|Home||Reference/Search||About Dr. Bragman||Related links||Audio Library||Free Press Column Library|
More than 25 million Americans run regularly, and 70 percent of them sustain an injury sometime during their running careers. Anatomical flaws, particularly in the feet, lead to the great majority of problems. The surface you run on, the shoes you wear, and the way you train also influence your risk of incurring a running injury.
One out of three runners can expect to visit a sports doctor this year because of a running-related injury. Despite all the coaching and training tips, world-class runners are just as likely as recreational runners to suffer injuries. In general, sprinters suffer hamstring strains and ten-dinitis, middle-distance runners commonly have backaches and hip problems, and marathoners complain of foot and leg problems.
Contrary to popular belief, runners are no more susceptible to arthritis than nonrunners. The old doctrine that "the more you use a joint, the faster it will wear out" is probably not true. Running seems to keep bones strong. Studies of marathon runners show no degeneration of their knees. It may be that long-time runners have the genetic traits to be runners and that people whose joints are more susceptible to running problems tend to drop out of the sport.
When the jogging craze first hit, I saw many people with lower-back pain. I measured the lengths of the two legs, and they were the same. I couldn't figure out what was causing the pain.
Then I asked where they were running. Many of them were running along the slanted edge of roads. They would run near the curb, cross the street, and then run back along the curb on the other side. One leg, in effect, was always shorter than the other when they ran. I prescribed running against the traffic and coming back with the traffic, and their backs improved.
Lower-back pain is usually caused by a difference in the lengths of the legs. A difference as small as a quarter-inch can be significant for a runner. The back pain is usually felt on the side of the longer leg, which takes more pounding.
When a runner with back pain has a pronating foot on one side and a supinating foot on the other side, I suspect a leg length discrepancy. The body is trying to compensate by shortening the long leg with pronation and lengthening the short one with supination. People with a shorter leg also tend to bend the knee of the longer leg while standing to even out the difference.
You must have the lengths of your legs measured while standing. Your family doctor or a sports doctor can measure them for you. The measurement should go from the spine in front of the pelvis to the floor just inside the prominence of the ankle. The treatment is to put a lift in the heel of the short leg.
I also watch young runners carefully. As they grow, their leg lengths may even out, in which case they need no treatment. If the discrepancy gets worse, I prescribe a heel lift.
If you have a back problem, it may be more than a leg length discrepancy. If a lift doesn't ease your pain, see a doctor. You may have a disc problem, spondylolysis, or a muscle weakness.
One of the most commonly misdiagnosed problems among runners is iliotibial band syndrome. This is characterized by pain in the bony prominence of the hip or the outer side of the knee. A sharp pain comes on gradually with each run. You may get in a mile or two before you feel the pain, and then it becomes progressively worse than before. As soon as you stop running, the pain goes away. But each time you run, the pain becomes worse than before. As you will quickly find out, you cannot run through the pain of iliotibial band syndrome.
The iliotibial band runs down the outside of the thigh from the rim of the pelvis to below the knee and provides lateral stability to the hip. In active runners, this fibrous band overdevelops and tightens down. Each time you flex and extend your leg, the band is sawed across the bone of the hip or the center of the knee, resulting in pain.
The easy treatment is to stretch the band. As with a rubber band, if you stretch one part, the entire band stretches. The Knee-over-Leg iliotibial band stretch is presented in Chapter 1. Above is a standing stretch for runners. It is not as effective as the floor stretch, but if you are not in a position to lie on the floor or the ground, the standing stretch is better than not stretching at all.
Once the pain is gone, put iliotibial band stretches into your regular routine before and after a run.
Most of the rotational force from an abnormal foot strike is absorbed by the knee, but some can be transferred to the thigh bone, or femur, causing a stress fracture. This injury requires resting the leg until the sharp pain disappears, which usually takes a few months. Again, correcting the foot strike will prevent a recurrence.
The most common muscle pull for runners is a hamstring pull. The hamstring is the main driving force in running, so it's important for you to warm up and stretch this muscle before going out for a run.
A sudden, sharp pain in the back of the thigh that causes you to hobble is a sure sign of a hamstring pull. You must rest until the severe pain stops and you can get around, which usually takes a few days. Ice the sore muscle initially as much as you can. Then gently stretch it to the point of discomfort, not pain, and restrengthen it with the Leg Curl, as described in Chapter 1.
