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A prospective study of running injuries: The Vancouver Sun Run "In Training" clinics

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Seventeen running training clinics were investigated to determine the number of injuries that occur in a running programme designed to minimise the injury rate for athletes training for a 10 km race. The relative contributions of factors associated with injury were also reported. A total of 844 primarily recreational runners were surveyed in three trials on the 4th, 8th, and 12th week of the 13 week programme of the "In Training" running clinics. Participants were classified as injured if they experienced at least a grade 1 injury-that is, pain only after running. Logistic regression modelling and odds ratio calculation were performed for each sex using the following predictor variables: age, body mass index (BMI), previous aerobic activity, running frequency, predominant running surface, arch height, running shoe age, and concurrent cross training. Age played an important part in injury in women: being over 50 years old was a risk factor for overall injury, and being less than 31 years was protective against new injury. Running only one day a week showed a non-significant trend for injury risk in men and was a significant risk factor in women and overall injury. A BMI of > 26 kg/m(2) was reported as protective for men. Running shoe age also significantly contributed to the injury model. Half of the participants who reported an injury had had a previous injury; 42% of these reported that they were not completely rehabilitated on starting the 13 week training programme. An injury rate of 29.5% was recorded across all training clinics surveyed. The knee was the most commonly injured site. Although age, BMI, running frequency (days a week), and running shoe age were associated with injury, these results do not take into account an adequate measure of exposure time to injury, running experience, or previous injury and should thus be viewed accordingly. In addition, the reason for the discrepancy in injury rate between these 17 clinics requires further study.
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ORIGINAL ARTICLE
A prospective study of running injuries: the Vancouver
Sun Run “In Training” clinics
J E Taunton, M B Ryan, D B Clement, D C McKenzie, D R Lloyd-Smith, B D Zumbo
.............................................................................................................................
Br J Sports Med
2003;37:239–244
Objectives: Seventeen running training clinics were investigated to determine the number of injuries
that occur in a running programme designed to minimise the injury rate for athletes training for a 10
km race. The relative contributions of factors associated with injury were also reported.
Methods: A total of 844 primarily recreational runners were surveyed in three trials on the 4th, 8th,
and 12th week of the 13 week programme of the “In Training” running clinics. Participants were clas-
sified as injured if they experienced at least a grade 1 injury—that is, pain only after running. Logistic
regression modelling and odds ratio calculation were performed for each sex using the following pre-
dictor variables: age, body mass index (BMI), previous aerobic activity, running frequency, predomi-
nant running surface, arch height, running shoe age, and concurrent cross training.
Results: Age played an important part in injury in women: being over 50 years old was a risk factor
for overall injury, and being less than 31 years was protective against new injury. Running only one
day a week showed a non-significant trend for injury risk in men and was a significant risk factor in
women and overall injury. A BMI of > 26 kg/m2was reported as protective for men. Running shoe age
also significantly contributed to the injury model. Half of the participants who reported an injury had
had a previous injury; 42% of these reported that they were not completely rehabilitated on starting the
13 week training programme. An injury rate of 29.5% was recorded across all training clinics
surveyed. The knee was the most commonly injured site.
Conclusions: Although age, BMI, running frequency (days a week), and running shoe age were asso-
ciated with injury, these results do not take into account an adequate measure of exposure time to
injury, running experience, or previous injury and should thus be viewed accordingly. In addition, the
reason for the discrepancy in injury rate between these 17 clinics requires further study.
From 1996 to 2000, the Vancouver Sun Run “In Training”
Clinics have helped over 12 000 people train for one of the
largest 10 km races in the world. Designed primarily for
the beginner, the training regimens within the 47 separate
clinics provide a graduated programme that intersperses
walking with jogging or running in order to minimise the
chance of sustaining an injury in the training period leading
up to, and during, the Vancouver Sun Run.
However, we are unsure how effective these clinics are at
achieving that end. Although there has been a focus in the lit-
erature on understanding the factors that contribute to the
risk of injury for a given population of runners, there has been
less emphasis on developing running programmes that would
be optimal—that is, minimise the injury rate—for decondi-
tioned or novice runners. This study is a preliminary prospec-
tive analysis of the injuries that occur in these training
programmes. The objective was to determine the injury
pattern in a sample of the In Training clinics during their 13
week programme. Certain factors associated with the risk of
injury are analysed and odds ratio calculation performed
based on logistic regression modelling. The associated risk
factors for injury were identified by previous authors and
include: age, body mass index (BMI), previous activity, arch
height, running shoe age, concurrent cross training, predomi-
nant running surface, and running frequency a week.1–8
METHODS
Subjects
The 844 subjects were registered in 17 of the In Training clin-
ics administered by The Sport Medicine Council of British
Columbia. These were primarily recreational runners inter-
ested in either completing the 10 km race distance or improv-
ing their existing race time. There were no fitness require-
ments for enrollment with the In Training clinics. Subjects
were recruited, out of a possible 1020 runners, by virtue of
being registered in the selected clinics. A total of 176
participants elected not to participate in this study.
