Athletic development specialists dedicated to the art and science of excellence in movement

The Nine "I's" of Running Injuries

Injuries remain a nefarious part of the running culture, despite years of scientific advancement. Gather a group of runners, and it is a virtual guarantee that everyone has been hurt. This information is less heartening when we consider that the number one predictor of future injury is past injury. When you are injured you can’t train. When you can’t train, you can’t improve.

The path of injury follows a predictable downward spiral. The positive corollary to this spiral is each stage of the spiral offers exit points for runners to get themselves back on track. Unfortunately, most runners don’t avail themselves of these exit points for a variety of reasons, from denial to simply not knowing any better.

Several years ago Coach Mike Boyle came up with the three I’s (Ingestion, Injection, and Incision) to describe the endurance athlete’s plunge into injury despair. Sadly, this progression describes the plight of countless runners. Below, I’ll take these three I’s and expand them further into nine layers that most injured runners go through. Hopefully you don’t make it to the ninth layer, but there are plenty of runners who have.

1)  Injury - Runners like to have titles for injuries. It is part of the reductionist approach in modern medicine. Plantar fasciitis is seen as a foot problem, IT band is a knee problem, and Achilles tendonitis is an ankle problem. While these may be the sites of various injuries, rarely are they the source. Runners will often curse the offending body part, but in reality the painful body part is sometimes working best. The offending body part often gets cranky because it has to do the work that other body parts should have been doing but aren’t doing. You can avoid descending into deeper layers by attacking the cause of the problems. However, since most of us in running like to take the hard way over the easy way, we stubbornly persist and look for a quick fix…

Exit ramp: Treat the source, not the site. Consult medical help to rule out serious issues (stomach pain can be anything from a side stitch to a kidney problem), but once cleared, address risk factors predisposing you to injury. Most importantly, avoid activities that will undo corrective work.

2)  Internet - When something goes wrong with our most sacred possession on earth (the human body), what better place to turn than such noted goldmines of information such as the Runners World message board or a 17 year old HS junior on Dyestat. I mean come on, who wouldn’t want the sage medical advice from a six hour marathoner workin’ the double knee Patt-Strap or a high school kid messin’ on his iphone during lunch period? 

In all seriousness though, I get why the Internet has become a source of injury information for runners. There’s no doubt that our current healthcare system is expensive and at times unfriendly. We deal with this every day with people talking to us about matters that cross the line to medical issues ("my hamstring is a little stiff" is one thing…"it hurts to walk to the coffee maker" is another), but going to a message board is much cheaper than doctors. With a much friendlier front office staff and no insurance intermediary, fellow runners on the Internet have become a point of first contact. I get that. But that’s still no reason to subvert the entire health care system out of convenience. It just takes a little work sometimes to find the right team of coaches and medical professionals to restore the body to optimal health and performance.

Exit ramp: Build a team of competent professionals, much like the pit crew for a race car. Communication is key…not keeping everyone at arm’s length so you can maintain some faux sense of control.

3)  Ingestion - There’s truth to the old adage that Advil is runners’ heroin. Advil facilitates running which facilitates endorphin release. While judicious use of anti-inflammatories is recognized as an appropriate medical intervention for the short term, it should be used only as an adjunct, not as an entire treatment plan. It should not be used as a masking agent to get through the day’s workout.

Exit ramp: If it hurts…maybe you shouldn’t run.

4)  Immersion - After a couple of days off, the runner inevitably gets restless worrying about a potential loss of fitness. Enter the aqua jogger. Yes, it has been shown repeatedly that high intensity aqua jogging is the best way to mitigate lost fitness from taking off from "real" running. The problem here is that many coaches and high level athletes act with denial in thinking that the cause of injury will magically disappear. If your ankle mobility is poor, core is unstable, and muscle timing is uncoordinated, a few days in the water won't reset these movement patterns.

