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Marathon injuries (and how to avoid them!)
Blog | April 20, 2016

By Dr Courtney Kipps

The marathon is a healthy event for most but can be a physical challenge for some. Injuries that occur on the day receive a lot of attention, not least because they often look dramatic, like bloody nipples, chafing groins and blisters, but also because they have a big impact on the runner’s plans to enjoy the day. 

Every year there will be a handful of ankle or knee ligament injuries, and occasionally a more significant injury such as a fractured leg. These problems are expertly managed by the 1500 first aiders, 150 physios, 150 doctors and 180 podiatrists that make up the medical team at the London Marathon as Dr Courtney Kipps, Consultant Sports Physician at the ISEH and Assistant Medical Director of the London Marathon explains:

Who gets a running injury?

The vast majority of runners will successfully complete the marathon. In fact only 1% of the 37 000+ starters DNF (do not finish). Most runners can expect to have tight muscles and sore legs for a few days, but nothing that a few short recovery runs over the next week won’t  quickly fix. 

It’s before the race where the real burden of injuries will occur. In studies following runners through a full season, up to 80% of injuries occurred during training. Over the course of a standard marathon training programme 1 in 2 runners, whether beginner or elite, will take time off from training with an injury.   

Why do runners get injured? 

These are usually overuse injuries, such as Achilles tendinopathy, medial tibial stress syndrome (“shin splints”), iliotibial band syndrome, or bone stress fractures. An overuse injury is defined by the IOC as one “caused by repeated micro-trauma without a single, identifiable event responsible for the injury.” The opposite to a twisted ankle for example where the injury happens in a single identifiable event (slipping off the curb). In essence the body’s capacity to absorb load in training and rebuild in response to that load is overwhelmed by the rate of tissue breakdown caused by that same load. Or, as described by the Overuse Rule of 2’s, the athlete is at risk of an overuse injury by pushing “Too hard, Too fast, Too soon or Too much.” 

Can we prevent overuse injuries?

Injury rates in running have remained static for many years despite changes in running style and advances in shoe technology and training theory. We often infer cause by observing certain characteristics in athletes presenting to clinic with specific injuries such as patello-femoral pain syndrome (“runner’s knee”). Yet these characteristics, like muscle weakness, inflexibility and inefficient movement patterns, have not been backed up in studies where researchers have tried to correct these issues before an injury surfaces. In fact large scale studies have found limited evidence for the commonly perceived intrinsic, non-modifiable, risk factors such as leg length difference and knee varus (knock-knees) being direct causes of injury in runners. Equally so with extrinsic, more easily modifiable, risk factors such as greater training frequency, longer races, running on concrete surfaces, level of experience in running, and shoe age. 

This should not come as a big surprise: Injuries are rarely attributable to one specific cause. More often than not they are multi-factorial.  Addressing only one potential issue at a time, whilst a good place to start, cannot hope to prevent all overuse injuries. 

So we may not be able to prevent injury, but surely there are steps we can take to avoid an injury?

Across all the studies, incorporating training history and injury data from many thousands of runners,  the most significant predictor of injury was actually having an injury beforehand. This was followed a fair distance behind by a greater training distance per week. 

There are simple methods which you can incorporate into your daily training to help keep you running comfortably and without leaving you exposed or at significant risk of injury. 

a. Keep your training varied

As with most things in life moderation is key. Keep a healthy balance in your training and avoid excessive training in one area only I.e: avoid excessive hills, stairs, cambers, or track work, all of which can place unduly heavy loads on individual structures like the ITB. 

b. Run in shoes that are comfortable

This may sound obvious, but do not buy a pair of running shoes which are not comfortable when you’re actually wearing them. By all means have your feet analysed and take advice about the type of shoes that may be more suitable to your running style, but whatever you do choose a pair which is comfortable to run in. If you wear a comfortable running shoe you are at no greater risk of injury and, what’s more, you’ll enjoy your running. You can’t say the same about a pair which doesn’t fit you properly or is uncomfortable to wear. 

c. No need to overdo the stretching before training

Despite what you were taught in PE lessons at school, stretching before running does not prevent injuries. Increasing your range of movements by stretching to the extremes is unlikely to provide protection against overuse injuries which in the main occur within a normal range of movements. Surprisingly, stretching before exercise can even increase your risk of injury by separating the muscle fibre links vital to effective muscle contraction. Stretching may leave you with a greater range but it may also be a weaker one. Dynamic stretches have also been known to cause acute muscle injury by the sudden stretch in an unprepared muscle. Warm-up exercises, on the other hand, can effectively prime the vital muscles for action and therefore can be more effective. 

d. Finally, get your injuries sorted out properly. 

You should address all injuries, even minor ones, before you carry on running. It’s difficult to tease out the precise mechanisms which makes a history of injury such an important risk factor, but whether it’s that the athlete continued running through an injury, that the injury was not adequately treated before the athlete returned to running, or that scar tissue is inherently weaker than normal muscle or ligament, the fact remains this is the most reliable predictor of future injury. It simply does not pay to run through an injury. Most minor injuries will settle with a few days rest but those that persist, those where the pain is increasing,or those which are associated with swelling, may require more formal assessment and occasionally a scan. With an accurate diagnosis a thorough rehab program can be arranged to allow you to return to running pain-free. 

In summary

Sticking to a gradually progressive and suitably varied training program; running in comfortable shoes; and addressing any injuries by obtaining an accurate diagnosis and working through a thorough, exercise-based, active rehab program before a gradual return to training are all key to reducing your chances of future injuries.

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