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Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, we are diving into the latest running research. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who just like you have been through vicious injury cycles and when searching for answers, struggled to decipher between common myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. scholars I forgot to mention last week, just because I am pre recording these episodes ahead of time. Happy holidays. Happy holidays to everyone. Sorry that I didn't mention it last episode. ah I am heading to the beach over Christmas and uh don't really like recording when I get there. I will be working a few hours here and there some half days here and there. um And obviously taking the public holidays off but Because I don't like recording and I'll be there for a couple of weeks, decided to pre-record a lot of these episodes. um with that said, like when I was recording last week's episode, which is coming out around the Christmas time, I forgot to wish you all a happy holidays. And so hope you enjoyed, you had a good festive season, but also looking forward to the new year and bringing that on and bringing along all the goals that we have and ambitions and passions and... Yep. allow me on this episode to send my warmest regards to all who are listening, very loyal fans. I absolutely love hearing from you, hearing your feedback and how much you love this podcast. And as always, this is the last episode of the month. And so we are doing the latest research to be released. I would say that jumping a little bit of head because it is the 18th of December now. And so we're looking at what this month. has delivered in terms of quality, interesting, valuable running research in the first 18 days of the month. And so if there is any other valuable research that comes out for the remainder of December that is uh worth your time and attention and paying attention to, I will carry it over into the end of January's latest running research episode. uh But I've got some bangers here. I'm really excited to deliver some of these. oh The one I am most excited about I'm going to start with because as you probably know, I love looking at more of a holistic approach to injury prevention, increasing running performance, anything that's really compelling in relation to reducing your risk of running related injuries. I'm really excited for I know it's a topic that a lot of people ask questions about. I think the audience that listens to this. The two big things are how can I increase my running performance safely? And how can I reduce my risk of injuries? And so this paper, as I kind of gave a little bit of a teaser to last episode talking about the latest running research was about sleep. The title is Poor Sleep Quality is associated with an increased risk of running related injuries, a prospective study of 339 runners over six months. ah Thank you to Matthias Skålberg who was gracious enough to reply to my email and give me access to this paper. I have gone through and highlighted all the key points that I want to talk about but can't cover this entire paper nor can I cover the entire papers of the others that I will discuss on this episode. So if you do want to learn more about this, it is available in my Google Drive as all of my probably thousands now of running related research papers. If you are interested to sign up and get access to that, you can obviously go to the show notes, but let's dive into this paper. Before then we talk about a second paper around running related injuries for marathons. And then the third paper we're going to discuss today is strength training to increase running economy. So let's start off with the introduction of this particular paper just to set the stage. And so this paper starts off by saying that running is one of the most widely practiced types of a physical activity worldwide. While its regular practice offers numerous health benefits, running related injuries remain a major concern. Given the complex and multifactorial nature, a better understanding of the etiology of running related injuries is essential for the development of effective prevention strategies. A substantial portion of these injuries are classified as overuse injuries characterized by gradual onset resulting from an imbalance between training loads and recovery capacity. Training factors, recovery parameters, and their balance have been explored as risk factors, but the findings remain inconclusive, prompting further investigation into the major recovery related factor. This really lines up with what we talk about on this podcast all the time. Overuse injuries, running related injuries, the balance between what load you put on your body and your ability to recover. If your recovery is top notch, it's very, very hard to... overloaded structure, I've had recovery experts on the podcast before, and some have gone as far to say, as it's, you won't be able to get an overuse injury if your recovery is 10 out of 10, because there's the balance between the two. And some people say, you know what, I train really slowly, I adapt really slowly, I build up my mileage by like 5 % week over week over week over week, so I'm very, meticulous with that. But I just get to 50 kilometers per week and I just break down that seems to be my limit. And the first thing I go to is maybe that's where your recovery halts you. Maybe that's where that's the benchmark that tips the scales and now you are under recovering. And what needs to be done instead of slowly building up ever more gradually is recovering harder, recovering smarter, recovering better. And as I've talked about numerous times on the podcast, sleep is the best recovery tool you have. I've had Shona Halston on the podcast before. and she's a recovery expert. And she goes as far to say that if you were to take all other recovery modalities, talking about stress management, talking about foam rollers, hydrotherapy, hot, cold therapy, stretching, all those sorts of things, you can stack all of them up on top of one another, and it won't surpass the benefits of aiding, having really good quality sleep. So it's the best recovery tool we have. which is why it's nice that this paper sets a stage of recognising not only its importance, but the balance between training load and recovery when it comes to running related injuries and preventing injuries. It continues, among