The 4 Most Common Running Injuries and How to Address Them

Use corrective exercise to help clients stay on track with their mileage goals.

By Justin Price, MA
Jan 13, 2017

Every personal trainer has clients who enjoy running. They can become notably upset when an injury prevents them from engaging in their beloved pastime. Running is a popular and accessible exercise that millions of people like doing; in the United States alone, there are almost 40 million regular participants (Messier et al. 2008). While running is an effective way to maintain health, lose weight, enhance performance and ward off disease, it's also associated with a high risk of injury, with almost half of all runners reporting an injury at least once a year (Messier et al. 2008).

Most running injuries affect the lower body, with up to 79% occurring in the lower extremities (Van Gent et al. 2007). The four lower-body injuries runners experience most often are plantar fasciitis, Achilles tendinitis, patellofemoral syndrome ("runner's knee") and iliotibial (IT) band syndrome (Hespanhol et al. 2011). These common injuries result from musculoskeletal and movement imbalances compounded by overuse—especially in runners who clock more than 20 miles per week (Messier et al. 2008).

In your role as a fitness professional, you will work with many clients who develop—or want to avoid—running injuries. Clients will often share with you concerns about an injury diagnosis they've received from a licensed medical professional. While it is not within your scope of practice to confirm or diagnose medical conditions, it is important to have a basic understanding of common running injuries, because it helps you communicate effectively with clients about their diagnoses. Master your role in addressing the musculoskeletal and movement imbalances underlying clients' problems by educating yourself about the most common injuries and how to use corrective-exercise techniques to address them.

Basic Biomechanics

The musculoskeletal system experiences a lot of stress and strain during running. Gravity exerts tremendous downward pressure on both the skeleton and the soft-tissue structures. Once the foot strikes the ground, impact (ground reaction forces) creates an equal amount of force that transfers back up through the system. Fortunately, the human body has many important structures and clever techniques for dissipating these forces (Ayyappa 1997).

When we run (or perform any full-body, dynamic movement), the body moves in all three planes of motion (i.e., side to side, in rotation, and forward and backward). Side-to-side movements enable us to take alternating steps from left to right, helping to propel us forward or backward. As we move our legs forward or back, we also swing our arms forward and back, which creates rotation in the torso, thus enabling the spine, hips and legs to move. This movement combination helps us temporarily overcome gravity in order to complete an activity. However, these movements also help us absorb shock—those ground reaction forces—by allowing the body to move in the direction of impact, which is opposite to the direction of the pull of gravity. An effective way to comprehend how the musculoskeletal system manages these equal but opposing forces is to bring to mind the famous crash-test dummy commercials in which the dummy recoils as the vehicle hits the wall.

In addition to movement, the body has other strategies for dealing with gravity and ground reaction forces. Soft-tissue structures (especially our muscles) dissipate energy as impact travels back up the body (Ayyappa 1997). When a person is running, for example, certain muscles contract to swing the leg forward. As the foot strikes the ground and the body has to deal with impact, the muscles of the foot, ankle and leg lengthen under tension—like a trampoline skin stretching under tension when you jump on it. The muscle tension helps the body absorb shock and creates energy for subsequent movements (in the same way the stretched skin of the trampoline helps you jump higher).

If muscles are not healthy, flexible and strong, they are less effective at transferring weight and absorbing shock—much like an old trampoline skin. As a result, other soft tissues in the body—such as fascia, tendons and ligaments—must work harder. Over time, these structures become overworked, stressed and strained, leading to injury, pain and further dysfunction. That is why common overuse injuries manifest in connective tissue (see the sidebar "The Four Most Common Running Injuries" for more).

Tipping Movements

Similarly, if muscles aren't working correctly the joints can become inflamed or lack range of motion. Movements then become restricted and the body becomes less effective at dissipating gravity, absorbing shock and creating energy for movement. This often manifests as inflammation and joint problems. If you want to help clients gain or retain the ability to run without pain, and you want to help them minimize their potential for injury, then it is crucial to understand how muscular limitations—and associated skeletal and movement imbalances—cause running injuries (Price & Bratcher 2010).

Which Muscles/Movements Are Most Important For Running?

