New in Running Research – Technique for Injury Reduction

Running has continued to grow in popularity since the early 2000’s (1). Increasing numbers of both recreational and competitive runners are enjoying the numerous positive effects running has on overall health and wellbeing. Running is unfortunately not without risk. Injury estimates for runners range from 19 – 78% in a given year (2). Some of the most common running injuries include; exertional lower leg pain, plantar fasciopathy, calf pain, medial tibial stress syndrome, stress fractures, patellofemoral pain (PFP), iliotibial band syndrome (ITBS), and tendinopathies (Achilles, patellar, proximal hamstring and gluteal) (2). Runners, coaches and therapists are constantly looking for ways to reduce risk of injury, whether it is for initial injury or to reduce re-occurrence. Research in this field is continually evolving, with more details emerging about ways to reduce injury risk. A recent study has summarised current literature and expert opinion on the role of running retraining for lower limb injuries (3). Here we discuss some of its findings, which can help you run with great technique and reduce injury.

Running has numerous positive effects on overall health and wellbeing. #running Click To Tweet

Risk factors for Running Related Injury

A number of factors a currently proposed to increase running related injury (3). Proposed intrinsic factors:

• Older age
• Higher BMI
• History of prior injury
• Limb length discrepancy
• Abnormal anatomical alignment and foot posture
• Faulty foot loading patterns

Proposed extrinsic factors:

• Level of competition
• Training accumulation/training load
• Shoe type
• Training surface

Multiple interventions have been developed to reduce these risk factors to minimise injury. This can include footwear modification, orthotics, exercise programs to improve strength, stability, flexibility and or neuromuscular control, taping and management of training volumes. An area which remains lacking in evidence, is the role of running retraining on reducing pain and injury. Running retraining here refers to observing running biomechanics and then altering any aspects of technique. Alteration of running technique is proposed to reduce pain or injury by altering load over particularly muscles or joints.

Findings on the Effects of Running Retraining

The authors comment on the general lack of studies and evidence describing the effects of running retraining. There was evidence, although limited, showing benefit for anterior exertional leg pain and PFP. When considering numerous expert opinions, running retraining was also strongly advocated for in medial tibial stress syndrome (MTSS), PFP, ITBS), hamstring tendinopathy and gluteal tendinopathy. Mixed responses were given for its role in Achilles tendinopathy, plantar fasciopathy, patella tendinopathy and calf pain (3).

Running Retraining – So What Do We Do?

1) Reduce Overstride and Increase Step Rate

Addressing overstriding was considered one of the most beneficial retraining strategies. Overstriding refers to a person’s point of footstrike landing in front of the body’s centre of mass. Clinically this is often reflected by the foot’s position relative to the knee upon footstrike. By landing in front of the body’s centre of mass, vertical ground reaction forces are backward, thereby increasing breaking forces and energy needed to continue running forward. One of the key methods to reduce overstriding is by increasing step rate (cadence). By increasing step rate, footstrike is often closer to the centre of mass, and peak loading forces on the hip and knee are reduced.

Increased step rate should be gradual, with 5-10% increases generally recommended (5). This helps to ensure manageable changes and reduce calf fatigue. The aim is to increase to a cadence that is consistently 180 steps per minute. Various different methods for cadence changes have been advocated including music, metronomes and verbal cues (eg shorter, faster steps). A manual count can also be of great assistance, counting 1 minute for every 5 minutes of running. Persistence and is key to developing consistent long-term cadence changes across different speeds, terrain and elevation.

To learn more about how to increase your cadence and run with good technique click HERE>> (Great Technique Principle 1: Running Cadence)

2) Reduce impact loading

Some experts have considered high impact loading (kinetics) may play a role in injury. It was suggested that impact noise during running may be closely related to actual impact loading variables such as vertical loading rates, and therefore may be used as an indicator of higher loads. If you therefore seem to land ‘heavy,’ some cue might be helpful to incorporate to reduce impact forces. Often using cues of ‘running softer and lighter’ and trying to hear or feel the difference with this. Additional aspects that may be helpful include reduced heelstriking, higher cadence, landing closer to the centre of gravity, more knee bend (landing on a flexed knee can reduce knee loads) and higher tendon stiffness may assist reducing impact forces.

3) Decrease Crossover Gait Patterns

Crossover gait patterns, or scissoring occurs when each footstrike crosses the bodies midline. So instead of each foot landing on the same side of an imaginary string in the middle of the runner’s body, the feet cross the midline and land on the other side of the string. Runner’s who have such patterns often have their knees touching or close together during a run. Limited evidence has suggested it is a factor increasing the risk of PFP, and less strongly in ITBS and MTSS. Retraining to address this involves trying to increase step width, such as using a mirror or trying to run either side of a line. Caution is recommended as overcorrection can lead to a different set of injuries or problems. Changing this goes hand in hand with strengthening of gluteal muscles and hip external rotators to help minimise crossover, and additionally to minimise additional knee collapse patterns.