If someone offers a formal aqua jogging training plan to maintain fitness, ask yourself "how did this person become so knowledgeable in this area?" Were they themselves injured by poor coaching, thus giving them plenty of time to think about optimal aqua jogging development during their own convalescence? Many of these people have learned from the mistakes of others and can help others avoid the same fate. Alternatively, have they as a coach become so heavily practiced at hurting people that they have honed the skill of designing aqua jogging plans (and maybe they rent pool space for their athletes to aqua jog)? Just a couple things to consider…

Exit ramp: If the body is in a weakened state, which often contributes to musculoskeletal injury, then intense aqua jogging may be not be the answer. Restore equilibrium to the central nervous system to not only get through the current injury, but to prevent additional cases in the future.

5)  Ice - Ice is probably the least controversial element in the process, but not every situation calls for ice. Ice is often appropriate to reduce swelling, but know that sometimes an inflammatory response is needed before adding ice.

Exit ramp: Understand when ice is and is not optimal. It’s still not too late to address the factors causing the condition.

6)  "I need…" - Couldn’t think of a single "I" word for this category, so we’ll have to settle for "I need." When a few days off, a week’s supply of ice massage cups, and a mild overdose of Advil fail to relieve the damage, it’s time to call in the big guns. At this point runners conclude "I need ART/Graston/acupuncture" to solve the problem.

There’s no doubt these are extremely valuable techniques when used properly in the right situations. Many runners have heard about A.R.T., Graston, and other massage techniques from their friends. They don’t know much about when the tools should be used, or how these methods complement corrective exercise techniques. The best results come when these tools are paired with corrective exercise interventions to repair movement dysfunction, but sadly most athletes don’t supplement their treatment with the appropriate steps to undo negative habits and relearn quality movement. Insurance will often pay for the painful area to be worked on, but often areas away from the painful site are what need the work.

Exit ramp: Consider manual therapy a force multiplier in the equation. If you just go the ART guy to dig into the painful site and help the pain go away, any relief will likely be temporary since the true cause of the injury will remain.

7)  Imaging - Things get serious when we start taking pictures. Pictures don’t lie, right? Here's an article that would suggest otherwise ("Sports Medicine Said to Overuse MRI's"). None of this is new information in the progressive wings of sports medicine, but it can be frustrating when both athletes and medical professionals look for a definitive diagnosis via imaging that probably won't answer questions anyway. Pain is often independent of pathology, and pathology is often independent of pain. Stuff can be broken but not hurt, though pain can be excruciating with minimal injury.

Exit ramp: MRI’s have become the default standard of care, so expect many docs to push for imaging when no one can figure out the problem. Certainly the MRI may be necessary if a serious medical condition is possible, but often it is an act of desperation when no one has bothered to ask the right questions previously. Usually the MRI enters the equation after a series of discharges from medical and false starts in training, which are often poorly supervised with the athlete trying to survive in the wilderness without intelligent coaching (sometimes coaching is available, but they often consult the coach who hurt them in the first place!).

8)  Injection - Now we're nearing the point of no return. Once the shot goes in, the game changes. Shots may provide immediate pain relief, but have powerful side effects. In some conditions, putting up with side effects is necessary. With running injuries, a shot usually means "I have no friggin clue why you can walk out of here pain free, but start to hurt again when trying to train again, so let’s just inject you."

Exit ramp: The main exit ramp here is to place the shot in context. If you’ve gotten to this point, you have missed several exit ramps along the way. I’ve said it before and I’ll say it again: Unless the medical professional is able to get involved in the coaching side (rare, but it happens), they are doing a disservice if you leave the clinic without a coaching referral. If your coach can’t speak the language of the medical professional, then maybe you need a new coach. If you waited too long to augment your performance team with a medical professional, then the onus is on you.

9)  Incision - When all else fails it’s time to go under the knife. Let’s think for a moment about the absurdity of how running in a straight line without anyone trying to make a tackle on you can lead to a potential need for orthopedic intervention. The sad part is that long before surgery is needed, there were many junctures along the way where the pain and damage could have been avoided. It truly is frustrating when so many people exercise their way onto the operating table or have damage done to them by clueless coaching, though most of the time they don’t recognize the cluelessness until several years later after too many missed races, poor performances, and ruined seasons.


The descent from injury onto the operating table has been described as a hellacious experience by many runners. Even if you don’t make it all the way to the "bottom", no place along this downward spiral is fun. If you find yourself on this path, find the nearest exit and get off! If you can’t identify the exit yourself, find a team of capable medical professionals and coaches who know how to escape.  


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