The “High Ankle Sprain” vs. The Common Ankle Sprain- What’s The Difference?

By Dev Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • High ankle sprains happen with body rotation, such as being tackled with the foot planted at the same time as changing direction
  • Most mild and moderate high ankle sprains are treated without surgery
  • Expect return to play to take longer than common ankle sprains- typically 6 to 12 weeks for young athletes, depending on the sport

We’ve recently written about the usefulness of ankle bracing in reducing the risk of football high ankle sprain - Version 2common ankle sprains with basketball. But there is a different type of ankle sprain, commonly called a “high ankle sprain” that behaves differently. What is the difference between a common ankle sprain and a high ankle sprain? And why do athletes with a high ankle sprain seem to be out for a longer period of time? The explanations center on the anatomy of the ankle and the different ligaments injured in a common vs. high ankle sprain.

The common ankle sprain involves injury to a ligament on the outside of the ankle called the “ATFL”, which stands for the anterior talofibular ligament. This ligament runs between the end of the fibula to the talus on the outside of the ankle. It is one of the primary stabilizers of the ankle and is frequently injured when an athlete “rolls” the ankle. Athletes frequently will have pain, swelling, and even bruising in more severe sprains. These symptoms can be experienced on the outside of the foot, just below the ankle joint.

In the high ankle sprain, however, a different ligament is injured, called the “syndesmosis”. The syndesmosis is a tough sheet of tissue that lies between the tibia and fibula and holds these two bones together. In normal walking and running the syndesmosis is preventing the tibia and fibula from being pulled apart. The high ankle sprain typically occurs with rotation of the body around the planted foot, such as with a player being tackled at the same time he is making a cut or direction change. This is very different from the rolling that results in a common ankle sprain.

The high ankle sprain can be mild, moderate, or severe, similar in grading to the common ankle sprain. Severe high ankle sprains will cause a widening of the space between the tibia and fibula. The severe high ankle sprain will usually need surgery to repair the proper space between the bones. Most mild high ankle sprains can be treated without surgery. We will typically place the leg in a boot with some weight support with crutches. As healing progresses the boot and crutches are stopped, and physical therapy started.

Return to play after high ankle sprains almost always takes longer than return after a common ankle sprain. The reasons for this are not known. With adolescent athletes I find that return to full sport participation will take 6 to 12 weeks, depending on the sport and the position. Physical therapy is very helpful to help the athlete regain strength, agility, power, and confidence. I send all my young athletes to physical therapy after high ankle sprains. The good news about these injuries is that they tend to be “one and done” events and tend not to happen over and over. If they are treated correctly, keep your spirits up, you’ll almost always get back to normal activity but just expect it to take a bit of time.

 

 

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Heel Pain In Young Athletes: Calcaneal Apophysitis or “Sever’s Disease”

By Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • Heel pain in young athletes is a very common condition in young growing athletes
  • Most often this is a condition called “Sever’s Disease”, and can be managed with heel cushioning, proper shoe wear, and activity modification Severs-Disease-1

Heel pain is one of the most common complaints in young athletes. This generally occurs during the early portion of the growth phase around 8-10 years old, and can recur towards the end of growth (14-16 years old). Symptoms are typically in the back portion of the heel, can occur in one heel or both, usually having a gradual onset. The heel bone’s growth plate is in this area, which is immature soft bone and cartilage. A “tug of war” occurs in this region from the foot growing longer and the leg bones getting taller, which puts tension on this heel bone area known as the calcaneal apophysis. The inflammation is called calcaneal apophysitis or “Sever’s disease”.

Activities with more impact and running aggravate the pain, which can be a throbbing, aching discomfort. Thin and hard soled shoes also can aggravate the condition. Cleated shoes can actually accentuate the tension on the area; grass cleats are worse as they can actually have a “negative” heel. Turf cleats are better due to the higher heel and more cushioning. Even if games are played on grass, turf shoes usually work better as symptoms are less.

