by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Long distance running has become a popular sporting activity, with millions of recreational runners around the world. However, the risk of sustaining a running-related injury (RRI) is high; literature shows up to an 80% incidence of RRIs worldwide. While injuries to runners are rarely severe, they can be frequent and persistent, requiring medical treatment associated with high treatment costs.

Researchers in the study, Analysis of Running-Related Injuries: The Vienna Study, looked at training, footwear, anatomic malalignment, and injury data from 178 injured runners in a case-controlled, retrospective format. The researchers’ goals were to present injury data from a running population, investigate different running footwear categories and specific injuries, and analyze a broad range of potential contributing factors for the most common RRIs.

Injured runners were recruited at an orthopedics practice in Vienna, Austria, during a three-year period. Patient examinations were performed by a sports medicine surgeon. The participants completed a questionnaire which included footwear and training data followed by the examiner performing a subjective history, anatomical assessment, and a physical examination of the injured area.

The anatomical assessment included inspection of the spine, pelvis, knee, ankle, and foot for malalignment. An injury was considered a RRI if the patient had pain or symptoms during or immediately after a running session, the pain was significant enough to keep the runner away from training for more than three days, and the patient sought medical assistance. Following data collection, the researchers analyzed the results to observe for any correlations among the variables.

All but one participant able to name brand of shoe
Fewer than half (45%) were able to name the specific shoe model
Only 39 % of patients with pes valgus used a motion-controlled running shoe despite wide spread literature recommendation that this type of shoe corrects foot malalignment
Varus knee: 83.1%
Pelvic obliquity: 80.8%
Patellar squinting: 52.2%
Pes cavus: 5%
Pes plans: 34.8%
Scoliosis: 31.4%
Pes valgus: 3%.
All seven injuries recorded were overuse injuries
Body part most injured was the knee (41%), followed by the ankle (15%), and the foot (11%).
The five most common injuries were:
Patello-femoral pain syndrome (PFPS) (13.4%)
Iliotibial band friction syndrome (ITB) (12.3%)
Patellar tendinopathy (12.3%)
Spinal injuries (11.2%)
Ankle instability (8.4%).
BMI: Patients with spinal injuries tended to have higher BMIs while lower BMI was observed in patients with knee injuries, ITBFS, and patellar tendinopathy.

Injury History: A prior history of injury was associated with an increased risk of reinjury. Injury history contributed mainly to knee injuries. Twenty out of 21 patients with ITB friction syndrome presented a history of similar complaints.

Training History and Load: While higher overall training load seemed to protect against PFPS and patellar tendinopathy, higher training load was positively associated with injuries of the lower leg and ankle instability. While a higher training load can signal greater experience, less training errors, and more efficient anatomical adaptation, higher training load can also result in a higher degree of fatigue and altered kinematics.

Footwear Analysis: Researchers were surprised there was a lack of knowledge regarding the type of running shoe the participants used. Researchers note that this finding could be lack of awareness or not of great importance, especially in more novice runners. In addition, the study results show the proportion of patients with pes valgus who wear a motion-controlled shoe is low. Shoe wear that corrects pes valgus has been controversial in recent literature so this finding could lead to ongoing discussion.

Spine and Pelvic Malalignment: The authors found that scoliosis was positively correlated with lower back, hip, and pelvic injuries. Although a leg length discrepancy can cause a pelvic tilt and secondary scoliosis, it was not associated with any specific injury.
Knee: Malalignment of the knee included all patella anomalies, ligamentous or general instability, and shortening of the thigh muscles. There was a positive association of knee malalignment with injuries in the patellofemoral joint. Also, a lower training load will likely result in weaker active and passive stabilizers of the patellofemoral complex exposing the runner to a higher risk of suffering PFPS.
Leg Axis: The researchers observed the highest incidence of the varus knee in patients diagnosed with knee injuries. The varus knee alignment induces higher stresses in the lateral musculature and stresses in the medial aspect of the knee as well as the mistracking of the patella, which would coincide with the reported pathologies.
Foot Malalignment: Excessive foot pronation and associated higher lower limb rotation in runners with pes planus is considered to be associated with PFPS and stress fractures. This study revealed a correlation with present pes planus deformity and knee injuries. Interestingly, pes planus was protective of foot/ankle injury. As expected, pes cavus was associated with ankle instability.
In conclusion, RRIs are multifactorial and are associated with personal data, training load, anatomic malalignments, and injury history. In general, runners at a high risk of injury could be identified from a patient-specific training profile and running form as well as from pre-existing malalignments such as scoliosis, knee malalignments, and/or varus knee and. Identification of runners at high risk of injury can help therapists to introduce an appropriate and balanced training adaptation.

Furthermore, awareness of injury risks and prevention should be raised in running schools and by medical specialists. The authors strongly recommend further studies focused on specific injuries in combination with related malalignments and detailed training habits, in addition to research on running-related injuries as a generalized pathology.

The therapists at Physical Therapy First have extensive experience in evaluating and treating runners. Come see us if you run for fun or are training for an upcoming race. We can determine your risk for sustaining an RRI and create an individualized training program to keep you on track to maintain a healthy running lifestyle.

Benca, E., Listabarth, S., Flock, F., Pablik, E., Fischer, C., Walzer, S….Ziai, P (2020). Analysis of Running-Related Injuries: The Vienna Study. Journal of Clinical Medicine. 9, 438.