Injured! What are the Chances?
Predicting Running Injuries for the Recreational Runner
Abstract
So many recreational runners acquire injuries of various types and many of them wonder why their running partners/groups are not experiencing the same problems. Biomechanical factors, nutrition, previous injury history, overtraining and kinetic chain breakdown are some of the reasons why runners sustain injuries making them take time off or even quit running altogether. Based on research in Health and Human Performance, this article identifies potential causes that may prevent running injury free.
Injured! What are the Chances?
Predicting Running Injuries for the Recreational Runner
By Robin Warnken
Do you ever think about why you suffer from running injuries more than your running partners? You run the same mileage and the same routes, but you are hurting, limping and having to take time off from what you love. Many runners are suffering from injury or pain for many different reasons. Whether you are about to engage in recreational running or have been running for years, what are the chances that you will sustain an injury and what factors determine that injury?
Although overtraining and inconsistent training continue to be the top reasons for injuries in runners, biomechanical, anthropometric and nutritional factors can lead runners through a web of breakdown throughout the body, identifying further risk for injury.
Previous Injury/Existing Conditions
Even if you thought that the injury during high school or even last year was over, it may not be. Whether you had a sprained ankle, knee pain or even a stress fracture, if you did not properly rehabilitate those injuries, you could have muscle imbalances and incomplete repair causing a breakdown throughout the body7. The body is designed to alter, or compensate, in order to take care of itself thus increasing the probability of injury. In the Vancouver Sun Run “In Training” clinics, researchers found that 50% of the injured runners in the training program had suffered previous injury, 42% of them had not completely recovered and suffered from pain and injury during their training16.
If you suffer from low pain including spinal disc compression, bulging disc(s) or degeneration even before you begin a running program, you may be at risk for further injury. A research study by Carrigg and Hillemeyer found that after a seven mile run, the vertebral column height is decreased and is a warning that the high impact of running can promote damage to the spine unless proper care is given2.
From the Foot, to the Knee, to the Hip
Can you hear The Body Song? You know, the song that goes, “The knee bone connected to the thigh bone, the thigh bone connected to the hip bone, the hip bone connected to the back bone…” It’s all connected with what physiologists call the kinetic chain. So, at the “root” of the kinetic chain, we can begin predicting injury patterns based on the type of foot, high or low arch.
Many times Dr. Richard L. Childers, doctor of podiatric medicine, will see a patient that says that he/she was diagnosed with having high arches in the past. But, this high arch structure can change. Dr. Childers says, “Even if patients have had high arches in the past, over time, the tissues (including plantar fascia) in the arch break down causing a collapse in the foot” (oral communication, November 2008). The arch structure of the foot may also be compromised if there is even a slight leg length difference12.
We can take the results of a case study of forty runners, divided into groups of high arch and low arch, to help map injuries based upon the highest percentage of injuries for each group. Twenty of the subjects with high arches reported greater lateral injuries and bone injuries. The group of twenty diagnosed with low arches suffered from a larger number of soft tissue injuries including knee injuries like patellar tendinitis, medial knee pain and general knee pain. In four other studies, patellar femoral pain was deemed the most common injury among runners12,15-17. Both groups reported plantar fasciitis symptoms giving us reason to believe that atypical arch height can increase the chance of injury within the foot18.
In both of the high arch (supinated foot) and the low arch (pronated foot or flat foot) groups, runners can see several different types of injuries that may cause cessation of running. Plantar fasciitis is the inflammation of the plantar fascia that runs along the center of the bottom of the foot. Plantar fascia can become overstretched if it is not properly supported with exercise, strength conditioning or therapy, or the use of orthotics. It causes pain in the bottom of the foot and at the heel as well as tightness in the calf muscles as they try to keep the foot stabilized.
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High Arch |
Low arch |
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Increased risk of tibial stress fractures |
Patellar Tendinitis |
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Lateral Ankle Sprains |
Medial knee pain |
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ITB syndrome |
General knee pain |
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Plantar fasciitis |
Plantar fasciitis |
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Metatarsal stress fractures: 5th metatarsal |
Metatarsal stress fractures: 2nd & 3rd |
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References: (3, 5, 6, 8, 11, 12, 18)
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Several researchers have found that pronation or supination of the foot can lead to further injury in runners. Documented in the chart to the right are the most common injuries according to arch height. The table shows that the risk for stress fractures in the tibia can increase with a high arch. The ankle also becomes marked for a chance at injury and an even greater chance if the foot rolls over a rock or you are running on unstable ground. ITB (iliotibial band) syndrome is shown to be a popular one among those with a high arch. Both arch heights have risks of metatarsal (foot) fractures, but you can see that the high arch group reports more fractures in the 5th metatarsal, on the outside of the foot, compared with the low arch group reporting the majority of stress fractures toward the middle foot and inward (2nd and 3rd). Even though arch height seems to cause a whirlwind of disorder throughout the body of a runner, remember that all bodies are different. The Vancouver Sun Run clinics also found that arch height had minimum effect on training injuries16.
