Photo: Brad Kaminski
One of the hard truths we must all accept as runners is that this sport can be tough on the body. Regardless of whether you’re new to the sport, a seasoned marathoner, or a sturdy trail runner, avoiding common running injuries is hard to do. Studies show that 50 percent of runners get hurt every year. That can be a brutal reality, especially when you’re running to improve your health. But armed with the right information, there is plenty you can do to minimize the chance of being hit by the injury bug.
We spoke with two expert physical therapists from the running mecca of Boulder, Colorado, both of whom are longtime runners themselves, to find out how to best prevent the most common running injuries.
Nicole Haas, PT, DPT, OCS, is a physical therapist, the founder of Boulder Physiolab, and a board-certified orthopedic clinical specialist who has treated scores of injured runners over the past 20 years.
She says one of the biggest mistakes she sees many runners making is ignoring minor injuries until they become exacerbated. There can be a gray area between the soreness derived from a workout and the pain stemming from an injury, but any kind of lingering malady should be identified and addressed immediately in order to start the healing process and to reduce aggravating the situation any more.
“The quicker you seek help, the quicker you can get it to go away, even if it’s one visit to a PT,” Haas says. “The alternative is you leave it for months, spinning in a cycle of not really getting rid of the source of your pain.”
Realizing that it can be hard to know exactly when to seek professional help, Haas advises “giving it a week or two” to see if you can change or offload the source of your pain. If it feels better after this time, then you know you’re in the clear, she says, but if not—and every time you run it’s the same or worse—then it’s time to seek professional help.
“Many people think I’m going to tell them not to run, but that’s not it,” Haas says. “A lot of the time I help people continue doing what they’re doing.”
She says that it’s often about managing variables in small, smart ways. That could mean avoiding hills if you’re dealing with a bout of Achilles tendinitis, temporarily reducing mileage and intensity while running on softer surfaces, looking more closely at your choice of running shoes, or even just getting up from your desk more often if you’re sitting for most of your working day.
Carol Passarelli, a physical therapist at the University of Colorado Sports Medicine and Performance Center, holds a similar viewpoint. As an orthopedic doctor of physical therapy for Team USA’s mountain and trail running teams, she knows how important it is to keep runners running whenever possible.
As someone who regularly treats elite runners, she commonly prescribes an impressive array of exercises designed to help prevent and manage the full gamut of running injuries, so if you’re not already doing plenty of run-specific strength exercises, then her first nugget of advice will always be to do that.
As we dig into four of the most common running overuse injuries, you’ll see that there’s significant commonality among them all: glute and hip strengthening and gait control. A lack of glute strength is typically characterized by the inability to keep the knee from collapsing inwards on impact and the hip dropping excessively. “If you have this pattern, then you have the problem,” Haas says.
“When it comes to knee pain, it’s actually your brain that’s in charge,” she continues. “It will use what it thinks is the most efficient and effective pattern to achieve its goal. If it doesn’t have all the tools to use—like the strength of the glutes—then it defaults to other compensatory patterns that can lead to pain. Glute strengthening in functional patterns can teach that femur (thigh) to steer itself straight, instead of steering right into the pattern that’s causing the pain.”
Read on to find out how to fix those patterns—and how to avoid four of the most common running injuries.
Common Overuse Injury #1: Runner’s Knee
The most common running overuse injury is patellofemoral pain syndrome, otherwise known as runner’s knee. It typically presents as a dull ache to moderate pain around the front of the knee or inside the knee cap. Although those sensations can be present, it is typically felt when running, walking up stairs, hiking, or other daily movements such as getting in and out of a car.
Common causes: An increase in mileage without adequate rest that causes deviations in gait patterns that causes the kneecap to be misaligned; weakness/lack of control in the hips, glutes, quadriceps, hamstrings, particularly when starting a new running program; limited mobility; movement deficits, such as your knee collapsing inwards when you land and/or your hips dropping excessively.
Treatment: “Glute strength and issues related to running mechanics are definitely the key to this issue, so be prepared for plenty of glute strengthening in any treatment of runner’s knee,” Haas says. “Hands-on stuff can also help with this, along with a proper gait running analysis.”
Prevention: There are many exercises that can help keep runner’s knee at bay, but Haas emphasizes it’s important to not do these exercises using the same pattern that’s caused you to suffer in the first place (e.g., your knee collapses on impact). “It’s important to rewire the brain here and not let the knee collapse in,” she says. “That’s why proper and precise form is key here and as you execute each movement be mindful of how your knee is tracking.”
Key Preventative Exercise: Standing Clam Shells
- Stand on your right leg in a runner’s/athletic stance (slightly bent at the knee).
- Lift your left leg to reach to the wall behind you, keeping all of your weight in the right leg.
- Open your left leg like a clam shell (and very quickly you should feel this in your right hip).
