If you run and have pain in your knee, shin, heel or a tendon, the cause is almost always overload. Here you'll find the most common running injuries, what ultrasound shows, how they're treated and how to get back to running.
Running injuries are almost always overuse injuries: repeated load exceeds the ability of a tendon, bone or joint to adapt. They're common: in studies they affect about 4 in 10 runners, mainly at the knee, lower leg, ankle and foot1.
The factor you control most is progression. The risk rises when a single run is more than 10% longer than your longest run in the past 30 days2. More than weekly mileage, what matters is the long run that's too long.
Having the right shoe matters, and sometimes a shoe suited to your specific needs helps. Studies don't show, however, that one type of shoe reduces injuries more than another3: prevention is mainly about load.
Tap a point on the figure or a box to open it.
Pain lying on your side and climbing stairs.
Most likely cause Gluteal tendinopathy →
Comes on after a certain distance; worse running downhill.
Most likely cause IT band syndrome →
Pain around or behind the kneecap, worse going downstairs, squatting and sitting for a long time.
Most likely cause Patellofemoral pain (runner's knee) →
Pain at a precise point just below the kneecap, worse with jumps, bounding and fast starts.
Most likely cause Patellar tendinopathy →
Diffuse pain along the bone, related to running.
Most likely cause Shin splints (medial tibial stress syndrome) →
Worse when running, then also when walking or at rest.
Most likely cause Suspected stress fracture →
Discomfort when sitting, running uphill and striding out.
Most likely cause High hamstring tendinopathy →
Sudden sharp pain, difficulty pushing off.
Most likely cause Calf strain →
Stiffness in the first steps of the morning, pain when pushing off.
Most likely cause Achilles tendinopathy →
Pain in the first steps of the morning.
Most likely cause Plantar fasciitis →
For each condition you'll find the essentials and a link to read more.
Knee
Pain at the front of the knee, around or behind the kneecap, worse with squats, stairs, running and sitting for a long time4. The diagnosis is clinical; ultrasound helps rule out other causes, such as patellar tendinopathy. It's treated by strengthening the hip and knee and managing load4.
Pain on the outside of the knee that comes on after a certain distance. The diagnosis is clinical; ultrasound helps rule out other causes of pain in that area. Stretching is unlikely to change the iliotibial band5: the work is on load, hip strength and a gradual return.
Pain at a precise point at the lower tip of the kneecap, more typical with speed work, jumps and downhill running. Ultrasound assesses the state of the tendon.
Lower leg
Pain along the inner edge of the shin bone, spread over at least 5 cm. The diagnosis is made at the examination, without tests6. In the same visit, ultrasound assesses nearby muscles and tendons. Pain concentrated at one spot, on the other hand, suggests a stress fracture.
An overload injury of the bone: the pain is at a precise spot, gets worse when running and then also appears when walking or at rest. Treatment depends on the site: some heal by reducing load, others (femoral neck, front of the tibia, navicular bone of the foot) need offloading or surgery7. Here, running through the pain is dangerous.
Sudden sharp pain while running, with difficulty pushing off the foot. In the first days: protection and early loading guided by pain, following the PEACE & LOVE model12. Ultrasound shows where the injury is and how large it is.
Heel and foot
Pain and stiffness in the tendon, in the first steps of the morning and when pushing off. Ultrasound assesses the state of the tendon and helps set the load. It's treated with progressive loading exercises8. You can often keep running at reduced doses, keeping the pain in check11.
Pain under the heel, worst in the first steps of the morning. Ultrasound assesses the plantar fascia and helps rule out other causes of heel pain. The cornerstone of treatment is progressive strengthening of the foot and calf, supported by plantar fascia stretching and advice on load and footwear9.
Hip and thigh
Deep pain at the crease of the buttock, running uphill, striding out and sitting on hard surfaces. Ultrasound assesses the tendon where it attaches to the pelvis. Recovery is often long.
Pain on the outside of the hip, lying on your side and climbing stairs; often called "hip bursitis". Ultrasound assesses the gluteal tendons and the bursa. Exercise with education on load gives better results than a cortisone injection10.
Diagnosis starts with the examination. Ultrasound is useful for tendons, muscles, plantar fascia and bursae. For bone and the inside of the joint, other tests are needed.
| Condition | Role of ultrasound |
|---|---|
| Achilles, patellar, high hamstring and gluteal tendinopathy | Useful Assesses the state of the tendon. To be read together with the examination. |
| Plantar fasciitis | Useful Assesses the plantar fascia. |
| Calf strain | Useful Shows where the injury is and how large it is. |
| IT band syndrome | Supportive Clinical diagnosis. Helps rule out other causes. |
| Patellofemoral pain | Supportive Clinical diagnosis. The cartilage behind the kneecap can't be seen. |
| Shin splints (medial tibial stress syndrome) | Supportive Clinical diagnosis6. Ultrasound neither confirms nor rules it out. |
| Stress fracture | Not enough A normal ultrasound doesn't rule it out. The reference test is MRI. |
| Menisci, cruciate ligaments, cartilage | Not enough Internal structures: MRI is needed. |
Pain localised on a bone that gets worse when running: a normal ultrasound isn't enough. Stop running and get seen.
At the clinics where I work, in Italy and in Lisbon, the examination and the ultrasound scan are done in the same session. If you live far away, you can start with an online consultation →
Treatment rests on two things: managing load and strengthening with exercise. Everything else is supportive. The examination and ultrasound establish which structure is involved and what load to start from.
It doesn't mean stopping: running (distance, pace, elevation) is reduced to a tolerated level and fitness is maintained with cycling or swimming. With tendons and the knee you can often keep running at reduced doses (the pain rule). With a suspected stress fracture, running stops.
