Injury Modifications
9 injury guides
Guidelines for safely modifying workouts when dealing with common injuries. Always consult a healthcare professional for specific medical advice.
Achilles Tendinopathy
Achilles tendinopathy is degeneration of the Achilles tendon, the largest tendon in the body connecting the calf muscles to the heel. It affects up to 10% of recreational runners. There are two distinct types with different treatment: - Mid-portion (2-6cm above heel): Most common, responds well to eccentric loading - Insertional (at heel bone): Different treatment, do NOT do eccentrics over edge The condition develops from repetitive overload exceeding the tendon's capacity to repair. It's a failed healing response, not inflammation (hence "-opathy" not "-itis"). Recovery requires progressive loading, not rest.
Warning Signs
- ⚠Pain that worsens during the run instead of warming up
- ⚠Increased morning stiffness lasting longer
- ⚠Visible tendon swelling
- ⚠Limping after running
- ⚠Pain at rest or at night
Red Flags - Seek Immediate Care
- ●Sudden pop with immediate inability to push off - COMPLETE RUPTURE, seek care immediately
- ●Unable to stand on toes on single leg - possible complete or significant partial rupture
- ●Palpable gap in tendon - likely rupture, seek immediate evaluation
- ●Positive Thompson test (squeeze calf, foot should plantarflex - no movement suggests rupture)
- ●Complete rupture is a surgical consideration - delay worsens outcomes
When to Seek Professional Care
- →Any red flag symptoms (suspected rupture)
- →No improvement after 6-8 weeks of consistent eccentric loading
- →Pain affecting daily activities despite modification
- →Uncertainty about diagnosis (is it mid-portion or insertional?)
- →Previous Achilles injury on same or other side
General Principles
- •Tendons respond to progressive loading, not complete rest
- •Mid-portion: Eccentric heel drops are evidence-based first-line treatment
- •Insertional: Do eccentrics on FLAT surface only - loading over edge is contraindicated
- •Complete rest often makes tendons weaker and more susceptible to injury
- •Expect 3-6 months for full recovery - tendons heal slowly
- •Pain during exercise is acceptable if it stays below 5/10 and doesn't worsen
Contraindicated Movements
Recommended Exercises
Eccentric heel drops - Alfredson protocol (mid-portion)
3 sets × 15 reps
Evidence-based protocol: perform with straight knee AND bent knee, twice daily. For insertional, do on flat ground only.
Isometric calf raise holds
5 sets × reps
Reduces pain acutely and maintains tendon loading capacity. Good starting point for severe cases.
Single leg calf raises (progressive)
3 sets × 15 reps
Build load tolerance progressively as symptoms improve
Soleus eccentric drops (knee bent)
3 sets × 15 reps
Targets soleus specifically, important for running
Hip and glute strengthening
3 sets × 12 reps
Reduces compensatory strain on Achilles by improving proximal strength
Return to Full Training
Criteria:
- ✓No pain during daily activities for 2 weeks
- ✓Pain-free walking including stairs
- ✓Can complete full eccentric protocol without pain
- ✓Successfully completed walk-run progression
- ✓Single leg calf raises pain-free with full range
Progression:
- 1.Week 1-2: Walk only, daily eccentrics, isometrics
- 2.Week 3-4: Walk-run intervals (3 min walk : 1 min run)
- 3.Week 5-6: Walk-run intervals (1:1 ratio)
- 4.Week 7-8: Continuous easy running, short duration
- 5.Week 9-12: Gradual volume increase (10% per week max)
- 6.Week 12+: Reintroduce hills and speedwork gradually
Hamstring Strain
Hamstring strains are tears in the muscle fibers of the hamstring group (biceps femoris, semitendinosus, semimembranosus). They occur during high-speed running, sudden acceleration/deceleration, or overstretching. There are two main types: - Acute strain: Sudden injury during activity (sprinting, lunging) - Proximal hamstring tendinopathy: Chronic overuse at the sit bone (ischial tuberosity) Hamstring injuries have HIGH recurrence rates (up to 30%) if return is rushed. Adequate rehabilitation and progressive loading are essential.
