Prevention of running injuries by warm-up,
cool-down, and stretching exercises
WILLEM van
HAN C. G. KEMPER,* PhD, WIM J.
From the *Department of Health Science, Faculty of Human Movement Sciences, Vrije
Universiteit, and the §Central Computer Department, and the ‡Department of Clinical
Epidemiology and Biostatistics, Faculty of Medicine, University of Amsterdam,
ABSTRACT
The purpose of this study was to evaluate the effect of
a health education intervention on running injuries. The
intervention consisted of information on, and the sub-
sequent performance of, standardized warm-up, cool-
down, and stretching exercises. Four hundred twenty-
one male recreational runners were matched for age,
weekly running distance, and general knowledge of
preventing sports injuries. They were randomly split
into an intervention and a control group: 167 control
and 159 intervention subjects participated throughout
the study. During the 16-week study, both groups kept
a daily diary on their running distance and time, and
reported all injuries. In addition, the intervention group
was asked to note compliance with the standardized
program. At the end of the study period, knowledge
and attitude were again measured. There were 23
injuries in the control group and 26 in the intervention
group. Injury incidence for control and intervention sub-
jects was 4.9 and 5.5 running injuries per 1000 hours,
respectively. The intervention was not effective in re-
ducing the number of running injuries; it proved signifi-
cantly effective (P < 0.05) in improving specific knowl-
edge of warm-up and cool-down techniques in the
intervention group. This positive change can perhaps
be regarded as a first step on the way to a change of
behavior, which may eventually lead to a reduction of
running injuries.
The popularity of running as a form of exercise and recrea-
tion has grown rapidly since the 1970s, first in North Amer-
t Address correspondence and repnnt requests to Willem van Mechelen,
MD, PhD, Department of Health Science, Faculty of Human Movement So-
ences, Vnje Universiteit, van der Boechorststraat 7-9, 1081 BT Amsterdam,
the Netherlands
MECHELEN,*&dagger; MD, PhD, HYNEK HLOBIL,* MD,
VOORN,&Dagger; PhD, AND H. ROB de JONGH,&sect; PhD
Amsterdam, the Netherlands
ica and later in Europe. Reasons for jogging include health
and fitness, pleasure or relaxation, and competition or per-
sonal performance.lo>3’ From a health point of view, benefits
from regular physical activity include reduction of risk fac-
tors for cardiovascular disease, such as obesity, hyperten-
sion, and smoking.’ 5,18 28 38
On the other hand, runners, as any other athletes, sustain
sports injuries. In the Netherlands, van Galen and
Diederiks2° performed a telephone survey on sports injury
incidence with a 4-week recall period. They used a repre-
sentative sample of the Dutch population and included all
self-reported injuries, both medically treated and not medi-
cally treated. Based on their results, calculations were made
for injury incident for the total Dutch population. The total
number of sports injuries was estimated at 2,700,000. In
absolute numbers, running was ranked 4th for the number
of injuries incurred, with 126,000 injuries per year (54,000
medically treated), behind outdoor soccer, volleyball, and
indoor soccer. If running exposure was taken into account,
running was ranked as the 14th injury sport, with 3.6 injuries
per 1000 hours of running (44% medically treated).
Most running injuries are localized to the lower extremity,
with a predominance in the knee .6 1,1 23 24,31,33,37,47,48 Running
injuries are of a diverse nature and vary, as outlined by
Powell et al.,39 from metabolic abnormalities such as anemia,
amenorrhoea, hypothermia, and hyperthermia to extrinsic
hazards such as dog bites and traffic collisions. However,
most running injuries are musculoskeletal injuries associated
with overuse. 2,1 15,17,29,36 This is understandable since run-
ning involves the constant repetition of the same move-
ments.
According to Powell et al.,39 the
etiologic factors related
to musculoskeletal running injuries can be roughly divided
into factors related to the runner, factors related to running,
and factors related to the running environment.
