Complete Guide to Running Injuries - Prevention, Recovery and Relief
Updated: Jul 12, 2019
More than any other sport or exercise that I have experienced and treated injuries for, running is probably the most addictive. As many of us in New York and beyond know, the endorphin-induced runner’s high is real and it is powerful, as is the feeling of pushing your body without the help or need for anything other than yourself.
But as New Yorkers also know, running on hard pavements and uneven sidewalks can take their toll on the body, from the toes up to the low back and even higher.
As great as running is, it is well-documented that as much as 82% of runners get injured to the point in which they either cannot run or they run with constant pain during or following a run.
Is this you? Are you part of the 82% of runners who have experienced a frustrating running injury? If yes, you're not alone! Join the club. More than perhaps any other sport, running injuries are all too common but with proper injury prevention strategies, self-care and targeted recovery therapies, you can keep running! The information below will help you do so.
I am also part of that 82%. As a competitive high school cross country and track runner, I experienced chronic “shin splints” and patellar tendonitis. There was nothing more frustrating than running through pain and not being able to compete at the high level that I wanted and expected to be able to. These injuries cost me many races and made running uncomfortable rather than enjoyable. I wish I knew then what I know now.
Of course there is no one size fits all treatment.
This all begs the fundamental question: Why do runners get injured so easily and so often?
Runners World lists the “Big 7” most common running injuries as:
• Runners’ Knee (Patellofemoral Pain Syndrome)
• Plantar Fascitis
• Achilles Tendonitis
• Shin Splints (Medial Tibial Stress Syndrome):
• Hamstring ‘Issues’
• Iliotibial Band Syndrome
• Stress Fracture
Do any of these running injuries sound familiar? How many of these injuries have you or one of your teammates and running partners experienced? How many of your running companions or competitors have been sidelined from running because of them? If so, how long did you struggle with the injury for? What treatments did you try? Which treatments helped you recover fastest and which ones were a waste of time and money? Did you have to stop running for an extended period of time?
In general, many of the same factors that contribute to a lot of muscle and joint injuries also cause many of the running injuries listed above. 5 of the factors that can increase the risk of a wide spectrum of sports injuries including injuries from running are the following:
1. Overtraining: Doing too much too fast before the body is ready. Joints, muscles, tendons, fascia and ligaments need time to adapt to the stressors caused by running and too often runners don’t let that process take place.
In addition, overtraining can also occur when runners do not take enough time off from running to let their bodies rest and recover. Whether it is weight lifting, playing professional base ball or boxing, your body needs time off. Running is no different, especially given the continuous and intense impact running creates.
2. Poor Biomechanics: Just as with weight-lifting, pitching, a golf swing or playing basketball, technique and form matter with running. There are many factors that contribute to poor biomechanics, including the ones below. The bottom line is that staying injury-free requires optimal mechanics from the feet all the way up the body.
3. Muscle Imbalances: Whether it is a weak, under-active muscle such as the gluteus medius or a shortened and inflexible muscle such as the soleus (calf) or hip flexor, muscle imbalances and weaknesses often play a huge role in running injuries. And it’s not just muscles in the foot and ankle but often in the hip that are the problem.
For example, having over-active and shortened hip flexors such as the psoas, TFL and rectus femoris can compress the lumbar spine and lead to back pain. It can also de-activate the gluteus maximus and thereby increase the risk of hamstring strains, as we'll discuss below. A similar dynamic can play out in the lower leg leading to shin splints, perhaps the most painful of all running injuries.
4. Structural Factors: Whether it is a leg length discrepancy, flat feet, high arch or an increased Quadriceps angle (Q-angle), sometimes we just can’t control what we are born with. However in many cases we can work around these issues through orthotics, proper footwear, good running techniques, running on only certain surfaces, stretching, manual therapies, active release techniques, muscle activation and strength training.
5. Improper Footwear: Too often people don’t make the best running sneaker choices for a variety of reasons or they don’t change running shoes often enough. Over and over again I have heard of people buying shoes at a running store after some random employee, who may have only taken a 2-hour training seminar, tells them that they ‘over-pronate’ and thus should buy this or that shoe.
Foot shape, gait and running style are complex, detailed topics and you should only consult a true expert for advice. Be careful whom you take important advice from!
Any one or combination of these 5 factors as well as other injury-specific factors can lead to micro-traumas, and common overuse injuries such as shin splints, hamstring strains and plantar fasciitis.
People here in Manhattan come to me all the times with one or more of these issues not even knowing they have them. Most sports massage therapists and personal trainers don't have the considerable expertise required to spot them.