In addition to using turf cleats for athletes in sports such as soccer, football, baseball, and field hockey, adding heel cushions can help. Stretching and icing may have temporary benefit. X-ray’s and other imaging usually are not helpful. Sometime inserts to help address other foot deformities can help, but usually just heel elevation is sufficient. The other key item in controlling symptoms is activity modification and even reduction.

Sometimes calcaneal apophysitis worsens and becomes a stress fracture. The symptoms become more constant and patients have swelling, it hurts to hop on the involved limb and to squeeze the heel. The treatment at this point is rest and immobilization in a boot. Other conditions that can occur in this area are an “avulsion” or displacement of the growth plate and bursitis in the back of the heel. An avulsion happens from a severe landing on the heel, whereas bursitis (aka “pump bump” or “Haglund’s”) is more of chronic condition due to a prominent portion of the heel.

Calcaneal apophysitis is generally self-limiting and resolves after 6-12 months. Maintaining cushioning, proper shoes and activity modification is key in controlling symptoms. It is really not a disease, but rather a common condition of active youth athletes and can be controlled while allowing the young athlete to continue sports activity.

 

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Ankle Braces Can Reduce The Number Of Ankle Sprains In Football And Basketball

Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

 

Brian Cole, M.D.

Head Team Physician, Chicago Bulls

Professor of Orthopedic Surgery, Rush University, Chicago, IL

Key Points:

  • There is good evidence that lace-up ankle braces will reduce the number of ankle sprains in youth football and basketball
  • Athletes wearing a lace-up brace generally will not notice any decrease in sprint speed or performance
  • We have not seen any harmful effects of wearing the braces, so it makes good sense for youth football and basketball players to wear lace-up braces

We see a lot of ankle sprains in our clinical practices, and if they make their way to the basketball rolledankle2_3orthopedic surgeon’s office it generally means it was a significant injury. Severe ankle sprains can take many weeks to properly heal, can be costly to treat, and can place the athlete at risk for future ankle sprains. What then can we do try reduce the number of ankle sprains, or reduce the severity of an ankle sprain if one does happen?

One simple and cost effective option is to wear a lace-up ankle brace. These braces are effective in stabilizing the ankle in side-to-side and landing movements (the type of movements typically risky for ankle sprains) but allow excellent movement for straight ahead activities such as sprinting and jumping.

Ankle sprains are classified in three grades. A Grade 1 injury is a mild stretching or sprain and generally allows the athlete to return to full play in a couple of weeks. A Grade 2 injury is a partial tearing of the ankle ligaments and can take considerably longer and will often require physical therapy. A Grade 3 injury is a complete tear of the ligament. This severe injury can take months to recover, sometimes needs surgery, and places the athlete at risk for future sprains. If we can prevent ankle sprains, or at least reduce the number of Grade 3 injuries it will be a big benefit for the young athlete.

We have two high quality clinical studies showing the effectiveness of lace-up ankle bracing to reduce the number of ankle sprains in football and basketball. Both of these studies, by author Timothy McGuine, were published in the American Journal of Sports Medicine in 2011 and 2012. The authors tested the effectiveness of a lace-up ankle brace and injury rates in high school basketball and football players.

The results of the two studies were remarkably similar. In one study, comprised of 1,460 male and female high school basketball players, the rate of acute ankle injury was 0.47 in the braced group and 1.41 in the control (non-braced) group. In the other study, which included 2,081 male high school football players, the rate of acute ankle injury was 0.48 in the braced group and 1.12 in the control group.

In other words, using a lace-up ankle brace reduced the incidence of acute ankle injuries threefold in basketball and more than twofold in football. Also, the studies concluded there was no increased risk of knee injuries associated with wearing an ankle brace.

From our perspective it makes a lot of sense for young football and basketball players to wear lace-up ankle braces. Players tell us there is no negative effect on performance and the science shows the number of sprains can be significantly reduced. No ankle brace can completely eliminate all ankle sprains but in our experience they definitely make a difference. They are simple to put on, inexpensive, and can be used over and over. As you are finishing up football season or starting basketball season take a look at lace-up ankle braces. Your ankles will thank you for it.

