Anatomy of a Running Injury – Part 1

Stay the CourseOne of the best running gifts I’ve ever received was a copy of Dr. Tim Noakes’ formative work, The Lore of Running. In this exhaustive resource on all topics running, Dr. Noakes outlines his “Rules of Running Injuries.” Front and center at number one:

Running injuries are not an act of God.

In the ultra world, there may be a few God-inspired injuries – that root the reaches up and grabs your toe or the rocky formation that gives way beneath you – but that’s a topic for another time.

So if not God, luck, or superstition, then what?

An injury is the result of an abnormality in the interplay between forces – training load, surface, and gait mechanics – and tissues – muscle, tendon, bone, joint, nerve, or anything that’s you! Let’s take a closer look at that interplay:

Normal Forces on Normal Tissue
Normal forces – namely training load and running techniques – are those deemed reasonable and tolerable to the human body. Normal tissues are those deemed to have healthy degrees of strength, flexibility, nutrition (blood flow), and power supply (nerve connection).

Normal is seldom equated to ultrarunning. But via tissue adaptation, we advance our fitness – and ability to survive ultra training and racing – by increasing force loads gradually. This gives our tissues enough time to adapt, creating new normals of both forces and tissues. Simply put, we load the tissue with our easy runs, interspersed with harder, longer runs that over time push the envelope of normalcy to a new level. This is the scenario of the healthy, and often successful, athlete.

Abnormal Forces on Normal Tissue
Problems arise when the forces become abnormal. Any force that the body’s tissue cannot absorb in a finite time – be it a hundred-mile week or a single leap off a high rock – is deemed abnormal. This results in an adverse tissue response: pain, inflammation, and/or mechanical compromise such as a strained calf or tweaked Achilles. These are straightforward examples that everyone has experienced, and they’re typically deemed “training errors.”

Normal Forces on Abnormal Tissue
Abnormal tissues are those that no longer have requisite strength, range of motion, nutrition, or power. This can occur for a variety of reasons: being overloaded by abnormal forces in running or losing flexibility and strength after a long lay-off. Non-running stressors, such as work or home tasks, can also change the nature of your tissues. A common example is traveling: sitting on a plane or car stiffens the spine, resulting in a back strain during an easy run or race.

Abnormal Forces on Abnormal Tissue
This is the area where chronic injury is born and raised. Tissues are made abnormal by the injury process. Inflammation results in tissue shortening: muscles tighten, tendons scar, joints stiffen. But just as likely, the resting process can make tissue abnormal, by taking tissues that were kept fed and flexible by exercise are now lying dormant.

But what about forces? Shouldn’t they be normal, or “better than normal,” due to lower training loads when we come back from injury or a lay-off? Perhaps, but what if running mechanics become abnormal?

A less-recognized – but arguably more threatening – example is when the abnormal force becomes one’s own running mechanics. Abnormal or inefficient running mechanics – occurring either suddenly or gradually – put abnormal forces on tissues that, under previously normal volumes, were well-tolerated. But now, they create injury.

Pain As Your Teacher
Pain is the world’s greatest teacher: it is the feedback system that protects us from danger. Without it, we’d all be dead. As such, it has tremendous ability to change the way we function, without any knowledge or conscious control. Consider if we had to think about whether or not to remove our hand from a red-hot stove burner.

Pain changes how we run. It changes how powerfully we use a muscle, or how much weight we put through a joint or limb. It changes how much we move a limb through space or how quickly. So when we experience the pain of an injury, the potential for changes in our running mechanics – however minor or seemingly insignificant – is substantial and altogether shocking.

Previously normal running mechanics have now become abnormal. Coupled with abnormal tissues equates to poor tolerance to even miniscule loading forces, resulting in chronic injury.

This is why Dr Noakes’ 7th rule rings true: “Complete rest is seldom the most appropriate treatment.” Unless you change the abnormal tissues or abnormal mechanics, the symptoms will invariably return with resumption of running.

A good case study was a friend of mine with left knee pain. She’s had pain for three months since running a 50k race. Prior to the race, she had no knee pain, so we can assume pre-race forces and tissues to be normal. She successfully finished the 50k, but experienced minor knee soreness in the week afterward (assumption: the race was an abnormal force). Following a three or four day rest, she completed a short run without pain (normal force). But upon her next run, she experienced knee pain.

Since that time, every subsequent run, despite taking days to weeks off running, and returning with very light trial runs, resulted in pain.