At On Your Mark NYC, certified and licensed therapists and trainers make all the difference when it comes to injury repair, rehabilitation, and prevention.
“Shin Splints”, or Medial Tibial Stress Syndrome (MTSS) is characterized by chronic and in many cases intense pain usually along the inner side of the tibia, which is the larger bone running between the knee and ankles. It is a term used to describe overuse symptoms involving the Flexor Digitorum and especially the Tibialis Posterior muscles which are deep and strong muscles that play a central role in stabilizing and moving the foot and ankle.
While “Shin Splints” is a common and in many cases debilitating condition experienced by many runners and other athletes, this condition can in reality be very easily and effectively treated using medical massage therapies such as Active Release Techniques®.
Let’s take a closer look at what Shin Splints actually is and how ART® and other injury therapies can help:
The initial process in the development of “Shin Splints”, medically known as Medial Tibial Stress Syndrome, is when muscle fibers of the Flexor Digitorum Longus and Tibialis Posterior literally tear from their attachment on the bone (known as the peristeal attachment). As these muscle fibers heal, they become fibrotic which reduces their pliability, resilience and ability to lengthen and/or contract properly. This leads to a vicious cycle in which the failure to contract and/or lengthen causes an exponential increase in the tension on the bone, leading to further injury.
When muscles fail to contract and lengthen fully they can become injured due to an altered length-tension relationship, increased tension, improper biomechanics, poor muscle fiber recruitment, decreased blood circulation and micro-tearing.
Risk Factors for the development of Shin Splints:
Previous history of Shin Splints: The greatest risk factor for future injuries is previous injury.
Running Experience: less experience = greater risk.
An increased navicular drop, otherwise known as flat feet or hyper-pronation. Because the medial longitudinal arch of the foot is the primary shock absorber and load-bearing structure, when it does not exist or is not strong as with hyper-pronation and navicular drop, proper foot mechanics cannot take place and injury risk goes up
Insufficient Dorsiflexion: Too much plantarflexion: Plantarflexion is when the foot and ankle are pointed downward. Too much plantarflexion combined with not enough dorsiflexion can prevent proper joint mechanics and muscle activation.
Females: research shows that females are at higher risk than males.
Obesity and high Body Mass Index (BMI): This puts more stress on the bones, muscles, ligaments and tendons.
Improper Training: Doing too much too fast or abruptly changing training program without sufficient preparation and transition.
Orthotics Use: Be careful with this one because it doesn’t mean orthotics are bad.
Shin Splints Symptoms:
Shin Splints consist of mild to intense pain along the lower half of the inner (medial) surface of the tibia during and after running or constant pain and/or increased pain upon waking up in the morning. Pain is often described as throbbing, bruising, inflamed, stress fracture and sharp.
Active Release Techniques, Medical Massage and Other Treatments:
As mentioned above, muscle fibers in the lower leg get torn due to the combination of overuse with altered tissue length leading to scar tissue, muscle adhesions, lack of movement or “slide” in the muscles and repeated micro-tearing.
Active Release Techniques are specifically geared towards breaking up the fibrotic tissue that causes and is caused by improper tissue length. This is what Active Release therapy is all about and what makes it a unique and effective injury therapy. In Active Release, the muscles are brought through their full range of motion while pressure is applied.
"A client came to me with chronic shin-splints, a painful injury experienced by many runners. By targeting the 3 most common muscles indicated in this condition, she was running pain-free within 4 sessions over a 2-week period. In her half marathon two months later, she posted a personal best time." - Mark
Medical Massage: In addition to Active Release treatments, other manual therapies such as deep tissue massage, trigger point therapy and myofascial release can be effective treatments for Shin Splints by eliminating trigger points, breaking up muscle adhesions and bringing nutrient and blood flow to muscles.
Physical Therapy and Corrective Exercises: Correcting muscle imbalances through corrective exercises using muscle activation of under-active and weak muscles, stretching short muscles and postural re-education are key in improving lower-body mechanics. Physical Therapy for chronic shin splints may be necessary to help calm things down using recovery therapies such as ultrasound.
Self Myofasical Release: In addition to seeing an injury therapist for Active Release, Graston therapy and other medical massage therapies, you can do your own self-myofascial release using a foam roller or trigger point ball. I highly recommend seeing an injury therapist and using other self education mechanisms such as instructional videos to learn how to safely and effectively perform self trigger point release because you can irritate and damage tissue if not done correctly.
