Injury Prevention For Runners

Injury Prevention for Runners
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Introduction
W elcome to the second book of the Injury Prevention for Runners program! Here
we’re going to discuss specific treatment protocols for the most common
running injuries:
1. Illiotibial Band Syndrome (ITBS)
2. Plantar Fasciitis (PF)
3. Achilles Tendinopathy (more commonly known as Achilles tendonitis)
4. Patellofemoral Pain Syndrome (more commonly known as Runner’s Knee)
Each injury has evidence-based action steps you can take to speed the recovery
process and get back to running as quickly as possible.
Like all of my coaching methods, these have been tested on me and hundreds of other
runners. I know they work. With that said, every individual is unique and you may not
respond as favorably to a particularly treatment protocol.
Some runners take longer to heal. Others won’t adhere to the protocol as closely. And
others will continue to make poor lifestyle choices that prolong recovery.
Nevertheless, I’ve purposefully designed these programs to make them as actionable

and simple to follow as possible. You’ll get an overview of the injury, the most plausible
causes of the injury, and finally a step-by-step method of treating it yourself. Note that I
said yourself; I’m not going to cover surgery, cortisone shots, and other methods that
require a medical professional. If your injury doesn’t respond to self-treatment, you
need to see a doctor.
Some recovery treatments are more useful than others. For example, compression
socks could help speed your Achilles tendinopathy recovery, though they’re far less
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effective than eccentric exercises. But I’ve included those methods regardless since
they are relatively low cost, very low risk, and potentially helpful.
The treatment protocols in this program are comprehensive and I’ve included every
helpful option that’s available. What you see is the best treatment protocol possible,
even if some methods aren’t as useful as others.
Consider it a “best case treatment scenario” that exists in an ideal world.
Ready to get healthy? Let’s get started!
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Treatment Program for IT

Band Syndrome
I lliotibial band syndrome (also known as IT Band Friction Syndrome) has a special
place in my heart: it struck my running down for six months and made me almost
quit indefinitely.
My IT band still bothers me when my training gets too aggressive or I slack on strength
exercises designed to keep the injury from resurfacing.
And for years, I’ve been helping runners get healthy and recover from ITBS – in fact,
recovery plans for ITBS represent my most popular segment of custom rehabilitation
plans. So far, I’ve written nearly 100 of them.
Unfortunately, there’s a lot of misinformation about this injury. I visited three physical
therapists who had no idea what they were doing when it came to effectively treating
ITBS. It’s a shame that it’s often not treated properly.
I’ve also talked with runners who think rest, ice, or stretching will help them recover
(and seen countless “experts” who say the same thing). These treatment methods are
virtually worthless for IT band syndrome. If you take time off, stretch your IT band and
ice it a few times a day you can expect to remain sidelined.
But before we get into what you should do to treat ITBS, let’s go over the injury itself.
ITBS: What is it and why does it happen?

The Illiotibial band is a thick piece of connective tissue that runs parallel to the femur
from the outside of your hip to the outside of your knee. It’s not exactly a tendon (it
doesn’t have a specific connection point like a regular tendon, among other reasons),
but it’s very similar. It attaches along the gluteus maximus and tensor fasciae latae on
the side of the hip and connects on the lateral side of the tibia. Its function is to help
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move the hip in multiple planes of motion and stabilize the knee during walking and
running.
IT band syndrome is diagnosed when pain presents typically at the insertion point of
the IT band on the outside of the knee. Many believe that ITBS is due to excessive
friction, though the band itself is so stiff it barely moves. Instead, a more plausible
explanation is compression due to an abnormal movement pattern of the femur.
So what causes your femur to move abnormally? Typically, it’s a weak butt. Your gluteus
maximus and medius are the two major muscles that control the position of the pelvis
and overall stability of the leg during the running stride. Weak hips also contribute to
the pelvis “dropping” down on the non-stance leg. If your pelvis was a bowl, you’d be
pouring its contents out as you tilt the bowl to the left or right.
All this talk about the position of the pelvis is critical. Because when your pelvis moves
into an unfavorable position, the IT band pulls away from the knee. Just think: if the left
hip drops when the right foot is planted, that means the right hip is actually lifted
higher – away from the knee.
How do I know if I have IT Band Syndrome?

ITBS presents with a clear and relatively intense pain on the outside, lateral side of your
knee. If that’s what you’re experiencing, you almost always will have ITBS. But if your
pain is in the front of your knee (under the knee cap), it’s more likely “Runner’s Knee” or
patellofemoral pain syndrome.
ITBS pain will usually start suddenly or “come out of nowhere. Within a few minutes,
the pain will be very intense, often making it virtually impossible to continue running.
Pain while running downhill or walking down stairs is another ITBS red flag.
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Myth #1: “My ITB is too tight!”

Many people wrongly assume it’s because the ITB is “too tight” so they proceed to
stretch, massage, and foam roll to loosen the band.
But the reality of the situation is that the IT band is virtually impossible to stretch or
loosen. It has the consistency of a truck tire – it can’t be stretched. Nor would you want
to stretch it! Its function is to provide stability during dynamic movement. Loose
connective tissue doesn’t work.
Moreover, static stretching isn’t effective at relieving pain or healing the injury. Since
ITBS is most likely caused by abnormal movement patterns, static stretching is
worthless. Relief from stretching represents luck: your recovery was likely due to some
other factor.
So you see it’s not a problem with the IT band being too tight. ITBS is a problem with
excessive, abnormal movement of the pelvis that must be controlled.
Myth #2: “My ITB is inflamed!”

This myth is popularized by almost every runner and by clinicians who don’t understand
ITBS. First, the Illiotibial band is not muscle and can’t truly experience inflammation,
though the surrounding tissue certainly can.
Second, the classic type of inflammation we think of results from an acute injury (like
bumping your head – that bump is the result of inflammation that helps heal the
trauma) or from disease. The specific biochemistry in and around your IT band won’t
look like classic inflammation: the rush of white blood cells that your immune system
sends to fight pathogens.
The distinction between inflammation and the cause of your ITB pain is actually
degeneration. Or in other words, tissue has been broken down because of repetitive
stress and abnormal movement patterns.
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This degeneration is what’s causing your pain. This may seem like we’re debating
minutiae but it’s critical for how you’ll treat your ITBS. If the pain is not the result of
inflammation, then it doesn’t make sense to treat ITBS with non-steroidal anti-
inflammatories (NSAIDs) like ibuprofen. That strategy won’t help you heal faster or run
any sooner.
Instead, you treat the cause of your injury, which is probably an abnormal movement
pattern of the femur made worse by too much repetition.
With that said, you may find that an NSAID like ibuprofen is helpful during the first 1-2
days when pain can be more severe. This is strictly a pain management option and not
a treatment option. Avoid using NSAIDs for more than 1-2 days, however. They can
slow the body’s own healing mechanism and prolong your recovery.
Healing ITBS: Your Treatment Strategy

There are quite a few ways that you could attempt to recover from ITBS:
★ Rest
★ Ice
★ Strength exercises
★ Compression
★ Cortisone shots
★ Surgery
★ Massage
★ Orthotics
★ Stretching
★ Fixing your running form
Some have more benefit than others and I consider some of these options useless to
healing from this particular injury.
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The treatment protocol I recommend includes strategies that help fix the probable root
cause of your ITBS (excessive, abnormal movement) and several that aren’t entirely
proven in the scientific literature, but have no downside and are worth a shot.
As soon as you experience a sharp pain on the outside, lateral side of your knee, you
should assume that you have ITBS. If you have chronic ITBS, your treatment protocol
should necessarily include a more conservative approach. In other words, you’ll likely
heal slower so you’ll have to take more time off from running.
Step 1: Stop running. Despite the fact that running through ITBS pain may not be that
detrimental, it could certainly prolong your recovery. How much time off you take varies
on how severe the pain is and how long you spend running through pain.
My recommendation is 7-14 days off from running depending on the severity of your
injury. I don’t recommend long walks or hikes (particularly on hilly terrain) during this
time since that could exacerbate your symptoms.
Step 2: Complete a “Recovery Workout” every day. This is where my treatment

approach differs from what most runners do: I’m incredibly aggressive when it comes to
treating any injury. These “workouts” are similar to what you would do at a physical
therapist’s office.
A Recovery Workout includes several treatment methods and exercises that focus on
your pain and the cause of your injury. Every day perform these steps in this order:
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1. Foam roll the hip, glute, hamstring, and

quadriceps of the affected leg. Spend
about one minute foam rolling each muscle
(any longer could just make you too sore) at
a moderate intensity. Notice that I don’t
recommend rolling the IT band itself. It’s as
tough as a truck tire, remember? Roll
around it to break up any muscle adhesions
or trigger points in the surrounding
muscles.
2. Use a tennis or lacrosse ball to focus on

