Common Running Injuries

by Janet Hamilton, MA,CSCS,PTA, Team Oregon
Though most running injuries are not life threatening (with the exception of heat stroke of course) they are annoying and over time can interfere not only with running for fitness, but also the pursuit of other active hobbies. In that sense, they are serious enough to devote your attention to and make an effort to treat them immediately. The best course of action is to prevent the injury in the first place and as you will see in the material that follows, most injuries can be prevented with a few simple changes.

Many, if not most running injures can be traced back to determine some causative factors and some aggravating factors. Some of the more common causative or aggravating factors include:

  1. Training errors
  2. Inappropriate footwear
  3. Inadequate flexibility
  4. Inadequate strength
  5. Poor biomechanics

Rarely are injuries due to just one of these factors; more commonly it is a combination. Likewise, injuries are rarely "fixed" by changing only one thing; usually a comprehensive approach is required. By understanding some of the more common running injuries, a sensible approach to self treatment can be initiated early and further injury can sometimes be avoided altogether. Generally, ignoring an injury invites more problems. If treated early with rest, ice and a sensible approach to resumption of training, many injuries can be effectively managed allowing the runner to return to running fairly quickly. If conservative self care doesn't net some substantial improvement in a matter of a few days to a week, then professional help should be sought as soon as possible. The sooner you treat, the quicker you can return to running.

Some of the more common running injuries are presented below:


    Plantar Fascitis

    Literally speaking, this is an inflammation ("itis") of the plantar (bottom of the foot) fascia. The most common symptom is pain in the bottom of the heel when first arising in the morning or after being seated for a period of time. The pain usually dissipates fairly quickly after moving about, and in some cases may return later in the day after prolonged standing. Many people describe the first symptoms as feeling like a "stone bruise" on the bottom of the foot. Left untreated, these symptoms may accelerate to the point where acute pain is present with nearly all activity. The plantar fascia is a tough fascia, much like a ligament, that spans the arch of the foot attaching at one end to the heel bone and at the other end to the ball of the foot. When your foot contacts the ground, your arch is "unlocked" so that your foot can absorb shock and adapt to uneven terrain. As your arch drops, the plantar fascia is stretched. If your calf muscle is a little tight, it places additional stress on the plantar fascia as your heel comes up off the ground. Microtrauma occurs and this sets the stage for the inflammatory process to begin.

    Probable causes:

    • tight calf muscles (other leg muscles may also be involved)
    • inadequate support from the running shoe
    • training errors (too many hills, too much speed too soon)
    • biomechanical (excessive or prolonged pronation)
    Treatment strategies:
    • stretch calf muscles (3-5 times per day is helpful)
    • examine shoes for wear & replace frequently
    • ice (10 minutes 2-3 times/day if possible)
    • adjust training schedule (decrease speedwork & hills)
    • see a biomechanical specialist for a full assessment, gait analysis and treatment
    • .


    Achilles Tendonitis

    This is an inflammation of the Achilles tendon. This large tendon attaches your calf muscle group to your heel, and not surprisingly is a common site of injury in runners. The first symptoms are a vague, dull, aching in the tendon after running. There is also frequently stiffness and aching in the tendon upon first arising in the morning. If ignored, the symptoms usually worsen to the point where pain is present on the initiation of running and increases with sprinting. Untreated, the symptoms eventually become present at all times and the individual is unable to run due to acute pain, and may be unable to walk without pain. Although the primary cause of Achilles tendonitis is lack of flexibility in the calf muscle group, stretching these muscles when in an acute flare up will only make things worse. This is one time when stretching must be delayed until the acute soreness has subsided. If the symptoms are caught early, a short rest of about 2 weeks will often settle things down. Pain that has been present for more than 3 to 6 weeks usually requires 6 weeks or more of rest to resolve. Symptoms that persist for 8 or more weeks are often accompanied by a thickening and scarring of the Achilles tendon, making it weaker and at greater risk of rupture in the future.

    Probable causes:

    • tight calf muscles (as well as hip flexors and others)
    • excessive shoe wear, allowing for excessive pronation
    • too much speed work too soon
    • too much hill work too soon
    • biomechanical faults
    Treatment strategies:
    • small heel lift until symptoms subside, then stretch
    • REST
    • reduce speed work and hills
    • ICE after training
    • see a biomechanical specialist for comprehensive assessment, gait analysis and treatment


    Runner's Knee

    Really a catch-all term, this refers to pain in and around the knee cap or "patella." This odd shaped bone is really an integral part of the quadriceps muscle on the front of the thigh. This large muscle is very active in running, especially when going downhill. The patella rests in a groove on the femur and acts as a fulcrum to improve the angle of pull of the quadriceps muscle which attaches to the lower leg bone (tibia) through a thick tendon called the patellar tendon. The early symptoms are usually a dull aching in and around the patella, after running. There may be a stiffness in the knee as well, partly due to a swelling of the inflamed tissues. Depending on the biomechanics of the individual runner, the pain may be localized to one area or another of the patella. If the pain is localized to the patellar tendon it is often referred to as Patellar Tendonitis. If the biomechanics of the runner are such that the patella does not sit properly in its femoral groove, the underside of the patella will over time wear down and become rough and deteriorated. This condition is known as Chondromalacia Patella. As in most cases of inflammatory processes, left untreated the symptoms generally get worse and over time deterioration and /or scarring of the involved tissues takes place.

