Pain when running: why it occurs and what helps

Pain when running is not a diagnosis, but a symptom. For one runner, it indicates patellofemoral joint strain, for another, medial tibial stress syndrome, for three, Achilles tendinopathy, for four, plantar fasciopathy, and for five, a bone stress injury. Therefore, the main clinical question is always: where exactly does it hurt, when does it hurt, how does the pain change during and after a run, and are there any signs of a condition that should not be "run around." [1]

Running remains one of the most accessible and beneficial forms of physical activity, yet the incidence of running injuries remains high. A systematic review found that approximately 50% of runners experience an injury within a year that requires them to stop running at least temporarily, and approximately 70% to 80% of problems are related to overuse rather than acute injuries. This is an important clinical guideline: running pain often develops through a "too much, too soon" pattern rather than from a single, overt injury. [2]

The knee, shin, foot, and Achilles tendon area are the most commonly affected areas. A systematic review of running injuries found that the most common pathologies included patellofemoral pain, Achilles tendinopathy, and overuse pain in the anterior shin. This doesn't mean that every runner with knee pain has the same cause, but it does indicate where to look first. [3]

Current evidence increasingly confirms that injury risk is determined not only by weekly mileage but also by sudden changes in individual workouts. In an 18-month cohort study of 5,205 adult runners, an increase in the distance of a single run by more than 10% compared to the longest run of the previous 30 days was associated with a significant increase in the incidence of overuse injuries. This is one of the most practical findings for real-world training. [4]

Finally, not all running pain is orthopedic. Chest pain, unexplained shortness of breath, palpitations, dizziness, lightheadedness, syncope, rapidly increasing swelling, and redness of the lower leg require a different route and sometimes urgent evaluation. Therefore, an article on running pain should cover not only common athletic overloads but also dangerous scenarios that cannot be overlooked. [5]

Table 1. Where does it hurt when running and what does it most often make you think about?

Localization of pain	What is most often suspected?	Typical hint
Anterior surface of the knee	Patellofemoral pain	Increased pain on descents, when squatting, accelerating, and after prolonged sitting
The outer surface of the knee	Iliotibial band syndrome	Pain during long runs, descents, and sometimes at the beginning of contact with the support
Inner edge of the shin	Medial tibial stress syndrome	Diffuse pain along the tibia
Point pain in the bone	Stress injury to bone	The pain is local, increases, and often does not go away like normal overload.
Back of the heel	Achilles tendinopathy	Morning stiffness, pain when accelerating and climbing
Sole of the heel	Plantar fasciopathy	Pain on first steps in the morning and after rest
Hypochondrium during running	Transient abdominal pain with exertion	A stabbing pain in the side, often after eating or drinking

Sources for the table: [6]

Why does pain occur when running?

The primary mechanism of running pain is a mismatch between the load and the tissue's ability to tolerate it. This can affect a joint, tendon, fascia, muscle, or bone. When the volume, intensity, frequency, terrain, speed, or structure of training changes faster than the tissues have time to adapt, overuse pain occurs. Recent reviews emphasize that risk factors are multifaceted and include training, morphological, biomechanical, medical, and behavioral factors. [7]

One of the most common causes of pain in runners is patellofemoral pain. It is characterized by anterior knee pain, especially on descents, during squats, accelerations, and after prolonged sitting. The 2024 Best Practice Guidelines (BPG) recommend that knee and hip-focused exercises and patient education be the foundation of care, with additional interventions selected after assessing specific limitations. [8]

External knee pain is often associated with iliotibial band syndrome. This syndrome is considered a common running problem, accounting for approximately 10% of all running injuries, yet systematic reviews highlight the lack of a single, non-surgical protocol guaranteed to be best for everyone. This means that treatment is almost always individualized and focused on load, strength, pelvic control, and symptoms. [9]

Pain along the medial margin of the shin most often suggests medial tibial stress syndrome. This condition is now considered an early stress injury in the continuum of tibial stress injuries, rather than simply a harmless "shin splint." In practice, this means that diffuse pain along the margin of the shin is usually treated conservatively, but a progression to pinpoint pain, severe local tenderness, and worsening symptoms requires ruling out a stress fracture. [10]

