Training overload in runners: What are the most common running injuries, and how they can be avoided.

Ultrarunning means to stress your body above and beyond the normal amount. That only works when you put in the appropriate training. Novices, in particular, often increase their training load too quickly despite muscles, tendons, ligaments and bones not being accustomed to the stresses. But novices aren’t the only ones who battle overload injuries again and again – so too do experienced runners. That’s why we asked physical therapists Sandra, Markus and Andy from Outdoor Physio for their advice:

Andy: Based on scientific research, overload injuries such as muscle or ligament injuries are based not only on coordination skills but also on conditioning components. Coordination components are recognizable by a deficient movement control that leads to inappropriately placed stresses and overuse which can then result in injuries. An accumulation of injuries after physical exertion on the other hand is an indication of conditioning components (see VBG Sport-Report 2016) while a combination of deficient movement coordination and fatigue in the context of intense exertion increases the risk of overload injuries.

Andy: By targeting core stability with specialized strength and coordination exercises, the risk of injury to lower extremities region can be significantly decreased. Neural activation in this area can be optimized by doing this, which in turn leads to increased muscular coordination and improved neural feedback. Furthermore, targeted and sports-specific stability and movement exercises for the legs can significantly decrease the risk of classic running injuries specifically on downhills.

Sandra: Here is where opinions differ widely. For one, from athlete to athlete even and due to his or her (sometimes) over-estimation or incorrect judgment, often guided by personal ambition or also perhaps from adrenalin during a race. And, alternatively, from support crew, trainers and medical personnel who can assess a situation more objectively and professionally.

Quality of training is decisive here! As soon as pain appears during training, the root cause should be sought. Sometimes there are already functional flaws with the musculoskeletal system Here, it is vital to eliminate it before the athlete returns fully to training. When pain exists, the body will compensate in other ways. The body can for a certain time balance this out – but at the expense of healthy and whole structures. In the process of compensation, healthy muscles, bones and tendons are overloaded through increased workload, and it is only a matter of time until some other malfunction or pain pattern surfaces.

To start a race day with pain is certainly a nightmare of every athlete. Thus, not so infrequently he or she reaches for pain medication. Since pain medications have numerous side effects, they should be particularly avoided on race day. E.g. essential organ functions can become limited or even fail in ways that can damage health over the long term. As soon as pain surfaces during a race it is advisable to listen to the body’s signals to avoid unnecessary delays in any recovery.

Markus: The really cruel commonality of running injuries from overload is that they do not arrive unannounced. Pain during running is traditionally the first sigh when the problem is first manifested. Questionnaires have shown quite well, however, that taking into account the relationship of loads and overloads can determine the risk of injury in individuals. Whether ultrarunner or novice: With poor running mechanics, incorrect footwear, and insufficient stability of torso and feet, running injuries are only a matter of time.

Markus: First, the most important thing for the treatment of running injuries is not to simply take a break until the pain itself is gone and everything is like it was before. Without working to find the cause of the overload, one will never achieve success long term. In the short term most certainly, it is helpful to do symptom-based treatment (rest, cold or warm applications, taking or injecting anti-inflammatories or using natural or homeopathic alternatives). However, this should only have a priority during the acute phase. At the same time, one should remember that the inflammatory phase is an important component of the healing of a wound. And that can be delayed when taking pain medications.

In order to find the root and to prevent chronic injuries, a specialized rehab professional working together with a medical professional and perhaps an orthopedic professional can help significantly. A comprehensive diagnostic assessment with muscle function testing and a movement analysis – potentially also additional assessment such as blood tests, imaging, and foot pressure analysis – can also be important. Only in that way can you create an optimum treatment strategy to balance muscular imbalances and to improve mobility and coordination. Plus, this can help create a targeted training and nutrition plan and help pinpoint the correct running footwear with the option of finding personal footbeds or orthotics.

