Common Running Injuries and Prevention

JANUARY 2004 • PODIATRY MANAGEMENTwww.podiatrym.com 57

This article is the third in a seven-part sports podiatry series written bymembers of the American Academy ofPodiatric Sports Medicine. This sport-specific series is intended as a practical“how-to” primer to familiarize you withthe specific needs of patients who partici-pate in these sports, and the types of in-juries and treatment challenges you’relikely to encounter.

Each day millions of Americansrun. From the elite athlete-in-training to the casual jogger,

runners hit the trails or the track forfun, sport and health. Running is oneof the most frequently employedforms of vigorous aerobic exercise.Running is often used to assist inweight control and evidence also sug-gests that running may ease stress,lower blood pressure and lower totalcholesterol, while increasing HDL’s.

Running is relatively safe and usu-ally results in enhanced health. GeorgeSheehan often said that he did not be-lieve that running would make himlive longer, but would help him livebetter and healthier. Runners do seemto be injured more often than swim-mers or walkers, but most of these in-juries are readily treated and often pre-ventable. Running involves far greaterforces than walking, and these forcesare applied over a shorter period oftime. Running is the chosen exercisefor many and our job is to assist therunner in the pursuit of the sport.

Your local running communitywill be happy to learn of anotherpodiatrist who is knowledgeableabout both injury treatment and in-jury prevention. Treatment and pre-vention of running injuries areclosely related. As your interest andskill in treating runners grows, con-tact local quality running stores andrunning clubs. Give talks to the run-

ning clubs on injury prevention anddiscuss the characteristics of the run-ning shoes that you like to use fordifferent clinical entities. Devise areferral form to be used for yourshoe recommendations.

Approaching Running InjuriesThe most frequent cause of run-

ning injuries is over training or whatcould be termed the “terrible too’s.”Too much, too soon, too often, toofast, and too little attention paid topain all too often lead to injury. Re-cently, a new phenomena that I callthe “Sudden Runner’s Syndrome” hasappeared. Not that many years ago,most authorities recommended thatnew runners consider running forone year before considering trainingfor the marathon. Today many run-ners have a plan to start running to-morrow and complete a marathon in6 months. This can result in a consid-

By Stephen M. Pribut, D.P.M.

Continued on page 58

A Quick Look at Running

Injuries

Look for these common conditions in runners and joggers.

S P O R T S P O D I A T R YS P O R T S P O D I A T R Y

Assessment of Problem: History

The lower extremity is the areamost often injured in running,with the knee, Achilles tendon,tibia and foot being the most fre-quently affected structures. The po-diatrist is one of the most impor-tant consultants for the runner.

Besides the usual questionsthat you will be asking in yourhistory taking regarding timeand nature o f onse t , type o fpain and so on, you will need tospend considerable time review-ing your pa t i ent ’ s t r a in ingschedule (log) and secondarilytheir training and racing shoes.

Biomechanics is only part ofthe problem and will only offer aportion of the solution to mostrunning-related injuries. As wehave noted, most running injuriesare caused by overtraining and itis important to evaluate wherethe training error was made. Cor-recting the overtraining is notusually sufficient to treat many ofthe problems seen in cl inicalpractice. Shoe changes, lower ex-tremity strength improvement,c o r e b o d y s t r e n g t h ,a n d stretching to enhance flexi-bility need to be prescribed aswell as a revised training s c h e d -u l e . O r thotics of course do play

erable number of injuries, even whencarried out within the context of arun/walk program. This new athletedeserves respect and should be well-treated and encouraged to continuethe new found exercise regimen withappropriate modifications and treat-ment for the injuries.

Improper running shoes are an-other major factor in the develop-ment of running-related injuries.Contributing to overuse injuries isthe overused shoe. It is importantto examine all aspects of your pa-tient’s use of running shoes from fitto design to how long the shoeshave been worn to differences intraining and racing shoes.

When you treat experiencedrunners, they will rarely want tohear the advice “stop running”. Savethat for severe injuries. Keep inmind the concept of relative rest.Advise your runners to avoid run-ning to the point of pain during arun or what would create pain fol-lowing the run. Review their sched-ule and if possible, try to determinewhat, if any, running is possible thatwill not cause a rebound increase inpain. Prescribe alternative forms ofexercise that may be less stressfulsuch as cycling, pool running, swim-ming, or the elliptical trainer.

a role in the treatment and pre-vention of future running relatedinjuries, but the other parts of theequation must not be neglected.

