Marathon training injuries and treatment-part1

Common injuries and how to prevent them

Sebastian CormierMsc Physio, Bsc Sports Med, CSCSChartered PhysiotherapistStrength & Conditioning Specialist

Overview

1. Very quick recap on understanding your training programme.

2. The big three:1. “Runner’s knee” or Iliotibial friction syndrome (ITB)

2. “Shin Splints” or medial tibial stress sydnrome (MTSS)

3. “Achilles pain” or achilles tendinopathy

3. The running gods exercise tips

4. Summary

Less than 2 months to go!!

HOW FAR TO GO?

TaperBase 1 Base 2 Speed

Base 2 – The volume phase (milage/duration) 4-8 weeks.

Prepare the body for the intense speed phase to come!

EASY – HILLS – UP-TEMPO (60-75% effort)

Goals:

1. High mileage/ duration

2. Low-intensity training

3. Improve recovery rate

4. Improve tolerance to running

Common mistakes in Base 2 Too much mileage too soon

Too much speedwork too soon

Hills too often too fast

Too little recovery

Copying programmes of more experienced runners may lead to injuries

• Some up-tempo work can be included, but remember base 2 phase is slow!

• Hills – slow strides with emphasis on legs NOT lungs!

Speed training phase (4-8 weeks)

Working at 75-95% of effort in:

Intervals training on track i.e. 400m sprints with 90 sec rest X 5. Reduce rest/ increase intervals

Hill intervals I.e. Sprint up Primrose hill, down slow X 20. Increase gradient, decrease rest, increase distance

Long run 50 % run at race pace (20km) +- intervals

Prepares you psychologically and physiologically for the race! THE CRITICAL ZONE!

Stimulate race conditions and intensities

Common mistakes in Speed Phase

Assess the intensity based on your running experience and your preparation during base 2.

Remember, training volume decreases while intensity increases!

Not enough RECOVERY time built in!

Make sure to contrast speed and slow sessions to avoid repetition

Ouch – I am hurt, what now?

How common are injuries with running

65%-90% of runners get injured each year

Previous injuries, age and muscle weakness are the most consistent INTRISIC risk factors for injuries

Sudden increase in running load and intensity are the most EXTRINSIC risk factors

Overuse injuries are more common than acute injuries

Br J Sports Med. 2002 Apr;36(2):95-101.

Clin Sports Med. 2004 Jan;23(1):55-81, vi.

How common are injuries with running

Beginners more prone to injury than veterans

Low BMI in females prone to stress fractures

Higher risk of injury zone when running more than 40miles/weeks

Sports Med. 2007;37(4-5):437-9.

Myths about injury prevention in running

Stretching pre running does not reduce injuries

There is no evidence to suggest that running shoes prevent injuries

No evidence for insoles/ orthotics

No evidence to suggest specific biomechanical contributors predispose for running injuries, including individual running technique and foot strike patterns

Br J Sports Med. 2007 Aug;41(8):469-80;

Key messages from the evidence

EXPERIENCE offers real injury prevention value:

The stronger and more coordinated the better

Recurrent injuries are warning signs for lack of stability and control of joints

Too many consecutive days running does not give the body adequate time to heal

Post running stretching seem to be beneficial

Archives of Internal Medicine, vol. 149(11), pp. 2561-2564, 1989

Acute vs. overuse injuryACUTE INJURY

Onset is acute, sharp, shooting pain

Localized

Immediate inability to run further without aggravation

Maybe associated with muscle power loss according to severity of damage

Common sites with running are calf belly, hamstring strains and ankle sprains.

Example of an acute grade 2 Hamstring tear

Treatment for acute injuriesBEST PRACTICE in the first 48 Hours:

1. PRICE

2. Avoid use of NSAID’s

3. Ice & compression critical

4. Early movement useful, but avoid stretching

5. Avoid direct soft tissue work

6. Avoid excessive travel

Orchard et al. (2008)

PRICEP – Protection Don’t stretch/ crutches/ brace/ tape

R – Rest Give adequate healing time depending on severity

I – Ice Crushed ice for 15 min every 2h

C – Compression Tape, double tubigrip,

E – Elevation

ACPSM (2011) Executive summary on PRICE guidelines

Overuse injuriesOVERUSE INJURY CATEGORIES:

1. Training volume/intensity

2. Anatomical variation

3. Biomechanical factors

However, etiology of overuse injuries remains multifactorialand can include all of the above.

Early DIAGNOSIS is KEY!!!!

