Injury-Free Running

Dr Catherine Laraman explains how to prevent running injuries from occurring, and how to treat them if they do strike

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Nothing stops a triathlete in his or her tracks quite like an injury. Here is a guide to some of the more common ailments, and how you can avoid them and treat them if they do arise.

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Remember: if you’re in doubt about an injury, it’s important to reduce your training and seek advice from a qualified professional, such as a sports physician, physiotherapist or osteopath. Never train on in the hope that it will simply go away.

You should get any significant trauma to your legs that causes you severe pain or makes walking difficult checked out – in an A and E department, if necessary. If you have any joint swelling – for example, a swollen knee after a fall – don’t ignore it. It may be a sign of significant damage to structures within the knee, like the cartilage.

Prevention is better than cure

The best way to treat injuries is to avoid getting them in the first place. A few simple, preventative measures will keep you and your body in great shape to accept the training load and reduce the danger of damaging yourself.

A warm-up should be part of everyone’s exercise routine. The aim is to elevate your body’s temperature and increase the blood flow to the muscles and soft tissues, preparing you for exercise. Warming up increases heart rate, oxygen delivery, the speed of nerve impulses and the elasticity of tissues. Studies have shown that a structured warm-up programme can not only increase your performance, but reduce the risk of injury, too.

The most efficient warm-up should involve light cardiovascular work – say 5-10mins of gentle jogging, to give you a feeling of mild sweating without fatigue – followed by stretching. Stretches should involve all of your body’s major muscle groups: quads (front of your thighs); hamstrings (back of your thighs); calf and soleus muscles (back and inner part of your shins); adductors (where your legs meet your groin); glutes (your bottom); upper body (chest and back); and your trunk (abdomen). After all, you don’t run with your legs alone!

Never stretch when you’re cold, and stretch slowly and gently to the point of tension but never pain. To enjoy the full benefits of stretching, hold each position for at least 30secs. If you run with a partner, you could learn some paired stretches.

Should you stretch before running?

Five essential stretches for triathletes to stay injury-free

So you’re all warmed up and raring to go. But have you thought about what you aim to gain from your run? Planning ahead may seem boring, but it will help your fitness progress faster and, if you know what each session will involve, you’ll be less likely to suffer an injury due to a training error. While your training needs will vary depending on your goal, there are pitfalls that are common to everyone’s training, whether it’s for an Ironman or simply for pleasure.

A triathlete’s guide to warming up

Sub-1hr session: Warm-up to win

       
One of the most common mistakes that runners and triathletes make is to underestimate the importance of rest. Without adequate rest periods your body simply can’t adapt to the training loads you place upon it, and injuries such as tendon problems and stress fractures can result.
In terms of how far you run, a rough rule of thumb is to not increase your total weekly mileage by more than 10% per week. If you’re new to triathlon, you should aim to increase the amount of ‘time on your feet’ first, and then consider building in speedwork and hill work later.

Never train intensely for more than two successive days, and remember to include easy runs within the week. Consider the surfaces you run on, and try to get a mixture of soft and hard ground (for example, trail runs and road runs).

How much rest do triathletes need?

Chrissie W on… The importance of rest days

   
It’s vital to get the right kind of shoes for your feet. Your shoe type will depend on whether you’re an overpronator, supinator or a neutral runner (see Jargon Buster to your left). Go to a specialised shop for runners and, if you’re unsure which sort of runner you are, ask a sports podiatrist or sports physio. Bin your trainers after 500 miles, however clean they look, as they won’t give you enough biomechanical support after that kind of mileage.

Running shoes buying guide: what to look for

Guide to off-road running shoes

   

Climate problems

Running in hot weather places a lot of demands on your body and it’s important to consider the climate you’ll be training in. If you’re training in very warm weather, it makes sense to train earlier and/or later in the day, to avoid the heat of the midday sun. 

You should always maintain a good level of hydration with plenty of isotonic drinks, which will reduce your chances of cramps.

Pay particular attention to warming up if you’re training in chilly conditions, as cold, inflexible muscles are at risk of strains and tears. Consider wearing layers of clothing that you can peel off as you warm up and never stretch when cold.

Footcare: best practice

Just as you need to maintain your bike, it’s important to look after your feet. Everyday you should take a good look at them to check for any blisters, cuts, verrucas, signs of athlete’s foot or in-growing toenails. Wash and dry them daily, especially after doing exercise. Ensure your toenails are kept trimmed – cut the nails off straight across, rather than on a curve, which may encourage in-growing of the nail. Socks with a high cotton content may help guard against athlete’s foot, while wicking socks are useful if blisters are a problem for you. Well-fitting, roomy shoes are important, and you should have more than one pair, alternating them to ensure they have time to dry out in between runs.

