1. Overall Approach
  2. Top Concern
  3. Causes
    1. Training error
    2. Flexibility
      1. Strength and flexibility
    3. Muscle imbalance
    4. Bad form
    5. Footwear
  4. Common Injuries
    1. Plantar Fasciitis (PF)
    2. Iliotibial Band Syndrome (ITBS)
    3. Achilles Tendon Injuries
      1. Treatment
  5. Anterior cruciate ligament (ACL) injury
    1. Overview
    2. Evaluation
    3. Prevention
    4. Resources
  6. A Note on Rest
  7. References

Overall Approach

Honestly, I have been many injuries myself, and my approach is always to put my body’s message before everything else.

  1. Be sensitive and cautious
    • Stop at any median level discomfort
    • Test, diagonize, evaluation before return to normal training
    • Be sensitive
  2. Short-term
    • Fix the symptom/pain through rest (or/and anti-inflammation drugs with professional instruction).
    • Inspect and fix external factors, such as shoes.
    • If it is related to over-training, adjust training plan.
    • Use equipments to reduce the pain and help body to heal.
  3. Long-term
    • Identify the root cause (e.g., bad forms, muscle imbalance/inflexibility/weakness).
    • Fit in cross training with focus on mitigating the root cause (e.g., strength/stability training, stretching).
      • Strong runners are much less likely to get injuries. So don’t be afraid of weight training.
    • Consider more warm-up/cool-down, and/or active recovery (e.g., massage/icing).
    • Consult professional (e.g. physical therapist)

Top Concern

For any runner, injury prevention should be the top priority!

This is not only for general health concern. Injury is probably the top factor that impacts runners’ performance and training.

Causes

Training error

Over-training andd insufficient recovery probably contributed to majority of runners’ injury.

Remediations:

  • Start with a good plan
  • Listen to your body’s recovery – adjust frequently while keep the big goal. Let go the ego.
  • Stick to a “dynamic” plan – don’t over train within the plan

Flexibility

This is can be controversial. In general, inflexibility increases the chance of injury, but often not the direct cause.

Remediations:

  • More warm-up/cool-down (note, DO NOT over-do it)
  • stretching
  • Cross training
  • Also, improve muscle balance

Strength and flexibility

Interestingly, strength and flexibility is naturally conflicting in our body. A heavily trained muscle group is often stiff, which is human body’s way to improve its strength.

Stretching, which is believed to improve flexibility, also reduces the body’s effort to make the muscle stronger.

You will need to find a balance in pursuing the two - strength vs flexibility.

Muscle imbalance

Muscle imbalance often leads to muscle fatigue during training, which increases the chance of injury.

Remediations:

  1. Cross training
  2. Drills
  3. Improve flexibility

Bad form

It is challenging to change the forms by oneself. Interesting, pros also have various forms if you observe carefully. It is not saying forms are not important. Rather, human body’s great adaptation over one’s life time can make everyone’s form specific to itself.

Remediations:

Footwear

It might be the hottest topic everyone cares. But, I don’t believe too much in the shoes’ mysterious mileage limit. I’d rather pay attention to how it feels on my feet everyday.

Common Injuries

Disclaimer - I am not a professional physical therapist. Rather, I am just sharing what I learned over my research and personal experiences.

Plantar Fasciitis (PF)

PF is a common injury typically in a form of pain in the heel, or bottom of the heel. Often it is the worst in the morning with the first few steps. It is related to overuse of the plantar fascia. That is, *feet are used too much, so that the fascia is used to compensate in place of muscles.

As for treatments, short-term is often to reduce pain and let it heal, while maintain the muscle groups that should have taken the load instead of the fascia. The long-term solution is to progress training slowly while keep the muscle groups strong.

Treatment of Plantar Fasciitis is so far the best reference I have found.

High level

  1. Identify training errors - Relative rest, apply ice after training and evaluatoin of shoes.
    • Shoes - to reduce the load on feet
      • Change for wider/larger shoes
      • Better cushioned midsole
  2. Correct biomechnical factors with stretching and strengthening.
    • Stretching - calves
    • Strengthening
      • Towel curl

      towel curl

  3. Running forms
    • Land softly reduces the stress.
    • Avoid excessive landing on toes or balls.
  4. If no improvement, consider night splints and orthotics.
    • Equipment
      • Arch support and orthotics
      • Night splints
  5. If still no improvement, check if professionals for more serioues treatment.
    • Drugs (short term)
      • anti-inflammatory drugs – results unclear. Ok for short term pain relief.
      • Ice 10-15min might help
    • Other serious treatments, e.g., corticosteroid injections, surgery.

