Overview of Running Injuries of The Lower Extremity

6/19/22, 11:55 PM 16321
Official reprint from UpToDate®
www.uptodate.com
© 2022 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Overview of running injuries of the lower extremity

Author: Lisa R Callahan, MD
Section Editor: Karl B Fields, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2022. | This topic last updated: Apr 14, 2021.
INTRODUCTION
Running is one of the world's most popular forms of exercise with millions of regular
participants. In the United States alone, up to 40 million people run regularly, with more than
10 million running at least 100 days a year [1]. Although running is an effective way to achieve
many health benefits, it is associated with a high risk of injury; yearly, up to half of runners
report an injury [2]. Although some injuries are traumatic, most are due to overuse.
Given the popularity of running and the high rate of associated overuse injuries amenable to
nonsurgical management, the primary care physician is likely to manage many injured runners
and should be familiar with the diagnosis and treatment of common problems. The risk factors,
diagnosis, management, and prevention of common lower extremity injuries associated with
running are reviewed here. Detailed discussions of some specific injuries are found separately,
including those listed here. (See "Ankle sprain in adults: Evaluation and diagnosis" and
"Patellofemoral pain" and "Iliotibial band syndrome" and "Hamstring muscle and tendon
injuries" and "Stress fractures of the metatarsal shaft" and "Stress fractures of the tarsal (foot)
navicular" and "Plantar fasciitis".)
GENERAL EPIDEMIOLOGY
The incidence of lower extremity injuries in runners ranges from 19.4 to 79.3 percent [3]. The
knee is the most commonly injured body part. The most common diagnoses include:
patellofemoral pain, medial tibial stress syndrome (shin splints), Achilles tendinopathy, iliotibial
band syndrome, plantar fasciitis, and stress fractures of the metatarsals and tibia [3-6].
https://www.uptodate.com/contents/16321/print 1/47
6/19/22, 11:55 PM 16321
According to a 2009 survey of more than 11,000 year-round runners, more than 10 percent
experienced hip and/or low back pain in the previous 12 months [7]. Among marathon runners,
men report more hamstring and calf problems, whereas women report more hip complaints
[8]. Running is a common cause of injury among military personnel [9].
One retrospective survey of 2886 runners reported an overall injury rate of 46 percent, but
found a higher incidence of soft tissue injuries to the calf, Achilles tendon, and hamstring
among masters runners (>40 years), who comprised 34 percent of the participants [10]. Injured
runners were more likely to be male and to run six days per week and more than 30 miles each
week.
A prospective cohort study of 300 runners followed for two years showed that 73 percent of
women and 62 percent of men sustained an injury, with 56 percent of the injured runners
sustaining more than one injury during the study period [11].
RISK FACTORS
Despite the popularity of running and the prevalence of related injuries, few studies have
successfully identified the individual factors most responsible, suggesting that many running
injuries are multifactorial. A history of prior injury is one of the few variables that has
consistently been shown to increase the risk of incurring a subsequent running injury [2,4,12].
Therefore, every injured runner seeking medical attention should be questioned about prior
injuries, including treatments. Incomplete rehabilitation and failure to address potential risk
factors associated with a prior injury increases the likelihood of recurrence. Greater mileage is
another factor that is consistently associated with increased injury risk [13]. Obesity is
associated with an increased risk [14,15].
Multiple risk factors are likely to contribute to running injuries. These can be stratified into
intrinsic risk factors (eg, anatomic and other individual variables, including gender and BMI)
and extrinsic risk factors (eg, training variables and equipment).
Intrinsic risk factors
Anatomy — Running injuries have been attributed to a number of anatomic variables, but the
literature does not support many of these commonly held beliefs. A prime example is
patellofemoral pain, a common cause of knee pain in runners. Lower extremity alignment that
results in a greater Q angle at the knee (common in women) has often been cited as a cause of
patellofemoral pain, but the large majority of studies refute this assertion.
6/19/22, 11:55 PM 16321
Foot type is another purported risk factor, but most studies of runners have not found
consistent relationships between foot structure and specific injuries. One group studying
collegiate cross country runners failed to identify any association between structural variations
and the likelihood of developing exercise-related leg pain [16,17]. One notable exception is
cavus foot (high arch), which is associated with myriad injuries [2,18]. Specific injuries
implicated in one or more studies include tibial stress fractures, patellofemoral pain, plantar
fasciitis, and Achilles tendinopathy. (See "Stress fractures of the tibia and fibula" and
"Patellofemoral pain" and "Plantar fasciitis" and "Achilles tendinopathy and tendon rupture".)
Some researchers have proposed that limb asymmetry (ie, leg length discrepancy) may increase
injury risk, including stress fracture, [19,20], but not all studies support this conclusion. These
conflicting results suggest that anatomy alone is not sufficient to explain the high risk of injury
among runners. Many experienced sports medicine clinicians believe that the important issue is
whether the difference in leg length affects gait, rather than whether some measurement
threshold is reached.
Gender and age — Gender and age may play a role in some running injuries, but the
literature is conflicting in this regard:
● A prospective study of 844 male and female runners following a training program in
preparation for a 10 km race reported an increased risk of injury among women age 50 or
older and a lower risk among those 30 or younger [21].
● A prospective study of 532 novice runners participating in a 13-week training program

noted that higher BMI was a risk factor for male but not female runners (hazard ratio [HR]
1.15; 95% CI, 1.05-1.26) [22]. Conversely, navicular drop was associated with injury in
females but not males (HR 0.85; 95% CI, 0.75-0.97).
● A longitudinal study of former high school cross country runners over a 15 year period
reported that girls had significantly higher injury rates than boys (16.7 versus 10.9 injuries
per 1000 athletic exposures) [23].
Studies consistently report an association between female gender and stress fracture risk,
particularly among females with lower bone density, menstrual disturbances, and dietary
deficiencies, as seen in the female athlete triad. The risk factors for stress fracture are discussed
separately. (See "Overview of stress fractures", section on 'Risk factors'.)
While not consistently identified as a risk factor for running injury, age has been associated with
a number of injuries in several observational studies. In contrast to the prospective study
described above [21], a retrospective study of more than 2000 runners found that age under 34
6/19/22, 11:55 PM 16321
was associated with an increased risk for patellofemoral pain in both men and women and an
increased risk for iliotibial band syndrome, patellar tendinopathy, and tibial stress syndrome
among men [5]. These findings may reflect that master runners (>40 years) are primarily those
with low injury rates, while runners who sustain multiple injuries are more likely to give up the
sport.
It is not known whether weight, regardless of gender, is an independent risk factor for injury.
One prospective cohort study of 300 runners followed for two years found that knee stiffness,
associated with weight greater than 80 kg, was associated with higher risk of injury [11].
Extrinsic risk factors — Studies have not consistently supported many traditional beliefs about
the association between anatomic variations and injury risk [24]. This has led many researchers
to focus both on the effects of extrinsic factors on running injury and on the combination of
intrinsic and extrinsic variables.
Training variables — Measures to reduce running injuries often include modifying training

variables, such as mileage and intensity. A systematic review concluded that reducing the
distance, frequency, and duration of running may be effective in preventing soft tissue injuries
in runners [25].
In male runners, excessive mileage is associated with higher injury rates. Multiple observational
studies report that training volumes of 65 km (40 miles) or more per week increase the risk of
injury [2,3,10,13]. While most sports medicine practitioners believe excessive mileage also
affects female runners, well designed clinical studies have not been performed. It is unclear if
more experienced runners are less susceptible.
Abrupt changes in training regimens can contribute to running injuries. Studies of military
recruits report that sudden increases in training volume or changes in the type of training (eg,
adding hill running) increase injury rates [26]. Although many sports medicine physicians
advocate the 10 percent rule (ie, increase training volume by no more than 10 percent per
week), a randomized trial of this approach in 532 novice runners reported no reduction in
injuries (20.8 versus 20.3 percent with standard training) [27]. Nevertheless, common sense
would suggest that gradual increases in training volume are less likely to cause injury than
sudden increases.
Some types of training may be protective. As an example, one research group found that
regular interval training is protective against knee injury [28]. Running surface probably affects
injury rates. Running on concrete is associated with increased risk, while running on a treadmill
reduces the stresses placed on the tibia and may thereby reduce the risk of tibial stress
fractures [29].
6/19/22, 11:55 PM 16321
A prospective study of 264 recreational runners showed an association between being active in
sports other than running and a reduced incidence of running-related injuries, supporting the
commonly held belief that cross-training is an effective technique for reducing sports injury risk
[30].
Stretching and warm-ups — It is hard to draw firm conclusions about the effectiveness of
stretching for reducing the risk of running injuries due to the large number of variables
involved. These variables include a runner's baseline flexibility, the timing of stretching (pre-
exercise, post-exercise, or not in conjunction with exercise), and the method of stretching (eg,
dynamic, static, or proprioceptive neuromuscular facilitation). Despite a dearth of convincing
evidence, many sports medicine physicians, running coaches, and runners believe that
stretching is beneficial. However, further research is needed to determine which runners
benefit and what methods to use.
Multiple studies question the benefit of stretching, long a piece of injury prevention advice
given to runners [31,32]. A systematic review of randomized trials that assessed multiple
interventions designed to prevent running injuries included six studies involving 5130 runners
that looked at stretching exercises and concluded that stretching regimens do not protect
against soft tissue injury [32]. The stretching regimens included in these studies varied in the
muscle groups targeted, the timing of the intervention (eg, before or after training), whether a
warm-up was also performed, and other factors. Another review that included both randomized
trials and cohort studies investigating the effect of stretching on injury reduction during sports
also concluded that stretching was not associated with a reduction in total injuries (OR 0.93; CI
0.78-1.11) [31].
Stretching may have other benefits. As an example, in a study of 900 military recruits, those
who stretched regularly experienced lower rates of low back and soft tissue pain [33].
Stretching may also play a useful role in the management of other injuries, such as plantar
fasciitis and Achilles tendinopathy. (See "Plantar fasciitis" and "Achilles tendinopathy and
tendon rupture".)
There is insufficient high-quality research in runners to determine whether warming up reduces