Posterior heel pain is usually associated with Achilles tendinopathy, while pain under the heel is associated with plantar fasciopathy. For Achilles tendinopathy, current recommendations emphasize progressive tendon loading exercises, while for plantar fasciopathy, they emphasize a combination of stretching, manual techniques, taping, and, in some patients, night splints. In both cases, prolonged complete rest is usually inferior to guided rehabilitation. [11]

A separate issue is lateral colic, or transient abdominal pain with exertion. This is usually a benign, stabbing pain under the ribs, particularly characteristic of running and other activities involving repetitive torso movements. A review noted that approximately 70% of runners experienced this pain over the course of a year, and in a single running event, it can occur in approximately 1 in 5 participants. Although the condition is usually harmless, it is still important to distinguish it from chest pain, diaphragmatic problems, and acute abdominal pathology. [12]

Table 2. Common causes of pain when running and their typical symptoms

State	Key features	What usually makes pain worse?
Patellofemoral pain	Front knee, aching or bursting pain	Descents, squats, accelerations
Iliotibial band syndrome	Pain on the outside of the knee	Long runs, descents
Medial tibial stress syndrome	Diffuse pain along the inner edge of the shin	Increased running load, hard surface
Achilles tendinopathy	Pain and stiffness behind the heel	Climbs, accelerations, quick push-offs
Plantar fasciopathy	Pain under the heel	First steps in the morning, start after rest
Stress injury to bone	Point bone pain, tenderness on palpation	Continued load, jumping, speed work
Lateral colic	Stabbing pain under the ribs while running	Running after eating, sudden effort

Sources for the table: [13]

Red flags

The most important red flag in running medicine is localized bone pain. If the pain is localized, worsens with jumping, normal walking, or palpating a single, distinct area, and does not behave like a "warming up" soft tissue overload, a stress injury to the bone should be considered. For such conditions, radiography may be a first step, but its sensitivity is low, and magnetic resonance imaging is considered the preferred confirmatory test. [14]

The second group of red flags relates to cardiovascular safety. Chest pain or pressure during exercise, palpitations, unexplained shortness of breath, dizziness, lightheadedness, or fainting during running should be considered warning signs. Reviews of athlete screening explicitly describe such symptoms as red flags that require evaluation rather than an attempt to "run through the workout." [15]

The third group includes signs of a vascular or infectious problem in the leg. Severe unilateral swelling of the lower leg, redness, localized warmth, and pain not only when running but also at rest, especially when combined with general weakness or fever, are poorly consistent with normal overuse. In this situation, it is necessary to rule out inflammation, vascular pathology, and other non-orthopedic causes. [16]

Another important scenario is rapidly progressing pain that causes a change in gait and persists for more than 24 hours after a light workout or intensifies week after week. This dynamic is no longer reminiscent of the typical adaptive muscle soreness after returning to running. It is the progression of the symptom, rather than the pain itself, that most often distinguishes an overuse injury from a brief reaction to an unusual load.

Finally, if the pain is accompanied by significant numbness, weakness, loss of support, the inability to perform normal walking without limping, or if the runner cannot endure even a short, pain-free walk, an in-person examination is necessary. This is especially true if high-risk stress injuries are suspected, such as those of the femoral neck or anterior tibial cortex, where delayed treatment can lead to complications. [17]

Table 3. When pain while running requires urgent or rapid in-person assessment

Sign	Why is this important?
Point bone pain	Stress injury to the bone must be ruled out.
Chest pain during exertion	Cardiovascular cause possible
Fainting, pre-fainting, severe dizziness	Red flag for immediate assessment
Unilateral severe swelling and redness of the lower leg	Vascular and inflammatory differentiation is needed
Night pain and pain at rest	Not typical for simple overload
Severe lameness and inability to walk without pain	The load must be stopped
Rapid increase in pain from week to week	There is a high probability of structural overload

Sources for the table: [18]

Diagnostics

Diagnosing running pain begins not with an X-ray, but with a thorough interview. It's important to clarify the location, nature, and timing of the pain, its behavior during and after running, the presence of morning stiffness, localized bone tenderness, and its relationship to the running surface, climbs, high-speed work, new shoes, and sudden changes in distance. In modern running traumatology, it's the patient's medical history that often differentiates a tendon problem from a bone or joint problem right from the start. [19]

