Optimizing Outcomes for Running Injuries

Wouldn’t it be great if you could read this article and have the answers on how better to treat your running athletes? Unfortunately, there are no scientific algorithms, magic shoes or proper form when it comes to running.  

When you close your eyes and think of a runner, you probably picture a lean, tall, well-muscled individual on the cover of a running magazine. While some of my patients fit that image, the majority of them do not. My runners are young/old, male/female, slim/husky, short/tall, and almost every combination thereof.

What do they all have in common? Goals! They are all driven by something that brings them back to lace up their sneakers and get the opportunity to run. In my experience, the desire to overcome a physical challenge motivates runners. Unfortunately, it sometimes drives them to want to accumulate metrics—that is, more miles, faster times, and decreased time between workouts, all of which can lead to overuse injuries. Sedentary work environments, where sitting with poor posture dominates our waking hours, may further exacerbate the risk of injury for the overzealous and underprepared runner.

All runners know that injuries are a part of the sport. They also understand that feeling of intense loss and frustration when they are unable to run. Statistics show that 82 percent of all runners get hurt and up to 50 percent of runners experience a running injury each year.¹ Most of those injuries result from overuse rather than trauma. The three main categories of risk are:¹

Biomechanical factors—how runners move and position different parts of their bodies.
Anatomical factors—limb length, arch height, and flexibility, to name a few.  
Training errors—overtraining leads to breakdown of tissue, which needs time to heal.

Most running injuries are musculoskeletal overuse syndromes related to cumulative overload of the lower leg. Of all running injuries, 75 percent occur from the knee down.² These include runner’s knee, medial tibial stress syndrome, Achilles tendinopathy, stress fractures, and plantar heel pain.

I consider a runner injured once his or her natural movement patterns become altered by pain and the runner resorts to compensations in gait pattern. Runners are known for pushing through pain, but understanding the difference between discomfort associated with exertion and the pain of injury is critical. Once the athletes realize they are injured, their path of treatment varies widely. There is a mountain of information available on possible pathologies and treatment plans. The majority of the runners I see usually present self-diagnosed through information they obtained on the internet and have already devised personal strategies.  

Another initial attempt patients may try when seeking help may come from the running retailer. The running shops are experts when it comes to offering the best fit and selection of shoes. But retail employees who have been longtime runners are not qualified to offer medical advice. Fortunately, the majority of the independent running retailers I have encountered are excellent sources of information. More than likely retailers will suggest possible pathologies as well as over-the-counter products, but will steer a patient to the appropriate medical team member that could best offer proper diagnosis and treatment.

How to Listen to an Injured Runner

Once these patients reach our office, they are usually frustrated in being restricted from their passion for running. As a sports podiatrist I believe it is imperative that our staff understand that these patients must be prioritized in our schedule. Runners cannot wait weeks for an appointment while their pathology goes untreated. By the time the patients present to you they likely have been through the gamut of professionals to potentially include the emergency room, primary care physician, chiropractor, physical medicine, and perhaps other podiatric physicians. I see these patients on a daily basis, usually toting bags full of shoes, gadgets, and devices, all of which have been of no help in relieving their pain.

So, what tool will make this patient experience different, and get the clinician to listen? I tell all my patients, “Tell me your story.” I do not interrupt until they are done. Many times, patients become emotional as they relate their injury journey. They are entitled to experience those feelings, and it is our job to listen. During this process, the sports podiatrist will ask open-ended questions in order to gather as much clinical information as possible. With every patient I use the acronym NLDOCAT that I learned as a student:

Nature of problem: Heel pain
Location: Have patient point to the pain area and show if it radiates.
Duration: How long have you been experiencing the problem?
Onset: Did the pain come on suddenly, possibly due to an injury, or gradually?
Characteristics: Describe the pain (aching, stabbing, throbbing, sharp, dull, etc.)
Aggravating or Alleviating factors: What makes the pain better or worse?
Treatments: What have you tried at home to provide relief? Have you been treated for similar problems before? If yes, what was the course of treatment?

The above steps are critical in order to populate your differential diagnosis. Most patients do not improve simply because the clinician did not take the time to make the correct diagnosis or to consider the “zebras”—the irregularities that might have been overlooked. 

How to Perform an Effective Physical Exam and Diagnosis

Once the NLDOCAT is completed the physical exam can commence. A proper exam will include a dynamic assessment of the athlete. It is essential for the runner to stand and to move bearing weight in order for you to get the full story. Visually you can easily assess asymmetries and anatomical differences, as well as lack of flexibility and mobility of a body part. The important point here is to visualize the whole body. The reason for the pathology may be at a structure proximal or distal to the injury. Focus on the why rather than on the what.

Pick any lower extremity overuse injury—metatarsal pain, medial tibial stress syndrome, plantar fasciitis, or Achilles pathology. The “why” to all of them is a lack of forefoot control and a poor stability point.³ When runners with these injuries are not able to control the load at the level of the first metatarsophalangeal joint, pathology occurs proximally. As a sports podiatrist I must recognize this weakness and help the patient to feel it, sense it and understand it. When individuals have proper control of intrinsic muscles there is less length and, therefore, less strain of muscles upstream. I like the saying that if you can’t control proximal stability, then you also cannot achieve distal mobility.  