Bone and stress fractures have a complex road to run down, especially with women, nutrition and bone tissue. Nutrition plays a major role in training in any sport and in daily life. Lack of complete nutrition can weaken the bones and increase the risk of osteoporosis and stress fractures in the tibia and beyond4,8,10,14. Without the proper diet in all runners, the ability for repair is limited.
What about the hips? Studies in Health and Human Science have found that the weakness in the muscles surrounding the hip and knee, rather than the infamous Q angle, have a greater negative effect on the knee leading to patellar femoral pain and IT band syndrome13. Although the hip angle may not be responsible, the angle at which the knee presents itself compared to the hip and ankle, lateral to the gait, can increase the risk of injury at the knee and hip if the muscles are weak and imbalanced17. Weight training and cross training are effective in prevention and in rehabilitating previous injuries as well as giving you the perk of greater stabilization, muscle balance and strength needed for the force that is laid upon it during your runs1,9.
Although a pattern may exist, expected injuries based on prediction of injury pattern simply are not 100%. The human body behaves differently for each individual. Injuries are caused by many factors, including improper recovery time. Allan Besselink, physical therapist, injury prevention specialist and coach, reminds us that we need to look deeper into the body on the cellular level to determine stress within the tissues and the importance of recovery time rather than on the structure as a whole (oral communication, November 2008). Many people can run ultra distances injury free. Why? They give the cells enough time to regenerate glucose and collagen in between runs. Is this the missing link as to why some runners experience more injuries than others? Maybe cell biology is much more important than we thought. After all, it is all connected.
Each person should be treated individually and not categorized, although this article is based upon scientific information, if you are suffering from an injury, please refer to your physician.
References
1. Bach DK, Green DS, Jensen GM, Savinar E. A comparison of muscular tightness in runners and nonrunners and the relation of muscular tightness to low back pain in runners. J Orthop Sport Phys. 1985;6(6):315-323.
This comparison study shows the relationship of muscle tightness in runner versus nonrunners with regard to hip movement and low back pain. While this study found no significant correlation between tightness and back pain in runners, it raises awareness about the importance of maintaining muscle balance and strength.
2. Carrigg SY, Hillemeyer LE. The effect of running-induced intervertebral disc compression on thoracolumbar vertebral column mobility in young, healthy males. J Orthop Sport Phys. 1992;16(1):19-24.
Within this correlational study comparing pre-run and post-run vertebral column hieght, there is evidence that while running decreases vertebral column height after a 7 mile run, increasing mileage or even beginning a running program can have a negative effect on someone who already has spinal disc compression, or degeneration issues. This contributes to the previous injury section.
3. Cavanagh PR, Andrew GC, Kram R, Rodgers MM, Sanderson DJ, Hennig EM. An approach to biomechanical profiling of elite distance runners. Int J Sport Biomech. 1985;1(1):36-62.
This study takes into consideration many biomechanical aspects of running and the relationship each has to injury and performance improvement. The study is used in my project by supporting that the shorter leg has greater loading which can lead to fracture or other injuries and to determine injuries due to foot arch height.
4. Dufek JS, Mercer JA, Teramoto K, Mangus BC, Freedman JA. Impact attenuation and variability during running in females: A lifespan investigation. J Sport Rehab. 2008;17(3):230-242.
By using a ANOVA to analyze variance, this study shows that impact varies among age groups in women, giving indication that menstruation, normal or abnormal, can have negative effects on lower extremity bone tissue increasing chances for stress fractures.
5. Engsberg JR. A new method for quantifying pronation in overpronating and normal runners. / une nouvelle methode pour quantifier la pronation chez des coureurs a pied. Med Sci Sport Exer. 1996;28(3):299-304.
After comparing the two groups and using a t-test for analysis of variance, this study shows that overpronators have greater plantarflexion and abduction. This finding leads to ankle instability with pronation increasing a runner’s chances of injury over time.
6. Hasegawa H, Yamauchi T, Kraemer WJ. Foot strike patterns of runners at the 15-km point during an elite-level half marathon. J Strength Cond Res. 2007;21(3):888-893.
This study uses first non-parametric methods because of abnormal distribution of the speed of 50 runners in three groups comparing rear foot strike, mid foot strike and forefoot strikes. After the researchers found a significant value and order of each group (p< or equal to 0.05), they were able to use a Pearson product to determine the order of the group and their contact time at foot strike. This study helped validate that the pronated foot has greater load, leading to greater breakdown, even throughout the body.