“In Training” protocol
The 13 week training protocol was designed by sport medicine
doctors practicing at the Allan McGavin Sport Medicine Cen-
tre, and includes two sections to accommodate novice and
intermediate runners. The novice group is primarily sedentary
and deconditioned people interested in establishing a running
programme probably to improve health and fitness. The
programme for this group incorporates run/walk repeats that
eventually lead to a continuous running session in the 12th
week.
The intermediate programme is designed for people who
have completed the novice walk/run programme and would
like to increase their running endurance and intensity in a
safe and effective way. Hill training, interval, and fartlek ses-
sions are implemented.
Both training programmes require the participants to run
three times a week; two of these sessions are separate from the
group run on the day of their respective clinic. It is
recommended that participants allow one day of rest (or cross
training) between any two running sessions. Training sessions
vary in length from 35 to 66 minutes, depending on their pro-
gression in the programme.
Procedures
The same questionnaire was administered on three separate
trials over the In Training clinics’ 13 week duration. No base-
line measures were taken. The first trial was conducted in the
4th week, the second trial in the 8th week, and the final trial
See end of article for
authors’ affiliations
.......................
Correspondence to:
Dr Taunton, Allan McGavin
Sports Medicine Centre,
University of British
Columbia, Vancouver, BC,
Canada V6T 1Z3;
jtaunton@interchange.ubc.ca
Accepted 8 July 2002
.......................
239
www.bjsportmed.com
in the 12th week. The personal and activity profiles (see
below) were administered during all trials to accommodate
any runners that were absent during the 4th and 8th weeks
respectively. Before the first questionnaire was given to a clinic
population, a brief presentation outlining the objectives of the
survey was conducted by either a researcher or one of the
clinic coordinators. The two page survey was then adminis-
tered at the beginning of the session, and collected
immediately. Survey packages, mailed to selected clinic
coordinators, included survey forms, pencils, and a cover letter
outlining any changes or recommendations for the survey
administrators.
Questionnaire
The two page questionnaire consists of 19 questions divided
into four separate sections: personal profile, activity profile,
injury history, and injury profile. The personal profile asked for
the participant’s full name, age, sex, height, weight, and train-
ing level (walker,run/walk, or intermediate). This section also
included questions on arch height and brand and age of run-
ning shoes. A diagram of a foot imprint with selected arch
heights was included to assist the participants in their self
classification of neutral, high, or low arches. This tool, along
with the question on previous aerobic activity, has yet to be
validated by doctors. Nevertheless, it was felt that including
these variables would improve the scope of the risk factors
analysed.
The activity profile investigated previous activity level (des-
ignated by aerobic activity three times a week for the previous
six months), running frequency in days a week, predominant
running surface, whether the participant recorded their
sessions, and whether he/she had incorporated cross training
into their In Training regimen.
In the injury history section, the participant was asked to
indicate whether they had experienced an injury in the past as
a result of running, and, if so, to provide details such as injury
location and diagnosis.
The injury profile section determined whether the partici-
pant was currently experiencing an injury, and if so,to provide
injury location and diagnosis. A question was included to
ascertain the presence and severity of an injury based on the
following guidelines: 1, pain only after exercise; 2, pain during
exercise, but not restricting distance or speed; 3, pain during
exercise and restricting distance and speed; 4, pain preventing
all running. A runner was classified as being injured if they
experienced at least a grade 1 injury (pain only after exercise).
Both the injury history and injur y profile sections asked if a
qualified doctor or physiotherapist had diagnosed their previ-
ous or current injury. Diagnoses from participants that did not
consult a professional were not included.
Risk factors were recorded for a given injury based on the
corresponding survey return. If a runner experienced an
injury throughout the entire 13 week period and aspects of
their activity or personal profile changed, the initial profile
data were used.
Statistical analysis
Descriptive statistics were used for baseline calculations. Odds
ratios were approximated, including their 95% confidence
interval. This multivariate logistic regression model assessed
the relative contribution of the predicted risk factors (age,
BMI, previous activity, arch height, running shoe age, concur-
rent cross training, predominant running surface, and
running frequency a week) to the overall number of injuries.
