Content uploaded by Sten Rasmussen
Author content
All content in this area was uploaded by Sten Rasmussen on Dec 11, 2024
Content may be subject to copyright.
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 1
ABSTRACT
Purpose: The purpose of this systematic review was to examine the link between training characteristics
(volume, duration, frequency, and intensity) and running related injuries.
Methods: A systematic search was performed in PubMed, Web of Science, Embase, and SportDiscus. Stud-
ies were included if they examined novice, recreational, or elite runners between the ages of 18 to 65.
Exposure variables were training characteristics defined as volume, distance or mileage, time or duration,
frequency, intensity, speed or pace, or similar terms. The outcome of interest was Running Related Inju-
ries (RRI) in general or specific RRI in the lower extremity or lower back. Methodological quality was eval-
uated using quality assessment tools of 11 to 16 items.
Results: After examining 4561 titles and abstracts, 63 articles were identified as potentially relevant.
Finally, nine retrospective cohort studies, 13 prospective cohort studies, six case-control studies, and three
randomized controlled trials were included. The mean quality score was 44.1% of 100%. Conflicting results
were reported on the relationship between volume, duration, intensity, and frequency and RRI.
Conclusion: It was not possible to identify which training errors were related to running related injuries.
Still, well supported data on which training errors relate to or cause running related injuries is highly
important for determining proper prevention strategies. If methodological limitations in measuring train-
ing variables can be resolved, more work can be conducted to define training and the interactions between
different training variables, create several hypotheses, test the hypotheses in a large scale prospective
study, and explore cause and effect relationships in randomized controlled trials.
Level of evidence: 2a
Key words: Duration, frequency, injuries, intensity, running, training, volume
1 Aarhus University, Department of Public Health, Aarhus C.
Denmark
2 University Centre for sport, exercise and health, University of
Groningen, Groningen, The Netherlands
3 Department of Orthopedics Aarhus University Hospital,
Aarhus C., Denmark
4 Aarhus University Hospital - Aalborg Hospital, Orthopaedic
Surgery Research Unit Research and Innovation Center,
Aalborg C. Denmark
IJSPT
SYSTEMATIC REVIEW
TRAINING ERRORS AND RUNNING RELATED
INJURIES: A SYSTEMATIC REVIEW
Rasmus Oestergaard Nielsen, PT1,4
Ida Buist, PhD2
Henrik Sørensen, PhD1
Martin Lind, PhD3
Sten Rasmussen, MD4
CORRESPONDING AUTHOR
Rasmus Oestergaard Nielsen
Department of Sport Science
Dalgas Avenue 4
8000 Aarhus C.
Denmark
Tel: +45 89 42 91 63
Fax: +45 89 42 91 97
Email: Ragn@rn.dk
IJSPT-7_1-00-Nielsen_120010.indd1 1IJSPT-7_1-00-Nielsen_120010.indd1 1 1/19/12 7:30:49 PM1/19/12 7:30:49 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 2
INTRODUCTION
Weight loss and smoking cessation have been associ-
ated with running,1 and it has been stated that run-
ning has positive effects on health and fitness.2
However, Running Related Injuries (RRI) of the
lower extremities are commonly a negative side
effect. Depending on injury definition and length of
follow up period, the injury incidence among run-
ners varies between 11–85%1,3-15 or 2.5 to 38 injuries
per 1000 hours of running.9,16-18 Several risk factors
contributing to injuries have been reported18-21 and
general consensus exists with regard to training
characteristics and previous running injuries being
associated with the development of RRI. Training
characteristics are of particular importance, since
the training regimen is under the control of the run-
ners (and coaches) and can be modified in contrast
to previous injuries which cannot be modified.22,23
Furthermore, anecdotal evidence suggests that train-
ing errors (i.e. excessive distance, sudden change of
training routines, etc.) are the cause of 60–70% of all
running injuries.16,24,25 In a review of the etiology and
prevention of and intervention for overuse injuries
in runners, Hreljac20 concluded that the causes of all
overuse running injuries could be classified as train-
ing errors, and thus, all overuse running injuries
should be preventable. In order to summarize and
present the information that examines the evidence
about training errors and RRI, a systematic review
may be a starting point to identify which training
errors have been reported to be associated with
injury development. To date the authors have found
no published systematic review that aims to present
an overview of the literature, investigating the rela-
tion between volume, duration, intensity, and fre-
quency of running, herein defined as training
characteristics, and the development of RRI. There-
fore, the purpose of this systematic review was to
investigate the association between training charac-
teristics and running related injuries.
METHOD
Search strategy and inclusion criteria
The Cochrane database was searched, revealing no
systematic reviews about training characteristics and
RRI. A search of the Pubmed, Web of Science, Embase,
and Sportdiscus databases was conducted October 11th
2011 to identify studies that met the inclusion criteria
using the search strategy presented in Appendix 1.
The search was limited to studies of humans, pub-
lished in the English language, and included only
original articles.
Prospective cohort studies, cross-sectional studies,
case-control studies, and randomized controlled trials
were included in the current systematic review if a
relationship between training characteristics and RRI
was investigated. Studies with novice, recreational,
and elite runners between the ages of 18 to 65 were
included. Articles were excluded if participants were
sprinters or middle distance runners, or were pre-
dominantly exposed to types of sporting activity other
than running such as triathlons, and military training
programs. Articles on cadavers, computer modeling,
and simulation studies were excluded.
The exposure variables of interest were training char-
acteristics including volume, distance, mileage, time,
duration, frequency, intensity, speed, and pace. Dif-
ferent methods for analyzing or reporting these char-
acteristics were accepted. For instance, volume could
be measured as kilometers or miles per day, per week,
per month or as the gradual increase in mileage per
week over a given period of time. The outcome of
interest was RRI in general or specific RRI of the
lower extremity or spine. Muscle cramps, corns, blis-
ters, and calluses were not included as RRI.
Data collection and analysis
Each study identified as a result of the electronic
search was initially evaluated independently by two
authors (RON and IB) by screening the title and
abstract. Articles without an abstract were excluded.
All articles of interest were retrieved and evaluated
for eligibility. Articles were excluded if no informa-
tion was provided on injuries during follow up, in
case of overview articles, or articles about degenera-
tive diseases only.
Methodological quality assessment
The methodological quality of the cross sectional stud-
ies, case-control studies, and prospective cohort stud-
ies was assessed by means of a methodological quality
assessment list developed and used by van der Worp
et al,26 which was based on a list developed by van der
Windt et al.27 The list was adapted slightly to make it
specific for training and RRI. The assessment contains
IJSPT-7_1-00-Nielsen_120010.indd2 2IJSPT-7_1-00-Nielsen_120010.indd2 2 1/19/12 7:30:50 PM1/19/12 7:30:50 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 3
items on information and validity and/or precision in
five categories: study objective; study population; out-
come measurements; assessment of the outcome, and
analysis and data presentation. Separate quality assess-
ment lists were constructed for cross-sectional studies,
case-control studies, and prospective cohort studies.
