In January 2016, Melbourne city chiropractor Dr. Shannon published his first journal paper titled “Running Medicine: A Clinician’s Overview” which was published the the peer reviewed Chiropractic Journal of Australia. This paper would be the impetus for a series of journal papers Melbourne city sports chiropractor Dr. Shannon would go on to write which included papers co-authored by sports medicine physicians and orthopaedic surgeons on shoulder injuries, injuries in elite tennis players and sports concussion.

Below is a text copy of the paper with a link to the journal at the end.

INTRODUCTION

Running is associated with a variety of sports, but as a stand-alone activity its popularityhas exploded. Running is an efficient way to increase physical fitness and lose weight. As a result there has been a rise in charity fun runs and races [1, 2]. Today the number of recreational runners far exceeds competitive runners [3].


Like all physical activities there are injury risks associated with running, with injuries rates reported from 19-79% of participants per year [4]. Despite the great advancements in shoe technology and materials since the inception of the modern running shoe in the 1970s, running injury rates have remained largely unchanged [5].


Acute injuries in running are generally rare, with 80% of all injuries due to overuse. 37-56% of runners are expected to endure an overuse injury each year [1,6]. The most common injury sites in runners are the knee and Achilles tendon, which account for nearly 20% of all running injuries [6]. When expressed as a percentage of body part, the knee accounts for 25% of all injuries, followed by the lower leg (20%), the foot (16%), ankle (15%), upper leg (10%), hip/pelvis (7%) and the lower back (7%) [7].


The most prevalent injuries seen in runners are Achilles/calf injuries, iliotibial band injuries, meniscal injuries, patellofemoral pain syndrome, hamstring and quadriceps injuries [2]. Running injuries are associated with 2 consistent predictors, total miles run and previous injury [6].

With such high participation rates and high injury rates there is a strong probability that primary care physicians will see patients with a running-related injury. It is therefore important to understand the types of injuries runners have, the potential biomechanical and technique related-causes associated with running injuries and the different foot striking patterns runners adopt. This paper will provide an overview of the more common running injuries encountered in practice, the mechanical and technique deficiencies associated with running injuries and the different types of foot-striking patterns.

Discussion

Common Running Injuries Seen In Practice

There are scientists who believe we were born to run [9]. This was created out of a need to hunt for prey to survive and it is this belief that has driven the trend of barefoot running. When shoes are removed one can appreciate the anatomical complexities involved with running. This primarily involves the great toe, heel, ankle, knee, hip, pelvis and lower back. These are the areas which assist in absorbing the ground reaction forces associated with running, and higher ground reaction forces may be associated with a greater risk of injury [10,11].


Running injuries can be linked to overuse, higher ground reaction forces, previous injuries, orthotic inserts, and biomechanical and technique deficiencies [1,6,10,11]. These may result in complaints such as tendinopathies, tendon and muscle strains and tears, stress reactions and fractures [2,12,13]. Table 1 shows some of the more common running injuries seen in clinical practice.


Since 80% of running injuries are associated with overuse, it is important to establish the potential cause(s) of the injury, with many injuries being multifactorial [14-16]. Stress reactions and fractures are related to higher ground reaction forces, which are often associated with running kinematics. Mileage, improper footwear, training surfaces and poor musculoskeletal conditioning are associated with tendinopathies and strains.

Common Clinically Seen Biomechanical Deficiencies

Biomechanical and technique deficiencies have been identified as potential risk factors for running injuries [13,17,18]. One of the most common running injury, patellofemoral pain syndrome, which accounts for 17% of running injuries [19], has been linked to several different biomechanical factors, including reduced muscle strength and altered mechanical loading, lower limb kinematics and muscle activation patterns during running [20].

Table 1. Common running injuries

Lower limb kinematic studies tend to investigate the hip angle (flexion, adduction, drop, internal rotation), knee angle (flexion) and ankle angle (flexion, eversion, inversion) [21]. These joints are most prevalent in absorbing ground reaction forces and as a result, deficiencies here will lead to injury. Tables 2 and 3 show some of the deficiencies runners may have.

