Common running injuries in marathon training: how physio guides your return to running
Marathon training is going well, the long runs are getting longer, and then something twinges. The knee. The Achilles. The calf that won't stop nagging on every other Tuesday. Most of the runners we see at Complement in Islington arrive midway through a marathon block, hoping there's a way to keep training rather than stop altogether. Often there is, provided you address the actual cause of the load problem rather than rest and hope. Tommaso founded the clinic to bring osteopathy, physiotherapy and Pilates under one roof, and Rowan, one of our physiotherapists, holds a specific clinical interest in running injuries. This is what we see most often in our physiotherapy in Islington clinic, and what actually works.
The most common running injuries in marathon training
The most common running injuries in marathon training are runner's knee, IT band syndrome, shin splints, calf strain, Achilles tendinopathy, plantar fasciitis and stress fractures.
NHS guidance on running injuries (nhs.uk/live-well/exercise/knee-pain-and-other-running-injuries) lists knee pain, Achilles pain, shin splints, heel pain and muscle strains as the five most common. In a marathon-training context we add IT band syndrome (because the volume increase tends to expose hip-stability issues) and stress fractures (which become a real concern in higher-mileage weeks).
Runner's knee (patellofemoral pain syndrome) is the most common of all. The pain sits at the front of or just around the kneecap, and tends to be worse going downstairs, after long sitting, or in the final few kilometres of a long run. It's usually a hip and quad strength problem dressed up as a knee problem, so the treatment focus is rarely the knee itself.
IT band syndrome shows up as a sharp, localised pain on the outside of the knee that comes on at a predictable point in a run (mile three, mile five) and worsens if you push through. The iliotibial band itself is not inflamed in the way runners often imagine; the pain is a compression issue, and again it responds best to glute strength work and a temporary reduction in downhill running.
Shin splints (medial tibial stress syndrome) produces a dull, diffuse ache along the inside of the shin. It usually surfaces when weekly mileage has jumped sharply or when a hard surface, a lot of pavement, has been substituted for softer footing.
Calf strain typically presents as a sudden, sharp pain in the calf during a faster effort, often described by patients as "feeling like someone kicked me." Grade matters here, and an in-person assessment helps you decide whether to keep walking, jog gently, or fully unload for a few days.
Achilles tendinopathy starts as morning stiffness in the heel cord and pain at the start of a run that eases as you warm up. The classic mistake is to interpret that easing as the tissue settling, when it's actually masking ongoing load. Left unmanaged, it becomes chronic and far harder to clear.
Plantar fasciitis is sharp pain under the heel, worst on the first few steps in the morning. It's strongly linked to calf tightness and to footwear that has lost its support.
Stress fractures are the one injury on this list you cannot run through. The pain is localised, often pinpointable to a specific bone (the second or third metatarsal, the shin, the femoral neck), and worse with impact. Any suspicion of a stress fracture warrants a same-week assessment and probably imaging.
Many of the sports injuries we treat in clinic are these exact problems in runners who have ramped mileage too quickly.
How to know if you have a running injury (and when to stop training)
Pain that changes your gait, gets worse mid-run, or lingers more than two or three days post-run all warrant assessment.
A useful working rule: discomfort that fades as you warm up and doesn't change your stride is usually nothing to worry about. Pain that makes you alter your gait, that worsens within a single run rather than easing off, or that's still present 48 to 72 hours after the run is a different category. So is any pain you have to mentally negotiate around, any pain that wakes you at night, and any pain that hurts when you load the area (a hop, a single-leg squat, pressing the spot firmly).
There's also the "two-out-of-three" pattern we use clinically: if the pain hurts during the run, hurts when you press the area, and hurts the next morning, you almost always have an injury that needs intervention rather than rest alone. Resting changes the load for a few days, but it doesn't change the reason the tissue was failing to tolerate it in the first place. That's where physiotherapy assessment adds value.
Why marathon mileage triggers these injuries
Marathon-block injuries are almost always overuse problems caused by mileage rising faster than tissue capacity can adapt, often compounded by uneven training intensity.