The items of the quality assessment list are presented
in Table 1. Each item was evaluated as either positive
(+) or negative (-) by two reviewers independently. In
cases where it was unclear whether a study did or did
not meet an item, or if no clear information regarding
the item was stated, the item was scored as negative (-).
Results of the quality assessment made by the two
reviewers were compared, and any disagreement con-
cerning an item was resolved in a consensus meeting.
The total quality of each study was calculated by count-
ing the number of items being positive (+) from item 3
to 16 divided by the total number of items for the study
type (11 for case-control studies, 9 for prospective
cohort studies, and 8 for cross sectional studies).
The methodological quality of the randomized con-
trolled trials included was rated using the PEDro rating
scale (REF) which is based on the Delphi list devel-
oped by Verhagen and colleagues.28 The total method-
ological quality score was found by evaluating the
internal validity and statistical reporting using an 11
criteria list. The total quality of each randomized con-
trolled trial was calculated by counting the number of
items being positive (+) from item 2 to 11 divided by
ten. Previously, the PEDro scale has demonstrated an
inter-rater agreement of [k] = 0.73–0.82.29
Results
After examining 4561 titles and abstracts, 62 articles
were identified as potentially relevant. After refer-
ence checking, one additional study was identified.30
The full texts of all 63 articles were retrieved and
were subsequently evaluated by both RON and IB.
Review of the complete texts excluded 32 articles. Of
the excluded articles, four were overview articles,31-34
four included persons under 18 years of age,35-38 three
included persons with degenerative diseases only,39-41
eight articles did not describe the relationship
between training characteristics and RRI,42-47 three
had no control group,48-50 two were modeling arti-
cles,51,52 seven had a faulty injury definition or none
at all,53-59 and one was a design article.60 Finally, 30
articles were included in the review.
Risk of bias in included studies
The quality of included studies is presented in Table
2. The overall methodological quality of the included
prospective studies, case-control studies, and cross
sectional studies was 44.1% ranging from 9 to 89%.
The most problematic areas were 1) the main pur-
pose of many of the studies was different than the
relation between training and RRI, 2) description of
the demographic characteristics (gender, age, body
mass index) of the participants was lacking, and 3)
lack of adjustment for the effect of multiple training
variables. The overall quality of the three randomized
controlled trials was 43% ranging from 30 to 70%.
Description of studies and injury defi nition
The year of publication for the included studies
ranged from 1977 to 2008. The studies represented
populations in USA, Canada, New Zealand, The Neth-
erlands, Denmark, Switzerland, Germany, and Swe-
den. The total sample size of included participants
was 24,066 ranging from 28 to 4,335 subjects in each
study. Of the 30 included studies, nine were retro-
spective cohort studies, 12 were prospective cohort
studies, six were case-control studies, and three ran-
domized controlled trials. The study characteristics of
the selected studies were described to obtain insight
into the homogeneity of the study populations (Table
3). The types of participants (novice, recreational,
and elite), and the injury definition used varied con-
siderably between the studies. For instance Lysholm
et al16 used “all injuries that markedly hampered train-
ing or competition for at least 1 week were noted”
while Valliant61 used “injury was defined as physiolog-
ical damage or bodily pain which interfered with
one´s ability to run”. The mean age of all participants
in the 30 studies varied from 19.5 years to 44 years
with an average of 35.4 years. Mean body mass index
was 22, ranging from 20.97 to 25.86. Four studies
included only males while two included only females.
For the remaining studies an average of 67.6% of the
participants included were males. Table 3 presents
summary data from each study regarding the type of
runner, demographic characteristics, and injury defi-
nition as quoted verbatim from the article.
Description of training characteristics
In 22 studies the training characteristics were assessed
retrospectively by a questionnaire. The recall period
varied from two weeks to 10 years. In eight studies,
IJSPT-7_1-00-Nielsen_120010.indd3 3IJSPT-7_1-00-Nielsen_120010.indd3 3 1/19/12 7:30:50 PM1/19/12 7:30:50 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 4
Table 1. Summary of quality scoring criteria for cross-sectional studies, case control studies, and prospective cohort
studies.
IJSPT-7_1-00-Nielsen_120010.indd4 4IJSPT-7_1-00-Nielsen_120010.indd4 4 1/19/12 7:30:50 PM1/19/12 7:30:50 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 5
daily running diaries9,16,17,30,62-64 or an internet based
log15 were used. In five studies, training interventions
were used.5,9,15,17,30 Odds Ratio (OR), Hazard Ratio
(HR), and Relative Risk (RR) were the most common
measures of association. The unit of measurement in
this review is miles. However, some articles used kilo-
meters. In these cases kilometers were converted into
miles using 0.62137 as conversion factor. Different
definitions were used in the reviewed studies for
training volume, duration, intensity, and frequency.
Volume
In 28 articles out of 30 articles, the link between training
volume and RRI was investigated. The most commonly
used approach to define exposure was to measure the
average weekly miles4,13,14,16,22,61-63,65-69 or kilometers10,11,17,70
of running over a period of time. In other studies, weekly
distance per weekly frequency7 or total running dis-
tance64,71 were used as the measure of exposure.
Duration
In three articles, average hours9,17,69 or minutes15 spent
running per week were used as the exposure variable.
In another study, the weekly progressive increase in
duration during a graded training program was used15
while two other studies used minutes per day3,30 as
their measure of exposure.
Intensity
In sixteen articles, training intensity was described.1,4,9,
11,13,14,17,22,63-70 In a majority of these, average pace of
workout was used to express intensity during training,
measured as minutes per mile (min/mile) or minutes
per kilometer (min/km).13,22,63,65-70,72 Other studies used
Table 2. Summary of quality scoring for all included studies. Note use of PEDRO scoring system used for quality scoring
randomized control studies.
IJSPT-7_1-00-Nielsen_120010.indd5 5IJSPT-7_1-00-Nielsen_120010.indd5 5 1/19/12 7:30:54 PM1/19/12 7:30:54 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 6
Table 3. Descriptions of included studies.
IJSPT-7_1-00-Nielsen_120010.indd6 6IJSPT-7_1-00-Nielsen_120010.indd6 6 1/19/12 7:30:56 PM1/19/12 7:30:56 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 7
Table 3. (Continued) Descriptions of included studies.
