There is nothing more infuriating than not being able to run due to injury, or running with a ‘niggle’ that slows you down. But what is your ‘Injury Tipping Point?
Dave Mott from Physio Fitness in Bournemouth has over 22 years’ experience dealing with elite sportsmen and sportswomen. He understands the frustration involved when you can’t run because your body isn’t letting you. Here he explains why and how injury occurs. Armed with this knowledge, Dave will help you form a strategy to minimise your chances of stopping running due to injury.
What is the Injury Tipping Point?
A published running injury review found that for the average recreational runner who is steadily training and who participates semi-regularly in a long-distance event, the overall yearly incidence rate for a running injury is between 37% and 56%. And a more recent Scandinavian study found the incidence rate of running-related injury to be as high as 92.4%!
The sad fact is that if you’re in the very small percentage of runners who’ve not already had an injury, you are probably due one… or two, or three. Great news for us physios waiting in the wings. But if you don’t fancy helping your local physio pay off their mortgage, you need to pay attention!
There are essentially two categories of factors involved in the aetiology of running injury: intrinsic and extrinsic. The intrinsic factors involve your body and its makeup and function. The extrinsic factors are everything external to your body that has an influence on your running.
There are many combinations of factors that cause a running injury, but generally it takes two or three factors across both intrinsic and extrinsic categories to take you beyond the Injury Tipping Point (ITP). The most common cause will be a combination of muscle tightness, weakness in the gluteals, and sudden changes in training load.
Often the intrinsic factors have been present or gradually getting worse over many years (for example, tight calves and stiff ankles), but the addition of increased running load, such as hill running, may well take you over the ITP. Previous injury like an ACL (knee ligament) tear many years ago combined with tight quadriceps may not have been a problem until a new pair of trainers caused an increased heel strike taking you over the ITP.
By now you should be getting the gist of the ITP and maybe an idea of how close you are to it. It wouldn’t be unusual for someone to be permanently dipping above and below the ITP. You might call them, or yourself, ‘injury prone’!
Once you have this idea of how injury can occur, you’ll probably be able to visualise your position on the ITP spectrum. Whether you think you are close or far from it at this moment in time, there are factors such as pelvic control, core stability, weakness and tightness that tend to ‘creep up’ on you over time, taking you ever closer to the ITP.
Staying away from the Injury Tipping Point
As we have said, injury can occur if several of these factors (usually a combination of intrinsic and extrinsic) get worse and accumulate. We will be mainly addressing the intrinsic factors, which are essential to minimise injury risk.
Think of a car with poor suspension, low tyre pressure, rust and poor wheel balance. These are all intrinsic factors that will make it vulnerable to breaking down or crashing if it’s driven fast, driven on rough ground, or made to brake quickly (extrinsic factors).
Every individual will have a unique set of intrinsic factors that may or may not have an influence on their injury risk.
If there is a single set of muscles that influence injury or running performance in equal measure, more than any other muscles, it will be the gluteals. Let’s be more specific: the gluteus maximus (GMax) and gluteus medius (GMed).
These two muscles can be dysfunctional in a variety of ways. They can also be dysfunctional individually or together as a pair. So, a runner could have good functioning GMax muscles, but poor GMed, or vice-versa. The runner could also have differences between their right side and their left. There can also be differences in the timing of the muscle activation, in particular, the GMax – a runner could have a late-activating GMax, again on one or both sides.
There are many different combinations of gluteal dysfunction. It’s not as simple as just saying a runner has ’weak glutes’. As a runner, only by understanding your specific gluteal dysfunction, do you stand a chance of producing a training/rehab programme that will minimise your injury risk and maximise your performance potential.
Testing your gluteal muscles
At Physio Fitness, we do a series of simple tests to tell us what gluteal dysfunctions runners have. We can then be very specific about what running drills and exercises to prescribe. This produces extremely effective results in terms of recovery from injury, reducing injury risk and maximising performance.