Warning Signs
- ⚠Tightness returning during or after runs
- ⚠Pain during acceleration or deceleration
- ⚠Feeling of pulling or catching
- ⚠Any sharp pain
- ⚠Compensation patterns (limping)
Red Flags - Seek Immediate Care
- ●Significant bruising tracking to back of knee - possible complete tear, seek evaluation
- ●Palpable defect or gap in muscle - complete tear, seek evaluation
- ●Popping sound with immediate severe weakness - possible avulsion, imaging needed
- ●Unable to bear weight - seek medical evaluation
- ●Complete tears and avulsions may require surgical repair
When to Seek Professional Care
- →Any red flag symptoms
- →Suspected moderate or severe strain
- →No improvement after 1-2 weeks
- →Recurrent hamstring injuries
- →Pain persisting despite adequate rest
General Principles
- •Hamstring reinjury rate is very high - don't rush return
- •Progressive loading (eccentrics) builds tissue tolerance
- •Nordic curls are the gold standard for prevention and rehab
- •Hip flexibility affects hamstring load during running
- •Adequate warm-up before speed work is essential
- •Return when you can sprint at 100% without fear or hesitation
Contraindicated Movements
Recommended Exercises
Nordic curls (progress gradually)
3 sets × 5 reps
Gold standard for hamstring injury prevention and rehab. Start with partial range, progress to full.
Prone hamstring curls (isometric → eccentric)
3 sets × 10 reps
Controlled loading in shortened position before progressing to lengthened
Single leg Romanian deadlifts
3 sets × 10 reps
Eccentric loading in lengthened position - progress to this from bridges
Glute bridges → Single leg bridges
3 sets × 15 reps
Foundational hip extension strength, start here for moderate/severe
Hip flexor stretching
2 sets × reps
Tight hip flexors can increase hamstring strain during running
A-skips and running drills
3 sets × 20 reps
Neuromuscular re-education before return to running
Return to Full Training
Criteria:
- ✓Full pain-free range of motion
- ✓Pain-free walking and jogging
- ✓Symmetrical strength on testing (within 10%)
- ✓Can complete Nordic curls without pain
- ✓Pain-free during progressive sprint protocol
- ✓Psychologically ready to sprint at 100%
Progression:
- 1.Week 1-2 (acute): Rest, ice, gentle movement, isometrics
- 2.Week 2-4: Walking, bridges, prone curls, pain-free stretching
- 3.Week 4-6: Jogging, eccentrics (Nordics), single leg work
- 4.Week 6-8: Progressive running (50% → 75% → 90% effort)
- 5.Week 8+: Return to sprinting, sport-specific drills
Hip Glute Injuries
Hip and glute injuries in runners encompass several conditions affecting the hip joint, surrounding muscles, and associated structures. This file covers the most common running-related hip/glute issues: - Hip flexor strain: Iliopsoas or rectus femoris strain from hip flexion - Piriformis syndrome: Buttock pain with sciatica-like symptoms - Greater trochanteric pain syndrome (GTPS): Lateral hip pain, formerly "bursitis" - Gluteal tendinopathy: Degeneration of glute tendons at greater trochanter Proper diagnosis is important as treatment differs between conditions.