specific trigger points you might have that
are particularly painful (most likely in the
glute or hip musculature). This type of self-
massage can be more painful so stay
tough! More pain doesn’t mean Massage These Areas, Not the IT Band
you’re doing a better job, though.
Press the ball into the trigger point for 30 seconds to 1 minute, applying your own
body weight for more pressure, and then slowly release.
3. Complete a strength routine from this program. Alternate between the ITB
Rehab, Standard Core, and the Stiletto Routine every three days (one routine per
day). These routines build the necessary strength and stability in the glutes and
hips without the risk of further injuring the IT Band by lifting heavy weights.
4. Optional: ice the affected leg for 15 minutes 1-2 times, with enough time in
between to allow the skin to return to normal temperature (this usually takes at
least 20 minutes). You can place a bag of ice on the side of your knee or freeze
water in a paper cup and tear off a small strip near the mouth to create a block of
ice with a semi-insulated handle. This is a great tool for a light ice massage.
Step 3: Test Run! If you experience progress within 7-14 days (you have no pain while
walking or going down stairs), you’re probably ready for a test run (with a dynamic
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warm-up, of course) to see if your ITBS has started the healing process. The goal of this
run is to simply see if you can run without pain – it is not to gain any fitness. For that
reason, your pace is not important. Run comfortably and relaxed. There’s no reason to
run at an unreasonably slow pace, but don’t run hard either.
During these test runs, stay on flat ground and avoid any hills (especially downhills),
which can exacerbate ITBS pain. If possible, try to run on a treadmill with a 1% incline.
This helps reduce impact forces and allows you to stop running immediately if you
experience significant pain.
As you run, it’s important to maintain good form. The strength work you’ve been doing
every day will help reinforce proper form, though several form “cues” are also helpful
in promoting an efficient stride.
Pretend there’s a golf ball between your knees. This cue forces your knees a few
centimeters further away from one another.
This simple action reduces the abnormal rotation of the thigh that causes many injuries
and is common among injury-prone runners, particularly those with ITBS.
Check your cadence. Increasing your cadence has been shown to relieve ITBS pain on
the outside of the knee. If your cadence (or the number of steps you take per minute) is
under 170 then it’s critical you take faster steps – while running the same pace.
It may seem awkward at first, but that’s normal. The simple reality is that a low cadence
of 165 or less predisposes you to a host of injury problems and needs to be corrected.
This tweak to your running form also reduces heel-striking and over-striding while
helping you land underneath your hips.
Correct a Cross-Over Gait. If you run down the road on top of the solid white line, a
cross-over gait has your feet crossing this white line. In other words, you have a narrow
running gait where the foot crosses the midline of the body.
Not every runner with ITBS will have a cross-over gait. But if you have both, then it’s
smart to widen your gait.
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Start by finding a line on the road and run down it. If your feet cross it across your
midline, take 30 seconds to widen your stride just enough so that your feet stop
crossing the line.
Repeat this pattern 4-6 times during your run, taking a minute or two to “recover” in
between each interval of running with a wider gait. This process takes time so be
patient and expect progress over months, not days or weeks.
Step 4: Rinse and Repeat. You may have to repeat this cycle several times before you
start seeing progress. I’ve coached many runners through this particular injury and
often it takes just a week of focused self-massage and targeted hip and glute strength
exercises to make running possible again.
If your ITBS is severe, it may take longer. Don’t become discouraged! Some runners are
slow responders so stay patient and focus on the process of healing.
Once you can run without pain, return to your normal training workload gradually. See
the Q&A with Coach section in the Prevention Guide for more guidance on this
subject.
ITBS Q&A
Should I get an MRI?
Usually you don’t need one. An MRI is usually used to confirm a diagnosis – and ITBS is
quite easy to diagnose. If you have pain on the outside of your knee that wasn’t caused
by a traumatic incident (like falling on a rock or severely twisting it while playing
soccer), you almost always have ITBS.
With that said, an MRI could reveal an issue that complicates your particular case of
ITBS. You could also have dysfunction in your hip or quadriceps that makes healing
more problematic.
If you experience a prolonged case of ITBS that doesn’t respond to standard treatment
strategies, or your injury presents with slightly different pain than lateral knee pain, an
MRI could be very helpful.
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I don’t have pain on the side of my knee; instead, it’s at my hip.

You probably don’t have ITBS! This injury presents with lateral knee pain and by
definition, if that’s not the pain you’re experiencing then you don’t have this injury.
Hip pain can accompany ITBS and the resulting pain on the side of your knee, but you
have to have pain on the side of your knee to be afflicted with IT Band Syndrome.
Can I run through IT Band Syndrome?

First, why would you want to? The intense pain will probably stop you in your tracks no
matter how committed you are. And in addition to the pain, you could make your
recovery take even longer. Take my coaching advice: it’s not worth it.
With that said, there’s very little evidence that ITBS pain will lead to permanent knee
damage. Your knee won’t break and the ITB won’t snap. You theoretically could run
through this injury while you’re treating it, even though it’s not the best idea. But if your
goal race is a few days away, you have my very reluctant acknowledgment that you
could still race.
Now the disclaimer: if you’re older (50+) and have had ITBS for a long time (6+
months), you’re at a higher risk for doing more damage. The repetitive stress could
result in even more tissue degeneration, possibly to the padding underneath the knee
insertion of the IT band. And because overall I am more conservative as a coach when
it comes to injury treatment, I don’t recommend running through ITBS pain.
Can I cross-train while I have ITBS?

In addition to the core and strength workouts prescribed in your treatment plan, it’s
possible to also cross-train during your injury. The two best forms of aerobic cross-
training for runners are cycling and pool running. They’re zero-impact and non-load
bearing (unlike the Elliptical machine) and more specific to running than swimming.
Because both forms of exercise include bending of the knee, it’s possible that either
can cause additional strain on the injury. This depends on your individual biomechanics
and the nature of your injury. The only way to find out is to go for a pool run or bike
ride.
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Of course, while it’s possible to cycle or pool run during a case of IT Band Syndrome, I
recommend taking 7-14 days off completely instead (unless you are a very competitive
runner and 1-2 weeks of time off would cripple your racing goals). Rather than risking
additional pain and reducing your body’s ability to heal the injury, it’s best to take this
time off completely.
After this period of time off, however, you can start more cross-training to promote
healing blood flow to the injury. But at first, it’s more effective to focus on conservative
recovery with pure rest.
Do “knee straps” help relieve ITBS pain?

Interestingly enough, maybe! It depends on a host of factors and your results may vary
from any other runner, but straps that are adhered with Velcro above the knee (not
below it, which is more commonly used for Runner’s Knee or patellofemoral pain
syndrome) may provide some pain relief.
Note that you may experience some pain relief that could help you run a little more
with ITBS. But these straps won’t help you heal more quickly from the injury.
Why these straps work is largely a mystery, but the most plausible explanation is that
they alter how the knee feels to us so pain signals are changed. Proprioception (our
perception of how the body moves in space) is an interesting field and the function of
our knee partly depends on sensory input from our body. The strap changes that input
and can reduce pain for some runners.
How should my training change once I get healthy from ITBS?

Most runners who suffer from IT Band Syndrome are predisposed to the injury because
of their particular anatomy and running mechanics. Because of that reason, it’s critical
to maintain a strength program after your injury that builds glute and hip strength.
In addition to bodyweight strength and core work, once you’re healthy it’s a good idea
to get in the gym 1-2 times per week. A workout that focuses on compound, multi-joint
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lifts (like the squat and dead lift) can be very helpful in building the strength necessary
to stay healthy. The Pike Workout is a gym routine that includes these strength
exercises.
If you haven’t been doing a dynamic warm-up before all of your runs, now is the best
time to start. Increasing mobility in the hips, quadriceps, and hamstrings can help ward
off trigger points that contribute to immobilizations and weakness that can contribute
to ITBS.
Just as hill running can exacerbate ITBS, it can also be protective from the injury when
you’re healthy. Uphill running builds running-specific strength in the glutes and hips –
just be careful and don’t pound the downhills. That’s where ITBS can rear its ugly head!
The bottom line: to prevent ITBS from recurring, you must consider it a permanent part
of your anatomy. A little depressing, I know. But the preventive efforts in this treatment
protocol – plus the training upgrades in the Prevention Guide – can help you stay
healthy in the long-term.
Tips & Tricks

There are several strategies that you can use to help yourself recover from ITBS more
quickly (or prevent it in the future). I have researched these methods and found them to
be effective for myself and many runners I’ve worked with, though there’s no data to
back them up yet. I consider these “nice to do” but not necessary.
Avoid prolonged sitting. Sitting weakens your glute muscles, which is a main
contributing factor to ITBS.
Avoid crossing your legs. As a fidgety leg-crosser who can’t sit still, this is nearly
impossible for me but I’ve learned to sit with both my feet on the ground over time.
Crossing your legs promotes poor posture, tilts your pelvis at an odd angle, and
stretches your hip muscles unevenly. This can lead to an imbalance as your soft muscle
tissue has “memory” and will “remember” the positions you put them in. Another
point for good posture!
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Avoid the road’s camber Almost every road is sloped toward the curb from its center
to promote drainage. If you’re always running on the right side of the road, your right
leg is always landing lower than your left leg on this slope.
The uneven running gait caused by staying on one side of the road for too long can
cause major irritation to the IT band, resulting in an asymmetrical movement pattern
that could cause the injury. Instead, run on more even roads, switch sides every 5-10
minutes, or run on the sidewalk. Running on uneven terrain is fine – as long as the
variations don’t always occur on one side of the body.
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Treatment Program for

Plantar Fasciitis
A nother injury with a special place in my heart! Come to think of it, most do since
I’ve had just about every injury there is…
During the summer of 2004 I experienced sharp pain on the underside of my foot while
running a hill workout to prepare for cross country at Connecticut College. I was
running about 80 miles per week and my weekly mileage had almost doubled since
spring.
After seeing a specialist – and then a physical therapist – I got the bad news that my
injury was plantar fasciitis. PT began and I lost weeks of training as I slowly rehabbed
my foot. But since then, I’ve never had a recurrence of the injury even though I’m
predisposed to foot injuries (I pronate significantly and have very low arches).
This treatment protocol is the result of what I learned from several physical therapists,
plus my coaching experiences and countless research on the best treatment methods.
It represents a systematic approach that reduces pain but more importantly focuses on
the underlying reasons why PF occurs. Let’s begin!
Plantar Fasciitis: What is it and why does it happen?

The plantar fascia is a piece of connective tissue that’s most similar to a tendon. It runs
from the heel to the ball of the foot and supports the arch. Plantar fascia function is
also related to the Achilles tendon; tightness in one structure can cause tightness in the
other. This relationship will affect treatment of the injury.
Plantar fasciitis is a type of tendinitis that affects the plantar fascia connective tissue.
The pain is commonly more severe in the morning and tends to be located closer to
the heel of the foot.
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It’s caused by continuous and chronic irritation to the plantar fascia without allowing for
adequate recovery. As the foot flattens during mid-stance (the plantar fascia acts like a
spring and absorbs energy by elongating during the mid-stance phase of gait), this
puts additional strain on the fascia. Weak musculature causes excessive flattening and if
you’re not strong enough to handle this constant strain, your risk of developing PF is
significantly higher.
So a high amount of strain causes plantar fasciitis. But what causes that high level of
strain? There are three likely culprits: excessively tight calves, significant pronation, and
signification supination (or in other words, under-pronation). These cause abnormal
movement patterns of the foot during mid-stance and we’ll cover how to address each
in the upcoming treatment section.
Additionally, there seems to be a chronic problem among many runners: we have weak
feet. After years of wearing stiff dress shoes, never going barefoot or wearing zero-
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drop flip flops that promote normal movement of our feet, we’ve let the musculature of
our feet degrade over time.
No wonder it can’t support the strain of running!
The injury is also very common in hikers, walkers, and folks who stand for work (like
nurses or cashiers).
Since this injury is not necessarily running-specific, there are several treatment options
that will focus on aspects of lifestyle.
How do I know if I have Plantar Fasciitis?

Runners who suffer from PF will experience a sharp, burning pain on the bottom of their
foot. Like I mentioned above, it’s most likely worse in the morning (or during your first
few steps after a prolonged period of sitting) and where the fascia connects to the heel.
The pain is most commonly located at the heel because this part of the fascia is pulled
on the most to lift the body while walking and running. Pronation will also cause
excessive pull on the part of the fascia closest to the heel.
Since this connective tissue is actually quite broad and connects to the bones of your
toes, the stress is more widely distributed on the ball of your foot. But at the heel, the
fascia connects at a single point where strain is more concentrated, hence the
resulting pain.
Myth #1: “My Plantar Fascia is Inflamed!”

