How to Prevent Common Running Injuries

Proper form, strength training, and the right shoes can prevent injury.

Friday, May 17, 2013, 12:00 am
Joshua Simpson

It's an all too common scenario: Runner begins training program. A month or so later, a twinge settles on a knee. Runner stretches, pops ibuprofen, keeps running. A few—or maybe 100—runs later, runner is on the couch, ice pack on knee. What are the chances? The answer isn't exactly clear: A review of studies suggests that as few as 19 percent or as many as 79 percent of runners are sidelined each year. Many multiple times. Some—ouch—never run again.

The good news: Researchers are on the hunt for an injury solution, perhaps more fervently than ever, in part thanks to the release of Born to Run in 2009. The best-selling book, which claims that the modern running shoe is the culprit behind the sport's high injury rate, got runners talking about shoes and form, and it spotlighted the debate about the cause of injuries. Is it the way we run? The shoes we wear? Because we sit all day? Or do we keep repeating training mistakes: big jumps in mileage; running the same five-mile route, on the same side of the road, week after week?


The true cause is all of the above. Injury—and injury-prevention—is multifaceted. "A combination of things—for example, an anatomical issue plus a training error and the wrong shoes—can add up to injury," says Joseph Hamill, Ph.D., a biomechanist at the University of Massachusetts, Amherst. Plus, every runner is a puzzle, with a different anatomy and injury history, says Anthony Luke, M.D., director of RunSafe at the University of California, San Francisco. "Which is why injury prevention is so challenging." But over the last decade, running science has shifted its focus from treatment to the prevention of injury. Scientists are studying uninjured runners to decipher who gets hurt—and who doesn't—and why.

Most experts agree that to lower injury risk, you need not a magic bullet but a loaded gun. One with a three-bullet chamber: a strong body, good form, and the right shoe. On the following pages, we take a closer look at each, offering exercises, form tweaks, and shoe advice that all runners can use to lessen their chance of injury and enjoy a long, happy, ice-pack-free running future.

Add Strength
In the battle against injury, a runner's best armor is a strong body. Strong muscles, ligaments, and tendons guard against impact, improve form, and lead to a consistent gait. "If muscles are weak, one footfall will not be like the rest," says Reed Ferber, Ph.D., director of the Running Injury Clinic at the University of Calgary. "How your knee turns in, your hip drops, your foot pronates changes with each step. But with strength, these movements are the same each time, so your mind and body know what to expect."

When a strong body runs, the brain tells the muscles to brace for impact before the foot hits the ground. The glutes and core contract to steady the pelvis and leg. The foot and ankle muscles are activated, providing a solid foundation to land upon.

But if one stabilizer isn't strong enough or isn't recruited, other muscles get overworked, and the entire chain of movement is disrupted, says Eric Orton, a running coach featured in Born to Run and the creator of the recently launched B2R Training System, which combines strength training with form changes to reduce injury risk.


Most runners lack strength in at least one muscle group, as well as in their neuromuscular pathways, the lines of communication between brain and body, says Jay Dicharry, M.P.T., the director of the REP biomechanics lab at Rebound Physical Therapy in Bend, Oregon, and author of Anatomy for Runners. Strong pathways help muscles fire more efficiently and in quick succession, which enables you to run with greater control and stability.

These exercises, adapted from Dicharry's and Orton's programs, strengthen running's key muscles and those neuromuscular pathways. You can do them as a full routine or insert them into your day while watching TV two or three times a week. If possible, do the moves barefoot.

This video shows you how to perform the exercises below:

Donkey Kicks with Bar  
Why: By adding a bar (or broomstick) to this old-school move, you teach the body to fire the glutes without arching your back—just like you should while running.
Bonus: You're also strengthening the transverse abdominus, a stabilizing muscle in your core.
How: Begin on all fours with the bar across your lower back. Lift one leg back, knee bent at 90 degrees, keeping the bar still. If the bar moves, perform smaller movements. Do 50 reps on each leg.


Wall Press  
Why: Activates the gluteus medius in a bent-knee position, similar to running
How: Stand with your left side near a wall. Bend your left knee 90 degrees and make contact with the wall. Push your knee into the wall and hold, while keeping your body stable (i.e., don't press your shoulder against the wall). Hold for 20 to 30 seconds. Do two or three sets on each side.

Single-Leg Balance on Forefoot  
Why: Increases strength in the entire leg chain: big toes, calves, ankles, and hips
How: Balance on one leg on your forefoot (barefoot is ideal), heel off the ground. You should feel the side of your hip (gluteus medius) working. Hold for as long as you can keeping the body tall. When you lose balance, rest, then repeat three more times.

