If this book had been written without thought for any downside to running, we would have done readers a great disservice. It would be naive in the extreme to imagine that it is possible to run and exercise in a more efficient manner without meeting some of the pitfalls that almost every runner encounters at some time. Some of these are beyond human control, but others are
certainly preventable if thought is given to the long-term aim of the training program.
    If the exercises in this book are followed, the time allocated both to exercise and to running will increase. One handy rule is never to step up either the mileage or the time spent running by more than 5 to 10 percent per week. This cannot apply in the initial stages of a training schedule, where less than 10 miles a week are run, but above these levels, this guide will help to prevent overuse
injuries. Pain is probably the best warning sign of injury, but it may appear in a variety of forms. Although the suffering that occurs during a tough training session is probably ultimately beneficial in the improvement of performance, the experienced runner will soon learn to recognize pain in other parts of the anatomy that does not disappear when the exercise has ended.
    External factors that may induce injury include the surface run on and the clothing and shoes worn by the runner. The force of landing with something like three to four times your body weight onto concrete affects the joints much more than a more forgiving and softer surface like sand or even snow. Too many runners use only one side of a road and forget that the camber will pitch
them toward the sidewalk and cause a tilt to the pelvis, which may translate into a twisted lower back or strain to the ligaments of the ankle joint. Running demands thought just as much as other sports that require different skills. It is too easy to be dazzled by a new pair of running shoes, which cause blistering on the first occasion on which they are used, simply because you forgot to
break them in. All shoes and clothing should be worn in but not worn out!
    Because the diagnosis of injury is likely to be complex, any unexplained pain or symptom should be rapidly assessed by a professionally qualified doctor. However, a considerable number of commonsense first aid measures can and should be taken in the early stages of injury.
    It would seem sensible to follow the guidelines that any doctor would use. First, take a history. Ask yourself these questions: Was the injury sudden, or did it build up over a series of runs? Does it cover a small area, or is it more diffuse? Does it hurt to touch? Does it disappear with rest? There are countless more questions, but the object is to make you think about the injury. Next, a doctor will look at the injury. Observation can distinguish asymmetry, swelling, discoloration, and so on. You can do the same in a mirror. Only this stage of examination by gentle palpation, followed by active and passive movement, will elucidate the cause. By this stage there may be a differential diagnosis, a choice of likely and then less common causes. If the diagnosis is pretty much certain, first aid treatment can begin; if not, further tests can be arranged after a visit to the doctor. To a certain extent these can run concurrently, as treatment can be started while test results are awaited. If the results suggest a different diagnosis, then treatment can be amended. The diagnosis and treatment phases of an injury should be interrelated and reciprocal so that if the one is questionable or ineffective, then the other can be reviewed and reassessed.
    The areas of the body that are likely to suffer most from running are the lower back, the groin, the muscles of the leg, the knee and ankle areas, and the feet. The tissues that suffer most are joints, bones, ligaments, muscles, and tendons. Some choice!
    A typical muscle tear is most likely to occur if the runner overstretches between two joints, especially if a halfhearted warm-up procedure has been used. The pathology behind this is that a blood vessel inside the muscle will be pulled beyond its limits, burst, relatively flood the area with blood, and stop bleeding only when the counterpressure exerted by the surrounding soft tissues or strapping is equal to that of the blood seeping out. The pressure of this bleeding causes pain in the soft tissues and is always a good indicator of injury. Cooling is another major factor that speeds up healing, so the rapid application of an ice pack to any acute injury, muscle or otherwise, is unlikely to do much harm; if it limits the swelling, it may well reduce the time spent in recovery.
    Statistically, the back and the knee are the most commonly injured sites for runners. A runner's back pain will usually be localized to the lower lumbar and sacral areas (figure 10.1), and all too often it is a result of repetitive training with a lack or loss of low back flexibility, accompanied by attempts to run through the pain. It may be related to poor posture, a real or artificial difference in leg length (such as what occurs with the camber running referred to earlier), or a sudden move to hill work. If there is any suggestion that the pain is referred down either leg or is associated with numbness or weakness of the limb, then this could signify a more serious condition such as a prolapsed intervertebral disc, for which a more urgent medical opinion should be sought.