    Probable causes:

    • tight quadriceps muscles
    • tight calf muscles (hamstrings may also be tight)
    • biomechanical faults (usually excessive or prolonged pronation)
    • worn or improper shoes
    • training errors (too much hill work too soon)
    Treatment strategies:
    • stretch tight muscles (quadriceps and calf muscles)
    • examine shoes for wear and replace frequently
    • ICE (several times a day for ~ 10 minutes)
    • Rest, and reduce hill work and speed work
    • see a biomechanical specialist for comprehensive assessment, gait analysis, and treatment


    Tibial Stress Syndrome

    This is another catch-all term that covers several more specific diagnoses including posterior shin splints, anterior shin splints, and perhaps could even include compartment syndromes. For the purposes of our discussion we'll look at the two most common: posterior and anterior shin splints. Anterior shin splints are really an inflammation of the tendons that attach to the front of the shin bone to the outside. One large muscle, the Tibialis Anterior, is primarily responsible for keeping your toes from dragging when you swing your leg through to take a step, and acts to gently lower the forefoot to the ground when the heel strikes. It also is responsible to help decelerate the pronation of the foot that occurs shortly after heelstrike. This muscle acts in opposition to the larger calf muscle group in the back, and hence a primary cause of irritation is a lack of adequate flexibility in the calf muscles. Early symptoms usually consist of aching in the muscle on the front outer part of the shin during running, and gradually persist until there is a defined and sharp pain along the front outer tibia (shin bone) even with walking. Posterior shin splints are an inflammation of the tendons that attach to the inner side of the shin bone. A common muscle involved is the Posterior Tibialis. This muscle is quite active in decelerating the pronation (inward rolling) motion of the foot. Symptoms usually consist of an aching that occurs along the inner front surface of the shin bone and may progress down to the arch of the foot. Generally the pain occurs when you first run, and may subside later in the run only to return later. As the inflammation worsens, the symptoms are present with walking and may also present as a tenderness and stiffness when first arising. With either of these syndromes, there may be localized tenderness to the touch and there may also be some swelling. If there is acute tenderness, warmth, redness and swelling, a stress fracture should be ruled out by a physician using X-Ray or bone scans. The most common causes for both of these syndromes are lack of adequate calf muscle flexibility, and faulty biomechanics. If rest, ice and stretching don't give substantial relief fairly quickly you should definitely pursue the advice of a biomechanical specialist.

    Probable causes:

    • tight calf muscles
    • biomechanical faults (excessive or prolonged pronation)
    • increasing mileage too fast
    • excessive shoe wear
    • training errors (too much hill work or speed work too soon)
    Treatment strategies:
    • stretch tight calf muscles (several times a day is good)
    • decrease mileage and hill work / speedwork
    • assess shoe wear and replace frequently
    • see biomechanical specialist for full gait analysis and treatment as needed

    Iliotibial Band Syndrome

    The iliotibial band is a long, thick band of fascia that runs from the outer hip area to the outside of the knee and attaches to the lower leg bone (the lateral tibia) just below the knee joint. It attaches to large muscles of the lateral (outside) hip, including the Gluteus medius and Tensor Fascia. Its length crosses the hip joint and the knee joint, hence it is important in the actions of both. It's function in gait is dynamic and changes with the position of the knee joint. Initially it acts to decelerate the inward rotation of the leg and flexion of the knee that occurs in response to pronation of the foot. As the knee flexes beyond a certain point, the angle of pull changes and the Iliotibial band now functions to assist the Hamstrings in flexion of the knee. Iliotibial Band Syndrome is an inflammation of the Iliotibial Band, most commonly at its insertion below the knee. The symptoms include discomfort in the lower outside thigh or knee area that are first present only when running. As with all inflammatory processes, if left untreated the symptoms will gradually worsen to the point where they are present with most activity. One popular misconception is that only "supinators" get this problem. Nothing could be farther from the truth. Though in rare cases it is brought on by chronically running on the same slant of the road, (the leg that is downslope is most affected) it is much more commonly seen in runners with either poor biomechanics or poor flexibility (or both).

