In triathlon training, consistency is king. But what if that consistency was a culprit in your latest injury? As all too many of us know, like IT band syndrome, shin splints, and stress fractures often present themselves at the worst times and have been the bane of many great race preparations.

Consistent, repetitive motion with improper running form often causes these injuries. But according to new research out of the University of Florida, you probably don’t even know your form could use a tune-up – and your shoes might be the reason why.

The study, published in the journal , consisted of 710 runners from various backgrounds. After asking each runner if they were a heel striker, non-heel striker (mid-foot or forefoot strike) or they “didn’t know,” the researchers examined each runner’s gait with a high-tech slow-mo motion capture system and analyzed their past running injuries.

The results were abundantly clear. Those runners who “didn’t know” their gait pattern had, by far, the greatest likelihood of sustaining a running-related injury.

The main contributing factor to runners not knowing their foot strike, or how their feet were hitting the ground, was the heel-to-toe drop of their training shoes. A higher drop, as well as higher shoe weight, led to less accurate body awareness and a higher likelihood of injury.

Additionally, those runners who changed their shoe type in the past six months were more likely to sustain a running-related injury.

So if shoes are part of the problem, is the solution simply changing them out? Yes and no. Let’s look at the takeaways and how can you apply them to reduce your risk of injury.

Shoe Choice Matters

As the study highlights, a shoes with high heel-to-toe drop and greater weight contribute to less awareness of foot strike. Opting for a shoe that has a lower drop and weight is an effective way to become more engaged (literally) with the ground and how your foot is interacting at the impact, loading, and takeoff stages of your run gait. A healthy foot will feel the ground, fully load, then utilize its “free” stored energy to push you forward.

A more minimalistic shoe will let the foot function as it should. Further, a large heel-to-toe drop alters how the force of impact is distributed throughout the body. As shown in  on the effect of shoe drop on joint stress, a higher-drop results in much larger stress at the patellofemoral (knee) joint. Opting for a lower-drop shoe allows the body to distribute stress as it was designed to do, reducing excessive loading to individual joints.

Opting for trainers with a mild drop (4-6mm) and not too much “clunk” could be an easy way to become more aware of how you’re running and stay injury-free.

If you’ve been running in a high heel-toe drop shoe and dealing with injury, it might be worth trying a different shoe. Just remember, as with any change, to progress gradually into your new shoes to allow the body time to adapt. Start with one to two runs per week, and slowly progress over four to five weeks until you can wear your new shoes full time.

Self-Awareness Matters More  

Yes, the type of shoes you wear can be a culprit in running-related injury, especially if they blunt the signals your body needs for good running form. This study clearly shows that enhanced body awareness while running, particularly when it comes to foot strike, leads to lowered injury risk.

Becoming more cognizant of how your body is moving and how your foot interacts with the ground is a free way to decrease your risk of injury. Yes, it’s nice to listen to music or zone out with a podcast during a long run. However, it’s likely worth it to zone in to the task at hand now and then to ensure you’re moving well.

One helpful tip is to run in front of a mirror on a treadmill so you can watch yourself run in real time. It’s easy to adopt poor running mechanics without realizing it, especially when fatigue sets in. Unlike the friendly spectator yelling, “Looking good!” at mile 23 of the marathon, the mirror doesn’t lie.

The best part about working on your running form is that it will help you develop movement patterns that make you stronger instead of more likely to get injured. More importantly, it might even help you actually look good at mile 23!

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As an endurance athlete, I spent the better part of my twenties training for and running ultramarathons. My body was resilient, productively absorbing 60- to 100-mile training weeks and races just as long, and I thought that would continue indefinitely.

Then, over the course of nine months, I developed intermittent but often excruciating sciatica, nerve pain that originates in the lower back and radiates down the leg, and eventually, as a result of changing my running gait to compensate for this pain, a torn hip labrum. I expected rest—the do-nothing, on-the-couch type rest—to eventually heal me, but the pain persisted. I saw massage therapists, chiropractors, acupuncturists, bone and joint specialists, and nerve doctors. No one had a clear answer and no treatment worked.