    Much the same is true of the knee (figure 10.2). An injury followed by swelling or locking within the joint, especially if this happens rapidly over a few hours, is not a simple runner's knee and needs prompt diagnosis. Runners are more prone to patellofemoral pain as a result of the failure of the patella to glide through the center of the groove at the base of the femur rather than
severe internal disruption as might occur with a skiing or football injury. When we stand, our knees and ankles are usually together, but the hip joints can be separated by 12 inches or more. The effect is that when the quadriceps muscles contract, the forces of nature pull the patella laterally and twist it within the femoral groove. The vastus medialis muscle counteracts the pull of the outer
quads, but can do so only if it has been strengthened and developed sufficiently, which requires it to be exercised with the knee locked and extended. If pain can be localized, it is easier to diagnose the cause. Pain on the outside of the lower thigh is in all probability a result of iliotibial band (lTB) syndrome, in which this piece of generally inelastic connective tissue rubs against the
lateral condyle of the femur. If appropriate exercises to stretch it fail, podiatric adjustment of shoes and insoles may bring about a cure. 


    This treatment may also help with the foot pain of metatarsalgia. With a dropped longitudinal arch (known as pes planus, or flat feet), constant landing on a particular bone in the foot and a pull
on the surrounding ligaments can be extremely painful, but proper support to the arch with exercises for the intrinsic muscles of the feet may dissipate the pain rapidly.
    Pain associated with bones is deeper and more resistant to analgesia than that from the soft tissues. One particularly important cause of bone pain is the socalled stress fracture, which can
be equated with metal fatigue or the crack that can occur in a china cup. (Figure 10.3 shows the most common sites of stress fractures in runners, in the tibia and fibula.) The fracture is undoubtedly present, but the opposing surfaces remain together because of surface tension and the binding from soft tissues. It is characterized by "crescendo" pain, which worsens with increasing distance run; it most commonly but not exclusively affects the lower leg or foot, and it stops only when the run finishes. On the next run it will begin earlier and worsen sooner. If this symptom is ignored, it may proceed to a complete fracture, with all the potential for disability of any broken bone, and will take at least double the time of a stress fracture to heal. Any runner with these symptoms who suspects a stress fracture is strongly advised to stop running immediately and seek a definitive diagnosis.


    Plantar fasciitis is often such a painful condition that it commonly prevents any running at all. The weakest part of this sheet of fibrous tissue that runs between the heel and the metatarsal heads (figure 10.4) is at the heel, where it becomes injured through chronic overuse, ill-fitting shoes, or sudden stretching from an irregularity in the running surface. The typical sufferer will wince when the underside of the heel is even lightly touched. If the exercises in this chapter are ineffective, then a physician's steroid injection can produce a cure.


    If an Achilles (figure 10.5) or any other tendon is injured, healing is delayed by the poor blood supply to these tissues. Although the diagnosis may not be too difficult---the tendon becomes locally tender and stiff, especially if stretched-there has been much dispute concerning the best method of treatment. Current opinion tends toward a regimen of extensive stretching, which needs to be repeated endlessly even after a cure has been effected in an attempt to prevent recurrence. To be of value, a stretch should be uncomfortable rather than painful, held for between 15 to 30 seconds, and never used in a jerky or unstable position, such as the performance of a quadriceps stretch by standing on one leg.


    Note, however, that self-diagnosis of any sporting injury is fraught with danger. Every injury is different in some way from every other and each requires individual assessment and management. It would be irresponsible of us to attempt to manage injury in a book that is aimed at improvement, so the preceding paragraphs should encourage you, the runner, to be aware that your body is not just a mean, well-oiled speed machine but, like all machinery, may need a little fine-tuning!

