Running is a common form of exercise; however, the rate of running related injuries has been reported to be as high as 85%.8 With an injury rate that high, you are likely to have a runner come to your clinic with a running related injury. Even if you do not work in outpatient orthopedics, as a PT you may have friends or relatives who approach you looking for advice on their running related injury.
Just like treating any other type of orthopedic injury, you need to examine and treat the painful area. However, in order to successfully return the injured runner to running, you need to also think more globally. Anterior knee pain may be from hip weakness for ankle dorsiflexion inflexibility, or both. Achilles tendonitis may arise because the Achilles tendon is being overloaded as it is overcompensating for a lack in hip extension.
Just like any good subjective and objective evaluation, the more questions you ask, and the more thoroughly you look at your patient’s movement, the clearer your picture of what their injury is and how to properly treat it will be. During your subjective evaluation, you should ask about weekly mileage, how many runs per week, speed workouts, running pace, and cross training. Does your patient have any upcoming races or running events? Does your patient have an occupation that is physically demanding, or sedentary? Also ask about stressors and amount of sleep, as these can impact the patient’s pain level and healing.
Your objective evaluation should include analysis of your patient’s running gait. This may be difficult to perform on the day of evaluation if the patient does not have their running shoes and clothes, but should be done at the second visit if not at the first. 2D Video Gait Analysis: Valid and Reliable Measure for PTs, by Kelsey Hattersley, SPT, is a great resource to learn more about running gait.
A period of active rest is key to the successful treatment of most running injuries. Active rest in this case means that the patient should focus on activities and exercise that do not put excessive stress on the injured area, and most importantly do not cause pain. So the rest only refers to taking a rest (or break) from running. Otherwise, the patient should remain active as this will help to maintain fitness and strength while allowing the injured area and the patient's nervous system to calm down. Examples of activities that may be appropriate for this active rest include: bicycling, spinning, swimming or Pilates. Activities such as yoga or crossfit may be appropriate for certain patients who have a good understanding of their limitations, and are willing and able to modify certain exercises and poses so that they are not putting excessive stress on the injured area, or pushing themselves into pain.
This period of active rest may be different for different patients. Factors determining how long to have an active rest period include: acuity of the injury, the amount of pain that the injury is causing, age, lifestyle and prior injuries.
1. Patellofemoral pain
What it is: Knee pain that is typically caused by the patella not tracking properly along the femur.
What this patient will look like: Patients may feel that the pain is at their knee, but can move around. Sometimes it's lateral to the patella, sometimes it is inferior or superior to the patella. Sometimes patients will report that their knee feels "full" or swollen; however, there is no swelling observed. Often times these patients will demonstrate altered leg biomechanics where they are in femoral internal rotation and their knee is plunging toward their midline on their stance leg.
What to do about it: Decrease mileage or cross train to maintain fitness.
Soft tissue mobilization to the quadriceps, tensor fascia latae, and possibly Achilles can help to increase soft tissue extensibility in these areas. This increase is soft tissue extensibility can help to improve altered biomechanics, or to lessen the tension on areas such as the ITB. Using a foam roller on the ITB can help to decrease some of the acute pain associated with patellofemoral syndrome. Foam rolling and performing soft tissue massage on areas such as the ankle plantar flexors, tensor fascia latae, vastus lateralis, gluteus medius and gluteus maximus can help to increase soft tissue extensibility in those areas, and in turn help to improve leg alignment when running.
Correct running form if knees are going into midline: lateral hip and adductor strengthening. You may also want to ensure that your patients are able to attain adequate hip extension during running, and do not look like they are bent forward or sitting down while they are running.
2. Patellar tendon pathology
What it is: Tendon pathologies were thought to be inflammatory in nature. The more that tendon pathology is studied, the less we are finding out that is the case. While swelling can be a component to some more acute tendon injuries, there are other tendon injuries where there is no observed swelling. Often, this tendon pathology is caused by an overload of the where tendon are not allowed time to adapt to the increased load. As a result of this inability to adapt, structural changes take place at the tendon.3
What this patient might look like: With tendon pathologies, there may or may not be tenderness and swelling at the area of the patellar tendon. The patient may report pain that happens initially with running, and then decreases over the course of the run. Their running gait may lack hip extension in the toe off phase and the patient may appear to be bent over, or sitting down while running.
What to do about it: A period of active rest is beneficial for tendon pathologies that are both acute, and chronic in nature. During this time, the patient should focus on non-painful activities, core and gluteal strength. Some therapists will use cross friction massage, or other types of manual soft tissue work to help increase blood flow to the tendon. While these treatments do make sense in theory, there is little research to support them. One review looked at two randomized control trials of deep transverse friction massage used in conjunction with other physical therapy modalities to treat tendon pathologies. Both trials were inconclusive, with the authors pointing to the small sample size of both studies as a possible reason for not yielding a more decisive result.2
Once the patient's pain levels have decreased, you can start some specific training. Eccentric exercise has been shown to be most effective in the treatment of this injury. You may start with double leg squats, then progress to single leg squats. Once the patient is able to perform concentric exercise without pain and with good form, you can progress to eccentric exercises such as jump downs (dropping off of a box, or step that is about 6 in high and landing with legs in good alignment).
