Contents 1. Introduction 2. Common injuries
3. Influences on Injuries
4. Understanding load/load tolerance
1. Introduction
The AIHW (Australian Institute of Health and Welfare) stated that for those above the age of 15, in 2020-21, 4.4 million Australians (out of 18.8 million) completed running or athletics as their physical activity.
This comes 3rd behind walking (9.9 million) and gym/fitness (8.6 million). At High Line Active, anecdotally, we have seen a spike in our clients taking up recreational running which has lead us to create a bit of an overview of running and running-based injuries as a resource for our clients. We love working with our clients who run. There is such a range of running types that we deal with. We treat clients who do Ultramarathons, Trail runners, Marathon runners, Triathletes, 5-10km race runners, and those who just run because they enjoy staying fit and active but don’t have a goal in mind.
Our goal is to keep our runners running.
Running is a fantastic low-cost exercise that become increasingly popular throughout the past few decades. Running serves as a great form of exercise for those looking to improve their physical fitness and promote a healthier lifestyle. Running is linked to longevity and reduction of risk factors for cardiovascular diseases (Kakouris, 2021)
Despite these benefits, running does expose itself to some running-related musculoskeletal injuries which we will discuss for the remainder of this blog.
2. Common running injuries
Unfortunately, running does have the risk of suffering from an injury.
There’s an extremely wide range of incidences of running injuries in the research of running-related injuries. However, it is fair to say that there’s a level of risk of injury when running. Some risk factors for running injuries included
A previous injury
Age
Inexperience (<0-2 years)
Beginning running from a break
The use of inserts in shoes (used incorrectly)
Training errors
(van der Worp, 2014) So if you are beginning to run or taking it back up, use this masterclass as injury prevention and consult your physio about a running plan
Common types of injuries
Patellofemoral Joint (PFJ) Pain Patellofemoral joint pain is an umbrella term for pain that is in and around the patellofemoral joint and its surroundings. The patellofemoral joint is where the patella joins with the femur’s groove called the trochlea notch. This helps to form part of the knee joint, the front aspect of the knee joint. This joint is comprised of many structures which may be affected when irritated.
Cardinal signs and symptoms
Pain in the anterior (front of) knee
Pain with knee loading (running/stairs/squatting)
Pain with knee bending (flexion)
Pain with palpation in and around the Patella
Potentially some swelling of the knee
Prevalence PFP is the most common running-related injury with 48.8% of knee injuries experienced and is more prevalent in women (62%) (Taunton, 2002)
Tibial stress fractures or stress reactions Tibial stress fractures are loading-based injuries where someone’s bone strength does not meet the mechanical stress (usually chronic) placed on it which results in a cascade of injuries (microfractures/inflammation) which then may lead to a complete stress fracture. This generally is a result of repetitive bone loading over time, which you can imagine is relevant for the running population Pain usually presents itself as gradually worsening over time when continuing the aggravating activity. Swelling and tenderness will also likely be apparent in the medial tibia (Inside of your shin). Pain can persist for hours or even days following the aggravating activity.
Prevalence Tibial stress fractures make up 2.2 - 7.8% of running injuries and are more common in females (73% of all tibial stress fractures) (Lowry, 2019)
Iliotibial Band Pain (ITB pain) The Iliotibial Band (ITB) is a thick band of fascia that runs on the outside of our thigh from our hip to our knee. The band is comprised of fibres of the gluteus maximus and tensor fascia latae (TFL) muscle. The best way to think of the ITB is that it is a long tendon arising from our glute max and TFL. Pain can present itself along the ITB but more commonly at its attachment site at the lateral knee (Gerdy’s tubercle).