Two specific patterns drive most of them. The first is the rate-of-progression problem. You may have heard the "10% rule," the idea that you should never increase your weekly mileage by more than 10%. A 2025 British Journal of Sports Medicine cohort study of more than 5,200 runners (often referred to as the Nielsen study) found this rule has limited predictive value. What matters more is the size of single-run jumps relative to your longest run in the previous 30 days. Stay below roughly 110% of that recent longest run on any individual session, and your overuse injury risk drops sharply.
The second is intensity distribution, which is what runners often mean when they ask about "the 80% rule." This refers to the 80/20 (or polarised) training principle, pioneered by the exercise physiologist Stephen Seiler: roughly 80% of your weekly running time should be at a genuinely easy, conversational pace, and the remaining 20% at hard intensity. Most amateur runners we see have crept into a grey zone where almost every run is moderately hard, and that pattern significantly raises tissue load week on week. Slow down the easy runs and the hard ones get easier to nail.
A third factor, more often overlooked: capacity in non-running muscles. If your glutes, calves and intrinsic foot muscles can only support 30 miles a week of running biomechanically, an 18-week block that hits 50 will find that ceiling. Strength work is what raises the ceiling.
How physiotherapy guides a return to running
A physiotherapist-led return to running combines hands-on treatment, targeted strength work, and a graded reintroduction of running volume that stays inside your current tissue tolerance.
Your first session focuses on three things. First, a clear diagnosis: which structure is loaded beyond capacity, and why. The "why" is usually not where you feel the pain. A runner's knee patient nearly always has a glute strength or hip mobility deficit. A calf strain patient often has a foot loading pattern that's overworking the gastrocnemius. Naming the actual driver is what stops the injury coming back.
Second, settling the painful tissue. Hands-on treatment (soft tissue work, joint mobilisation, the targeted use of techniques drawn from both osteopathy and physiotherapy) brings symptoms down faster than rest alone in most cases. This is where Tommaso's dual training is useful in the clinic: he can treat with osteopathic and physiotherapy techniques in the same session, so you don't need to see two clinicians.
Third, building back. We use a load-led progression rather than a calendar one. Rather than "you can run again in two weeks," we set the criteria: pain-free single-leg hop, full-range single-leg squat to a target depth, pain-free walk-jog intervals, and we test against them at each review. Strength work is layered in throughout, not bolted on at the end.
For most non-fracture overuse injuries we see in marathon training, this looks like one or two sessions a week for two to four weeks, then weekly until the runner is back to full mileage at full pace.
Our integrated approach in Islington: osteo, physio and Pilates working together
Our integrated approach treats the runner, not just the injury, blending osteopathic mobility work, physiotherapy rehabilitation and Pilates-based strength into a single plan.
Most clinics offer either physiotherapy or osteopathy. We offer both, and increasingly we find that runners benefit most from the combination. The osteopathic side handles the mobility piece: the stiff thoracic spine that's limiting arm swing, the hip joint capsule that's locking out internal rotation. The physiotherapy side handles assessment, diagnosis and progressive loading. And private Pilates for runners takes care of the deep stability work, particularly through the lateral hip and the foot intrinsics, which generic gym strength tends to miss.
Pregnancy osteopathy at our Islington clinic is built around one clinician carrying your case forward. You explain the problem once. The plan adjusts week by week without you having to translate between practitioners. For runners in particular, this matters: a marathon block is a moving target, and the rehab plan needs to keep up with the training plan.
Our Islington clinic sits a short walk from Highbury & Islington station, in the heart of an area that runs heavily towards Highbury Fields and out along the Regent's Canal towpath. Many of our runners are training on those routes, and that familiarity matters when we're discussing surface, gradient and route choice as part of a return plan.
Book your session at Complement Osteo & Physio
If a marathon-block niggle is starting to dominate your training, book an assessment now rather than waiting to see if it settles.
The earlier we see a running injury, the less running you tend to miss. A first assessment includes a full case history, a movement and strength screen, hands-on treatment for the symptomatic tissue, and a written return-to-running plan you can follow between sessions. We accept most major insurance providers and offer multi-session packages for runners working through a full marathon block.
