CHAPTER 7
PREVENTING AND COPING WITH INJURIES
A few years ago, Runner’s World set out to answer some of the most pressing questions on every runner’s mind: How can you get fit without getting hurt?
He’s joking, of course, but the point is that science doesn’t have any firm answers that apply to all people. He interviewed the world’s top injury experts—in biomechanics, sports podiatry, and physical therapy. Like the studies, they didn’t always agree. But the more he talked with them, the more he was able to identify certain universals.
From these, he developed some golden rules of injury prevention that seem to work for most people most of the time. There’s no guarantee they’ll prevent you from ever getting hurt. But if you incorporate these guiding principles into your exercise routine, you’ll be more likely to enjoy a long and healthy running life.
Avoid the terrible toos. Doing too much too soon and too fast is the number-one cause of running injuries. The body needs time to adapt to increases in mileage or speed. Muscles and joints need recovery time so they can handle more demands. If you rush that process, you could break down rather than build up. So be the tortoise, not the hare. Increase your weekly and monthly running totals gradually.
Use the 10 percent rule as a guide. Build your weekly mileage by no more than 10 percent per week. So if you run 5 miles the first week, run 5.5 miles the second week, about 6 miles the third week, and so on. There may be times when even a 10 percent increase proves too much. Use the 10 percent rule as a guideline, but realize that it might be too aggressive for you.
Let the body be the boss. Most running injuries don’t just come out of nowhere and blindside you. Usually, there are warning signs—aches, soreness, and persistent pain. It’s up to you to heed those signs. If you don’t, you could hurt something else as you try to change your gait to compensate for the pain.
Get good shoes. Running shoes have changed a lot over the years, and there’s a dizzying variety of models, brands, and types to choose from. There are even minimalist shoes designed to mimic barefoot running (although there’s no scientific evidence that forgoing shoes decreases injury risk).
There’s no single best shoe for every runner—your goal is to find the one that offers the best support and fit for your unique anatomy and biomechanics. Don’t buy a shoe just because it’s the cheapest, because it “looks fast,” or because it matches your favorite workout gear.
You should replace your shoes every 300 to 500 miles. Note the date that you bought your shoes in your training log so that later you’ll know when it’s time for a change. And when it’s time to buy, visit a specialty running store—the staff there will ask you lots of questions, watch you walk or run, and take other steps to help you find the right shoe. (For more on buying shoes, see “Get Good Running Shoes.”)
Take good notes. A detailed workout log can help keep you motivated and injury free. Take some time after each workout to jot down notes about what you did and how you felt. Look for patterns. For instance, you may notice that your knees ache when you run on consecutive days, but you feel great when you rest in between running days. This will help you determine the best routine for you. Plus, it will help get you out the door when the going gets tough. You can draw confidence from seeing all the miles pile up. And the next workout doesn’t seem as daunting when you see how much you’ve already accomplished. There are lots of online training logs available, but a notebook and a pencil work just as well. Here are some data that you should consider including in your training diary.
1. Daily or weekly goal
2. Mode of exercise (run, elliptical, swim, bike, etc.)
3. Distance (in miles or kilometers)
4. Workout time in minutes
5. Weather conditions
6. Time of workout (this can influence how you feel)
7. Route and terrain (hills, treadmill, track, trail)
8. How you feel before, during, and after the run
9. Shoes and gear used
10. Music
11. Interesting things you saw along the way
12. Notes about the people you worked out with
Cross-train. Running is hard on your body, there’s no doubt about it. So experts agree that most runners can benefit from cross-training activities to help improve muscle balance and stay injury free. Swimming, cycling, elliptical training, and rowing will burn a lot of calories and boost your aerobic fitness. (For more, see “Cross-Training.”)
Respect your limits. Each person has his or her own unique “orthopedic threshold”—that is, how far and fast you can go before you get hurt. This threshold is as one of a kind as an individual’s fingerprint. It’s determined by genetics, anatomy, biomechanics, age, level of fitness, history of injury, gender, lifestyle, time in your schedule to work out, and a whole host of other factors, many of which you can’t control. And unfortunately, there’s only one way to find it. By crossing that threshold, i.e., getting hurt. Some people find that they break down if they take one step beyond 25 miles a week. Others can run at an easy pace forever but are left aching for days after speedwork. Figure out where your threshold is and respect it. If you can only run 4 days per week before you get injured, but want to exercise more, cross-train with activities like cycling or working out on the elliptical machine.
