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Running requires energy, and recovery depends on it. Low energy availability is increasingly recognised as a contributor to injury, not just in elite athletes but in recreational runners as well.
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No matter how much you know or how carefully you train, running injuries happen. We started this series by talking about injury prevention, and while many injuries can be avoided, it's unrealistic to think we can eliminate them entirely without stopping running altogether.
And that's not the goal.
So what should you do when something goes wrong?
Many runners will have been injured before. Some are currently dealing with a niggle. And for a lot of people, the frustrating part isn't the first injury, it's what happens next. You take some time off, things settle, you return to running, and then the same issue comes back.
One of the biggest risk factors for a running injury is previous injury (Burke et al., 2023). If this article does anything, it's to help break that cycle. The return-to-running process doesn't start when you feel better. It starts the moment pain changes what you can do. That's when you begin figuring out what happened and how to avoid repeating it.
Step 1: Figure out why the injury happened
Running injuries are rarely caused by one single thing. More often, they sit at the intersection of multiple contributing factors. Broadly, there are five areas to consider: load, tissue capacity, biomechanics, energy availability, and medical factors. Understanding which of these played a role is key to planning a successful return.
Load error
Our bodies adapt to stress when the balance between training and recovery is right. When that balance tips too far, something usually gives. A load error is a mismatch between how much stress you apply and how well you recover from it. This might look like increasing your running volume, intensity, frequency or terrain too quickly. It might also come from the recovery side, such as poor sleep, under-fuelling, increased time on your feet, or external life stress.
Importantly, the consequences of a load error are not always immediate. Injuries like bone stress injuries or shin pain can show up weeks after the initial mistake (Kardouni et al., 2021). Identifying where the load error occurred helps ensure you don't repeat it when you return.
Tissue capacity
Your body is made up of different tissues, each with its own role and tolerance to load. Muscle generates force, bone resists bending, and tendon stores and releases energy. Injury can occur when a tissue is asked to do more than it is prepared for, either because it is not strong enough, not functioning well, or because load has been shifted onto it from somewhere else.
In practice, this means looking at whether certain tissues are underprepared for the demands of your training. Strength testing and side-to-side comparisons can help identify where capacity is lacking and guide more targeted rehab.
Biomechanics
How you move influences how load is distributed through your body. There is always an interplay between biomechanics and tissue capacity. A movement pattern is only a problem if it loads a structure beyond what it can tolerate.
It's also important to assess biomechanics at the right time. Early in an injury, movement patterns are often altered by pain, which can make interpretation misleading. Later in rehab, when movement is more natural, it becomes easier to identify whether a pattern is contributing to overload.
Foot strike is a good example. Changing from a heel strike to a forefoot strike might reduce load in one area, but increase it elsewhere. That may be appropriate later, but it's rarely the first step during early rehab.
Energy availability
Running requires energy, and recovery depends on it. Low energy availability is increasingly recognised as a contributor to injury, not just in elite athletes but in recreational runners as well (Kim & Weber, 2023). It often happens unintentionally when training increases but food intake does not.
You can maintain body weight while still under-fuelling. The body compensates by prioritising essential functions and down-regulating recovery and adaptation. Over time, this reduces tissue resilience. Bone health is particularly affected. Low energy availability and low carbohydrate intake can impair bone formation and increase the risk of stress injuries (Fensham et al., 2022). If this is suspected, working with a dietitian can be an important part of recovery.
Medical factors
Sometimes, even after reviewing training, strength and nutrition, the cause of injury is not obvious. In these cases, underlying medical factors such as micronutrient deficiencies or hormonal imbalances may be involved. These can often be identified with blood tests and managed with appropriate support from a GP or sports physician.
Step 2: Injury-specific management
Once you have a clearer understanding of why the injury occurred, the next step is managing it appropriately. Pain is usually the first guide, but it behaves differently depending on the tissue involved. Bone, tendon and muscle injuries each require slightly different approaches.
Bone stress injuries
Bone injuries require patience. The priority is allowing the bone to regain structural integrity before reintroducing load, which can take several weeks. During this time, loading needs to be carefully managed so it does not interfere with healing. Once pain has settled in daily activities, hopping and jumping are pain-free, and enough time has passed, you can begin reintroducing load.