Labeling PF as a type of tendinitis is actually somewhat misleading because it implies a
level of inflammation. Truthfully, your plantar fascia is most likely not inflamed – and
therefore can’t be treated effectively with NSAIDs (non-steroidal anti-inflammatory
drugs like ibuprofen) or ice therapy.
Instead, plantar fasciitis patients see a degeneration of the tissue. In other words, your
fascia is damaged due to overuse with microscopic tears in the connective tissue.
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While ice can be effective in managing pain and reducing a small amount of
inflammation in the early stages of the injury (the first 1-2 days), it’s not the best way to
treat the injury or get back to running any sooner.
Myth #2: “I Need Motion Control Shoes to Stabilize My Foot”

This is the worst idea and unfortunately has been popularized by clinicians who haven’t
read the latest science on the “pronation control paradigm” and the effect of shoes on
injury rates.
In a fascinating study, a group of runners was randomly divided into three groups who
wore either neutral shoes, stability shoes, or motion control shoes. Every single runner
who wore motion control shoes got hurt.
Moreover, it turns out that motion control shoes don’t actually control pronation.
According to Dr. Chris Lee, a specialist in Orthopedics and Sports Medicine, pronation
at the ankle does not even come from the ankle or foot! Instead, it’s caused by weak
hips and glutes (and we’re right back to the weak hips and glutes issue again. Noticing
a pattern?).
Back to the study: it turns out that runners who pronate more than others fared better
in neutral shoes. And those who would have most likely been prescribed a neutral shoe
(those with the least pronation), fared best in the stability shoe.
So if you go into a running store and your low arch result from the “wet foot test”
makes the clerk recommend a motion control shoe, run away! It’s clear this person has
no idea what he’s doing. Most runners would be just fine in a neutral shoe.
Healing PF: Your Treatment Strategy

Traditional treatment of plantar fasciitis often focuses on pain management rather than
addressing the actual cause of the injury. You might have been told to rest, ice, take
Advil, do calf exercises, or massage the area to get healthy.
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Some of these strategies work. Some don’t. At best, it’s an incomplete treatment
protocol that won’t deliver consistent results. Instead, I prefer a more systematic
approach.
Let’s manage the pain and address the root causes of PF so that you can recover faster
and get back to doing what you love: running.
As soon as you experience pain on the bottom of your foot on or near the heel, the
likely culprit is PF and you should start these treatment steps.
Step 1: Stop running. You can’t run through plantar fasciitis so it will be necessary to
take anywhere from a week to a month off from running depending on the severity of
your injury. There’s no getting around this! Running will make it worse – so don’t run.
Step 2: Pain Management. While PF is not an inflammatory condition, some

inflammation exists when the injury first begins. Icing can be helpful to reduce this
initial period of inflammation and provide some relief.
Simply fill a small bucket with some water and ice to create a mini-ice bath for your
foot. Alternatively, you can freeze ice in a paper cup, tear off the top of the cup, and
you have a block of ice you can massage over the bottom of your foot that has an
insulated handle. Ice for about 15 minutes twice per day during the first two days.
The best time to ice is at the end of the day or after your “recovery workout” (in other
words, after all activity).
I don’t recommend anti-inflammatory medication like ibuprofen or acetaminophen as

they can blunt the body’s internal recovery process. If the pain is unbearable then you
can use them for 1-2 days as directed.
Step 3: Evaluate your shoes. Shoes that promote poor alignment can not only weaken
your feet, they can prolong recovery and further aggravate PF symptoms. Avoid
wearing shoes with a high heel, narrow toe box (a “pointed” toe box), constrictive
design, or are otherwise uncomfortable. Almost every “dress shoe” for men and
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women falls into this category (no wonder why about 10% of the US population is
affected by plantar fasciitis!).
This analogy can be helpful when thinking about shoes and plantar fasciitis: if you had
a sore lower back, would sitting with poor posture be conducive to relieving your back
pain? Of course not! Wearing constrictive shoes that place your feet in poor “posture”
is effectively doing the same thing.
Running shoe options change annually and every runner is unique so I can’t
recommend specific models. Look for neutral shoes that have a heel-toe drop of
6-8mm. This is a moderate drop – true minimalist shoes are typically 0-4mm while more
traditional shoes are 10mm or more. Transition slowly when you’re able to run again
(see the Tips & Tricks section on how to transition to minimalist running shoes).
Your casual shoe collection also needs attention if you suffer from PF. You can afford to
be even more minimalist with your casual shoes if you don’t stand all day. With far less
impact and strain on the plantar fascia for most office workers and those with sedentary
jobs, you can wear flexible shoes with a heel-toe drop of 0-4mm like driving loafers,
flats, or boat shoes.
Web resource:
SR’s growing collection of running shoe reviews
Step 4: Complete a “Recovery Workout” every day. Just because you’re not a
physical therapist doesn’t mean you can’t act like one when you’re injured! This
protocol is similar to what you might do at the PT but you can do it at home.
It includes several treatment methods that focus both on pain and the actual cause of
your PF. Each day perform these steps in this order:
1. Spend 5 minutes foam rolling the soleus and calf muscles of the affected leg; if
these muscles are tight they can exert additional strain on the plantar fascia.
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2. Use a lacrosse or golf ball to perform about 5 minutes of light self-massage along
the plantar fascia and arch of each affected foot. Roll the underside of your foot
to break up any muscle adhesions, scar tissue, or trigger points. Massage will also
increase healing blood flow to the area without adding extra stress.
3. Complete one strength routine from this program (your choice!). It’s most effective
to take a full body approach to prevention and treatment (pain is often referred
by a different muscle – like weak hips that I mentioned above) so it’s best to rotate
through the routines. However, you should always complete the Chakram Routine
barefoot as the final workout in the sequence as it will strengthen the foot and
lower leg.
4. After spending 15-20 minutes doing both routines, it’s time for more targeted
strength. Start with 2 sets and build to 5 sets of the following exercises:
a. Towel Scrunches: lay a hand towel on the floor and place a 1-2lb weight on
the end, like a hardcover book. Sit down and place your foot on the opposite
end of the towel and using your toes, scrunch the towel toward you (1 set). Put
the towel back in its original placement and repeat.
Watch a video demonstration here.
b. “The Claw”: place 15-20 small objects (marbles, army men, blocks) on the
ground around a cup. Sit down and use your toes to pick up the objects and
drop them in the cup. One set is completed when you’ve dropped all of the
objects in the cup. Focus on extending and spreading your toes and firmly
gripping the object while you pick it up.
Watch a video demonstration here.
5. Optional: Some research suggestions that static stretching of the Achilles and calf
can help cure plantar fasciitis. I’m not entirely convinced but it can’t hurt if it’s
done at the end of a workout before any icing. For best results, lightly hold a
static stretch for 60-90 seconds. Stretching should never be painful. You can
perform this stretch by standing a few feet in front of a wall, leaning forward while
22
keeping your feet planted, and leaning into the wall. Another option is to foam
roll the calf and soleus instead of stretching.
6. Optional: ice the affected foot for 15 minutes 1-2 times, with enough time in
least 20 minutes).
Step 5: Test Run! If you experience progress within 7-10 days (you experience no pain
during normal activity), you’re ready for a test run. The goal of this run is to simply see
if you can run without pain – it is not to gain any fitness. For that reason, your pace is
not important. Run comfortably and relaxed. There’s no reason to run at an
unreasonably slow pace, but don’t run hard either.
During these test runs, stay on flat ground and avoid any hills (especially uphills), which
can put additional stress on the plantar fascia. Remember to maintain proper running
form and ensure your cadence is at least 170 steps per minute. If it’s slower, you’re
putting extra strain on your feet (and every other leg muscle).
If you feel good, you can continue to run cautiously for 1-2 weeks. Add 5-10 minutes
to each run and follow the best practices of increasing mileage from the Injury
Prevention guide.
During this time you should also complete a daily strength/core routine plus the
targeted strength exercises for your feet. When you’re healthy, you can reduce the
number of times you do the foot exercises though it’s helpful to do them 1-2 times per
week as prevention.
Plantar Fasciitis Q&A

Will minimalist shoes (like Vibram Five Fingers) cure plantar fasciitis?
Your mileage may vary on this treatment strategy. I am a “cautious minimalist” and
believe in using barefoot-styled running shoes strategically in your training. Consider
this analogy: long runs and track intervals have their place in almost every training
23
program. But that doesn’t mean you do them every day! The same is true for minimalist
shoes – they are “tools” that help you accomplish a specific goal.
You’ll see a moderate approach to minimalism in the treatment section. For some, this
approach will be relatively aggressive if they’re used to traditional footwear and motion
control running shoes. Other runners might want an even more aggressive approach
than I’ve outlined.
This approach to minimalism is designed to fit most runners – since we’re all
individuals, feel free to tweak it slightly to fit your needs!
With all that said, wearing minimalist footwear will dramatically help those who suffer
with plantar fasciitis. Once the existing damage is healed, your foot will benefit greatly
from minimalist shoes: better alignment of the toes, increased strength, and returning
the Achilles tendon and calf muscles to their normal length (shoes with higher heels
shorten these structures).
Of course, any transition to minimalist footwear for running must be done gradually
over weeks, months, and ultimately years.
Can barefoot running treat or prevent plantar fasciitis?

First, see my answer to the above question about minimalist shoes. I also recommend
those with weak feet and lower legs to run barefoot strides 1-2 times per week if the
weather allows and you have access to a synthetic turf field or well-manicured grass area.
Just one or two sessions of 4-6 barefoot strides every week will strengthen your feet and
lower legs. There’s no reason you have to also run barefoot or in very minimalist shoes.
Web resource:
What Are Strides?
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Tips & Tricks

How to Transition to More Minimalist Running Shoes
Your body will need time to adapt to the stress of minimalist running shoes. Remember
that it’s a long-term process!
This is important: the goal should not be to run in less and less shoe until you’re
barefoot. The goal is to wear minimalist shoes as a tool to help you develop a more
economical stride and prevent injuries by increasing your lower leg and foot strength.
As you transition to a more minimalist shoe, remember these basic rules:
★ You shouldn’t gradually transition to the most minimalist pair of shoes possible.
Any runner who’s overweight, has very flat arches, or severe pronation should
transition with caution. You may not want to run in lightweight trainers at all, but
instead stick with foot strength exercises (more on that later).
★ There are no short-cuts to running in less shoe. It’s a long-term process so if

anybody says you can do it quickly, you know they’re lying. Safety should be your
#1 priority.
★ Most running shoes only last between 300 – 500 miles. How long yours last will
depend on the type of shoe, your preferred running surface, your stride pattern,
and how much you weigh. Lightweight shoes may last fewer miles.
★ Always alternate at least two pairs of shoes – alternating helps prevent injuries
and allows you to wear one lightweight pair and a more traditional pair of shoes.
Now that the ground rules are set, let’s look at the specific steps you can follow to
transition safely into a more minimalist pair of running shoes.
1. Buy a more supportive pair of minimalist shoes that’s has a slightly lower heel-toe
drop, weight, and profile of your current pair. Alternate shorter runs in this pair
with longer runs in your more traditional pair of shoes.
2. In conjunction with wearing more minimalist shoes, you should also strengthen
your feet 2-3 times every week using the exercises in the PF protocol above.
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3. After 2-3 weeks of alternating short runs with your lightweight trainers and doing
your foot exercises, run a weekly session of 2-4 barefoot strides after an easy run.
It’s best to do these on an artificial turf or manicured field.
4. About two weeks later you can increase the number of strides to 4-6 per session.
After another two weeks, try running two sessions per week.
5. Once you’re doing steps 1-4, you’re getting almost all the benefits of barefoot
running! Stronger feet and lower legs, more running efficiency, but with a
dramatically smaller injury risk.
6. If you want to do more, replace your traditional running shoes with another pair of
“more supportive” minimalist shoes.
You can continue this pattern of replacing one pair of shoes with a slightly less
supportive shoe until you have two pairs of neutral shoes with heel-toe drops of 4-8mm
and a weight of 9 ounces of less.
Remember: the goal is not to continue transitioning so you’re running barefoot or in

