Overuse injuries

Avoid injury by not running with your hands in the air - photo by David Knight

Avoid injury by not running with your hands in the air

Whenever runners are gathered together, they talk about injuries; injuries they have had, injuries they have got now, injuries that explain the absence of mutual friends.

So if runners are always injured, running must be bad for you, right?  Wrong. Running is good for you. However, runners often push themselves near to their limits, which means that, although they are in generally better shape than couch potatoes, they get more injuries than they would if they spent their day watching TV.  Because runners are stubborn, and sometimes a little obsessed, they often don’t do what they should to avoid injuries, and they don’t treat them properly when they occur.

Overuse injuries

Runners often suffer from injuries which can be loosely grouped together as “overuse” injuries – that is, which are not caused by an external force or accident, but which appear to be the result of many miles and hours of running.  As we shall see in this chapter, many of these injuries are caused by (often minor) biomechanical imbalances and defects which, when combined with running, lead to stresses on joints, muscles and other tissues.  The cure for these injuries is very rarely found by addressing the symptoms: instead it is necessary to identify the underlying problem which leads to the problem.

The problem is not that we run too much; it is the opposite.  Because so many of us have sedentary lifestyles, including long hours sitting in chairs, we develop weaknesses and imbalances which then cause problems when we run.  So the underlying cause of overuse injuries is generally not running (though it is running that triggers the symptoms), but the deterioration in the strength and flexibility in our bodies which prevent us from running efficiently and without pain.  Fortunately, many of these problems are easy to fix, if you get the right advice and tackle the underlying the causes rather than the symptoms.  Sadly, all too few doctors know how to do this.

There are seven main overuse injuries which affect runners.

1. Runner’s knee

Runner’s knee is the usual description for pain just below the kneecap.  The pain occurs at first during running, and gradually gets worse.  Walking up or down stairs, and squatting, cause pain.  Sitting with the knee bent for a long time – such as in the cinema – also causes discomfort. These symptoms are the result of bruising near the bottom of the kneecap, which may be caused by incorrect tracking of the kneecap as you run.

Runner’s knee is usually caused by over-pronation, often combined with inappropriate running shoes or excessive increases in training load. Because of the different alignment of the pelvis and legs, runner’s knee is more common in women than men.

Runner’s knee is often misdiagnosed by non-running doctors as chondromalacia patella, which is a deterioration of the cartilage in the knee joint, or as damage to the back of the knee-cap.  If your doctor or physio says that you have damaged cartilage, you should get a second opinion from an experienced sports doctor.

Once correctly diagnosed, runner’s knee can be corrected by fixing the causes of the biomechanical problems that caused it.  Studies have shown that up to 80% of runners with this condition can be cured by the use of orthotics.[i]

2. Iliotibial band (ITB) friction syndrome

It is common for runners to experience severe pain on the outside of the knee joint, which becomes worse as you run.  The pain often stops as soon as you stop running.  The iliotibial band is a band of tissue that runs from the hip, down the outside of the thigh, past the knee, and connects to the lower leg.  It helps to keep the knee joint stable.

ITB friction syndrome occurs when the band becomes irritated as it rubs over a bony prominence near the knee (technically called the lateral epicondyle of the femur) which it passes over as you bend your leg at the knee.   ITB friction syndrome is often caused by excessive ankle pronation, but there are other possible causes, including tightness of the Tensor Fasciae Latae (TFL) muscle, or unequal leg length which tilts the pelvis.  It can be exacerbated by increasing training too rapidly, running downhill or on heavily cambered roads.

The symptoms are alleviated by stretching the ITB band, ice and deep friction massage.  Treatment may require a reduction in training mileage and intensity, or complete rest while the underlying causes are addressed.

3. Achilles tendonitis

The Achilles tendon runs down the back of your heel, connecting the calf muscles to the heel.  Achilles tendonitis begins as an inflammation of this tendon; but if left untreated it can develop into a rupture of the tendon.  In its early stages, the symptoms are stiffness behind the ankle when you first get out of bed in the morning.  The symptoms often disappear while you are running.

Achilles tendonitis is typically caused by excessively tight calf muscles, over-pronation, wearing high heels, worn out shoes and overtraining.   The symptoms can be relieved with ice after each run; but reduction in training or complete rest may be needed while the causes are addressed.  It is generally advisable to avoid hills and speed work while you have Achilles tendonitis.

4.  Shin splints

All too often, any pain in the lower leg is lazily described as “shin splints”.  The term is correctly used to describe medial tibial stress syndrome, which is an irritation of the muscles and tendons at the point where they attach to the shin bone.