Increase your stride rate. Increasing your stride rate has been linked to a lower rate of injuries. Ideally you’ll have 170 to 180 steps per minute. But a shorter stride should produce lower forces with each footfall. Overstriding is a common mistake that can lead to decreased efficiency and increased injury risk. See “How to Increase Your Stride Rate” on the next page.
HOW TO INCREASE YOUR STRIDE RATE
Increasing your stride rate has been linked to a lower rate of injuries. Ideally, you’ll have 170 to 180 steps per minute. But the best way to increase yours is to find your current stride rate (by counting your steps) and aim to boost it by 5 percent at a time, says running coach Jeff Gaudette, founder of RunnersConnect, a Boston-based online training service. Once that new stride feels natural, try boosting it by another 5 percent. “It’s going to feel uncomfortable at first,” he says. Count your steps on two or three runs a week. Then focusing on using it on every other run. If you count steps during a speed session (see this page on why you should run faster and this page for speed workouts), it has the added benefit of distraction, Gaudette says. “Because you’re counting, it takes your mind off the fact that it’s hard.”
Below are Gaudette’s tips on how to count your stride rate and improve it.
1 Warm up with 10 minutes of easy running.
2 Count how many steps one foot takes for 30 seconds.
3 Double this number. That’s how many steps that foot takes in 1 minute.
4 Double that number. That’s how many steps both feet take in 1 minute. That’s your stride rate.
5 Repeat this every 10 minutes of the run.
The Most Common Running Injuries
Working out can be uncomfortable (especially when you’re just getting started), but it should never hurt. Aches and pains in the feet, ankles, and shins are common among new runners, says Clint Verran, an elite marathoner and physical therapist in Lake Orion, Michigan.
“Most people don’t realize how easy it is to overstep their training,” he says. To be sure, it takes times for the musculoskeletal system to adapt to the impact of running and walking.
“The bones, muscles, and connective tissues are not used to hitting the ground. They’re not hardened to the stress of training,” he says. “There’s an adaptation process. And the only way to overcome it is to start slow, with short workouts, and gradually progress.”
Indeed, the best way to avoid injury is to gradually increase your time spent running, run on soft surfaces as much as possible, and make sure you’ve got shoes that offer the fit and support your feet need, and orthotics if you need extra support. Go to a specialty running store where you can get guidance in finding the pair that works best for you.
Below are some of the most common injuries for new runners. If you do feel any of these aches and pains, Verran recommends taking 2 days off, icing for 15 to 20 minutes a day twice a day, starting back again, and building up slowly. “When you have pain, you just have to dial something back—distance, intensity, or both,” he says.
You may be able to cross-train to keep up your fitness while you give your running injuries time to heal. (To find out which forms of cross-training are safe for which injuries, see “Cross-Training.”)
And when in doubt, rest and have your pain checked out. It’s better to spend a little time and money seeing the doctor than to be sidelined for months by an injury that you could have prevented or minimized. (For a more detailed guide on which pains to run through and which pains require medical attention, see “Should I Run or See the Doctor?.”)
Shin Splints (Medial Tibial Stress Syndrome)
Shin splints happen when there are small tears in the muscles around your shinbones. You might feel a tight, aching pain when you first start running or just after you’re done. Shin splints are common among new runners, those returning after an extended layoff, and those who have built up mileage too quickly. Overpronation, running on cambered roads, and wearing worn-out running shoes can also lead to shin splints. “About 90 percent of the time, it goes away with some rest,” says Verran. “It’s just a matter of backing off, starting slowly, and letting the body adapt to hitting the ground.”
HAMSTRINGS HURT?
Achiness and tightness in the back of the thighs isn’t a common injury for new runners, but it can crop up. At first, it might force you to slow down and shorten your stride. As it gets worse, the pain can become sharp. Overstriding, overextending your legs while trying to speed up, or bending forward from the waist too much to increase your forward lean can all contribute to hamstring strains. Going too far or too fast too soon or doing too many hills can also strain the hamstrings. Sticking with easy runs and shortening your stride can help alleviate the strain. Avoid stretching your hamstring when it’s sore, which can worsen the strain. To avoid overstriding, see “How to Increase Your Stride Rate” on the opposite page.
Foot Pain (Metatarsalgia)
If you suddenly start running a lot, you can develop pain and achiness in the forefoot that’s due to inflammation around the metatarsals, the small bones in the front of the foot that run from the arch to the toe joints. That’s the area that absorbs the force when you run. Carrying around extra weight can also contribute to the condition, because the extra pounds put added pressure on the metatarsals. Shoes that have a toe box that’s too narrow or that don’t offer proper support can also make your feet hurt. “New runners’ feet are just not used to getting pounded against the concrete,” says Verran. “There’s an adaptation process, and [you need time to] build up your tolerance for hitting the ground.”
