Running Injuries

The question that changes everything: tendon or bone?

Tendinopathy and bone stress injury can feel similar early on, and they are managed almost oppositely. A tendon generally tolerates — and needs — progressive loading. A bone stress injury needs load taken off it, and continuing to run on one risks progression to a fracture.

The features that push us towards bone are pain that is sharply localised to a small area of bone, pain that comes on earlier in each run rather than warming up, night pain, and a recent jump in training volume. Add in relative energy deficiency, low bone density, previous stress fracture, or an athlete who is training through amenorrhoea, and the threshold for imaging drops considerably.

This is the single most common thing we see managed as a soft-tissue problem when it is not.

Do I need a scan before I run again?

Often not. For most gradual-onset running pain, a careful history and examination will identify the problem, and imaging changes nothing about the plan. Routine early imaging for musculoskeletal pain is specifically discouraged in Australian guidance because incidental findings are extremely common and can be actively unhelpful — plenty of pain-free runners have tendon changes and disc bulges on scan.

Imaging earns its place when the answer would change management: suspected bone stress injury, a suspected tear, a locked or unstable joint, symptoms that do not fit the examination, or a problem that has not responded to a genuine trial of rehabilitation.

Dr Hatch worked as a musculoskeletal MRI radiographer for ten years before medicine, so the imaging decision — whether a scan is warranted, which one, and how its findings sit against what your examination actually shows — is worked through with you in the consultation rather than deferred to a report.

Returning to running is a set of criteria, not a date

Asking how many weeks until you can run is the wrong question, and any answer given before you have been assessed is a guess. The better question is what you need to be able to do before running is a reasonable thing to attempt, and what the first four weeks back should look like.

A return plan generally covers pain behaviour during and 24 hours after loading, single-leg strength and capacity on the affected side compared with the other, tolerance of impact in graded doses, and a running volume progression that does not repeat whatever caused the problem. Where a specific target event matters to you, say so at the assessment — it changes the sequencing, and sometimes it changes what is realistic.

Where treatment fits

Progressive loading is the treatment for most running tendinopathy, and it has the strongest evidence by a wide margin. Nothing offered here substitutes for it.

Shockwave therapy is considered for tendon problems that have not settled after a genuine trial of loading, usually around three months — the trial evidence favours shockwave combined with loading over either alone, and it is best supported in plantar heel pain and mid-portion Achilles tendinopathy. Injection options are discussed against your specific diagnosis, including where the evidence for them is thin.