Journal Pre-proof

In training for a marathon: Runners and running-related injury prevention

H. Hofstede, T.P.C. Franke, R.P.A. van Eijk, F.J.G. Backx, E. Kemler, B.M.A.
Huisstede

PII: S1466-853X(19)30202-0
DOI: https://doi.org/10.1016/j.ptsp.2019.11.006
Reference: YPTSP 1126

To appear in: Physical Therapy in Sport

Received Date: 26 April 2019

Revised Date: 10 November 2019
Accepted Date: 11 November 2019

Please cite this article as: Hofstede, H., Franke, T.P.C., van Eijk, R.P.A., Backx, F.J.G., Kemler, E.,
Huisstede, B.M.A., In training for a marathon: Runners and running-related injury prevention, Physical
Therapy in Sports (2019), doi: https://doi.org/10.1016/j.ptsp.2019.11.006.

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In training for a marathon: runners and running-related injury prevention

H Hofstede1 BSc, TPC Franke1 PT MSc, RPA van Eijk2 MD MSc, FJG Backx1 MD PhD, E

Kemler3 PhD, BMA Huisstede1 PT PhD

1 Brain Center, Department of Rehabilitation, Physical Therapy Science & Sports,

University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.

2 Brain Center, Department of Neurology, University Medical Center Utrecht, Utrecht

University, Utrecht, the Netherlands.

3 Consumer Safety Institute (VeiligheidNL), Amsterdam, the Netherlands.

The are no acknowledgements

The authors declare that they have no conflicts of interest

Address correspondence to Bionka M.A. Huisstede, PT, PhD, Brain Center, Department of

Rehabilitation, Physical Therapy Science & Sports, University Medical Center Utrecht,

Utrecht University, PO Box 85500, 3508 GA, Utrecht, the Netherlands. Fax: 088-755 54 50

Tel: +31-88-7560945. E-mail: B.M.A.Huisstede@umcutrecht.nl.

In training for a marathon: runners and running-related injury prevention

Word count abstract: 200

Word count manuscript: 3567

Number of tables: 4

Number of figures: 1

1
In training for a marathon: runners and running-related injury prevention

Abstract

Objective: To investigate which preventive measures runners use when preparing for a half-

or full-marathon and whether the use of these measures at baseline and during the

preparation-period differs between runners who sustained no/non-substantial running-related

injuries (NSIRs) or substantial running-related injuries (SIRs).

Design: Prospective cohort study.

Setting: 16-week period before the XXXXX-marathon.

Participants: Runners who subscribed for the half- or full-marathon.

Main Outcome Measures: The occurrence of RRIs was registered every 2-weeks, using the

Dutch version of the Oslo Sport Trauma Research Centre(OSTRC) questionnaire on Health

Problems. The OSTRC was used to differentiate between runners with SIRs(question 2/3

score>12 and NSIRs(question 2/3 score<13). The use of different preventive measures, was

registered every 4-weeks.

Results: 51.6% of the runners reported at least one RRI in the 12-months prior to this study

(history of RRIs). The SIRs with a history of RRIs more often asked for running shoe advice

than NSIRs with a history of RRIs(67.9%vs43.4%, P<0.05); 18.9% of the SIRs with a history

of RRIs used supportive materials for knee and/or ankle versus 0% of NSIRs with a history of

RRIs (P<0.05).

Conclusion: SIRs with a history of RRIs might be using their preventive measures for

symptom reduction or secondary prevention.

Keywords: Running [MeSH]; Oslo Sports Trauma Research Center Questionnaire; running

shoes; bandages; prevention.

