Lower Extremity Musculoskeletal Injuries Associated with Marathon Running

Abstract

Purpose of Review

To evaluate lower extremity musculoskeletal injury incidence, distribution, and risk factors associated with marathon preparation and race-day running. Evolving trends in specific injury types and body region(s) affected, as well as runner demographics, are highlighted, along with advances in footwear and wearable technologies that may influence injury patterns. The impact of these factors on athlete preparation and race-day participation is discussed.

Recent Findings

Recent studies demonstrate a rising proportion of marathon runners requiring medical attention during races, with musculoskeletal injuries accounting for the largest proportion of race-day injuries. Injuries to the knee, thigh, hip, and leg remain the most prevalent, with varying injury rates between male and female runners. Both non-modifiable (e.g., age, sex, prior injury) and modifiable (e.g., training volume, technology use, alcohol consumption) factors contribute to injury risk.

Summary

As marathon participation continues to grow and runner demographics shift, an increased understanding of injury patterns, during both preparation and on race-day, is essential to optimize runner safety and performance.

Introduction and Background

According to the 2019 The State of Running report, in conjunction with the International Association of Athletics Federations, approximately 1.1 million individuals complete a marathon-distance race annually [1], representing 0.01% of the global population. While running provides numerous health benefits, participation in marathon running carries a risk of injury, both during training and on race-day. One of the strongest predictors of running-related injury is total running distance, defined as >65 km/week, which is often achieved during training for a marathon [2]. Race-day injuries range from minor sprains and strains to more severe injuries that may impact post-race work activities and activities of daily living. Specifically, Van Middelkoop et al. [3] reported that 13.6% of runners injured in a major global marathon were unable to perform work tasks, and 11.9% were unable to perform activities of daily living within one week following marathon participation.

As marathons vary in terrain, weather, and timing, with a diverse population of participants, aggregating data on marathon injury incidence and type remains challenging. Additionally, few studies differentiate injuries sustained during training from those sustained on race-day. As such, when counseling patients regarding common injury types and risks during marathon participation, an updated review of currently reported race-day injuries is warranted. The purpose of this review is to summarize the evidence for marathon race-day injury incidence and types, while providing participants and medical providers with a better understanding of potential modifiable and non-modifiable injury risks in order to optimize athlete health and performance.

Marathon Participant Demographics

Several noteworthy changes have been observed in the average marathon runner over the past 30 years [1], including shifts in demographics and other athlete-specific factors that may predispose athletes to injury. Namely, the mean age of marathon participants has increased from 35.2 to 39.3 years [1]. Female runners, who have been reported to possess unique injury risks during running when compared to their male counterparts [4], currently account for over half of marathon participants as of 2018 [1, 5]. Marathon completion times have also been reported to be slower on average, with mean finishing times rising from 3:52:35 to 4:32:49, attributed to the growth of ‘hobby’ running as opposed to achievement-focused racing [1]. The approach to running as a hobby is important, as injuries are more commonly reported among less experienced runners with a limited ability to recognize developing problems compared to more experienced runners [6]. Moreover, increased travel to marathon race destinations has been reported [1], which can lead to issues secondary to time zone adjustments, less restful sleep, and changes in pre-race preparation.

Marathon Injury Epidemiology

Contemporary studies report an increase in medical assistance and runners experiencing an injury during race-day. Specifically, during the 1993 Auckland Marathon [7], 6.2% of runners sought assistance at medical tents, compared to 17% of runners participating in the 2005 Rotterdam Marathon [3]. Meanwhile, a three-year review from 2010 to 2012 of an unspecified, nationally recognized marathon in the United States reported that a total of 30% of participants self-reported an injury during race-day [8]. Greater use of medical tents during race-day tends to occur in a bimodal distribution, with the majority of injured runners seeking assistance either midway through the marathon (~ 13.1 miles) or at the conclusion of the race [9]. A recent investigation revealed a notable rate of lower extremity musculoskeletal injuries during marathon training, affecting up to 42% of amateur runners. These injuries included medial tibial stress syndrome, iliotibial band syndrome, plantar fasciitis, and Achilles tendinopathy sustained over a 16-week training period [10]. Another recent study reported no difference in injury incidence between triathletes and marathon runners, indicating that diversified training may not inherently protect against injuries, while also highlighting the need for further investigations to identify specific risk factors and training behaviors that may be predictive of injury in marathon participants [11].