IJSPT-7_1-00-Nielsen_120010.indd7 7IJSPT-7_1-00-Nielsen_120010.indd7 7 1/19/12 7:30:58 PM1/19/12 7:30:58 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 8
kilometers per hour,17,64 16 km running time,14 or per-
centage of maximal attainable heart rate.9
Frequency
The number of weekly training sessions was reported
in a variety of ways as number of training sessions,71
times,9 frequency,22,73 days,5,11,13,30,64 runs,74 or work-
outs4 per week. Most often the data were analyzed by
dividing the weekly amount of days running into dif-
ferent categories. The comparisons vary widely across
studies, however. The reference groups were defined
as either 1, 1-2, 1-3, 1-4, or 1-5 days per week, and
were compared to either one or several exposure
groups varying between 3, 4, 5, 6, 7, 4-5, 5-7, 6-7 days
per week. In one article, a regression model was used
to investigate the risk of RRI as the weekly frequency
increased during training prior to a marathon.6
Relationship between training
characteristics and RRI
Volume
Hootman et al4 found an increased risk of injury
among males (HR = 1.66 [1.43, 1.94]) and females
(HR = 2.08 [1.45, 2.98]) running more than 20 miles
per week. Lysholm et al16 found a significant correla-
tion (r = 0.59) in long-distance/marathon runners
between the distance covered in a given month and
the number of injury days during the following
month. Walter et al11 found no significant difference
in relative risk between the reference group who ran
less than 10 miles per week and the groups who ran
distances between 10 and 39 miles per week.
However, the relative risk of injury was significantly
higher among males (RR 2.22 [1.30-3.68]) and females
(RR 3.42 [1.42-7.85]) running ≥40 miles per week. This
was supported by Macera et al22 who found a signifi-
cantly increased odds ratio for sustaining injury
among males running ≥40 miles per week over a
period of 3 months (OR = 2.9 [1.1-7.5]). In the same
study no association was found between weekly mile-
ages and risk of injury among women.22 Although a
majority of studies reported a relationship between
weekly mileage and RRI, no significant association
between miles per week and likelihood of injury was
found in two prospective studies and one retrospec-
tive study.7,62,74
Table 3. (Continued) Descriptions of included studies.
IJSPT-7_1-00-Nielsen_120010.indd8 8IJSPT-7_1-00-Nielsen_120010.indd8 8 1/19/12 7:31:00 PM1/19/12 7:31:00 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 9
In retrospective studies several authors compared
total volume per week between injured and non-
injured subjects. Koplan et al12 investigated the pro-
portion of injuries over a 10 year period in different
mileage strata. The proportion of women reporting
injury was highest in those who ran 40-49 miles per
week. For men the proportion was highest among
those who ran 30-39 miles per week. Those running
greater or fewer miles per week had a smaller pro-
portion of injuries. Marti et al14 found runners who
sustained injuries during the study period ran greater
weekly mileage when compared to non-injured run-
ners (26.3 km [3.2-83.8] versus 22.0 km [2.1-78.6], p
0.01). In a one-way analysis Valliant61 also indicated
that injured runners ran significantly more miles per
week than non-injured runners (47.5 ± 20.5 versus
29.6 ± 16.7, p < 0.01). This is supported by Jacobs
et al13 and Koplan et al1 who found mileage run per
week to be highly associated with injury.
In two studies, the RRI per 1000 hours of running in
groups running different mileages per week was
investigated.9,17 The number of injuries per 1000 hours
of running appeared to decrease with increasing
weekly mileage (Figure 1).
Walter et al11 investigated the relationship between
longest run per week and risk of injury. The relative
risk of sustaining an injury when the longest run each
week is >5 miles, is 2.49 [1.64-3.71] among males and
1.78 [0.99-3.13] among females compared with a ref-
erence group having their longest run below 5 miles.
Van Middelkoop et al7 measured weekly distance per
weekly frequency. Running an average of 6.8–9.3 miles
per training session was not associated with increased
or decreased risk of sustaining an injury compared to
average runs above or below 6.8–9.3 miles.
Several authors have investigated the relationship
between training volume and specific running inju-
ries. Reinking et al10 investigated subjects sustaining
exercise related lower leg pain and found no signifi-
cant difference in injury between individuals training
more or less than 40 miles per week. Satterthwaite
et al6 found an increased odds ratio for hamstring (1.07
[1.02, 1.13]) and knee (1.13 [1.04, 1.23]) injuries by a
weekly increase in mileage of 6 miles. Wen et al69
found a significant difference in weekly mileage
between subjects sustaining hip (18.7 miles per week)
or hamstring injuries (22.4 miles per week) compared
to controls (13.3 and 13.4 miles per week). Kelsey
et al8 found miles run per week in the past year to be
non-predictive of stress fractures. Wen et al69 found
weekly mileage and hours per week protective against
overall injuries, knee injuries, and foot injuries. In
case-control studies no difference in weekly mileage
was found between controls and persons with plantar
fasciitis,65 shin splints,65 achilles tendinitis,70 or ante-
rior knee pain,68 while patients with patellofemoral
pain ran significantly less than healthy controls.66 For
iliotibial band friction syndrome Messier and col-
leagues found conflicting results in two different arti-
cles. In one article injured participants ran significantly
less than healthy controls and in the other article no
significant difference in weekly mileage between
injured and healthy participants was reported.65,67
Figure 1. Relationship between miles per week and Running Related Injury (RRI) reported as mean [95% confi dence interval] for
different comparisons. Results from the articles by Bovens and Jakobsen are calculated based on fi gures in the articles. RRI = Run-
ning Related Injury. Adj = adjusted. Hrs = Hours.
IJSPT-7_1-00-Nielsen_120010.indd9 9IJSPT-7_1-00-Nielsen_120010.indd9 9 1/19/12 7:31:01 PM1/19/12 7:31:01 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 10
Duration
Pollock30 found an increasing injury incidence among
novice runners who ran in 15, 30, and 45 minute
duration groups of 22%, 24%, and 54%, respectively.
Jakobsen et al17 reported 7.4 and 6.9 RRI per 1000
hours of running among marathon runners who ran
204 [95% CI: 198-210] and 162 [95% CI: 156-168] min-
utes per week on average over a one year period.
Over a time period of 18 months Bovens et al9
reported 12.1, 10.0, and 7.0 injuries per 1000 hours of
running among marathon runners who ran 162, 192,
and 240 minutes per week. Buist et al15 found an
average of 33 [95% CI: 27-40] RRI per 1000 hours of
running in two groups of novice runners. One group
were instructed to run an average of 52 minutes per
week over a 13 week period of time (30 RRI/1000
hours), while the other group were instructed to run
an average of 59 minutes per week over a 8 week
period of time (38 RRI/1000 hours). Figure 2 shows
the RRI/1000 hours of running in groups running dif-
ferent minutes per week.
Buist et al15 investigated the relationship between
weekly progression in running duration and likeli-
hood of injury. There was no significant difference
in the incidence of RRI in a group of runners with a
13-week training program with a mean duration
increase of 10% per week compared to the incidence
of RRI in a group of runners training an 8-week train-
ing program with a mean duration increase of 24%
per week. However, although not significant, the
mean survival time of runners in the 13-week train-
ing group was 212 minutes, compared to 167 min-
utes in runners of the 8-week training group.
