Risk Factors for Running-Related Injury in High School and Collegiate Cross-country Runners: A Systematic Review.

Cross-country running carries a steady risk of overuse injury, and coaches and clinicians working with high school and college runners have long wanted clearer answers about who is most likely to get hurt. This systematic review pulled together 24 studies that followed runners prospectively for at least one season, looking at what factors were linked to running-related injuries. The clearest signals were being female and having a prior running injury, both of which raised injury risk but obviously can't be changed. There was moderate-certainty evidence that runners with more risk factors for relative energy deficiency in sport, a condition involving inadequate fueling for training demands, were more likely to be injured, especially with bone stress injuries.

Evidence on training load changes, sleep quality, and early sport specialization was weaker and less certain, though it pointed toward possible increased risk. Overall study quality was low to moderate, so these findings should be read as suggestive rather than definitive.

If you're a young cross-country runner, or you coach or treat one, you've probably wondered what actually predicts injury. This review gathered 24 studies that tracked high school and college runners over at least a season to find patterns. The strongest and most consistent findings were that female runners and those who'd been injured before were more likely to get injured again during the season, though neither of these can be changed.

There was also moderate confidence that runners showing signs of not fueling adequately for their training, sometimes called relative energy deficiency in sport, faced higher injury risk, particularly for bone stress injuries like stress fractures. Other factors, such as sudden changes in training amount, poor sleep, and focusing on running exclusively from a young age, showed weaker but suggestive links to injury. Because many of the individual studies were only low to moderate quality, these patterns give useful clues rather than firm answers, and more research is needed before drawing strong conclusions.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

For clinicians managing high school and collegiate cross-country runners, this review addresses which risk factors for running-related injury actually have supporting evidence, an area where individual studies vary widely in quality and design. The synthesis pooled findings from 24 prospective studies, each following runners for at least one season, and graded certainty using GRADE alongside study quality via the Newcastle-Ottawa Scale. The most robust findings, sex and prior injury history, were the strongest predictors but are nonmodifiable, limiting direct clinical application beyond risk stratification.

Moderate-certainty evidence linked increased relative energy deficiency in sport risk factors to greater injury risk, particularly bone stress injuries, which may inform screening conversations around energy availability. A quadriceps angle greater than 20 degrees and lower step rate were also associated with injury risk, and weaker thigh musculature was linked to anterior knee pain specifically.

Evidence regarding training volume changes, sleep quality, and specialization was rated low certainty, meaning these associations are plausible but not well established. Overall study quality across the included work was low to moderate, so this review should be read as identifying candidate risk factors worth further prospective study rather than establishing causal or clinically actionable thresholds for practice.