The Dogma of Running Injuries: Perceptions of Adolescent and Adult Runners
Adults perceive certain factors to increase or decrease the risk of sustaining running-related injuries, but many of their perceptions are not supported by research. Little is known about the perceptions that adolescent runners hold. Investigating perceptions for adolescent runners is needed to assist in the development of future injury educational materials, as these resources may need to be tailored differently for adolescents and adults. To identify factors that adolescent runners perceive as risk or protective factors for running-related injuries and to compare these perceptions with those of adult runners. Cross-sectional study. Online survey. We surveyed 302 adolescent (164 females, 138 males; age = 16.0 ± 1.4 years [range, 12–19 years]) and 357 adult runners (197 women, 160 men; age = 40.7 ± 11.8 years [range, 20–77 years]). Participants completed a survey with questions about whether factors related to training habits, footwear, biomechanics, strength, stretching, or nutrition influence the risk of sustaining a running-related injury. If ≥75% of adolescents indicated that a factor increases or decreases the risk of sustaining an injury, we considered that factor to be a perceived risk or protective factor, respectively. We also performed Fisher’s exact test to compare the proportion of adolescent and adult runners who responded with “increase,” “decrease,” “neither increase or decrease,” or “I don’t know” to each question. Adolescent runners perceived training habits, footwear, biomechanics, strength, stretching, and nutrition to increase or decrease the risk of sustaining a running-related injury. A larger proportion of adolescents than adults perceived that more footwear cushioning and stretching decrease injury risk, but a smaller proportion perceived that overtraining increases injury risk and strength decreases injury risk. Differences in perceptions exist between adolescent and adult runners, and future educational materials and research questions may need to be tailored for different running populations.Context
Objective
Design
Setting
Patients or Other Participants
Main Outcome Measure(s)
Results
Conclusions
The repetitive nature of running contributes to high rates of running-related injuries (RRIs), with nearly 50% of runners experiencing an RRI.1 These injuries are complex and may be influenced by training habits, footwear, biomechanics, strength, stretching, and nutrition.2–6 However, the scientific literature contains varying, and often conflicting, levels of evidence for these factors. Adult runners perceive that footwear (eg, structure and age), training habits (eg, weekly distance, surface, and terrain), biomechanics (eg, foot pronation, posture, and technique), strength, stretching, and nutrition influence the risk of sustaining an RRI.7–11 How a runner perceives factors to increase or decrease the risk of sustaining an RRI may influence their decision-making process regarding their running habits, but evidence for many of these risk factors is limited. Adult runners may ultimately engage in behaviors that they believe will mitigate injury risk but that are not supported by the current literature.
Running is also popular among adolescents, and RRIs are common for adolescents, with more than one-third of high school cross-country runners experiencing an RRI.12 Although injury rates for adolescent runners are high, this population remains understudied. Factors including training habits, biomechanics, sport participation, injury history, and nutrition have been linked to RRIs among adolescent runners, but little is known about adolescent runners’ perceptions of how factors influence RRIs.12–14 Although the perceptions of how factors influence RRIs have been investigated in adult runners, caution should be used when generalizing results from adults to adolescents. Differences in perceptions have been observed between adults and adolescents for psychological and physical function after injury, suggesting that adolescents cannot be assumed to have the same perceptions as adults.15 Authors of only 1 study have reported the perceptions of adolescent runners, and, similar to adult runners, they perceived that footwear structure is an important factor for selecting a running shoe to reduce the risk of injury.16 However, it remains unknown what other factors adolescent runners perceive to influence the risk of sustaining an RRI or if these perceptions are similar to those of adult runners.
Dhillon et al reported that an educational program was successful in changing the perceptions of adult runners and health care professionals about factors associated with RRIs.11 Educational programs have not been developed for adolescent runners. Without knowing the perceptions of adolescent runners, we do not know if educational programs for adults are appropriate for adolescents. If adolescents and adults have different perceptions about RRIs, educational materials for adolescents will need to be specifically tailored to them. Therefore, the primary purpose of our study was to assess the perceptions of adolescent runners regarding what they believed to be factors that influence the risk of sustaining an RRI. We hypothesized that adolescents would perceive factors related to training habits, footwear, biomechanics, strength, stretching, and nutrition to influence the risk of sustaining an injury. The secondary aim was to compare perceptions between adolescent and adult runners. We hypothesized that perceptions would differ among adolescent and adult runners.
