Runner’s Injuries: Prevention and Treatment

Runner’s injuries

Running is one of the most practiced sports in the world, with millions of enthusiasts in Italy. It is accessible, economical, beneficial for cardiovascular health and psychological well-being. However, running is also one of the sports with the highest injury rate: it is estimated that 50-70% of runners suffer at least one injury per year that forces them to stop or reduce training.

The vast majority of runner’s injuries are overuse type: there is no acute trauma but a progressive accumulation of repeated microtraumas that exceeds the tissues’ capacity for adaptation. This means that most injuries are preventable with proper training load management, muscle strengthening, and attention to running technique.

The Most Common Runner’s Pathologies

1. Patellofemoral Pain Syndrome (Runner’s Knee)

The most common cause of knee pain in runners (25% of all injuries). Anterior knee pain, around and behind the kneecap, which worsens downhill, with stairs, and after prolonged sitting.

In-depth: Runner’s knee pain and patellofemoral pain syndrome

2. Iliotibial Band Syndrome

The second cause of knee pain in runners. Sharp, burning pain on the outside of the knee, which appears after a consistent number of kilometers.

In-depth: Iliotibial band syndrome

3. Plantar Fasciitis

Pain under the heel, especially in the first steps of the morning. Running on hard surfaces and increased volume predispose to it.

In-depth: Plantar fasciitis

4. Achilles Tendinitis

Pain in the Achilles tendon, 2-6 cm above the heel bone. Frequent in runners over 40 and after sudden increases in volume.

In-depth: Achilles tendinitis

5. Medial Tibial Stress Syndrome (Shin Splints)

Pain along the inner edge of the tibia. Typical in beginners and due to training errors.

In-depth: Medial tibial stress syndrome

6. Stress Fracture

Micro-fracture of the bone due to overuse, especially in the tibia, metatarsals, and heel bone. The pain is pinpoint, progressive, and does not improve with warm-up.

7. Hamstring Strain/Tear

Muscle injury to the back of the thigh, typical of sprints and changes in pace.

In-depth: Muscle strain and Muscle tear

8. Patellar Tendinitis

Pain below the kneecap, in the area of the patellar tendon. Frequent in runners who also jump or run downhill.

In-depth: Patellar tendinitis

9. Metatarsalgia

Pain under the forefoot, in the region of the metatarsal heads. Linked to inadequate footwear and foot biomechanics.

In-depth: Metatarsalgia

10. Runner’s Low Back Pain

Low back pain in runners is often linked to core weakness, iliopsoas stiffness, and imbalances in the kinetic chain.

Main Causes of Running Injuries

Training Errors (60-70% of causes)

• Too rapid increase in volume: the number one cause. The 10% rule (do not increase weekly volume by more than 10%) is fundamental.
• Too much, too soon: beginners who start with excessive volumes and intensities.
• Load monotony: always running at the same speed, on the same surface, on the same route.
• Lack of recovery: not respecting rest days between sessions.
• Increased intensity: interval training, repetitions, and tempo runs too frequent without an adequate aerobic base.

Biomechanical Factors

• Overstriding: the foot lands too far in front of the center of mass, increasing impact forces.
• Too low cadence: less than 170 steps per minute increases flight time and impact forces.
• Excessive pronation: flat foot or pronated foot alters lower limb biomechanics.
• Gluteal weakness: weak gluteus medius causes pelvic drop and knee valgus during running.

Extrinsic Factors

• Inadequate footwear: worn shoes (>800 km), shoes with drop or cushioning not suitable for the foot type.
• Surface: always running on hard asphalt, uneven terrain.
• Climate: cold (muscle stiffness), hot (dehydration).

The Prevention Program

1. Load Management

• 10% Rule: maximum 10% increase in weekly volume.
• Alternate running day and rest day: especially for beginners.
• Vary training: alternate slow running, fartlek, repetitions, long runs.
• Cross-training: include cycling, swimming, or elliptical to reduce running load.

2. Strength Training (2-3 times a week)

Strength training reduces the risk of injuries by 50% in runners.

3. Stretching and Mobility (after running)

4. Running Technique

• Cadence: 170-180 steps per minute.
• Foot under the body: avoid overstriding.
• Forward lean: slight lean of the torso from the hips (not the waist).
• Relaxed arms: swing back and forth, not sideways.

Prevention Exercises for Runners

# The Most Common Runner’s Pathologies

1. **Patellofemoral Pain Syndrome (Runner’s Knee):** Anterior knee pain around the kneecap, worsening with stairs and downhill running, affecting 25% of runners.

2. **Iliotibial Band Syndrome:** Sharp, burning pain on the outer knee appearing after consistent running distances.

3. **Plantar Fasciitis:** Heel pain,. The prevention program should be performed 2-3 times a week, preferably on non-running days or after a light run. Your physical therapist will personalize the program.

Gluteal Strengthening

Single-leg squat

[IMAGE: Person standing on one leg on a step. The other leg hangs in the air in front. The knee of the supporting leg slowly bends up to 45-60 degrees, ensuring it does not collapse inwards (valgus). Arms are open for balance. Front view with a vertical line showing knee-foot alignment.]