Why would this scenario – tons of time to rest, then significantly shorter and easier runs – result in the same pain?

Upon examination, I found the following issues:

  • Range of motion losses in the ankles and knees, namely the quadricep and patellar tendon on the left side. These represent abnormal tissues.
  • During run gait, she was pushing off less powerfully, resulting in a valgus (sidebending) force during landing. Also, she bent her left knee less during the swing phase. These represent abnormal forces.

Without addressing the abnormal tissues and forces, my friend would continue to have pain. Therefore, to successfully treat this injury, we addressed the tissue mobility and the gait mechanics. Once those two issues are ameliorated, there is no reason why she cannot return to running soon, and eventually run another 50k.

* * * * *

Given that, the most effective way to both treat injury – and remain injury-free – is, quite simply, to keep both forces and tissues normal. This is easier said, than done. But here are some brief things to focus on:

  • Be Consistent. Consistency in training and life keeps both forces and tissues near-normal. Abrupt changes can result in overload and changes to both tissues and gait mechanics.
  • Know “Your Normal” and Keep It That Way. I am frequently asked, “What do I need to stretch as a runner?” My answer is, “Whatever needs stretching.” Know your norms: can you normally touch your toes or your heel-to-your-butt? Can you squat down and keep your heels down (e.g., ankle flexibility)? If so, keep it that way.
  • Know How You Run. This is a tough one (and fodder for more than one subsequent post, for sure). Do you know how you run, or how to sustain your stride when fatigued, or sore? Keep your mechanics consistent at all costs: consider working with a coach or knowledgeable runner to provide feedback or develop drills that help maintain a consistent stride. Even in an absence of pain, the natural aging process can – and does – change our stride by slowly making our tissues stiffer. Stay flexible and stay consistent. Don’t go down without a fight!
  • Never, Ever, EVER Limp.* We have but one rule at our clinic, “No Limping Allowed.” Limping, or compensatory gait, changes both tissues and forces: over- (or under-) loading tissues, and changing our mechanics. Most people suffer a slight injury, compensate, then suffer greatly from the compensatory changes in tissues and mechanics. Don’t do it!

(*unless you’re on the Placer High School track at Western States)

In our next column we will delve into Part II and talk about how to make Abnormal become Normal again, and how subtle changes to mechanics in response to pain can create chronic injury.

Call for Comments

  • Do you have any examples of abnormal forces and abnormal tissues resulting in injury?
  • What do you do to maintain “normal tissue” (e.g. strength, flexibility)?
  • How mindful are you about your own running mechanics? Have you ever sought out assistance from a coach or health care provider to improve your form?

[The contents of this column as well as the author’s comments are provided for general informational purposes only and are not intended as a substitute for professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition.]

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 30 comments

  1. pat

    I have definitely experienced an injury incurred through sudden rest and then a re-start of normal training. This article seems very useful, I wish I had read it a month ago! Thanks!

  2. Bartman

    Thanks Joe.

    Nice article that digs deep for perspective.

    In a couple of weeks I will be 67 years old/young/indifferent, so the math says I have been running for 53 years. The following is what a life time of running has taught me and still learning about:

    Be Consistent. I run every day. When I can’t run I walk, or walk and run, walk and jog (“wog”). In other words keep moving and don’t stop. If you stop moving long enough they will start throwing dirt on you; so don’t stop moving.

    “Your Normal”. Yoga and some type of resistance work (weights, bands, whatever) every day. If you don’t, it will come back to bite you. If your core gives out you’re screwed. I grew up during the Percy Cerutty era and I still embrace most of what he taught when it comes to strengthening the anatomy.

    Know How You Run. If it wasn’t for Danny Dryer and ChiRunning I probably would not be running as well I am now, if at all. I owe Danny a huge debt of gratitude for his teachings, encouragement and philosophy. Find something or someone to give you a base or point reference, to work from.

    Never Limp. Agreed. If you begin to limp while running then walk. If you limp while walking then ride a bike, get in the pool do whatever. Work the problem area and focus on healing which will require movement; unless you broke something. Again…keep moving but don’t run and limp; you are wasting time and making the problem worse.

    Looking forward to Part II

    1. OOJ

      Bartman-

      Great post, and definitely a recipe for longevity in the sport!

      I truly feel that most of us "old guys" (post-collegiate) lose our speed not because of losses in V02Max or muscle mass, but because of tissue changes — joint and muscle stiffness. We lose joint ROM, we lose stride length, we lose speed, we get turn, repeat, ad nauseum.