injury rates. One randomized trial involving 421 runners found that an educational intervention
regarding warm-up, cool-down, and stretching did not significantly reduce the risk of injury
[34]. Nevertheless, many clinicians advocate a dynamic warm-up or light jogging before
engaging in strenuous running and we concur with this approach.
Running shoes
6/19/22, 11:55 PM 16321
Running shoe design — Debate continues about the role running shoes and orthotics
may play in reducing the risk of injury. Based on limited evidence and clinical experience, we
suggest using the running shoe that feels most comfortable, fits properly, and is well suited to
the shape of the runner's foot [24,35,36].
There are three basic types of running shoes:
● Shoes for runners with a low foot arch (over-pronators) that are designed to minimize foot
motion and maintain the foot in a neutral position
● Shoes for runners with a neutral foot shape
● Shoes with extensive cushioning for runners with a cavus foot (over-supinators)
Many clinicians and runners believe that selecting the shoe best suited to the runner's foot type
prevents injury; however, this concept is not well supported by the literature and further study
is needed. Studies of recruits in the United States Marine Corps and Air Force undergoing basic
training found that assigning shoes to recruits based on foot type did not significantly reduce
injury rates [37,38]. In addition, a systematic review found insufficient evidence to support the
prescription of running shoes based upon foot type [39].
Softer soles in running shoes may reduce the risk of injury, at least in some runners. In a
randomized trial of 848 healthy runners, those given shoes with harder soles had a higher rate
of injury (subhazard rate ratio [SHR] 1.52; 95% CI 1.07-2.16) [40]. The risk was greatest in lighter
runners (males <78 kg; females <63 kg). In this trial, injury was defined as any complaint that
interrupted running for at least seven days. Nevertheless, the evidence around running shoe
cushioning is inconsistent, as the results of an earlier randomized trial suggest that the level of
cushioning may not affect injury rates [14]. In this trial, 247 recreational runners were randomly
assigned to wear running shoes that differed only in midsole hardness for five months and to
report their running volume and all running-related injuries. No significant difference was
noted in injury rates between the two groups.
However, it remains possible that particular shoe types reduce the risk of injury in particular
subpopulations of runners (eg, runners with cavus feet or pronated feet). One crossover
randomized trial found that some popular, neutral-cushioned running shoes reduced plantar
pressures in the cavus foot, theoretically reducing injury risk [41]. A prospective observational
study of 372 recreational runners reported a reduction in injury rates among runners with foot
pronation who were given motion control shoes; no comparable reduction was seen among
runners with neutral or supinated feet [42]. Thus, control of pronation may reduce injury in this
subpopulation of runners, but further study is needed.
6/19/22, 11:55 PM 16321
Regardless of shoe type, several studies of the shock absorption properties of running shoes
have shown that new shoes lose up to half their cushioning after 250 to 500 running miles [43].
Therefore, many sports medicine practitioners counsel runners to change their running shoes
every 350 to 500 miles. The results of a prospective observational study involving 264
runners suggest that alternating between two pairs of running shoes may reduce the risk of
lower extremity injury compared with using aa single pair [30].
Orthotics — Orthotics appear to reduce the risk of some running-related lower extremity

injuries [44-46]:
● In a randomized trial of 400 military officer trainees, those provided with customized
orthoses sustained 21 lower extremity injuries compared with 61 injuries sustained by
trainees who did not receive customized orthoses during seven weeks of basic training
[44].
● In a randomized trial of 306 military recruits, those provided with contoured, prefabricated
orthoses sustained 27 injuries compared with 40 sustained by recruits who trained in flat
insoles [46]. Injuries included medial tibial stress syndrome, patellofemoral pain, Achilles
tendinopathy, and plantar fasciitis.
Other reports have found that orthotics reduce the pain associated with patellofemoral pain
and cavus foot, both common issues in runners [45,47-49]. Studies performed primarily in
military recruits have found that orthotics reduce the risk of lower extremity stress fractures.
(See "Patellofemoral pain" and "Overview of stress fractures".)
The role of orthotics in reducing the risk of stress fractures is reviewed separately. (See
"Overview of stress fractures", section on 'Prevention'.)
Shoe drop — An important design feature of running shoes is the "drop" of the shoe,
which is the change in height from heel to forefoot. Depending upon a person’s running gait
mechanics and training volume, different drops may predispose or conversely help to prevent
injury, according to some researchers. In one trial, 553 recreational runners were randomly
assigned to use identical running shoes that differed only in drop (0, 6, or 10 mm) and followed
for six months [50]. Although the overall injury rate did not differ by group, regular runners
using low drop shoes (0 or 6 mm) sustained injuries at a significantly higher rate than regular
runners using high drop shoes (HR, 1.67; 95% CI, 1.07-2.62). This finding is consistent with our
clinical experience, and suggests that many recreational runners benefit from the reduced
impact associated with a larger drop, although additional study is needed to confirm this
finding.
6/19/22, 11:55 PM 16321
Overall, we suggest caution when runners, particularly those who run regularly (eg, several
times per week), are considering a change in running shoe design. If a particular shoe design
fits well and there is no history of injury, it seems prudent to continue with a shoe of similar
design.
Running barefoot or with minimalist shoes — Although running barefoot or with

"minimalist" shoes (eg, Vibram FiveFingers) is gaining popularity, few controlled studies of these
approaches to running have been performed, and it remains unclear whether such shoes have
negative or positive effects upon performance or injury rates [51,52]. A review by a noted
authority concludes that little is known about barefoot running, and there is much work to be
done to determine whether a barefoot style can be used to treat or prevent injury [53]. The
potential benefits of barefoot running or the use of minimalist shoes may be due to the
changes in gait that are required when using such an approach. These include a shorter stride
length and a midfoot or forefoot strike, which is thought to reduce impact compared with the
rearfoot strike used by many runners wearing traditional, cushioned running shoes.
Given the limited studies available, the indications and guidelines for transitioning to a barefoot
style or minimalist running shoes are largely anecdotal [54,55]. One of the few randomized
trials of minimalist running shoes found that greater body mass and higher mileage appear to
increase the risk of injury [56]. In this trial, 61 trained runners with a rearfoot strike were
randomly assigned to minimalist or standard running shoes, and then gradually increased the
time spent running in the designated shoes over 26 weeks. Of the 27 injuries sustained, 16
occurred in runners using minimalist shoes and 11 in runners using conventional running
shoes. Injury risk was increased among runners with increased body mass using minimalist
shoes (HR 2.00; 95% CI 1.10-3.66 for runners with a body mass of 85.7 kg).
Based on available evidence and our clinical experience, we suggest that those making the
transition to barefoot running or running in minimalist shoes do so gradually, starting with
relatively low mileage, and increasing their weekly training by no more than 1.7 km (1 mile) per
week. In addition, available evidence supports running no more than 35 km (22 miles) total per
week in minimalist shoes or barefoot, as additional mileage may increase the risk of injury.
Furthermore, we suggest that runners over 85 kg (187 lbs) not use minimalist shoes, and even
runners over 75 kg (165 lbs) may sustain fewer injuries by using conventional running shoes.
Runners who develop lower extremity pain during or following the transition to minimalist
shoes are likely better off training solely in conventional running shoes.
A few studies, mostly observational and involving small numbers of runners, suggest that some
injuries (eg, stress fractures of the foot) occur more often in those using minimalist shoes,
particularly if the transition to such footwear is not made gradually [57-61]. However, other
6/19/22, 11:55 PM 16321
observational studies report no increase in injuries overall among younger and fitter runners
who use minimalist shoes [62]. (See "Stress fractures of the metatarsal shaft" and "Stress
fractures of the tarsal (foot) navicular".)
Gait, strength, and biomechanics — Many laboratory and observational studies have tried to
determine the role of running biomechanics, vertical load, and plantar pressures in the
development of running injuries. However, it is difficult to draw firm conclusions because many
studies involve small numbers, few prospective clinical trials have been performed, and
multiple factors are likely to contribute to the risk of injury [63-65]. The following studies are
illustrative:
● Multiple studies included in two systematic reviews have tried to assess ground reaction
forces (GRF) and vertical load in runners with and without stress fractures and the results
are mixed. Higher GRF and vertical load may be risk factors for stress fractures but such
associations remain speculative [63,66].
● A study of 46 college students with running-related lower extremity injuries reported that
specific components of gait, including increased pronation associated with increased
pressure under the medial side of the foot, increased the risk of injury [64].
● A study of 45 healthy recreational runners found that subtle increases in step rate reduce
the loads placed on the hip and knee during running, possibly reducing injury risk [67].
Nutrition and supplementation — Little data exists to confirm or refute associations

between nutritional factors and running injuries, with the important exception of stress
fractures in female runners. Multiple studies report that inadequate vitamin D, calcium, and
calorie intake increases the risk of stress fracture in female military recruits and runners. In
addition, a prospective study of 86 female runners found that low fat intake increased the risk
of sustaining a lower extremity injury [68]. (See "Overview of stress fractures", section on 'Risk
factors'.)
While there is little high-quality evidence to support any particular diet to prevent running
injuries, optimal nutrition does enhance performance and recovery; common sense suggests
that runners should eat a balanced diet that includes adequate lean protein and all essential
vitamins and minerals. A position paper on nutrition and performance authored jointly by
Dietitians of Canada, the American College of Sports Medicine, and the American Dietetic
Association makes the following recommendations for athletes [69]:
● Consume adequate calories. Insufficient calories can lead to reduced muscle mass and
bone density, cessation of menses, and delayed recovery, and can increase fatigue and the
6/19/22, 11:55 PM 16321
risk of injury and illness. In general, fewer than 1800 to 2000 kcals/day is inadequate for
an exercising individual, although many female runners restrict calories to this level.
Several tools are available to estimate calorie needs, including the Dietary Reference
Intakes (available here) and the Dietary Guidelines from the United States Department of
Agriculture (available here).
● Consume adequate carbohydrates. Runners need approximately 6 to 10 g/kg body weight

of carbohydrates daily. Carbohydrates are important for maintaining blood glucose during
exercise and replenishing muscle glycogen stores. Unhealthy, processed carbohydrates
should be avoided. (See "Dietary carbohydrates".)
● Consume adequate protein. Endurance athletes need 1.2 to 1.7 g/kg body weight of
protein daily.
● Consume adequate healthy fats. Healthy fats are a source of energy and provide essential
fatty acids and fat-soluble vitamins, and should comprise 20 to 35 percent of total calorie
intake. (See "Dietary fat".)
● Stay hydrated. Water loss of as little as 2 percent body mass can decrease performance
[69]. Runners should drink before, during, and after exercise. An easy rule of thumb is to
weigh yourself before and after running, and drink 16 to 24 ounces (450 to 675 mL) of
fluid for every pound (0.5 kg) lost during exercise. For long or intense exercise (eg,
marathon), it is also important to replace electrolytes. (See "Exercise-associated
hyponatremia".)
The timing of nutrient intake is important [69-71]. A snack high in carbohydrate, moderate in
protein, and low in fat and fiber is generally well-tolerated prior to exercise, whereas a snack
higher in fat and fiber may cause gastrointestinal cramping or other distress. During exercise
that lasts more than one hour, the athlete needs fluids and small amounts of carbohydrate,
such as that found in sports drinks. The runner should be encouraged to replenish glycogen
stores by consuming carbohydrate, 1.0 to 1.5 g/kg of body weight, within 30 minutes of
exercise, and to continue "refueling" every two hours for four to six hours. These goals can be
met with relatively small amounts of food.
Some researchers suggest adding protein to post-training snacks to aid muscle recovery; this is
likely most beneficial to the runner who does not consume adequate carbohydrate following
exercise [72]. Regardless of the specific approach, it is helpful for runners to become familiar
with the concepts of "grams" and to learn how to apply this to their preferred foods.
6/19/22, 11:55 PM 16321
Although an adequate, well-rounded diet provides the majority of vitamins and minerals
needed by athletes, special mention should be made of iron. Iron requirements are greater in
endurance runners than in non-endurance athletes [73]. Iron is lost through sweat, the
gastrointestinal tract, and menstruation. Thus, iron depletion is particularly common among
premenopausal female runners. Any runner complaining of fatigue and decreased
performance, especially females, should have a serum ferritin measured. If low, iron levels can
be increased through diet and supplementation, but dietary replacement appears to be more
effective [70].
Although muscle adapts to regular exercise, some exercise-induced muscle damage occurs,
mediated in part by the production of reactive oxygen species (ROS). As antioxidants reduce
ROS, some athletes take high doses of the antioxidants (eg, vitamins C and E) hoping to
attenuate muscle damage. However, there is little evidence to support this practice, and there is
some evidence that interfering with ROS signals may impair muscle performance [74]. Runners
should be informed of the potential risks associated with taking high doses of antioxidants
[75,76].
Psychology — There is little evidence that psychological factors play an important role in

