Can I Keep Running? Running With Common Injuries

Posted March 1, 2021

Runners commonly experienced pains and niggles throughout their training and racing. It can be tough to know what pain and soreness is worth training through, what symptoms tell you to modify training or rest altogether. The last thing any runner wants to do is to stop running, so it can be helpful to know if you are helping or hurting yourself by continuing to run. Here we discuss a general guide for running with common running injuries; patellofemoral pain, ITB pain syndrome, tendinopathy, plantar fasciitis, bone stress injuries and muscle strains.

It is not uncommon for runners to experience pain. In one study the prevalence of musculoskeletal pain prior to a race was 27 % in women and 20% in men (1). Prevalence of runners having pain has also been found to be 20% in two other studies (2, 3). The pain is not always mild with one study reporting a high percentage (more than the half at rest and almost three quarters during activity) of the symptoms reported were rated greater than 3/10 on the numerical rating scale (3). It is also common for runners to continue running with pain. A UK study of 1100 runners participating in parkrun, over 50% had a current self-reported injury and 86% were continuing to run despite their injury causing pain, directly affecting their performance and causing a reduction of running volume (4).

Before discussing running with common injuries, it is first important to discuss why a short-term change in running load or rest might be necessary.

Tissue Healing – in some injuries there is a breakdown or physical damage to tissue integrity (muscle, tendon, bone) which influences its ability to handle the stress of running. If the stress of easy running exceeds the capability of the tissue, then the necessary healing response cannot occur. At some later stages of tissue healing or mild injuries easy running may not exceed the capability of tissue and running can continue.
Highly Irritable Tissue – In some common running injuries the tissue may not be ‘damaged’ but rather highly sensitive (eg ITB Syndrome, PFP). This sensitivity, irritability or in some cases inflammation may be so significant that it forces rest or a reduction in running load. Running loads then can then continue once symptoms are more mild.
Performance – Levels of pain or discomfort can alter one’s ability to complete intended runs or key workouts and performance may decline; where performance may be decreasing, a short-term reduction in volume or intensity may better achieve longer term performance goals.

Running With Specific Injuries

A final note before we discuss specific injuries, the suggestions below should always be taken into context of short and long term running goals and individual circumstances. It is also important to be sure you are dealing with the correct diagnosis, particularly where a bone stress injury may be involved.

1. Patellofemoral Pain

Patellofemoral pain (PFP) or kneecap pain is a common occurrence in runners. Almost 50% of running injuries occur at the knee, of which 48.8% occur at the patellofemoral joint (5). We have discussed previously rehabilitation for patellofemoral pain here and detailed how structure alone does not account for pain at the knee joint (6). It is often due to this reason that you can continue running with PFP if the pain is mild. For simplicity it can be useful to rate pain mild, moderate or severe; which takes a level of honesty with yourself. A key feature of mild pain is you can manage not to focus on it, or think about it for the duration of the run and pain doesn’t increase after (on a numerical scale it would be less than 3 out of 10). Patellofemoral pain may also be less significant with increases in cadence, due to reduction in overstriding (7). Once easy running is comfortable, speed and hills can look to be added.

2. Iliotibial Band Pain Syndrome

IIliotibial band pain syndrome refers to lateral knee pain where there is increased compression at the lateral knee (8). This can be due to a number of reasons which are detailed in a 5-part blog starting here. ITBP is another injury in which someone can continue running. The amount of running (distance or duration) can vary greatly depending on symptoms. If symptoms are mild often flat running can continue, but pain progressing with longer durations. Speed and hills are often avoided as both speed and downhill tends to aggravate symptoms. Some biomechanical characteristics have been linked to ITB pain including a crossover gait (think running along a line, with left foot landing on right side of the line and right foot landing on the left side, creating a criss-cross action) or overstriding. Modifying these factors may decrease pain (7). Uphill treadmill running can also be implemented with reduced symptoms as there is less compression on the lateral part of the knee. With an incline sometimes faster speeds can also be tolerated.

3. Tendinopathy (Achilles, Hamstring)

Painful tendons are common in runners particularly the Achilles tendon and hamstring origin (proximal hamstring tendinopathy (PHT)). If a runner has a classic mid-portion tendinopathy (as opposed to other related diagnoses) or PHT pain is often present at the beginning of running and warms up as exercise progresses. It is common to continue easy running whilst completing rehabilitation exercises. Speed or hills may be limited depending on the symptom levels and then strategically added back into regular training as symptoms improve. Use of heel wedges in running footwear has been used to reduce achilles tendon pain whilst running (9).

4. Muscle Strains (Calf, Hamstring)

Muscle strains, particularly to the calf and hamstring are a common injury for runners. One of the standardised ways of classifying these injuries is using the British athletics muscle injury classification. It has 5 grades of injury; grade 0 – through to grade 4. Grade 1 to 4 is further subcategorised into a, b or c, based upon the site and extent of injury (10). The particular details of the degree of injury have been elaborated on in this previous blog. Grade 0 injuries commonly referred to as delayed onset muscle soreness or neuromuscular soreness, whilst grade 1 injuries are small tears to the muscle. The athlete will usually present with pain during or after activity. These injuries may often only require 2-7 days off before resuming easy running. More significant injury grades (G2-3) are often memorable in their onset and force the runner to cease activity. As they involve greater disruption of muscle and in some cases tendon fibres (2b, 2c, 3b, 3c); time off running is often required as tissue healing and remodelling takes place. The length of time off can be longer when the tear extends into the muscle better so returning to run for one particular calf strain may vary greatly compared to another. Calf strain rehab has been discussed extensively here. With hamstring injuries easy running is often possible early in the rehabilitation process but due to significant hamstring forces with high-speed running or sprinting, this is not introduced until much later in the rehabilitation process under the guide of your physiotherapist.