This is commonly seen in those participating in activities with repetitive knee flexion and extension (bending) such as running and cycling
Prevalence ITB pain accounts for 1.9-12% of all running injuries and roughly 22% of all lower limb injuries. Due to a few anatomical factors, this is more common in women (62%) (Van der Worp, 2012)
Achilles Tendinopathy The Achilles tendon is the biggest and strongest tendon in the human body. The tendon can resist large tensile forces. The Achilles tendon begins from the gastrocnemius and soleus muscles (Calf muscles) and inserts at the bottom of the calcaneus (heel). Similar to the other pathologies, pain is commonly associated with overloading the Achilles tendon exposing it to microtrauma over time. Common signs that someone is suffering from an Achilles tendinopathy
Pain and tenderness around the Achilles tendon
Pain with the first few steps in the morning
Pain in the Achilles following (later in the day or the next day) physical activity
Prevalence
Achilles tendinopathy is another somewhat common running injury with it making up 9.1 - 10.9% of all running injuries. This tends to be slightly more common in males (58%) compared to females
(Chen, 2023)
Other running injuries that we see in the clinic include
Plantar Fasciitis
Tibialis Posterior tendinopathy
Peroneal tendinopathy
Morton’s neuroma
Hamstring tendinopathy
We won’t be directly discussing these injuries however many of the principles apply to these injuries however please consult your Physiotherapist before acting on the advice from this blog.
3. Influences on Injury
Once we get injured, we are quick to try and find something to blame for that particular injury.
“It must be my shoes”
“I did a new exercise at the gym”
“Had a busy week of work”
“I landed funny”
The truth is, it’s never that simple. Many factors contribute to any injury, let alone a running injury.
Influences of running injuries can range from the following:
Psychosocial influences
Training load errors
Running hard, downhills, higher intensity
Biomechanics
Mobility deficits
Fitness level
Bone and tendon capacity
Muscle performance
Pain beliefs
Previous history
So clearly there is a lot that can impact running-related injuries
Education about the above factors is critical for recovery from running-based injuries, particularly when it comes to loading and loading-based injuries.
We will focus very strongly on loading, what that means, and how it can impact running injuries.
Loading
Loading is the amount of internal and external force that is being applied to a particular area. Load often refers to a volume of force that has been placed on a particular area over time. Load has many aspects that contribute to the amount of force being applied such as frequency, intensity, and overall volume.
Tissue Capacity
We can apply load to all parts of our body however we do have a flexible level of capacity that we can impact both positively and negatively. We can increase our capacity to withstand load over time with specific training however when we load a tissue (muscle, tendon, and bone) over the tissue’s capacity for some time, that can predispose us to injury.
This principle covers the basis of the “Too Much Too Soon” statement that we hear very often
Training Load Vs. Tissue Capacity This balance between Applied Load vs Tissue Capacity is critical for a few different aspects.
Let’s look at a few examples below Tissue Homeostasis: This is a nicely balanced relationship between applied load vs capacity. This is a nice maintenance relationship where we can comfortably deal with the applied load as it doesn’t surpass our capacity
Capacity Deficit: This next example looks at a capacity deficit that can lead to injury. This example shows an increased applied load that surpasses the tissue capacity. This isn’t just one event/activity moment. This example likely expresses load over time.
Stress Shielded: If our applied load is below our current capacity, we will likely have no symptoms. This can inversely be detrimental to our current capacity. If we don’t train close to our capacity then over time then our capacity will begin to decline.
“If you don’t use it, you lose it”
This can actually be quite dangerous because it is easy to be comfortable in this range as often we don’t have many symptoms. Once we look to apply previous levels of training load then we overload and go back into a capacity deficit but now with a reduced capacity.
This ultimately leads to what we see time after time here at High Line Active. This process can be frustrating when looking to rehab from an injury however it is just crucial to effectively apply otherwise rehabilitation will have many speed bumps. We are here to guide you through this process as well as avoid the ‘Cycle of Loss of Load Capacity'
Finding the right amount of “Applied load’ is very important to consult with your physiotherapist.