Training Evaluation AndAssessment

Ask your patients to bring intheir running logs. These logsshould have daily and weeklymileage and brief notes on the run.Feelings of pain and discomfort areoften listed. You’ll be able to seewhen an injury began and whattraining preceded the injury. Lookfor sudden increases in mileage.Look for a large jump in the longrun. Usually in marathon training,the long run will only increase byone to two miles per week. An in-crease of three or four miles in thelong run and the absence of “easy”weeks, during which there is a de-crease in mileage are red flags.

Note the time of day and thetype of terrain your patient hasbeen running on. A change to run-ning on hills may aggravate plantarfasciitis or Achilles tendonitis.Downhill running often aggravatesperi-patellar pain syndrome. Run-ning at night or in dim light condi-tions may aggravate mild balanceimpairment. A patient recoveringfrom an ankle injury may need torun in daylight if a proprioceptivedeficit remains.

Gait changes that occur with anincrease in speed work include anincrease in the number of stridesper minute and an increase in

Running Injuries...


58 www.podiatrym.comPODIATRY MANAGEMENT • JANUARY 2004

CHART 1Risk Factors

A variety of contributing factors to running injuries shouldbe noted:

• Overuse or training errors - Inexperience - Terrible 2’s

* Too much, too soon, too often, too fast - Intensity

• Miles run per week - Perhaps but may be related to overuse

• Previous running injury • Incorrect shoe • Flexibility issues • Strength issues • Surface issues • Abnormal biomechanics

CHART 2ExerciseRegimen

ModificationRelative or absolute restStrength exercisesStretching Footgear changes Form changes

(including avoiding over-striding)

Orthotics


stride length. Over-striding is one of the most frequenttraining flaws and among other deleterious effects thismay aggravate calf and Achilles tendon problems,hamstring injuries, and increase stress in the anteriortibial muscle group.

Physical Examination The physical examination will lead you to direct

knowledge of what structures are injured. You shouldalso perform a thorough biomechanical examinationand note how well-balanced is the muscle strengthand what muscle groups require stretching orstrengthening.

When performing a physical examination I followthe principles of “Look, Touch, Move.” I start awayfrom the area that I suspect will be most tender andthen work towards it. This limits responses from thepatient anticipating pain.

Shoes It is clear to most that shoes play a role in the

cause, the prevention and the treatment of run-ning injuries. Even Abebe Bikila, the barefoot win-ner of the 1960 Olympic Marathon, decided towear shoes while winning the 1964 OlympicMarathon.

Be sure to examine your running patient’s shoes.How long have the shoes been worn and for howmany miles have they been worn? What is the overallappearance of the shoe? Does it have appropriatepronation protection features? Has the upper shiftedabnormally? Is the sole excessively worn? Is the wearsymmetrical? Do the characteristics of the shoe in-crease the risks for the type of injury that the patienthas? The vast majority of our patients are not world-class athletes and should not do much, if any, runningin racing flats.

The aging shoe exhibits more than just a wornsole. The midsole compresses and loses its shock ab-sorption. The heel may no longer sit perpendicularto the ground. The upper may have holes in it andmay no longer line up properly with the rest of theshoe.

Running Injuries...


CHART 3Outline of Training

EvaluationCheck for Overtraining Excessive racing Running with pain Running while injured or after injury Terrain Time of day

JANUARY 2004 • PODIATRY MANAGEMENTwww.podiatrym.com 61

factured over acombination,board or Cali-fornia last ,have a f i rmand long heelcounter, an ex-ternal heelcounter, a rear-foot stabi l i typost or rollbar,and a multi -density mid-sole.

More detailon the role ofshoes and in-juries has ap-peared in previ-ous articles inPodiatry Man-agement. Youmay also up-date yourknowledge byattending anAAPSM shoeworkshop.