A similar model was attempted to establish the contribution of
the risk factor to severe running injuries (grades 3 and 4), and
new injuries (injuries in subjects with no history of injur y).
Significance was declared if one or more of the risk factors
exceeded a p value of 0.05 for the Wald statistic. Baseline
characteristics across sex, and associations with orthotic use
were analysed using a χ2contingency table, with αset at 0.05.
RESULTS
Table 1 gives baseline characteristics of the participants. A
large discrepancy was noted among the training clinics with
respect to sex, with 635 (75.2%) female and 205 (24.3%) male
participants. The run/walk programme included most of the
runners of both sexes. Significantly more women (p = 0.021)
were registered in the novice programme (64.9% v59.0%), and
the intermediate programme appeared to have a significant (p
= 0.021) majority of male participants (29.3 v20.0%). There
was no significant difference in the number of injuries
between runners in the novice (run/walk) and intermediate
programmes.
Significantly more women reported having a BMI less than
19 (4.3 v1.0%; p = 0.002) and a BMI of 20–26 (69.8 v55.1%;
p = 0.003). Conversely, significantly more men were registered
with a BMI greater than 26 (41.0 v16.7%; p<0.001). In addi-
tion, more women than men (43.9 v33.7%; p = 0.010)
declared they were active before beginning the 13 week
programme, and women were significantly (p<0.001) more
likely to keep a running diary (52.0 v35.1%). No significant
differences were not found in the different designations of
arch height (normal, low, and high) or concurrent cross train-
ing between sexes.
A large number of the participants wore shoes less than
three months old (42.3%). The only shoe age category that
showed an injury rate above the mean was one to three
months (31.6%), and participants with shoes more than two
years old recorded an injury rate of 27.9% or 1.6% below the
mean.
Figure 1 outlines the relative percentages of predominant
running surfaces. Most runners (69.1%) chose to run
primarily on roads, 18.6% preferred trails/off-road, and 12.3%
ran on other surfaces such as grass, track, or treadmill.
Table 1 Baseline characteristics of study population
Men
(n=205)
Women
(n=635)
Age (years)
<30** 25 (12.3) 116 (18.6)
31–49** 105 (51.5) 397 (63.6)
50–55** 39 (19.1) 72 (11.5)
>56** 35 (17.2) 39 (6.3)
Missing 1 11
BMI (kg/m2)
<19** 2 (1.0) 27 (4.3)
20–26** 113 (55.1) 443 (69.8)
>26** 84 (41.0) 106 (16.7)
Missing 6 59
Programme
Novice (run/walk)** 121 (59.0) 412 (64.9)
Intermediate** 60 (29.3) 127 (20.0)
Walker** 24 (11.7) 93 (14.6)
Missing 0 3
Arch height
Normal 121 (59.0) 367 (57.8)
Low 33 (16.1) 102 (16.1)
High 46 (22.4) 145 (22.8)
Missing 5 21
Orthotic use 35 (17.1) 113 (17.8)
No orthotic 168 (82.0) 521 (82.0)
Missing 2 1
Previously active** 69 (33.7) 279 (43.9)
Not previously active** 135 (65.9) 355 (55.9)
Missing 1 1
Concurrent cross training 109 (53.2) 324 (51.0)
No cross training 96 (46.8) 311 (49.0)
Missing 0 0
Regular run diary recording** 72 (35.1) 330 (52.0)
No recording** 133 (64.9) 305 (48.0)
Missing 0 0
Values are numbers with percentages in parentheses.
**Significance p<0.05.
BMI, Body mass index.
240 Taunton, Ryan, Clement, et al
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Close to 60% of the participants surveyed complied with the
recommended running frequency of three times a week (table
2). Almost 30% (29.0%) of the runners reported running twice
a week, and 5.8% and 1.1% documented running one day and
five days a week respectively.
Overall, 29.5% (249 recorded injuries for 844 runners) of the
runners surveyed in this 13 week training programme experi-
enced an injury (grade 1 severity or greater). Figure 2
illustrates the variation in the injury rate across the clinics
surveyed. Certain clinics registered injury rates as high as
48%, whereas others reported rates below 20%. As this finding
was unexpected, it would be inappropriate to pursue a statis-
tical analysis on these data until more information is
gathered.
Owing to the nature of this study design, we were unable to
determine if a subject experienced multiple injuries over the
13 week period. For example,runners citing an injury in week
4 and recovering in week 8 only to be injured again in week 12,
and runners citing an injury over all three trials, would be
classified as experiencing one injury.