Specific Training Guidelines
    Warm up by doing some light running before performing the stretch. If the stretch is part of a rehabilitation of a tight iliotibial band and running is not an option, walk or perform a warm-up exercise for the legs for 10 minutes to promote blood flow.
    There are many supposedly therapeutic treatments for running injuries, and many methods of performing those treatments. For example, the role of stretching in running training is widely debated. How often, what body parts to stretch, and how long to hold the stretch are some of the questions most runners ask running experts. Because the emphasis of this book is anatomy and
strength training, an in-depth examination of these topics and the unraveling of the mysteries of stretching are left to you. We offer some best practices, but we also believe in the authorship of your own running training system. Attempt the strength-training and rehabilitation exercises prescribed in this book, and supplement these with others that your experience has proven successful.


ITB Stretch


Execution for Standing ITB Stretch
    1. Stand next to a wall. Cross the outside leg in front of the inside leg (closest to the wall). Press a hand against the wall for support.
    2. Lean the inside hip toward the wall, touching the wall if possible. Both feet should remain flat on the ground.
    3. Hold the static stretch for 15 to 30 seconds. Repeat multiple times. Switch sides.


Execution for Sitting ITB Stretch
    1. Sit on the floor with one leg extended and the other leg crossed at the knee, knee in the air, and foot firmly on the ground. The opposite hand is supporting the knee joint.
    2. Gently press the outside of the knee that is crossed toward the opposite armpit.
    3. Hold the static stretch for 15 to 30 seconds. Repeat multiple times. Switch sides.

Muscles Involved
    Primary: gluteus maximus, tensor fasciae latae

Soft Tissue Involved
    Primary: iliotibial band

Running Focus
    As mentioned in chapter 9, tight iliotibial bands are normally a result of supination, not overpronation. The inversion of the foot can cause tight calves, lateral knee pain, and tight iliotibial bands. Even pronators who are overcorrected by their stability shoes or orthotics, essentially creating underpronation, can suffer from this injury. Performing the standing and sitting iliotibial band stretch will help stretch this thick band of soft tissue, preventing the painful rubbing over its attachment at the lateral femoral epicondyle. These stretches can be performed several times a day.


Proprioceptive Standing Balance


    1. Stand between two walls, one on each side. Extend the arms sideways at shoulder height for balance. Do not use the walls to balance unless needed to prevent falling.
    2. Lift one knee until it is at a 90-degree angle with the hip and the tibia is at a 90-degree angle to the femur. Close your eyes.
    3. Hold the position for 15 to 30 seconds. Lower the leg and repeat with the other leg. Perform multiple reps.

Muscles Involved
    Primary: peroneus longus, peroneus brevis

Soft Tissue Involved
   Primary: plantar tendon

Running Focus
    This exercise has a neuromuscular and physiological component. It may take a while to establish proper balance, but the foot and lower leg are working to find equilibrium, so the exercise is productive even if you don't find balance immediately.


Standing Calf Stretch


    1. Stand, facing a wall with one leg extended backward, foot planted on the ground. The other leg, flexed at the knee, has the foot planted on the ground straight down from the hip. Arms are extended forward at upper-chest height, shoulder-width apart. Hands are placed on the wall.
    2. Press gently into the wall and gradually press the heel of the extended leg into the floor. A stretch should be felt through the length of the gastrocnemius.
    3. Stretch statically for 15 to 30 seconds and repeat multiple times, or switch legs after every rep.

Muscles Involved
gastrocnemius, soleus, hamstrings

Running Focus
    Runners with neutral or underpronated biomechanics often suffer with tight calves. This stretch helps alleviate the pain of a chronically injured calf and also helps prevent calf injuries by keeping the muscle supple.


Standing Heel Raise with Eccentric Component


    1. Stand with both feet on a step with the heels off the step. Hands are pressed against the wall in front.
    2. Raise up onto the metatarsal heads of both feet to full extension (plantarflexed) .
    3. Lower gradually to full extension (dorsiflexed).

Muscles Involved
    Primary: gastrocnemius, soleus

Soft Tissue Involved
    Primary: Achilles tendon


    ►Do not forcefully dorsiflex; it will place too much stress on the Achilles tendon.

