Running Injury

1. Epidemiology
   1. Running is primary Exercise for 40-50 million in U.S.
   2. Overuse is responsible for 80% of Running injuries
   3. Significant injury occurs in 27% of novice runners, 32% of long distance runners, 52% of marathon runners each year
      1. Knee (42%)
      2. Leg and Ankle (28%)
      3. Foot (18%)
      4. Hip (5%)
      5. Low Back (4%)
      6. Thigh (3%)
2. Risk Factors
   1. Prior lower extremity injury
   2. Weekly mileage exceeds 20 to 40 miles (50 to 100 km)
3. Causes: Running Injury
   1. Training Error
      1. High intensity Exercise without rest days
      2. Sudden increase in mileage or intensity
      3. Single intense training episode or competition
      4. Overtraining related conditions
         1. Tibial Stress Fracture or other Stress Fracture
         2. Achilles Tendinitis
         3. Patellar Tendinitis
         4. Plantar Fasciitis
   2. Anatomic Error
      1. Overweight patient
      2. Leg Length Discrepancy
      3. Femoral neck anteversion
      4. Weak or inflexible quadriceps or hamstrings
      5. Genu Valgum or Genu Varum
      6. Q Angle exceeds 15 degrees
      7. Tibial torsion or tibia varum
      8. Gastroc-soleus insufficiency
      9. Patella alta
      10. Pes cavus with high soft tissue arch >3.1 cm
      11. Pes Planus or flat feet (low injury risk)
   3. Functional Error
      1. Over pronation (most common cause)
      2. Excess supination without compensatory pronation
         1. Higher risk in pes cavus foot
         2. Associated with Iliotibial Band Syndrome
   4. Extrinsic Factors
      1. Shoe Problem
         1. Inadequate heel wedge or heel counters
         2. Inflexible soles
         3. Narrow toe boxes
         4. Lateral heel wear
         5. Old Running Shoes with lost shock absorption
            1. Limit to 500-700 km (312-438 miles) per pair
      2. Running surface or terrain
         1. Arched track related conditions
            1. Iliotibial Band Syndrome
         2. Rigid or hard surface related conditions
            1. Tibial Stress Fracture
            2. Shin Splints
            3. Patellofemoral Syndrome
         3. Hill Running related conditions (esp. down hill)
            1. Patellar Tendinitis
            2. Patellofemoral Syndrome
            3. Iliotibial Band Syndrome
         4. Loose surface Running (e.g. gravel)
            1. Meniscus Injury
4. Causes: Common Running Musculoskeletal Injuries
   1. Pelvis and thighs
      1. Adductor Strain
      2. Hamstring Strain
      3. Iliac Apophysitis
      4. Piriformis Syndrome
         1. Consider for Sciatica in runner
   2. Knee
      1. Patellar Tendinitis or Patellar Tendinopathy (most common Knee Injury in runners)
      2. Patellofemoral Syndrome (26%)
      3. Iliotibial Band Syndrome (4%)
   3. Foot, ankle or calf
      1. Achilles Tendinitis (30%)
      2. Medial Tibial Stress Syndrome or "Shin Splints" (13%)
      3. Plantar Fasciitis (5%)
      4. Exertional Compartment Syndrome
      5. Ankle Sprain
   4. Stress Fracture (2-3%)
      1. Tibial Stress Fracture (41%)
         1. Similar presentation to Shin Splints
      2. Metatarsal Stress Fracture, Freiberg's Disease (29%)
         1. Consider for chronic Metatarsalgia in adolescent
      3. Fibula Stress Fracture (18%)
      4. Cuneiform Stress Fracture (6%)
      5. Tarsal Navicular Stress Fracture (6%)
         1. Consider for persistent medial arch pain
5. Management: Injuries
   1. Standard Injury Management
      1. See injury specific therapy
      2. See RICE-M Therapy
      3. See Cold Therapy
      4. Consider NSAIDs for 1 to 2 weeks
   2. Modify training regimen
      1. Reduce or eliminate pain triggering activities
      2. Reduce speed and mileage
         1. Week 1: Slow run, every other day for 1/3 distance
         2. Week 2: Slow run, every other day for 2/3 distance
         3. Week 3: Slow run, every other day for full distance
         4. Week 4: Baseline pace every other day
      3. Consider straight-away runs instead of curved track
      4. Add rest days to training schedule
      5. Move runs to a softer training surface
   3. Cross-Train with other aerobic activities
      1. Wet vest
      2. Biking
      3. Swimming
      4. Stair climbing (Stairmaster)
      5. Ski machine (Nordic Track)
   4. Strengthen and rehabilitate involved muscle groups
      1. Consider physical therapy or athletic trainer
      2. Modalities
         1. Education on stretches and Exercises
         2. Ultrasound (and Phonophoresis and Iontophoresis)
         3. Eccentric Exercises (tendon stretch while loaded)
6. Prevention: Overuse Running Injuries
   1. See Overtraining
   2. Find the right Running Shoes
      1. Change Shoes every 500 miles or every 6 months
   3. Consider Orthotics
      1. Flat foot (Pes Planus)
      2. Over-pronation
   4. Strengthen the quadriceps muscles
   5. Maintain flexibility
      1. Stretch before and after Exercise
      2. Assess knee extension in clinic
         1. Patient supine with hip flexed to 90 degrees
         2. Expect knee extension within 15 degrees of full
7. References
   1. Fields (1997) Lecture: AAFP Sports Medicine, Dallas
   2. Arnold (2018) Am Fam Physician 97(8): 510-6 [PubMed]
   3. Ballas (1997) Am Fam Physician 55(7):2473-80 [PubMed]
   4. Johnston (2003) Can Fam Physician 49:1101-9 [PubMed]
   5. Wexler (1995) Postgrad Med 98(4):185-93 [PubMed]