Can You Prevent Running Injuries?

We have been seeing some runners in our clinic recently. Some seasoned runners, but quite a few new, novice runners. My definition is unless the runners have been training, running and/ or racing for at least 5 years, they are still considered novice runners.

As a runner I would love to run long and hard daily, alas if we do that injury definitely beckons. How do we prevent that from happening? Can we actually prevent running injuries?

I came across an article investigating if it was possible to prevent running injuries. In this particular study (Leppanen et al, 2024), there were 325 participants who were fairly new runners (less than 2 years of running experience) and aged between 18-55 years. Interventions were completed before the actual runs. The runners attended group training twice a week with a physiotherapist for 6 months.

They were divided into 3 training groups, 2 intervention and 1 control group. All 3 groups followed a similar training program and all runners were taught about the basics of running technique. The first intervention group (108 runners) did strength and conditioning exercises for the hip and core. The 2nd group (111 runners) did exercises to strengthen the ankle and foot, while a third control group (106 runners) did static stretching.

Each training session lasted about 30 minutes twice a week with the exercises and difficulty level progressing over the course of 6 months. Each exercise had 4 different versions with different levels of difficulty and intensity. After the training session, the participants ran outdoors for 30-75 minutes. The participants reported all running related injuries each study week using a mobile application.

Results show that the group that focused  on hip and core training sustained the least injuries among the 3 groups. They had 39 percent lower prevalence of all overuse injuries and 52 percent lower prevalence of overuse injuries compared to the control group. 

I was surprised that the  ankle and foot exercise group did not prevent running related injuries compared to the stretching group. The incidence of acute injuries was lower in the control group than ankle and foot exercise group perhaps suggesting that stretching may help prevent acute running injuries. However, do take note that there were a low number of acute running injuries in this study so this observation should be approached with caution.

This study shows that beginner or novice runners injury rates can be significantly reduced by training the hip and core muscles. Overuse injuries can be cut by about half by strengthening this area compared to stretching which has always been traditionally thought to prevent injuries. And it's really easy to do with just body weight and/ or resistance bands.

Come see our physiotherapists at Physio Solutions and Sports Solutions to learn about what stregthening exercises would help prevent running injuries for you.

Reference

Leppanen M, Viiala J, Kaikkonen P et al (2024). Hip And Core Exercise Program Prevents Running-related Overuse Injuries In Adult Novice Recreational Runners: A Three-arm Randomised Controlled Trial (Run RCT). BJSM. 58: 722-732. DOI: 10.1136/bjsports-2023-107926.

Intense Static Stretching Versus Strength Training For Muscle Growth

Static stretching device

Who says that strength training is needed to make muscles bigger and stronger? A study published 2 days ago showed that intense static stretching of the pectoralis major (chest) muscles 4 times a week produced similar hypertrophy gains to strength training done 3 times a week. 

What? Just as effective as strength training? I was surprised to say the least. Well you know I am not a big fan of static stretching at all. Skeptical? I was too!

81 participants were allocated to 3 groups in this study. A static stretching group, strength training and control group. Pec stretching was done for 8 weeks, 4 days per week for 15 minutes per day. Those in the strength training group trained 3 times a week doing 5 x12 repetitions. All the subjects were instructed to maintain their regular exercise routine during the study. They exercised at least twice a week in a wide range of sports like fitness training, team sports or strength-endurance training. 

Results showed significant strength increase in the static stretching and strength training group compared to the control group. There were no significant differences between the static stretching and strength training group.

There was moderate muscle thickness increases in the static stretching and strength training group compared to the control group. Muscle thickness was measured using ultrasound imaging. There was actually no difference between the static stretching  and strength training group.

Range of motion test

In terms of range of motion (ROM), static stretching group had significant moderate ROM increases compared to the strength training group. No difference in ROM between the strength training and control group.

It has been suggested that the shared underlying physiological mechanism between stretching and strength training is the high stretching tension both produces to induce stretch mediated hypertrophy (Warneke et al, 2023). This tension translates into chemical signals that stimulate anabolic processes to generate new muscle tissue.

Wow. Increased size, strength and range in 8 weeks compared to strength training. However, note that static stretching via a stretching device like in this study needed a second person to assist and adjust the stretching device. Moreover, regular strength training can prevent osteoporosis and sarcopenia.

References

Warneke K, Wirth K, Keiner M et al (2023). Comparison Of The Effects Of Long-lasting Static Stretching And Hypertrophy Training On Maximal Strength, Muscle Thickness And Flexibility In The Plantar Flexors. Eur J Appl Physiol. 123(8): 1773-1787. DOI: 10-.1007/s00421-023-05184-6

Wohlann T, Warneke K, Kalder V et al (2024).Influence Of 8-weeks Of Supervised Static Stretching Or Resistance Training Of Pectoral Major Muscles On Maximal Strength, Muscle Thickness And Range Of Motion. Eur J Appl Physiol. DOI: 10.1007/s00421-023-05413-y

Evidence For Using Floss Bands

showing how Flossing is done

Remember the floss band courses we used to teach? We often had participants asking what is the evidence behind increasing joint range of motion (ROM), sporting performances, helping with recovery and decreasing pain. In short, they all wanted to know how it works. 

I wrote previously that you've got to try it to believe it, well there is now a published *scoping review article for floss bands (Konrad et al, 2021), referenced below.

The review paper summarizes the existing evidence for the effect of floss band treatment on range of motion (ROM), sporting performance (strength or jump performance), recovery (due to DOMS) and pain (due to disease or injuries).

In all, 24 studies met the inclusion criteria with a total of 513 subjects. 15 of the 24 studies investigated the effects of a single floss band application on the ROM of several joints. On the ankle joint, flossing was found to have a significant change of 11.17% in the dorsiflexion ROM.  