Vibram FiveFingers! As long as you avoid motion control shoes and are wearing a
neutral or slightly minimalist shoe for most of your runs, you’re not creating conditions
conducive to plantar fasciitis.
Using Compression Socks to Treat Plantar Fasciitis

Compression socks can be valuable in speeding the recovery process from plantar
fasciitis. There’s no data or current research (that I’m aware of) that supports
compression as a treatment method, but logic indicates that it can be helpful.
Compression works by literally squeezing your foot, ankle, and lower leg. Good
compression gear is graduated so it’s tighter around the ankle and looser around the
calf muscle. This helps “pump” the blood from the foot back to the heart.
Promoting extra blood flow can speed the healing process. This is the same principle
that’s behind the “active recovery beats passive recovery” maxim and contrast baths.
26
Fresh blood brings nutrients to damaged tissue and helps clear waste products,
creating a sound environment for faster healing.
As long as your socks aren’t too tight (which is difficult to do with what’s available on
the market), wearing compression socks is virtually risk free. I consider it a viable part of
an effective treatment protocol. Here are a few things to remember:
★ It’s most helpful to wear compression socks after exercising (the claim of some
manufacturers that the products reduces muscle damage caused by running
hasn’t been proved).
★ One effective strategy is to wear compression socks to bed so you have them on
for an extended period of time.
For more information on compression gear, see the Recovery section of the Injury
Prevention guide.
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Achilles Tendinopathy
A chilles tendinopathy (AT) is more commonly known as Achilles tendonitis – one
of the most common injuries among runners and one that I’ve experienced
multiple times.
My approach to healing AT has changed over the years as the science has evolved so
this is the most up to date method for getting healthy. Unlike other injuries like chronic
ITBS, you can typically get back to running relatively quickly once the acute pain phase
of AT is over.
Once you’re healthy and running again, many activities that put you at risk for Achilles
Tendinopathy can also be used to prevent it! We’ll get to that but you should know that
much of the specific prevention advice is counterintuitive.
Onward!
Achilles Tendinopathy: What is it and why does it happen?

First, it’s helpful to know that while Achilles Tendinopathy is often called Achilles
tendonitis, that label isn’t accurate. Since any “-itis” implies swelling and inflammation –
and the Achilles rarely has significant swelling during AT (however, there could be some
inflammation during the acute phase of the injury – we’ll get to this in the treatment
section). This is very important because it directly affects how you treat the injury.
Instead, AT represents a weakened or dysfunctional tendon that isn’t doing its job
properly. The reason why your Achilles is weak or dysfunctional could be due to a
variety (or combination) of reasons:
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High-heeled shoes shorten the Achilles and make it weaker. Minimalist shoes with zero-
drop profiles (the difference in height between the forefoot and heel of the shoe) have
the opposite effect: they cause more strain if you’re not adapted to having your
Achilles in its most stretched position.
Hills place the Achilles in a stretched position while putting even more demand on it.
Plus, depending on how you run, you could be aggressively forefoot striking which puts
a huge amount of additional stress on the Achilles.
There could also be intrinsic factors (meaning, factors associated with your body) that
put you at risk for Achilles Tendinopathy, like:
★ not activating your glutes well, resulting in too much activation of the Achilles (this
was my problem).
★ Severe pronation
★ Leg length discrepancy
★ General problems like joint and muscle asymmetries and weaknesses
We’re going to address many of these issues when we focus on your treatment.
And of course, any injury can be caused by the classic “3 Too’s” – too much, too soon,
too fast.
29
How do I know if I have Achilles Tendinopathy?
If you experience stiffness in your Achilles tendon followed by more intense pain while
running, you likely have AT. It may feel like a sharp pin is stabbing your Achilles during
every foot strike.
The pain will be directly on the Achilles tendon rather than the heel, soleus, or calf
muscle. Some runners have mistaken a soleus or calf strain for tendinopathy of the
Achilles so be sure the pain is on the tendon itself.
You may also experience a crunchy sensation when you rub the Achilles or dorsiflex
your ankle. This is scar tissue – a normal result of Achilles Tendinopathy.
30
Most runners with AT will be able to start running without pain. But after 5-10 minutes
the pain will become too sharp to run through comfortably (don’t try!). If your pain
progresses in a similar way, that’s a good indicator that you have Achilles Tendinopathy.
Myth #1: “Take anti-inflammatories to heal your Achilles”

Remember that the Achilles isn’t inflamed when you have Achilles Tendinopathy.
According to Jay Dicharry, a renowned physical therapist, strength and conditioning
coach, and running biomechanics expert, it’s impossible to have inflammation in the
Achilles tendon (though you can experience it around or underneath the tendon).
So if inflammation isn’t a problem, why take medication to reduce inflammation? Any

application of NSAIDs (non-steroidal anti-inflammatory drugs like ibuprofen) or ice is
mostly a waste of time.
Instead, the Achilles is damaged due to overuse or dysfunction.
While ice can be effective at managing pain during the first several days of the injury,
it’s not an ideal way to treat the injury or get back to running any sooner.
Myth #2: “I need to stretch my Achilles and calf to get them

loose”
This is a popular misconception and many runners actually make their Achilles
Tendinopathy worse with excessive static stretching! That’s because the root cause of
this injury is not a tightness of the calf or soleus or a problem with your range of
motion: it’s a weakened or damaged Achilles tendon.
The Achilles is the largest tendon in the body, comprised of strands of collagen fibers.
When you engage in static stretching, you pull on those damaged fibers, preventing
them from healing properly and prolonging your recovery.
Rather than making things worse, an effective treatment strategy should focus on
rebuilding your damaged Achilles.
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Healing AT: Your Treatment Strategy

The conventional treatment of Achilles Tendinopathy often focuses on pain
management and addressing the symptoms of the injury rather than addressing its
actual cause. You might have been told to rest, ice, take Advil, do calf raises, or wear
orthotics/a heel pad to elevate the heel and relieve stress on the Achilles.
Some of these strategies offer a small amount of relief. But most are misguided and
don’t offer an effective treatment.
Instead, let’s use a more systematic approach to manage the pain and address the root
causes of AT so that you can recover faster and get back to running.
As soon as you experience pain in the Achilles that’s consistent with its definition in the
section above, you should start these treatment steps.
Step 1: Stop running. You can’t run through Achilles Tendinopathy so it will be
necessary to rest for 7-14 days depending on the severity of your injury. Running on an
injured Achilles could prolong your recovery – or lead to a ruptured tendon – so be
sure to rest completely.
Step 2: Pain Management. While AT is not an injury caused by or associated with

inflammation, icing the affected area can be helpful in reducing pain or discomfort that
you may be experiencing.
The preferred method is dunking your entire foot and lower leg in a small bucket of ice
water. Alternatively, you can freeze ice in a paper cup, tear off the top of the cup, and
now you have a block of ice you can massage over the Achilles and soleus that has an
insulated handle. Ice for 15 minutes twice per day during the first two days.
32

can use them for 1-2 days as directed, but it’s preferable that you skip them entirely.
Step 3: Evaluate your shoes. Just like Goldilocks, you need to find shoes that are “just
right” for you. Those with excessively high heels can shorten your Achilles – but
provide some relief from the symptoms of AT. Minimalist shoes with very low profiles
can put extra stress on the Achilles – but place the tendon in the correct position.
During the first several days of recovery, it’s best to utilize footwear with a more
elevated heel to let the Achilles “rest.” Once you’re 3-4 days into your recovery phase,
you can take a moderate and varied approach to shoes.
When you’re healthy, minimalist shoes can be worn casually, for short runs, or during
some fast workouts. More cushioned shoes are better suited for longer runs.
This varied approach ensures your Achilles is not chronically shortened (or stressed)
while providing most of the benefits of minimalism.
See the previous section on How to Transition to Minimalist Shoes for step-by-step
instructions in the Plantar Fasciitis Treatment chapter.
Running shoe options change annually and every runner is unique so I can’t
recommend specific models. Neutral shoes will have a heel-toe drop of 6-8mm. This is
a moderate drop – true minimalist shoes are typically 0-4mm while more traditional
shoes are 10mm or more.
Web resource:
SR’s growing collection of running shoe reviews
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Step 4: Complete a “Recovery Workout” every day. Now we’re going to mimic the
recovery protocols of many physical therapists – with a few upgrades.
It includes several treatment methods that focus both on pain and the actual cause of
Achilles Tendinopathy. Each day perform these steps in this order:
1. Spend 2-4 minutes foam rolling the Achilles, soleus and calf muscles of the
affected leg.
2. Complete a strength routine from this program. It’s most effective to take a full
body approach to prevention and treatment (pain is often referred by a different
muscle or leg movement – like the hips or glutes) so it’s best to rotate through the
routines. However, I recommend that you complete the Stiletto Routine, the Sand
Routine, and Standard Core Routine twice each per week.
3. After spending 15-20 minutes completing a strength routine, it’s time for more
targeted strength with eccentric heel drops. These exercises are the centerpiece
of your treatment strategy so do not skip them!
Straight Leg Heel Drop – 3 sets of 15 repetitions: Stand on a step and put the
ball of your foot of your injured leg on the edge of the step in a “calf raise”
position. Slowly lower your heel so that it’s slightly beneath the edge of the step.
Use your uninjured leg to raise your foot back to the starting position (never do a
standard calf raise with Achilles Tendinopathy).
Note: a moderate amount of pain is fine during these exercises – it won’t make
your injury worse!
Bent-leg Heel Drop: This exercise is performed exactly the same as the straight-
leg heel drop, except that the affected leg has a slight bend in the knee to target
a different area of the Achilles tendon. Watch a video demonstration here
Note: These exercises are demonstrated barefoot to give a better demonstration.
34
Wearing shoes makes eccentrics slightly easier and it’s recommended that you
wear shoes for the first 2-3 sessions.
4. Optional: Spend another 2-4 minutes foam rolling after the eccentric exercises to
further loosen the Achilles/Soleus complex.
Note: For those with Insertional Achilles Tendinopathy (a variation of this injury which
involves the lower portion of the heel), perform straight-leg heel drops on flat ground
rather than on a step. Don’t do the bent-leg heel drops.
It’s important to begin the exercise in the most plantarflexed position possible (in other
words, start as high on your tip-toes as possible) to work the forward position of the
Achilles tendon.
Step 5: Test Run! You can start running if you experience no pain for 3-4 days.
Remember that you need to continue this protocol and it could take 1-4 weeks to
completely heal your Achilles. The goal of this first run is to simply see if you can run
without pain – it is not to gain any fitness. For that reason, your pace is not important.
Run comfortably and relaxed. There’s no reason to run at an unreasonably slow pace,
but don’t run hard either.
can put additional stress on the Achilles tendon. Remember to maintain proper running
form and ensure your cadence is at least 170 steps per minute. If you feel good, you
can continue to run cautiously for 1-2 weeks. Add 5-10 minutes to each run and follow
the best practices of increasing mileage from the Injury Prevention guide.
During this time you should also complete a daily strength/core routine plus the
eccentric calf drops. When you’re healthy, you don’t have to perform the calf drops but
can start using them immediately if pain resumes.
35
Achilles Tendinopathy Q&A