Side-lying hip abduction with resistance band

[IMAGE: Person lying on their side with a therapeutic resistance band placed just above the knees. Knees are slightly bent. The top leg lifts sideways against the resistance of the band. Hand is on the hip to ensure the pelvis does not rotate. Front view.]

Hip hike on a step

[IMAGE: Person standing on a step with one leg. The other leg hangs in the air. Without bending the knee, the pelvis on the suspended side lifts and then slowly lowers (the gluteus medius of the supporting leg controls the movement). Front view with arrows indicating the lifting and lowering of the pelvis.]

Eccentric Strengthening (Hamstring Prevention)

Nordic hamstring curl

[IMAGE: Person kneeling with feet secured (partner or under a sofa). The torso is upright and slowly leans forward, maintaining a straight line from knees to head, braking the fall with the hamstrings. Hands are ready to break the fall. Side view showing the body angle during the eccentric phase.]

Core Strengthening

Front plank

[IMAGE: Person supported on forearms and toes. The body forms a straight line from head to heels. The abdomen is contracted. Side view.]

Side plank with hip abduction

[IMAGE: Person supported laterally on forearm and lower foot. The body is in a straight line. The top leg lifts (abduction) while maintaining body alignment. Front view.]

Eccentric Calf Strengthening

Eccentric calf raise on a step (gastrocnemius and soleus)

[IMAGE: Person standing on the edge of a step with the front of their feet on the step. Two positions: left with STRAIGHT knee (gastrocnemius), right with BENT knee (soleus). In both cases, the heel slowly lowers below the level of the step (eccentric phase). Side view with the two variations side-by-side.]

Post-Run Stretching

Hamstring stretch

[IMAGE: Person standing with one foot resting on a bench or low wall at hip height, leg straight. The torso leans forward with a straight back until a stretch is felt in the back of the thigh. Side view.]

Calf stretch

[IMAGE: Person standing facing a wall with one leg back, knee straight, heel on the ground. The other leg is forward. Side view.]

Iliopsoas stretch

[IMAGE: Person in a low lunge position with the back knee on the ground. The torso is upright, pelvis pushed forward. Side view.]

When to Consult a physical therapist

• Pain that persists for more than 3-5 days despite rest.
• Pain that always appears at the same kilometer or at the same point in the run.
• Pain that progressively worsens despite reduced volume.
• Pinpoint pain on a bone (suspected stress fracture).
• Pain that prevents normal walking.
• Persistent swelling of a joint.
• Knee giving way during running.

Your physical therapist will evaluate your running biomechanics, identify the cause of the injury, and set up a personalized rehabilitation program.

Recovery Times for Major Injuries

Frequently Asked Questions (FAQ)

Frequently Asked Questions

Does running hurt your knees?

Running does not inherently damage healthy knees. However, improper training, biomechanical imbalances, or sudden increases in load can contribute to overuse injuries such as patellofemoral pain syndrome. Adherence to proper training principles, including gradual load management and strength conditioning, helps mitigate this risk.

Should I stop running if I have pain?

Persistent or sharp pain experienced during running often signals an underlying issue that warrants attention. Continuing to run through significant pain risks exacerbating an injury and prolonging the recovery period. It is generally advisable to reduce or temporarily cease activity and seek professional evaluation to determine the cause and appropriate management.

Is strength training really necessary for runners?

Yes, strength training is highly beneficial and often considered essential for runners. It plays a crucial role in improving running economy, correcting muscular imbalances, and significantly reducing the risk of common overuse injuries. A comprehensive strength program, targeting key muscle groups such as the glutes, core, and calves, supports efficient movement and enhances the body’s resilience to training loads.

Do cushioned shoes prevent injuries?

The role of cushioned shoes in injury prevention is a complex topic with varied findings. While they can offer comfort and impact absorption, excessive cushioning may not inherently prevent injuries and could potentially alter natural running mechanics. Optimal footwear selection should consider individual biomechanics, running style, and overall comfort, rather than solely relying on cushioning for injury mitigation.

Sources and Scientific References

1. Strauss EJ et al. (2011). Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 19:728-36. DOI | PubMed
2. Friede MC et al. (2022). Conservative treatment of iliotibial band syndrome in runners: Are we targeting the right goals? Phys Ther Sport. 54:44-52. DOI | PubMed
3. van Poppel D et al. (2021). Risk factors for overuse injuries in short- and long-distance running: A systematic review. J Sport Health Sci. 10:14-28. DOI | PubMed
4. Baker RL et al. (2016). Iliotibial Band Syndrome in Runners: Biomechanical Implications and Exercise Interventions. Phys Med Rehabil Clin N Am. 27:53-77. DOI | PubMed
5. Leppänen M et al. (2024). Hip and core exercise programme prevents running-related overuse injuries in adult novice recreational runners: a three-arm randomised controlled trial (Run RCT). Br J Sports Med. 58:722-732. DOI | PubMed