Warning Signs
- ⚠Radiating pain down leg (piriformis/disc)
- ⚠Night pain not related to lying position
- ⚠Pain worsening despite rest
- ⚠Groin pain (may indicate different pathology)
- ⚠Clicking, catching, or locking in hip
Red Flags - Seek Immediate Care
- ●Inability to bear weight after fall - possible hip fracture, seek ER
- ●Groin pain with fever - possible infection, seek immediate care
- ●Severe groin pain with running (especially in female athletes) - stress fracture risk, stop running and get imaging
- ●Progressive leg weakness - possible disc herniation, seek evaluation
- ●Saddle anesthesia, bladder/bowel changes - cauda equina, go to ER
- ●Pain with passive hip flexion and internal rotation - possible intra-articular pathology
When to Seek Professional Care
- →Any red flag symptoms
- →Radiating leg symptoms (sciatica) not improving
- →Clicking or locking in hip joint
- →Pain with impact activities (possible stress fracture)
- →No improvement after 4-6 weeks of conservative treatment
- →Uncertainty about diagnosis
General Principles
- •Hip weakness (especially glute medius) underlies many running injuries
- •Piriformis stretching helps piriformis syndrome but diagnosis matters
- •For GTPS: Avoid sleeping on affected side, don't stretch ITB aggressively
- •Address proximal strength to prevent distal injuries
- •Neural mobilization may help piriformis syndrome with sciatica symptoms
Recommended Exercises
Side-lying hip abduction
3 sets × 15 reps
Glute medius strengthening - key for all hip conditions
Clamshells with band
3 sets × 15 reps
External rotator and hip abductor strengthening
Glute bridges → Single leg bridges
3 sets × 15 reps
Hip extension strength and gluteal activation
Hip flexor stretching
3 sets × reps
For hip flexor strain - gentle prolonged stretch
Piriformis stretch (figure-4 stretch)
3 sets × reps
For piriformis syndrome - avoid if acute
Sciatic nerve flossing
3 sets × 10 reps
For piriformis syndrome with radiating symptoms
Lateral band walks
3 sets × 15 reps
Functional hip abductor strengthening
Return to Full Training
Criteria:
- ✓Pain-free during daily activities
- ✓Pain-free during rehabilitation exercises
- ✓Completed progressive return protocol
- ✓Symmetrical hip strength
- ✓Can sleep on affected side (GTPS)
Progression:
- 1.Week 1-2: Rest from aggravating activities, begin rehab
- 2.Week 3-4: Easy flat running if tolerated
- 3.Week 5-6: Build volume gradually
- 4.Week 7+: Reintroduce hills and varied terrain
It Band Syndrome
Iliotibial band syndrome (ITBS) is one of the most common overuse injuries in runners, causing pain on the outside of the knee. The IT band is a thick band of fascia running from the hip to below the knee. Modern understanding: ITBS is NOT caused by a "tight IT band" that needs stretching. The IT band cannot meaningfully stretch. Instead, it's caused by weak hip muscles (especially glute medius) that allow excessive hip adduction and internal rotation during running, creating friction/compression at the knee. Key insight: Hip strengthening is the primary treatment, not foam rolling the IT band (though this may provide temporary symptom relief).
Warning Signs
- ⚠Pain appearing earlier in runs
- ⚠Pain persisting longer after runs
- ⚠Pain with walking or stairs
- ⚠Swelling at lateral knee
Red Flags - Seek Immediate Care
- ●Knee locking or giving way - may indicate meniscus or ligament issue
- ●Significant swelling - warrants evaluation
- ●Lateral knee pain with trauma - possible LCL injury
- ●Pain at rest or at night - may not be ITBS
- ●Numbness or tingling - nerve involvement
When to Seek Professional Care
- →No improvement after 4-6 weeks of hip strengthening
- →Symptoms severe enough to affect daily activities
- →Any red flag symptoms
- →Uncertainty about diagnosis (lateral knee pain has other causes)
- →Considering cortisone injection
General Principles
- •Hip strengthening is THE treatment - specifically glute medius
- •The IT band itself cannot be stretched meaningfully
- •Foam rolling may provide temporary relief but doesn't fix the cause
- •Downhill running and cambered surfaces aggravate symptoms
- •Shortening stride and increasing cadence often helps
- •Recovery time correlates with how long you've had symptoms
Contraindicated Movements
Recommended Exercises
Side-lying hip abduction
3 sets × 15 reps
Targets glute medius directly - key muscle for ITBS prevention