2
In training for a marathon: runners and running-related injury prevention

Introduction

Marathon-running has grown in popularity.1 Unfortunately, long-distance running is

associated with injuries, especially of the lower extremity.2 The cumulative incidence

proportion and prevalence of running-related injuries (RRIs) in long-distance runners has

been reported to range from 5.6-14.8% and 29.2-43.5% respectively.3 Looking specifically at

time-loss RRIs, then the incidence is reported at 52% within a one year period.4,5 One of the

most important risk factors for RRIs in marathon and other long-distance runners is a history

of previous RRIs (odds ratio 2.62;95%CI (confidence interval) 1.82–3.78).2,6 Other risk

factors for injuries runners are: ‘not performing interval training on a regular basis’ and ≤ 5

years of running experience.7

In order to prevent RRIs, more needs to be known not only about potential risk factors but

also about potentially effective preventive measures. Studies to date have focused specifically

on different measures, such as stretching, warming-up and cooling-down, as potential risk

factors or protective factors for RRIs, but none have been found to affect the occurrence of

RRIs in marathon runners.6-8 However, these studies had a long recall period for RRIs, which

could potentially lead to underestimation of the proportion of runners with a RRI and

consequently affect the results of potential preventive measures.6,8 In addition, one study that

examined RRIs in marathon runners only focused on RRIs during the marathon and did not

focus on RRIs in the period before the event.7 These study limitations make it difficult for

clinicians and athletic trainers to provide evidenced-based preventive advice for runners.9

In order to develop effective prevention programmes for marathon (full or half) runners, it is

essential to know which preventive measures runners use and whether they become injured or

not when preparing for an event. A review of preventive measures for all kind of sports

3
injuries from 2017 concluded that preventive measures, especially ankle tape or ankle braces

to prevent the recurrence of ankle injuries in general, were the subject of multiple studies.10

However, preventive measures specifically for marathon runners have never been the main

subject of prospective cohort studies.8

Therefore, this study investigated which preventive measures runners take when preparing for

a marathon and whether there are differences in the use of preventive measures at baseline

and during the 16-week preparation period between runners who sustain no/minor or

moderate/severe RRIs while preparing for the event.

Methods

Design and study participants

This prospective longitudinal cohort study is part of the SUccess Measurements and

Monitoring XXXX Marathon 2016 study, which was approved by the University Medical

Center XXXXX ethics committee (protocol number 15-592). The SUMMUM-2016 study

followed marathon runners who signed-up for the XXXXX marathon for a 16-week period

(November 2015-March 2016). The XXXXX half (21.1 kilometres) and full (42.195

kilometres) marathons were held on March 20th, 2016.

All runners who had signed up for the XXXXX marathon up to November 21th 2015 were

recruited via a newsletter and a symposium on RRIs. Interested runners were sent an

information letter about the study. Contact information was included in the email, so that

runners had an opportunity to ask questions about the study. Before filling-in the baseline

questionnaire, runners were asked to provide their informed consent. Runners could only fill-

4
in the baseline questionnaire if they provided informed consent. Runners, age≥18years were

included in the cohort if they: 1) signed up for the half or the full XXXXX marathon; 2)

signed informed consent; 3) had an email address available; and 4) had adequate Dutch

language skills. In this study, the term ‘marathon runner’ is used for runners who took part in

either the half or the full marathon.

Data collection

Data were acquired by means of online questionnaires during the preparation period. For the

online questionnaires, NetQ software (NetQ software, Amsterdam, the Netherlands) was used.

Runners received one questionnaire at baseline (16 weeks before the event) and thereafter a

questionnaire on RRIs every 2 weeks, and a questionnaire about preventive measures every 4

weeks.

Baseline questionnaire

The baseline questionnaire contained questions about demographic factors (sex, age, body

mass index, educational level), lifestyle factors, and training-related factors. A high education

level was defined as an academic bachelor degree or higher. Lifestyle factors comprised daily

smoking, daily alcohol use, non-musculoskeletal comorbid diseases (such as chronic

obstructive pulmonary disease, asthma, diabetes, epilepsy), and use of special food

supplements, such as vitamins B12, C, and D, zinc, magnesium, and iron. Training-related

factors included the following items: already started training at baseline (frequency, hours,

and kilometres), in training for the half or full marathon, training surface (hard, soft, gravel, or

tartan), use of a heart rate monitor in training, experience with running a marathon, and

occurrence of RRIs in the past 12 months (history of RRIs). A RRI in the past was defined as

5
an injury located in muscles, tendons, joints and/or bones due to running which resulted in

any reduction of running-frequency, running-time, running-distance and/or running-velocity.

