Running Injuries – 80/20 Endurance

Running Injuries

I’ve always considered myself an injury-prone runner. I used to half-jokingly say that I had suffered more running-related injuries than any runner my age in the history of running, and it wouldn’t shock me if this turned out to be true. Between the ages of 28 and 48 I picked up no fewer than four major injuries—right knee, left Achilles, right hip flexor, and left hip flexor—that each kept me out of competition for more than a year. And those are just the big ones. I’ve dealt with dozens of smaller breakdowns that have sidelined me for days or weeks.

Early on, some of my injuries were caused, at least in part, by training errors. But while I may be slow to learn, I do learn, and eventually I stopped making stupid decisions in my training. I did not stop getting injured, however. Clearly, then, training errors were not the real reason for my proneness to injury.

In the early 2000s, a structuralist paradigm of nontraumatic sports injury became ascendant. According to this model, so-called overuse injuries are caused by flawed movement patterns which are in turn caused by musculoskeletal imbalances, particularly overly weak and overly tight muscles. The way to prevent such injuries, according to this model, is to iron out such imbalances through strength and mobility training.

It was all very pat, and I bought in completely, doubling down on strength and mobility training in a quest for corporeal balance, but all for naught. The injuries kept right on coming, same as before. So I wasn’t too surprised when the structuralist just-so story began to fall apart, with study after story failing to validate the model’s predictions. Just recently, for example, Medicine & Science in Sports & Exercise published a study by Irish researchers titled “Do Injury-Resistant Runners Have Distinct Differences in Clinical Measures Compared with Recently Injured Runners?

The short answer was no. Two hundred and twenty-three runners, including 116 who were recently injured and 61 whose last injury was at least two years past, were subjected to a battery of tests of musculoskeletal balance. The only difference observed was slightly greater hip abduction strength among recently injured runners, causing the researchers to conclude, “Commonly used clinical measures of strength, joint motion, and functional foot alignment were not superior in injury-resistant runners compared with recently injured runners, questioning their relevance in identifying future injury resistance of runners.”

So it appears that my ongoing susceptibility to injury is caused neither by training errors nor by musculoskeletal imbalances. What, then, is the true culprit? A clue comes from the fact that all of my major injurious have been tendinous. I’ve never experienced a nontraumatic bone injury and I can count on one hand the times I’ve strained a muscle over the past 50 years. Yet this clear pattern escaped my notice until 2015, when I stumbled across an article about the genetic underpinnings of injury in The Atlantic.  From it I learned about a gene called COL1A1 that affects the consistency of collagen in connective tissues, certain variations of which are underrepresented in frequently injured athletes. I’d be willing to bet my life savings I’m one of them.

Mystery solved? I’m not so sure. Lately I’ve been taking a deep dive into pain science as I collaborate with Ryan Whited on a book about self-managing athletic pain and injury. One of the things I’ve learned is that the vast majority of nontraumatic athletic injuries aren’t really injuries. They’re pain experiences. In other words, the pain is real but there is no significant underlying tissue pathology. Upon learning this I felt the hairs on the back of my neck stand up. I’d had imaging done on three of my four multiyear injury sites, exploratory surgery done on the fourth, and in all four cases no significant tissue pathology was found. I was in pain but not injured.

Ryan subscribes to a biopsychosocial model of pain which holds that pain experiences are always multifactorial, with nontraumatic musculoskeletal “injuries” being no exception. There is almost always some kind of tissue insult at play, but psychological and social factors are involved as well. As many readers of this blog know, my wife, Nataki, has bipolar disorder. Throughout the long period when most of my injuries occurred, I was under tremendous stress as Nataki and I struggled together to manage her condition. But in 2013, a few things fell in place, our lives gained a level of stability they’d lacked for more than a decade, and my injury rate subsequently plummeted.

I’m not blaming my injuries on Nataki’s mental illness, mind you. I’m attributing my frequent pain experiences to life stress and to my inability to manage it. Pain and stress are almost the same thing, as psychiatrist Claire Lunde and pain scientist Christine Sieberg of Boston Children’s Hospital explain with great cogency in this review paper. Others have described pain as a cup that’s running over. The cup itself is your physical and mental stress receptacle. Stress of all forms ranging from marathon training to trying to keep yourself and your spouse safe in the midst of a mental health crisis go into the stress receptacle. When it fills up and begins to flow over, you become symptomatic. Anything you can do, therefore, to keep new stressors from entering the cup or to siphon existing stressors out of the cup will reduce the likelihood of symptom manifestation. Thanks to fragile tendons and a high-strung personality, I may have a smaller cup than other athletes, but I have less life stress going into it and therefore my tendons don’t hurt as much.