recovery factors, sleep is the key regulator for physiological and psychological functions with growing evidence supporting its role in enhancing performance and reducing running related injuries. Prospective studies have highlighted associations between inadequate sleep, whether due to poor quality or sufficient quantity and an increased risk of injury. I think one of the papers that I draw to is Dr. Amy Bender, who trying to think of the numbers off the top of my head, but she was showing that less than a, I think it was looking at adolescent runners and showing that less than seven hours sleep increased the risk of a running light injury by around about 30%. And so that's a pretty key metric there. Collectively, these studies present several limitations such as the assessment of a single sleep outcome over months and a narrow focus on sleep quantity. Thus, the relationship between sleep and running related injuries remains insufficiently understood. Addressing these knowledge gaps requires prospective studies, employing regular self-reported data over extended periods and a more advanced approach to sleep analysis, i.e. more than one sleep parameter. The present study aimed to investigate whether sleep quality and quantity, along with training load and complementary recovery factors, are associated with the risk of a running-related injury. So what was the design of this study? We conducted a prospective longitudinal observation study among runners with data collected at baseline. So this would be during week one. and weekly up until week 26, i.e. six months, using a smartphone app specifically developed for this project. When it comes to the population that they used, they said runners were eligible for inclusion if they met all the inclusion criteria. One, agreed to participate following written informed consent and reported no medical contradictions to running. Two, completed a full baseline questionnaire. Three, responded to the running related injury questionnaire for at least three consecutive weeks. Four, had at least one year's running experience. Five, performed running workouts at least twice a week. And six, reported that running was their main sport, i.e. more than 50 % of their weekly training volume was spent running. So these don't have to be necessarily elite runners. I mean, these could be just like recreational hobbyists if they're been running for a bit over a year, running twice per week and not really doing any other aerobic activity. They could be considered a part of this study. So then when it came to the data collection phase, they went through weekly questionnaires, collecting data on their running related injuries, their training load, their sleep quality and quantity, as well as their muscle soreness, fatigue and perceived stress. So we're gathering a whole bunch of metrics here. Runners reported whether they had experienced pain during the past week, and if so, completed follow-up questions to assess whether the condition met the criteria for a running-related injury. Now, this is where some limitations or contradictions happen within different papers because their definition of a running-related injury can change from paper to paper. So this paper says that a running-related injury was defined as any pain affecting running practice resulting in partial limitations, either you have to change or modify your distance, your speed, your duration, or the number of training sessions due to that pain, or total inability to train or compete for at least seven days or three consecutive sessions, or requiring consultation with a doctor or a healthcare professional. So all of those things, if you encounter all of those things, you would consider or any one of those things you consider to have a running related injury. Runners could either connect their data through their app, connect Strava to their application, or connect their Apple Watch so they could just naturally connect their running data to this app. They could manually report their training sessions into the app itself. After each training session, runners were also required to report their rate of perceived exertion on a scale of one to 10 to evaluate their perceived intensity during training. To evaluate sleep and other recovery factors on a weekly basis, only subjective measures were considered in this study. So that was consistent with the standard practice that they found in other protocols. So they're not using devices like an aura ring or smartwatches to analyze their data. um They seemed to be inaccurate. The paper continues to say that although objective metrics from running watches were available, They were excluded due to the lack of validity, reliability and interbrand variability in algorithms and measurement standards, which limited their suitability for meaningful comparison within the study. To extend the sleep assessment, a modified version of what they call the Hooper and McKinnon questionnaire was used. This questionnaire assessed fatigue, that uh ranked their fatigue on a scale of one to seven, how fatigued are you? your sleep quality of a scale of one to six, how was your last night's sleep, the sleep quantity, a scale from one to seven, how many hours did you sleep last night, then muscle soreness from one to seven, the perceived stress from one to seven, and this is just gathering all of that data. In addition, there was an item assessing sleep latency. So on a scale of one to six, how long it took you to fall asleep. And they say that sleep latency is a recognised marker of sleep disturbances and can indicate difficulties falling asleep due to stress, anxiety or pain. So gathering some useful data here, what are the results? They said of the 1,982 runners registered, 339 were included in the analysis. Both male and female participants were included in the study with males representing 83.8 % of the sample. So that's a very, very large male dominant field, you could say. During this period, 37 out of the 1,423 data points, so 2.6 % were missing from the Hooper questionnaire. 