Marathon Injury Risk Factors

Both modifiable and non-modifiable risk factors have been reported to contribute to race-day injuries. Non-modifiable factors, primarily related to runner age, may increase the risk of joint-related injury (i.e., hip, knee, foot/ankle) and hamstring strains [12, 13]. Meanwhile, male runners have been reported as being more prone to injuries involving the calf [14], with female runners more likely to experience hip injuries [15]. The presence of prior running-related injuries, defined as having sustained a running-related injury within 12 months of marathon participation, has also been reported as a strong predictor for subsequent injury [14, 15]. Runners reporting an illness within two weeks of a race have also been reported to be at higher risk for injury [14]. An increase in the number of years of running experience, while not explicitly quantified, has been found to correlate with a decreased risk of injury [6]. Toresdahl et al. found that runners who had completed half marathons prior to their marathon study were less likely to get injured (OR 0.40, p = 0.05) [16]. They also found an inverse association between the longest training run distance and incidence of race-day injuries. Modifiable factors, including poor conditioning due to lack of proper preparation and training, inadequate recovery, and alcohol consumption, have been reported to predispose runners to injury [6, 14]. Specifically, when evaluating injury etiology in marathon runners, Satterwhite et al. reported that alcohol use, even minimal consumption (e.g., one beverage per month), was correlated with an increase in injury incidence [14]. While regular strength training has been linked to a 23.8% reduction in lower extremity musculoskeletal injuries, structured warm-ups and cross-training have also been found to be beneficial [10].

The use of garments and running technology, as well as their impact on injury incidence, has been increasingly investigated. When compared to older shoe designs that prioritized cushioning and durability, newer designs have been reported to decrease racing times and reduce the energetic cost of running. Specifically, Whiting et al. reported that Nike™ Vaporfly shoes, a heavily cushioned carbon fiber-plated (CFP) design, effectively reduced metabolic expenditure by 3.8% on level terrain, 2.8% uphill, and 2.7% downhill when compared to conventional racing shoes (all p < 0.001) [17]. However, the use of CFP footwear has also been reported to increase the risk of bony stress injury (BSI) in the foot, namely navicular stress injuries [18]. As such, authors have advocated that runners undergo a formal transition, focusing on a gradual increase in distance and intensity when getting used to a CFP shoe [17]. Carbon fiber plating is also known to result in a stiffer sole of the shoe, which can lead to weaker foot muscles, reduced arch strength, and subsequent excessive pronation. As noted by Lieberman et al., this may lead to plantar fasciitis [19]. Although natural differences, as well as features of some sneakers, can alter foot strike and impact, orthotics may be utilized to correct problems with gait [20, 21], particularly when part of the body is being strained [19], However, orthotics do add to the weight a runner must carry during a race, so depending on the goals of the runner, a decision must be made to prioritize comfort or limit energy expenditure [20]. Meanwhile, the use of compression garments remains popular among runners; however, their use has not been reported to prevent injuries or improve performance [22, 23].