    Probable Causes:

    • Poor Biomechanics - usually excessive pronation
    • Inadequate flexibility - Especially calf muscles and buttock muscles and outer thigh or buttock muscles
    • Training errors - always running the same slope of the road, excessive speed work
    • Excessive shoe wear, or inappropriate shoe choices
    Treatment Strategies:
    • Address Biomechanical Issues
    • Stretch tight calf muscles, hamstrings and hips
    • Decrease mileage and speedwork
    • Replace worn shoes


    Metatarsal Stress Syndrome

    The metatarsals are the bones in your foot that correspond to the bones in the palm of your hand. They run from about the middle of the arch to the ball of your foot where they attach to the toes. They function first as a flexible platform to adapt to uneven terrain, then as a lever to propel you forward. Their function as either a flexible adapter or a rigid lever is determined by the joints of the midfoot (arch) and rearfoot (heel area). One of the most common causes of metatarsal pain is poorly fitted shoes. If the toe box of the shoe is either too short or too narrow, it compresses the metatarsals and interferes with their natural actions. As an example, imagine how hard it would be to write, or open a jar if someone were squeezing your palm tightly. The symptoms of metatarsal stress syndrome generally start as an aching sensation under the ball of the foot (where the toes join the foot). This is usually first felt only on long runs or during speedwork, but is also commonly felt in dress style shoes that typically have a very narrow toe box. The symptoms are relieved by removing the shoes, only to return again the next time they are worn or during the next run. Some people describe the early sensation as feeling as if their socks have "wadded up" under the ball of the foot. The symptoms can become more frequent and intense, eventually causing discomfort with most activities. The other primary causes of this problem are lack of flexibility in the calf muscles and inadequate support to the arch of the foot, allowing excessive pronation to take place.

    Probable causes:

    • poorly fitted shoes
    • inadequate flexibility in calf muscles
    • biomechanical - excessive or prolonged pronation
    • excessive shoe wear
    Treatment Strategies:
    • Insure proper shoe fit (at least one thumb's width between the end of the longest toe and the end of the toe box of the shoe
    • stretch tight calf muscles
    • replace worn shoes
    • see a biomechanical specialist for analysis of biomechanical faults


    Stress Fractures

    Stress fractures are partial or complete cracks in the outer layers of the bone that occur as a result of repetitive stress. Generally they occur in the lower limbs, but can occur anywhere there is a chronic pattern of excessive stress. In runners, the common sites for stress fractures include: tibia (shin bone), metatarsals (long bones of the foot), femur (thigh bone), and occasionally the pelvis. The symptoms of a stress fracture include pain that is worst when exercising but may also be present at rest. The pain is generally quite localized to a specific bony area and is most noticable when the area is pressed or tapped. What specifically causes stress fractures is the subject of some debate. One theory suggests that muscles are fatigued by repetitive exercise and lose some of their shock absorbing ability, placing a greater load on the bone and eventually a fracture. Another theory implies that the repetitive stress does not allow the bone adequate time to heal from the microtrauma, eventually leading to a breakdown and fracture. Still another perspective suggests that the repetitive actions of muscles on bones creates excess tension and eventual microfractures and stress fractures. Whatever the physiological mechanism may be, the physical causes are usually related to training errors and biomechanical factors. Other factors to be considered are a low bone mineral content caused by insufficient dietary calcium, and hormonal insufficiencies (low blood estrogen in women and low blood testosterone in men). Routine X-rays are often inconclusive and true diagnosis must often be made through the use of a bone scan. Treatment for stress fractures consists of a period of active rest that may last 4-7 weeks and in some cases up to 3 months or more. During this time the athlete may be allowed some weight bearing on the affected leg, but generally will be restricted from any aggressive weighted activity. In addition, the athlete may be encouraged by the physician to take supplemental calcium (up to 1500 mg. per day). Once the stress fracture has healed, the return to running must be slow enough to allow the bone adequate time to adapt successfully to the stresses imposed by running.

    Probable causes:

    • training errors: abrupt changes in training, mileage intensity, duration, or equipment.
    • biomechanical faults: excessive pronation or supination
    Treatment strategies:
    • REST
    • Biomechanical evaluation and gait analysis with orthotic intervention as needed
    • address training errors
    • supplemental calcium as directed by physician and avoidance of diet soft drinks (they often inhibit the body's ability to absorb calcium)

REFERENCES

1. Gould, J A III (editor): Orthopedic and Sports Physical Therapy. Second Edition, C.V. Mosby Company, 1990.

2. Warwick R, Williams PL (editors): Gray's Anatomy (35th British edition). Philadelphia: W. B. Saunders Company, 1973.

3. Hough David O., MD, Ray Richard, Ed.D., A.T.C., Gatorade Sports Science Exchange. 7:(1), 1994.

4. Gross MT: Lower Extremity Screening for Skeletal Malalignment - Suggestions for Orthotics and Shoewear. J Orthop Sports Phys Ther 21(6)389-405,1995.

5. Gray, G: Lower Extremity Functional Profile. Adrian, MI: Wynn Marketing, 1995.

6. Rodgers MM: Dynamic Foot Biomechanics. J Orthop Sports Phys Ther 21(6)306-316,1995.


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