Interestingly, long-distance running is not always the best starting point. Bone responds better to varied, higher-impact loading, such as strength training for runners and controlled plyometric work. Early in rehab, sessions may need to be spaced every few days to allow adequate recovery.
Tendon injuries
Tendons sit in the middle ground between rest and load. They don't respond well to complete rest, but they also flare with excessive load. Rehabilitation focuses on restoring the tendon's ability to handle and store load. This is best achieved through heavy, controlled strength work, which improves tendon stiffness.
Running can often continue in some capacity, but load needs to be carefully managed. A useful guideline is to monitor pain over the following 24 to 48 hours. If symptoms settle within that window, the load is usually appropriate. If not, adjustments are needed.
Muscle injuries
Muscle injuries vary depending on their severity and location. Some may require a short period away from running, particularly if the muscle is heavily loaded during running, such as the calf. Others, like low-grade hamstring strains, may allow continued running at reduced intensity. Strength work is an important part of recovery. When introduced at the right time, progressive loading can help restore strength and reduce the risk of recurrence.
Closing thoughts
Understanding why an injury occurred, and how different tissues respond to load, is the foundation of a successful return to running program. While the principles are straightforward, applying them is not always simple.
Injury management often benefits from input across multiple areas, including coaching, physiotherapy, strength training and nutrition. If you find yourself stuck in a cycle of injury and reinjury, getting the right support can make a significant difference. It may take more time and effort in the short term, but it's what allows you to return to running safely and stay there long term.
Looking for more expert advice and running tips? Check out rebel RUN and level up your running game.
A trainer assessing foot posture and movement in a gym highlights proper running technique, injury prevention, and performance improvement.
Disclaimer
The information provided in this article is of a general nature only and is not intended to replace professional medical, health, or fitness advice. It does not take into account your individual objectives, physical condition, medical history, or needs. Before acting on any of the guidance or recommendations provided, you should consider whether it is appropriate for you in light of your personal circumstances. You should always seek the advice of a qualified healthcare professional (such as a physiotherapist, podiatrist, dietitian, or medical doctor) before starting, changing, or relying on any exercise, training, or nutrition program. Rebel Sport accepts no liability for any loss, injury, or damage suffered by any person relying on the information provided.
References
- Burke, A., Dillon, S., O'Connor, S., Whyte, E. F., Gore, S., & Moran, K. A. (2023). Aetiological Factors of Running-Related Injuries: A 12 Month Prospective "Running Injury Surveillance Centre" (RISC) Study. Sports Medicine - Open, 9(1), 46. https://doi.org/10.1186/s40798-023-00589-1
- Dorn, T. W., Schache, A. G., & Pandy, M. G. (2012). Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance. The Journal of Experimental Biology, 215(Pt 11), 1944–1956. https://doi.org/10.1242/jeb.064527
- Fensham, N. C., Heikura, I. A., McKay, A. K. A., Tee, N., Ackerman, K. E., & Burke, L. M. (2022). Short-Term Carbohydrate Restriction Impairs Bone Formation at Rest and During Prolonged Exercise to a Greater Degree than Low Energy Availability. Journal of Bone and Mineral Research, 37(10), 1915–1925. https://doi.org/10.1002/jbmr.4658
- Kardouni, J. R., McKinnon, C. J., Taylor, K. M., & Hughes, J. M. (2021). Timing of Stress Fractures in Soldiers During the First 6 Career Months: A Retrospective Cohort Study. Journal of Athletic Training, 56(12), 1278–1284. https://doi.org/10.4085/1062-6050-0380.19
- Kim, D., & Weber, K. (2023). Relative Energy Deficiency in Sport (RED-S) and Bone Stress Injuries. Operative Techniques in Sports Medicine, 31, 151025. https://doi.org/10.1016/j.otsm.2023.151025
- McMahon, G. (2022). No Strain, No Gain? The Role of Strain and Load Magnitude in Human Tendon Responses and Adaptation to Loading. Journal of Strength and Conditioning Research, 36(10), 2950–2956. https://doi.org/10.1519/JSC.0000000000004288
- Warden, S. J., Edwards, W. B., & Willy, R. W. (2021). Optimal Load for Managing Low-Risk Tibial and Metatarsal Bone Stress Injuries in Runners: The Science Behind the Clinical Reasoning. The Journal of Orthopaedic and Sports Physical Therapy, 51(7), 322–330. https://doi.org/10.2519/jospt.2021.9982
