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What Do Recreational Runners Think About Risk Factors for Running

Injuries? A Descriptive Study Of Their Beliefs And Opinions.

Article in Journal of Orthopaedic and Sports Physical Therapy · August 2014

DOI: 10.2519/jospt.2014.5710 · Source: PubMed

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 [ research report ]
BRUNO TIROTTI SARAGIOTTO, PT, MSc1 • TIÊ PARMA YAMATO, PT, MSc1 • ALEXANDRE DIAS LOPES, PT, PhD1

What Do Recreational Runners

Think About Risk Factors for Running
Injuries? A Descriptive Study
of Their Beliefs and Opinions

R
unning is one of the most popular types of physical activity them feel happier, more relaxed, and en-
worldwide. The benefits attributed to recreational running ergetic.2,8,9 However, training less or stop-
ping can make some runners feel guilty,
include improvements in physical and mental health, weight
with greater irritability, less energy, and
control, stress reduction, and social participation.2,5,26 After even signs of depression and addiction.2,8
starting to run on a regular basis, runners report changes in their Despite the benefits of running, the
lifestyles, including better eating habits, better sleep, and decreased number of running injuries reported in
intake of alcohol and tobacco. They also report that running makes the literature is worrisome. The inci-
dence and prevalence of running-related
injuries have been reported to range be-
TTSTUDY DESIGN: Qualitative study based on 71 years were interviewed. Of those interviewed,
semi-structured interviews. the average running experience was 5.5 years and
tween 19% and 92%,16,17,26 depending on
the population studied and the definition
TTOBJECTIVES: To describe the beliefs and approximately 45% had experienced a running-
related injury in the past. The factors suggested by of running-related injury.11,26 In general,
opinions of runners about risk factors associated
with running injuries. the runners were divided into extrinsic and intrinsic running injuries are believed to have a
TTBACKGROUND: Despite the health benefits
factors. The most cited extrinsic factors were “not multifactorial etiology and are commonly
stretching,” “excess of training,” “not warming up,” related to overuse (repetitive microtrau-
of running, a high prevalence of injury has been
“lack of strength,” and “wearing the wrong shoes.”
reported in runners. Preventive strategies for run- ma that overloads the musculoskeletal
For the intrinsic factors, the main terms cited were
ning injuries may be more successful with a better structures).4,12 Some factors commonly
“not respecting the body’s limitations” and “foot-
knowledge of runners’ beliefs. associated with running injuries are a
type changes.”
TTMETHODS: A semi-structured interview of
TTCONCLUSION: Recreational runners mainly
history of previous injuries and poor
recreational runners was based on the question, training habits, such as running greater
“What do you think can cause injuries in runners?” attributed injury to factors related to training,
running shoes, and exceeding the body’s limits. weekly distances.26,31
Analysis of the interviews was performed in 3
steps: (1) organizing the data into thematic units, Knowing the factors identified in this study To create an effective strategy for pre-
(2) reading and reorganizing the data according may contribute to the development of better vention of sports injuries, Finch6 devel-
to frequency of citation, and (3) interpreting and educational strategies to prevent running injuries, oped a framework that takes into account
summarizing the data. The runner interviews were as some of the runners’ beliefs are not supported
the behavioral aspects of the athletes, in-
continued until no new beliefs and opinions of by the research literature. J Orthop Sports Phys
Ther 2014;44(10):733-738. Epub 25 August 2014.
cluding their beliefs and opinions about
runners regarding injuries were being added to the
data, indicating saturation of the topic. doi:10.2519/jospt.2014.5710 injury prevention. This framework com-
TTRESULTS: A total of 95 recreational runners TTKEY WORDS: prevention, qualitative research,
plements previous theoretical models
(65 men, 30 women) between the ages of 19 and running, shoes based on the understanding of the injury
etiology and its relationship to internal

