Training Principles for the Runner

Athlete, Ecosystem, and Ground Rules Related to Pain

Every runner has a unique ecosystem, story, and motivation to train. As a clinician/coach, taking the time to fully ascertain key information along these lines not only has the potential to establish a meaningful therapeutic or working alliance but is also requisite to designing an effective training program. A critical first step in working with any runner is to clearly identify the various biological and nonbiological factors that have the potential to influence the training response. Naturally, this would entail documenting a runner's past medical and training history while screening for any risk factors and/or pathology that could lead to fatigue, injury, illness, and/or in severe cases death. Furthermore, a thorough review of bodily systems and functions while attempting to gain a window into an athlete's current stress status is also mandated and often requires a team-based approach. The culmination of this information will ultimately serve to refine the personalization of specific training for every runner.

It is important for the clinician/coach to consider the various demographics of runners that they may encounter as well as any special considerations and behavioral traits (i.e., “perfectionism” and “self-blame) that could lead to negative training outcomes. For example, if the clinician/coach is working with an adolescent or collegiate female runner, it would be important to be familiar with various risk factors associated with bone stress injuries (BSIs) such as reduced energy availability, low BMI, menstrual dysfunction, history of stress fracture(s), and/or disordered eating as this would afford a lens into their bone health while directly impacting strategies related to the prescription and management of workloads. On the other hand, perhaps the clinician/coach is working with a masters level runner with a family history of cardiovascular disease who is on medication(s) to control blood pressure. In such cases, understanding the runner's normal response to training while being vigilant with managing his or her training intensity would be of critical importance, let alone establishing communication lines with the cardiologist or primary physician overseeing the runner's medical care.

It is also essential for the clinician/coach to have a broader conversation about “life” with every runner seeking their services. A growing body of evidence highlights the implications and negative impact stress history and elevated life stress can have on training and performance outcomes. In the context of low stress resilience and/or when high levels of psycho-emotional stress are reported, cardiovascular and positive fitness adaptations have been shown to suffer, even in well-conditioned endurance athletes. Appreciating the sequelae of recent negative stressful life events (i.e., loss of a loved one) is also critical considering that running economy has been shown to be reduced for up to 3 weeks following such an event. The culmination of excessive stressors both in and outside of running invariably seems to blunt positive adaptation and recovery while increasing an athlete's risk for injury in ways that seem to parallel overtraining syndromes. It is therefore essential to gain a window into the athlete's family and social situation, their professional/occupational or academic demands, general lifestyle, as well any perceived psychological stress, pressures, and recent negative stressful life events for the sake of refined decision making related to training. Through understanding the various stressors and wellness factors (i.e., sleep, energy, mood, soreness, and diet) each runner must contend with, training can be more effectively managed to impose the appropriate stimulus and desired response. In the event that this is successfully accomplished, the runner should ideally get stronger, develop injury resistance, and enjoy consistent training.

Despite the fact that most organisms have an inherent capacity to adapt, sometimes the cumulative stress or load is too great resulting in injury. Oftentimes, pain accompanies injury and has the potential to corrupt movement and disrupt or even sideline a runner from training. Considering the fact that runners are likely to experience pain at some point during their training, a critical and routinely overlooked initial step for the clinician/coach and athlete is to have a conversation about pain that is grounded in the biopsychosocial model. It is important to appreciate the multifactorial and personal element of pain. Establishing consensus in terms of ground rules related to training in the context of pain is therefore mandated. Engendering the notion that runners will always be able to enjoy pain-free training is not always a reality and likely misleading. For example, 75% of marathon runners who compete at the elite level reported the presence of pain in the previous 12 months. Additionally, among recreational runners who were about to race, 22% reported having pain thereby suggesting that one out of every five runners is likely competing with an RRI. Fortunately, running-related pain is generally mild to moderate in nature, is atraumatic, and often resolves within a few weeks to a couple months with appropriate desensitization measures.