Strengthening calfs help runners maintain performance as they age

   

Regularly stretching your calf muscles helps maintain good foot flexibility and function and should be part of your everyday routine. Don’t ignore persistent problems – seek the advice of a chiropodist or podiatrist.

Early morning run

Triathletes are particularly susceptible to five injuries: iliotibial band syndrome, runner’s knee, plantar fasciitis, shin splints and Achilles tendinopathy, as well as five more minor, but still inconvenient, ailments that could hamper your training. However always seek professional advice rather than ‘diagnosing’ the problem yourself.

1. Iliotibial band syndrome

This condition occurs when the iliotibial band (ITB) creates a frictional problem where it flicks under the lower, outer edge of your femur (thigh bone). (Pic above shows ITB in the left leg.) The iliotibial band is a band of soft tissue that runs down the outside of your thigh and transmits force from the tensor fascia lata muscle and gluteus maximus muscles to your leg.

ITB gives you a digging/aching sensation on the outside edge of your leg, a couple of centimetres above your knee, which is tender to the touch. The pain often starts at about the same time on each run – usually the middle or towards the end – and is worse if you run downhill or on a cambered road. ITB is more common if the band has become tight, if you’re an overpronator, if you’re knock-kneed or if you have an imbalance in your hip muscles (weak hip abductors (gluteus medius) compared with dominant hip adductors). Diagnosis is usually made on your story and the pattern of the pain, but gait analysis can show any biomechanical problems.

Treatment involves correcting any biomechanical problems (which may involve a change of trainer type or wearing orthotics), strengthening weak muscles, stretching your ITB or self massage. You may need physio treatments, such as sustained myofascial release, ultrasound therapy, trigger point needling and, if the syndrome is causing you a lot of discomfort, an injection of corticosteroid. Fortunately, surgery is rarely needed.

You can resume running when there’s no tenderness and you can perform strengthening exercises without pain. Cross training with an elliptical trainer can be done in the meantime, although some find that cycling is also uncomfortable while the inflammation remains.

Recovery from ITB syndrome tends to take weeks not months. When you return to running, do so on alternate days initially, and avoid downhill running.

The few simple exercises below will help you prevent or alleviate iliotibial band problems by strengthening, stretching and stabilising the muscles it connects to.

To strengthen your gluteus medius (which stabilises the pelvis):

Pelvic dips

Stand sideways on one foot on a box or a step. Keep the weight-bearing knee locked. In a controlled manner, lower your other leg so that your hip drops down on that side. Raise yourself back up by squeezing your bottom and repeat 10 times. Ideally, do this three times a day.

Side-lying leg raise

Lie on your uninjured side with your back against a wall. Tighten the thigh muscles of your injured leg to raise it about 25cm (10in) above the other leg. Ensure you don’t roll forwards or backwards. Lower it slowly and repeat so that you do 3 x 10 reps.

Wall squat with a ball

Stand with your back flat against a wall with a block between your knees. Your feet should be shoulder-width apart and about 30cm (12in) away from the wall. Keep the back of your head against the wall and slowly squat down, gently squeezing the block, until you’re almost in a sitting position. Hold this position for 10secs and then slowly slide back up the wall. Build up to 3 x 10 reps.

How to stretch your ITB

   
Side-leaning stretch

Stand sideways with your injured leg nearest a wall. Place the hand of your injured side on the wall for support. Cross your injured leg behind your uninjured leg, keeping yourself stable and with both knees straight. Lean into the wall and hold the stretch for 30secs. Repeat three times.

Forward-leaning stretch

Stand upright with your hands on a sofa or table for support. Bend your uninjured knee, keeping your foot stable on the ground. Cross your injured leg behind your uninjured leg, keeping the knee straight, and then slowly lean over, flexing at your hip while leaning a little towards the foot of your injured leg. Hold for 30secs and repeat three times.

How to recover from an IT band injury

2. Runner’s knee

This is also known as anterior knee pain syndrome or patellofemoral pain syndrome. It’s a condition that produces pain on the front of your knee, which may also be felt behind or just below your kneecap (patella). It often causes the most discomfort when running or walking downhill, or sitting with a bent knee for any length of time. You may also find it’s accompanied by a clicking sensation when flexing and extending your knee.