Eccentric Heel Drop  
Why: Strengthens calves, ankle muscles, and Achilles tendons, which allow for a stable landing when running
How: Stand on one leg on a curb or step with your heel off the edge. Lift up onto your toes, then slowly lower down until your heel is below the step. Start with a set of 10 on each leg. Build to three sets of 15.

Clam Shells  
Why: Strengthens gluteus medius to improve knee and pelvis stability
How: Lie on the floor on your side, legs stacked. Bend both knees, keeping legs and feet aligned. Open the knees like a clam shell while keeping your feet together. Do two sets of 30 on each side.
Next Level: Put a resistance band around your thighs.

Stability Ball Bridge  
Why: Strengthens and activates the gluteus maximus and the multifidus (small muscles in the back that aid spine stability)
How: Lie on the ground with calves on a stability ball, arms extended out. Lift your hips up off the floor so your body forms a straight line from ankles to shoulders. Hold. Once you can hold comfortably—and without your hips dropping—for 60 seconds, move on to a greater challenge.
Next Level
1) Place your feet on the stability ball and cross your arms over your chest to perform the move.
2) From the lifted position, do single leg lifts, alternating lifting your left and then your right leg into the air.
3) From the lifted position, rotate your body in each direction, with control, to activate more core muscles.

Stability Ball Walkout  
Why: Strengthens core, arm, and shoulder muscles for better running posture
How: Lie face down, stomach on the ball, palms on the floor in a push-up position. Walk your arms out, keeping your abdominals tight, until your shins are on the ball. Keep your back straight. Hold for 30 seconds; build to two sets of 60 seconds.
Next Level
1) Walk out until just your feet are resting on the ball.
2) From a plank position with shins on ball, pull your knees to your chest.

Single-Leg Balance and Squat  
Why: Develops balance in pelvis, ankles, and feet so your body lands on a secure platform every time you take a step
How: Balance on one foot (shoes off, ideally), with your back straight, arms in running motion, and your weight evenly distributed between your fore and rear foot. Once balanced, press your big toe into the floor and hold for 30 seconds. Aim for three sets on each leg.
Next Level Standing on one leg, lower your hips back, bending your standing knee. Then push back up. If you can't keep your hips even and your knee aligned over your foot, stick with just the balance move.

Jumping exercises increase elasticity—the springs that give running a light, bouncy feel. But they can also teach you how to minimize your impact on landing. If you're not currently strength training, add these moves after performing the other exercises in this program for eight weeks.

Standing Jump  
How: Use a step at a gym (or find wide steps at a park or building) about midshin height. Standing with the step directly in front of you, jump up with both feet landing softly. Step back down. Do 10 to 20 times.
Next Level: When you can no longer hear your feet landing, jump up and then jump back down off the step.

Lateral Jumps  
How: Place a pole (or broom) on the ground and jump over it quickly side to side, staying on the ground as little as possible. Aim for three sets of 10 jumps.
Next Level: Switch out the pole for something taller, like a foam roller; the added height creates a bigger challenge.

The natural stress-recovery cycle of training can cause muscle fibers to knot up and stick together, limiting their function and leaving you more susceptible to injury. Breaking down these adhesions increases what's known as tissue mobility, which allows muscles to properly contract and lengthen. These exercises increase mobility in notorious problem areas for runners. Do them after a run.

Kneeling Hip-Flexor Stretch  
Why: The leg swings like a pendulum from the hip when you run, and if you have tight hip flexors, the back swing is limited. That can contribute to overstriding (landing too far out in front of your body), which puts more stress on the leg joints.
How: Kneel on one knee in a doorway so that your back is pressed against the inside of the door frame. Tuck your pelvis under so that you feel a stretch in the front of your thigh. For a deeper stretch, rotate your front foot slightly out. Hold for three minutes.

Foot Massage  
Why: Your plantar fascia, a band of tissue along the bottom of the foot, guides the foot from landing through to toe-off when you run. Limited mobility can affect this motion and lead to problems all the way up to the hip.
How: Sit down and prop one ankle on top of your knee. Using your thumbs, apply pressure to the arch of your bare foot, prodding for tender areas. Press firmly on any sore, tight spots, then flex and extend the toes to release the tissue. Do for three minutes daily until the soreness is gone.

Calf Smash   
Why: Knotted calf muscles are less-effective shock absorbers.
How: Sit on the floor with a foam roller under the calf of your extended leg. Roll your calf over the roller, and when you find a painful spot—a sign of knotted tissue—press into the roller. Hold until the pain dissipates (usually 30 to 90 seconds). Alter your position slightly and repeat. When that no longer hurts, ask a partner to press down on your shin to add pressure.