This is essential for recovery and performance and should not be taken lightly. The example above gives a very simple presentation of different approaches that many take to injury but as we learned earlier, it is never that simple. The following section should be completed with a physiotherapist to help guide you through this tricky process. Remembering to also have treatment to help with symptom management at all stages of rehabilitation is also beneficial for recovery
4. Restoring Function
Training and restoring running loads must take many factors into account. Exercise prescription has to be accurate during this phase and should be conducted with your physiotherapist. There are different goals for different stages of your recovery which range from symptom management to Return to Activity Stages of Rehab / Restoring function 1. Symptom management / Gentle Loading / Offloading where possible 2. Heavy Slow Resistance / Relative protection of the affected area 3. Heavy Slow Resistance / Wean protection / Can add some impact 4. Heavy Slow Resistance / Plyometrics / Return to running
Consulting a physiotherapist is quite important in these stages to ascertain how much load is appropriate for the runner.
Expectations
Throughout these stages, understanding pain levels helps guide our recovery.
It is fine to allow some levels of pain and research suggests this doesn’t hinder performance (Smith, Hendrick, Smith, et al - 2017). Following an injury, our body is conscious and on high alert that it doesn’t get injured again, so when we increase our applied loads we become cautious and may have discomfort as a warning sign. This is our body being protective following an injury and is somewhat expected when we increase our applied loads. Remember that pain at a safe/acceptable level does not hinder performance. You do not need to have zero pain to continue your recovery. Following a loading-based injury, like the ones discussed above, it is important to know WHEN to monitor your symptoms. Unlike acute injuries, loading-based injuries may experience pain during an activity or recovery but also following the activity, that night, and the next morning.
Muscle forces during running
When your High Line Active physiotherapist creates a recovery/rehabilitation program they keep in mind the forces that are applied to the lower limb when running.
For example, looking at the following muscle forces during running in comparison to body weight (BW) Gluteal muscles
Gluteus Maximus = 1.5 - 2.8 x BW
Gluteus Medius = 2.6 - 3.5 x BW
Thigh Muscles
Quadriceps = 4 - 6 x BW
Calf muscles:
Soleus = 6.5 - 8 x BW
Gastrocnemius = 2.5 - 3 x BW
These figures show the varied forces required during running and the jump it takes to go from ‘resting’ back to ‘running’. As we look to increase our applied loads during our recovery and rehabilitation we must keep these numbers in mind when it comes to our heavy slow resistance loading. Key features to note from these statistics are the levels of force required from the calf muscles during running and potentially why injuries such as Achilles tendinopathies, Plantar fascia and more can be quite common. A similar trend applied to the quadricep muscle and its required loads which may lead to patella tendinopathies. Knowing these required forces, accurate exercise prescription is crucial when recovering and returning to running. Creating a Base / Stages of Recovery
Symptom management / Gentle loading Generally in the symptom management / gentle loading phase, we can use two key methods
Cross-training (Walking if tolerable)
We referenced the differing forces applied to the body when running and how we should have them in mind when recovering. In the early stage of recovery, walking serves as a really good alternative to cross-training if bearable. Forces vary considerably between walking and running particularly through the knee where Patellofemoral force is 4.6x greater in running compared to walking.
2. Isometric contractions
An isometric contraction is when a muscle contracts but there is no change in the muscle length. An isometric contraction is often a ‘hold’ type contraction.
Isometric contractions are a great starting place for early-stage loading. This can be quite beneficial when someone has a sensitive tendon and when a person is fearful of early-stage loading for tendons following an injury. For particular tendons, isometric contractions can serve as acute pain relief as an additional benefit (Clifford, et al. 2020)
Heavy, slow resistance training
Heavy slow resistance training aims to introduce loading to the affected area in a tolerable fashion. Most running injuries are loading-based in nature which often involves tendons (Achilles, Patella tendon, ITB etc). Tendons LOVE heavy slow resistance training and have shown to be very effective in the management of tendon injuries in knees (Lim & Wong, 2018) and Achilles (Radovanović, Bohm, Peper, et al. 2022). It is recommended that 70% of repetition max (RM) is ideal in ‘Heavy’ loading for tendons. After the first stage of recovery and restoring function (symptom management / gentle loading), we look to introduce some heavier loads into the runner’s exercise program. Once again, this needs to be safely administered by your physiotherapist. Both Dane and Nicole are level 1 strength and conditioning coaches (ASCA) so will be able to accurately prescribe your exercise program and will take into account the % of force required for running
Plyometrics Introducing some impact loading and plyometrics is naturally the next step of recovery when returning to running. Think of the heavy slow resistance phase as creating a platform to then load up with more intensity going forward. Tendons have a spring-like effect and can store and release energy very quickly. Impact loading (landing, jumping, and hopping) and Plyometrics (explosive) are a way to load particular areas of the body with a higher intensity. If we think of running as a series of hops then it makes a lot of sense to focus on this as an isolated area before returning to running.