Runners were also asked if they performed warming-up, cooling-down, and/or stretching

exercises to prevent RRIs. In addition, they were asked if they had asked for advice when

buying running shoes, if they used insoles, braces, bandages, or kinesiotape for the knee or

ankle, compression socks, and/or different shoes for different training surfaces to prevent

RRIs.

RRI questionnaire

The runners filled-in a questionnaire to monitor the occurrence of RRIs every 2 weeks, using

the Dutch version of the Oslo Sports Trauma Research Centre (OSTRC) questionnaire on

Health Problems.3,11 The OSTRC was translated to Dutch by using ‘back and forth’

translation technique according Beaton et al.12 The OSTRC contains four multiple-choice

questions, from which the occurrence of RRIs and/or illness symptoms can be determined.

The scores on the four multiple-choice questions were summed in order to calculate the

OSTRC severity score (range 0–100, higher score indicates a greater severity). If the OSTRC

severity score was >0, the runners were asked to report if it concerned a RRI or illness

symptom. In case of a RRI follow-up questions were asked regarding the anatomical location

and type of the RRI. In case the OSTRC severity score was >0, a differentiation was made

between non-substantial and substantial injuries as described by Clarsen et al.11 If OSTRC

question 2 or 3 were scored <13 the RRI was considered as a non-substantial injury. If the

answer scores were ≥13 the RRI was considered a substantial injury. Clarsen et al. described

that a substantial injury leads to a moderate to severe reduction in training volume and/or a

moderate to severe reduction in participation or achievement in training or competition or

6
complete inability to participate in sport.11 Runners were considered as substantially injured

runners (SIRs) if they had at least one substantial RRI in the preparation period. Runners

without substantial injuries, which were runners with non-substantial injuries, and runners

with no injuries at all in the preparation period, were both considered as non-substantial

injured runners (NSIRs). We differentiated between non-substantial injured runners and

substantial runners, because in our opinion it is of importance to excluded the minor pain

symptoms, which might not lead to a certain reduction in training volume or training

achievement, because these minor symptoms could also be normal responses to heavy

training. For example: a delayed-onset of soreness after a heavy training could be reported as

pain which leads to a little reduction in achievement in training and thus be reported as a non-

substantial injury. However, we are aware of the fact that the subject or ‘the good RRI

definition per study population’ is open for discussion and remains difficult.13

Additional preventive measures

Every four weeks the participants were asked if they had started using additional preventive

measures (i.e. preventive measures that they used for the first time and were not reported at

baseline).

Statistical analysis

For the purpose of this study, the runners who completed the baseline questionnaire and

filled-in at least one 2-week RRI questionnaire were included in the analyses. A response rate

was calculated per measurement by dividing the number of questionnaire respondents by the

7
total number of runners invited to fill-in the questionnaire. After which, the mean response

rate was calculated by dividing the sum response rates by the number of measurements.

Descriptive statistics were used to analyse the baseline characteristics; continuous variables

are summarized as means±standard deviation (SD). To compare the baseline characteristics of

NSIRs with SIRs, a chi-square test or an independent sample T-test was used. A chi-squared

test was performed to compare the use of preventive measures at baseline and during the

preparation period by the two groups of runners. If ≥20% of the cells in the crosstab had an

expected count lower than 5, Fisher's exact test was used.

Missing data for any of the covariates was imputed by multiple imputations (10 iterations).

The imputation model contained all available variables. The chi-square statistics were pooled

as described by Enders.14

To obtain more specific information about differences in the use of preventive measures,

stratified analyses for a history of RRIs were performed.2,6,15-18 Stratified analyses were

performed if there was a significant difference between the two groups of runners in the use

of preventive measures at baseline and during the preparation period in the first analysis and if

the total cell count was ≥ 10 for the stratified analysis. A chi-squared test was performed to

compare the use of preventive measures at baseline and during the preparation period by the

two groups of runners, based on a prior history of RRIs.

