Medical Aspects of Running and Running-related Injuries

Sacha Dumont
UltraMarathon Running Seminar

"Runners are the 'healthiest sick people in the world'", according to ultrarunner Jeff Robbins. In an email that I received from him he added, ďOne of the problems with the ultras is that you are always stressing things to the limits. Therefore problems tend to crop up. Half the fun in this sport is learning to deal with adversity no matter how it comes." Injury is a runner's most dreaded and aggravating obstacle. Sometimes no matter how much the mind wills it, the body cannot go on without causing itself permanent damage. Pushing beyond these limitations will eventually cause the body to rebel and self-destruct. There are preventative measures that can be taken to stop these injuries from occurring, however, runners still get hurt. It is most important to treat not only the injury itself, but the cause of the injury. "Running injuries have a unique feature; an identifiable and treatable cause. And until that cause is rectified, the conventional approach- the rest, drugs, injections, and surgery- is just an expensive waste of time" (Noakes 450). Running injuries an intrinsic; the result of "the athlete's genetic build, training environment, and training methods" (Noakes 453). Each running-related health problem has a cause and that cause needs to be corrected before the runner can rid himself of the injury permanently. George Sheenan, an expert on the medical aspects of running, believes that runners and doctors should, "Treat the reason, not the result. Treat the cause, not the effect." Too many runners do not listen to their bodies and continue to aggravate these injuries. "It is wise to listen to your body, for your stubborn mind can lead you astray" (Glover 260).

In preparing this paper a few members of the American University UltraRunning listserve were very helpful. Jason Hodde, Jeff Robbins, Norm Yarger, and Karl King each personally emailed me with insightful information on running-related injuries. The listserve is such a great interactive source of information. Who better to learn from but the runners themselves? They are the ones who have to cope with the injuries. Any amount of personal experience through trial and error is better advice than book knowledge. This is the reason why so many runners advise that running-related injuries should be taken to a doctor who has running experience because he will be more inclined to look to rectify the cause of the injury instead of resorting to surgery.

The best way to prevent injuries from occurring is to take the appropriate precautionary actions. The first major rule is: donít strain. The majority of running injuries occur from overtraining. It is important for a runner to incorporate hard days and easy days into his/her exercise routine. You need to give your body time to rest so that it can repair itself. Fatigue accumulates and if you don't ease up occasionally, you won't improve. Being overtired will eventually lead to injury because your body needs a chance to recover and strengthen itself. Also, avoid doing too much too soon. Dr. Stephen Pribut suggests that "Mileage should usually only be increased approximately ten percent per week. Every third week, you should drop back a small amount. For most runners one or two days a week, at least, should be devoted to rest or non-running activities." Rule 2: run efficiently. Find a running stance that best suits you. Every runner has a different style that is most effective for his individual body. It is most important to feel comfortable and natural. One suggestion that everyone should follow, however, is to land on your heels and roll forward, pushing off with your toes. Rule 3: wear good shoes. All the experts agree that the most important part of a runnerís equipment is his shoes. High quality shoes will minimize blistering, reduce wear and tear on leg muscles, and cushion shocks. Dr. Pribut advises, "If you are running 20 miles per week, you should be replacing your shoes between four and eight months depending upon your shock absorption needs." Rule 4: STRETCH! Tightness in the hamstrings and calf muscles needs to be alleviated with stretching. Also, stretching will help to strengthen the quadriceps, abdomen, and shin muscles which tend to be underdeveloped in distance runners. This muscular imbalance is a common cause of injury. Dr. George Sheehan has compiled a routine of effective stretches. This regimen includes the wall push-up, a hamstring stretch, the knee clasp, chest push-ups, the backward stretch, the shin splinter, leg extensions, and bent leg sit-ups (Fixx, 178).

If, despite all your preventative measures, you become injured it is important to find the root of the problem. Ask yourself, "Have I recently changed to a different type of running shoe?" and "If the shoes are not new, are they worn out?" Supportive and comfortable shoes are vital to the sport of running. Badly manufactured or worn-out shoes can cause foot, ankle, leg, hip, and back problems. This is due to the face that most running-related injuries start with a foot problem. A clunk foot rotates inward (pronates) too little and a hypermobile (flat) foot rotates too much. The clunk foot causes injury because it is unable to absorb sufficient shock which puts added stress on the other joints. Another heredity induced cause to injury is unequal leg length. However, usually it best not to do anything about this abnormality unless it causes pain. The next questions you need to ask yourself are, "Have I recently changed my training methods or racing patterns?" and "Have training surface recently changed?" Your body will not adjust well if you suddenly change the intensity, duration, or frequency of your workouts. These changes should be introduced gradually. When running you should take into account the hardness and degree of camber of your running surface. Switching from dirt or other soft surfaces to hard pavement can cause added stress to muscles and bones. Another less obvious factor is that when you run on a cambered road "the foot nearest the center of the road will be forced to pronate excessively, whereas the foot nearest to the edge will have restricted pronation" (Noakes 499).

