Beginning a running program is an excellent way to lose weight, improve cardiovascular fitness, and decrease illnesses related to chronic diseases, such as diabetes, hypertension, cancer, and coronary artery disease. The American College of Sports Medicine recommends a minimum of 150 minutes of moderate-intensity exercise a week; however, longer periods of vigorous exercise have resulted in improved cardiovascular fitness in most adults (9). It is reasonable that many seeking the benefits of running would be interested in training for races of increased distance. It should be noted that more than half a million people finished a marathon in 2011 (14).
Traditionally, medicine primarily has been reactive, focusing on diagnosis and treatment of medical conditions after they happen. With a treatment plan, a focus on secondary prevention is often used to try and prevent the illness or injury from reoccurring. Ideally, primary prevention of common ailments facing runners is the better strategy. The purpose of this article is to review strategies for injury prevention in the novice runner.
Hamstring Muscle Strain
Hamstring muscle strains are a very common injury to those in sports that involve running. High-speed lengthening contractions can produce very high joint and muscle forces resulting in pain and tissue damage. Such strains are the most common cause of muscle injuries (10). The athlete typically will present to the doctor with pain in the posterior thigh. This typically occurs during acceleration or deceleration but can occur at any time. The biggest risk factor for a hamstring injury is a previous hamstring injury (22). Other risk factors include age and fatigue. So, a middle-aged runner, in the process of building up his or her training for a longer race, is a likely candidate for hamstring injuries.
Although several methods of hamstring injury prevention have been proposed, there only is one well-done, randomized, controlled trial that has shown a primary preventive effect on hamstring injuries (16). The use of an eccentric hamstring exercise in Danish soccer players reduced the incidence of hamstring injury from 13.1 to 3.8 per 100 player-seasons. This is done by the athlete lying prone (facedown) with either a person or object anchoring the feet. The athlete then performs a “backwards sit-up” at the knees, which strengthens the hamstring. Dynamic stretching exercises and early manipulation therapy (e.g., massage) have been shown to show benefit in secondary prevention of hamstring injuries and may have a preventive effect on other injuries to the lower extremity (11).
Iliotibial Band Syndrome
Another common problem to novice runners is that of iliotibial band (ITB) syndrome. The most common complaint that a runner will have is pain over the lateral femoral condyle (outside of the knee). It is unclear whether it is an impingement of the ITB, a compression syndrome, or inflamed bursitis over the lateral femoral condyle that is responsible for the syndrome. Risk factors associated with ITB syndrome include downhill running, genu varum (outward bowing of the leg in relation to the thigh), foot pronation, and poor hip abductor strength (19).
Although there is no research that clearly demonstrates primary prevention, efforts to reduce the incidence of ITB syndrome include core-strengthening programs, orthotics, and stretching (with a foam roller, running partner, or self) (7). Core-strengthening primarily focuses on the hip abductors (muscles taking the leg away from the midline of the body) as they are thought to play a role in stabilization of the femur in the acetabulum. Recommended abductor exercises include side-lying hip abduction exercises with eventual progression to standing with Thera-Bands (20). Two sets of 15 repetitions are recommended 3 times a day for each leg.
Ankle sprains most often occur as an inversion injury with damage to the anterior talofibular ligament (3). This ligament provides resistance to the foot moving forward in relation to the tibia (shin bone). A complete tear of this ligament will result in ankle instability and potentially predispose the athlete to subsequent ankle sprains. The largest risk factor for an ankle sprain is a history of a previous ankle sprain (21).
Bahr et al. (1) has shown a reduction in the incidence of acute ankle sprain in athletes who undergo physical therapy right after an ankle sprain compared with those who do not. One study evaluating the use of ankle braces in female soccer players has shown significant prevention of recurrent ankle sprains in those who used braces versus those who used other modalities of prevention (17). One of the larger issues with this strategy is that the lack of motion that the brace is designed for may not be well tolerated by athletes in running sports. This may lead to athletes being inconsistent about wearing the brace, making it a less feasible option for primary prevention. A systematic review completed in 1999 concluded that athletes who had sustained an ankle sprain should undergo supervised rehabilitation before return to athletics and that athletes suffering from a moderate to severe ankle sprain should wear appropriate orthoses (ankle braces) for at least 6 months after the injury (21).
