Risk Factors, Prevention, and Recovery of Knee Joint Injuries in Marathon Runners
DOI:
https://doi.org/10.54691/1n7gnx65Keywords:
Marathon running; Knee joint injury; Risk factors; Prevention strategies; Recovery strategies.Abstract
Driven by the national strategies of "Fitness for All" and "Building a Strong Sports Nation," marathon running has experienced rapid growth in China, with a significant increase in participants. However, due to the high-load nature of marathon running, knee injuries have become a common health risk among runners, severely affecting their performance and overall health. Despite this, domestic research has yet to establish a systematic understanding of the risk factors, prevention, and recovery strategies for knee injuries in marathon runners. Given the extensive research on marathon-related knee injuries abroad, this study aims to review and synthesize international research on the risk factors, prevention, and recovery strategies for knee injuries in marathon runners. In terms of risk factors, the primary internal factors for knee injuries include muscle strength and running technique, while external factors encompass excessive training load and footwear type. Effective prevention strategies include balancing muscle strength, optimizing running technique, managing training load, and selecting appropriate running shoes. For injured runners, initial recovery strategies involve physical therapy, medication, and exercise therapy. In the intermediate phase, gradual load increase and progress monitoring are essential, followed by a step-by-step return to running to ensure a scientifically guided recovery. This study provides marathon runners with a systematic approach to the prevention and management of knee injuries, aiming to support their long-term healthy running careers.
Downloads
References
[1] Ding N, Su W L, Mu N, et al. 2023 China Road Race Blue Book [EB/OL]. (In Chinese). https://sdxw.iqilu.com/share/YS0yMS0xNTQ3MTYwNg.html
[2] FRANCIS P,WHATMAN C,SHEERIN K, et al. The proportion of lower limb running injuries by gender, anatomical location and specific pathology: a systematic view. J Sports Sci Med, 2019,18(1):21-31.
[3] Yang C, Wan X L, Feng R, et al. Influence of knee pain on knee joint biomechanics during the stance phase of running and landing jump in amateur runners with patellofemoral pain. China Sport Science and Technology, 2016, 35(06): 62-68.
[4] Ren S, Yin Y, Zhang S, et al. Gait analysis characteristics and guiding significance of runners after anterior cruciate ligament rupture. Science & Technology Review, 2016, 35(06): 43-48.
[5] Ren H J, Wei J B, Liu Y, et al. Application of MSCT combined with MRI in the diagnosis of knee joint injuries in marathon runners. Imaging Science and Photochemistry, 2016, 35(06): 971-975.
[6] Yu H X, Shen Y Y, Zhang Y J, et al. Application progress of quantitative MRI technology in knee cartilage of running populations. International Journal of Medical Radiology, 2016, 35(06): 588-593.
[7] Gao F. Research on prediction method of potential knee joint injury in marathon runners. Journal of Guangzhou Sport University, 2020, 40(01): 109-112+125.
[8] Chen Q H, Bi Q. Analysis of sports injuries and influencing factors in Hangzhou mountain marathon. Chinese Journal of Sports Medicine, 2016, 35(06): 557-560.
[9] Gao C M. Investigation on basic information, training characteristics and lower limb injuries of marathon enthusiasts [C]// China Sport Science Society. Proceedings of the 13th National Sports Science Congress -- Special Report (Sports Sociology Branch). Chengdu Sport University, 2023: 836-838.
[10] Hu H Y, Zheng Y L, Wang X Q, et al. Analysis of knee joint injury status and influencing factors in Shanghai International Marathon runners. Chinese Journal of Rehabilitation Medicine, 2016, 35(06): 297-302.
[11] Yang Y Z, Jiao W, Yuan S T. Investigation and analysis of running injuries and influencing factors in amateur marathon runners. Journal of Shandong Sport University, 2016, 35(06): 91-97.
[12] Zhou J, Zheng X Z, Ding J P, et al. MRI-based study on the correlation between thigh muscles, knee injuries and running factors in amateur marathon runners. Journal of Clinical Radiology, 2016, 35(06): 1956-1960.
[13] ABULHASAN J F, GREY M J. Anatomy and physiology of knee stability [J]. J Funct Morphol Kinesiol, 2017,2(4): 34.
[14] ELLINGER S, NEUROHR G A. Evidence-based treatment options for common knee injuries in runners [J]. Ann Transl Med, 2019,7(Suppl 7): S249.
[15] PETERSEN W, ELLERMANN A, GÖSELE-KOPPENBURG A, et al. Patellofemoral pain syndrome [J]. Knee Surg Sports Traumatol Arthrosc, 2014,22(10): 2264–2274.