The prevalence of substantial RRIs per anatomical location was calculated every two weeks

during the 16-week preparation period as described by Clarsen et al. It was calculated by

dividing the number of runners that had a substantial RRI (SIRS; i.e. runners with a

substantial injury were those who scored OSTRC question 2 or 3 ≥13) by the total number of

8
questionnaire respondents.11 The average biweekly prevalence of substantial RRIs was

calculated by dividing the biweekly prevalence by the total number of measurements (i.e. 9).

All analyses were performed with SPSS (SPSS version 24, IBM, Armonk, New York, USA.),

using a 0.05 level of significance.

Results

Study population

In total, 249 runners were invited to participate in this study, of these 74 runners did not

respond and 3 runners did not provide informed consent. Of the 172 runners who provided

informed consent, 11 did not complete the baseline questionnaire and were therefore excluded.

All 161 runners who completed the baseline questionnaire, completed at least one 2-week

RRI questionnaire, so 161 runners were included in the analyses (Figure 1). The average

response rate for the questionnaires during the 16-week preparation period was 74.1% (range

68.5-79.9%).

9
At baseline, the mean (±SD) age of the 161 runners was 40.7±11.7 years, the height was

177.7 ± 9.4 cm, the weight was 72.6 ± 12.2 kg, and 78.3% of the runners were highly

educated. 44.1% of the runners were women and there were no significant differences

between the number men and woman who had ≥1 substantial RRI during the study.

With regard to lifestyle factors, 1.2% of the runners were daily smokers, 15.5% used alcohol

every day, 17.4% had non-musculoskeletal comorbidities (such as COPD, asthma, diabetes,

epilepsy etc.), and 23% used special food supplements (such as vitamins B12, C, and D, zinc,

magnesium, iron).

Overall, 69.6% of the runners were already in training at baseline. These runners trained

(mean±SD) 2.6±1.2 times per week, 2.2±1.5 hours per week, and 26.2±17.6 kilometres per

10
week at baseline. 71.4% of all runners were registered for the half marathon and 28.6% the

full marathon. In total, 36% of all runners often or always used a heart rate monitor, and

63.3% often or always trained on a hard surface. Overall, 32.9% of the runners had completed

one or more full marathons and 72.7% had completed one or more half marathons.

11
Table 1. Characteristics of marathon runners of NSIRs versus SIRs
Total runners NSIRs1 SIRs2
Mean ± SD / n (%)
(n=161) (n = 90) (n = 71) P

Demographic characteristics
Sex (female, n (%)) 71 (44.1) 34 (37.8) 37 (52.1) 0.069†
Age (years, mean ± SD) 40.7 ± 11.7 41.7 ± 12.0 39.5 ± 11.4 0.229⁋
Height (cm, mean ± SD 177.7 ± 9.4 178.7 ± 9.1 176.5 ± 9.8 0.143⁋
Weight (kg, mean ± SD) 72.6 ± 12.2 73.2 ± 11.7 71.9 ± 13.0 0.486⁋
Educational level (high, n (%)) 126 (78.3) 72 (80.0) 54 (76.1) 0.547†

Lifestyle factors, n (%)

Smoking (daily smokers) 2 (1.2) 1 (1.1) 1 (1.4) 0.963†
Alcohol use (daily alcohol users) 25 (15.5) 13 (14.4) 12 (16.9) 0.838†
Non-musculoskeletal comorbidity
(COPD, asthma, diabetes, epilepsy etc.) 28 (17.4) 17 (18.9) 11 (15.5) 0.572†
Special feeding supplements
(vitamins B12, C, and D, zinc, magnesium, iron, etc.) 37 (23.0) 24 (26.7) 13 (18.3) 0.211†