If you find a black-and-blue area on the back of your thigh, you probably have torn the hamstring muscle. This may take weeks to heal. If the pain persists, have a doctor check for sciatica, as the sciatic nerve runs down through the thigh. The symptoms of sciatica can mimic a severe hamstring pull or tear.
Runners are less likely to pull a quadriceps muscle, but it does happen. The treatment is the same as for a hamstring pull.
If you step in a hole or on a stone while running, you may fall and twist your knee. The knee will swell up, and you will have trouble bearing weight on it. These are signs of a sprained knee, which you need to treat with the RICE formula described in Chapter 4.
If you have pain under the kneecap, you probably have the most common sports injury, runner's knee (chondromalacia patella). The cartilage in the kneecap wears down because the kneecap is tracking improperly. With raw bone rubbing on raw bone, your knee aches with each stride you take.
Even though the pain is in your knee, the cause of the problem is the way your foot strikes the ground. A pronating or Morton's foot rolls the knee inward and destroys the alignment of the kneecap, pulling it off to one side. You feel the pain either on the inside or on the outside of the kneecap, depending on where it's rubbing the hardest. You may also feel pain in the back of the knee due to fluid build-up, or it may be referred pain: Your body senses the pain in the back of the knee in the same way a person feels the pain of a heart attack down the left arm.
You need to correct an improper foot strike with an arch support or orthotic, and then build up the inner side of the quadriceps muscle in the front of the thigh. Do the 30° Leg Extension, described in Chapter 11. You also can take two aspirins, four times a day, to ease the pain.
Although jumper's knee is more common in jumping sports (hence the name), it can interfere with a runner's routine. The sudden, severe stress of straightening the leg with each stride tears the tendons above or below the kneecap away from the bone, causing inflammation.
If you develop jumper's knee, you must rest until you get over the pain. Ice the knee off and on during this time, and take anti-inflammatory agents to reduce swelling. Then you can begin to restrengthen these tendons with a full leg extension program.
If you don't warm up and stretch before a run, you are liable to pull a calf muscle. If the pull is severe, rest your leg and ice it intermittently for a few days. Then gently stretch the injured muscle. It's important to stretch it while it's healing; otherwise, the next time you go for a run, it will pull again because it's too short. When you can painlessly stretch the muscle as far as you can stretch the one on the other side of the body, you are ready to resume running.
Do the Wall Push-up and the Heel Drop in Chapter 12 to stretch the calf muscles.
When you run regularly, you build up the muscles in the lower leg, and these muscles fill the space within the compartments on the side and front of the leg. Running increases blood flow to the working muscles, and they become engorged. This increases the pressure in the leg compartments and can cause severe pain.
Not many competitive runners develop compartment syndrome. But because it can be a true medical emergency, you should be cautious about any lower-leg pain.
Some runners are born with tight compartments. Others develop a chronic problem with compartment syndrome and must have surgery to continue running. Once the compartments are opened, the thick casings won't regrow, so the problem is solved.
In the running world, "shin splints" is a catch-all term used to describe pain on the inner side of the shin. True shin splints are caused by overuse of the muscle that pulls the arch back up. This muscle contracts with every stride in response to the stretching of the tendon attached to it.
The common treatment for shin splints is to put an arch support in your running shoe. This props up the foot so that the muscle doesn't keep contracting. The first time you run with the arch support, you may feel some residual pain, but it should stop within a few days. Stretching the calf muscles helps relieve the pain.
Only 5 to 10 percent of runners have true shin splints. The vast majority have tibial stress syndrome or a tibial stress fracture. The excessive inward roll of the pronating or Morton's foot causes the whole lower leg to rotate inward, twisting the tibia. This causes the tibia to become painful and, if continued long enough, can cause a stress fracture.
One way to tell which injury you have is to note when you feel the pain. If it hurts only when you run, you probably have stress syndrome. If it also hurts when you walk, it may be a stress fracture. Less than 1 percent of runners develop stress fractures, but you should be aware of the possibility.
If you have stress syndrome, you can prop up your foot with an arch support and keep running, using pain as your guide. If the pain doesn't get any worse, keep going. The stress syndrome should heal within a few weeks. If the pain worsens, have your shin examined by a doctor. The doctor may need to take a bone scan to make sure you don't have a stress fracture.