The use of electronic technology, including fitness watches and smartphone applications, has increased, with 90% of runners reportedly utilizing electronic resources [24]. Smartwatches provide biometric data for monitoring training load and recovery, including heart rate and rhythm, oxygen saturation, VO2 max, body temperature, and sleep patterns. Runners also rely on smartwatches to monitor their pacing and distance through continuous feedback, as well as tracking of personal goals. Many devices will alert the user if specific values become abnormal, which can be helpful in the event of any race-day emergencies related to the particular metrics assessed by wearable technology [25]. Evidence regarding the impact of these devices on injury risk remains ambiguous. Van Hooren et al. [26] reported that runners who received real-time feedback had significantly lower injury rates compared to those who did not (hazard ratio, 0.53; p = 0.03). However, this technology may pose an injury risk, as runners may pay less attention to their health and subjective physical symptoms (e.g., fatigue, discomfort) due to a greater focus on objective data and metrics, such as maintaining pace and achieving personal goals. Specifically, Chowdhary et al. [27] reported that runners using smartwatch technology had a higher likelihood of experiencing injuries when compared to those without a smartwatch (odds ratio, 0.31; p < 0.001). Such conflicting findings demonstrate that despite the increased popularity of wearable technology, further investigation into the impact of such technology on injury incidence is warranted. Nonetheless, smartwatches have provided researchers with valuable, large-volume feedback through industry-led studies such as Garmin-RUNSAFE. Such efforts to collect wide-scale data across thousands of running athletes have offered insights into training patterns and related metrics, as well as their relationship to running-related injuries [28].

Musculoskeletal Injuries

While issues such as blisters, chafing, and dehydration are frequently reported in marathon runners [14, 29], musculoskeletal (MSK) injuries represent the highest proportion of reported race-day injuries [7, 9]. A study of the 2018 Chicago Marathon reported that 61% of all race-day complaints at medical tents were MSK-related [9]. Overuse-related MSK injuries are reported to occur with a greater incidence compared to acute injuries [13], with symptoms typically experienced gradually throughout the race [9]. Prior studies have generally classified MSK injuries based on body regions, most frequently involving the hip, thigh, knee, and lower leg/ankle. (Table 1)

Table 1.

Marathon race-day injuries according to body region

	Auckland, 1993* (Satterthwaite et al.[7]) (N = 846)	Rotterdam, 2005† (Van Middelkoop et al.[3]) (N = 118)	Tokyo Gorge, 2013–2018‡ (Hsu et al.[15]) (N = 421)	NYC, 2019§ (McGrath et al.[13]) (N = 907)	Unspecified nationally ranked US marathon, 2021¶ (Mohseni et al.[8]) (N = 190)
Hip	14.2%	6.8% hip, 0.8% groin	NR	17.2%	19%
Thigh	60.1% front thigh, 24.2% hamstring	17.8% thigh	20% thigh	19.5% thigh	18%
Knee	25.6%	27.1%	38%	20.3%	29%
Lower leg/calf	45.3% calf	33.9% calf, 1.7% shin	32% calf	7.8%	6% lower leg
Ankle	NR	4.2% ankle, 7.6% Achilles	19%	10.9%	13%
Foot	NR	18.8%	16%	18.0%	24%

NR not reported, NYC New York City, US United States

* Reported as percentage of total participants experiencing pain/stiffness at various anatomic locations during or immediately after the race

† Male marathon runners only; reported as the percentage of total race-day injuries according to anatomic location in a post-race questionnaire

‡ Reported as the percentage of injuries at various anatomic locations evaluated at the physical therapy station

§ Reported as the percentage of race-day injuries at various anatomic locations in a survey distributed one week after the race

¶ Reported as the percentage of race-day injuries occurring at each anatomic location, according to a post-race survey

Hip Injuries

The reported incidence of hip injuries has increased over time, accounting for nearly one-fifth of all reported race-day injuries [8, 13]. Commonly reported hip injuries include hip flexor tendonitis, iliopsoas bursitis, abductor tendonitis, trochanteric bursitis, adductor strains, iliotibial band syndrome, and stress fractures/reactions [13]. In particular, female participants have been reported to experience a greater risk of hip-related injuries when compared to their male counterparts. Satterthwaite et al. [14] reported females to be 1.88 times more likely to report hip stiffness or pain during the 1993 Auckland Citibank Marathon. Fredericson and Misra [6] similarly reported that females experienced a greater incidence of hip issues, while Hsu et al. [15] reported that hip injuries represented 10% of overall injuries in females compared to 4% in males, at the Tokyo Gorge Marathons from 2013 to 2018 (p = 0.001). Greater hip adduction and internal rotation during stride in female runners, when compared to males, have been theorized to increase stress on hip muscles and tendons during running activities, potentially accounting for the greater risk of hip-related injuries in females when compared to males [30].