Running Focus
    This exercise both concentrically contracts (shortens) the calf muscle during plantarflexion and eccentrically contracts (lengthens) the muscle during dorsiflexion. As mentioned in chapter 9, including an eccentric, or negative, component adds value to this specific calf and Achilles tendon exercise. Studies have found that performing exercises with an eccentric component
actually shortens the time it takes to heal an injury.


Hamstring Stretch

    1. Sit upright lengthwise on a bench in a stable position. The leg with the hamstrings to be stretched is on the bench, and the other leg is placed on the floor with the foot flat to help stabilize the position. Place a towel or soft roll under the knee to be stretched with the knee bent no more than 5 degrees, and rest the heel lightly on the bench.
    2. Move the torso forward toward the bench and flex at the hip joints to stretch the hamstrings. Maintain the position for 10 seconds or so, then slowly unwind. (There is no need to stretch out with the arms or to grasp the shin. This may lead to poor posture and an ineffective stretch!) Repeat three times. Alternate both legs in turn.

Muscles Involved
   Primary: hamstrings
    Secondary: piriformis

    ►There is no need to perform a hamstring stretch with the knee straight for specifically increasing hamstring muscle flexibility. When the leg is straightened, the tendency is for the stretch to be
taken up more by the tendons and less by the hamstrings.

Running Focus
    There are some runners whose particular style is to "pitter-patter" along with a short stride. Even if they are successful, this sort of running does them no favors if the race speeds up or a final sprint is involved. This exercise helps to increase the stride length without putting more strain on the lower back and sacroiliac regions. It should enable the stride length to be maintained longer as the runner tires, and eventually lead to improved performance.


Seated Knee Press

    1. Sit upright in a comfortable position with room to extend the legs and knees. The back should be against a solid, supportive object. Both knees are slightly bent, heels on the floor.
    2. Slowly straighten one knee in an attempt to push the back of that knee into the ground. Hold this position for six seconds.
    3. Relax and allow the knee to flex slightly back to its resting position. Repeat the exercise but with the opposite leg. Do 10 repetitions with both knees.

Muscles Involved
    Primary: vastus medialis
   Secondary: rectus femoris, vastus lateralis, vastus intermedius, hamstrings, gastrocnemius

Soft Tissue Involved
    Primary: posterior cruciate ligament, hip joint ligaments

    ►If you perform this correctly, you should have a pulling sensation at the back of the knee, and a visible bulge will appear above and medial to the knee as the vastus medialis is contracted and its bulk develops.

Running Focus
    Knee pain is the greatest source of difficulty for most runners; runner's knee is the biggest culprit. This exercise strengthens the vastus medialis muscle and counteracts the slightly lateral (outward) pull of the other quadriceps muscles, which tends to cause patellofemoral pain as the bone shifts in the femoral groove. There is no nonoperative cure other than the development
of the vastus medialis muscle, so this should be an essential exercise in every runner's training program.


Knee-to-Chest Stretch


    1. Lie on your back on a firm but comfortable surface.
    2. Use the quadriceps to lift and bend the knee to 90 degrees, then grasp behind the knee with both hands and pull it toward the chest so that you feel a pulling sensation in the lowest part of the back and upper buttocks. At the same time, resist the urge to flex the other hip, but push it down onto the surface.
    3. Hold the position for 15 to 30 seconds and repeat no more than five times, two or three times per day. Alternate with the other leg.

Muscles Involved
    Primary: hamstrings
    Secondary: piriformis, erector spinae

Running Focus
    The lower back is usually ignored as a vital element of running until pain develops. By then it may be too late to correct. This exercise and those that follow give the lower back flexibility and strength. This is particularly important when climbing or descending hills. If the back can accommodate the changes of gradient, the stride length will also be increased by this flexibility
in the hips and lower back. As with all stretching exercises, the aim should be to achieve discomfort without pain.


Wall Press


    1. Stand approximately 18 inches from a wall with feet shoulder-width apart, toes pointed inward.
    2. Press your pelvis to the wall, adjusting the distance from the wall and the angle of the toes to gain the best stretch of the soleus. Keep your heels on the floor.
    3. Hold stretch for 15 to 30 seconds and repeat.