Foot Types Different foot types have dif-

ferent basic shoe requirements.The under-pronating high archedfoot presents a higher lateral loadto the shoe and will not do wellwith a spongy midsole and manypronation control devices. Theover-pronating flat foot presentsan excessive medial load to theshoe and often is present withthe problems of medial t ibialstress syndrome, peri-patel larpain syndrome and plantar fasci-itis. The shape of the last shouldalso be matched to the shape ofthe pat ient ’s foot . An over-pronated foot often does best in astra ight lasted shoe, a higharched under-pronated foot doesbetter in a curved last and theneutral foot is most often morecomfortable in a straight lastedshoe.

An ideal shoe for an over-pronating patient should likelyinclude a straight last, be manu-

Running Injuries...

Cont. on page 61

CHART 4Shoe-Related Problems

Excessive shock absorption: Achilles tendinopathy—eccentric overload of tendon Plantar Fasciitis—often too unstable, with little flexural and torsional stability

Lacing System: Met-cuneiform exostosis Dorsal intermediate cutaneous nerve compression Anterior ankle impingement

Lack of Heel Padding: Haglund’s

Improper Fit: Subungual hematoma BlistersToo Narrow Width: Neuroma pain

a 10 minute easy warm-up and gentlestretching after running. In resistantcases, some researchers have recom-mended eccentric stretches. Heel lifts areoften helpful, and the use of orthoticsshould be considered to eliminate tri-pla-nar stress through the Achilles tendon.

During the recovery phase the pa-tient should use relative or absolute rest.An elliptical trainer is often helpful. Thetreadmill should be avoided because thegait alterations that occur are not con-ducive to recovery from this injury.When returning to overground runninga shortened stride may help avoid pain.

Medial Tibial Stress SyndromeUntil recently, the term “shin

splint” was used to refer to manylower leg pains which included bothbone and soft tissue injuries. Medialtibial stress syndrome (MTSS) is amore appropriate and specific termfor what had been called medial shinsplints. It must be distinguished froma tibial stress fracture. Clinical onsetand location of pain help making thediagnosis. Pain is reported at the me-dial aspect of the leg, adjacent to themedial aspect of the tibia. Tendernessis usually found between 3 and 12centimeters above the tip of the medi-al malleolus at the posterio-medial as-

Most Common InjuriesThe most common running injuries

reported are to the knee, calf andAchilles tendon, medial tibia, heel andlower back. The specific injuries mostoften reported include: patello-femoralpain syndrome, calf and Achilles tendoninjury, ilio-tibial band syndrome, medialtibial pain, heel pain and sesamoid in-jury.

Other notable injuries includestress fractures of the metatarsals,tibia, hip and femur. The preliminaryresults of an online survey indicatedthat there has been a recent decreasein patello-femoral pain syndrome(14% vs. 25% in earlier studies) andan increase in ITB syndrome (11% vs.3.9%) and Calf and Achilles Tendonpain (18% vs. 7.9%).

Tips On Selected Injuries

Achilles Tendon & Calf InjuriesThe calf and Achilles tendon are

the most often injured lower leg re-gion. Your patients with this problemshould be advised to avoid hills. Theyshould also avoid shoes that are eithertoo rigid or too soft and be certain tosteer clear of shoes with viscoelasticcompartments or soft air cells. Shoesthat are too soft exhibit an excessivedeformation of the heel. The calca-neus is moving downwards when itshould be on solid ground. The mus-cles leading to the Tendo Achilles re-flexively fire to control ankle plantarflexion after foot strike. The eccentriccontraction causes the muscles to ef-fectively fire earlier, longer andstronger than usual.

I recommend gentle stretching after

Running Injuries...



A variety of materials can be used in the fabrication of orthotics for runners.

The flexion stability test is easily per-formed. Hold the heel of the shoe andpress it into a flat surface at about 45-60degrees. The shoe should bend at the ballof the foot. If it bends proximal to thispoint (bottom photo), it fails the test.


pect of the tibia. The area of tenderness is more longitudi-nal in the medial tibial stress syndrome rather than the

Running Injuries...

CHART 5Achilles Tendon and CalfInjury Treatment Outline

Relative restCut back mileageLower intensityAvoid hills, speedwork, plyometrics

Avoid over-stretchingGentle stretch after warm-up

Start with straight leg calf stretch, build up much later to bent leg. Consider eccentric stretch even later.