Progressive strengthening is the treatment with the most evidence for tendinopathies and patellofemoral pain4. It's built around the structure involved. How progressive loading is set up →
They're not the first treatment. They can help in selected cases, always alongside work on load. Not indicated for stress fractures or shin splints.
Unlikely to change the iliotibial band5.
The right shoe matters, and a shoe suited to your needs sometimes helps. No type has been shown to reduce injuries more than another, though3.
Live far away, in another city or abroad? I can set up your load and exercises by video call too, in English, with a physiotherapist near you or through telerehabilitation: online consultation and telerehabilitation →
The return is decided by criteria, not by the calendar.
Short stretches of easy running, every other day, on flat ground.
First duration, then frequency, and last of all pace, uphills and downhills.
No more than 10% longer than your longest run in the past 30 days2.
Strengthening exercises continue after you're back running.
You can run if: pain during the run doesn't go above 3 out of 10; the next morning it's back to 3 out of 10 or less; pain and stiffness don't increase from one week to the next. Otherwise, go back to the previous step.
After a stress fracture, you only restart when pain-free7.
Your return to running can also be followed remotely, with check-ins by video call: how the online consultation works →
Get seen if the pain doesn't improve after two weeks of reduced load, comes back every time you restart, or changes the way you run.
Near Modena or Lisbon, examination and ultrasound in the same session. If you live far away: online consultation →
Causes and prevention
Achilles tendinopathy, shin splints (medial tibial stress syndrome), runner's knee (patellofemoral pain), plantar fasciitis and IT band syndrome. They're almost always overuse injuries. Read more →
The strongest evidence concerns the single run: the risk rises when it's more than 10% longer than your longest run in the past 30 days. Lengthen your longest run in small steps. Read more →
Having the right shoe matters, and sometimes a shoe suited to your needs helps. Studies don't show, however, that one type protects more than another: prevention is mainly about how you progress your load.
Recognising the problem
Not always. Without swelling, locking or giving way, it's usually enough to cut back distance, pace and downhills and start strengthening the thigh and hip. If it doesn't improve within two weeks, get it assessed. Runner's knee · IT band syndrome
With shin splints the pain is spread along the inner edge of the shin bone over at least 5 cm. With a stress fracture it's concentrated at one spot and also appears when walking or at rest: in that case stop running until you've been examined. Shin splints · Stress fractures
The most common cause is IT band syndrome: the pain comes on after a certain distance and gets worse downhill. The diagnosis is clinical; ultrasound helps rule out other causes. Read more →
If the pain is under the heel and worst in the first steps of the morning, the most likely cause is plantar fasciitis. If it's at the back of the ankle, on the tendon, Achilles tendinopathy is the likely cause. Plantar fasciitis · Achilles tendinopathy
A sudden sharp pain with difficulty pushing off suggests a calf strain. Stop, protect the leg for the first few days and get it assessed: ultrasound shows where the injury is and how large it is. A swollen, warm, painful calf without an injury, on the other hand, needs to be checked straight away. Read more →
Deep pain at the crease of the buttock, felt running uphill, striding out and sitting on hard surfaces, suggests high hamstring tendinopathy. Ultrasound assesses the tendon where it attaches to the pelvis. Read more →
Usually gluteal tendinopathy, often called hip bursitis: pain on the outside, lying on your side and climbing stairs. Groin pain that gets worse when putting weight on the leg, on the other hand, should be assessed early. Read more →
Ultrasound and other tests
Not reliably: a normal ultrasound doesn't rule it out. When a stress fracture is suspected, the reference test is MRI. Read more →
Not for the diagnosis: it's recognised at the examination. Ultrasound helps rule out other causes, such as patellar tendinopathy.
For tendons, muscles, plantar fascia and bursae, ultrasound is usually enough. For bone, menisci, cruciate ligaments and cartilage, MRI is needed.
Treatment and return to running
Often yes, at reduced doses: pain during the run no higher than 3 out of 10, back to 3 out of 10 or less the next morning, and not increasing from one week to the next. Tendinopathy guide: Achilles tendon →
The cornerstone is progressive strengthening of the foot and calf, supported by plantar fascia stretching and advice on load and footwear. Ultrasound assesses the fascia and helps rule out other causes of heel pain. Tendinopathy guide: plantar fascia →
Probably not much: it's unlikely to change the iliotibial band. The work is on load, hip strengthening and a gradual return.
Rarely as the first treatment. It can help in selected cases, always alongside work on load.
When you can walk briskly for 30 minutes, manage stairs and pass the single-leg tests without pain. Then you alternate running and walking, increasing one thing at a time. Read more →
In most cases, yes. By video call, in English, I assess pain, movement and strength, review your training load and set up the strengthening and return-to-running plan. If a stress fracture is suspected, you need imaging and an in-person visit. Online consultation →
Seeing a doctor
If the pain doesn't improve after two weeks of reduced load or comes back every time you restart. Straight away if it's localised on a bone, if you feel a sudden stab in the calf or Achilles tendon, or if your knee swells, locks or gives way. Read more →
A doctor who deals with the musculoskeletal system: a sports medicine doctor, an orthopaedic specialist or a rehabilitation physician. What matters is that the assessment combines the examination with ultrasound, to understand which structure is involved and to set load and exercises.
In person in Italy (Modena, Maranello, Casalecchio di Reno and Carpi) and in Lisbon. If you live far away, you can have an online consultation by video call, in English. Online consultation →
Video consultation in English to set your load, exercises and return to running, with a physiotherapist near you or through telerehabilitation. Near Modena or Lisbon, also in person, with examination and ultrasound in the same session.
Request an online consultation Clinics in Italy (page in Italian) →