1
Masters and Doctoral Program in Physical Therapy, São Paulo Running Injury Group, Universidade Cidade de São Paulo, São Paulo, Brazil. This study was approved by the
Research Ethics Committee of the Universidade Cidade de São Paulo (protocol 0084.0.186.000-11). The authors certify that they have no affiliations with or financial involvement
in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Bruno Tirotti Saragiotto,
Universidade Cidade de São Paulo, Rua Cesário Galeno, 448 Tatuapé, São Paulo, SP, Cep 03071-000 Brazil. E-mail: [email protected] t Copyright ©2014 Journal of
Orthopaedic & Sports Physical Therapy®

journal of orthopaedic & sports physical therapy | volume 44 | number 10 | october 2014 | 733
 [ research report ]
and external factors.19,27 The cognitive
aspects related to running-related inju- TABLE 1 Characteristics of the Participants (n = 95)
ries may be directly related to a runner’s
behavior toward prevention of injuries.
Understanding the runner’s beliefs has Characteristic Value
the potential to contribute to the de- Age, y* 40.1  12.6
velopment of more effective prevention Sex, n (%)
programs by taking into account the Male 65 (68)
pre-existing beliefs of runners as well as Female 30 (32)
the behavioral factors related to running Professional supervision (trainer or coach), n (%)
injuries. Yes 32 (34)
Further, the importance of investi- No 63 (66)
gating athletes’ attitudes and beliefs has Race participation, n (%)
been reported in recently published stud- Yes 54 (57)
ies18,29,30; however, only a few studies have No 41 (43)
investigated the potential relationship Number of training sessions per week* 3.7  1.4
between cognitive or behavioral factors Weekly distance, km/wk* 34.9  24.8
and injuries in sports. A systematic re- Experience, y* 5.5  5.5
view18 showed that out of 100 published Injury at the moment of the interview, n (%)
injury-prevention studies, only 11 clearly Yes 10 (11)
used behavioral or social theories. A re- No 85 (89)
cent qualitative study28 has suggested Previous injury, n (%)
that the beliefs and opinions of athletes Yes 43 (45)
and coaches should be included in pre- No 52 (55)
vention programs to increase the effec- *Values are mean  SD.

tiveness of these programs.

To our knowledge, no studies have during the data analysis. This study was to a text document. Another researcher
investigated the beliefs of runners about approved by the Research Ethics Com- (T.P.Y.) compared all the transcribed in-
running injuries. Thus, the aim of this mittee of the Universidade Cidade de São terviews with the recorded audio material
study was to describe the beliefs and Paulo, São Paulo, Brazil. All participants to confirm the accuracy of the transcrip-
opinions of recreational runners about read and signed the consent form, and tions. Before the interviews, all partici-
the risk factors associated with running their rights were protected. pants filled out a form about personal
injuries. data, training habits, professional super-
Data Collection vision during training, and injury infor-
METHODS All interviews were conducted by the mation (current and previous injuries).
same interviewer (B.T.S.). The interview- A running-related injury was considered
Participants er was trained to adopt a neutral position as any pain or discomfort associated

W
e conducted a qualitative while conducting the semi-structured with running that caused a restriction
study using semi-structured in- interview, so that the participant being on training or running activities. We also
terviews. Recreational runners interviewed could speak freely and con- considered professional supervision as
were recruited from different parks from tribute as much information as possible any supervision by a health professional
the city of São Paulo, Brazil. The inclu- about the topic. Runners were inter- (eg, trainer, coach, or physiotherapist)
sion criteria were (1) running for at least viewed until saturation of the theme was during individual or group training. No
6 months, (2) running a minimum dis- reached, which was determined when further investigations were performed re-
tance of 10 km per week, and (3) being no new information emerged in the in- lated to the accuracy or diagnosis of the
18 years of age or older. We designed the terviews. The semi-structured interview injury reported by the participants.
inclusion criteria to ensure that the par- began with the question, “What do you
ticipants had a minimum level of experi- think can cause injuries in runners?” Data Analysis
ence as runners. The sample size of this The interviews were audiotaped using A descriptive analysis of the character-
study was determined when interviews an Olympus VN-8100PC digital voice re- istics of the participants was performed.
did not add new information on risk fac- corder (Olympus Imaging Corporation, Analysis of the interview transcripts was
tors, leading to saturation of the theme Tokyo, Japan), and transcribed afterward performed in 3 steps: (1) organization