Ice Massage—10 to 20 minutes after exerciseNSAID’s—Aleve, Motrin, etc. 10-14 days.Check Running Shoes

Replace if heel is wornReplace if excessive heel shock absorption(soft air sole cushion, excessive visco-elastic shock absorption)Replace if shoe is excessively stiff at the “break point” (ball of foot).

Physical Therapy ModalitiesHVGS (electrical stimulation)Ultrasound Exercise instruction: Strength and flexibility

CHART 6Return to Running Schedule

(after injury with four-week layoff)

Week Walk/Run Schedule1 Walk 10-20 min. every other day2 Walk 20-40 min. 5 days per week3 Jog at easy pace 10 min. + 20 min. walk4 Jog 15 min. + 20-30 min. walk5 Alternate for 4-5 Days of week:

Run 15 min. / Run 25 min.6 Alternate 20 min./30 min. runs7 Alternate 20 min./30-35 min. runs8 Alternate 25 min./30-40 min. runs


often seen horizontal zone of tender-ness in a stress fracture. Periostitismay occur in this location.

The injured structures usually in-clude posterior tibial tendon and mus-cle; however, both the flexor digitorumlongus and flexor hallucis longus mayalso be involved. A bone scan may beused to assist in the diagnosis. Compart-

ment syndromes may also occur in thisregion, but have been covered in past is-sues of Podiatry Management.

The primary causes of MTSS areovertraining combined with excessivepronation. Running on a canted sur-face or excessive track training willplace the higher leg (or outside leg) ata greater risk for this injury.

Your patients should be advised todiminish their training. While runningon soft surfaces has been recommend-ed for this problem, it is not likely to

Running Injuries...



CHART 7Pribut Pain Staging of Overuse

Injuries in AthletesStage 0. No pain is present before, during or after activi-

ty. Minor discomfort may be experienced at various timesduring training or racing.

Stage 1. Pain or stiffness after activity. The pain is usuallygone by the next day.

Stage 2. Mild discomfort before activity that goes awaysoon after exercise is commenced. No pain is present in thelatter part of the exercise. Pain returns after the exercise iscompleted (starting within 1 to 12 hours later and lasts up to24 hours).

Stage 3. Moderate pain is present before sport. Pain ispresent during sport activity, but is somewhat decreased. Thepain is an annoyance which may alter the manner in whichthe sport is performed.

Stage 4. Significant pain before, during, and after activity.The pain may disappear after several weeks of rest.

Stage 5. Pain before, during, and after activity. The ath-lete has stopped his/her sports participation because of theseverity of the pain. The pain does not abate completely evenafter weeks of inactivity.

Aged orthotics should be replaced

CHART 8Do’s and Don’ts of Winter Running

1. Dress in layers. Use light weight wicking fibers as the layer closest to your body.2. Do wear socks made of synthetic fibers that wick moisture away from your skin to help pre-

vent blisters and athlete’s foot.3. Remember that your head may be responsible for about 40% of heat loss. Keep your head

covered and wear gloves.4. Apply skin protection using sun block and moisturizers as appropriate.5. Don’t forget to replace your fluids on long runs.6. Do fit your running shoes or other sports shoes with the type of sock you intend to wear

them with. Do replace your running shoes often. Replace them at least every 350-450 miles run.7. Do wear sport specific running shoes. Running shoes do not have the lateral support need-

ed for tennis. Help yourself avoid ankle sprains and other injuries.8. Warm up slowly and gently before your runs and especially before doing speed work.9. Be careful running in low light conditions both because of road traffic and uneven pave-

ment, and also be aware of increased balance problems.10. Don’t do speedwork in bone chilling cold. You are risking injury. Most wise runners use

this season for maintenance runs.

ment of Acute Achilles Tendon Rup-tures A Systematic Overview and Meta-analysis. Clinical Orthopedics and Re-lated Research (400) July 2002 pp. 190-200.

Web Resources:AAPSM http://www.aapsm.org/Dr. Pribut’s Running Injuries Site

http://www.drpribut.com/sports/sport-frame.html

P r e s i d e n t ’ s C h a l l e n g e :http://www.presidentschallenge.org/misc/links.aspx

be helpful. The foot will pronate moreon softer surfaces, such as grass orsand. Packed dirt would be an idealsurface. I specifically advise againstrunning on concrete. Motion controlshoes should also be recommended.Gentle posterior stretching exercisesmay help, but control of pronation isdirectly related to the cause of this syn-drome. Ice applications following run-ning may be helpful.