Do you consider yourself injury prone? You might actually be pain prone. And there might be more you can do about it than you think.

Injuries are the bane of the runner’s life. More than any other impediment, they thwart the efforts of runners to build fitness and achieve competitive goals. For this reason, injury risk management is a critical component of the training process. If there is a way to reduce injury risk, you want to know about and, if possible, implement it.

A new study in the International Journal of Sports Medicine sheds new light on how manipulating your training workload over time can help you avoid injury. A team of Dutch and German researchers enlisted 23 recreational runners to keep detailed training diaries for two years. An analysis of the data collected revealed that increases in the acute:chronic workload ratio predicted injury, where acute training load (ATL) was calculated as the average of running duration multiplied by intensity over a period of one week and chronic training load (CTL) was calculated as the average of running duration multiplied by intensity over a period of four weeks. What this study found, essentially, was that when a runner’s acute training load exceeded their chronic training load by 10 percent or more, the likelihood of an injury occurring within the next two to three weeks spiked.

The phrase “keep the ball rolling” is a summation of a training philosophy shared by a lot of today’s top running coaches that relates to the study I just described. I reflects the belief that the training process should aim toward slow, steady progress and avoid sudden leaps. Of course, a runner must first get the ball rolling in order to keep it rolling, and there’s inherent risk in this critical phase. But once you’re past it, the goal is to reduce the risk associated with workload increases as close to zero as possible without allowing progress to stall out altogether. This approach works best if you generally keep your chronic training load close to the highest sustainable level, which is to say the highest level you could keep up more or less indefinitely without burning out.

This study helped me better understand something I’ve noticed about my own running, which is that I don’t get injured as much as I used to. I’ve come to think this is largely because I keep the ball rolling. In the past, I kept repeating a cycle of getting injured, taking time off and losing fitness, getting healthy again and resuming training, going after big race goals, and getting injured again. I seldom took foolish risks in ramping up my training, but I reckon my ATL was more than 10 percent greater than my CTL more often than I realized. In any case, over time I learned what my body could and couldn’t handle, what it likes and doesn’t like, and today my personal training formula consists almost exclusively of what my body likes and can handle.

Keeping the ball rolling, for me, entails doing 14 hours per week of training in 12-12 sessions as a baseline. I repeat this routine week after week, with the majority of sessions (a lot of one-hour easy runs, uphill treadmills walks, indoor and outdoor bike rides, and elliptical rides; 30 minutes of strength training every third day) never changing. What do change are the key workouts: the higher-intensity runs and long runs. These become gradually more challenging and more race-specific as I get closer to my next targeted “peak.” The training load does increase, but very gradually, which keeps me healthier than I used to be and is okay from a fitness perspective because it’s pretty high even at baseline (except when I get COVID-19 and am out for an entire month).

Although I rely mainly on experience and tacit knowledge to keep the ball rolling in my training, there are some rigorous, quantitative online tools that runners of all experience levels can use to manage their injury risk by properly managing their training load. One is TrainingPeaks’s performance management chart, which tracks acute training load (“fatigue”) and chronic training load (“fitness”) continuously as you upload your training data. Another, which we’ve told you about in previous newsletters, is PWR Lab, an app that app analyzes smartwatch data to monitor injury risk and help runners make smart training decisions to stay healthy. PWR Lab is offering a coupon code that members of the 80/20 Endurance community.

Every runner should have a collection of mantras to use as appropriate in both training and racing. Add “Keep the ball rolling” to your collection.

Many runners don’t know how to train during the winter. They know that they should train, but they lack a clear sense of the purpose of winter workouts. And if you don’t know why you’re running, it’s difficult to determine how to run.

Objectives of Winter Training

Assuming you wish to be in good racing shape for one or more spring events, then your winter training has not one but three distinct objectives: developing general fitness, increasing durability, and improving body composition. Let’s take a look at each of these objectives.

Developing General Fitness

When you’re training for a specific event, you want to develop a type of fitness that is specific to that event. Although a 100 km mountain race and a 5000-meter track race both qualify as distance-running events, each demands a specific type of fitness that is very different from what the other requires. During the winter, however, when your next race is many weeks away, you want to be pretty good at everything rather than great at one thing. Therefore your training should be balanced, featuring a mix of easy runs, long runs, and faster runs at every intensity from marathon pace to full sprints, as well as a little hill work to boost your stride power.

While some runs should be harder than others, none of the runs you do during this period should be more than moderately challenging. For example, a good peak workout to do before a 10K race is 6 x 1 mile at 10K race pace with 1-minute passive recoveries between efforts. A more appropriate workout targeting the same intensity during the winter would be 6 x 1 km at 10K pace.

