If you are a runner who hasn’t experienced an overuse injury…are you sure you’re a runner?

All kidding aside, most of us who run, whether from 5Ks to ultramarathon distances, have struggled with an overuse injury at one point or another. A study in the Journal of Orthopaedic and Sports Physical Therapy, examining 161 half and full marathoners over a 16-week training period, determined that nine out of 10 participants reported an overuse injury or illness symptom, with a one out of seven chance of developing a new injury or symptom for every two weeks of training. If that seems high, it’s the unfortunate reality for too many runners.

If an unexpected injury has hampered your training, then this article is for you. But even those who haven’t experienced issues should consider these overlooked aspects of overuse injuries to avoid them in the future.

Injuries are not just a result of too much time on your feet, but too little time off your feet.

Before we go further, I suggest we switch our terminology to cumulative-use injuries. Overuse gives the impression that we have simply done too much of a good thing. In contrast, cumulative-use means that the sum total amount of stress on our body, even if each stress we place on our body by itself is seemingly appropriate, exceeds our body’s ability to repair itself in time for the next workout. Cumulative-use puts recovery into perspective: These injuries are not just a result of too much time on your feet, but too little time off your feet.

The strength of evidence for most injury risk factors for runners varies across research literature, but I commonly reference two numbers: 30 percent over time or 10 percent at once. A prospective study of 874 runners in the Journal of Orthopaedic and Sports Physical Therapy found that an increase in bi-weekly running distance of 30 percent or more is a clear risk factor for injury. Another prospective study of 5 200 runners in the British Journal of Sports Medicine determined a significant risk of injury whenever a single running session exceeded 10 percent of your longest run in the last 30 days.

However, in my medical practice, I see runners who might stay below the above-referenced limits but then experience injury when one unbalanced aspect of their running gait or training plan gets compounded by an increase in step count. For example, insufficient glute strength can lead to knee pain over time, or training that doesn’t include enough slow runs and recovery days in proportion to the increased distance can lead to injury.

A cumulative-use injury is not an easy thing to identify or manage, so here are some strategies to ensure that each of us knows how to treat a current injury while avoiding the next one.

Distinguish hurt from harm.
It is important to understand the difference between what is truly dangerous (harm) versus simply annoying (hurt).

Symptoms (feelings) that could indicate harm until proven otherwise include numbness, tingling, weakness, or a sense of instability. Signs or outward behaviours that could indicate danger include an increased difficulty to bear full weight (at first when running, but particularly when simply walking) or the more subtle asymmetry of gait (when you feel that running turns into stiff hopping or walking turns into waddling or limping).

A stress fracture or neurologic (e.g., degenerative disc disease of the spine) injury will take far more time completely away from running than most other injuries, so it is important to first distinguish what requires medical attention – that is, those symptoms and signs that indicate harm more than just hurt.

Determine the root cause.
Assuming you have determined that your cumulative-use injury is not leading to harm, it is time to take the next step: It’s not the what, but the why that matters most.

It is important to address the root cause of your pain as much as the painful area itself. For example, even if you are experiencing patellofemoral pain syndrome (a.k.a. runner’s knee) or shin splints, the pain in the knee and shin may be more the consequence of inadequate strength at the hip. Even if you are doing squats in the gym or incorporating side-lying leg lifts with a resistance band, gluteal (butt) muscle strength is not measured by how heavy an object one can move, but how fatigue-resistant the muscle is over the course of a bout of exercise. After all, endurance sports, such as running, are not defined by how strong you are at a given time, but how strong you are over time.

Too often, an athlete will ask me if a certain treatment will relieve their pain. The answer can be complicated, because pain is not unlocked with a key, but instead a combination lock. Put another way, we can rarely fix anything with a single tool. Instead, we rely on the right combination of tools to get any job done. For example, when applied to patellofemoral pain syndrome, gluteal strengthening is critical, but it’s often insufficient without abdominal strengthening, stretching of the quadriceps or hamstrings, or even changing shoes to reduce pain at the knee.

Keep in mind that a high-tech treadmill gait analysis might not uncover what a highly experienced physician or physical therapist can reveal. A meta-analysis in Sports Medicine could not find a clear difference in stride time, contact time, cadence, and stride length averages between runners with or without a history of cumulative-use injury. The research shows we don’t have to change every running style just because an injury occurred.

Pinpoint dysfunction.
Many of my physician and surgical colleagues can have a difficult time addressing the needs of runners because they are trained to focus on what is broken more than what is dysfunctional in runners. Too often, there is a rush to obtain advanced imaging such as an MRI (magnetic resonance imaging), but it becomes awkward when trying to make sense of what to do with the information.

For example, a runner with iliotibial (IT) band syndrome will commonly present with pain at the lateral knee (toward the outside) but rarely shows a structural abnormality on an MRI. Or, excess foot pronation can cause shin splint pain in the lower leg, and imaging may not show an abnormality, but adequate arch support and/or gait retraining can eliminate the leg pain.

Conversely, an MRI might reveal a small labral tear in the hip or a meniscus tear in the knee, but this finding may not correlate with where the runner has pain.

An often-cited study in the American Journal of Sports Medicine demonstrated that in 45 volunteers, with an average age of 38 and without any history of hip pain, an MRI revealed abnormalities in 73 percent of hips, with labral tears noted in 69 percent. What this means is that the structure on imaging does not equal functional results. This can be hard to reconcile because athletes can have pain with a normal MRI, have no pain with an abnormal MRI, or have referred pain unrelated to the abnormalities on MRI. This is all the more reason to find a good sports medicine physician who can help you discern what your body looks like compared to what it needs to succeed.

So, what is the best strategy when dealing with a cumulative-use injury that is annoying (rather than dangerous) and dysfunctional (rather than broken)? First and foremost, if your injury is interrupting your training plan, it is time to see a sports medicine physician.

Keep moving.
As you work out your injury, keep in mind that you should be fixing the wing of your plane while you’re still flying. Unless you are in danger, I will always recommend finding a way to keep moving.

This means cross-training with low-impact cardio (elliptical, cycling, swimming), resistance training, and agility, such as yoga or Pilates. Remember that exercise is not a switch to turn on and off, but rather a series of dials focused on intensity, duration, and frequency.

Cross-training and dialling down help you maintain your health while you heal a cumulative-use injury. Rest from all activity does reduce pain, but it will not address the root cause of the pain. It’s like resting your bicycle after sustaining a flat tyre; without a strategy to fix the flat, no length of time off will allow you to get back on the bike the way you want.

Cumulative-use injuries are inevitable for almost every runner. However, to succeed in an endurance sport requires three key elements: setting a clear goal and then a strategy for achieving that goal; knowing when to pause the training to seek assistance from a physician, physical therapist, or coach; and understanding that a cumulative-use injury is not a reason to end a fitness journey, but instead an opportunity to better understand what it takes to sustain fitness over a lifetime.

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