It was at this vulnerable moment, in 2020, that I discovered the Knees Over Toes Guy. Ben Patrick, a then 30-year-old based in Clearwater, Florida, posted videos of himself on Instagram performing scroll-stopping feats of circus athleticism without any apparent discomfort: springing from a stationary deep squat up to dunk a basketball; where, from a standing position, he drops his knees out forward to touch the ground. These exercises put a remarkable amount of pressure on very vulnerable joints.

In nearly every video, Patrick shares that he has had three knee surgeries, and doctors told him he would never be able to squat or play basketball without pain again. But through an unconventional—and some might say dangerous—strength training protocol, Patrick was not only able to effectively eliminate his pain, but he says he was able to increase his speed and vertical jump to well beyond his youthful PRs. His message was that anyone can achieve that same ability and resilience. But in order to do so, you’d have to forget most everything you’ve been told about strength training.

The internet is rife with fitness hucksters and overpriced, overcomplicated training plans, but Patrick seemed different. As I read the hundreds of comments under his videos, I was struck by how universally positive everyone was, with sincere-seeming testimonials for his online program, gratitude for introducing them to these unconventional movements, and encouragement towards users who shared their stories of chronic pain.ĚýI was also impressed by the numerous physical therapists . Desperate to regain autonomy over my athleticism, I decided to give his exercises a try.

Over the last four years, Patrick has exploded in popularity, going from a trainer and gym owner to an online fitness mega-personality with 2.4 million Instagram followers. Patrick, who declined to speak with us for this article, has shared his origin story on many podcasts, including the mega-popular Joe Rogan Experience, which has 14.5 million followers on Spotify and 17.6 million on YouTube.

As an obsessive youth basketball player, his passion for the sport and penchant for grueling drills (he would frequently perform 1,000 daily layups) led to painful, fragile knees. His teammates nicknamed him Old Man. After Patrick underwent those three knee surgeries—the first while he was still a teenager—he discovered the late, famed Canadian strength coach Charles Poliquin, who preached a style of strength training where each rep is taken to its stretched end range. The priority is not just the amount of weight you can lift, but the body’s ability to move into deeper positions while doing so. (Poliquin was noted for his Seussian soundbite: “Strength is gained in the range it is trained.”)

Patrick adopted Poliquin’s training techniques and not only eliminated his chronic knee pain, he says, but began to redevelop his athleticism. At age 23, he was offered a full-ride scholarship to play D1 basketball at Eastern Florida State College. Now, as a trainer, he proselytizes this training philosophy through his unsubtly named app and online coaching business, Athletic Truth Group.

Part of Patrick’s success can be attributed to his origin story and his social media savvy: his videos are short, attention grabbing, and feature practical training advice. With the bracing sincerity of a youth camp counselor, he talks directly to the camera, appearing trustworthy and capable. But the other part is that this style of training—which Poliquin pioneered and Patrick champions—is, by historic standards, radical.

If you have ever spent time in a weight room, you’ve likely been warned that your knees should never go past your toes in a squat. Instead, you should push your butt backwards and stop when the upper and lower leg form a 90-degree angle. Failing to do so will put too much pressure on your knee and cause injury.

This is only half true. Squatting with your knees over your toes does put pressure on the joint, but that pressure may actually help you avoid injury.

“Tendons, cartilage, ligaments—all those things will toughen up to load,” says Erik Meira, a physical therapist and rehab specialist based in Portland, Oregon, who works with NBA and NFL players. For most athletes, especially those in endurance sports, injuries occur in the connective tissues of the joints. Tendons, while quite different in composition than muscles, still operate under the same principle: to get them stronger, you must use them in a mildly stressful manner, then back off and let them recover.

“Knees over toes is something that has been vilified for a long time as causing pain to the front of the knee,” says Meira. “The reality is it will cause pain if you’re not conditioned to take that kind of load. But the best way to condition yourself to that kind of load is to get used to positions like that.”

Patrick has taken this philosophy—that bending your knees under progressive load will make them healthy and strong—and applied it to other vulnerable parts of the body including the ankles, hips, lower back, shoulders, and elbows. In a way, Patrick’s protocol could be seen as a gym routine structured entirely around proactive physical therapy: he identifies problem areas and develops strength and range of motion in the local musculature and connective tissue.

It is a tremendously appealing proposition to many endurance athletes, who are traditionally averse to the gym. Here is a style of strength training that doesn’t prioritize muscle mass, is singularly focused on avoiding pain, and will allow you to fully express yourself physically outside of the gym.