A running related injury gradually progresses from slight discomfort to acute pain. This is why if they are detected and treated early on they can be stopped before they become too serious. Again, this is another reason why it is important be aware of your physical limitations. George Sheenan once addressed this topic when he said, "One of the basic rules is 'Listen to your body.' I am responsible for my health, and to respond to my body I must listen to it, learn from it." The four levels of injury severity that Noakes lists in his book The Lore of Running are: "Grade I: Causes pain only after exercise and is often felt only some hour after exercise has ceased. Grade II: Causes discomfort, not pain, during exercise but is insufficiently severe to reduce athlete's training or racing performance. Grade III: Causes more severe discomfort, recognized as pain, that limits the athleteís training and interferes with racing performance. Grade IV: So severe that it prevents any attempts at racing." An example of a Grade IV injury would be a stress fracture. Noakes states that, "athletes with stress fractures simply cannot run, however much they may wish to." This wise medical statement was definitely not taken to heart by Tom Rogozinski, a participant in the 1992 TransAmerica Footrace. He developed a severe stress fracture of the foot after about 2,088 miles into the race. He was intent on finishing the race, especially since they would be entering his home state of Pennsylvania soon. Despite the pain Rogozinski hobbled on and eventually finished the race about 800 miles later. His inspiration to run through the pain was also attributed to the story of Henry Marsh, a world class runner. Rogozinski said, "He (Marsh) crashed into a barrier while he was training for the '83 World Championships and he broke a couple ribs. The doctor told him he could still run but that it would hurt like hell. 'Pain is pain,' said Marsh, 'That's all it is.' That's where I am. It's not getting any worse, it just aches like a son of a bitch" (Lewis 132). Luckily Rogozinski didnít cause himself any permanent damage.

One of the smallest yet dehabilitizing** injuries is the blister. This small annoyance can cause even the best runners to drop out of a race. During the 1992 TransAmerica Footrace Al Howie, the prerace favorite, was forced to discontinue the race due to the severe blistering of his feet. "When Howie undid his shoes and bandages, the physician couldn't believe what he saw. The rough road had done more damage to the raw heels, and the blood seeped from the exposed layers of the tissue the way sweat does in a sauna, dripping from the pores" (Lewis 39). Blisters can be the result of many different factors. Improperly fitting shoes are a major cause. Rubbing caused by shoes that are either too lose or too tight, and rough threading may result in blisters. To prevent blisters use high quality, thick-soled running shoes and dab a little Vaseline on sore spots of the feet to stop friction. Manufacturers have produced some helpful products such as Second Skin and New Skin. I used New Skin all through soccer season to protect my feet from blisters. It is a liquid that is placed on the skin and when it dries it provides a extra layer of protection against friction. If a blister does form there are a few rules about whether or not to drain the fluid. Small blisters should just be dabbed with tincture of benzoin and covered with tape. Larger and more painful blisters can be punctured in order to relieve the pressure. Leave the skin, coat it with Vaseline and cover it with gauze. Time and rest should then heal the wound. What most runners donít know is that if blisters arenít treated immediately they could cause other more serious problems. The blister might cause the runner to favor the affected leg and therefore alter his/her running stance which can result in leg, knee, or back injuries.