The next step is a clinical examination. For patellofemoral pain, provocation is assessed by squatting and descending; for Achilles tendinopathy, localized tenderness and tendon stiffness; for plantar fasciopathy, tenderness of the medial calcaneal tuberosity and pain with the first steps; for medial tibial stress syndrome, extended tenderness along the tibia. In many runners, the diagnosis is made clinically, without the need for imaging at the initial visit. [20]

Imaging isn't always necessary. When a bone stress injury is suspected, radiography is often the first choice, but its early sensitivity is low, so when clinical suspicion is high, magnetic resonance imaging (MRI) becomes the preferred confirmatory method. This is especially important for runners, as an early stress fracture can be easily missed if one relies solely on a "clear" X-ray. [21]

When patellofemoral pain, iliotibial band syndrome, Achilles tendonitis, and plantar fasciopathy are suspected, imaging is often unnecessary in the typical case if the clinical picture is clear and there are no red flags. Evaluation of kinematics, strength, tissue tolerance, and training errors is far more useful. This is consistent with the modern shift from "picture-perfect" diagnostics to functional diagnostics. [22]

Training process analysis is a special focus. Cohort data from 2025 showed that it was the variations in distance of a single run, rather than necessarily weekly fluctuations in volume, that were more closely associated with overuse injuries. Therefore, diagnostics must consider not only "how many kilometers per week" but also "what was the longest run," "how sharply did the first workout increase," and "what has changed over the past 30 days." [23]

Finally, the diagnosis of running pain must always take into account multifactorial factors. A 2024 systematic review emphasizes that training characteristics, lifestyle, health status, biomechanics, and morphological features influence runners' injuries, and the quality of some reviews remains low. This means that no single test or universal "technique error" explains all cases of running pain. [24]

Table 4. Practical diagnostic route

Clinical situation	What to do first	What's next?
Anterior knee pain without red flags	Clinical assessment and exercise history	Rehabilitation plan without mandatory visualization
Runner's external knee pain	Assessment of pelvic load, strength, and control	Individual conservative therapy plan
Diffuse pain along the inner edge of the shin	Inspection and palpation along the length of the bone	If worsening, rule out stress injury
Point pain in the bone	Radiography as a starting step	Magnetic resonance imaging in high index of suspicion
Pain behind the heel	Clinical evaluation of the Achilles tendon	Progressive exercise therapy
Pain under the heel, especially in the morning	Examination for plantar fasciopathy	Stretching, taping, night splints as indicated
Chest pain, fainting, severe shortness of breath	Immediate cessation of load	Urgent evaluation of cardiovascular cause

Sources for the table: [25]

Treatment and return to running

The main principle of treatment is to address not just the word "pain," but the specific structure and mechanism of overload. A simple break of a few days can reduce the symptom, but if the underlying factors aren't addressed, the pain often returns with the next increase in load. Therefore, the modern approach emphasizes active rehabilitation, training, and measured management of running loads.

For patellofemoral pain, the best support is knee and hip exercises combined with education. The 2024 guidelines explicitly state that exercise and education should be the foundation of treatment, with additional interventions such as prefabricated foot orthoses, taping, manual therapy, and running retraining tailored to the patient's specific profile. This is a crucial shift away from the "one-size-fits-all" model. [26]

In Achilles tendinopathy, tendon loading exercises are the primary treatment. The 2024 guidelines recommend that clinicians use tendon loading exercises, at the maximum tolerated load, as a first-line treatment, and that patients perform such exercises at least twice a week, as tolerated. This makes Achilles tendinopathy a good example of how the tendon often requires properly dosed work rather than complete rest. [27]

For plantar fasciopathy, modern conservative management also involves multiple steps. The 2023 guidelines support manual therapy, plantar taping for short-term pain reduction and improved function, and stretching of the plantar fascia and gastrocnemius-soleus complex. If pain is particularly severe with the first steps in the morning, night splints may be prescribed for 1-3 months. However, foot orthoses are not recommended as a stand-alone short-term treatment. [28]

For iliotibial band syndrome and medial tibial stress syndrome, treatment almost always begins with reducing the irritating load and gradually rehabilitating. For iliotibial band syndrome, reviews emphasize the multifactorial nature of the problem and the lack of a single optimal regimen for everyone, while for medial tibial stress syndrome, the goal is to prevent an early stress condition from progressing to more serious bone damage. This typically means temporarily reducing running volume, avoiding triggers, and focused strength training. [29]