7.2 % of data was missing from training volume. And these were imputed as median values. They just mean that like sometimes people who were included in this study, didn't necessarily complete all data fields some of the time. So 2.6 % of the time, some data was missing from the questionnaires, from the sleep questionnaires, and 7.2 % of the time training volume was missing or not completed. And so that is used normative average values to replace those missing data points. And the drum roll of these findings. The time to event analysis revealed that lower sleep quality was significantly associated with an increase in running related injuries at any given time. Importantly, each one point increase in the sleep quality score. So I think the higher your score means that your sleep is poorer. So one point increase in your sleep questionnaire score was associated with a 36 % increase in the risk of injury. No other factors. were significantly associated with running related injuries. So this paper goes on to dive a bit deeper into uh certain metrics, particularly the weeks preceding a running related injury. They said that in this data set, 1,853 weeks were categorized as a non-running related injury week. And then they had 56 weeks uh were categorized as week one or one week before. and 52 were counted as two weeks before, two weeks leading up to the injury to find if there's any differences. And differences were observed for fatigue and muscle soreness across these conditions. More precisely, compared to non-running related injury weeks, muscle soreness was higher during running related injuries two weeks out and one week out, whereas fatigue was elevated during just one week out. No other differences were found between week, the week categories. So let's break this down in the discussion. What did they say? The study provided the first prospective investigation into running related injuries, sleep quality and quantity over six month period in adult runners, while also accounting for the training volume, muscle soreness, fatigue and perceived stress. I should highlight, I think they highlight later in the paper, but this association was with sleep quality. not quantity, so not the number of hours, they didn't find a link there with how much hours they reported, uh but how well they slept. So just going back to that sleep questionnaire, the description of the quality was, how was your sleep last night? That's what you need to score out of one to six. That's what they found linked to running related injuries, rather than your sleep quantity, how many hours of sleep did you sleep last night? That didn't find an association. So very important differences there. Findings revealed that worse sleep quality was significantly associated with an increased risk of running related injuries. Although the dropout rate should be considered when interpreting the association. There is a flow graph in this paper if you want to check it out about the number of dropouts. So they started off with 1,982 runners. That's a lot of people that have registered, but following certain exclusion criteria, Um, the dropouts continue and continue and continue, but there was a big drop off from the last criteria that meant that, uh, people needed to complete three consecutive weeks of data collection. And so they, they had a big drop off of about 800 runners in that three week period, cause they just didn't complete the data. just didn't, what seems like in this paper just didn't follow guidelines of, um, adherence. so. It went from 1143 and dropped all the way down to 339. Very disappointing for people completing this study. This is a very important study. We need people to be consistent. ah But that is significant drop off rate. The paper highlights means that, you know, we should be careful with interpreting these results. Furthermore, increased levels of muscle soreness and fatigue were observed during the previous weeks, preceding a running late injury, indicating that these markers may serve as early warning signs. of insufficient recovery. However, contrary to our initial hypothesis, neither sleep quantity nor training volume was significantly associated with a running related injury. So what can this tell us? We can learn a lot from this. Let's pay attention to our muscle soreness and our fatigue levels. This falls in line with uh researcher Eric Hegadis that I've had on the podcast before. He highlighted, he said this is early data, it's not really published yet, but this seems to be what research is emerging. I'm glad, know, several years later, we are starting to see this trend. He said, if you want to reduce your risk of running related injuries, you need to significantly focus on sleep, stress, muscle soreness, and fatigue. Those were the four, I guess, subjective measures that all could be objective, I guess you could call it. They're the four buckets that you need to keep a close eye on. Because while Ranking poorly in one of them is okay, seems to be okay. His advice was if you're starting to rank poorly in multiple, and if you're ranking poorly, definitely in all of them, don't wait for an injury. An injury is just around the corner. Do not push your training. Don't even hold steady with your training. I would back off if you're ranking poorly on all four of these conditions, being sleep, doms, fatigue, and stress, meaning like emotional stress and daily stresses. Please, please, please just back off your training. Don't wait to get an injury before then you have to back off. Let's be proactive and yeah, reduce it. I think it's really nice that he provide that advice so many years ago and now it's coming out in the research um to show that one to two weeks out muscle soreness and fatigue, if that's higher than usual, let's recognise that and let's take a deload week. Let's take your minds off and... Focus on recovery, focus on building up your recovery cues, because this is what these four domains seem to indicate. It means, hey, not only we might be training too much, but these are good signs that we're lacking recovery. So we need to build up the recovery, dial down your training in the meantime, while these domains fill up and get back to optimal before then dialing your training back up again. What else do these papers say about lower sleep quality and associated running related injury risk? While our research is the first perspective within runner study linking poor quality to running related injuries over several weeks, a high dropout rate and shortened follow-up period warranted caution when interpreting this association. Yet the physiological mechanisms linking subjective sleep quality and running related injury remain unclear. It is not yet established whether sleep disturbances play a crucial role in injury occurrence or just reflect underlying factors. It can be suggested that