Sports Medicine Research: In the Lab & In the Field: Follow TRAILS to Understand Running Injuries (Sports Med Res)


Monday, June 18, 2018

Follow TRAILS to Understand Running Injuries

A 2-Year Prospective Cohort Study of Overuse Running Injuries: The Runners and Injury Longitudinal Study (TRAILS).

Messier SP, Martin DF, Mihalko SL, Ip E, DeVita P, Cannon DW, Love M, Beringer D, Saldana S, Fellin RE, Seay JF. Am J Sports Med.  2018 May 1:363546518773755. doi: 10.1177/0363546518773755. [Epub ahead of print]

Take Home Message: Among recreational runners, females and those with greater knee stiffness (often runners with a higher body mass) were more likely to develop overuse injuries.  Many long-established factors (e.g., arch height, Q-angle) had no relation with new overuse injuries.
While running is a popular form of physical activity, the causes of running injuries remain a mystery. Very few researchers have followed runners over a long time and completed a comprehensive assessment of risk factors. Therefore, the authors undertook a prospective study to identify risk factors associated with running-related overuse injuries. The authors recruited 300 active recreational runners who ran 5-100 miles/week, with an average of 11 years running experience. At the start of the study, participants provided information regarding training behaviors and completed physiologic testing (i.e., flexibility, arch height, Q-angle, strength) and a biomechanical gait assessment. They also completed questionnaires on psychosocial factors (i.e., self-efficacy, mental and physical quality of life, life satisfaction, positive or negative affect, anxiety, and pain). The authors then followed the runners for 2 years. Runners completed biweekly surveys to disclose any injuries and changes to training or footwear. They also completed questionnaires at 6- and 12-months. When a runner reported an injury, they were seen by the study physician and physical therapist. The authors to conclude three main results: 1) women were more likely to have an overuse injury than men (73% and 62%, respectively); 2) runners with higher body mass (>80kg) tended to have greater knee stiffness while running, which increased the odds of having an overuse injury; and 3) lower extremity strength and flexibility, arch height, Q-angle, rearfoot motion, weekly mileage, footwear, and previous injury were not major factors contributing to running-related overuse injury. Additionally, injured runners reported worse mental health-related quality of life and more negative emotions at baseline than runners who remained injury free. However, this relationship did not stay significant after adjusting for other factors and likely doesn’t directly influence injury risk.

The complex causes of running-related overuse injuries have perplexed clinicians and researchers alike for decades. Some long-established factors (previous injury history, weekly mileage, footwear, strength and flexibility) were unrelated to new overuse injury. Concentric hip, knee, and ankle weakness are highly debated injury risk factors in runners. The investigators reported no relationship between these risk factors and overuse injury. They suggested that rather than strength, neuromuscular control may contribute to injury; however, this hypothesis needs to be tested. The differences between the injured and uninjured runners regarding baseline mental health-related quality of life is interesting because it may shed light on the contribution of mental health on the overall physical health of active individuals. The authors acknowledge more research is needed to further understand how psychological factors relate to physical injury. Overall, the authors could only account for 12% of the variance to predict injury, which indicates there are other unidentified factors contributing to these injuries. The authors think injured runners are unable to withstand the repetitive and increased loads sustained while running thus “overwhelming the tissues’ resiliencies.” However, measuring tissue physiology is not an easy feat, thus the influence of this remains unknown. A major limitation of this study is the lack of re-assessment of any biomechanical or physiological measurements, which could have provided further insight into the multifactorial nature of risk factors for sustaining a running related injury. In the meantime, clinicians should perform pre-injury screenings on at-risk female runners or individuals with a body mass >80kg and monitor their progress during training to catch any inclinations of overuse injury development.

Questions for Discussion: Do you take into consideration psychological factors in addition to physiological mechanisms when designing a treatment plan for injured runners? Should we stop assessing a runners’ baseline concentric strength and solely focus on neuromuscular control?

Written by: Danielle M. Torp
Reviewed by: Jeffrey Driban

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