Internationally, running is one of the most popular, practical, and effective forms of physical activity with participation spanning cultural, age, gender, economic, and education spectrums. Runners live approximately 3 years longer than nonrunners and have a 25% to 40% reduction in premature mortality (1). Despite the numerous health benefits, running also carries a relatively high risk of injury. Running-related injury (RRI) prevalence rates vary with specific populations and researchers’ definition of injury but range from 10% to nearly 92%, with an average of 42.7% (2). Although various risk factors contribute to RRI, a previous injury remains a significant predictor of future injuries and sustaining an injury is the primary reason people quit running (3). Accordingly, universal injury prevention is essential to help runners avoid an initial injury, reduce the risk of subsequent injuries, and optimize their health.
Runners live approximately 3 years longer than nonrunners and have a 25% to 40% reduction in premature mortality. Despite the numerous health benefits, running also carries a relatively high risk of injury. RRI prevalence rates vary with specific populations but range from 10% to nearly 92%, with an average of 42.7%.
RRI prevention approaches are mixed, with most programs focusing on a specific risk factor or injury, but none definitively superior. Effective, comprehensive RRI prevention programs are scarce and necessitate a multifaceted approach because of the various risk factors (4). Regardless of the particular method, education, balance, and strength are foundational to most injury prevention philosophies. Injury management and prevention education inform runners of common risk factors and prudent training modifications (4,5). Functional balance training improves postural control (6), which is recognized to reduce injury (7). Lastly, general resistance training is known to reduce chronic injuries in sport (8), but focusing on hip abductor strength may be particularly valuable for runners (9–12). This article aims to detail a novel multifaceted approach to RRI prevention, including education, functional balance, and hip strengthening, which may serve as a broad and effective RRI prevention strategy.
Given the popularity of running, fitness professionals (e.g., coaches, personal trainers, exercise physiologists) will likely encounter recreational runners in their practice and should be armed with appropriate information to reduce their injury risk. Most runners value injury prevention, and some may already perform basic prevention strategies, but the most commonly reported barrier to implementing injury prevention is not knowing what to do (13). Prevention information can be grouped into several broad categories: personal characteristics, training strategies, running technique, and footwear. Adapted from previous research (4,5), Table 1 describes risk factors and recommendations within each category. Injury prevention education should primarily focus on the modifiable risk factors and strategies; however, a keen awareness of the nonmodifiable (e.g., higher age, previous injury) or slowly modifiable (e.g., underweight or overweight, inexperience with running or exercise) risk factors is valuable to emphasize the elevated need for injury prevention. Fitness professionals are in a uniquely appropriate position to disseminate this vital information among athletes and clients.
TABLE 1 -
RRI Risk Factors and Prevention Recommendations
||Overweight or underweight
||• Start slowly and with partial weight-bearing activities
• Use walk–run intervals
||• Ensure full rehabilitation
• Slowly return to training with walk–run intervals
• Avoid running with pain above 2/10, lingering pain, or increased pain (5)
||Inexperience with running or exercise
||• Build slowly and progress from walking to walk–run, to running
• Follow a training program
||Distance, frequency, overload
||• Stay below ~40 miles/week
• Run between 2 and 6 days/week
• Follow a periodized training plan to allow for adequate recovery
||• Run on softer surfaces such as dirt roads or trails and avoid concrete
||• Use dynamic stretching before running
• If performing postrun static stretching, do so consistently
||• Keep cadence at ~90 steps/minute (count foot strikes on one side)
||• If suffering from recurrent injuries, consider slowly converting to forefoot strike, otherwise, do not alter
||• Convert very slowly or not at all
||• Consider a video analysis to guide shoe selection (neutral, motion control)
• If there are no injuries, avoid switching shoe type
||• Avoid using as a preventative measure, unless suffering from recurrent injuries
||• Watch for wear patterns
• Alternate between multiple pairs
• Replace after 6 months and before 12 months, depending on training volume
Adapted from Fokkema et al.