A runner with a supinating foot pounds the outside of the foot into the ground. This transmits shock up the outer bone of the shin, leading to a stress fracture of the fibula. This injury is much easier to diagnose. Just press along the bone on the outside of your calf. But don't press too hard, because you will feel intense, shooting pain if you have this condition. Rest for four to six weeks, put padding in the outer edge of your running shoe, and you will be back on track.
An ankle sprain means that you have over-stretched or torn ligaments in the ankle. Typically, you mildly sprain an ankle from stepping in a hole and moderately sprain it from slipping off the edge of a curb. Rarely will a runner suffer a severe sprain, because running does not impose enough force to tear ligaments.
If you have recurrent ankle sprains, you can wear an orthotic with a lateral flange at the side of the heel, which prevents the ankle from rolling over. Elastic bandages may feel good, but they provide little support; they stretch right along with the ankle as it is spraining. An inflatable stirrup (Air-Cast) or a lace-up brace holds the ankle more firmly in place and gives you real support when you run.
The Achilles tendon in the back of the heel can become inflamed either by excessive foot pronation or by a shortening of the tendon.
If you are a pronator, an arch support will relieve the pain. Have someone look at your Achilles tendon as your foot hits the ground when you run. If the tendon flares to the outside at the heel, that means your foot is turning in, and you are a pronator.
If you are not a pronator and you feel this pain, you probably are not stretching enough. The Achilles tendon will shorten if you don't stretch the calf muscles. Women who wear high heels or high boots also tend to feel this pain. The high heel props the foot up so that the Achilles tendon doesn't stretch when the foot hits the floor.
The Wall Push-up and Heel Drop in Chapter 12 are the best stretches for Achilles tendinitis. Runners should do five repetitions of these exercises, holding the stretch for 15 to 20 seconds, six to eight times a day.
Inserting heel lifts into your running shoes will help alleviate the pain. Buy four packages of Dr. Scholl's® heel pads and put a pair of pads, stuck together, in each shoe. You must even out the height in your shoes, even if you feel the pain on only one side.
Pain under the surface of your heel is commonly said to be due to a heel spur. This occurs when the plantar fascia pulls too hard at its attachment to the heel bone. This overstimulates the bone and causes a hook or spur to grow. This piece of bone hurts when you put pressure on it while running.
However, it's more likely that any heel pain you feel while running is from the inflamed plantar fascia, rather than a bone spur. The treatment for this type of pain is an arch support. Heel spurs almost never require surgery.
Pain from placing weight on the inner side of the heel is due to excessive pronation of the foot. This spot becomes tender to the touch. Supporting the arch prevents the pronation and provides relief within a few days.
When I see a young runner with Morton's foot, I tell her she is in good company. About 25 percent of the population inherits Morton's foot. One of the most famous individuals with this condition was the Italian sculptor Michelangelo. Look at his David and other statues, and you will know what a Morton's foot looks like. I spent one vacation roaming the museums and inns of Florence looking at statues. I could always tell a Michelangelo by looking at the feet.
Virtually all of the problems I see in runners occur in the lower body. It's not surprising that 95 percent of these problems are due to the foot striking the ground improperly.
Three types of foot problems plague runners. A pronating foot rolls toward the inside. A supinating foot rolls to the outside. A Morton's foot is a combination of these two abnormalities. The foot strikes the ground on the outside and then rolls all the way across to the big toe, which is shorter than normal.
You can correct a pronating foot by propping it up with an arch support. However, for 10 percent of runners, an arch support provides too little lift, and for another 10 percent an arch provides too much lift. These 20 percent of runners will need a custom-made shoe insert, or orthotic device. If you need an orthotic, make sure to see a sports podiatrist who understands how to fit an orthotic to meet a runner's needs.
To correct a supinating foot, put padding under the outer part of your foot to absorb the shock. Use this modified arch in your running shoe.
Someone with a Morton's foot may get by with an arch support but will probably find that they need an orthotic with a built-up area under the big toe.
A sudden, severe pain in the front part of your foot during running, preceded by a period of mild pain, is a clear signal of a stress fracture. The upper and lower surfaces of your foot will be tender, and the upper surface may be swollen.