7. Hockey J. Injured distance runners: A case of identity work as self-help. Sociol Sport J. 2005;22(1):38-58.
Many athletes continue to run through injury for social purposes, identity and physical and mental habit. This case study helps to support the prediction of injury based on previous or current injury in the recreational runner.
8. Korpelainen R, Orava S, Karpakka J, Siira P, Hulkko A. Risk factors for recurrent stress fractures in athletes. Am J Sports Med. 2001;29(3):304-310.
This study shows that there was no association between weekly running mileage and number of fractures, but does show that a high longitudinal arch can lead to greater forces and time on the midfoot, causing greater chance of stress fractures (especially in the tibia)- through analysis of variance. This study also had two amennhoric women who reported greater stress fractures because of low bmd and supports the greater risk of injury due to lack of proper nutrition.
9. McQuade KJ. A case-control study of running injuries: Comparison of patterns of runners with and without running injuries. J Orthop Sport Phys. 1986;8(2):81-84.
Within this common topic comparing injured and non-injured runners, there was significant difference demonstrating that if runners are experienced and take their time increasing mileage, the chances of becoming injured are less. The runners that were not injured in this case had a well rounded fitness regimen that included weight training and cross training.
10. Micklesfield LK, Hugo J, Johnson C, Noakes TD, Lambert EV. Factors associated with menstrual dysfunction and self-reported bone stress injuries in female runners in the ultra- and half-marathons of the two oceans. Br J Sports Med. 2007;41(10):679-683.
This study, by way of a one way analysis of variance and then a Fisher’s exact test, shows that the female triad of disordered eating, menstrual dysfunction and low bone mass can lead to many injuries in the runner stressing the importance of proper dietary intake – nutrition rather than decreasing the training load.
11. Pohl MB, Mullineaux DR, Milner CE, Hamill J, Davis IS. Biomechanical predictors of retrospective tibial stress fractures in runners. J Biomech. 2008;41(6):1160-1165.
Hip adduction and rear foot eversion can be causes of not only patellofemoral pain/injury but also tibial stress fractures (also noted in reference 8). This descriptive statistic study also supports that if previous injury is not properly taken care of through rehab, the chances of the injury reoccurring is increased.
12. Ryan MB, MacLean CL, Taunton JE. A review of anthropometric, biomechanical, neuromuscular and training related factors associated with injury in runners. Int Sportmed J. 2006;7(2):120-137.
This review article gives a variety of information and resources that helped guide my topic and research.
13. Schache AG, Blanch PD, Rath DA, Wrigley TV, Bennell KL. Are anthropometric and kinematic parameters of the lumbo-pelvic-hip complex related to running injuries? Res Sport Med. 2005;13(2):127-147.
Several studies, and people in general, give us reason to believe that the wide angle (Q angle) of the hip (particularly in women) compared to the knee increases the chance of running injury. After comparison of injured vs. a control group and female vs. male using two-way ANOVA, the results of this study conclude that the relationship does not exist.
14. Smolak L, Murnen SK, Ruble AE. Female athletes and eating problems: A meta-analysis. Int J Eat Disord. 2000;27(4):371-380.
This meta-analysis of 34 different studies supports the need for accurate nutrition in the athletes to prevent bone loss leading to stress fractures.
15. Stefanyshyn DJ, Stergiou P, Lun V, Meeuwisse WH, Worobets JT. Knee angular impulse as a predictor of patellofemoral pain in runners. Am J Sports Med. 2006;34(11):1844-1851.
This comparison study focuses on the relationship between runners that present patellofemoral pain versus those who do not. The researchers found that the abduction of the knee during running can lead to patellofemoral pain, but can be interrupted through footwear or change in running mechanics.
16. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A prospective study of running injuries: The Vancouver Sun Run "In Training" clinics. Br J Sports Med. 2003;37(3):239-244.
Descriptive statistics were used to relate risk factors such as age, BMI, arch height, exercise history, surface, running frequency to the number of running injuries. Significance was set at 0.05, the arch height did not significantly contribute to injury, but the clinic shows that when previous injuries are not 100% rehabilitated, it increases the chance of recurring injury at high percentages.
17. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36(2):95-101.
The analysis comparing an injured group and control group with multiple variables assists in the way of showing the biomechanical affects of the varus knee on injuries in runners, agreeing with the idea of lack of control at the hip and knee complex causing pain or even injury.
18. Williams DS, McClay IS, Hamill J. Arch structure and injury patterns in runners. Clin Biomech. 2001;16(4):341-347.
This study compares the high and low arch in runners using a chi square analysis with promising significance values important and relevant to this topic of discussion.