[16] HAN S. Changes in patellofemoral joint mechanics in the presence of quadriceps muscle imbalance [D]. University of Calgary, Canada, 2020.
[17] COLLADO H, FREDERICSON M. Patellofemoral pain syndrome[J]. Clin Sports Med, 2010, 29(3): 379–398.
[18] ONSEN L T, KOH J L. Principles of prevention and rehabilitation for the patellofemoral joint[J]. The Patellofemoral Joint: A Case-Based Approach, 2022: 45–55.
[19] FINNOFF J T, HALL M M, KYLE K, et al. Hip strength and knee pain in high school runners: a prospective study [J]. PM&R, 2011, 3(9): 792–801.
[20] SOUZA R B, DRAPER C E, FREDERICSON M, et al. Femur rotation and patellofemoral joint kinematics: a weight-bearing magnetic resonance imaging analysis [J]. J Orthop Sports Phys Ther, 2010, 40(5): 277–285.
[21] DOS ANJOS RABELO N D, LUCARELLI P R G. Do hip muscle weakness and dynamic knee valgus matter for the clinical evaluation and decision-making process in patients with patellofemoral pain? [J]. Braz J Phys Ther, 2018, 22(2): 105–109.
[22] BURKE A, DILLON S, O’CONNOR S, et al. Risk factors for injuries in runners: a systematic review of foot strike technique and its classification at impact [J]. Orthop J Sports Med, 2021,9(9): 23259671211020283.
[23] GIANDOLINI M, POUPARD T, GIMENEZ P, et al. A simple field method to identify foot strike pattern during running [J]. J Biomech, 2014,47(7): 1588–1593.
[24] HANLEY B, BISSAS A, MERLINO S, et al. Most marathon runners at the 2017 IAAF World Championships were rearfoot strikers, and most did not change footstrike pattern [J]. Journal of Biomechanics, 2019,92: 54–60.
[25] LARSON P, HIGGINS E, KAMINSKI J. Foot strike patterns of recreational and sub-elite runners in a long-distance road race [J]. J Sports Sci, 2011,29: 1665–1673.
[26] DAOUD A I, GEISSLER G J, WANG F, et al. Foot strike and injury rates in endurance runners: a retrospective study [J]. Med Sci Sports Exerc, 2012,44(7): 1325–1334.
[27] RICE H M, JAMISON S T, DAVIS I S. Footwear matters: influence of footwear and foot strike on load rates during running [J]. Med Sci Sports Exerc, 2016,48(3): 10–15.
[28] YONG J R, SILDER A, DELP S L. Differences in muscle activity between natural forefoot and rearfoot strikers during running [J]. J Biomech, 2014,47(15): 3593–3597.
[29] KULMALA J-P, AVELA J, PASANEN K, et al.. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers [J]. Med Sci Sports Exerc, 2013,45(12): 2306–2313.
[30] ROONEY B D, DERRICK T R. Joint contact loading in forefoot and rearfoot strike patterns during running [J]. J Biomech, 2013,46(13): 2201–2206.
[31] LANKHORST N E, BIERMA-ZEINSTRA S M, VAN MIDDLEKOOP M J. Risk factors for patellofemoral pain syndrome: a systematic review [J]. J Orthop Sports Phys Ther, 2012,42(2): 81–94.
[32] LIEBERMAN D E, WARRENER A G, WANG J, et al. Effects of stride frequency and foot position at landing on braking force, hip torque, impact peak force and the metabolic cost of running in humans [J]. Journal of Experimental Biology, 2015,218(21): 3406-3414.
[33] EIDERSCHEIT B C, CHUMANOV E S, MICHALSKI M P, et al. Effects of step rate manipulation on joint mechanics during running [J]. Med Sci Sports Exerc, 2011,43(2): 296–302.
[34] BENCA E, LISTABARTH S, FLOCK F K J, et al. Analysis of running-related injuries: the Vienna study [J]. J Clin Med, 2020,9(2): 438.
[35] DESAI P, JUNGMALM J, BÖRJESSON M, et al. Recreational runners with a history of injury are twice as likely to sustain a running-related injury as runners with no history of injury: a 1-year prospective cohort study [J]. J Orthop Sports Phys Ther, 2021,51(3): 144–150.
[36] SARAGIOTTO B, YAMATO T, HESPANHOL E, et al. What are the main risk factors for running-related injuries? [J]. Sports Med, 2014,44: 1153–1163.
