Subjective Assessment of Running Injuries
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Running is a popular sport. Running is an acceptable and well-known choice of health, sports and leisure activity. It is well promoted and highly desirable for many people. Endurance running has benefits on body mass, body fat, resting heart rate and cholesterol levels. Runners live an average of 3 years longer than non-runners, with a 25-40 percent reduction in risk of premature mortality.
Running, like most sports, can also lead to injury and or dysfunction, as running puts specific high loads and demands on joints and soft tissue. Statistically speaking, 25 percent of long-distance runners are currently injured, and about half of these injuries interfere with daily activities and cause restrictions for a period of time.
The incidence of running-related injuries (RRI), ranges from 18.2% to 92.4%, with a prevalence rate ranging from 6.8 to 59 injuries per 1,000 hours of training.
Running-related injuries (RRI) are defined as musculoskeletal ailments that are attributed to running, which cause a restriction of running speed, distance, duration, or frequency for at least 1 week. These injuries are usually induced by overuse and repeated musculoskeletal microtrauma. RRIs are influenced by several risk factors such as the personal characteristics of the runner, training overload (volume, overall weekly distance) and running experience.
A systematic review showed the overall injury rate was 20.8 injuries per 100 female runners and 20.4 injuries per 100 male runners.
Subjective History Considerations
Types of Running
Not all running is the same. Different types of running have different characteristics and specific aspects should be considered for each. When asking your patient about the type of running, it is good to know about external factors that influence running such as running ground, gears, type of shoes and the runner's rhythm or style of running. Specific shoes for specific terrains are important, as they protect the foot structure and provide better gripping for the runner.
Road running: Road running is free, easily accessible and will offer the largest continuous route to run on. From a safety aspect, road runners may have their safety compromised by sharing the road with vehicles in areas where there is no dedicated running lane. Some roads may be in hilly areas, which may in turn make road running less desirable for beginner runners.
Trail running: Trail running is always different. The dynamics change based on the type of trail. The rhythm tends to be slower in long, sandy roads or long dirt roads. Mountainous or local trails involving uneven surfaces or grounds cause cadence and step rate to change rapidly when compared to road running where cadence remains similar throughout the run. Running uphill and downhill create different loading. Side to side movement might be expected when a runner is climbing unlike on the road. Trail running usually requires special trail running shoes.
Treadmill running: Treadmill running is convenient, but it is always difficult to recreate natural "road" conditions on a machine. Many long distance athletes will stay away from treadmill running or training as the biomechanics demands are so different to road running. The treadmill surface is smoother compared to the road and more bouncy. However, the biggest factor to consider is that the runner and treadmill belt move on the treadmill, whereas the road does not move during road running. Thus. the treadmill impact factor may need to be considered. Treadmill running is ideal for someone who wants cardiovascular exercise in combination with other gym based exercises. There is also a safety aspect to consider with treadmill running/walking, especially with older people.
Track running: Track running is unique. It is ideal for short to middle distance athletes. Track athletes often do warm-ups in the opposite direction of running in order to avoid muscle shortening on the one side if they are leaning into the corners the whole time. Track shoes are also different. They have very little to no cushioning, and they have studs underneath for gripping. Track runners generally are going to be faster athletes with a very different running style. They mostly run on their toes and high power is needed.
Triathlons: Running is the third and final discipline in a triathlon after swimming and cycling. The the success of the running leg of a triathlon is determined by the performance of the athlete during the swim and the cycle. If athletes push too hard during the swim and cycle, they may struggle during their run. Many triathletes have one strong discipline and one weaker one. Training for a triathlon may involve focussing on individual disciplines initially and then combining multiple disciplines during a training session closer to the event.
Pace refers to the average speed of running. Pace is usually tracked on a sports watch or smartphone application such as Strava. We can classify runners by their pace.
- Average runner tends to run at 5.30 minutes/ km
- Medium runner tends to run at five, 5:40 to 6-6:30 minutes per/km
- Slower athlete tends to run at 6:30-7 minutes and above per/km
Tracking your pace can help when the athlete is returning to running after an injury, as they can compare their speed to their pre-injury speed as a baseline. It is also an excellent way to set goals.
Cadence refers to steps per minute. Cadence can be tracked on a smartphone application. Cadence can indicate over-striding, which refers to the position of the foot placed in front of the midline when running which predisposes the runner to injuries. Depending on the trail, faster runners tend to be over 180 steps per minute on a trail run.