      As for "Never Limp" — sometimes when something hurts to walk on, what it needs is *more weight*! Sometimes (but *not* always) joints need approximation for joint mobility, stability, and nutrition. Limping robs the joint of these things.

      Keep it up!

      1. Bartman

        OOJ,

        Good point regarding loading. Countless times I have "repaired" a suffering joint (knee, ankle, hip, etc.) with light weights or some other type of resistance.

        I cannot emphasize enough the theraputic benefits of walking and hiking. My running is very "Van Aaken oriented" in that sense even when healthy. When I deviate to far from Van Aaken's principles I find myself suffering, hurting and the quality of running dropping off. Maybe this is an age problem but years ago when I trained in the summer with some the xc skiing guys in Norway we did a lot of fast walking and hiking when out for 4 – 6 hours on a long day and followed much of the same routine for shorter days during the week.

  3. patrick stewart

    Joe,

    Great article. What's your take on running while sore? Even with a couple easy/recovery days per week, I find that I'm sometimes sore going into a workout. Is some residual fatigue/soreness ok even if I have a hard workout planned?

    Thanks,

    Patrick

    1. OOJ

      Soreness *usually* is a sign of fatigue and stiffness/range of motion loss of tissue. Given that, gentle mobility is the key.

      Most current research on stretching states that we're best off with *active warm-up*. Tissues move, get warm, get blood flow and nutrients.

      I have a friend, let's call him "El Bee", who has recently instituted what he calls "The Morning Constitutional" — a brisk morning walk, not fitness oriented, just to get his body moving. This is a great way to keep tissue "normal" and ready for your hard workout.

      For example: just this morning, I was out at 6AM to run one mile. ONE. It wasn't for fitness; it was to get me loosened up for my tempo run planned in the afternoon.

  4. JeremyJ

    I am in the same situation as your friend. Left knee pain and shuffle mode(with less left leg swing). It was the same thing for me. Take a week off, then try again, and the pain was there. I decided to run through it, with abnormal mechanics and all-just decided to go slow enough that it didn't hurt too bad. It wasn't necessarily very fun, and it was super slow, but I thought that it would at least induce some blood flow to aid in the healing. I don't know if this was the best idea, but I have slowly been getting better(back to normal).

    I am looking forward to seeing how you would go from abnormal to normal again.

    1. OOJ

      Thanks for the post!

      As I stated above, sometimes joints need *more* loading. The knee is a prime example. The knee gets its stability from the pelvis and trunk (or "hip", depending on who you talk to). Pain makes us favor – and makes us stop being strong and supportive through the pelvis/trunk. Less strength –> Less stability –> aberrant, irritating motions/forces into the knee –> more pain –> Even less strength…etc.

      In Part II we'll address the knee as the example of "Abnormal to Normal"!

      1. Digger

        Good stuff, I have "runner's knee" again and was going to rest it until it stopped hurting going up and down the stairs. Orthotics and patella strap are not helping. NSAIDs work but I'm taking too many of them and hurting my stomach and liver.

        I don't want to wind with arthritis in my knee, as I'm in my mid 50's.

  5. Timm H

    Great article. I have an abnormality in my stride. After I push off with my right foot, it inevitably kicks out to the right while in the air. I regularly work on strengthening my stability muscles in my ankles and knees, which has drastically reduced knee pain on my long runs, but the foot still does its thing. Is there any way to correct such an abnormality?

    1. OOJ

      Timm-

      That issue is *usually* one that stems from the hip and pelvis – the lack of a *strong* push-off, which is supposed to initiate from there. That usually stems from a pain history — your body not wanting to push-off into a painful or injured joint.

      This is a difficult one to describe herein: but pushing more strongly with the gluteal muscles ("into the ground" beneath you, as opposed to kicking long behind) may help.

      However, an issue such as that, especially if longstanding, may have more complicated "tissue" and "force" issues that need addressing.

      Here's what NOT to do: try to correct it by simply "turning in" your foot or hip. It will not work and will only result in more pain and dsyfunction!

      Seek out a good running PT or other professional to help you with that!

  6. Alison Gittelman

    Great post. I have very tight hips that often come out of alignment. If I don't get the alignment fixed I end up with hamstring, knee, calf, issues. I find that yoga really helps and I try to find time every day for a pigeon pose.