In 2020, I was one of many impressionable scrollers transfixed by Patrick and his message. Without much to lose, I dedicated myself to 16 weeks of his program through the app. The first cycle, a full-body general protocol called Zero, was easy. I did repetitive, progressive bodyweight exercises—some familiar, some novel—to strengthen mind-muscle connections and expose my joints to new movement patterns. Then, four weeks later, came Dense, where you take these same and other similar exercises, add weight, and perform many sets to condition your joints through repetition under manageable load. Four weeks after that, I moved on to a back-specific training program.

The most significant movement for me in this block was the , which you perform on a forward-angled, hip-high bench that allows you to hinge forward from the hips and directly strengthen the lower back muscles. This was terrifying, as I thought putting my injured back in that exposed position would only hurt it further. But this is precisely what this program is trying to teach: safely training in a vulnerable position creates resilience in that position.

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“The most important part of rehabilitation is graded exposure,” says Mike Istraetel, the popular online fitness commentator who holds a doctorate in exercise science. “You want a little bit of irritation, then back off and heal up… The biggest mistake people make in a gym is assuming a degree of fragility to their body.”

And while Patrick emphasizes the importance of developing strength in tendons themselves, there’s also another factor at work. “Tendons take up to nine months, if not more, of consistently loading to heal and grow stronger,” says Matt Klein, a rehabilitation and movement science professor at George Fox University. “But patients can have an acute decrease in pain [when they first start training the injured joint] and that’s not because the tendon has changed. That’s because their perception of pain—a fear response—has changed.”

Meira explains that fear activates our nervous system and sends us into a dysfunctional “protective mode.”  “We see this a lot with low back pain,” Meira says. “An individual starts to fear taking load and their back gets weaker. Then they ł¦˛ą˛Ô’t take more load, then they fear it more, and they end up in a downward spiral where their back is made out of glass.”

With this mindset, I performed small reps at first, barely leaning forward a few inches, then the next time I went a little deeper, and so on until months later, I was doing 20 full range reps. Eventually I started holding a weight to my chest as I leaned forward, taxing my low back further. And an amazing thing happened: my sciatica went away. Gone, vanished. The insidious nerve pain that for years—literally years—I tried to roll, massage, stretch, and rest away, finally disappeared. All it needed, it turned out, was to get stronger.

“The biggest mistake I see with athletes is resting for wellness,” says Meira. “Let’s say the front of my knee gets sensitive when I run. I think I’m going to stop putting any load on it and let that heal. Then once it heals I’ll go back to what I’m doing. But when I’m resting it, the front of that knee isn’t getting any stimulus, so it’s not learning to take load. It’s being de-conditioned to load. Being overprotective is often what gives us issues.” This is ultimately Patrick’s message: to heal your body, you must use your body.

“Ten years ago we still had a postural fear model: you should not put your knees over your toes because that’s going to cause you knee pain; you should not slouch because that’s going to cause you neck pain,” says Klein. “The current evidence suggests that the perfect posture is the one you’re in for the least amount of time. Move. People are going to be slumped forward and extended and everything in between. Your body is meant to move in these ways. If your body is having trouble in a position, train in that position more.”

As I progressed through the program, it became evident that there are only about two dozen total exercises that Patrick repeatedly prescribes. If you’ve never performed these movements, the app—which coaches you through proper form—is invaluable. The back extension machine was revelatory for me and got me out of pain and back to the sport I love.

But as I rebuilt my running body and tried to progress deeper into his program, I ran up against his one-size-fits-most approach, an unfortunate and necessary limitation of mass-marketed fitness programs. For instance, deadlifts, which Ben prescribes, still hurt my back no matter how gentle or light I went.

No program will serve as the answer to everything, says Klein. “I think [Patrick] is helping a lot of people,” he says. “But I also think it can hurt a lot of people.” Klein points out that athletes should only try these training protocols after taking the time to pursue an accurate diagnosis with doctors and physical therapists—to ensure they’re treating the right thing.