Three most common overuse running injuries

1. “Runner’s Knee” or Iliotibial friction syndrome

2. “Shin Splints” or medial tibial stress syndrome

3. “Achilles pain” or achilles tendinopathy

Runner’s knee – ITB friction syndrome

• Most common injury to the lateral knee (21%)

• Inflammation of the fat pad/ perosteum/distal ITB tendon

• Grad increase in pain during running, which may disappear afterwards. Can be stiff later especially with walking down stairs.

Runner’s knee – ITB friction syndrome

Internal risk factors:

• Weak or tight hip/ pelvic muscles

• Weak or tight hamstrings

• Poor control/ balance with single leg stance/landing

• Excessive overpronation

• Bony abnormalities

External risk factors:

• New to running/ sudden increase in mileage

• Excessive hill running esp. downhill

• Running on a camber

Runner’s knee – ITB friction syndrome

TREATMENT:

ACUTE onset (less than 2 weeks):

Active rest from running

Anti-inflammatories as prescribed

Regular icing for 15 min every 3 hours

Stretching gluts, hamstrings, front of thigh, calves.

Foamrolling along ITB and front of thigh to release tight tissue

Sports massage

CT guided corticosteroid injection if it doesn’t settle or race is imminent.

Ellis R, Hing W, Reid D. Man Ther. 2007 Aug;12(3):200-8.

Runner’s knee – ITB friction syndrome

ACUTE AND CHRONIC ITB syndrome (2 weeks+)

Correct biomechanical issues affecting compression forces of distal ITB:

Strengthen hip, pelvic and core muscles

Increase power in the lower limb muscles to improve shock absorption

Stretch or foamroll tight muscles of the thigh

Correct shoe wear or orthotics

Ellis R, Hing W, Reid D. Man Ther. 2007 Aug;12(3):200-8.

“Shin Splints” Misleading terminology: Most commonly associated

with medial tibial stress syndrome

Associate with diffuse irritation to the bone lining of the tibia

Different to compartment syndrome and stress fractures

“Shin Splints”

Internal risk factors:

Excessive pronation

Calf muscle tightness

Weakness hip and pelvic musculature

Decrease calf endurance

External factors:

New to running/ sudden increase in volume/intensity

Worn out shoes

Luke T Madeley, Shannon E Munteanu, Daniel R BonannoJournal of Science and Medicine in Sport, Volume 10, Issue 6, December 2007, Pages 356-362

“Shin Splints”TREATMENT

ACUTE onset:

Active rest from running

Anti-inflammatories as prescribed

Regular icing for 15 min every 3 hours

Stretching Calves and anterior shin +++

Sports taping to offload anterior and/or posterior shin

Sports massage

“Shin Splints”ACUTE AND CHRONIC symptoms (2 weeks+)

Correct biomechanical issues affecting load to the shinbone:

Strengthen hip, pelvic and core muscles

Increase power in the lower limb muscles to improve shock absorption

Improve especially calf muscle endurance

Correct shoe wear or orthotics

Riley, R. Journal of Science and Medicine in Sport, Volume 6, Issue 4, Supplement 1, December 2003, Page 13

Achilles tendinopathy• Overuse tendon

injury that is characterized by a changes in tendon structure and a reduction in function

• Usually occurs in the mid-tendon of the Achilles

• Some respond to simple treatment, some fail ALL treatments

Achilles tendinopathy

Diagnosis is most important here as it guides further interventions !!! Seek help from physiotherapist or sports physician EARLY!

Tendon changes are reversible if early warning signs are recognized and training volume and intensity are modified IMMEDIATELY!

If an intense bout of exercise flared-up the Achilles, it will respond to a reduction in load, adequate recovery, ice and anti-inflammatories.

Achilles tendinopathy Chronic overload of the Achilles tendon will result in a

focal “thickened tendon” (not inflammed), that is painful with forceful push-off and stiff in the morning.

Often present in the elite athlete with chronically overloaded tendons or the middle-aged recreational runner.

Stories.. Dame Kelly Holmes, GB 800

and 1500m runner, won Double Gold with bilateral chronic Achilles tendinopathy

Liu Xiang, Chinese 110 meter Hurdler, Triple Crown winner unable to continue training 6

months prior to Olympics Beijing

Biggest Medical Budget in the World unable to get him starting at the Games 2008.

Achilles tendinopathyTREATMENT:

Anti-inflammatories are not helpful in the chronic stage

Exercise with an eccentric(lengthening) / heavy slow resistance component to it i.e calf raises off step with straight and bend knee

Extracorporeal shockwave therapy

Ultrasound guided injections (not cortisone)

Surgery if all fails

Cook JL, Purdam CR. Br J Sports Med. 2009 Jun;43(6):409-16.

Question and Answers

"If you want to win something, run 100 meters.If you want to experience something, run a marathon." –

Emil Zatopek