Injured runner series part III: Evaluation of a runner
This is part 3 of my “Injured Runner Series” blog posts. You can read parts 1+2 here!
How a Physical Therapist Actually Evaluates a Runner
Most runners who walk into a PT clinic expect are given a similar narrative: “your feet are flat, your hips are weak, and your knees caves in, which is why you’re having pain XY and Z”. How did the therapist come to these conclusions? I think far too often narrative and dogma drives treatment selection, not the results of a thorough clinical examination.
A good running evaluation is really two evaluations happening at once. There's the general orthopedic assessment that any PT would perform on any musculoskeletal complaint — movement assessment, range of motion, strength, and special testing. Secondly, layered on top of that is a runner-specific assessment that takes into account specific pain provocation as it relates to running, a movement assessment that is specific to runners, a muscle function test that tests capacity of the muscles that are actually used while running, and a biomechanical gait assessment. These two things together give us all the information we need to design elite training programs for runners.
Here's how I approach it.
Why Runners Need Both a General and a Specific Evaluation
Running injuries tend to fall into two broad categories: tendon-related pathologies and bone-related pathologies. The most common running injuries — medial tibial stress syndrome, achilles tendinopathy, patellofemoral pain, plantar fasciitis, patellar tendinopathy, stress fractures — are almost entirely products of these two tissue types being loaded beyond their current capacity.
That framing matters because tendons and bones behave very differently under load, heal through different mechanisms, and require very different management. A tendon problem and a bone problem at the same shin can look almost identical to the untrained eye. Getting the diagnosis right changes everything about the treatment plan. Especially when we are dealing with high risk vs low risk bone stress injury sites.
A general evaluation catches movement deficits, asymmetries, mobility restrictions, and strength gaps that create the mechanical environment for injury. The runner-specific layer answers the deeper question: how is this person actually moving when they run, and what about their training or biomechanics is feeding this problem? You need both to make a real plan.
The Subjective Examination
General Intake
Before anything else, we need to understand the person, not just the injury. That means asking about:
Pain location and behavior. Where exactly does it hurt? Does it hurt at rest, during activity, after activity, or first thing in the morning? These details aren't trivial — they're among the most reliable ways to distinguish between tissue types before you've even touched the patient.
Training history. How many miles per week are they running? Did they recently ramp up volume or intensity? Have they changed shoes, surfaces, or terrain? A sudden spike in training load is one of the most consistent risk factors for both bone stress injuries and tendinopathies.
Prior injury history. A history of previous injury to the same area is one of the strongest predictors of future injury. It changes the baseline.
General health and lifestyle. Sleep quality, nutritional status, stress load — these all affect tissue resilience. In runners, we always want to screen for Relative Energy Deficiency in Sport (RED-S) because inadequate caloric intake impairs bone remodeling and increases fracture risk significantly.
The Running-Specific Symptom Picture
This is where the subjective exam earns its keep for runners specifically. The timing of pain relative to running is one of the most diagnostically useful pieces of information you can gather:
Tendon pain typically shows a warm-up effect — it's stiff and sore at the start of a run, eases as the runner warms up, then often returns or worsens in the hours after. Morning pain and stiffness is also common. Tendons are particularly sensitive to compressive loads (relevant at insertional sites like the achilles or proximal hamstring) and to rapid changes in load volume or intensity.
Bone stress pain, by contrast, does not warm up. Pain at rest, pain that persists through activity without easing, and point tenderness over bony landmarks should immediately raise your index of suspicion for a stress reaction or stress fracture. This is crucial. Missing a high-risk stress fracture (femoral neck, navicular, anterior tibia) and sending someone back to training can have serious consequences.
Asking a runner specifically about when during a run pain begins, whether it eases or worsens as the run continues, and how they feel the following morning gives you a remarkably clear picture before the objective exam even begins.
The Objective Examination
General Movement Screen
The movement screen establishes baseline mobility, symmetry, and neuromuscular control. For runners, I typically include:
Spinal mobility: forward flexion, extension, rotation, and sidebending — particularly relevant for hip and lower extremity mechanics. Even if we are dealing with a problem in the foot or the ankle, I’m not sure how relevent or irrelevent their spine is until I assess it.
Squat: bilateral squat quality reveals hip, ankle, and knee function simultaneously
Single leg balance and single leg step: single-leg stability is the foundation of running mechanics, since every stride is a series of single-leg balance tasks
Lunge and lateral lunge: assesses frontal and sagittal plane control under load
Hip and ankle range of motion: hip mobility restrictions (particularly internal rotation and extension) and ankle dorsiflexion deficits are frequently implicated in lower leg running injuries
What you're looking for is not just whether the person can do these things, but whether they can do them symmetrically, without compensations, and with reasonable control. An asymmetry in a general movement screen often predicts where the mechanical stress is concentrated during running.
ROM Testing
Joint-specific ROM testing follows the movement screen. Key areas for runners:
Ankle dorsiflexion (weight-bearing lunge test) — restricted dorsiflexion is implicated in achilles tendinopathy, plantar fasciopathy, and altered tibial loading mechanics
First MTP extension: Test in open and closed chain. Assesses for soft tissue and joint mobility restrictions as well as general sensitivity.
