Injury Prevention for Runners

June 15, 2022

Musculoskeletal Injury Epidemiology

Most evidence of injury patterns with trail running are from surveys, primarily from single-day events. Irrespective of global location, the lower leg (knee through the foot) is the most common region for acute and chronic injuries. One study from Greece found that the low back and the knee were the most frequently injured locations, but the most severely injured location was the Achilles tendon. Specific musculoskeletal injuries are patellofemoral pain syndrome, muscle strains (quadriceps femoris, hamstrings, tibialis anterior, calf, back), Achilles tendinopathy, trochanteric bursitis, iliotibial band (ITB) syndrome, ankle inversion injuries, plantar fasciitis, and stress fractures (foot, tibia).

Key mechanical stresses to the musculoskeletal system during trail running and motion strategies required to mitigate injury risk.

Running Through Noncritical Chronic Pain

Runners with persistent musculoskeletal pain demonstrate altered mechanics. For example, patellofemoral pain is related to elevated frontal plane knee excursion and less knee flexion and less pelvic drop on the unloaded side. Runners with ITB pain increase hip adduction at foot contact, knee rotation during the stance phase and knee abduction at push-off compared to runners without this pain. Running through pain can produce compensatory biomechanics and loading at other anatomical sites. Our clinical experience is that runners with initial pain at one site who continue training develop secondary pain(s) elsewhere.

Injury Prevention and Rehabilitation

Prevention of trail running injuries requires a multifaceted approach, including education, strengthening, and flexibility exercise, neuromotor control exercise, and plyometrics.  

Education About Musculoskeletal Pain

Four key rules can be used to educate runners before an injury becomes serious. Pain affects up to 79% of runners, but many do not know how to interpret pain to determine continuation of training. These rules are:

1) running should be stopped immediately if pain increases during a run, or changes in quality from achy to sharp;  

2) joint pain should not linger or increase by 24 hours after a run, as this indicates that the volume was excessive and should be scaled back,

3) if pre-existing pain is present (<3 points out of a 10-point numerical pain rating scale), this pain should not increase during the run or persist into the next day, and  

4) run-training should stop until pain-induced compensation to running form disappear (foot interaction with the ground, limping, hiking a hip). These rules can guide trail running participation to avoid serious injury in the first place.

When to Start Injury Prevention Before Competition

Ideally, injury prevention exercise does not stop throughout the year irrespective of run training volume or season. At minimum, elite orienteers used a 6-8 week pre-competition stage before competitive season to allow neuromuscular and skeletal adaptations to occur for short events. Longer trail events >100K will require more preparation, which may range from 6 months to 1 year depending on physical starting point, habitual training distance, and body weight. Prehabilitation should begin at the start of the training process for any event.

Health suggestions for running and jogging

Some tips to help prevent injuries include:

  • Warm up before running. Include plenty of slow, dynamic and sustained stretches. Make sure you thoroughly stretch the muscles in your thighs and calves.
  • Cool down after running. Incorporate stretches into your cool-down routine.
  • Drink plenty of water before, during and after your run.
  • Don’t push too hard beyond your current level of fitness. Plan to gradually increase how long and how often you run over a few months.
  • Start slowly at a pace at which you can have a conversation without breathlessness.
  • Avoid running during the hottest part of the day in summer. Plan to run during the morning or evening.
  • Apply SPF 30+ sunscreen to all exposed areas of skin.
  • Wear layers of clothing on your upper body to avoid overheating. Wear clothing which wicks sweat away from the skin.
  • Consider having regular professional massage to relax tight, sore muscles.
  • Avoid running near roads. Inhaling vehicle exhaust fumes can cause a range of breathing-related (respiratory) problems.
  • Run on a clear, smooth, even and reasonably soft surface. Avoid uneven surfaces, sand and concrete.
  • Gradually introduce surface changes.
  • Take adequate recovery time and get a good night’s sleep.  

Don’t wear regular trainers when running. Professionally fitted shoes designed for running will support your feet and reduce your risk of injury. Take your old runners with you when purchasing new ones so the salesperson can identify where your shoes wear the most

REFERENCES - the text

1. International Trail Running Association Discover trail running.

2. Viljoen C.T., Sewry N., Schwellnus M.P., Janse van Rensburg D.C., Swanevelder S., Jordaan E. Independent risk factors predicting gradual onset injury in 2824 trail running race entrants: SAFER XVIII Study. Wilderness Environ Med. 2021;32:293–301. doi: 10.1016/j.wem.2021.04.002. [PubMed] [CrossRef] [Google Scholar]

4. Viljoen C.T., Janse van Rensburg D.C., Verhagen E., et al. Epidemiology of injury and illness among trail runners: A systematic review. Sports Med. 2021;51:917–943. doi: 10.1007/s40279-020-01418-1. [PubMed] [CrossRef] [Google Scholar]

5. Viljoen C.T., Janse van Rensburg D.C.C., Jansen van Rensburg A., et al. One in four trail running race entrants sustained an injury in the 12 months training preceding the 2019 SkyRun race. Phys Ther Sport. 2021;47:120–12

6. doi: 10.1016/j.ptsp.2020.11.029. [PubMed] [CrossRef] [Google Scholar]6. Gajardo-Burgos R., Monrroy-Uarac M., Barría-Pailaquilén R.M., et al. Frequency of injury and illness in the final 4 weeks before a trail running competition. Int J Environ Res Public Health. 2021;18:5431. doi: 10.3390/ijerph18105431. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

7. Matos S., Silva B., Clemente F.M., Pereira J. Running-related injuries in Portuguese trail runners: A retrospective cohort study. J Sports Med Phys Fitness. 2021;61:420–427. doi: 10.23736/S0022-4707.20.11304-5. [PubMed] [CrossRef] [Google Scholar]

8. Malliaropoulos N., Mertyri D., Tsaklis P. Prevalence of injury in ultra trail running. Human Movement. 2015;16:52–59. doi: 10.1515/humo-2015-0026. [CrossRef] [Google Scholar]Images -

Start your health journey.

Let’s find the perfect LEAR Health Partner for your starting point and future goals! Take a moment to register your interest with us. A member of our team will then get in touch with you to talk about next steps.