Stride length is dependent on the height of the runner, and their cadence should also be taken into consideration when measuring stride length. This objective measure is used to reflect the effort and energy expenditure into running. Different styles of running will have different energy expenditures for different people.
Running Experience and Races
Some runners have been running regular specific distances for years, and have completed many races successfully and injury free. Over the years of running, they build running capacity and their connective tissue has been primed to take load. This gives an idea on their duration of running, the capacity of their lower limb muscles and connective tissue, their history of injuries and the races a runner has participated in. Some runners are very new to running, and they are still unsure about what kind of a runner they want to be, or whether they want to take up running as a long term sport at all. Some runners are only training for one or two specific events. All of these factors are important as they will give a baseline of what the runner is expecting, or hoping to achieve. Some of the running goals set by patients may also be unattainable in short time frames and busy training schedules. The more experienced runners are often more reasonable when it comes to seeking help, and often know when to back off from running at the right time to prevent a niggle from turning into an injury. This can help plan out the injury rehabilitation, prevention and next race.
Strength training is an essential component to running, especially when it comes to building running capacity. Strength training may involve running related strength training such as hill work, and non-running related strength training such as free weight functional exercises. It is important to ask a runner about their strength training regime (if they have one at all).
A running coach is often the next step for a novice runner who wants to move up in the ranks and improve their performance. Running coaches could be employed on a short term basis (to improve technique), or more long term to improve long term performance. Coaching could be face to face or online, especially with running smart watches and applications to track your running statistics. Collaborating with coaches as a physiotherapist can yield benefits in addressing the runner's injuries and training programme.
Running clubs are a great way of committing to running. Running clubs offer the social support and training structure and opportunities that many runners need for motivation. Other runners in the club can offer training tips and support, and there is often secondary support for club members during major races. Some running clubs are also more professional, and specifically only recruit runners to join who have achieved threshold race paces. Some of these runners may be financially remunerated to be a member of the club.
Goals of Running
Understanding the reasons why people run (e.g. weight management) is important to help motivate and address the psychological aspects of running. The language that patients use to describe their motivation for running is key to understanding any emotional pressure they experience and also to learn what drives their running. Some runners may never lack motivation or drive to run, and some runners may not be happy with advice to manage their running load during or after an injury. Establishing a baseline for every patient gives the physiotherapist insight into the runner's goals.
Caution for Ultra Marathon Runners
Ultra marathon runners are particularly at risk of developing the follow conditions during and or directly after an ultra marathon.
- Digestive problems
- Gastro-intestinal bleeding
- Cardiovascular changes
- Renal impairment
- Upper respiratory infections
- Musculoskeletal problems
These factors may need to be considered during a subjective assessment of a ultra marathon runner.
- Vitez L, Zupet P, Zadnik V, Drobnič M. Running injuries in the participants of Ljubljana Marathon. Slovenian Journal of Public Health. 2017 Oct 9;56(4):196-202.
- Lee DC, Brellenthin AG, Thompson PD, Sui X, Lee IM, Lavie CJ. Running as a key lifestyle medicine for longevity. Progress in cardiovascular diseases. 2017 Jul 1;60(1):45-55.
- Fields KB. Running injuries-changing trends and demographics. Current sports medicine reports. 2011 Sep 1;10(5):299-303.
- Saragiotto BT, Yamato TP, Junior LC, Rainbow MJ, Davis IS, Lopes AD. What are the main risk factors for running-related injuries?. Sports medicine. 2014 Aug;44(8):1153-63.
- Hollander K, Rahlf AL, Wilke J, Edler C, Steib S, Junge A, Zech A. Sex-Specific Differences in Running Injuries: A Systematic Review with Meta-Analysis and Meta-Regression. Sports Medicine. 2021 Jan 12:1-29.
- Rehabilitation of Running Biomechanics. (2020, October 27). Physiopedia, . Retrieved 00:17, March 30, 2021 from https://www.physio-pedia.com/index.php?title=Rehabilitation_of_Running_Biomechanics&oldid=257618.
- Nunes D. Subjective Assessment of Your Runner Course. Physioplus (2021)
- Knechtle B, Nikolaidis PT. Physiology and pathophysiology in ultra-marathon running. Frontiers in physiology. 2018 Jun 1;9:634.