Endurance athletes rarely walk into a clinic with a single, obvious problem to fix. More often, they arrive with pain that defies imaging, symptoms that recur despite rest and a singular frustration: they can’t train the way they want to.
For John Vasudevan, MD, associate professor of clinical physical medicine and rehabilitation and co-director of the Philadelphia-based Penn Medicine’s running and endurance sports program, that distinction shapes every aspect of care.
“What’s unique about endurance athletes is that very often there’s not something that is broken,” Dr. Vasudevan said. “Instead, they’re dysfunctional in their movement, and that leads to pain and a hindrance in performance.”
Unlike many traditional musculoskeletal patients, endurance athletes frequently present without clear structural pathology. MRIs may appear normal. Arthritis may be insufficient to warrant surgery. Yet pain persists, amplified by the cumulative demands of miles logged, week after week.
That reality requires clinicians to shift their focus from what is broken to how the body moves.
“You have to think more mechanically,” Dr. Vasudevan said, “about the kinetic chain — how someone moves rather than what is broken.”
The injuries that keep coming back
In practice, runners make up the majority of endurance athletes seeking care, followed by cyclists and, less frequently, swimmers. As a result, injuries most often involve the lower extremity.
Dr. Vasudevan commonly sees knee pain, followed by hip and ankle issues, with diagnoses including patellofemoral pain syndrome, iliotibial band syndrome, gluteal and hamstring tendinopathy, Achilles tendinopathy and plantar fasciitis.
While some cases involve more serious pathology, such as stress reactions or stress fractures, many stem from smaller issues that compound over time.
“Some small errors that all of us might have may never expose themselves,” he said, “unless we were to engage in endurance sport.”
Past medical history also plays a larger role than patients often realize. Old nerve injuries, strength asymmetries or prior spine issues can quietly influence biomechanics years later, setting the stage for recurrent pain.
“That history may not be acutely painful,” Dr. Vasudevan said, “but it’s influencing the problem.”
Breaking the injury cycle
For endurance athletes, injury often feels cyclical, resolving one issue only to see another emerge. Dr. Vasudevan knows the pattern well, both clinically and personally.
“I run enough to get all of the injuries,” he said, “so that I can share that experience with my athletes.”
The goal of his program is not simply to quiet symptoms, but to interrupt that cycle by examining the athlete as a whole: training load, movement patterns, medical history and future goals.
“People come in because one problem is bothering them,” he said, “but it’s an opportunity to look at how their entire training program and body are working.”
Central to that approach is clarity around what the athlete wants to accomplish.
“Are you trying to run for fitness? Complete a 5K? Finish a marathon? Win a marathon?” Dr. Vasudevan said. “Those are very different scenarios.”
Once goals are defined, treatment becomes more targeted and more motivating.
“When there’s a goal in mind, everyone gets excited,” he said. “It becomes a marker of whether treatment is getting us closer to, or further from, that goal.”
Race day as a stress test
Dr. Vasudevan’s perspective is further shaped by his work as medical director for endurance events, where race day serves as a real-world stress test of preparation.
“Race day is an expression of the preparation for that day,” he said.
In medical tents, he often sees the consequences of overlooked variables, inadequate nutrition, hydration, weather planning or medical screening, rather than isolated orthopedic failures.
One patient, training for his first marathon, developed an unusual stress fracture in the sacrum. His training program and gait were sound. The missing piece was nutrition.
“He decided to go vegan in the middle of training,” Dr. Vasudevan said, without adjusting caloric or nutritional intake. “He had two goals that were moving in the wrong direction.”
The lesson, he noted, is that endurance care extends beyond musculoskeletal mechanics alone.
A multidisciplinary model built for endurance
To meet those demands, Dr. Vasudevan’s program relies on a deeply collaborative model. Physical therapists with endurance-specific expertise are central, but the network extends further to sports dietitians, sports psychologists and, when needed, endocrinologists.
“It’s not just musculoskeletal,” he said. “Sometimes it’s diet. Sometimes it’s hormonal. Sometimes it’s mental.”
Advanced imaging and ultrasound-guided procedures play a role as well, particularly when pain sources are ambiguous.
“Ultrasound isn’t just to reduce pain,” Dr. Vasudevan said. “It helps clarify the diagnosis when pain could be coming from different structures.”
He also uses platelet-rich plasma and other regenerative therapies selectively, particularly when long-term tissue health matters more than short-term relief.
“Steroid injections can help in the short term,” he said, “but in the long term can be harmful to tendons and joints.”
Beyond the clinic: building community
What truly differentiates the program, Dr. Vasudevan said, is its engagement beyond clinic walls.
Endurance athletes are not just patients — they’re part of a community.
“For a lot of people, this is their happy place,” he said. “Running or cycling makes them feel fulfilled and rejuvenated.”
That understanding drives the team’s involvement with running clubs, specialty stores and races, not just as medical support, but as participants themselves.
Physicians and physical therapists in the program routinely run and train alongside the athletes they care for, giving them firsthand insight into the physical and mental demands of the sport.
“We want to speak the same language and share that culture,” Dr. Vasudevan said.
Internally, the team works toward a shared clinical vocabulary, which is especially important when evaluating movement patterns that don’t show up on imaging.
“If I write something in my note, the physical therapist knows exactly what I’m talking about,” Dr. Vasudevan said. “And vice versa.”
The result is care that is individualized, coordinated and grounded in evidence, but also deeply aligned with what endurance athletes value most.
At its core, the model recognizes a simple truth: for these patients, success isn’t just pain relief. It’s the ability to keep moving forward.
