Finish line SPRINT: is an evidence-based approach the gold standard?

Running is one of the world’s most popular sports. It is easy to perform, requires little specialized equipment, and can have multiple well-known health benefits⁽¹⁾. However, increasing participation means that the incidence of injuries will likely increase. The low entry barriers mean that participants may be underprepared for the demands. Furthermore, the improvements can be exponential initially; thus, people may increase their mileage or speed too soon and thus increase their risk of injury. Another challenge with running-related injuries (RRI) may be the definition of an injury. Athletes can continue to participate with mild injuries, so they may not report to a medical professional for treatment. Therefore, the actual incidence may be much higher than the literature shows.

Running-related injury prevention is challenging for many reasons. Injury incidence is multifactorial, and therefore designing interventions is challenging. The interplay between the biomechanical and psychological factors is complex and nuanced. The most significant injury risk factor is a history of previous injury and orthotics use⁽²⁾. The risk factors in female runners include age, previous sports activity, running on a concrete surface, marathon participation, weekly running distance (48–63 km), and wearing the same running shoes for 4-6 months⁽²⁾.

On the contrary, in male runners, a history of previous injuries, having running experience between 0–2 years, restarting running, weekly running distance (32–47 km), and a running distance of more than 64kms per week increase RRI risk⁽²⁾. To prevent injuries, practitioners will need to establish interventions that meet the individual needs of the athletes. Athlete education may be the key to minimizing the high incidence of RRI, but what do practitioners tell them?

Along with the low entry barrier, information on RRI is freely available to athletes online. Although this poses a challenge to practitioners as the information may not be evidence-based, it also provides an opportunity. Athletes may access high-quality advice at their fingertips if practitioners can create a reputable, respectable, and trusted information source. This would lower the barriers to accessing medical care and potentially improve injury reporting and treatment. But do online programs work? Researchers at the Erasmus Medical Centre in the Netherlands aimed to examine the effectiveness of an enhanced online injury prevention program on the number of RRI in recreational athletes (SPRINT study).

In 2017, the same group of researchers designed the Intervention Study on Prevention of injuries in Runners at Erasmus MC (INSPIRE) trial⁽³⁾. The INSPIRE trial was an RCT assessing the effectiveness of a multifactorial online prevention study on the incidence of RRI. The study results demonstrated that an online program does not decrease the incidence of injuries⁽³⁾. However, since then, the same group of researchers has gained new insights into how to enhance injury prevention strategies (see figure 1)⁽⁴⁾. The insights indicate that running prevention advice should be more directive and personalized⁽⁴⁾.

The researchers used the new insights to create an enhanced online injury prevention program called “10 steps 2 outrun injuries” (see figure 2)⁽⁵⁾. The researchers aimed to investigate the effectiveness of the enhanced online program on the number of RRI in recreational runners. They recruited runners who registered for various races between 10 and 42.2km across the Netherlands. As this study was a follow-up to the INSPIRE trial, the researchers excluded any runners who participated in the original study⁽⁶⁾.

The researchers randomized 4105 runners into two groups. The intervention group had access to the enhanced online prevention program while continuing to train for their events. The program has actionable steps and includes animations, videos, and interactive tools. As the INSPIRE trial suggests that an online intervention may negatively affect the occurrence of injuries in people without a history of RRI, athletes without a history of RRI were advised not to change anything. Instead, the online program is for runners with a prior history of RRI. The control group continued with their regular training schedule and had no access to the intervention. Furthermore, researchers defined RRI as a self-reported injury of the muscles, joints, tendons, or bones in the lower back or lower limb⁽⁶⁾. The injury had to be severe enough to cause:

1. A reduction in speed, distance, duration, or frequency for at least seven days or three consecutive scheduled training sessions or,
2. require consultation with a medical professional⁽⁶⁾.

The study’s primary outcome was the difference in injury proportion between the intervention and the control group. The secondary outcome included injury location and severity of RRIs. With only 55 participants lost to follow-up, the large sample size positively impacts the sensitivity of the results (see table 1)⁽⁶⁾.

Table 1: Total number of injuries⁽⁶⁾.

To assess compliance, researchers required participants to apply at least one item of the online program to their training schedule. The most common items applied by runners were ‘take enough time for rest and recovery’ (51.6%), ‘make sure there is variety in movement using specific exercises’ (50.4%), and ‘do not train too much’ (49%). Interestingly, the injury proportion in the subgroup of compliant participants was 44% compared to 35.4% in the control group. This poses a serious question to medical professionals, as greater compliance (number of items applied) positively correlates with the number of RRI sustained⁽⁶⁾.

Clinical Implications

The analysis of the results places medical professionals in an uncomfortable position. The enhanced online program, which is directive and actionable, appears to worsen the outcomes and place runners at greater risk of RRI. Researchers never assessed the timing of the advice application, and it is possible that athletes applied more interventions after they were injured (tertiary prevention)⁽⁶⁾. This may imply that compliance improves once athletes are injured. Runners may continue running with mild discomfort and react once the injury affects their performance.

The study results allow practitioners to introspect and require in-depth discussion to dissect what the results mean for running injury prevention. One thing is clear, despite a high-quality, evidence-based prevention program, execution is the key. Injury prevention is multifactorial and complex. The complex biopsychosocial interplay places runners at risk of injury but provides practitioners with an opportunity. The research on load management, strength training, shoe selection, running biomechanics, and pain management are robust and, when assessed in isolation, has a clear role in injury prevention⁽⁶⁾.

The skill is applying the evidence to the patient. As it stands, most runners cannot independently apply the evidence effectively to reduce injuries. Understanding the research, clinician experience, and athlete preference is most likely the key to injury prevention in reality. Athletes’ previous injury experience may also shape their prevention strategy selection and timing. In preparation for events, athletes typically neglect minor injuries and thus place themselves at significant risk.

Furthermore, understanding how to apply prevention strategies effectively requires a foundational scientific background and experience. Practitioners have both. Therefore, they can best navigate the complexity and create individualized approaches with the available evidence.

A clinician’s ability to adjust and tinker with the program to meet the athlete’s individual needs is also key to being proactive instead of reactive as problems arise. An evidence-based practice approach is “the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of individual patients” ⁽⁷⁾.

The evidence points to the qualitative factors as critical differentiators in sports medicine. As the evidence base expands, our understanding of injury prevention improves. However, it isn’t easy to replace the core values that make practitioners human – empathy. The human nature of understanding and sharing the feelings of another remain critical in injury prevention and rehabilitation.

Clinical take-home message

• There is good evidence to support load management, strength training, running biomechanics, shoe selection, and pain management in injury prevention.

• Injury prevention is complex.

• An individualized, evidence-based approach is the current gold standard in injury prevention

• Empathy and the patient-clinician relationship remain at the heart of injury management and prevention.

References

1. Sports Med 2015 Oct;45(10):1455-68
2. PLoS One.2015; 10(2): e0114937.
3. BMJ Open Sport Exerc Med 2017;3:e000265.
4. J Orthop Sports Phys Ther. 2019 Oct;49(10):736-742.
5. BMJ Open Sport & Exercise Medicine 2020;6:e000780.
6. Br J of Sports Med 2022;56:676-682.
7. BMJ. 1996 Jan 13;312(7023):71-2.