How to Prevent Running Injuries: Using Prehab to avoid Rehab

December 17, 2013 0 Comments

Anyone who has ever had a running injury (and let’s face it that probably includes most of you) will be familiar with receiving a list of strengthening exercises designed to help get you back to 100%. Most therapists will tell you (myself included) that the runners who recover the quickest tend to be those who find/make time to do their rehab exercises.

Unfortunately, once runners are back on the road, that’s when the strengthening exercises normally stop.

In a world where free time is more and more precious, the idea of sacrificing running time in order to perform some conditioning exercises is normally met with resilience. Before long your efforts return once again to either building up weekly mileage so you can achieve that PB or simply getting out of that front door as quickly as possible because running is what you love to do.

The thing is, those exercises that helped you get over your injury—they could well help you avoid a repeat injury; in other words, rehab becomes prehab.

To become a better runner , just running is not enough

Increasing weekly mileage or volume plays a major part in improving race performance especially in marathons. Exercise physiologist and author Dr. Jason Karp found a strong correlation between training volume and performance in male and female qualifiers for the U.S. Olympic Team Trials marathons, as running expert Matt Fitzgerald points out in his article Are You Running Enough Miles?

However, as Dr. Karp also points out, at least 50% of runners deal with at least one injury a year, and 25% of runners are injured at any moment in time.

Constantly trying to increase your volume may come at a price and just running more does not seem to help prevent it.

Given that injury is the number one cause for delays in training and failure to achieve goals, is there anything else we should be doing that will allow us to reap the benefits of running more without inviting injury?

Volume, frequency, intensity

A commonly quoted reason for injury is doing too much, too often, too soon. If we accept that increasing volume is necessary to improve performance, maybe we can avoid injury by simply just avoiding sudden increases in how often we run (frequency) or how quickly we run (intensity)?

Though there is much logic to this argument, there is surprisingly little evidence to support it.

The research that has been done either contradicts itself or fails to provide any significant conclusions due to the methods used. In an attempt to group together and analyze valid research, Nielson et al. (2012) carried out a systematic review (meta-analysis) to explore the relationship between running-related injury and training volume, intensity and frequency.

Thirty two relative studies were analyzed, involving 24,066 runners of varying experience. The conclusions of the review are summarised below. (For an in depth look, see the article written by Physiotherapist Tom Goom here.

  • Volume. The review supported the idea that running more miles a week than what your body is used to may increase risk of injury but stated that there is very little conclusive research on how much of an increase in weekly volume is safe.
  • Frequency. Though studies reveal a “U-shaped” curve with regards to frequency, i.e. a higher injury risk from training once per week and 6-7 times per week (compared to running 2-5 times per week), the variety in results lead to the conclusion that it is not possible to determine the specific role of running frequency with regard to injury.
  • Intensity. The relationship between average training pace and injury risk is conflictive in research results with the majority of studies finding no significant relationship.

All very inconclusive. Though on a clinical level it may seem that injured runners have often made sudden changes in volume, frequency or intensity, many have not. Something else seems to be missing from the equation.

Strength training and injury prevention

Could strength training be the missing ingredient? Could prehab be better than rehab? Is there any evidence that adding strength training to our weekly running program reduces risk of injury?

A second systematic review this time by Laursen et al. (2013) entitled “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials” may provide us with some encouraging results.  Twenty-five relative studies were involved, with a total of 26,610 participants and 3464 injuries. The following conclusions were reached:

Strength training can reduce sports injuries to less than a third and overuse injuries by almost 50%.

Though it is important to point out that this review was not specific for runners, the link between running and overuse injuries means it does have interesting implications in favor of runners adding strength training to their weekly program in order to reduce the risk of injury.

The review also highlighted the benefits of proprioception training (exercising in an unstable environment to stimulate development of coordination of joint motion and acceleration) and “no beneficial effect for stretching” (presumably ‘static’ stretching). For a more in depth analysis of the review, Running Research Junkie Craig Payne takes a look here.