Table 2. Biomechanical deficiencies [22-24]

Since running injuries are multifactorial, treatment should focus on addressing all of the deficiencies involved with the injury. This may include rehabilitation and strengthening, changes in training habits, correcting technique errors and/or footwear, changes in step rate and alterations to foot strike [2,6,27].

Striking Patterns

Striking patterns refers to how a runner hits the ground with their foot. Runners can be a rearfoot striker (RFS), a midfoot striker (MFS) or a forefoot striker (FFS). RFS strikers account for 75% of all runners in traditional shoes, MFS 24% and FFS 1% [28]. RFS and FFS strikers exhibit differing load absorbing behaviors of the lower limb which can potentially lead to injuries or can potentially be used to help prevent injuries [26,28]. MFS impact loads sit in between RFS and FFS [28].


RFS have been shown to exhibit higher vertical impact peaks and load rates which have been associated with tibial shock,stress fractures, plantar fasciitis and patellofemoral pain [11,29,30]. RFS are also associated with increased loading of the muscles in the anterior compartment as a result of the dorsiflexed ankle. This may then lead to hypertrophy and increased pressures in the anterior compartment, and ultimately to exertional compartment syndrome [31].

Table 3. Technique deficiencies [25-27]

To combat the injury risks associated with RFS, a FFS pattern has been suggested as a way of reducing running-related injuries [26]. FFS has been shown to reduce patellofemoral contact force and patellofemoral stress [26]. There is also limited evidence to suggest that during the braking phase of the gait cycle, there is lower eccentric quadriceps work compared to RFS, potentially resulting in lower knee loading [32]. However, FFS results in greater plantar flexion of the ankle and this causes higher plantarflexion movement and Achilles strain, compared to RFS, which may increase the risks of foot and ankle injuries [25,33,34].


Step rate change (the number of steps per minute), has been associated with lower ground reaction forces and has been suggested as a possible avenue to help reduce the risk of running injuries. Forefoot running is closely associated with barefoot running and evidence suggests barefoot runners have reduced rates of loading compared to RFS in shod shoes, as well as a shorter stride length, which also has a load reducing effect [28]. Increasing the step rate by 5-10% helps to reduce bounce, lower extremity stiffness and moves the striking foot under the body. Reducing energy absorbed by the hip, knee and ankle and reducing the energy in the patellofemoral joint; however, it may increase the impact loading of the tibia if the rate is greater than 164 steps per minute [27].

CONCLUSION

Due to the high participation and injury rates seen in runners it is important for primary care physicians to be aware of the more common running injuries, the deficiencies that potentially contributed to the injury and how foot strike pattern may contribute to injuries but may also be beneficial in treating running injuries. When working with runners a multifactorial approach is required to improve lower limb strength, correct any malalignments and reduce ground reaction forces through strategies like changes to training habits, strengthening programs and changes to step rates and foot striking.

The article can be found at the Chiropractic Journal of Australia website. If you would like to read more about running related injuries you might find our blog on “Running Injuries Slowing You Down?” or our article in The Australian Chiropractor magazine on Achilles Tendinopathy.

If you are struggling with a running related injury or keep breaking down with injuries, make an appointment to see Melbourne city chiropractor Dr. Shannon today. Additionally, for those looking for sports massage to help flush their legs during training, our Melbourne remedial massage therapist Paula Pena is available. Our Melbourne CBD chiropractic clinic is located on Collins Street, opposite the Melbourne Town Hall.