Iliotibial Band Syndrome (ITBS)

Symptom - Often pain at hip or outside of the knee.

Causes - irritated iliotibial band (ITB). Often the tightened ITB will cut into the knee, which causes the pain there.

Treatments are similar to PF

  1. Rest to reduce the on-going pain and inflammation.
  2. Apply ice or other therapy to speed up recovery.
  3. Stretch
  4. Strengthen muscle groups in glute and thigh (e.g., quad, hamstring).
  5. Improve balance

Achilles Tendon Injuries

Causes - the common cause is over-use.

Treatment

Note, tendon heals very slowly. The way our body heals is to lay down new fibers. However, such newly formed layers can be damaged by excess stretching.

To avoid it, pay special attention to calf stretching/strengthening exercises. You can replace stretching calves with foam roller, or massage.

Avoid low-heel (or low drop) shoes to reduce load on the tendon. Some amount of cushion can be considered as well.

  • Reduce impact - more cushioning, low workload (distance, pace, slope)
  • Rehab exercise
    • isometric (still-motion) exercise. Stressed relaxation - the only proven exercise to stimulate healing. tendon slowly extend
      • the right amount of tension - 70% of max force output (that’s a lot!)
      • ~30 seconds, 3-6 sets. 2-3 kinds of exercises. Every 2 days.
      • make sure recovery to baseline <=24 hours.
      • For achilles, e.g., isometric calf raise with weights.
    • Also acceptible to use slow and eccentric exercise to strengthen the muscles while maintaining reasonable load
  • Nutribution - gelatin (?) & Vitamin C
  • Massage - improve flexibility of connected muscles
  • Healing takes multiple 3-18 months

Traditionally, we want to reduce inflammation and pain to get back to running quickly. It might treat the sympton, but may result a poorly recovered tendon.

Different stages of injury:

  1. Stage 1: Reactive Tendinopathy - acute, non-inflammatory - easy to recover
  2. Stage 2: Tendon Dysrepair - if continue to be overloaded. Healing is increasely attempted, but is disorganized. Still reversible with proper treatment and rehabilitation.
  3. Statge 3: Degenerative Tendinopathy - Large structure disorganization and breakdown.

Sample exercise

  1. Phase 1: Isometrics & Basic Loading (Approx. Weeks 0-2):
    • Goals: Settle tendon reactivity, introduce pain-free load.
    • Interventions: Seated or standing isometric calf raises (3-5 sets of 45s holds). Progress to isotonic, two-legged heel raises on a flat surface (3 sets of 15). Avoid stretching into deep dorsiflexion.  
    • Progression Criteria: Tolerable pain (<4/10) during exercises; no morning stiffness flare-up.
  2. Phase 2: Heavy Slow Resistance (HSR) (Approx. Weeks 2-12):
    • Goals: Build robust strength in the gastrocnemius and soleus muscles.
    • Interventions: Perform HSR 3x/week, progressing load from 15RM to 6RM.  
      • Standing Straight-Knee Calf Raises: (Targets gastrocnemius) 3-4 sets.
      • Seated Bent-Knee Calf Raises: (Targets soleus) 3-4 sets. Use a slow tempo (3s concentric, 3s eccentric). Perform on a leg press, Smith machine, or with a backpack for added weight.
    • Progression Criteria: Consistent strength progression with good form and tolerable pain.
  3. Phase 3: Energy Storage & Release (Plyometrics) (Approx. Weeks 8-16+):
    • Goals: Re-train the tendon’s spring-like function.
    • Interventions: Introduce plyometrics 2x/week.
      • Quick-rebounding heel raises: (pogo hops) 3 sets of 20.  
      • Progress to skipping, hopping in place, and eventually box jumps.
    • Progression Criteria: Able to perform 3x20 pogo hops with minimal pain; demonstrates good control.
  4. Phase 4: Return to Sport (Approx. Week 12+):
    • Goals: Gradually return to running and sport-specific activities.
    • Interventions: Implement a structured walk-to-run program. Gradually re-introduce hills, speed work, and sport-specific drills, always guided by the 24-hour pain-monitoring model.  
    • Progression Criteria: Can complete sport-specific training sessions without a significant flare-up of symptoms.