Intensity
In fourteen studies, the relationship between training
intensity and development of RRI was investi-
gated.1,4,11,13,14,17,63-70 Jacobs et al13 found a pace above
8 min/mile to increase the risk of injury as compared
with a pace below 8 min/mile (p<0.05). Hootman
et al4 found a reduced odds ratio (OR=0.51 [0.35,
0.74]) for sustaining an injury among males who ran
at 15+ min/mile compared to those who ran at a
faster pace (p=0.0004). A similar significant differ-
ence was found for female subjects (p≤0.05). How-
ever, lack of adjustment for other predictor variables
such as weekly mileage weakened this association.
This is supported by Marti et al14 who found that run-
ning speed calculated from 10 mile race time was
positively related to study period injury incidence in
univariate analysis, but adjustment for mileage clearly
weakened this association. In eight studies, no signifi-
cant relationship between average training pace and
likelihood of injury were found.1,11,17,63-66,68 Wen et al63,69
reported that no association was found between run-
ning pace and injury. However, it was reported that
interval training increased the risk of shin injury
(p<0.05).63 In a case-control study, Messier et al67
found runners with iliotibial band friction syndrome
to run on average 3 seconds/mile faster than the con-
trol group during non-competition training (p=0.05).
McCrory et al70 found training pace to be a significant
(P 0.05) discriminator between persons with achilles
tendinitis when they examined pace in minutes per
kilometer, where the pace of those injured was 4.64 ±
0.08 as compared to controls which was 4.87 ± 0.07.
Frequency
In eight articles the relationship between training
frequency and development of RRI was investi-
gated.5,6,11,13,22,30,64,71,74 Results are presented in Figure 3.
In six articles RRIs in general were investigated,5,11,13,22,74
one investigated front thigh injuries,6 and one
shin splint.71 In several studies an increased risk,
relative risk, or odds ratio for sustaining an RRI
was reported when the weekly running frequency
Figure 2. Relation between minutes per week and number of Running Related Injury (RRI) per 1000 hours (hrs) of running.
Results from the articles by Bovens and Jakobsen are calculated based on fi gures in the articles. Int = intervention. Con = controls.
RRI = Running Related Injury. Hrs = Hours.
IJSPT-7_1-00-Nielsen_120010.indd10 10IJSPT-7_1-00-Nielsen_120010.indd10 10 1/19/12 7:31:02 PM1/19/12 7:31:02 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 11
increased.11,13,22,30,69,71,74 Persons running 6-7 times per
week had the highest risk. On the contrary, Taunton
et al5 found an increased risk of injury among females
running one time per week. Males also showed a sim-
ilar trend, although it was not statistically significant
(p=0.064). Satterthwaite et al6 found the odds ratio
for sustaining an anterior thigh injury increased by
1.19 [1.05-1.34] per one day increment in running fre-
quency. No significant association was found for ham-
string, hip, knee, or calf injuries. Knobloch et al71
reported an increased risk of shin splints among indi-
viduals running more than five days per week.
DISCUSSION
The purpose of this study was to investigate the rela-
tionship between training characteristics and run-
ning related injuries using a systematic review of
the literature. Training characteristics were catego-
rized into four groups: volume, duration, intensity,
and frequency. The majority of the included pro-
spective studies had a higher methodological quality
when compared with the case-control studies and
cross sectional studies.
Volume and duration
Previously, several authors19,75 proposed that a high
weekly mileage is associated with an increased risk of
sustaining RRI. This is generally supported by the
findings from the current systematic review. How-
ever, Fields et al62 questions the reliability of mileage
as an injury predictor, since they found injured run-
ners averaging essentially the same mileage as healthy
runners. According to Jakobsen et al17 it is therefore
correct to use the incidence (injury per time) for com-
parison purposes because the risk of injury must be
related to the time spent engaged in running. If inju-
ries are related to exposure time, expressed as 1000
hours of exercise, Bovens et al9 found that the number
of injuries decreased when weekly mileage during an
18 month period increased from 15 miles per week to
37 miles per week. The assumption that injury inci-
dence is decreased when running greater distances is
supported in other studies which investigated injury
incidence among runners training different mileages
per week. In the study by Bovens et al9 the mileage
increase was accompanied by maturation as a runner,
which possibly can explain the reduced risk of injury
as weekly mileage increase. Experienced runners
may know the injury threshold better than novice
runners. If this is the case, maturation as a runner
would have to be considered an uncontrolled, con-
founding factor. The incidence is reported from 2.5 to
7.4 injuries per 1000 hours of exercise among mara-
thon runners16,17 while injury incidence per 1000
Figure 3. Relationship between running frequency (days per week) and Running Related Injury (RRI). OR = odds ratio; RR =
relative risk; CI = Confi dence Interval.
IJSPT-7_1-00-Nielsen_120010.indd11 11IJSPT-7_1-00-Nielsen_120010.indd11 11 1/19/12 7:31:02 PM1/19/12 7:31:02 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 12
hours of running among novice runners who trained
30 to 90 minutes per week is 33.15 Based on these find-
ings a hypothetical example of the number of RRI
over a 26 week period can be calculated for novice
and marathon runners. If novice runners run for 30
minutes 3 times per week over 26 weeks they will
run 39 hours in total. Taking into account the risk of
injury of 33 per 1000 hours of running reported by
Buist et al15 the novice runner will sustain 1.29 inju-
ries when running 39 hours. Similarly, marathon run-
ners with the risk of 7.4 RRI per 1000 hours of running
reported by Jakobsen et al17 can expect 1.15 injuries if
they run 156 hours (2 hours 3 times per week) over
the same period of time. In this hypothetical example,
the absolute numbers of injuries would be higher
among novice runners. This is consistent with the
findings by Walter et al11 who stated that the risk of
injury per mile of training declines with total mile-
age, so the small absolute increment in risk associ-
ated with increasing mileage may be acceptable to
many athletes. All in all, these findings suggest that
the relative injury threshold becomes higher in run-
ners with higher weekly mileage.
In overview articles, authors35,76 have suggested a max-
imal increase of weekly volume of no more than 10%
per week, the so called “10% rule”, in order to reduce
the risk of injury. This suggests that runners who
increase the weekly volume by less than 10% have
reduced risk of RRI compared to runners with an
increase above 10%. In a randomized controlled trial
by Buist et al15 the 10% rule was tested in novice run-
ners. No significant difference in injury rates were
found between runners following a graded training
program with an increase in weekly duration of 10.5%
compared to runners with an increase in weekly dura-
tion of 23.7%. However, it must be noted that both
groups had a progression rate above 10%. If runners
with a progression rate below 10% per week were com-
pared with runners who increase their weekly volume
40–60% a statistically significant difference in injury
rates may be shown. However, it may be unethical to
conduct a randomized controlled trail with the inter-
vention group having an increase in weekly mileage
above 40%. In the study by Taunton et al5 all runners
had to participate in one weekly training session. The
length of this weekly training session was increased
every week. An increased risk of injury was found
among females who only participated in one training
session compared to runners who ran more training
sessions per week. Although not significant, a similar
trend was found for males. Taunton et al5 suggests that
it stands to reason that a person who does not build an
adequate training base during the other weekly train-
ing sessions will be more likely to be injured when
they participate in a program that steadily increases in
volume. However, information on progression rates
were not reported in the study by Taunton et al,5 and
because of this it is not possible to relate the results to
the 10% rule.