REFERENCES

1. van der Worp, Maarten P, ten haaf, Dominic SM, et al. Injuries in runners: A
systematic review on risk factors and sex differences. Sports Med 2015; 45(7):1017-26.
2. Fields Karl B. Running injuries: changing trends and demographics. Current Sports
Med Rep 2011; 299-303.
3. Running USA. Running USA’s Annual Marathon Report [Internet]. 2011. Accessed
Aug 2015. Available from: http://www.runningusa.org/node/76115#76116.
4. van Gent RN, Siem D, van Middelkoop M, et al. Incidence and determinants of lower
extremity running injuries in long distance runners: a systematic review. Br J Sports
Med 2007;41:469Y80.
5. Richards CE, Magin PJ, Callister R. Is your prescription of distance running shoes
evidence-based? Br J Sports Med 2009;43(3):159–62.
6. van Mechelen W. Running injuries. A review of the epidemiological literature. Sports
Med 1992;14(5):320–35.
7. Epperly T, Fields KB. Running epidemiology. In: Wilder, RP and O’Connor, FG
editors. Textbook of Running Medicine. New York: McGraw Hill. 2001:3-9.
8. Boven AMP, Janssen GME, Vermeer HGW, et al. Occurrence of running injuries in
adults following a supervised training program. Int J. Sports Med 1989;10 (Suppl.
3):S186Y90.
9. Bramble DM, Lieberman DE. Endurance running and the evolution of Homo. Nature
2004; 432:345Y52.
10. Milner CE, Ferber R, Pollard CD, Hamill J, Davis IS. Biomechanical factors
associated with tibial stress fracture in female runners. Med Sci Sports Exercise
2006;38(2):323–8.
11. Zadpoor AA, Nikooyan AA. The relationship between lower extremity stress
fractures and the ground reaction force: a systematic review. Clinical Biomechanics
2011;26(1):23–8.
12. Walther M, Reuter I, et al. Verletzungers und uberlastungsreaktionen im laufsport.
Othopade 2005;34:3999.
13. Taunton JE, Ryan MB, Clement DB, et al. A prospective study of running injuries:
the Vancouver Sun Run “In Training” clinics. Br J Sports Med 2003;37:239–44.
14. Hoeberigs JH. Factors related to the incidence of running injuries. A review. Sports
Med 1992;13:408–422.
15. Macera CA. Lower extremity injuries in runners. advances in prediction. Sports Med
1992; 13:50–57.
16. Noehren B, Hamill J, Davis I. Prospective evidence for a hip etiology in
patellofemoral pain. Med Sci Sport Exercise 2013;45(6):1120-1124.
17. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle
activation between subjects with and without patellofemoral pain. J Orthop Sports Phys
Ther 2009;39(1):12-19. 18. Ryan MB, MacLean CL, Taunton JE. A review of anthropometric, biomechanical,
neuromuscular and training related factors associated with injury in runners. Int J Sports
Med 2006;7:120–37.
19. Taunton JE, Ryan MB, Clement DB, McKenzie D.C., Lloyd-Smith D.R., and Zumbo
B.D.: A retrospective case-control analysis of 2002 running injuries. Br J Sports Med
2002;36:95-101.
20. Escullier JF, Roy JS, Bouyer LJ. Lower limb control and strength in runners with and
without patellofemoral pain syndrome. Gait Posture 2015;(41)3: 813-819.
21. Napier C, Cochran CK, et al. Gait modification to change lower extremity gait
biomechanics in runners: a systematic review. Br J Sports Med 2015;(0):1-8.
22. Ross JA. Examination of the foot and ankle and when to return to play. American
College of Sports Medicine, Annual General Meeting, San Diego, May15-17, 2015
23. Davis I. Reducing injury risk with soft, well aligned landings. American College of
Sports Medicine, Annual General Meeting, San Diego, May15-17, 2015.
24. Franz JR, Pavlo KW, et al. Changes in the coordination of hip and pelvis kinematics
with mode of locomotion. Gait Posture 2009;29(3):494-9.
25. Kumar D, McDermott K, et al. Effects of form focused training on running
biomechanics: a pilot randomised trial in untrained individuals, Phys Med Rehabil 2015
(epub ahead of print).
26. Kulmala JP, Avela J, et al. Forefoot strikers exhibit lower running induced knee
loading than rearfoot strikers. Med Sci Sport Exercise 2013;2306-2313.
27. Heiderscheit B. Another step to improve running injury management. American
College of Sports Medicine, Annual General Meeting, San Diego, May15-17, 2015
28. Altman A and Davis IS. Barefoot running: biomechanics and implications for running
injuries. 2012. Current Sports Med Rep; 244-250.
29. Bowser BJ, Davis IS. A prospective study of loading variables in female runners
who develop plantar fasciitis. In: Proceedings of the American Society of Biomechanics,
Providence (RI), 2010.
30. Pohl MB, Hamill J, Davis IS. Biomechanical and anatomic factors associated with a
history of plantar fasciitis in female runners. Clin J Sport Med 2009;9:372Y6.
31. Kirby RL, McDermott AG. Anterior tibial compartment pressures during running with
rearfoot and forefoot landing styles. Archives Phys Med Rehabil 1983;64:296Y9.
32. Arendse RE, Noakes TD, Azevedo LB, Romanov N, Schwellnus MP, Fletcher G.
Reduced eccentric loading of the knee with the pose running method. Med Sci Sports
Exercise 2004; 36(2):272–7.
33. Perl DP, Daoud AI, Lieberman DE. Effects of footwear and strike type on running
economy. Med Sci Sports Exercise 2012; 44(7):1335–43.
34. Williams D, McClay I, Manal K. Lower extremity mechanics in runners with a
converted forefoot strike pattern. J Applied Biomechanics 2000; 16:210–8.

