Long-Term Running Concerns

Welcome to running season! Here in Chicago, the month of May brings more optimal running weather, which is well received by the running community. There are so many options to get out and enjoy a run in the city, but two of my favorites are the Chicago Lakefront Trail and the Bloomingdale Trail at the 606. The Chicago Lakefront Trail is 18.5 miles of majestic scenery to sooth and relax all different types of runners from novice runners to ultra-runners. It runs from West Ardmore Avenue on the north to East 71^st Street on the south. The 606 is an elevated 2.7 miles trail across the West Side of Chicago. It was built on the previous Bloomingdale train line which shuttered in late 1990’s. Its east entrance is at North Ashland Avenue at Walsh Park and the west entrance is at Ridgeway Trailhead Park at North Ridgeway Avenue.

Wherever you decide to run, prevention of injury is the key to allow you to achieve the positive overall effects of exercise and performance. There is a motto; “The Human Body is Built for Distance”, however, there are concerns with long-term running. There are 570 Marathons in the United States each year and O.5% of US population has run a marathon. Up to 90% of marathon trainees can get injured.

I have been a volunteer podiatric physician for the Chicago Marathon since 2003 where I provide podiatric medical care at the finish line of the marathon to injured runners. However, the majority of the medical care I provide to participants of the Chicago Marathon each year occurs prior to the race. These are injuries that occur during the training process leading up to the marathon. The majority of these injuries are preventable overuse injuries. These injuries can not only be physically debilitating to the runner but also involve an emotional element as the injuries may jeopardize the runner’s ability to participate in the race. The good news is that most overuse running injuries can be prevented and if encountered can be treated by a medical running professional without compromise to the requisite training program.

What Causes Injuries for Runners?

So why do runners get hurt? Most running injuries are associated with errors in training causing overuse conditions.  There was a study concerning the 2005 Rotterdam Marathon (1) which helped to answer the concern of why many runners training for a marathon may sustain an injury. The authors distributed questioners to male marathon participants and 725 were returned. Within 1 year of the marathon, 54.8% of respondents had an injury. More specifically leading up to the race, 15.6% of the responding runners indicated one new lower extremity injury in the month before the marathon and 18.6% had a lower extremity injury during the marathon! However, within 1 week after the marathon, no matter their running injury the respondents were able to return to their activities of daily living.

One of the most important studies concerning running is the 2007 Stanford Study (2). The main take-away from this study continues to be recognized as a marker for concerns with long-term running.  We now recognize 40 miles per week of running as the threshold concerning injury thanks to the study findings and conclusions. The risk of injury from running exponentially increases when running more than 40 miles per week. What the study also determined is that experience helps and recovery helps and suggests to avoid sudden increases in running load and running intensity. Therefore, it is important to follow a training program when training for a race, especially a marathon. There are many training programs that can be utilized. The training program needs to be a fixed plan that is followed by the runner which is individualized to the beginner, recreational, or competitive runner.  For beginning runners, a slow ramp up will decrease the risk of injury. It is advised not to run too hard immediately. An increase in mileage and speedwork are best to occur gradually over time.

How to Prevent Injury

Therefore, the key to being injury free prior to a marathon is preparation.  The following insights can enhance training with limiting the risk for injury.

Following training program:  This is second nature to most runners and is the process by which the body is prepared for the rigors of a 26.2-mile race. Following a specific training program increases performance and decreases injury. These training programs can be found online or can be performed and followed through a group running club or training group. The programs are specific to the participants running level from beginner up to expert. In addition, there should always be an emphasis whole body work outs, especially core as running is not just with the legs.  Also, it is important to eat properly and hydrate accordingly.

Wearing appropriate running shoe gear:  It is imperative to go to a reputable running shoe store and go through a fit process for your training shoe gear. An overwhelming number of running related injuries can be directly attributed to running in an inappropriate running shoe category for your foot type. In addition, running in worn-out running shoes can be significantly detrimental as well. Running shoe should be replaced every 350-500 miles or 6 months.   Running in a shoe which is too small or does not give enough room in the toe box can cause injuries such as blisters or toenail issues. All of these conditions can be managed with the purchase of an appropriate shoe determined by a fit process.

Wearing appropriate running socks:  The skin of the feet are at high risk for injury secondary to the friction involved with high end running. With running, moisture accumulates around the feet which can lead to friction and blistering. Cotton socks feel comfortable and soft against the feet, however for running these socks do not wick away moisture which allows for increased friction and blistering. Therefore, it is important to purchase and use synthetic blend running socks which wick away moisture and prevent blistering and skin irritation.

