Running: the cheapest sport with the most injuries

Running requires shoes and time, which makes it among the most accessible forms of exercise, and produces injury rates that are high enough to end many people's involvement in the first year.

Where the injuries come from

The evidence is reasonably consistent.

Training error — increasing volume, intensity or frequency faster than tissues adapt — is the dominant modifiable cause.

Previous injury is the strongest predictor of future injury.

Sudden changes in surface, terrain or shoes.

Inadequate recovery.

And, less than commonly believed, biomechanics — where the evidence linking specific gait or foot type to injury is weaker than the industry built on it implies.

Progression

The single most useful concept.

Bone, tendon and connective tissue adapt more slowly than the cardiovascular system, which is why people feel able to run further before their tissues are ready.

The traditional ten per cent weekly increase rule has limited direct evidence and is a reasonable heuristic in the absence of anything better.

What matters more: avoiding large spikes relative to recent training load, building consistency before volume, and increasing one variable at a time.

Structured beginner programmes that alternate walking and running over several weeks have good completion rates and low injury rates, and are freely available.

The common injuries

Recognisable patterns.

Patellofemoral pain: pain around or behind the kneecap, worse on stairs and prolonged sitting, responding to hip and quadriceps strengthening and load management.

Iliotibial band syndrome: lateral knee pain, typically after a consistent distance.

Achilles tendinopathy: pain and stiffness at the tendon, worst first thing in the morning, responding to progressive loading rather than rest.

Plantar heel pain: pain under the heel, worst on the first steps of the day.

Shin pain, ranging from medial tibial stress syndrome to bone stress injury.

And bone stress injuries generally, which are the ones to take seriously: localised bone pain that worsens with running, hurts on hopping, and persists at rest requires assessment and rest from impact, since continuing risks a full fracture.

Shoes

Where a great deal of money is spent on a weak evidence base.

Trials assigning shoes based on foot type or pronation have generally failed to show reduced injury rates.

Comfort at the point of trying has some evidence as a predictor of injury risk, which is a simpler criterion than any gait analysis.

What matters practically: shoes that fit, with adequate room at the toes; replacement when the midsole is compressed, generally after several hundred kilometres though this varies; and avoiding sudden changes in shoe type, particularly to a substantially lower heel drop, which shifts load to the calf and Achilles abruptly.

Carbon-plated racing shoes improve running economy measurably and are expensive and unnecessary for anyone not racing.

What actually reduces injury

The measures with support.

Gradual progression, which is the largest factor.

Strength training, where trials of strength and neuromuscular programmes show reductions in overuse injuries.

Adequate energy intake, since low energy availability is associated with bone stress injuries and with a wider syndrome affecting bone, hormones and performance in both men and women.

Sleep.

Varying surfaces and routes.

Including easy running rather than making every run hard, which is the most common error in self-directed training.

And addressing niggles early rather than running through them, since most overuse injuries announce themselves before becoming disabling.

What running is good for

The reason to bother.

Large cohort studies associate running with reduced all-cause and cardiovascular mortality, with benefit appearing at modest weekly volumes and with the curve flattening rather than continuing to improve at high volumes.

Which means that relatively small amounts — well below what serious runners do — capture most of the health benefit.

Effects on mood, sleep, bone density and metabolic health are well documented.

And the cost is a pair of shoes.

Starting from nothing

Practically.

Begin with walking, then walk-run intervals, following a structured programme over several weeks.

Run slowly enough to hold a conversation, which most beginners do not.

Three sessions a week with rest days between is sufficient.

Add strength work twice a week.

Expect the first few weeks to feel harder than they should, and expect the adaptation to be uneven.

Free timed community events exist in many countries and are a good structure for beginners.

And seek advice before starting if you have cardiovascular disease, are significantly deconditioned, or have joint problems.

General information only, not medical advice. Consult a qualified clinician before starting running if you have a medical condition, and seek assessment for localised bone pain that worsens with activity.