After two years, I stopped following Patrick’s program through his app, but his philosophies have fundamentally changed how I think about exercise. Now, four years since I began his protocol, running is still my priority, but I only run four days a week instead of six. Strength training two to three times a week is non-negotiable. Each session is full-body and joint-focused, and at least half of the exercises I perform are ones I learned through his program. I haven’t gone a week without a back extension in two years. But the most important thing the Knees Over Toes Guy has taught me is as simple and radical as this: to keep athletically progressing and doing what you love into your thirties and beyond, you have to get strong. Spending time in the gym is a real-time fight against aging.

Despite the reduction in my running volume, I’m still getting faster, winning races, and setting PRs. But the thing I’m most proud of: I’m doing it all without pain.

The Knees Over Toes Philosophy

Strength Train

If you are injury-prone, aging, or looking to maximize your body’s potential, you MUST strength train. Full stop. Two or three times a week is ideal, but once a week is better than nothing. Perhaps this is obvious, but it bears repeating to strength-shy endurance athletes.

Measurably Strengthen Vulnerable Areas

Identify the muscles that support your body’s most vulnerable areas and train them unyieldingly. For ankles, this means targeting your calves (encompassing both the soleus and gastrocnemius) and tibialis anterior, the oft-ignored muscle on the front of the lower leg. For knees, it’s mainly quads and hamstrings. And for hips and back, well, it’s your hip flexors and back muscles. Do this in a manner that you can measure, such as weight lifted or reps completed, and work to improve those metrics. This is in contrast to many other runners’ strength programs, where you’ll likely find complex kettlebell swinging workouts, yogic core stability routines, or resistance band “activation” drills. There’s nothing inherently bad about these exercises, but they fail to give you a way to measure their progress. They are also inefficient at genuinely strengthening the muscles and tendons that do the most for you.

Build Balance

Nearly everyone has practiced squatting. But when was the last time you did the opposite–that is, lifted weight up off the ground with your legs instead of lowering weight toward the ground? Over time, certain exercises have become popular while their counterbalancing movements have not. Most athletes train their calves but not their tibialis anterior; their squat but not their hip flexors; their abs but not their lower back. To be a high-performing pain-free athlete, you must train both sides of the body, and both sides of any joint.

Regress

If pain pops up, as it is bound to, do not stop training that area. Instead, regress the movement (e.g. less weight, smaller range of motion, and/or fewer reps) to the point where you feel no pain. But do not cease to use that area of the body entirely. Pain is bad and you should never work through pain—but motion is lotion.

Length Through Strength

Static stretching is not the panacea for health that it was once thought to be. However, the mobility (i.e. range of motion) of your joints and muscles is incredibly important and is correlated with healthier tissue. So how do we reconcile those two truths? We work to lengthen while strengthening. This means that for every exercise, you should be feeling a stretch at the top or bottom of the movement, and you should perform every exercise with the greatest bend in the targeted joint that you can achieve without pain. (Often, this means starting by lifting lighter weights.)

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For some athletes, taking pain relievers like Tylenol (acetaminophen) or Advil (NSAID) to ease muscle soreness after a hard workout is second nature. However, while pain relievers may have their place in lessening discomfort, pain can also be an important signal from the body that you’ve overdone it.Ěý

So, how do you know when to take an occasional Advil for an achy knee, and when to see a professional for help?

Muscle Aches vs Injuries

One of the most common reasons people feel sore after a workout is due to delayed onset muscle soreness, or DOMS. This can feel like tenderness in the muscles, stiffness, or mild swelling. For instance, if you had a tough leg workout, you might spend the next few days walking funny up and down the stairs. You can still exercise when you experience this kind of soreness as long as the tenderness doesn’t affect your movement. However, if you ł¦˛ą˛Ô’t properly execute an exercise without shifting form, then it’s wise to take it easy. It’s always important to warm up before a workout, especially if you’re feeling muscle fatigue. This can decrease the chance that your soreness will get in the way of your routine.

, Doctor of Osteopathic Medicine, the Director of the Center for Sports Medicine, and Assistant Dean of Clinical Operations at the New York Institute of Technology, says that this kind of soreness is typical and shouldn’t be cause for concern. “After exercising, our muscles are inflamed,” he says. “If there’s no larger injury, this is normal and healthy. When the muscle heals after inflammation, it becomes stronger.”

