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Understanding and Preventing Common Running Injuries
Adam Cadez-Schmidt, M.S., AT, PES, Tarin Cadez-Schmidt, M.S., AT/LAT and Len Kravitz, Ph.D.

Long distance running is a popular physical activity practiced throughout the world that continues to attract new enthusiasts (Tonoli et al. 2010). It is positively associated with health benefits to the cardiovascular system, lowered risk of mortality, reduction in the incidence of obesity and improvement in many chronic health problems (van Gent et al., 2007; van Middelkoop et al., 2008). Despite its popularity and health benefits, runners are prone to some common lower extremity injuries (van Middelkoop et al., 2008).

What is a Running Injury and How Prevalent Do They Occur?
O'Toole (1992) describes a running injury as a “condition that causes an athlete to decrease his/her weekly training mileage.” She explains that when the body receives repetitive micro-trauma, an injury will occur at the weakest anatomical location in a vulnerable structure. O'Toole summarizes previous research indicating 45% to 70% of endurance athletes suffer from a running injury within the course of twelve months. Ellapen et al. (2013) reported that 90% of 200 recreational half-marathon runners experienced one or more running injuries within a twelve-month training period.

Novice runners have higher injury rates than experienced runners (Tonoli et al., 2010; Fredericson and Misra, 2007). Experienced runners tend to have a decreased risk of injury because they develop an innate ability to recognize the onset of an injury and prevent its severity (Fredericson and Misra).

What are the Most Common Types of Running Injuries?
Study estimates suggest knee-related injuries have the greatest injury occurrence rate, ranging from 26% to 50% of all the lower extremity injuries (Ellapen et al., 2013; Van Gent et al., 2007; O'Toole 1992). The lower leg, ankle and foot have a combined occurrence rate up to 50%. The hip and lower back are also vulnerable to running injuries (O'Tool, 1992).

What are the Most Common Factors Associated with Injury?
Fredericson and Misra (2007) submit there several training errors associated with running injuries described below. 1) A rapid increase in weekly mileage (O'toole, 1992)
2) Continuous high mileage; O'toole summarizes research suggesting runners averaging 50 to 70 miles/week have a 50% chance of having an injury. Fredericson and Misra (2007) suggest that at &Mac179; 40 miles per week the risk appears to begin to meaningfully increase.
3) Abrupt change in running surface (O'toole, 1992)
4) A failure to follow hard training days with light training days (O'toole, 1992)
5) Wearing inadequate or worn-out footwear (O'toole, 1992)
6) Running on uneven surfaces (O'toole, 1992)
7) Returning to previous mileage to fast after a layoff (O'toole, 1992)
8) Running 12 months without a break from training (Van Gent et al., 2007)
9) A history of previous injuries (Van Gent et al., 2007)
10) Too much hard interval training (O'toole, 1992)
11) Training for competition (Fredericson and Misra, 2007)
12) Muscle imbalances about a lower extremity joint and/or inadequate muscular strength or range of motion (O'toole, 1992)

Table 1: Common Lower Extremity Running Injury Sites and Mechanisms
*KNEE: Patellofemoral Pain Syndrome
Patellofemoral pain syndrome or “runner's knee” is associated with pain originating from the patella (kneecap). A common mechanism of injury is when the patellar tendon is placed into repetitive eccentric (lengthening) loading by the quadriceps muscle group from running; syndrome may be worsened with downhill running (Lopes, et al., 2012).

*KNEE/HIP: Iliotibial Band Syndrome
Iliotibial band syndrome (ITBS) presents as a sharp pain along the iliotibial (IT) band, which lies along the lateral portion of the thigh from the hip to the knee. In the early stages, pain dissipates once running has stopped; however, it will resume when running is attempted again. If the runner continues to ignore the pain it will affect daily living with consistent pain while walking, sitting and ascending/descending stairs. O'Toole (1992) notes that ITBS occurs more frequently in women the men. This could be attributed to the more pronounced quadriceps-angle in women and/or thigh muscle imbalances.

*LOWER LEG: Medial Tibial Stress Syndrome
Medial tibial stress syndrome (MTSS), commonly known as “shin-splints,” is associated with pain located on or near the anterior midline of the distal (lower) tibia (shin bone) (Lopes et al. 2012). MTSS is caused by excessive stress on the medial (inside) border of the tibia from biomechanical running factors such as over-pronation, leading to pain and inflammation.

*LOWER LEG: Achilles tendinopathy
Achilles tendinopathy (tendonitis) presents with a pain and or stiffness along the Achilles tendon and is associated with inflammation of the tendon and/or the tendon sheath. Excessive eccentric loading (running) and uphill running are common mechanisms of injury for the development of this condition (Lopes et al., 2012).