The knee was the most commonly injured anatomical site
for both sexes, with 36% and 32% of men and women respec-
tively reporting injuries to this area (table 3). Tibial stress syn-
drome was reported as the most commonly diagnosed injury.
Injuries to the shin, foot, ankle, hip/pelvis, low back,
hamstring, and thigh were reported in that order of frequency,
equivalent across the sexes.
The 29.5% figure includes both new injuries and injuries
that were felt by the subject to be a result of a complication
from a previous injury. Half of those reporting an injury had
previously sustained an injury to the same anatomical area,
and a large percentage of these (42%) declared themselves not
100% rehabilitated on starting the In Training programme.
Most injuries (35.5%) were grade 2 (pain during a run, but not
restricting distance or speed grade).
The multivariate regression model was found to be signifi-
cant for both men (χ2(3 df) = 15.876, p = 0.001) and women
(χ2(3 df) = 15.318, p = 0.002) comparing overall number of
injuries as the dependent variable (table 4). The difference
between the respective sex models, however, lies in the factors
found to be significantly associated with the injury rate. Being
over the age of 50, wearing running shoes four to six months
Figure 1 Breakdown of running surfaces.
Table 2 Running frequency
No %
1 day/week 49 5.8
2 days/week 244 29.0
3 days/week 501 59.6
4 days/week 36 4.3
5 days/week 9 1.1
Data were not provided in five cases.
Figure 2 Injury rate distribution with selected In Training clinics.
Table 3 Distribution of injuries by
anatomical site
Location Men Women
Knee 21 (36) 62 (32)
Shin 10 (17) 28 (15)
Foot 8 (14) 25 (13)
Achilles/calf 5 (8) 20 (10)
Ankle 6 (10) 20 (10)
Hip/pelvis 4 (7) 19 (10)
Low back 4 (7) 10 (5)
Hamstring 0 (0) 6 (3)
Thigh 0 (0) 2 (1)
Values are numbers with percentages in
parentheses. Certain subjects indicated multiple
injury locations.
Running injuries 241
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old, and only running one day a week were reported as risk
indicators for injury in women.
For the men, having a BMI of 26 or greater and running in
shoes four to six months old were associated with a lower
number of injuries.
The model investigating the odds ratio of experiencing a
new injury incorporating the same proposed associating vari-
ables was significant only for women (χ2(2 df) = 8.114).
Being less than 31 years old and wearing new running shoes
(one to three months old) were associated with less injuries
for female respondents. The model examining these same
associated variables in the contribution of only severe injuries
was not significant in either sex.
DISCUSSION
Injury analysis
The 29.5% injury rate reported in this study is in line with
other documented injury rates of 25–65%.19 The injury
incidence in this study was expected be lower than that found
in the general literature on running because of the specific
design of the In Training clinics’ programme to minimise run-
ning injuries. However, it is difficult to put the injury incidence
of this investigation into perspective as very few, if any, of the
studies in the literature followed runners for such a short
time. Furthermore, differences in injury definition used by
different authors may further confound appropriate compari-
son across studies.
The injury rate disparity (fig 2) between the clinics studied
was surprising, given that the In Training clinics are marketed
at, and primarily comprise, a similar group—that is, normally
sedentary people that are novice to running. All clinics follow
the same running programme for the same duration and at
the same time of the year. However, the participants attend
only one training session a week with the clinic, therefore the
clinic coordinators/run leaders only have influence over this
one session. The other training sessions during the week are
performed according to the individual participant, which
indicates that at least two out of the three recommended
training sessions are outside the control of the In Training
clinic programme. Our results warrant further investigation
into the level of compliance of clinic coordinators and/or run
leaders with the overall programme agenda, the efficacy of the
training programme itself, and other factors that could influ-
ence the epidemiology of running injuries between the various
clinics.
There are a few limitations to this study that the reader
should consider. Unfortunately, clinic attendance levels were
not consistent, resulting in some participants not filling out all
three survey trials. The data from these participants were still
included in our analysis of injury incidence, with the
understanding that it was our objective to ascertain the scope
of injuries within the In Training clinics, not calculate an
injury rate. For this reason, data from all survey trials were
incorporated such that an injury during any of the three
trials—that is, week 4, 8, or 12—would constitute one injury
for that runner.
