With the advent of modern fabrics, there are now vast selections of garments ­available. It is important to consider body temperature and dryness from both the inside (perspiration) and the outside (precipitation). Layering of clothing allows the runner to adapt clothing in response to changes in temperature and weather conditions, which occur rapidly at altitude or in mountainous conditions. Technological breakthroughs have enabled garments to be produced that are breathable, ­windproof, waterproof, lightweight, antibacterial, lightweight, and that wick away any personal moisture. Runners must carefully assess conditions before selecting appropriate apparel for both training and racing as this could be crucial for safety. In good weather, a lightweight running vest and shorts might be sufficient, whereas waterproof, full body protection may be necessary in adverse conditions.

When selecting footwear, the runner needs to take into account:

The shoe needs to provide flexibility and speed, but comfort, traction, support, stability, motion control, cushioning, breathability, and, at times, protection from rocks must be considered. Sometimes advanced lacing or webbing systems are used to help hold the foot stable within the shoe, and various soles have been developed ranging from pyramid “studs” for mud to a “sticky rubber” for grip on wet rock. The shoe uppers need to be quick drying and allow any water collecting in the shoe to easily seep back out. The most suitable shoe for a short race through mud is completely different to that for tricky rocky terrain or a 2-day event carrying overnight equipment. Runners often have several pairs of running shoes to suit the varying conditions. Some of the market leaders are Salomon, Inov-8, Montrail, Walsh, and La Sportiva.

The climate is a serious factor, and representatives from the various committees and race organizers must decide whether weather conditions are suitable for races to proceed as planned. Where adverse weather conditions could endanger competitors, marshals, or volunteers assisting at the race, the race may be abandoned or a safer alternative course is used. It is the responsibility of the race organizers to make sure that the course is as safe as possible and not unnecessarily dangerous.

A runner may need to carry food and drink while racing or on long-training runs to avoid hypoglycemia or dehydration. It is a race requirement in some events, but athletes are generally advised to carry sufficient supplies whenever they are racing for longer than 1 h [1].

The skyrunning races and some of the mountain and endurance events involve racing at altitude. When the athlete resides at a much lower level and has little time to acclimatize, they must be very careful in appropriate race preparation. Athletes often train at altitude to benefit from the physiological adaptations when racing at sea level, but racing at altitude is the opposite extreme and places serious demands on the body. The effects of altitude on the heart generally begin around approximately 1,000 m (3,048 ft) above sea level. Runners are advised to train at altitude of approximately 8,000 ft for at least 4–5 days before running above 13,000 ft, although if they live above 6,500 ft is not always necessary. The guidelines suggest that once above an altitude of 2,500 m, the altitude at which one sleeps should not be increased by more than 600 m in 24 h, and that an extra day should be added for ­acclimatization for every increase of 600–1,200 m in this altitude [2].

Altitude and acclimatization are taken very seriously by organizers of races such as the Everest Mountain Marathon. This race is preceded by a 15-day trek in the Everest region to allow for acclimatization, all while under careful medical supervision [3]. Physical fitness is not protective against high-altitude illness [2], but instead it seems to be influenced by the rate of ascent, the altitude achieved, the height at which the person sleeps (sleeping altitude), and the individual’s physiology. Skyrunners may adapt their running style when racing at altitude by generally slowing down, shortening their stride, and walking where the gradient exceeds 25 %.

The WMRA does not impose any specific safety requirements, but the Fell Runners Association in England, the International Ski Federation, and races such as the Original Mountain Marathon (OMM), which is a 2-day mountain marathon, all carry their own regulations. These recommendations are made with the safety of the runner being the main priority (Fig. 13.4).

The FRA requires competitors to arrive at races prepared to carry body cover appropriate for the weather conditions, a map, compass, and whistle, and emergency food in long races. Race organizers can also impose additional safety requirements or waive some of the requirements in settled, fine weather.