Rest: Give the muscles, bones and connective tissue a chance to heal but don’t rest for too long and make sure you use additional recovery strategies. Otherwise the injury is bound to return once you return to running. Too often runners will stop running cold-turkey and then start up without correcting the source of the problem, resulting in re-injury. This is why it is so important to be proactive and find the right injury recovery therapies for you. It might take some jumping around and trial and error until you find what works best for you.
Alter Running Program: In addition to, instead of or after a period of rest, you should dial your training regiment down a notch or two to allow your body to gradually adapt to the stresses being placed on it. This might mean running every other day, doing more cross-training for a while, running shorter distances for a while and only running on a soft track or treadmill with suspension rather than running on New York City streets. The take-home message with this point is that you can run - you just might need to modify your running temporarily.
All in all, Medial Tibial Stress Syndrome (Shin Splints) does not have to slow and completely derail your running program if preventive measures and proactive treatments are employed early on once the injury arises.
Hamstring strains are one of the most frustrating sports injuries experienced by runners, dancers, soccer, baseball and football players alike. They take a long time to heal and are easy to re-injure. I have personally experience this frustration and despite being a manual therapy and injury rehabilitation expert, it took almost 6 months to get rid of the injury. That is not an uncommon length of time needed to recover from moderate to severe hamstring strains.
Elite athletes such as U.S. soccer star Josie Altidor and former/current New York Mets all-star shortstop Jose Reyes have struggled throughout their careers with hamstring issues. Josie Altidor was forced to miss the entire World Cup after straining his hamstring not more than 20 minutes into the opening game versus Ghana in 2014. Despite Josie probably being in as good shape as any one on the planet, he just couldn't recover fast enough from his hamstring injury.
There is a huge misunderstanding about what cause hamstring injuries in runners and other athletes because most people think that hamstring strains occur because the muscles are short or ‘tight’. Therefore, stretching of the hamstrings has become one of the go-to remedies. In reality, the hamstrings are very often long (over-stretched) and overactive, not short. The hamstrings often feel short because there is tension in the muscles but that tension is often due to being stretched and overworked because the gluteus maximus muscle is under-active.
Any stretching in this case should be kept to 30 seconds or less and not done through full range of motion but rather should specifically isolate the problematic muscle fibers to prevent and break up scar tissue. Injury recovery techniques such as active isolated stretching, self-myofascial release using a trigger point therapy ball and active release therapy can do just that.
To that point, “Counterintuitive as it might seem, very flexible people are prone to hamstring problems because their overly stretched-out muscles are more vulnerable to damage” (Runners World). The implications for this are important because in many cases people sometimes use the wrong treatment recovery strategies to deal their hamstring strains. Getting this right is important.
With that said, some people do have short hamstrings, so as with any injury, an accurate assessment by an injury therapist or diagnosis by a physician is crucial in determining the appropriate treatments for this and any other nagging running injury. Such an assessment should include muscle length testing, muscle strength testing, postural and dynamic movement assessments, gait analysis and palpation of affected muscles.
There is a large body of research with conflicted data as to why hamstring strains occur. Keeping this in mind, here are some of the causes and risk factors associated with hamstring strains. You’ll notice that many of these same factors apply to many soft tissue injuries, including shin splints and other running injuries.
• Increasing frequency, intensity or volume of running too fast.
• Previous hamstring strains create high risk for re-injury.
• Weakness in the gluteus maximus and other hip muscle.
• Shortness and weakness in the hamstring themselves.
• Poor running technique created by muscle imbalances, improper footwear, flat
feet or high arches.
• Over-activity and/or shortness in hip flexors, low back muscles and quadriceps.
This is not an exhaustive list but one that I have found to be the most important in the development of hamstring strains. Also keep in mind that treatment interventions vary depending on the severity of the strain and whether the injury is acute or chronic.
Active Release Techniques, Medical Massage and Other Treatments:
According to an article in Runners World magazine, ”In chronic cases, active release technique (ART) and deep-tissue massage may be necessary”. This is one of the premier publications for runners worldwide advocating that Active Release therapy and medical massage can be effective treatments for hamstring strains. That is a noteworthy endorsement.
Why and how can Active Release and medical massage help?
As mentioned above and in our other articles, Active Release effectively breaks up scar tissue and reduces muscle adhesions. Scar tissue is very common when there is a muscle strain – even if the muscle in question has normal flexibility - and unless it is broken down, the muscle cells cannot receive proper blood flow and nutrition nor can they contract and lengthen in the direction and to the extent that they need to.
