Dr Jordan Metzl

CNA/NEW YORK TIMES – With marathons starting up again and the pandemic running boom, there are more people showing up in sports medicine clinics like mine with injuries such as shin splints, Achilles tendinitis and runner’s knee.

On a recent day, I saw eight patients in a row with marathon-training injuries. Other times of the year I might see eight in a month.

An estimated 30 per cent of runners training for a marathon suffer some kind of injury, and roughly 15 per cent will never make it to the starting line because of it. This also holds true for shorter-distance events, such as half marathons, where the injury rate is comparable.

Whether you’re training for a marathon or walking in your neighbourhood, preventing injuries is far easier than treating them after they’ve occurred. Rather than waiting for an injury to find you, here are several useful considerations to keep you on the road.

DON’T OVERDO IT

Once upon a time, the default view among athletes was best summarised by an old quote from the war hero General Lewis Puller: “Pain is weakness leaving the body.”

This meant pushing training volume – be it miles, weight or intensity – to achieve athletic success. Today, sports medicine experts recognise this philosophy can cause injury in any sport.

The number of innings thrown per season in baseball affects a pitcher’s risk for shoulder and elbow injury.

In basketball, the number of minutes played affects the risk of ankle and knee injury. To reduce these, teams use something called “load monitoring” – playing fewer back-to-back games or pitching fewer innings – to lower the stress on specific muscles or joints.

The same is true in running. In a recent study published in The British Journal of Sports Medicine, my colleagues and I evaluated the risk factors for injury in 735 runners training for the New York City Marathon. We found that, of all the modifiable factors, like body weight or number of marathons completed, the strongest predictor of injury was rapidly increasing training miles. This was true for all levels, from novices to experienced runners.

In short, don’t do too much, too fast, whether marathon training, preparing for a walking event or just trying to meet a particular running goal. Even the age-old 10 per cent increase per week rule of marathon training may be too much for many people.

PAY ATTENTION TO ACHES AND PAINS

Even under the best circumstances, running is uncomfortable, but not all aches and pains are equally serious. How do you know when to seek medical help? I have a simple rule for athletes of all ages: If pain alters the mechanics of your movement, get it checked out. For example, if you’re a tennis player and the elbow pain during your forehand changes how you swing the racket, your easily treatable tennis elbow could be turning into a tear in the extensor tendon, a more serious injury.

The same is true with running. When shin splints are so painful that your running mechanics are altered and you’re hobbling, every foot strike could be turning the inflammation on the surface of the tibia into a far more serious tibial stress fracture.

Recognising an injury is step one. Treating the injury is step two. Preventing it the next time is step three.

Left undiagnosed, repetitive use injuries become more severe, and recovery takes longer.

Once your running injury is diagnosed, work with a sports medicine doctor or physical therapist to find the cause.

KEEP MUSCLES STRONG

As runners train for longer distan-ces, whether two miles or 26.2, their backs, hips and knees become achier. I tell my patients that run-ning is a constant battle between gravity and your body.

To win this battle, build strength. The stronger your muscles, the better able you are to withstand the forces from the ground that make everything hurt. High repetition, light weight strength training has been shown to reduce joint loading forces. Stronger muscles including hip flexors, glutes, quads and hamstrings are better able to withstand the pounding on the road and allow runners to better tolerate the miles, although scientists still haven’t found the perfect training method.

FIND COMFORTABLE RUNNING SHOES

One of the most important choices a runner makes is what shoes to buy.

Studies show that most runners choose their running shoes based on comfort, price and recommendations from peers, which aren’t bad places to start. Although some companies claim their shoes reduce injury-risk, studies have shown there’s no evidence that a specific type of running shoe dramatically reduces injuries.

When choosing your shoes, go to a running specialty store and try on several pairs. Put them on and walk around the store and place the most importance on what feels best on your feet. Getting the right pair might require trial-and-error, but once you find something that works, it should help make running and walking more comfortable.

Gretchen Reynolds

THE WASHINGTON POST – Almost all runners, whether veterans or newcomers, poky or fleet, youthful or antique, share one bond. Someone soon will warn us that we are ruining our knees.