[37] MANCINO F, GABR A, PLASTOW R, et al. Anterior Cruciate Ligament Injuries in Female Athletes: Is It Time for a New Approach? [J]. The Bone & Joint Journal, 2023,105(10): 1033-1037.
[38] BESSON T, MACCHI R, ROSSI J, et al. Sex differences in endurance running [J]. Sports Med, 2022,52(6): 1235–1257.
[39] HEWETT T E, FORD K R, HOOGENBOOM B J, et al. Understanding and preventing ACL injuries: current biomechanical and epidemiologic considerations - update 2010 [J]. N Am J Sports Phys Ther, 2010,5: 234–251.
[40] SMITH H C, VACEK P, JOHNSON R J, et al. Risk factors for anterior cruciate ligament injury: a review of the literature-part 2: hormonal, genetic, cognitive function, previous injury, and extrinsic risk factors [J]. Sports Health, 2012,4: 155–161.
[41] KHOWAILED I A, PETROFSKY J, LOHMAN E, et al. 17beta-estradiol induced effects on anterior cruciate ligament laxness and neuromuscular activation patterns in female runners [J]. J Womens Health (Larchmt), 2015,24(8): 670-680.
[42] HALSON S L. Monitoring training load to understand fatigue in athletes [J]. Sports Med, 2014,44(2): 139–147.
[43] VAN DER WORP M P, TEN HAAF D S, VAN CINGEL R, et al. Injuries in runners; a systematic review on risk factors and sex differences [J]. PLoS One, 2015,10(2): e0114937.
[44] KLUITENBERG B, VAN DER WORP H, HUISTEDE B M, et al. The NLstart2run study: training-related factors associated with running-related injuries in novice runners [J]. J Sci Med Sport, 2015,19(8): 642-646.
[45] DALLINGA J, VAN RIJN R, STUBBE J, et al.Injury incidence and risk factors: a cohort study of 706 8-km or 16-km recreational runners [J]. BMJ Open Sport Exerc Med, 2019,5(1): e000489.
[46] FOKKEMA T, VAN DAMME A A D N, et al. Training for a (half-)marathon: training volume and longest endurance run related to performance and running injuries [J]. Scand J Med Sci Sports, 2020,47(1): 33–38.
[47] NIELSEN R O, NOHR E A, RASMUSSEN S, et al. Classifying running-related injuries based upon etiology, with emphasis on volume and pace [J]. Int J Sports Phys Ther, 2013,8: 172–179.
[48] WARDEN S J, DAVIS I S, FREDERICSON M. Management and prevention of bone stress injuries in long-distance runners [J]. J Orthop Sports Phys Ther, 2014,44(10): 749–765.
[49] DAMSTED C, PARNER E T, SØRENSEN H, et al. The association between changes in weekly running distance and running-related injury: preparing for a half marathon [J]. J Orthop Sports Phys Ther, 2019,49(4): 230–238.
[50] NIELSEN R Ø, PARNER E T, NOHR E A, et al. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury [J]. J Orthop Sports Phys Ther, 2014,44(10): 739–747.
[51] DORN T W, SCHACHE A G, PANDY M G. Muscular strategy shift in human running: dependence of running speed on hip and ankle muscle performance [J]. J Exp Biol, 2012,215: 1944–1956.
[52] PETERSEN J, SØRENSEN H, NIELSEN R Ø. Cumulative loads increase at the knee joint with slow-speed running compared to faster running: a biomechanical study [J]. J Orthop Sports Phys Ther, 2015,45: 316.
[53] PETERSEN J, NIELSEN R O, RASMUSSEN S, SØRENSEN H. Comparisons of increases in knee and ankle joint moments following an increase in running speed from 8 to 12 to 16 km·h⁻¹ [J]. Clin Biomech, 2014,29: 959–964.
[54] FREDETTE A, ROY J S, PERREAULT K, et al. The association between running injuries and training parameters: a systematic review [J]. J Athl Train, 2022,57(7): 650–671.
[55] HOITZ F, MOHR M, ASMUSSEN M, LAM W-K, et al. The effects of systematically altered footwear features on biomechanics, injury, performance, and preference in runners of different skill level: a systematic review [J]. Footwear Sci, 2020,12: 193–215.
[56] RYAN M, ELASHI M, NEWSHAM-WEST, et al. Examining injury risk and pain perception in runners using minimalist footwear [J]. Br J Sports Med, 2014,48(16): 1257–1262.
[57] SQUADRONE R, RODANO R, HAMILL J, et al. Acute effect of different minimalist shoes on foot strike pattern and kinematics in rearfoot strikers during running [J]. J Sports Sci, 2015,33(11): 1196–1204.
