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Understanding Running Injuries And How To Prevent Them

April 17, 2024

Running can be fun, challenging, energising, stress relieving and a great form of exercise. Some argue we were made for running as it meant we could be successful at catching succulent prey and saving ourselves from scary predators. Quite a contrast with nowadays running after the morning bus or for 30 minutes of fitness during lunch breaks. But regardless of the reason for running, most of us agree running is great and a very healthy activity.

Nothing, however, comes without risks... running is also a skill, and as such, it requires practice and some technical knowledge to prevent injuries. Indeed, we cannot overlook stats that show that runners have a 20 – 90% chance of developing a lower extremity injury from doing it regularly. According to the British Medical Journal (BMJ), some of the most common issues with running include knee pain, shin splints, heel pain and achilles tendinopathy. Here we will try to understand why aches and pains often affect runners, whether they are returning from a break or consistently training.

How do we hurt ourselves

In simple terms, we hurt ourselves when we do more running than what our muscles and joints are able to take: the load exceeds the capacity of our body tissues. In most cases it is nothing serious, a week or so of resting and tissues should recover stronger and more resilient. So why, despite not being serious injuries, many of the problems affecting runners can be so stubborn to recover from? Let's scan this further!

Too much, too early

This is the most common reason for running injuries. After a lazy winter or a chilled out summer, our body has a need to pace itself back to activity. This means slowly progressing in our running plan by adding the right amount of miles each week. In fact, each time we run, new strength is built, the movement pattern is learnt by our nervous system and we become better at running and recovering from it. And remember, ‘rest time’ can be an essential part of this process as that is when most of the wonderful repair processes take place. 

The reality, though, is that pacing is much harder than what we’d think. As we are caught in the ‘high’ of a run, our body feeling strong and lungs free, we are often led to run a bit more than planned. Then the next day another quick run. And by the time of the next one, we might be in pain… our body was not ready for this ‘high demand’, the pain system has detected a ‘threat of injury’ and it decides to protect you by making you feel pain! Yes, this may sound confusing (unless you’ve been reading our other blogs)… but keep reading and, hopefully, your questions will be answered.

Pain system

Pain is the system our body uses to protect itself from possible damage. For instance, touch a burning candle and the pain you feel tells you to remove your hand from there... nice work, you’ve prevented damage! Similarly, you’ve increased your mileage quickly after a winter of sporadic runs and your knee starts hurting. Your pain system has detected a threat to your tissues (in this case your knee) and prompted you to take action by stopping what you’re doing to avoid further damage. 

So, let’s clarify the sentence from the previous paragraph “we hurt ourselves when we do more running than what our muscles and joints are able to take”. This is not totally correct as, most often, we will hurt when we do more running than what our pain system thinks is ‘safe’ for our tissues. There’s often little or no damage to the muscles and joints of the knee (although we are led to think there is something wrong as that’s what pain is there for!) because our pain system has succeeded in stopping us before we could do serious damage. Just like we (hopefully) remove our hand from the candle before we injure ourselves, the pain is a warning signal of possible future damage, not tissue injury itself. So what decides how sensitive this warning signal is and how relevant it is to prevent damage?

When is our pain system more likely to detect threats?

There are numerous factors that make our pain system more likely (sensitive) to detect the threat of injury and thus make us feel pain during or after a run. Knowing this may allow us to understand better why we are feeling pain in the first place during/after a run and identify things that help us prevent it the next time round:

  • Lacking general conditioning or fitness before running: our muscles may simply not be ready or strong enough to do the amount of running we’d like to do…  or , if you’re a new runner, this may be a movement your body is unaccustomed to do, thus making the pain system more likely to detect ‘threat’.
  • Long durations of inactivity: spending most of a day inactive before diving into exercise can be enough to keep our pain system in an ‘alert’ state.
  • Feeling anxious or stressed in our everyday life: this puts our nervous system in a ‘fight or flight’ mode (stress system), speeding up our metabolism, muscles growing tense and our nervous system becoming more sensitive to pain.
  • Lack of sleep: the negative effects on mood, anxiety and the activation of the stress-system associated with sleep deprivation are consistently associated with a greater sensitivity to pain.

The stubborn aches

Sometimes our pain system keeps detecting threats even though your tissues are healthy and there is no realistic chance of injuries (see our blog on Living Well with Chronic Pain for more on this topic). The pain system remains in “protective mode” although your joints and muscles are healthy. The pain you feel is real (it always is), but that pain does not always equal damage. This is the case for many stubborn injuries that, despite resting, changing shoes and trying various therapies, just seem to not get better...

Let’s take the example of the stubborn knee pain: in most cases, after 2 or 3 months that we’re suffering with this injury, there is hardly any of that redness or puffiness typical of damage and inflammation. Also, scans tend to show very little joint damage, or changes that are either normal wear-and-tear or a result of being in pain for so long (less activity, muscles guarding, wasted muscles etc). On the other hand, there are many examples of runners with seemingly worn out joints that do not experience pain at all. Our bodies are impressive at adapting to changing conditions and the pain we experience from running often has little to do with damage to our knees and more with our pain system that remains in ‘protective mode’.

Why does the pain system remain in ‘protective mode’?