In conclusion there is some evidence suggesting
weekly mileages to be associated with injury. How-
ever, the relative injury threshold becomes greater
in runners with higher weekly mileage. Clearly,
more studies must be conducted to investigate the
link between weekly increase in running volume
and development of RRI, taking into account the
influence of intensity, duration, and frequency.
Intensity
The literature showed conflicting results with regard to
training intensity and development of injuries. Thus,
the way of assessing and reporting training pace may
be the reason for inconsistent results. In all included
studies training intensity was measured subjectively
by assessing the self-reported running pace. This may
be a major problem, since self-reporting may be
affected by recall bias. Furthermore, the participants
only reported the average pace. The variation in train-
ing pace within and between sessions is therefore not
accounted for. Thus, the variation in training intensity
is likely unknown and may or may not play a role in
the relationship between training intensity and risk of
RRI. One possible solution is to measure the training
intensity objectively in each training session. To date,
no studies were found that described a quasi-objective
measure such as perceived exertion or other objective
measures of training in relationship to injury. Again,
more studies have to be conducted to ascertain if there
is a relationship between training intensity and devel-
opment of injury.
Frequency
A “U-shaped” pattern between frequency and develop-
ment of RRI may exist: Taunton et al5 found an increased
risk of injury is higher among female runners training
one time per week. While McKean et al,74 Jacobs et al,13
IJSPT-7_1-00-Nielsen_120010.indd12 12IJSPT-7_1-00-Nielsen_120010.indd12 12 1/19/12 7:31:04 PM1/19/12 7:31:04 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 13
Macera et al,22 and Walter et al,11 reported an increased
risk among runners training 6-7 times per week com-
pared with those training 2-5 times per week. Based on
this, one might conclude that the ideal frequency is 2-5
running sessions per week. However, in the studies by
Macera et al22 and Walter et al11 no additional risk was
found after controlling for running volume. Therefore,
Brill and Macera23 suggested that cumulative distance is
a better indicator of injury risk than the lack of rest
between runs. Thus, based on all the studies included
in this review it must be concluded that it is not possi-
ble to determine the specific role of running frequency
with regard to injury.
Running experience
The experience of the runners included in the dif-
ferent studies may bias the results, since the included
studies include a wide variety of types of runners.
Jakobsen et al17 and Marti et al14 reported that expe-
rience was an important factor for injury risk,
because high running experience diminished the
risk of injury. In the study by Buist et al15 novice
runners reported the highest number of RRIs per
1000 hours of running. This was supported by Macera
et al22 who reported new runners to be at greater risk
for injury than more experienced runners. Perhaps
habitual and experienced runners know their own
injury threshold better as compared to novice run-
ners and are therefore less likely to sustain RRI. This
may seem to lead to the conclusion that novice run-
ners have greater risk of injury. However, novice
runners may be more likely to report injuries com-
pared to experienced runners who, in many cases,
have sustained several injuries previously and there-
fore do not consider some conditions or pain severe
enough to classify them as injuries.
Defi nitions of Running Related Injury
In the study by Mechelen et al64 no attempt was
made to compare the injury patterns between stud-
ies because of the differences in definitions and
research methods, as well as research outcome. A
similar problem exists in the current systematic
review. In Table 3 the different injury definitions
used in the 30 studies included was presented. There
is a large variation in injury definition and it must be
questioned if the different definitions of RRI in the
studies included in this review are comparable. In
their review, Ryan et al77 stated that a standardized
definition of running injury would benefit the under-
standing of injury prevalence, and can ultimately
assist in injury prevention. Additionally, Satterth-
waite et al6 and Reinking et al10 question the validity
and reliability of measuring injury by self-reporting,
as this method of describing RRI may be affected by
subject recall bias.
Measurement of training characteristics
The methods used to collect information on expo-
sure data are very similar. In all studies included in
this review, questionnaires, surveys, or self-report
diaries were used to collect information on training
exposure. In this regard, several authors have con-
cluded that the training exposure may have been
estimated or reported incorrectly71 again due to
recall bias.4,7 Therefore, the methods used in all stud-
ies to measure training exposure by subjective mea-
surements (questionnaires, surveys, diaries) should
be taken into careful consideration. Methods that
utilize technology such as Global Positioning Sys-
tems (GPS) and actual distance recording may pro-
vide more valid and reliable information on training
volume, frequency, and intensity.78
Analysis of training characteristics
Analysis of training characteristics is complex, since
one or more training variable may interact with other
training variables. In most papers included in the cur-
rent review, only the crude association between a sin-
gle training variable and the risk of injury was
investigated, without accounting for the confounding
or modifying effect of other training variables. Volume
and duration are two partially independent variables.
Running intensity is dependent on volume and dura-
tion, since intensity is volume divided by duration.
Since volume, duration, and intensity all affect one
another it may be relevant to measure and analyze all
three variables. Since it seems likely that the relation-
ship between the exposure variable and RRI may
depend on the level of other training variables, future
studies should allow for such comparisons. Further-
more, the frequency should be included in the analy-
sis74 even though it is not directly linked with volume,
duration, or intensity. This approach is supported by
Buist et al15 who stated that the increase of running
duration, intensity, and frequency should be taken
IJSPT-7_1-00-Nielsen_120010.indd13 13IJSPT-7_1-00-Nielsen_120010.indd13 13 1/19/12 7:31:04 PM1/19/12 7:31:04 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 14
into careful consideration. Hootman et al4 investigated
the relationship between an exposure variable and the
risk of RRI while adjusting for other training related
variables. However, it was not mentioned which train-
ing variables were adjusted for. Walter et al11 used a
better approach by described the training variables
which were adjusted for. An increased risk of injury
was found among those performing interval training.
However, the association was considered unimportant
once the result was adjusted for the effect of total train-
ing volume. Another example was in the study Marti
et al.14 In this study, running speed was positively
related to injury in univariate analysis, but again
adjustment for mileage clearly weakened this associa-
tion. The approaches used by Walter et al and Marti
et al are clear examples of authors trying to take into
account the interactions between several training vari-
ables. It must be emphasized that the analysis of train-
ing characteristics should use, to some extent, the
same assumption: that training variables are related
and affect each other. Based on this, the current
approaches used to analyze exposure data in order to
investigate the relationship between training charac-
teristics and RRI in a majority of the reviewed articles
must be taken into careful consideration when the
results are interpreted. In future studies the interac-
tion between running volume, duration, intensity,
and frequency must be considered.
