Whack-A-Mole and Sinking Ship: Compensatory and Repetitive Injuries

Physiotherapist Joe Uhan writes about compensatory and repetitive running injuries.

By on January 12, 2021 | Comments

Stay the CourseRegarding chronic running injury, a local coach and friend recently asked, “If a runner incurs a minor injury that results in a cascade of compensatory, repetitive new injuries, should that athlete discontinue training until all injuries–including minor aches and pains–have resolved?”

It’s a common question. Or is it? On one hand, a pained runner wrestling with the run-or-rest question is as central to the running experience as what to wear and which direction to turn on that run. But what about a cascade of compensatory, repetitive pain? Those two words are potent qualifiers. Let’s define them:

Compensatory – Aches, pains, or injuries directly or indirectly caused by a previous injury or dysfunction, such as a muscle, joint, or system that does not function efficiently.

Repetitive – Aches, pains, or injuries that recur as carbon copies, or variations of similar pain despite repeated and thorough treatment efforts.

A compensatory and repetitive running injury represents a higher level of complexity and challenge. How different is the treatment approach? And what are the implications for runners and the coaches and medical professionals charged with helping them?

The Whack-A-Mole and Sinking Ship: Two Complex Injury Syndromes

Reflecting on my professional (and, at times, personal) experience with compensatory and repetitive injuries, such cases have quickly distilled into two different injury syndromes, what I call the whack-a-mole and the sinking ship.

The Whack-A-Mole

A runner with whack-a-mole syndrome experiences a cascade of repetitive and compensatory injuries that often arise from a central stride inefficiency or imbalance. For instance, a runner may have a stiff, weak, or otherwise inefficient right hip. Their right hip extension range of motion and strength is less than the left.

This group is aptly named because central stride imbalances often cause recurring aches, pains, and overuse injuries to pop up. And, such pains are resistant to standard treatment attempts, including RICE (rest, ice, compression, and heat), anti-inflammatory medication, and general stretching and strengthening techniques. Such techniques often do whack down the pain, but too often they recur with any attempts to resume normal training. Often, the whack-a-moles must resort to toughing out and tamping down these repetitive injuries, or else surrender with a near-total cessation of running.

The Sinking Ship

The sinking ship syndrome’s repetitive pain represents next-level complexity. It is often more frustrating than the whack-a-moles because the aches, pains, and injuries tend to be less variable, but highly repetitive and far more stubborn to treat.

The severity of tissue injury is often more serious, too. While whack-a-mole pain mostly stems from dysfunctional tissue irritation, the sinking ship’s pain is often true injury, including the presence of inflammation and actual tissue damage.

Moreover, among the sinking ships, tissue damage often takes 50 to 200% longer than standard (scientific literature-based) healing times.

Worst of all, subsequent injuries tend to occur with less training load and less provocation. In the most severe cases, unless running is done with utmost efficiency and with extremely conservative loads, flare-ups–even serious injury such as soft-tissue tears and bone fractures–can be imminent. This is what defines the sinking ship: injuries abound while training load, performance, and overall physical integrity sink lower and lower.

Comparison of Whack-A-Mole and Sinking Ship Syndrome Characteristics

Here’s a comparison of whack-a-mole and sinking ship syndrome characteristics:

Factor Whack-A-Mole Sinking Ship
Excessive Training Load Yes Maybe (Often No)
Type of Injury Dysfunctional* Inflammatory*
Tissue Damage Less Frequent More Frequent
Injury Variability Moderate to High Low to Moderate
Non-Running Life Stress Moderate High to Severe
Nutritional Deficits Less Common More Common
Sleep Deficits Less Common Very Common
Non-Orthopedic Health Effects Less Common Very Common
Root Cause Mechanical Imbalance Physiological Overload

*To learn about these injuries, check out the article “Dysfunction or Injury?: The Key to Injury Prevention.”

Compensatory and Repetitive Pain Treatment Strategies

To reiterate, both the whack-a-mole and sinking ship syndromes require a level of care beyond the simple modulation of training load and application of rehabilitative (strength and mobility) exercise.

Whack-A-Mole Treatment Strategy

Imbalances derived from strength and mobility deficits are often blamed for running injuries. It seems straightforward: running-injury research typically finds an association between weakness, stiffness, and injury. As such, sports-medicine researchers and treatment professionals are quick to blame runners’ personal shortcomings for causing injury. So much so that many runners have developed a strong inferiority complex: “Aches and pains? Injury? I must be weak! I need to stretch more!”

While that may be true, there is often more to an injury than essential strength and mobility deficits. And this is certainly true with the whack-a-moles.

Central to the plight of the whack-a-mole is stride inefficiency. While strength and mobility deficits may set off a stride imbalance, it is often the brain that perpetuates inefficient and pain-generating movement patterns. Thus, any successful treatment approach that exterminates whack-a-moles must center around restoring holistic stride efficiency.

Once the roots of the inefficiency are identified, specific, targeted interventions can be assigned and executed. These, plus focused gait-retraining strategies can successfully knock out those whack-a-moles once and for all.

Sinking Ship Treatment Strategy

The causes of sinking ship injuries often reach beyond orthopedic. While mobility, strength, and efficiency may, indeed, be deficient, addressing those deficits often has little restorative effect. Instead, sinking ship injuries stem from deeper, more systemic causes. Those causes are a two-sided coin of deficient resources–namely sleep and nutrition–and excessive stress–material and psychological life stresses.