Hip internal rotation and extension — restrictions here often drive compensatory mechanics further down the chain
Hamstring and calf flexibility — muscle length affects tendon strain and joint kinematics under load
Strength Testing
Strength deficits are almost always present in running injuries, but the question is whether they're a cause or a consequence — and sometimes both. Useful tests include:
Calf raise endurance (single leg): a validated benchmark, with normative targets around 25+ reps for women and 30+ for men. Achilles tendinopathy and posterior tibial stress syndrome are both associated with calf strength deficits.
Hip abductor and external rotator strength: gluteus medius weakness is one of the most frequently cited contributors to patellofemoral pain, IT band syndrome, and tibial stress injuries
Quad/hamstring muscle strength: Do they have knee pain? Surely want to test these things. Prior history of knee pain? Did they ever restore their full capacity? We can’t know until we assess.
Hip extension strength: gluteal function during the propulsive phase of running is essential for reducing load on distal structures
Handheld dynamometry is useful here when precision matters, but manual muscle testing gives you enough information to identify meaningful side-to-side differences and symptom provocation.
Specific Tests for Bone Stress Injury
When the subjective exam raises concern for a bone stress injury, targeted provocation testing is important:
Palpation: localized point tenderness over a bone, particularly in a span of 10 cm or less along the posteromedial tibia, is clinically meaningful. Research suggests that medial tibial stress fractures tend to produce tenderness over a shorter, more focal segment, while medial tibial stress syndrome typically produces tenderness over a longer, broader band.
Hop test: the single-leg hop test is highly sensitive for tibial stress fractures when tibial pain and tenderness are already present — a negative hop test essentially rules out a stress fracture in that context, while a positive hop test substantially raises the probability.
Fulcrum test: less diagnostically reliable than the hop test for the tibia specifically, but still useful as part of a cluster.
Classifying the injury site matters enormously. Low-risk sites (posteromedial tibia, fibula, 2nd-4th metatarsal diaphyses) can typically be managed conservatively with load modification and a structured return-to-run progression. High-risk sites — femoral neck (especially tension-sided), navicular, anterior tibial cortex, medial malleolus, sesamoids — require specialist referral and, in some cases, urgent surgical consultation.
Runner-Specific Functional Tests
Before someone returns to full training, functional benchmarks give you objective criteria to work toward:
Double leg pogo jumps: 30 seconds at 150 bpm — assesses elastic stiffness and reactive capacity
Single leg pogo hops: 15 seconds per side at 150 bpm — a closer simulation of running's single-leg demand
Single leg bridge hold: 20 seconds per side — assesses posterior chain endurance under single-leg load
Side plank: 20 seconds per side — proxy for frontal plane stability
The ability to produce and absorb force rapidly under single-leg load is essentially what running requires, and someone who can't meet these thresholds under controlled testing conditions isn't ready to meet the demands of the road. We also know from Milgrom et al ‘21 that a single leg hop test has a sensitivity of 100% in the diagnosis of lower limb BSI.
Running Gait Analysis
This is the piece that separates a running evaluation from a standard orthopedic eval, and it's where some of the most actionable information lives.
Treadmill gait analysis should assess:
Foot strike pattern: rearfoot, midfoot, or forefoot — relevant to how ground reaction forces distribute through the lower leg
Step rate (cadence): this is perhaps the single most important variable. Lower step rates are associated with higher vertical oscillation, longer ground contact time, and greater peak impact forces — all established risk factors for bone stress injury. Research shows that risk decreases approximately 5% with each one step-per-minute increase in step rate, and runners in the lowest step rate tertile show injury rates nearly seven times higher than those in the highest tertile. A cadence of 170-180+ steps per minute is generally the target.
Vertical oscillation: excessive bounce amplifies ground reaction forces and is correlated with bone stress injury development
Step width and crossover: a narrow step width or crossover gait pattern increases lateral hip muscle demand and medial tibial stress
Shank angle at contact: affects tibial and knee loading mechanics
Symmetry: side-to-side asymmetries in any of the above are often more informative than the absolute values
Shoes also matter and are worth documenting — brand, model, heel-to-toe drop, and approximate mileage on the current pair.
Putting It Together
The evaluation informs everything that comes after it: the differential diagnosis, the initial load modification strategy, the exercise prescription, the return-to-run timeline, and the contributing factors that need to be addressed to prevent recurrence.
Tendon injuries require progressive loading — the tissue needs stress to remodel, and the art is in calibrating how much stress at what point in recovery. Bone stress injuries require an initial period of true load reduction before progressive reloading begins, and the timeline is dictated by injury grade and site risk classification.
In both cases, gait retraining — increasing step rate, reducing vertical oscillation — is often one of the most powerful tools available, because it directly addresses the mechanical inputs that caused the problem in the first place.
A runner who gets a thorough evaluation at the front end doesn't just heal faster. They're far less likely to come back with the same injury six months later.
