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Running injuries, treatment and prevention

This is an excerpt from Training Young Distance Runners-3rd Edition by Larry Greene & Russell Pate.

Dealing With Injuries

Given the physical demands of distance running, a fine line separates peak performance and injury risk. Over a long career, despite following a sound training program, few runners will completely avoid getting hurt, so it's important for coaches, parents, and runners to know the causes, symptoms, and approaches to treating and rehabilitating running injuries. Common causes of injuries include the following:

• Training errors: Sudden, sharp increases in training volume and intensity; overuse (running more miles or kilometers than the body can handle); failure to take sufficient recovery time between demanding workouts; running too much on very hard or very soft surfaces
• Anatomical abnormalities: Flat feet, high arches, excessive pronation or supination, knock knees, bowed legs, inwardly rotated thigh bones, unequal leg lengths
• Muscle imbalances: Differences in the strength of opposing muscle groups (hamstrings and quadriceps, calf and tibialis anterior, hip flexors and hip extensors), differences in the flexibility of opposing muscle groups, excessively tight or loose muscles
• Poor technique: Excessive turning and twisting motions, overstriding, striking too hard on the heel or forefoot
• Inappropriate footwear: Insufficient cushioning, inadequate control for excessive pronation or supination, insufficient arch support, overly worn shoes
• Suboptimal nutrition: Insufficient intake of calories, fluids, calcium, electrolytes, or other nutrients

By considering the causes of running injuries, coaches might find that some aspect of their training programs increases injury risk. By eliminating the risk factor or adding training methods that counteract it, they can prevent injuries. For example, impact-related injuries, such as shinsplints and stress fractures, are often caused by running long distances on hard surfaces such as asphalt roads. Runners can reduce their risk for these injuries by training on dirt roads and trails.

To effectively deal with injuries, both athletes and coaches must heed their symptoms and understand the best approaches to treatment and rehabilitation (see the Common Running Injuries sidebar later in this chapter). Although some injuries require immediate medical treatment, others, especially those caused by chronic overuse, may not pose an immediate danger. In some cases runners can self-treat these injuries, ideally under the supervision of a sports doctor or certified athletic trainer. Self-treatment of many running injuries involves RICE, which stands for rest, ice, compression, and elevation. Rest can mean a complete cessation of all training for at least a few days, but for many injuries it's possible to keep training with supplemental methods to maintain fitness. For example, runners with knee pain will make their injuries worse if they continue to run, but they can maintain a high level of cardiorespiratory and muscle fitness by swimming and doing upper-body circuit training.

Some leg and foot injuries that keep athletes from running are not affected by activities such as cycling and deep-water running. In deep-water running, the athlete mimics the running action while suspended in a pool by a flotation vest. Because cycling and deep-water running can elevate the heart rate for prolonged periods, they're great for maintaining cardiorespiratory fitness. The duration of supplemental training depends on the injured runner's familiarity with the exercise. For example, injured runners who have never done deep-water running might start out with only 10 or 15 minutes a day and gradually build up to a duration that approaches their longest continuous aerobic run. Runners who are accustomed to riding bicycles can start cycling at 45 minutes or more.

The second component of RICE, applying ice to the injured area, is often very effective for reducing swelling and pain as well as for promoting healing. Injuries that involve chronic inflammation, such as plantar fasciitis and Achilles tendinitis, respond especially well to ice treatment. The protocol is to simply apply a plastic bag filled with crushed ice to the injured area. To avoid freezing the skin, the runner should place a thin cloth between the bag and the injured area. Freezing water in a paper cup and using it to perform an ice massage is another option. A general guideline is to apply ice two or three times a day for 10 to 20 minutes each time. We strongly recommend that runners consult a sports doctor or athletic trainer for an injury-specific icing protocol.

Compression of the affected area is also often an effective treatment for injuries that cause swelling. The most common method of compression is applying an elastic bandage. The placement of the bandage depends on the injury and the person. Athletic trainers know the proper techniques for wrapping injuries.

The fourth component of RICE, elevation, involves raising the injured area to reduce blood flow to it, thereby reducing swelling. A runner who has a knee injury, for example, should lie on a bed or couch and elevate the affected leg with a pillow or two. The leg should be raised slightly above the heart.

Common Running Injuries

To prevent and treat running injuries, coaches and runners benefit from knowing their causes, symptoms, and rehabilitation methods. Following are descriptions of some common running injuries; an extensive discussion of running injuries is beyond the scope of this book.

Stress fractures are tiny breaks that occur in the bones of the feet, shins, thighs, and hips. The symptoms include localized pain and tenderness on the surface of the affected bone. This injury is commonly caused by overuse, or the excessive loading of the bones from the repetitive stress of running on hard surfaces. Stress fractures tend to occur in girls who, as a result of inadequate caloric intake and excessive training, experience athletic amenorrhea, or cessation of normal menstruation. Cyclical increases in estrogen levels, which occur with regular menstruation, are necessary for maintaining bone density. Diagnosing a stress fracture is typically complicated because the fracture may not show up on X-rays for several weeks after the onset of symptoms. To avoid serious bone damage and to promote healing, athletes who experience the symptoms of stress fractures should stop running and see a sports doctor. If a stress fracture is diagnosed, rehabilitation involves alterations in training and diet, a change in footwear or the use of orthotics, and cardiorespiratory training methods such as swimming, pool running, and cycling that don't stress the affected bone.

