Training Load: The Primary Modifiable Driver
The most consistently cited driver of RRIs is training load specifically, sudden increases in volume, intensity, or frequency. A landmark systematic review by Kluitenberg et al. (2022, Journal of Athletic Training) synthesised 36 studies involving 23,047 runners and found directionally consistent evidence: injured runners across multiple cohorts had frequently increased weekly distance by over 30–50% in the 4 weeks before their injury. The review underlined that the interaction between multiple training parameters, not any single metric, is what drives risk.
Biomechanical Factors
Running places up to three times body weight on the lower limb at each foot strike. How forces are distributed across joints and tissues depends heavily on biomechanics. A 2022 systematic review by Willwacher et al. (Sports Medicine) examined biomechanical risk factors for the seven most common running overuse injuries including patellofemoral pain, iliotibial band syndrome, Achilles tendinopathy and tibial stress fractures, and confirmed that biomechanical risk factors are injury-specific. For example, higher hip adduction velocity and peak hip adduction angle are more relevant to patellofemoral pain, while increased vertical impact loading rates are implicated in bone stress injuries.
Previous Injury History
Prior injury is one of the strongest and most consistently identified risk factors for future injury. Recurrence rates for common running injuries including Achilles tendinopathy and stress fractures, are well documented. Athletes who return to full load too quickly, or who fail to rehabilitate strength and movement quality, face substantially elevated re-injury risk.
Lifestyle and Non-Training Factors
Sleep, psychological stress, immune status, and nutritional state all influence injury risk. A 2025 study tracking endurance athletes over 12 weeks (Sanchez et al., International Journal of Sports Science & Coaching) found that sleep impairment was the only variable that differed significantly between injured and non-injured weeks, outperforming training load as a predictor. This highlights that injury risk is not purely a function of what happens during running.
Injury prevention is not one-dimensional. An integrated approach addressing training load, movement quality, tissue strength, and lifestyle factors offers the greatest protection.
Footwear and Running Surface
While footwear choice and surface type are frequently cited as injury contributors, the evidence remains mixed. A comprehensive scoping review on injury risk reduction (Vincent et al., Arthroscopy, Sports Medicine and Rehabilitation, 2022) notes that abrupt changes in footwear or running surface, particularly transitioning to minimalist shoes without adequate preparation increase injury risk, whereas gradual transitions appear safe.