poor sleep quality may disrupt the training recovery balance contributing to an increased injury risk, i.e. you are taking away your most effective recovery tool and therefore under recovering and therefore increasing your risk of uh overuse injury, tipping that balance like we suggested at the start. As injuries results from a combination of various factors, modifying one of them such as improving sleep quality may potentially reduce the risk of running related injuries. Several targeted sleep hygiene education interventions based on weekly sleep quality monitoring may improve sleep quality, especially for individuals with the lowest sleep quality scores and may be implemented as a key priority for future injury prevention programs. This relationship may also be bi-directional as increased training load can impair sleep shown in football players. They reference another paper by Barbara Etel. where higher training intensity was associated with poorer sleep, while training volume was not associated with injury in the present study. This suggests that poor sleep may not only contribute to injury risk, but could also reflect periods of high training stress, fatigue, or overreaching, which may present in the early stage in the development of injuries, highlighting the complex interplay between training load, recovery, and sleeping athletes. So what they're talking about is, There may be times when we do have poor sleep. Maybe it's, um, birth of a newborn baby. Maybe it's stress from, um, conflict in your family or at work or deadlines or what have you. we're taking away your recovery tool, or maybe we are over training and are overreaching. And sometimes when we overreach, we don't sleep very well. Sometimes when our training is too intense, we don't sleep very well. So maybe there's that interplay there. But as they mentioned in this paper, uh if that latter example were the case, we'd probably see an association with training volume and a risk of running-related injury, which they didn't find in this paper. Well, no significant association between sleep quantity and running-related injury risk was found here. Earlier studies reported an increased injury risk in athletes sleeping less than seven hours per night. So if we wanted a guideline to follow, less than seven hours per night ah seems to be ah the benchmark for increasing risk of injury in some cases. I know I mentioned on the last episode, going to, I've spent the last several years trying to improve my sleep, but the last, I'd say six months really focusing hard, well can't focus hard, can't really, that's the weird thing about sleep, you can't try harder at sleeping. The harder you try, the harder it is. ah So I'll use my words carefully, uh but. layering in interventions to help my sleep. I think most nights, ah seven and a half hours is what I would get. But I seem to have to be in bed for eight and a half hours to achieve that. But can have poorer night's sleep can have better seems to be teetering on and seven and a half hours seems to be where I don't get tied throughout the day. I think any less than that definitely less than seven I'll feel tied throughout the day. So I think for me that seems to be a pretty good uh benchmark for me to follow. I think it's also important work mentioning the limitations of the study. I did mention a few briefly before, but let's just go through the limitations section and then we'll dive into some of these other papers. So they say first, despite the use of appropriate statistical methods, the relatively moderate sample size, the low response rate and participation dropout over time may reduce the strength of the findings. Nonetheless, we addressed this limitation with full transparency. All instances of missing data were systematically reported and we employed validated statistical techniques such as median imputation to manage these incomplete responses. Second, due to missing data, prior running injuries, a known predictive running related injuries or training load using RPE could not be evaluated. Third, The inclusion of runners with varying practices likely introduced variability in training loads and may have masked potential associations for running related injuries. For example, like they used a lot of trail runners, they used a lot of just like road runners and like there's a big mix bag in there. Moreover, the small number of long sleepers, they said that 3.2 % of the field were considered as long sleepers. I don't know exactly what that is, but uh they say, Moreover, the small number of long sleepers likely limited the power to detect potential associations with running related injuries, even though some evidence suggests that long sleep duration may also be linked to adverse outcomes. Additionally, injuries and running related factors were associated through subjective self-report. The lack of medical diagnosis remains a limitation as the way athletes determine the status of their injuries may be linked to their behavior regarding injury management and participation restriction. So we always need to factor in the data, maybe limited just based on like the athletes are the ones interpreting their status, whether it's an injury or not, whether it's pain or not. And, you know, some runners can be a little bit reckless when it comes to those sort of decisions. nonetheless, great, great findings. If you want to go check out the paper, it is in Google Drive. If you don't have access and you want access, you can check out the link in the show notes. Let's keep the ball rolling with this next paper, um which is just a useful paper giving us, I guess, a general updated landscape of where we're at with marathon participation, demographics, running related injuries, the frequency of injuries, the area of certain injuries, just to, I guess, give you a better understanding of where everything falls at the moment and how you can adjust your training based on that. Seeing the stage, it says that while running provides numerous health benefits, participation in marathon running carries a risk of injury both during training and on race day. One of the strongest predictors of a running related injury is total running distance defined as more than 65 kilometres per week, which is often achieved during training for a marathon. Race day injuries range from minor sprains and strains to more severe injuries that may impact post-race work activities. and activities of daily living. Specifically, they