Oftentimes, runners can even train through some pain provided that it is relatively low-level, stable, “acceptable,” not associated with altered running mechanics, nor suggestive of a BSI. Of equal importance is ensuring that the pain or symptoms resolve or at least settle to baseline levels within the ensuing 24–36 hours following a run. Otherwise, the condition should be considered “unstable” and further desensitization measures are likely indicated. Naturally, in the event a BSI is suspected, the coach/clinician should err on the side of caution especially in the context of regions classified as high risk (e.g., femoral neck, tarsal navicular). This is particularly the case in working with female runners, who present with one or more risk factors associated with BSIs. Some simple ground rules pertaining to training in the context of pain are listed below.

• Experiencing pain around running is not uncommon.

• Avoid running in the context of altered form or mechanics unless you are racing and see the finish line in the distance.

• Stop running if your pain is progressively worsening to a level that is “disconcerting” or “unacceptable.”

• If your pain “warms up” and remains stable, it is generally safe to train through provided that it returns to baseline within 24–36 hours.

• If the pain you are experiencing prevents you from resting or sleeping, strongly consider seeking medical consultation.

• Pain over bones suspected of having stress fractures almost always require cessation of running to remove the impact of loading.

• No pain or running is permitted with certain stress fractures identified by medical personnel; especially those that are classified as high risk.

Given the high incidence of RRIs coupled with the complex nature of pain, ensuring that clinicians and athletes both possess an accurate and modern understanding of pain marks a critical aspect of training that often goes overlooked. Through establishing open and honest communication, clinicians and coaches can more effectively demystify factors that have the potential to modulate any potential pain experienced by a runner. By establishing ground rules related to training in and around pain, runners will likely be better positioned to make more sensible decisions to foster healthy and consistent training while appreciating their adaptable and robust nature.

Return to Sport Continuum and Considerations

Understanding where a runner falls on the injury to performance spectrum while establishing mutually agreed upon goals among stakeholders is the critical first step in designing a training plan. Failure to address these items can jeopardize even the best training plan while increasing the propensity for fatigue, nonfunctional overreaching, illness, and/or (re)injury. For example, a masters level runner, who is returning to training after a recent calf muscle strain and is interested in running for weight management and stress relief, will have vastly different needs and priorities relative to an elite distance runner who has been consistently training and looking to set a personal record or perhaps qualify for the Olympic trials in the marathon. Although training loads will have to be managed in both cases, different considerations are at hand. In the case of the masters runner, they will likely have to gradually increase their running volume while avoiding any hill or speed work in the short term to avoid overstressing the involved tissues, whereas the performance-based runner may be engaging in high intensity interval exercise to engender specific physiological and metabolic changes for the sake of improved performance. For runners who are in the process of returning to training following injury, it is imperative to pinpoint where they fall on the return to sport continuum as described by Ardern and colleagues. Contextual considerations such as the nature of the injury or illness, athlete's age and tissue capacity, and level of participation must also be considered. For runners who have been training consistently and free of injury or symptoms this may not directly apply though it behooves the clinician/coach and runner to be aware of this continuum since it seems that any runner who trains consistently over the course of a year is likely to sustain an injury.

Training Plan Design, Workload Management, and Athletic Monitoring

Outlining a sensible evidence-informed training plan or framework, which gives the athlete agency, interfaces with their daily routine/schedule, and evolves with time-sensitive information, is the next priority. Discussing the rationale and thought process of the training plan with the athlete also lends to “buy-in.” Of equal importance is to establish and maintain an open and ongoing dialogue that affords the runner the ability to express or relay their concerns, thoughts, and opinions pertaining to the training process, plan, and related matters. Given that successful endurance performance essentially blends optimal physical conditioning with appropriate rest periods to engender physiological adaptation, it is important to consider the various factors related to these domains. While mechanical factors such as training intensity, frequency, and distribution play a paramount role in driving fitness gains, psycho-emotional considerations should not be overlooked as they invariably influence biological adaptation despite the fact that they are not as readily quantifiable. The training plan, monitoring and use of feedback systems, and communication strategies should therefore be customized to the runner and may involve subjective and/or objective information using available resources and technology that ideally reflect and reliably capture one's training response, readiness to train, and changes in health and performance.