Why do eccentric heel drops work?
Nobody has a definitive answer to this question, but most clinicians are in agreement
that “eccentric” muscle contractions (when muscles contract and lengthen at the same
time) help strip your Achilles of damaged collagen fibers.
Furthermore, eccentric contractions like heel drops strengthen the tendon and help
new tissue deposit correctly along the tendon. So instead of scar tissue criss-crossing
your collagen fibers, the new tissue is lined up correctly with your existing fibers.
During the running stride, most of the energy returned by the Achilles is because it acts
like a spring. So rather than strengthening the forward propulsion of the spring (which
in my view doesn’t do much), it’s better to strengthen the more demanding function of
the Achilles: the way it controls the movement of the heel and slowly lowers it to the
ground while running. Eccentrics replicate that function very well.
Should I get orthotics?

If you visit a podiatrist (especially a non-runner who’s not keen on the latest research),
they’ll likely encourage you to order custom orthotics. The problem here is that more
support and an even higher heel height have nothing to do with recovery from
Achilles Tendinopathy.
Significant pronation can be a contributing factor to this injury and your podiatrist
might claim that orthotics help control it – but unfortunately no scientific study has
found that orthotics consistently reduce pronation. Still, if you’ve tried this protocol and
you’ve dealt with chronic Achilles problems for several months, orthotics may be worth
the investment as an alternative treatment option.
Tips & Tricks

Avoid minimalist shoes during recovery. Shoes with a heel-toe drop of 6mm or less
put more stress on the Achilles, soleus, and calf and could prolong your recovery. While
a balanced approach is most effective during training while you’re healthy, your
36
recovery phase should be more conservative. That means no spikes, racing flats, or
other super minimalist shoes while you’re experiencing Achilles pain.
Avoid motion-control shoes. While the vast majority of runners don’t need motion
control shoes, runners with a history of Achilles injuries should reject this shoe type if
they want to get healthy.
Motion control shoes are inherently stiff and they increase strain on the Achilles by
increasing the length of the lever arm from the ankle to the forefoot.
Run on even surfaces during recovery. Uneven terrain like soft grass or technical trails
could aggravate your Achilles because of increased twisting of the tendon. It’s best to
stay on smooth surfaces like roads, smooth grass (like a golf course), or crushed gravel
walking paths.
Use compression socks to aid recovery. While there’s no data or current research (that
I’m aware of) that supports compression as a treatment method for Achilles
Tendinopathy, I consider it a low-risk and potentially valuable addition to your treatment.
One reason why tendon injuries are difficult to heal is because they don’t get much
blood flow. Compression gear can enhance blood flow so it stands to reason that it can
help, with no negative effects. Here are a few things to remember:
37
manufacturers that the products reduces muscle damage caused by running
hasn’t been proved).
Prevention guide.
Avoid shoes that put pressure on the Achilles. Many running shoes have a heel
counter with a forward angle that puts unneeded pressure on the tendon. This can
cause pain, especially during the healing process.
Find running shoes that don’t put any pressure on the Achilles tendon. Some runners
may even want to cut out part of the heel counter so it stops touching the tendon.
38

Patellofemoral Pain
Syndrome (Runner’s Knee)
O f all the injuries that affect runners, Patellofemoral Pain Syndrome (PFPS) is one of
the few that I’ve been fortunate to never experience (along with stress fractures).
And I’m even more fortunate because there’s no consensus on what causes PFPS or
how to treat it. So if you do have runner’s knee, the treatment options are muddled and
not definitive. Frustrating, isn’t it?
Thankfully, there are still some very good options. Patellofemoral Pain Syndrome
responds well to conservative treatment and the pain is typically a dull ache, rather
than a sharp stabbing feeling.
Your ongoing health and prevention of future cases of PFPS will also depend more on
your training than specific preventive exercises. Indeed, how you train is critical to
staying healthy and is the entire subject of the Prevention book in this program.
The nature of PFPS is that you may experience mild symptoms of the injury for a long
time. While your training may not be significantly limited by the injury, it’s often
punctuated by the constant annoying ache of runner’s knee.
Let’s dive into this injury and see what our best options are for managing your PFPS.
39
Patellofemoral Pain Syndrome: What is it and why does

it happen?
Patellofemoral Pain Syndrome is a knee injury common among runners, cyclists, hikers,
and those who engage in “jumping sports” like basketball, volleyball, or the jump
events in Track & Field.
PFPS is a mysterious injury in that there’s no consensus on why it actually occurs. Some
claim it’s because the kneecap (patella) does not track well in its groove in the femur.
Others claim that it’s because the quadriceps is weak and does a poor job of
controlling the kneecap during activity. And some others go on to claim that PFPS
occurs because the cartilage of the knee has degenerated. While some research has
concluded that there can be some cartilage degeneration accompanying runner’s knee,
it’s not necessarily the cause.
Many theories abound yet there is no conclusive answer as to what specifically causes
PFPS. The best answer is likely a combination of factors, including weakness in the
quadriceps and hips (especially the hips), overuse, and inflexibility. Your individual
running form may also predispose you to developing this injury.
If we continue diving into the cause of PFPS, it’s helpful to understand that your knee is
a living joint and it’s stressed virtually all the time (even when you’re sitting!). It’s very
likely that your PFPS isn’t a significant, traumatic injury but rather your knee “telling
you” that it’s tired, potentially inflamed, and overused.
This irritation of the knee is because the joint is experiencing constant abuse – potentially
made worse by slight biomechanical inefficiencies. This perspective on runner’s knee
helps explain why most cases respond very well to rest and conservative treatments.
How do I know if I have PFPS?

Runner’s knee is characterized by pain in a very specific location. Like lateral knee pain
(on the outside of your knee) being correlated with IT Band Syndrome, there’s a
particular location for knee pain that makes it highly probable you have runner’s knee.
40
If your pain is directly on or along the outside edges of the kneecap, you most likely
have PFPS. The pain is typically a dull ache but can occasionally be sharp; it feels like
it’s located deep underneath the patella.
Along with the location of the pain, PFPS sufferers typically have more pain when
they’re walking up stairs, running uphill, squatting, or after prolonged periods of sitting
down. You may also experience pain while pushing on the kneecap.
It’s important to note that PFPS is different from patellar tendonitis, which is an entirely
separate injury characterized by pain in the patellar tendon. This is the thick tendon that
connects your patella to your shin. This is a more injury, particularly among runners.
Myth #1: Runner’s knee is caused by leg length discrepancy,

wide Q-angle, or severe pronation.
Erroneous on all accounts! Let’s keep this simple: there is no research that supports
these claims.
PFPS is a more mysterious injury than some others, so I don’t blame clinicians who may
blame the “usual suspects.” But the truth is this: no studies have confirmed these
issues as contributing to runner’s knee.
These biomechanical issues could certainly contribute to runner’s knee, but nobody
knows for certain and it’s irresponsible to make those claims as definitive.
Myth #2: “My kneecap doesn’t track properly, so I get

runner’s knee.”
This is the most commonly cited cause of Patellofemoral Pain Syndrome. The idea is
that the patella “tracks” within the groove in your femur. But when it doesn’t slide
evenly in this track, you can end up with PFPS.
This tracking problem is why most treatments focus on strengthening the quadriceps,
stretching the IT Band (if you’ve read the ITBS section, you know it’s impossible to
41
stretch this thick piece of connective tissue), using knee braces, and taping the knee.
But unfortunately, there’s no clear relationship between a tracking problem and your
PFPS (it could be a contributing factor, but not the direct cause of the injury).
The patella is more dynamic than we give it credit for: it can move all over the place. If
you lie down so your leg is straight and you’re not holding any tension in your knee,
you’ll notice the patella seems to hover over the knee joint. Manipulating it in all
directions is quite easy.
Like many things in biology, there’s no clear definition of what “normal” tracking is for
the patella. Several studies have shown that tilting or displaced kneecaps during
activity shouldn’t be construed as “abnormal.” Indeed, abnormal may be normal.
Healthy knees do all kinds of weird things and it’s virtually impossible to tell an injured
knee from a healthy knee by looking at the position of the patella.
So if your treatment focuses on correcting the alignment or function of your patella,

you should find better treatment.
Healing Runner’s Knee: Your Treatment Strategy

Most PFPS treatments focus on one thing based on the particular perspective of the
clinician, like patella tracking or quadriceps weakness.
The problem with these strategies is that we’re not entirely sure what causes PFPS (though
we have some good ideas) and relying on one treatment could be entirely ineffective.
Instead, let’s combine several treatments into one protocol that focus on the most likely
contributing factors that result in runner’s knee.
As soon as you experience an ache in or around the patella that gets worse when
you climb stairs, run uphill, or after long periods of sitting you should begin this
treatment protocol.
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Step 1: Stop running. Remember that PFPS is likely an overuse problem and the knee
is “tired.” Running through the injury is like trying to keep an infant awake when all it
wants is sleep. Let your knee sleep!
Take a full week off from running and try not to stress your knee with any activity that
could cause pain (see the Tips & Tricks section below for more on this subject).
Step 2: Pain Management. PFPS is not an inflammatory condition but some

inflammation may exist, particularly when the injury first begins. Icing can be helpful to
reduce this initial period of inflammation and provide some relief.
The most effective way to ice your knee is to fill a small bag (like a Ziploc freezer bag)
with crushed ice and apply directly to the area that presents with pain. If you use cubes
that are too large, you may leave areas of tissue untreated. Ice for 15 minutes 2-3 times
per day for the first 3-7 days or as long as pain persists.