Once the patient can perform jump downs without pain and with good form, they can progress to double leg jumps, single leg jumps before returning to sport.
While corticosteroid injections show some benefit when used as an early intervention for other tendon pathologies,4 their benefit in treating lower extremity tendonopathies is not clear. Prolotherapy, in addition to eccentric exercise may help in the treatment of Achilles tendon pathology.9 Platelet rich plasma also shows some benefit in the treatment of tendonopathies; however, more research may be needed on this modality.5
3. Achilles tendon pathology
What it is: As with patellar tendon pathology, this is an injury where the tendon is unable to adapt to the stresses placed upon it. There is also a noted structural change at the level of the tendon.
What will this patient might look like: This patient may have anterior knee pain that comes on when they start running, and then decreases as they progress through their run. Other times, pain from tendon pathologies can rear its ugly head later into a run, and then persist for the duration of the run. The patient may have increased their activity load in the form of increased mileage or increased intensity. They may have also recently changed their footwear going from a more cushioned shoe with a larger drop (height difference between the rear foot of the shoe and forefoot of the shoe) to a lower drop, zero drop or minimalist shoe. Also, beware of the 36-50 year old male. This population is at an increased risk of Achilles tendon rupture. You may want to be more conservative, and err on the side of caution when treating this group.
What to do about it: Find deficiencies in the patient’s running form and go after those while encouraging active rest and participation in non-painful activities to maintain fitness. You may find that a patient is overusing their ankle plantar flexors because they are lacking hip extension, gluteal strength or passive great toe extension. After a period of active rest, you may start with concentric strengthening, such as double leg heel raises and progress to single leg heel raises. Once the patient is able to perform those without pain, you can progress to eccentric strengthening such as double leg heel raises and lower down off of step and progress to single leg heel raises and lower down off of step. Once those are pain free, you can progress to jumping activities and plyometrics.
4. Medial tibial stress syndrome, aka Shin splints
What it is: Some research suggests that increased activity as well as increased pronation of the foot may cause of medial tibial stress syndrome.7,1
Other research suggests that a tight Achilles might be to blame.
What this patient might look like: Pain along the tibia or shin that either occurs with running, or soon after. They may demonstrate excessive pronation either in standing, or during the stance phase of running.
What to do about it: Again, active rest. During the active rest period, prescribe exercises to improve core and hip strength. While boney structure does determine how much a foot will pronate, other factors such as extensor hallicus longus strength, gluteal strength and passive extension of the great toe can also impact how much the foot pronates when active (i.e. while running). Soft tissue massage and working with a foam roller can help to decrease tension in the ankle plantar flexors. One case controlled study suggests that those with medial tibial stress syndrome also exhibit decreased strength of their ankle plantar flexors. A good rehab program for these athletes may also include strengthening of these muscles once the patient’s pain is under control. In some cases, orthotics may also help to decrease symptoms.6
5. Plantar fasciitis
What it is: When the plantar fascia (the fascia that runs lengthwise along the bottom of the foot) becomes irritated. Sometimes there is an inflammatory component to this injury and the patient will note that their heel feels swollen.
What will this patient look like: They will have heel pain the typically occurs during their first few steps out of bed, of upon walking after sitting for a while. Sometimes this pain will go away for the rest of the day, other times it will recur after sitting for a while, or when walking. Many patients with plantar fasciitis will demonstrate excessive pronation in standing. Increases in activity such as increases in mileage, frequency of running or intensity can also lead to this type of pain. They may also have decreased ankle dorsiflexion.
What to do about it: Again, orthotics and shoes that are well cushioned can help with patients that have more acute pain. Rolling a frozen water bottle under the foot has anecdotal evidence to support it; however, the research to support this is lacking. Increasing ankle dorsiflexion through soft tissue massage, foam rolling of the ankle plantar flexors and mobilizing the ankle into dorsiflexion can also be helpful.
Once a patient’s more acute symptoms are under control, you may focus on exercises to improve foot control to help decrease overpronation. This may include strengthening the extensor hallicus longus, gluteals and ankle plantar flexors as well as increasing great toe passive extension.
Final notes on common running injuries
This is a sampling of common injuries. You may encounter some injuries that are similar to, but not quite like the injuries mentioned above. You may even encounter patients that have pain from more than one of the injuries mentioned above. The principles here are to look at the patient's running form, ask about training (have they started to increase their mileage, or intensity?), and ask about their running goals. If you see something off in their gait, go after that first. If you see something off in their training, then go after that.
With this guide, a timeline has been purposely left out. As a clinician, I find that following a timeline rather than the patient’s symptoms can cause the clinician to progress a patient too quickly through strengthening. Timelines for healing such as the 4-6 weeks for tissue healing is a best case scenario and does not allow for confounding variables such as family, work, travel and other stressors that accompany these patients.