Fortunately for the state of health in America, many more people are long-distance running and participating in road races than ever! In fact, road race finishers have nearly tripled from 5 million in 1990 to 15 million in 2011, according to Running USA. Not only is this increase great for the sport, increasing interest in running is an effective means in fighting the chronic disease epidemic. So, what’s the drawback?


Incidence of Long-Distance Running Injuries

Running clearly increases your risk for injury, as does almost any sport. The exact incidence of long-distance running injury is not quite known because tracking injuries can be difficult. In a 2007 systematic review of running injuries (Van Gent, Br J Sports Med, 2007) 19% to 79% of runners were noted to have injuries. Among the studies included in the review, an increased risk of injury was correlated with running distance and a rapid increase in running volume (mileage). In addition, those who had a previous running injury that was not fully rehabilitated also were at an increased risk for a new running injury. Therefore, addressing these risk factors with proper rehabilitation and an appropriate training schedule  is the first step in preventing a running injury.

Most Common Long-Distance Running Injuries

The most common long-distance running injury primarily involves the knee (~30% of all injuries) and most other injuries involve the lower leg, foot and ankle (Taunton, et al, Br J Sports Med, 2003; Lun, et al, Br J Sports Med, 2004). While it doesn’t take a rocket scientist to figure that the lower body is most commonly injured in running, this knowledge does help us to address biomechanical factors that may contribute to a long-distance running injury. In fact, the way you are running may mostly increase your long-distance running injury risk.

Proper Running Mechanics

Teaching the proper way to run goes well beyond the scope of this article. However, we can touch on a few key points that may help you prevent a long-distance running injury.


Starting from the ground up, overpronation of the foot is a common problem that can significantly increase your risk of a running injury. Overpronation occurs when the foot turn outward as it impacts the ground.

Here is a video that illustrates overpronation:

As you see, an outward turning foot can cause problems over the “long run.”

Correcting Overpronation

Correcting overpronation can be done one of two ways.

Forefoot run. Not only is forefoot running a more efficient way to run, it also helps to prevent overpronation altogether! Logically, if your heel never touches the ground, you eliminate the opportunity for your foot to overpronate (Liebermann, et al, Nature, 2010). 

Use an medial wedge shoe orthotic. A medial wedge shoe orthotic can either be professionally built into your running shoe or simply inserted into your shoe. Unfortunately, the research supporting the benefit of a medial wedge orthotic isn’t that great. In 2008, Richards et al published a study showing that running shoes with modifications did not decrease the risk for long-distance running injury.

Muscle Weakness

Moving up the lower limb, we have to address how to prevent the most common running injury, a knee injury. Specifically, patellofemoral pain is the most common knee injury. Patellofemoral pain occurs when the knee cap improperly moves in the groove in front of the knee, which results in significant anterior knee pain.

The cause?

Well, according a presentation at the 2013 Association of Academic Physiatrists, Dr. Kevin Vincent of the University of Florida Running Medicine Clinic, states that improper adduction and internal rotation of the hip while running is a likely cause of patellofemoral pain. In other words, the hips are too close together and turn in during the running stride, which pulls the knee cap out of place when running. Over time, the back of the knee cap becomes chronically damaged, which results in pain.

To correct this improper running gait, Barton et al, (Br J Sports Medicine, 2012) recommends strengthening the glute medius muscle, which is primarily responsible for preventing the hip from turning inwards during running.


The Side Lying Hip Abduction Exercise: view here.

How Much to Run?

The next question to ask when trying to prevent long-distance running injuries is to know whether or not you are overdoing it? As each individual varies, there is no hard answer, and probably never will be. However, according to Fredricson, 40 miles per week appear to be the point where the injury risk significantly increases. 

If you are new to running, no way should you be running 40 miles per week. Starting of with a mile or two each day and gradually increasing a few miles each week may help to prevent your risk of long-distance running injury. If you have been consistently running 40 or more miles per week without injury, then you are most likely okay to continue with your current weekly mileage.

Prevention of Long-Distance Running Injury

Back to The Importance of Forefoot Running

I did not intend to base most of this guide on forefoot running; however, the truth is that forefoot running is not only the most efficient means of running, but is also the best way to run to prevent injury.

As mentioned earlier, if you are a forefoot runner, there is no chance that you can overpronate or improperly strike the ground because your heel never touches! There is minimal foot rollover that occurs if you strike the ground with your forefoot/mid-foot. Because there is minimal rollover, your ankle joint stays stable, which decreases your risk for injury. Also, Liebermann noted in a 2010 article in nature that kinematic analysis confirmed that striking the ground with your forefoot or mid-foot resulted in smaller ground reaction forces that striking the ground with your heel. Because there is less force, there is less risk for injury.

Makes sense to me. Personally, this has made a huge difference in my efficiency and has considerably reduced my tendency for injury.

If you are a heel striker and are convinced that switching to forefoot running is the way to go, then you must be careful in making the switch. You can’t make a complete 100% switch overnight. Try alternating minutes between heel striking and forefoot striking. Once you are comfortable forefoot striking for a full minute, try 1:30. Increase by 30 seconds each run or every other run until you have made the full transition.

Forefoot Running Shoes

Forefoot running and barefoot running are two terms that commonly get confused. Barefoot running is strictly running without shoes… Barefoot. I do not recommend running without any protection on your feet for obvious reasons…

Forefoot running can be done with the proper shoe that is made for forefoot running. Don’t get me wrong, you can forefoot run in almost any shoe, but it can be difficult when you wear shoes with an elevated heel. Therefore, you want to try to find a zero drop shoe. To date, it appears that Altra and Newton are leading the industry, but the movement towards forefoot running is strong and gaining momentum. Soon, every running shoe company will be offering zero drop shoes.


What about stretching?

I have written a previous article on stretching.

In a nutshell – stretching does not decrease or increase your chance of a running injury. If you like to stretch, then stretch. If you don’t like to stretch, there is no need to start.

Straightforward enough?

Core Strength

If everyone had a strong core, musculoskeletal physicians would probably go out of business. Seriously.

Having a strong core keeps everything in alignment during your long-distance run. Think about the amazing biomechanics and forces involved in running. A strong core is the glue that keeps these forces balanced. Perform core strength workouts at least 2-3 times per week to both improve your efficiency and decrease your injury risk.

Training Surface

For the most part, research evidence is weak in recommending the optimal training surface. However, expert opinion (and common sense) leads me to believe that a softer surface is better to prevent long-distance running injury. A rubber track is probably better than asphalt, which is probably better than concrete. I would use caution when running on grass because you never know if you will trip over a root or step in a pot hole.

 Been there… Sprained that…

Shoe Inserts – Orthotics

A shoe orthotic can be beneficial is you have an anatomical imbalance, such as a pes planus (flat feet) or a leg-length discrepancy (one leg is longer than the other). It may also be beneficial if you have chronic knee pain, shin splints or plantar fasciitis. In this case, it is best to see your doctor or visit an shoe specialist to determine what type of insert is best for you. However, if you become a forefoot striking runner, an orthotic may be useless.


Long-distance running injuries can be prevented with proper technique, training schedule and realistic goals. Changing your running style to more of a forefoot strike may potentially improve both your performance and decrease your risk for long-distance running injury. Gradually increasing your running distance and incorporating shorter sprint training days into your workout schedule will also improve performance and decrease your injury risk. Finally, setting realistic goals for yourself and level of fitness is important in avoiding both frustration and overuse injuries. Work with your doctor and/or personal trainer to get a personalized training program that will get you running in the right direction!