METHODS
Participants
We recruited adolescent (age of <20 years)17 and adult (age of ≥20 years) runners to participate in our study. Included participants were at least 9 years old, read English, and self-reported participation in long-distance running activities (eg, club or school cross-country, track [distances of >800 m], road races, or recreational running [≥5 mi/wk (8 km/wk)]). Electronic informed consent (or parental permission and assent for participants aged <18 years) was obtained before study enrollment, and the University of Toledo Institutional Review Board approved the study.
Design
The Checklist for Reporting Results of Internet E-Surveys was used to ensure study quality.18 We developed an open online survey for a convenience sample of adolescent and adult runners for this cross-sectional study. Participants self-reported their perceptions of how factors influence the risk of sustaining an RRI using a 6-point Likert scale (1 = strongly decreases, 2 = somewhat decreases, 3 = neither decreases nor increases, 4 = somewhat increases, 5 = strongly increases, and 6 = I don’t know). Survey responses were collected and stored on a password-protected platform (Qualtrics XM, SAP).
Development and Pretesting
We developed survey questions after reviewing the literature on adult long-distance runners’ perceptions of factors that influence the risk of sustaining an RRI and through consultation with experts in RRI risk.7–9,11 We piloted the survey with 3 adolescent long-distance runners to receive feedback on content and clarity of questions. We revised the wording of survey items according to feedback from these participants to elucidate the survey items.
Recruitment
We recruited participants internationally via emails to our institution’s runner database, recreational running clubs, and middle and high school cross-country teams. We also performed snowball sampling by posting recruitment materials to social media.
Survey Administration
From October 26, 2021, to December 10, 2021, participants voluntarily and anonymously completed an open online survey through Qualtrics (see Supplemental Figure, available online at https://dx.doi.org/10.4085/1062-6050-0164.23). Participants accessed the survey via a link that was emailed or posted on social media. The survey consisted of 93 questions across 14 pages related to demographic information, training habits, footwear, biomechanics, strength, stretching, and nutrition (median completion time = 13 minutes). Questions were presented in a consistent order with adaptive logic and required responses. Participants were able to go back to items within sections, but they could not make changes to their responses after initiating a new section or submitting their responses. They voluntarily provided their contact information after completing the survey to be entered into a gift card raffle.
Response Rates
Of the 939 surveys that were initiated, 659 were completed (completion rate = 70.2%), including 302 completed by adolescents (164 females, 138 males; age = 16.0 ± 1.4 years [range, 12–19 years]) and 357 completed by adults (197 women, 160 men; age = 40.7 ± 11.8 years [range, 20–77 years]). We are unable to report view or participation rates because the number of survey views was not available. We did not implement cookies or remove duplicate IP addresses, as different participants (eg, family members) may have used the same device to complete the survey. Therefore, we did not remove multiple entries and considered each survey response to be a unique response.
Data Analysis
Data were exported from the Qualtrics database to a spreadsheet, and participants were categorized as adolescent or adult runners. To identify perceived risk and protective factors, we collapsed increases (strongly increases and somewhat increases) and decreases (strongly decreases and somewhat decreases) responses, respectively. We arbitrarily identified perceived risk and protective factors when ≥75% of adolescents indicated that a factor increases or decreases the risk of injury, respectively. Fisher’s exact test was used to compare the proportion of adolescent and adult runners who responded with increases, decreases, neither increases nor decreases, or I don’t know for each statement. We performed pairwise comparisons with a false discovery rate adjustment if values were different (P < .05) and calculated 95% confidence intervals (95% CIs) for the difference in proportions. We calculated Cohen h effect sizes and interpreted the magnitude of differences as negligible (h < 0.13), small (h = 0.13–0.27), medium (h = 0.28–0.54), or large (h ≥ 0.55).19 We set a priori criteria that medium and large effect sizes indicated meaningful differences between adolescent and adult runners. Analyses were performed using R (version 1.2; RStudio, Inc).