In relation to sports in general, some authors have sug-
711
712
gested stiffness of the muscles of the lower extremity and
subsequent lack of range of motion of adjacent joints as an
athlete-related etiologic factor for musculoskeletal inju-
ries. 1,11,19, 22, 36, 41,42 In terms of the prevention of lower extrem-
ity injuries, it seems advisable to recommend stretching
exercises of muscles of the lower extremity. It is known that
hip flexion can be improved by such exercises. 21
In line with stretching exercises, a lack of or improper use
of warm-up and cool-down techniques is mentioned as a risk
factor for musculoskeletal overuse injuries of the lower ex-
tremity in sports in general22,41 and for running in particu-
lar. 35,39
Sound epidemiologic evidence for the preventive effect of
warm-up, cool-down, and stretching exercises on lower ex-
tremity running injuries is scarce and contradictory. Jacobs
and Berson,24 as well as IJzerman and van Galen,23 found
injured runners stretched significantly more before running
than noninjured runners. Jacobs and Berson reported that
certain stretching exercises, such as the hurdler stretch, can
lead to injury of the medial collateral ligament and to the
medial meniscus. Both studies suggested that runners, who
are at high risk of sustaining recurrent injury, stretch be-
cause they have previous injuries, thereby biasing research
results. Walter et al. 41 found runners who &dquo;sometimes&dquo;
stretch to be at greater risk for injury, in contrast to runners
who &dquo;always, usually, or never stretch.&dquo; They leave this
finding unexplained. Blair et al.’ found that frequency of
stretching was not associated with running injuries. Macera
et al. 32 found that stretching before running was not asso-
ciated with running injuries. With regard to warmup, Walter
et al. 41 found that runners who say &dquo;they never warm up&dquo;
had a significantly smaller risk of running injury compared
with runners who say they &dquo;always, usually, or sometimes&dquo;
warm up. In the same study, regular use of cool-down
exercises was not related to running injuries at all. There
may be a negative, rather then a positive, relation between
the above-mentioned preventive measures and the risk of
lower extremity running injuries, although the findings are
inconclusive.
The purpose of this study was to investigate the effect of
a health education intervention program by which runners
were provided with information that encouraged them to
perform standardized warm-up, cool-down, and stretching
exercises to reduce the incidence of injuries of the lower
extremity. Health education by providing information is
only effective if it is put forward as a planned strategy. Kok
and Bouter2’ argued that such a planned strategy should be
aimed at a favorable modification of the determinants of
health behavior.
Kok and Bouter described attitude as an important deter-
minant of healthy behavior. They refer to attitude as the
knowledge and beliefs of a person concerning the specific
consequences of a certain form of behavior. An attitude is
the weighing of all consequences of the performance of the
behavior as seen by the individual. Consequently, this study
was also aimed at the effect of the health education inter-
vention on knowledge and attitude of runners with respect
to the prevention of running injuries in general and with
respect to warm-up, cool-down, and stretching exercises in
particular.
DESIGN AND SUBJECTS
Design
An experimental black-box design was chosen in which two
groups ofsubjects, a control and an intervention group, are
compared with respect to differences in running injury in-
cidence as a direct effect of the health education interven-
tion. Both groups were also compared with regard to differ-
ences in knowledge and attitude toward the prevention of
running injuries in general and warm-up, cool-down, and
stretching exercises in particular as intermediate effects of
the health education intervention.
We know that age and weekly running distance can be
considered important predictors of running injuries.39 We
therefore decided to match control and intervention subjects
for these two variables. If one assumes that a health educa-
tion intervention by providing information will lead to the
performance of the standardized program of warm-up, cool-
down, and stretching exercises, one should realize that this
requires a modification of behavior. This process of behavior
modification comprises a number of stages that must be
completed if any modification is to be achieved.44 These
stages are as follows: knowledge modification leads to atti-
tude modification leads to intention modification leads to
behavior modification.
Since knowledge is the starting point in the chain of
events leading to behavior modification, we decided to match
control and intervention subjects for their knowledge on the
prevention of running injuries as well.
Subjects and matching
If one assumes a yearly running injury incidence rate of
60%,’ and if the intervention should lead to a significant
(25%) reduction of injury incidence rate,45 both the control
and intervention groups should contain at least 237 subjects
by the end of the experiment if a one-tailed chi-square test
was to be applied.4° To recruit such a number of subjects for
this study, 32,506 questionnaires were sent to all civil ser-
vants employed by the city of Amsterdam, with a request to
participate in a study on running; 1057 questionnaires were
returned from 982 men and 75 women. For reasons of
homogeneity and because of the relatively small number of
responding women, we decided to exclude all female volun-
teers. The responses of 463 civil servants met the criteria
set to enter the study: healthy, no current injury, not home
from work on sick leave, running at least 10 km/week all
year-round, not performing sports as a part of their profes-
sion (police officers and firefighters were excluded), and
written consent to participate in the study.
Age and estimated weekly running distance for these
subjects were gathered from the questionnaire. To facilitate
the matching procedure, we had to first assess the level of

knowledge on the prevention of running injuries of each
subject. This was done using a knowledge and attitude
questionnaire, which was mailed to all 463 volunteers; 421
questionnaires were returned. From the questionnaire, a
knowledge and attitude score was calculated, but only the
knowledge score was used for matching. Subsequently, 421
subjects entered the matching procedure (Fig. 1).
Classes were a way that for each variable
defined in such
the number of in every class was approximately
subjects
equal. Subjects were subdivided into three classes for esti-
mated weekly running distance: 10 to 18 km/week (N
126), 19 to 32 km/week (N 146), and 32 km/week or more
=
(N=149). Subjects were also subdivided into 3 classes for
age: born after October 1, 1953 (N 129), born between
=
October 1, 1946 and September 30, 1953 (N 155), born
=
before October 1, 1946 (N = 137). Finally, subjects were
subdivided into 5 classes depending on their score on the
knowledge questionnaire. Consequently, 45 different cells (3
x 3 x 5) were filled with a minimum of 2 to a maximum of
18 subjects (Table 1). From each cell, subjects were randomly
selected for the intervention (N 210) or the control group
=
(N =
211).