Clamshells with band
3 sets × 15 reps
External rotation strengthening, complements hip abduction
Single leg bridges
3 sets × 12 reps
Glute max strengthening with pelvic stability
Lateral band walks
3 sets × 15 reps
Functional hip abductor strengthening in weight-bearing
Single leg deadlift
3 sets × 10 reps
Hip stability and proximal control during single leg stance
Side plank with hip abduction
3 sets × reps
Advanced hip strengthening combining core and glute medius
Return to Full Training
Criteria:
- ✓Pain-free during hip strengthening exercises
- ✓Negative Ober's test or symmetric
- ✓Can descend stairs without pain
- ✓Successfully completed progressive return
- ✓Hip abductor strength symmetric or improving
Progression:
- 1.Week 1-2: No running, hip strengthening 5x/week
- 2.Week 3-4: Short flat runs (15-20 min), stop at first sign of pain
- 3.Week 5-6: Build duration on flat terrain
- 4.Week 7-8: Gradually add hills and varied terrain
- 5.Week 9+: Return to normal training with ongoing hip strength maintenance
Knee
Knee injuries are among the most common issues for runners, affecting up to 50% of runners annually. The knee absorbs significant impact forces during running (2-3x body weight per step). Most running-related knee pain responds well to activity modification, hip strengthening, and gradual return. Common conditions covered here: - Patellofemoral pain syndrome (runner's knee): anterior knee pain - Patellar tendinopathy: pain at patellar tendon below kneecap - Meniscus irritation: medial or lateral knee pain with possible catching - General overuse knee pain Note: For IT band syndrome (lateral knee pain), see the dedicated ITBS file.
Warning Signs
- ⚠Swelling increasing
- ⚠Pain worsening despite modification
- ⚠Knee locking or catching
- ⚠Knee giving way
- ⚠Night pain
Red Flags - Seek Immediate Care
- ●Knee locking (cannot fully extend) - possible meniscus tear, seek evaluation
- ●Knee giving way repeatedly - possible ligament injury, seek evaluation
- ●Large effusion (significant swelling) within hours of injury - possible ligament tear
- ●Unable to bear weight after acute injury - seek immediate evaluation
- ●Trauma with obvious deformity - ER evaluation
- ●Fever with knee swelling - possible septic joint, urgent evaluation
When to Seek Professional Care
- →Any red flag symptoms
- →Pain not improving after 2-3 weeks of modification
- →Swelling that doesn't resolve
- →Mechanical symptoms (locking, catching, giving way)
- →Pain affecting daily activities
- →Uncertainty about diagnosis
General Principles
- •Reduce impact forces through softer surfaces and shorter strides
- •Avoid excessive downhill running (eccentric quad loading)
- •Strengthen glutes and hips to reduce knee valgus
- •Consider gait analysis for form corrections
- •Increasing cadence by 5-10% often reduces knee loading
- •VMO (inner quad) strengthening helps patellar tracking
Contraindicated Movements
Recommended Exercises
Terminal knee extensions (TKEs)
3 sets × 15 reps
VMO strengthening for patellar tracking and stability
Clamshells with band
3 sets × 15 reps
Strengthens glute medius to stabilize knee and reduce valgus
Single leg glute bridges
3 sets × 12 reps
Hip strength reduces knee valgus during running
Side-lying hip abduction
3 sets × 15 reps
Lateral hip stability - key for knee health
Mini squats (pain-free range)
3 sets × 15 reps
Quad strengthening in functional position
Step-ups (low step)
3 sets × 12 reps
Eccentric control training for stairs and hills
Return to Full Training
Criteria:
- ✓No pain during or after easy 30 min run
- ✓Full range of motion
- ✓Single leg squat without knee collapse or pain
- ✓No swelling after running
- ✓Pain-free stair descent
Progression:
- 1.Week 1-2: Pain-free easy running, continue hip strengthening
- 2.Week 3-4: Add tempo work (reduced volume)
- 3.Week 5-6: Add intervals (reduced volume)
- 4.Week 7-8: Return to full training
Plantar Fasciitis
Plantar fasciitis is the most common cause of heel pain in runners, affecting the thick band of tissue (plantar fascia) connecting the heel to the toes. It typically causes stabbing pain with first steps in the morning or after periods of rest. The condition is often related to tight calf muscles, excessive training load, or inadequate footwear support. Despite the name "-itis" (inflammation), chronic cases are often more degenerative than inflammatory, similar to tendinopathy.