“A lot of people think that running is bad” for knees and other joints, said University of British Columbia clinical professor of physical therapy in Kelowna Jean-Francois Esculier, who studies running.

But accumulating research, including studies from Esculier and others, generally shows the reverse. In these studies, distance running does not wreck most runners’ knees and, instead, fortifies them, leaving joints sturdier and less damaged than if someone had never taken up the sport.

There are exceptions, though, so it is important to understand the nuances of the science, the unique history of your knees and the mechanics of what really happens behind our kneecaps with each stride we take.

Ever since the first marathon ended with the death of its entire field (consisting of the one soldier, Pheidippides), some people have been convinced running must be hard on us, especially our knees. An online survey conducted by Esculier and his colleagues, its results published this year in the Orthopaedic Journal of Sports Medicine, found more than half of the 2,514 respondents believed distance running damages knees.

This stubborn idea persists despite evidence to the contrary. Study after study indicates running rarely causes or exacerbates arthritis in most runners’ knees, even older runners, who are at relatively high risk for arthritis.

CAN RUNNING BUILD STRONGER KNEES?

Shifting the public’s perceptions is hard, however, said University College London orthopedic surgeon and research professor Alister Hart, who used to worry about his own knees, especially after he finished his first marathon and limped afterward for days. At that point, he decided, he should delve more deeply into the effects of this consuming activity on runners’ joints.

So, for a 2019 study, he and his orthopedic colleagues recruited 82 middle-aged, first-time racers who had signed up for the 2017 London Marathon. Few had done much, if any, previous running and none felt knee pain. The researchers scanned the runners’ knees before they began a structured, four-month training programme and, again, two weeks after most completed the marathon. (Eleven dropped out during training.)

Although none of the runners reported knee problems at the start, most of their first scans showed signs of incipient joint injuries, including cartilage tears and bone-marrow lesions, any of which could be early steps toward arthritis.

But this damage had been partially reversed by training and racing. Two weeks after their first marathon, most of the runners’ existing bone marrow lesions had shrunk, as had much of their frayed cartilage.

But some runners showed symptoms of new, if slight, damage in the bones and cartilage right around their kneecaps, a part of the joint that absorbs much of the pounding from running. “We could not ignore this, since it likely happened because of the training and racing,” said University College London and the Royal National Orthopaedic Hospital study co-author and orthopedic surgeon Johann Henckel. “So then, we had to ask, does this damage last or get worse?”

If it did, running was harming people’s knees.

The scientist-surgeons helped settle that concern, though, with a follow-up study, published in 2020, during which they scanned the runners’ knees again, six months after their race. Most of them still ran, although with reduced mileage.

The new scans showed their knees were healthier now than in the weeks right after the marathon. Many of the lesions and tears that had begun shrinking during training were smaller and the fresh damage seen around some kneecaps had largely dissipated, with few remaining signs of lesions and tears.

“I feel comfortable at this point saying running should not harm most people’s knees and can, in fact, be beneficial,” Hart said.

How, though, does running revamp knees?

Hart and his colleagues believe running strengthens the major leg muscles supporting the knee, allowing them to take on and offload more of the strains involved in repeatedly striking the ground.

PLUMP UP THE CARTILAGE

The knee’s cartilage probably also bulks up, thanks to the repeated squishing it receives during running, Esculier said.

“For a long time, we thought that cartilage could not adapt” to running or other activities, he said, because it lacks blood supply and nerves. “But in fact, cartilage does adapt,” he said, “By becoming stronger and more tolerant to compression.”

In a 2022 review of past MRI studies he co-wrote, he and his colleagues found evidence that the knee’s cartilage flattens immediately after a run, but then bounces back into shape within a few hours. With long-term recreational running, he said, the cartilage probably thickens, although that possibility still needs to be studied.

“Bottom line is that cartilage does become more robust” with running, Esculier said.

Some runners will develop knee injuries or arthritis, though. So will many non-runners.

A helpful online summary of the science of knees and running, created by Esculier and others, points out that people who are overweight, past age 50, with a family history of arthritis or a personal history of knee injuries face a substantially higher risk of knee problems than other people, whether they run. “If running makes your knees hurt, you don’t have to run,” Hart said. “It’s fine to try something else.”