Stress fractures are a potentially devastating ailment facing the running community with both physical and mental ramifications. The most common site for a stress fracture is the tibia but it also can occur in the tarsal navicular, metatarsals, fibula, femur, pelvis, and spine (16). Areas at the greatest risk for poor healing include the base of the fifth metatarsal, anterior tibial cortex, superior femoral neck, and the navicular bone (13). This is secondary to the poor blood circulation to these areas that causes prolonged recovery and increases the risk that surgery is the preferred therapy. Risk factors for stress fractures include mechanical causes but also may include an underlying pathology including the female triad (decreased bone density, abnormal menstruation, and disordered eating) or other conditions such as malabsorptive disorders, low testosterone, and parathyroid or thyroid dysfunction (2).
A good preventive strategy for stress fractures is to know your athlete’s medical history. Should he or she have an underlying chronic condition, such as vitamin D deficiency or hypothyroidism, be sure that the condition is well controlled. If abnormal menstruation is occurring, try to identify if it is attributable to an energy imbalance. In addition, should your athlete start a new training regimen, it is recommended that he or she starts at a low mileage and gradually increases his or her mileage each week (17). Orthotics may help in athletes with certain disorders of the foot (15). Many practitioners use video-assisted gait analysis in the rehabilitation program to provide secondary prevention in athletes who have had a previous stress fracture that does not have a clearly identifiable cause. In this setting, a runner’s foot strike, vertical motion, foot mechanics/position, stride length, and crossover gait can be analyzed and altered in a training program. The use of calcium and vitamin D also may show some benefit in stress fracture prevention (15).
Patellofemoral Pain Syndrome
Patellofemoral pain syndrome is a common disorder, accounting for approximately 25% of the knee pain visits to primary care sports medicine clinics (8). Its cause is a combination of mechanical and overuse factors that ultimately contributes to either patellar misalignment or maltracking. The athlete typically will complain of pain in the anterior knee that is worsened with going up stairs or up a hill. Risk factors for developing this condition include a large Q angle (more common in women), sulcus angle (defined by the intersection of the lines connecting the highest point of the femoral condyles to the deepest point of the trochlear groove) and patellar tilt ankle, decreased hip abduction strength, low knee extension strength, and decreased hip external rotation strength (12).
Because of the mechanical nature of this disorder, preventive strategies primarily should be aimed to core strengthening of the hip abductors and external rotators as well as obtaining a strength balance between the vastus medialis oblique and vastus lateralis (6). Surgery with a release of the lateral retinaculum was a previous treatment option; however, this has fallen out of favor and is now used for cases that don’t respond to simple physical therapy (longer than 12 months) (5).
Running is an excellent way to maintain one’s health and fitness. Although many treatment options are available after an injury has occurred, there is not very strong literature from a primary prevention standpoint. Some literature suggests that evaluation and correction of mechanical causes can lead to a reduction in injuries. Some forms of injury prevention can be obtained by ensuring that the athlete’s comorbidities (e.g., preexisting problems) are properly addressed and treated. In our opinion, the following should be considered when advising a novice runner about preventive strategies before beginning a training program:
- 1. perform a thorough medical history that includes menstrual history in females
- 2. evaluation of anatomy and evaluation for potential factors that may be corrected with orthotics (pes planus, etc.)
- 3. prehabilitation physical therapy, with an emphasis on core and hamstring strengthening
- 4. video-assisted gait analysis, with focus on proper running technique
- 5. education on environmental factors, running progression (start at a low mileage and increase by 20% per week), and avoidance of excessive inclines and declines when first starting
- 6. consider the use of calcium and vitamin D supplements
Primary injury prevention is an area of research that would provide a great amount of benefit to the field and (more importantly) to the athlete seeking a long running career. We would encourage those inspired by sports medicine or by running itself to submit high-level evidence-based studies to journals regarding primary prevention.