In skyrunning races, the use of ski poles is permitted, although this is regulated by each race organizer. It is compulsory to have windproof jackets, trail-running shoes, and socks, plus it may be a requirement to carry tights, gloves, water, helmets, and sunglasses. The recommended equipment for each skyrunning race is stated in the race briefing.

The 2008 Original Mountain Marathon in England suffered from sudden adverse weather conditions. The race had over 2,000 competitors scattered over the fells and had to be abandoned due to torrential rain and high winds. Previous experience of the competitors – a requisite to participating in the event – along with the safety equipment carried by the athletes ensued there were no fatalities and only one reported injury.

As yet there are few published studies regarding the frequency and type of injuries specifically experienced by mountain runners, although a systematic review published in 2007 reported on the incidence and determinants of lower extremity running injuries in long-distance runners [4]. The literature published on ultra races, the Marathon Des Sables and the World Deca Iron Triathlon, has focused on weight and body water composition changes related to performance and is probably beyond the scope of this text [5, 6]. Analysis of the presenting complications reported by the 69 competitors in the 219-km Al Andalus 5-day ultramarathon stage race showed that in this competition over half (56.5 %) reported injuries. The majority of these were minor with foot blisters comprising 33.3 % and chafing 9 %. Lower limb musculoskeletal injuries accounted for 22.2 % and predominantly affected the knee [7]. Van Gent’s review included studies where subjects ran >5 km per training or race, which, while useful, is not totally representative of mountain, sky, and ultradistance running.

Park has conducted a questionnaire survey of the injuries experienced by mountain, sky, and endurance runners over a 6 months period identified sites of injury, possible causes, and subsequent treatments received. As the runners were unable to be medically assessed and diagnosed accurately, they were asked to stipulate the area of injury rather than the specific medical diagnosis. The survey population comprised of 200 runners from 11 countries −100 competing at international level including 6 previous world champions and 100 “club” runners.

Of the 200 responses, 142 runners (71 %) reported at least one injury during the previous 6 months, although this was not necessarily representative of the frequency of injuries in the sport. Twenty-seven percent of the runners reported more than one injury suggesting some may have been compensatory.

For the male athletes, the number of injuries increased as the standard of the athlete decreased (33 % of non-GB international athletes reported injuries, compared to 89 % of club athletes). Van Gent similarly found that an increase in training distance per week appeared to protect the individual against knee injuries, rather than being causative [4].

The most commonly reported injury in Park’s survey was to the knee (22 %), followed by the shin or calf muscles (15 %), foot (14 %), ankle (12 %), thigh muscles – hamstrings or quadriceps (10 %), pelvis/buttocks (9 %), Achilles tendon (9 %), spine (8 %), and upper body (1 %) (Fig. 13.5). The majority of these injuries were overuse in nature particularly tendinopathy and tenosynovitis.

The males had a much higher incidence of knee injuries compared to the females (Table 13.1) despite studies suggesting females experience a higher incidence of sports-related knee pain [8]. Females reported more foot injuries, although the ­reasons why require further investigation.

The higher incidence of male knee injuries could be because:

Fatalities due to mountain running are rare, but adverse weather conditions while training or racing can result in exposure, fatigue, hypothermia, and occasional tragedy.

In 2008, 2 runners were killed and 6 seriously affected in the Zugspitze Mountain Race in Germany. A sudden change in weather brought temperatures below ­freezing point, with strong gusts of wind and snow. Five hundred runners were competing in the race, most of them only clad in t-shirts and shorts, but the fitness of the individuals involved helped most of them cope with the extreme conditions [11].

There have been very few deaths reported when weather has not played a major factor, but the consensus of opinion is that these deaths have been due to other preexisting conditions such as heart disease or congenital abnormalities. While this has been proven in road marathon running, no specific studies are available relating to mountain running [12].

