Strength Training for Runners to Prevent Injury

I have to admit the the use of strength training for runners, especially to prevent injury is not something I have paid a lot of attention to. I am ‘old school’ and just want to go for a run. You train for running by running. I have been noticing more and more people talk about the usefulness of strength training for runners and there has been some research to show it might be helpful and other research that says its not, which is probably why I did not take a lot of notice to the conflicting evidence. I do listen to and read what people like Brian Martin have been saying about it, but (….and sorry Brian), I have to admit that I did not take a lot of notice of the concept. I always struggled to comprehend the mechanism behind how having a stronger muscle could help prevent an injury. How does being able to do a dozen deep squats with a heavy weight help in the last kilometer of a marathon? Overuse injuries are prevented by reducing the load in the tissue and adapting the tissue to take the load, so how does strength training help with that? The cynic in me was wrestling with these types of issues.

However, recently I noticed that whenever I try to do things like lunges and squats my legs are not like they were a few years ago (I do a ‘boot camp’ like group fitness class twice a week) and was started to get a bit concerned that something was wrong as my strength should not be declining with the exercise I was doing. Then this research turned up last month. It showed that when runners reach a certain age that they loose up to about 5% in muscle strength in the legs each year. I had reached that age, so no wonder I was struggling with the lunges and squats. Fortunately that meant that there was nothing wrong with me, it was just part of the normal aging process. It also meant I had better start paying more attention to the issue of strength training to supplement the running!

The problem I recall with what research I had seen on the role of strength training especially to prevent injury is that the data was not really clear one way or the other with some studies saying yes and some studies showing no. There were some strong studies and some weak poorly designed studies, so it could be easy for anyone to cherry pick a few studies to make whatever point they want to make. When this situation exists, that is when we rely on the systematic reviews and/or meta-analysis of all the studies. A search strategy is used to locate all the studies; then criteria is applied to select only the methodologically sound studies; then the data from them all is pooled to try and reach a conclusion and make sense of it all. Fortunately, especially in the context of the issues I am facing myself, such a review turned up this morning:

The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials
Jeppe Bo Lauersen, Ditte Marie Bertelsen, Lars Bo Andersen
Br J Sports Med doi:10.1136/bjsports-2013-092538
Background Physical activity is important in both prevention and treatment of many common diseases, but sports injuries can pose serious problems.
Objective To determine whether physical activity exercises can reduce sports injuries and perform stratified analyses of strength training, stretching, proprioception and combinations of these, and provide separate acute and overuse injury estimates.
Material and methods PubMed, EMBASE, Web of Science and SPORTDiscus were searched and yielded 3462 results. Two independent authors selected relevant randomised, controlled trials and quality assessments were conducted by all authors of this paper using the Cochrane collaboration domain-based quality assessment tool. Twelve studies that neglected to account for clustering effects were adjusted. Quantitative analyses were performed in STATA V.12 and sensitivity analysed by intention-to-treat. Heterogeneity (I2) and publication bias (Harbord’s small-study effects) were formally tested.
Results 25 trials, including 26 610 participants with 3464 injuries, were analysed. The overall effect estimate on injury prevention was heterogeneous. Stratified exposure analyses proved no beneficial effect for stretching (RR 0.963 (0.846–1.095)), whereas studies with multiple exposures (RR 0.655 (0.520–0.826)), proprioception training (RR 0.550 (0.347–0.869)), and strength training (RR 0.315 (0.207–0.480)) showed a tendency towards increasing effect. Both acute injuries (RR 0.647 (0.502–0.836)) and overuse injuries (RR 0.527 (0.373–0.746)) could be reduced by physical activity programmes. Intention-to-treat sensitivity analyses consistently revealed even more robust effect estimates.
Conclusions Despite a few outlying studies, consistently favourable estimates were obtained for all injury prevention measures except for stretching. Strength training reduced sports injuries to less than 1/3 and overuse injuries could be almost halved.

Nothing jumps out at me as anything being problematic in the way the authors did this review and their analysis of the data, except perhaps it did include sports other than running, but it did divide the studies into acute and overuse for the nature of the injury. The diverse nature of the included studies in terms of the exact nature of the interventions and the wide range of sports may be problematic in generalizing the results to any one specific sport.