Plantar fasciitis is an inflammation of the band of connective tissue that runs along the insole of the foot from the heel to the arch. This injury is characterized by gripping pain and tenderness in the arch, close to the fleshy part of the heel. The pain is especially intense in the morning and during running. Plantar fasciitis is common in runners who have flat feet and who overpronate. Recovery time from this injury can often require several weeks or months of reduced or no running. Doctors may prescribe exercises for strengthening muscles in the feet, orthotics, anti-inflammatory medication, and steroid injections.

Achilles tendinitis is the degeneration and inflammation of the Achilles tendon, which connects the calf muscles to the heel bone. The main symptoms of this overuse injury are pain, tenderness, and swelling along the tendon. The pain is especially severe when athletes run on their toes, up hills, and in low-heeled racing flats or spikes. Runners with tight calf muscles are at particular risk, so they should regularly stretch these muscles. In some cases, rehabilitation time can be lengthy because the Achilles tendon receives limited blood flow and is stressed in daily activities such as walking. The main treatments - icing, anti-inflammatory medication, and ultrasound - increase blood flow to the tendon to reduce inflammation and promote healing. Swimming and deep-water running are good training methods for maintaining fitness while the tendon heals.

Patellofemoral pain syndrome results from cartilage degeneration behind the kneecap. Runners with this syndrome experience stiffness and grinding pain in the knee, especially after sitting for long periods and bending the knee in activities such as squatting and stair climbing. Patellofemoral pain syndrome occurs most often in runners with knock knees, bowed legs, and flat feet. Another cause is strength imbalances between the hamstrings and quadriceps. Doctors recommend anti-inflammatory medicine and exercises that strengthen the quadriceps and stretch the hamstrings.

Osgood- Schlatter syndrome refers to inflammation, tenderness, and pain where the patellar tendon (in front of the knee) attaches to the tibia, or shin bone. This syndrome, which is unique to young athletes, develops as a result of a combination of rapid bone growth and repetitive stress. During the adolescent growth spurt, the bones grow faster than the muscles and connective tissue. When the growth of the tibia outstrips that of the patellar tendon, the tendon pulls hard on its attachment site at the top of the shin. The excessive tugging causes irritation and pain. In addition, the force can lead to small bony formations and fractures. In most cases, the swelling and pain go away with reduced running and skeletal maturation.

Iliotibial band syndrome refers to inflammation and pain caused by the rubbing of the iliotibial band tendon against the lateral side (outside) of the knee. The iliotibial band runs along the lateral side of the thigh from the hip to the knee. In adult runners the syndrome is typically caused by a combination of repetitive stress from running and tightness of the iliotibial band and the muscles around it. In young runners an additional cause is rapid growth of the femur. Runners should cease running, ice the injured area, and stretch the iliotibial band (see chapter 6) and hamstring muscles (see chapter 6).

Shinsplints is a term referring to pain and tenderness along the shin bone. When the pain runs along the inner side of the shin from a few inches (around 5 or 6 cm) below the knee to the ankle, doctors refer to the injury as medial tibial pain syndrome. The pain associated with this syndrome is caused by inflammation of the tissue that lines the bone. When the pain is on the outer side of the shin, the cause may be compartment syndrome - swelling of the muscles in the lower leg, which overstretches the elastic sheath that covers the muscles and creates pressure on nerve endings in the muscles. Runners with shin pain should consult a sports doctor because appropriate treatment depends on the cause, which is difficult to self-diagnose, and because continuing to run without appropriate treatment can result in stress fractures.

Risk Factors for Running Injuries

To prevent injuries, coaches and runners benefit from knowing factors that increase their risk. This was the aim of a study conducted by Dr. Adam Tenforde and colleagues at Stanford University (Tenforde et al., 2011). The researchers surveyed 748 high school distance runners (442 girls and 306 boys) between 13 and 18 years old, asking them to report previous injuries, training mileage, and performance bests in the mile and 5K. Most of these young runners, 68 percent of the girls and 59 percent of the boys, reported at least one injury from a list that included Achilles tendinitis, ankle sprains, iliotibial band syndrome, knee pain, plantar fasciitis, and shinsplints. The proportion of these injuries was greater for girls. For example, 41 percent of the girls and 34 percent of the boys had experienced shinsplints. Around 6 percent of the girls and 3 percent of the boys had had at least one stress fracture. Compared with noninjured runners, those who reported injuries were older and covered more miles in their weekly training. For girls, significant risk factors for injury included greater amounts of running on pavement and faster performance times in the mile and 5K.

Based on their findings and other related research, Tenforde and coauthors concluded that high school runners can reduce injury risks by limiting running on hard surfaces and by performing injury-specific strength training and balancing exercises. The researchers' recommendations are summarized in table 10.3.

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