If the hamstring itself and other hip muscles such as the hip flexors are indeed short and inflexible, Active Release can help restore these muscles to their proper length using movement through full range of motion combined with manual pressure. In a pilot study of 20 physically active males with no known history of hamstring strains it was found that Active Release Techniques had a significant impact on range of motion. Despite this study focusing on non-injured patients, the results of this and other studies support the notion that Active Release increases range of motion and pain reduction.
It may take anywhere from 1-10 sessions to accomplish this, depending on the severity and stage of injury and the extent of compensations and muscle imbalances throughout the Lumbo-Pelvic-Hip-Complex, leg, ankle and foot. In my sports massage practice I try to get people in and out of treatment as fast as possible with as little cost and time to my clients as possible. Unfortunately, a hamstring strain is not one of the injuries that I can do so for. Effective resolution of this chronic running injury using Active Release Techniques and sports massage requires 1-2 treatments per week for 4-6 weeks.
There are many other treatment options in addition to Active Release and medical massage. These include:
• Rest: complete rest followed by a gradual return to physical activities
• Ice or heat: the science is mixed and changing in this area
• Physical Therapy
• Acupuncture/Dry Needling
• Platelet-rich plasma (PRP)
• Active Isolated Stretching
Remember, hamstring strains can take a very long time to heal, even with aggressive treatment, so you’re best bet is to prevent it from happening in the first place and to avoid exacerbating a small strain into a more severe and chronic one, like I did a few years ago when I pushed myself too much during a sprint workout despite the hamstring issue having surfaced on a previous run. Because I was training for a race, I didn't want to skip or modify the workout and it ended up costing me the rest of my running season. Moral of the story; don't sacrifice months of running for the immediate and very temporary reward you'll get from a few runs.
Build up your running program slowly and carefully. Choose the right footwear for you and replace running shoes when they start to wear down. And very importantly, strengthen, activate and stretch the appropriate muscles. If you’re not sure what is appropriate for your body, then consider hiring a qualified personal trainer with a specialty in corrective exercises who can help you identify your imbalances, weaknesses, asymmetries and compensations in order to get you on the right track.
If you’ve experienced Plantar Fascitis like I and a lot of runners here in New York City have, you probably know it to be a very painful injury that lingers on despite rest and a myriad of treatments. It’s one of those injuries that, when you have it, you always think about it and when it is gone, it’s like it was never there. When I had it about 6 years ago, it felt like I had a sharp piece of glass in my heel. I couldn’t run, I couldn’t walk around my apartment without wearing sneakers and when I woke up in the morning I was in agony upon walking and limped around until it began to loosen up.
If this sounds familiar, it’s because these are signature plantar fascitis symptoms along with some others.
• Pain near the heel usually on the inside portion of the foot
• Pain from standing for long periods
• Pain during and after running and other intense sports
• Increased pain when taking first steps in the morning
I was fortunate in that my injury disappeared within a few weeks of wearing new, custom-made orthotics. I’ve never had a problem since.
Unfortunately, treating and resolving plantar fascitis isn’t always that easy and the verdict is still out on what causes the injury, what the injury actually is and what the most effective treatments are. There are strong and opposing opinions ranging from the barefoot and minimalist proponents to those who recommend corrective footwear and orthotics.
Here is what we do know:
The Plantar Fascia is a strong, dense layer of connective tissue that runs from the undersurface of the calcaneus (heel bone) and spreads out to attach to the toes in a fan shape. It is an important shock absorber and foot stabilizer.
When the plantar fascia is stretched, pulled, irritated or weakened it can cause a dull and/or sharp pain in the heel which often progresses into severe and chronic pain.
The incidence rate among Americans is 10% (over 30 million) according to many sources and of that 10%, 22% are runners, meaning that over 650,000 runners have had plantar fasciitis and the Injury may account for as many as 1 million doctor visits annually in the U.S. The exact numbers vary depending on the information source.
Nonetheless, plantar fasicits is a common injury. The exact nature of the injury is still debated, specifically whether it is an inflammatory or degenerative condition.
Causes and Risk Factors: Based on my research from over a dozen sources, these are the most common risk factors and causes:
• Excessive foot pronation
• High BMI and obesity
• Limited ankle dorsiflexion (short calf muscles)
• Prolonged standing due to occupational requirements
• Inappropriate shoe choices
• Rapid increases in activity level
• Women more than men, in part due to high heels and poor footwear choice
• Muscle imbalances in the foot, ankle, knee and hip
Notice that there is a lot of overlap in the causes of all 3 running injuries explored in this article: shin splints, hamstring strains and plantar fasciitis.
