Running Injuries:

Evaluation, Treatment, Prevention

 Objectives
• Discuss Common Running Injuries
• Identify Possible Risk Factors for Running
Injuries
• Briefly Discuss Evaluation of Various
Running Injuries
• Discuss Treatment of Common Running
Injuries
• Review Possible Preventive Strategies

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 Why Run?
• Increase focus on healthy
lifestyle
• Convenient
• Flexible
• Affordable
• Minimal Equipment
• Individual or Group
Participation
• Health Benefits
• Mental Health

3
 Running Injury Incidence

• Annual rates of running

injuries 19.4%-79.3%
• Incidence in those
training for a marathon
is as high as 90%
• Experienced runners are
less frequently injured
• Most injuries are
overuse

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 Running- The Basics

• Gait Cycle
– Begins with heel strike of one foot and ends with heel
strike of the same foot
– Has 2 basic periods, stance 60% and swing 40%
– Stance can be broken into 3 (or 4) phases
• Initial contact, (flat foot), Mid stance, Push/Toe Off
– Swing begins once the foot is no longer in contact with
the ground and has 3 phases
• Acceleration, Mid Swing, Deceleration

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 Running- The Stance Period

Initial Contact Mid Stance Toe- Off

• Foot strike or • Foot makes full • Push off to
impact contact propel runner
• Actively decelerates • Body weight shifts forward
the forward- from rear to
swinging leg forefoot
• Passively absorbs • Lengthening LE
the shock of the with concentric
ground reaction contraction of hip
and knee
extensors
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 Running- The Swing Phase

Initial Swing Mid Swing Terminal Swing

• Foot • Foot positions
advances itself for weight
forward acceptance
through the • 3 Foot Strikes:
air • Rear, Mid,
Fore Foot
Most injurious the moment is
when the foot collides with the
ground
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 Terminology

GRF at initial
contact

• Ground Reaction Force: forces exerted by the ground on the foot

• Impact forces: when foot comes to sudden stop upon impacting ground
• Concern has been with various foot strike patterns creating higher
collision forces
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 Established Risk Factors
• Extrinsic • Intrinsic
– Training – Poor flexibility
program/errors – Malalignment
– Shoes – Muscle imbalance
– Running surface – Previous injury
– Mileage – Running experience
– Competitive nature
– Age/Sex

3 most common independent risk factors:

-Increase in mileage too quickly
-Previous injury
-Competitive training motive
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 Extrinsic Risk Factors-Training
Program
• Ask about training program
– Specific program, cross training, etc
• Running without a break from training
– Training for more than 1 year
• Less is more?
– Running 1-3 days/week less likely to be injured
• Change in training technique
– 1/3 of those injured had changed training technique or
shoes

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 Extrinsic Risk Factors- Mileage

• Ask about Mileage

– Longest run, total distance, recent change
• Running distance is considered to be one
of strongest contributors to injury
• Increase in training distance
– Injury rate increases with >20m/wk
– Increase injuries in marathoners
– Longer races associated with LE injuries

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 Extrinsic Risk Factors-
Shoes
• Ask about and evaluate shoes
– Type, how long worn, recent
change
• No studies with sufficient
quality of evidence for “shoe
prescription”
– Many shoes have medial posts or
varus wedges
• Increase supination
• Shoes should be replaced every
300-500 miles

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 Extrinsic Risk Factors-
Surface Type
• No statistical evidence to
link surface type to injury
rates
• Some surfaces have been
linked to certain injuries:
- Harder- PFPS and tibial stress
- Loose surface- meniscal
- Up/down hill- ITB and patellar
tendinopathy

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 Intrinsic Risk Factors- Previous
Injury
• Ask about previous injury
– Where, when, evaluation and rehab
• Previous injury is a significant predictor of
re-injury
– “The timing of recovery is just as important as the
loading of exercise”
– Incomplete healing, uncorrected biomechanical
abnormality, abnormal functioning of repaired tissue
contributes to re-injury
– Studies have shown the injured runners have an
almost 75% increased risk of sustaining another
injury

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 Intrinsic Risk Factors-
Age and Sex and Experience

• Incidence of injury decreased with age and

increases with less experience
• BUT duration of symptoms of injury
increased in older injured runners
• Mean age of 30-40’s for injuries
• Is there selection bias as only injury free
persons continue to run?

