Where Do Runners Get Injured Most?

Running is pretty simple on paper.

You put one foot in front of the other and repeat it over and over again.

The problem is that you’re also repeating the same loads thousands of times, so the muscles, tendons, joints and bones involved need to be able to tolerate that.

And when you look at the research, most running injuries happen in the lower limb, particularly from the knee down.

In fact, one research paper found 70% of running injuries happened at or below the knee. Something that I’m sure regular runners are very aware of.

So where are runners actually getting injured?

The Knee

The knee is one of the biggest problem areas in runners.

One of the most common issues is patellofemoral pain, which is usually pain around or behind the kneecap.

You’ll often notice it with things like:

• Running

• Hills

• Stairs

• Squats

• Lunges

• Sitting for long periods with the knee bent

The important thing to understand is that patellofemoral pain isn’t usually one specific bit of tissue being “damaged”.

It’s often better thought of as a load problem.

Basically, the amount of work you’re asking the knee to tolerate has gone beyond what it is currently prepared for.

That might be because you’ve suddenly increased your mileage, added hills, introduced more speed work, or simply increased your overall training load faster than your body has adapted.

And not every increase in load is obvious. If you’ve gained a few kilos, every running step is now being performed at a slightly higher absolute load, even if your mileage hasn’t changed.

IT Band Syndrome and Lateral Knee Pain

Pain on the outside of the knee is another really common running complaint, and iliotibial band syndrome is one of the more frequently reported running injuries.

The IT band is a strong piece of connective tissue running down the outside of the thigh but spending 20 minutes trying to absolutely destroy it with a foam roller probably isn’t achieving what you’d hope.

If foam rolling or massage helps, I’d be more interested in spending a couple of minutes working around the TFL - tensor fasciae latae - the glutes and the surrounding tissues, rather than trying to “lengthen” the IT band itself.

That may help the area feel more comfortable in the short term, but it still doesn’t really explain why the symptoms have started.

This is where you need to look at the bigger picture.

Things like:

• Running volume

• Recent increases in mileage

• Hills or speed work

• Overall training load

• Strength and running tolerance

• Previous injury

• What has changed recently

Because again, there usually isn’t one magical cause.

So if rolling your TFL for two minutes helps, great.

Just don’t confuse short-term symptom relief with actually fixing the reason the problem appeared in the first place. We need to address that issue first, not just alleviate the symptoms.

Achilles Tendon and Calf Complex

Your calves and Achilles work unbelievably hard when you run.

The Achilles tendon acts a bit like a spring or shock absorber.

Every time your foot hits the ground, it stores and releases energy to help propel you into the next stride.

Depending on running speed and how it is measured, the Achilles can experience loads of around 4-8 times your bodyweight.

And that happens over and over again.

So the muscles of the calf (Soleus & Gastrocnemius) and the Achilles tendon are repeatedly dealing with huge amounts of force, meaning that Achilles tendinopathy is extremely common especially with increases in training volume. This can often be felt as a localised pain/stiffness in the Achilles tendon which is normally more intense in the morning and reduces with movement.

And this is exactly why calf strength should be a big part of a runner’s training.

Lower Leg and Shin Splints

“Shin splints” are another really common running injury.

The proper term most people are usually referring to is medial tibial stress syndrome (MTSS).

Your tibia is exposed to repeated stress every time you run. That isn’t necessarily a bad thing, bones respond and adapt to load, and impact exercise can be beneficial for bone health.

The problem comes when the amount of stress being placed on the bone increases faster than it has time to adapt.

That’s when we can start to see problems ranging from persistent shin pain and MTSS through to bone stress injuries and stress fractures. That doesn’t mean shin splints automatically turn into a stress fracture, but both are good examples of what can happen when repeated loading exceeds the capacity of the tissues involved.

Alex has worked providing medical support at half marathons and marathons, where many people are completing their first long-distance event. One of the common injuries she encountered is suspected stress fracture, with runners needing referral to A&E for further assessment.

This is exactly why suddenly increasing your mileage can cause problems. You may have the fitness to run another 10 miles, whilst your tibia has a slightly different opinion.

Ankle Sprains

Not every running injury is an overuse problem.

Sometimes you just roll your ankle.