Thigh Injuries

Hamstring and quadriceps strains represent the most frequently reported injuries involving the thigh [12, 13]. Satterthwaite et al. [7] reported that during the 1993 Auckland Marathon, 60.1% of survey participants reported pain or stiffness in the anterior thigh, with injury risks associated with cycling during race preparation, fewer rest days prior to race-day, and the consumption of alcohol more than once a month. Moreover, 24.2% of participants reported pain or stiffness involving the hamstrings, which was more prevalent among males, runners aged 30–34, first-time marathon participants, those with increased weekly mileage during training, and runners who reported performing aerobic exercises beyond running [14]. During the 2019 Rome Marathon, Longo et al. [12] reported that 76.7% of survey respondents were diagnosed with varying degrees of hamstring tendinopathy based on clinical criteria and questionnaire responses. The authors found that older age, increased body weight, and greater impact profile were associated with hamstring strains. [12] In addition, McGrath et al. [13] reported that during the 2019 New York City Marathon, thigh injuries represented the second most common injury location, with 54% of thigh injuries consisting of hamstring strains and tears. Hsu et al. [15] reported a higher proportion of thigh injuries among male participants over the course of the 2013–2018 Tokyo Gorge Marathons, comprising 25% of the overall injuries reported in males compared to 13% in females (p < 0.001). Marathon distance running has also been shown to result in hamstring muscle injuries, which may be clinically asymptomatic. Specifically, Higashihara et al. [31] reported that when examining pre-race versus post-race magnetic resonance imaging scans of the thigh, a greater extent of hamstring muscle damage was evident on post-race T2-weighted imaging, with injuries primarily involving the distal and medial aspects of the hamstrings.

Knee Injuries

Knees represent the most commonly reported injured body region associated with marathon running [6]. Namely, a three-year review of a nationally recognized annual marathon with both half- and full-marathon runners found that the knee was the most commonly injured site for both race distances [8]. While not separated by training versus race-day running, McGrath et al. [13] reported that the most common knee injuries at the 2019 NYC Marathon included iliotibial band syndrome, patellofemoral syndrome, patellar tendonitis, meniscal tearing, and stress fractures or stress reactions. Satterthwaite et al. [7] further reported that 25.6% of survey participants at the 1993 Auckland Marathon experienced knee pain, which was correlated with first-time marathon participation, current medication use, and lower weekly pre-race mileage.

Lower Leg/Ankle Injuries

Following the 2019 NYC Marathon, McGrath et al. [13] reported that the most common lower leg injuries involved gastrocnemius strains or tears and stress fractures or stress reactions, specifically medial tibial stress syndrome. Hsu et al. [15] reported that over the course of the 2013–2018 Tokyo Gorge Marathons, calf injuries comprised 34% of injuries in males and 28% in females. During the 1993 Auckland Marathon, Satterthwaite et al. [7] found that 45.3% of survey participants experienced calf injuries, which were associated with male sex and illness within two weeks leading up to the race, while runners aged 30–34 years and those aged 40 years and older were at lower risk for injury [14]. Ankle injuries, predominantly consisting of Achilles tendinitis, posterior tibial tendinitis, stress fractures or stress reactions, as well as peroneal tendinitis, have also been reported. [13] In addition, common foot injuries include plantar fasciitis, stress fractures or stress reactions, and neuromas. [13]