*FOOT: Planter Fasciitis
Plantar fasciitis is a widespread running injury to the foot (Lopes et al., 2012). Lopes et al. observed that more experienced runners, particularly master runners, are predisposed to plantar fasciitis due to a decrease in absorbability of the plantar fascia and plantar fat pad degeneration, due to age. The anatomy of the plantar fascia is that it is a thick connective tissue that supports the arch on the bottom of the foot; extending from the medial tubercle of the calcaneus to the metatarsal heads. Inflammation of the plantar fascia typically presents as a sharp, throbbing, or searing pain on the medial side of the calcaneus (heel bone) (Lopes, et al. 2012). Other predisposing mechanisms include excessive pronation, high arches, inappropriate shoes, a tight Achilles tendon and/or training errors (O'Toole, 1992).

What is the Best Treatment of Running Injuries?
In general terms, treatment begins with rest, ice and non-steroid anti-inflammatories (NSAIDs) to help reduce inflammation. A decrease in inflammation will assist with better range of motion of the joint affected and a better healing time. Fredericson and Misra (2007) observed stretching was not substantiated to be helpful to prevent injury but O'Toole (1992) explains that stretching exercises may help to develop appropriate ranges of motion to prevent scarring and shortening of the healing tissue after injury. Further discussion with a medical practitioner or therapist is needed for the client to choose the best rehabilitation strategy. Clients need to also understand that people heal at different rates and to seek a medical professional to assist in their education and appropriate treatment plan that best suits their bodily needs (O'Toole, 1992).

While recovering and rehabilitating it is important to maintain one's level of physical fitness by cross training (Fredericson and Misra, 2007). This allows time for injury to heal while maintaining a high level of fitness (O'Toole, 1992). Examples to consider are running in water, swimming, biking and cross-country skiing (Fredericson and Misra, 2007).

Strengthening one's muscular deficiencies can improve the balance of forces around the joint affected and help reduce imbalances (O'Toole, 1992). O'Toole (1992) explains that eccentric training has been shown to be beneficial during the rehabilitation phase. Strengthening the hamstrings eccentrically after an overuse injury of the knee is an example.

Running Injuries: Final Thoughts
Personal trainers need to educate clients about the many factors that lead to running injuries. A client must pay close attention to the overall training progression with respect to moderation in increasing distance and the number of hard running days he/she is doing. O'Toole (1992) suggests that multiple studies recommend following the 10% rule, whereby the runner increases her/his mileage no more than 10% each week. It is important to schedule days off for recovery and avoid excessive downhill running in consecutive days, due to the stresses placed on the body (O'Toole, 1992). Another suggestion is to regularly vary the direction running on a track or road (O'Toole, 1992). If proper training steps are followed, enthusiasts will reap the many health benefits of running for years to come.

Ellapen, T.J., Satyendra, S., Morris, J., & Van Heerden, H.J. (2013). Common running
musculoskeletal injuries among recreational half-marathon runners in KwaZulu-Natal. South African Journal of Sports Medicine , 25(2), 39-43.
Fredericson, M., & Misra, A.K. (2007). Epidemiology and aetiology of maraton
running injuries. Journal of Sports Medicine, 37(4-5), 437-439.
Lopes, A.D., Hespanhol Junior, L.C., Yeung, S.S., & Pena Costa, L.O. (2012). What are the
main running-related muscloskeletal injuries. Journal of Sports Medicine, 42(10), 891-905.
O'Toole, M.L. (1992). Prevention and treatment of injuries to runners. Medicine and
Science in Sports and Exercise, 24(9), S360-S363.
Tonoli, D.C., Cumps, E., Aerts, I., Verhagen, E. & Meeusen, R. (2010). Incidence, risk factors and prevention of running related injuries in long-distance running: a systematic review. Sport and Geneeskunde, 43(5), 12-18.
Van Gent, R.N., Siem, D., van Middelk, M. et al. (2007). Incidence and determinants of
lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine, 41, 469-480.
Van Middelkoop, M., Kolkman, J., Van Ochten, J., Bierma-Zeinstra, S.M.A, & Koes, B.
(2008). Prevalence and incidence of lower extremity injuries in male marathon runners. Scandinavian Journal of Medicine and Science in Sports, 18, 140-144.

Adam Cadez-Schmidt, MS, AT, PES is a recent graduate from the University of New Mexico with concentrations in Sports Administration and Exercise Science. Special interests include endurance performance development and injury rehabilitation in clinical populations.

Taryn Cadez-Schmidt, MS, AT/LAT is a doctoral student in the Exercise Science Program at the University of New Mexico, Albuquerque. Special interests include injury prevention and rehabilitation and body composition research.

Len Kravitz, PhD, is the program coordinator of exercise science and a researcher at the University of New Mexico, Albuquerque, where he won the Outstanding Teacher of the Year award. He has received the prestigious Can-Fit-Pro Lifetime Achievement Award and American Council on Exercise Fitness Educator of the Year.