refer to a previous paper Van Middlecoop et al reported that 13.6 % of runners injured in a major global marathon were unable to perform work tasks and 12 % were unable to perform activities of daily living within one week following marathon participation. So it wrecks us. As marathons vary in terrain, weather and timing, with a diverse population of participants, aggregating data on marathon injury incidents and type remains challenging. As such, when counselling patients regarding common injury types and the risks during marathon participation, an updated review of currently reported race day injuries is warranted. The purpose of this review is to summarise the evidence for marathon race day injury incidents and types while providing participants and medical providers with a better understanding of potential modifiable and non-modifiable injury risks in order to optimize athlete health and performance. Let's look at marathon demographics. Several noteworthy changes have been observed in the average marathon runner over the past 30 years, including shifts in demographics and other athlete-specific factors that may predispose athletes to injury, namely, The mean age of marathon participants has increased from 35 to 39 years old. Female runners who have been reported to possess unique injury risks during running, when compared to their male counterparts, currently account for over half of marathon participants as of 2018. Marathon completion times have also been reported to be slower on average with the mean finish time rising from three hours and 52 minutes to four hours and 32 minutes. That's a big shift. It's almost like a 40 minute shift in terms of average attributing to the growth of hobby running as opposed to achieving as opposed to achievement focused racing. The approach to running as a hobby is important as injuries are more commonly reported among less experienced runners with a limited ability to recognize developing problems. compared to more experienced runners. Moreover, increased travel to marathon race destinations have been reported, which can lead to issues secondary to time zone adjustments, less restful sleep, and changes in pre-race preparation. Let's look at the injury epidemiology. Other studies report an increase in medical assistance and runners experiencing injury during race day. A three year review from 2010 to 2012 of an unspecified nationally recognized marathon in the United States reported that a total of 30 % of participants self-reported an injury during race day. 30 % of participants, that's huge. With the majority of injured runners seeking assistance either midway through the marathon or at the conclusion of the race. A recent investigation revealed a notable rate of lower extremity musculoskeletal injuries during marathon training, affecting up to 42 % of amateur runners. These injuries included medial tibial stress syndrome or shin splints, ITB syndrome, plantar fasciitis, and Achilles tendonopathy sustained over a 16 week training period. Let's dive into marathon injury risk factors. Both modifiable and non-modifiable risk factors have been reported to contribute to race day injuries. Non-modifiable factors primarily related to the runner's age may increase the risk of joint related injuries, for example around the hip, knee and ankle, and hamstring strains. Meanwhile, male runners have been reported as being more prone to injuries involving the calf, while female runners more likely experience hip injuries. The presence of prior running related injuries defined as having sustained a running related injury within 12 months of marathon participation have also been reported as a strong predictor of subsequent injury. So if you've been injured in the past 12 months, it increases your likelihood of being injured again. It could be a different injury. They say runners reporting an illness within two weeks of the race have also been reported to have a incidence of injury. An increase in the number of years of running experience while not explicitly quantified have been found to correlate with a decrease risk of injury. And another paper found that runners who had completed half marathons prior to their marathon were less likely to get injured. They also found an inverse association between the longest training distance and incidence of race day injuries. So your training, your long runs in your training leading up to the marathon does seem to be important. And I guess a lack of long run distance leading in might show a lack of preparedness. They say that modifiable factors, including poor conditioning due to lack of proper preparation and training, inadequate recovery and alcohol consumption have been reported to predispose runners to injury. They say another paper reported that alcohol use, even minimal consumption of one beverage per month was correlated with an increase in injury incidents. While regular strength training has been linked to a 23 or 24 % decrease in lower extremity musculoskeletal injuries, structured warmups and cross training have also been found to be beneficial. Going back to the alcohol side of things. So they said that there's an increased risk or is it increased association with a risk of injury and those who consume alcohol, even if it's more than one, even those who have one beverage per month doesn't seem like a lot at all, but. Hard to me thinks that there might be a healthy user bias here. So if we look at the total people that have had zero alcohol and don't drink any alcohol, they're probably being very, very healthy in other things, as opposed to the casual people who might not drink a lot of alcohol, but just like your average diet goers, you know, they're probably not as extreme with. really ticking everything off the list. So it might not be the fact that it is alcohol that's causing injuries or linked to injuries. It may just be like a correlation rather than causation just because of that healthy user bias. That's what I think about anyway. They talk about carbon fiber plated shoes. However, they say the use of carbon fiber shoes has also been reported to increase the risk of bone stress injuries in the foot, namely, Navicular stress injuries, the navicular is just one of the bones in the foot. As such authors have advocated that runners undergo a formal transition focusing on a gradual increase in distance and intensity when getting used to carbon fiber shoes. Carbon fiber plating is also