 

 

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“Why Exercise Will Make You Smarter.” Radio CaptainU Interviews Gretchen Reynolds, noted New York Times columnist.

Summary By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Gretchen Reynolds writes a column for the New York Times. She is a very entertaining writer focused principally on health and fitness.
  • In this podcast focused on the young athlete, she discusses the benefits of lifelong exercise on brain and physical health, ACL prevention programs, and the usefulness of dynamic warmup.

Gretchen Reynolds writes for the New York Times, her columns are posted in the Well blog. I’ve enjoyed her posts for a number of reasons. First, she takes a reasonable balanced approach to her topics, it’s based on good science, it’s entertaining, and her focus is typically on various aspects of fitness rather than on specific diseases or medical conditions. Many of her columns are highly applicable to young athletes. For example, you might also check out this column on how “How Exercise Can Boost Young Brains”.

For this CaptainU podcast, Avi Stopper interviewed Ms. Reynolds. The interview starts with opinion on some of the big questions in medicine/science such as the benefits of exercise or even life-long physical activity in slowing down the aging process. So much of our focus for young athletes is on competition, dealing with injuries, getting a scholarship to college, etc., but keeping these young athletes active into adulthood is a key point that needs emphasis.

She also emphasized the benefits of exercise on brain health (see her column I reference above). The benefits are present for young people, there is some evidence that exercise can improve conditions such as ADHD, and at the other end of the spectrum there is now evidence that lifelong exercise can stave off cognitive decline.

They go on to discuss other topics such as ACL prevention programs, the uselessness of static stretching, the benefits of dynamic warmup, and others.

Ms. Reynolds is a talented, entertaining writer and from this podcast you’ll hear that she’s an engaging speaker too. This podcast is well worth a listen.

 

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Stingers and Burners In Football

Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

 

Tim McAdams, M.D.

Head Team Physician and Medical Director, San Francisco 49ers

Associate Professor of Orthopedic Surgery, Stanford University

 

Key Points:

  • Stingers are common in youth football. The player will feel a burning or stinging sensation from the shoulder to the hand
  • The player can return to play with a completely normal arm: no stinging or burning, full motion, normal strength
  • Practicing Heads Up Tackling is a good way to minimize your risk of stingers, neck injury, or concussion

As football season rolls along we are seeing a fair number of injuries called “stingers”, also known as “burners”. The injury is named for the stinging or burning pain that spreads from the shoulder to the hand. This can feel like an electric shock down the arm. Stingers are fairly common injuries in collision sport athletes, and fortunately most of these injuries are temporary with rapid return to normal function. A stinger occurs when there is an injury to the network of nerves surrounding the neck and traveling to the shoulder, arm, and hand. In football we commonly see stingers when the neck is stretched to the side during a tackle. We will also see stingers occasionally when the side of the player’s head makes contact with the ground. stinger

Symptoms include neck pain, numbness, burning, or weakness in one arm. In the classic stinger there will be no neck pain. If neck pain accompanies the burning sensation in a young athlete, we would consider that a potential spine injury and would strongly recommend that the player be transported from the field of play to the local emergency department by qualified emergency medical personnel. When neck pain is present, the player should not be moved from the field of play until emergency medical personnel arrive. Keep the helmet and shoulder pads on, and do not move the young athlete.

In the typical stinger the player will often be seen jogging off the field while shaking or wringing his arm to try and get the feeling back into it. Symptoms of the stinger usually get back to normal within minutes, but can sometimes take longer.

The player with a suspected stinger should be observed on the sideline and not return to play until the symptoms are completely back to normal. This means he should have no arm or shoulder pain, his sensation is normal, shoulder motion is normal, and arm strength is normal. A player who returns with some symptoms is not able to adequately protect himself in another collision, and risks making the injury much worse.

In rare cases, stingers can recur or become chronic. In these cases it’s very important to have a thorough evaluation from an orthopedic surgeon or spine specialist. Recurring stingers can indicate an underlying problem such as a narrow spinal canal or disc injury.