Shin splints cause pain along the inner border of the shin, about 5-10 cm above the ankle. At first, the pain may be felt at the beginning of a run; sometimes it recedes as the workout continues, and then recurs afterwards; in other cases it is only felt at the end of the run. In the early stages, the pain usually disappears after several minutes’ rest. As the injury gets worse, the pain becomes more severe, sharper, and more persistent, until eventually it becomes difficult to walk normally.

This injury is quite common in new runners (often within their first three months of running) who have increased their training load too rapidly, or who are using inappropriate running shoes.  It can also be caused by uncorrected ankle pronation.

Treatment at first includes regular ice, together with reduced mileage or rest.  Addressing the causes is likely to include ensuring that shoes have adequate cushioning and stability, and building up training mileage slowly.

5. Stress fractures

Stress fractures are hairline fractures of bones in the lower leg, usually the tibia, fibula or a bone in the foot (e.g. a metatarsal), though they can also occur in the thigh bone and pelvis.  Stress fractures generally become painful very rapidly, and they can be identified by exquisite, highly localised pain under gentle pressure.

Stress fractures are usually caused by excessive increases in training or low bone density, possibly related to poor diet.  They are more common in females than in males, and women with irregular menstrual cycles are especially at risk (see Chapter 4).

This injury heals itself with 2-3 months of complete rest.

6. Muscle tears

These are extremely common injuries among runners.  Muscle tears can occur suddenly – most commonly in explosive sports such as sprinting or football – or accumulate slowly over time.   The hamstrings, groin and calf muscles are most at risk from muscle tears.

Sudden muscle tears are easy to diagnose: the runner suddenly feels severe pain in the affected muscle, which goes into spasm and swells up.  The muscle cannot be used at all.  Sudden muscle tears are caused by muscular imbalances, and exercising while insufficiently warmed up. The symptoms should be treated immediately with ice and elevation, and the application of a firm compression bandage immediately after icing.  With intensive treatment an athlete can return to running in as little as a fortnight; though recovery generally takes a bit longer for non-elite athletes.

With gradual muscle tears, or “muscle knots”, by contrast, the pain comes on gradually.  At first, symptoms are noticeable after exercise, and they are mild enough to continue training. Over time the pain becomes worse and eventually prevents running altogether.  To identify a muscle tear for certain, a doctor or physio should press the affected muscle with two fingers: they will feel a small knot in the muscle, which, when pressed, causes excruciating pain to the runner.

Gradual muscle tears will not go away without the correct treatment, which is cross-friction massage by a physiotherapist.  (Good luck: this hurts).  Gradual muscle tears tend to recur in the same places.  Runners need to be especially careful to stretch those muscles, especially before speed workouts and when it is cold.  At the first sign of the symptoms returning, you should get more massage.

7. Plantar fasciitis

This injury manifests itself as pain directly in front of the heel, which can radiate down the arch or up the back of the heel.  The pain is often worse when you first get out of bed.  It generally hurts at the start of a run, but goes away when you are warmed up.

Plantar fasciitis is the result of stress and inflammation of the fibrous tissue in the bottom of the foot, called the plantar fasciia.  It is usually caused by overpronation, or poor flexibility in the calves or hamstrings. It is also more common in people who are overweight.

Initially, treatment is aimed at stretching the tight plantar fascia and calf muscles, cushioning the heel, and decreasing inflammation with ice or anti-inflammatory drugs.


[i] Gross, M.L., Davlin, L.B., Evanski, P.M. (1991) “Effectiveness of orthotic shoe inserts in the long distance runner.”  American Journal of Sports Medicine 19, 409-412.

3 Responses to Overuse injuries

  • Linnéa:

    Chondromalacia patella is an older name what you are calling Runner’s knee, it is now known as Patellofemoral syndrome. Just wanted to clear that up, it isn’t a “misdiagnoses”, just an older name.

  • Brenda:

    I used to walk 7-8 miles a day , one day I did this also did a lot of kneeling gardening and then kneeling again cleaning oven . I felt as though behind my knees were swollen . It didn’t hurt right away but after walking on uneven ground , behind my knees , slightly up my thighs and my calves hurt . I went to see a physio who said I had damaged the small muscles behind my knees ,and they were like golf balls , he gave my deep tissue massage for some weeks and my partner massages my legs every evening . I do hamstring and calf stretches morning and evening and before and after walking . The physio said the muscles were now ok but I still have pain when walking and can not manage to walk far . Do you have any suggestions , this is really getting me down , I cannot even stand for very long without pain , in fact my legs never feel right .

  • […] Your shoes are the most important item in your running equipment. Their main functionalities are to provide stability, shock absorption and cushioning. Worn-out running shoes do not fulfill these functionalities anymore and your body needs to compensate and this is when overuse injuries occur.  […]

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