[58] FU F, GUO L, TANG X, et al. Effect of the innovative running shoes with the special midsole structure on the female runners’lower limb biomechanics [J]. Front Bioeng Biotechnol, 2022,10: 866321.
[59] MALISOUX L, CHAMBON N, URHAUSEN A, et al. Influence of the heel-to-toe drop of standard cushioned running shoes on injury risk in leisure-time runners: a randomized controlled trial with 6-month follow-up [J]. Am J Sports Med, 2016,44(11): 2933–2940.
[60] RIXE J A, GALLO R A, SILVIS M L. The barefoot debate: can minimalist shoes reduce running-related injuries? [J]. Curr Sports Med Rep, 2012,11(3): 160–165.
[61] MALISOUX L, DELATTRE N, URHAUSEN A, et al. Shoe cushioning influences the running injury risk according to body mass: a randomized controlled trial involving 848 recreational runners [J]. Am J Sports Med, 2020,48(2): 473–480.
[62] RODRIGUES P, CHANG R, TENBROEK T, et al. Medially posted insoles consistently influence foot pronation in runners with and without anterior knee pain [J]. Gait Posture, 2013,37(4): 526–531.
[63] LEWINSON R T, WILEY J P, HUMBLE R N, et al. Altering knee abduction angular impulse using wedged insoles for treatment of patellofemoral pain in runners: a six-week randomized controlled trial [J]. PLoS One, 2015,10(7): e0134461.
[64] KHOSHKHOO M, KILLINGBACK A, ROBERTSON C J, et al. The effect of exercise on vastus medialis oblique muscle architecture: An ultrasound investigation [J]. Clin Anat, 2016,29(6): 752-758.
[65] BUCKTHORPE M, LA ROSA G, DELLA VILLA F. Restoring knee extensor strength after anterior cruciate ligament reconstruction: a clinical commentary [J]. Int J Sports Phys Ther, 2019,14(1): 159.
[66] CHANG W D, HUANG W S, LAI P T. Muscle activation of vastus medialis oblique and vastus lateralis in sling-based exercises in patients with patellofemoral pain syndrome: a cross-over study[J]. Evid Based Complement Alternat Med, 2015(1): 740315.
[67] LEE J, LEE H, LEE W. Effect of weight-bearing therapeutic exercise on the Q-angle and muscle activity onset times of elite athletes with patellofemoral pain syndrome: A randomized controlled trial [J]. J Phys Ther Sci, 2014,26(7): 989-992.
[68] FERBER R, KENDALL K D, FARR L. Changes in knee biomechanics after a hip-abductor strengthening protocol for runners with patellofemoral pain syndrome [J]. J Athl Train, 2011,46(2): 142–149.
[69] CONTRERAS B M, CRONIN J B, SCHOENFELD B J, et al. Are all hip extension exercises created equal? [J]. Strength Cond J, 2013,35(2): 17–22.
[70] POHL P. The Patriot Program: a dynamic warm-up for the risk reduction of anterior cruciate ligament injuries in high school female basketball players [D]. Albany, NY: The Sage Colleges, 2013.
[71] FUTRELL E E, GROSS K D, REISMAN D, et al. Transition to forefoot strike reduces load rates more effectively than altered cadence [J]. J Sport Health Sci, 2020,9(4): 341–347.
[72] CHEUNG R T, DAVIS I S. Landing pattern modification to improve patellofemoral pain in runners: a case series [J]. J Orthop Sports Phys Ther, 2011,41(12): 914–919.
[73] ALMEIDA M O, DAVIS I S, LOPES A D. Biomechanical differences of foot-strike patterns during running: a systematic review with meta-analysis [J]. J Orthop Sports Phys Ther, 2015,45(12): 912–922.
[74] IRENE S. DAVIS, HANNAH M. RICE, SCOTT C. Why forefoot striking in minimal shoes might positively change the course of running injuries [J]. J Sport Health Sci, 2017, 6(2): 154-161.
[75] GAMEZ-PAYA J, ALADRO-GONZALVO A R, MARCOS D G, et al. Footstrike pattern and cadence of the marathon athletes at the Tokyo 2020 Olympic Games [J]. Appl Sci, 2023,13(11): 6620.
[76] BARNES A, GAMEZ-PAYA J, CASTELLI A, et al. Foot strike patterns in runners wearing floating heel, minimalist and conventional footwear [C]// Proc 33rd Int Conf Biomech Sports, Poitiers, France, 29 June–3 July 2015: 519–522.