734 | october 2014 | volume 44 | number 10 | journal of orthopaedic & sports physical therapy
 was the second most cited, with “foot-
Intrinsic Factors Reported type changes” being the most quoted
TABLE 2
by the Participants term. This category is related to altera-
tions in the foot type that runners believe
Category/Factor Number of Citations may cause injuries (eg, pronated, highly
Personal characteristics pronated).
Overweight 8 For the extrinsic factors (TABLE 3),
Genetic predisposition 5 the majority of runners who were inter-
Lack of experience 4 viewed believed that training was the
History of injury 2 primary cause of injuries in runners. The
Anatomic abnormality 2 most cited terms in this category were
Older age 2 “not stretching,” “excessive training,” “not
Stress 1 warming up,” and “lack of strength.” The
Biomechanics/technique extrinsic category with the second highest
Foot-type changes 14 number of citations was running shoes,
Poor posture during running 7 in which “wearing the wrong shoes for
Wrong running technique 6 one’s foot type” was the most cited theme.
Running impact on the body 1
No foot-strike evaluation 1 DISCUSSION
Behavior

T
Not respecting the body’s limits 18 his is the first study, to our
Lack of attention during running 3 knowledge, to examine runners’
Haste to train more 2 beliefs regarding running-related
Fear of injury 2 injuries. The sample consisted of 95 rec-
Ignoring the pain 1 reational runners who were, on average,
Hurrying to participate in races 1 40 years of age, predominantly men, had
Competitive running 1 approximately 5 years of running experi-
Overprotection of injuries 1 ence, and ran on a regular basis (an av-
Other erage of 35 km per week). Additionally,
Bad luck 1 almost half of these runners had sus-
tained a previous running-related injury.
of the transcribed data into thematic RESULTS The primary extrinsic factors mentioned
units (words or phrases that described were not stretching (before or after train-

A
the themes presented in the participants’ total of 95 runners (65 men, 30 ing [running]), excessive training (run-
answers); (2) data exploration, which women) between the ages of 19 ning), and wearing the wrong running
involved the careful reading and organi- and 71 years were interviewed, shoes. The most frequently reported in-
zation of the data into categories (these leading to saturation of the topic, with trinsic factors were not respecting the
categories were created according to the no new themes emerging from the data. body’s limits and changes in foot type.
frequency of the thematic units identi- The characteristics of all participants are The interviewees mentioned “not
fied in step 1); and (3) interpretation of described in TABLE 1. Based on the data stretching” as a primary factor associated
the data and summarization. All authors analysis, intrinsic factors were divided with running injuries in this study. In the
approved the thematic units and catego- into 4 categories: personal characteris- following quotation, we can understand
ries created during the data analysis. Af- tics, biomechanics/technique, behavior, the power of this belief in runners: “…I
ter the data analysis, the categories were and other. Extrinsic factors were also believe that stretching is the main cause
divided into intrinsic or extrinsic factors. divided into 4 categories: running shoes, of running injury … when I run without
Intrinsic factors were those related to the nutrition, training, and other. stretching well before, I feel that I’m
individual characteristics of the runners, For the intrinsic factors (TABLE 2), running differently and I get worried…”
such as sex, age, anthropometric char- the category related to behavior was the (subject 11). Clearly, runners believe that
acteristics, and behaviors. The extrinsic most often cited by the runners. The most stretching before or after running may
factors were those related to the environ- common term cited in this category was prevent injuries, despite the lack of scien-
ment, climate, equipment, and training.20 “not respecting the body’s limitations.” tific evidence to support this belief. A sys-
The category of biomechanics/technique tematic review of randomized controlled

