1 Why Runners Get Hurt

Injuries are inevitable due to overuse, lack of recovery, poor diet, lousy form, and failure to shore up your infrastructure and create a fat-burning engine. Here, Bob Forster explains how to keep your running safe.

One of the most basic rules of sports medicine is, “You need 2 days off from running for every day that you’ve run in pain.” So if you’ve felt some pain for a week, then you should not run for 2 weeks. If all you remember from this book is that rule, you might add decades to your running career.

It became clear to me in my first years as a physical therapist that most running injuries are actually overuse injuries, and they take a long time to develop. It’s much easier to understand and treat an acute injury. But repetitive motion injuries that create inflammation (discussed in “The Anatomy of Overtraining Injuries” on pages 22–23) and accumulate scar tissue over months and years can’t be addressed with a quick fix. It doesn’t matter whether you’re an elite runner or a back-of-the-packer—you have probably ignored an injury for way too long, to your detriment.

In 1978, when I first began treating runners, they were seen as an enigmatic group of loners who spent hours of solitude slogging through longer and longer workouts. Finding solitude became harder as millions more laced up running shoes over the years, motivated by the health benefits of regular exercise and the simplicity and economy of the sport. After all, running was easy and required little investment in goods or coaching. Everyone already “knew” how to run: just like they did as kids.

After a few years, the exhilaration that comes with the repetitive cyclic motion of running was identified as the runner’s high. The exhilaration was also tied to the release of morphine-like chemicals in the brain called endorphins. Runners didn’t really understand endorphins, but they knew they made them feel good. Before long, millions of runners were hooked. They ran every day, through rain and cold and even snow.

Back then no one knew how to stretch—or how to buy shoes. There were only a few brands on the market with limited choices. They didn’t know pronation from supination or why it mattered. Their social group outside running shrank down in size because their friends thought they were a bit crazy, and their spouses and family felt left out—but none of this stopped runners from running. They defended their fanatical dedication to running by citing literature that promised near immortality from the cardiovascular health benefits of aerobic exercise. Hard-core runners, so caught up in their addictive overtraining, seemed to believe that one missed day of running would clog their arteries overnight and they would die of heart disease.

It was therefore inevitable that the only thing that would stop obsessed runners who did not yet know that too much of a good thing is bad would be injury. By the mid-’80s, too many runners landed in my physical therapy office in Santa Monica with severe and debilitating injuries. Why? Because they ran too much, too often, and too far. They came in the office with bags of running shoes whose wear pattern they hoped would provide an answer to their chronic injury pattern. In an attempt to manage the fanatical allegiance to their sport, many doctors were reluctant to tell runners to stop running. It was the ignorant leading the obsessed; soon, shin splints turned into stress fractures, heel bones grew bone spurs, and running through injuries caused irreversibly damaged tendons.

I know this firsthand because I became one of them. As a former college wrestler from New York who needed to find a transition sport to feed my need to stay fit, the sun-drenched bike path along Santa Monica beach was too alluring to avoid falling prey to the running obsession.

Robert Forster, P.T., working on three-time Olympic gold medalist Jackie Joyner-Kersee before the 1992 Olympics.

Only months after beginning to run, I built my mileage up to marathon-training volume and I unwisely ran two marathons in the first year. I was hooked now, too. Even as a freshly minted physical therapist who knew better, I couldn’t keep myself from running through pain. Suffering chronic shin splints, I applied physical therapy treatment to my aching legs and did exercises to strengthen the sore tendons to the point where I could move a small house with my ankle inverters. I even got fitted for orthotic devices in my shoes. But still the pain persisted, because my vision was too limited.

Although we clinicians were proficient at identifying common running injuries, the focus of clinical treatment remained reactive and not proactive. The treatment for foot or leg injuries was orthotic devices or an exercise or two in an attempt to strengthen the overburdened tendons. The problem was that the source of the injury, which can be remote from the painful area, was not addressed.

At the same time I was working with one of the most successful running coaches in the world, Bob Kersee, and I began to think there was a better approach. My work with Kersee and his elite track and field athletes changed my treatment focus to address the mechanics of the whole athlete. When I changed my approach and instructed runners in proper running technique, and then used stretching and strengthening exercises that facilitated those good mechanics, the new approach served to normalize and reduce the forces that bore down on the commonly injured tissues of the lower extremities and pelvis. With correct running mechanics, along with a bit of local treatment for the injured structures, runners not only got past their current painful condition, but started to break the chronic injury-reinjury cycle.