Training-related factors
Intention to run the half marathon, n (%) 115 (71.4) 62 (68.9) 53 (74.6) 0.422†
Intention to run the entire marathon, n (%) 46 (28.6) 28 (31.1) 18 (25.4) 0.422†
Training Surface*, n (%)
Hard (often – always) 102 (63.3) 30 (33.3) 26 (36.6) 0.740†
Soft (often – always) 25 (15.5) 61 (67.8) 48 (67.6) 0.817†
Tartan (often – always) 7 (4.3) 33 (36.7) 25 (7.8) 0.766†
Gravel (often – always) 3 (1.9) 30 (33.3) 26 (36.6) 0.740†
Using a heart rate monitor
in endurance plus interval training, n (%)
never 64 (39.8) 30 (33.3) 34 (47.9) 0.061†
rarely-sometimes 15 (9.3) 11 (12.2) 4 (5.6) 0.153†
often-always 58 (36.0) 36 (40.0) 22 (31.0) 0.237†
Already started training at baseline, n (%) 112 (69.6) 62 (68.9) 50 (70.4) 0.834†

(n=112) (n=62) (n=50)

Running frequency/week (mean ± SD) 2.6 ± 1.2 2.8 ± 1.2 2.4 ± 1.2 0.028⁋
Running hours/week (mean ± SD) 2.2 ± 1.5 2.5 ± 1.5 1.9 ± 1.6 0.052⁋

12
 Running kilometres/week (mean ± SD) 26.2 ± 17.6 29.2 ± 19.5 22.6 ± 14.4 0.046⁋

Running experience, n (%)

Completed a 21-km race (≥ 1 race) 117 (72.7) 68 (75.6) 49 (69.0) 0.355†
Completed a 42-km race (≥ 1 race) 53 (32.9) 32 (35.6) 21 (29.6) 0.423†

Running injuries, n (%)

Running injury in previous 12 months 83 (51.6) 30 (33.3) 53 (74.6) 0.000†

* Study participants could choose to train on more than one training surface in questionnaire
† = P-value as a result of a chi-square test
⁋ = P-value as a result of a independent sample T-test
1 = Runners with non-substantial injuries, and runners with no injuries at all in the preparation period, were both considered as non-substantial injured runners (NSIRs). A sum score < 13 for
questions 2 and 3 of the OSTRC but a OSTRC severity score higher than 0 was indicative of a non-substantial injury. A OSTRC score < 1 was indicative for no injury at all.
2 = Runners were considered as substantially injured runners (SIRs) if they had at least one substantial RRI in the preparation period. A OSTRC sum score ≥ 13 for questions 2 and 3 was
indicative of a substantial injury.

13
RRIs in the 12-months prior to this study

At baseline, 51.6% of the runners reported a RRI in the previous 12-months; of these runners

74.6% had a substantial RRI, and 33.3% had no or a non-substantial RRI during the

preparation period (P=0.029) (Table 1). Overall, regardless of history of RRI, NSIRs trained

more than SIRs (2.8±1.2 versus 2.4±1.2 times/week; P=0.028) and ran longer distances

(29.2±19.5 versus 22.6±14.4 km/week; P=0.046). Of the remaining baseline characteristics,

there were no significant differences between the two groups of runners (Table 1).

RRIs during the 16-week period

The mean prevalence of substantial RRIs was 17.7% (95%CI 16.3–19.2%) during the

preparation period. RRIs in the lower leg were most frequently observed (4.27%±1.53%),

followed by RRIs of the ankle (3.05%±0.55%), RRIs of the foot/toe (2.77%±1.43%), and

RRIs of the knee (2.59%±1.52%) (Table 2).

14
Table 2. Mean prevalence of substantial running-related injuries (RRIs) in the 16-week marathon
preparation period per anatomical location.

