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A Closer Look At Preventing Running Injuries

Noting a recent case involving a 36-year-old runner who presented with left lateral ankle pain with no obvious precipitating cause, these authors provide a comprehensive review of the literature on injury prevention in runners.

A 36 year-old female reported to the clinic with a chief complaint of left lateral ankle pain for the last 10 days without any traumatic injury or specific inciting event. The pain gradually worsened over the last week. She has been training for a marathon, which is in nine days. While she has already completed her longest training run, the patient is now starting to have pain with walking. She has pain along the peroneal tendons and with active strength testing. The patient also has mild pain to the lateral most aspect of her Achilles tendon at the insertion. She has been using supportive running shoes with a heat molded over-the-counter insert that she had for about the last year. Although her diagnosis is rather clearly and easily presenting as peroneal tendonitis and mild Achilles tendinitis from overuse, her question is much more difficult: “What did I do wrong?”

Reviewing her training log, it is typical for a marathon buildup with the replacement of shoes within a reasonable time, denial of running on uneven terrain, etc. Fortunately, with rest (aqua jogging allowed) and the addition of a small lateral wedge to her insole, her pain improved, she completed her marathon and continued to improve (more rest was actually prescribed). However, the question remains: can running injuries be prevented?

Unfortunately, this scenario is rather common. According to a systematic review, the incidence of any lower extremity injury in long distance runners reportedly ranges from 19 to 79 percent with a 32 percent incidence of foot injuries and a 9 percent incidence of lower leg injuries.1 The wide range of incidence can be explained, in part, by the vague terms of both “injury” and “runners.” Injuries in some studies can be self-reported and rather minor, resulting in no or minimal loss of participation whereas others can lead to permanent cessation of running. The term “runner” can range from ultra-marathon participants to the novice. Not surprisingly, ultra-marathoners have a high incidence of injuries (65 percent in one systematic review) but in comparison to the novice runner, they have low rates of injury per exposure hours (7.2 injuries per 1,000 hours in the ultra-marathoners in comparison to 17.8 per 1,000 hours in the novice runner).2,3 It is also important to note that the majority of running injuries are considered overuse injuries such as Achilles tendinitis, plantar fasciitis, stress fractures, etc.4

Considering the elevated rate of injury, one has to wonder if running is worth these risks. Looking at mortality data, it appears that the long-term benefits outweigh the short-term injury risks. Running, even at lower doses or slower speeds, is associated with a significant life expectancy benefit. In general, runners have a 25 to 40 percent reduced risk of premature mortality and live approximately three years longer than non-runners.5 More specifically, runners have a 30 percent lower adjusted risk of all-cause mortality and a 45 percent lower risk of cardiovascular mortality.6 Several studies have suggested slightly lower or no mortality benefit at higher doses of vigorous activity.7-9 Other studies show a linear dose-response relation between running and the risk of cardiovascular disease with greater benefits at higher doses of running.6,10-13

Running And Osteoarthritis: What You Should Know

Another concern is the possibility of developing early osteoarthritis. As we have already discussed, running puts individuals at an increased risk for trauma and injuries that are consequently risk factors for osteoarthritis.14 However, running promotes a lower body mass index, combating a known risk factor for osteoarthritis.15-19 Exercise may also increase both articular cartilage volume and glycosaminoglycan content, and prevent the loss of proteoglycans.20-23 Cartilage thinning and focal loss of proteoglycans are prominent features with osteoarthritis.14,21,24

The notion that running may propagate osteoarthritis is controversial but the literature is heavily in favor of no causal relationship. Marti and colleagues found an association with running pace, and in a survey of physical activity that included running, Cheng and coworkers found an association in a subset of individuals less than 50 years old.25,26 However, the majority of published work seems to find no difference and some even have found a possible protective effect.27-30 In a recent meta-analysis, recreational runners had a lower risk of osteoarthritis in comparison to both competitive runners and sedentary individuals.31