4) Encourage Forward Lean

Leaning ‘into’ your run (i.e. leaning forward from the ankles) allows gravity to pull you forwards, reducing the workload of the legs. It is closely related to overstriding, whereby backwards body lean or overstriding can create braking forces that are encountered with foot strike impact. The alternative is to run with the body positioned well, with forward lean from the ankles (not the waist) and a ‘tall, upright torso.’ Forward lean that occurs from the ankles (not the waist) at angle of approximately 10 to 15 degrees is often recommended (practice the Michael Jackson Drill) (6). Alongside forward lean, keeping the chest up and ‘lengthening the spine’ has been advocated (3). Forward lean and a high torso can also be assisted by reducing anterior tilt, whether this be a motor or running pattern, or due to increased hip flexor and quads tightness and/or gluteal muscle weakness. There are a variety of different cus that can be utilised to try achieve some forward lean and a tall upper body.

5) Changing Foot-strike

Footstrike was something that was approached cautiously by the experts in this study (3). There were a number of proposed potential benefits of strike pattern alteration, including both transition from rearfoot towards forefoot or midfoot (eg, knee injuries), and from forefoot towards rearfoot or midfoot strike (eg, Achilles tendinopathy and calf pain). However, caution was recommended when changing a runner’s strike pattern, with a substantial adaptation period suggested if choosing to make alterations. Greater importance was often placed on other aspects of retraining, such as not overstriding and improving cadence, being more important than trying to change a heelstrike pattern. This may often be utilised as an aspect of retraining after aspects have been addressed or if loading patterns are of greater significance with the particular injury (eg a really forefoot strike in Achilles pain).

Leaning ‘into’ your run allows gravity to pull you forwards, reducing the workload of the legs. Click To Tweet

To read more about foot strike for runners click HERE>>  (Optimise Your Foot strike)

Before you Change Anything

Although here we primarily discuss technique changes that may help in rehabilitating certain lower limb injuries it is important to understand that this is only piece of the injury management puzzle. The experts interviewed consistently discussed the importance of addressing joint and muscular deficits in strength, stability and flexibility. Mixed opinions were held about how to navigate the footwear maze and the use of orthotics.

To read more about how to navigate the footwear maze click HERE>> (What Running Shoes Should I Buy?)

To read more about pronation and orthotics click HERE>> (The Truth About Pronation and Orthotics)

Additionally it is important to realise that it’s not a one size fits all approach, certain techniques will work for some and not others. It is vital that any changes are made under the care of a good running coach or physiotherapist with the aid of video analysis. Unfortunately we often see in clinic a runner presenting with an injury shortly after attempting to rapidly change aspects of technique. For example shifting from a heel-strike to forefoot strike can potentially developed calf soreness, Achilles pain or metatarsal stress fractures. Additionally shifting from heel-strike to forefoot strike may still pose injury risk if overstriding is still occurring. Experts in the study have also advocated not trying to change everything at once, pick one or two things to work on, one or two cues to follow. Hopefully this has shed some light on the role of running retraining and assessing running technique has in managing and reducing injury risk.

Lewis Craig (APAM)

POGO Physiotherapist

References:

1. Fields KB, Sykes JC, Walker KM, Jackson JC (2010) Prevention of running injuries. Curr Sports Med Rep 9: 176–182. doi: 10.1249/JSR.0b013e3181de7ec5 PMID: 204635022)
2. van Gent R, Siem D, van Middelkoop M, van Os A, Bierma-Zeinstra S, et al. (2007) Incidence and determinants of lower extremity running injuries in long distance runners: A systematic review. Br J Sports Med 41: 469–480. PMID: 17473005
3. Barton, C. J., Bonanno, D. R., Carr, J., Neal, B. S., Malliaras, P., Franklyn-Miller, A., & Menz, H. B. (2016). Running retraining to treat lower limb injuries: a mixed-methods study of current evidence synthesised with expert opinion. British journal of sports medicine, 50(9), 513-526.
4. van der Worp MP, ten Haaf DSM, van Cingel R, de Wijer A, Nijhuis-van der Sanden MWG, Staal JB (2015) Injuries in Runners; A Systematic Review on Risk Factors and Sex Differences. PLoS ONE 10(2): e0114937. doi:10.1371/journal.pone.0114937
5. Heiderscheit BC, Chumanov ES, Michalski MP et al. Effects of step rate manipulation on joint mechanics during running. Med Sci Sports Exerc 2003; 35:307-313.
6. Beer, B –Running Technique Principal: Optimal Body Position

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