Plantar Fasciitis (PF)
PF is an inflammation of the plantar fasciae, tendons on the bottom of the foot, from the heel to the toes. It feels like a dull ache or bruise along the arch or on the bottom of the heel, and it can be most painful first thing in the morning and at the beginning of a workout. Overpronation and wearing worn-out shoes are the most common causes of PF. A sudden mileage increase in hill running can also set it off, as can long periods of standing. Those with high arches are more at risk of PF, and often it’s made worse if you wear shoes with no arch support or often walk around barefoot. PF can get worse and more difficult to treat if you let it linger. To prevent it, stick to soft surfaces, rest and reduce your mileage, and go to a specialty running store to make sure you have the shoes that offer your feet the support and fit they need.
Iliotibial (IT) Band Syndrome
This is a strain within the IT band, the connective tissue that runs along the outside of your thigh, from your hip to your shin. When your knee flexes and extends during running, the IT band can rub against the bone, causing irritation. It can feel like a dull pain on the outside of your knee. As it gets worse, it can radiate up and down your leg, even while you’re walking downstairs or down a hill. Piling on too many miles too quickly can irritate the IT band, as can running on cambered roads. Your best bet is to rest, decrease your mileage, and replace worn-out shoes.
Achilles Tendinitis
This condition is the tightening and irritation of the Achilles tendon, which connects the two calf muscles to the back of the heel. It may start as a dull ache. As it progresses, you may develop severe pain and swelling—even when you’re not running. It’s caused by doing too much too soon, doing too many hills, or wearing the wrong shoes. It’s important not to try to run through this; doing so can make it last for months. Avoid aggressive stretching and wearing high heels and flip-flops, both of which can irritate the Achilles. Resting and icing can help alleviate symptoms.
Runner’s Knee (Patellofemoral Pain Syndrome)
This is a soreness or pain around the front and inside of the kneecap that can get worse during a workout or while going down hills and stairs. It’s often caused by inflammation in the tendons around the knees or in cartilage under the kneecap. It’s often linked to running in worn-out shoes, inadequate footwear, or overpronation (excessive inward foot rolling). It is also linked to weakness in the quads or the glutes, which can lead to poor tracking of the knee. You may feel twinges early in the workout that go away only to reappear later. As it worsens, the pain may be on the inside or outside of the knee (toward your other knee or toward the outside of your leg) and may persist even after you’re done with your workout. Take 2 or 3 days off. Avoid downhills and leaning too far forward during your workouts, which can add stress to the knees. And strengthen your quads and glutes, which control the tracking of your knees. When you start running, you’re introducing “a new force, and the body just isn’t used to it,” says Verran. “It’s just like going into the gym and doing a whole bunch of bench presses when you’d never done it before.”
Should I Run or See the Doctor?
It can be tough to determine which pains to run through and which pains demand surrender. Bruce Wilk, a physical therapist, coach, and owner of The Runner’s High specialty shop in Miami, has developed a five-point checklist that you can use to determine whether you should run, walk, rest, or rush to a doctor.
Stages one to three encompass the normal discomforts that go along with pushing your body farther and faster than it’s gone before. Take 2 or 3 days off from working out, ice five times a day, and use compression and elevation.
But if you see a red flag, or you reach stage four or five, stop working out and seek professional help ASAP. See a sports medicine specialist or orthopedist, preferably someone who has experience working with runners. A local running club or store may be able to recommend someone.
STAGE ONE: An unfamiliar and disconcerting pain while running—It hurts when I run; it stops hurting when I’m done.
Red flag: It forces you to alter your stride.
STAGE TWO: An unfamiliar or disconcerting pain at rest—It may hurt when I run, and it definitely aches when I’m done.
Red flag: The pain interferes with your rest.
STAGE THREE: Pain during normal daily activities—It hurts when I walk or climb the stairs, or when I’m sitting at my desk after I run.
Red flag: The pain forces you to avoid the stairs, walk barefoot, or alter any other normal daily activities.
STAGE FOUR/RED FLAG: Pain that makes you take medication, including shots or prescription or over-the-counter meds—It hurt, but once I took the ibuprofen (or got a cortisone shot), it went away.