In cases such as this, you can take an anti-inflammatory (such as ibuprofen) until DOMS subsides. Take note, however, of how often you’re doing this. , a Board-Certified Sports Medicine Physician, Holistic Pain Management Expert, and the Chief Medical Advisor at Sunrider International, notes that DOMS isn’t necessarily reoccurring, and thus you shouldn’t need to be popping pain relievers after every workout. In fact, as you progress in your physical fitness, DOMS should go away completely within a few weeks to a month.

“If there’s occasional swelling in the knee joint, for example, then taking an anti-inflammatory would be appropriate,” says Chen. “But if you notice the need to take an anti-inflammatory every time you exercise because of swelling and pain, then it’s time to seek professional help.”

To differentiate between injury and DOMS, you should pay attention to how the painful spot feels when you move around. With DOMS, the pain should lessen when you warm up and move your body. Injuries, however, usually become more painful with movement. Instead of soreness, an injury will feel like localized sharp pain and bruising that doesn’t go away.Ěý

What Is the Best Pain Reliever for Workout Soreness?

Chen makes it clear that, while NSAIDs can be helpful for short-term pain management, continuous use can be dangerous. shows that long-term usage can impair healing, make someone more prone to injury, and create health problems down the line. He adds that, if you really need a pain reliever, it might be best to take Tylenol, which has been shown to in the future.Ěý

“Try some other over-the-counter (OTC) medications, like Tylenol, about 30 to 60 minutes before you hit the gym,” Chen advises. “Also, be sure to consult with your doctor on any OTC meds you take and stay hydrated by drinking fluids before and during any workout.”

Chen, who has a background in traditional Chinese medicine, recommends also considering some Eastern medicine modalities for managing aches and pains. He adds that acupuncture is a beneficial holistic pain reliever alternative. suggest that it’s effective at treating various forms of pain, including osteoarthritis and myofascial pain syndrome.

“Modalities like controlled breathing, ice, and osteopathic manipulative medicine (OMM), are safe, inexpensive, and effective ways to reduce pain,”  Zwibel says. “They also empower patients by allowing them to feel more involved in their own care.”

Food, as we know, can often be the best medicine. Turmeric, for example, has been for its anti-inflammatory effects on irritable bowel syndrome, psoriasis, atherosclerosis, and other diseases. Hydrolyzed , fatty , and also have anti-inflammatory properties. The good thing about these options is that you can consistently take them, unlike NSAIDs that, over time, with your heart, kidney, liver, and blood circulation. It’s always a good idea to look into alternatives before opting for pills. Overall, it’s best to avoid regular use of pain relievers like Advil and Tylenol after a workout to ease sore muscles.But if you need to occasionally take the edge off muscle aches and soreness, Tylenol is the best option.

Most importantly, remember to listen to the signals your body is giving you. If that aching isn’t clearing up, or seems more sharp and pronounced, it’s time to see a doctor.

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When your lower back or glutes flare up painfully after going too hard trail running over the weekend, your default instinct might be to add some extra stretching to your routine or schedule some time with your massage therapist or chiropractor.Ěý If the pain is excruciating, you might even consult with a sports medicine doctor.

But there’s another accessible and effective treatment option for aches and pains. One that has only limited side effects and that’s been practiced for thousands of years.

It’s acupuncture. And although the mechanisms through which acupuncture works in the body aren’t fully understood, and there may be a placebo effect in play, research repeatedly indicates that acupuncture is effective at treating various forms of pain, including those related to , the back, and .

Here’s what you need to know about acupuncture’s potential role in treating sports injuries.Ěý

Acupuncture and Sports Medicine

is a practice in Traditional Chinese Medicine (TCM) that involves inserting small, thin needles through the skin and often into the superficial layers of the muscle to relieve pain and address health conditions like menstrual cramps, , and arthritis. The points where needles are inserted are pathways, each corresponding to a particular organ or system, along which energy, or qi, is believed to travel. According to TCM, the needle helps unblock meridians.Ěý

From a Western medicine perspective, it’s believed that the needles stimulate the body’s muscles, connective tissue, and central nervous system, which can help with recovery from illnesses and pain. “Basically, what we’re doing with acupuncture is we’re using your body’s inherent means of healing itself,” says , DO, who is a primary care and sports medicine physician and licensed acupuncturist at Houston Methodist.Ěý

Sports medicine acupuncturists specifically treat sports injuries using the same foundations of TCM, but also incorporate functional anatomy, muscle testing, and range of motion testing. “Using this approach, I can precisely identify complex injuries and their sources, especially when checking for posture issues during various movements,” explains sports medicine acupuncturist .Ěý

a doctor of Chinese Medicine and licensed acupuncturist who works with the Minnesota Vikings, believes combining TCM and sports medicine really helps nudge the body along on the path to healing. “The body wants to be in harmony, it wants to be balanced, it wants to be functional,” she says. “But sometimes it has to be told what to do because it’s gotten out of alignment.”