running injuries. One study of 30 runners found that those with type A personality traits did not
have higher injury rates than others, but did have a higher risk of multiple injuries [77]. General
studies of athletes have found a weak association between injury risk and such psychological
factors as aggressiveness, exhaustion, and stressful life events [78].
Training suggestions to reduce injury risk — Despite the dearth of high-quality evidence to

determine best practice [32], we have found the training tips listed below to be helpful and to
reduce the risk of injury for many runners:
Beginning runners:
● Inexperienced runners often progress best using a combination of running and walking
for a set time and gradually increasing the percentage of time spent running.
● Beginning runners should start with no more than 20 minutes of total training time per
day and increase training time no more than 5 minutes every 14 days.
● Most beginners do best on an every other day training program, which enables gradual
improvement of their aerobic and musculoskeletal fitness.
Mileage and rest guidelines:
6/19/22, 11:55 PM 16321
● With the exception of elite runners, most individuals develop fewer injuries by limiting
their total mileage to 40 miles (65 km) per week. (See 'Training variables' above.)
● Runs longer than 13 miles (20 km) are best done no more frequently than once every 14
days.
● Most individuals do best running no more than four or five days per week, with at least
one rest day and one to two days doing other activities (ie, cross training).
● Runners should limit themselves to two to three marathons per year.
Warm-up:
● Ease into training with a dynamic warm-up or light jog.
● Stretching before runs does not appear to reduce injuries; runners may do better
stretching after their run or improving their strength and flexibility using other
techniques, such as yoga or Pilates. (See 'Stretching and warm-ups' above.)
Training variables:
● Runners who experience frequent injuries are likely to benefit from running on a treadmill
or a soft surface. Older athletes reduce their injury risk by running on soft surfaces. (See
'Training variables' above.)
Training techniques:
● Runners need a solid base of aerobic fitness before adding speed work.
● Speed work is generally less risky if runners begin with the "Fartlek" (speed play) approach
for 20 to 30 percent of their continuous runs for at least one month, before progressing to
interval training (alternating fixed activity and rest periods) or timed repeat speed
distances (eg, 10 sets of 200 m runs). Fartlek training consists of running at a faster pace
at random times of variable duration during an otherwise standard distance run.
● Most runners need to limit the total mileage for interval or repeat distance speed training
to 3 miles (5 km) or less.
● Fast downhill runs increase impact and injury risk and should be avoided.
Footwear:
6/19/22, 11:55 PM 16321
● Athletes should select a running shoe that feels extremely comfortable and is well-suited
to their foot structure (eg, high arch). (See 'Running shoe design' above.)
● Barefoot running, while it may help to improve the biomechanics of some runners,
probably only benefits those with sound running biomechanics at baseline and a foot
structure that does not increase their injury risk, and should be limited to softer surfaces.
Many running clinics are seeing an increase in metatarsal stress fractures in individuals
new to this approach. Barefoot running and running in minimalist shoes is discussed in
greater detail above. (See 'Running barefoot or with minimalist shoes' above.)
Nutrition and recovery:
● Runners should maintain adequate hydration and increase their salt intake if they tend to
sweat heavily.
● Carbohydrate and protein intake soon (within about 30 minutes) after an intense workout
speeds recovery. (See 'Nutrition and supplementation' above.)
Supplemental strength training:
● Many runners have disproportionately strong hamstrings. Cross training with a road or
stationary bicycle or other equipment that develops quadriceps strength, or following a
properly designed, supplemental weightlifting program, helps to balance the hamstring
dominance of runners. (See "Practical guidelines for implementing a strength training
program for adults".)
● Many runners have weak hip flexors and hip abductors. Performing supplemental
strength exercises for these muscles may reduce the risk of injury.
● Exercises to improve ankle and foot strength and mobility may reduce the risk of running-
related injury.
In a randomized trial involving 118 recreational runners, those assigned to an eight-week

training course and subsequent online support involving a progressive series of exercises
to improve mobility and strength primarily in the ankle and intrinsic muscles of the foot
sustained significantly fewer injuries (20 versus 8) over 12 months than those in the
control group, who were given a program of static stretching [79]. Further study is needed
to confirm these findings.
● Achilles tendon flexibility wanes with age. Regular performance of eccentric strength
exercises for the calf complex may help prevent injury. (See "Achilles tendinopathy and
6/19/22, 11:55 PM 16321
tendon rupture", section on 'Rehabilitation using resistance exercise'.)
EVALUATION OF THE INJURED RUNNER
Evaluation of the injured runner begins with a thorough history, which should include inquiries
about:
● Prior injuries and related treatments (including the runner's compliance with treatment)
● Current training patterns, including mileage, frequency, and training methods (eg, hill
running); Inquire about changes in training that preceded the injury
● Shoe and orthotic use, including any recent change in shoes
● Training surface, including any recent change
● Injury details (eg, what provokes and reduces symptoms, duration of symptoms)
● Athletic activities other than running
● Detailed training history, including running and racing experience
● Medical conditions; prior surgeries
● Medication and supplement use
Examination of the injured runner includes assessment not only of the injured area but of all
related structures (ie, the runner's entire "kinetic chain"), noting any imbalances or deficits in
structure (eg, leg length discrepancy), strength, flexibility, or motion. Discrepancies may exist
between legs or between muscle groups of the same leg (eg, quadriceps disproportionately
stronger than hamstrings). One way to organize each element (eg, observation, strength
testing) of the physical examination is to begin with proximal structures (eg, spine and pelvis)
and work distally. Careful observation of the patient's walking and running gaits helps to
confirm that the anatomic problems identified during a stationary examination affect
biomechanical performance. (See "Clinical assessment of walking and running gait".)
Begin your assessment by asking the injured runner to stand in front of you, noting their
posture and lower extremity alignment. Observe the legs from hip-to-foot looking for
symmetry. Note the structure of the knee, especially genu varum (which may be associated with
iliotibial band syndrome or medial meniscal pathology) or valgus (often seen in women with
patellofemoral pain). Note the position of the patella and any apparent muscular asymmetry.
Ask the patient to stand on one foot and then the other, watching for balance, control, and
posture. Does the unsupported hip sag (ie, a positive Trendelenburg test)? A positive
Trendelenburg test suggests weakness of the gluteus medius, a common finding in runners
with hip and knee pain. Make note of foot structure and position. Does the runner have a
6/19/22, 11:55 PM 16321
normal, high, or flat arch? Ask the patient to walk and to squat. Watch for a limp, stiffness of
one limb, and a tendency to shift weight off one limb.
Screen for tenderness and altered mobility of the spine, pelvis (including sacroiliac joints), hips,
knees, ankles, and feet before turning your attention to the area of complaint. Be sure to assess
muscle strength and neurovascular status throughout the lower extremity. Weakness of the hip
musculature (particularly hip abductors) is common among novice runners, frequently
contributing to lower extremity pain, especially patellofemoral pain. (See "Patellofemoral pain".)
The following findings may be noted during the examination:
● Hip flexion, rotation, or abduction weakness is present with many lower extremity injuries,
particularly those affecting the hip or knee.
● Increased lumbar lordosis suggests weak anterior core muscles, a common condition in
runners with hip weakness.
● Vastus medialis atrophy or asymmetry can occur with patellofemoral pain, or in athletes
who have had knee surgery.
● Tenderness along the medial tibial border bilaterally is often present with medial tibial
stress syndrome (MTSS), or "shin splints."
● Loss of normal lumbar lordosis (with or without back pain) is often present with tight
hamstrings.
● Loss of internal rotation of the hip occurs with femoral neck stress fracture.
● Asymmetry of the quadriceps muscles is common in runners with osteoarthritis of the hip.
● Pain and/or a sense of "catching" in the groin with the knee flexed to 90 degrees suggests
a labral tear, but also may be seen with iliopsoas tendinopathy.
● Localized tenderness and a positive hop test suggest a tibial stress fracture.
● Achilles tendon thickening or nodules suggests Achilles tendinopathy.
● Tenderness at the medial insertion of the plantar fascia into the calcaneus suggests
plantar fasciitis.
● Hallux limitus or hallux rigidus and reduced ankle dorsiflexion can develop with plantar
fasciitis or calf muscle injuries.
6/19/22, 11:55 PM 16321
● Splayed toe sign and forefoot widening can occur with metatarsalgia.
● Leg length inequality may be present with stress fractures, and possibly with iliotibial band
syndrome and lower back and pelvic injuries.
Diagnostic imaging, including plain radiographs, ultrasound, magnetic resonance imaging

(MRI), computed tomography (CT), and bone scan may be necessary in some cases to make a
definitive diagnosis. However, the clinician should have a clear differential diagnosis in mind
before ordering such studies.
Once a diagnosis is made and a treatment plan established, the clinician and athlete should
work together to uncover and eliminate potential contributing factors, as many running injuries
appear to be multifactorial. The mainstay of treatment for the vast majority of running injuries
is "relative rest," which means stopping running, or at a minimum significantly reducing
mileage, while the injury heals. Depending upon the injury, most runners can maintain
reasonable conditioning by performing non-impact exercises in a pool or on a bike, or by using
other equipment (eg, rowing machine).
SPECIFIC INJURIES
Hip injuries
Overview and approach — Hip injuries are less common in runners than injuries to the lower
extremity and they can be difficult to diagnose. Nevertheless, during jogging, the hip joint is
subjected to loads up to eight times body weight and both acute and chronic injuries can occur
[80]. In runners, the differential diagnosis of hip pain includes gluteus medius tendinopathy,
piriformis syndrome, stress fracture of the femoral neck, labral tear, and, less often, radicular
pain from the lumbar spine. Better understanding of the functional anatomy of the hip
suggests a correlation between hip muscle weakness and injury to the low back or lower
extremity in athletes, including runners [81-83].
Gluteus medius weakness and tendinopathy and piriformis syndrome — The gluteus

