part of your ankle.

Symptoms of Ankle Ligament Strains:

In general ankle ligament strains tend to be fairly memorable events: usually the person will have tripped or stumbled and then felt a sharp pain at their ankle. This is then followed by swelling, pain and occasionally bruising over the area and often an inability to weight bear. Things tend to slowly improve over the following weeks but only slowly and often patients describe having several flare ups of the pain and swelling as they recover.

Causes of Ankle Ligament Strains:

As with most ligament strains trauma including a stumble or a trip is the usual trigger for the injury but it is worth having a think about the causes of ankle ligament strains in a bit more detail as there are two main types of ankle ligament problems that do need treating in different ways.

1. Trauma: in this case the patient has no history of ankle strains and has been out running and has stumbled or tripped and strained their ATFL. It swells up, bruises and is extremely painful. However, the key point is that this is a one off event and not part of a pattern of ankle strains and as such can be thought of as a bit luck that then needs some rehab.
2. Chronic Ankle Instability: in this case the patient again has been running and had a trip and had the same initial problems such as pain and swelling. However here this is part of a long history of ankle strains and these are fairly common for the patient. Often they will have seen many physios before and will have tried a fair amount of rehab in the past. The underlying cause here is chronic ankle instability.

Okay, I think that is probably enough on ankle injuries, if you wish to know more about the ankle and injuries in this region please have a look at our articles here and here.

Achilles Tendinopathy

This is a fairly common complaint in runners and especially in anyone taking up running for the first time. The Achilles Tendon comes under enormous load during running and as such can get overloaded. It is easy to locate: simply put your hand behind your ankle and pinch the tendon. It is formed by the two main calf muscles gastrocnemius and soleus and connects to the heel bone (calcaneus). It has many roles such as energy storage during running but its main role is to transmit force from the calf muscles to the heel/foot and allow the foot to push off during gait.

Symptoms of Achilles Tendinopathy

Generally anyone with Achilles Tendinopathy will feel pain at the back of the ankle. It is often quite intense and tends to worsen with running or walking extended periods although sometimes it is painful for the first 10 minutes then eases off during the run and then is very bad in the evening afterwards.

Causes of Achilles Tendinopathy

I think it is fair to say that Achilles Tendinopathy is at least initially an overload injury which means that something you did put too much load through the tendon and caused it to become irritated. In terms of running specifically there are a few common likely culprits for your Achilles Tendinopathy:

1. Going too Far or too Fast: yes, I know you are bored of me harping on about not pushing things too far or too fast but it really is the case that most running injuries occur because of these factors. Achilles Tendinopathy is no different and is generally caused by putting too much load through the Achilles Tendon or not giving it enough time to adapt to new distances or speeds.
2. More Hill Running: if you have predominantly been a road or flat runner and then you start doing a lot of hill work then you need to be aware that this change in angle of foot movement and intensity of work in the calf area needs time to adapt to, especially for your Achilles Tendon.
3. Sprint Work: as with hill work, the change in angle of the foot and ankle plus the increased intensity of the load takes time to adapt to. If you have never done any sprint work and then suddenly start doing 1 hour sessions of sprint work then it is likely to overload your tendon.
4. Change in Footwear: if you have always worn a particularly supportive shoe and then change over to minimalist running footwear you need to be aware that this can significantly alter the load going through your Achilles Tendon and you need to give things time to adapt.

Okay, Achilles Tendinopathy is a particularly thorny and complex condition and if you wish to know more then I suggest you should take a deep dive into our article on the subject here.

Shin Splints

This is a particularly tricky condition for runners and it has over the years been the subject of much debate and argument. I think for the sake of simplicity it is best to say that here we are not thinking about compartment syndrome (a swelling of the muscles causing pain and requiring surgery) or a stress fracture of the tibia. Shin splints here relates to pain at the outside of the lower leg over the muscles there. There are several muscles and other structures in this area that are especially important during running and these can get overloaded causing pain and discomfort.

Symptoms of Shin Splints:

Although the actual nature of what is causing shin splints may have been under a large amount of scrutiny the symptoms of shin splints are fairly easy to define. Pain is located in the lower leg around the front and outside of the shin. It is generally only there during exercise and settles with rest. It often worsens throughout running until the person will need to stop but occasionally it is only there during the initial part of a run.

Causes of Shin Splints:

I think it is best not to get bogged down in discussing what the underlying structure involved with shin splints is and rather I think we should concentrate on some potential causes of shin splints in runners.

1. Going too Far too Fast: for shin splints this is almost certainly the number one cause of symptoms. Running places enormous loads through the muscles of the feet and shins and as these muscles are in general fairly small they take a long time to adapt. Doing too much or increasing running too quickly leads to overloading the structures in this area and pain.
2. Cross Over Gait: there is some research that associated pain in the outside of the shins with a type of running gait called a crossover gait. It is easy to check if this is your gait: simply look at yourself running and see if your feet cross over each other in straight line (think about if you look like you are running on a tight rope).
3. Changing Terrain: going off road and running on bumpy surfaces can require more effort from the muscles of your shins in order to keep balance and as such these can become overloaded if you have changed your running surface.