METHODS
General outline of the experiment
The intervention was aimed at a change of behavior by
providing information with regard to warm-up, cool-down,
and stretching exercises. If such an intervention is to be
effective, the &dquo;message&dquo; should meet criteria like attracting
attention, simplicity, recognizability, and clarity. Also, the
estimated reliability of the sender of the message is impor-
tant, as well as the fact that the proposed behavior should
not greatly deviate from the current behavior of the recipient
of the message.26 The actual intervention was planned taking
these factors into account.
Figure 1. Flow chart representing the selection of subjects.
713
TABLE 1
Distribution of subjects according to estimated weekly running
distance and knowledge of prevention of running injuries&dquo;
=
a Knowledge 1 =
very low, knowledge 5 =
very high; see text for
details.
After matching, all subjects from the intervention group
received a booklet with written instructions on the stand-
ardized program. This booklet was specially prepared for use
in this study with the help of the coach of the Dutch National
Marathon team and several other experts. During each of 4
evenings, about 50 to 60 subjects were instructed by the
same coach on why and how to perform the program. All
exercises were practiced in a gymnasium to make sure that
all subjects had understood the contents of the intervention.
Then a 16-week intervention period started, which lasted
from September 12, 1988 until January 1, 1989. All subjects
were asked to continue running in the same way as they had
done before the start of the intervention and they were
asked to keep a daily diary on running distance, running
time, and the occurrence of a running injury. They were also
asked to record their daily compliance with the program:
whether warm-up, cool-down, and stretching exercises were
performed in the prescribed way. This obligation to write
down daily compliance was part of the intervention strategy
and can be regarded as a &dquo;cue to action.&dquo;14
Diaries covered four 4-week periods and were mailed to
and from subjects. At the end of the 16-week intervention
period, postintervention knowledge and attitude scores were
assessed in both the control and intervention groups using
the same knowledge and attitude questionnaire used to
obtain the baseline scores. In addition to this questionnaire,
the control group was asked to fill in a supplementary
questionnaire on their warm-up, cool-down, and stretching
behavior during the intervention period.
To enhance continuous participation of all subjects
throughout the experiment, all subjects were given a t-shirt
and a subscription to the monthly magazine, Runners.
Knowledge and attitude questionnaire
A questionnaire measuring knowledge of and attitude toward
the prevention of running injuries was constructed on the
714
basis of a literature survey.35 The initial knowledge ques-
tionnaire contained 79 questions that were scored on a 3-
point scale (3 points for &dquo;true,&dquo; 2 points for &dquo;don’t know,&dquo;
and 1 point for &dquo;false&dquo;) and 45 attitude questions that were
scored on a 5-point scale varying from 5 points for &dquo;total
agreement&dquo; to 1 point for &dquo;total disagreement&dquo; with an
attitude statement. This questionnaire was tested for valid-
ity and reliability in a pilot study 12 according to a method
described by Swanborn.43 This method applies principles as
described by Ebel.16 The final version of the knowledge and
attitude questionnaire as it was used in this intervention
study contained 56 knowledge questions and 31 attitude
questions. Neither part of the questionnaire contained ques-
tions with an item-rest correlation coefficient of less than
0.20 (this means that the correlation coefficient of each item
with the total score was at least 0.2). Cronbach’s alpha of
the knowledge part of the questionnaire was 0.89 and of the
attitude part 0.79.
From the questionnaire, the following seven scores were
calculated: 1) general knowledge of the prevention of run-
ning injuries, 2) specific knowledge of warm-up exercises, 3)
specific knowledge of stretching exercises, 4) specific knowl-
edge of cool-down exercises, 5) general attitude toward the
prevention of running injuries, 6) specific attitude toward
warmup, and 7) specific attitude toward cooldown.
Intervention
The content of the intervention, as described in the booklet
and as explained during the instruction evening, was based
on a literature survey.35 The intervention consisted of a
warmup of 6 minutes of running exercises, 3 minutes of
loosening exercises, and 10 minutes of stretching to be
performed before each running session. The stretching ex-
ercises included three bouts (10 seconds each) of static
stretching of the iliopsoas and quadriceps muscles, the ham-
strings, and the soleus and gastrocnemius muscles. A cool-
down after each running session consisted of the inverse of
the warmup. Stretching exercises were performed as outlined
above twice a day regardless of running performance.
Injury registration
A running injury was defined as any injury that occurred as
a result of running and caused one or more of the following:
1) the subject had to stop running, 2) the subject could not
run on the next occasion, 3) the subject could not go to work
the next day, 4) the subject needed medical attention, or 5)
the subject suffered from pain or stiffness during 10 subse-
quent days while running. Any injury that met this defini-
tion was to be noted in the daily running diary. Every injury
was also to be reported by a special postage-paid reply form.