We are going to show you one of the tests and what it could mean to you as a runner, in terms of gluteal dysfunction. This will give you an idea of your specific pattern of gluteal dysfunction and hence help you understand what needs to be done to address these issues. We use a GMed dysfunction test (one of three tests, but this tells us most information): a single leg partial squat.
As a physio, we would look at the runner from the front to assess many potential dysfunction possibilities. However, here we’re suggesting you watch yourself in the mirror and assess yourself. Watch out for: knee drop, hip drop, side bend and knee drop combined with hip drop. All these possible scenarios indicate a degree of GMed weakness.
Runners demonstrate GMed weakness in a variety of ways but, essentially, however they perform the above test usually means they run with that particular type of pattern with every step (remember, running is a single leg sport!). Now, imagine running with any of the above mechanics and relate that to unwanted pressure on the hips, knees, ankles, Achilles, back, etc.
A good single leg squat
What you should notice is that the angle between the pelvis and the thigh bone (femur) is 90 degrees. All of the other scenarios shown here have an angle less than or greater than 90 degrees. For example, in the image showing a hip drop, there is a more acute angle (probably about 60 degrees) compared to the correct squat position.
Prone hip extension
There are other tests for the GMax as well. Here is a good example: prone hip extension. Perform this simple move, but feel for your GMax activity (put your hand on your bum!).
There are three possible outcomes:
- Your GMax works straight away (that’s a good thing)
- Your GMax activates late (ie, when the leg is already in the air)
- Your GMax does not activate at all (not helpful for runners!)
As a physio, I’m always amazed at how many runners we see that have scenarios 2 or 3. If you fall into either of these categories, there are several exercises that will help, but over the last few years I’ve tended to give the single best exercise (in my opinion): running backwards!
If you have weak GMeds, there are many strengthening exercises to help address this. Most injuries occur with repeated repetitions with an intrinsic factor, such as weakness of GMed causing poor mechanics in combination with another intrinsic factor (eg tight calves) and an extrinsic factor (eg old worn-out trainers). If each factor is addressed individually, the likelihood of injury or repeated injury will reduce drastically.
There are many GMed exercises available, but beware! There are some good, some not so good (they encourage ITB tightness), and some great ones.
So, you now have great glutes (maybe!). But this means nothing if your extrinsic factors are problematic.
The main factors that affect the ITP are the top two factors we listed earlier: training errors and/or inappropriate footwear. A good running shop will help you with footwear. However, training errors can be the most problematic. I would say that increasing your speed and distance too quickly are the most common reasons.
Also, introducing hills too soon. Some runners will do a combination of some or all of these; combined with poor glutes, they will no doubt go over the ITP and create injury.
The type of injury you might incur depends on other intrinsic factors that relate to the area of injury. For example, poor GMed causing a knee drop combined with a tight gastrocnemius (calf muscle), could easily contribute to Plantar Fasciitis (heel pain) or Achilles Tendonopathy (Achilles tendon pain).
But a weak GMed causing a hip drop combined with a tight ITB (Ilio Tibial Band) might contribute to a Trochanteric Bursitis (pain on the side of the hip) or ITB Friction Syndrome – pain at the outside of the knee). A side bend scenario is more likely to contribute to Facet dysfunction (low back pain) or hip joint issues.
The final word
As a recap, it is so important to recognise that several factors contribute to injury. You might think that an injury ‘came out of the blue’, or that you ‘slept funny and woke up in pain’, but the reality is you had an existing intrinsic factor or two and overdid or created an extrinsic factor that took you over the Injury Tipping Point causing pain or discomfort.
Inflammation takes about 12-24 hours to manifest itself, so it’s common to wake in the morning, or the following morning, with pain. You may think you’ve done nothing to cause the injury, but the intrinsic factors can take weeks, months and even years to develop, and the extrinsic factors, especially related to training errors.