Lifestyle and Fitness

Running 102 – Focus on the Female By Max Prokopy

When we think of sports injuries, images of big hits and nasty falls often come to mind.  However, it’s far more likely that recreational athletes and casual runners will suffer an overuse injury.  By definition, overuse implies a steady level of small insults until the bone or tissue is substantially damaged.  Female runners are a particularly significant percentage of the afflicted.  In this article, I’ll delve a bit deeper into reasons why and what might be done about them.

A March 2012 report by Yang, Tibbetts et al., in the Journal of Athletic Training confirmed that female athletes have nearly double the risk of overuse injury as males.  Although the study was conducted on NCAA athletes, surveys and anecdotal evidence suggest the same is true for recreational athletes.  The most common injuries are IT band syndrome, shin splints, knee arthritis, and plantar fasciitis.   Female athletes also have anywhere from a 2- to 10-fold increased risk of ACL tears.  In my experience as a college and professional conditioning coach, the parallel of acute ACL’s and chronic overuse injuries is no accident.  The female exerciser has some important differences that warrant special consideration.

Why are females at greater risk of injury?

Understand that most females have overuse injuries in and around the knee.  Therefore, it makes sense that the joints above and below (hips and ankles) merit the most attention.  Beginning with issues we can’t control:

  1. Q angle (figure 1).  The knee is a simple hinge; twisting it stresses the connective tissues and joint itself.  If the hip was stacked vertically on top of the knee, twisting would be minimal.  However, the wider the Q angle, the more the knee is at risk.

    Figure 1. This photo shows how wider hips can lead to unhappy knees. Source
  2. Hypermobilty.  According to a 1999 study by Decoster et al., women are about 2.5 times more likely to be hypermobile.  While mobility is often a good thing, hypermobile people are at increased risk for ACL tears and lower body overuse injuries.  The cause for the disparity in hypermobiltiy is largely hormonal.
  3. Menstrual cycle.  A 1998 report by Wojtys, Huston et al. found an association between menstrual phase and risk of ACL injury.  Specifically, women in the ovulation phase had significantly more ACL tears and knee laxity than those in the follicular or luteal phase.

Millions of apparently normal women are able to exercise without insult.  So let’s look at injury pathways that are under your control.

1. Knee stability.  The leg muscles (especially hamstrings) are important for power production.  From an injury perspective, they are critical because they stabilize the knee.   Running a mile requires about 1500 foot strikes with all your body weight landing on one foot.  Stable knees are key to staying healthy.  A 2009 study by Blackburn et al. says it all:

“These results suggest that neuromechanical hamstring function in females may limit dynamic knee joint stability, potentially contributing to the greater female ACL injury risk.”

2. Poor strength training.  It’s very rare for me to see a female college athlete with anywhere near the strength training experience of her male counterparts.  Thus, it’s no surprise when pre-season camp or an increased training schedule leads to injury.  Keep in mind the plantar fascia, tendons, and ligaments which get over-stressed do so because muscles are not strong enough to carry their fair share of the load.  Getting stronger equals a smaller burden on the “emergency” tissues.  To fix this, society and individuals alike must respect the facts and encourage genuine strength work.

3. Female athlete triad.  The combination of calorie restriction/eating abnormalities, poor bone density, and one-dimensional exercise (e.g., endurance work only) is a recipe for overuse injury.  Add weak bones to nutrients that are insufficient for repairing a stressed body, and it’s easy to get hurt.

Figure 2. The triad will increase your chances of injury. Source

4. High heels.  Style and fashion need not get you hurt.  Unfortunately, many high heels restrict the ankle from its proper movement.  Over time, ankles get stiff.  If you need mobile ankles to run correctly, what happens when they’re stiff?  Something else has to move, and that’s usually the mid-foot and the knee.  Excess motion in these joints will lead to plantar fasciitis, knee arthritis, shin splints, heel pain, etc.

OK, so what can be done?

I’ve been lucky enough to work with about 1000 female athletes in my coaching career.  Out of that number, just two suffered ACL tears, one of which was a re-injury.  Since many of the same problems underlie both ACL’s and overuse injuries, let’s look at simple training philosophies that work.

  1. Learn to decelerate.  Coaches and athletes are always eager to add horsepower, but the healthiest athletes have the best brakes.  Learning to control landings is critical to effective running (1500 strikes per mile), especially for women.  The scientific literature on this is lengthy and very positive.  Because they place different demands on the body, it’s important to learn to land on one leg (hops) and two legs (jumps).  Do these early in a workout when you’re fresh.  It’s always quality over quantity.     
    Figure 3. Box jump. “Stick” the landing, pause, stand up, and step down. Source

                a.Box jumps (figure 3).  Jump to a height that is comfortable; remember we’re worried about a quality landing.  Landing position is balanced (knees not caved in) and should be held for 1-2 seconds before standing up.  Do about 5 sets of 5 reps each. Single-leg hop.  This video outlines the idea.  Again, it’s all about quality landings.  Do them linearly and laterally.  You want to be able to control yourself in all directions.  Begin with about 3 sets of 5 each leg.  They are challenging and quality is the most important aspect.

  2. Get stronger.  Emphasis should be on single-leg work with free weights, focusing on the backside especially.  Lunges, Bulgarian Squats, and slide hamstring curls work well.  Try 4-6 sets of about 5 reps each leg.  Sets and reps are variable because quality is most important.  Doing this 1-2 times per week will get you strong but not big.  If you’re completely against any type of gym, sprinting up hills is a viable alternative.
  3. Self-massage.  A foam roller and tennis ball are cheap ways to feel better.  Find a spot that hurts (usually quads, calves, and glutes), and roll on it for 60 seconds.
  4. Ankle mobility.  It may sound fancy but is actually simple.  Do lots of things with bare feet or at least without high heels.  Try to get high heels with flexible forefeet and do this drill before your run or work out.

Note: these ideas may not appear running-specific, but they apply directly.  For running-specific thoughts on cadence, shoe type, etc., refer to my running 101 article.

Conclusions: Healthy exercise is all about taking a few minutes to work on landings, strength, and muscle knots. Quality is always the most important part of these drills. The equipment required is minimal: a bench, curb or box; a couple free weights and a towel (for slide curls); and a foam roller and tennis ball. All tolled it may cost you $40 and a bit of courage to lower your risk of injury and improve your performance. 

Max Prokopy is a second-year Biochemical and Molecular Nutrition PhD student who has certifications and experience with training prep, collegiate and professional athletes with a particular focus on ice hockey.


The Friedman Sprout is a monthly student run newspaper that aims to serve the student population at the Friedman School of Nutrition Science and Policy, prospective students, and alumni. Our mission is to report on newsworthy information that affects the Friedman community including nutrition research, food policy, internship and volunteer opportunities, as well as school events. Our editorial slant is that of sustainability in food and nutrition.

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