In the rehabilitation of runners, the proper fitness equipment and technology can improve compliance, efficiency, and outcomes

By Lauren Loberg, DPT

In the American history of running, there have been two booms. The first, born in the 1970s, was filled with serious, conventional events, unlike the younger and more “rebellious” boom of the 1990s which was characterized by unconventional types of running events. As befits a rebel, approaches for treating runners of the second boom may require methods outside the mainstream. Choosing the right equipment to treat these individuals can lead to an improvement in efficiency as well as patient compliance and the level of enjoyment the patient will experience with treatment. To understand this approach, therapists must first slip into the minds and culture of the runners of the second boom.

Running for Fitness: A Brief History 

Before the 1970s, running for fitness was not commonplace. The sport of distance running was perceived as a grueling event for elite men. Some credit Frank Shorter’s highly televised Gold Medal win during the 1972 Munich Olympics to have changed the public’s view, popularizing running and making distance running appear attainable. This boom was simply fueled by runners who loved running, and liked to run a lot. The experience of these runners is shown when looking at the mean marathon times back in 1980: 3:32 for men and 4:03 for women, according to Running USA’s Annual Marathon Report. The runners of this boom trained meticulously and delved into the physiology and technology that could be brought to running.

Then in the mid 1990s, boom number two started, with strong, steady growth in the standard distance road races. But since 2009, a rapid explosion of a new category within the second boom—the nonconforming events—has gained serious traction. More than one-third of all running events are now in this category, and participants include individuals who are non-runners as well as serious runners. Both populations have helped popularize these events.

Participants in this expanding category are being enticed by the camaraderie, challenge, and sense of accomplishment created by the nontraditional races. Such events include obstacle courses, mud runs, beer runs, and trail and adventure races. Many participants choose to run for the sense of involvement these races can offer, rather than for competition. This can lead to many more overuse injuries from the weekend warriors, and injuries that you expect from the cutting sports—such as ACL tears and ankle sprains—in the adventure racers.

On the other end of the spectrum are the ultra runners. Anything greater than marathon distance could be considered “ultra”; in reality, ultra tends to imply 50- to 100-mile races, extreme terrain, and/or climates. Due to the high training volumes taken on by these athletes, ongoing injury prevention is vital. For them, there is no time to cut back mileage for the sake of recovery.

Across categories, this boom has been more inclusive to the less experienced runners. Mean race times are slowing. For instance, Running USA’s Annual Marathon Report for 2012 shows the increase in time to be 45 minutes for men and 39 minutes for women when compared to 1980. Many individuals who consider themselves far from the physique of an endurance athlete are now stepping into the endurance arena.

Tailored Rehabilitation for Runners

Rehabilitating and training these athletes requires elements of nonconformity. No age or ability level is left out of this boom with differences in motivation, commitment levels, and physiology. The most common running injuries I see in clinic are patellofemoral pain, IT Band Syndrome, Achilles tendinopathy, and lower-extremity stress fractures. I examine each athlete’s training habits, run form, joint mobility, strength, and flexibility. A change in one of these aspects, or a change in the body’s ability to recover from workouts can typically be identified. Following is a variety of tools I have found successful at customizing therapy for the participants of this second running boom.


A treadmill is a must to treat any runner, and the Woodway Pro Treadmill, manufactured by Woodway USA Inc, Waukesha, Wis, is one of my favorites. Preferably, the treadmill design is minimal to afford the therapist a clear view of the runner, such as the Woodway Pro with its minimal side bars. I also like that it features a wide belt, allowing the therapist to implement lateral movements into treatment or examination. More recently, curved treadmills have gained popularity. These treadmills have a concave running surface that is self-propelled to increase recruitment of the hip extensors. Another benefit is that they have no ramp-up time. Meaning, the therapist can have an athlete quickly change from one pace to another.

Although a treadmill can be a wonderful examination and training tool, it is not the surface most runners are racing on, and it should not be relied upon solely. Simulation of race terrain and variation in surface is important for a body’s accommodation to impacts. I tend to have runners with knee pain stray away from treadmills to get the variation in footing that can help keep their form fresh. For a runner returning from Achilles injury or a stress fracture, a treadmill can provide a nice, controlled progression of impact and inclines.


To fully assess a runner’s form, a video camera with the capability of capturing at least 120 frames per second is needed, along with frame-by-frame or slow-motion playback options on either the camera or playback software. I often use a compare mode to play two videos of a runner simultaneously. This can be extremely effective feedback when changing an athlete’s form and checking for compensations. Programs that I like are Dartfish by Dartfish, headquartered in Fribourg, Switzerland, for its preciseness and depth of video interpretation, and tablet apps like Ubersense by the Boston-based Ubersense Inc, and Kinesio Capture from Kinesio Capture LLC, based in Bethesda, Md, for their ease and affordability.

