Written by: Eric Power, MD (NUEM ‘24) Edited by: Justin Seltzer, MD (NUEM '21) Expert review by: Terese Whipple, MD (NUEM '20)
With over 40 million runners in the United States alone and an ever-increasing interest in fitness among the general population, the frequency of running injuries presented to urgent care and emergency departments will only grow with time. This is especially true due to the high rate of injury among runners, with a published annual incidence rate ranging from 19% to 79%; with even conservative estimates, that is nearly 8 million running injuries annually.
There are several risk factors for running injuries with which the emergency physician should be familiar. Running injuries are generally the sequela of repetitive stress. Acute injuries represent a small minority of cases and are usually not serious. The strongest risk factors include older age, high mileage running, beginners or suddenly restarting running, those making a rapid increase in speed and/or distance, low bone density, and those with a history of previous injuries.
This article will focus primarily on several “low acuity” running injuries along with their initial evaluation and management. A vast majority of running injuries are not serious, however, the evaluation of the injured runner still demands detailed musculoskeletal examination and thoughtful consideration of more dangerous potential causes of the symptoms. Proper clinical diagnosis and recommendations can certainly speed recovery and return to activity.
Iliotibial (IT) band syndrome
Major population: Young, active with a recent change in running mileage and/or runs on hilly terrain
Presentation: Lateral knee pain, especially with activity, with or without lateral thigh and hip pain
Diagnosis: Tenderness along lateral thigh extending into the lateral knee, swelling at the distal aspect may be present, Ober’s test for IT band tightness (not diagnostic)
EM differential: meniscus injury, stress fracture, lateral ligamentous injury
Initial treatment: No running until pain resolves then gradual return at painless speeds, distances, home exercise program to stretch IT band
Follow-up: Routine primary care, consider PT referral
Patellofemoral pain syndrome
Major population: Young, usually female, participating in sports with high volume running and/or jumping
Presentation: Anterior, aching knee pain worse with knee flexion (e.g. climbing stairs)
Diagnosis: Anterior patella tenderness; pain with patellar grind test, deep knee flexion
EM differential: meniscus injury, stress fracture, ligamentous injury
Initial treatment: home exercise program or formal physical therapy to strengthen quadriceps, core, and hip abductors. consider a patella stabilizing knee brace
Follow-up: Routine primary care, consider PT referral
Medial Tibial Stress Syndrome (“Shin Splints”)
Major population: Any patient with a recently initiated intense exercise regimen
Presentation: Anteromedial tibial pain provoked by activity and improved with rest
Diagnosis: Reproduction of pain with palpation of a diffuse area of the posteromedial border of the tibia
EM differential: stress fracture, DVT, exertional compartment syndrome
Initial treatment: Rest, icing (~20 minutes per hour) until the pain has resolved, then a gradual return to activity at painless speeds, distances
Follow-up: Routine primary care, consider PT, sports medicine referral due to high failure rate of conservative management
Achilles Tendinopathy
Major population: Usually middle-aged with recently initiated exercise or increased intensity/frequency
Presentation: Chronic, gradually worsening posterior heel and foot pain, often worst in the morning, with an impaired plantarflexion and explosive movements of the ankle
Diagnosis: Tendon palpation reproduces the pain, diminished range of motion and strength, calf muscle atrophy (late finding)
EM differential: calcaneal stress fracture, DVT, Achilles tendon rupture
Initial treatment: Reduce the intensity of activity to walking only until pain resolves, home exercise program to stretch and eccentrically load the Achilles tendon
Follow-up: Sports medicine and PT referrals due to benefit of rehabilitation and availability of multiple specialized therapies; some cases are treated surgically
Plantar Fasciitis
Major population: High volume or newly initiated/increased running or sports, slightly more common in women
Presentation: Classically plantar midfoot to heel pain worse with the “first step” in the morning
Diagnosis: Pain reproduced with palpation of the medial tubercle of the calcaneus and proximal plantar fascia, positive windlass test
EM differential: Foot stress fracture
Initial treatment: Avoid triggering activities, home exercise program to stretch and deeply massage the plantar fascia
Follow-up: Referral to PT and a foot and ankle specialist (orthopedic surgeon or podiatrist) as chronic symptoms are common
Key points
A majority of running injuries are not serious or acute but can be function limiting if not properly diagnosed and managed
It is important to rule out major relevant differential diagnoses such as stress fractures, DVT, and ligament/tendon injuries prior to discharge
Universal management is with rest, as needed NSAIDs, a gradual return to activity when the pain has resolved, and routine primary care follow up; primary care sports medicine or orthopedic surgery should be reserved for severe symptoms or failure of conservative management
Alongside home exercises and stretches, consider PT referral routinely
References
Li HY, Hua YH. Achilles Tendinopathy: Current Concepts about the Basic Science and Clinical Treatments. Biomed Res Int. 2016;2016:6492597.
