Running and the musculoskeletal system

Wernicke, A Gabriella


Most running injuries are caused by overuse.

Biomechanical abnormalities contribute to running injuries.

The nature of the injury usually can be determined by the history and physical exam.

It is unusual for recreational running to cause osteoarthritis.

Generally, rest, symptomatic therapy, correction of underlying abnormalities, crosstraining, and gradual increase in mileage allow resumption of running.

Popularity of Running

Approximately 11 million people in the United States run more than 100 days per year. Why? Exercise, particularly running, not only improves the quality of life but also actually increases the length of our lives (1). Salutary effects of running range from improved cardiopulmonary status to enhanced mental health (evidenced by less depression), less anxiety, and a greater sense of tranquility.

Regular exercise results in the decrease of all causes of mortality, disability, hypertention, diabetes, cancer, strokes, osteoporosis, better sleep patterns, better sex life (perhaps), enhanced appetite, healthier weight, and a more stable (stronger) musculoskeletal structure. Except for walking, running is the easiest and least expensive form of exercise.

However, there may be health consequences from running as well. These include risk of sudden death, musculoskeletal injuries, and adverse effects on joints, as well as others that are beyond the scope of this presentation. Because approximately 45% to 70% of runners experience musculoskeletal injuries each year, medical practitioners need to be able to recognize and manage common running injuries.

Frequency of Injuries

The majority of running injuries in both adults and children are caused primarily by overuse due to training errors (ie, running too far or too much too soon) or by repetitive microtrauma rather than to a single traumatic event. Table 1 lists overuse running injuries from one sports medicine center, which is similar to most reports (2,3). All of the injuries were the result of overuse.

The factors that predispose and contribute to runners’ risk status for overuse injury are extrinsic (eg, training errors, old shoes, and running surface irregularities) and intrinsic (eg, poor flexibility and malalignment). Optimally the physician and the runner should work together to decrease the likelihood of injury.

Evaluation For Injuries

At the very least, the history elicited from a patient who presents with injuries related to running should include the number of miles run per week; pace; any change in the intensity, duration, or distance of running; the amount of hill running; racing; the type of running surface; the age and type of the running shoes; and the location and character of pain.

Higher mileage per week (25 to 35 miles) increases a runner’s risk of incurring an overuse injury (2). Running more than 45 miles per week, according to some reports, does not lead to a significantly healthy benefit (4,5). A sudden increase in the duration and intensity of training also puts the runner at risk for developing a stress fracture, tendinitis, or fascitiis (2,6).

A rigid running surface may increase the risk of stress fracture or tibial stress syndrome, and arched roadways may worsen iliotibial band syndrome (2,5-7). Running up and down hills may predispose to exacerbation of knee pain caused by patellar tendenitis and patellofemoral pain syndrome (8). In addition, the injury is most likely to occur when a runner’s shoes are worn, and thus the recommendation is that shoes be changed every 300 to 600 miles or every 6 months or so (9).

The physical examination of an injured runner should not only focus on the area of pain and adjacent joints but also on an evaluation of alignment and flexibility. Although the relationship between specific running injuries and structural abnormalities is controversial, 20% to 40% of injuries can be directly related to structural abnormalities.

The physical examination of an injured runner also should include an assessment of flexibility. Some think that as many as 50% of running injuries can be corrected with a good stretching program (10). Hamstring and calf flexibility can be assessed with the runner in the supine position on the examining table, the femur at 90 degrees to the table and the foot at 90 degrees to tibia. The physician should be able to passively extend the knee to within 15 degrees of full extension.

Orthotics help the majority of runners with certain injuries for which rest and stretching were unsuccessful. A flat foot (pes planes) or a hyperpronated foot may be more likely to be helped by orthotics than is a high arched (caves) foot. Considering that excessive pronation increases stress on the medial structures of the ankle, shin and knee, and dissipation of 110 tons of energy by the foot with each mile run, the combination of increased pronation and the large load experienced in the lower extremity increases the risk of overuse injury.