If you get injured, get seen:  A major worry for runners is the thought that if they present to a doctor for a running injury, the doctor will advise them to stop running. For the overwhelming majority of running injuries, a running medical professional can provide treatment and rehabilitation protocols for the running injury while allowing the runner to continue training and continue towards the goal of participating in the Marathon. A small number of overuse running injuries require the physician to “shut down” a runner. Even with these types of detrimental injuries, there is the ability to have an athlete perform cardiovascular training activity in a pool or on an antigravity treadmill in an attempt to possibly return at some point to the training program for the marathon.

Identifying and Preventing Overtraining Injury

After a marathon, runners need time to recover. The entirety of the body, mentally and physically, are taxed over 26.2 miles. Running several marathons over a limited period of time can be detrimental. Overtraining is a major concern with long-term running. Running one or two marathons a year or three marathons in two years is ideal and will allow you to properly recover.  Otherwise, runners are at risk of developing overtraining syndrome. Overtraining syndrome is a condition which can occur in athletes who work out too much or too hard causing a negative effect on physical performance. There are a number of signs and symptoms which may indicate the presence of overtraining syndrome. Signs and symptoms of overtraining include:

• Decreased appetite and weight loss
• Feelings of depression or change in mood
• Headaches
• Multiple injuries
• Insomnia
• Irregular heart rate or heart rhythm
• Generalized fatigue
• Decreased competitiveness
• Decreased immunity with increased number of colds
• Generalized aches, joint pain, and muscle soreness
• Inability to concentrate
• Reproductive issues

The most common injury category of the foot and ankle associated with overtraining are stress fractures. Stress fractures are due to overuse on a bone and are usually the result of the following factors: excessive pressure over a long distance, running or walking much further than normal, repeated minor injuries to the same bone, constant pressure on a bone for a period of time, and repetitive vertical forces. These are all characteristics of running! What happens with these fractures is that the rate continued injury to the bone exceeds the rate of healing of the bone, ultimately causing a fracture analogous to breaking a pencil. So not surprising that running, especially long-distance running, can cause these injuries. These overuse stress fractures can occur in any bone of the foot and ankle, but are most commonly encountered in the tibia and fibula bones of the ankle, the calcaneus/heel bone of the foot, or one of the metatarsal bones of the middle of the foot, most commonly the second metatarsal. The unfortunate thing concerning stress fractures is that they often are not visible on initial radiographs.  It takes about ten to fourteen days for these fractures to show up on radiographs.  In certain cases, an MRI may be necessary to diagnose a stress fracture. The treatment for stress fractures is rest and time with immobilization in a walking boot.

Returning From Injury

A major question of runners who present with injury such as a stress fracture is how one returns to running once their injury has healed. This is a very important consideration, especially during marathon training. Marathon training programs are developed and utilized to increase performance and decrease injury. An injury during a marathon training program is a cause for concern. The injury requires modification of the training program during recovery. This may include limiting mileage or days running per week or using other exercise methods for cardiovascular endurance such as water jogging, biking, or use of an elliptical machine. These modifications are runner and injury specific and require coordination between the physician, athlete, trainer, therapist, and coach to determine specifics of the training regimen.

Modification is easier to accomplish towards the beginning or the end of the program. An injury within the central portion of the program creates more disruption and difficulty with marathon preparation. If injury is severe with a prolonged recovery time, the physician and runner may elect to forgo marathon training and participation in the race. In cases of severe injury, once the athlete is cleared resume running, a return to running program is necessary to build up fitness while preventing re-injury. Most return to running programs are 4 weeks in length and incorporate a gradual walk-run progression. I utilize the following program it is not level specific as each runner is able to modify the pace they choose for walking and running based on how they are feeling post-injury and adjust throughout the program accordingly.

Running is a wonderful recreational and competitive athletic activity. It is our goal as sports medicine physicians to keep runners running! Hopefully I have provided you with some pointers on how to prevent running related issues and keep you moving forward toward better health, mentally and physically.

Reference 1:

Scand J Med Sci Sports. 2008 Apr;18(2):140-4. Epub 2007 June 6. Prevalence and incidence of lower extremity injuries in male marathon runners. Van Middelkoop M, Kolkman J, Van Ochten J, Bierma-Zeinstra SM, Koes B.

Reference 2:

Sports Med. 2007;37(4-5):437-9. Epidemiology and aetiology of marathon running injuries. Fredericson M, Misra AK.