Aside from all the factors making our pain system more likely to signal threat (as described in the previous paragraph), one of the major elements causing our pain system to remain overprotective is the repetition of the same ‘threatening’ activity over and again. Let’s explain this better. As running is what triggered the ‘danger messages’ to be sent to the pain system in the first place, our smart pain system will remember that running can be a ‘potential threat’. So, as we get back to running our pain system will be very wary and ready to stop us as soon as we do a little more than what it considers ‘safe’ for us. If, over and over again, we repeat the activity that caused pain in the first place, before the alarm system feels ready and safe to do so (which is not the same as being 100% healed) our pain system will get better and better at associating running with this potential threat and over time pain will occur sooner and more intensely, so that even a slight jog may be enough to trigger the pain system. To better understand this, you may also want to read our blog ‘Understanding Repetitive Strain and Overuse Injuries’.

Pacing yourself back to running

This is why, despite not having any serious tissue damage, it is ever so important to gradually pace ourselves back to running when returning from an injury. We simply want to keep our pain system in its safety zone, which will naturally expand as we gradually increase our running. This is known as graded exposure. As a general rule, you should consistently keep to the amount of activity (duration, weight, reps etc) that you know won’t cause much more than very slight discomfort that day or the day after (super important!) for a few sessions, before increasing the amount of activity (longer, more weight etc). If the next stage of activity  triggers pain, don’t get frustrated, go back to the previous level and patiently start the process again. The safe zone is very subjective, you’ll have to figure it out yourself, trying to listen to your body, avoiding being overzealous but also overcautious too. 

Keeping a running log

Keeping a training log can help you keep your miles under control. This is good for both pacing yourself back to full activity and for preventing injuries in the first place. Logging your mileage weekly and developing a training schedule that gradually increases your distance over time is a wise strategy, rather than solely relying on the feeling of a particular day . 

Keeping fit and speeding up recovery

As you’re going through a paced return to running, it is good to stay fit and active in other ways. Do some core strengthening, very important muscles for runners, or train your flexibility, general balance and stability. You can also do lower body strength training and pleasantly realise your knee is totally pain free… indeed, the pain system may associate running with ‘threat’ and not movements like squats, lunges or other strength exercises. So jump into it as your knee is strong and healthy, and build your self-confidence! Other options to get generally fit are swimming, hiking, cycling or any other activity you enjoy and that does not trigger your pain system!

Are technique and body alignment important?

Though body alignment and perfect techniques certainly make us look good while running, this study shows that subtle differences in how we position our body are not as relevant as we commonly think. Moreover, there is no solid evidence that links a specific running technique with less injuries despite a lot of research trying to prove that. We’re not saying that how we run doesn’t play a role in the big picture of an injury. The point is that for years a lot of research has focused on finding a ‘perfect technique’ to prevent injuries, forgetting that each of us have different needs and bodies, and what works for you may not work for others. This is particularly evident when you look at this picture comparing the foot strike of 48 professional runners… each one of them has a different foot positioning at the same stage of their gait, and they were all injury and pain free! There is probably no right or wrong way of running to prevent injuries. You will naturally develop the style that most suits your body, needs and style; just keep running and listening to your body. 

So if you hurt yourself, don’t blame your running technique right away. Look at how intensely you have been training, what your running/resting ratio has been, how much sleep you had, how your general fitness is, how coordinated you are feeling and so on... As a disclaimer, we must point out that if a past injury caused you to change the way you run, then this change may predispose you to future injury. But if you healed completely and the injury did not abruptly change your running technique, then we also need to look at other reasons. 

Foot orthotics

Generally, when ‘experts’ try to change the way you are running in order to have perfect technique, think twice… studies have shown how the use of foot orthoses acting as cushions for shock absorption or to sustain the arches of the feet are not effective at preventing running injuries. Actually, people with foot orthoses may be prone to more injuries than those without… it looks like our body finds its own way of efficiently dealing with our own weird and wonderful characteristics; so, why change it?

Muscle activation exercises

Many experts in the field of running also support the idea that specific muscle groups should be ‘activated’ and strengthened in isolation from other muscles in order to prevent injuries - ie. gluteal or core strength training. However, the evidence seems to show that muscles are unlikely to be ‘underactive’ during running, so specific training regimes may not be needed in order to prevent injury. This is quite eloquently shown by this large study that shows hip strengthening programmes to be no better than general fitness at preventing knee pain. What is clear, however, is that being generally strong and coordinated can definitely help prevent injuries. 

Why osteopathy helps

Osteopaths will take time to understand a patient’s life routines, running patterns and tissue health, and will be able to tell what is causing the pain (diagnosis), how long they can expect it to take before they start to feel better (prognosis) and what the patient can do in the meantime to help the issue improve. 

Osteopathic treatment also involves hands-on techniques, with joints and tissues being moved and pressed upon where necessary in order to reduce the sensitivity of the overprotective pain system increase mobility and influence the circulatory and lymphatic system to speed up recovery. You and your osteopath will be able to create a rehabilitation plan based on your needs (ie. greater strength, stability or cardio) and effectively pace you back to activity. 

To see how osteopathy helped one of our patients read Lindsey's story.

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