What type of strength training do runners need?

If I said “just go out there and do something you don’t normally do,” you would probably stop reading this article. We like rules. We like explanations.

In rehab, strengthening exercises are prescribed with the purpose of “correcting” an “undesirable” movement pattern and/or promoting a change in your running gait that will reduce the likelihood of you suffering the same pain, maybe even help you run more efficiently.

In reality, the benefits we get from strength training are often not for the reasons originally sought in the exercise prescription phase.

A good example is assigning hip abduction exercises (clams, lying leg lifts to the side, fire hydrants, etc.) to a runner suffering from knee pain and exhibiting hip valgus (thighbone angled inwards in relation to hip) and femoral internal rotation when running.

As Greg Lehman (one of the guest lecturers on the Runners Connect Improve Your Running Form course) points out, sometimes we do see the strengthening program being followed by a reduction in hip valgus/femoral internal rotation but often we do not. Sometimes there is no mechanical change but the original pain is no longer present.

In my opinion, the mechanism behind modifications in pain or movement is not understood enough that we can afford to always favor some exercises and reject others. Given the dominant role of the brain and central nervous system in producing both pain and movement, maybe introducing the body to variety of movement is key.

But aren’t “functional” exercises the only ones that really help us become better runners?

In pursuance of variety, watch out for trainers telling you that certain exercises are not “functional” enough to benefit you as a runner.

Yes, specificity (performing exercises that mimic as closely as possible the movement you are trying to improve) has been shown to play a major part in improving performance, but this does not in my opinion mean that exercises failing to meet the “functional” criteria are useless or detrimental.

The plank is a great example of an exercise that is often dismissed these days as “non-functional” and not suitable for runners.

When running your body is vertical, so a horizontal plank has no value. I disagree. All exercises can have a carry over. The plank strengthens the trunk and hip muscles. Using its many variations it can be used to enhance coordination, balance and mobility. Greg Lehman defends the plank wonderfully in his article Postural correction and changing posture. Can we treat our patients like puppets?  and also reminds us that performing a few planks a week will not cause us to somehow become so rigid that our spines will stop moving when we run.


Adding strength training to your weekly training program could well reduce your risk of injury by 50%. Think prehab as opposed to rehab.

As far as which exercises to choose, think variety!

Challenge the brain by selecting exercises that encourage you to learn new movement. Coordination, proprioception, balance, skill, agility – all of these are vital to runners and will not be improved by just running more.


Practice movements that involve moving the body in all three planes of movement. Though running ultimately involves moving forwards (what we refer to as the sagittal plane – see picture), to promote variety you also need to ensure you are practising movement in the side (frontal) plane and rotational (transverse) plane.. Before long your efforts return once again to either building up weekly mileage so you can achieve that PB or simply getting out of that front door as quickly as possible because running is what you love to do.

The thing is, those exercises that helped you get over your injury—they could well help you avoid a repeat injury; in other words, rehab becomes prehab.

At In Balance Physical Therapy we do Prehab with our Peak Performance Running Analysis: the most in depth evaluation a runner can have : video analysis of running and functional movements, postural analysis, strength and flexibility analyzed to find asymmetries in the body that can lead to injuries as you increase intensity and mileage.

Call NOW for you Peak performance Running Analysis. 305-251-2912  WE are the running experts.

Article by Matt Phillips of Runners Connect


1. Karp, J.: Training Characteristics of Qualifiers for the U.S. Olympic Marathon Trials (2007). 2. Fitzgerald, M.: Are You Running Enough Miles? (2013). 3. Nielsen et al.: Training errors and running related injuries: a systematic review (2012). 4. Goom, T.: Injury prevention in runners – Skimpy Research (2013) 5. Lauersen at al. “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. 6. Payne, C.: Strength Training for Runners to Prevent Injury (2013) 7. Lehman, G.: 8. Martin, B.: Strength training and running technique 9. Fitzgerald, J.: Developing Running Coordination (2011)


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