Evaluation of the Injured Runner


Running has become popular among the diverse population of recreational and competitive runners. As such, each runner who presents with injury has a unique set of circumstances that contribute to the problem. Evaluation of the injured runner should therefore include a systematic review of medical and training history, prior treatments, functional ability, pain symptom characteristics, shoewear, and running biomechanics to identify individual features that may be associated with injury. A physician exam is vital if the runner is symptomatic, and a physical therapy consult is necessary to propose programs for correcting biomechanical aberrations of running motion. Other specialists such as sport psychologists, pain specialists, orthopedic surgeons, and endocrinologists need to be involved depending on the nature and chronicity of the symptoms. Sports dieticians should be consulted in cases of recurrent chronic injury, body weight–related injuries, and suspected malnutrition. Once the evaluation is complete, the results should be discussed and used to develop a rehabilitation plan to correct any deficits. While all runners should undergo a careful history review, a biomechanical analysis may be delayed if the injury is acute and unsafe to be stressed with testing. Thus, the evaluation components may be combined together or separated temporally depending on the individual case.

Medical and Training History

The first encounter with a runner involves a medical review of systems and training history. This process is needed to identify triggers for and risk factors of injury. The review items are in Table 3.1 . An important concept about the evaluation is that there is an art to piecing a profile together from details provided by the runner. Medical review should include chronic conditions (e.g., asthma, osteopenia, anxiety, or depression) and recent conditions or changes to health status (e.g., onset of thyroid dysfunction, postpartum). For girls and women, onset and regularity of menarche is important, as these can be associated with elevated stress fracture risk. Obtaining details of the runner's goals is important to frame the context of training patterns and outlook for rehabilitation. Is the runner novice or experienced? Is the individual preparing for a competitive event or engaging in running for health and fitness? Determination of training patterns and participation in competitive events from approximately the last year can provide insight on physical demand experienced by the runner. Novice runners who self-design their exercise program are more likely to become injured than those who follow a structured program, and runners with more than 2 years of experience have approximately 60% the risk of injury than novice runners. Self-directed use of virtual applications with predefined training schemes or participation in running groups may push runners beyond their individual capabilities and increase risk for injuries and, thus, should be considered in the history review. History of previous injuries is a predictor for subsequent injuries in short- and long-distance runners.

Table 3.1
Medical and Training History Factors to Be Reviewed with the Injured Runner.
Factor Additional Questions to Ask
Medical history
Demographics, past and current medical conditions Menstrual history, previous running injuries, has health status changed?
Any previous running injuries? What were they, when did they occur, what was the treatment? Any residual pain left from that injury?
Reason for engaging in running Fitness, weight management, social reasons, stress management, competition
Pain symptoms
Where is the pain, how intense? Does pain worsen during running?
Describe your pain.
Does it get worse after running?
How long have you had the pain?
What makes it worse? What makes pain better?
Does the pain make you change your running gait or limp?
Have other pains developed since this one? If yes, what were these and when did these appear?
Training history
How long have you been running?
Training status Recreational, competitive, elite
Current training sessions, mileage, and runs per week
Average distance for a long run?
Typical running surface and route description? Beveled roads, same route all the time
Currently doing speed work? If yes, how many times a week?
Currently training for a race? If yes, what distance and when is it?
Are you in a running group? Do you have a coach?
Changes in running volume, frequency, terrain or surface, or shoes in the past 6 months? If yes, what were they?
Perceived foot strike pattern How long have you had this strike
Recent changes to training regimen, volume, or added cross-training? If yes, describe
Rapid increase in mileage (more than 10% per week) or sudden start of a program with inadequate transition? If yes, when?
Did you increase the number of days or sessions per week running? If yes, when?
What other forms of exercise do you participate in other than running?
Are you a novice runner? What are your typical run times? Typical mile pace?
Did you try and change from rear foot to mid- or forefoot strike? If yes, when?
Did you add speed work or track work to your routine? If yes, when?
Have you increased your pace of running? If yes, when?
Have you added hill training to your routine? If yes, when?
Have you changed running terrain? If yes, when?
Shoe wear and orthoses
Current shoe make and model Did you get advice on the shoe to choose? What was the reason for picking your shoe?
Do you regularly use orthotics or inserts? What kind are they? How long have you used them and what is the reason for use?
Do you run barefoot?
Do you have new shoes or inserts? What was the change? When did you make the change?
Do you wear poorly fitting, tight, or worn shoes?
Have you changed from a standard running shoe to minimalist shoes or barefoot? If yes, when?

Running Load

Running load (weekly distance, frequency, speed intensity) modifies stresses on the body. Sudden changes to these running load factors can overwhelm the ability of musculoskeletal tissues to adapt, causing an injury. Rapid progression of running distance is a potent trigger for injuries, with a 10% increase in weekly distance being a reasonable threshold. Increasing distance by more than 30% compared with less than 10% increases injury risk. These distance-related injuries can include patellofemoral pain, iliotibial band syndrome, medial tibial stress syndrome, patellar tendinopathy, and greater trochanteric pain syndrome. If a runner reports training 7 days a week or performs more than one running session a day, the limited rest between training sessions is generally insufficient to permit bony and soft tissue recovery, especially over the long term. Participation in speed work may place significant stress to the hamstrings and lower back. While all runners irrespective of experience can develop pain, the experienced runner may have higher pain tolerance and incur performance decrements before seeking medical care and a running analysis. A key goal of the running load evaluation is to reveal triggering factors for pain. “Red flags” related to running load include rapid volume progression of more than 10% per week, frequency of running sessions with minimal time for systemic adaptations, and no participation in other exercise types but running.

Running Surface

Running surface or modifications to the running surface can change gait mechanics that can lead to injury. Running the same route on a beveled road consistently stresses the iliotibial band and medial knee compartment of the lower limb that lands on the outer side of the road. Running on different surfaces activates lower leg muscle groups differentially; asphalt requires stiff ankle joints, gravel requires ankle stability, and grass is the least demanding on muscles. Other evidence shows that surface type also modulates the vertical acceleration of the tibia (risk for bony injury) while running at preferred speed. Specifically, running on wood chip trail is related to slower tibial vertical acceleration than synthetic track or concrete. Careful assessment of whether the runner is dynamically strong and controlled enough to run on variable or softer surfaces is important. Even if a runner runs on a soft surface and reduces impact loading, they may not be able to maintain stability during the stance phase of gait, thereby leading to soft tissue stress. The age of the individual can also modify the relationship between running surface and overuse injury. In master runners, running in sand can increase occurrence of soft tissue injuries such as Achilles tendinopathy compared with running on asphalt. The introduction of downhill (decline) bouts confers unaccustomed stressors to the lower limb, including eccentric loading to the knee extensors and patellofemoral joint stress.

Use of Additional Running Gear

Habitual use of additional gear, including water bottles, electronic devices, and strollers, can create small biomechanical asymmetries that accumulate over time or worsen with fatigue. We have found that one-handed carriage of water bottles changes transverse pelvic rotational excursions and upper limb sagittal motion differences. Jogging strollers reduce trunk movement in the transverse and frontal planes and also increase forward trunk lean and pelvic tilt. Our clinical observations indicate that individuals who wear arm-band phone holders or carry phones or other electronic devices display arm motion restriction on the ipsilateral side, a subtle lateral trunk lean, and pelvic tilt. These findings may have implications for runners who report back or knee pain.

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