RESULTS
Perceived Risk and Protective Factors of Adolescent Runners
Adolescent runners perceived that poor bone health (93.1%), tight muscles (92.7%), hard landing (85.0%), a low-calcium diet (83.5%), running with narrow steps (83.3%), having a previous injury (83.1%), running on hard surfaces (76.9%), running in footwear with >500 miles (800 km; 76.2%), and consuming fewer calories than what are burned (75.2%) were risk factors for sustaining an RRI (Figure 1; Supplemental Tables 1–5). However, adolescent runners perceived that dynamic stretching before running (90.4%), static stretching after running (85.0%), having strong legs (81.4%), incorporating off days (81.5%), having a strong core (79.2%), cross-training (77.2%), and running in footwear with more cushioning (76.5%) were protective against injury (Figure 1; Supplemental Tables 1, 2, and 4).
Citation: Journal of Athletic Training 59, 9; 10.4085/1062-6050-0164.23
Adolescent versus Adult Perceptions
A greater proportion of adolescents than adults, with a medium effect size, perceived that lifting heavy weights for few repetitions (difference = 21.2%; 95% CI = 12.6%, 29.7%; h = 0.48), running in footwear with less cushioning (difference = 18.7%; 95% CI = 11.5%, 26.1%; h = 0.39), running uphill (difference = 13.5%; 95% CI = 6.4%, 20.9%; h = 0.31), having tight muscles (difference = 10.9%; 95% CI = 5.9%, 15.9%; h = 0.33), summer/preseason running (difference = 8.4%; 95% CI = 3.1%, 13.7%; h = 0.31), cross-training (difference = 7.9%; 95% CI = 2.6%, 13.1%; h = 0.38), lifting light weights for many repetitions (difference = 7.8%; 95% CI = 2.9%, 12.7%; h = 0.33), and alternating long and short runs (difference = 5.9%; 95% CI = 3.3%, 8.6%; h = 0.49) were risk factors for sustaining an RRI (Figure 2; Supplemental Tables 1, 2, and 4). A smaller proportion of adolescents than adults, with a large or medium effect size, perceived that running with long strides (difference = −39.2%; 95% CI = −46.3%, −32.1%; h = 0.82) and running with a low cadence (difference = −25.5%; 95% CI = −32.7%, −18.2%; h = 0.57) were risk factors for sustaining an RRI (Figure 2; Supplemental Table 3). A smaller proportion of adolescents than adults, with a medium effect size, perceived that being overweight (difference = −15.8%; 95% CI = −22.7%, −8.8%; h = 0.35) and static stretching before running (difference = −15.2%; 95% CI = −22.6%, −7.8%; h = 0.35) were risk factors for sustaining an RRI (Figure 2; Supplemental Tables 4 and 5).
Citation: Journal of Athletic Training 59, 9; 10.4085/1062-6050-0164.23
A larger proportion of adolescents than adults, with a large effect size, perceived that static stretching before running (difference = 33.0%; 95% CI = 25.7%, 40.2%; h = 0.67) and running with long strides (difference = 21.7%; 95% CI = 15.8%, 27.8%; h = 0.57) were protective against injury (Figure 2; Supplemental Tables 3 and 4). A larger proportion of adolescents than adults, with a medium effect size, perceived that running in footwear with more cushioning (difference = 20.0%; 95% CI = 12.9%, 26.9%; h = 0.43) and static stretching after running (difference = 11.3%; 95% CI = 5.3%, 17.5%; h = 0.28) were protective against injury (Figure 2; Supplemental Tables 2 and 4). A smaller proportion of adolescents than adults, with a large effect size, perceived that lifting heavy weights for few repetitions (difference = −31.2%; 95% CI = −38.6%, −24.1%; h = 0.64) was protective against injury (Figure 2; Supplemental Table 4). A smaller proportion of adolescents than adults, with a medium effect size, perceived that alternating hard and easy runs (difference = −19.8%; 95% CI = −25.8%, −13.7%; h = 0.51), cross-training (difference = −14.1%; 95% CI = −19.7%, −8.6%; h = 0.40), having a strong core (difference = −13.5%; 95% CI = −18.9%, −8.3%; h = 0.40), alternating long and short runs (difference = −12.4%; 95% CI = −19.2%, −5.6%; h = 0.28), incorporating off (rest) days (difference = −11.5%; 95% CI = −16.7%, −6.4%; h = 0.35), and having strong legs (difference = −10.7%; 95% CI = −15.9%, −5.5%; h = 0.32) were protective against injury (Figure 2; Supplemental Tables 1 and 4).
