In the early ‘90’s a sports study came out from the Seattle area called The Rice Study. It was a survey of over 10,000 high schoolers to determine the incidence and frequency of injuries high school athletes face. To the embarrassment of some (track coaches) and the amazement of others (everyone else) the most “dangerous” high school sport was found to be girls cross-country running. More than football, wrestling and cheerleading.

How could this be? The way the injuries were determined was the percentage of competitions missed per athlete. For the girls the simple combination of five-mile runs on legs that had effectively never run before was a recipe for disaster. One needs to remember that the whole concussion issue at the time was addressed with a band-aid and a few minutes of “walk it off.”

Interestingly the stats that the Rice Study produced showed that 79% of the XC girls suffered injuries from the knee down with shin splints or the more technically correct, tibial tendonitis leading the charge.

In truth, as a former running coach, all this amazed me. The last XC team I coached had 44 guys and we had one case of shin splints all season. That guy had feet flatter than this screen. Add to that fact hardly anyone got injured at all. How could that be?

One needs to remember that running is a “ground contact sport,” as in 1000’s if not tens of thousands of ground contacts over the course of a season. You could blame gravity or the ground, but really, those givens are the same for everyone. I assumed the position that everyone needed to have the strength, balance and proprioception to manage the thousands of ground contacts. This starts at the foot.

One needs to remember that the foot has a multi-axal subtalar joint (talo-calcaneal), an almost multi-axial mortise joint (tibio-talar) and the talo-navicular joint that is a limited ball and socket joint. The foot has the potential for a great deal of movement and if it is unregulated, excessive movement can initiate too much (pronation, supination, inversion, eversion – you chose) movement that can result in foot, shin, knee, hip or low-back problems. But the “too much” can be managed with preventive actions that are simple, easy and free. Detailed below are recommendations that should be compatible with most everyone’s treatment philosophy that are simple, easy, and effective and will prevent a multitude of running related injuries.

The 6 Foot Drills – The foot drills are a series of six walking foot exercises that improve foot balance and proprioception. They can be practiced for 25m. Five of the drills are done barefooted, one with the shoes on. Results can be seen in 10-14 days and will include a lessened severity (or absence of) plantar flexion-inversion ankle sprains, Achilles tendonitis, plantar fasciitis and tibial tendonitis or shin splints.

The six drills are to walk 25m on the inside and outside of the foot (inversion and eversion), walk toeing in and toeing out, walk backwards on the forefoot (not letting the heels touch) and finally, with the shoes on, heel walk 25m. The shoes protect the heel from bruising. The drills should be done daily. There is a YouTube clip “The 6 Foot Drills” for the visual learners.

Bed Sheets – Virtually everyone sleeps with the foot in a plantar flexed position. This “toes down” position leads to a chronic shortening of the gastroc-soleus complex. Upon awakening and assuming an upright posture the gastroc-soleus, part of Myers’ superficial back line fascia, undergoes a tremendous traction stretch without the benefit of a gentle warm-up. Contributing to this problem is that most people sleep with the bedsheets tucked in at the foot of the bed promoting the plantar-flexed foot posture.

Most of us spend upwards of 1/3 our life in bed. This chronic foot posture can be a contributing factor for the chronic adaptive shortening and subsequent Achilles and plantar fascia problems common for the serious runner. The simple solution is to untuck the bed sheets to allow a greater degree of foot movement during the bed-time hours. And if your feet get cold? Wear some socks.

Side Lunges – Dynamic stability is the ability to hold “postures” while moving. As we age our movement patterns become more linear in nature which negatively effects our dynamic stability. It is the loss of dynamic stability that contributes to falls the elderly suffer from. Running, by and large, is a linear activity that promotes atrophy of the dynamic stabilizers which can lead to instability related problems at the foot, knee, hip or low back. Side luges or side lying leg raises can tone the dynamic stabilizers of the hip.

The major dynamic stabilizer of concern here is the glut medius. Glut medius dysfunction presents with the very obvious Trendelenburg Sign. Minor, seemingly imperceptible glut medius dysfunction can present with hip, knee or low back pain. This dysfunction can be addressed by daily performance of 10 side leg lunges or 10 side lying leg raises. Coincidentally dynamic stability at the foot comes from the functional integrity of the posterior tibialis which controls the velocity of mid-foot pronation (the too much, too soon or too fast of pathologic pronation). The conditioning of the posterior tibialis is addressed with the inversion foot drill discussed above.

100m Rehab Running – As a suggestion for runners returning to running one strategy we used successfully was the 100m rehab runs. This workout involved repeat 100m runs back and forth on a track. The running is done pain free with a conscious effort at symmetry of motion. The runner may start with 500m of running and progress to 20 minutes. There are several advantages to this idea. The runs are not too far and not too fast. The ground is flat and consistent from one step to the next. If a problem flares up one is only 100m from home. The goal here is to re-establish symmetry of pain-free motion, not to derive any particular training effect.

The problem of the knee – It is an established fact that instability issues at the foot or hip can present with knee problems. Attention to the dynamic stability of the hip and foot mentioned above can address this problem. Nonetheless the knee must sustain 4-7x body weight compression with each ground contact. Terrain changes such as running downhill or repeatedly jumping off a curb for an urban runner can present with knee specific aches and pains. Chondromalacia patella, patellar tendonitis, medial/lateral ligament sprains or meniscus problems may present with long-term use. Conditioning of the quadriceps muscle can stabilize the knee. In fact, the simple mantra of “strengthen the quad, stabilize the knee” is a truism. The preferred exercise here is to do 2-3 sets of 10 each week on a leg extension machine to strengthen the quad. Machines are not the ideal and some would argue this exercise is not the best but for most this exercise is simple, safe and effective.

I have always been troubled by the findings of the Rice Study, even 30 years later. As you can see some simple precautions can go a long way in preventing a host of common injuries for many runners. The possibility of stepping on a stone or getting clipped by a car is always there but for the majority of runners prevention of repetition or overuse injuries can be averted with the inclusion of some simple preventive measures done on a daily basis.

Russ Ebbets DC

Dr. Russ Ebbets, DC is the editor of Track Coach, the technical journal for USA Track and Field. His most recent book, A Runner’s Guide is a wide ranging collection of essays that address training and competition, growth and development and health related issues all runners face.  A Runner’s Guide is available from Amazon.com. He maintains a private practice in Union Springs, NY.