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Epidemiology and Aetiology of Marathon Running Injuries - Fredericson and Misra, 2007

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    PADCD sports M ed 2007.-37 (4-5): 437-439OH2-1642/07/0004-0437/S44.95/I )O 2007 AdS Da ta Inform at ion BV. All rights reserved.

    redericson^ a n d Anuruddh K. Misra^De partm ent of Orthop aedic Surgery, Division of Physical Medicine and Rehabilitation,Stanford University School of Medicine an d T eam Physician, Stanford UniversityCross-Country and Track Teams, Stanford, California, USADe partm ent of Internal Medicine, Saint M ary's Hospital and Medical Center, San Francisco,California, USA

    ov er the last 10-15 years, there has heen a dramatic increase in popularity ofrunning marathons. Numerous articles have reported on injuries to runners of allexperience , with yearly incidence rates for injury reported to he as high as 90% inthose training for marathons. To date, most of these studies have heen cohortstudies and retrospective surveys with remarkahly few prospective studies. How-ever, from the studies availahle, it is clear that more experienced runners are lessprone to injury, with the numher of years running heing inversely related toincidence of injuries. For all runners, it is important to he fully recovered from anyand all injury or illness prior to running a marathon. For those with less experi-ence, a graduated training programme seems to clearly help prevent injuries withspecial attention to avoid any sudden increases in running load or intensity, w ith aparticularly high risk for injury once a threshold of 40 miles/week is crossed. Inhoth sexes, the most common injury hy far was to the knee, typically on theanterior aspect (e.g. patellofemoral syndrome). Iliotihial hand friction syndrome,tihial stress syndrome, plantar fasciitis, Achilles tendonitis and meniscal injuriesof the knee were also commonly cited.

    During the course of a year, approximately two - are aware of only one prospec tive study''*! that ex-f runners sustain at least one injury that amined possihle risk factors independen t from the

    an interruption in their non nal training pro- injury. Th e main goal of the current article is tome .!" For those training for marathons, the review the literature evaluating the epidemiology

    rate can he higher and has heen and aetiology of marathon injuries and provide sug-he as high as 90%.[2l Nu me rous articles gestions for future research,

    of all experience levels, from novice to elite ' " 9 OU ahut mainly non-elite. To date, most of these Ow ing to the fact that more people mn today than

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    438 Fredericson & M

    ries occur in runners. In the last 10-15 years, therehas been an emphasis on remaining healthy viabalanced diets and choosing running programmesup to marathon d istances. Thus, there has been a risein mnning injuries.'^' However, there are not muchdata from which to generate recommendations forprevention or treatment strategies.Efforts have been m ade to gather as much data aspossible for marathon runne rs of all skill levels. Thishas provided a relatively high number of runners to

    study and to estimate how much certain factors haveinfluenced the incidence and prevalence of mara-thon running injuries, from the level of runner, rela-tive number of miles run weekly, markers of lowerextremity alignment and the degree of stretchingprior to and after a race, to a host of other con-founding and contrihuting factors.2. Epidemiology and AetioiogyOne in three of those injured stated that s/he wasadversely affected by injury.'*' In spite of this, therewas a reluctance to seek treatment.'*' Data fromSwitzerland noted that running injuries are 2-2.5times less frequent than injuries from all other sportsand six times less frequent than ski injuries onaverage.'^' Older, more experienced runners wereleast affected by injury across the majority of thedata.'^'^' Serious health prohlems were rare.'^'Injuries in marathon runners can be multifactori-

    al , but are often attributable to training e rro rs.'' ' Thethree most commonly cited independent factors forinjury are: (i) an increase in weekly mileage tooquickly; (ii) previous injury; and (iii) a competitivetraining motive.'^' Clearly, running distance is oneof the strongest risk factors associated with injury,as well as any sudden increase in running m ileage orchange in training volume or intensity.'^'^-^l There isa particularly high risk for injury when crossing athreshold of 40 miles/week. If running >40 miles,the adjusted relative risk for injury was 2.88.'*' Avery strong second predictor is previous injury.'^'^^ It