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 Intrinsic Risk Factors-
Malalignment
• Pes Cavus- more rigid foot
– Recurrent stress fractures, PFPS
• Overpronation
• Leg Length Discrepancy
– Anatomical
– Biomechanical
• Muscle flexibility
• Knee alignnment
– Genu Varus: PFPS, ITBFS, Tibial stress fx
– Genu Valgus: PFPS, patellar tendinopathy

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 Intrinsic Risk Factors-
Muscle Imbalance
• Closed kinetic chain theory
– If one joint of lower extremity is not
functioning properly, injuries manifest
in other joints
– Proximal core hip strength needed to
control distal segments
– At foot strike the trunk laterally flexes
towards same side
• Stabilized by balancing contraction of hip
abductors

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 Intrinsic Risk Factors-
Muscle Imbalance
• Hip muscle weakness and overuse injuries
– Injured side
• Weak hip abduction and external rotation
• Hip flexors weaker, hip adductors stronger
• Trend towards hip extensor weakness
• Abdominal muscles control stability of pelvis
– Athletes with injury
• Less core stability
• Lower abdominal performance

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Location of Injury
• 5 most common
injuries:
– PFPS
– ITBF syndrome
– Plantar fasciitis
– Medial tibial stress
syndrome
– Knee meniscal
injuries
• Most injuries are
overuse rather than
acute

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 ITB Friction Syndrome
• Friction between ITB
and lateral femoral
epicondyle
• During foot strike
• Aggravated by
downhill running or
uneven surface
• Exam:
– + Ober’s & Noble
– Tight TFL and gluteal
muscles but weak
strength
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 ITB Friction Syndrome

• Treatment:
– Symptomatic treatment
• Ice, NSAIDs
– Stretching
– Soft tissue friction
massage
• Foam roller, trigger point
– Strengthening hip and
glut muscles
– Gait Analysis
– CS injection

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Case 4

• 35 year old male

• Has been doing a
lot of 5k races
• Started getting
posterior buttock
and leg pain
• Worse on end of
race with stride
lengthening

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 Hamstring Strain
• More related to explosive ballistic activity
• Very high recurrence rate- 30% +
• Most at the muscle-tendon junction of the biceps
femoris
• Exam
– TTP (check ischial tuberosity), deformity, flexibility,
strength
• Graded based on pain and strength
– 1- pain but strong
– 2- painful and weak
– 3- extremely weak but painless

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 Hamstring Strain
• Imaging:
– Pelvic X-ray
• Treatment:
– Relative to the grade
• RICE
– NSAIDs may blunt normal healing
• Crutches if limp or avulsion
– Referral Sports Medicine
– PT
• Soft tissue and manual therapy, modalities
• Stretching, eccentric strengthening, progression to
activities

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 Hip and Pelvis Overuse Injuries
• Gluteal tendinosis
– Pain at the insertion or musculo-
tendon junction and bursa
– Pain with resisted strength testing
• Clam, side lying st leg extension
– PT: eccentric exercises, core strength
– US guided CS inj

• Greater trochanteric bursitis

– TTP of the bursa lateral to the greater
trochanter Gluteus medius bursa
Trochanteric bursa
– Rest, PT with
stretching/strengthening, CS injection

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 Hip and Pelvis Overuse Injuries
• Piriformis syndrome
– TTP, piriformis stretch, pain with
resisted external rotation
• sciatic nerve passes through in 10%
– PT: stretching external rotators,
core strength, massage

• SI joint dysfunction
– TTP over SI joint, leg length
discrepancy, trendelenburg gait,
FABER test
– PT with core stability and focus
on abdomino-lumbo-sacro-pelvis-
hip complex

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 Prevention
• Shoes/orthotics/insoles
– No significant reduction in injuries
– Assess need/response with gait analysis
• Stretching
– Insufficient evidence in reduction of injuries
• Graded program
– To minimize risk of injury most recommend not
increasing training by more than 10% per week
• Cross training and strength training
• Barefoot/chi
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 Conclusion

• Running is a very popular economical

sport
• Multifactorial etiology of running
related injuries
• The history is extremely important in
diagnosis
• Difficult for runners of all levels to
follow the advice to “stop running”

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Thank You

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