medius originates along the external surface of the ilium and runs distally and laterally to its
attachment on the greater trochanter of the femur ( figure 1). The gluteus medius abducts
the hip and assists with pelvic stability during running. Weakness of the muscle typically causes
pain with hip abduction and rotation. Pain generally increases when the muscle is stretched and
there may be focal tenderness at the muscle's insertion, just medial and superior to the greater
trochanter. Difficulty maintaining a level pelvis while standing on one leg (positive
Trendelenburg sign) may be noted.
6/19/22, 11:55 PM 16321
The piriformis muscle is a small but important external rotator of the hip that crosses the sciatic
nerve and is believed by some to cause sciatica-type pain when it compresses the nerve [84,85].
However, the existence of this so-called "piriformis syndrome" remains controversial and
diagnosis is difficult [86-88]. Piriformis syndrome in the runner may be associated with foot
overpronation, weakness of the gluteal muscles and other hip abductors, and tightness of the
hip adductors.
The mainstay of treatment for both gluteus medius tendinopathy and piriformis syndrome is
physical therapy and correction of biomechanical abnormalities. Orthotics and massage
therapy may be useful; acetaminophen and nonsteroidal antiinflammatory drugs may be used
for analgesia. There are reports of using injections of local anesthetics, glucocorticoids, and
botulinum toxin (Botox) to treat piriformis syndrome [89].
Femoral neck stress fracture — Stress fractures of the femoral neck are an uncommon but
important cause of hip or groin pain in the adult runner because of the relatively high risk of
nonunion. (See 'Stress fractures' below and "Femoral stress fractures in adults".)
Labral tear — The acetabular labrum is a ring of fibrocartilage and dense connective tissue
attached to the bony rim of the acetabulum. It is thought to be largely avascular. Although the
labrum's function is not fully understood, it is thought to provide stability and decrease the
stress placed on the hip joint. Therefore, a significant tear in the labrum can increase stress on
the hip joint, decrease stability, and ultimately lead to damage of the articular cartilage.
Labral tears are reported in sports that require frequent hip rotation, such as soccer and
hockey, and in runners, especially female runners. Runners with a labral tear typically complain
of pain in the anterior hip or groin. They may have mechanical symptoms, including clicking,
locking, catching, or giving way (so-called "snapping hip"). Other hip injuries that may produce
such mechanical symptoms include iliopsoas tendinopathy.
Labral tears are complex and often frustrating to treat. Physical therapy has mixed results.
Arthroscopic surgery is often helpful, but the recovery can be prolonged. Runners diagnosed
with labral tears should be counseled carefully regarding the paucity of evidence for
determining the best treatment and the benefits and risks of each approach.
Iliopsoas tendinopathy — Iliopsoas tendinopathy produces symptoms similar to a labral tear

but presents more often as anterior hip pain in younger athletes, especially after a rapid growth
spurt, and is more easily treated. Athletes who repeatedly engage in forceful flexion of the hip,
including track and field athletes (eg, hurdlers, jumpers), are at greatest risk. Examination
usually reveals tight, painful hip flexors ( figure 2). Iliopsoas tendinopathy typically responds
6/19/22, 11:55 PM 16321
within a few weeks to activity modification, acetaminophen and nonsteroidal antiinflammatory

drugs, and physical therapy.
Knee and thigh injuries
Knee pain (patellofemoral pain) — Knee pain is among the most common complaints from
runners. Most such runners are diagnosed with patellofemoral pain (PFP). Despite the
prevalence of this diagnosis, no consensus exists about its etiology or the factors most
responsible for causing pain. Overuse and malalignment are commonly cited causative factors.
In addition, runners (especially females) with PFP often have decreased strength in hip
abduction, external rotation, and extension compared to healthy controls. Patients with PFP
typically complain of anterior knee pain that worsens with squatting, running, prolonged
sitting, or when ascending or descending steps. Pain is often poorly localized "under" or
"around" the patella. Details about the diagnosis and management of PFP are provided
separately. (See "Patellofemoral pain".)
Iliotibial band syndrome — The iliotibial band (ITB) consists of connective tissue that runs
from the ilium to the anterolateral aspect of the proximal tibia ( figure 3). It is involved in hip
abduction and internal rotation, knee extension and flexion, and helps to stabilize the knee
during running.
The iliotibial band syndrome (ITBS), which occurs primarily in runners, is characterized by an
aching or burning pain at the site where the ITB courses over the lateral femoral condyle;
occasionally the pain radiates up the thigh toward the hip. Runners often complain of such
lateral knee pain while running, but pain may persist after training, especially with activity that
requires repetitive flexion and extension of the knee, such as ascending or descending stairs or
standing from a seated position. The diagnosis of ITBS is clinical; no imaging is typically needed.
A detailed discussion is provided separately. (See "Iliotibial band syndrome".)
Hamstring injuries — Hamstring injuries are typically acute; the injured runner complains of
developing a sudden, sharp pain in the posterior thigh while running at high speed or up hills (
figure 1). Examination findings depend upon the severity of injury and may include a limping
gait (due to the inability to fully extend the knee); ecchymosis; a visible or palpable defect in the
hamstring muscle; focal tenderness; and pain or weakness with muscle contraction. Details
about the diagnosis and management of hamstring muscle injuries are provided separately.
(See "Hamstring muscle and tendon injuries".)
Knee and hip osteoarthritis — Exercise is recommended for most patients with osteoarthritis
(OA) of the hip or knee. Although water-based exercise is often suggested, multiple studies
6/19/22, 11:55 PM 16321
confirm the value of regimens involving full weightbearing exercise. (See "Management of knee
osteoarthritis", section on 'Exercise'.)
Despite this evidence, many clinicians subscribe to the traditional teaching that patients with
osteoarthritis (OA) of the knee or hip should not run because it exacerbates the condition. The
medical literature, however, does not support the contention that running contributes to the
degeneration of articular cartilage [90-92]. A systematic review of 15 studies on the relationship
between running and OA noted that the while available evidence is too limited to reach
definitive conclusions, it suggests no association between the two [92].
Representative studies of the relationship between running and OA include the following:
● A large follow-up study using questionnaires completed by established cohorts of runners

and walkers reported reduced risk among runners for developing OA or requiring hip
replacement surgery compared with those participating in other exercise [91]. Risk
dropped substantially in those who ran ≥12.9 km/week (8 miles/week). The authors
attribute much of the effect to the lower body mass index among runners.
● A prospective cohort study followed 45 runners and 53 controls over 18 years and, using a
validated score to assess for OA, found no difference between the two groups in the
progression or the number of severe cases of knee OA [93].
● Several small prospective and retrospective studies have reported no evidence of

premature damage of articular cartilage or increased risk for OA among long-distance
runners [94-97].
● Small clinical and laboratory studies using MRI to evaluate the knees of long-distance
runners report no significant damage to articular cartilage following a race and no major
differences when images were compared to those of active non-runners [98-100].
Stress fractures — Stress fractures in runners occur most often in the tibia, but can develop in
any bone of the lower extremity, including the metatarsals, navicular, and femoral neck [101].
Detailed discussions of stress fractures, including a description of those at high risk for
nonunion, appear separately; a brief description and information of particular importance for
runners is provided here. (See "Overview of stress fractures" and "Stress fractures of the tibia
and fibula" and "Stress fractures of the metatarsal shaft" and "Femoral stress fractures in
adults" and "Stress fractures of the tarsal (foot) navicular".)
When evaluating the runner with a suspected stress fracture, the clinician should ask for a
description of the pain, running patterns and recent changes in training, shoe and orthotic
6/19/22, 11:55 PM 16321
wear, and prior injuries. Information about the patient's nutrition and menstrual history, and
any family history of metabolic bone disease, are also important.
Typically, the runner with a stress fracture complains of focal pain that is insidious in onset,
increases as a run progresses, and improves with rest. Over time, if the athlete persists in
running despite such symptoms, pain occurs with less strenuous activity and ultimately at rest.
Some runners present with acute onset of severe pain, which may result from a complete
fracture at the site of a preexisting stress fracture.
Important risk factors for developing stress fractures include a history of prior stress fracture,
increasing volume and intensity of training, poor running biomechanics, female gender and
menstrual irregularity, a diet poor in calcium, and poor bone health [12]. The management of
stress fractures in runners is discussed separately. (See "Overview of stress fractures", section
on 'Treatment concepts'.)
The clinician should be aware that stress fractures at high risk for nonunion (eg, femoral neck
and navicular) are more common in runners than in other athletes. If a high-risk stress fracture
is suspected, an aggressive work-up (including advanced imaging if necessary) is warranted and
immediate orthopedic consultation should be obtained if the diagnosis is confirmed. A history
of recurrent stress fracture or a fracture in cancellous bone suggests that the runner's bone
mineral density may be low and should be measured. (See "Screening for osteoporosis in
postmenopausal women and men".)
Femoral neck stress fractures should be suspected in any distance runner with groin pain of
insidious onset, especially female distance runners at risk for the "female athlete triad" (eating
disorder, amenorrhea, and osteoporosis). The female athlete triad is reviewed separately. (See
"Femoral stress fractures in adults" and "Functional hypothalamic amenorrhea:
Pathophysiology and clinical manifestations".)
Navicular stress fractures occur more often in male athletes participating in track and field
events (eg, hurdlers, jumpers, sprinters) and middle distance runners [101]. The athlete with a
navicular stress fracture often presents with insidious pain in the midfoot or arch that increases
with jumping. (See "Stress fractures of the tarsal (foot) navicular".)
Medial tibial stress syndrome (shin splints) and tibial stress fractures — Clinicians
confronted by runners with shin pain must distinguish between stress fractures of the tibia and
medial tibial stress syndrome (MTSS), often referred to as "shin splints." Although the history
may be similar, a focal, palpable area of tenderness is present in most patients with stress
fractures, whereas tenderness is much more diffuse and there are no discrete palpable lesions
in those with MTSS. Imaging may be necessary in some cases to rule out a stress fracture. Plain
6/19/22, 11:55 PM 16321
radiographs are normal in patients with shin splints, but may also be unrevealing early in the
course of a stress fracture. (See "Stress fractures of the tibia and fibula", section on 'Clinical
presentation and examination' and "Stress fractures of the tibia and fibula", section on
'Diagnostic imaging'.)
Distinguishing between the two diagnoses affects treatment: a runner with a stress fracture
should avoid running and pursue non-impact activities like swimming or cycling while the stress
fracture heals, while the runner with MTSS can continue running but should reduce the total
mileage. A systematic review found that shock-absorbing insoles may reduce symptoms and
prevent recurrence of MTSS [102]. Risk factors may include obesity and limited mobility of the
ankle and hip [103].
Chronic exertional compartment syndrome — Chronic exertional compartment syndrome

(CECS) occurs when increased pressure within a muscle compartment reduces blood flow,
leading to muscle ischemia and pain when metabolic demands cannot be met. The patient with
CECS is often a young runner who describes gradually increasing pain in a specific muscle
region (usually the lower leg) during exertion. The pain may be described as aching, squeezing,
cramping, or tightness. Pain generally begins within several minutes of starting a run, often at a
specific point in training. Runners can often describe the time or distance required for
symptoms to develop. Pain resolves completely with rest, although not immediately upon
stopping exercise. The diagnosis and management of CECS is discussed in detail separately.
(See "Chronic exertional compartment syndrome".)
Foot and ankle injuries — Foot and ankle injuries account for up to 20 percent of running
injuries, and are the most common injury reported by distance runners and marathoners [104].
This is not surprising given that the ground reaction forces the foot must absorb with each
stride are several times body weight. The most common foot injuries in runners are overuse
injuries of soft tissues, including tendons and fascia.
Plantar fasciitis — Plantar fasciitis (PF) is the most common cause of rearfoot pain in runners.
The predominant symptom of PF is pain in the plantar region of the foot that increases when
initiating push-off while walking or running. The hallmark for diagnosis is focal point
tenderness. The etiology of PF remains unclear but the condition is often attributed to training
errors, biomechanical problems, and excessive foot pronation or supination, and is more
common in older and heavier runners [104-106]. The biomechanical abnormality most often
associated with PF is decreased dorsiflexion of the foot and toes and thus stretching is an
important part of treatment. Another common biomechanical problem is weakness of the
plantar flexors, which some clinicians believe is best treated with eccentric strengthening
exercises. The diagnosis and management of PF is reviewed separately. (See "Plantar fasciitis".)
6/19/22, 11:55 PM 16321
Tendon injuries — Runners are susceptible to tendon injuries at a number of sites, the