CONDENSED VERSION AND BOTTOM LINE
In initiation of a training program, mechanics and comorbidities (injuries or illnesses that occur together) can have a significant effect on injury risk in the novice runner. Although there are little data proving the value of primary prevention in this group, it is the opinion of these authors that a personalized approach to this problem (including a thorough medical history, analysis of mechanics, and education) may result in fewer initial injuries to the novice runner.
1. Bahr R, Lian O, Bahr IA. A twofold reduction in the incidence of acute ankle sprains in volleyball after the introduction of an injury prevention
program: a prospective cohort study. Scand J Med Sci Sports. 1997; 7: 172–7.
2. Bennell K, Matheson G, Meeuwisse W, Brukner P. Risk factors for stress fractures. Sport Med. 1999; 28 (2): 91–122.
3. Brukner P, Khan KM. Clinical Sports Medicine. 3rd ed. San Francisco (CA): McGraw-Hill; 2006. p. 612–30.
4. Chung C. Gross Anatomy. 5th ed. Baltimore (MD): Lippincott Williams & Wilkins; 2005. 101.
5. Dixit S, Difiori J, Burton M, Mines B. Management of patellofemoral pain syndrome. Am Fam Phys. 2007; 75 (2): 194–202.
6. Fagan V, Delahunt E. Patellofemoral pain syndrome: a review on the associated neuromuscular deficits and current treatment options. Br J Sport Med. 2008; 42 (10): 789–95.
7. Fredericson M, Weir A. Practical management of iliotibial band friction syndrome in runners. Clin J Sport Med. 2006; 16: 261–8.
8. Fredericson M, Yoon K. Physical examination and patellofemoral pain syndrome. Am J Phys Med Rehabil. 2006; 85 (3): 234–43.
9. Garber C, Blissmer B, Deschenes M, et al. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011; 43 (7): 1334–59.
10. Goldman E, Jones D. Interventions for preventing hamstring injuries: a systematic review. Physiotherapy. 2011; 97: 91–9.
11. Goldman EF, Jones DE. Interventions for preventing hamstring injuries [Review]. Cochrane Database Syst Rev. 2010; 2: 1–42.
12. Lankhorst NE, Bierma-Zeistra SM, van Middelkoop M. Factors associated with patellofemoral pain syndrome: a systematic review. Br J Sport Med. 2013; 47 (4): 193–206.
13. Liong SY, Whitehouse RW. Lower extremity and pelvic stress fractures in athletes. Br J Radiol. 2012; 85: 1148–56.
14. Statistic Brain Research Institute. Marathon Running Statistics — Statistic Brain. 2012. Available from: http://http://www.statisticbrain.com
15. Patel D, Roth M, Kapil N. Stress fractures: diagnosis, treatment and prevention
. Am Fam Phys. 2011; 83 (1): 39–46.
16. Petersen J, Thorborg K, Bachmann Nielsen M, Budtz-Jorgensen E, Holmich P. Preventative effect of eccentric training on acute hamstring injuries in men’s soccer: a cluster randomized control trial. Am J Sport Med. 2011; 39 (11): 2296–303.
17. Romani W, Giek J, Perrin D, Saliba E, Kahler D. Mechanisms and management of stress fractures in physically active persons. J Athl Train. 2002; 37 (3): 306–14.
18. Sharpe S, Knapik J, Jones B. Ankle braces effectively reduce recurrence of ankle sprains in female soccer players. J Athl Train. 1997; 32 (1): 21–4.
19. Strauss E, Kim S, Calcei JG, Park D. Iliotibial band syndrome: evaluation and management. J Am Acad Orthop Surg. 2011; 19 (12): 728–36.
20. Tenforde AS, Sayres LC, McCurdy ML, Collado H, Sainani KL, Fredericson M. Overuse injuries in high school runners: lifetime prevalence and prevention
strategies. PM R. 2011; 3 (2): 125–31.
21. Thacker SB, Stroup DF, Branche CM, Gilchrist J, Goodman RA, Weitman EA. The prevention
of ankle sprains in sports. A systematic review of the literature. Am J Sports Med. 1999; 27: 753–60.
22. Verrall GM, Slavotinek JP, Barnes PG. The effect of sports specific training on reducing the incidence of hamstring injuries in professional Australian Rules football players. Br J Sport Med. 2005; 39: 363–8.