Moderation once again appears to be essential. One concern with some of the studies is that runners who develop osteoarthritis become non-runners, creating a selection bias. However, many of the studies were longitudinal with long durations of follow-up to control for this concern. It appears quite unlikely that osteoarthritis is a consequence of running for most. Conversely, there is strong evidence that age, prior joint injury, greater body mass index, heavy manual labor and cutting sports are associated with the development of osteoarthritis.27,32-38

Pertinent Insights On Stretching, Strength Training And Proprioception Training

Some of the most common advice runners will hear is to stretch. Although this advice seems logical, the data just does not support these claims. In a meta-analysis including 26 randomized trials of interventions to prevent sports injuries, stretching had no effect on injury rate whereas strength training and proprioception had a significant effect on lowering injury rates (relative risk of 0.3 and 0.55 for strength and proprioception respectively).39

This should not be taken as evidence to stop stretching but merely to redirect the emphasis of stretching to other areas much more likely to impact the incidence of injury. One randomized study actually found an increase in rate of injury in runners who typically stretch and were randomized into the no stretch group.40 Not only is it surprising that the meta-analysis from Lauersen and coworkers did not find stretching to impact injury rates but also the degree to which strength and proprioception training decreased injuries.39 Certainly, clinicians should pay more attention to these two interventions. Of note, the meta-analysis by Lauersen and colleagues was not specific to runners but rather to multiple sports and nonspecific to injury location.39 Thus, this data is extrapolated but extremely promising. There are registered trials underway.41,42

How much, how often and what specific exercises are best is not entirely clear, but strength training is generally recommended at least two times a week. Decreased muscle strength to the plantar flexors of foot, quadriceps, hamstrings and hip abductors have all been associated with common running injuries.43-46 Thus, strength training that incorporates these lower extremity muscle groups is often targeted. The advantages of strength training also appear to improve running performance  with running economy being a critical factor in long-distance running.47-51 In a recent systematic review of strength training, Blagrove and coworkers found that the addition of strength training (heavy resistance, explosive resistance and plyometric training) on two to three occasions per week will likely improve middle- and long-distance running performance.47 Informing runners of the dual benefit of reduction of injury risk and improved performance will likely result in higher adherence.

Proprioception training is closely related to strength training but incorporates functional movements in order to improve neuromuscular control. Often individuals are performing both in exercises such as single leg squats. Functional balance training for lower extremity strength reportedly increases muscle strength and equalizes muscular imbalances.52,53 Isolated ankle exercises may also result in increased joint stability and reduce joint loading.54 Combining these exercises with strength training is likely more convenient for the runner.

Do We Overemphasize The Role Of Running Shoes In Preventing Injuries?

As podiatrists, most of us have been questioned as to the best running shoe for an individual. Although this is the prevailing preconceived notion, data is rather weak for any specific shoe. Shoe technology has grown rapidly over the last 30 years but reported injury rates have been arguably unchanged during this time.55 In 2011, a Cochrane review found no significant reduction in injuries with wearing running shoes based on foot shape in comparison to standard running shoes.56

However, since 2011, two randomized trials from Malisoux and colleagues have suggested there may be some reductions with pronation support in pronators and lower heel drop heights in occasional runners, indicating that shoe design may, as previously believed, impact injury rates in subsets of populations.57,58 Others have suggested that foot type may be an oversimplification and have suggested comfort may be important to an individual’s “preferred movement pathway.”59

 Still others have advocated barefoot or minimalist running shoes. Frequently, the absence of data supporting that shoes reduce injury rates is used as an argument for minimalist shoes but here again, the same argument could be reversed. Transitioning to minimalist shoes can also be burdened by extremely high injury rates.60 Forefoot striking patterns have decreased the demand on the knees and anterior compartment of the lower leg, but at the cost of increasing force to the ankle, Achilles and forefoot.61,62 This tradeoff and the fact that the majority of injuries are overuse injuries suggests minimalist shoes will likely decrease injuries at certain locations and increase injuries at others. Thus, minimalist shoes may be much more inviting as a treatment for certain individuals (such as exertional anterior compartment syndrome) rather than the general population. Others have discussed the pros and cons in much more detail.63