Patello-Femoral Dysfunction/Peri-Patellar Pain Syndrome

Patello-femoral pain has longbeen a common running problem,but has troubled fewer runners late-ly. The recommendations for treat-ment remain the same. Assess thebiomechanics of your patient, in-cluding limb length. My usual rec-ommendations include prescribinga decrease in training, avoidance ofdownhill running, a return to run-ning with run/walk intervals,straight leg lifts (10 sets of 10 repe-titions), if needed a motion controlshoe, and possibly orthotics. ■

References:Pollock ML, Gaesser GA, Butcher JD,

et al: The recommended quantity andquality of exercise for developing andmaintaining cardiorespiratory and mus-cular fitness, and flexibility in healthyadults. Med Sci Sports Exerc1998;30(6):975-991.

http://www.pueblo.gsa.gov/cic_text/health/walking/walking.htm Presi-dent’s Council on Physical Fitness(GSA)—accessed October 19, 2003.

Paavola, et. al.:Current Concepts Re-view: Achilles Tendinopathy. JBJS 84-A:2062-2076. November 2002.

Man. Komi, et al.: In vivo measure-ments of Achilles Tendon Forces MedSci Sports Exer 1984; 16:165-6.

Biomechanical Loading ff Achillestendon during normal locomotion. ClinSports Med. 1992;11:521-531.

Tallon, et al.: Ruptured AchillesTendons are more degenerated thenTendinopathic Tendons. Med Sci SportsExer 2001; 33:1983-1990.

Astrom M., Westlin, N: Blood Flowin the Human Achilles Tendon. J. Or-thop Res. 1994;12:246-252.

Puddu G. et al.: Classification ofAchilles Tendon Disease, Am J SportsMed. 1976; 4:145-150.

Paavola M: Long-term prognosis ofpatients with Achilles tendinopathy,Am J Sports Med 2000, 28:634-641

Bhandari, M; Guyatt, G, et al.:Treat-

Running Injuries...


Dr. Pribut isvice-presidentof the AmericanAcademy of Po-diatric SportsMedicine andhost of the pop-ul a r s p o r t smedicine web-site www.dr-pribut.com. Heis a clinical assistant professor at GeorgeWashington School of Health Sciencesand practices in Washington, DC.

About The American Academy ofPodiatric Sports Medicine

The American Academy of Podiatric Sports Medicine is thesecond largest affiliate of the American Podiatric Medical As-sociation. Over 150 of its 500 plus members have achievedFellowship status in the AAPSM.

The AAPSM has a major goal of advancing the under-standing, prevention and management of lower extremitysports and fitness injuries. The AAPSM believes that providingsuch knowledge to the profession and to the public will opti-mize enjoyment and safe participation in sports and fitnessactivities. The AAPSM accomplishes this mission through pro-fessional education, scientific research, public awareness andmembership support.

The AAPSM has long been the organization looked to bythe public and media for authoritative information on all as-pects of podiatric sports medicine. Members of the AAPSMhave all demonstrated significant interest in podiatric sportsmedicine and are sought out by athletic trainers, teams, andpatients alike for their expertise. In general, members of theAAPSM have extremely busy practices and attract patientswho are physically active and have a commitment to healthand wellness.

One of the most popular sources the AAPSM has availableis the website (www.aapsm.org.), which offers information tothe podiatric profession as well as the general public. Themost popular section of the website is the AAPSM shoe evalu-ations. The AAPSM evaluates over 100 shoes each year inover 15 categories and they are posted on the AAPSM web-site.

Any practicing podiatrist with an interest in sportsmedicine should become a member of AAPSM. Join otherAAPSM members who are dedicated to promoting theAAPSM mission statement as well as demonstrating to theirown patients that they have made a commitment to thispractice specialty. If you are interested in becoming a mem-ber, please contact Rita Yates, AAPSM Executive Director, [email protected] or call toll free at (888) 854-FEET.

For more information, circle #199 on the reader service card.

Common Running Injuries and Prevention

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