4 studies investigated the effects of calf flossing on the ankle, showing a very large increase of 19.95% in dorsiflexion of the ankle.

Similarly 4 studies measured thigh flossing and found a significant increase in knee bending (3.61%), and knee straightening (7.38%). However, another study showed no improvement in hip ROM after flossing the thigh. None of studies showed any decrease in range after flossing.

Of the two studies that investigated the effects of flossing on DOMS, one study reported significantly reduced DOMS 24 and 48 hours post exercise in the study group (in the upper arms) compared to the control group. The other study (on leg muscles) found no difference in the intervention versus control group following 12, 24, 36, 48 60 and 72 hours post exercise.

When comparing flossing to other treatment like dynamic stretching, flossing had a more noticeable effect in increasing hip range of motion and maximal eccentric knee extension (Kaneda et al, 2020b). With regards to static stretching and flossing, rate of force development was more pronounced in the flossing group compared to the static stretching group (Kaneda et al 2020a). Kaneda and colleagues concluded in both studies that flossing should be applied as a warm up rather than as a stretching exercise. This is exactly what my patients who do CrossFit tell me. They normally use a floss band for warm up before they start their easier routines, before the heavy lifting.

I know all athletes are after improved performances. Results from the individual studies showed that 11 of of the 44 performance measures showed a significant improvement (comparing pre and post floss band application, Table 3 in article). There is some evidence that joint flossing (ankle and knee) can increase jump height, although sprint performance (5 to 20 m sprints) seems to be unaffected after ankle flossing. (Personally, I would floss the quads and hamstrings and calf muscles if I wanted to improve sprint times rather than the ankle). 

One study showed improvement in maximal voluntary contraction (strength) in the quadriceps muscle and hamstrings after thigh flossing.

The researchers suggest this is possibly due to hormonal responses related to the flossing. Similar to other occlusion (or blood flow restriction methods), enhanced growth hormone and norepinephrine levels increase may be responsible for increase in performance reported. More importantly, the review concluded that from the involved studies there was no detrimental effects on performance from a single floss band treatment.

Evidence also show that a single floss band treatment is able to increase ROM of the related joint and can positively affect jumping and strength performance. Possible mechanism is suggested to be changed neuromuscular function rather than changed mechanical properties.

after surgery in 2016

After Ronald Susilo (above) ruptured his patella tendon and tore his anterior cruciate ligament at the same time, he came to see me after the surgeon reattached his patella tendon. He did not have the range to even pedal one round on the stationary bike. I definitely increased his knee ROM with a single floss band treatment. He could pedal immediately after a single floss band application. 

Yes, back then it was only one subject (or n=1), however it was a definite improvement. Those of you reading then may be critical and probably not even believe it, but I have since replicated it many times in our clinic. Hence I feel that clinical evidence (what we see in the clinic) is just as good as published evidence (like this scoping review).

There will probably be long term studies about the effects of flossing treatment on joint ROM, sporting performance, whether it helps with recovery and decreasing pain. I am sure there also will be studies that say there are no benefits to it. The question is does it work for you?

Reference

Konrad A, Mocnik R and Nakamura M (2021). Effects Of Tissue Flossing On The Healthy And Impaired Musculoskeletal System: A Scoping Review. Front. Physiol. 21 May 2021. DOI: 10.3389/fphys.2021.666129

*A scoping review has a broader scope compared to traditional systematic reviews with correspondingly more expansive inclusion criteria.

Let's do the twist

Does Stretching Improve Performance Or Help Prevent Exercise Related Injury?

Me and a gymnast at the old National Stadium

Alright folks, I have a controversial topic to discuss. Trainers, coaches and of course physios have for the longest time asked both elite athletes and patients to stretch be it for rehabilitation or in pursuit of improved performance.

Do physios, coaches and trainers advise and patients/athletes practice it out of habit, outdated beliefs or current best practice?

In this day and age, we want everything to be evidence based. But are there any evidence based benefits of stretching? Does stretching help prevent exercise related injury?

The  articles discussed by Shrier (2004) and Weldon and Hill (2003) are both systematic reviews. (A systematic review is a computer aided search for ALL randomized & controlled clinical trials, meaning it's top of the pile in terms of quality).

Well, with regards to improving performance, here's the evidence. In Shrier's review paper, only one article suggested running economy (running more efficiently) was improved. Four articles studied running speed or sprinting, with one study being beneficial, one detrimental while two was inconclusive.

The paper concluded that stretching does not help to improve maximum strength or how high you can jump. There is some evidence however, to suggest that regular stretching performed outside of the pre exercise period (and not stretching before exercise) improves strength, jump height and sprinting. 

In fact, a few studies actually show that stretching before exercise has actually shown to increase your chance of sustaining an injury. Especially so if you are an endurance athlete with reduced flexibility.

The evidence also suggests that stretching immediately prior to exercise is detrimental to activities that require isolated force or power. There is also insufficient evidence to show that it helps with running economy (running more efficiently).

Well, here you go, not quite what you expected right? I know what our patients are gonna ask us. What do we do? Do we still stretch or not? Here's my opinion based on my work and observations with our athletes and patients. 

1. Minimize pre exercise static stretching since it hinders power and maximum strength.

2. Do your pre game or exercise warmup with movements that simulate your sport.

3. Stretch after exercise or at a time not related to exercise since regular stretching helps.

Please email me if you want the articles.

References

Shrier, I. (2004). Does Stretching Improve Performance? A Systematic and Critical Review of the Literature. Clinical Journal of Sports Medicine. 14(5) p 267-273.

Wendon, SM and Hill, RH. (2003). The Efficacy of Stretching for Prevention of Exercise-related injury: A Systematic Review of the literature. Manual Therapy. 8(3) p 141-150