Common Running Injuries Stress Fractures

Stress fractures, usually of the tibia, frequently occur in runners. The risk factors for stress fracture include older age and female gender. The history includes recent increase in mileage. There is the development of localized pain with insidious onset and progressive worsening with continued training. On exam, there is localized tenderness and swelling in the area of the involved bone.

When this injury is suspected, a radiograph of the affected area may be obtained and evaluated for a hairline radiolucency or periosteal callus. If the radiographic findings are negative, as they may be for 3 to 6 weeks, but a stress fracture is nevertheless strongly suspected, the runner should be treated accordingly. If the radiographs are negative and a definitive diagnosis is necessary, a triple-phase bone scan (a nuclear scan that is very sensitive in picking up early stress fractures) should be pursued.

The runner with a stress fracture has to cross-train for 3 to 6 weeks, using activities which should not cause pain such as swimming, biking, exercise on elliptical machine, or running in water. Crutches should be utilized if weight bearing causes pain. Prior to resuming running, the radiograph should show good callus formation and alignment and the runner should be free of pain for 7 to 10 days while walking. The average time to full recovery from a stress fracture is 6 to 8 weeks. If a stress fracture becomes symptomatic again, running is decreased to a level of being pain-free, and it is kept at that level for one week.

The primary care physician should be able to manage most stress fractures and to recognize fractures at high risk of nonunion. These are fractures in the anterior medial third of the tibia, the tarsal navicular and the diaphyseal-metaphyseal junction of the fifth metatarsal (Jones’s fracture) all of which warrant a referral to an orthopedic surgeon. Fractures in the hypovascular areas are at high risk for nonunion and may require surgical intervention (3-5).

Pelvis, Hip, and Thigh

Groin injuries are associated with hill or speed work. The tendon of the adductor longus is most commonly strained. This is manifested as pain in the thigh or groin. Pain will be elicited by resisted adduction of the involved leg and with full abduction of the hip. Tenderness may be present over the symphysis pubis or the myotendinous junction. The differential diagnosis of groin pain includes femoral neck or pelvis stress fracture, apophysitis of anterior superior and inferior iliac spines and ischium and lesser trochanter in the adolescent, hip joint disease, sacroilitis, osteitis pubis, and bursitis (6).

Knee Injuries

Pain from the patellofemoral syndrome stems from weakness of vastus medialis, which favors lateral displacement of the patella, causing abnormal tracking of the patella as the knee is flexed or extended. Runners typically experience an insidious onset of an ill-defined ache in the knee, aggravated by hills or stairs or have pain after prolonged sitting with knees flexed (theater sign).

On physical exam, the Q angle between femur and tibia should be measured. An angle greater than 16 degrees is associated with a higher incidence of patellofemoral syndrome. Also the patient has pain with compression of the patella on the femoral condyles.

Iliotibial band syndrome results from the inflammation of iliotibial band rubbing -the lateral femoral condyle, which is exacerbated by long runs or running up and down hills. The pain is described as burning and occurs on the lateral aspect of the knee after covering some running distance. It is exacerbated with flexion and adduction of the hip (Ober’s sign) (4).

Lower Leg Injuries

Patients with medial tibial stress syndrome (or shin splints) – musculotendinous inflammation of anterior and posterior calf musculature or periostitis of the tibia – present with diffuse, nagging pain over the tibia that worsens with running. However, if the pain persists after running and is noted with daily ambulation, then the diagnosis of a tibial stress fracture should be considered.

When a patient presents with leg pain at the onset of running that resolves shortly after the cessation of exercise, a compartment syndrome should be considered. The definitive diagnosis can usually be made with a compartment test, which measures the pressure in the specific compartment while the athlete is running. Surgical fasciotomy may be necessary to treat this condition (11).

Ankle and Foot Injuries

A runner may complain of pain in the substance of Achilles tendon, which connects the soleus and the gastrocnemius muscles to the calcaneus. The foot is described as being stiff in the early morning, at the start of the run and aggravated by hill running. On physical exam there is tenderness upon palpation of the tendon, with plantar flexion against resistance and with active stretching.