Warning Signs
- ⚠Pain worsening despite treatment
- ⚠Pain spreading to other parts of foot
- ⚠Swelling or bruising
- ⚠Inability to bear weight
Red Flags - Seek Immediate Care
- ●Sudden pop with immediate severe pain - possible plantar fascia rupture, seek care
- ●Fever with foot pain - possible infection
- ●Night pain not related to activity - warrants evaluation
- ●Foot numbness or tingling - nerve involvement
- ●Trauma with inability to bear weight - possible fracture
When to Seek Professional Care
- →No improvement after 4-6 weeks of consistent stretching
- →Pain affecting daily activities despite modification
- →Any red flag symptoms
- →Uncertainty about diagnosis
- →Interest in orthotics or other interventions
General Principles
- •Calf stretching is the most important intervention - do it multiple times daily
- •Never walk barefoot on hard surfaces, especially in the morning
- •The first steps of the day matter - stretch before getting out of bed
- •Arch support (shoes or orthotics) reduces fascial strain
- •Avoid flat, unsupportive shoes (flip flops, ballet flats)
- •Ice rolling can provide temporary relief (frozen water bottle under foot)
Contraindicated Movements
Recommended Exercises
Calf stretching (gastrocnemius - straight knee)
3 sets × reps
Primary intervention - tight calves are the main driver. Hold long stretches, multiple times daily.
Calf stretching (soleus - bent knee)
3 sets × reps
Targets the deeper soleus muscle which also contributes to fascial tension
Plantar fascia stretch (cross leg, pull toes back)
3 sets × reps
Direct stretch to the fascia, especially effective before first steps
Towel scrunches
3 sets × 15 reps
Strengthens intrinsic foot muscles, supports arch
Eccentric calf raises
3 sets × 15 reps
Builds calf strength and flexibility simultaneously
Frozen water bottle roll
1 sets × reps
Massage and ice combined - provides temporary pain relief
Return to Full Training
Criteria:
- ✓Morning pain resolved or minimal (<2/10)
- ✓No pain during or after walking
- ✓Successfully completed progressive return
- ✓Calf flexibility significantly improved
Progression:
- 1.Week 1-2: Aggressive stretching 5x/day, no running, walking only
- 2.Week 3-4: Short easy runs (15-20 min), continue stretching
- 3.Week 5-6: Build duration gradually, flat terrain
- 4.Week 7-8: Return to normal volume, add hills carefully
- 5.Ongoing: Maintain calf stretching routine
General Return
General Principles
- •Patience is faster - proper return prevents re-injury
- •Walk before you run, literally
- •Build volume before intensity
- •Monitor for warning signs daily
Contraindicated Movements
Return to Full Training
Criteria:
- ✓Completed all 4 phases without setback
- ✓90%+ of pre-injury weekly volume
- ✓Quality sessions at pre-injury intensity
- ✓No pain during or after running
- ✓Normal sleep and energy levels
Shin Splints
Conditions Covered
Red Flags - Seek Immediate Care
- ●Point tenderness on bone (vs diffuse muscle pain) - POSSIBLE STRESS FRACTURE, needs evaluation
- ●Pain that doesn't warm up - possible stress fracture
- ●Night pain - bone stress, needs imaging
- ●Pain with hopping on one leg - high suspicion for stress fracture
- ●Swelling directly over tibia - may indicate stress fracture
When to Seek Professional Care
- →Point tenderness on bone
- →Pain not improving after 2 weeks of rest
- →Night pain
- →Pain with walking
- →Previous stress fracture history
General Principles
- •Gradual return is critical - shin splints can progress to stress fracture
- •Address training errors: volume spikes, inappropriate footwear, hard surfaces
- •Strengthen calves and anterior tibialis
