Preventing Running Injuries

By Dr. Craig Smith, PT, DPT

My interest in running grew out of my passion for preventing injuries.  No physical activity creates more overuse injuries than running: however even those who may not be experiencing pain may have underlying factors that increase the likelihood of an injury happening in the future.   One day,  you may lace up your shoes, run a mile and feel a horrible pain in your knee.  It is at this point you seek help with some kind of intervention (rehab, consult, injection, etc.)

Although these injuries may generate physical therapy business, my career goal and research interest is to prevent the injury from happening in the first place.  With this goal in mind,  our team at ProActive Physical Therapy has developed a screening and injury prevention system tailored to the individual being tested.

Our goal of being “ProActive” is to identify the risk factor and make the correct preventative intervention possible BEFORE the injury happens.  So how do we do this?  How can we find out if a problem is present before we actually experience it?

In the field of injury prevention, a four step model was proposed by van Mechelen (2) in response to the disorganized methodology of the research community to answer those very questions (Figure 1).   Today we will briefly investigate the rates of injury and the concept of a risk factors.  This will set the stage for deeper explorations into running, screening tests, and injury prevention techniques.

Running Injuries

To solve any problem, it must be adequately defined and characterized.  We begin by defining the current rates and types of injury that occur with running.  (The answer depends upon a clear working definition of injury.  A recurring issue is the lack of consensus on the word injury, chronic, and overuse (1), which can change the findings of a research report dramatically.

The incidence of running injuries ranges from 20-70% in a year (3).   A review of 2002 running related injuries found the following diagnoses as the most common:

  • Patella femoral pain syndrome

  • Iliotibial band friction syndrome

  • Plantar facsiitis

  • Meniscal injuries

  • Tibial stress syndrome

  • Patellar tendinitis

  • Achilles tendinitis

  • Gluteus medius injuries

  • Stress fracture at tibia

  • Spinal injuries

  • Hamstring injuries

  • Metatarsalgia

  • Anterior compartment syndrome

  • Gastrocnemius injuries

  • Greater trochanteric bursitis

  • Adductor injuries

  • Osteoarthritis at knee

  • Sacroiliac injuries

  • Stress fracture at femur

  • Ankle inversion injuries

  • Iliopsoas injuries

  • Chondromalacia patellae

  • Peroneal tendinitis

  • Morton’s neuroma

  • Abductor injuries

  • Calcaneal apophysitis

  • Tibialis posterior injury

Knee injuries account for 50% of all running injuries and patellofemoral pain syndrome is the most common diagnosis. The first thought that struck me however was the variety of injuries occurring. Instinctually we expect the knee injury but what about the sacroiliac joint injury?  Or the spine?  The bolded injuries had a significant relationship to gender, meaning that it was more common in one sex.


This information tells us something that we already know:  that men and women are different (Figure 2) and multiple factors are implicated.  From here, we begin to look at risk factors that can be identified.

Risk Factors

This is step two in the process outlined above: what risk factors and mechanisms lie behind the injury?  Before I hit this question, let’s go more basic and define risk factor.  An injury risk factor is a variable associated with increased risk of experiencing an injury.  Association is the keyword because this does not mean causation.  For example, a risk factor found in a sample of runners for an overuse injury may be running volume in a week.  Increased running volume has a protective effect while decreased volume increases risk of injury.  At first glance this does not make sense.  Wouldn’t more running place you at even more risk?  Increased running mileage may indicate a more seasoned runner who has adapted to running this amount while the lower mileage indicates a novice that is pounding their body for the first time with a consistent running program.  Therefore, risk factors always need to be examined specific to the population in which they found.  

Generally, risk factors are split into extrinsic and intrinsic categories.  Extrinsic simply means it is not the person.  Examples include the type of shoe or the surface you run on.  When I speak to injured runners, there is always an over emphasis on the shoe and glaring oversight on internal (intrinsic) problems.  The research behind foot and impact loading and association with increased injury risk is far from conclusive despite the billion dollar industry surrounding the issue (4).  Intrinsic indicates variables related to the individual like anatomy characteristics, sex, age, height, bodyweight, flat feet or rigid feet, balance, strength,  and flexibility (5).   Depending on the paper you read, the variables related to injury are different.  Further, if considered in relationship to previous injury history, sex, and age, then risk factors can change.

The final component of a risk factor is if it is modifiable or non-modifiable.  Your injury history will tell us a lot about your risk for a future injury, but you cannot change it (unless you can go back in time).  When I screen a runner to find risk factors for a future injury, I attempt to find variables that can be modified.  A side to side imbalance or leg dominance is a BIG risk for a future injury.  This can be changed and improved with balance training or single exercises  to such an extent that it is no longer a risk.  Injury risk factors that should be considered for each running athlete based on clinical experience and research are as follows:

  • Leg imbalance, dominance, and asymmetry

  • Poor balance

  • Weak hip musculature

  • Injury history

  • Sex

  • Age

  • Foot type

  • Range of Motion

  • Training history

  • Training volume

As you can see, none of these are based on findings from running analysis.  This is another large component that will be explored in great depth in the future.

Are you at risk of a running injury?

The takeaway from today’s post is that even the currently uninjured may benefit from consultation to reduce the likelihood of becoming injured.  Modifiable factors that you are not aware of may contribute a future problem unless caught early.  This intro is setting the stage for a deep dive into running mechanics, mechanisms of injury, and how you can prevent an injury when running.

If you have any questions are interested in a running screen, please email me at

Until next time,

Craig Allen Smith


1. Finch CF. An overview of some definitional issues for sports injury surveillance. Sports Med 1997;24(3):157–63.

2. Van Mechelen W, Hlobil H, Kemper HC. Incidence, severity, aetiology and prevention of sports injuries. A review of concepts. Sports Med 1992;14(2):82–99.

3. Nielsen RO, Buist I, Sørensen H, Lind M, Rasmussen S. Training errors and running related injuries: a systematic review. Int J Sports Phys Ther 2012;7(1):58–75.

4. Nigg BMD sc. The Role of Impact Forces and Foot Pronation: A New Paradigm. Journal of Sport Medicine January 2001 2001;11(1):2–9.

5. Wen DY. Risk Factors for Overuse Injuries in Runners. Current Sports Medicine Reports October 2007 2007;6(5):307–13.

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