). Copyright © 2017 BMJ Open Sports & Exercise Medicine
. Used with permission.
Essential to exercise and sport, functional balance incorporates holding a static posture and maintaining that stability with movement (6). Poor postural control (i.e., the inability to effectively stabilize and mobilize) is associated with inefficient kinematics, falls, injury potential, and diminished performance. Functional balance training is recognized to improve postural control (6,7) and, particularly given the dynamic alternating single-legged nature of running, is vital to broad RRI prevention. Keeping specificity in mind, functional balance training for runners must incorporate substantial static and dynamic unilateral activities. The recommended exercises (single-leg stance, single-leg squat, lunges, and single-leg hops) can be regressed or progressed to accommodate client needs and are illustrated below in Figures 1–4. Universal regression and progression variables for functional balance exercises are described in Table 2 and include altering support, vision, surface, and footwear. Performing functional balance training at least two times per week for 8 weeks is recommended to optimize benefits (7).
TABLE 2 -
Functional Balance — General Regression or Progression
||Regress by holding onto a solid object, such as a bar, rail, or doorframe.
||Each exercise should initially be performed with eyes open and potentially in front of a mirror for alignment feedback—progress to closing eyes (14), which requires more proprioceptive awareness.
||Progress from a stable surface (even ground) to unstable surfaces, such as a foam pad or wobble board (14).
||Running shoes can be worn for all exercises, but completing them barefoot will provide an additional challenge to balance and intrinsic foot musculature (15), as would standing only on the forefoot.
- Single-leg stance cues: Maintain ankle, knee, and hip alignment. Keep hips level, spine erect, and a slight bend in knees.
- Specific progressions: Move contralateral arm forward or sideways. Move unweighted leg forward, sideways, or diagonally.
- Exercise session parameters: Hold for 30 seconds. Repeat 2 to 3 times per leg.
- Single-leg squat cues: Maintain ankle, knee, and hip alignment. Keep hips level and spine erect. Avoid moving knee past toes when squatting. Maintain weight over the entire foot surface.
- Specific progressions: During squat movement, reach forward, sideways, or in a half-circle motion with the unweighted leg. Touch contralateral hand to the outside aspect of stance-leg knee or ankle.
- Exercise session parameters: 2 × 10 repetitions for each leg.
- Lunge cues: With left leg planted, step right leg back into a lunge, then return to center and balance for 2 seconds before stepping right leg forward into a lunge and returning to center. Aim to keep the right leg off the ground. Keep the spine erect and knees at ~90° during the lunge.
- Specific progressions: Progress to lateral lunges, transverse-plane lunges, and skater lunges (if standing on the right leg, the left arm and leg move across the body toward the right side into a skating-like position)
- Exercise session parameters: 2 × 5 to 10 repetitions for each leg.
- Single-leg hop cues: Maintain ankle, knee, and hip alignment on takeoff and landing. Land softly from forefoot to heel and hold for 2 seconds. Keep the spine straight. Arms can be in running position or on hips.
- Specific progressions: Hop forward and back, side to side, or diagonally. Hop up and down a stair.
- Exercise parameters: 2 × 5 to 10 repetitions for each leg.
Runners may shy away from resistance training with unfounded fears of bulking up and compromising performance. Yet, aside from muscular hypertrophy, resistance training also influences muscle strength, power, and endurance, making it critical for general wellness and recognized to enhance performance and reduce sports injuries (8). Biomechanically, running has multiplanar elements, but sagittal plane movement is predominant. Without attention to stability, mobility, and strengthening in each plane, runners can experience muscle imbalance and relative weakness in the frontal and transverse planes, leading to injury. Specifically, hip abduction weakness or dysfunction is linked to higher injury prevalence in runners (9,11,12), whereas high hip abduction strength is associated with reduced injury prevalence (10). Accordingly, hip abduction strengthening is essential to include in broad RRI prevention programming. The recommended exercises (clamshells, monster walks, and side planks) can be modified, regressed, or progressed to accommodate each client’s needs and are illustrated in Figures 5–7. General regression and progression can be accomplished by switching between light, moderate, and heavy bands.