Customized inserts are also a closely related topic to shoes. Some have demonstrated a decrease in lower extremity injuries in military recruits with customized inserts in randomized trials whereas other studies have not demonstrated a difference.64-66

When data are unconvincing in either direction, personal bias tends to prevail. In our opinion, as overuse is the predominant cause of running injuries, any shoe modification risk reduction could easily be overcome by increases in training. Thus, the runner is often left with a choice to titrate the level of support with an increased or decreased level in training that one can tolerate. Finally, often a runner comes in convinced the shoe gear is the vital component but if many attempts at finding the “right” shoe and insert do not provide success, one must consider that the underlying issue may not exist in the foot or be modifiable by shoe gear. This is not to say shoes and inserts do not matter but to simply state that shoes and inserts are more likely to need fine tuning as opposed to being the major underlying issue for many runners. However, there certainly can be shoe gear that exacerbates an underlying issue and thus be a wrong shoe for the individual.

Other Considerations With Potential Risk Factors

Common sense must prevail in other situations. A graduated increase in mileage does seem to have lower injury risk in some studies but the commonly stated “10 percent rule” is not actually supported by much evidence.67-71 This is the recommendation to increase weekly mileage by no more than 10 percent. However, a sudden increase of three miles a week to 40 miles a week will undoubtedly end in an injury. For the novice, more regimented protocols may circumvent many training errors committed until more experience can provide a more intuitive understanding of training progression.

Other factors influence risk of injury but are less modifiable. In nearly every study the authors identified and was reported, history of previous injury appears to supersede effectiveness of an intervention.4,72-77 Increase in body mass index increases risk as well as being inexperienced at running.3,4,72,74,78 In both of these situations, the individual is likely actively attempting to overcome these factors. Women may also be at higher risk for stress fractures.75,79

Final Notes

Understanding what can actually be determined from studies in the era of big data is once again important in running injury prevention as it is for other topics. Big data, such as data gleamed from meta-analyses and even large randomized trials, are not always relevant to the individual. This is a combination of populations and not necessarily predictive of any one individual’s response as there may be a special case that precludes the patient from obtaining a benefit from an intervention. In any study, there are individuals with positive responses and negative responses to an intervention but the overall average of all participants is used to determine the intervention success. Thus, as with any meta-analysis, one must be mindful that subsets of the population may not experience the same results. For example, although stretching does not benefit the average runner, there may be a subset (such as those that habitually stretch) that does benefit.

Second, the outcome of reduction of risk of injury may be at odds with the outcome of performance. For example, decreases in frequency and duration of running decreases rate of injury. These are not desirable interventions for the average runner training for a marathon. Strength training, on the other hand, appears to be beneficial for both performance and risk reduction.

Third, although experienced runners are at lower risk of injury, it is difficult to determine what it is that decreases this risk. Likely, there are understudied interventions or techniques that have an effect on injury rate. This may be a cumulative effect of learned knowledge (such as when to change shoes, how hard to push, when rest is necessary, what pain is okay to run through, etc). However, ethical restraints may also make the study of generally accepted knowledge difficult to prove. For example, the purposeful prospective study of a generally accepted training error (such as wearing shoes for 1,000 miles) to determine if it is in fact harmful would be rather concerning in our modern day society.

Runners are, in general, a very well informed group of individuals but are often inundated with a plethora of information from both reliable sources and marketing. Understanding the current state of literature may help you reduce the risk of injury of your patients and yourself as well as earn their respect. Currently, redirecting more emphasis on strength training and proprioception as opposed to stretching and, in many cases, one particular shoe, appears to be in order. Encourage runners to consider adding strength training with heavy resistance as well as plyometric and balance training exercises two times per week. However, authors caution against over-reliance on the current state of evidence as the review of the literature is not overwhelmingly convincing and many studies are warranted on subsets of the population of different runners.

Dr. Thorud is board-certified by the American Board of Podiatric Medicine, and is a Fellow of the American College of Foot and Ankle Surgeons. Dr. Thorud is affiliated with Mercy Health System in Illinois.

Joslin Seidel is a fourth-year medical student at the Kent State College of Podiatric Medicine.