can use them for 1-2 days as directed.
Step 3: Complete a “Recovery Workout” after an initial recovery period. After 7

days of no activity, you’re ready to start a more aggressive treatment approach that
focuses on building strength and functional flexibility
Each day perform these steps in this order:
1. Spend 5 minutes foam rolling the quadriceps, hamstring, and hip muscles of the
affected leg; if these muscles are tight they can limit your range of motion while
running or compromise your movement patterns.
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2. Complete a strength routine from this program, alternating between the Standard
Core Routine, ITB Rehab Routine, Stiletto Routine, and the Claymore Routine.
The goal is to build overall strength while focusing on the hips, which have been
shown to contribute to PFPS.
3. Optional: ice the affected knee for 15 minutes 1-2 times, with enough time in
least 20 minutes).
Step 5: Test Run! If you experience progress within two weeks (one week of complete
rest and one week of pain free strength work), you’re ready for a test run (with a
dynamic warm-up, of course). The goal of this run is to simply see if you can run
without pain – it is not to gain any fitness. For that reason, your pace is not important.
Run comfortably and relaxed. There’s no reason to run at an unreasonably slow pace,
but don’t run hard either.
can put additional stress on the knee. Remember to maintain proper running form and
ensure your cadence is at least 170 steps per minute.
If you feel good, you can continue to run cautiously for 1-2 weeks. Add 5-10 minutes
to each run and follow the best practices of increasing mileage from the Injury
Prevention guide.
During this time you should also complete a daily strength/core routine and gradually
introduce hillier terrain to your runs.
Patellofemoral Pain Syndrome Q&A

Does the pain from PFPS come from degenerated cartilage in my knee?
This is a simple question to answer: nope! The cartilage underneath your patella and
on the femur doesn’t have any nerves – it’s relatively inert.
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What actually hurts is probably the synovial lining, a fancy word for the soft tissue and
fluid that surrounds your knee joint. It acts as lubrication between the moving parts of
your knee. It’s capable of irritation which is why it’s the specific part of your anatomy
that hurts.
Should I get an MRI or Bone Scan?

In all my research, I’ve never found mention of MRI or CT Scans being helpful in
diagnosing Patellofemoral Pain Syndrome. Nor have they helped those with chronic
PFPS gain new understanding of their injury.
However, bone scans have shown to be worthwhile for chronic sufferers who want a
more definitive diagnosis. If the patella is truly “distressed” or “tired” like we discussed
in the previous section, it will show up on a bone scan. A bone scan works when you’re
given an injection with a tiny amount of radioactive material. It shows up on the scan
and spreads wherever your blood goes (this indicates metabolic activity, like
inflammation or a bone fracture).
Bone scans are expensive and I’d ask your doctor if it’s appropriate if you have chronic
PFPS. My research has concluded that this type of scan can confirm a PFPS diagnosis
and help isolate the overused tissue.
Could I just have arthritis?

Sure, especially if you’re an older runner over the age of 55. Typical arthritis is due to
wear and tear and you may be at a higher risk of developing arthritis if you’ve
experienced a traumatic injury to the knee in the past.
Visit your doctor and get an x-ray to confirm the diagnosis. But don’t worry, just
because you have some arthritis doesn’t necessarily mean you’re experiencing any
pain. Degeneration of cartilage in the knee doesn’t always cause pain while running.
Defer to your doctor’s prescribed treatment of arthritis, as it will be different from PFPS.
Can I run through Patellofemoral Pain Syndrome?

Even though I said before that running on PFPS is a bad idea, it likely won’t make the
pain worse (though it certainly won’t make it better).
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You won’t destroy your kneecap by running through the dull ache that accompanies
PFPS. You probably won’t wear away the cartilage underneath your patella. You’ll be
forced to stop by more severe pain before you do anything truly destructive.
But there are risks. You’ll prolong your recovery and you could set yourself up for more
severe problems in the future. Carefully weigh these risks with your love of running.
Tips & Tricks

Reduce pressure on the patella. Your kneecap is under pressure right now as you’re
reading this – if you’re sitting down with your bent legs. The only time your patella is
truly at “rest” without being under pressure is when your leg is straight and there’s no
tension in the knee.
If you have Patellofemoral Pain Syndrome, sitting down for hours with bent knees may
seem like taking it easy and resting your knee. But in fact, you’re not relieving the knee
of any pressure. PFPS is unique in this regard; it’s so difficult to rest and “rest” doesn’t
necessarily mean rest!
While you are recovering from runner’s knee, be sure to vary the position of your leg
during the day so you are not constantly keeping pressure on the patella. Straightening
your legs under your desk is the most practical way to do this if you’re an office worker.
Lying down with straight legs is the most effective recovery position.
If possible, put your feet up while you work. Tell your boss it’s an accepted method of
reducing pressure on the patella and you’re suffering from Patellofemoral Pain
Syndrome (all those big words will definitely convince her).
During recovery, avoid pain. This sounds intuitive, but it’s imperative to your recovery
that you avoid activities and positions (like sitting) that aggravate your PFPS. Because
of the nature of how we use our knee, the list is long:
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★ Walking
★ Strength exercises like squats or leg press
★ Driving a manual car in traffic
★ Prolonged sitting
★ Jumping
★ Running
★ Elliptical machines
★ Cycling
While you’re recovering, you must abide by the “no pain, all gain” maxim to enhance
your PFPS recovery.
Of course, this is difficult in practice because it’s so damn easy to load the knee. You use
it almost all the time on an average day (never mind a day you’re attempting a long run!).
You might need to try this “complete rest” thing a few times before you get it right –
and remember that just because an activity can be completed pain free doesn’t mean
it’s ok to continue. You must decrease the load on the knee, which includes things like
driving a manual car and sitting with bent legs.
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Shin Splints
S hin splints (technically medial tibial stress syndrome – or MTSS) are one of the
most common injuries experienced by runners. In fact, the group that’s the most
susceptible to shin splints is runners.
Looking back over my own running career, there were two time periods that I suffered
through shin splints: my high school freshman cross country season and my college
freshman cross country season.
The reason I experienced shin splints during these two seasons – four years apart – speaks
to the nature of this injury. They’re primarily an injury that afflicts beginning runners.
So, when I started running, I got shin splints.
And when I started running double the volume of what I normally ran, I got shin splints.
Shin splints is an injury that occurs because of a dramatic change in effort: too much
mileage, run too quickly, too soon before you’re ready. Beginners are most susceptible
since any running is a dramatic change in effort.
The good news is that once you develop consistency in your training and get a bit
more experience, shin splints will likely become a distant (bad) memory.
Shin Splints: What are they and why does this injury happen?
Shin splints are characterized by a tender ache, dull throbbing, or even sharp pain
while running.
The location of the pain is typically along the inner (medial) or outer (anterior) edge of
the shinbone – called the tibia.
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Scientists and medical professionals aren’t entirely clear on what exactly causes shin
splints. Some of the most common explanations are:
★ Small tears in the muscles that cover the tibia
★ Inflammation of the periosteum (the sheath of connective tissue that wraps

around the tibia)
★ Inflammation of the shin muscle
★ An imbalance between the calf and shin muscles
★ Calf and/or soleus muscles that are too tight, restricting proper movement of the
lower leg
★ A combination of any of these factors
These problems occur when runners fall prey to the “Three Too’s” that we discussed
previously: too much, too soon, too fast. Training errors that result in a workload that’s
too high for your current ability almost always result in injuries.
Thankfully, shin splints are rarely serious and they’re easily treated. In fact, I barely
consider them a real “running injury” because most of the time they can either be
trained through or resolved quickly.
How do I know if I have Shin Splints?

If you have shin splints, then you’ll probably know it immediately.
You’ll suffer from a dull ache or throbbing along the medial or anterior edge of the tibia.
It will be generalized over most of the shin area and will be quite tender to the touch.
But first, it’s important to rule out two more serious injuries: compartment syndrome or
a tibial stress fracture.
Compartment syndrome (most commonly Anterior Compartment Syndrome) occurs

when the shin muscle swells inside the “compartment” of fascia that make up your
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entire shin muscle complex. If one or more of these compartments are too tight, blood
flow will become constricted and oxygen levels might drop.
This scenario results in a lot of pain, often debilitating, that makes running virtually
impossible. It’s much more common to the anterior side of the tibia and requires
surgery to release the pressure from the shin muscle compartments.
Compartment syndrome is much rarer than shin splints, but if your pain meets these
requirements, it’s best to see a physical therapist or doctor:
★ The pain is located on the anterior (outer) side of the shin

★ The pain is ongoing, often lasting for weeks or months
★ The pain is in the shin muscle, not the tibia (bone)
The second possibility is a tibial stress fracture. A stress fracture occurs when repeated
stress leads to a small break in the bone. Stress fractures typically don’t hurt at all
during normal activity but are very painful while running.
Another telltale sign that you have a stress fracture is sharp pain located at a specific
point on the shin bone. Shin splints are not located on a specific point – they’re a more
general pain that occurs along the length of most of your shin. If your pain is localized
and focused on a small area, you may have a stress fracture.
Stress fractures typically feel better in the morning after a night’s rest. Conversely, shin
splints often feel worse in the morning because the shin muscles have tightened
overnight during the healing process.
The only way to definitively diagnose a stress fracture is with an MRI scan.
Once compartment syndrome and a tibial stress fracture are ruled out, then you can
confidently label yourself a sufferer of shin splints.
Just don’t believe this prominent myth!
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Myth #1: “I just need to realign my foot!”