Resistance Bands

Great for those who travel or have limited space for equipment, these multipurpose bands make a great addition to exercises. Adding resistance to an exercise can be a valuable cue when trying to isolate specific muscles. For runners, I use these most when teaching pelvic stabilization, for instance with standing hip abduction. Runners with IT Band syndrome often have a hard time with the pelvifemoral control of this exercise. The added resistance of a band can help reinforce what both good and bad control feels like. And if a patient can feel confident in their ability to perform an exercise correctly, compliance improves. Resistance bands are available from companies such as OPTP, Minneapolis, Stretchwell Inc, based in Warminster, Pa, Thera-Band, Akron, Ohio, and Roscoe Medical Inc, Strongsville, Ohio.

Plyo Boxes 

Therapists may find plyo boxes are an excellent way to train power and to work into a greater range of motion at the hips in exercises such as the step up. This is beneficial for hill running and obstacle jumping. It can also help to challenge the hamstrings to prevent strains that come from uphill accelerations and finish line sprints. To work the core more, holding a medicine ball overhead can raise an athlete’s center of balance. Additional benefits of plyo boxes are the advanced eccentric work on the controlled step down or jump down landings. Tendon strengthening exercises such as these eccentrics should be a focus within the 40-year-old age group runners and part of an injury-prevention program for ultra-distance runners.

After an Achilles tendinopathy I will progress from the standard heel drop off a step, to plyo box step downs, then to plyo box landings. For progression, a therapist can vary pace and move to more unstable surfaces like the Bosu Ball, available from BOSU, Ashland, Ohio. With an unstable surface, a slow pace is more difficult to control, a higher pace for greater force production.

Balance Boards

Good balance, reaction time, and ankle strength are musts for trail runners. A multidirectional board like a wobble board with single-leg balance is both effective at improving ankle stabilization and fun. I will work with an athlete to coordinate motion from both distally at their ankle and proximally at their hips and pelvis to improve body awareness. Also, boards like the Fitter Rocker Balance Board from the Canada-based Fitter International Inc, are great for assessing symmetry in the lower extremities, which may be skewed from compensations postinjury. Balance boards come in a wide price range, including those affordable for home use. Minneapolis-based OPTP is also a source for these types of products.

Hurdles, Agility Ladders, and Cones

These can be placed in patterns for shuttle runs or figure-eight patterns. Use these over a variety of surfaces, like a hard gym floor, a thick gym mat, or grass to train an athlete to be responsive over a variety of surfaces. I have seen many runners who have rolled ankles or twisted knees rounding the last obstacle of an event, and did all their training on a treadmill or pavement. If any part of the race is off road, training must account for this variation.

Interval Timer 

Timers are good tools to use for runners who lack variation. Long, slow runs at the same pace can be a common mistake of those training for longer events and one of the number one factors that lead to IT band syndrome in the patients that I see. This can create too much repetition in the same range at the joints. Timers can be used for faster pace intervals. They can also be used for plyometric drills to fatigue an athlete before form work. This can create too much repetition in the same range at the joints. Adding in faster-paced intervals can refresh a run. Timers can be used with plyometric drills to fatigue an athlete before having them jog it out while working on relaxed and light run form. The purpose here is to gain carryover of good form when pushing the limits in a race.

Myofascial Release Products 

There are many fun products on the market for independent soft-tissue work. Foam rollers are used to release tightened or overworked muscles, often the IT band and the lateral quads in runners. Rollers can be purchased at different densities and textures for more comfort or deeper isolation. The Grid is a product with varied lower-profile textures on one roller. High-profile knobs for deeper and specific trigger points are a feature of the RumbleRoller from STI, Baton Rouge, La. Varied sizes of balls can be used to target tight areas, like the Myo-Release ball, available from companies such as Power Systems Inc, Knoxville, Tenn. The piriformis is a common muscle to target with these balls. Another common and very affordable tool is a lacrosse ball for rolling the plantar fascia. Many long-distance runners have ongoing soft-tissue work as a part of their training repertoire with products like these.

Technology for Injury Prevention 

Many of the athletes in this second boom are less experienced, so using some of the latest technologies to educate them about proper progression and training volumes can help keep them injury-free. For example, smartphone apps such as Map My Run can log distance, average speed, and vertical gain of runs. Garmin International Inc, Olathe, Kan, offers Garmin watches, which have similar stats and are costing less as technology improves. For the overly motivated runners, these can help keep volume and intensity of workouts in check. And for the non-tech-savvy athlete, a pen and paper workout log is worthwhile to keep training errors at bay. PTP

Lauren Loberg, DPT, is a physical therapist at TRIA ORTHOPAEDIC CENTER in Bloomington, Minn, specializing in the treatment of runners, cyclists, and swimmers. She is an avid runner, triathlete, and fitness promoter with a background in coordination of performance enhancement and injury-prevention programs. For more information, contact [email protected]