Every reported injury was seen by one of the two physi-
cians involved in the project. Location, injured structure,
type of injury, and most likely medical diagnosis were noted.
In case of a reported injury, a subject was excluded from
reentering the study. All diary data gathered after the re-
ported date of onset of injury were excluded from data
analysis.
Data analysis
Incidence was calculated taking exposure into account and
expressed the
as number of newly sustained running injuries
per 1000 hours of running. If applicable, overall differences
between the intervention and control group were analyzed
by applying a two-tailed t-test, a chi-square test, or by
calculating a relative risk and its 95% confidence interval.
Differences in baseline attitude scores between the control
and intervention group were tested by applying a two-tailed
t-test.
The effect of the intervention was assessed by analyzing
differences per cell by means of a one-tailed sign test be-
tween the control and intervention group with regard to
injury incidence per exposure. The effect of the intervention
was also assessed by applying the same procedure for differ-
ences between baseline and postintervention delta values
with regard to knowledge and attitude scores. For all tests,
P < 0.05 was considered statistically significant.
RESULTS
All materials (diaries and questionnaires) were returned by
168 control and 159 intervention subjects. However, at the
end of the intervention 1 cell contained only 1 control
subject, which made comparisons between control and in-
tervention values for this cell impossible. For this reason,
this cell and its subject were excluded from data analysis at
cell level, thereby reducing the number of cells from 45 to
44. Whenever data analysis was performed at group level
the results of this subject were included. Consequently,
results from 167 control and 159 intervention subjects dis-
tributed over 44 cells were analyzed at cell level, and results
from 168 control and 159 intervention subjects were ana-
lyzed at group level. The total drop-out rate after 16 weeks
was 94/421 x 100% =
22.3%.
In Table 2, overall descriptive values of running perform-
ance are summarized for the control and intervention
groups. None of the variables show any statistically signifi-
cant (Student’s t-test, P > 0.05) difference between the
control and intervention groups. The average runner in this
study ran about 2.7 times a week for 8.8 km per session at a
speed of 12.4 km/hr.
Table 3 summarizes compliance with the prescribed inter-
vention as reported by daily diary by the intervention group.
Table 4 summarizes information from the control group
on the performance of warm-up, cool-down, and stretching
exercises during the intervention period. This information
was obtained at the end of the intervention period by ques-
tionnaire.
Since the two methods of data collection with regard to
the performance of warm-up, cool-down, and stretching
exercises during the intervention period were different for
both groups, the results from Tables 3 and 4 can only be
globally compared. The tables show that in both groups a
 715

TABLE 2 per 1000 hours of running (95% confidence limit: 3.6 to 8.0);
Mean and standard deviation of running variables as written down the relative risk for injury was 1.12 (95% confidence limit:
a
by subjects during the 16-week intervention period&dquo; 0.56 to 2.72). To evaluate the effect of the intervention
program, the injury incidence per 1000 hours of running was
calculated per cell for both the intervention and the control
groups. In 13 cells the injury incidence of the control subjects
exceeded the injury incidence of the intervention subjects,
in 14 cells the opposite was found, and in 17 cells no
difference was found with regard to injury incidence between
groups. By applying a one-tailed sign test, these differences
proved not significant (P > 0.05). We concluded that the
intervention program did not result in a reduction of the
incidence of running injuries per 1000 hours of running.
Differences in injury pattern between the control and
intervention groups were analyzed by a chi-square test (P <
0.05 is significant) using information from the 44 evaluated
°
Differences between the intervention and control groups were injuries. No differences were found between the intervention
tested by a two-tailed t-test. (No comparisons showed significant
and control groups with regard to all registered variables:
difference, P > 0.05.) location of injury, injured anatomic structure, medical di-
TABLE 3 agnosis, and nature of injury (acute versus overuse and
Compliance with intervention by the study group (N recurrence of injury). The locations of the 44 evaluated
=

159)a
injuries are presented in Table 5.
All injuries were equally distributed on the left and right
sides of the body. The injured anatomic structures were:
muscle (11), tendon (9), joint (9), tendon-muscle (8), tendon-
bone (4), bone (2), and skin (1). The distribution of the most
likely medical diagnosis was as follows: strain (16), inflam-
°
Data derived from daily diaries. mation (11), sprain (3), blister (1), chondromalacia (3),
miscellaneous (3), and diagnosis not clear (3). Seventy-five
TABLE 4 percent of the injuries were classified as overuse injuries
Performance of warm-up, cool-down, and stretching exercises that had developed over the course of hours or days; 25% of
among the control group (N =
167)
.....................
the injuries were classified as acute. Thirty percent of the
runners had sustained a similar injury some time during
their running careers.
Mean data of both groups were calculated for six knowl-
edge and attitude questionnaire scores. The general knowl-
edge score is not included because the subjects were matched
on this score over the control and intervention groups.