Achilles being most common. Others include the peroneal, posterior tibial, and anterior tibial
tendons ( figure 4).
Achilles tendinopathy occurs in up to 10 percent of elite runners annually [107]; runners with
more than 10 years of experience are at higher risk [108]. Among former elite male distance
runners, the lifetime risk is reported to be as high as 52 percent [109]. The biomechanical
factors that predispose runners to Achilles tendinopathy remain unclear but are the subject of
research [110-112]. Poor flexibility of the Achilles tendon, overpronation, and valgus or varus
deformity of the calcaneus all affect rear-foot mechanics, possibly increasing torque on the
Achilles. Some clinicians advocate using a heel pad or orthotic in runners to counteract this
effect.
Patients with Achilles tendinopathy typically complain of pain or stiffness 2 to 6 cm above the
posterior calcaneus. The pain is frequently described as burning, increases with activity, and is
relieved by rest. Runners with the condition often have recently increased their training
intensity or have been training rigorously for a long time. A history of excessive foot supination,
increased speed work or hill training, or improper (eg, poorly fitting shoes, tennis instead of
running shoes) or worn out footwear may be found. The diagnosis and management of Achilles
tendinopathy is discussed separately. (See "Achilles tendinopathy and tendon rupture".)
Peroneal tendon injury may be traumatic, usually from a lateral ankle sprain, or related to
overuse and associated with excessive foot pronation and weak foot plantar flexors.
Examination reveals tenderness along the course of the tendon posterior or inferior to the
lateral malleolus, which increases with resisted eversion. The diagnosis and management of
non-Achilles tendinopathies are discussed separately. (See "Non-Achilles ankle tendinopathy".)
Posterior tibial tendinopathy is typically an overuse injury that develops following an abrupt
increase in training intensity, and is associated with poor foot and calf flexibility and excessive
foot pronation. Examination findings include tenderness along the course of the posterior tibial
tendon posterior or inferior to the medial malleolus, which increases with resisted inversion.
Anterior tibial tendinopathy is a common cause of anterior ankle pain in runners, and often
develops following abrupt increases in training, particularly hill running. Examination often
reveals tenderness, and possibly swelling, of the tendon as it crosses the ankle joint. Pain
increases with resisted dorsiflexion.
Overuse tendinopathy generally is reviewed in detail separately. (See "Overview of the

management of overuse (persistent) tendinopathy" and "Overview of overuse (persistent)
tendinopathy".)
6/19/22, 11:55 PM 16321
Navicular stress fracture — Stress fractures of the tarsal navicular are more common in
runners. These injuries present in a manner similar to other stress fractures and are associated
with vague medial midfoot pain and focal tenderness, most often along the dorsal aspect of the
navicular. (See 'Stress fractures' above and "Stress fractures of the tarsal (foot) navicular".)
First metatarsal phalangeal joint — Running generates substantial forces across the

forefoot and thus can aggravate hallux rigidus or hallux valgus (bunion) of the metatarsal
phalangeal (MTP) joint of the great toe (ie, first MTP joint). The sesamoid bones located on the
plantar surface of the MTP joint can become inflamed from running and may cause discomfort.
Hallux rigidus and hallux valgus (bunion) — There is little high-quality evidence to

provide insight into the causes and guide the management of hallux rigidus. Hallux rigidus is
presumed to be a degenerative condition of the first MTP joint associated with either an acute
injury (eg, forced hyperextension of the great toe, so-called "turf toe") or repetitive
microtrauma, as would occur with running [113,114]. Genetic predisposition may play a role.
The result is limited dorsiflexion of the first MTP joint; approximately 60 degrees of dorsiflexion
is needed for normal gait. (See "Evaluation and diagnosis of common causes of forefoot pain in
adults", section on 'Hallux rigidus and hallux limitus'.)
Runners with hallux rigidus are typically older than 30 and complain of pain at the dorsum of
the great toe. However, some runners may present with vague lateral forefoot pain. This
presentation is likely due to runners shifting their body weight to the lateral foot during the
foot-strike phase of running to reduce the load on the great toe. It remains unclear whether
running is a cause of hallux rigidus or aggravates symptoms elicited by other factors. Shoes
with a toe box that is too small or pointed may contribute.
Hallux valgus (ie, bunion) deformity is defined as a lateral deviation of the hallux (great toe) on
the first metatarsal. The etiology of hallux valgus is multifactorial and likely involves abnormal
mechanics and anatomy. Patients generally complain of a deformed and painful great toe. (See
"Hallux valgus deformity (bunion) in adults".)
In runners with either of these conditions, mechanically limiting first MTP joint motion by using
appropriate shoes and unloading techniques can be helpful. We suggest walking shoes with a
wide toe box, stiff soles, rocker bottoms, and low heels. Comfortable running shoes with a wide
toe box combined with techniques to reduce the impact on the first MTP joint, such as custom
orthotics or cushioned insoles, reduce symptoms in many runners. Acetaminophen or
nonsteroidal antiinflammatory drugs may be used for short-term pain relief. Ice can be applied
following running. Glucocorticoid injections may provide short-term pain relief for those with
mild hallux rigidus [115]. Consultation with a foot surgeon should be obtained for severe or
6/19/22, 11:55 PM 16321
recalcitrant cases, although there is little high-quality evidence to guide decisions about surgery
or conservative care.
Sesamoiditis — The sesamoids are pea-sized bones that function as pulleys for tendons
(just as the patella does for the knee extensors) and assist with weightbearing. Inflammation or
injury of the sesamoid bones located on the plantar surface of the first MTP joint can cause
focal pain in runners, particularly sprinters ( image 1 and figure 5). The runner with
sesamoiditis typically complains of pain at the area of the MTP joint with weightbearing that is
exacerbated by walking, and even more so by running. Exquisite tenderness of the sesamoids is
present, and is exacerbated by dorsiflexion of the great toe. Imaging is required to differentiate
between sesamoiditis and a stress fracture.
Both sesamoiditis and sesamoid stress fractures are notoriously difficult to treat and may
require a short period of immobilization followed by prolonged rest from running. Runners can
use alternative, nonweightbearing forms of exercise to maintain fitness. Treatment with custom
orthotics, soft pads cut to relieve pressure on the sesamoids, and in severe cases glucocorticoid
injections may be helpful, but there is little evidence to guide treatment. Women runners
should avoid wearing high heels; shoes with a stiff sole (eg, clog) are often helpful. Consultation
with a foot surgeon is reasonable in recalcitrant cases.
Treatment of sesamoiditis does not differ significantly from that for sesamoid fractures. The
evaluation and management of sesamoid fractures is discussed separately. (See "Sesamoid
fractures of the foot".)
Metatarsal stress fracture and metatarsalgia — Pain in a runner's forefoot that is not due
to a metatarsal stress fracture is likely due to metatarsalgia or an interdigital neuroma. (See
'Stress fractures' above.)
Metatarsal stress fractures typically present in a manner similar to other stress fractures and
are associated with vague forefoot pain of insidious onset and focal tenderness over a
particular metatarsal. (See "Stress fractures of the metatarsal shaft".)
Metatarsalgia is a general term for pain that occurs along the ball of the foot. Most runners
with metatarsalgia complain of pain in the forefoot during running; the examiner will find
tenderness along the plantar surface just proximal to the metatarsal heads. The condition is
often associated with overpronation and/or collapse of the transverse arch. A metatarsal pad
placed proximal to the area of tenderness often relieves symptoms; in more severe cases, a
custom orthotic may be needed.
6/19/22, 11:55 PM 16321
Morton neuroma — Interdigital neuromas (often referred to as Morton neuroma) are thought

to be due to swelling and scar tissue formation on the small interdigital nerves. They most
commonly involve the third interdigital space, but may also develop in the second and fourth.
An intermetatarsal bursitis can cause a similar pain.
The runner with a neuroma may complain of numbness of the involved toes or pain that
increases with activity and is usually felt between the third and fourth toes ( figure 6).
Examination may reveal a clicking sensation (Mulders sign) when palpating this interspace
while simultaneously squeezing the metatarsal joints. Overpronation and tight shoes are often
associated with the condition.
Ultrasound offers an inexpensive option for identifying Morton neuroma with accuracy
comparable to magnetic resonance imaging (MRI), and can help to distinguish a neuroma from
intrametatarsal bursal swelling or synovitis in adjacent joints.
Conservative treatment should precede expensive diagnostic procedures. This approach

involves decreasing pressure on the metatarsal heads by using a metatarsal support or bar or
padded shoe insert. Strength exercises for the intrinsic foot muscles are often part of
conservative treatment. Treatment inserts are often placed in both shoes, even when symptoms
are unilateral, to ensure that the patient walks evenly, but bilateral pads are not always needed.
A broad-toed shoe that allows spreading of the metatarsal heads may be helpful. Morton
neuroma is discussed in greater detail separately. (See "Evaluation and diagnosis of common
causes of forefoot pain in adults", section on 'Morton neuroma'.)
Tarsal tunnel syndrome — Tarsal tunnel syndrome (TTS) is an uncommon source of foot pain
in runners due to entrapment of the posterior tibial nerve (PTN) or one of its branches as it
courses behind the medial malleolus ( figure 7). The most common causes include an acute
injury and its sequelae (eg, scar tissue) or repetitive microtrauma, as occurs with running,
particularly in runners who overpronate. Runners with TTS complain of numbness or burning
pain, usually along the plantar surface of the foot, although complaints may be localized to the
medial plantar surface of the heel, mimicking plantar fasciitis. TTS typically worsens with
running or at night. Findings are almost always sensory; muscle weakness is uncommon. A
positive Tinel sign may be present. As in carpal tunnel syndrome, a positive sign occurs when
symptoms are elicited by tapping over the path of the nerve. TTS is discussed in detail
separately. (See "Overview of lower extremity peripheral nerve syndromes", section on 'Tarsal
tunnel syndrome'.)
Toenail injuries — Athletes in many sports sustain toenail injuries from repetitive trauma to
the nail or nail bed. In runners, this condition is commonly called "jogger's toenail", and it most
6/19/22, 11:55 PM 16321
frequently affects the great toe ( picture 1) [116]. The nail may turn black (due to subungual
bleeding) or may fall off, especially after a long distance run such as a marathon. The
differential diagnosis for these injuries includes fungal infection and subungual melanoma. The
management of acute subungual hematoma, fungal infection of the nail (onychomycosis), and
melanoma are reviewed separately. (See "Subungual hematoma" and "Onychomycosis:
Epidemiology, clinical features, and diagnosis".)
In the author's experience, toenail injuries in runners are most often due to poorly fitting shoes.
Thus, injuries can be prevented by using properly fitted running shoes. Such shoes provide
sufficient space in the toe-box and are sized to accommodate the longest toe. The midfoot
portion of the shoe should fit properly and be sufficiently snug to prevent the toes from
slipping forward and striking against the end of the toe box.
Friction blisters — Friction blisters are caused by continual rubbing or pressure on the skin,
and are common among runners. They affect runners of all levels of experience, from novices
to professionals, and all distances, from sprinters to ultramarathon competitors. In a study of
204 amateur runners over the age of 18, blisters were self-reported as one of the three most
frequent injuries (along with sprains and abrasions) [117]. Blisters develop most often on the
toes, ball of the foot, and heel. (See "Friction blisters".)
Runners and clinicians have used various interventions to prevent blisters, with varying results
reported. In our clinical experience, the following interventions are helpful:
● Wear properly fitting running shoes. (See 'Running shoe design' above.)
● Wear properly fitting socks made from materials that reduce friction and wick moisture
from the skin. Make sure the portion of the sock between the shoe and the skin is wrinkle-
free.
● At areas known to be susceptible to blisters ("hot spots") in particular runners, apply a