Our finding that the knee was the most common site of
injury is well supported.46In a review of 5992 cases seen at the
Division of Sports Medicine of the University of British
Columbia between 1978 and 1991, the knee was found to be
the most often injured site among runners, and patellofemo-
ral pain syndrome the most commonly occurring injury.10 11
Ballas et al12 also reported that patellofemoral pain syndrome
Table 4 Significant factors associated with the injury rate
Risk factor
Relative risk (95% confidence interval)
Overall injury New injury
Men Women Men Women
Age (years)
Less than 31 0.575 (0.342 to 0.967)
31 to 37
38 to 43
44 to 50
Greater than 50 1.919 (1.107 to 3.328)
BMI (kg/m2)
Less than 21
21 to 24
24 to 26
Greater than 26 0.407 (0.211 to 0.785)
Running frequency
1 day/week
3.648 (1.082 to 12.297)
––
2 days/week
3 days/week
4 days/week
5 days/week
Arch height
Normal – –
Low – –
High – –
Running surface
Road – –
Trail – –
Grass – –
Treadmill – –
Running shoe age
1–3 months 0.611 (0.378 to 0.987)
4–6 months 0.355 (0.151 to 0.834) 1.735 (1.009 to 2.984)
7–12 months
1–2 years
Previous activity
Cross training
BMI, Body mass index.
242 Taunton, Ryan, Clement, et al
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was the most common injury in a breakdown of 860 overuse
running injuries presented at the Franciscan Sports Medicine
Center.
Tibial stress syndrome was the most documented diagnosed
injury in this investigation. Unfortunately, this provides little
indication of the most common injury during the 13 week
programme, as diagnoses were obtained from only 43.7% of
the injured population.
Factors significantly associated with injury
The results from the logistic regression show that women over
50 years old, who wear running shoes four to six months old,
and who run only one day a week have a higher odds ratio of
experiencing an injury. Conversely, wearing running shoes
four to six months old was associated with a reduced
likelihood of injury in men, as was having a BMI of greater
than 26 kg/m2. Women less than 31 years old had a
significantly lower odds ratio of sustaining a new injury.
Unfortunately, as it was expected that the participants would
run the same approximate distance on a weekly basis because
everyone was following the same running programme, weekly
mileage was not included as a variable of interest. Given the
discrepancy in the running frequency—that is, more than 30%
of the subjects did not comply with the recommended
running frequency—this assumption is probably not accurate.
Therefore it is difficult to interpret the results of the logistic
regression without this important risk factor (weekly running
distance) included in the model. In the reviews of Van
Mechelen2and Brill and Macera,3running distance is consid-
ered to be one of the strongest contributors to injury. In fact,
these authors assert that it is difficult to determine accurately
the risk of injury to a population, despite recording numerous
other risk factors, unless exposure time is taken into account.
It is recommended that future investigations into the risk of
injury for this running population include a method of
recording exposure time.
Despite the fact that weekly mileage was not included in the
injury model, our results with respect to age appear to be in
line with military studies in which all subjects, regardless of
age, had to undergo the same training volume.13 These studies
show a significant trend for injury with increasing age.13 14
Conversely, in civilian populations, older age has been reported
as potentially protective against injuries by virtue of experi-
ence allowing a runner to “listen to the language of their
body” and know how to avoid possibly compromising training
habits.9However, these protective effects are proxy variables
that age is felt to incorporate, and not necessarily the direct
result of the aging process. It has been reported that age is not
a significant risk factor for runners in a comparable
population of male and female recreational entrants to road
races or members of fitness clubs.156One study did conclude
that increasing age was associated with a significant decrease
in running injuries, but suggested that the “healthy runner
effect”, whereby only runners who remain free of injuries
continue to run, was probably responsible for this finding.4
We found that a higher BMI was a protective factor against
injury for the men in this training programme. Marti et al4
found that men with a BMI less than 19.5 kg/m2and greater
than 27 kg/m2were at greater risk of injury, although it should
be noted that only 1.8% of their 4358 subjects actually had a
BMI over 27. Macera et al1and Walter et al5both found that
BMI was not related to running injuries in their respective
multivariate regression analyses.
It has been speculated that running frequency (days
running a week) may affect risk of injury. In examining a sub-
group running the same weekly distance in 2, 3 or 4 weekly
sessions, Marti et al4reported no significant differences in the
incidence of running related injuries. Consequently, it has
been suggested that running frequency does not play a part
beyond the effect of increased weekly mileage.2The results
from this study offer a different context for running frequency
and its effect on the injury rate. Women involved in a fixed
training programme in which there is a group session on one
of three suggested training days, yet who only run in the group
session, are at an increased risk of injury. Men also showed a
similar trend, with an odds ratio of 4.162 (95% confidence
interval 0.920 to 18.837), but this was not significant (p =
0.064). The group run session in this study increased in mile-
age with progression of the programme. Therefore it stands to
reason that a person who does not build an adequate training
base during the other sessions will be more likely to be injured
when they do run in a session that steadily increases in
distance. These results suggest that coordinators of similar
walk/run programmes should strongly recommend compli-
ance with the training sessions prescribed.