Protective equipment can be used to help limit neck motion in a player who’s had a stinger. This can be a cowboy collar or neck roll worn above the shoulder pads.

In terms of preventing a stinger, the best advice we can give is to practice proper Heads Up Tackling. Even perfect technique will not completely eliminate the risk of a stinger, but it can go a very long way towards reducing the risk of stingers, serious neck injury, or concussion. Another factor sometimes overlooked is to play on a team of similarly size-matched players. In high school the problem we see is smaller freshman players suiting up against larger, faster, older players. The freshman is often at a significant physical mismatch against these bigger players and that can be a recipe for injury.

 

 

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Treating IT Band Syndrome In Young Runners

By Brian Fullem, DPM

Fellow, American Academy of Podiatric Sports Medicine

Tampa, FL

 

Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • A three phase treatment plan of reducing inflammation, massage and stretching, followed by strengthening can reliably get the runner back successfully

Last week we wrote about IT Band Syndrome in runners, including potential causes of the problem. ITBS remains one of the main causes of knee pain in runners. Use this three-phase treatment plan to reduce inflammation and strengthen the area in question. IT band stretch

Phase 1: REDUCE PAIN AND INFLAMMATION

The initial phase focuses on reducing pain and inflammation and increasing mobilization of the ITB. Rest, ice, NSAIDs and topical anti-inflammatories are all effective in this initial phase. Occasionally, a corticosteroid injection can help–when used judiciously with the understanding that the injection is not curing the injury–to reduce the pain and enable one to move on to the next phase.

Phase 2: MASSAGE AND STRETCHING

Treatment progresses by using deep-tissue massage, a necessary step before moving on to strengthening. We recommend frequent massage: every day for elites and two or three times per week for recreational runners. If you cannot afford the expense or time of going to a certified massage therapist, a foam roller can work well for self-massage, or a tool such as the ROLL Recovery R8 or the Stick. (Roll all the way from knee to hip.) Maintain fitness with cross training that does not aggravate the condition. (If it hurts, try something else.) After the pain subsides, add stretching while continuing deep tissue massage.

Phase 3: STRENGTHENING

Begin strengthening as soon as the exercises below can be performed painlessly. If you have access to an AlterG treadmill, that may also allow continued running during the rehabilitation phase.

Check out this article from Runnersworld.com for descriptions of specific exercises and stretches to help you recover from IT Band Syndrome. In the article you’ll learn the key principles such as:

  • The lengthening stretch- the single best stretch for the IT Band
  • Clamshell resistance band strengthening
  • Side lying leg lifts
  • Single leg squats
  • Hip hikes
  • And a brief description of return to running principles

IT Band Syndrome can be annoying because it can take away from something you love- running. But it can be fixed. Follow the principles above and you’ll have a great chance of getting back on your feet.

 

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IT Band Syndrome In Young Runners

By Brian Fullem, DPM

Fellow, American Academy of Podiatric Sports Medicine

Tampa, FL

 

Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • IT Band Syndrome is a common cause of knee pain in young runners
  • IT Band Syndrome is often caused by weakness in the hip abductors

Iliotibial Band Syndrome (ITBS) remains one of the main causes of knee pain in runners. The IT band, or ITB, as it is commonly known, can become so painful that a runner is unable to train at all. IT band

WHAT IT IS, WHAT GOES WRONG

The ilitotibial band is a fibrous structure that assists the stability of the leg during the stance phase of the stride, works with the hip muscles in abduction (outward movement) of the thigh, and helps to resist torsional movements around the knee joint. The ITB begins in the hip as the tensor fasciae latae muscle and ends below the knee joint, inserting into the tibia at a bump known as Gerdy’s tubercle.

When the ITB becomes stressed through repetitive overuse, runners most commonly feel pain in the lateral (outside) portion of the knee, above where the ITB crosses the joint. This condition is sometimes accompanied by a clicking sensation, caused by the ITB snapping across the joint. The pain usually occurs just after heel contact and gets progressively worse as the run goes on. Downhill and long, slow running tend to cause an increase in symptoms.

