Running is one of the most popular forms of aerobic exercise, with numerous benefits for cardiovascular health, bone health, lower limb strength, sleep and mental health. It is also low cost and easy to do.
“If you run, you are a runner. It doesn't matter how fast or how far. It doesn't matter if today is your first day or if you've been running for twenty years.” John Bingham
Despite the health benefits of running, it is also is associated with a higher rate of injuries than other forms of aerobic exercise such as walking, swimming and cycling. The prevalence of running-related injuries has been reported to range between 26% and 92%, depending on the population studied and the definition of a running-related injury (Van Gent, 2007).
Running injuries are usually overuse injuries (what we call overload). Repetitive microtrauma to bodily tissues can result in breakdown of the sites in question. Pain onset is insidious and gradually increases over time. A running-related injury is not always a reason to give up running and will not lead to long-term problems if managed properly. Understanding the proven risk factors and addressing these will help you to keep injury-free.
Fact: The most common running injuries occur at or below the knee
Around 70% of running injuries occur at or below the knee. The most common running injuries are patellofemoral pain syndrome (anterior knee pain), Achilles tendinopathy and medial tibial stress syndrome or ‘shin splints’ (Messier et al. 2018).
Note: Women tend to have a larger proportion of knee injuries compared to men. This may be due to structural differences (such as the Q-angle) or differences in their running pattern. Women in childbearing years are also more susceptible to knee injuries due to increased knee laxity. This may be due to cyclic changes in the female hormones estrogen, progesterone and relaxin during the menstrual cycle. Increased knee laxity results in increased knee joint loads, and is thus a potential risk factor for injury (Park et al., 2009).
Myth: Running will destroy my knees
While many running injuries occur at the knee, this does not mean that running damages the knee joint. Evidence has shown that running does not increase the onset of knee osteoarthritis. A study which followed long-distance runners over 18 years found that running in older adults was not associated with increased knee osteoarthritis compared with healthy nonrunner counterparts. The study concluded that “Long-distance running or other routine vigorous activities should not be discouraged among healthy older adults out of concern for progression of knee OA” (Chakravarty et al. 2008)
Knee pain associated with running is most often caused by muscle imbalance and weakness, or due to suboptimal running mechanics. A specific exercise programme can help to strengthen the muscles (quadriceps and gluteals) around the knee and hip joints. This will help to improve lower limb control in order to reduce symptoms when running (Barton et al, 2015).
Fact: Previous injuries are a risk factor for developing further injuries
A number of studies have found previous injury, especially in the last 12 months, to be one of the main risk factors for running related injuries. (Saragiotto et al., 2014a). When a tissue is injured, it’s capacity to manage loads (i.e. running) is greatly reduced and this is part of the reason why injury recurrence is common. The key is to reduce running load and frequency to a manageable amount, gradually building up volume, speed and distance overtime.
Physiotherapists play an important role in rehabilitation following running-related injuries. We can help you identify the cause and deal with it appropriately to minimise its recurrence. This is done by working on strength, mobility, control and running pattern through a targeted exercise programme. Guidance will be provided on running patterns, frequency & load when recovering from injury.
Myth: Wearing an inappropriate shoe for my foot type causes injuries
Despite the widespread beliefs of runners, there is currently no evidence that the use of running shoes based on foot type is effective in reducing running-related injuries. Studies have shown that there is no difference in injury risk between individuals who received motion-control, stability, or neutral shoes, based on their foot type (Saragiotto et al., 2014b).
The main advice is to find a shoe that you find comfortable and to replace them appropriately with wear and tear, approximately every 300-400 miles.
Myth: Stretching will prevent running injuries
There is a lack of scientific evidence to support the belief that stretching on its own before running prevents running injuries (Yeung et al., 2011). Stretching even after a session of running or outside of running also does not appear to have a protective effect for running injury.
Performing a proper warm-up is still an important part in preparing the body for exercise. A good warm up should focus on increasing body temperature and activating the muscles involved. This can be done through 5 minutes of sub-maximal running to raise the heart rate and dynamic stretches (active movements where joints and muscles go through a full range of motion)
Fact: Strength and conditioning can increase the body’s tolerance to running
While previous injury may reduce the amount of running your body can manage, strength and conditioning can help increase tolerance to running, reduce injury risk and improve performance. There is emerging evidence to show that strength training reduces sports injuries to less than 1/3 and overuse injuries could be almost halved (Lauersen et al., 2014).