viscous lubricant or a protective bandage.
For lubricants, the author has found SkinLube and Blisterblock to be useful products. We
have found Vaseline to be less effective. For protective bandages, we have found
Blisterderm and Moleskin to be helpful.
Several randomized trials of paper tape for blister prevention were performed during
RaceThePlanet ultramarathons (250 km/155 mile race) in 2010 to 2011, and again in 2014.
During the first trial, all 136 runner participants developed blisters during the race, and
reported that paper tape was not protective [118]. In a subsequent trial involving 128 race
6/19/22, 11:55 PM 16321
participants, the authors reported that paper tape reduced blisters by 40 percent [119]. In an
observational study of ultra-distance runners, no prophylactic measures, including taping,
application of talcum powder and antiperspirants, and different types of socks, reduced blister
rates [120]. In this study, the only factor associated with a reduction in blisters was prior ultra-
distance race experience [120]. A study from 1990 reported that acrylic fiber socks were
associated with fewer and smaller blisters, but a 1993 follow-up study clarified that acrylic socks
were only superior when they were knitted in such a way as to provide "anatomical padding"
[121,122].
If a friction blister has formed, it should not be unroofed in most cases. However, large, fluid-
filled blisters in problematic locations may be drained in sterile fashion, and covered with a
clean bandage. Runners generally do not need to wait until a blister has completely healed
before resuming running, but it makes sense to perform alternative exercises (eg, cycling,
swimming) that do not aggravate the affected area for a few days while the blister is allowed to
heal. Proper technique for draining a friction blister is described separately. (See "Heel pain in
the active child or skeletally immature adolescent: Overview of causes", section on 'Friction
blister'.)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Plantar fasciitis" and
"Society guideline links: Patellofemoral pain" and "Society guideline links: Muscle and tendon
injury".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
6/19/22, 11:55 PM 16321
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Achilles tendon injury (The Basics)" and "Patient
education: Metatarsalgia (The Basics)" and "Patient education: Patellofemoral pain (The
Basics)" and "Patient education: Iliotibial band syndrome (The Basics)" and "Patient
education: Hamstring injury (The Basics)" and "Patient education: Shin splints (The
Basics)")
SUMMARY AND RECOMMENDATIONS
● Up to half of regular runners report an injury each year. Some injuries are traumatic, but
most are due to overuse and many of these involve the knee. The most common
diagnoses include: patellofemoral pain, medial tibial stress syndrome (ie, "shin splints"),
Achilles tendinopathy, iliotibial band syndrome, plantar fasciitis, and stress fractures of the
metatarsals and tibia. (See 'General epidemiology' above.)
● A number of intrinsic and extrinsic risk factors are associated with running-related lower
extremity injuries. Perhaps the most important and most easily changed are training
variables, such as mileage and intensity. The role of other factors, such as shoes,
stretching, and biomechanics, is less clear. Training suggestions to reduce the risk of injury
are provided in the text. (See 'Risk factors' above and 'Training suggestions to reduce
injury risk' above.)
● A careful history and physical examination are essential for determining the differential
diagnosis and the need for diagnostic imaging. Guidance about how best to evaluate the
injured runner is provided in the text. (See 'Evaluation of the injured runner' above.)
● Descriptions of important and common causes of running-related lower extremity injuries,

organized anatomically, are provided in the text, along with links to more detailed
discussions. (See 'Specific injuries' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
1. Messier SP, Legault C, Schoenlank CR, et al. Risk factors and mechanisms of knee injury in
runners. Med Sci Sports Exerc 2008; 40:1873.
6/19/22, 11:55 PM 16321
2. Fields KB, Sykes JC, Walker KM, Jackson JC. Prevention of running injuries. Curr Sports Med
Rep 2010; 9:176.
3. van Gent RN, Siem D, van Middelkoop M, et al. Incidence and determinants of lower
extremity running injuries in long distance runners: a systematic review. Br J Sports Med
2007; 41:469.
4. Wen DY. Risk factors for overuse injuries in runners. Curr Sports Med Rep 2007; 6:307.
5. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002
running injuries. Br J Sports Med 2002; 36:95.
6. Junior LC, Carvalho AC, Costa LO, Lopes AD. The prevalence of musculoskeletal injuries in
runners: a systematic review. Br J Sports Med 2011; 45:351.
7. USA State of the Sport Report. www.runningusa.org (Accessed on May 01, 2011).
8. Fredericson M, Misra AK. Epidemiology and aetiology of marathon running injuries. Sports
Med 2007; 37:437.
9. Hauret KG, Bedno S, Loringer K, et al. Epidemiology of Exercise- and Sports-Related Injuries
in a Population of Young, Physically Active Adults: A Survey of Military Servicemembers. Am
J Sports Med 2015; 43:2645.
10. McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J
Sport Med 2006; 16:149.
11. Messier SP, Martin DF, Mihalko SL, et al. A 2-Year Prospective Cohort Study of Overuse
Running Injuries: The Runners and Injury Longitudinal Study (TRAILS). Am J Sports Med
2018; 46:2211.
12. Wright AA, Taylor JB, Ford KR, et al. Risk factors associated with lower extremity stress
fractures in runners: a systematic review with meta-analysis. Br J Sports Med 2015; 49:1517.
13. Bovens AM, Janssen GM, Vermeer HG, et al. Occurrence of running injuries in adults
following a supervised training program. Int J Sports Med 1989; 10 Suppl 3:S186.
14. Theisen D, Malisoux L, Genin J, et al. Influence of midsole hardness of standard cushioned
shoes on running-related injury risk. Br J Sports Med 2014; 48:371.
15. Vincent HK, Vincent KR. Considerations for initiating and progressing running programs in
obese individuals. PM R 2013; 5:513.
16. Reinking MF, Hayes AM. Intrinsic factors associated with exercise-related leg pain in
collegiate cross-country runners. Clin J Sport Med 2006; 16:10.
17. Reinking MF, Austin TM, Hayes AM. Exercise-related leg pain in collegiate cross-country
athletes: extrinsic and intrinsic risk factors. J Orthop Sports Phys Ther 2007; 37:670.
6/19/22, 11:55 PM 16321
18. Cowan DN, Jones BH, Robinson JR. Foot morphologic characteristics and risk of exercise-
related injury. Arch Fam Med 1993; 2:773.
19. Brunet ME, Cook SD, Brinker MR, Dickinson JA. A survey of running injuries in 1505
competitive and recreational runners. J Sports Med Phys Fitness 1990; 30:307.
20. Korpelainen R, Orava S, Karpakka J, et al. Risk factors for recurrent stress fractures in
athletes. Am J Sports Med 2001; 29:304.
21. Taunton JE, Ryan MB, Clement DB, et al. A prospective study of running injuries: the
Vancouver Sun Run "In Training" clinics. Br J Sports Med 2003; 37:239.
22. Buist I, Bredeweg SW, Lemmink KA, et al. Predictors of running-related injuries in novice
runners enrolled in a systematic training program: a prospective cohort study. Am J Sports
Med 2010; 38:273.
23. Rauh MJ, Margherita AJ, Rice SG, et al. High school cross country running injuries: a
longitudinal study. Clin J Sport Med 2000; 10:110.
24. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting
and a proposal for two new paradigms: 'preferred movement path' and 'comfort filter'. Br J
Sports Med 2015; 49:1290.
25. Yeung EW, Yeung SS. Interventions for preventing lower limb soft-tissue injuries in runners.
Cochrane Database Syst Rev 2001; :CD001256.
26. Ryan M, MacLean C, Taunton JE. A review of anthropometric, biomechanical,
neuromuscular and training related factors associated with injury in runners. Int J Sports
Med 2006; 7:120.
27. Buist I, Bredeweg SW, van Mechelen W, et al. No effect of a graded training program on the
number of running-related injuries in novice runners: a randomized controlled trial. Am J
Sports Med 2008; 36:33.
28. Van Middelkoop M, Kolkman J, Van Ochten J, et al. Risk factors for lower extremity injuries
among male marathon runners. Scand J Med Sci Sports 2008; 18:691.
29. Milgrom C, Finestone A, Segev S, et al. Are overground or treadmill runners more likely to
sustain tibial stress fracture? Br J Sports Med 2003; 37:160.
30. Malisoux L, Ramesh J, Mann R, et al. Can parallel use of different running shoes decrease
running-related injury risk? Scand J Med Sci Sports 2015; 25:110.
31. Thacker SB, Gilchrist J, Stroup DF, Kimsey CD Jr. The impact of stretching on sports injury
risk: a systematic review of the literature. Med Sci Sports Exerc 2004; 36:371.
32. Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue
running injuries. Cochrane Database Syst Rev 2011; :CD001256.
6/19/22, 11:55 PM 16321
33. Amako M, Oda T, Masuoka K, et al. Effect of static stretching on prevention of injuries for
military recruits. Mil Med 2003; 168:442.
34. van Mechelen W, Hlobil H, Kemper HC, et al. Prevention of running injuries by warm-up,
cool-down, and stretching exercises. Am J Sports Med 1993; 21:711.
35. Reinschmidt C, Nigg BM. Current issues in the design of running and court shoes.
Sportverletz Sportschaden 2000; 14:71.
36. Nigg, Benno. Biomechanics of Sports Shoes, University of Calgary, 2011.
37. Knapik JJ, Trone DW, Swedler DI, et al. Injury reduction effectiveness of assigning running
shoes based on plantar shape in Marine Corps basic training. Am J Sports Med 2010;
38:1759.
38. Knapik JJ, Brosch LC, Venuto M, et al. Effect on injuries of assigning shoes based on foot
shape in air force basic training. Am J Prev Med 2010; 38:S197.
39. Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes evidence-
based? Br J Sports Med 2009; 43:159.
40. Malisoux L, Delattre N, Urhausen A, Theisen D. Shoe Cushioning Influences the Running
Injury Risk According to Body Mass: A Randomized Controlled Trial Involving 848
Recreational Runners. Am J Sports Med 2020; 48:473.
41. Wegener C, Burns J, Penkala S. Effect of neutral-cushioned running shoes on plantar
pressure loading and comfort in athletes with cavus feet: a crossover randomized
controlled trial. Am J Sports Med 2008; 36:2139.
42. Malisoux L, Chambon N, Delattre N, et al. Injury risk in runners using standard or motion
control shoes: a randomised controlled trial with participant and assessor blinding. Br J
Sports Med 2016; 50:481.
43. Cook SD, Kester MA, Brunet ME. Shock absorption characteristics of running shoes. Am J
Sports Med 1985; 13:248.
44. Franklyn-Miller A, Wilson C, Bilzon J, McCrory P. Foot orthoses in the prevention of injury in
initial military training: a randomized controlled trial. Am J Sports Med 2011; 39:30.
45. McMillan A, Payne C. Effect of foot orthoses on lower extremity kinetics during running: a
systematic literature review. J Foot Ankle Res 2008; 1:13.
46. Bonanno DR, Murley GS, Munteanu SE, et al. Effectiveness of foot orthoses for the
prevention of lower limb overuse injuries in naval recruits: a randomised controlled trial. Br
J Sports Med 2018; 52:298.
47. Murley GS, Landorf KB, Menz HB, Bird AR. Effect of foot posture, foot orthoses and
footwear on lower limb muscle activity during walking and running: a systematic review.
6/19/22, 11:55 PM 16321
Gait Posture 2009; 29:172.