This misconception is popular in the Personal Trainer world, especially among those
who subscribe to “natural” or “caveman” philosophies that dictate we’d all be
outstanding athletes if we didn’t live a modern lifestyle.
The problem, of course, is that we do live a modern lifestyle.
We can’t change the fact that we probably grew up wearing shoes for a majority of the
day. Or that we may lack the strength, function, and mobility to have a perfectly
aligned foot.
The other major problem with this line of thinking is that it assumes it’s even possible to
realign the foot. But that’s not always the case!
The reality is that your foot’s alignment is the result of genetics (which you can’t control)
and behavior over the last few decades (which can be changed, but slowly over a long
period of time).
We can’t simply try to “realign” the foot without acknowledging two truths:
★ It may not be possible to alter your foot’s alignment because of your anatomy
★ It may be possible to realign your foot – but it will take years of consistent, hard work
Our goal then becomes to strengthen and mobilize the foot and lower leg, while at the
same time eliminating the training errors that contribute to shin splints.
Healing Shin Splints: Your Treatment Strategy

In the past, I’ve often said that shin splints are not really an injury – more of an
annoyance that only afflicts new runners or those who are training improperly.
But shin splints technically are an injury – and should be treated carefully so they do not
progress into compartment syndrome or a stress fracture.
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Our treatment protocol reflects changes in training (to reduce stress and eliminate
training errors) and strength (to build resilience to factors that cause shin splints).
You’ll notice that the protocol below includes both general strength and specific
strength. General strength focuses on the muscles important to runners like the hips,
glutes, hamstrings, and core. You might ask, “Why do these strength routines when my
SHINS are what’s hurting?”
The answer is that what hurts is not always the problem. Your shin splints could be
caused by a weakness further up the kinetic chain. In fact, researchers from Belgium
published a study a few years ago indicating that those with weak hip abductors were
more likely to suffer from shin splints.
So, while we’ll definitely focus on your shins, we’re also going to make you stronger
everywhere else, too.
Step 1: Stop Running or Run Less

While suffering through shin splints, it’s necessary to either take time off from running
completely or reduce your overall workload so that running pain-free (or nearly pain-
free) is possible.
Any cross-training that exacerbates pain should be avoided, most notably hiking,
walking, elliptical, or cycling.
If you push through shin splint pain, you’re increasing the risk of a more serious injury
so please observe our “Patience” principle and rest!
Step 2: Pain Management

Inflammation may be present in your shin muscles so it can be beneficial to reduce any
pain at the outset of the injury.
Icing is one of the best ways to locally reduce inflammation without taking a non-
steroidal anti-inflammatory drug (NSAID) like Ibuprofen (which can reduce your body’s
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ability to heal itself by blunting the adaptation and recovery signals sent by your body).
If pain is severe, you can take NSAIDs for 1-2 days as directed.
Simply fill a small bucket or cooler with some water and ice to create a mini-ice bath for
your lower legs. Alternatively, you can freeze ice in a paper cup, tear off the top of the
cup, and you have a block of ice to massage your shins that has an insulated handle.
Ice for about 15 minutes twice per day during the first two days.
Step 3: Complete a Daily “Recovery Workout”

Most runners who suffer from shin splints will rest, apply ice, take some Advil, and hope
for the best.
I don’t like to hope for the best. I like to plan for success.
So instead of a half-hearted treatment approach, we’re going to be far more strategic.

A Recovery Workout is one that you might do at a physical therapist’s office that
focuses on the general and specific causes of the injury.
Every day, perform these steps in this order:
1. Foam roll the calf and soleus of the affected leg. Spend about 1-2 minutes on this
area – any longer is unnecessary.
2. Use a golf or lacrosse ball to roll the underside of the foot. Focus on the arch and
plantar fascia, working through any scar tissue or muscle adhesions that might be
inhibiting movement.
3. Complete a strength routine from this program without any shoes on, alternating
between them. Focus on the fundamental routines like Standard Core, ITB Rehab,
and Ballista (these are your general strength routines).
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4. Twice per week, do the Chakram Routine barefoot to strengthen the ankle and
lower leg musculature. This should be in addition to the general strength routine
you’re doing on a daily basis.
5. Twice per week, do the Sand Routine barefoot. This routine should also be done
in addition to the general strength routine you’re doing on a daily basis.
6. After spending about 15-20 minutes with these routines, it’s time for more
targeted strength. Start with two sets and build to three sets of the following
exercise:
Heel Walks: With your weight on your heels, take 20 small steps forward. Keep
your toes dorsiflexed upwards during this exercise. Maintain an upright posture
with toes pointed straight ahead. Walk normally back to the starting position and
begin the next set. Watch a video demonstration here.
7. Some research indicates static stretching of the calf and soleus can help relieve
shin splints. While I’m not entirely convinced, some static stretching can’t hurt as
long as it’s done at the very end of the training session. For best results, hold a
static stretch for 60-90 seconds. Stretching should never be painful. You can
perform this stretch by standing a few feet in front of a wall, leaning forward while
keeping your feet planted, and leaning into the wall. Another option is to foam
roll the calf and soleus instead of stretching.
Step 4: Fix Any Training Errors

Up until this point, we’ve focused on the problem at hand: your current shin splint injury.
But to be as effective as possible, it’s necessary to change how you train to not only
treat the injury, but prevent it from happening in the future.
Since the exact cause of shin splints is still a mystery – and your injury could be caused
by an issue that’s different from another runner with shin splints – it’s important to treat
this section like a buffet. Experiment with what works for you, keep what does, and
throw out the suggestions that aren’t giving you results.
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★ Introduce more variety in your running, particularly by rotating 2-3 different pairs

of shoes and running trails. Refer to the principle of Variety for more ideas.
★ Avoid smooth, hard surfaces like concrete sidewalks or asphalt roads.
★ Avoid the “three too’s” – too much, too soon, too fast. Sudden increases in
volume or intensity are the predominant cause of shin splints.
★ Don’t tie your shoes so tight. Doing so can restrict the movement of your shin
muscles and tendons where they attach to your ankle.
★ If you wear very bulky trainers like motion-control shoes, you could be at a
higher risk of aggressively heel striking or slapping your foot down on the
ground. The vast majority of runners should be running in Neutral or Stability
running shoes instead.
★ Don’t run cold. Warm-up before you head out the door with a dynamic
flexibility routine. Your muscles work better when they are warm and primed to work.
★ Consistency is king. If you regularly take significant breaks from running then your
body is not being trained to adapt to the stress of running.
★ Improve your form to eliminate inefficient movement patterns. Refer to the

section on Running Form for more cues and principles of efficient form (in
particular, measure your cadence and improve it if it’s too low).
★ Be patient! Sometimes, it takes 3-6 weeks for you to run pain-free after shin splints.
Step 5: Test Run!

If you’re feeling good without any pain during everyday activity for 4-7 days, you can
attempt a short, easy run. Remember that shin splints can take 3-6 weeks to heal so
the goals of this first run are to evaluate your progress and determine if you can run
with a low amount of pain. For that reason, your pace is not important. Run
comfortably and relaxed. There’s no reason to run at an unreasonably slow pace, but
don’t run hard either.
During these test runs, avoid any significant downhills or smooth, hard surfaces like
concrete. This type of terrain may put additional stress on the shins.
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Maintain the principles of proper running form – in particular, ensure that your cadence
is over 170 steps per minute if you’re a runner who runs under 10:00 minutes per mile.
If you run slower, a cadence of 160 or higher is fine.
If you don’t experience any setbacks, you can begin building your mileage (and then
your intensity) to pre-injury levels over the course of 1-4 weeks.
During this time you should also complete a daily strength/core routine and the heel
walk exercise. When you’re finally healthy, you can skip the heel walks.
Shin Splints Q&A

Can I run through shin splint pain?
Maybe! It really depends on whether you actually have shin splints or are suffering from
a more serious injury like compartment syndrome or a tibial stress fracture.
If you do indeed have shin splints, it’s fine to run through mild pain if it’s dull or achy.
But if it becomes severe or sharp, then you’re making the problem worse and should
take a break from running.
Ideally, you’ll take time off from running so that you’re not exacerbating the injury. But
if you absolutely must do some easy running, keep it short and don’t run through any
substantial pain.
Can barefoot running help treat or prevent shin splints?

If strength exercises are prescribed to treat shin splints, then it’s reasonable to conclude
that some barefoot running can also help this injury (since barefoot running strengthens
the feet and lower legs as well).
But it’s critical to transition very gradually to any amount of barefoot running. I
recommend 1-2 sessions of 4-6 barefoot strides every week if you have a history of foot
or lower leg injuries.
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Web resource:
What Are Strides?
Start with one session of four strides with the final two barefoot. Over the course of 4-6
weeks, build up to two sessions of six strides.
You don’t need to run in minimalist shoes or do any additional barefoot running if
you’re doing barefoot strides.
Do running shoes contribute to shin splints?

Maybe! Shoes can cause shin splints when there is a sudden, often dramatic change in
the type of shoe that you wear.
Often, competitive athletes who transition from the base phase of training to the
competition phase of training begin running workouts in racing flats or spikes without
any preparation. This is a scenario that often results in shin splints.
Another scenario that can cause shin splints is failing to replace shoes when necessary.
Shoes that are beyond their normal life cycle (typically 300 – 500 miles of running) don’t
provide the support needed and often exacerbate existing biomechanical inefficiencies.
Finally, as mentioned previously, restrictive motion-control shoes can contribute to

shin splint pain. These shoes are heavier, provide higher levels of support, and
usually have higher heel-toe drops, arch supports, and stack heights (the height of
the shoe off the ground).
All of this “technology” makes for more awkward running. You’re better off by wearing
a neutral or stability shoe and doing the strength work necessary to strengthen your
lower legs.
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Tips & Tricks

Using Compression Socks to Treat Shin Splints
Compression socks can be valuable in speeding the recovery process from shin splints.
There’s no data or current research (that I’m aware of) that supports compression as a
treatment method, but logic indicates that it can be helpful.
manufacturers that the product reduces muscle damage caused by running hasn’t
been proved).
Prevention guide.
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Muscle Strains
S ince 2010, I’ve fielded hundreds of questions specifically about muscle strains:
groin, hamstring, hip flexor, and calf strains are the most commonly strained
muscles among runners.
Thankfully, a strain is usually not a serious injury. It does not warrant an overhaul of your
training program nor does it indicate that you have a host of biomechanical
inefficiencies that make injuries far more common.
Here we’ll be focusing on mild to moderate strains (Grade 1 and less serious). If you
have a severe strain that doesn’t respond to self-treatment, you may need to see a
medical professional.
This treatment protocol will be more general than the previous protocols because
there’s not much complexity to a muscle strain.
That’s good news! You could be back on the road in just a few days.
Muscle Strains: What are they and why does this injury happen?
A muscle strain is an overstretched or torn muscle. It’s commonly called a “pulled
muscle” or a “muscle pull.”
This muscular damage can also extend to any tendons attached to the muscle and can
result in damage to small blood vessels.
Muscle strains occur when a muscle is used improperly – either outside its intended
range of motion or during a stressful activity like heavy lifting or sprinting before the
muscle is ready for that level of effort.
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There are several scenarios that might produce a muscle strain:
★ Not warming up adequately before a difficult training session
★ Poor conditioning (i.e., you’re not physically prepared for the training)
★ Attempting to lift something that’s too heavy
★ A slip, fall, or stumble while running
When the weather is cold, you’re more likely to suffer a strain because muscles are not
as warm and their flexibility is reduced.
How Do I Know If I Have a Muscle Strain?

