31% of runners struggle with injuries lasting more than a year. Learn how to be proactive when navigating your body's white flags. đłď¸
By Patrick McGlade – CTS Ultrarunning Coach and Physical Therapist
Ultrarunning is an exercise in controlled excess. Athletes enjoy pushing themselves beyond what they previously thought possible. We can train for the time on our feet, for elevation changes, the heat and cold, but at a certain point our bodies will wave the white flag and break down. Collectively, ultrarunners are historically poor at avoiding injuries.
Throughout my time in the clinic and as an ultra running coach for CTS several commonalities arose amongst ultra runners. I wonât delve into traumatic injuries which are certainly more prevalent in ultras than road marathons. Rather, I will discuss plantar fasciitis, achilles tendonitis, knee pain, proximal hamstring tendinopathy, and ankle injuries. The discussion below is meant to be a starting point for common ailments, not a diagnostic tool or comprehensive treatment plan.
Cause: Irritation to the connective tissue that runs from the bottom of the heel along the arch of the foot and connects to the ball of the foot. Irritation can arise from poorly fitting shoes, significant increases in running volume, elevation gain, or intensity without modulation.
Symptoms: Pain at the heel, particularly after rest or first thing in the morning.
Pitfalls: PF can almost completely disappear after a warm up period, which can be deceptive because athletes will easily ârun throughâ the injury prolonging the recovery.
Remedies: Temporary use of OTC orthotics can help offload the tissues while you are working on strengthening exercises like toe yoga, calf raises with a ball, and single leg stability work. The orthotics wonât benefit you long term, so make sure youâre discussing the use and discontinuation of the orthotic with your provider once strength has been improved and irritation is decreased. Decrease the training load that led to the injury. When you look back over your training log, try to identify patterns for what changed in the time since the injury began. Use this as the starting point for decreasing the training load.
Toe yoga – play with your toes. Seriously – just take off your shoes and while sitting or standing, try to spread out your toes, bunch them up together, try to move different toes in isolation, just become more familiar with your feet.
Calf raise with a tennis ball between your heels – Just as it sounds. Take your shoes off and in a slow and controlled manner do calf raises while squeezing a tennis ball between your heels. Complete three sets of 15 repetitions with one minute rest between sets.
Stand on one foot – Take your shoes off and balance on one foot. If that is too easy, then reach for something outside your immediate area. Compare each side – is one easier than the other?
Cause: If the pain didnât start after a fall or trauma, then knee pain is typically caused by tight quads or hips.
Symptoms: Each knee injury is going to present a little differently. Patellar tendonitis is typically characterized by pain on the patellar tendon (area just distal to the patella), often in conjunction with downhill running. Iliotibial band issues typically present with pain and tenderness through the lateral knee, and pain increases with a bent knee.
Pitfalls: If knee pain is only present while running downhill it can be difficult to identify before you are in a position where you need to get yourself back down the mountain. Very few runs start downhill⌠unless youâre running into the Grand Canyon.
Remedies: A good warm up routine with dynamic stretches; no static stretching prior to running.
Foam rolling – Use foam rolling on your quads, the front of the hip, and tensor fascia lata (TFL) are good places to start to alleviate pain. A little goes a long way. Youâre better off doing five to ten minutes in the morning and five to ten minutes in the evening than you are tenderizing yourself for an hour straight.
90/90 Hip wipers – Sit with your feet on the floor and your knees bent at about 90 degrees. Let both knees fall to one side, which puts one hip in external rotation and one hip in internal rotation. Repeat on the other side. Move back and forth through the rage of motion noting tightness side to side. Complete 3 sets of 15 repetitions with one minute rest between sets.
Long term remedies include identifying the exact underlying cause with a qualified physical therapist, and general strengthening. As with plantar fasciitis, decrease the training load that changed. When you look back over your training log, try to identify patterns for what changed in the time since the injury began, use this as the starting point for decreasing the training load.
Cause: Degradation of the hamstring tendon. Many times it is due to high eccentric forces (downhill or fast running) with weak hamstrings.
Symptoms: A dull ache where the hamstring originates. Athletes typically describe this as a deep pain in the buttocks that becomes worse with prolonged sitting, downhill running, or high intensity running.
Pitfalls: Proximal hamstring issues tend to linger for quite some time if not addressed early. They can also gradually worsen to the point where activities outside of running are affected.
Remedies: Decrease the intensity of your runs to decrease the eccentric forces. Get up from your desk frequently and before you notice the ache creeping in.