Data may also have to be analyzed differently than it
has been previously, especially if training variables
are measured by GPS or other objective methods.
Since data from GPS measurements are extensive
they could be analyzed in a variety of ways. For
example variability between training sessions or vari-
ations within sessions could be analyzed in addition
to sudden increases in one or more training variables.
Based on their measurements Wen et al69 stated, that
the possibility to examine for sudden increases in
training variables was limited. This may be a key
point, since it has been suggested that a sudden
increase in running duration or intensity can over-
whelm the ability for adaptive change, tissue repair,
and result in injury.79 The lack of ability to objec-
tively measure such increases defined as “sudden”
may affect the possibility to investigate the relation-
ship between training exposure and RRI, since Jacobs
et al13 reported that one third of those injured
described they had changed their training just prior
to their injuries. Although it is not possible to exam-
ine this statement based on articles included in this
review, an interesting focus for future research would
be to investigate if the sudden increase in one or more
training variables, as suggested by many,24,75,79-81 is
more strongly related to injury than the absolute vol-
ume which is currently suggested to be the main
contributor to injury.18-20,82 It must be emphasized
that there is a strong need for future studies regard-
ing RRI with the primary purpose of investigating
the link between training characteristics and the
development of RRI.
CONCLUSION
Based on the studies reviewed it was not possible to
identify which training errors are related to running
related injuries. Running experience and injury
threshold seem to play a role in the relationship
between training characteristics and development
of injuries, while volume, duration, intensity, and
frequency seem to have a complex interaction with
each other which is not accounted for in the major-
ity of the included studies. All training variables
should be measured and accounted for when studies
on the relationship between training characteristics
and injuries are examined in future studies. If meth-
odological limitations can be solved by objectively
measuring the training characteristics more studies
can be conducted to carefully define training vari-
ables and their interactions, and then plan a large
scale prospective study or randomized controlled
trial to determine whether cause and effect relation-
ships exist.
REFERENCES
1. Koplan JP, Powell KE, Sikes RK, Shirley RW,
Campbell CC. An epidemiologic study of the benefi ts
and risks of running. JAMA. 1982;248(23):3118-3121.
2. Reuser M, Bonneux LG, Willekens FJ. Smoking kills,
obesity disables: A multistate approach of the US
health and retirement survey. Obesity (Silver Spring).
2009;17(4):783-789.
3. Colbert LH, Hootman JM, Macera CA. Physical
activity-related injuries in walkers and runners in
the aerobics center longitudinal study. Clin J Sport
Med. 2000;10(4):259-263.
4. Hootman JM, Macera CA, Ainsworth BE, Martin M,
Addy CL, Blair SN. Predictors of lower extremity
injury among recreationally active adults. Clin J
Sport Med. 2002;12(2):99-106.
IJSPT-7_1-00-Nielsen_120010.indd14 14IJSPT-7_1-00-Nielsen_120010.indd14 14 1/19/12 7:31:04 PM1/19/12 7:31:04 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 15
5. Taunton JE, Ryan MB, Clement DB, McKenzie DC,
Lloyd-Smith DR, Zumbo BD. A prospective study of
running injuries: The vancouver sun run “in
training” clinics. Br J Sports Med. 2003;37(3):239-244.
6. Satterthwaite P, Norton R, Larmer P, Robinson E.
Risk factors for injuries and other health problems
sustained in a marathon. Br J Sports Med.
1999;33(1):22-26.
7. Van Middelkoop M, Kolkman J, Van Ochten J,
Bierma-Zeinstra SM, Koes BW. Risk factors for lower
extremity injuries among male marathon runners.
Scand J Med Sci Sports. 2008;18(6):691-697.
8. Kelsey JL, Bachrach LK, Procter-Gray E, et al. Risk
factors for stress fracture among young female cross-
country runners. Med Sci Sports Exerc.
2007;39(9):1457-1463.
9. Bovens AM, Janssen GM, Vermeer HG, Hoeberigs
JH, Janssen MP, Verstappen FT. Occurrence of
running injuries in adults following a supervised
training program. Int J Sports Med. 1989;10 Suppl 3:
S186-S190.
10. Reinking MF, Austin TM, Hayes AM. Exercise-related
leg pain in collegiate cross-country athletes:
Extrinsic and intrinsic risk factors. J Orthop Sports
Phys Ther. 2007;37(11):670-678.
11. Walter SD, Hart LE, McIntosh JM, Sutton JR. The
ontario cohort study of running-related injuries. Arch
Intern Med. 1989;149(11):2561-2564.
12. Koplan JP, Rothenberg RB, Jones EL. The natural
history of exercise: A 10-yr follow-up of a cohort of
runners. Med Sci Sports Exerc. 1995;27(8):1180-1184.
13. Jacobs SJ, Berson BL. Injuries to runners: A study of
entrants to a 10,000 meter race. Am J Sports Med.
1986;14(2):151-155.
14. Marti B, Vader JP, Minder CE, Abelin T. On the
epidemiology of running injuries. the 1984 bern
grand-prix study. Am J Sports Med. 1988;16(3):
285-294.
15. 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):33-39.
16. Lysholm J, Wiklander J. Injuries in runners. Am J
Sports Med. 1987;15(2):168-171.
17. Jakobsen BW, Kroner K, Schmidt SA, Kjeldsen A.
Prevention of injuries in long-distance runners. Knee
Surg Sports Traumatol Arthrosc. 1994;2(4):245-249.
18. 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;38(2):273-280.
19. van Gent RN, Siem D, Van Middelkoop M, van Os
AG, Bierma-Zeinstra SM, Koes BW. Incidence and
determinants of lower extremity running injuries in
long distance runners: A systematic review. Br J
Sports Med. 2007;41(8):469-480.
20. Hreljac A. Etiology, prevention, and early
intervention of overuse injuries in runners: A
biomechanical perspective. Phys Med Rehabil Clin N
Am. 2005;16(3):651-67, vi.
21. Fields KB, Sykes JC, Walker KM, Jackson JC.
Prevention of running injuries. Curr Sports Med Rep.
2010;9(3):176-182.
22. Macera CA, Pate RR, Powell KE, Jackson KL,
Kendrick JS, Craven TE. Predicting lower-extremity
injuries among habitual runners. Arch Intern Med.
1989;149(11):2565-2568.
23. Brill PA, Macera CA. The infl uence of running
patterns on running injuries. Sports Med.
1995;20(6):365-368.
24. Renstrom AF. Mechanism, diagnosis, and treatment
of running injuries. Instr Course Lect. 1993;42:
225-234.
25. Johnson R. Common running injuries of the leg and
foot. Minn Med. 1983;66(7):441-444.
26. van der Worp H, van Ark M, Roerink S, Pepping GJ,
van den Akker-Scheek I, Zwerver J. Risk factors for
patellar tendinopathy: A systematic review of the
literature. Br J Sports Med. 2011;45(5):446-452.
