The Running Definition of Injury Insanity


Anybody who knows me will tell you that I’m not anti-physio.

Far from it, in fact!

This post simply offers a reminder to injured runners to get assessed properly as a runner when dealing with overuse injuries.

A Familiar Story

Regularly I meet new coaching clients who suffer from long-term running injuries. Their frustrating story often goes something like:

‘I take time off running, get regular treatment, do my rehab exercises, then gradually reintroduce running – only for the injury to come back.’

No doubt, to many this will sound like a familiar pattern!

Injury Insanity?

It saddens me how frequently I hear runners say that, having been treated for long-term overuse injuries, and having gone through failed reintroductions to running, still nobody has ever looked at how they are running. It happens more than you’d like to think…

Running is one of the most cyclical, repetitive, high load movement patterns we put our bodies through. Where there’s an overuse injury caused by running, especially when the injury returns upon reintroduction to running after adequate rest, there is most likely a fundamental biomechanical dysfunction or technique flaw.

The following quote seems to fit quite well here in the context of injurious running biomechanics:

“The definition of insanity is doing the same thing over and over and expecting different results.”

Often misattributed to Albert Einstein, but possibly first coined in the Basic Text of Narcotics Anonymous (a bit of useless information for you!).

Put simply. In my experience, runners can do their rehab exercises at great lengths and get stronger / become more flexible / improve control, but if they return to running with the same technique that caused the overuse injury in the first place, they’re probably going to end up injured again.

Of course, every case is different. Some athletes will react well to rest and strengthening alone, for example. Others however will need to make fundamental changes to form to avoid a similar injury outcome when running is reintroduced to their programme.

My point really, is to make sure that as an injured runner, you see somebody who can give you proper feedback on your running form.

N.B. I obviously have a vested interest in offering running analysis through Kinetic Revolution, but that’s not the point of this article. What I’m saying is find somebody local to you who can help with your running form. Ask around for local recommendations!

Issues With Treadmill Based Analysis

I hold a strong belief that treadmill based gait analysis is redundant when it comes to authentically assessing running and walking gait. For the last couple of years I’ve insisted that all assessment I do are outdoor based. We are runners – we run outdoors.

Frequently the point is made that Jones and Doust (1996) shows us that adding 1% elevation to the treadmill most accurately reflects the energetic cost of outdoor running. This is true in terms of running efficiency from a metabolic point of view, as the slight elevation makes up for the wind-resistance experienced when running outdoors.

However, this doesn’t take into account the change in movement patterns experienced when the treadmill belt does the propulsive work for you.

This is well explained by Graeme Turner in his post Don’t Become a Treadmill Addict. On a treadmill at 1% elevation, you may be using the same amount of effort as outdoors – but you’re most likely moving completely differently in doing so.

Realistically speaking, having a treadmill in a sports injury clinic is clearly a good thing though. It enables the therapist to cast a cursory eye over running form in general terms. Treadmills are also particularly useful as a way to reintroduce loading in a more sterile, controlled clinical environment. I’d rather an athlete’s running was looked at on a treadmill than not at all!

As a simple example of what I mean – it’s certainly not uncommon for me to receive referral letters from other professionals stating something like: “Watching Client X on the treadmill, she runs with a forefoot striking pattern…”.

Yet when videoed running outdoors the runner displays a typical heel striking, over striding gait pattern.

As with all things running technique related, the way in which athletes adapt their gait patterns to run on the treadmill are entirely subject specific, as described by Nigg et. al. (1995). Changes in posture, cadence, strike pattern, upper body motion etc… are all fairly common when comparing an athlete running on a treadmill versus outdoor at the same pace. Some runners will show no significant change across the two surfaces, in some athletes the changes will be obvious. That’s what makes our job as coaches and therapists interesting!

Factoring In Fatigue

We all run with better form when we’re fresh, at the beginning of a session or race. Intuitively, most of us will have felt that our running form begins to deteriorate pretty quickly with the onset of fatigue. Various studies have looked at this, including this recent research by Koblbauer (2013) who set out to observe changes in running form with the onset of fatigue, and the relationship to ‘core endurance‘.

Craig Payne and Dr. Andy Franklyn-Miller both provide interesting commentary on this recent piece of research via their respective blog post and newsletter. Particularly interesting are these two observations:

  • Significantly increased trunk inclination and increased ankle eversion peak angles when the runners were fatigued.
  • The observation that ‘participants who displayed better core endurance exhibited larger trunk kinematic changes when fatigued‘. Core endurance had been tested using traditional core exercises such as side planks and lumbar extensions.

In the context of gait analysis, I feel it is very important that once an athlete is at a point in their rehab where they can begin to push their running to the point of fatigue – we as coaches and therapists need to assess how their movement patterns degrade with fatigue. We know that this is where underlying dysfunctions will come to the fore, and increase overuse injury risk factors.

Movement Dysfunction + Fatigue + Increased Milage = Probable Injury

Once we observe how the individual athlete’s form changes under fatigue, we’ll have a much better idea of what to strengthen, control and work on in general!

Last updated on March 2nd, 2021.


  1. Great piece, James.

    Reducing risk of re-injury is an area I am particularly interested in. It forces us therapists to question & re-evaluate both the treatment and rehab we provide. It also calls on us to educate the client with regards to the difference between healing and recovery. In my experience, too many runners ( and therapists) fall prey to allowing a full return pre-injury running demand without having achieved the latter. All forms a fascinating part of changing our understanding of pain and the need to “treat” the brain ( neural system) as opposed to just the damaged tissue in order to achieve full recovery as opposed to just tissue healing. Tony Ingram of bboyscience has written some great articles on this.

    As far as your comments on using a treadmill for Gait Analysis, I understand how filming a client outside can have advantages, but if specificity is the intention I suggest you’d need to film them where they habitually run to get true advantage of taking it away from the treadmill. If your client runs round the block once a week, filming them on a track is not really going to give you much more an accurate representation than filming them on a treadmill. Plus emotional state will be a big factor in how they run, so though some individuals may be happy being filmed outdoors, others may feel more comfortable in the privacy of a clinic. I think something like a Sprintex Ortho treadmill is a must of you are going to film the client on a treadmill.
    In an ideal world you’d be able to offer whatever the client felt most comfortable with I guess. And I’d have a private track out back!

    1. Thanks Matt.

      Well said – I think the most important factor is observing a client’s movement patterns in their normal environment.

      The article was (perhaps wrongly) written with the many non-treadmill runners in mind. The many who if asked will say they dislike running on a treadmill.

      If an athlete’s normal is running on a treadmill 90% of the time, then that’s probably what we need to assess, as treadmill running may be the injurious situation / pattern for them.

      I think you hit the nail on the head in suggesting we go with the situation the client is most comfortable with. It’s weird enough knowing that you have cameras and the eyes of scrutiny on you at the best of times!

      Now to find that facility with rehab gym, pool, trails to go and run on, and a track on the roof 🙂

  2. More of a question than a comment; can you overdo exercising to support running? I started running 2 years ago. I do a kettlebell workout (learnt from a qualified instructor) once a week; core work 2 to 3 times a week, glute work and therabands. Do have at least 1 rest day per week (usually 2) as I’m nearly 50. Have been to the running school to improve my form etc. Rotate shoes, none have more than 160 miles on them. Try to run 3 times a week, but hardly ever get beyond 10 to 15 miles a week. Only build up 5% a week, really cautious when returning from rehab. Plagued by injury. Trouble is, it never seems to be the same problem – piriformis, adductor, calf, currently achilles. Now I’ve discovered running, I just want to run! Should I cut the exercise back?