The results from this study with respect to age of running
shoes are inconclusive. Wearing shoes four to six months old
was associated with fewer injuries overall in men, and wearing
new shoes (one to three months old) was associated with
fewer new injuries in women. On the other hand, running in
shoes four to six months old was associated with overall injury
in women. Interpretation of this apparent discrepancy is diffi-
cult without taking into account weekly mileage, running
experience, and previous injury. Although it is commonly felt
that new shoes are protective against injuries by virtue of their
cushioning and support qualities, it has also been suggested
that injured runners may try to solve their problem by
frequently changing shoes.2Therefore, newer running shoes
(less than six months old) would appear to act as both a pro-
tective and risk factor for the onset of running related injuries
in this population. Although this is speculation, these results
illustrate the need to understand more clearly the direct effect
of running shoe age on a large population of novice runners.
Other associated risk factors for injury
Both Marti et al4and Macera et al1reported that a previous
injury is a significant predictor of reinjury in runners. Our
results appear to be in line with their conclusion: half of the
injured subjects reported a previous injury to the same
anatomical location. However, only injured runners were
instructed to provide details of their injury history. As a result,
we do not have data from subjects who had a previous injury
and were not injured. It was for this reason that history of
injury was not included as a risk factor in the regression
model.
Of those with a previous injury,42% indicated they were not
completely (100%) rehabilitated before starting the In
Training clinics. Macera7states that it is not clear whether this
high rate of reinjury suggests incomplete healing of the origi-
nal injury,a personal propensity for reinjury,or an uncor rected
biomechanical problem. Again, only the injured runners pro-
vided details of their state of rehabilitation on entering the 13
week programme, and therefore we do not have adequate
information on the number of participants who were not
completely rehabilitated and did not experience an injury. This
variable was also excluded from the regression model for
reasons previously stated.
This analysis of runners training for this 10 km run
reported no significant effect of arch height on the injury rate
model. In contrast, Krivickas8associated a cavus foot with
plantar fasciitis and stress fractures, Kvist15 reported that a
cavus arch is related to the incidence of Achilles tendinitis,
Wen et al16 associated abnormal arch height with hamstring
and shin injuries, and Ogon et al17 measured a higher rate of
impact loading to the lower back with a low arched foot. Our
lack of significance may be a result of the lack of professional
biomechanical assessment performed on the participants in
this study, or the considerably shorter time frame for injuries
to occur in runners with high or low arches.
Our finding that the predominantly novice runners who
registered in the run/walk programme had an equivalent
Running injuries 243
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number of injuries to their more experienced counterparts in
the intermediate programme warrants further discussion.
Macera7and Marti et al4both found that experienced runners
were at a decreased risk of injury during a one year follow up.
In fact, van Mechelen,2in his review of the literature,
concluded that lack of running experience is one of the four
outlined factors contributing to injury in runners. We
maintain that the lower injury rate among more seasoned
runners may be due to the self selection by injury prone people
for other types of activity, or a result of a musculoskeletal
adaptive process. The lack of a significant difference in this
study is probably attributable to both groups of runners (nov-
ice and intermediate) being inexperienced in absolute terms.
Unfortunately, as running experience was not investigated,
definitive conclusions on the injury rate between the two run-
ning levels within the In Training clinics cannot be drawn.
Although previous aerobic activity was not found to
contribute significantly to the injury model in this study, it has
been implicated as a risk factor for musculoskeletal injury
during physical training by Neely14 and Jones and Knapik13.
Most studies that have assessed the effect of physical fitness
on the risk of injury have been of military personnel, for
whom there is almost universal agreement that a lack of
fitness positively contributes to the risk of injury.13
We found that incorporating cross training into the In
Training regimen did not influence the injury rate. However, it
has been suggested that cross training can decrease the risk of
injury in two ways18:(a) by correcting strength imbalances by
conditioning key muscles not affected by running; (b) a non-
weight bearing activity such as swimming or cycling can
replace some of the weekly running mileage, eliminating some
of the impact forces that contribute to injury.
We also found that running terrain did not influence the
number of injuries. James et al19 also found no association of
running on hard surfaces with an increased risk of injury after
controlling for weekly distance.10 12 The apparent lack of effect
of training surface may stem from the difficulty of adequately
quantifying the time and intensity of running spent on each of
the running surfaces.