ITBS typically starts with tightness on the run and often advances to the point where the pain is debilitating. While the ITB will become tighter when it is injured or overstressed from excessive training, this tightness is not the root of the problem. The cause of this injury lies in the function of the ITB and weakness surrounding it.

The ITB is not a strong structure; any weakness in the surrounding muscles can lead to injury. Runners are notoriously weak in their hip and core muscles, particularly if they haven’t done any strength training or participated in sports that involve side-to-side movement.

In 2000, Dr. Michael Fredericson, a sports medicine physician at Stanford University, discovered that weakness of the hip abductor muscles (mainly the gluteus minimus and gluteus medius) was the leading cause of ITBS. Research in the interim has only served to prove that Fredericson was correct in his original assumptions. In 2007, Brian Noehren, Irene Davis and Joseph Hamill reported in the journal Clinical Biomechanics that studying 3D kinematics of female runners revealed those who develop ITBS have an increased hip abduction motion, along with greater knee internal rotation, both likely caused by weakness in the hip abductors.

Next week: fixing IT Band Syndrome

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To Brace Or Not To Brace

By Lance LeClere, M.D.

LCDR MC, United States Navy

Orthopaedic Sports Medicine and Shoulder Surgery

Naval Medical Center, San Diego, California

Note: this article first appeared in InMotion, published by the American Orthopaedic Society for Sports Medicine and is available as a free resource

Key Points:

  • Use of prophylactic (or “preventive”) knee braces is common in youth football
  • Evidence for effectiveness in reducing the severity of MCL injuries for some position players such as linemen, linebackers, and tight ends is fairly solid
  • There is no evidence that knee braces can reduce the incidence of ACL tears

Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and other ligament football knee braceinjuries of the knee can be devastating for football players and may result in significant loss of playing time and/or require surgical treatment. As player safety and injury prevention continue to be a priority, many players and parents wonder if a knee brace can help prevent major football injuries. Several factors come under consideration when trying to decide whether a player should wear a knee brace:

  • Effectiveness in preventing an injury
  • Play hindrance
  • Added weight
  • Unnatural feel
  • Cost
  • Practicality of routine use
  • Possibility of increases in injuries in the hip or ankle

Prophylactic knee bracing or using a knee brace to prevent injury in football is controversial, with no clearcut answer from quality studies. Some studies suggest that prophylactic knee bracing helps prevent MCL injuries in “high risk positions” such as offensive and defensive linemen, linebackers, and tight ends and may decrease the severity of injuries when they do occur.1 However, there is no strong evidence to suggest that the rate of ACL injuries is decreased by routine use of knee braces.1 Two published review articles on prophylactic bracing for prevention of knee injuries in football players concluded that data was not clear enough to make a recommendation for or against prophylactic bracing.1,2

Widespread, routine use of prophylactic knee braces is not supported by available evidence or professional society recommendations. However, each player must consider individual factors such as position, level of competition, comfort, and cost when deciding if prophylactic bracing is advisable. As always, open dialogue among players, parents, coaches, athletic trainers, and team physicians is encouraged. 

References

  1. Salata, MJ, Gibbs AE, Sekiya JK. The Effectiveness of Prophylactic Knee Bracing in American Football:?A Systematic Review. Sports Health. 2010; 2(5): 375-379.
  2. Pietrosimone BG, Grindstaff TL, et al. A Systematic Review of Prophylactic Braces in the Prevention?of Knee Ligament Injuries in Collegiate Football Players. J Athl Train. 2008;43: 409-415.

 

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“Injuries Are The Result Of Coaching Incompetence.” Radio CaptainU Interviews Raymond Verheijen, Dutch soccer coach.