Effective treatments include:
Correcting flat feet and high arches through stretching calf muscles, orthotics and muscle activation of weak muscles throughout the lower extremity and hip
Platelet-rich Plasma therapy
Active Release Techniques
Medical massage including deep-tissue massage, cross-fiber friction and myofascial release.
Instrument-assisted therapies such as Graston
Ultrasound and electrical stimulation therapies including extracorporeal shockwave therapy.
Ice and Heat
Rest and activity modification
You have many treatment options and thus do not have to live with the pain. You just have to be proactive and patient, as frustrating as the healing process can be.
“I've sustained some pretty serious injuries from sparring in martial arts. If I ever have any difficulties or injuries, Mark is my go-to guy. Mark's specialization in Active Release Technique (ART), his deep understanding of body mechanics and overall movement make him an expert in injury repair." - Clay
Active Release Techniques and Medical Massage for Plantar Fascitis:
Active Release can be beneficial for the treatment of any soft tissue injury, including plantar fasciitis. And as with other injuries, Active Release should be one piece of the treatment puzzle. Specifically, ART will help increase plantarflexion by releasing trigger points and adhesions in the calf muscles. In addition, ART can assist in breaking up scar tissue in the plantar fascia itself at the site of pain in the heel and through very targeted tissue stretching with pressure to each portion of the fascia that attaches to individual toes.
As for medical massage techniques, a small study in Israel found that 8 deep-tissue massage treatments over a 6-week period had statistically and clinically significant benefits. Additional studies support the efficacy of manual therapy treatments. Cross fiber friction near the heel can break up scar tissue and trigger point therapy can bring oxygen, blood and nutrient flow to tight and short muscles.
In summary, the vast majority of runners will get injured. The key to preventing and treating these injuries rests with you. If the information above makes you think you might be vulnerable to a running injury, seek advice from experts to help ensure you are doing the right things to keep yourself healthy. If and when an injury does take place, don’t ignore it or hope it will just go away. Modify your activity, rest temporarily and seek out conservative treatments such as corrective exercises and manual therapies.
You have many treatment options so don’t give up.
“Anatomy for Runners” by Jay Dicharry, MPT, SCS
Runners World (web site)
“Anatomy of Movement” by Blandine Calais-Germain
“Active Release Techniques Soft Tissue Management System for the Lower Extremity” by P. Michael Leahy, DC
Open Access Journal of Sports Medicine: “Risk factors associated with medial tibial stress syndrome in runners”.
British Journal of Sports Medicine: Risk factors for medial tibial stress syndrome in physically active runners such as runners and military personnel: a systematic review and meta-analysis”.
Selective Functional Movement Assessment - Seminar Manual
The Student Physical Therapist (web site)
Runners World (web site)
Journal of Bodywork Therapies: “Massage treatment and medial tibial stress syndrome”
National Academy of Sports Medicine: “NASM Essentials of Corrective Exercise Training”.
“Anatomy for Runners” by Jay Dicharry, MPT, SCS
Brookbush Institute: “Stop stretching your hamstrings”
Brookbush Institute: “Gluteus Maximus Activation (more glut & less hamstring)”
Runners World (web site)
Active Release Techniques (web site)
Journal of Manipulative Therapy: “The effects of active release technique on hamstring flexibility: a pilot study”.
Journal of Bodywork Movement Therapies: “Immediate effect on pain thresholds using active release technique on adductor strains: Pilot study”.
“Why ice may delay healing”: Dr. Gabe Mirkin on Fitness, Health and Nutrition (web site)
“Platelet rich plasma for hamstring tears” by David C. Karli, MD and Brent R. Robinson, BS
New York Times: “No consensus on a common cause of foot pain”.
Natural Running Center: “How runners can avoid plantar fasciitis: go minimalist or go barefoot.”
Journal of the Oklahoma State Medical Association: “Orthotics Compared to Conventional Therapy and Other Non-Surgical Treatments for Plantar Fasciitis”.
Orthopedics: “Chronic Plantar Fasciitis: Effect of Platelet-Rich Plasma, Corticosteroid, and Placebo”.
American Family Physician: “Diagnosis and Treatment of plantar fasciitis”.
Manual Therapy: Deep massage to posterior calf muscles in combination with neural mobilization exercises as a treatment for heel pain: A pilot randomized clinical trial.
Massage Magazine: “Plantar Fasciitis.”