Anatomical location Mean prevalence† % (SD)

(n = 161)

Head, spine and trunk 1.17 (1.17)

Upper extremity 0.20 (0.40)
Hip 1.64 (1.06)
Groin 0.20 (0.40)
Upper leg (including hamstring) 1.68 (1.08)
Knee 2.59 (1.52)
Lower leg 4.27 (1.53)
Ankle 3.05 (0.55)
Foot/toe 2.77 (1.43)
Other 0.00 (0.00)

† = Mean prevalence of substantial RRIs is the mean of the 8 follow-up assessments during the 16-week preparation period.
The prevalence of RRIs was calculated for each anatomical area each 2 weeks by dividing the number of athletes that
reported a substantial injury by the number of questionnaire respondents.

15
Preventive measures at baseline and during the preparation period

Overall at baseline, 46% of the runners performed warming-up/cooling-down, and stretching

exercises, 14.9% only performed stretching exercises, 3.1% only performed warming-up

exercises, and 1.9% only performed cooling-down exercises (Table 3). In total, 24% of the

runners wore customized shoes, 24% used several pairs of shoes, 21.1% used compression

socks, 18% used insoles, 5% used bandages or kinesiotape, and 2.5% used braces. During the

preparation period, 59.6% used at least one additional, not previously used, preventive

measure. There were significant differences in the use of shoe-advice, insoles, and supportive

materials during the preparation period between NSIRs and SIRs (Table 3).

16
Table 3. Use of preventive measures of marathon runners in NSIRs versus SIRs

Total runners NSIRs1 SIRs2

(n = 161) (n = 90) (n = 71) P

Warming-up plus cooling-down plus stretching, n (%) 74 (46.0) 42 (46.7) 32 (45.1) 0.840
Solely Warming-up 5 (3.1) 2 (2.2) 3 (4.2) 0.655
Solely Cooling-down 3 (1.9) 1 (1.1) 2 (2.8) 0.583
Solely Stretching 24 (14.9) 13 (14.4) 11 (15.5) 0.853

Running shoes and socks, n (%)

Custom shoes 39 (24.2) 21 (23.3) 18 (25.4) 0.767
Shoe advice 97 (60.2) 48 (53.3) 49 (69.0) 0.044
Use of several shoes (for different kind of training or
for different training surface) 38 (23.6) 25 (27.8) 13 (18.3) 0.160
Insoles 29 (18.0) 11 (12.2) 18 (25.4) 0.031
Compression socks 34 (21.1) 15 (16.7) 19 (26.8) 0.119

Supportive materials for knee and/or ankle, n (%)

Brace 4 (2.5) 0 (0.0) 4 (5.6) 0.036
Bandage or kinesiotape 8 (5.0) 1 (1.1) 7 (9.9) 0.022
Brace, bandage or kinesiotape 11 (6.8) 1 (1.1) 10 (14.1) 0.001

Use of additional measures3, n (%) 96 (59.6) 49 (54.4) 48 (67.6) 0.137

1 = Runners with non-substantial injuries, and runners with no injuries at all in the preparation period, were both considered as non-substantial injured runners (NSIRs). A sum score < 13 for
questions 2 and 3 of the OSTRC but a OSTRC severity score higher than 0 was indicative of a non-substantial injury. A OSTRC score < 1 was indicative for no injury at all.
2 = Runners were considered as substantially injured runners (SIRs) if they had at least one substantial RRI in the preparation period. A OSTRC sum score ≥ 13 for questions 2 and 3 was
indicative of a substantial injury.
3 = Runners who used an additional, not previously used, preventive measure ≥ 1 time in the 16-week preparation period.

17
Preventive measures and RRIs

Analysis by history of RRI revealed that 67.9% of the SIRs with a history of RRIs sought

advice regarding their choice of running shoes compared with 43.3% of the NSIRs and a

history of RRI (P=0.029) (Table 4). Of the runners without a history of RRIs, more SIRs had

been given advice about running shoes than had NSIRs, but the difference was not significant

(P=0.288) (Table 4). Moreover, 18.9% wore braces, bandages, or kinesiotape for ankle or

knee compared with none of the NSIRs and a history of RRI (P=0.012). There was no

difference in the use of insoles (P=0.403).