Historically, training diaries/logbooks and direct observation by coaches were used to measure and monitor workloads. While such approaches may have value, they can be subjective and lack accuracy. On the contrary, a wealth of technology now exists and continues to emerge that can provide a scientific explanation for changes in performance through more precisely capturing the dose-response relationship. By no means, however, does utilizing such technology guarantee successful training and racing. In many cases, it poses a different set of challenges and can be a source of distraction. It is therefore important for the clinician/coach to have a discussion with the athlete to gauge their interest, experience, and potential preferences with monitoring as well as their available resources. A sustainable monitoring system should possess the following characteristics: reliable, practical, accurate, readily implementable, nonintrusive, efficient with reporting, applicable to training and competition, and consistent with the athlete's preferences and knowledge to give them a sense of ownership. Finally, establishing why the monitoring is occurring, what will be monitored, the frequency of collection, and how it is reported and interpreted in regard to decision making will help improve confidence in the overall plan and system.

Training loads are typically broken down into two categories: external and internal . External loads measure work completed by the athlete independent of internal characteristics. Examples related to running may include but are not limited to the following: frequency of training, pace, weekly mileage, and hours per week. Internal loads, on the other hand, provide a barometer of the relative physiological and psychological stress experienced by the runner and may include rating of perceived exertion (RPE), heart rate (HR), training impulse (TRIMP), HR variability, and sleep.

Oxygen consumption and blood lactate testing are two additional methods used by scientists to quantify internal training loads that receive considerable attention. Whereas oxygen consumption is a marker of metabolic rate that is directly proportional to the intensity of training, blood lactate serves to quantify the metabolic stress of exercise and helps to establish specific thresholds or training intensity zones. While these methods provide an interesting lens into internal training loads, they are relatively impractical for most runners even with the development of portable measurement instruments. It therefore comes as no surprise that the most common or well-known internal loads used by runners are RPE and HR.

RPE has been defined as “the conscious sensation of how hard, heavy, and strenuous physical work is.” While various factors can influence RPE such as personality, mental fatigue, and psychological traits as well as environmental conditions, research suggests that it affords a practical, valid, and reliable method of measuring training load during steady state exercise. It also happens to correlate well with HR during steady state exercise. Traditionally, the Borg category ratio scale has been used to establish RPE and consists of a 0 to 10 scale. However, a combination of internal and external loads should ideally be obtained to gain a more comprehensive lens into the training or competition load. Accordingly, Foster et al. developed the “session RPE” method of quantifying training loads as a means to eliminate the need for HR monitors or other methods of assessing exercise intensity that possess inherent limitations. Simply put, session RPE is the product of the intensity (on a 1–10 scale) and duration (minutes). The terms used to capture the difficulty of the training session using the category ratio and session RPE scales are listed below.

In essence, session RPE yields a single value solution to capture the global effort of a training session. For example, if a runner completes a 50 minute training session that he or she rates at 4/10 RPE, then the session RPE would be the product of these two values therefore yielding 200 A.U. (arbitrary units).

Heart rate monitoring is another common and relevant form of monitoring internal loads in endurance athletes and is based on the linear relationship between HR and O ₂ consumption during steady state exercise. Nowadays, nearly every sport watch or wearable enables the user to record their heart rate. Several coaches and athletes also continue to base their training solely focused on heart rate zones. While HR can effectively be used in managing and monitoring endurance training, it is critical for athletes and coaches to appreciate the underlying assumptions and limitations to safeguard against specious interpretations. Considering that submaximal HR can vary up to 6.5% it is important to appreciate the impact that certain factors such as environmental conditions, hydration status, cardiac drift, and competition can have on HR. In reality HR is likely best considered alongside RPE to help explain some of the potential variance. Lastly, bear in mind that HR requires the runner to go through max testing in order to establish zones which may not always be appropriate, especially when runners are returning to sport following an RRI.