For many years, this problem was thought to be due to a softening of the cartilage, but we now know runners can experience the pain because the patella doesn’t move correctly when the knee flexes and extends – so called ‘maltracking’. This is due to imbalanced forces across the patella, and can occur if you have wide hips (a large Q angle), knock knees, an imbalance in your quads muscles (weak VMO, dominant VL), weak glutes, tight hamstrings/ITB/calf muscles and if you’re an overpronator.
Treatment usually consists of correcting any pronation with motion-control shoes or orthotics, and then rebalancing and lengthening muscles by training up the VMO and gluteus medii muscles. You may benefit from physio/sports massage to help stretch out any tight structures on the front of the knee.

You should avoid too much downhill running, which can exacerbate the problem. Some people also benefit from applying a brace during their recovery, which can take several weeks. You should also undertake strengthening exercises in the long term to prevent a recurrence, including step-ups onto a box.

How to prevent runner’s knee, and four exercises to treat it

   

3. Plantar fasciitis

Sometimes known as ‘Policeman’s heel’ or ‘heel spur syndrome’, this condition causes pain in the sole of your foot or around your heel or arch areas. The ‘fascia’ is a gristle-like band that connects the front part of the foot to the heel. It helps support the arch of the foot and aids shock absorption. Sometimes the integrity of the fascia can begin to break down at the points where it attaches, typically leading to pain under your heel or arch. This is often at its worst first thing in the morning or if you’ve been on your feet all day. It can cause traction and a bony spur to form where the fascia attaches to the heel, although this isn’t thought to be the cause of the pain per se.

Your foot flattens out during the walking or running gait cycle, particularly when you push off from the big toe. This creates a strain across the fascia, which is problematic for individuals with flat feet (pes planus) or a high arched foot (pes cavus). Other contributing factors include unsupportive footwear, tight calf and hamstring muscles, a change in training (lots of speedwork or hill work involving running on the balls of your feet) and weight gain.

Most cases of plantar fasciitis can be treated by avoiding aggravating factors, using ice after activity, stretching the fascia (and, very importantly, the gastrocnemius and soleus muscles), strengthening the muscles that hold up the arch of your foot and wearing corrective orthotics. Also, try self massaging the arch of your foot using a golf ball or roller, and wearing splints on your feet at night or a ‘Strasburg Sock’ (type of foot support).

Sometimes, a steroid injection – and, rarely, surgery – is needed. If you’re not improving you should seek the advice of a physio or sports physician. Recovery time depends on how long it takes to put all the contributing factors right. If it’s too painful to run, then restrict your training to the bike and the pool. But remember: you should also consider getting tailor-made orthotics for your bike shoes.

Explained: plantar fasciitis

   

    

Stretch the gastrocnemius muscles

Lean towards a wall, using your hands for support. Extend the leg behind you, as shown. Hold for 30secs, repeating three times.

Stretch the soleus muscles

Lean towards a wall, using your hands for support, as shown. Keep the knee slightly bent. Hold for 30secs, repeating three times.

Plantar fasciitis – exercises to fix it

    

4. Shin splints

This is a general term used in place of three conditions in the lower leg that have similar causes – medial tibial stress syndrome (MTSS), compartment syndrome and stress fracture.It’s perhaps best to think of symptoms that runners can get in two areas of the lower leg. One is on the inside of the shinbone (pain can arise here because of MTSS); the other is on the front and outside of the leg (this is generally caused by anterior compartment syndrome but, occasionally, a stress fracture).
MTSS causes pain along a large section of the medial side of the tibia (shin bone). The cause of the pain is thought to be the inflammation that occurs where the tibialis posterior muscle in the lower leg attaches to the shin. A stress fracture can also occur on the medial side, but this tends to be located at a much smaller, well-defined area.

Stress fractures and MTSS tend to happen if you’re an overpronator running without corrective trainers, or if you’ve increased your training with insufficient rest, or have been running on cambered surfaces. You should always seek medical advice in this situation, as it’s likely physiotherapy will be needed. You may need to have some diagnostic testing done and you should immediately cut back on your training. However, it’s fine to go swimming and biking during recovery, which can take several weeks. The best way to avoid the problem in the first place is to wear good footwear, follow a sensible training programme and run on soft surfaces.

Anterior pain in the shin can be caused by a compartment syndrome. This means there’s excessive swelling of the muscles on the front of your shin due to overuse. These muscles swell and, because they are housed in an enclosed pocket of fascia, the swelling can restrict the blood supply and cause you pain.

It’s generally novice runners who haven’t yet acclimatised to running who tend to get this, but it also occurs if you fail to stretch your calf muscles enough. Running on hard surfaces in trainers with poor shock absorbing can also contribute. If you experience these symptoms, you should immediately cut back on your training. Don’t run if you experience pain during or after your running. You may need physio advice – and it’s important to stretch your calves regularly.