- Vary the amount of hip hinge (flexion) across sets and/or put a band above your knees.
- “Do five repeats followed by a five-second hold, and you should feel it quickly,” Haas says.
Are you wondering why so many PTs recommend clamshells? Passarelli says it’s because the clamshell exercise is highly effective at targeting your gluteus medius, which is one of the three gluteal muscles, and it plays a big role in your quadriceps activation and ability to safely control your knee. “Clamshells—even for athletes—should feel challenging,” she says. “If you don’t feel the correct muscle turning on, it’s very possible you’re compensating.”
Other Preventative Exercises:
1) Hip abduction single-leg squats [three sets of 15];
2) Bulgarian split squats [three sets of 15];
3) Single-leg squat with isometric hip abduction [three sets of 10 per leg]
Common Overuse Injury #2: Plantar Fasciitis
Plantar fasciitis is characterized by dull to irritable pain on the bottom of the foot that, like an annoying dinner party guest, can seem to take forever to finally disappear. The plantar fascia is a thick, spring-like fascia that runs from the heel to the toes, and plantar fasciitis occurs when the fascia becomes inflamed. This injury can often first present as a nagging pain in the heel that hurts the most when taking your first few steps in the morning.
Common causes: A sudden increase in mileage or intensity; loading with improper mechanics; running too much in minimalist shoes; movement deficits, such as your knee falling inwards when you land and/or your hips dropping excessively during a stride, often due to poor glute strength or control.
“Plantar fasciitis can often be related to stiffness in the big toe or ankle,” Haas says. “But also if it gets loaded improperly or you simply run too much, too fast, and you don’t control the load then you can often encounter plantar fascia problems.”
Haas likens it to pulling at someone’s hair repetitively: eventually it will cause pain in the scalp—even though the scalp has done nothing wrong.
Treatment: Buckle up, because this one can take a while to finally clear up, and it often gets worse before it gets better because merely walking on it can exacerbate the inflammation, Passarelli says.“This condition can niggle for a long time, and it can get excruciating,” she says. “If you’ve had light irritation that you notice every time you run then it’s paramount you intervene and see a healthcare provider.”
Prevention: As with many of the injuries highlighted here, improving proper foot and ankle mobility can help prevent plantar fasciitis. One of Haas’ go-to assessments is the knee to wall lunge test that will give you a hint as to whether you need to work on foot mobility. If you have a restriction, or stiffness, in one or both ankles, this can cause plantar fasciitis or problems in your calves, knees, hips, and back. You can do this simple test to assess your ankle-joint mobility at home.
With your toes facing a wall, place one foot roughly a hand width away. Keeping your heel flat on the ground, bend your knee as if you were lunging into the wall. If your knee cannot touch the wall without your heel lifting, move it closer and try again. If your knee easily touches the wall, move your foot back and repeat. The idea is to find the distance where your knee can just barely touch the wall without your heel lifting. A distance of five or more inches is considered a normal range of motion.
Key Preventative Exercise: Heel Raises with Ball Between Heels
- Stand facing a wall with a lacrosse ball positioned between your heels
- Holding onto the wall for balance, slowly rise up off your heels, squeezing the ball to keep it in position as you rise onto your toes
- Slowly lower back down, maintaining pressure on the ball
- Keep your knees soft, do not hyperextend (lock out)
- Repeat for 15 reps
Other Preventative Exercises:
- Calf Stretches
- Activating Your Arch Muscles
- Banded Isolated Toe Motions [step 3 of this video]
In addition, the old favorite, Monster Walk (stepping laterally with a sports band providing resistance around the upper legs), will help activate the muscles that help control the pattern as the foot loads on the ground that are typically lying dormant when they need to be active.
Another favorite from Haas is single-leg balance work that can be achieved as follows:
- Standing on a single leg, lift the opposite leg into a fire hydrant position (out and back at a 45-degree angle). You should begin to feel your glutes “kick on” in the standing leg.
- Next, bounce a soccer or basketball in different planes of motion around your standing leg. “The single-leg position helps turn on the glute while the ball bounce adds distraction for the brain, which is so good for running,” Haas says. “This exercise is a big bang for your buck.”
RELATED: 3 Things to Know About Training After an Injury
Common Overuse Injury #3: IT Band Syndrome
The iliotibial (IT) band is a thick band of fibrous tissue that runs from the outside of the hip to the outside of the shinbone, just below the knee joint. You typically know you have IT band problems when you’re feeling pain at the outside of the knee and up the outside of your upper leg, but as much as you want to stretch it, the pain simply doesn’t go away. You can’t stretch an IT band, it’s a ligament and a tendon, Haas says, but you can address mobility in the muscle attached to it—the TFL (tensor fasciae latae). It can cause a sharp burning sensation on the outside of the knee.