Analysis by means of a two-tailed t-test proved that the

form of warmup and cooldown was performed by about 90% differences between the intervention and the control groups
of the runners, whereas a form of daily stretching exercises were not significant (P > 0.05) concerning baseline score
was performed by about 58% of the runners. for which the two groups were not directly matched (baseline
Forty-nine injuries, 23 in the control group and 26 in the score general attitude, baseline score specific knowledge of
intervention group, were registered in the diaries. Of these warming up, baseline score specific knowledge of cooling
49 injuries, 44 were also reported by means of a postage- down, baseline score specific knowledge of stretching exer-
paid injury reply form and subsequently evaluated. This TABLE 5
means that no information on the nature and location of
Localization of 44 evaluated injuries
the injury was available from 5 subjects. From these 5
subjects, we know only the date on which they reported
themselves in the daily diary as being injured.
Injury incidence analysis was performed using data refer-
ring to the 49 injuries as registered in the diaries. There
were no significant differences between these 2 groups (chi-

square 0.45, df 1, P > 0.05).

= =

For both groups, injury incidence was calculated taking

exposure into account. In the control group, 4.9 injuries per
1000 hours of running (95% confidence limit: 3.1 to 7.4)
were calculated, and in the intervention group 5.5 injuries
716
cises, baseline score specific attitude toward warming up,
and baseline score specific attitude toward cooling down).
We concluded that at baseline there were no differences
between the intervention and control groups with respect to
general attitude and specific knowledge and attitude scores.
The effect of the intervention was also assessed by ana-
lyzing the difference per cell between the intervention and
control groups with respect to general and specific knowl-
edge and attitude scores. For both groups per cell the mean
difference (delta score) between the baseline and postinter-
vention scores was calculated for each questionnaire vari-
able. In Table 6, the mean difference (delta score) between
baseline and postintervention scores is summarized for each
variable.
From Table 6 we concluded that, except for specific knowl-
edge scores of stretching exercises by subjects in the inter-
vention group, all knowledge and attitude scores in both
groups had improved at the end of the intervention in
comparison with the score at baseline measurement. The
improvement of scores of the intervention group with regard
to specific knowledge about warming up, specific knowledge
about cooling down, specific attitude toward warming up,
and specific attitude toward cooling down was significantly
greater when compared with the improvement of scores of
the control group.
We identified, per cell, whether this mean difference (delta
score) was in favor of the intervention or the control group
or whether there was no difference between both groups
with respect to the mean difference (delta score) between
baseline and postintervention scores. The differences in
mean difference (delta score) were then analyzed for signif-
icance by means of a one-tailed sign test. The results of this
procedure are summarized in Table 7. We concluded that,
in comparison with the control group, the intervention pro-
gram had led to a significant improvement of specific knowl-
edge of warming up and cooling down in the subjects of the
intervention group. ,
DISCUSSION
This study was aimed at a change of behavior of runners
with regard to warm-up, cool-down, and stretching exercises.
An important prerequisite in this study is the assumption
TABLE 6
Mean value and standard deviation of the difference (A score) between the baseline and postintervention
variable for both the control and intervention group’
°
Small differences in numbers of subjects (N) within each group
b
P > 0.05 =
not significant.
that there is a positive relationship between preventive
behavior (i.e., warm-up, cool-down, and stretching exercises)
and injury prevention. If this prerequisite is valid, one must
conclude that the intervention in this study has not been
successful since there was no significant effect on the inci-
dence of running injuries per 1000 hours of running at the
level of the matched cells or at group level.
Yet, since the study concerned a health education inter-
vention in which the provision of information played a major
role, the effect of the intervention can also be judged at the
level of the matched cells from changes in knowledge and
attitude of the runners with respect to the prevention of
running injuries in general and from changes in knowledge
and attitude with respect to the specific preventive measures
related to the desired change in behavior. We can therefore
conclude that the intervention has been successful, given
the significant improvement of the specific knowledge scores
of warmup and cooldown in the subjects of the intervention
group compared with the control group. None of the other
measured differences between baseline and postintervention
knowledge and attitude scores showed a significant differ-
ence between the control and intervention groups. From the
standpoint of health education by providing information,&dquo;
this improvement of knowledge of warmup and cooldown
can be regarded as a positive effect of the intervention.
Some remarks with regard to the effects of the interven-
tion must be made. Damoiseaux 13 has argued that the extent
of the modifying effect of health education by providing
information depends on the way in which the information
is provided to the target group: on an individual (person-to-
person) basis, on a group basis, or on a mass media basis
(Table 8). In the present study, the information was provided
on a group basis by means of a booklet and an evening of
instruction. The improvement of knowledge with regard to
warmup and cooldown, but not of attitude or of injury
incidence, is in line with the modifications one may expect
if health education information is provided on a group basis.