Increasing Durability

In order to get in peak shape for a race or series of races, you have to take some risks in your training. More precisely, you must train close enough to your limits that there’s a chance you might get injured or (less likely) become overtrained. One of the major objectives of winter training is to reduce the likelihood that you get injured or burn out later by increasing your body’s durability.

The most effective way to do this is to gradually increase your running volume until it reaches a level that is at or near the highest level that is indefinitely sustainable for you. If you plan to peak at 50 miles per week right before your next race, for example, build gradually up to around 40 miles per week during the winter.

What most runners fail to recognize is that, whereas running injuries are caused by running a lot (obviously), running a lot is also the best way to prevent running injuries. That’s because running increases the body’s ability to withstand the stress of running. Think of it this way: Who is more likely to get injured trying to run 50 miles in one week—a runner who routinely runs 40 miles a week or a runner who has never run more than 20 miles in one week? The answer is plain. The key to increasing durability through winter running is to find a mileage sweet spot that is relatively high for you but at the same time well within your body’s limits.

You can also increase your injury resistance through strength training and mobility work. You should do these things throughout the year, of course, but the winter is a good time to prioritize them because doing so will make your body more balanced before you start really piling on the miles. It is beyond the scope of this short article to offer detailed guidelines on strength and mobility training, but there are many good existing sources available. One that I recommend is Jay Dicharry’s book Running Rewired.

Improving Body Composition

You can’t race your best without being lean. Where body composition is concerned, form follows function, so you will tend to get leaner automatically as you train for peak performance. But the best time to prioritize shedding excess body fat is during the off-season, before you begin a race-focused training cycle. The reason is that when you are taking on training workloads that are close to your limit, you need to make sure you are eating enough to maximize performance and recovery. Attempting to sustain the sort of daily calorie deficit that is needed to shed body fat relatively quickly could pull the rug out from under your training. But during the winter, when your workloads are lower and you’re not concerned about maximizing performance, intentionally eating 300-500 fewer calories per day than your body uses will stimulate fat loss without negative consequences other than a little hunger.

Strength training also promotes a leaner body composition by increasing resting metabolism. The best types of exercises to use for this purpose are compound movements involving large muscle groups and performed with heavy loads. Examples are deadlifts and back squats. These are not the best exercises to do during race-focused training, when you’ll want to focus on movements that increase stability, but during the winter these bread-and-butter heavy lifts should come to the fore.

There are two rationales for changing the way you run. One is to improve performance by reducing the energy cost of running at any given pace. The other is to reduce injury risk. Scientific research going back decades has consistently shown that when runners intentionally alter their natural running form, they do not become more economical. In fact, they often become less efficient. But a separate thread of research has demonstrated that certain changes in running form do reduce the risk of particular injuries.

A new study published in the International Journal of Sports Medicine is the first experiment I know of that has investigated the effects of altered running form on both efficiency and injury risk in the same group of subjects. Sixteen runners, all of them heel strikers and all suffering from patellofemoral pain (a.k.a. runner’s knee), participated. Half of them were trained to switch from heel to forefoot striking while the others served as a control group. All of the runners were subjected to tests of running economy and were asked to subjectively rate the level of pain in their knees during running. Switching from heel to forefoot striking was found to have no effect on running economy either immediately following gait retraining or after one month of practice, but it did reduce knee pain.

These findings affirm the advice I’ve been giving runners for years: Don’t change the way you run for the sake of improving your running economy and performance. It won’t work. Instead, alter your running form only if you have suffered an injury that was caused by a correctible “flaw” (scare quotes used because it’s only a flaw if it causes an injury) in your running mechanics, the heel striking-runner’s knee link being one example.

Now, every time I make this argument, at least one skeptic counters that a month (or six weeks, or however long it is) is not long enough for the energy-saving effects of a form change to manifest. Runners, they say, need more time to adapt to their new running style. There are two problems with this objection. The first is that there is simply no evidence to support it. Studies lasting as long as 12 weeks have shown that the loss of efficiency resulting from modified running form persist despite continued practice. How long is enough? Six months? A year? What is the basis for the faith that switching to a forefoot striking pattern or reducing stride length or reducing vertical oscillation will eventually pay often when it has never been found to do so?

The other problem with the common objection to my advice on running form is that running form tends to improve over time in all runners. Coaches who do teach “proper” form have told me that in their own long-term testing they have observed improvements in running economy in runners whose form they’ve modified. But what these coaches don’t realize is that these runners would have become more efficient anyway, and in fact it they probably would have improved more if their form had been left alone to evolve naturally.

This is precisely why no runner should change his or her running style for the sake of performance. The human running stride is a self-optimizing system that advances automatically toward maximum efficiency through simple repetition. You can’t make it happen any faster through conscious manipulation. Like growing a beard, you have to just let it happen.

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