Muscles Involved
    Primary: soleus, gastrocnemius, tibialis anterior

Running Focus
    Shin splints, or diffuse anterior lower leg pain, can be either soft-tissue related or bone (tibia) related. Both problems usually stem from overpronation: however, the soft-tissue variety is normally associated with midfoot horizontal plane abduction. This exercise can help prevent muscle pain in the anterior compartment of the gastrocnemius. This exercise can be performed multiple times daily and is effective when done regularly.


Ankle Plantarflexion



    1. Sit upright on a comfortable, hard-backed chair. The foot is initially flat on the floor, with the knee bent about 45 degrees or so, depending on the height of the chair. Raise the heel off the ground, then invert the foot as though pointing the toes like a ballet dancer. Hold the position for 15 seconds and repeat up to 10 times, two or three times per day, with both feet.

    2.  Place the chair in a position where a piece of flexible elastic such as Theraband can be attached to an immovable object on a wall in a loop. Sit in the same stretched position as previously and put the elastic around the midfoot farthest away from the wall. Use this as resistance to ease the foot farther into inversion and pull against it, strengthening the tibialis anterior muscle. Hold the position for 15 seconds and repeat up to 10 times, two or three times per day, with both feet.


Muscles Involved
    Primary: tibialis anterior

Running Focus
    The importance of the tibialis anterior muscle is in the flexibility it gives to the ankles and feet. It is very involved in increasing stability when running on uneven terrain because it helps to adjust the position of the foot and therefore the leg. As such, any prolonged hill or undulating rough ground will bring it increasingly into use. If untrained, it will tire rapidly and slow the runner down, as well as increase the risk of a sprained ankle. When strengthened, it will also help to limit the pronation and supination of the foot, the cause of further problems for the runner.


Partial Sit-Up


    1. Lie on a firm, supportive surface on your back with both knees bent and feet flat on floor. Have the hands resting loosely on or hovering slightly above the thighs.
    2. Lift the arms a couple of inches and slowly raise the head and shoulders off the floor. Reach with both hands toward the knees and attempt to hold the position for 10 seconds. Repeat five times. Concentrate on performing the exercise smoothly without jerking; just as important, also ensure a slow return to the resting position between stretches.


Muscles Involved
    Primary: rectus abdominis
    Secondary: transversus abdominis, external oblique, internal oblique


Running Focus
    It is impossible to overemphasize the importance of a stable core for a runner. Weak abdominal muscles cannot help support the back. If the torso crumples under the weight of the upper body, running becomes difficult and painful. This exercise also helps to preserve the link between the abdomen and the lower limbs, and it adds some strength to the knee lift, which in turn will enable the stride length to be maintained.

Seated Straight-Leg Extension


1. Sit on the floor with your arms behind you for support and one leg outstretched. In the early stages the ankles should not have weights attached, but as you become more adept, you may wish to attach up to 10 pounds of weight incrementally to improve strength.
    2. Turn the foot outward and slowly lift the leg, locked straight but not hyperextended at the knee, until it is no more than six inches off the floor. Hold for 10 seconds, then, equally slowly, lower the ankle to the ground and rest. Repeat the exercise 10 times for 10 seconds and alternate with the opposite leg. The foot position can be changed to work all the muscles of the quadriceps evenly.

Muscles Involved
vastus medialis
    Secondary: rectus femoris, vastus intermedius, vastus lateralis

Soft Tissue Involved
    Primary: medial collateral ligament, patellar tendon

    ►At first this may seem difficult, which is why you should not attach weights. The upper leg may well develop a tremor when first exercised in this fashion, but as strength is acquired, this will
reduce and the whole exercise becomes easier.

Running Focus
    If sports medicine clinics banned runners with knee pain, they would become very lonely places! Unfortunately, too many coaches place far too much emphasis on general quadriceps development and fail to comprehend the role of the vastus medialis in stabilizing the knee and the prevention of patellofemoral pain. This is the most effective way of producing the increase
in strength and power in this muscle to ward off the demon of anterior knee pain.


FROM: RUNNING Anatomy By Joe Puelo and DR. Patrick Milroy---Chapter 10 via Ross Dunton