If a stress injury to the bone is suspected, the treatment logic changes most significantly. Here, the key factors are stopping the provoking load, assessing the risk of the area, early intervention, and a gradual return to the sport. For high-risk areas, such as the femoral neck, a lower threshold is required for consultation with a sports medicine or orthopedist, while for low-risk injuries, a return to running is planned only after pain has disappeared while walking and sufficient support is tolerated. [30]

Return to running shouldn't be based on a "2 weeks in, you're good to go" calendar. A review of return to running after tibial stress injury (TSI) found that running should be resumed after pain-free walking, in the absence of bone tenderness, and with a gradual increase in load; for high-risk injuries, the requirements are even stricter. And cohort data from 2025 adds a rule of thumb: don't make a large jump in distance in a single workout compared to what the tissues were prepared for in the previous 30 days. [31]

Table 5. What is considered the mainstay of treatment for different causes of pain

Cause of pain	The basic approach	What usually doesn't work as a sole measure
Patellofemoral pain	Knee and hip exercises, training	Taping only or insoles only
Achilles tendinopathy	Progressive loading exercises	Long periods of complete rest
Plantar fasciopathy	Stretching, taping, manual therapy, night splints as indicated	Isolated orthoses as a whole therapy
Iliotibial band syndrome	Reduction of provocateurs, strength and functional correction	Finding 1 "Magic" Exercise
Medial tibial stress syndrome	Unloading, gradual return, load control	Continuing to run through pain
Stress injury to bone	Stopping the provoking load, risk stratification, gradual return	Trying to "run away" bone pain

Sources for the table: [32]

Table 6. Practical principles for a safe return to running

Principle	Why is it important?
First, painless walking	This is a basic criterion for tissue readiness for impact loading.
Absence of local bone pain	Especially important after stress injuries
Build up gradually, not in a sudden way	Large jumps in 1 workout increase the risk of overuse injury
Monitoring the reaction for the next 24 hours	Helps differentiate between tolerable load and overload
First volume, then intensity	Speed and intervals dramatically increase the mechanical cost of a step
Return to the ups and downs at the end	They often increase the stress on the knee and shin.

Sources for the table: [33]

Prevention and prognosis

Running pain prevention is now understood as a system, not a single piece of advice about shoes or stretching. A 2025 review of running injury prevention shows that studies most often focus on gradual running programs, strength training, technique retraining, footwear issues, rehabilitation, and educational support. In other words, the best results come not from a single "secret," but from a combination of several smart solutions. [34]

The most practical preventative measure is to avoid sudden jumps in a single workout. A 2025 cohort study found that even a small jump in distance of more than 10% in a single session was associated with an increased incidence of overuse injuries, and with larger jumps, the risk becomes even higher. For the real runner, this means that the danger is often not a "general tough week," but a single, overly ambitious long run. [35]

Strength training remains a central preventative measure, but its value lies beyond the abstract "strengthening of everything." For the knee, hip and quadriceps control are important; for the Achilles tendon, gradual load tolerance of the gastrocnemius-soleus complex; for the foot, the ability to withstand repeated weight-bearing cycles. Modern recommendations increasingly support the idea of specific training for risk zones, rather than a one-size-fits-all fitness kit. [36]

The prognosis for most running-related overuse injuries is favorable if the diagnosis is made promptly and the runner does not continue to systematically load the irritated tissue. The worst prognosis usually occurs when pain is ignored for weeks, technique is changed "as is," the problem is compensated for with new shoes without adjusting the load, or speed work continues despite obvious bone pain. This is especially true for stress injuries of bone and chronic tendon problems. [37]

It's also important to understand that biomechanics is only part of the picture. A 2024 review of risk factors emphasizes the role of not only technique and morphology, but also health, lifestyle, training process, and even methodological limitations of the studies. Therefore, running pain prevention should be individualized: for one runner, the key will be monitoring long training sessions, for another, correcting energy deficits, for three, a gradual transition to speed work, and for a fourth, a review of recovery and sleep patterns. [38]

FAQ

Can running pain be "normal" if someone is just starting out?
Short-term muscle discomfort after returning to exercise is possible, but pain that alters technique, causes limping, is localized to one area, intensifies week after week, or doesn't subside after a light workout should no longer be considered normal adaptation. This type of pain is more consistent with overload or tissue damage.