Diminutive volumes of food and sleep and a fast-paced lifestyle outside of running may at first be tolerated by the new (and usually young) runner. In fact, early on, a runner may thrive under such austere conditions. As such, they develop either implicitly or explicitly a causal relationship between his/her cutting corners on calories and shut-eye, and successes in and out of their running shoes.

But then the sinking ship springs its first leak. This first leak often appears as a minor injury, an initial hole that can be easily plugged. Then comes another, and another. Standard orthopedic approaches and medical care that were effective early on become less useful. Training volume decreases are inevitable; yet, even with drastic decreases, the repetitive and compensatory ails may continue to add up.

The physiological roots of the sinking ship syndrome are based on a disorder of two biological processes: anabolism, or rebuilding, and catabolism, or destruction. Both processes are a part of healthy biological function that continuously occur in our bodies at a cellular level: tearing down inferior structures and replacing them with newer, stronger, and better-functioning ones.

Indeed, the ability to run faster and farther stems from load application, finite tissue micro-damage, and restoration and growth to withstand the initial stressor, and then some. But if the body is deficient in essential resources to rebuild, catabolism outstrips anabolism. Load application results in tissue damage that is inadequately prepared. Or, the body will tear down tissue in another part of the body in order to repair the stressed area: a de facto soft tissue line of credit. When such debts go unpaid, they compound internally.

While deficiencies in nutrition and sleep represent a dearth of anabolic supplies, excessive stress increases catabolic strain. Chronic non-running stress related to work, family, finances, or relationships may significantly increase pro-inflammatory hormones and chemicals unrelated to tissue injury, and exacerbate healing or even create abnormal and unrelated tissue brea. Relentless cortisol flowing throughout our system indeed compromises soft tissue throughout the body.

Sinking ship syndrome often progresses slowly at first. But over time and left unchecked, it gets scary. The most modest training efforts may result in serious fractures, joint injuries, or even serious infections or systemic illness. Worst of all, this ailing runner’s medical team is often slow to connect these myriad medical issues to an underlying stress-rest deficit.

And while Relative Energy Deficiency in Sport (RED-S) is gaining the attention it deserves, many still believe falsely that it only affects women and focuses merely on nutrition deficits and training errors as causal factors. In reality, successful treatment of the sinking ship must be multi-dimensional. At first, the training load must significantly decrease. But far more importantly, life stresses must be mitigated and physiological resources in the form of enhanced nutrition and sleep must be top priorities.

In the long term, successful recovery must endeavor to achieve true balance in aggregate life (both running and non-running) stresses, but more systematically and pervasively increase the available resources to achieve essential homeostatic balance, let alone training capacity.

Comparison of Whack-A-Mole and Sinking Ship Treatment Strategies

Here’s a comparison of treatment strategies for the whack-a-mole and sinking ship syndromes:

Treatment Strategy Whack-A-Mole Sinking Ship
Training Load Mild to Moderate ¯ Moderate to Severely¯
Mechanical Assessment Very Important Less Important
Mobility Important Less Important
Strength and Stability Important Less Important
Efficiency Very Important Less Important
Nutrition Focus Moderately Important Very Important
Sleep (and General Rest) Moderately Important Very Important
Life Stress Mitigation Less to Moderate Important Very Important

The Next Steps

If you think you might be whacking moles or riding on a sinking ship, what are your options? My first advice is to take pause. Cut back on your run training, including your fast running and racing. Next, if possible, find a skilled, hands-on medical practitioner to:

  • Evaluate your whole body – Perform a complete assessment of your orthopedic system, not just the painful areas;
  • Closely observe and analyze your running stride – Ideally, this person already knows your stride and can see deviations from your normal;
  • Evaluate your whole person – Take into account all aspects of your health, including sleep, nutrition, and other non-running symptoms and signs; and
  • Take the time – A holistic approach takes more than a few rushed minutes. They should also help you develop a plan of action to restore any deficits in and outside of running.

After that, consider looking inward. How might your thoughts and actions be possibly conspiring to keep you in pain? What are your answers to these two questions and how might they be pulling you into impaired health?

Lastly, if you and your medical team recognize a significant life stress management deficit, it may be time to consider adding a psychologist to the team. Psychological professions–especially those with a sports background–can be immensely helpful in helping to restore stress balance and increase coping resources. As both a physiotherapist and coach, I routinely refer athletes to a psychologist, and it is often the missing link for restoring optimal health and running.


The whack-a-mole and sinking ship syndromes represent a stubborn but common cohort of ailing runners. Helping those runners get and stay better requires a holistic approach as well as a unified effort between the athlete, coach, and medical team to develop a multi-dimensional strategy to address the root causes.

The good news is that doing so should not only result in sustainable recovery from stubborn aches, pains, and injuries, but it should also significantly improve running and non-running quality of life! Being the best possible runner requires us to be the best possible people. A balanced approach to running and life is the best possible path for both.

Call for Comments

  • Do you think you’ve had a compensatory and repetitive running injury? What was your situation?
  • And do you think you fell into either the whack-a-mole or sinking ship syndrome categories?
Joe Uhan

Joe Uhan is a physical therapist, coach, and ultrarunner in Auburn, California. 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.