48. Razeghi M, Batt ME. Biomechanical analysis of the effect of orthotic shoe inserts: a review
of the literature. Sports Med 2000; 29:425.
49. Sinclair J, Janssen J, Richards JD, et al. Effects of a 4-week intervention using semi-custom
insoles on perceived pain and patellofemoral loading in targeted subgroups of recreational
runners with patellofemoral pain. Phys Ther Sport 2018; 34:21.
50. Malisoux L, Chambon N, Urhausen A, Theisen D. Influence of the Heel-to-Toe Drop of
Standard Cushioned Running Shoes on Injury Risk in Leisure-Time Runners: A Randomized
Controlled Trial With 6-Month Follow-up. Am J Sports Med 2016; 44:2933.
51. Altman AR, Davis IS. Prospective comparison of running injuries between shod and
barefoot runners. Br J Sports Med 2016; 50:476.
52. Hall JP, Barton C, Jones PR, Morrissey D. The biomechanical differences between barefoot
and shod distance running: a systematic review and preliminary meta-analysis. Sports Med
2013; 43:1335.
53. Lieberman DE. What we can learn about running from barefoot running: an evolutionary
medical perspective. Exerc Sport Sci Rev 2012; 40:63.
54. Goss DL, Gross MT. A review of mechanics and injury trends among various running styles.
US Army Med Dep J 2012; :62.
55. Jenkins DW, Cauthon DJ. Barefoot running claims and controversies: a review of the
literature. J Am Podiatr Med Assoc 2011; 101:231.
56. Fuller JT, Thewlis D, Buckley JD, et al. Body Mass and Weekly Training Distance Influence the
Pain and Injuries Experienced by Runners Using Minimalist Shoes: A Randomized
Controlled Trial. Am J Sports Med 2017; 45:1162.
57. Ridge ST, Johnson AW, Mitchell UH, et al. Foot bone marrow edema after a 10-wk transition
to minimalist running shoes. Med Sci Sports Exerc 2013; 45:1363.
58. Salzler MJ, Bluman EM, Noonan S, et al. Injuries observed in minimalist runners. Foot Ankle
Int 2012; 33:262.
59. Giuliani J, Masini B, Alitz C, Owens BD. Barefoot-simulating footwear associated with
metatarsal stress injury in 2 runners. Orthopedics 2011; 34:e320.
60. Ryan M, Elashi M, Newsham-West R, Taunton J. Examining injury risk and pain perception in
runners using minimalist footwear. Br J Sports Med 2014; 48:1257.
61. Cauthon DJ, Langer P, Coniglione TC. Minimalist shoe injuries: three case reports. Foot
(Edinb) 2013; 23:100.
6/19/22, 11:55 PM 16321
62. Grier T, Canham-Chervak M, Bushman T, et al. Minimalist Running Shoes and Injury Risk
Among United States Army Soldiers. Am J Sports Med 2016; 44:1439.
63. van der Worp H, Vrielink JW, Bredeweg SW. Do runners who suffer injuries have higher
vertical ground reaction forces than those who remain injury-free? A systematic review and
meta-analysis. Br J Sports Med 2016; 50:450.
64. Willems TM, Witvrouw E, De Cock A, De Clercq D. Gait-related risk factors for exercise-
related lower-leg pain during shod running. Med Sci Sports Exerc 2007; 39:330.
65. Anderson LM, Bonanno DR, Hart HF, Barton CJ. What are the Benefits and Risks Associated
with Changing Foot Strike Pattern During Running? A Systematic Review and Meta-analysis
of Injury, Running Economy, and Biomechanics. Sports Med 2020; 50:885.
66. Zadpoor AA, Nikooyan AA. The relationship between lower-extremity stress fractures and
the ground reaction force: a systematic review. Clin Biomech (Bristol, Avon) 2011; 26:23.
67. Heiderscheit BC, Chumanov ES, Michalski MP, et al. Effects of step rate manipulation on
joint mechanics during running. Med Sci Sports Exerc 2011; 43:296.
68. Gerlach KE, Burton HW, Dorn JM, et al. Fat intake and injury in female runners. J Int Soc
Sports Nutr 2008; 5:1.
69. American Dietetic Association, Dietitians of Canada, American College of Sports Medicine,
et al. American College of Sports Medicine position stand. Nutrition and athletic
performance. Med Sci Sports Exerc 2009; 41:709.
70. Bonci LJ. Eating for performance: bringing science to the training table. Clin Sports Med
2011; 30:661.
71. Skolnik, Heidi and Chernus, Andrea. Nutrient timing for peak performance, 1st ed., Human
Kinetics., Champaign, IL. 2010.
72. Beelen M, Burke LM, Gibala MJ, van Loon L JC. Nutritional strategies to promote
postexercise recovery. Int J Sport Nutr Exerc Metab 2010; 20:515.
73. Whiting SJ, Barabash WA. Dietary Reference Intakes for the micronutrients: considerations
for physical activity. Appl Physiol Nutr Metab 2006; 31:80.
74. Peake J, Nosaka K, Suzuki K. Characterization of inflammatory responses to eccentric
exercise in humans. Exerc Immunol Rev 2005; 11:64.
75. McGinley C, Shafat A, Donnelly AE. Does antioxidant vitamin supplementation protect
against muscle damage? Sports Med 2009; 39:1011.
76. Ristow M, Zarse K, Oberbach A, et al. Antioxidants prevent health-promoting effects of
physical exercise in humans. Proc Natl Acad Sci U S A 2009; 106:8665.
6/19/22, 11:55 PM 16321
77. Fields KB, Delaney M, Hinkle JS. A prospective study of type A behavior and running
injuries. J Fam Pract 1990; 30:425.
78. Van Mechelen W, Twisk J, Molendijk A, et al. Subject-related risk factors for sports injuries: a
1-yr prospective study in young adults. Med Sci Sports Exerc 1996; 28:1171.
79. Taddei UT, Matias AB, Duarte M, Sacco ICN. Foot Core Training to Prevent Running-Related
Injuries: A Survival Analysis of a Single-Blind, Randomized Controlled Trial. Am J Sports Med
2020; 48:3610.
80. Anderson K, Strickland SM, Warren R. Hip and groin injuries in athletes. Am J Sports Med
2001; 29:521.
81. Nadler SF, Malanga GA, DePrince M, et al. The relationship between lower extremity injury,
low back pain, and hip muscle strength in male and female collegiate athletes. Clin J Sport
Med 2000; 10:89.
82. Nadler SF, Malanga GA, Feinberg JH, et al. Relationship between hip muscle imbalance and
occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med
Rehabil 2001; 80:572.
83. Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ. Hip muscle weakness and overuse injuries
in recreational runners. Clin J Sport Med 2005; 15:14.
84. Filler AG, Haynes J, Jordan SE, et al. Sciatica of nondisc origin and piriformis syndrome:
diagnosis by magnetic resonance neurography and interventional magnetic resonance
imaging with outcome study of resulting treatment. J Neurosurg Spine 2005; 2:99.
85. Lewis AM, Layzer R, Engstrom JW, et al. Magnetic resonance neurography in extraspinal
sciatica. Arch Neurol 2006; 63:1469.
86. Halpin RJ, Ganju A. Piriformis syndrome: a real pain in the buttock? Neurosurgery 2009;
65:A197.
87. Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification
and review of the literature. Orthop Clin North Am 2004; 35:65.
88. Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome:
a systematic review. Eur Spine J 2010; 19:2095.
89. Stewart JD, Foye PM, Cole JL. Piriformis syndrome. Muscle Nerve 2010; 41:428.
90. Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med 2010; 29:417.
91. Williams PT. Effects of running and walking on osteoarthritis and hip replacement risk. Med
Sci Sports Exerc 2013; 45:1292.
92. Timmins KA, Leech RD, Batt ME, Edwards KL. Running and Knee Osteoarthritis: A
Systematic Review and Meta-analysis. Am J Sports Med 2017; 45:1447.
6/19/22, 11:55 PM 16321
93. Chakravarty EF, Hubert HB, Lingala VB, et al. Long distance running and knee
osteoarthritis. A prospective study. Am J Prev Med 2008; 35:133.
94. Panush RS, Hanson CS, Caldwell JR, et al. Is Running Associated with Osteoarthritis? An
Eight-Year Follow-up Study. J Clin Rheumatol 1995; 1:35.
95. Konradsen L, Hansen EM, Søndergaard L. Long distance running and osteoarthrosis. Am J
Sports Med 1990; 18:379.
96. Lane NE, Bloch DA, Jones HH, et al. Long-distance running, bone density, and
osteoarthritis. JAMA 1986; 255:1147.
97. Sohn RS, Micheli LJ. The effect of running on the pathogenesis of osteoarthritis of the hips
and knees. Clin Orthop Relat Res 1985; :106.
98. Stahl R, Luke A, Ma CB, et al. Prevalence of pathologic findings in asymptomatic knees of
marathon runners before and after a competition in comparison with physically active
subjects-a 3.0 T magnetic resonance imaging study. Skeletal Radiol 2008; 37:627.
99. Schueller-Weidekamm C, Schueller G, Uffmann M, Bader TR. Does marathon running cause
acute lesions of the knee? Evaluation with magnetic resonance imaging. Eur Radiol 2006;
16:2179.
100. Kessler MA, Glaser C, Tittel S, et al. Volume changes in the menisci and articular cartilage of
runners: an in vivo investigation based on 3-D magnetic resonance imaging. Am J Sports
Med 2006; 34:832.
101. Harrast MA, Colonno D. Stress fractures in runners. Clin Sports Med 2010; 29:399.
102. Craig DI. Medial tibial stress syndrome: evidence-based prevention. J Athl Train 2008;
43:316.
103. Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in
physically active individuals such as runners and military personnel: a systematic review
and meta-analysis. Br J Sports Med 2015; 49:362.
104. Barr KP, Harrast MA. Evidence-based treatment of foot and ankle injuries in runners. Phys
Med Rehabil Clin N Am 2005; 16:779.
105. Buchbinder R. Clinical practice. Plantar fasciitis. N Engl J Med 2004; 350:2159.
106. Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for Plantar fasciitis: a matched case-
control study. J Bone Joint Surg Am 2003; 85-A:872.
107. Wheaton MT, Molnar TJ. Overuse injuries of the lower extremity. In: Orthopedic Knowledge
Update, Griffin LY (Ed), American Academy of Orthopaedic Surgeons, 1997. p.225.
6/19/22, 11:55 PM 16321
108. Knobloch K, Yoon U, Vogt PM. Acute and overuse injuries correlated to hours of training in
master running athletes. Foot Ankle Int 2008; 29:671.
109. Zafar MS, Mahmood A, Maffulli N. Basic science and clinical aspects of achilles
tendinopathy. Sports Med Arthrosc 2009; 17:190.
110. Donoghue OA, Harrison AJ, Coffey N, Hayes K. Functional data analysis of running
kinematics in chronic Achilles tendon injury. Med Sci Sports Exerc 2008; 40:1323.
111. Williams DS, Zambardino JA, Banning VA. Transverse-plane mechanics at the knee and tibia
in runners with and without a history of achilles tendonopathy. J Orthop Sports Phys Ther
2008; 38:761.
112. Child S, Bryant AL, Clark RA, Crossley KM. Mechanical properties of the achilles tendon
aponeurosis are altered in athletes with achilles tendinopathy. Am J Sports Med 2010;
38:1885.
113. Coughlin MJ, Shurnas PS. Hallux rigidus: demographics, etiology, and radiographic
assessment. Foot Ankle Int 2003; 24:731.
114. Nihal A, Trepman E, Nag D. First ray disorders in athletes. Sports Med Arthrosc 2009;
17:160.
115. Solan MC, Calder JD, Bendall SP. Manipulation and injection for hallux rigidus. Is it
worthwhile? J Bone Joint Surg Br 2001; 83:706.
116. Adams BB. Jogger's toenail. J Am Acad Dermatol 2003; 48:S58.