STAGE FIVE/RED FLAG: Pain that stops you from running or even walking without pain
MAKING A COMEBACK
So you get hurt and take time off. You’re pain free and ready to start back. What do you do? “Do not start again where you left off,” says Reed Ferber, associate professor at the University of Calgary and director of the Running Injury Clinic. “Start at a point that allows you to complete the run injury free.” Use the checklist on this page (“Should I Run or See the Doctor?”) to determine the length of your run. This may mean that you start a few weeks behind the rest of the group, but you can adjust the schedule, and with the help of a coach, “catch up” in a reasonable amount of time. The other important thing is to strengthen the muscles in the site that are injured. For instance, if your Achilles is hurt, with the guidance of a physical therapist or athletic trainer, do heel raises and strengthen the hip-stabilizing muscles. Use “active rest,” that is, no running but improving muscle strength to get back on the wagon and prevent the injury from reoccurring.
HOW TO STAY ACTIVE WHEN YOU CAN’T RUN
Cross-training can help you stay fit when you can’t run, but choose wisely, says runner and sports podiatrist Stephen Pribut, DPM, of Washington, DC. Some activities may worsen an injury. Below is a list of common running injuries and what cross-training activity is safe to do with the injury’s symptoms.
Runner’s knee
Swimming: Usually
Stationary Bike: Sometimes
Ellipitcal: Sometimes
Rowing Machine: No
IT band syndrome
Swimming: Usually
Stationary Bike: Sometimes
Ellipitcal: Sometimes
Rowing Machine: Sometimes
Calf pain, Achilles strain
Swimming: Usually
Stationary Bike: Usually
Ellipitcal: Usually
Rowing Machine: Usually
Plantar fasciitis
Swimming: Usually
Stationary Bike: Usually
Ellipitcal: Usually
Rowing Machine: Usually
Shin splints
Swimming: Usually
Stationary Bike: Sometimes
Ellipitcal: No
Rowing Machine: No
Stress fractures
Swimming: Usually
Stationary Bike: Sometimes
Ellipitcal: No
Rowing Machine: No
Blisters
Annoying and painful, blisters are caused by friction, usually your shoes or socks rubbing against your skin. Anything that intensifies rubbing can start a blister, including a faster pace, poor-fitting shoes, and abnormalities such as bunions, heel spurs, and hammertoes. Heat and moisture intensify friction by making your feet swell.
That explains why many runners only suffer blisters during races or in the summer.
The body responds to the friction by producing fluid, which builds up beneath the part of the skin being rubbed, causing pressure and pain. A blood blister occurs when the friction ruptures tiny blood vessels.
While most blisters don’t pose a serious health risk, they should be treated with respect. A painful blister can cause you to change your gait—so you avoid aggravating it—and that can lead to injury. The biggest risk is that the blister gets infected, which can lead to a need to see a doctor.
How to Prevent Blisters
• Moisten your feet. Just like sweaty skin, dry skin is also more prone to friction. Use skin creams and lotions liberally on a daily basis to maintain proper moisture.
• Choose blister-free socks. Synthetic socks wick moisture away from the skin. Cotton may be lighter, but it retains fluid. Socks with reinforced heels and toes also help reduce friction.
• Run with slick skin. Coat your feet with Vaseline or another lubricant before you run. Or use Second Skin, a padded tape that stays on even when wet. Both methods form a protective shield between your skin and sock.
• Double up. Wear two pairs of socks so the friction occurs between the two socks, rather than between the sock and skin. If your shoe now feels too tight, go up a half size as long as your foot doesn’t slide around, making blisters a possibility.
• Wear shoes and socks that fit. Shoes that are too small will cause blisters under the toes and on the ends of the toenails. There should be a thumb’s width of space between the toes and end of the toe box. Your socks should fit smoothly, with no extra fabric at the toes or heels.
AMBY’S ADVICE
Runners aren’t defined by how much they run; they’re defined by their attitude about exercise. Even when injured and unable to run as much as they would like, runners find alternative ways to stay fit or even build fitness. When your legs hurt so much that you can’t run, you can still train your upper body in the gym. And you might be able to exercise your legs on a bike, rowing machine, elliptical trainer, or in the pool. All these alternatives are good examples of “cross-training,” but you don’t even have to think of it as training. Just think of it as “moving,” and be sure to get in an hour or so a day. The easiest way to do this: Turn off the TV and head outside.
How to Treat Blisters
If you have a large blister, drain it. If you don’t drain it, your blister will hurt, and it could puncture on its own.