In the ensuing decade, a body of scientific research began to reveal the physiological adaptations needed to transition from couch potato to runner. Slowly, training programs based on science and not obsession were emerging as we learned how to train for the specific adaptations needed for injury-free, peak performance. We learned the necessity of rest days, the value of stretching to reverse the natural shortening of connective tissues that is accelerated with running, the importance of increasing mileage slowly, and the role of differently constructed running shoes to match foot types.

Runners changed, too. By the mid-’90s, more runners were cross-training and spreading the stress of their workouts over more joints of the body. Soon many runners became triathletes and adventure racers; the more balanced training helped them become fitter and avoid injury. The loneliness of the long distance runner began to erode as running clubs emerged with a less fanatical devotion to back-to-back hard workouts and weeks and months of high mileage.

So why then do runners still get injured so often? After years of treating runners, I have found that the same personality traits that attract individuals to choose running often work against them and lead them to injury.

Too often I meet runners who fall in love with running but pick and choose from the other aspects of training that they need to keep them running injury-free. This is especially true for those not focused on performance, who don’t necessarily care whether they get on the podium because they just run for the love of it.

Well, the fact is that runners can’t just run—and they can’t cherry-pick. To keep your running injury-free, stay healthy, and protect against common running injuries that can sideline you for a while or end your running career, and alter your lifestyle, you have to do all the things that you may not like doing, such as stretching, lifting weights, eating better, and correcting your running mechanics. These four training variables—structural integrity, metabolic efficiency, nutritional optimization, and running technique—are no secret, because the healthiest, most successful athletes do them. I’ve come to call them the Four Pillars of Health and Performance.

Over the years, as I scrutinized the most successful athletic programs anywhere—for example, USC football, the Los Angeles Lakers, and, most of all, Bob Kersee’s track and field group—it has become clear that they were successful year after year because they stayed focused on all of the Four Pillars. Ignore any of them for too long, and you will run into problems.

For instance, if you don’t improve your structural integrity—the strength and flexibility of joints, bones, muscles, and connective tissue—you will be unable to perform correct running mechanics, and eventually overburden your body as it struggles to withstand excessive forces. If you don’t pay attention to your metabolic efficiency—particularly the ability to use fat as a major fuel source for running—you will fatigue early in your workout and risk injury, as your deteriorating muscle function causes you to suffer strains and sprains. Ditto if you don’t optimize your nutrition to support your training and recovery efforts. And the best-trained and -fed runner can still wreck his joints without adopting the proper running technique.

Bottom line: You can’t run in isolation or train just some of the Four Pillars and expect not to break down. You have to pay some attention to each of these key areas of training. Ideally, you work them simultaneously.

THE FOUR PILLARS IN THE HOUSE OF HEALTH AND PERFORMANCE

The foundation of the Four Pillars in the House of Health and Performance is recovery. Without it, all work is futile because it is during periods of rest that your fitness actually evolves. Governing all your training efforts is the psychology of healthy living and self-improvement.

1. STRUCTURAL INTEGRITY (STRENGTH AND FLEXIBILITY)

Structural integrity refers to how well the muscular and skeletal systems function to propel you forward and protect you against injury. This is a function of strength, flexibility, joint alignment, and the resiliency of tissues to withstand the repetitive stress of running. Structural integrity is best achieved with a progressive, science-based running program along with strength and flexibility training. The components of structural integrity are explained in chapters 4 and 5. Strength and flexibility are developed simultaneously with Pillar #2, metabolic efficiency, during Periodization training.

2. METABOLIC EFFICIENCY

The word metabolism describes the internal processes that turn food into usable energy needed for all bodily functions. The body uses carbohydrates and fats for energy (some protein as well, but only in small percentages). You establish metabolic efficiency by training at specific intensities to create a metabolism in which fat becomes the preferred fuel for exercise and daily activities. Fat is the best fuel for runners because it provides an almost unlimited supply of energy; the average person has more than 80,000 calories of stored fat. It burns clean without producing lactic acid, a harmful waste product of carbohydrates, and provides more energy per gram than carbs. Also, a fat-burning metabolism allows for less reliance on external energy sources during prolonged exercise, such as gels, bars, and energy drinks. Limiting your reliance on these energy sources will help you avoid the most common source of failure in the marathon: gastrointestinal distress, including abdominal cramping, bloating, gas, and worse. Metabolic efficiency is explained in detail in chapter 5.