known to result in a stiffer sole of the shoe which can lead to weaker foot muscles, reduce arch strength and subsequent excessive pronation. So it has been noted that this may lead to plantar fasciitis as the muscles and the arch themselves become weaker. But you'd have to be wearing these carbon fiber shoes a lot in order to experience that. I think if you're rotating them out with shoes that offer more engagement of the foot muscles, then you should be okay. Just my thoughts. They break this down, the rest of the paper down into injuries of certain. areas of the body. So let's dive into that now. While injuries such as blisters, chafing and dehydration are frequently reported in marathon runners, musculoskeletal injuries represent the highest portion of reported race day injuries. A study of the 2018 Chicago marathon reported that 61 % of all race day complaints at the medical tents were musculoskeletal related. They break it down to hip injuries. They say the reported incidence of hip injuries has increased over time, accounting for nearly one fifth of all reported injuries. Commonly reported hip injuries focus around the hip flexor tendonitis, iliopsoas bursitis, which is a bursa of the hip flexor, so the front of the hip, abductor tendonitis, trichanteric bursitis, which is a bursa on the most outer part of the hip, adductor strains, iliotibial band syndrome, and stress fractures. So stress fractures in and around the hip. In particular, female participants have been reported to experience a greater risk of hip related injuries when compared to their male counterparts. Another study reported that hip injuries represented 10 % of the overall injuries in females compared to 4 % in males. Greater hip adduction and internal rotation during running stride in female runners when compared to males. has been theorised to increase the stress on hip muscles and tendons during the running activities, potentially accounting for the increased risk in hip related issues in females compared to males. So they're saying that when you run, uh anatomically speaking, females tend to have wider hips. And so if you then contact your foot directly underneath you, you have more of this cutting in action, your thigh adducts more towards the midline. And as a result, the tibia tends to internally rotate a little bit more. And that slight change in angle means that the hip has been placed under slightly different forces and can lead to slightly different strains and therefore slightly different injury profiles. What about thigh injuries? So around your quad and hamstring. They say that the hamstrings and quad strains represent the most frequently reported injuries involving around the thigh. Another paper reported that during the 1993 Auckland Marathon, 60 % of survey participants reported pain or stiffness in the anterior thigh, so the quad muscle, with injury risks associated with cycling during marathon race preparation, fewer rest days prior to rest day, and the consumption of alcohol more than once per month. More over 24 % of the participants reported pain or stiffness involving the hamstrings, which is more prevalent among male runners aged 30 to 34. Also first time marathon participants, those with an increased weekly mileage during training and runners who reported performing aerobic exercises beyond running. So all of those things were associated with having stiffness and pain around the hamstrings. During the 2019 Rome Marathon, a paper reported that 77 % of survey respondents were diagnosed with various degrees of hamstring tendinopathy based on clinical criteria and questionnaire responses. The authors found that older age, increased body weight and greater impact profile were associated with hamstring strains. What did this paper say to have about knee injuries? They say knees represent the most commonly reported injured body region associated with marathon training. Namely a three year review of a nationally recognized marathon that consisted of both half and full marathon runners found that knee, the knee was the most commonly injured site for both racing distances. While not separated by training versus race day running, McGraw et al reported that the most common knee injuries around the New York City Marathon included the ITB syndrome, patellofemoral syndrome, patellotendinitis, meniscus tearing, and stress fractures or stress reactions. Another paper reported that 25 % of participants reported in the 1993 Auckland Marathon experienced knee pain, which was correlated with first time marathon runners, current medication use, and lower weekly pre-race mileage. when comes to injuries around the lower leg and the ankle. They said following the 2019 New York City Marathon, McGraw reported that most common lower leg injuries involved the gastrocnemius or calf strains, calf tears, or stress fractures or stress reactions, specifically medial tibial stress syndrome, which would be around shin splints. Another paper that reported that over the course of the 2013 to 2018, marathon in the Tokyo Gorge Marathon. Calf injuries comprised 34 % of injuries in males and 28 % in females. During the 1993 Auckland Marathon, this paper found that 45 % of participants experienced calf injuries which were associated with the male gender associated with illness within two weeks leading up to the race while runners age. was about 30 to years and those aged 40 years and older were lower risk of injury. Ankle injuries predominantly consisting of Achilles tendonitis, posterior tibial tendonitis, stress fractures and stress reactions, as well as peroneal tendonitis have also been reported. In addition, common foot injuries include plantar fasciitis, stress fractures or stress reactions and neuromas. which would be just a disruption or irritation of the nerves in between the toes, classically or characteristically brought on by either the shoes being too tight, the forefoot being too tight and sort of the bones in between the toes irritating the nerves or someone having like a narrow crossover step width where the foot is kind of compressed, squashed at impact. Okay, injury considerations. Self-regulation of injury awareness remains crucial as different injuries affect individual runners differently with each athlete possessing unique motivations for marathon participation and race completion. While no universal consensus exists, injuries that alter normal gait or worsen with continued race preparation, especially