Decreased muscle strength, flexibility and control or altered running biomechanics can contribute to overload on the body. By identifying muscle imbalances and targeting deficits in strength, balance and flexibility through an individualised strength and conditioning programme, we can help maximise the load the tissues can take and therefore increase the amount of running the body can tolerate. It is also important to note that resistance training doesn’t negatively impact VO2 max (fitness levels) and helps to improve running economy.
Fact: Excessive amounts of running may cause damage to body structures, resulting in overuse injuries.
As discussed above, decreased ability of body tissues to tolerate running increases risk of injury. However, excessive load on the body can also occur through increasing frequency, speed or distance of runs too quickly, or running on unfamiliar terrain. Estimates suggest 60-70% of running injuries are due to these training errors. Many runners make the mistake of increasing mileage too quickly and doing ‘too much too soon’.
To avoid the risk of overtraining, a progressive running programme with gradual increases in volume and intensity, and adequate rest is essential. Changes in intensity (pace/ introduction of hills) of training should be added in isolation, rather than combined with increase in distance or volume. While there is a common rule of thumb to not increase weekly mileage by more than 10% each week (Johnston et al., 2003), the most important thing you can do is to know your own limits and respect the presence of pain. Ideally you should have minimal pain with running which should settle quickly with no reaction the next day. The RunningPhysio has an excellent blog on how to avoid injury through overtraining https://www.running-physio.com/trainerror/.
A combined approach of modifying training and appropriate strength and conditioning is ideal for reducing running injury risk and redressing the balance between loading habits through training and tissue capacity to manage load.
Myth: Having rest days will affect my progress
Not only can taking a few days off help your performance, it also won't decrease your fitness levels. Studies found that there is little decrease in VO2 max (marker of aerobic fitness) over the first 10 days of inactivity in trained athletes.
Listen to your body and take time to recover when sick or injured. Don’t be afraid to rest or replace running with cross training (such as swimming, cycling, yoga or resistance training) to help reduce the risk of overtraining.
Take home messages:
The key risk factors for running injuries are training error and previous injury. Managing these risks are essential to prevent overuse injuries.
Injury prevention can be targeted through gradually increasing running distance, intensity and volume, weekly strength and conditioning, managing injuries appropriately and including adequate rest.
Running is a safe and enjoyable activity- and will not destroy your knees!!
References
Van Gent, R.N., Siem, D., van Middelkoop, M., Van Os, A.G., Bierma-Zeinstra, S.M.A. and Koes, B.W., 2007. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine, 41(8), pp.469-480.
Messier, S.P., Martin, D.F., Mihalko, S.L., Ip, E., DeVita, P., Cannon, D.W., Love, M., Beringer, D., Saldana, S., Fellin, R.E. and Seay, J.F., 2018. A 2-year prospective cohort study of overuse running injuries: The runners and injury longitudinal study (TRAILS). The American Journal of Sports Medicine, 46(9), pp.2211-2221.
Park, S.K., Stefanyshyn, D.J., Ramage, B., Hart, D.A. and Ronsky, J.L., 2009. Relationship between knee joint laxity and knee joint mechanics during the menstrual cycle. British journal of sports medicine, 43(3), pp.174-179.
Chakravarty, E.F., Hubert, H.B., Lingala, V.B., Zatarain, E. and Fries, J.F., 2008. Long distance running and knee osteoarthritis: a prospective study. American Journal of Preventive Medicine, 35(2), pp.133-138.
Barton, C.J., Lack, S., Hemmings, S., Tufail, S. and Morrissey, D., 2015. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning. British Journal Sports Med, 49(14), pp.923-934.
Saragiotto, B.T., Yamato, T.P., Junior, L.C.H., Rainbow, M.J., Davis, I.S. and Lopes, A.D., 2014a. What are the main risk factors for running-related injuries?. Sports Medicine, 44(8), pp.1153-1163.
Saragiotto, B.T., Yamato, T.P. and Lopes, A.D., 2014b. What do recreational runners think about risk factors for running injuries? A descriptive study of their beliefs and opinions. Journal of Orthopaedic & Sports Physical Therapy, 44(10), pp.733-738.
Yeung, S.S., Yeung, E.W. and Gillespie, L.D., 2011. Interventions for preventing lower limb soft‐tissue running injuries. Cochrane Database of Systematic Reviews, (7).
Lauersen, J.B., Bertelsen, D.M. and Andersen, L.B., 2014. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48(11), pp.871-877.
Johnston, C.A.M., Taunton, J.E., Lloyd-Smith, D.R. and McKenzie, D.C., 2003. Preventing running injuries. Practical approach for family doctors. Canadian Family Physician, 49(9), pp.1101-1109.