Sandra: Here too is a working partnership between doctors and rehab specialists highly recommended. These pros offer long-time experience in rehab and can work with an athlete through re-entry into sports activity. Since every body is different, recovery and healing from the same injury can take different lengths of time. Essential is in this case to eliminate self-pressure since mental stress also can inhibit healing. Highly recommended is slow reintegration of athletic loads that is gradually and continually increased based on healing progress, pain, etc. A return too early to full training loads can result in a setback since injured structures must move through the healing process. And that can be interrupted by loads too early.

Sandra: Here again a close working partnership of orthopedic professional, sports medicine experts and rehab specialists is very important. Often, the cause of muscular imbalances stem from insufficient mobility or stability, or from footwear. A detailed medical history of the musculoskeletal system as well as walking and running analyses are very important and illuminating. In this way, a targeted therapy plan can be the result, and further pain or even injury can be prevented.

Markus: With Runner’s Knee or IT Band Syndrome, there is a rubbing of the tendons of the same name or the underlying bursa directly above the lateral knee joint. The IT Band runs along the lateral thigh and enables lateral leg stability through a firm connection between pelvis and shin. A change in the axis of the leg into a bow-legged stance or too much muscle contraction along the tensor fasciae latae (which tightens the IT Band) increases abrasion of the aponeurosis across the lateral bony protrusion on the lower upper thigh bones, which can lead to irritation. Furthermore, deficient activation of this muscle can lead to lateral knee pain during running. From the so-called “knock-kneed” position more commonly the result is an overload of the lateral knee joint with a resulting edema of the medulla or damage to the lateral meniscus and cartilage.

Treatment

Short term, cold applications and electrotherapy as well as anti-inflammatory steps can be helpful. Cause-oriented treatment looks at restoration of the physiologic joint alignment of the knee during trail running. To that end, exercises for relaxing and stretching of the tensor fasciae latae as well as fit of the running shoe (neutral alignment) are productive. This should be complemented by targeted leg alignment and core training with attention to strength endurance components so the physiologic leg axis can be maintained during long-distance running.

How can this injury be proactively prevented?

With regular stretching, rolling and activation of the musculature of the upper leg, one can prevent Runner’s Knee. A precise running analysis, ideally directly after a long training run, is also recommended. In this case, the deviations of the leg alignment can be revealed, and one can thus work on the pain from physical weaknesses prior to its appearance.

Andy: With Jumper’s Knee, it entails an irritation of the patella tendon under the knee cap. This comes about from an accumulation that is unnatural for the specific runner of peak stresses to this area. This result typically from extreme jumping and braking stresses and thus frequently can be found among trail runners with deficient technique in downhill running.

The injury mechanism comes about via a high forward pressure of the knee cap into the knee joint, which produces a massive tensile load to the patella tendon crossing the bone. Often the reason for this is poor coordination of the front and rear upper leg musculature.

How can this injury be proactively prevented, and how is patellofemoral syndrome treated?

Relieving the strain on the anterior patella through activation of the rear upper thigh musculature (hamstring) can reduce the forward pressure on the patella. Since often with Jumper’s Knee the front thigh muscles (Quadriceps femoris) can be too loaded too greatly, particularly on downhills, it should be relaxed, e.g. by using a fascia roller. Furthermore, targeted leg alignment training and technical education (downhill running) are desirable as preventative measures.

Markus: With shin splints, we are talking about a painful periosteum inflammation originating from the foot flexing musculature at the front edge of the shin bone.
During trail running in particular and especially in ultras and multi-day stage races, we come across this overload phenomenon quite frequently. Such races demand a high increase in volume due to their long distances and as such cannot truly be trained in that capacity. In addition, there is the constant change in running technique from the climbs and descents. Due to the increased heel placement on downhills, the muscles that lift the foot and toes must absorb extreme forces in order to control the plantar flexion of the foot. This can irritate the shin bone periosteum with insufficient adaptation. Flat-splayed foot can in face exaggerate this effect because it already overloads the front shinbone muscle (tibialis anterior).