those that fail to improve after a period of rest despite medical intervention or management, generally merit discontinuation. However, regardless of the injury type, it remains largely at the discretion of the runner to determine if and when further evaluation of injuries is required and if race discontinuation is indicated. So they just thought adding in this bit as a bit of information, if you're finding that your pain or your injury is changing how you move when you run, probably a good indication that it's not worth continuing to run. because if you alter your gait, means the pain levels are somewhat higher than what we would deem acceptable if it's so high that you have to actually change how you move. And changing how you move also changes the stress on your body, which could really spike loads elsewhere in the body, which is exactly what we don't want. In conclusion, they say that the demographics of marathon runners continue to evolve with participants regularly being older, slower, and less experienced. A growing number of female participants has also been reported as well as races more frequently traveling to compete. Ongoing assessment of race day injury patterns is crucial for preparedness and prevention, particularly as marathon participant characteristics involve and technology advances. This next paper is similar to other papers I've talked about in the past around how strength and what they call complex strength training can help improve efficiency. uh This one particularly focuses on the adolescent population, which may not apply to you. think what the exercises that they include in this paper is similar to what we've seen in other papers. So it can be a bit of a reminder if you did want to make adjustments to your current strength training based on what's found here. But also if you have kids that are teenagers and wanting to move into running, improve their running, Um, these ones that were included were younger of age, were quite elite and I guess consistent and taking their running quite seriously. And they did see some really good improvements. with that said, like a few of you will definitely gain insights from this paper. Um, I just want to move through it quickly. I don't really feel like we need to go through the introduction and set the stage and those sorts of things, but the title of the paper is the effect of complex training on lower limb strength and running economy. in adolescent distance runners. When we talk about running economy, we're talking about how efficiently you're moving and how much energy and oxygen you are producing, how efficient you are with negotiating through space. If you improve your running economy, you will be a better runner, you will get better times, or you can run at the same speed with feeling less tired. So overall important. The participants that they used in this study were male runners and they aged between 16 and 18 years old. with a minimum of two years of distance running experience. The inclusion criteria was there had to be a current member of a provincial team. Number two, they had to have a minimum of three years of systemic training. Number three, had to be of healthy status and engage in all physical fitness tests. We'll talk about the tests in a second. Number four was they had to have no previous injuries in the previous three years. Number five, regular competition experience at the country, regional, national or international level for medium distance events. So medium distance being between 800 and 3000 meters and consistent training volume. So their consistent training volume of more than 35 kilometers per week during the three months leading up to this particular study. So what did they do? They took the study itself was spanned over 12 weeks in four different phases. So they had this two week, I guess, preparation phase, preparing them for the type of strength training and certain movements. Then they had one week of pre-testing. They tested the athletes back squat, squat jump, counter jump, drop jump, and running economy, as well as their VO2 max. So not only testing running performance with the VO2 max and running economy tests, but also a bunch of strength and power tests. Then they went through an eight week, resistance training intervention and then one week of follow up post intervention testing. And so the total number of participants was 32 split into two different groups. So 16 were randomized into the strength training group and 16 were randomized into the complex strength training group. And I'll go through those now. The, start with the just generic resistance training program. So those who are just doing strength based exercises, uh they included a back squat. They included what they call here is a hexagonal barbell pull up, which I'm going to interpret as a hex bar deadlift. uh That's my best, I guess, interpretation of it. They also had a weighted Bulgarian split squat. So a split squat is kind of like a lunge, but your rear foot is elevated on a box or a bench or a stair or something like that. As you do that squat, they also did heel raises, what they call weight bearing heel lifting. I would call those calf raises to some effect. And then those were the four exercises that they did. And they didn't do any plyometric power-based stuff. They just did the heavy stuff. If you want to look up this paper, there's a clear table of the percentages of their one RM, the sets and reps and how that progressed over the eight week period. But just as an example, if we're using the back squat, their back squat was three sets of six to 12, where they progressed the weights per section. So weeks one to two was about 60 % of their one rep max. when they progress to stage two, they lifted 70 % of their one rep max. And then in the last two weeks, they increased their back squat to 80 % of their one rep max, finishing with four sets of eight to 12 reps. Apologies, just making sense of this now. The resistance training groups are the one that didn't do any power-based stuff. They did an extra set. So it seems like all sets were four or five sets for the strength training group. but three to four sets in the complex group because they did one extra set of the complex stuff. So just making sure that the overall training volume remained the same yet the only difference being the complex group would do some extra volume based on the power based stuff. So let me talk about the complex training