References

  1. Van Gent RN, Siem D, van Middelkoop M, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8): 469-80; discussion 480.
  2. Kluitenberg B, van Middelkoop M, Diercks R, van der Worp H. What are the differences in Injury proportions between different populations of runners? A systematic review and meta-analysis. Sports Med. 2015;45(8): 1143-61.
  3. Videbæk S, Bueno AM, Nielsen RO, Rasmussen S. Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports Med. 2015;45(7):1017-26.
  4. Van Mechelen W. Running injuries. A review of the epidemiological literature. Sports Med. 1992;14(5):320-35.
  5. Lee DC, Brellenthin AG, Thompson PD, et al. Running as a key lifestyle medicine for Longevity. Prog Cardiovasc Dis. 2017;60(1):45-5
  6. Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol. 2014;5;64(5):472-81. Erratum in: J Am Coll Cardiol. 2014;7;64(14):1537.
  7. Schnohr P, O'Keefe JH, Marott JL, Lange P, Jensen GB. Dose of jogging and long-term mortality: the Copenhagen City Heart Study. J Am Coll Cardiol. 2015;10;65(5):411-9.
  8.  Paffenbarger RS Jr, Hyde RT, Wing AL, Hsieh CC. Physical activity, all-cause mortality, and longevity of college alumni. N Engl J Med. 1986;314(10):605-13.
  9. Williams PT, Thompson PD. Increased cardiovascular disease mortality associated with excessive exercise in heart attack survivors. Mayo Clin Proc. 2014;89(9):1187-94.
  10. Chomistek AK, Cook NR, Flint AJ, Rimm EB. Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men. Med Sci Sports Exerc. 2012;44(10):1898-905.
  11. Chomistek AK, Cook NR, Rimm EB, et al. Physical activity and incident cardiovascular disease in women: is the relation modified by level of global cardiovascular risk? J Am Heart Assoc. 2018; 12;7(12).
  12. Williams PT. Reductions in incident coronary heart disease risk above guideline physical activity levels in men. Atherosclerosis. 2010;209(2):524-7.
  13. Eijsvogels TM, Molossi S, Lee DC, Emery MS, Thompson PD. Exercise at the extremes: the amount of exercise to reduce cardiovascular events. J Am Coll Cardiol. 2016;26;67(3):316-29.
  14. Hunter DJ, Eckstein F. Exercise and osteoarthritis. J Anat. 2009;214(2):197-207.
  15. Williams PT. Effects of running and walking on osteoarthritis and hip replacement risk. Med Sci Sports Exerc. 2013;45(7):1292-7.
  16. Williams PT. Maintaining vigorous activity attenuates 7-yr weight gain in 8340 runners. Med Sci Sports Exerc. 2007;39(5):801-9.
  17. Williams PT. Asymmetric weight gain and loss from increasing and decreasing exercise. Med Sci Sports Exerc. 2008;40(2):296-302.
  18. Cooper C, Snow S, McAlindon TE, et al. Risk factors for the incidence and progression of radiographic knee osteoarthritis. Arthritis Rheum. 2000;43(5):995-1000.
  19. Felson DT, Zhang Y, Hannan MT, Naimark A, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40(4):728-33.
  20. Jones G, Ding C, Glisson M, et al. Knee articular cartilage development in children: a longitudinal study of the effect of sex, growth, body composition, and physical activity. Pediatr Res. 2003;54(2):230-6.
  21. Jones G, Glisson M, Hynes K, Cicuttini F. Sex and site differences in cartilage development: a possible explanation for variations in knee osteoarthritis in later life. Arthritis Rheum. 2000;43(11):2543-9.
  22. Roos EM, Dahlberg L. Positive effects of moderate exercise on glycosaminoglycan content in knee cartilage: a four-month, randomized, controlled trial in patients at risk of osteoarthritis. Arthritis Rheum. 2005;52(11):3507-14.
  23. Tiderius CJ, Svensson J, Leander P, Ola T, Dahlberg L. dGEMRIC (delayed gadolinium-enhanced MRI of cartilage) indicates adaptive capacity of human knee cartilage. Magn Reson Med. 2004;51(2):286-90.