Can Strength Training Fix Faulty Form?
Strength training can improve your form (makes it more stable, corrects imbalances), but it can't resolve faulty biomechanics. If you have knock knees, for example, you will need to train your body to run differently through a process called gait retraining, says Irene Davis, Ph.D., P.T., director of the Spaulding National Running Center at Harvard Medical School. In two studies, Davis gave runners visual and verbal cues to gradually retrain their movement patterns. The runners were able to correct their flawed form and maintain the new improved mechanics after just eight training sessions. Davis advises seeking out a physical therapist with gait-retraining experience instead of attempting it on your own. Without proper feedback, it's difficult to know if you're making the right corrections, she says.

Improve Form
If you want to stir up debate in your running group, bring up form. Proponents of minimalist-style running and other methods (see "Finding My Chi") believe that just as there is a correct way to swim or swing a tennis racket, there is a right technique for running. Other experts say the way we run is individual, and messing with it invites injury. (Find an in-depth discussion of this debate at Does Running Form Matter?.) But there is some common ground: Both camps agree that certain components of form, such as good posture and proper stride (as demonstrated here by Olympian and world champion triathlete Andy Potts), can help prevent injuries. Here's a look at these elements.

Just before the foot strikes, the brain sends a signal to the muscles to prepare for impact. The muscles contract so they can stabilize the joints. If this line of communication is weak or slow, the muscles won't get this heads-up.

1. Run with Good Posture
What It Means: Upper torso straight, lower back not arched, head directly over shoulders
Why It Matters: Poor posture can put excess stress on back and knees. If your back arches, your body weight tends to shift back, making you more prone to overstriding.
Try This: Strengthen your core and upper body. Practice good posture during the day. Bad postural habits carry over to your run.

2. Swing Arms Efficiently
What It Means: Arms moving forward and back
Why It Matters: Arm swing affects trunk stability. An across-the-body arm swing tends to rotate the shoulders, or cause the trunk to sway, compromising core stability.
Try This: Bend your elbows about 90 degrees and let your arms swing relaxed. Keep your elbows close to your body with your hands loose, which helps the entire body relax.

Some studies connect the impact forces of this touchdown phase to stress fractures and other injuries. And while midfoot- and forefoot-strikes minimize forces, experts agree that the greater hazard is overstriding—when the foot lands well ahead of the knee.  

3. Land Lightly
What It Means: Consciously landing more softly
Why It Matters: "When we try to run quietly, we make natural adjustments like shortening our stride and landing on our midfoot, which lessens impact forces," says Anthony Luke, M.D., of RunSafe.
Try This: Run in place, letting your knees rise naturally for 10 seconds. Then lean forward and run for 50 yards holding that posture. Repeat three times before you run.

The foot is moving through pronation, and forces are at their peak, which makes this phase the most potentially injurious. Loads as high as 2.5 times your body weight pushing down on unstable hip, knee, ankle, and foot joints can wear down muscle, tissue, and bone.

4. Lead with Your Hips
What It Means: Initiating the running motion from the center of your body
Why It Matters: Running from your hips and driving forward with your knees rather than your feet helps you maintain a tall posture and avoid overstriding.
Try This: Engage your core muscles and imagine stepping over logs while you run.

5. Evaluate Your Cadence
What It Means: Your step rate, the number of footfalls you take in a minute
Why It Matters: A faster cadence can minimize overstriding and reduce forces on the joints.

Should You Increase Yours? Some experts see the value if your easy stride rate is 160 steps or less (a sign of overstriding) or if you're injury-prone. Count every footfall. If you're above 160, not injured, and not overstriding (ask a friend to shoot a video of you and check your foot and knee position), there's little reason to change. If you want to experiment, increase it by five percent.

The hip goes into maximal extension; if hip flexors are tight, you're more apt to excessively arch your back.

6. Engage Your Glutes
What It Means: Tapping your butt just for a second or two occasionally as you run is a simple way, says Dr. Luke, to remind your body to contract and engage your glute muscles.
Why It Matters: It keeps you thinking about form. &quot;Having an awareness of what your body is doing, where your feet are, what muscles are working helps you become a better runner,&quot; Coach Orton says.

Should You Change Your Footstrike?
It depends whom you ask. Some experts believe that landing on your mid- or forefoot, rather than your heel, greatly reduces injury risk, and some data supports that. Others believe there's a strong chance you'll trade one injury for another because landing on the forefoot increases impact forces on the calf and Achilles tendon. Further complicating the matter: Studies show that it's difficult to know how you're striking the ground (you think you're midfoot- or forefoot-striking but you're actually heel-striking, and vice versa).