    1. OOJ

      An excellent stretch; one of a few that I recommend to runners as "routine"! No matter how well you run, your hips — given many miles of running — will get stiff.

  7. Joshua

    Great article! I find that stretching post run along with getting a Rolfing session about once a month keeps me flexible, in good alignment and injury free.

  8. tam

    Thanks for the article–super informative!

    I've been experiencing a sore piriformis muscle, which eventually aggravated my sciatic nerve. After many weeks of cross training and rolling on a tennis ball, the piriformis feels normal. I've returned to an almost normal amount of running, but the sciatic nerve is still mildly irritated (I feel it behind my left knee.). It feels better and better as I run; however, my left foot turns inward a bit. I don't think I'm limping, but my stride feels different because of the turned in foot. Do you think continuing to run is wise?

    1. Bartman

      tam,

      Not trying to scare you but you sound like the run-up to my problem a little over a year ago. After suffering through a month of sleeping two hours a night because of the pain, my doctor prescribed an MRI. We then discovered a ruptured disk in the lower lumbar. No surgury but an excellent PT worked me through a series of strengthening exercises for several weeks. Its all about pain management. The disk is still screwed up but we took care of other problems in the hip where the sciatic passes that relieved the pain. I do the exercises everyday and I will for the rest of my life. I am back to full activity taking an AG first at 10k trail championshipcs in August and ran my first trail ultra last fall. In the midst of the pain and suffering of an injury sometimes you just have to believe; sometimes that's all you got.

    2. OOJ

      Tam-

      There are many structures that could cause your symptoms in your low back, pelvis and into the leg (e.g. sore piriformis, sciatic-like pain, etc): lumbar joints and discs, the sacroiliac joint and all in-between.

      As Bartman says, consult your MD to rule anything nasty; then get your stride observed: Are you striding as long and firmly on the involved leg?

      Rotations through the legs tend to signal that the body isn't happy – either trying to unload or stabilize something. Have your MD check you over first, then find a good running PT to give your stride a once-over.

  9. Melissa

    I currently have an injury to my left inner Achilles region. I'm seeing a chiropractor/sports medicine guy who confirmed it has to do with how I land (I overpronate). The last two weeks of my half marathon training, I've had to sit and rest. The race is next Saturday and I'm still unsure as to if I'll be able to run it. I'll be interested in reading Part 2 of this post!

  10. OOJ

    Sniffer-

    Research on shoe type and running outcomes (performance, health) is as widely varied as the models, themselves.

    Here's what we (seem to) know so far:

    1. A lower foot drop seems to be more natural than traditional/higher foot drops

    2. Neither foot drop or cushioning seems to make a consistent difference in gait mechanics across the board.

    That said: "Whatever you need". I will commonly have my runners to *tiny* amounts of barefoot running, simply to learn not to heel strike. What is known about lower foot drop shoes is they demonstrate less heel-striking tendency…

  11. Tessa

    Joe,

    I'm curious as to what ever happened to your friend–did her injury resolve itself? What proved to be the most successful treatment? I was almost jumping up and down when I read it, because this is my exact scenario (although it occurred after a half marathon–still working toward my first ultra). Half was on June 23. Since then, I have seen a sports chiro who tried heat therapy/massage/ultrasound therapy, and a sports orthopaedist/knee specialist, who basically tried to dismiss me from his office as quickly as possible after my x-rays came out perfectly normal.

    I have quit the heat therapy and have been stretching, as well as icing about 3 times per day. I've not run more than 6 miles a week or 2 per session and have been swimming in the interim. The pain is on the right knee, on the inner side of the leg just above the joint, right where all the tendons, etc. meet up (or so I've been told). It's vastly improved, but it's kind of plateaued now, and I still experience mild to the beginning of severe pain depending on the type/duration of activity. I would best describe it as inflammation (but zero swelling) with delayed onset after activity. I'm really interested if your friend's eventual healing would have any applicability to my injury. I'm also desperate to find a good doctor, who won't dismiss me just because I'm an amateur. I still have a big goal of running my first ultra in 2014! (and my significant other is also ready to kill me given my irritability that my training is derailed!)

  12. Max-Evan aguayo

    I have suffered from a limp while running for over 10 years, my legs do 2 different things,I am 31 now I last did a marathon at 20 I really didn’t rest or but struck much I run at times, with a limp, only because I miss it so much, for a time I limited while I walked too but I’ve corrected that, do you know didn’t hood pts in the NYC area,I live in jersey city, thank you

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