Treatment

In order to reduce pain, there should be a break from running of one to two weeks, which should include ice applications, electrotherapy and, as needed, medications to fight inflammation. As long as only the musculature demonstrates an overload response and no inflammation of the periosteum can be shown, then methods to relax the muscle as well as kinesio taping can lead to the desired result so as to avert the need to quit, particularly in multi-day stage races.
Long term, of course, the underlying causes should be investigated. That for example can mean training of the arch of the foot with the potential of acquiring an orthotic, downhill technique training to improve the shift of the center of mass downhill, and strength and coordination exercises to rebalance muscle imbalances between the front and back of the thigh muscles.

How can this injury be proactively prevented?

Ultraruns in the mountains and also on the flats are something only experienced runners should take on. Indeed, the high increase in volume demanded by such runs, hold a high risk for training overload syndromes such as shin splints. Even with ideal physical preconditions regarding anatomy, strength balances and coordination abilities, a gradual increase in running distances is extremely essential. This allows tendinous muscle attachments along the edge of the shin as well as of course in other parts of the body to adapt to the loads demanded.

Depending on the runner, one could also forgo raised heels in footwear. These can in fact exaggerate the effect of an overload on the shin muscles due to the increased forward tilt of the upper subtalar joint they produce. In particular flatter footwear have been proved in this matter to prevent shin splints.

Sandra: With Achilles tendinitis, it is a matter of an inflammation of the paratenon (gliding tissue) and tendinous tissue of the Achilles. if this inflammation is not sufficiently treated and cured, the injury can become chronic quickly. Achilles tendinitis can have many causes. Usually caused by deficiencies and overloads, it can result in a degeneration of the partenon and tendon. Even the incorrect footwear can be a possible cause.

How can this injury be proactively prevented, and how is Achilles tendinitis treated?

Short term, Achilles tendinitis can be treated with ice massage in order to curtail inflammation. Kinesio taping, too, can be applied in acute cases. Long term, the musculature around the Achilles tendon must be strengthened and stretched for it to be able to withstand the loads of trail running.

Andy: With plantar fasciitis, we are speaking about an inflammation of the aponeurosis or fibrous tissue, of the foot. This overload syndrome of the tendinous tissue can tend to become chronic. What is striking here is how the overload pain is broken into various stages. Tendon irritation can occur along or at the osteotendinous junction.

With an overload of this tissue, small injuries occur; thus, when the tendon moves, they can easily lead to tendinitis (tendon inflammation). In addition, poor neurovascularization can mean the tendon does not react well to stimuli. From an orthopedic viewpoint, poor leg alignment, orthopedic misalignment of the foot or an inappropriate orthotic can be responsible for an overload of the tendinous tissue in the sole of the foot.

How can this injury be proactively prevented, and how is plantar fasciitis treated?

Foot mobilization prior to any exertion as well as warmups should always be undertaken prior to training and races. Taping and footbeds as passive aids can also support the relief of the loads placed on the plantar tendon. Fascia treatment and core stability can also be built into every workout to ensure good neurovascularization.

Sandra: A stress fracture is a break in the bone or of several bones due to stressful overloads. In runners, stress fractures most commonly occur in the foot and leg areas. Reasons include training loads that are increased too quickly, excessive training, misalignments of the leg axis, ignoring prior pain, or malfunction of the musculoskeletal system. Too, improper or poor footwear can facilitate the risk of stress fractures.

How can this injury be proactively prevented, and how are stress fractures treated?

Stress fractures demand a break of at least six weeks. Possibly even longer, dependent on the degree of the fracture. Afterward it is essential to increase any loads quite carefully to avoid another injury. During the break, aquajogging is recommended in order to maintain the running movement as well as the cardiovascular system.

Stress fractures occur most frequently without warning. That’s why it is especially important to carefully increase training volume to allow the musculoskeletal system to become accustomed to the loads.