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Our very own Physiotherapist Ky Wynne gives you some theory behind running injuries. Ky is one of our Running Assessment Physiotherapists who can design a comprehensive exercise program that will help make you a more efficient runner and keep you out there ‘pounding the pavement’.
Running injuries are very common, with an incidence ranging between 19.4% to 79.3% (1, 2). The focus of this post is to look into the factors causing running injuries and methods of reducing running injury risk.
There are a number of risk factors contributing to injury. The risks are displayed in the figure below (see figure-1).
The aetiology of running injuries is often multi-factorial, involving a combination of overuse/load, previous injury, abnormal mechanics/movement patterns and more. The risk factors in the figure above all contribute and impact on running injuries.
Overuse/overload injuries are very common in running, associated with the repetitive nature of running and the impacts received during running. For example, a runner completing 32kms of running a week (20miles), will endure up to 1.3 million lower limb impacts per year (3). This repetitive impact force leads to a fatigue effect, which can inhibit the body’s normal repair and remodeling processes (4). Furthermore, when looking at load, a large number of running injuries occur when there is a specific change in training parameters (e.g. volume, intensity, equipment) (5). Most commonly, injuries occur after an acute increase in load (e.g. increase distance or speed).
The repetitive nature of running requires the athlete to have movement patterns that are efficient at absorbing impact forces and to have appropriate co-ordination between muscle and joint movements. Whilst not always injurious in isolation, movement patterns are important to consider, as small training changes on top of non-optimal movement can have a big effect on injuries (6). Movement patterns can be hard to change, and alterations are not always indicated, however, an athlete running with a non-biomechanically efficient movement pattern can run into trouble, especially with load changes (e.g. increasing load in preparation for a fun run) (6).
Every time you go for a run, you complete thousands of foot strikes per session. It has been found that injured runners demonstrate altered co-ordination between lower limb segments, likely and adaptation to pain associated with the injury (1). Assessment and adjustment of movement control variables to reduce the impact on certain joints or areas may reduce the cumulative stress on this region, assisting with recovery and/or lowering injury risk (6, 7, 8). Completing kinematic (movement/motion) assessments of patients and athlete’s running mechanics is a common method of diagnosing and managing running injuries (6, 7, 8). This is something I complete weekly, and often daily, in my clinical work at Physiosports Brighton.
Adjustment of biomechanical running variables including cadence, foot-strike and body/trunk posture are very common when managing running injuries (6, 7, 8). Along with running technique changes, other interventions can include footwear modification, foot orthoses and taping techniques (9) all which have evidence-based reasoning behind their implementation. Finally, the strategy that may have the greatest effect on injury recovery, injury prevention and performance enhancement… exercise programmes; including strength, neuromuscular control and flexibility (9).
Running retraining principles primarily include changing cadence (steps per minute), trunk position and postural cues (1, 6, 8). Evidence has supported the use of these strategies, when appropriate, to assist in injury reduction for certain body regions (9). Increasing running cadence has been shown to decrease the load on the hip and knee joints (1, 10, 11), also reducing overstride (the distance the leg contacts out from the body) (12). It has been shown that increasing cadence and reducing overstrike doesn’t adversely affect running economy (12, 13). Therefore, it is a common strategy used in patellofemoral pain (anterior knee pain) management (9, 15). Other changes such as mirror feedback, verbal and visual feedback, and altering trunk position all have evidence supporting their use in certain populations and injuries (8, 14, 15, 16).
Importantly, with any gait modifying strategy, by taking load off certain joints and regions, you will load another region. When increasing cadence, and especially changing foot strike patterns (e.g. changing from slow cadence and heel strike to faster cadence and forefoot strike), this load is shown to be shifted to the calf, Achilles tendon and the metatarsal heads (bones of the foot) (10, 11). Therefore, one can no simply transition from heel strike and slower cadence to a forefoot strike without adequate planning and calf muscle conditioning, otherwise you will predispose yourself to injury in this region. I would strongly recommend a review with an appropriately training physio or running coach prior to changing running gait/technique.
Strength and conditioning for runners is a vital, and often under-completed, method of improving running performance and reducing injury risk. Strength training contributes to enhanced endurance performance through improving maximal speed, improving anaerobic capacity, delaying fatigue and improving movement economy (17). Pretty handy right? Furthermore, plyometric training (dynamic training using jumps or explosive movements) has been shown to improve running economy in distance runners (18).