117. de Araujo MK, Baeza RM, Zalada SR, et al. Injuries among amateur runners. Rev Bras Ortop
2015; 50:537.
118. Lipman GS, Ellis MA, Lewis EJ, et al. A prospective randomized blister prevention trial
assessing paper tape in endurance distances (Pre-TAPED). Wilderness Environ Med 2014;
25:457.
119. Lipman GS, Sharp LJ, Christensen M, et al. Paper Tape Prevents Foot Blisters: A Randomized
Prevention Trial Assessing Paper Tape in Endurance Distances II (Pre-TAPED II). Clin J Sport
Med 2016; 26:362.
120. Scheer BV, Reljic D, Murray A, Costa RJ. The enemy of the feet: blisters in ultraendurance
runners. J Am Podiatr Med Assoc 2014; 104:473.
121. Herring KM, Richie DH Jr. Friction blisters and sock fiber composition. A double-blind study.
J Am Podiatr Med Assoc 1990; 80:63.
122. Herring KM, Richie DH Jr. Comparison of cotton and acrylic socks using a generic cushion
sole design for runners. J Am Podiatr Med Assoc 1993; 83:515.
Topic 16321 Version 43.0
6/19/22, 11:55 PM 16321
6/19/22, 11:55 PM 16321
GRAPHICS
Muscles of gluteal region and posterior thigh
Superficial and deep dissections of the gluteal region (A) and the posterior compartment
of the thigh (B) are demonstrated.
Reproduced with permission from: Moore KL, Dalley AR. Clinically Oriented Anatomy, 5th ed, Lippincott Williams
& Wilkins, Philadelphia 2006. Copyright © 2006 Lippincott Williams & Wilkins. www.lww.com.
Graphic 53747 Version 11.0
6/19/22, 11:55 PM 16321
Iliopsoas anatomy
The psoas muscle arises from the transverse processes of the

lumbar spine, while the iliac muscle arises from the inner surface of
the ilium. Both insert along the medial aspect of the proximal femur,
primarily at the lesser trochanter, and act as the primary flexors of
the hip.
Reproduced with permission from: Novachek TF. Adductor and Iliopsoas Release. In:
Operative Techniques in Orthopedic Surgery, Wiesel SW (Eds), Lippincott Williams &
Wilkins, Philadelphia, 2011. Copyright © 2011 Lippincott Williams & Wilkins.
www.lww.com.
6/19/22, 11:55 PM 16321
Iliotibial tract anatomy
This lateral view of the thigh reveals the iliotibial band (or tract). The
gluteus medius lies deep to the gluteus maximus on the external
surface of the ilium.
Reproduced with permission from: Moore KL, Dalley AR. Clinically Oriented Anatomy,
5th ed, Lippincott Williams & Wilkins, Philadelphia 2006. Copyright © 2006
Lippincott Williams & Wilkins. www.lww.com.
6/19/22, 11:55 PM 16321
Anatomy of the Achilles tendon and superficial posterior calf

muscles
Note that the subtendinous bursa is also referred to as the retrocalcaneal bursa.
6/19/22, 11:55 PM 16321
First metatarsal joint sesamoids (arrows)
This oblique view shows the two most common foot sesamoids:
medial (ie, tibial) and lateral (ie, fibular) sesamoids below the
metatarsophalangeal joint of the great toe. A nondisplaced,
transverse fracture of the proximal phalanx of the little toe
(arrowhead) can also be seen.
Courtesy of Robert L Hatch, MD, MPH.
6/19/22, 11:55 PM 16321
Foot anatomy: Superior view
6/19/22, 11:55 PM 16321
Morton neuroma
Symptoms of a Morton neuroma include hyperesthesia of the toes,

numbness and tingling, and aching and burning in the distal forefoot. Pain
radiates forward from the metatarsal heads to the third and fourth toes. It is
aggravated by walking on hard surfaces and wearing tight or high-heeled
shoes. Physical examination reveals tenderness in the plantar aspect of the
distal foot over the third and fourth metatarsals; compressing the forefoot
reproduces the symptoms.
6/19/22, 11:55 PM 16321
Tarsal tunnel anatomy
The tarsal tunnel syndrome is caused by entrapment of the posterior tibial nerve beneath the flexor retinacu
on the medial side of the ankle. Entrapment may also include the two branches, the medial and lateral plant
nerves. Note that the bifurcation of the tibial nerve, which is depicted occurring proximal to the retinaculum
the diagram above, can occur more distally in the region of the retinaculum.
Reproduced with permission from: Moshrefi S, Curtin C. Nerve repair and reconstruction—Tibial nerve. In: Operative Techniques in Pla
Surgery, Chung KC (Ed), Wolters Kluwer, Philadelphia 2020. Copyright © 2020 Wolters Kluwer Health.
6/19/22, 11:55 PM 16321
Injured toenail ("black toe") in a runner
Runners sometimes sustain toenail injuries from repetitive trauma to the

nail or nail bed. This condition is commonly called "jogger's toenail", and
it most frequently affects the great toe (photo above), which may appear
black from subungual bleeding.
Courtesy of Karl B Fields, MD.
6/19/22, 11:55 PM 16321
Contributor Disclosures
Lisa R Callahan, MD No relevant financial relationship(s) with ineligible companies to disclose. Karl B
Fields, MD Consultant/Advisory Boards: Allard USA [Sports medicine].
All of the relevant financial
relationships listed have been mitigated. Jonathan Grayzel, MD, FAAEM No relevant financial
relationship(s) with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

Overview of Running Injuries of The Lower Extremity

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overview of Running Injuries of The Lower Extremity

Uploaded by

Copyright:

Available Formats

6/19/22, 11:55 PM 16321

Official reprint from UpToDate®

Overview of running injuries of the lower extremity

Intrinsic risk factors

● A prospective study of 532 novice runners participating in a 13-week training program

Training variables — Measures to reduce running injuries often include modifying training

There is insufficient high-quality research in runners to determine whether warming up reduces

There are three basic types of running shoes:

● Shoes for runners with a neutral foot shape

Orthotics — Orthotics appear to reduce the risk of some running-related lower extremity

Running barefoot or with minimalist shoes — Although running barefoot or with

Nutrition and supplementation — Little data exists to confirm or refute associations

● Consume adequate carbohydrates. Runners need approximately 6 to 10 g/kg body weight

Psychology — There is little evidence that psychological factors play an important role in

Training suggestions to reduce injury risk — Despite the dearth of high-quality evidence to

Mileage and rest guidelines:

● Runners should limit themselves to two to three marathons per year.

● Ease into training with a dynamic warm-up or light jog.

Nutrition and recovery:

Supplemental strength training:

In a randomized trial involving 118 recreational runners, those assigned to an eight-week

tendon rupture", section on 'Rehabilitation using resistance exercise'.)

EVALUATION OF THE INJURED RUNNER

The following findings may be noted during the examination:

● Achilles tendon thickening or nodules suggests Achilles tendinopathy.

Diagnostic imaging, including plain radiographs, ultrasound, magnetic resonance imaging

Gluteus medius weakness and tendinopathy and piriformis syndrome — The gluteus

Iliopsoas tendinopathy — Iliopsoas tendinopathy produces symptoms similar to a labral tear

within a few weeks to activity modification, acetaminophen and nonsteroidal antiinflammatory

Knee and thigh injuries

● A large follow-up study using questionnaires completed by established cohorts of runners

● Several small prospective and retrospective studies have reported no evidence of

Chronic exertional compartment syndrome — Chronic exertional compartment syndrome

Tendon injuries — Runners are susceptible to tendon injuries at a number of sites, the

Overuse tendinopathy generally is reviewed in detail separately. (See "Overview of the

First metatarsal phalangeal joint — Running generates substantial forces across the

Hallux rigidus and hallux valgus (bunion) — There is little high-quality evidence to

Morton neuroma — Interdigital neuromas (often referred to as Morton neuroma) are thought

Conservative treatment should precede expensive diagnostic procedures. This approach

● At areas known to be susceptible to blisters ("hot spots") in particular runners, apply a

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Descriptions of important and common causes of running-related lower extremity injuries,

Use of UpToDate is subject to the Terms of Use.

Gait Posture 2009; 29:172.

116. Adams BB. Jogger's toenail. J Am Acad Dermatol 2003; 48:S58.

Muscles of gluteal region and posterior thigh

Graphic 53747 Version 11.0

The psoas muscle arises from the transverse processes of the

Graphic 52413 Version 11.0

Iliotibial tract anatomy

Graphic 70825 Version 13.0

Anatomy of the Achilles tendon and superficial posterior calf

Graphic 58376 Version 8.0

First metatarsal joint sesamoids (arrows)

Courtesy of Robert L Hatch, MD, MPH.

Graphic 80813 Version 7.0

Foot anatomy: Superior view

Graphic 71857 Version 3.0

Symptoms of a Morton neuroma include hyperesthesia of the toes,

Graphic 65666 Version 4.0

Tarsal tunnel anatomy