McClure CJ, Oh R. Medial Tibial Stress Syndrome. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538479/
Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surg Sports Traumatol Arthrosc. 2014;22(10):2264-2274.
Petraglia F, Ramazzina I, Costantino C. Plantar fasciitis in athletes: diagnostic and treatment strategies. A systematic review. Muscles Ligaments Tendons J. 2017;7(1):107-118. Published 2017 May 10.
Strauss EJ, Kim S, Calce JG, Park D. Iliotibial Band Syndrome: Evaluation and Management. American Academy of Orthopaedic Surgeon. 2011;19(12):728-736.
van der Worp MP, ten Haaf DS, van Cingel R, de Wijer A, Nijhuis-van der Sanden MW, Staal JB. Injuries in runners; a systematic review on risk factors and sex differences. PLoS One. 2015;10(2):e0114937. Published 2015 Feb 23.
Expert Commentary
Thank you to Drs. Power and Seltzer for their concise and relevant review of common overuse injuries seen in runners. Although most of these injuries would not be considered emergent, correct diagnosis and referral of these patients is important to keep them active and decrease their likelihood of suffering the heart attacks, strokes, and chronic pain we see daily. This post did an excellent job of walking through several common injuries however, there is one more that I would like Emergency Physicians to consider in their differential for runners with extremity pain: Stress Fracture.
A stress fracture is break down in bone that occurs when abnormal stress is applied to healthy bone or normal stress is applied to unhealthy bone (osteopenia/porosis)
Female athletes are at particular risk if they are not fueling well enough, sometimes manifesting in menstrual dysfunction and decreased bone density
Commonly occurs in healthy runners when an athlete is increasing their training volume or intensity, or other new stress is applied such as a new running surface
Complain of insidious onset pain that worsens with running and other pounding activity. Pain is often better with rest early on.
If the bone is palpable from the surface, it will have point tenderness over the area. Pain will be reproduced with the hop test and the fulcrum test.
X-rays may be normal early on, later in the course, they may show periosteal reaction or fracture line. MRI can be obtained on an outpatient basis if needed.
Most stress injuries can be managed by decreased weight bearing through alterations in training, however, sometimes offloading with a walking boot or crutches may be necessary depending on severity and location.
High-risk stress injuries that warrant prompt sports medicine or orthopedics referral: femoral neck (superior aspect), patella, anterior tibia, medial malleolus, talus, tarsal navicular, the proximal fifth metatarsal, tarsal sesamoids.
If strong suspicion of a high-risk stress injury or diagnosis is confirmed in the ED, these patients should be given crutches and made non-weight bearing until follow-up.
Hopefully, this post will help you build a differential for overuse injuries you may encounter in the ED, and provide proper follow-up in order to keep our patients healthy, active, and engaged in the activities they enjoy.
Terese Whipple, MD
Assistant Professor
Department of Emergency Medicine
University of Iowa Hospitals and Clinics
How To Cite This Post:
[Peer-Reviewed, Web Publication] Power, E. Seltzer, J. (2022, Jan 3). Running Injuries. [NUEM Blog. Expert Commentary by Whipple, T]. Retrieved from http://www.nuemblog.com/blog/runninginjuries
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