Should you stop running completely if you experience any pain?
Not always. For some conditions, such as patellofemoral pain or early Achilles tendinopathy, it's possible to transition to a graduated load with reduced volume and intensity. However, if you experience pinpoint bone pain, chest pain, severe lameness, lower leg swelling, or the inability to walk painlessly, stop running immediately until an in-person assessment is performed. [39]

When is magnetic resonance imaging (MRI) needed?
Primarily when a bone stress injury is suspected and clinical suspicion remains high. Radiography may be a first step, but it often misses early stages, while MRI is considered the preferred confirmatory method. [40]

If pain is located in the anterior knee, is it always "runner's knee"?
No. Anterior knee pain often corresponds to patellofemoral pain, but clinically it must be differentiated from tendinopathy, intra-articular pathology, and other causes. Nevertheless, patellofemoral pain is the most common diagnosis in this area among runners. [41]

Is it true that the Achilles tendon should only be protected and not overloaded?
No. Modern recommendations, on the contrary, prioritize measured exercises with loads on the tendon within the tolerance range. Complete rest may temporarily reduce pain, but usually does not improve the tendon's long-term ability to withstand running. [42]

Do insoles and shoes alone help?
Sometimes they are useful as part of a plan, but rarely solve the problem alone. For patellofemoral pain and plantar fasciopathy, supportive interventions can be used in addition, but load correction and exercise remain the foundation. [43]

How do you know if shin pain is dangerous?
The most alarming symptom is a pinpoint, rather than a diffuse, pain, especially if it intensifies, doesn't subside with reduced load, interferes with walking, and is locally very painful to palpation. This symptom suggests a stress injury to the bone rather than simple medial tibial stress syndrome. [44]

What to do about side pain while running?
Most often, it's transient abdominal pain during exertion, which is quite common among runners and is usually benign. However, if the pain is unusually severe, accompanied by nausea, radiates, recurs without exertion, or resembles chest pain, it shouldn't be automatically dismissed as harmless "colic." [45]

Key points from experts

Bradley Stephen Neel, PhD, a lecturer in physiotherapy at the University of Essex, is a specialist in sports and musculoskeletal physiotherapy and lead author of the 2024 best practice guideline for patellofemoral pain. The key practical takeaway from his work is that for anterior knee pain in runners, knee- and hip-targeted exercises and patient education should be the mainstay of care, with taping, braces, manual therapy, and running retraining being supportive rather than the primary interventions. [46]

Ruth Chimenti, DPT, PhD, associate professor in the Department of Physical Medicine and Rehabilitation Sciences at the University of Iowa, is a co-author of the 2024 Achilles tendonopathy clinical guidelines. Her work highlights a key point for runners: the Achilles tendon heals better through progressive loading therapy within the limits of tolerance, rather than through indefinite sparing. This is why tendon-loading exercises are now considered a first-line treatment. [47]

Michael Frederickson, MD, professor of orthopedic surgery and sports medicine at Stanford University and director of sports medicine and physical and rehabilitation medicine at Stanford, consistently promotes one important thesis: bone pain in runners deserves respect because stress injuries to bone are not a "minor overload" but a continuum from an early stress response to a full-blown fracture, where early detection and loading modification fundamentally change the prognosis. [48]

Rasmus Østergaard Nielsen, associate professor of epidemiology at Aarhus University, a physiotherapist, and head of the MOVE research group and the larger Garmin RUNSAFE project, said: "His data are particularly important for practicing runners because they shift the focus of prevention from abstract weekly formulas to specific training: a sharp increase in the distance of a single run turns out to be more closely associated with injury than many popular weekly load calculations." [49]

Christopher G. Baize, DPT, PhD, assistant professor at the University of Pittsburgh, is a co-author of clinical guidelines for plantar fasciopathy. The practical implication of this line of work is that heel pain in runners typically requires not just one treatment but a combined program: stretching, manual therapy, taping, and, if morning pain is severe, sometimes even night splints. However, insoles alone should not be considered a complete substitute for rehabilitation. [50]