Hamstring extenders – lie on your back with one leg bent at the knee and hip, hands laced behind the knee. Gradually straighten your knee until you feel a productive stretch, but not pain. Return to the starting position. Complete three sets of 15 on each side with one minute of rest between sets.
Single leg hamstring eccentric curls – Lie on your back with your feet on a ball, sliders or a towel on a hard floor. Bridge your hips up by squeezing your glutes. Bring both feet in together. Then lift one leg and slowly push your heel out away from your body while keeping your hips off the floor. Once your leg is straight, pull back in using both legs to the start position. Complete three sets of eight on each side with one minute of rest between sets.
Cause: These injuries typically stem from trauma to the ankle (rolls, sprains etc); Achilles injuries can be caused by adding too much vertical or volume (or both) to your training at once.
Symptoms: Pain is often on the outside of the ankle after rolls. Achilles injuries can present with pain anywhere from the back of the heel all the way up to the musculotendinous junction at the calf.
Pitfalls: Depending on the severity, runners sometimes run through this injury but subconsciously favor one side, which can cause issues on the other side over time.
Foam rolling the calf muscles – A little goes a long way. Youâre better off doing five to ten minutes in the morning and five to ten minutes in the evening than you are tenderizing yourself for an hour straight.
Single leg stability – Much like the balance work from the plantar fasciitis section, just practice standing on one foot. Eyes open, eyes closed, reach for something, brush your teeth, shift on to the ball of your foot. Anything you can do to challenge your single leg balance is going to be beneficial.
Calf raises – Start with double leg, progress to single leg eccentric (up with two legs, down with one), and progress to single leg up and down. For a true Achilles tendinopathy diagnosis and treatment plan, visit a qualified physical therapist. They may incorporate various modalities, including soft tissue work to loosen any restrictions, and then guide you with the most appropriate level of exercises to strengthen the calf muscles without aggravating the already-irritated Achilles tendon.
Our bodies are very efficient at sending signals, but we need to know what to do when we receive them. Runners have a high incidence of injuries, and research indicates that 31% struggle with injuries lasting more than a year (sportsshoes.com 2024). Not all injuries are preventable, but runners can absolutely be proactive about their recovery. Surrounding yourself with a team can help differentiate injuries from the normal aches and pains of training.
The best thing you can do for injury management is have a team in place before there is a problem. Having a doctor, physical therapist, or other qualified medical professional as a resource is vital. Itâs important to develop a relationship so they know you, your exercise habits, and can look at you as the whole patient as opposed to just the injury. A coach you communicate well with is another integral partner in early recognition. This is a person who can remain objective when it comes to the management of the injury process and help with appropriate deloading, identification of pain-free patterns, and help you find creative ways to keep moving toward your training goals.
Kluitenberg, B., van Middelkoop, M., Diercks, R., & van der Worp, H. (2015, August). What are the differences in injury proportions between different populations of runners? A systematic review and meta-analysis. Sports medicine (Auckland, N.Z.). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513221/
Hoffman, M. D., & Krishnan, E. (2014, January 8). Health and exercise-related medical issues among 1,212 ultramarathon runners: Baseline findings from the Ultrarunners Longitudinal Tracking (ultra) study. PloS one. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3885517/
Nielsen, R. Ă., Bertelsen, M. L., Ramskov, D., Damsted, C., Brund, R. K., Parner, E. T., Sørensen, H., Rasmussen, S., & KjĂŚrgaard, S. (2019, September 1). The Garmin-RUNSAFE running health study on the aetiology of running-related injuries: Rationale and design of an 18-month prospective cohort study including runners worldwide. BMJ Open. https://bmjopen.bmj.com/content/9/9/e032627.long SportsShoes running report: Running Statistics 2023/24. SportsShoes.com. (2024, March 20). https://www.sportsshoes.com/advice/running-hub/health-wellbeing/running-report
Interested in training with Coaches like Patrick McGlade? Use the code ULTRASIGNUP and get $200 toward personalized coaching from an experienced ultramarathon coach.
Patrick McGlade is a coach who gets more interesting every time you meet him. Driven by curiosity, he graduated from Virginia Commonwealth University and continued on to become a Physical Therapy Assistant. As his interest in coaching and performance grew, he raced to finishes at Western States, Grindstone, and the Leadville 100 and earned coaching and nutrition certifications from UESCA as part of his journey to becoming a CTS Ultrarunning Coach.
