PLAY IT SAFEInjury Prevention in the Novice Runner

by David Tietze, M.D. and Thomas M. Best, M.D., Ph.D., FACSM

LEARNING OBJECTIVES

To have the reader gain a further understanding of common

injuries to the novice runner. In addition, the reader should gain an

understanding of potential preventive strategies.

Key words:Running, Injuries, Novice, Prevention

INTRODUCTION

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 SportsMedicine

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.

MUSCULAR INJURY

Hamstring Muscle StrainHamstring muscle strains are a very common

injury to those in sports that involve running.

High-speed lengthening contractions can pro-

duce 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

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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 SyndromeAnother 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 SprainAnkle 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).

BONE INJURY

Stress FracturesStress fractures are a potentially devastating ailment facing the

running community with both physical and mental ramifica-

tions. 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 condi-

tions such as malabsorptive disorders, low testosterone, and

parathyroid or thyroid dysfunction (2).

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Copyright © 2014 American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

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 men-

struation 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 hermileage eachweek (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 iden-

tifiable 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 SyndromePatellofemoral pain syndrome is a common disorder, account-

ing 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).

CONCLUSIONSRunning 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 lowmileage and increase by 20%perweek), 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.

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Disclosure: The authors declare no conflict of interest and do

not have any financial disclosures.

David Tietze, M.D., currently is a fellow of

Primary Care Sports Medicine at The Ohio

State University. He holds membership with

ACSM and AMSSM. His training includes

medical school at the University of Oklahoma

and internal medicine residency at Baylor

University Medical Center of Dallas. He is

going to join Texas Metroplex Institute in

Arlington, TX, this fall.

Thomas M. Best, M.D., Ph.D., FACSM, is

the Pomerene Endowed Chair of Primary

Care at The Ohio State University. He

holds joint appointments in the College of

Engineering and the School of Allied

Health Medical Professions. An active

member of ACSM for 21 years, Dr. Best

is a fellow and the 2010 to 2011 president.

He is an associate editor-in-chief of Medicine & Science in

Sports & ExerciseA and serves as an Associate Editor for

Current Sports Medicine Reports.

CONDENSED VERSION AND BOTTOM LINE

In initiation of a training program, mechanics andcomorbidities (injuries or illnesses that occur together)can have a significant effect on injury risk in the novicerunner. Although there are little data proving the value ofprimary prevention in this group, it is the opinion ofthese authors that a personalized approach to thisproblem (including a thorough medical history, analysisof mechanics, and education) may result in fewer initialinjuries to the novice runner.

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Injury Prevention in the Novice Runner

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