18
Table 4. Preventive measures within those with and without a history of RRI for NSIRs versus SIRs

Total runners NSIRs1 SIRs2

with history of RRI with history of RRI with history of RRI P
(n = 83) (n = 30) (n = 53)

Running shoes and socks, n (%)

Shoe advice 49 (59.0) 13 (43.3) 36 (67.9) 0.029
Insoles 21 (25.3) 6 (20.0) 15 (28.3) 0.403

Supportive materials for

knee and/or ankle, n (%)
Brace, bandage or kinesiotape 10 (12.0) 0 (0.0) 10 (18.9) 0.012

Total runners NSIRs1 SIRs2

without history of RRI without history of RRI without history of RRI P
(n = 78) (n = 60) (n = 18)

Running shoes and socks, n (%)

Shoe advice 48 (61.5) 35 (58.3) 13 (72.2) 0.288

1 = Runners with non-substantial injuries, and runners with no injuries at all in the preparation period, were both considered as non-substantial injured runners (NSIRs). A sum score < 13 for
questions 2 and 3 of the OSTRC but a OSTRC severity score higher than 0 was indicative of a non-substantial injury. A OSTRC score < 1 was indicative for no injury at all.
2 = Runners were considered as substantially injured runners (SIRs) if they had at least one substantial RRI in the preparation period. A OSTRC sum score ≥ 13 for questions 2 and 3 was
indicative of a substantial injury.

19
Discussion

This study investigated whether there are differences in the use of preventive measures at

baseline and during the preparation phase between runners who sustained no/minor (NSIRs)

or moderate/severe RRIs (SIRs) while preparing for a half- or full marathon, stratified by a

history of RRIs. Among runners with a history of RRIs, we found that SIRs more often sought

advice about the choice of shoes compared with NSIRs and that they wore braces, bandages,

or used kinesiotape more often than runners with NSIRs.

There is no evidence that advice when buying new running shoes helps prevent RRIs19-21,

overall 60% of the runners in this study asked for advice when buying running shoes. This

high percentage is in accordance with the 88.8% and 87.5% reported in earlier marathon

studies.6,7 Possibly within those with a history of RRIs, SIRs more often asked for shoe advice

in order to find ways to mitigate their complaints or for secondary prevention compared to

NSIRs. For example, in a recent study of Franke et al. it was reported that mitigation of

complaints and secondary prevention are among the most important reason for runners to use

compression garments.22 These motivations may also apply to SIRs with a history of RRIs

seeking shoe advice. Moreover, a similar explanation could be applied to the greater use of

bandages, braces, or kinesiotape by SIRs with a history of RRIs compared with NSIRs with a

history of RRIs is that the past injury was serious enough to warrant treatment and that they

self-diagnosed and purchased these aids or that their doctor/physiotherapist advised them to

use these aides from then onwards, either to prevent another RRI or to prevent worsening of

the RRI.

There were no significant differences in the use of other preventive measures between the two

groups of runners. Shoe-advice (60%) and warming-up, cooling-down, and stretching

20
exercises (46%) were the most used preventive measures, consistent with the findings of other

studies.6,7,23 Interestingly, these earlier studies concluded that warming-up, cooling-down, or

stretching exercises were neither risk factors nor protective factors against RRIs.6,7,23 Baxter et

al. concluded that (active- and passive-) stretching is not protective for over-use RRIs in

endurance runners.23

We found that 23.6% of the runners used different running shoes for different training

surfaces or for different types of training, whereas an earlier study reported that 86.5% of

runners used different running shoes.6 The difference might be explained by the fact that the

study from van Middelkoop et al. only asked the runners if they used different running shoes

in contrast with our specific questions about the use of running shoes: we asked the runners if

they used running shoes for different training surfaces or different types of training, which

might have excluded the runners who used different running shoes for other or no particular

reasons In addition, in this study 21.1% of the runners wore compression socks to prevent