Plantar fasciitis is the most common cause of heel pain in runners. Classically it is a sharp pain at the fascial insertion on the plantar surface of the anteromedial calcaneus. Physical exam reveals exquisite focal tenderness over the medial calcaneal tuberosity, which may spread for several millimeters along the fascia. Individuals with chronic plantar fascial pain have microtears and partial rupture of the plantar fascia near its origin.

Radiographs to look for heel spurs are not needed for the routine evaluation of plantar fasciitis since the presence of heel spurs does not correlate with the clinical. course. Differential diagnosis should include heel pad atrophy, tendonitis of the flexor hallucis longus, entrapment of the first branch of the lateral plantar nerve and tarsal tunnel syndrome (12).

Long-Term Consequences of Running

An important consideration is the possible long-term consequences of regular running and exercise on the joints and musculoskeletal system. Might running, while promoting cardiovascular and other health benefits, be deleterious to the joints? Generally not for recreational runners with healthy joints (13-15). However, there is a possible association between competitive running and development of osteoarthritis (OA) of the knees and hips. Furthermore, if there is radiographic evidence of abnormal joints, there is increased of a chance for developing OA (Table 2).


Runners should avoid overuse due to training errors. They should increase mileage gradually in increments of 10% or less each week, wear proper shoes, perform stretching exercises, and not “run through pain.”

Treatment of overuse running injuries includes relative rest, nonsteroidal antiinflammatory drugs, cross-training, and stretching exercises, with a return to running as tolerated. An adjunctive treatment measure for correction of biomechanical problems may be the use of orthotics.

It should be possible for recreational runners to enjoy running with minimal injury and without fear of joint deterioration (Table 3). Primary care physicians should be able to advise running patients about injury prevention and to treat most of the injuries.


1. USA Track and Field USATF Road Running Information Center, http:llwww.usaldrorg.

2. Ballas MT Tytko J, Cookson FD. Common overuse running injuries: diagnosis and management. Amer Fam Physician 1997:2473-80.

3. Matheson GO, Clement DB, McKenzie DC, Taunton JE, Lloyd-Smith DR, Maclntyre JG: Stress fractures in athletes. A study of 320 cases. Amer J Sports Med 1987;15:46-58.

4. O’Toole ML Prevention and treatment of injuries to runners. Med Sci Sports Exer 1992;24:5360-3.

5. McBride AM Jr Stress fractures in runners. Clin Sports Med 1985;4:737-52.

6. Glancy WG Jr Specific rehabilitation for the injured recreational runner Instr Course Lecture 1989;38:483-6.

7. Guten GN. Running Injuries. Philadelphia: WB Saunders Co., 1997; pp. 1-3.

8. Davidson K. Patellofemoral pain syndrome. Amer Fam Physician 1993;48:1254- 62.

9. Cook SD, Kester MA, Brunet ME, Haddad RJ Jr: Biomechanics of running shoe performance. Clin Sports Med 1985;4:619-26.

10. DAmbrosia RD, Drez D Jr: Prevention and Treatment of Running Injuries. 2nd ed Thorofare, NJ: Slack, 1989.

11. Meyer SA, Saltzman CI, Albright JP Stress fractures of the foot and leg. Clin Sports Med 1993;12:395-413.

12. Myerson MS, Biddinger K Achilles tendon disorders: practical management strategies. Physician Sports Med 1995;23:47-54.

13. Panush RS, Lane N (editors): Exercise and rheumatic disease. Clinical Rheum (Bailliere’s) 1994;8:XI-239.

14. Panush RS: Physical activity, fitness and osteoarthritis. In Physical Activity, Fitness, and Health International Proceedings and Consensus Statement. Champaign, IL: Human Kinetics Publishers, 1994; pp. 712-23.

15. Panush RS, Hanson CS, Caldwell JR, Longley S, Stork J, Thoburn R: Is running associated with osteoarthritis?An eight-year follow up study. J Clin Rheum 1995;1:35-9.

16. Noakes T. Lore of Running. Champaign, IL: Leisure Press, 1991; pp. 1-706.

A. Gabriella Wernicke, MD Richard S. Panush, MD Department of Medicine Saint Barnabas Medical Center Livingston, NJ

Copyright Arthritis Foundation 2001

Provided by ProQuest Information and Learning Company. All rights Reserved

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