DISCUSSION
We investigated the perceptions of factors that influence RRIs for adolescent long-distance runners and compared these perceptions with those of adult long-distance runners. As expected, adolescents perceived that training habits, footwear, biomechanics, strength, stretching, and nutrition influence the risk of injury. Of the factors that adolescent runners perceive to influence the risk of injury, a history of previous injury is the only factor that is moderately supported by the current literature, and the remaining factors have limited or inconclusive evidence.2,6 Perceptions also differed between adolescent and adult runners, with adolescents more likely to perceive that footwear cushioning and stretching influence injury risk but less likely to perceive that overtraining (eg, alternating short and long runs and easy and hard runs, including off days, and cross-training) and strength influences injury risk. Future educational materials should be tailored individually for adolescent runners because their perceptions do not fully align with the perceptions of adult runners.
We were not surprised to find that adolescent runners perceived many training habits to increase or decrease the risk of sustaining an RRI, as errors in training habits have been proposed to contribute to RRIs.2 More adolescent runners were concerned with surface type, and fewer adolescents were concerned with overtraining than adult runners. Adults were previously reported to perceive excessive progression of weekly distance and insufficient recovery to increase the risk of injury.8 Given that postexercise recovery time is shorter for adolescents than adults, adolescent runners possibly do not experience symptoms (eg, fatigue, aches, and pain) as often as adult runners when training on consecutive days.20
More adolescent runners were concerned with footwear cushioning than adult runners, and adolescent runners perceived that footwear breakdown increases injury risk. Researchers have reported that adolescent and adult runners perceive footwear to be important for reducing the risk of injury; however, most evidence indicates that footwear does not influence the risk of sustaining an RRI.7–9,11,16,21 Adolescents may intuitively perceive that more cushioned footwear promotes more force absorption (ie, softer landing), but footwear cushioning may actually increase impact forces.22 The concern that adolescent runners have with footwear breakdown does not seem to be substantiated either, as stability and cushioning properties are maintained even after 1000 km of use.23 Footwear structure may not be as important as perceived by adolescents, and runners should consider selecting footwear based on comfort rather than cushioning or technologies.5,21
Adolescent runners perceived running biomechanics to influence the risk of sustaining an RRI, which was comparable to findings reported in previous research on adult runners.7–10 However, adolescents were generally more unsure whether biomechanical factors influence injury risk than adults. Hard landing was the biomechanical factor that the largest proportion of adolescent runners (85.0%) perceived to increase the risk of injury. No conclusive evidence exists that hard landing increases the risk of injury, but gait retraining to decrease impact loading was observed to reduce the occurrence of RRIs in novice runners.7,10,24 Less than 20% of adolescent runners perceived that running with a low cadence could increase the risk of injury. Running with a lower cadence is related to increased risk of injury for adolescent and adult runners, whereas increasing cadence reduces impact forces (ie, hard landing), a variable most runners perceived to increase injury risk.4,25,26 Many perceptions on biomechanical factors (eg, foot morphology, foot pronation, and foot-strike pattern) remain unsubstantiated, as no to very limited evidence is available to support or refute the perceptions of how these factors influence the risk of sustaining an RRI.6,27
Adolescent runners perceived that being strong and flexible reduces the risk of injury. More adolescents perceived stretching to be protective against injury, whereas more adults perceived strength to be protective against injury. Weak knee extensors but not weak hip muscles are associated with a higher risk of RRI, and stronger hip muscles are actually associated with a greater risk of patellofemoral pain in adolescents.27,28 Many adolescent runners perceived that having a strong core reduces injury risk, but this perception is unsubstantiated, as the association between core strength and injury risk has not been reported. Strengthening programs generally improve running economy and performance and, therefore, add value to a training program, even though muscle strength may not be protective against injury.27,29 Limited evidence also indicates that stretching, warming up, cooling down, and range of motion are not associated with injury risk for long-distance running.3,30