    First-time marathon participants had increadifficulty if they had an illness in the 2 weeks pto the race, consumed alcohol (even only one beage a month) or were using other medications different medical problems.'^' Experienced runnwere found to be at a decreased risk of injury cause they were able to listen to the "languagetheir body."'' ' They were able to avoid oveinjuries and developed musculoskeletal adaptato running but were found to heal slower winjured. They were also less susceptible to consttional problems than younger, less-experienced rners.'^'

    We know of one study that has evaluated alment measures and marathon injuries.f**' The dfrom that study suggest the following: (i) high aindex is protective against overall injuries and kinjuries in particular; (ii) increased heel valgus pears to be protective a gainst knee and foot injuand (iii) increased knee varus and increased tucle-sulcus angle were both associated with greshin injuries.

    The p receding study was limited by its reliabof alignment measu res, poor power and, perhapssample bias (healthy participant effect).'"*' For treasons, further study is recommended to substaate or disprove these fmdings.3. iVIore Common injuriesIn both sexes, the most comm on injury by far to the knee.'*' '" Knee injuries were most common the anterior aspect, namely patellofemoral psyndrome. lliotibial band friction syndrome, tistress syndrome, plantar fasciitis, Achtendonitis and meniscal injuries of the knee walso common.'*' Additional complaints incluthigh muscle sorene ss, blistered feet, chaffmg, asions, malaise, lateral ankle sprains, alimentary orders and extreme exhaustion.'^''-' ' Men were s

    to have hamstring and calf problems more women, whereas women tended to have

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    439

    4. Prevention

    4. It is especially important to be fully recoveredfrom any and all injury or illness prior to running amarathon.5. Knee injuries are the most common injury seen inmarathon runners.

    The best advice to help avoid injury is to pay

    ured runners could include running

    Stretching was not substantiated to be helpful to

    ruse injuries in runne rs.''"' Fur-ffect relationship and whether distance runners

    5. ConclusionThere rem ains a need for prospective studies that

    Mo re experienced runners are less prone to injury,

    . A graduated treiining programme seems to clearly

    AcknowledgementsMichael Fredericson receives royalties from orthopaedic

    physical therapy products.

    References1. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med

    1987; 15: 168-712. Satterthwaite P, Larmer P, Gardiner J, et al. Ineidenee of injuries

    and other health problems in the Auckland Citibank Marathon,1993. Br J Sports Med 1996; 30: 324-6

    3. Marti B, Vader JP, Minder CE, et al. On the epidemiology ofrunning injuries: the 1984 Bern Grand-Prix study. Am J SportsMed 1988; 16: 285-94

    4. Wen DY, Puffer JC, Schmalzried TP. Injuries in runners: aprospective study of alignment. Clin J Sport Med 1998; 8:187-94

    5. Macera CA, Pate RR, Woods J, et al. Postrace morbidity amongmnners. Am J Prev Med 1991; 7: 194-8

    6. Maughan RJ, Miller JD. Incidence of training-related injuriesamong marathon runners. Br J Sports Med 1983; 17: 162-5

    7. Taunton JE, Ryan MB, Clement DB, et al. A Prospective studyof mnning injuries: the Vancouver Sun Run "In Training"clinics. Br J Sports Med 2003; 37: 239-448. Walter SD, Hart LE, Mclntosh JM, et al. The Ontario cohortstudy on mnning-related injuries. Arch Inter Med 1989; 149:2561-4

    9. Satterthwaite P, Norton R, Larmer P, et al. Risk factors forinjuries and other health problems sustained in a m arathon. BrJ Sports Med 1999; 33 (2): 22-6

    10. Niemuth PE, Johnson RJ, Myers MJ, et al. Hip muscle weaknessand ovemse injuries in recreational mnners. Clin J Sport Med2005; 15 (1): 14-21

    Correspondence: Dr Michael F redericson, Department oOrthopaedic Surgery, Division of Physical Medicine and

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