27. van der Windt DA, Thomas E, Pope DP, et al.
Occupational risk factors for shoulder pain:
A systematic review. Occup Environ Med.
2000;57(7):433-442.
28. Verhagen AP, de Vet HC, de Bie RA, et al. The delphi
list: A criteria list for quality assessment of
randomized clinical trials for conducting systematic
reviews developed by delphi consensus. J Clin
Epidemiol. 1998;51(12):1235-1241.
29. Collins NJ, Bisset LM, Crossley KM, Vicenzino B.
Effi cacy of nonsurgical interventions for anterior
knee pain: Systematic review and meta-analysis of
randomized trials. Sports Med. 2012;42(1):31-49.
30. Pollock ML, Gettman LR, Milesis CA, Bah MD,
Durstine L, Johnson RB. Effects of frequency and
duration of training on attrition and incidence of
injury. Med Sci Sports. 1977;9(1):31-36.
31. Fredericson M, Misra AK. Epidemiology and
aetiology of marathon running injuries. Sports Med.
2007;37(4-5):437-439.
32. Ballas MT, Tytko J, Cookson D. Common overuse
running injuries: Diagnosis and management. Am
Fam Physician. 1997;55(7):2473-2484.
IJSPT-7_1-00-Nielsen_120010.indd15 15IJSPT-7_1-00-Nielsen_120010.indd15 15 1/19/12 7:31:04 PM1/19/12 7:31:04 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 16
33. McKenzie DC, Clement DB, Taunton JE. Running
shoes, orthotics, and injuries. Sports Med.
1985;2(5):334-347.
34. O’Toole ML. Prevention and treatment of injuries
to runners. Med Sci Sports Exerc. 1992;24(9):S360-
S363.
35. Paty JG, Jr., Swafford D. Adolescent running injuries.
J Adolesc Health Care. 1984;5(2):87-90.
36. Plisky MS, Rauh MJ, Heiderscheit B, Underwood FB,
Tank RT. Medial tibial stress syndrome in high
school cross-country runners: Incidence and risk
factors. J Orthop Sports Phys Ther. 2007;37(2):40-47.
37. 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):110-116.
38. Rauh MJ, Koepsell TD, Rivara FP, Margherita AJ,
Rice SG. Epidemiology of musculoskeletal injuries
among high school cross-country runners. Am J
Epidemiol. 2006;163(2):151-159.
39. Chakravarty EF, Hubert HB, Lingala VB, Zatarain E,
Fries JF. Long distance running and knee
osteoarthritis. A prospective study. Am J Prev Med.
2008;35(2):133-138.
40. Cheng Y, Macera CA, Davis DR, Ainsworth BE,
Troped PJ, Blair SN. Physical activity and self-
reported, physician-diagnosed osteoarthritis: Is
physical activity a risk factor? J Clin Epidemiol.
2000;53(3):315-322.
41. 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):91-93.
42. Niemuth PE, Johnson RJ, Myers MJ, Thieman TJ.
Hip muscle weakness and overuse injuries in
recreational runners. Clin J Sport Med. 2005;15(1):
14-21.
43. Chorley JN, Cianca JC, Divine JG, Hew TD. Baseline
injury risk factors for runners starting a marathon
training program. Clin J Sport Med. 2002;12(1):
18-23.
44. Thijs Y, De CD, Roosen P, Witvrouw E. Gait-related
intrinsic risk factors for patellofemoral pain in
novice recreational runners. Br J Sports Med.
2008;42(6):466-471.
45. Van Ginckel A, Thijs Y, Hesar NG, et al. Intrinsic
gait-related risk factors for achilles tendinopathy in
novice runners: A prospective study. Gait Posture.
2009;29(3):387-391.
46. Van Middelkoop M, Kolkman J, Van Ochten J,
Bierma-Zeinstra SM, Koes BW. Course and predicting
factors of lower-extremity injuries after running a
marathon. Clin J Sport Med. 2007;17(1):25-30.
47. Ryan M, Fraser S, McDonald K, Taunton J.
Examining the degree of pain reduction using a
multielement exercise model with a conventional
training shoe versus an ultrafl exible training shoe for
treating plantar fasciitis. Phys Sportsmed.
2009;37(4):68-74.
48. Sullivan D, Warren RF, Pavlov H, Kelman G. Stress
fractures in 51 runners. Clin Orthop Relat Res.
1984(187):188-192.
49. Sutker AN, Barber FA, Jackson DW, Pagliano JW.
Iliotibial band syndrome in distance runners. Sports
Med. 1985;2(6):447-451.
50. Taunton JE, Ryan MB, Clement DB, McKenzie DC,
Lloyd-Smith DR, Zumbo BD. A retrospective case-
control analysis of 2002 running injuries. Br J Sports
Med. 2002;36(2):95-101.
51. Edwards WB, Taylor D, Rudolphi TJ, Gillette JC,
Derrick TR. Effects of running speed on a
probabilistic stress fracture model. Clin Biomech
(Bristol , Avon). 2010;25(4):372-377.
52. Edwards WB, Taylor D, Rudolphi TJ, Gillette JC,
Derrick TR. Effects of stride length and running
mileage on a probabilistic stress fracture model. Med
Sci Sports Exerc. 2009;41(12):2177-2184.
53. Caselli MA, Longobardi SJ. Lower extremity injuries
at the new york city marathon. J Am Podiatr Med
Assoc. 1997;87(1):34-37.
54. Haglund-Akerlind Y, Eriksson E. Range of motion,
muscle torque and training habits in runners with
and without achilles tendon problems. Knee Surg
Sports Traumatol Arthrosc. 1993;1(3-4):195-199.
55. McKelvie SJ, Valliant PM, Asu ME. Physical training
and personality factors as predictors of marathon
time and training injury. Percept Mot Skills.
1985;60(2):551-566.
56. Schueller-Weidekamm C, Schueller G, Uffmann M,
Bader T. Incidence of chronic knee lesions in long-
distance runners based on training level: Findings at
MRI. Eur J Radiol. 2006;58(2):286-293.
57. Holmich P, Christensen SW, Darre E, Jahnsen F,
Hartvig T. Non-elite marathon runners: Health,
training and injuries. Br J Sports Med. 1989;23(3):
177-178.
58. Brunet ME, Cook SD, Brinker MR, Dickinson JA.
A survey of running injuries in 1505 competitive
and recreational runners. J Sports Med Phys Fitness.
1990;30(3):307-315.
59. Samet J, Chick T, Howard C. Running-related
morbidity: A community survey. Annals of Sports
Medicine. 1977;1:30-34.