This injury is particularly common among runners with Morton's foot. The thick long bone just behind the big toe is designed to support large amounts of weight. But in a Morton's foot, the thinner long bones behind the other toes must bear more weight than they are meant to. This stress can cause the thinner bones to crack.
By using an orthotic to redistribute the weight, you can continue to run with a lower risk of recurrence.
Runners typically feel two types of arch pain. One is the dull ache that results from over-stretching the plantar fascia, which holds up the arch. The other is a sudden, sharp pain in the bottom of the foot and is usually due to a torn plantar fascia. You will feel either of these pains when your weight is on your foot or when you push off for the next stride.
The treatment is to use an arch support or to strap your foot with tape. Run strips of athletic tape from behind the toes to the back of the heel in a fanlike pattern. Then run more strips across the bottom of the foot. Using a simple arch support, however, is much less trouble than taping. With your arch supported you should be running without pain within a few days.
Pain in the big toe joint is common among people with Morton's foot. Side stress on the toe as the foot rolls over strains the ligaments that hold the inner side of the joint together. The big toe is designed to move up and down, not from side to side.
A big push off the big toe places enormous force on the ligament, and the joint can sprain. This injury is better known as "turf toe."
To treat either of these problems, rest the toe until the pain disappears. Meanwhile, ice it occasionally for 20 minutes at a time to reduce the pain and swelling, and take anti-inflammatory agents. When you first return to running, tape the toe down so that it can't come up when you push off it. You also should wear an orthotic in your running shoe to correct the abnormal movement of your foot.
Tenderness, possibly accompanied by swelling, on the upper surface of the foot only is usually a sign of tendinitis of the toes. You may be lacing your shoes too tightly or wearing too little padding under the tongue. Rest and ice the tendons occasionally until the pain and swelling subside, and take anti-inflammatory agents if necessary. Put a foam pad under the tongue of your running shoe to prevent the pain.
Cross-country runners have an extremely high injury rate. Covering long distances daily during training, as well as running two meets a week for high school athletes, causes the body to break down as the season progresses. Injuries can take place on the first day of practice when the coach sends runners out for a 7-mile run, and the sore muscles that result may last throughout the season.
Any lower-extremity pain should be attended to early on. Trying to run through the pain can lead to disabilities and severe injuries. During the season runners may develop runner's knee, shin pain, and stress fractures of the foot, shin, leg, and even the pelvis.
Hilly courses can intensify the pain of runner's knee, since running downhill aggravates this condition. Shin pain may indicate the need for an arch support or orthotic to prevent a tibial stress fracture.
A stress fracture in any body part can be difficult to diagnose with an x-ray and may require a bone scan. A runner who feels constant pain while walking as well as while running should stop training and, if a stress fracture is confirmed, hang up his or her running shoes for the rest of the season.
Running on natural, uneven terrain can cause ankle sprains and even broken bones from falls, as well as cuts and bruises.
TRACK AND FIELD
Track and field athletes suffer all of the same injuries as runners, as well as some others, depending on the demands of the individual event.
Muscle pulls are the most common injury for sprinters. The speed and length of the stride require rapid, violent contraction and then stretching of the leg muscles, which may pull or tear as a result.
Young sprinters (under age 16) may injure their growth plates. The drive out of the starting blocks can pull the iliac spine off its growth plate, and running longer sprints can pull the rim of the pelvis off its growth plate. These painful injuries, which can be diagnosed through close inspection of an x-ray, require four to eight weeks of rest to heal.
Hamstring and hip muscle pulls are fairly common in hurdling because the lead foot must make a long stretch over the hurdle. Hitting a hurdle can lead to a fall, resulting in deep cuts and bruises.
The constant repetition of step after step over long distances can lead to runner's knee, tibial stress syndrome, and tibial stress fractures. Orthotics can help correct any problems with the foot strike.
In the high jump, leg muscle pulls may occur in conjunction with the old-fashioned straddle jumping technique. The newer flop technique, where the jumper lands on the back of the neck and shoulders, may cause soreness in these body parts.
A high-speed explosive maneuver requiring a long stride, the long jump involves a high incidence of lower-body muscle pulls.
The most dangerous of all events, the pole vault requires speed as well as tremendous upper-body strength. In addition to the hazard of lower-body muscle pulls, the great stress on the shoulder can cause tendinitis and a partial dislocation.