journal of orthopaedic & sports physical therapy | volume 44 | number 10 | october 2014 | 735
 [ research report ]
this conviction, which has become stron-
Extrinsic Factors Reported ger over the years.10 Another explanation
TABLE 3
by the Participants could be the belief that runners confuse
warming up before exercise with stretch-
Category/Factor Number of Citations ing. The term warm-up is defined as a pe-
Running shoes riod of preparatory exercise to enhance
Wearing the wrong shoes for foot type 22 subsequent competition or training.7 A
Wearing the wrong shoes for running 8 systematic review reported that studies
Shoes without cushioning 4 found warming up to be ineffective at
Heel too low 1 reducing injury when it focused mainly
Old shoes 1 on stretching, but studies that focused
Worn-down shoes 1 on warming up to increase body tem-
Low-quality running shoes 1 perature did find a significant reduction
Nutrition in the risk of sport injury.7 Educational
Inadequate/unbalanced diet 20 interventions are needed so that run-
Dietary supplements 1 ners understand the differences between
Training stretching exercises, which seem not to be
Not stretching 31 effective in prevention, and warming up
Excessive training 28 to increase the body’s temperature pre-
Not warming up 20 paratory to exercise, which may reduce
Lack of strength 19 injury risk.
No professional supervision 17 Runners also expressed great con-
Lack of physical fitness 11 cern about running shoes, as shown in
Irregular training 9 the following report: “…I think if you do
Excessive speed/pace 7 not have good shoes appropriate for your
Competitive training 4 foot type, you will get injured, since you
Training year-round 4 are wearing the wrong shoes…” (subject
Running uphill or downhill 4 21). Our findings show that many run-
Not following the program/orientation from the trainer/coach 4 ners believe that an inappropriate shoe
Not stretching properly 4 for running or their foot type may cause
Muscle fatigue 3 injuries. They also express concerns with
Sudden change in training intensity 3 lack of cushioning, the heel height, and
Not resting 3 excessive wear or usage time of the shoes.
High weekly distance 2 However, the few studies that have inves-
Poor orientation from the trainer/coach 2 tigated the influence of shoes on running
Training with advanced running groups 2
injuries show contrasting results with
Not stopping when tired 2
the runners’ opinions. Nielsen et al,21 in
Other
a recent 1-year prospective cohort study,
Obstacles (street holes, stones, road conditions) 6
found no significant differences in run-
Participation in races 3
ning distance before occurrence of the
Falls 3
first injury between different types of foot
Running while listening to music 1
postures (highly supinated, supinated,
pronated, and highly pronated) com-
trials32 on interventions to prevent run- association between stretching and the pared with neutral feet in novice runners
ning injuries concluded that stretching, development of injuries in runners.24 using the same type of shoe. Three large-
either before or after a session of running, A large number of publications have scale studies,13-15 performed with military
or even outside of running sessions, does shown that stretching does not reduce personnel, showed no difference in injury
not have a protective effect for running the risk of running injury.24,25 So why do risk between individuals who received
injury. This conclusion is in agreement runners believe that stretching prevents motion-control, stability, or neutral
with a recent systematic review of pro- injury? Reports of the mistaken belief shoes, based on their foot type, compared
spective cohort studies on risk factors for that stretching helps reduce muscle sore- with those who received a stability shoe
running-related injuries that found no ness after exercise may be the origin of irrespective of their foot type. Another