Other factors that influence the effect of this kind of
health education intervention are who provides the infor-
mation and whether the provided information &dquo;appeals&dquo; to
the recipients. Ooijendijk and van Agt37 conducted a study
on running injury prevention. Two hundred fifty-six men
and 60 women with an average age of 39 years and an
scores for each questionnaire
are because of missing values on some questionnaire scores.

TABLE 7
Comparison of A scores between the control and the intervention groups’
° Figures given are number of cells in which the score differed.
b NS, not significant.
TABLE 8
Effect of modifying effecta
° The X indicates the maximal expected extent of the modifying
effect of health education by providing information with respect to
the modification of knowledge, attitude or of behavior, depending
on how the subject is approached.
Adapted from Damoiseaux.l3
average weekly running distance of 30 km served as subjects.
These runners were asked by questionnaire if they wanted
to obtain information on injury prevention and, if so, in
what way and from what person. Seventy-six percent of the
runners were interested in information on injury prevention:
78% wanted to obtain information from leaflets and 40% by
oral instruction given by either a fellow runner (61%) or a
coach (41%). In light of these results it seems valid to
conclude that the way of providing information in our study
(booklet in combination with an instructional group session
using a well-known coach as instructor) must have appealed
to our subjects, thereby not hindering the transfer of infor-
mation.
The aim of our study was to bring about a reduction in
the incidence of running injuries by the performance of a
standardized behavior concerning warm-up, cool-down, and
stretching exercises. From the results as presented in Tables
3 and 4, we concluded that in both the intervention and
control groups a form of warmup and cooldown was per-
formed by about 90% of the runners, whereas a form of daily
stretching exercises was performed by about 58% of the
runners. On the basis of this finding, one should question
whether the aim of the study in terms of a change in behavior
with regard to warm-up, cool-down, and stretching exercises
to prevent running injuries, was a realistic one to start if the
same proportion of the control and intervention group show
a more or less similar behavior.
From the study of Ooijendijk and van Agt,37 we know that
most runners (93%) perform some sort of warmup. In their
study, 88% of the subjects performed stretching exercises as
a part of the warmup, and 64% performed a cooldown.
From a preventive point of view, it seems better to focus
future health education intervention strategies on behavior
717
that is not
already conducted &dquo;naturally&dquo; to such an extent
as warm-up, cool-down, and stretching exercises, such as the
early detection of symptoms of overuse injuries, full reha-
bilitation after injury to avoid the recurrence of injury, and
the distribution of training load (running frequency, weekly
running distance, and running speed). These factors are
important predictors of running injury.32,33,47
We know of only 2 large-scale prospective studies con-
cerning running injuries. In the study by Macera et all
monthly diaries were used as a method of data collection. In
their 1-year study, data were analyzed on all subjects who
returned 80% of their monthly diaries, including the last
diary. The drop-out rate in this study was 39% (310 male
subjects). In our study, with a drop-out rate of 22.3%, data
were analyzed only from subjects who had all diaries and
questionnaires present at the end of the study. When com-
paring these two drop-out rates, it should also be noted that
the Macera et al. study lasted 1 year and our study lasted 16
weeks.
In a 1-year prospective study by Walter et al., 47 data were
collected by telephone survey 4, 8, and 12 months after the
start of the study. In their study, 88% of all planned tele-
phone contacts took place. In light of these two prospective
studies, the drop-out rate in our study seems acceptable.
The drop-out rate may have been influenced by the fact that
the intervention took place at the end of autumn and the
beginning of winter when weather condition are usually not
as good as spring and summer. However, a recent national
survey on sports participation conducted in the Netherlands
showed that participation in recreational running is not
much influenced by the season. 21
The runners in this study were all men who ran on the
average about 2.7 times a week for 8.8 km per session at a
speed of 12.4 km/hr. If compared with the populations of
other studies, the average runner in our study can be con-
sidered as representing the recreational runner who runs for
pleasure and health rather than for competition, and who
participates in an organized roadrun every now and
then 6,20,28,32,33,37
Although many researchers in the field of sports etiology
research advise taking exposure to sports participation into
account,3,7,25.30,31,34,46.49 this is seldom the case. We know of
only 3 studies regarding running that calculate injury inci-
dence per 1000 hours of running. van Galen and Diederiks2°
718
found in their retrospective national survey an overall inci-
dence for self-reporting running injuries of 3.6 per 1000
hours of running. Lysholm and Wiklander 31 performed a 1-
year prospective study with competitive male and female
runners from various disciplines: sprint, middle-distance,
and marathon. They found incidences for running injuries
varying from 5.8 injuries per 1000 hours of running for
sprinters to 2.5 injuries per 1000 hours of running for mar-
athon runners. Finally, Bovens et al.’ found, in a prospective
study of 58 men (average age, 35 years), injury incidences
varying with average weekly running distance from 12.1
injuries per 1000 hours of running (average weekly running
distance, 24 km/week) to 7.0 injuries per 1000 hours of
running (average weekly running distance, 44 km/week).