Anterior cruciate ligament (ACL) injury

(Note, this is mostly my notes from the “Resources” section below)

Overview

About 2/3 people suffered from ACL injury can’t return to the sports, and many of them develop chronicle issues. Many atheletes suffer from ACL injury since it is one of the most volunerable part of our lower body that bears extreme stress during sports.

There is a recent trend of such injury in young atheletes, possibly indicating increased risk due to new life style or increased competition levels.

Evaluation

A 3 point inspection is proposed by different sources, which focuses on three parts of our body.

  1. Upper body alignment:
    • Ear-shoulder-hip should be in a straight line.
    • Chest up. Eye up. Shoulders down, back and even.
    • While standing by the wall: heel, hip and back of head should touch the wall. Standing tall.
  2. Middle body alignment / core control:
    • Pelvis(waist line) should be horizontal, when viewed from front and side. Maintain horizonal pelvis while performing different positions:
      • Lower to the quarter squat position (thigh 45 degree, arms straight forward)
        • To find the right position, tilt pelvis back and force, to find a natural position.
        • For Anterior pelvis tilt (tilt too much forward):
          • Ribs down, belly button towards spline
        • For posterior pelvis tilt (tilt too much backward):
          • Chest up, arch lower back
        • (Stability) Make sure can maintain such position while being pushed lightly on the back.
      • Single leg knee up stand
      • Plank – spine in neutral position
  3. Lower body alignment:
    • Hip-knee-ankle in a straight line, when viewed from front
    • Knee cap over pinky toe
    • Maintain such alignment while in different positions and movements:
      • Quarter squat
      • Running forward (both knees should be in alignment at any time)
      • Jumping (jumping jack, squat jump, forward/backward hop)
      • Changing direction (lateral jump, run-then-stop, run-then-stop/turn).

Prevention

Fortunately, neuromuscular training is proved to reduce such risk dramatically. Such training should cover all following phases:

  • Movement prepare
    • A/B/C Skip - keep all 3 points in the right positions
  • Core control
    • Plank (standard, side)
    • Superman position
    • Single leg knee up (or touch the heel with hand), while maintaining the 3 points.
  • Lower body strengthening
    • Lounge
    • Standard squat
    • Single leg squat
    • Toe up
    • Jump
  • Jump and landing
    • Double leg hop (left and right)
    • Scissor jump (lounge, jump, switch legs and land).
    • Squat jump
      • Start from standing position
      • Small hop to the quarter squat position, make sure to check all the 3 points
      • When landing, move hip slightly backwards to absorb the shock, and land softly on the balls of the feet
      • Arms forward to keep balance
      • (advanced) Vertical/forward jump, and back down to the squat position
      • Cues – hip back, chest up, eye forward, land softly
  • Change speed and direction
    • Run forward and stop
      • Lower center of gravity
      • Move/run forward
      • Widen the base of support (leg spread out wide)
      • 3 steps to a full stop
      • (Mutation) 3 steps to a full stop with 90-degree turn. In this case, the exerior leg bear more force.
    • Snake run - run around a series of cones.

HSS provides a greate collection of neromuscular warmups based on skill levels.

Resources

A Note on Rest

It is a bit contraversial that lying-flat kind of rest is not suggested, since it reduce the muscle and other performance ability quickly, which may not idea for overcoming the symptoms. Rather, controlled exercise is often suggested.

Depending on the severity of the condition, the pain may kick in only after certain distance (e.g. 2 mile of running). So try to run in a moderate pace and stop before 2 miles. You can repeat after some rest. This kind of run-and-rest will allow the muscles some time to rest and recovery, while still being stimulated to perform. Note, don’t push it too hard, and it may reduce the speed of recovery.

Another suggestion is to consider other (hopefully related) sports, that can maintain physical conditions while reduce the load on the particular area (foot in this case). So things like cycling and rolling are good options. Actually, many runner may find symptom reduced by simply running on threadmills or rubber running tracks, where the extra cusion from the ground reduces shocks to the feet.

References