Some movements that occur while running require more eff ort than others, which can increase muscle fatigue and cause subsequent connective tissue and joint damage. Leaning forward or backward is an easy movement to initiate, because gravity helps to pull you in either direction. Resisting this downward pull is more difficult, though. It requires a lot of effort from muscles that help to keep you erect: the erectors and hamstrings, which work posteriorly to slow you down as you lean forward; and the abdominals and hip flexors, which lengthen to slow you down as you lean backward. Similarly, tipping to one side is easy because once you initiate the sideways bend, gravity pulls you in that direction. However, sideways movement is also difficult to resist, as it requires a lot of strength from the obliques, quadratus lumborum, erectors and abductors to prevent you from falling over (Myers 2008).

Rotating the body on a vertical axis is different. Rotation requires more muscular strength to start, because gravity doesn't help initiate the movement. Once rotational movements begin, however, they're easier to maintain because they're driven by momentum and unfettered by gravity. In addition, many of the largest muscles in the body are designed to help control rotation, because they wrap around the body (e.g., latissimus dorsi, obliques, glutes, etc.). Thus, when the body rotates well, movement stress is minimized because these large, powerful muscles transfer weight and absorb shock. Moreover, these big muscles also store energy by lengthening under tension (like a stretched bungee cord) when the body rotates. When released, this tension helps counter the rotation, making it easier to run faster and more efficiently. For example, when you turn your torso to the left , your obliques lengthen/stretch under tension to slow down stress to your spine and torso. Release of this tension then helps you turn to the right (Price 2010).

Effective rotational movements, therefore, are the key to avoiding running injuries because these are the movements least affected by gravity and impact. To understand the importance of the body being able to rotate when running, think of a spinning top. Once the top is turning, it can spin for a long time, as it is being driven by momentum. However, if the top starts wobbling and teeter-tottering from side to side (and forward and backward), it slows down quickly as gravity pulls it over and it comes to an abrupt stop. Therefore, the easiest way to dissipate stress throughout the body when running—and to minimize the risk for injury—is to ensure that the major joint structures in the body can rotate and the muscles that facilitate rotation are strong, healthy and flexible (see the sidebar "Rotational Movement Assessments" for more).

The Finish Line

Although running with correct mechanics improves health and function, musculoskeletal and movement imbalances—if left unchecked—can make the activity a painful and frustrating experience. When you learn how to properly assess and correct clients' limitations, you decrease the potential for pain and you increase your reputation as the "go-to" fitness professional for addressing sports-related injuries.

THE FOUR MOST COMMON RUNNING INJURIES

4 common running injuries

THREE ROTATIONAL MOVEMENT ASSESSMENTS

The three most important areas of the body that need to rotate effectively when running are the ankles, hips and spine. Use the following assessments to evaluate your client's rotation capabilities.

1. Ankle Rotation

During running, ankle rotation facilitates foot pronation and internal rotation of the leg. These movements also turn on the tibialis anterior, tibialis posterior and peroneals—muscles that decelerate stress to the foot, ankle and knee complex—helping the body interact softly withthe ground, transfer weight, and reduce impact throughout the kinetic chain.The assessment below helps you evaluate mobility in the ankle as it rotates toward the body's midline:

Toes-Out Torso Rotation Assessment

Toes-Out Torso Rotation Assessment

  • Have client stand with feet just wider than hip-width apart, turned out to about 45┬░, arms away from sides.
  • Coach client to swing arms right as he rotates his body right, and as he does, check mobility in his left ankle (it's okay if left knee bends slightly).
  • Ask client to swing his arms left and rotate left while you check mobility in his right ankle (allowing right knee to bend slightly).
  • Evaluate whether ankles are rolling in and whether one side is less mobile than the other. Ideally, ankles will roll in easily toward body's midline as arms and torso rotate.
  • Instruct client to rotate back and forth from left to right until he can feel how his ankles move toward midline.
  • Ask him to notice any movement difference between his ankles.

Additional considerations:

  • This assessment is best performed in bare feet on nonslip surface.
  • Slight "popping" noises at ankle mean that the joint is naturally adjusting and client will have more mobility as a result.
  • If client feels knee discomfort, instruct him to turn his feet out less.

