Hey all, I hope it’s ok that I post this but I see so many people here struggling with injury and I’d love to help where I can.
I’m an Australian Physical Therapist who’s really passionate about uncovering and solving the root cause of common aches and pains - particularly those associated with running. And if it's ok, I’d love to pass on some really important information I’ve come to learn over the course of the last 15 years in terms of why running injures happen and what’s important to focus on if you want them to go (and stay) away.
Apologies in advance for the length of the post!
Firstly, I think there are two really important things to consider when discussing injuries and running:
#1 - The onset of most running-related injuries should be considered the last straw, not the start of something new.
#2 - Running is, by definition, normal for the human body to do.
In my experience, running injuries are usually a consequence of something else, and the repetition of running just exposes what you took into running. It doesn’t mean running is bad for anyone, just that it's really good at exposing hidden flaws we accrue in other areas of our lives.
Take common running-related issues like Plantar Fasciitis, Achilles Tendonitis, Shin Splints, Patellofemoral pain, Patella Tendonitis, ITB Syndrome, Anterior Hip Pain, Gluteal Tendonitis, Low Back Pain, etc. It’s important to consider that these are actually not isolated, different issues divorced from each other. Yes, they're all considered different injuries to different parts of the body, but they are actually just a different expression of similar root dysfunctions - which I’d like to highlight.
For example, even though issues like plantar fasciitis, Achilles tendonitis, and patellofemoral joint pain are considered completely different issues, they generally come from the same basic dysfunction - ankle stiffness, hip rotational tightness/weakness, and even low back dysfunction in a lot of cases. Essentially, the presence of these kinds of “hidden” features force the leg to work around them ultimately loading up the foot, the heel, and the knee differently to what they’re designed to handle. And if exposed to repetitious movements over time (hello running), something within the entire system can be set up to fail. And I think this is really important to mention because many common treatments for each of the above issues are very specific to those areas - arch supports, heel raises, isolated stretches, vmo strength, etc. And the problem with these ideas is that, although still helpful, they don’t solve the underlying issues that created the problem, leaving many frustrated if there’s a lack of overall progress.
So the point I’d love to make to anyone trying to overcome any running injury at the moment is that you need to look at how your whole leg and low back are going regardless of where your issues currently are. Yes, there will be some specific things that will help manage your pain in the short-term, but a broader focus can shut the door entirely. And to help figure this out, here is a list of the most common issues I’ve found clinically set other things up to fail and why:
- Joint stiffness at the junction of the Thoracic Spine and Lumbar spine: Stiffness here can short-circuit gluteal function. Do you have weak glutes? They may not actually be weak, just dampened by spinal stiffness. Interestingly, I’ve found stiffness here also contributes to the onset and persistence of hip flexor pain, and patella tendonitis.
- Stiffness in the lower lumbar joints: These relate heavily to the sciatic nerve which supplies and influences many of the muscles down the back of the leg. Hamstring issues, calf issues, Achilles issues, and even plantar fasciitis can be the expression of basic joint stiffness in the lower back.
- Muscular and joint restrictions at the front of the hip: Restrictions at the front of the hip can contribute to anything from low back pain, hip pain, all knee pain, anything associated with poor arch function - Achilles tendonitis, plantar fasciitis, ITB pain, shin splints, etc
- A lack of rotation at the hips: This contributes to almost everything. It’s insane how often improving someone’s hip external and internal rotation leads to an immediate improvement in the foot, ankle, knee, hip, and low back complaints when running.
- Ankle joint stiffness: Put this alongside hip rotational deficits as a leading hidden cause of almost everything. Plantar fasciitis, shin splints, Achilles pain, almost all knee pain, etc can be improved by decreasing the presence of ankle joints stiffness. This one is so important to work on as a stiff ankle genuinely forces the entire leg to move differently in order to work around it. Any structure in close proximity to ankle joint stiffness will be forced to take up the load a rusty ankle can’t support, opening many runners up to aches and pain. It's also worth noting that ankle joint stiffness is different from muscle tightness.
You may notice that I haven’t mentioned much about weakness. Clinically, I find you can’t out-strengthen stiffness - meaning I’d prioritize getting rid of stiffness over going after strength if you only have time to focus on one. Clearly, you can (and should) go after both, but I find stiffness to be the bigger factor in causing the compensation needed to create adjacent injury. Interestingly, as mentioned above gluteal weakness is often a symptom of low back dysfunction. As the low back improves I find the glutes wake back up again. Clearly, you can do gluteal strength exercises to round this off nicely, but without the low back stuff, you’ll most likely have to keep focusing on those strength exercises until you get sick of them rather than stopping because you don't need them anymore.
Here are a few other ideas that I’m happy to discuss in the comments if anyone is interested.
- Variations in footwear do not make a genuine change in your underlying mechanics. They're a bandaid. Clinically I’ve found that if any footwear “improves” how you feel or run, it's compensating for something you are missing with your body mechanics. If arch support makes you feel nicer then that tells me that some hidden issues need to be addressed so you don’t need to rely on arch support forever. The same goes for heels. I find barefoot shoes are a great way to “expose” flaws in someone's mechanics. If you can’t tolerate being barefoot and running (which are both normal) then it’s a clear sign to me that something is missing behind the scenes.
- The two biggest creators of the list of hidden issues that I've found over the years are time spent sitting and heeled shoes/flip flops. Sitting - particularly slouching is often responsible for much of the hidden low back dysfunction I see. The act of sitting itself tends to account for the majority of hip stiffness and tightness I see. Heeled shoes and flip flops are a haven for stiff ankles. Any range you don’t get to use thanks to the size of the heel is essentially lost the longer you wear them.
Ultimately, I just hope that some of these ideas turn out to be the missing piece to someone's pain puzzle. Or at least the little spark in perspective that helps you find it. Especially if it's stopping you from doing something you love. Again, I’d love to answer any questions that might arise from this!
Also, I have a YouTube channel that covers a lot of these ideas in more detail if anyone would like to go down a rabbit hole or two!
Hope this was interesting and helpful 👍