Common causes: Increased uphill and downhill running/loading; lack of glute control causing the hip and knee to roll in; general lack of core strength or weakness in hip rotation/abduction; and possibly from a tendency to overpronate with one or both feet.
Treatment: If seeking PT treatment, a lot of hands-on treatment can help to jumpstart your recovery in the right direction, such as myofascial decompression cup therapy (cupping with movement). “You want to unload the myofascial compression as you move through the pattern you’re having trouble with,” Haas says.
You’ll also want to work on functional mobility. “You can’t stretch it [the IT band], but you can improve the mobility of the tissues around it,” Haas says. She emphasizes avoiding laying on a foam roller to treat this pain as that can make it worse, but instead opting for tools such as myofascial sticks or massage guns that can gently and comfortably help you massage and mobilize the muscles around the affected area.
Prevention: Passarelli says ITB irritation often stems from muscle imbalances, so general strength work and specific leg strength exercises will go a long way in keeping IT band syndrome at bay. “To put it simply, if you strengthen the heck out of your quads, a lot of your pain will likely go away,” Passarelli says. “Hit the gym, and hit it hard.”
Key Preventative Exercise: Trail Leg Lunge
Passarelli recommends a rear-foot elevated split-stance lunge—a hip mobility strengthening exercise—to work into your routine on a daily basis to help keep your IT band a happy camper.
- Begin in a wide staggered stance position with your back foot resting on a step.
- Bend your knees, lowering your body into a lunge position, then raise yourself back up and repeat.
- Make sure to keep your abdominals tight and do not let your knee move forward past your toe or collapse inward during the exercise.
- Do 2 sets of 15 reps [per leg].
Other Preventative Exercises:
1) Side Plank with Clam and Resistance [4 sets of 10 reps]
2) Standing Hip Abduction with Bent Knee [2 sets – 15 reps]
3) Lateral Step Down [2-3 sets of 8-12 reps]
Common Overuse Injury #4: Achilles Tendonitis
After runner’s knee, Achilles Tendonitis is the runner-up in the not-so-highly sought-after league of most common running injuries—and it’s particularly common in master’s athletes, possibly due to the pliability of the tendon as we age.
Common causes: Load and rate of load; tightness and stiffness or a lack of functional mobility in the foot, ankle, and calf complex; sudden onset of hilly running; sudden change in shoe drop.
“If you’ve been running in 8mm drop shoes and then suddenly start running in zero drop shoes then you’re putting yourself at risk of Achilles tendonitis if you don’t have good ankle mobility,” Haas says.
When issues are already present or flared up, she also advises runners to be aware of their everyday shoe choices and how this can impact the Achilles, e.g., wearing flip flops a lot in the summer. (Note: this can also be significant when treating plantar fasciitis too). “A sudden change in tension can have a big impact,” she says. The same applies for sudden changes in terrain covered or weekly mileage.
Treatment: Trying to calm the Achilles requires a similar approach to the plantar fascia: offload it and undo tension. “This doesn’t mean you have to stop running,” Haas says. “You may just need to undo tension in your system before you run or modify terrain to help ease the load on the Achilles.”
Prevention: The knee to wall lunge test, as mentioned in the plantar fasciitis section above, can help determine whether you have ankle stiffness contributing to the issue. If you don’t, i.e., your knee collapses inwards on landing and/or your hips drop, then you are likely to fall victim to one or more of the injuries listed in this piece. Eccentric loading will be your greatest ally in helping to prevent Achillees problems going forwards, with exercises such as heel raises among the most effective.
Key Preventative Exercises: Heel Raises
- Stand facing a wall, lightly resting your hands on it for balance
- Gently lift your heels off the floor, making sure to keep your weight on all 10 toes and hold for 5-10 seconds.
- Slowly lower your heels to the ground and repeat 10-15 times
Other Preventative Exercises:
1) Straight-Leg Calf Stretch
2) Single-Leg Standing Dumbbell
3) Farmer’s Walk on Toes
Conclusion: Keeping Injuries at Bay
As you might have already detected, there are commonalities to the most prevalent running injuries and the most effective way to bulletproof yourself against them is to employ a consistent run-specific strengthening routine that will yield a strong and resilient body with a particular emphasis on glute control.
“The glutes—that’s where it’s at when it comes to running injuries,” Haas says. “Strengthening your glutes and your entire hip complex, training them to help prevent the known pattern related to injuries, that’s what’ll keep you healthy and happy,” she says. And in order to run all the miles you want to without injuries weighing you down, you’ll want to ensure you have a healthy running pattern and gait with hips and knees that don’t collapse as you run. This, combined with sensible increases in weekly mileage and intensity, the right shoes, and adequate rest and recovery, should help keep you fit, fresh, and far away from the injury sidelines.