60. Buist I, Bredeweg SW, Lemmink KA, et al. The
GRONORUN study: Is a graded training program for
novice runners effective in preventing running
IJSPT-7_1-00-Nielsen_120010.indd16 16IJSPT-7_1-00-Nielsen_120010.indd16 16 1/19/12 7:31:04 PM1/19/12 7:31:04 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 17
related injuries? design of a randomized controlled
trial. BMC Musculoskelet Disord. 2007;8:24.
61. Valliant PM. Personality and injury in competitive
runners. Percept Mot Skills. 1981;53(1):251-253.
62. Fields KB, Delaney M, Hinkle JS. A prospective
study of type A behavior and running injuries. J Fam
Pract. 1990;30(4):425-429.
63. Wen DY, Puffer JC, Schmalzried TP. Injuries in
runners: A prospective study of alignment. Clin J
Sport Med. 1998;8(3):187-194.
64. van Mechelen W, Hlobil H, Kemper HC, Voorn WJ,
de Jongh HR. Prevention of running injuries by
warm-up, cool-down, and stretching exercises. Am J
Sports Med. 1993;21(5):711-719.
65. Messier SP, Pittala KA. Etiologic factors associated
with selected running injuries. Med Sci Sports Exerc.
1988;20(5):501-505.
66. Messier SP, Davis SE, Curl WW, Lowery RB, Pack RJ.
Etiologic factors associated with patellofemoral pain
in runners. Med Sci Sports Exerc. 1991;23(9):1008-
1015.
67. Messier SP, Edwards DG, Martin DF, et al. Etiology of
iliotibial band friction syndrome in distance runners.
Med Sci Sports Exerc. 1995;27(7):951-960.
68. Duffey MJ, Martin DF, Cannon DW, Craven T,
Messier SP. Etiologic factors associated with anterior
knee pain in distance runners. Med Sci Sports Exerc.
2000;32(11):1825-1832.
69. Wen DY, Puffer JC, Schmalzried TP. Lower extremity
alignment and risk of overuse injuries in runners.
Med Sci Sports Exerc. 1997;29(10):1291-1298.
70. McCrory JL, Martin DF, Lowery RB, et al. Etiologic
factors associated with achilles tendinitis in runners.
Med Sci Sports Exerc. 1999;31(10):1374-1381.
71. Knobloch K, Yoon U, Vogt PM. Acute and overuse
injuries correlated to hours of training in master
running athletes. Foot Ankle Int. 2008;29(7):671-676.
72. Hootman JM, Macera CA, Ainsworth BE, Addy CL,
Martin M, Blair SN. Epidemiology of musculoskeletal
injuries among sedentary and physically active
adults. Med Sci Sports Exerc. 2002;34(5):838-844.
73. Marti B. Benefi ts and risks of running among
women: An epidemiologic study. Int J Sports Med.
1988;9(2):92-98.
74. McKean KA, Manson NA, Stanish WD.
Musculoskeletal injury in the masters runners. Clin J
Sport Med. 2006;16(2):149-154.
75. Wen DY. Risk factors for overuse injuries in runners.
Curr Sports Med Rep. 2007;6(5):307-313.
76. Johnston CA, Taunton JE, Lloyd-Smith DR,
McKenzie DC. Preventing running injuries. practical
approach for family doctors. Can Fam Physician.
2003;49:1101-1109.
77. Ryan MB, MacLean CL, Taunton JE. A review of
anthropometric, biomechanical, neuromuscular and
training related factors associated with injury in
runners. International SportMed Journal.
2006;7(2):120-137.
78. Townshend AD, Worringham CJ, Stewart IB.
Assessment of speed and position during human
locomotion using nondifferential GPS. Med Sci Sports
Exerc. 2008;40(1):124-132.
79. Galloway MT, Jokl P, Dayton OW. Achilles tendon
overuse injuries. Clin Sports Med. 1992;11(4):771-782.
80. Rzonca EC, Baylis WJ. Common sports injuries to
the foot and leg. Clin Podiatr Med Surg. 1988;5(3):
591-612.
81. Fredericson M. Common injuries in runners.
diagnosis, rehabilitation and prevention. Sports Med.
1996;21(1):49-72.
82. Macera CA. Lower extremity injuries in runners.
advances in prediction. Sports Med. 1992;13(1):50-57.
IJSPT-7_1-00-Nielsen_120010.indd17 17IJSPT-7_1-00-Nielsen_120010.indd17 17 1/19/12 7:31:05 PM1/19/12 7:31:05 PM
The International Journal of Sports Physical Therapy | Volume 7, Number 1 | February 2012 | Page 18
APPENDIX 1: SEARCH TERMS
(“Running”[Mesh] OR (foot race)) AND (“Exercise”[Mesh] OR exposure OR “Physical Therapy Modalities”[Mesh]
OR “Clinical Protocols”[Mesh] OR (regim*) OR program OR programme OR “Healthy People Programs”[Mesh]
OR marathon OR marathon OR training OR (training characteristics) OR (running patterns) OR volume OR
intensity OR frequency OR speed OR pace OR distance OR mileage) AND (injur* OR syndrome* OR tendin*
OR fractur* OR (“pain”[Mesh]) OR fasciitis OR bursitis OR splint* OR tear* OR sprain* OR strain* OR entrap-
ment* OR ostei* OR osteopor* OR osteoa* OR rupture* OR arthros* OR arthri* OR lipoma OR sciatica OR
lumbago OR laceration* OR split* OR tenosynovitis OR blister* OR cramp* OR corn OR callus* OR edema*
OR sesamoiditis OR ganglion* OR hernia* OR muscle soreness OR delayed onset muscle soreness OR hem-
orrh* OR ischi* OR neuroma* OR abrasion OR wart* OR mold* OR dislocation* OR damage OR trauma OR
displacement OR periostitis) NOT (“addresses”[Publication Type] OR “bibliography”[Publication Type] OR
“biography”[Publication Type] OR “case reports”[Publication Type] OR “clinical conference”[Publication Type]
OR “comment”[Publication Type] OR “congresses”[Publication Type] OR “dictionary”[Publication Type] OR
“directory”[Publication Type] OR “editorial”[Publication Type] OR “festschrift”[Publication Type] OR “govern-
ment publications”[Publication Type] OR “interview”[Publication Type] OR “lectures”[Publication Type] OR
“legal cases”[Publication Type] OR “legislation”[Publication Type] OR “letter”[Publication Type] OR
“news”[Publication Type] OR “newspaper article”[Publication Type] OR “retracted publication”[Publication
Type] OR “retraction of publication”[Publication Type] OR “review”[Publication Type] OR “scientific integrity
review”[Publication Type] OR “technical report”[Publication Type] OR “twin study”[Publication Type] OR “vali-
dation studies”[Publication Type] OR pregnancy OR rugby OR soccer OR football OR rheumatoid)
IJSPT-7_1-00-Nielsen_120010.indd18 18IJSPT-7_1-00-Nielsen_120010.indd18 18 1/19/12 7:31:05 PM1/19/12 7:31:05 PM