Some injuries occur more frequently in mountain running because of the unique demands placed on the body when running steep ascents or descents. The common injuries associated with running are documented sufficiently in other sports’ injury textbooks, but some of the more obscure injuries deserve specific attention.

Runner’s knee – possibly more aptly named mountain runner’s knee – is the most frequent injury encountered by those regularly providing medical treatment for mountain runners, with almost a quarter of survey respondents complaining of this problem.

Noakes and Grainger [13] suggested that this is the most common injury associated with distance running but, combined with the biomechanics of the knee while mountain running, explains why it is so prevalent. Other textbooks refer to it as patellofemoral stress syndrome, lateral patellar compression syndrome, peripatellar syndrome, and retinaculitis [14].

The symptoms and signs are:

On clinical examination, there is:

Lumbar pain, pelvic pain, buttock pain, and thigh pain are all common in mountain running and often remain misunderstood and misdiagnosed by medical ­practitioners due to the confusing clinical presentation.

Running up- or downhill alters the pelvic tilt considerably (Fig. 13.6 and 13.7), affecting the body’s biomechanics. The structures that are associated with the lumbosacral spine, pelvis, buttocks, and hips (Fig. 13.8 and 13.9) are exposed to unaccustomed stresses which are completely different to those of flat, propulsive road running.

If eccentric loading exceeds eccentric strength (as in downhill running), there is an additional risk of accumulative microtrauma.

While minor lesions are initially asymptomatic, the continuous cycle of repair, reinjury, and re-inflammation ultimately becomes problematic, with compensatory damage occurring in the closely related structures [15].

The possible signs and symptoms are:

Clinically:

Further investigations do not usually help in the diagnosis of this complex problem, although imaging may occasionally identify a minor disc protrusion or superior hamstring lesions. The MRI report frequently suggests there is nothing untoward, which often causes the runner serious psychological distress. It is important to explain that there may be areas of micro-damage, which have not been identifiable, but the report excludes any serious pathology. The diagnosis of a disc lesion occasionally leads to other associated areas being neglected in the treatment plan, and personal experience has shown that the primary site and the associated areas must be addressed to achieve optimum recovery and avoid any future recurrences.

Tendon injuries are common in running, although mountain running affects different tendons to road running. Flexor hallucis longus (FHL), tibialis posterior, and both peronei tendons are at higher risk around the foot and ankle. FHL tendons have been known to rupture during uphill repetition training sessions. Many of the athletes run on their toes, so the undulating terrain put these structures under considerable stress. Pain is usually localized, and resisted muscle testing of the structure often identifies the problem. If resisted testing is negative (given it is impossible to replicate similar strains within the clinic), palpation is often paramount in locating the site of injury.

In ultramarathon running, the high-mileage training requirement has been associated with ankle extensor tendon tenosynovitis localized at the extensor retinaculum [16, 17]. These comprised 19 % of all injuries sustained during a 1,115-km ultramarathon race from Sydney to Melbourne [16]. Tenosynovitis of the extensor digitorum longus tendon has since been termed ultramarathoner’s ankle [16]. A typical ultramarathoner’s shuffling gait has been suggested as a causative factor in addition to excessive pronation, tight-fitting shoes, muscle imbalance, eccentric overload, and in one case talar head impingement [17].

Continuous overload means that mountain runners are susceptible to stress ­fractures, with several being reported in the survey. Signs and symptoms are:

Most runners want evidence of the injury due to the enforced period of rest from running, but radiographs may fail to reveal a fracture until at least 3 weeks ­post-injury when new bone growth is identifiable.

Osteoarthritis and the development of cardiac damage are often misconstrued as being prevalent in runners, but this is unproven. Animal and human studies have shown no evidence of increased risk of hip or knee osteoarthritis in subjects carrying out moderate exercise (in the absence of any traumatic injury). Sporting activity has even been shown to have a positive effect as a study of recreational runners who ran 12–14 miles per week for up to 40 years showed no increase in either radiological or symptomatic hip or knee OA [18].