According to The Lore of Running plantar fasciitis (PF) is one of the less common injuries, accounting for only about 5 to 14% of running injuries. However, after lurking on the American University Ultrarunning listserve, I was surprised by the number of ultrarunners who were bothered by this problem. Plantar Fasciitis is "an inflammation that occurs where ligaments in the sole of the foot join the heel, and its chief symptom is pain in the heel" (Fixx 187). It is a particular form of tendonitis. The pain is usually first noticed during running and then it becomes noticeable when the runner gets out of bed in the morning. Andy Holak wrote to the listserve, "I feel the pain most readily at night when I get up at 3:00 am to go to the bathroom. I limp all the way there, ouch, ouch, ouch!" The most frequent cause of this injury is the "excessive pronation" of the foot which causes the arch of the foot to dip too much while running. This movement causes the plantar fascia (connective tissue between the toes and the heel) to stretch and pull away from the heel bone. Other possible causes are an increase in training speed, duration, or style, an increase in body weight, or a change of shoes. Holak also wrote, "The interesting this is, it rarely hurts when I run. Before the ST50 in September, my arch was pretty sore, and I thought it would bother me during the race, but it didn't at all. Also, I haven't been running regularly lately, and it seems like my foot hurts more on the days that I donít run, than on the days that I do run. I assume that the activity keeps the tendon stretched and loose." This is true because the more stretched the plantar fascia is the better it feels. David Emmons elaborated on this topic, "The most frustrating thing about PF is that it does not hurt while running but running can further aggravate the condition." Over 98% of all cases of PF can be effectively treated without surgery (Dr. Pribut). The first step to correcting the problem is to check your shoes to make sure they are in good condition and that they give substantial support to the arch. Next, custom orthotics (shoe inserts) will help to stabilize the foot to stop the excessive pronation. According to Karl King "stretching is a good preventative, but massage is better when trying to heal an injured tendon." After his bout with PF he has learned the best way to massage is to use his thumb across the sole of the foot and then his fist along the sole of the foot. He now does this at least 4-5 times a week. I was very interested by Dave Cooper's contribution to the listserve about PF. He had come up with some very good ideas to help correct a PF problem. "In my mind the most useful stretching is that which is done most often and I hate to stretch, however for this malady I have found a very convenient method. First, get several tennis balls. Several because you will want one at the office, one in the car, and one at home. Now, anytime you are sitting down roll the ball back and forth under your arch. For most people this would amount to several hours of stretching a day as opposed to five minutes. As for icing I find that a small frozen juice can rolled under the foot after every run to be helpful." Also, it is most important to never walk anywhere without shoes. The arch of your foot needs constant support. To avoid re-injury of the PF every morning try using a night splint while you are sleeping. Jason Hodde wrote, "When you sleep, the ligaments and tendons in your feet (actually anywhere) tend to tighten up. The night splint keeps the PF in a stretched position and prevents the re-injury that occurs when you first step down in the morning." It is also important to remember "what took months or years to develop cannot be eliminated in just a few days" (Dr. Pribut).

Another injury that is more painful than PF and less easily cured is achilles tendonitis. "This is an inflammation of the sheath within which the tendon at the back of the ankle slides. When it becomes inflamed, it enlarges, creating too tight a fit, and friction and pain result" (Fixx 188). This can be the result of a lack of stretching, running on the balls of the feet, sudden bursts of speed, improper running shoes, or a narrow Achilles tendon. Its symptoms are pain and stiffness during and after workouts, as well as tenderness to the touch. I was hindered by a slight case of achilles tendonitis in the middle of my soccer season this fall. It was largely due to the new cleats that I had started wearing halfway into the season. The cleats werenít flexible enough under the ball of my foot. To help correct the problem and alleviate the tenderness the Lehigh athletic trainer put me on a therapy routine for a week. The first step was to soak my foot in a contrast bath for twenty minutes to reduce the swelling: alternating between warm water for 2 minutes and cold ice water for 1 minute. Then she treated my achilles tendon with ultrasound equipment to deep heat the sore area. Lastly, I needed to stretch the area gently. In this case excessive stretching is not good for the tender tendon. Rest of 2-10 days is also important because achilles tendonitis is "one of the most dangerous injuries to run with because it can lead to a partial rupture, which in turn could lead to a complete rupture requiring surgery" (Glover 233). Surgery should be avoided unless it is absolutely necessary. "The obvious danger of surgery is that it is irreversible; what is removed during surgery cannot be put back. It is a tragedy to undergo major knee, ankle, or back surgery for the wrong diagnosis" (Noakes 462). This is why it is better to go to a doctor who is more concerned with treating the cause of your injury and not looking to cut you open immediately. Sometimes the best doctors for runners to go to are podiatrists because they look to correct foot problems that are most often the root of the injury.

To ensure yourself of the best possible chance of a long, injury-free running career take the appropriate preventative measures. Some of the most important advice is to purchase high quality running shoes, stretch thoroughly, and only consult a doctor that has running experience. And if unfortunate medical problems do occur listen to the listserve's resident medical advisor, Jason Hodde, "If you take care of the problem right away instead of trying to live with the pain, you will have much better results in the long run." Works Cited Fixx, James. The Complete Book of Running. New York: Random House, 1977. Glover, and Jack Shepard. The Runner's Handbook. New York: Viking, 1978. Noakes, Tim. The Lore of Running. Campaign: Leisure, 1991. Dr. Stephan M. Pribut's Sports Pages. http://www.clark.net/pub/pribut/stayout.html Listserve members: Dave Cooper, Jason Hodde, Karl King, Andy Holak, Milt Scholl, Dave Emmons, and Norm Yarger.