- Clamshell cues: Place knees in front of the body such that the shoulder, hips, and ankles are aligned. Keep the hips stacked to prevent the top hip from moving forward.
- Specific regressions: Knee wall press (stand sideways next to a wall on one leg with the other leg at 90° hip and knee flexion, then press bent knee laterally into the wall); standing hip-hike (stand on stair or bench with one leg, let the other leg drop toward floor and raise back up, ensuring hips only move in the frontal plane); glute bridges with a band just above knees (push out against a strong band while raising into the glute bridge).
- Specific progressions: Switch to bands of increasing tautness just above the knees.
- Exercise parameters: 2 × 10 to 15 with a 2-second hold in the open position.
- Monster walk cues: Keep feet pointing straight and think about leading with the heels.
- Specific regressions: Standing hip abduction with bands or cables, side-lying hip abduction sliding leg up against a wall.
- Specific progressions: Use progressively stronger bands.
- Exercise parameters: 2 × 10 to 15 with a 2:4 (concentric–eccentric) tempo
- Side plank cues: Keep feet, hips, and shoulders stacked and in alignment. Maintain a straight spine.
- Specific regressions: Use knees (bent at 90°) instead of feet for support.
- Specific progressions: Add hip dip, star planks (top leg abduction while in plank position)
- Exercise parameters: 2 × 30-second hold. Alternatively, if performing hip dips or star planks, perform 2 × 10 on each side.
Most fitness professionals are familiar with periodization. We frequently schedule strength and cardiorespiratory or “cardio” sessions systematically and strategically, allowing for appropriate training stimuli and recovery. A component of injury prevention, as mentioned above, is following a periodized run training program, and ideally, injury prevention exercises should be integrated into that plan. Corrective exercises (e.g., improving balance and specific strength) are typically the main focus of the off-season and early-season phases of the macrocycle. It is well established that entering the primary training season, or in-season, with a stronger and more stable foundation leads to enhanced performance and injury reduction. Contrary to these standard periodization principles, many injury prevention programs to date are conducted concurrently with in-season training. Accordingly, we recommend implementing the focused RRI prevention strategies described above during the off-season phase of the macrocycle, although they can be implemented at any time for those not following a periodization schedule.
Another strategy for RRI prevention is incorporating dynamic stretching exercises in the warm-up. This remains consistent when performing prevention exercises. Exercise and fitness professionals should guide clients though a thorough warm-up, such as described in Table 3, before beginning the functional balance training and hip strengthening program.
TABLE 3 -
Dynamic Warm-up (~5–8 minutes)
|Easy jogging or jogging in place
|Static stretching (calves, iliopsoas)
||30 seconds each side for both muscles
|Dynamic stretching (deliberate leg swings front to back and side to side)
||×10 on each side
|Double-leg jumps (front to back and side to side)
||×5 on each side
Running is an extraordinarily popular form of physical activity with numerous health benefits. However, there is a relatively high risk of injury, which may negatively impact runners’ daily activities, prevent them from reaching health goals, and result in incurred medical expenses or time lost from work. Because of the varied risk factors, universal RRI prevention must take a multifaceted approach and include education, functional balance, and hip strengthening. Preferably, corrective exercises and prevention strategies will commence at least a couple of months before structured run training, allowing for a stronger foundation to begin the season. Fitness professionals are in an ideal position to disseminate risk factor information, personalize the functional balance and strengthening exercises, and reduce their clients’ injury potential.
BRIDGING THE GAP
RRI prevalence is relatively high among recreational runners. Risk factors are numerous and varied, requiring a multifactorial approach to injury prevention. Learning about and addressing the main risk factors along with performing functional balance and hip strengthening exercises can reduce injury risk and facilitate progress toward health and fitness goals.
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