3. NUTRITIONAL OPTIMIZATION

Food should be thought of as fuel—the fuel needed to run your body. Nutritional optimization refers to how well you fuel your body for daily activities, workouts, and racing. By optimizing what and when you eat, nutrition will maintain your energy levels, increase your metabolic fitness, and help achieve your ideal body weight and performance goals. Effective sports nutrition starts with good daily nutrition, including consuming sufficient amounts of macro- and micronutrients every day.

A sound nutrition plan takes into account your activity level and food preferences. A sustainable eating plan is one that includes a variety of foods and can be maintained over time while providing adequate nutrients and achieving your optimal competition weight.

4. RUNNING TECHNIQUE

For every sport or fitness activity, proper technique ensures optimum maximum benefit, decreased injury, and improved performance. Running technique is based on a few simple laws of physics. Your body must move in certain patterns to exploit the energy-saving aspects of these physical laws. Although our bodies were built for efficient running, our mostly sedentary lifestyles have robbed us of the ability to attain the most efficient mechanics. Technique training is the fastest, easiest, and most injury-free way to improve your times. Read about it in detail next in chapter 2.

Well, the fact is that running injuries don’t heal with rest alone. Because running is such a mechanical endeavor, injuries need to be addressed on a mechanical level. Unless the harsh G-forces (the accelerating forces of gravity that effectively multiply your body weight by three or four times at the point of a heel strike) that lead to injuries are redistributed, and the injured structure is unloaded, it doesn’t matter if you take 3 weeks or 3 months off running. The tissue will break down again once you return to running if you have deficiencies in your running mechanics.

Note the cross-chest arm swing and faulty knock-kneed, or valgus alignment, of the lower extremity in this example of bad running form.

If you answered “yes” to any of those, you are addicted to running. That’s not all bad, unless you find that the running is controlling you instead of you controlling your running. If your exercise becomes self-destructive, you are out of balance.

Find a sports physical therapist who has experience working with runners to treat your injury.

THE ANATOMY OF OVERTRAINING INJURIES:

CHRONIC INFLAMMATION, INCOMPLETE HEALING, AND LACK OF RECOVERY

Unless you fall down and break a bone or step wrong and sprain your ankle, the vast majority of running injuries you are likely to suffer are overuse injuries. Overuse injuries occur when we outpace our body’s ability to adapt to the stress of training. The micro-trauma suffered by the tissues during training, which would normally heal and make us stronger with adequate recovery (the foundation of the Four Pillars in the House of Health and Performance), instead builds into a macro-trauma with back-to-back hard days and weeks of training.

By the time pain arises, the typical overuse injury may be weeks or months in the making. The injured tissue most likely had been struggling to heal for quite some time, but the repetitive stress of running stalled the healing process.

The chain of physiological events that is put in motion to repair the damaged tissues begins with the inflammatory response. This is a characteristic reaction set in motion to first clean up the debris of the damaged cells and then begin the healing of the injured area with scar tissue.

These events are repeated throughout your body every time you run, and they go unnoticed if your training is progressive and designed with built-in time for recovery—and that means several recovery days every week, a recovery week every month, and some time off every year. You see, when your workouts are too frequent, or too hard, and go on for too long and without meaningful variation or enough time provided for recovery, the body struggles to stay ahead of the stress.

If the healing process from the microtrauma is incomplete and the scar tissue has not matured enough to withstand the stress of your next workout, it gets broken down and the process starts all over again. The problem then becomes one of excess scar tissue and chronic inflammation. The inflammation leads to scar tissue, and the scar tissue causes dysfunction in the injured structure, which propagates more tissue damage and chronic inflammation, the inflammation causes pain, and the pain causes muscle tightness or spasm and more dysfunction in a circular downward spiral that eventually stops you in your tracks.

Face it: Running is so addictive that even the most self-aware disciple of Periodization training can slip into overtraining and pick up an overuse injury if he or she gets a little distracted. That’s why it’s so important to be aware of the signs of overtraining, which include sleepless nights, weight gain or loss, frequent illness, and chronic injury—and then to do something about it. Step one in the recovery process is simple logic: Halt the damaging workouts. Then, find a pain-free cross-training modality and address the inflammation with aggressive icing. Next, relieve the muscle tightness with stretching and break up scar tissue with the foam roller or cross-fiber friction massage by a qualified professional.

The key is when you feel an injury developing, don’t delay. The sooner you start the recovery process, and address the mechanical cause, the sooner you’ll be back on the road.

Chronic inflammation can lead to muscle tightness or spasm.