2. Hip Rotation

When you run, hip rotation transfers weight forward and from left to right. Hip rotation is also imperative for "turning on" the larger muscles of the lumbo-pelvic hip girdle (gluteus maximus,hip flexors, etc.) that decelerate stress to the lower body as it comes in contact with the ground.

The assessment below evaluates mobility of the hips as they rotate inward toward the body's midline:

Toes-In Torso Rotation Assessment

Toes-In Torso Rotation Assessment

  • Instruct client to stand with feet hip-width apart and turn toes inward until they're almost touching.
  • Have him stand upright, both arms lifted away from sides.
  • Coach client to swing arms right as he rotates body right (right big toe stays in contact with ground—foot should not slide out). Ideally, right foot should stay in contact with ground and client should not experience excessive stress around hips or lower back on right side.
  • Ask client to swing arms left. Notice any tension around left hip and lower back.
  • Notice if left foot slides out toward left, or if left big toe comes off ground. If foot slides out, this means left hip (all the way down leg to foot) cannot maintain internally rotated position. Similarly, if client experiences knee, hip or lower-back tension/pain, then muscles that allow internal rotation are restricted in some way and not allowing full range of motion.

Additional considerations:

  • This assessment is best performed in bare feet on nonslip surface.
  • If client experiences knee discomfort, instruct him to turn his feet in less.

3. Torso Rotation

Being able to effectively rotate the torso helps maintain balance and prevents excessive side-to-side sway or forward-and-backward motion during running. Rotating the torso in the opposite direction to the lower body also decreases impact on the lower body and reduces stress to the entire region (which is why we swing opposite arm to opposite leg when walking and running).

The assessment below evaluates the mobility of the torso as it rotates:

Lying Torso Rotation Assessment

Lying Torso Rotation Assessment

  • Instruct client to lie on her back, knees bent and lifted over stomach.
  • Place foam roller between knees to minimize lower-back discomfort.
  • Coach client to drop knees to the left while keeping palms flat on floor. If right shoulder comes off floor when she drops knees left, then she lacks ability to rotate her torso effectively to the right.
  • Switch directions. If left shoulder comes off floor when she drops knees right, then she lacks ability to rotate to the left.
  • Ask client upon completion which way she found more di- cult to turn, or if both directions were hard.

Additional considerations:

  • If it is not obvious to you during the assessment which way your client lacks torso rotation, ask if she finds it difficult to breathe when she turns one way or the other. If breathing is restricted, this means turning that way is difficult for her and muscles around the rib cage are tightening up.
  • This assessment tip can be very revealing because clients will avoid a direction when they can't breathe properly while running, which affects biomechanics.
CORRECTIVE EXERCISES FOR INCREASING ROTATION

If your assessment results reveal a lack of rotational mobility in one, or all, of the major body parts, integrate the following corrective-exercise strategies into your client's personal training/running program. Before these exercises, use self-myofascial-release techniques to recondition and rejuvenate the soft-tissue structures that facilitate rotation in the area being targeted. Progress to gentle, isolated stretching techniques to help retrain joint mechanics before advancing to more dynamic, integrated strengthening techniques.

Ankle Exercises

The major muscles that control ankle rotation are the tibialis anterior, tibialis posterior and peroneals. To improve the capacity of these muscles to contract, lengthen and relax effectively during running, massage them using a foam roller, tennis ball or similar self-myofascial-release tool. Then progress to the following stretching exercise, designed to gradually introduce rotation to the ankle.

Ankle stretch

Ankle Stretch

  • Place toes of one foot up against base of wall or half foam roller.
  • Gently bend ankle forward and rotate it toward midline of body.
  • Make sure outside of foot, ball of foot and heel do not come off ground.
  • Return to start position.
  • Perform 8-10 repetitions, each side.

Heel-to-Toe Rocking

Heel-To-Toe Rocking

Once the client has improved ankle rotation with the controlled stretch detailed above, introduce dynamic activities like the one highlighted below to rotate and strengthen the ankle (and the parts above it) at a rate/speed that mimics real-life movements.