  24. Kim YJ, Bonassar LJ, Grodzinsky AJ. The role of cartilage streaming potential, fluid flow and pressure in the stimulation of chondrocyte biosynthesis during dynamic compression. J Biomech. 1995;28(9):1055-66.
  25. Marti B, Knobloch M, Tschopp A, Jucker A, Howald H. Is excessive running predictive of degenerative hip disease? Controlled study of former elite athletes. BMJ. 1989;299(6691):91-3.
  26. Cheng Y, Macera CA, Davis DR, et al. Physical activity and self-reported, physician-diagnosed osteoarthritis: is physical activity a risk factor? J Clin Epidemiol. 2000;53(3):315-22.
  27. Willick SE, Hansen PA. Running and osteoarthritis. Clin Sports Med. 2010;29(3):417-28.
  28. Lane NE, Oehlert JW, Bloch DA, Fries JF. The relationship of running to osteoarthritis of the knee and hip and bone mineral density of the lumbar spine: a 9 year longitudinal study. J Rheumatol. 1998;25(2):334-41.
  29. Ward MM, Hubert HB, Shi H, Bloch DA. Physical disability in older runners: prevalence, risk factors, and progression with age. J Gerontol A Biol Sci Med Sci. 1995;50(2):M70-7.
  30. Wijayaratne SP, Teichtahl AJ, Wluka AE, et al. The determinants of change in patella cartilage volume--a cohort study of healthy middle-aged women. Rheumatology (Oxford). 2008;47(9):1426-9.
  31. Alentorn-Geli E, Samuelsson K, Musahl V, et al. The association of recreational and competitive running With hip and knee osteoarthritis: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2017;47(6):373-390.
  32. Lindberg H, Montgomery F. Heavy labor and the occurrence of gonarthrosis. Clin Orthop Relat Res. 1987;(214):235-6.
  33. Davis MA, Ettinger WH, Neuhaus JM, Cho SA, Hauck WW. The association of knee injury and obesity with unilateral and bilateral osteoarthritis of the knee. Am J Epidemiol. 1989;130(2):278-88.
  34. Felson DT, Hannan MT, Naimark A, et al. Occupational physical demands, knee bending, and knee osteoarthritis: results from the Framingham Study. J Rheumatol. 1991;18(10):1587-92.
  35. Felson DT, Zhang Y, Anthony JM, Naimark A, Anderson JJ. Weight loss reduces the risk for symptomatic knee osteoarthritis in women. The Framingham Study. Ann Intern Med. 1992;116(7):535-9.
  36. Buckwalter JA, Mankin HJ. Articular cartilage: degeneration and osteoarthritis, repair, regeneration, and transplantation. Instr Course Lect. 1998;47:487-504.
  37. Yoshimura N, Nishioka S, Kinoshita H, et al. Risk factors for knee osteoarthritis in Japanese women: heavy weight, previous joint injuries, and occupational activities. J Rheumatol. 2004;31(1):157-62.
  38. Yoshimura N, Kinoshita H, Hori N, et al. Risk factors for knee osteoarthritis in Japanese men: a case-control study. Mod Rheumatol. 2006;16(1):24-9.
  39. Lauersen JB, Bertelsen DM, Andersen LB. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med. 2014;48(11):871-7.
  40. Pereles D, Roth A, Darby JS, Thompson MS. A large, randomized, prospective study of the impact of a pre-run stretch on the risk of injury in teenage and older runners. Available at: http://www.usatf.org/stretchStudy/StretchStudyReport.pdf
  41. Baltich J, Emery CA, Stefanyshyn D, Nigg BM. The effects of isolated ankle strengthening and functional balance training on strength, running mechanics, postural control and injury prevention in novice runners: design of a randomized controlled trial. BMC Musculoskelet Disord. 2014;15:407.
  42. Matias AB, Taddei UT, Duarte M, Sacco IC. Protocol for evaluating the effects of a therapeutic foot exercise program on injury incidence, foot functionality and biomechanics in long-distance runners: a randomized controlled trial. BMC Musculoskelet Disord. 2016;17:160.
  43. Baldon Rde M, Nakagawa TH, Muniz TB, et al. Eccentric hip muscle function in females with and without patellofemoral pain syndrome. J Athl Train. 2009;44(5):490-6.
