Running history credits the legendary Greek Philippides in 490 B.C. for completing the first marathon. On a hot summer’s day he ran 26 hilly miles from Marathon to Athens to deliver the news that the Athenian army defeated the Persians. Exhausted, the legend claims he died after the news reached the city. When the modern Olympic Games were inaugurated in 1896 in Greece, the legend of Philippides was revived by a 24.85 mile (40,000 meters) run from Marathon Bridge to the Olympic stadium in Athens. The first organized marathon on April 10, 1896 was especially important to the Greeks as the host nation. Twenty-five runners gathered on Marathon Bridge, and 2 hours, 58 minutes, 50 seconds later (7 minutes/11 seconds [7.11] per mile pace), the Greek postal worker Spiridon Louis finished 7 minutes ahead of the pack. The host nation was ecstatic, and the marathon was born (3).

Running has grown in popularity, and numerous running surveys point to its cost and time-efficient nature as reasons why many people choose the sport. Most clinicians agree that physical fitness is the best predictor of longevity. Individuals who run consistently have a reduced risk of cancer and cardiovascular disease, although the incidence of early arthritis and degenerative joint disease, long considered a side effect of running, is no higher than in sedentary controls.

Fields and Reece estimate that 40 to 50 million Americans run for fitness two to three times a week (4). This works out to be nearly one in seven people in the United States who are running several times a week. Recent studies indicate that 10 million people run on more than 100 days per year, and about 1 million compete in local races per year. Prospective studies reveal that 35% to 60% of runners have a significant injury each year. Running injuries are dependent on the age, experience, and size of the runners, as well as the type of running
(cross-country vs. track). There are different energy and physiologic demands, depending on the event in which the runner competes: sprints (100, 200 and 400 meters), middle distance (800 and 1,500 meters) and distance (3,000, 5,000, and 10,000 meters: a marathon) (4).

A runner must gradually, but consistently, stress his or her body to improve performance. Training overload leads to improved performance and adaptation of the musculoskeletal system (4). However, there is a fine line between maximal training and overtraining. Runners are often subject to overuse injuries. Improper training can be linked to most running injuries. Doing too much mileage, too fast, too soon is a common part of a runner’s history. A careful review of an individual’s training log often reveals the reason for an overuse injury. Clearly, runners who run 7 days a week with too-frequent interval workouts, tempo runs, or long distance runs are at risk for overtraining injuries. Tempo runs are designed to help runners run at race pace. The benefit of specific speed workouts appears to be the physiologic changes within the cardiopulmonary and musculoskeletal systems. These changes appear secondary to circulatory and enzymatic enhancements within muscle groups along with adaptations within the nervous system. It is evident that increasing distance must be done reasonably slowly in order to prevent injuries.

A common training principle is to increase weekly mileage by no more than 10% at a time. Long runs should be no more than 30% of the cumulative weekly miles. For example, if a runner is logging 20 miles a week, long runs should not exceed 6 miles. This is a reasonable and conservative measure by which to counsel runners about training programs, although many training program abound which may vary.

Another training principle for runners returning from injury is to return at 50% of the runner’s normal training mileage at a subtempo pace (4). The severity of the runner’s injury may create a need for less mileage upon return. This is also the opportune time to discuss the use of recovery runs. Understanding how much weekly rest a runner has built into his or her schedule and how much sleep is actually needed is a significant part of evaluating and treating an injured runner.

There is a progression involved for a successful return to running and training that is designed to help the runner reach a goal. This plan involves scheduled rest days. Referring to Fields and Reece again, it has been found that runners that train 7 days a week on a regular basis are injured more than those that take intermittent rest days (4). Rest days should be part of all training plans. The recreational runner usually does not run every day, so concern about injury prevention is centered more on footwear, gait problems, chronic injury, and sudden changes in distance or terrain. For the competitive runner, these are considerations, but attention must be given to the type of workouts incorporated into the training schedule as well.

A schedule for the competitive runner should be designed focusing on the specific events the runner will participate in. It is common for an elite athlete to design a cyclical schedule that incorporates not only rest days but also increases and decreases in intensity of training. This is as beneficial psychologically as much as it is physiologically. Getting into this habit is just as important for the competitive runner as it is for the elite-level runner. A healthy competitive drive exists at all levels, not just at the elite level. Because training error is the leading contributor to running injury, runners must have a healthy and safe running program that is tailored to their needs but controls and monitors total mileage (2).