How strong should you be as a runner? Well this depends on your distance/s, level of running (e.g. recreational vs elite), injury history, and more.. however, I’ve included a nice figure below from The Motion Mechanic. The post was shared on The Motion Mechanic’s channel (link here) on Instagram, and I feel it gives a great overview on rough strength ranges runners should aim for.
Ky’s recommendations & summary:
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1. Hafer, J. F., Freedman Silvernail, J., Hillstrom, H. J., & Boyer, K. A. (2016). Changes in coordination and its variability with an increase in running cadence. Journal of sports sciences, 34(15), 1388-1395.
2. van Gent, B. R., Siem, D. D., van Middelkoop, M., van Os, T. A., Bierma-Zeinstra, S. S., & Koes, B. B. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British journal of sports medicine.
3. Derrick, T. R., Dereu, D. A. R. R. I. N., & McLean, S. P. (2002). Impacts and kinematic adjustments during an exhaustive run. Medicine & Science in Sports & Exercise, 34(6), 998-1002.
4. Abt, J. P., Sell, T. C., Chu, Y., Lovalekar, M., Burdett, R. G., & Lephart, S. M. (2011). Running kinematics and shock absorption do not change after brief exhaustive running. The Journal of Strength & Conditioning Research, 25(6), 1479-1485.
5. Magrum, E., & Wilder, R. P. (2010). Evaluation of the injured runner. Clinics in sports medicine, 29(3), 331-345.
6. Gray, C., Poggemiller, M., & Tracy, I. (2017). Can Simple Postural Instructions Modify Running Forms in Recreational Runners.
7. Teng, H.L. and C.M. Powers, Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running. J Orthop Sports Phys Ther, 2014: 1-31.
8. Teng, H.L. and C.M. Powers, Influence of trunk posture on lower extremity energetics during running. Med Sci Sports Exerc, 2015. 47(3): 625-30.
9. Barton, C. J., Bonanno, D. R., Carr, J., Neal, B. S., Malliaras, P., Franklyn-Miller, A., & Menz, H. B. (2016). Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. Br J Sports Med, 50(9), 513-526.
10. Altman, A. R., & Davis, I. S. (2012). Barefoot running: biomechanics and implications for running injuries. Current sports medicine reports, 11(5), 244-250.
11. Goss, D.L. and M.T. Gross, A comparison of negative joint work and vertical ground reaction force loading rates in Chi runners and rearfoot-striking runners. J Orthop Sports Phys Ther, 2013. 43(10): 685-92.
12. Hafer, J. F., Brown, A. M., deMille, P., Hillstrom, H. J., & Garber, C. E. (2015). The effect of a cadence retraining protocol on running biomechanics and efficiency: a pilot study. Journal of sports sciences, 33(7), 724-731.
13. Heiderscheit, B. C., Chumanov, E. S., Michalski, M. P., Wille, C. M., & Ryan, M. B. (2011). Effects of step rate manipulation on joint mechanics during running. Medicine and Science in Sports and Exercise, 43(2), 296–302.
14. Cheung, R. T., An, W. W., Au, I. P., Zhang, J. H., Chan, Z. Y., & MacPhail, A. J. (2017). Control of impact loading during distracted running before and after gait retraining in runners. Journal of sports sciences, 1-5.
15. Neal, B. S., Barton, C. J., Gallie, R., O’Halloran, P., & Morrissey, D. (2016). Runners with patellofemoral pain have altered biomechanics which targeted interventions can modify: a systematic review and meta-analysis. Gait & posture, 45, 69-82.
16. Teng, H.L. and C.M. Powers, Influence of Trunk Posture on Lower Extremity Energetics during Running. Med Sci Sports Exerc, 2014.
17. Rønnestad, B. R., & Mujika, I. (2014). Optimizing strength training for running and cycling endurance performance: A review. Scandinavian journal of medicine & science in sports, 24(4), 603-612.
18. Turner, A. M., Owings, M., & Schwane, J. A. (2003). Improvement in running economy after 6 weeks of plyometric training. The Journal of Strength & Conditioning Research, 17(1), 60-67.