Running Injuries: Patellofemoral Pain, ITB Syndrome and Bone Stress

Running injuries are overwhelmingly overuse injuries, and the four below sit on a spectrum from irritable but forgiving at one end to bone stress requiring genuine time off at the other. Getting that distinction right at the first consultation matters more than any single treatment choice.

What are the Most Common Running Injuries?

A systematic review separating incidence from prevalence gives the most useful picture, since the two rank the same injuries differently, and the following are reported the most:

• Patellofemoral pain: The highest injury prevalence of any running-related diagnosis at 16.7%, though its incidence proportion is lower at 6.3%. The gap tells you it persists rather than resolves
• Medial tibial stress syndrome: 9.4% by incidence and 9.1% by prevalence, making it one of the few diagnoses that ranks similarly on both measures
• Iliotibial band syndrome: 7.9% by prevalence, with wider estimates ranging from 5 to 14%. The most common cause of lateral knee pain in runners
• Tibial stress fracture: Less common but the most consequential, and the end of a continuum that begins with medial tibial stress syndrome rather than a separate condition

The knee is the most frequently injured region in non-ultramarathon runners. Reported overall injury incidence varies enormously across the literature, from roughly 20% to 70% depending on definition and follow-up.

Patellofemoral Pain

Diffuse anterior or retropatellar knee pain that builds during a run and is provoked by stairs, hills, and prolonged sitting. Associated with rapid increases in running volume rather than pace.

Assessment

• Provocation: Single-leg squat and step-down, with pain reproduced rather than localized to one structure
• Load history: Recent change in weekly volume specifically, since volume rather than pace is the associated variable
• Capacity: Hip abductor and quadriceps strength on single-leg testing
• Kinematics: Hip adduction and internal rotation during stance, treated as one contributing factor rather than the cause
• Differential: Patellar tendinopathy, which localizes to the inferior pole and responds differently

Physiotherapy management

• Reduce volume rather than stopping, and rebuild it gradually
• Combined hip and knee strengthening, which outperforms knee-focused work alone
• Gait retraining as an option where hip mechanics are clearly contributing, not as a default
• Expect a course of weeks to months and set that expectation early, since this is the diagnosis most likely to persist
• Avoid framing the problem as maltracking, which oversells a mechanical explanation the evidence does not support

Iliotibial Band Syndrome

Sharply localized lateral knee pain at around 30 degrees of flexion, typically appearing at a consistent point in a run and worse downhill.

Assessment

• Provocation: Pain localized to the lateral femoral epicondyle, reproduced on single-leg squat or repeated flexion under load
• Load history: Recent volume increase, downhill running, and camber or track direction
• Capacity: Hip abductor strength and endurance, tested to fatigue rather than for peak force
• Differential: Lateral meniscal pathology and patellofemoral pain, both of which coexist

Physiotherapy management

• Reduce provocative exposure first, particularly downhill and cambered running
• Progressive hip abductor loading, with endurance emphasized over peak strength
• Do not attempt to stretch or foam roll the iliotibial band as a primary intervention, since it is not a structure that lengthens meaningfully and compression is often the provocation
• Reintroduce downhill running last, as a distinct stage
• Review cadence, since a modest increase reduces peak loading at the hip and knee

Tip: Ask at what point in the run the pain arrives, and whether it is the same point every time. In this presentation, the answer is usually yes, and it gives you the dose to work back from.

Medial Tibial Stress Syndrome and Tibial Stress Fracture

Exercise-induced pain along the posteromedial tibia. Diffuse and spread over several centimeters in medial tibial stress syndrome; focally tender over a short segment in stress fracture. These are two points on one continuum, and the distinction changes the plan entirely.

Assessment

• Palpation: Extent of tenderness along the tibial border, since diffuse tenderness over 5 cm or more suggests stress syndrome and focal tenderness suggests fracture
• Symptom behavior: Pain that eases as the run continues suggests stress syndrome; pain that worsens through the run, persists at rest, or occurs at night suggests bone stress
• Load history: Volume increase, surface change, and footwear age
• Energy availability: Screen for low energy availability, menstrual history in female runners, and prior stress fracture, which together carry more prognostic weight than any biomechanical finding
• Imaging: Consider where focal tenderness and night pain are present, since plain radiographs are frequently negative early

Physiotherapy management

• Establish which end of the continuum you are on before writing a plan, since stress syndrome tolerates modified loading and stress fracture does not
• For stress syndrome, reduce volume, maintain fitness through non-impact work, and rebuild calf capacity
• For a confirmed stress fracture, expect an extended period of relative rest followed by a graded return, and say so at the first consultation
• Address energy availability where it is a factor, and refer where it needs managing
• Rebuild running volume by small increments, treating the previous tolerated volume as the ceiling rather than the target

Before You Clear a Runner

Running asks for repeated loading at a consistent volume rather than peak performance, so clearance rests on tolerating the intended weekly volume rather than on a single test. Rebuild by increments from the last volume the runner tolerated without symptoms, keep the previous injury history in view since it is the strongest predictor of the next one, and for anything on the bone stress continuum, resist the pressure to compress the timeline.

References

https://www.sciencedirect.com/science/article/pii/S2095254621000454

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193581/ https://pmc.ncbi.nlm.nih.gov/articles/PMC11958822/ https://paahjournal.com/articles/10.5334/paah.109 https://pmc.ncbi.nlm.nih.gov/articles/PMC3625796/ https://www.aafp.org/pubs/afp/issues/2018/0415/p510.html