Summary By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Verheijen is an outspoken critic of many soccer coaches and often places the blame for athletes’ injuries on what he believes is improper player management and training from the coaches
  • He believes many injuries are the result of overtraining, fatigue, or ramping training intensity too quickly
  • This is an extremely entertaining podcast, well worth listening, but does lack some evidence so take it with a grain of salt

We are often asked by injured athletes to try and pinpoint the cause of injuries. Sometimes it’s pretty simple: a fall to the ground, or a hard tackle produces a bone fracture. But many times it’s not possible to accurately come up with a root cause to the injury. Take for example a noncontact ACL tear. We often say that it was just bad luck. But was it really? Raymond Verheijen believes that many injuries are due to improper training that results in muscle fatigue and susceptibility to injury. He goes as far as calling these injuries the result of “coaching incompetence”.

He believes that a disproportionate number of injuries especially in soccer occur at certain times in the season cycle: in the preseason after a time off from training; in the immediate return to sport after an injury layoff; and during a run of frequent games with limited recovery time.

We do have supportive scientific data for a number of his statements. For example, we do know that in some sports such as football there are higher numbers of injuries in the preseason two-a-days than there might be in the remainder of the season, and there is good evidence that in soccer there is an increased incidence of injury late in matches. The evidence is supportive but so far not completely definitive. One area where Verheijen gets it wrong is his belief that fatigue leads to slower nerve conduction velocity (meaning it takes longer for a nerve signal to reach the muscle). This does not happen, the most likely reasons fatigue affects performance are likely from loss of mental sharpness and possibly loss of muscle strength.

So take this interview with a grain of salt but it’s a really great discussion. I commend Captain U’s founder Avi Stopper for leading a balanced interview. It’s a controversial topic that will definitely make you think.

Posted in CaptainU, Coaches, Performance, Training | Leave a comment

The “Ten Percent” Rule For Runners: Fact or Fiction?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Common advice for runners returning from injury or other layoff is to increase weekly mileage by 10%
  • While I find that to be a generally good starting point, some runners are able to increase mileage faster and others must go even more slowly
  • From the orthopedic sports medicine standpoint, I often tailor return to running programs based upon the athlete’s unique injury situation

I often see young athletes with lower extremity stress fractures from running. We go through various treatments to allow the injury to heal, including preliminary running on an AlterG antigravity treadmill. After appropriate healing it becomes time to start overland running. ahs_White-TEAM-xc_4476

We generally recommend that the athlete follow the 10 percent rule, one of the most widely known in running. It does not specify a starting distance but says you should increase your mileage no more than 10 percent a week. The idea is that this is a safe way to increase your distance without risking re-injury. For example, we may recommend a novice young runner to go a total of 4.5 miles in the first week, and then if still pain free increase by about 10% to 5 miles total in the second week.

The interesting thing I find with this “rule”, like many others, is that athletes will often “cheat”. The higher the level runner, the faster they are likely to increase their mileage. And at the other end of the spectrum some athletes will have a recurrence of discomfort and we need to back off and go even slower.

So where did the “ten percent” rule come from? New York Times columnist Gina Kolata wrote a nice piece on the history of the 10% rule. She writes that there is one good scientific study on the subject. Conducted by researchers at the University of Groningen in the Netherlands.

They investigated the 10 percent rule because it is so popular and seemed to make sense with its gradual increase in effort. The study involved 532 novice runners whose average age was 40 and who wanted to train for a four-mile race held every year in the small town of Groningen.

Half the participants were assigned to a training program that increased their running time by 10 percent a week over 11 weeks, ending at 90 minutes a week. The others had an eight-week program that ended at 95 minutes a week. Everyone warmed up before each run by walking for five minutes. And everyone ran just three days a week.

It turns out they had almost the same injury rates – about 1 in 5 runners.

From a practical standpoint running is actually a fairly complicated thing to do, and then to stick with it. The “ten percent rule” might be more fiction than fact but I still find it a good starting point. The key I think is to then adapt the progression to the particular needs of the young runner.

“Nobody found out if it works or what is the basis of it,” wrote one of the Dutch researchers. And that is the way it often goes in exercise science. People “hear something, they read something,” he said, “and then it’s like a religion.”

 

 

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