Ankle sprains are still common in runners, especially if you’re running trails, uneven ground or anywhere where foot placement becomes less predictable. Or maybe you just step off the curb trying to overtake the pensioners walking three abreast that don't move in for you.

And no, I’m not still bitter about this one.

The problem is that once you’ve had one ankle sprain, your risk of doing it again increases.

And if that keeps happening, chronic ankle instability can develop. I’m sure everyone has met someone who seems to roll the same ankle over and over again. Quite often, that starts with one ankle sprain that was never properly rehabilitated.

That can leave you with things like:

• Poorer balance

• Reduced proprioception (awareness of the ankle joint)

• Reduced strength

• Reduced confidence

• Worse single-leg control

• More frequent ankle rolls

This is something I pay quite a lot of attention to.

I’ve worked with runners who can run ultras but struggle to stand properly on one leg.

Which, if you think about it, is pretty crazy.

Running is basically thousands and thousands of repeated single-leg contacts. You are pushing off a single leg and then landing and stabilising on the other.

You might not be doing a literal hop every stride, but you are repeatedly landing, accepting load and pushing off one leg at a time.

So if you struggle to control a simple single-leg stance when you’re fresh, then asking that same ankle to deal with thousands of repetitions, potentially on uneven terrain and under fatigue, is something worth paying attention to.

If your balance, proprioception and single-leg control are poor, especially after a previous ankle sprain, that should probably be part of your training.

Remember, being able to run for hours doesn’t automatically mean your control, balance and lower-leg capacity are where they should be.

Some simple benchmarks I often use with runners are:

1. 60-second single-leg balance hold, barefoot

2. 30 controlled single-leg calf raises in 60 seconds

3. 20 controlled bent-knee calf raises in 60 seconds

4. Single-leg hop and stick - land under control, absorb the landing and hold the position without excessive wobbling or losing balance.

These aren’t magic injury-prevention numbers, and they’re not formal return-to-running criteria.

They’re simply practical benchmarks I use to get an idea of someone’s single-leg control, calf capacity and ability to accept load.

If someone can run for hours but struggles badly with these basic tasks, that’s something I’d want to address.

Hamstring Injuries

Hamstring injuries become more relevant as running speed increases.

The faster you run, the more your hamstrings have to deal with.

And when hamstring injuries do happen, there is one muscle that gets injured far more often than the others.

Firstly we need to address – what are the hamstrings? They aren’t just one muscle but three – the biceps femoris, semitendinosus and semimembranosus.

Because during high-speed running, the hamstrings are working very hard, particularly late in the swing phase, when they are helping control the leg as it comes through.

This doesn’t mean hamstring strains are one of the most common injuries in someone doing steady 5Ks.

They become much more relevant when you start adding:

• Sprints

• Faster intervals

• Track work

• Football

• Explosive running

The faster you want to run, the more important hamstring strength becomes. And in competitive sports like football and rugby where athletes are repeatedly sprinting and changing direction they become more commonly injured.

So Why Do Running Injuries Happen?

Usually because of a combination of things.

There is very rarely one single cause.

Previous injury, training history, strength, recovery, sleep, surface, footwear, biomechanics and overall training load can all matter.

But one thing that comes up again and again is how quickly you change your training. This is particularly common in athletes, they often see high volume as better.

So if you go from:

10 miles per week

to:

30 miles per week

You probably shouldn’t be shocked if something starts complaining. Your cardiovascular fitness can improve quite quickly but your tendons, muscles and bones don’t always adapt at exactly the same speed.

That’s where people often get caught out and this is why load management is so important.

The Big Picture

Most running injuries happen around the:

1. Knee

2. Lower leg

3. Achilles and calf

4. Foot and ankle

And the common theme with a lot of them is repeated loading.

That doesn’t mean running is bad for you.

It means your body needs to be prepared for the amount of running you’re asking it to do.

You can’t completely injury-proof a runner.

But you can make them stronger, improve their balance and single-leg control, build tissue capacity and progress their training in a way that gives the body time to adapt.

Coming Next: The Runner’s Prehab Playbook

So what should runners actually be doing alongside their running?

In the next post we’re going to look at the exercises I think runners should be doing to help build capacity and potentially reduce their injury risk.

We’ll cover the exercises I personally recommend to reduce injury risk for runners.