Hierarchy of managing the runner: Part 1

Michael Nitschke SQR
By Michael Nitschke
With over a decade of clinical experience in private practice and exceptional anatomy and biomechanics knowledge, Michael Nitschke is a Partner at Adelaide’s Sports & Arthritis clinic where he focuses on the diagnosis and treatment of running injuries. As a former accomplished track athlete, Michael is well versed in working with amateur, junior and elite athletes. However, his passion for the sport has grown beyond just the competitive side. Michael is now committed to growing the entire running community in South Australia by providing an innovative running service which is accessible to all runners, both recreational and elite, while assisting coaches at the Adelaide Harriers Athletic Club. Michael is also currently in his master’s candidacy at the University of Adelaide. His research project is focused around the training characteristics of recreational runners and the relationship between performance and injury.
By John Osborne
Section Editor

A common limitation to consistent training is running related injury (RRI), with incidence rates ranging between 2.5 to 33.0 injuries per 1000 hours of running exposure. When we consider the incidence of injury relative to running exposure, novice runners are more susceptible to RRI and 30 per cent of novice runners report quitting running within six months, with RRI cited as the main reason.



However, we still tend to see more injuries in sub-elite and elite runners as their training exposure is far greater. This important injury and/or illness is associated with not reaching their performance goals


The truth behind RRI

What is the cause of RRI? Is it poor footwear? Is it poor running technique? Not enough stretching? These reasons are often perceived by runners as being the cause of RRI, yet it’s a lot broader than that. Despite RRI being multifactorial, it has been suggested that perhaps most RRI can be attributed to ‘training errors’. 


Training errors up close

So, what’s a training error? A training error isn’t really defined clearly, but usually it’s something that leads to a disturbance of the balance between stress and rest (such as ‘too much too soon’). A training error that results in an RRI will more than likely require a complex system model to solve the problem, in order to create an optimal intervention. Very rarely is there an isolated risk factor, which means no ‘silver bullet’ solution exists to eliminate RRI. 


If there was an isolated risk factor, incidence rates would have decreased by now, yet clearly they haven’t. To suggest an RRI can be prevented seems a bit far fetched perhaps, however we have knowledge of factors that increase risk. Unfortunately, knowing what may increase the risk of RRI does not necessarily protect individuals from getting injured. Humans may still make a training error despite knowing it is an error before making it.


A hierarchical approach

If it is helpful, I have found a hierarchical approach to triaging running related injuries to be of much use clinically (Figure 1).


Figure 1. Nitta’s hierarchy of sustainable running.


Simply put, one cannot sustain a running related injury without performing the act of running itself. If you buy a shoe that isn’t your ideal, or you have poor strength or flexibility and/or running biomechanics, these MAY increase your risk of a running injury, but you still need to run in order to get a RRI


The above hierarchy of managing sustainable running was designed to prioritise which risk factors I clinically tend to see as the most important in order to reduce the risk of injury (that being, training characteristics [stress] + adaptation [rest]). 


The hierarchy still places a focus on factors that may increase risk of injury, however, I don’t tend to consider these factors determining whether one will get injured, but perhaps more so WHAT structures may be at risk. 


I also consider these are factors that can dictate the DOSAGE of running that one can handle (based on adaptation, tissue tolerance, biomechanics + equipment).


In summary 

So after 22 years of physically running, and 15 years spent working with runners as a clinician (and now moving into practically coaching runners), my approach to working in this field has evolved. I consider my role as an educator who attempts to create a sustainable running model that reduces risk of injury or overtraining syndrome for the individual. Along the way, hopefully this will help to create a very self-efficacious runner who can maintain this with less assistance in the future. 


Next month, Michael Nitschke continues this exploration further to focus on why prioritising the organisation of one’s training characteristics may be the most important consideration for consistent running. He also looks at the characteristics that cause injury, manipulation of loading to avoid injury, what sustainable training organisation looks like up close, and more.