RRIs. Scientific literature regarding the effectiveness of compression socks on secondary

prevention is scarce. However, this is the most mentioned primary reason for runners to use

compression socks.22 In our study, we did not specify whether the runners wore the

compression socks for primary or secondary prevention, or also for additional reasons such as

curation, or the enhancement of recovery after the running activity.24

We found a significant difference in the history of RRIs between NSIRs and SIRs. A history

of RRIs has been shown to be a strong predictor of the occurrence of new RRIs.2,6,15-18 For

this reason, we performed stratified analyses with history of RRIs as risk factor. We found

significant differences in mean training frequency per week and running distance per week

between SIRs and NSIRs. In the literature, there is no strong evidence that the running

21
frequency or the number of running hours contribute to the occurrence of RRIs.2,15 Therefore,

no stratified analyses were performed for these factors (running frequency and running hours)

in this study.

Strengths and limitations

The major strengths of this study are its prospective design, its 16-week follow-up, its short

recall of RRIs (participants were asked about injuries every 2 weeks), and its use of a

validated questionnaire to monitor the injury status of runners (OSTRC). Moreover,

preventive measures used by marathon runners have never been the main subject of study

before.

A few limitations of this study need to be addressed. The number of participants in our study

was relatively small, therefore caution is warranted when interpreting the results. Therefore it

was not possible to determine whether there were differences in the use of preventive

measures between half and full marathon runners (75% versus 25% of study population). It is

known that there are differences in training characteristics between these runners. For

example, one study showed that half-marathon runners had fewer years of experience

(P<0.05), completed fewer weekly running hours (P<0.01), and ran fewer training kilometres

(P<0.001) compared with full-marathon runners.25 Therefore, it could be hypothesized that

other factors differ between these two groups of runners, such as preventive measures. Further

studies with more participants would enable us to establish whether the two groups of runners

differ in their use of preventive measures. Second, this study may have had selection bias

caused by the self-selection of healthy runners participating in the XXXXX marathon 2016. It

might also be possible that injured runners were more motivated to participate in this study.

This may have led to an underestimation or overestimation, respectively, of RRIs.

22
Conclusion

In conclusion, this study shows that runners used warming-up, cooling-down, and stretching

exercises and advice when purchasing running shoes when preparing for a half- or full

marathon. Overall, 59.6% of the runners used at least one additional, not previously used,

preventive measure during the 16-week preparation period. About half (51.6%) of the runners

had a RRI during the 12 months preceding the start of this study. The NSIRs did not use any

specific preventive measure more often than the SIRs. However, SIRs with a history of RRIs

more often had asked for advice when buying shoes and wore braces, bandages, and

kinesiotape more often. This paradoxical finding might suggest that runners use these

preventive measures because their earlier RRIs have not fully recovered. The use of these

preventive measures could therefore, serve as a signal, alerting health professionals to the

potential development of RRIs.

23
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27
Highlights

• When preparing for a half or full marathon runners use various preventive measures.
• 51.6% of the runners reported at least one RRI in the 12-months prior to this study
(history of RRIs).
• 71/161 (44%) of the runners had ≥ 1 moderate or severe RRI during the preparation
period (substantially injured runners).
• 60% of all runners used at least one additional preventive measure during the study
period.
• Subgroups of runners use various preventive measures.
• Substantially injured runners with a history of RRI more often used brace, bandages
or kinesiotape and more often asked for shoe-advice when buying running shoes.
Ethical statement

Ethical Approval
This prospective longitudinal cohort study is part of the SUccess Measurements and
Monitoring Utrecht Marathon 2016 study, which was approved by the University Medical
Center Utrecht ethics committee (protocol number 15-592).
All runners who participated in this study provided informed consent.
Conflict of Interest file

Conflict of Interest
The authors declare that they have no conflicts of interest.

Ethical Approval
This prospective longitudinal cohort study is part of the SUccess Measurements and
Monitoring Utrecht Marathon 2016 study, which was approved by the University Medical
Center Utrecht ethics committee (protocol number 15-592).
All runners who participated in this study provided informed consent.

Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors

Acknowledgments
None