Injury Considerations

There remains a general lack of consensus on injury prevention strategies due to the heterogeneity in runner demographics, as well as the different types and severity of injuries reported during marathon participation [26, 32]. Self-regulation and injury awareness remain crucial, as different injuries affect individual runners differently, with each athlete possessing unique motivations for marathon participation and race completion [33]. Athletes also arrive on race-day with unique medical and surgical histories that should be taken into account; in a survey offered to all participants of the 2019 and 2021 Chicago Marathons, 10.9% of respondents noted a history of hip or knee surgery [34]. When medical evaluation during race-day is sought, clinical decisions are often made in conjunction with medical personnel in the best interest of the runner. While resource allocation and medical provider preparedness are essential components of race-day planning [29], not all medical personnel in race tents may possess a sports medicine-specific background. As such, while no universal consensus exists, injuries that alter normal gait or worsen with continued race participation, especially those that fail to improve after a period of rest despite medical evaluation and management, generally merit discontinuation. However, regardless of the injury type, it remains largely at the discretion of the runner to determine if and when further evaluation for MSK-related injuries is required and if race discontinuation is indicated.

Conclusion

Marathon participation has become increasingly popular, resulting in a greater reported incidence of associated race-day injuries. Musculoskeletal injuries remain the most common reported injury among race-day participants, often involving the hip, thigh, knee, and lower leg/ankle. The demographics of marathon runners continue to evolve, with participants generally being older, slower, and less experienced. A growing number of female participants has also been reported, as well as racers more frequently traveling to compete. Based on the limitations of available literature and data, risk factors for specific injuries vary, potentially including both non-modifiable and modifiable variables. Advancements in race-related apparel and wearable technologies continue to play an important role, with questionable impacts on injury risk. Ongoing assessment of race-day injury patterns is crucial for preparedness and prevention, particularly as marathon participant characteristics evolve and technologies advance.

Key References

• McGrath TM, Fontana MA, Toresdahl BG. Injury patterns and healthcare utilization by runners of the New York City Marathon. BMJ Open Sport Exerc Med. 2024;10(1):e001766. doi:10.1136/bmjsem-2023-001766.

  • This recently published study examines injuries sustained before and during race-day at one of the major North American marathons, the NYC Marathon. Anatomical locations and types of injuries are specifically described, offering a comprehensive account of lower-body injuries encountered in marathon runners.
• Tenforde A, Hoenig T, Saxena A, Hollander K. Bone Stress Injuries in Runners Using Carbon Fiber Plate Footwear. Sports Med. 2023;53(8):1499-505. doi: 10.1007/s40279-023-01818-z.

  • This study examines the risks associated with carbon fiber-plated footwear, a growing choice among both competitive marathon athletes and less experienced runners participating in their first race. Recent updates in wearable running technologies, particularly footwear, are discussed. Given the impact shoes may have on energy distribution and running mechanics, various materials used in shoe design are examined, along with associated running-related injuries.
• Mohseni MM, Filmalter SE, Taylor WC, Vadeboncoeur TF, Thomas CS. Factors Associated With Half- and Full-Marathon Race-Related Injuries: A 3-Year Review. Clin J Sport Med. 2021;31(5):e277-e86. doi: 10.1097/jsm.0000000000000775..

  • This study analyzes data from a nationally recognized race, focusing on risk factors for injuries on race-day. It uniquely offers race-day-specific data collected over three years, centered on a single annual marathon event.

Author Contributions

J.M.P., D.C.T., D.M.K., and R.H.B. made substantial contributions to the conception or design of the work, analysis, and interpretation of data. J.M.P. and D.C.T. drafted the work, while D.M.K. and R.H.B. critically revised it for its intellectual content and approved the version to be published. J.M.P., D.C.T., D.M.K., and R.H.B. agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

No funding was received.

Data Availability

No datasets were generated or analysed during the current study.

Declarations

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Competing interests

• J.M.P.: None

• D.C.T.: None

• R.H.B.: support for education and hospitality payments from Elite Orthopaedics and hospitality payments from Zimmer Biomet

• D.M.K.: support for education from Synthes, Smith & Nephew, Elite Orthopedics, and Medwest Associates; hospitality payments from Arthrex, Elite Orthopaedics, Encore Medical, Stryker, and Smith & Nephew; honoraria from Encore Medical; and a grant from Arthrex