Melbourne sports chiropractor Dr. Shannon has been working in sports and exercise medicine since 2007, the same year he open his Melbourne city chiropractic clinic on Collins Street. Since then Dr. Shannon has undertaken further studies in the sports medical field, published papers, worked at a variety of elite sporting events and a variety of elite athletes both domestically and overseas. You can find more specifics by reading through “about sports chiropractor Dr. Shannon’s profile”.

Sports Chiropractor In The Press

In 2016, following on from working at the Macau GP, IRB Hong Kong Rugby 7’s and completing further sports and exercise medicine training in the US and Hong Kong, Melbourne city chiropractor Dr. Shannon was approached by Fairfax journalist for the Sydney Morning Herald and The Age Joshua Jennings to discuss the experience Dr. Shannon had during the IRB Hong Kong Rugby 7’s tournament, in addition to his career in sports chiropractic and sports medicine up to that point.

In these discussions sports chiropractor Dr. Shannon shed light on what it is like to be a part of the medical support team that covers an international event like the IRB Hong Rugby 7s, which at the time also included providing pitch side coverage to the lead up supporting events during the week which was called the “Hong Kong Rugby Fest“. This involved a domestic competition, as well as an international schoolboys competition which invited various aged school boys from a select number of countries across Asia.

Melbourne Sports Chiropractor Reflects

As wonderful experience it was to share sports chiropractor Dr. Shannon’s experience and passion for working in sports chiropractic and sports medicine, on reflection Dr. Shannon feels the attention of internationally renowned events like the Hong Kong 7’s can deflect from where the real pitch side trauma care is needed in sport; school and amateur level sports. What wasn’t covered in the article is that during the Rugby Fest there were more consistent high grade injuries seen than in the professional competition. Injuries Melbourne city chiropractor Dr. Shannon personally oversaw included an ACL rupture in a female athlete, a fractured wrist in a school boy, a concussion with an associated central cord neuropraxia amongst a host of cuts and abrasions. The toughest part being once a pitch side diagnosis was made, in many cases there was no avenue to allow for a follow up with the athlete to make sure they were receiving the appropriate care and treatment.

Following on from this experience, Dr. Shannon has continued working in elite sport, and has written various published papers on sports medicine related subjects including sports related concussion and injuries in elite tennis players with domestic and internationally renowned sports medicine physicians and orthopaedic surgeons.

To read The Age article you can find it here:

Dr. Nicholas Shannon – Sports Chiropractor