An example of this scenario is shin splints. In the examination room have your runner stand on one foot and ask him or her to isolate the hallux in plantarflexion while actively dorsiflexing the lesser digits. If the patient cannot control this task, the arch collapses, the posterior tibial tendon elongates, and this repetitive strain can lead to medial tibial stress syndrome, in my experience.

Most athletes have no problem training the big, bulky stabilizing muscles; not so the intrinsics. In order to develop foot dexterity and control the runner needs to perform frequent activity in small doses. This primes the nervous system and allows the brain to learn. In my practice, I utilize the Mobo Board developed by physical therapist Jay Dicharry, MPT, SCS. This novel tool engages intrinsic muscles, such as the flexor hallucis brevis and abductor hallucis, which can then lead to rearfoot steering through forefoot control.

A Closer Look at Innovations and Treatment

There are so many innovations in the sports medicine world that practitioners have at their disposal. Without question, I feel the number 1 game changer has been regenerative medicine, in particular extracorporeal shockwave therapy (ESWT). Runners today want non-surgical treatment options for faster healing, with no downtime, no anesthesia, and minimal risk.  

As a clinician, I am also drawn to solutions that are evidence-based and have high levels of peer-reviewed literature to back them up. Shockwave treats the cause of the pain, not just the symptom. Acoustic pressure waves induce angiogenesis and mechanotransduction, which in turn provides a vascular response and enhances blood circulation. Shockwave breaks down adhesion and scar tissue at the cellular level. I have found all of these mechanisms accelerate the healing process and decrease the patient’s pain while keeping the runner moving.

The newest of the regenerative tools is extracorporeal magnetotransduction therapy (EMTT), which acts by using high-energy electromagnetic radiation for regional treatment areas. These waves increase the porosity of the cell membranes, thereby eliminating negative cellular byproducts to the lymphatic system while opening the doorway for positive components, such as stem cells, to enter. EMTT can be used as a standalone therapy and as a supplement to ESWT to treat degenerative joint, muscle and tendon disorders, as well as for inflammatory forms of musculoskeletal disorders.⁴

Prescribing a Return to Running Protocol

A return to running protocol should be instituted for the injured runner. There are many variations of this but I find that basically a mixed walk-run/return-to-run protocol is ideal. These plans have a place for increasing tissue tolerance. I advise patients not to focus on distance, but rather on time. Aim for 30 minutes, provided there is no sharp pain, of lessening discomfort as the session continues, and aim for pain not altering one’s movement pattern or causing the runner to limp. As the runner reaches their pre-injury running level, he or she should not increase training duration by more than 10% per week in order to minimize the risk of injury recurrence.  

A more sophisticated approach is also to uniquely expose tissues to higher loads via targeted work. I advise my patients and my therapists to incorporate plyometrics. This type of ballistic exercise training uses the speed and force of different movements to build muscle power and increase bone loads. Examples are squat jumps, box jumps, and lateral jumps, all with an emphasis on hang time. Repeated speed training, which consists of a series of short sprints each separated by a short recovery period, can be tuned for return to run following tendon or muscular injury. The understanding of these programs and the ability to communicate with the athlete, physical therapist, athletic trainer, and coach is paramount to achieve maximum buy-in by the runner and, ultimately, a more effective recovery.

Golden Harper, foot health and running coach and creator and founder of Altra and P.R. Gear, shared some of the following thoughts with me. If you are like 98 percent of distance runners who have never had any formal technique training, Harper notes it would be wise to learn how to run in a way that is easier on your body, is faster, and is more fun! Unfortunately, in my estimation, distance running is about the only sport that people are not taught how to do safely and effectively before they start doing it. This likely explains the high injury rate for a sport that is non-contact. 

Advising the Runner on Shoe Choices

The question that patients always want to know is, “What is the right shoe for me that will keep me injury-free and help me perform better?” My answer always is that I would like to see them in the least amount of shoe that is right for them that will allow the foot to do its job and the runner to be more metabolically efficient.  

This is a very broad answer, but it allows me to be the expert on foot pathology and treatment plans, and it allows the runner to be the expert on his or her personal comfort level. This quest may take some trial and error, where the athletes may need to go through multiple pairs of shoes until they determine what works best for them. Returning to running after an injury is a great time to add shoes to your routine to help you do the sport safer and more efficiently.  

Look for shoes that let the toes totally spread out and have lower heel elevation or drop. Shoes like these will encourage better running form and more natural body mechanics and movement patterns. Be mindful of the shoes you wear everyday while not running. These too should have adequate toe space in both length and width.

The standard for recovery after a running injury is proper diagnosis and pre-return testing. Strengthening the whole body, implementing the period out of sports to examine the weaknesses that led to the injury, and using the time to prevent future injury all provide a better foundation for improved performance.

Dr. Conenello is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow and Past President of the American Academy of Podiatric Sports Medicine. He is an Honorary Police Surgeon for the New York Police Department and the Clinical Director of Special Olympics New Jersey and practices in Orangeburg, NY.

References

1.    Napier C. Science of Running: Analyze Your Technique, Prevent Injury, Revolutionize Your Training. DK, 2020.
2.    Epperly T, Fields K. Running Medicine. Chapter 1, Epidemiology of running injuries. Healthy Learning, 2017.
3.    Personal communication, Dicharry J. RPM2 podcast.
4.    Curamedix. https://www.curamedix.com/ .