Shin-splints stretch

Cross the leg to be stretched in front of other leg, as shown. Lean into the stretch so that the foot begins to roll and big toe points to ceiling. Hold for 30secs, repeating three times.

Exercises to get rid of shin splints

   

5. Achilles tendinopathy

This condition affects many runners, and if you experience pain around the back of your heel, it’s important to seek treatment soon to avoid it becoming a chronic problem.

The Achilles is a tendon that joins your calf muscles to your heel, and it has another sheath-like tendon covering it, called a paratendon. The trouble with the Achilles is that it has a very poor blood supply and so healing can be very slow. People tend to either develop problems with the paratendon – producing symptoms of generalised swelling and pain along the length of the tendon – or within the tendon proper.

Achilles tendinopathy typically leads to pain and stiffness in the morning, which slackens off after walking around or during training, only to recur again several hours later. You may also experience tenderness, a nodular swelling within the tendon and even a creaking sensation or sound (aka crepitus).

There is a breakdown of the fibres within the tendon and you’re most likely to develop it if you’ve been running for years, have increased your training and not included enough rest, if you’re an overpronator or if you have poor flexibility in your calf muscles. We’d always recommend seeking medical or physio advice for this, and do it sooner rather than later, as chronic problems can stop you running for months and, worse still, put you at risk of rupturing the tendon.

Stretching, ice, heel-lowering exercises and a change in training and footwear are usually needed, and you may require friction massages or ultrasound therapy. Cycling and swimming are fine if they don’t aggravate the symptoms. Expect recovery to take several weeks.

Heel-lowering exercise

Stand on the leg to be trained on the edge of a step or stair. Stand slightly on tip-toe and slowly lower your heel as far as it will go. Do 15 reps, three times a day for several weeks.

6. Blisters

Blisters strike runners when friction from your socks or trainers causes the outer layer of skin to separate from the deeper layer. Lymph fluid then collects between the two layers.

At the first sign of discomfort, you should remove whatever is rubbing, and apply a blister plaster, such as Compeed. Unless the blister is very large, don’t try to burst/fiddle with it, as doing so may introduce infection.

Blisters are preventable with properly fitting, dry trainers and socks. Ideally, your socks should be wicking ones that finish above the ankle to avoid any irritation in the heel tab area or double-layered socks such as 1000 mile. You may choose to run without socks when you’re racing, to save time in transition, but running with socks when you’re training is good advice for avoiding blisters. Apply Vaseline between your toes, and ensure your toenails are kept neat and trimmed.

7. Athlete’s foot

This is a fungal infection of the skin on your feet that typically leads to an itchy red rash between your toes, and sometimes splitting of the skin. It occurs if your feet and footwear are damp – for example, with sweat – or because of a failure to dry carefully between the toes. The best way to treat athlete’s foot is with a topical antifungal cream, such as clotrimazole, itraconazole or miconazole, which should be applied for a good two weeks. Always run in fresh socks, and consider alternating pairs of shoes to allow them to dry out fully between runs.

8. Bunions

This is a bony swelling on the joint where your big toe joins your foot, and sometimes there’s an additional soft tissue swelling overlying it, called a bursa. Problems can occur as a result of pressure of footwear, which can produce corns or inflammation within the bursa. Slip-on shoes worn during the day may contribute to them, and your best bet for prevention is to wear deeper, wider trainers for running.

9. Delayed Onset Muscle Soreness (DOMS)

This is a type of muscle soreness that develops 24-48hrs after unaccustomed physical activity, and often occurs following heavy eccentric training (such as downhill running). The cause is unclear, but it tends to occur more in novice runners. Careful warming down, massage and spa baths can help. Seek medical attention if it persists for more than 48hrs, as the cause of the pain may actually be a muscle tear.

Delayed onset muscle soreness in the calves – simple exercises to fix it

10. Bruised toenails

Black toenails are usually the result of bleeding within the soft tissue at the root of the nail, which causes bruising and sometimes detachment of the nail. You can dramatically reduce the chance of this happening by wearing roomier trainers – up to half a size bigger – as the cause tends to be the nail repeatedly bumping against the end of the shoe. If the problem persists, you should seek the advice of a podiatrist.

In summary

Most running injuries are preventable. Invest in properly fitting shoes that are correct for your feet. Change them regularly and always take time to warm up, stretch and cool down. 

Plan your training to avoid too many intensive sessions and include adequate rest each week. If you have a persistent problem, don’t avoid dealing with it, as chronic problems are harder to sort out and slower to heal. And, if in doubt, always seek advice from a qualified professional.

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Dr Catherine Laramen specialisise in musculo-skeletal therapy and sports medicine. She is also a keen triathlete.

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