Most road running injuries occur because of overuse as opposed to traumatic events. For example, it’s more common to develop achilles tendon pain than to suffer a sprained ankle. Here is a brief outline of common overuse running injuries in long distance runners (Lopes et al.,
2014; Lopes et al., 2012; Taunton et al., 2002), causes, signs and symptoms, contributing factors, early warning signs, and how to recover.

Most Common Risk Factors for All Overuse Injuries:

There are some similarities to developing most overuse running injuries:

• External causes:
  • Sudden increases in mileage, intensity, or frequency
  • Changes in footwear, terrain
• Internal causes:
  • Changes in medication, sleep, nutrition, mood

As runners, we are often trying to challenge our bodies to run further, faster, or to get back into running after taking a long time off. To do this, we constantly challenge our bodies to adapt to increased workloads and to recover in the shortest amount of time. We repeat this process again and again. There’s a fine line between building performance and overdoing it.

Most running injuries occur as a result of these external (training errors) and internal factors. Addressing these factors will be most helpful to avoid and recover from injury.

Achilles Tendinopathy:

Achilles Tendinopathy is caused by changes in the tendon itself, like more fibrosis, blood vessels and sensory nerves (Ackermann et al., 2018).

Early signs:

• Stiffness in the achilles tendon that can easily be relieved with stretching, calf tightness, morning stiffness in the achilles tendon that resolves after the first few steps

Later signs:

• Dull or sharp pain and/or swelling located at the back of the heel, pain with running/jumping activities

Contributing factors may include:

• High arches or flat feet, poor footwear, tight calves, mid foot or forefoot striker, leg length discrepancy, decreased calf/ankle flexibility, and certain genetic markers and medical comorbidities (Kozlovskaia et al., 2017)
• You can easily compare your calf and ankle flexibility with the knee to wall test shown to the right. Keep the heel on the ground and knee touching the wall. Slide your foot back as far as you can before the heel comes off. Compare both sides. Roughly 10 cm on both sides is great. If not equal, then you may need to stretch one calf more!

Early management:

• Stretch and roll calf muscles to restore ankle dorsiflexion

Later management:

• Continue to stretch and roll calf muscles (avoid overstretching if pain is located at base of heel where tendon attached to bone)
• Temporarily rest from hill and speed
• Wear shoes with a bit more heel lift
• Use maximalist shoes or foot orthoses temporarily
• Night splints that keep the foot stretched up
• Strengthening program such as the eccentric heel drop protocol (Alfredson & Cook, 2007), although any form of strengthening the calf (eccentric and concentric) is beneficial

Patellofemoral Pain Syndrome:

Many structures at the front of the knee can cause pain. Most common in runners is from the patellofemoral joint, but there are also bursa, fat pads, and the patellar tendon.

Early signs:

• Soreness or tightness at the front of the knee with activities like running, jumping, squatting, going downstairs, prolonged sitting

Later signs:

• Sharp or dull pain and/or swelling located at the front of the knee that is brought on earlier by the above activities.

Contributing factors may include:

• Weak quadriceps (Pappas & Wong-Tom, 2012) and delayed and reduced gluteus medius contraction (Barton et al., 2012)

Early management:

• Glute activation exercises (such as side stepping with a band between the knees, single leg squats, single leg bridges, lateral step ups), stretch and roll quadriceps, gluteals, TFL and calves to reduce muscle imbalances

Later management (Collins et al., 2018; Lack et al., 2014; Clijsen et al., 2014):

• Continue to stretch and roll quadriceps, gluteals, and calves
• Strengthen quadriceps, ideally in weight bearing and initially not going past 80° of bending. Strengthen and activate gluteus medius.
• Taping around the patella, foot orthoses
• Running form re-training (Agresta & Brown, 2015)

Physiotherapist, Midori Handford is testing a runner’s gluteus medius and minimus activation and strength in a runner. A key muscle to engage while running to prevent many overuse injuries from low back to foot.

Plantar Fasciitis:

Caused by structural changes such as thickening and wearing down of the plantar fascia at its attachment into the heel bone (Monteagudo, et al., 2018)

Early signs:

• Morning stiffness along sole of foot and heel for first few steps and/or while running, tightness in calves

Later signs:

• Sharper pain/burning sensation along sole of foot and heel that lasts longer than first few steps in morning and is present when standing up after prolonged sitting and walking, abnormal gait pattern of walking along the outside of the foot to avoid pain

Contributing factors may include:

• Poor or sudden change in footwear (such as sandals or very flexible shoes), less than 60 deg of weight bearing first toe extension, tight calves, mid foot or forefoot striker, and higher BMI or recent weight gain (such as from pregnancy)

Early management:

• Mobilize the first toe backwards if stiff
• Stretch and massage the calf and sole of foot to restore ankle dorsiflexion
• Wear supportive footwear (even at home, and especially when you roll out of bed)

Later management:

• Continue above
• Temporary foot orthoses to support arch, night splint to keep foot from falling into plantar flexion (toes pointed down which causes plantar fascia and calf to stay in a tight position all night)
• Strengthen arch muscles (such as towel scrunches with the toes) (Ryan et al, 2009), high load strength training (such as calf raises over step) (Rathleff et al, 2014)
• Maximalist (more cushioning under heel) or minimalist shoes (to strengthen foot muscles and perhaps alter running gait)
• Reduce running intensity

Shin Splints:

Shin splints is a common name to describe 3 common running injuries: medial tibial stress syndrome (MTSS), tibial stress fracture, or chronic exertional compartment syndrome (CECS). All cause pain along front-inner aspect of lower leg with impact activities

MTSS: May be caused by pain from where muscles attach to bone, muscle strain, periosteal inflammation or bone stress reactions (Newman, 2013)

Contributing factors may include:

• Female gender, prior history of MTSS, fewer
  years of running experience, orthotic use, flat feet, increased hip external rotation in males (Newman, 2013), and weakness in lower leg muscles (like tibialis posterior)

Management:

• Massage tight muscles such as tibialis posterior and tibialis anterior to reduced tension in muscles attaching to bone, temporarily reduce running speed, strengthen intrinsic foot muscles and others such as tibialis posterior

Stress fracture: a very small break in the tibia bone,painful with weight bearing and at night

Contributing factors may include:

• History of prior stress fractures, low body weight, amenorrhea, and under-nutrition

Management:

• Address nutrition and body weight, temporarily reduce running volume or rest completely, cross-train with non-weight bearing activities such as pool running/swimming, elliptical, biking.

CECS: Occurs during activity when the muscle expands beyond the space available within the ascia (fibrous tissue that separates muscle groups) and causes pain like burning, aching, pressure, muscle tightness or muscle dysfunction. Pain goes away when exercise stops

Contributing factors may include:

• Inherently small fascial compartments compared to muscle size (Tucker, 2010)

Management

• Stop or reduce intensity of exercise at earliest onset of symptoms until gone and repeating in this fashion, avoid downhill running, foot orthoses, and running form retraining (Agresta & Brown, 2015), potential surgery

Iliotibial Band Friction Syndrome:

Iliotibial Band Friction Syndrome is caused by repetitive irritation (friction or compression) of the iliotibial band (ITB) over the lateral femoral condyle (outer knee) between 20-30° of knee flexion leading to chronic inflammation and swelling. The ITB is a thick sheet of connective tissue running along the outer thigh, and the hip muscles (gluteus maximus and tensor fascia lata) attach to it.

Early signs:

• Tightness in outer thigh and knee with activities like running and cycling

Later signs:

• Dull or sharp pain in the outer knee as it bends between 20-30° during running or cycling, worse pain with speed and downhill running

Contributing factors may include:

• Weak hip abductors (gluteus medius/minimus) compared to unaffected side, greater rearfoot eversion and lower leg internal rotation at heel strike, leg length discrepancy (>2cm), female gender (Balachandar et al., 2019; Aderem & Louw, 2015)

Early management:

• Strengthen gluteus medius and minimus, stretch and massage glutes, TFL & quads to improve length and tension of ITB

Later management:

• Continue as above
• Reduce running distance, vary terrain, avoid downhill running, run/walk, running gait retraining (Balachandar et al., 2019)

Hamstring Proximal Tendinopathy (Goom et al., 2016):

Similar to the achilles tendon, Hamstring Proximal Tendinopathy is thought to be caused by changes in tendon. There is also a bursa that sits between the bone and hamstring tendon that can get compressed and cause pain.

Early signs:

• Tightness at the top or mid-muscle belly of the hamstring (in buttock) with activities like bending over, deadlifts, running, going up stairs

Later signs:

• Deep dull or sharp pain at the top of the hamstring with eccentric hamstring contractions (e.g. foot strike during running), overstretching (e.g. bending forward to touch toes) and prolonged sitting

Contributing factors may include:

• Leg length difference, pelvic rotations, and a heavy heel strike

Early management:

• Massage hamstring muscle (more mid-belly instead of over tendon) to reduce tension at attachment site, be cautious with over stretching as this may irritate it more

Later management:

• Continue as above
• Strengthening hamstrings (nordic hamstring curls considered gold standard), gentle stretching, running form re-training, reduce running speed, avoid uphill running

General Recommendations:

General rule of thumb to rehab for acute onset of overuse running injuries:

• Rest fully / significantly reduce running until symptoms are close to, if not fully gone
• Gradually re-build

General rule of thumb to rehab for chronic overuse injuries:

• During activity up to ~4/10 of pain is okay
• Post activity pain goes back down to baseline within 1-2 hours
• Next day pain is not worse

About the Author:

Midori Handford is a Registered Physiotherapist at the Plaza of Nations Allan McGavin Sport Medicine Clinic. Midori enjoys running 10km and half marathon distances. She has been a run club leader since 2017 and has taken the Running Clinics “New Trends in the Prevention of Running Injuries” course. Midori is also pursuing advanced training and clinical abilities in orthopaedic assessment and manual therapy. In her free time, Midori enjoys training for triathlons.

Midori Handford, Registered Physiotherapist, Functional Dry Needling, Bike Fitter

You can contact her at midori@allanmcgavinphysio.com.

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