- •Consider orthotics if overpronation present
Contraindicated Movements
Recommended Exercises
Calf raises (bilateral then single leg)
3 sets × 15 reps
Calf strength absorbs impact forces
Anterior tibialis raises (heel walking)
3 sets × reps
Strengthens front of shin
Toe taps
sets × reps
Low-level tibialis strengthening
Single leg balance
3 sets × reps
Improves lower leg stability
Foam rolling calves
sets × reps
Releases calf tension that can contribute to shin stress
Return to Full Training
Criteria:
- ✓No pain during walking for 1 week
- ✓No pain with hopping test
- ✓No tenderness on palpation of tibia
- ✓Single leg hop test pain-free
Stress Fracture
Stress fractures are overuse injuries where repetitive loading exceeds bone's ability to repair, causing microscopic damage that progresses to fracture. They represent a spectrum from stress reaction (bone edema, no fracture line) to complete stress fracture. Common sites in runners: tibia (most common), metatarsals, femoral neck, navicular, pelvis (sacrum, pubic rami). CRITICAL: Stress fractures require REST FROM RUNNING. There is no "running through" a stress fracture. Some locations (femoral neck, navicular) are HIGH-RISK and require strict non-weight-bearing and possibly surgery.
Warning Signs
- ⚠Localized bone pain that worsens with activity
- ⚠Pain that doesn't improve with rest
- ⚠Night pain
- ⚠Pain at rest
Red Flags - Seek Immediate Care
- ●Severe groin or hip pain with running (femoral neck stress fracture) - STOP running, non-weight-bearing, urgent imaging
- ●Hop test painful - likely stress fracture, stop impact activity
- ●Complete fracture symptoms (deformity, significant swelling) - ER evaluation
- ●Night pain not resolving - warrants imaging
- ●Femoral neck stress fractures can progress to COMPLETE FRACTURE requiring surgery
- ●Female athletes with stress fractures should be evaluated for RED-S / low energy availability
When to Seek Professional Care
- →Suspected stress fracture (localized bone pain with running)
- →Pain not improving with rest
- →Any red flag symptoms
- →Any hip/groin pain in runners (to rule out femoral neck)
- →Recurrent stress fractures (need metabolic workup)
- →Female athletes with missed periods + stress fracture
General Principles
- •Stress fractures require rest from impact - there is no alternative
- •MRI is the gold standard for diagnosis (X-ray often negative early)
- •Night pain and pain at rest suggest stress fracture, not soft tissue
- •High-risk locations require immediate orthopedic referral
- •Return too quickly = high risk of refracture
- •Address underlying causes: training errors, footwear, nutrition, hormones
Recommended Exercises
Pool running (aqua jogging)
1 sets × reps
Maintains running fitness without impact
Upper body strength training
3 sets × 12 reps
Maintain overall fitness during recovery
Core strengthening
3 sets × 15 reps
Maintain trunk stability for return to running
Single leg balance (unaffected leg)
3 sets × reps
Maintain proprioception and stability
Return to Full Training
Criteria:
- ✓Pain-free walking for 2 weeks
- ✓Pain-free with hopping (10-20 single leg hops)
- ✓No tenderness at fracture site
- ✓Cleared by physician (may require follow-up imaging)
- ✓Adequate time has passed (varies by location)
Progression:
- 1.Week 1-2 after clearance: Walk-run intervals (4 min walk : 1 min jog)
- 2.Week 3-4: Walk-run intervals (2:1 ratio)
- 3.Week 5-6: Continuous easy running, short duration (15-20 min)
- 4.Week 7-8: Build duration, maintain easy effort
- 5.Week 9-12: Build volume (10% per week max)
- 6.Week 12+: Reintroduce intensity gradually