The injury incidences in the present study fall within the
range of incidences found in the above-cited studies. How-
ever, it should be kept in mind that these figures may be
difficult to compare because of differences in definitions and
research methods.3No attempt was made to compare the
injury pattern found in this study with the pattern found in
other studies since potential differences between studies can
be explained by differences in definitions and research meth-
ods, as well as by research outcome.33
CONCLUSIONS
1. In a16-week prospective intervention study in which
matched for age, weekly running distance, and
subjects were
general knowledge regarding the prevention of running in-
juries, the running injury incidence was found to be 4.9
injuries per 1000 hours of running for the control group and
5.5 injuries per 1000 hours of running for the intervention
group.
2. A health education intervention, consisting of providing
information by means of booklet and an instructional group
session aimed at a change of behavior with regard to warm-
up, cool-down, and stretching exercises, did not result in a
reduction of running injury incidence expressed per hours
of running exposure. The intervention did lead to a positive
change of specific knowledge with regard to warmup and
cooldown. No further knowledge or attitude changes were
observed.
In terms of health education by providing information,
this change can be regarded as a positive effect of the
intervention.
3. Regardless of the intervention, 90% of both the inter-
vention and control group performed some form of warm-
up and cool-down exercises, whereas some sort of daily
stretching exercises was performed by about 58% of the
runners. It therefore seems advisable not to focus the pre-
vention of running injuries by a modification of behavior
with regard to these measures, but by a modification of
behavior with regard to the early detection of symptoms of
overuse injuries, full rehabilitation after injury to avoid the
recurrence of injury, and the distribution of training load.
ACKNOWLEDGMENTS
This study was funded by the Dutch Ministry of Health
Welfare and Cultural Affairs as the Dutch contribution to a
coordinated research project of the Council of Europe:
&dquo;Sports for All: Sports Injuries and Their Prevention.&dquo; This
study was also financially supported by the Municipal
Health Authority of the city of Amsterdam and by Sportcom,
publisher of Runners monthly magazine.
The authors express their gratitude to Mrs. Inge Crolla,
MSc, for her work as research assistant.
REFERENCES
1 Agre JC Hamstring injuries Proposed aetiological factors, prevention and
treatment. Sports Med 2 21-33, 1985
2 Andrews JR Overuse syndromes of the lower extremity Clin Sports Med
2 137-148, 1983
3 Backx FJG, Inklaar H, Koornneef M, et al Draft FIMS position statement
on the prevention of sports injuries Geneeskunde en Sport (Special Issue)
May 1990, pp 22-27
4 Berlin JA, Colditz GA A meta-analysis of physical activity in the prevention
of coronary heart disease Am J Epidemiol 132 612-628, 1990
5 Bijnen FCH, Zonderland ML, Enst GCv, et al Bewegen, fitheid en gezon-
dheid Geneeskunde en Sport 24(6) 163-169, 1991
6 Blair SE, Kohl HW, Goodyear NN Rates and risks for running and exercise
injuries Studies in three populations Res Q 58 221-228, 1987
7 Bol E, Schmickli SL, Backx FJG, et al Sportblessures onder de knie ,
NISGZ publication 38 Papendal, the Netherlands, Netherlands Institute of
Sports Health Care, 1991
8 Bovens AMP, Janssen GME, Vermeer HGW, et al Occurrence of running
injuries in adults following a supervised training program Int J Sports Med
10 S186-S190, 1989
9 Clement DB, Taunton JE A guide to the prevention of running injuries
Austr Fam Physician 10 156-164, 1981
10 Clough PJ, Dutch S, Maugham RJ, et al Pre-race drop-out in marathon
runners Reasons for withdrawal and future plans Br J Sports Med 21
148-149, 1987
11 Cornelius WL, Hinson MM The relationship between isometric contractions
of hip extensors and subsequent flexibility in males J Sports Med Phys
Fitness 20 75-80, 1980
12 Crolla I, Cuppens C Het meten van kennis en attitude ten aanzien van
preventie van hardloopblessures: de ontwikkeling van twee vragenlijsten,
doktoraalonderzoeksverslag Master’s thesis Vakgroep Gezondheid-
kunde Faculteit der Bewegngswetenschappen, Virje Universiteit, Amster-
dam, 1988
13 Damoiseaux V Sportblessure-preventie via massamediale voorlichting, in
Rijsewijk van M, Wieberdink EAM, Zuurbier MA (eds) Voorlichting en
