5 things every clinician should know about managing running injuries

Running-related injuries are one of the most common presentations in private practice clinics, with highly prevalent lower limb injuries including Achilles tendinopathy, bone stress injuries, patellofemoral joint (PFJ) pain, plantar fascia pain and iliotibial band (ITB) pain. These injuries can be debilitating for runners both at a professional and recreational level. Appropriately diagnosing and rehabilitating these injuries is critical to getting runners back on their feet as soon as possible, while minimising the risk of a secondary injury. In this blog, we’ll explore 5 things I learned from Rich Willy’s Masterclass on restoring load capacity in the injured runner.

If you want to learn from the expert himself, watch Rich Willy’s full Masterclass HERE.

1- Age isn’t just a number

There are clear differences in the type and prevalence of injuries sustained in older runners (>40 years old) versus younger runners. Due to changes in soft tissue qualities, such as reduced muscle mass and reduced tendon stiffness, older runners tend to experience a greater incidence of soft tissue-related injuries, including tendinopathies, plantar fascia pain and muscle strain injuries, for example to the calf complex (1, 2). In comparison, younger runners with greater tissue quality will experience more bone and joint-related problems, including bone stress injuries (BSI) and patellofemoral pain.

2 – Why do some get injured and not others?

Ultimately, all running injuries are due to an imbalance where training loads exceed our tissue capacity. While training loads are influenced by factors such as the terrain, intensity, frequency and volume, a number of factors make up our current tissue capacity, including:

• Tissue turnover rate – after loading, tissues such as bone undergo a turnover process, where older, damaged bone is replaced by newly formed bone. Novice runners are poorer at turning over tissues compared to well-trained runners.
• Systemic tissue health – for example, energy deficiency and disease processes such as diabetes will negatively affect tissue health.
• Nutrition – inadequate quantity and quality of nutrition will compromise both energy levels and tissue health.
• Age – young runners will turnover tissue much quicker than older runners and also have different tissue qualities, as discussed above.
• Previous injury in the same area – this is the biggest risk factor for injury. For example, a previous history of shin, knee or Achilles injury, all common running-related injuries, are highly predictive of experiencing a recurrence of the same injury (3).
• Medication – for example the use of certain antibiotics such as fluroquinolones has been linked to an increased risk of tendinopathies.
• Psychosocial factors (stress, sleep etc).

3 – Gait assessment – keep it simple

Assessment of a patients’ running can be as simple or as complex as we like. In his Masterclass, Rich Willy opts for a simple approach to identify the key points, looking for 2 main faults increasing the risk of injury:

a) The proximal mechanism

This is the ‘reduced knee window’ seen as a result of femoral internal rotation and adduction and pelvic drop on foot strike and through the stance phase – essentially meaning there is a smaller gap between the knees throughout the running cycle. This will increase loads on the PFJ, gluteal tendons, tibia and ITB.

b) Over-striding

Landing with the foot anterior to the centre of mass will increase ground reaction forces and muscle forces on bones such as the tibia, as well as the PFJ and ITB (4). If we can hear their foot strike and their shin isn’t vertical, they are likely a big over-strider and may benefit from adjustments to their running technique.

4 – Calf is king

All muscles throughout the lower limb play an important role in the running cycle, but arguably none are more important than the calf complex. The soleus is particularly important, generating forces up to 6-8x bodyweight during running, with the gastrocnemius generating forces up to 3x bodyweight. Ultimately, this means the calf delivers forces of up to 11x bodyweight through the Achilles tendon with running (5). We need to ensure we account for this in our rehabilitation planning, and include high-load strength and plyometric training such as skipping and hopping for the calf and Achilles, to prepare them adequately to perform their critical in running.

5 – When and why to keep runners running

As we all know, runners love to run, and keeping them running through injury if appropriate is highly important. But why? This is important both physically and psychologically. Physically, we need to account for the ‘stress shielding effect’. While sometimes stopping running may be required (for example for a tibial BSI), we need to be mindful that by off-loading a structure, our body will adjust by reducing our current capacity in the injured and surrounding structures. While the symptoms will improve, returning to the previous training load without building capacity again, through resistance training and progressive running loads, will likely lead to a secondary injury. This is important to keep in mind for injuries such as an Achilles tendinopathy, where if symptoms are low and stable, we may be able to keep the runner running throughout their rehabilitation and avoid a significant drop in capacity and fitness (6).

Wrapping up

This blog briefly outlines 5 tips to assist in diagnosing and managing those with running-related injuries. Keeping in mind the patient profile in terms of age and previous injury history is critical to diagnosis, while simple gait assessment and technique modifications (where required), resistance training and running programming are all important aspects of the rehabilitation process.

If you’d like to learn all about running-related injuries from an expert, watch Rich Willy’s full Masterclass HERE.