  44. Boling MC, Padua DA, Marshall SW, et al. A prospective investigation of biomechanical risk factors for patellofemoral painsyndrome: the joint undertaking to monitor and prevent ACL injury (JUMP-ACL) cohort. Am J Sports Med. 2009;37(11):2108-16.
  45. Leetun DT, Ireland ML, Willson JD, Ballantyne BT, Davis IM. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc. 2004;36(6):926-34.
  46. Mahieu NN, Witvrouw E, Stevens V, Van Tiggelen D, Roget P. Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study. Am J Sports Med. 2006;34(2):226-35.
  47. Blagrove RC, Howatson G, Hayes PR. Effects of strength training on the physiological determinants of middle- and long-distance running performance: a systematic review. Sports Med. 2018;48(5):1117-1149.
  48. Denadai BS, de Aguiar RA, de Lima LC, Greco CC, Caputo F. Explosive training and heavy weight training are effective for improving running economy in endurance athletes: a systematic review and meta-analysis. Sports Med. 2017;47(3):545-554.
  49. Štohanzl M, Baláš J, Draper N. Effects of minimal dose of strength training on running performance in female recreational runners. J Sports Med Phys Fitness. 2018;58(9):1211-1217.
  50. Vikmoen O, Rønnestad BR, Ellefsen S, Raastad T. Heavy strength training improves running and cycling performance following prolonged submaximal work in well-trained female athletes. Physiol Rep. 2017;5(5).
  51. Saunders PU, Pyne DB, Telford RD, Hawley JA. Factors affecting running economy in trained distance runners. Sports Med. 2004;34(7):465-85.
  52. Heitkamp HC, Horstmann T, Mayer F, Weller J, Dickhuth HH. Gain in strength and muscular balance after balance training. Int J Sports Med. 2001;22(4):285-90.
  53. Tropp H, Askling C. Effects of ankle disc training on muscular strength and postural control. Clin Biomech (Bristol, Avon). 1988;3(2):88-91.
  54. Cates W, Cavanaugh J. Advances in rehabilitation and performance testing. Clin Sports Med. 2009;28(1):63-76.
  55. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries:mythbusting and a proposal for two new paradigms: 'preferred movement path' and 'comfort filter'. Br J Sports Med. 2015;49(20):1290-4.
  56. Yeung SS, Yeung EW, Gillespie LD. Interventions for preventing lower limb soft-tissue running injuries. Cochrane Database Syst Rev. 2011;(7):CD0012
  57. Malisoux L, Chambon N, Delattre N, et al. Injury risk in runners using standard or motion control shoes: a randomised controlled trial with participant and assessor blinding. Br J Sports Med. 2016;50(8):481-7.
  58. Malisoux L, Chambon N, Urhausen A, Theisen D. Influence of the heel-to-toe drop of standard cushioned running shoes on injury risk in leisure-time runners: a randomized controlled trial with 6-month follow-up. Am J Sports Med. 2016;44(11):2933-2940.
  59. Nigg BM. The role of impact forces and foot pronation: a new paradigm. Clin J Sport Med. 2001;11(1):2-9.
  60. Salzler MJ, Kirwan HJ, Scarborough DM, et al. Injuries observed in a prospective transition from traditional to minimalist footwear: correlation of high impact transient forces and lower injury severity. Phys Sportsmed. 2016;44(4):373-379.
  61. Knorz S, Kluge F, Gelse K, et al. Three-dimensional biomechanical analysis of rearfoot and forefoot running. Orthop J Sports Med. 2017;5(7):2325967117719065.
  62. Williams DS 3rd, Green DH, Wurzinger B. Changes in lower extremity movement and power absorption during forefoot striking and barefoot running. Int J Sports Phys Ther. 2012;7(5):525-32.
  63. Blake R, McClanahan R. Point-counterpoint: Are maximalist running shoes better than minimalist running shoes? Pod Today. 2018;31(10):54-57.