Conclusion
The injury rate documented in this study is worrying because
of the specific intention of the programme’s designers to train
people to run a 10 km race with a minimum of injury. More-
over, the reason for the discrepancy between the injury rates
investigated in this study remains elusive, and it is recom-
mended that, in future investigations into this population,
time is devoted to solving this inequality. We found through
multivariate regression modelling that age was significantly
associated with the injury rate for only the women in this
study. In particular, being over 50 years old was associated
with overall injury,and being less than 31 was associated with
fewer new injuries in women. Having a BMI greater than 26
kg/m2was protective for men. Although there was a positive
trend for running only one day a week and increasing risk of
overall injury in both sexes, only in women was this
significant. Although running shoe age significantly contrib-
uted to the injury rate in this study, definitive conclusions are
difficult to draw with respect to the benefit of running in
newer shoes. Factors such as previous activity, arch height,
cross training, and running surface were not significant for
either sex in any model. We recommend that these results be
viewed with caution, because a measure of exposure time to
injury (for example, weekly running distance or time),
running experience, and previous injuries were not recorded.
Nevertheless, the data from this investigation provide a useful
introduction to the number of injuries that occur in a
programme designed to minimise the injury rate. Future
research, incorporating adequately quantified risk factors for
injury, including a measure of exposure time and previous
injuries, should provide a better examination of this successful
and popular training programme.
ACKNOWLEDGEMENTS
We acknowledge the Nike International Research Foundation and the
British Columbia Sports Medicine Research Foundation for their gen-
erous support.
.....................
Authors’ affiliations
J E Taunton, M B Ryan, D B Clement, D C McKenzie,
D R Lloyd-Smith, B D Zumbo, Allan McGavin Sports Medicine Centre,
University of British Columbia, Vancouver, BC, Canada
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Take home message
Novice participants in a training programme for a 10 km
run should remember to listen to the language of their
body, use common sense, and be conservative, particu-
larly if they are older than 50, run in old shoes, and are not
fully rehabilitated from a previous leg or foot injury.
244 Taunton, Ryan, Clement, et al
www.bjsportmed.com
... duration of symptoms (0-3 months, 4-12 months and >12 months), and injury severity grading (Grade I-IV: I only experience symptoms after exercise; I experience symptoms during exercise, but it does not interfere with exercise; I experience symptoms during exercise that may interfere with my training/competition; I am so painful that I may not be able to train or compete) commonly used for 'overuse' injuries in sport [21]. In addition, in order to compare the grading of injuries to that of other studies, we also reported GOIs severity in two groups of severity: a) less severe, where cyclists are still able to cycle and compete with no or minimal interference (Grade I and Grade II), and b) more severe, where the GOIs interferes with the cyclists' ability to, and even stop them from, training or competing (Grade III and Grade IV). ...
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Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs involving runners or military personnel in basic training that either compared a) a running shoe with a non-running shoe; b) different types of running shoes (minimalist, neutral/cushioned, motion control, stability, soft midsole, hard midsole); or c) footwear recommended and selected on foot posture versus footwear not recommended and not selected on foot posture for preventing lower-limb running injuries. Our primary outcomes were number of people sustaining a lower-limb running injury and number of lower-limb running injuries. Our secondary outcomes were number of runners who failed to return to running or their previous level of running, runner satisfaction with footwear, adverse events other than musculoskeletal injuries, and number of runners requiring hospital admission or surgery, or both, for musculoskeletal injury or adverse event. Data collection and analysis: Two review authors independently assessed study eligibility and performed data extraction and risk of bias assessment. The certainty of the included evidence was assessed using GRADE methodology. Main results: We included 12 trials in the analysis which included a total of 11,240 participants, in trials that lasted from 6 to 26 weeks and were carried out in North America, Europe, Australia and South Africa. Most of the evidence was low or very low certainty as it was not possible to blind runners to their allocated running shoe, there was variation in the definition of an injury and characteristics of footwear, and there were too few studies for most comparisons. We did not find any trials that compared running shoes with non-running shoes. 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Motion control versus stability (1 study, 56 participants) It is uncertain whether or not motion control shoes reduce the number of runners sustaining a lower-limb running injuries when compared with stability shoes because the quality of the evidence has been assessed as very low certainty (RR 3.47, 95% CI 1.43 to 8.40). Running shoes prescribed and selected on foot posture (3 studies, 7203 participants) There was no evidence that running shoes prescribed based on static foot posture reduced the number of injuries compared with those who received a shoe not prescribed based on foot posture in military recruits (Rate Ratio 1.03, 95% CI 0.94 to 1.13). Subgroup analysis confirmed these findings were consistent between males and females. Therefore, prescribing running shoes and selecting on foot posture probably makes little or no difference to lower-limb running injuries (moderate-certainty evidence). Data were not available for all other review outcomes. 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This retrospective study reports on 4,173 running injuries seen on referral over a 4-year period at a sports medicine clinic. Runners were grouped as recreational, marathon, or middle distance runners on the basis of their training, and data was examined for groupwise differences in age, gender, anatomical site of injury, diagnosis, and time of year the injury presented. Additionally, the results were compared to those of a 1981 study of 1,819 injuries from the same population in order to determine changes in injury patterns over time. The knee was the most common site of injury, with patellofemoral pain syndrome the most common overall diagnosis, although there were significant differences between the training groups for both injury site and diagnosis. The pattern of injuries has changed over the interval between the two studies, with a higher proportion of knee injuries and a relatively lower frequency of lower leg and foot injuries, and much of this change is attributed to improvements in footwear technology. (C) Lippincott-Raven Publishers.