Okay, there are potentially quite a few other causes of shin splints and the symptoms of shin splints can often be similar to other conditions. As such I would recommend an assessment by a physio.

Glutes and Hips

The bum, hip and low back area encompass a large number of muscles, ligaments and tendons and come under enormous load during running with the gluteal muscles being of particular importance. As such the structures in this area can get overloaded and are a common source of running injuries. Below are some common running injuries related to this area:

Piriformis Syndrome

For many runners piriformis syndrome really is a pain in the bum (quite literally!). The piriformis muscle runs right through the buttock area and has an important role in stabilising the hip. It also has the sciatic nerve run very close to it or in some cases go right through it and sometimes runners can overload this muscle and cause problems here. Piriformis syndrome is a highly debated issue in the world of physiotherapy and for a more detailed look at the condition please have a look at our article on the subject: piriformis syndrome myth or reality?

Symptoms of Piriformis Syndrome:

As mentioned piriformis runs right through the buttock area itself and also is very close to the sciatic nerve. As such symptoms tend to be located mostly in the buttock and can also run down the leg. Typically the symptoms of piriformis syndrome are pain in the glute area of an aching and dull kind of pain that worsens with activity and can be bad when sitting. Some patients will also describe a pain running down the back of the leg that also worsens when sitting.

Causes of Piriformis Syndrome

Generally it is best to think of piriformis syndrome in runners as an overload injury where the muscle has been working too hard. Below are some causes of piriformis syndrome in runners:

1. Hip Weakness: a weakness in the muscles of the hip such as the glutes can slowly over time and throughout running overload piriformis which has a stabilising role at the hip. It is only a small muscle and if the larger gluteal muscles are not working well enough it can get overloaded.
2. Weakness at the feet/ankle: if one ankle or foot is much weaker than the other side or potentially has worse balance then sometimes the muscles higher up can get overloaded. With the repetitive nature of running it is easy to see that a muscle like piriformis can get easily overloaded.
3. Going too Far and too Fast: I am afraid to say that as with most other common running injuries, piriformis is mostly caused by doing too much. Either by going too far or too fast or even worse both!
4. Change in Running Terrain: a large change in the terrain that you run on can sometimes overload piriformis. If for example you have mostly been road running and then you move to the countryside and start fell running it is possible that this will cause overload in piriformis due to the increased need for stabilising work at the hip.

Okay, as mentioned piriformis syndrome is a fairly complex condition and as such I would very much recommend an assessment by a physio in order to rule out any other potential causes of symptoms. Also we have an in depth article on the subject here.

Trochanteric Bursitis

At the outside of the hip the tendons of several muscles run across and over to join the femur, at this point they come under large amounts of stress and compression and also run over a bursa (gel filled sac). Sometimes runners can either irritate this bursa or the tendons running over it causing what is generally described as trochanteric bursitis. As our understanding of this condition has evolved over the years it has slowly been renamed Lateral Hip Pain Syndrome to reflect the likelihood that it is not only the bursa itself that is a cause of the pain. Regardless of the underlying complexities pain around the outside of the hip is a common running injury.

Symptoms of Trochanteric Bursitis

Unlike the underlying cause of pain, the actual symptoms of trochanteric bursitis (Lateral Hip Pain) are fairly easy to recognise. In general pain is located quite clearly at the outside of the hip very near the bump of the greater trochanter. This can easily be felt by putting your hand on the pockets of your jeans at the front and then moving your hand out to the side and around until you feel a distinct bump. Pain is generally worse after exercise or walking and can be very bad at night with pain radiating down the outside of the leg.

Causes of Trochanteric Bursitis:

Rather than consider whether it is the bursa or the tendons of the gluteal muscles that are causing the pain I think it is possibly better to simply consider why runners might get pain at the outside of the hip:

1. Instability During Gait: a lack of solid stability through your running gait can sometimes cause overload on one side. The underlying causes of this instability or lack of balance etc are complex and can be a lack of pelvic strength, core stability or general hip weakness.
2. Change in Surface: a sudden change in surface (road to bumpy tracks) or terrain (flat to hills) can sometimes overload the muscles of the hips.
3. Going too Far and too Fast: yes, the most likely cause of even his condition is simply doing too much!

As with the all the other common running injuries described in this article I would always recommend having an assessment by an experienced physiotherapist firstly to determine the exact diagnosis and secondly to design an effective rehab plan.

Okay, I hope that this article about common running injuries has been useful and helps you avoid getting any of them. Should you need any help with your running injuries pleas get in touch. We are a home visit physiotherapy service based in Lichfield and serving anywhere within a 20 minute drive such as Sutton Coldfield, Tamworth, Walsall and Cannock.