Sportblessures Utrecht, Handelijle Centrum GVO, 1986, pp 59-67
14 Dishman RK (ed) Exercise Adherence Its Impact on Pubhc Health Cham-
paign, IL, Human Kinetics Books, 1987
15 Dressendorfer RH, Wade ChE The muscular overuse syndrome in long-
distance runners Physician Sportsmed 11(11) 116-130, 1983
16 Ebel RL Essentials of Educational Measurement New York, Prentice Hall
Inc, 1972
17 Eggold JF Orthotics in the prevention of runners’ overuse injuries Physi-
cian Sportsmed 9(3) 125-131, 1981
18 Eichner ER Exercise and heart disease Epidemiology of the "exercise
hypothesis " Am J Med 75 1008-1023, 1983
19 Ekstrand J, Wiktorsson M, Oberg B, et al Lower extremity goniometric
measurements A study to determine their reliability Arch Phys Med
Rehabil 63 171-175, 1982
20 Galen W van, Diederiks J Sportblessures breed uitgemeten Haarlem, De
Vneseborch, 1990
21 Hardy L Improving active range of hip flexion Res Q 56 111-114, 1985
22 Hess GP, Cappiello WL, Poole RM, et al Prevention and treatment of
overuse tendon injuries Sports Med 8 371-384, 1987
23 IJzerman JC, Galen WCC van Blessures bij lange afstandlopers The
Hague, The Royal Dutch Athletic Association, 1987
24 Jacobs SJ, Berson BL Injuries to runners A study of entrants to a 10,000
meter race Am J Sports Med 14 151-155, 1986
25 Kennedy MC, Vanderfield GK, Kennedy JR Sport Assessing the risk Med
J Austr 2
: 253-254, 1977
26 Kok GJ GVO en sportletsels, in Rijsewjjk MV, Wieberdinck EAM, Zuurbier

ZA (eds) Voorlichting en sportblessures Rijswijk, Ministry of Health, 1986,
pp 41-49
27 Kok G, Bouter LM On the importance of planned health education
Prevention of ski injury as an example Am J Sports Med 18 600-605,
1990
28 Koplan JP, Powell KE, Sikes RK, et al An epidemiological study of the
benefits and risks of running JAMA 248. 3118-3121, 1982
29 Lehman WL. Overuse syndromes in runners Am Fam Physician 29 157-
161,1984
30 Loes M de, Goldie K Incidence rate of injuries during sport activity and
physical exercise in a rural Swedish municipality Incidence rates in 17
sports Int J Sports Med 9 461-467, 1988
31 Lysholm J, Wiklander J Injuries in runners Am J Sports Med 15 168-
171,1987
32 Macera CA, Pate RR, Powell KE, et al Predicting lower-extremity injuries
among habitual runners Arch Intern Med 149 2565-2568, 1989
33 Marti B, Vader JP, Minder CE, et al On the epidemiology of running
injuries Am J Sports Med 16 285-294, 1988
34 Mechelen WV 25 jaar schade door sport Geneeskunde en Sport 23(5)
196-198,1990
35 Mechelen WV, Hlobil H, Kemper HCG How Can Injuries Be Prevented?
NISGZ publication no 25E Oosterbeek, Netherlands Institute of Sports
Health Care, 1987
36 G The prevention and treatment of running injuries J Am Podiatr
Mirking
Med Assoc 66 880-884, 1976
37 Ooijendijk WTM, van Agt L Preventie van hardloopblessures Genees-
kunde en Sport 23(4) 146-151, 1990
719
38 Paffenbarger RS, Hyde RT Exercise in the prevention of coronary heart
disease Prev Med 13 3-22, 1984
39 Powell KE, Kohl HW, Caspersen CJ, et al An epidemiological perspective
on the causes of running injuries Physician Sportsmed 14(6) 100-114,
1986
40 Rumke CL, With C de De grootte van groepen bij het vergelijken van
twee percentages of twee kansen NTVG 121 944-949, 1977
41 Safran MR, Seaber AV, Garrett WE Warm-up and muscular injury preven-
ton. An update Sports Med 8 239-249, 1989
42 Shellock FG, Prentice WE Warming-up and stretching for improved phys-
ical performance and prevention of sports-related injuries Sports Med 2:
267-278,1985
43 Swanborn PG Schaaltechnieken, Theone en praktijk van acht eenvoudige
procedures Meppel, Boom, 1982
44 Vent de TGM, Hlobil H, Mechelen WV Sports injuries prevention by
information and education&mdash;a preparative study Report No 51, Consumer
Safety Institute, Amsterdam, November 1988
45. Vulpen AV Sport for All Sport Injuries and Their Prevention Oosterbeek,
Council of Europe, Netherlands Institute of Sports Health Care, Ooster-
beek, 1989
46 Wallace RB Application of epidemiologic principles to sports injury re-
search Am J Sports Med 16 S22-S24, 1988
47 Walter SD, Hart LE, Mcintosh JM, et al The Ontano Cohort Study of
running-related injuries Arch Intern Med 149 2561-2564, 1989
48 Watson MD, DiMartino PP Incidence of injuries in high school track and
field athletes and its relation to performance ability Am J Sports Med 15
251-254, 1987
49 Wiktorsson-Moller M, Oberg B, Ekstrand J, et al Effects of warming up,
massage, and stretching on range of motion and muscle strength in the
lower extremity Am J Sports Med 11 249-252, 1983