A muscle strain will usually produce a sudden onset of pain and a reduction in range of
motion and strength. You’ll probably feel it as soon as it happens.
Other symptoms include:
★ Lingering soreness, stiffness, or pain at the site of injury (even at rest)
★ Bruising, redness, or similar discoloration
★ Swelling
★ Muscle cramps or a “knotted up” feeling
Since muscle strains typically occur because of an acute trauma (lifting, running,
jumping, falling, throwing, etc.) rather than repetitive stress, you’ll immediately know
there’s a problem.
Myth #1: “Only Fast Workouts Cause Strains”

Some runners believe that a strain can only occur during a grueling session of intervals.
After all, a strain is basically an overstretched muscle, right?
How do you strain a muscle unless you’re engaged in vigorous, high intensity exercise?
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But a muscle can be overstretched – even to the point of tearing – by relatively normal
activity like lifting a heavy box or tripping on a rock during a trail run.
Strains are just as common during high intensity exercise as they are during any activity
in which you put yourself into an awkward position or move too quickly.
If you lift a heavy box as fast as you can, after being sedentary for hours, you might
strain a muscle.
Or you might get a muscle strain if you start running a very technical trail with no warm-
up at an aggressive pace.
Understand that a strain is always possible if you perform a physical task without warming
up properly, with incorrect form, or by moving outside the normal range of motion.
Healing a Muscle Strain: Your Treatment Strategy

The good news is that a muscle strain is rarely serious for distance runners.
The bad news is that the treatment is mostly rest.
Since strained muscles are essentially overstretched, resulting in damage, we need to

let that damaged muscle tissue heal. And because the cause of the injury was either
acute (like tripping) or a training error (not warming up enough before sprinting), then
we simply need to focus on rest now and avoid training errors in the future.
Step 1: Stop Running or Run Less

While suffering a muscle strain, it’s necessary to either take time off from running
completely or reduce your overall workload so that running pain-free (or nearly pain-
free) is possible. Any cross-training that exacerbates pain should be avoided.
A strain can be mild, moderate, or severe. Medically speaking, they’re either Grade 1,
2, or 3. These grades are defined as:
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Grade 1: Mild damage to 5% or less of individual muscle fibers. There’s minimal loss of
mobility and strength and recovery is optimistic after 1-3 weeks.
Grade 2: Moderate damage to a higher number of individual muscle fibers. The tissue
is not ruptured but there is significant loss of strength and motion that often takes
months to heal.
Grade 3: A complete rupture to the muscle that presents with significant swelling and
possibly a noticeable defect in the muscle itself. Recovery may require surgery.
Runners will rarely proceed beyond a Grade 1 strain. And in fact, most strains that
afflict runners are not severe enough to be classified as a Grade 1 strain – but they will
still prevent you from running comfortably!
Step 2: Pain Management

Inflammation will likely be present at the location of your strain so it can be beneficial
to reduce any pain at the outset of the injury.
Icing is one of the best ways to locally reduce inflammation without taking a non-
steroidal anti-inflammatory drug (NSAID) like Ibuprofen (which can reduce your body’s
ability to heal itself by blunting the adaptation and recovery signals sent by your body).
If pain is severe, you can take NSAIDs for 1-2 days as directed.
Most strains are best treated with a bag of ice or an ice cup. To make an ice cup, freeze
ice in a paper cup, tear off the top of the cup, and you have a block of ice to massage
the area that has an insulated handle. Ice for about 15 minutes twice per day during
the first two days.
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Step 3: Speed the Healing Process

To ensure your muscle strain is treated as quickly as possible, it’s critical to avoid any
activity that exacerbates the injury and prolongs recovery time.
These activities should be immediately stopped:
★ Fast running like structured speed workouts, hill sprints, or strides (with larger
ranges of motion, running fast can make strains worse by overstretching them)
★ Static stretching
★ Dynamic stretching
★ Any activity that causes pain
A note on that last bullet point: with a strain, you want to avoid stretching the muscle at
any point. That may mean different things for different strains.
For example, if you have a calf strain, you’ll want to avoid zero-drop minimalist shoes
and being barefoot for prolonged periods of time because this puts your calf in a more
stretched position.
For a hip flexor strain, you’ll want to avoid any motion that extends your femur behind
your body.
Step 4: Active Recovery

Like with other injuries, you don’t want to rest completely – active recovery is almost
always better in any injury scenario.
Instead of being sedentary while you recover, you’ll instead perform a “recovery
workout” every day – just like you might do at a physical therapist’s office.
Every day, perform these steps in order:
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★ Foam roll the affected muscle only if this doesn’t cause any pain. Spend about 1-2
minutes on this area – any longer is unnecessary.
★ Foam roll the surrounding musculature, both “upstream” and “downstream” (in
other words, above and below the strained muscle). For example, if you strain
your calf you should foam roll both the hamstring and soleus to loosen up the
surrounding areas.
★ Complete a strength routine from this program, alternating between them. Focus
on the fundamental routines like Standard Core, ITB Rehab, and Ballista (these are
your general strength routines). If any exercise causes pain, skip it.
★ Depending on the location of your muscle strain, complete more targeted

strength work for the strained muscle.
• If the strain is in the lower legs or feet, do the Chakram Routine and Sand
Routine barefoot with the specific foot exercises outlined in the Plantar
Fasciitis and Shin Splints protocols.
• If the strain is elsewhere, perform an extra set of exercises for that

particular muscle.
Step 5: Test Run!

If you’re feeling good without any pain during everyday activity for 2-5 days, you can
attempt a short, easy run. Remember that some muscle strains can take weeks to heal
so the goals of this first run are to evaluate your progress and determine if you can run
with a no or just a low amount of pain. For that reason, your pace is not important. Run
comfortably and relaxed. There’s no reason to run at an unreasonably slow pace, but
don’t run hard either.
It will be helpful to do a thorough warm-up before you start running. Spend a few
minutes on your foam roller, do a complete warm-up routine (but skip any exercises
that cause pain), and start the run very slowly to aid the warming up process.
While you’re running, maintain the principles of proper running form – in particular,
ensure that your cadence is over 170 steps per minute if you’re a runner who runs
under 10:00 minutes per mile. If you run slower, a cadence of 160 or higher is fine.
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If you don’t experience any setbacks, you can begin building your mileage (and then
your intensity) to pre-injury levels over the course of 1-4 weeks.
During this time, you should also complete a daily strength or core routine.
Muscle Strains Q&A

Can I run through a muscle strain?
Maybe! It really depends on the severity of the injury and if it impacts your running form.
If any pain that you’re experiencing is dull, achy, and gets better as you run then you’re
probably fine to run through it. Just keep the effort easy.
You should also never change your running form to accommodate the pain from an
injury. This essentially gives you a limp and causes your gait to change, increasing your
risk of future injuries.
But if the pain is sharp, severe, stabbing, requires you to alter your form, or progressively
gets worse as you run, then you should take a break entirely from running.
Ideally, you’ll take time off from running so that you’re not exacerbating the injury. But
if you absolutely must do some easy running, keep it short and don’t run through any
substantial pain.
How do I avoid strains in the future?

The most effective way to eliminating muscle strains is to avoid any substantial training
errors. If you adhere to these suggestions, your risk of a strain is considerably less:
★ Always do your strength work – stronger muscles are more resilient

★ Always warm up properly before a hard effort
★ Try not to do anything silly, like lift a heavy item as quickly as possible or start a
Tae Kwon Do class while you’re deep in marathon training
★ Make every effort to move in your normal range of motion
★ Avoid the 3 Too’s!
65
Tips & Tricks

Compression socks can be valuable in speeding the recovery process from a strain
provided that the strain is in your lower legs or feet. There’s no data or current research
(that I’m aware of) that supports compression as a treatment method, but logic
indicates that it can be helpful.
manufacturers that the product reduces muscle damage caused by running hasn’t
been proved).
Prevention guide.
66

Injury Prevention For Runners

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Injury Prevention For Runners

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Injury Prevention for Runners

1. Illiotibial Band Syndrome (ITBS)

2. Plantar Fasciitis (PF)

3. Achilles Tendinopathy (more commonly known as Achilles tendonitis)

4. Patellofemoral Pain Syndrome (more commonly known as Runner’s Knee)

Nevertheless, I’ve purposefully designed these programs to make them as actionable

Consider it a “best case treatment scenario” that exists in an ideal world.

Ready to get healthy? Let’s get started!

Treatment Program for IT

ITBS: What is it and why does it happen?

How do I know if I have IT Band Syndrome?

Myth #1: “My ITB is too tight!”

Myth #2: “My ITB is inflamed!”

Healing ITBS: Your Treatment Strategy

★ Fixing your running form

Step 2: Complete a “Recovery Workout” every day. This is where my treatment

1. Foam roll the hip, glute, hamstring, and

2. Use a tennis or lacrosse ball to focus on

I don’t have pain on the side of my knee; instead, it’s at my hip.

Can I run through IT Band Syndrome?

Can I cross-train while I have ITBS?

Do “knee straps” help relieve ITBS pain?

How should my training change once I get healthy from ITBS?

Tips & Tricks

Treatment Program for

Plantar Fasciitis: What is it and why does it happen?

No wonder it can’t support the strain of running!

How do I know if I have Plantar Fasciitis?

Myth #1: “My Plantar Fascia is Inflamed!”

Myth #2: “I Need Motion Control Shoes to Stabilize My Foot”

Healing PF: Your Treatment Strategy

Step 2: Pain Management. While PF is not an inflammatory condition, some

I don’t recommend anti-inflammatory medication like ibuprofen or acetaminophen as

Plantar Fasciitis Q&A

Can barefoot running treat or prevent plantar fasciitis?

Tips & Tricks

As you transition to a more minimalist shoe, remember these basic rules:

★ There are no short-cuts to running in less shoe. It’s a long-term process so if

Remember: the goal is not to continue transitioning so you’re running barefoot or in

Using Compression Socks to Treat Plantar Fasciitis

Treatment Program for

Achilles Tendinopathy: What is it and why does it happen?

★ Leg length discrepancy

★ General problems like joint and muscle asymmetries and weaknesses

How do I know if I have Achilles Tendinopathy?

Myth #1: “Take anti-inflammatories to heal your Achilles”

So if inflammation isn’t a problem, why take medication to reduce inflammation? Any

Instead, the Achilles is damaged due to overuse or dysfunction.

Myth #2: “I need to stretch my Achilles and calf to get them

Healing AT: Your Treatment Strategy

Step 2: Pain Management. While AT is not an injury caused by or associated with

I don’t recommend anti-inflammatory medication like ibuprofen or acetaminophen as

Note: These exercises are demonstrated barefoot to give a better demonstration.

Achilles Tendinopathy Q&A

Should I get orthotics?

Tips & Tricks

Treatment Program for

Patellofemoral Pain Syndrome: What is it and why does

How do I know if I have PFPS?

Myth #1: Runner’s knee is caused by leg length discrepancy,

Myth #2: “My kneecap doesn’t track properly, so I get

So if your treatment focuses on correcting the alignment or function of your patella,

Healing Runner’s Knee: Your Treatment Strategy