736 | october 2014 | volume 44 | number 10 | journal of orthopaedic & sports physical therapy
study23 found that runners identified as risks of overtraining is consistent with importance of foot type, and the use of
pronators wearing a motion-control shoe the literature; however, awareness about special running shoes were identified by
had a higher risk of injury than pronators rest and strategies to control the volume runners as important factors related to
wearing a neutral shoe. Additionally, in and intensity of training seems less un- running injuries, whereas the scientific
a systematic review, Richards et al22 con- derstood, and so should be promoted to literature does not support these beliefs.
cluded that prescribing running shoes runners. On the other hand, runners often cor-
based on foot type is not evidence based. Another factor commonly mentioned rectly mentioned excess training and not
Despite the general beliefs of the runners by the runners was not respecting or ex- respecting or exceeding the body’s limita-
who were interviewed, there is currently ceeding the body’s limitations. This factor tions, which have been shown in research
no evidence that the use of running shoes was similar to 2 other aspects, namely, ex- to be factors that may influence the prob-
based on foot type is effective in reducing cess training and the individual runner’s ability of injuries. Preventive running-
running-related injuries. It seems that perception of his or her body or train- injury programs should incorporate the
the runners’ belief about running shoes ing loads. A quotation from one runner beliefs of runners to improve effective-
based on foot type might have been in- shows how runners believe that the body’s ness and implementation. The beliefs
fluenced by media such as television, run- limits are individual and unique: “You identified in this study demonstrate that
ning magazines, and newspapers, as well can’t exceed your limits, because every- runners need more information on the
as the shoe industry. body has a limit and you need to respect research-related literature on risk factors,
Excessive training was reported by the it; everybody knows their own limits…” including clarification of the misconcep-
runners as one of the main factors related (subject 73). Knowing your own limits, tions previously identified. In addition,
to injury risk. The following quotation as suggested by some runners, seems to our findings may also help health profes-
from an experienced runner demon- be a subjective characteristic associated sionals to treat injured runners through
strates his concern about excessive train- with an individual’s perception about his a better understanding of runners’ beliefs
ing: “…Running excites me when I start or her own body and is difficult to mea- related to running injuries.
to run, when you are running you don’t sure. However, a preventive educational
want to stop, your body wants more, so program for runners may consider this CONCLUSION
you end up overloading your body and reasoning that many runners have about

T
get injured…” (subject 49). Some stud- respecting one’s body, not overstressing, he most frequently stated fac-
ies have associated the excitement or and respecting the presence of pain. tors leading to running injuries
pleasure of running with a certain state This study has some limitations. The mentioned by recreational runners
of dependency or addiction, which most convenience sample of runners inter- were related to training habits and run-
runners associate with a “good addic- viewed was selected from different parks ning shoes, such as not stretching, ex-
tion,” and perhaps with the numerous and races, and may not represent the cessive running, not wearing the correct
health benefits of running.2,3 However, opinions and beliefs of the entire com- running shoe, and foot-type changes. In
when excessive, running, similar to any munity of runners within and outside addition, many runners also mentioned
other sport or work activity, may cause São Paulo, Brazil. Because beliefs and the body’s limits and the importance of
damage to body structures, resulting in opinions are influenced by cultural back- respecting their bodies when running.
overuse injuries.1,12 This rationale seems ground, the outcomes of this study could We noted that some of the runners’ be-
obvious, but runners who tend to exces- be different in other cultural settings. liefs are not supported by the research
sively train appear to associate this excess Additionally, we did not investigate the literature. This study provides informa-
training to something more positive than source of the runners’ beliefs (ie, where tion on factors that recreational runners
negative, without adopting the necessary they get the information) that might have believe to be related to running injuries,
precautions to prevent excessive train- influenced their beliefs and attitudes. We and this knowledge may need to be con-
ing. A potentially effective strategy to interviewed a sample of recreational run- sidered when developing preventive ed-
avoid overtraining is periodic training: a ners; thus, the results of this study may ucational strategies for running injuries
progressive program of running, a strict not apply to competitive or elite athletes, and treating running injuries. t
control on volume and intensity, and add- who would likely have different sources
ing rest as part of training. The report of of information to mold their beliefs (eg, KEY POINTS
a runner who experienced a running in- coaches, health professionals). FINDINGS: The most frequently stated
jury reflects this rationale: “Some people This qualitative study demonstrates factors leading to running injuries men-
see rest as loss of training, but rest is part that runners have some misperceptions tioned by recreational runners were
of the training…” (subject 37). The be- about running-related injuries. For in- related to training, running shoes, body
lief of the interviewed runners about the stance, the practice of stretching, the limitations, and the importance of re-

journal of orthopaedic & sports physical therapy | volume 44 | number 10 | october 2014 | 737
 [ research report ]
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738 | october 2014 | volume 44 | number 10 | journal of orthopaedic & sports physical therapy
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