[77] DAVIS I S, FUTRELL E. Gait retraining: Altering the fingerprint of gait [J]. Phys Med Rehabil Clin N Am, 2019,27: 339–355.
[78] FOLLAND J P, ALLEN S J, BLACK M, et al. Running technique is an important component of running economy and performance [J]. Med Sci Sports Exerc, 2017,49: 1412–1423.
[79] SCHUBERT A G, KEMPF J, HEIDERSCHEIT B C. Influence of stride frequency and length on running mechanics: a systematic review [J]. Sports Health, 2014,6(3): 265–274.
[80] HEIDERSCHEIT B C, CHUMANOV E S, MICHALSKI M P, et al. Effects of step rate manipulation on joint mechanics during running [J]. Med Sci Sports Exerc, 2011,43: 296–302.
[81] BEGIZEW D M, GRACE J M, VAN HEERDEN H J. Lower-extremity running-related injuries among 10,000-meter long distance runners in Ethiopia [J]. J Hum Sport Sci, 2018,14(2): 358–373.
[82] RASMUSSEN C H, NIELSEN R O, JUUL M S, et al. Weekly running volume and risk of running-related injuries among marathon runners [J]. Int J Sports Phys Ther, 2013,8(2): 111.
[83] KLUITENBERG B, VAN MIDDLEKOOP M, DIERCKS R, et al. What are the differences in injury proportions between different populations of runners? A systematic review and meta-analysis [J]. Sports Med, 2015,45: 1143-1161.
[84] NIELSEN R O, BUIST I, SØRENSEN H, et al. Training errors and running-related injuries: a systematic review [J]. Int J Sports Phys Ther, 2012,7(1): 58.
[85] MAI P, ROBERTZ L, ROBBIN J, et al. Towards functionally individualised designed footwear recommendation for overuse injury prevention: a scoping review [J]. BMC Sports Sci Med Rehabil, 2023,15(1): 152.
[86] SINCLAIR J, JANSSEN J, RICHARDS J D, et al. Effects of a 4-week intervention using semi-custom insoles on perceived pain and patellofemoral loading in targeted subgroups of recreational runners with patellofemoral pain [J]. Phys Ther Sport, 2018,34: 21–27.
[87] KRUTSCH W, MAYR H, MUSAHL V, et al. Injury and health risk management in sports [M], 2020,2nd Edition: 34–45.
[88] NICOLA T L, EL SHAMI A. Rehabilitation of running injuries [J]. Clin Sports Med, 2012,31(2): 351–372.
[89] HARRAST M A, COLONNO D. Stress fractures in runners [J]. Clin Sports Med, 2010,29(3): 399–416.
[90] KWIECIEŃ S Y, MCHUGH M P. The cold truth: The role of cryotherapy in the treatment of injury and recovery from exercise [J]. European Journal of Applied Physiology, 2021,121(8): 2125-2142.
[91] PALANISAMY P, ALAM M, LI S, et al. Low-intensity pulsed ultrasound stimulation for bone fractures healing: a review [J]. J Ultrasound Med, 2022,41(3): 547–563.
[92] GOLDSTEIN C, SPRAGUE S, PETRISOR B A, et al. Electrical stimulation for fracture healing: current evidence [J]. J Orthop Trauma, 2010,24(Suppl 1): S62–S65.
[93] KURMIS A P, KURMIS T P, O’BRIEN J X, et al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: A review [J]. The Journal of Bone & Joint Surgery, 2012,94(9): 815-823.
[94] VAN MELICK N, VAN CINGEL R E, BROOIJMANS F, et al. Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus [J]. Br J Sports Med, 2016,50(24): 1506–1515.
[95] DALEY M M, GRIFFITH K, MILEWSKI M D, et al. The mental side of the injured athlete [J]. J Am Acad Orthop Surg, 2021,29: 499–506.
[96] UPADHYAY M K. Yoga in sports: a descriptive study [J]. Int J Yoga Physio Phys Educ, 2025,10(1): 4–5.
[97] MITHOEFER K, HAMBLY K, LOGERSTEDT D, et al. Current concepts for rehabilitation and return to sport after knee articular cartilage repair in the athlete [J]. J Orthop Sports Phys Ther, 2012,42(3): 254-273.
[98] WILLY R. Innovations and pitfalls in the use of wearable devices in the prevention and rehabilitation of running related injuries [J]. Phys Ther Sport, 2018,29: 26–33.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 Scientific Journal Of Humanities and Social Sciences

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.