  • Assume staggered stance, right foot back, hands placed on wall for balance.
  • Point feet forward, and transfer weight forward into left leg while raising right heel and rolling/rotating right ankle out.
  • Keep toes of right foot in contact with ground.
  • Lower right heel back to ground as right ankle rolls inward and foot flattens.
  • Repeat, rotating ankle "up and out" and "down and in." Slowly increase speed.
  • Perform 10-15 repetitions, each side.

The toes-out torso rotation assessment can also be used as a strengthening move. Perform multiple repetitions to mobilize the ankle joint and strengthen the muscles that affect rotation.

Hip and Torso Exercises

The major muscles that control hip and torso rotation—gluteus maximus, hip flexors, hamstrings, adductors, obliques and latissimus dorsi—are inherently linked, as they all come together at the pelvis. Therefore, exercises designed to facilitate rotation of these two body segments should be addressed simultaneously. Use a foam roller to massage the major muscles of the hips and trunk before progressing to the stretching techniques.

Glute Stretch with Rotation

Glute Stretch (with Rotation)

  • Sit on floor with one leg straight. Cross opposite leg over straight leg, and place foot on floor at knee height.
  • Pull bent knee toward chest and rotate toward bent leg to stretch glutes and muscles that wrap around torso.
  • Hold for approximately 30 seconds, each side.

Hip Flexor Stretch with Rotation

Hip Flexor Stretch (with Rotation)

  • Kneel on right knee, left foot forward.
  • Tilt pelvis under, and align from left to right.
  • Rotate torso over left leg. Do not let pelvis move as you rotate.
  • Hold stretched position for 2-3 seconds.
  • Return to start, and repeat.
  • Perform 6-8 repetitions, each side.

Hamstring Stretch with Rotation

Hamstring Stretch (with Rotation)

  • Place right leg on bench or chair.
  • Keep leg straight, both feet aligned facing forward.
  • Align pelvis left to right and keep hips "stacked" evenly over legs and feet.
  • Rotate torso over right leg without bending spine to side.
  • Hold stretched position for 2-3 seconds.
  • Return to start, and repeat.
  • Perform 6-8 repetitions, each leg.

Adductor Stretch with Rotation

Adductor Stretch (with Rotation)

  • Stand with feet about 2 feet apart.
  • Gently bend right knee, transfer weight into right leg and rotate torso over right hip.
  • Keep left leg and foot straight and in contact with ground.
  • Hold stretched position for 2-3 seconds.
  • Return to start, and repeat.
  • Perform 6-8 repetitions, each leg.

Progress to the following integrated strengthening techniques to improve the ability of the hips and torso to rotate together at real speed (mimicking running movements).


Hips and Torso Stretch with Rotation

Hips and Torso Stretch (with Rotation)

  • Stand in split step about 18 inches away from wall. Foot closer to wall is forward.
  • Keep head facing forward and rotate torso toward wall, placing hands on wall to rotate further.
  • Ensure pelvis stays perpendicular to wall during rotation. Do not let hips move forward, backward or to one side.
  • Keep shoulders level; do not lean to one side.
  • When movement can be performed correctly (without moving hips or side-bending), increase speed.
  • Perform 10-15 repetitions, each side.

Lunge with Rotation

Lunge (with Rotation)

  • Lunge forward with right leg as arms rotate right.
  • Keep feet facing forward, torso upright. Do not lean forward or to the side.
  • Return to start position, and repeat.
  • Perform 8-10 repetitions, each side.

The toes-in torso rotation and lying torso rotation assessments can also be used as strengthening moves. Perform multiple repetitions to mobilize hips and torso and to strengthen muscles that control rotation.

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Justin Price, MA

Justin Price is the creator of The BioMechanics Method® Corrective Exercise Specialist (TBMM-CES) program, the fitness industry’s highest-rated specialty certification. There are trained TBMM specialists in over 70 countries helping people alleviate pain and reach their performance goals. He is also the author of several books including the esteemed academic textbook The BioMechanics Method for Corrective Exercise. Justin is a former IDEA Personal Trainer of the Year, founding author of PTA Global, and a subject matter expert for The American Council on Exercise, PTontheNET, TRX, BOSU, Arthritis Today, BBC, Discovery Health, Los Angeles Times, Men's Health, MSNBC, New York Times, Newsweek, Time, Wall Street Journal, WebMD and Tennis Magazine. Learn more about The BioMechanics Method®

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