Acupuncture is used to treat all sorts of sports injuries, including joint problems, muscle sprains and strains, tight muscles and trigger points, lower back pain, cervical and lumbar herniations, and many other conditions. “It’s just so incredibly helpful because we can treat the whole body effectively in that one treatment,” Patzer says. “Those needles are like little magic wands.”

This broad approach means that when treating something like a quadriceps strain, an acupuncturist will also assess and potentially address other muscles around that injury that may be compromised or compensating. “If you don’t treat anything around [the injury], they’re going to continue to have that quad injury and it’s not going to heal nearly as fast as if you treat upstream and downstream as well,” Patzer explains.

How Acupuncture Helps Sports Injuries

Here are a few ways that acupuncture can be useful when treating sports injuries, according to the experts: 

1. Reduces Pain

Acupuncture is frequently used to of pain and is increasingly recognized as a non-drug alternative to painkillers. One reason for acupuncture’s pain relieving effect is that it’s known to , which can help decrease pain and lift your mood. “By boosting the production of endorphins, acupuncture directly counters pain, a primary concern with sports-related injuries,” Menard says.Ěý

2. Decreases Inflammation

Acupuncturists commonly use the practice to reduce inflammation following injuries. Menard explains that acupuncture improves to targeted muscles, fascia, tendons, and ligaments, which helps reduce swelling and repair injured tissues.

A recent published in the journal Nature found that acupuncture can trigger an anti-inflammatory response and suppress inflammation through the involvement of a nerve pathway between the vagus nerve and the adrenals called the vagal-adrenal axis. Other show similar findings, with acupuncture reducing or controlling inflammation by stimulating various pathways that connect the nervous and immune systems, both of which are known to play a role in the body’s inflammatory response. It’s important to note that these studies were conducted on mice, which isn’t always an exact predictor of human response.

Another found that acupuncture may reduce inflammation by stimulating the vagus nerve, which is part of the parasympathetic nervous system and plays a large role in the body’s stress response.

3. Corrects Muscle Imbalances

Acupuncture can enhance proprioception—meaning the body’s sense of its position and movement—by addressing trigger points and knots in the muscle tissue, Menard says. For athletes, proprioception is really important because it plays a role in balance, coordinating movements, and adjusting muscle activity. When proprioception is low, sports injuries may be to occur

“These knots, if untreated, can hinder muscles and their counterparts from functioning correctly, leading to imbalances and further complications,” Menard explains. “Acupuncture’s ability to identify and treat these points can provide immediate relief, helping athletes regain their proper form and function.”

Patzer compares muscle functioning to a slinky—when a muscle is functioning properly it opens and closes like a spring, and that’s a good thing. But if it’s pulled too long or locked up too tight, it may not perform at its best. Left untreated, this can sometimes lead to problems with nearby muscles, tendons, and joints. “With acupuncture, I’m able to help the muscle get that kind of proper movement and function back,” Patzer says.Ěý

Do All Acupuncturists Treat Sports Injuries?

Many acupuncturists may be able to help someone with a sports injury, but if you’re an athlete and experiencing pain, Patzer says it’s best to see someone who specializes or is certified in sports medicine acupuncture. If you have an X-ray or MRI results, bring a copy to your appointment to help inform treatment. “It’s essential to accurately diagnose each condition to tailor the most effective acupuncture treatment to the patient’s specific needs,” Menard says.

Keep in mind that acupuncture likely isn’t going to be a one-stop cure for any sports injury that arises, and it’s often most effective when used in conjunction with other types of treatment. Acupuncturists will even refer patients to other care facilities or professionals, like hospitals, chiropractors, physical therapists, and massage therapists. “We work in tandem, ensuring every patient gets the holistic care they need,”Menard says.

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