group. So they still did the back squats. They did three sets. They still did the same 60 % of their one RM, but after doing the back squat, they would then do a box jump. So they would have a box in front of them and they would jump up onto the box and come back down three sets of nine reps. I'm going to talk about these. Let's talk about the complex stuff in a bit more detail, not necessarily the strength sets and reps, but as the weeks, as the eight weeks progressed, these complex power-based exercises did progress to become more difficult. So the box jump specifically, in the stage two progress to a vertical jump. So instead of jumping onto a box, they jump up in the air and down to the ground, kind of like maybe a pogo jump would be something of uh something similar. And then in the last stage, weeks six to eight, that vertical jump progress to a drop jump. So now you're going from a box, you're starting off high, you're dropping down to the ground, and you are doing a rapid hit the ground and jump into the air. Doing that four sets of 10. And so that's what complemented the back squat. What complemented the uh hex bar deadlift was a double leg hurdle hop. So getting these hurdles of starting off 30 centimeters in height and jumping forwards over a hurdle, hitting the ground and then jumping forwards over the next hurdle and doing that for about nine reps. And as the weeks went on, that 30 centimeter hurdle turned to 35, then turned to 40 centimeter hurdle. When it comes to the Bulgarian split squat, that was complimented with a split squat jump or like a plyo lunge or a jump lunge or a lunge jump, however you want to call it. So you're going down into a lunge, you're jumping up in the air, you're swapping your legs over and then you're landing back into a lunge. That was then progressed over the six weeks or over the eight weeks, sorry. into a single legged side box jump. So to the best of my knowledge, you are placing a box next to you, to the side of you, and you're going from a single leg, you're jumping yourself in the air, and you're landing on that box. And then the final two weeks, it is now a single legged drop jump. So you're now taking that the box, you're starting on the box, you're dropping down onto a single leg and then you're jumping in the air. but I guess with more of like a sideways component. Accompanying the heel lifts or the calf raises was a jump on tiptoes. So staying up on the toes and jumping three sets of nine to 12. It doesn't seem like over the eight weeks, it didn't really change that much. In the last two weeks, the nine to 12 reps changed to four sets of 10 to 12 reps. So yeah, not a big difference. But in relation to these pairs, there was a four minute rest between. So after doing your heavy back squats, you then rest for four minutes before then moving into the box jumps. So just making sure you're fresh enough to execute the movement with really, really good quality. Let's dive into the results. In relation to running economy, this paper says that post hoc analysis showed that the complex group, which is the strength training on top of the power based stuff, achieved significantly greater improvements than the resistance training group who just did the heavy strength training in running economy at all three speeds. So we're talking at 12 kilometres per hour, 14 and 16 kilometres per hour, and also showed significant improvements in blood lactate at 14 kilometres per hour. Both groups exhibited significant improvements in VO2 max. So interesting to know that strength training can help with that. For blood lactate, the complex group showed significant reductions at 12 and 14 kilometres per hour. Whereas the strength training resistance training group showed no significant changes. So in the discussion, they say that this study demonstrated that complex training can effectively improve both running economy and lower limb strength. I didn't really go through the strength testing, but they improved their one RMS and those sorts of things. In adolescent distance runners offering advantages over traditional resistance training. Compared with traditional resistance training, complex training, which combines heavy resistance and plyometric exercises may induce superior neuromuscular and mechanical adaptations. Traditional resistance training primarily enhances maximal strength and muscle tendon stiffness, which can improve running economy by reducing energy costs during submaximal exercise. In contrast, the addition of plyometric exercises further stimulates neural adaptations, including improved motor unit synchronisation, increased rate of force development and reduced antagonist co-activation. So it's just layering in or suggesting adaptations to the body that can lead to these enhanced benefits. These adaptations can enhance the efficiency of the stretch shortening cycle leading to more economical force production and improved running efficiency. When it comes to the limitations of study, they say that several limitations should be acknowledged. Firstly, the relatively short training duration of just eight weeks may not fully reflect long-term adaptations or retention effects. And second, the exclusive inclusion of male adolescent runners limits the generalizability of findings to female athletes or other aged categories. Nonetheless, a good reminder and maybe a paper for you to be like, maybe I should try this exercise. Maybe I should try some plyometrics. Maybe I will add some. take one set off my back squats and add in box jumps or drop jumps instead. And so a nice reminder, I would say that similar findings have been found in the adult population in other studies. so yeah, prompts, maybe a few changes, especially if you're just wanting to change things up as well. If you're getting a bit stale or stagnant or not as motivated with your current strength routine, hey, here's some ideas of directions you can take. So hopefully you enjoyed. the papers covered in this month and we'll catch you in the next episode. If you are looking for more resources to run Smarter or you'd like to jump on a free 20 minute injury chat with me, then click on the resources link in the show notes. There you'll find a link to schedule a call plus free resources like my very popular injury prevention five day course. You'll also find the Run Smarter book and ways you can my ever-growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritising your running wisdom.