This is a reason some experts say it's more productive to focus on not overstriding, which is easier to determine on your own. The bottom line: If you're running injury-free, most experts say don't bother changing. But if you're chronically injured, footstrike is another tool that could aid treatment and prevention. If you decide to try it, the transition must be gradual (coach Eric Orton has his runners start with just 10 minutes of forefoot landing) and accompanied by plenty of foot, ankle, and calf strengthening.

Avoid Overstriding
What It Means: When the foot lands well ahead of the knee
Why It Matters: Overstriding increases forces on the body, putting excess wear and tear on muscles, joints, and tissue.
Try This: Focus on where your foot is landing in relation to your body, and land as close to your body as possible. Your lower leg should be vertical when your foot first contacts the ground. B2R running coach Eric Orton suggests this cue: When you run, rather than reaching with the foot, drive forward with the knee. Since it's tough to overstride when climbing inclines, he recommends incorporating a weekly hill workout into your routine to give you a feel for the correct form.

Find Shoes

Can a shoe help prevent injury?
Yes, shoes can reduce injury risk because they can alter your form and how the repetitive forces of running are applied to your body. For example, research shows that the firmness of shoe cushioning can influence the stiffness of your legs (i.e., amount of bend at the ankle, knee, and hip), which affects how forces impact your muscles, bones, and joints. If you're in a shoe that applies forces in a way that your body can manage and is a good match for your training (road or trail, for instance), the shoe can help reduce injury risk. Try rotating among a few pairs: A trainer for long runs, grippy shoes for trails, flats for speedwork, and minimal shoes for form drills. The variety mixes up how force is applied and may reduce stress in the legs and feet.
Peter Larson, Ph.D., associate professor of biology at Saint Anselm College, coauthor of Tread Lightly: Form, Footwear, and the Quest for Injury-Free Running, and author of Runblogger

How do I know if I'm in the right shoe?
You want a shoe that fits your biomechanics. Specialty-running-store assessments are helpful but not foolproof. My best advice is to go by comfort. If it doesn't feel good, it means it's putting stress somewhere you don't want it to. If you have aches and pains after you've run in a pair of shoes, it might be a sign you're in the wrong ones. If your shoe does feel good, it's likely a good one for you.
Benno Nigg,, Human Performance Laboratory, University of Calgary, author of Biomechanics of Sports Shoes

How can a shoe specialist help me find the right pair?
Our job is to find the shoe that best complements your foot shape and biomechanics. If we do that, we can minimize a shoe's role in the injury equation. Expect staff to ask about your training, look for wear patterns on your old shoes, examine and measure your bare feet, and watch you run in a few pairs. (If this doesn't happen, I'd go elsewhere.) When a shoe feels great and allows for neutral pronation—not too much or too little movement—it's likely a winner.
J.D. Denton, co-owner, Fleet Feet, Davis, California, and a 30-year veteran in the running industry

Should I switch to a minimal model for injury prevention?
There is no compelling evidence that says a minimal shoe will reduce injury. Some runners have switched and have had positive, transformative experiences. Others have been hurt and disappointed. Runners with smaller, leaner bodies, midfoot- and forefoot-strikers, and those with little or no injury history are most likely to make the switch without problems. Plus-sized runners, extreme heel-strikers, and anyone with chronic injury issues will take longer to adapt and may find that their more substantial, conventional shoes work better for them.
Martyn R. Shorten, Ph.D., director, Runner's World Shoe Lab, BioMechanica, LLC, Portland, Oregon

I bought minimal shoes. Now what?
Transition gradually. Spend the first week just walking in them. The following week you can start running in your new shoes—but wear them at most every other day for the first two to three weeks, and only do a mile or two in them. Whatever amount of running you start in your new shoes, hold at that level for at least a week. Then increase only by whatever your original amount was. Gradually introduce them to harder workouts.
Scott Douglas, author of The Complete Guide to Minimalism and Barefoot Running

Do orthotics work?
There has been surprisingly little research linking orthotics—a shoe insert that alters or controls motion—to injury prevention. But for people with excessive pronation or flat arches, inserts can help. Studies show that an over-the-counter orthotic can be just as effective as a custom-made one, so try those first. If you still have pain, see a physical therapist who specializes in running.
Reed Ferber, Ph.D., director of the Running Injury Clinic and associate professor of kinesiology, University of Calgary