  64. Larsen K, Weidich F, Leboeuf-Yde C. Can custom-made biomechanic shoe orthoses prevent problems in the back and lower extremities? A randomized, controlled intervention trial of 146 military conscripts. J Manipulative Physiol Ther. 2002;25(5):326-31.
  65. Franklyn-Miller A, Wilson C, Bilzon J, McCrory P. Foot orthoses in the prevention of injury in initial military training: a randomized controlled trial. Am J Sports Med. 2011;39(1):30-7.
  66. Mattila VM, Sillanpää PJ, Salo T, et al. Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects. Scand J Med Sci Sports. 2011;21(6):804-8.
  67. Van der Worp MP, ten Haaf DS, van Cingel R, et al. Injuries in runners; a systematic review on risk factors and sex differences. PLoS One. 2015;10(2):e0114937.
  68. Nielsen RØ, Parner ET, Nohr EA, et al. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44(10):739-47.
  69. Nielsen RO, Cederholm P, Buist I, et al. Can GPS be used to detect deleterious progression in training volume among runners? J Strength Cond Res. 2013;27(6):1471-8.
  70. Johnston CA, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing running injuries. Practical approach for family doctors. Can Fam Physician. 2003;49:1101-9.
  71. Buist I, Bredeweg SW, van Mechelen W, Lemmink KA, Pepping GJ, Diercks RL. No effect of a graded training program on the number of running-related injuries in novice runners: a randomized controlled trial. Am J Sports Med. 2008;36(1):33-9.
  72. Buist I, Bredeweg SW, Lemmink KA, van Mechelen W, Diercks RL. Predictors of running-related injuries in novice runners enrolled in a systematic training program: a prospective cohort study. Am J Sports Med. 2010 Feb;38(2):273-80. 
  73. Kozinc Ž, Šarabon N. Effectiveness of movement therapy interventions and training modifications for preventing running injuries: a meta-analysis of randomized controlled trials. J Sports Sci Med. 2017;16(3):421-428.
  74. Macera CA, Pate RR, Powell KE, et al. Predicting lower-extremity injuries among habitual runners. Arch Intern Med. 1989;149(11):2565-8.
  75. Rauh MJ, Margherita AJ, Rice SG, Koepsell TD, Rivara FP. High school cross country running injuries: a longitudinal study. Clin J Sport Med. 2000;10(2):110-6.
  76. Saragiotto BT, Yamato TP, Hespanhol Junior LC, et al. What are the main risk factors for running-related injuries? Sports Med. 2014;44(8):1153-63.
  77. van Gent RN, Siem D, van Middelkoop M, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med. 2007;41(8):469-80; discussion 480.
  78. Linton L, Valentin S. Running with injury: A study of UK novice and recreational runners and factors associated with running related injury. J Sci Med Sport. 2018 May 24. pii: S1440-2440(18)30179-8.
  79. Shaffer RA, Rauh MJ, Brodine SK, Trone DW, Macera CA. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med. 2006;34(1):108-15.

Additional References

  1. Mikkola J, Rusko H, Nummela A, Pollari T, Häkkinen K. Concurrent endurance and explosive type strength training improves neuromuscular and anaerobic characteristics in young distance runners. Int J Sports Med. 2007;28(7):602-11.
  2. Paavolainen L, Häkkinen K, Hämäläinen I, Nummela A, Rusko H. Explosive-strength training improves 5-km running time by improving running economy and muscle power. J Appl Physiol (1985). 1999;86(5):1527-33.
  3. Saunders PU, Telford RD, Pyne DB, et al. Short-term plyometric training improves running economy in highly trained middle and long distance runners. J Strength Cond Res. 2006;20(4):947-54.
  4. Spurrs RW, Murphy AJ, Watsford ML. The effect of plyometric training on distance running performance. Eur J Appl Physiol. 2003;89(1):1-7.
Online Exclusives
By Jakob C. Thorud, DPM, MS, FACFAS and Joslin L. Seidel, BS
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