Plyometrics are effective as they are often performed at maximal intensity but with a limited volume. For example, it is unlikely to be given more than 30 reps of plyometrics for a particular area so that we can focus on doing the exercise at a higher intensity. When are running we are exceeding 30 steps/strides so it is a way to load in this impact fashion at a reduced volume but at an increased intensity
Graded return to running / activity
Returning to running, much like the other stages, must be very deliberate and measured to allow for optimal recovery. Often the early stages of returning to running can be quite frustrating due to the reduced intensity that is recommended but at least we are back running. Over time we can increase your loads (generally distance before intensity) under physio guidance.
There are limited cases where running biomechanics may need to be altered however this is generally low on the priority list.
Throughout all of these stages, it is still important to monitor your symptoms during, after, and the next day.
Kakouris, N., Yener, N., & Fong, D. T. (2021). A systematic review of running-related musculoskeletal injuries in runners. Journal of sport and health science, 10(5), 513-522. van der Worp MP, ten Haaf DS, van Cingel R, de Wijer A, Nijhuis-van der Sanden MW, Staal JB. Injuries in runners; a systematic review on risk factors and sex differences. PLoS One. 2015 Feb 23;10(2):e0114937. doi: 10.1371/journal.pone.0114937. PMID: 25706955; PMCID: PMC4338213. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002 Apr;36(2):95-101. doi: 10.1136/bjsm.36.2.95. PMID: 11916889; PMCID: PMC1724490.
Lowry, Maryn E.. “Bone Stress Injuries in Collegiate Distance Runners: Review of Incidence, Distribution, and Risk Factors.” (2019).
van der Worp MP, van der Horst N, de Wijer A, Backx FJ, Nijhuis-van der Sanden MW. Iliotibial band syndrome in runners: a systematic review. Sports Med. 2012 Nov 1;42(11):969-92. doi: 10.2165/11635400-000000000-00000. PMID: 22994651.
Chen W, Cloosterman KLA, Bierma-Zeinstra SMA, van Middelkoop M, de Vos RJ. Epidemiology of insertional and midportion Achilles tendinopathy in runners: A prospective cohort study. J Sport Health Sci. 2023 Mar 23:S2095-2546(23)00037-6. doi: 10.1016/j.jshs.2023.03.007. Epub ahead of print. PMID: 36963760.
Smith BE, Hendrick P, Smith TO, et alShould exercises be painful in the management of chronic musculoskeletal pain? A systematic review and meta-analysisBritish Journal of Sports Medicine 2017;51:1679-1687.
Clifford C, Challoumas D, Paul L, Syme G, Millar NL. Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ Open Sport Exerc Med. 2020 Aug 4;6(1):e000760. doi: 10.1136/bmjsem-2020-000760. PMID: 32818059; PMCID: PMC7406028.
Lim HY, Wong SH. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int. 2018 Oct;23(4):e1721. doi: 10.1002/pri.1721. Epub 2018 Jul 4. PMID: 29972281.
Radovanović, G., Bohm, S., Peper, K.K. et al. Evidence-Based High-Loading Tendon Exercise for 12 Weeks Leads to Increased Tendon Stiffness and Cross-Sectional Area in Achilles Tendinopathy: A Controlled Clinical Trial. Sports Med - Open 8, 149 (2022). https://doi.org/10.1186/s40798-022-00545-5
Physionetwork Masterclass: Restoring running capacity (Rich Willy)
- With thanks for some of the content as well as visual resources from this Masterclass
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