Stop running injuries in their tracks—Assessment tips for physios

With the running bug taking the world by storm, it has never been more important for physios to stay across the assessment of running-related injuries. When a runner comes in with an injury, there are many factors to consider. Not only do you need to help them keep running or get back to peak performance as quickly as possible, but you must also assess the injury’s seriousness (e.g., bone stress injury) and prevent it from becoming a chronic issue (like tendinopathy) that could sideline them long-term. For such a repetitive, high-load activity, it’s inevitable that problems will arise, and effective problem-solving starts with a thorough assessment.

This blog highlights key insights from expert physio Brad Beer’s Practical on assessing injuries in runners. We’ll cover two major injury categories: tendinopathies and bone stress injuries.

If you’d like to see exactly how expert physio Brad Beer assess injuries in runners, watch his full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more here.

Tendinopathies

Understanding tendon behavior is the first step. In the subjective assessment, watch for signs like pain that “warms up” during a run, pain the following morning, short-lived morning stiffness, and pain triggered by changes in load (e.g., increased speed, distance, frequency). And be sure to get a detailed history from your runners!

Achilles tendinopathy

This is one of the most common tendon issues in runners. Brad demonstrates a simple, progressive assessment to gauge load capacity in the Achilles tendon, starting with a double-leg calf raise, progressing to single-leg, and then adding speed and plyometric elements.

Interestingly, Brad emphasises testing calf capacity by isolating it from the toe flexors, which can contribute up to 25% of plantarflexion strength. To do this, have your patient stand on a plank with their toes off the edge. This small modification offers a more accurate assessment of true calf capacity.

In terms of differential diagnoses from midportion Achilles tendinopathy, Brad notes the importance of considering the involvement of Plantaris. While it’s more common in rowers and cyclists, it’s worth checking in runners as well. Here’s a quick demo on how to assess Plantaris taken from his Practical:

Proximal hamstring tendinopathy

This injury is often aggravated by compressive activities like running uphill or sitting. Just like with Achilles tendinopathy, go through a standard load capacity assessment, starting with a squat and progressing to movements like the arabesque. Brad demonstrates a simple, equipment-free test for proximal hamstring tendinopathy in this clip from his Practical:

To further test hamstring capacity, Brad uses a hand-held dynamometer in the prone position or, if available, an eight-repetition maximum test on a prone hamstring curl machine with a metronome. A good benchmark is about 0.3–0.4 times the patient’s body weight.

Bone stress injuries

Bone Stress Injuries (BSIs) are a critical consideration for endurance runners. They can occur throughout the lower body, from the foot to the femoral neck. It’s essential to distinguish between “low-risk” and “high-risk” areas; the latter, like the femoral neck, has a higher risk of complications due to limited blood supply. Brad stresses the importance of gathering a detailed history of the runner’s training load over the previous months, as the pain will have developed after a cumulative loading phase rather than any one specific event. See the below snippet from his Practical in which Brad explains the physiology of bone repair and its implications for BSIs:

Tibial BSIs

Tibial BSIs are one of the more common bone stress injuries in runners. Differentiating between a true BSI and Medial Tibial Stress Syndrome (MTSS) is essential, as runners with MTSS can often keep running with modifications. Note the length of tenderness on palpation: pain over an area less than 5cm can indicate a BSI rather than the more diffuse MTSS. The single-leg hop test also has a 100% sensitivity for tibial BSIs—if the patient feels no pain on a single-leg hop, a tibial BSI is likely not the issue!

Femoral BSIs

Though less common, femoral BSIs are “high-risk” and require careful handling. Brad emphasises that BSIs on the tension (superior) side of the femoral neck require immediate orthopedic referral due to the risk of progressing to a full fracture. These injuries typically present with anterior hip pain, particularly during hip flexion activities. While there aren’t specific tests for femoral neck BSIs, the FADIR (Flexion-Adduction-Internal Rotation) test can help with pain provocation.

Wrapping up

These are just a few tricks of the trade when it comes to assessing running-related injuries. By understanding the root contributors to a runner’s pain, you’ll be better equipped to create a targeted treatment plan and guide their return to running safely and effectively. This blog only scratches the surface of Brad Beer’s full Practical on running injury assessments, where he covers a broader range of injuries—from gluteal tendinopathy to BSIs in the foot.

If you’d like a comprehensive insight into how an expert assesses running-related injuries effectively, watch Brad Beer’s full Practical HERE.