Women's Health
Running Injuries
You run. Injuries happen. Here's how to sort them out and stay on the road, with the specific context that matters for women over 40.
Book Your First VisitYou're a runner first. Running injuries are almost always overuse problems, not structural failures, and most can be managed without stopping running entirely. For women over 40, hormonal changes affect how tendons and bones respond to load, stress fracture risk is real, and the pace of return after a break needs to account for more than just cardiovascular fitness. The goal is to keep you running while addressing what's driving the problem.
Running and load: what's actually happening when injuries develop
Running injuries are almost always overuse injuries. Tissue loaded beyond its capacity to recover, usually from too much too soon, a biomechanical pattern that concentrates load unevenly, or inadequate recovery between sessions. Structural damage like stress fractures or full tendon ruptures is the exception. This matters for treatment: the answer for most running injuries is load management and mechanics work, not rest alone.
For women, there's additional context worth naming. Dynamic hip and pelvic mechanics during running contribute to higher rates of patellofemoral pain in female runners (Smith et al., 2018), and shape the pattern of IT band loading. Women's wider pelvis and larger Q-angle are part of the anatomical picture, but how the hip and pelvis actually manage load during each stride matters more than any static measurement. It means the assessment looks at lower limb alignment and targets the right muscles.
Common presentations
- IT band syndrome: lateral knee pain from iliotibial band tension where it crosses the lateral femoral condyle. Common with rapid mileage increases. The IT band doesn't stretch meaningfully, so foam rolling the band directly has limited benefit, though rolling the TFL and lateral quad proximal to the band is commonly included in clinical management. Hip abductor strengthening (gluteus medius) is a central component of rehabilitation (Charles & Rodgers, 2020), alongside load management: reducing weekly mileage and avoiding excessive downhill running while the tissue settles. Women's lower limb alignment patterns, including how the pelvis and hip manage load during stance, are why IT band issues are so prevalent in female runners.
- Patellofemoral pain syndrome (runner's knee): anterior knee pain from altered kneecap tracking. Driven by hip abductor weakness and quadriceps imbalance. Worsens going downstairs, squatting, or after prolonged sitting. The wider Q-angle in women means tracking problems tend to present earlier when hip stability is insufficient.
- Plantar fasciitis: heel pain worst with the first steps in the morning, from irritation of the plantar fascia at its calcaneal attachment. Driven by calf tightness and reduced ankle dorsiflexion. Responds well to targeted loading (calf raises on a step), Achilles and plantar fascia stretching, and ankle mobilization (Koc et al., 2023).
- Achilles tendinopathy: mid-portion pain 2-6 cm above the heel, typically from a training load increase. Oestrogen-related changes to collagen synthesis can affect tendon stiffness, particularly around perimenopause. Loading-based rehabilitation is the evidence-supported approach for Achilles tendinopathy and one of several effective options. Heavy slow resistance performs at least as well as eccentric-only protocols, with better adherence in practice (Beyer et al., 2015), consistent with current clinical practice guidelines (Chimenti et al., 2024).
- Low back pain from running: usually lumbar extension loading combined with hip flexor tightness and limited hip extension. Often driven by the same hip mechanics that cause lower limb injuries.
What helps, and what's different for women over 40
Treatment depends on the specific injury and what's driving it. The goal is to find a training load you can maintain without aggravating the injury, then gradually increase from there. Complete rest is rarely the right answer because tendons and bones need mechanical stimulus to remodel. If hormonal changes are part of the picture, whether that's the menstrual cycle or perimenopause, I'll factor that into how load and recovery are managed. There's more on this in the questions below.
Hip abductor strengthening is a component of almost every lower limb running injury program, and for good reason. Joint mobilization at the hip, knee, ankle, and foot addresses restrictions that alter load distribution. Combined with a specific progressive loading program for the affected structure, most running injuries respond well to conservative care as a first-line approach. Running injuries make up a significant part of what I see; the load management and biomechanics work is something I see regularly in practice.
The approaches here overlap with sports physiotherapy, but my assessment gives specific attention to spinal and pelvic mechanics: how the pelvis and spine move during each stride feeds into load distribution through the lower limb. In practice, a running assessment involves watching how you move (gait, single-leg stability, hip control), reviewing your load history, and identifying the biomechanical drivers rather than just assessing the site of pain.
Stress fractures and RED-S in women
Women are at higher risk of stress fractures than men, particularly in the foot, tibia, and femoral neck (Wentz et al., 2011). Contributing factors include relative energy deficiency in sport (RED-S, which expands on the female athlete triad), low bone density, and hormonal changes that affect bone remodelling (Mountjoy et al., 2014). Not all bone stress injuries require complete rest: severity determines the approach, and lower-grade reactions often allow modified loading rather than a full stop. Confirmed stress fractures need rest and imaging follow-up before returning to running. If your training has involved significant calorie restriction, or if you're perimenopausal and haven't discussed bone density with your GP, that conversation is worth having. If you have multiple risk factors, including low body weight, a prior fragility fracture, or low energy availability, DEXA bone density scanning may be worth raising with your GP.
Return-to-running timelines vary by injury. IT band syndrome and patellofemoral pain with good exercise compliance typically respond in 6-10 weeks from when structured rehab begins, though many presentations, particularly in women over 40 or those who have been symptomatic longer, take 12 weeks or more. Achilles tendinopathy is slower, with meaningful improvement typically taking 10-16 weeks (Chimenti et al., 2024), and full recovery often longer still. Most running injuries have identifiable mechanical drivers, and the goal is to keep you running while those are addressed. If you'd like to talk through your situation before booking, get in touch.