The practitioner treating running injuries should be familiar with some of the standard running workouts. Additionally, a good history often provides the information necessary to determine the cause of most running injuries. Along with a complete history, a thorough examination of the entire spine and lower quarter is essential if the practitioner is to accurately determine the ultimate cause of the injury. The foot, leg, thigh, pelvis, and lumbar spine respond to isolated deviant motions often leading to a change in gait. Just as overtraining can result in tissue and joint damage, faulty mechanics can also lead to debilitating injuries.

Recreational runners are only one type of runner to consider. Competitive runners sustain injuries at a level higher than recreational runners, with total mileage being the primary factor. With regard to running injury management, the same general principles apply to both the recreational and the competitive (elite) runner.

The kinetic chain theory of running refers to how the body must absorb tremendous
ground-reactive forces throughout the musculoskeletal system. The foot and ankle mechanism is the first link in the kinetic chain. Twenty-six bones articulating at 30 synovial joints, and supported by over 100 ligaments and 30 muscles, help to dissipate these ground-reactive forces (8). If the musculoskeletal system has a structural problem, it can alter a runner’s function and can overload certain anatomic areas. A runner returning from an injury may have lingering changes in the range of motion of the previously injured site. Theoretically, this may change the biomechanics of the runner. In addition, weakness of a muscle that had prior inflammation may change its energy absorption potential and the protection that it could provide the area.

A blocked or dysfunctional joint complex creates a need for nearby or adjacent structures to compensate for the structural problem. This altered function may be a contributing factor for a tendinitis, bursitis, or stress fracture. Most injuries are related to training errors, structural defects, or intrinsic running errors (leg-length discrepancies, excessive pronation or supination). Foot and ankle dysfunctions can lead to dysfunctions at the knee, which can alter pelvic mechanics, which in turn can affect the back and neck region. This type of musculoskeletal chain reaction is referred to as the kinetic chain theory of running.

Muscles absorb approximately 80% of the impact of running, with the rest of impact forces going to bone and adjacent tissues (4). One rehabilitative principle that has widespread applicability to runners is the concept of muscle imbalances. The goal of treating muscle
imbalances is the protection of the osteoarticular system. The repetitive and often excessive nature of running creates a host of musculoskeletal injuries and dysfunctions. Janda determined that muscle dysfunction is not a random occurrence but that muscles respond in characteristic patterns (9). These patterns manifest themselves in different ways, even in sports. The concept focuses on the aspect of dynamic and postural muscles (Table 37.1). Runners characteristically spend the majority of their time in hip flexion (iliopsoas) and little of the running stride in hip extension (gluteus maximus).

As a result, a pattern of dysfunction can occur within the iliopsoas mechanism, such that the muscle becomes facilitated, hypertonic, and shortened. This physiologic change, in turn, affects its antagonist muscle group, the gluteus maximus. Therefore, the hip extensors respond by inhibition, hypotonicity, and weakness. Janda describes the weakness as a pseudoparesis, due to inhibition rather than being intrinsically weak. Once this pattern develops, it can alter the arthrokinetics of the lumbopelvic region and lower quarter. This reciprocal inhibition of the tight and dysfunctional iliopsoas affects the antagonist gluteal mechanism (9).

A runner who exhibits such imbalance will also reveal signs of a tight anterior hip capsule. The conventional modified Thomas test reveals muscle tightness of the iliopsoas, rectus femoris, and tensor fasciae latae. Hip tightness may also be detected by assessing symmetry using the pelvic rock test (see Chapter 22.2), Hip and Pelvis: Physical Examination (Fig. 22.2.9). The side of restriction can be further evaluated by placing the athlete in a prone position and observing the motion of the hip and thigh with extension. A restricted anterior hip capsule resists extension of the hip (9).

A tight anterior hip capsule can be treated with a joint play technique for anterior hip mobilization (Fig. 37.1A) or muscle energy into the hip extension barrier. In both techniques, the athlete is positioned in the same prone position, and a sequential 1/8-in. impulse is directed in a posterior to anterior glide. To do muscle energy, bring the femur into extension while the athlete gently flexes the hip against the clinician’s resistance (Fig. 37.1B).

The goal of treatment, as noted previously, is to restore reciprocal interplay between the agonist and antagonist muscles for improved shock absorption to prevent impact loading on the joint surfaces. Correcting these muscle imbalances can restore normal lines of stress across the articular surfaces. Clinical evaluations have indicated that disturbances of function within the locomotor system appear earlier than do degenerative morphologic changes. Correcting muscle imbalances reduces strain on joint capsules and ligaments.