The conclusions were quite clear and carry a lot of weight as a meta-analysis sits at the top of the ladder when it comes to the hierarchy of evidence:

  • Stretching does not protect from injury
  • Proprioceptive training and ‘multiple exposure’ programs were effective
  • Strength training was highly significantly protective

Strength training decreases the risk for overuse injury by half, which is quite an important conclusion.

As always, I go where the evidence takes me, and it looks as though I going to be heading to the gym more for some lunges and squats!

Jeppe Bo Lauersen, Ditte Marie Bertelsen, Lars Bo Andersen (2013). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials Br J Sports Med DOI: 10.1136/bjsports-2013-092538

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About Craig Payne

University lecturer, runner, cynic, researcher, skeptic, forum admin, woo basher, clinician, rabble-rouser, blogger, dad. Follow me on Twitter, Facebook and Google+

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14 Responses to Strength Training for Runners to Prevent Injury

  1. Brian Martin October 8, 2013 at 5:07 am #

    And I thought you were listening :-) This is good stuff in this study that supports what I’ve been banging on about. I think it’s also more than absolute strength, you can get smarter at certain movements related to running and get strong and skilful enough to run a little better than you might have been able to before. No need for super heavy grunting and squatting small cars, lunges, bridging, step-ups and a multitude of other body weight exercises are a great place to start.

  2. Brian Hazard October 8, 2013 at 5:39 am #

    Good stuff! I’ve been struggling with this question myself, now that I’ve been forced to take time off with peroneal tendinitis.

    What I wonder is, what exactly does “strength training” encompass? I’d been doing Jay Johnson’s lunge matrix, pedestal, myrtle, and cannonball routines for 3 months, and still got injured. Maybe it helped, maybe it didn’t, but it’s not the same as doing, say 10-20 reps of single-legged squats to failure, once or twice a week.

    • Craig Payne October 8, 2013 at 6:41 pm #

      The results point to ‘global’ and not any specific exercises to prevent “all” and not any specific overuse injury.

      For eg to treat/prevent peroneal tendonitis you need to:
      1. Reduce the load in the tendon –> strengthening the peroneal muscles will not do that.
      2. Increase the ability of the tendon to take the load –> strengthening the peroneal muscles will not do that.
      3. Facilitate the healing of the tissues –> strengthening the peroneal muscles will not do that.

      Yet all over the blogosphere is advice on strengthening the peroneal muscles for this problem … go figure!

      • Brian Hazard October 9, 2013 at 3:09 am #

        I confess I was doing resistance band eversion exercises! So thank you for saving me from those ;). I’ll stick with single-legged and Bulgarian split squats, lunges, and calf raises. That should cover the major bases leg-wise.

      • Steven November 7, 2013 at 11:16 am #

        Hi Craig……great site/blog

        As a student I’m struggling with this one:

        “…….. adapting the tissue to take the load, so how does strength training help with that?”

        and from above

        2. Increase the ability of the tendon to take the load –> strengthening the peroneal muscles will not do that.

        Surely loading via strength training of any muscle or tendon increases its ability to take load.
        Does strength training push out further the point of failure in a stress-strain curve?
        Does adaptations to strength training include an increase in cross sectional area of a given muscle/tendon, therefore increasing its ability to handle load and stress?

        Thanks in advance

        • Craig Payne November 8, 2013 at 1:08 am #

          “2. Increase the ability of the tendon to take the load –> strengthening the peroneal muscles will not do that.”

          See below to my reply to Keith’s post. The mechanism here is probably the eccentric loading to the tendon that increases the ability of the tendon to take the load. Its the same principle that underpins Alredsens protocol for the eccentric loading of the Achilles tendon. So its not really the “strength” that matters, but the “strength training” loading the tissues.

    • Kevin A. Kirby, DPM October 8, 2013 at 9:45 pm #

      Brian:

      Runners with peroneal tendinitis often do better with getting into a running shoe with higher heel height differential (i.e. more “heel drop”), by adding a valgus forefoot and rearfoot wedge to their shoe sockliner, by icing and by using topical anti-inflammatory gels (e.g. Voltaren gel) and avoiding forefoot striking running.

