Common Overuse Injuries
Although stress fractures and patellofemoral pain syndrome are the most common running-related injuries among women, other overuse injuries can occur in female runners, including iliotibial band syndrome, plantar fasciitis, and Achilles tendonitis. These injuries are common in both recreational and experienced runners who increase their training load too quickly.
Iliotibial Band Syndrome
Iliotibial band syndrome (ITBS) is the most common cause of pain on the outside of the knee among runners and occurs from repetitive friction of the iliotibial band against the outside of the knee. The iliotibial band is a sheath of connective tissue that runs down the thigh from the hip to just below the knee (see figure 13.4). The main functions of the iliotibial band are to assist with outward movement of the thigh and to stabilize the outside of the knee. Symptoms are typically progressive and often begin with a sensation of tightness on the outside of the knee. Pressing on the outside of the knee while flexing it usually reproduces the pain. With time and continued activity, the tightness progresses into a localized pain or burning sensation on the outside of the knee. Some runners experience a clicking sensation caused by the iliotibial band tightening and snapping across the joint when the knee flexes and extends. The symptoms are often worse when running downhill.
Excessive or abrupt increases in mileage, preexisting iliotibial band tightness, running downhill, too much running around a track in one direction, too much running on cambered road surfaces, stiff shoes that limit pronation, highly arched feet that don’t adequately pronate (which transfers the shock of landing to other parts of the leg), and hip and gluteal muscle weakness contribute to this injury. Running mechanics, specifically internal rotation of the leg and changes in knee flexion as the heel strikes the ground, also appear to contribute to ITBS. Runners who have ITBS have greater knee flexion at heel-strike, a greater strain in the iliotibial band while the leg is on the ground during the running motion, and greater internal knee rotation at the end of a long, exhausting run than runners who don’t have ITBS.
Traditional treatment of ITBS has focused mainly on stretching and pain reduction. Rest from running may be necessary, along with ice and stretching. Cross-training that does not aggravate the condition can be done to maintain fitness. Using a foam roller can help mobilize, or loosen, the iliotibial band and surrounding tissues. A foam roller is a firm foam log about 6 inches in diameter available in various lengths. To use a foam roller effectively, lie on your side with the affected iliotibial band on top of the foam roller. Roll forward and back so that the foam roller moves between your knee and hip bones, using your body weight to apply pressure. Foam rollers can be purchased at sporting goods stores or ordered online. Massage also works well. Strengthening the hip and gluteal muscles, which improves control of the leg when it first lands on the ground can also alleviate symptoms. As with most injuries, the longer you experience symptoms the longer it may take to recover.
Achilles Tendinitis and Tendinosis
Achilles tendinitis and tendinosis are the most common forms of tendon injuries in runners. Runners, male and female alike, have a 30 times greater risk of developing Achilles tendon problems than nonrunners do. The Achilles tendon attaches the two calf muscles (gastrocnemius and soleus) to the heel and is the thickest and strongest tendon in the body. While inflammation (tendinitis) may contribute to your symptoms in the first few days, the symptoms are the result of a degenerative process (tendinosis) in the collagen fibers that make up the tissue. Over time, the fibers may weaken, leading to tearing of the tendon, although this occurs more commonly in males.
Regardless of the distinction, the symptoms are the same: a gradual onset of pain over the Achilles tendon. In mild cases, pain may occur only when running. As it becomes more severe, pain may be present during your normal daily activities or even at rest. The tendon area will become tender to your touch and visibly swollen. Pinching the tendon between your thumb and forefinger usually reproduces the pain.
Injury to the Achilles tendon occurs when the amount of stress on the tendon exceeds the ability of the tendon to adapt to the load. Factors that contribute to Achilles tendon problems include training errors such as too rapid of an increase in mileage, too much interval training or hill running, inadequate recovery between sessions, highly arched feet, calf weakness, and inflexible calf muscles.
Similar to treatment of other overuse injuries, initial treatment includes rest and activity modification. Activities that do not load the tendon, such as swimming or cycling, are alternatives while your tendon recovers. Evidence suggests that the most effective treatment for Achilles tendinosis is calf strength training with eccentric contractions (lengthening the muscle fibers as a load is applied) because it helps form new collagen, which is the main component of the tendon. Eccentric training can be done by performing a heel-drop exercise on a stair or step (see page 176). This exercise lengthens the muscle fibers as a load (your body weight) is applied. Heel lifts and orthotics are widely used despite limited evidence of their effectiveness. Interestingly, since the introduction of shoes that control pronation, an increase in Achilles tendon injuries has occurred. A recent review of research failed to identify any controlled, clinical trials to support their use in treating Achilles tendonitis.
Plantar fasciitis can be a debilitating injury for runners. A band of connective tissue on the bottom of the foot that runs from the heel to the toes, the plantar fascia acts like a ligament that helps support the arch of the foot when you run. Similar to Achilles tendinitis, plantar fasciitis is a degenerative condition. As a result of this degeneration, microscopic tears occur with overload and the plantar fascia loses its ability to support the arch. The result is heel pain, frequently on the inside edge of the heel, or pain along the arch. The pain is often worse during the first steps in the morning or after prolonged sitting, but it decreases with activity and then aches afterward. As the condition becomes more severe, the pain may be present all the time when walking and running. Both flat feet and highly arched feet can be risk factors, although research is divided on this issue. Tight calf muscles and weakness in the muscles in the sole of the foot can also increase your risk of plantar fasciitis.
Plantar fasciitis can be a stubborn injury. Numerous treatments have been used with limited evidence of their effectiveness. Once believed to be beneficial, current evidence no longer supports shockwave therapy. Avoiding the aggravating activity, stretching and strengthening the calf muscles, and strengthening the muscles of the foot can improve symptoms. Tension night splints, which hold the foot in a flexed position while you sleep, may be helpful. Orthotics may also help to reduce symptoms by decreasing tension in the plantar fascia. Studies have found no difference between the effectiveness of prefabricated or custom-molded orthotics. Although it is not something that runners like to hear, rest may be the best option. Of people with plantar fasciitis, 80 to 85 percent of them will experience a significant decrease in pain within the first six months regardless of the treatment used.