To drain the blister, wash your hands, then wipe a needle with alcohol to sterilize it. Don’t skip this step; serious infections can result when one uses a dirty needle to pop a blister.
Once you’ve punctured the blister, carefully drain the liquid by pushing gently with your fingers near the hole. Keep the skin or the roof of the blister on to help prevent infection. Then cover the blister with a tight bandage to keep bacteria from getting in.
You can take the bandage off periodically and soak your foot in Epsom salts (follow package directions) to draw out the fluid. After soaking, put on a fresh bandage. It’s a good idea to keep a bandage on until the skin closes up again.
If you’ve got a small blister—say smaller than the size of a pencil eraser—leave it intact. The skin acts as a protective covering. Leave small blood blisters intact also. Otherwise you risk getting bacteria into your bloodstream. Cut a hole the size of the blister in the middle of a piece of moleskin, then place it over the blister and cover it with gauze. The blister will dry out and heal on its own.
If you develop a blister under the nail bed, it’s best to see a doctor to get it treated. You never want to deliberately remove the toenail. That could lead to a serious infection.
How Running Changed My Life
Running helped Jodi Edwards gain control over MS and lose weight
Jodi Edwards had lost about 80 pounds and had another 30 pounds to lose when she was diagnosed with multiple sclerosis, a chronic, often disabling disease that attacks the brain, spinal cord, and optic nerves and can lead to numbness and paralysis.
She kept working out even after the diagnosis, but because she struggled with balance, she had been sticking with spinning classes and the elliptical machine. When a personal trainer suggested she try the treadmill, she was terrified. The first few sessions, she set the treadmill at 4 miles per hour and held on to the handrails.
“Even at that pace, I was getting so tired and winded,” she says. She fell off the treadmill once and landed on her face. Her legs would cramp up.
“It took me a long time to realize that the runner’s high wasn’t total crap,” she says.
Still, something kept bringing her back. “Every day, I was able to go out a little bit longer or feel a little bit better afterward. So I’d go in the next day, talk myself down from the fear again. And there was a sense of freedom, even when it was hard, because I could make my legs work like that. I was so thrilled that I was able to do it. Not only was I not walking with a cane, I was running.”
Eventually, she was able to finish a half-marathon and then full marathons.
“Running was a way of thumbing my nose at MS,” she says. “I figured if I could do this, nothing could stop me.”
AGE: 43
HOMETOWN: Lexington Park, Maryland
OCCUPATION: Veterinarian
What was the biggest hurdle, and how do you get over it? Sometimes I don’t want to get dressed and go, but I make myself do it anyway. A short run is always better than no run. There is sometimes a time issue. I work 10-hour days and work evenings. Sometimes it is hard to keep myself on a regular schedule so I can get the runs in and do the things I need and want to do around the house and have some time with my wife. (She is not a runner; she cycles.)
Did you have a weight-loss goal? My goal was to be healthier. Before I was diagnosed with MS, I was at 240 pounds. Now I am 134. It is a whole lot easier to push the chair when you weigh less. My family has a genetic predisposition to high cholesterol. Even now, mine runs toward the high end of normal. I ultimately wanted to be feel better. Looking back, I realize I didn’t really feel good.
What kinds of changes did you make to your diet? We have limited the times we eat out. We go out once, sometimes twice on the weekend, and usually it’s for a good reason. We eliminated high fructose corn syrup, which makes you hungrier after you are finished than when you started. We eat chicken or fish and avoid red meat. Everyone’s MS is different, but a steak will cause muscle spasms in my legs that make me unable to walk. I stick to a low-fat, higher-protein diet. I feel better on a higher-protein diet than the typical runner diet that is a little higher in carbs. I eat a lot of veggies, and we stay away from prepackaged and convenience foods. One of my personal mantras is “Self-discipline is remembering what you really want.” It is hard when someone brings cake to work, and the next day there is ice cream. I am a big-time sweets junkie. One of the biggest things I do is I don’t keep this stuff in the house. If I want it bad enough, I have to get up and go get it. That means there have been a few 9 p.m. ice cream runs, but more often, I skipped it.
What advice would you give to a beginner? Invest in good shoes and socks. Don’t just pick out a pair that looks good. Take the time and spend the money to go to a running store. The first time I went into the store I was embarrassed. But the new shoes made a huge difference. You may have sticker shock at a pair of $15 socks. But when your feet are dry in the summer or warm in the winter, you’ll be glad you did.
Favorite motivational quotes: One is my own, an answer to someone who asked me once why I ran a marathon—“I run because I can.”