      If you have a high arched foot, then the peroneal muscle/tendon overuse may be due to your peroneal muscles having too short of a moment arm about the subtalar joint axis, thus the recommendation for a valgus forefoot/rearfoot wedge to increase the ground reaction force lateral to the subtalar joint axis.

      Further information on the theory behind how peroneal tendinitis can be caused by lateral deviation of the subtalar joint axis can be found in a paper I wrote over a decade ago (Kirby KA: Subtalar joint axis location and rotational equilibrium theory of foot function. JAPMA, 91:465-488, 2001).

      Hope this helps.

      • Brian Hazard October 9, 2013 at 4:35 am #

        This helps immensely Kevin! Thank you!

        I just returned my Newton Distance, which has 100% exposed EVA on the heel. Obviously that won’t work. I picked up the Nike Free 3.0 v5, which at least has 4mm drop. All my other shoes are zero.

        If/when I do go back to thin flat shoes like Vapor Gloves and VFFs, is landing flat on the outside edge of the foot “close enough”? I’m not sure there’s a safe way to heel strike in VFFs!

        I’m going to order a lateral wedge from myfootshop.com. I’ve got a couple more weeks until my next doctor visit, where presumably I’ll get the green light to ease back into running.

        I have a low arch, fwiw.

  3. Matthew Spiegel October 8, 2013 at 7:35 am #

    First, I want to say thank you for maintaining this blog! It is a great resource for those of us interested in knowing what we actually do and do not know about running and injury prevention. (As opposed to doing things on the basis of “gee that sounds like it might work” science.) Regarding this post, what do “proprioceptive training and ‘multiple exposure’ programs” involve? Do what?

    • Craig Payne October 8, 2013 at 7:42 am #

      Thanks. One of the problems the authors had was to classify the interventions that were used in each of the studies as every study did it differently. Stretching was obvious. Strength training was obvious. ‘Multiple exposure’ was when the athlete was exposed to more than one interventios, so it might have been a program that combined strength and stretching and proprioception, so it was not possible to tease them out separately.

      Proprioceptive training is really getting better at joint position sense of more awareness of where the limb is in space.

  4. Christian October 8, 2013 at 8:39 pm #

    I am biased perhaps as I have an undergrad in EP and am a strength and cond coach but I think properly Rx strength training is essential to injury prevention and rehab.

    Whilst this is the case people’s lack of ynderstanding of sound strength programing principles means its full potential is often missed.

    Pumping out a few reps of the latest “glute” or “core” exercises of your favourite blog or fad site is far from effective strength training.

    As for your peroneal analogy, often if assesed properly the injury is often the symptom and not the cause. If you get the body the moving moreefficiently by addressing movement dyfunction, the loads in the peroneals will be better controlled.

  5. Keith Graham October 10, 2013 at 3:46 pm #

    Would be interesting to know if the “benefit” of strength training was through soft tissue adaptation or ability to absorb load. Or a function of a stronger muscle set to reduce the speed or amplitude of the body landing on the floor.
    Any thoughts as to what this “protective” function might be?

    • Craig Payne October 11, 2013 at 9:22 pm #

      Its hard to judge on a “mechanism” from the systematic review as they included “overuse injuries” and not specific injuries (though it looks like a lot might have been patellofemoral pain syndrome). I suspect the mechanism could be 3 fold:

      1. Not actually related to “strength”, but related to the eccentric contractions better conditioning tissues to take load.

      2. Strength allow better motor control proximal to help control the “gait” – see the study I just posted on MTSS and this and your point “educe the speed or amplitude of the body landing on the floor” –> but I not totally convinced on importance of reducing impacts

      3. Could be fatigue related – better stength –> less fatigue –> less detrimental changes in kinematics and kinetics later on in runs

  6. Strong Runner December 23, 2013 at 4:37 pm #

    Hi Craig,
    Great site! Nice work providing unbiased posts that enlighten runners on all levels.
    Keep up the excellent work.
    Cheers!

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