Adolescent runners perceived that nutrition is important for reducing the risk of injury. Researchers have recommended that adolescent runners consume an adequate number of calories to avoid energy deficiency along with an appropriate intake of micronutrients, such as calcium and vitamin D.2 Endurance athletes have been observed to be energy deficient, which may increase the risk of injury.31,32 Unfortunately, the detection and management of energy deficiency remains challenging to address, and the development of easily available tools for monitoring energy deficiency is needed.32 More than half of adolescents (62.9%) perceived being overweight to increase the risk of injury but perceived being skinny to not influence the risk of injury (58.9%). The opposite appears to be true; having a low body mass index (ie, underweight) is a risk factor for bone-stress injuries for adolescent runners, whereas adult runners with a high body mass index (ie, overweight or obese) experience a lower rate of knee injuries than runners with an average body mass index.2,33 Adolescent and adult runners with a history of RRI have also reported intentional weight loss to improve performance more frequently than runners with no history of RRI.34 Although most runners perceived that negative caloric intake and low calcium intake increase injury risk, the conflicting perceptions about nutritional intake and body weight may influence habits in runners and subsequent injury risk.
Our results should be interpreted within the context of our study’s limitations. First, it was common for a larger proportion of adolescents to respond, “I don’t know.” Although we piloted the questions with adolescent runners, we do not know if they did not understand the question or if they did not know if the risk factor influenced injury risk. We also do not know if perceptions are more supported by scientific evidence for adolescents or adults. Second, perceptions may not dictate behaviors, and it is unknown if runners implement strategies to reduce injury risk according to their perceptions. Third, few researchers have prospectively assessed RRI risk factors for adolescent runners, and it remains unclear what factors contribute to RRIs for adolescents and if the perceptions of adolescent runners are accurate. Fourth, we categorized participants according to commonly defined age groups in this initial study. In future studies, researchers may consider age or running experience as a continuous variable in their statistical analyses. Future studies should be done to investigate whether factors that adolescents perceive to influence injury risk indeed contribute to RRIs, risk-reduction strategies match running behaviors, and educational materials alter the perceptions of adolescent runners.
CONCLUSIONS
We observed that adolescent long-distance runners perceived training habits, footwear, biomechanics, strength, stretching, and nutrition to influence the risk of sustaining an RRI. However, most of these perceptions are unsubstantiated by the current literature. A larger proportion of adolescents than adults perceived that footwear cushioning and stretching influence injury risk, but a smaller proportion perceived that overtraining and strength influence injury risk. Given that differences in perceptions exist between adolescent and adult runners, future educational materials should be individually tailored for adolescents with a focus on footwear cushioning, running surfaces, and stretching.
Perceptions of adolescent long-distance runners on how factors influence the risk of injury. a Greater than or equal to 75% perceived the factor to increase injury risk. b Greater than or equal to 75% perceived the factor to decrease injury risk. Abbreviation: reps, repetitions.
Differences in the proportions of perceptions between adolescent and adult long-distance runners on how factors influence the risk of injury. a Large effect for decreasing injury risk. b Medium effect for increasing injury risk. c Medium effect for not influencing injury risk. d Medium effect for decreasing injury risk. e Large effect for increasing injury risk. f Medium effect for unsure if influences injury risk. Abbreviation: reps, repetitions.
Contributor Notes