When to seek care promptly
See a doctor if you have:
- A sudden pop or snap in the Achilles with loss of plantarflexion strength (possible Achilles rupture)
- Localised bone pain that worsens with running and is tender to direct pressure on the bone (possible stress fracture)
- Acute knee swelling after a twisting injury
- Hip or groin pain with restricted hip range of motion, particularly if you're returning to running after a period of low energy intake (possible stress fracture or RED-S)
- Foot pain after a fall or impact, or inability to weight-bear after an ankle roll
Most overuse running injuries are appropriate for conservative management. Stress fractures need rest and confirmed healing before returning to full training. I'll tell you if imaging is warranted.
If this sounds like your situation, get in touch to talk through it before you commit to anything.
Common questions
Usually not. Complete rest is rarely the right approach for running injuries. It removes load but doesn't address the underlying cause, and deconditioning makes return to running harder. The goal is to identify what's provoking the injury, modify training load appropriately, and keep you running at a level that allows recovery while the underlying issue is addressed. I'll give you specific guidance on volume, intensity, and any surface or terrain modifications at your current stage.
Maybe, but footwear and orthotics are sometimes prescribed without addressing the underlying biomechanical drivers. The evidence for specific shoe types preventing injury is weak (Agresta et al., 2022). What matters more is whether your footwear is appropriate for your foot type and running pattern, and whether an orthotic is addressing a real biomechanical issue rather than just adding arch support. I'll assess your lower limb mechanics and give you a clear picture of whether footwear or orthotics are actually relevant to your presentation.
Key features: very localised point tenderness over a bone (not diffuse muscle soreness), pain that starts during a run and progressively worsens rather than warming up, and pain that persists at rest or at night. Women with low bone density or relative energy deficiency in sport (RED-S) are at higher risk. If you have these features, stop running and get imaging. An MRI is more sensitive than X-ray for stress fractures. I'll assess the clinical picture and refer you for imaging if I think this warrants investigation.
Start lower than you think you need to. After a break of several months or longer, your cardiovascular fitness recovers faster than your tendons and bones do. This mismatch is exactly why return-to-run injuries happen. A walk-run progression over 4-6 weeks is sensible for most people coming back after a significant break. If perimenopause or hormonal changes have been part of the picture, bone density and tendon stiffness may have shifted too, which is worth factoring into the pace of progression. I'll help you build a realistic return plan.
Yes, and it's not talked about enough. Oestrogen plays a role in collagen synthesis, tendon properties, and bone density. As levels fluctuate or decline during perimenopause, bones can become more vulnerable to stress, and tendon behaviour can shift in ways that affect how well they handle load. Some research suggests hormonal fluctuations across the menstrual cycle may affect ACL injury risk and knee laxity (Herzberg et al., 2017). The evidence is still preliminary and the picture is complex, but it's another reason load management needs to account for where you are in your cycle. This doesn't mean you can't train hard. It means being aware of where you are hormonally: some research suggests women may experience higher perceived exertion at the same load during the luteal phase, which is worth factoring into session planning.
Related reading
References
- Herzberg SD, Motu'apuaka ML, Lambert W, Fu R, Brady J, Guise JM. The Effect of Menstrual Cycle and Contraceptives on ACL Injuries and Laxity: A Systematic Review and Meta-analysis. Orthopaedic Journal of Sports Medicine. 2017;5(7):2325967117718781. PMC5524267
- Beyer R, Kongsgaard M, Hougs Kjær B, Øhlenschlæger T, Kjær M, Magnusson SP. Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy: A Randomized Controlled Trial. American Journal of Sports Medicine. 2015;43(7):1704-1711. PubMed 26018970
- Chimenti RL, et al. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision 2024 Clinical Practice Guidelines. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(12). JOSPT
- Wentz L, Liu PY, Haymes E, Ilich JZ. Females Have a Greater Incidence of Stress Fractures Than Males in Both Athletic and Sedentary Populations: A Review. Military Medicine. 2011;176(4):420-430. PubMed 21539165
- Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad — Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014;48(7):491-497. PubMed 24620037
- Smith BE, et al. Incidence and prevalence of patellofemoral pain: A systematic review and meta-analysis. PLOS ONE. 2018;13(1):e0190892. PMC5764329
- Charles D, Rodgers C. A literature review and clinical commentary on the development of iliotibial band syndrome in runners. International Journal of Sports Physical Therapy. 2020. PMC7296998
- Agresta C, Giacomazzi C, Harrast M, Zendler J. Running injury paradigms and their influence on footwear design features and runner assessment methods: A focused review. Frontiers in Sports and Active Living. 2022;4:815675. PMC8959543
- Koc TA Jr, Becker BA, Spivey A, et al. Heel Pain, Plantar Fasciitis: Revision 2023 Clinical Practice Guidelines. Journal of Orthopaedic & Sports Physical Therapy. 2023;53(12):CPG1-CPG39. PubMed 38037331
This page is for general information only and does not constitute medical advice. Every person's situation is different. Nothing here should be used as a substitute for assessment and advice from a qualified health professional who can evaluate your specific circumstances.
If you are experiencing severe or rapidly worsening symptoms, loss of bladder or bowel control, progressive weakness, or any symptom that concerns you, seek medical care promptly rather than reading websites.
This page was written with AI assistance and reviewed by Erik Anderson for accuracy. If you find an error, please contact us and we will endeavour to correct it.
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