5. Bone Stress Injuries (Shin splints, stress fractures)

Bone stress injuries (BSI) occur on a continuum of overload to bone; progressing from normal remodelling to stress reactions and potentially stress fracture. Reported 1-yr incidence rates in competitive track and field athletes have ranged from 8.7% to 21.1% (11,12). Any bone stress injury requires time off running to allow healing of the overloaded bone, this includes no ‘test runs’. Time off varies depending on the location (high risk vs low risk) and the grade of injury (see below). In the meantime, cross training is implemented such as swimming, cycling or elliptical. A gradual return to running program is commenced after appropriate rest whilst ensuring the contributing factors that led to the bone stress injury are addressed. The exception to this is the rare ‘non-bony’ shin splints. Shin splints or exertional lower leg pain is an umbrella term used to describe pain on the inside lower third of the shin bone. Typically, this pain is due to a stress reaction or stress fracture; ie on the continuum of bone overload as illustrated below and therefore requires rest. In rare circumstances, more commonly with new runners, this pain can be from the local soft tissue and an MRI will show no stress reaction, in which cases running with mild pain can continue.

6. Plantar Fasciitis (Aka Plantar Heel Pain, Plantar Fasciopathy)

A 2012 scientific literature review reported that plantar fasciitis was the third most common musculoskeletal injury to afflict distance runners who were in training, behind medial tibial stress syndrome and Achilles tendinopathy. Amongst runners, the incidence of plantar fasciitis ranged from 4.5 to 10% (13). Load management is an important part of the initial treatment of plantar fasciitis. Depending on symptom severity reducing the volume of running so that pain is mild and easy running can continue is often reasonable. Signs that volume needs to be further reduced includes when pain after running is more significant than before or during the run and/or remains heightened the next day after a run.

In summary, we all want to keep running. As a physiotherapist and a runner, I want to keep my clients running where possible. It’s a juggling act between maintaining the highest possible volume or intensity of running, whilst respecting tissue healing times and tissue irritability so that the ultimate goal of long-term running and fitness is achieved. Unfortunately, some injuries such as bone stress and acute muscle strains necessitate ceasing running for a short while, whilst others such as patellofemoral pain, ITB syndrome, tendinopathy and plantar fasciitis need some modifications to training intensity or volume. These modifications can then maximise the earliest resumption of normal run training.

Lewis Craig (APAM)

POGO Physiotherapist
Masters of Physiotherapy

Featured in the Top 50 Physical Therapy Blog

References

Lopes, A. D., Costa, L. O. P., Saragiotto, B. T., Yamato, T. P., Adami, F., & Verhagen, E. (2011). Musculoskeletal pain is prevalent among recreational runners who are about to compete: an observational study of 1049 runners. Journal of physiotherapy, 57(3), 179-182.
Desai, N., Zapda, M., & Ansari, A. M. (2020). Prevalence of musculoskeletal pain among elite and recreational runners of South Gujarat: A cross sectional study. Knee, 10(8), 2.
Wilke, J., Vogel, O., & Vogt, L. (2019). Why are you running and does it hurt? Pain, motivations and beliefs about injury prevention among participants of a large-scale public running event. International journal of environmental research and public health, 16(19), 3766.
Linton, L., & Valentin, S. (2018). Running with injury: A study of UK novice and recreational runners and factors associated with running related injury. Journal of science and medicine in sport, 21(12), 1221-1225.
Taunton, J. E., Ryan, M. B., Clement, D. B., McKenzie, D. C., Lloyd-Smith, D. R., & Zumbo, B. D. (2002). A retrospective case-control analysis of 2002 running injuries. British journal of sports medicine, 36(2), 95-101.
Lack, S., Neal, B., De Oliveira Silva, D., & Barton, C. (2018). How to manage patellofemoral pain – Understanding the multifactorial nature and treatment options.
Barton, C. J., Bonanno, D. R., Carr, J., Neal, B. S., Malliaras, P., Franklyn-Miller, A., & Menz, H. B. (2016). Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. British journal of sports medicine, 50(9), 513-526.
Fairclough, J., Hayashi, K., Toumi, H., Lyons, K., Bydder, G., Phillips, N., Best, T. M. and Benjamin, M. (2006), The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy, 208: 309–316.
Farris, D. J., Buckeridge, E., Trewartha, G., & McGuigan, M. P. (2012). The effects of orthotic heel lifts on Achilles tendon force and strain during running. Journal of applied biomechanics, 28(5), 511-519.
Pollock, N., James, S. L., Lee, J. C., & Chakraverty, R. (2014). British athletics muscle injury classification: a new grading system. British journal of sports medicine, 48(18), 1347-1351.
Nattiv, A., Puffer, J. C., Casper, J., Dorey, F., Kabo, J. M., Hame, et al. (2000). Stress fracture risk factors, incidence and distribution: a 3-year prospective study in collegiate runners. Med Sci Sports Exerc, 32(suppl 5), S347.
Bennell, K. L., Malcolm, S. A., Thomas, S. A., Reid, S. J., Brukner, P. D., Ebeling, P. R., & Wark, J. D. (1996). Risk factors for stress fractures in track and field athletes: a twelve-month prospective study. The American journal of sports medicine, 24(6), 810-818.
Lopes, A., Hespanhol Jr, M., & Yeung, S. & Costa, L.,(2012). What are the Main Running-Related Musculoskeletal Injuries. Sports Medicine, 42(10), 891-905.

athlete, lower limbs, pain, runner, running injury, Tissue Healing