A fall from the top of a pole can lead to all sorts of traumatic injuries. I have seen several high school vaulters who broke their necks by landing in the wrong position or by missing the pit.
All of the field events require a combination of explosive speed and tremendous strength. The javelin throw is hard on the shoulder and leads to the same overuse injuries seen in tennis and baseball players, as outlined in Chapter 6. The shot put and hammer throw also place demands on the shoulder, as well as on the muscles of the back and the lower body, and can lead to muscle tears and tendon injuries.
How to Improve Your Performance
Preventing running injuries is easy if you warm up, warm down, and stretch properly. Slowly jog until you break a sweat, and then stop and stretch. Do a total body stretch, but concentrate on the lower body up through the lower back.
At the end of your run, slow down to a jog or walk for five minutes. Then it's imperative to stretch again. While you run, your muscles tend to shorten. Stretching after you run will prevent stiffness and soreness the next day.
Listen to your body. There will be days when your body is just not ready to run. If you force it, you may injure yourself. Most runners feel terrible for about the first mile. If you feel better during the second mile, keep going. If you feel worse, it may be time to head back home.
Leg strength is essential to runners. The extensor muscles in the leg drive your forward stride. The calves, hamstrings, quadriceps, buttocks, and lower-back muscles need to be strengthened to improve your performance.
Distance running improves your stamina and conditioning, but if you are interested in competitive running, even "fun runs," you need to do interval training to increase your speed. Interval training is running for short bursts followed by a slow run.
Take one or two days a week and do mostly interval training. Start with one 100-yard sprint in the middle of your normal run and gradually do more and longer sprints with each run. Build up to four fast quarter-miles interspersed with slow quarter- or half-miles. With practice, you will find your comfort level.
You may find that the backs of your thighs hurt more after interval training. It's not because you are using different muscles, but because the fast bursts work the hamstrings more. Make sure to stretch the hamstrings after interval training.
Cross-country runners should aim to build up their aerobic conditioning to allow them to run farther without shifting to the anaerobic energy cycle. Build up a good aerobic base and then add interval speed work, alternating sprints with longer distances.
For sprinters and hurdlers, as well as jumpers and vaulters, stretching and flexibility exercises of the lower body are of utmost importance. Remember to warm up and stretch before practice as well as before meets, and keep your muscles warm in between races or attempts. Long-distance runners should pay particular attention to increasing their leg strength. For field events, overall strength training is a must, in addition to flexibility exercises.
A proper shoe is crucial to an injury-free running program. Both the design and fit should be individualized. New shoes should feel comfortable both when you stand and run. Most runners choose a shoe that's one size too small. You need to allow a quarter-inch between the longest toe and the end of the shoe, because your feet swell when you run. Many shoe stores will let you road-test a shoe for a few blocks.
Running shoes should be constructed to absorb the shock of running and to stabilize the foot. The shoes should have a flexible, thick sole; a sturdy heel counter; a cushion for the Achilles tendon; a sole that is wider than the top; a comfortable arch support; a raised heel; and plenty of room in the toe. Training shoes generally have more cushioning and provide more shock absorption than racing shoes.
The shoes should also be matched to the surface you run on. A ripple sole is designed for cement and asphalt, and a waffle bottom is meant for grass and dirt.
The hardness of the running surface does not matter that much. The cushioning of running shoes has advanced to the point where an asphalt surface feels almost the same as grass. Many running injuries result from stepping in a hole or on a rock and falling. Running on a smooth surface, such as an asphalt road, makes it easier to pay attention to your running technique. Also, running barefoot on the beach is just asking for trouble. Because the sand is loose, running puts an unnatural strain on your calves and Achilles tendon. And if your foot pronates or supinates, sand provides absolutely no support for it, so any problems with your foot strike are automatically magnified.
Recreational runners with normal feet and no lower-body problems need not spend $300 on a running shoe. However, if you have leg problems, need ankle support, or have a foot abnormality, you need to look for a special running shoe.
There are different shoes for different types of feet, and you have to find the right one for you. If you pronate excessively, choose a shoe with a more rigid heel counter and a straighter last. A supinating foot needs a shoe with much cushioning, such as an air-sole, to disperse the landing shock. A person with Morton's foot really has a pronation problem and requires the same type of shoe as a pronator.