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Running is one of the most popular leisure sports activities. Next to its beneficial health effects, negative side effects in terms of sports injuries should also be recognised. Given the limitations of the studies it appears that for the average recreational runner, who is steadily training and who participates in a long distance run every now and then, the overall yearly incidence rate for running injuries varies between 37 and 56%. Depending on the specificity of the group of runners concerned (competitive athletes; average recreational joggers; boys and girls) and on different circumstances these rates vary. If incidence is calculated according to exposure of running time the incidence reported in the literature varies from 2.5 to 12.1 injuries per 1000 hours of running. Most running injuries are lower extremity injuries, with a predominance for the knee. About 50 to 75% of all running injuries appear to be overuse injuries due to the constant repetition of the same movement. Recurrence of running injuries is reported in 20 to 70% of the cases. From the epidemiological studies it can be concluded that running injuries lead to a reduction of training or training cessation in about 30 to 90% of all injuries, about 20 to 70% of all injuries lead to medical consultation or medical treatment and 0 to 5% result in absence from work. Aetiological factors associated with running injuries include previous injury, lack of running experience, running to compete and excessive weekly running distance. The association between running injuries and factors such as warm-up and stretching exercises, body height, malalignment, muscular imbalance, restricted range of motion, running frequency, level of performance, stability of running pattern, shoes and inshoe orthoses and running on 1 side of the road remains unclear or is backed by contradicting or scarce research findings. Significantly not associated with running injuries seem age, gender, body mass index, running hills, running on hard surfaces, participation in other sports, time of the year and time of the day. The prevention of sports injuries should focus on changes of behaviour by health education. Health education on running injuries should primarily focus on the importance of complete rehabilitation and the early recognition of symptoms of overuse, and on the provision of training guidelines.
Article
Recreational and competitive running is practised by many individuals to improve cardiorespiratory function and general well-being. The major negative aspect of running is the high rate of injuries to the lower extremities. Several well-designed population-based studies have found no major differences in injury rates between men and women; no increasing effect of age on injuries; a declining injury rate with more years of running experience; no substantial effect of weight or height; an uncertain effect of psychological factors; and a strong effect of previous injury on future injuries. Among the modifiable risk factors studied, weekly distance is the strongest predictor of future injuries. Other training characteristics (speed, frequency, surface, timing) have little or no effect on future injuries after accounting for distance run. More studies are needed to address the effects of appropriate stretching practices and abrupt change in training patterns. For recreational runners who have sustained injuries, especially within the past year, a reduction in running to below 32 km per week is recommended. For those about to begin a running programme, moderation is the best advice. For competitive runners, great care should be taken to ensure that prior injuries are sufficiently healed before attempting any racing event, particularly a marathon.
Article
This prospective study of 583 habitual runners used baseline information to examine the relationship of several suspected risk factors to the occurrence of running-related injuries of the lower extremities that were severe enough to affect running habits, cause a visit to a health professional, or require use of medication. During the 12-month follow-up period, 252 men (52%) and 48 women (49%) reported at least one such injury. The multiple logistic regression results identified that running 64.0 km (40 miles) or more per week was the most important predictor of injury for men during the follow-up period (odds ratio = 2.9). Risk also was associated with having had a previous injury in the past year (odds ratio = 2.7) and with having been a runner for less than 3 years (odds ratio = 2.2). These results suggest that the incidence of lower-extremity injuries is high for habitual runners, and that for those new to running or those who have been previously injured, reducing weekly distance is a reasonable preventive behavior.