The Most Common Running Injuries You'll See This Season

Michael T. Hilton, MD, MPH

Disclosures

May 15, 2017

Now that spring is in full swing and race season has begun, physicians may volunteer in medical tents, serve as race medical directors, or see injured runners in their emergency departments (EDs).

Physicians may be surprised by how sick these patients may appear, yet how quickly they improve. The treatment time for patients presenting to marathon medical tents ranges from 3 to 25 minutes.[1] Deaths are, thankfully, very infrequent, occurring at a rate of 0.8 per 100,000 participants.[2,3,4] If you're volunteering in a race medical tent, you should expect that most patients will have non–life–threatening problems and that nearly all can be released.[2]

Patient presentation rates are affected by several factors. Longer races and races with increased complexity have higher patient presentation rates. The rate increases when the weather is hot and humid, as measured by a wet-bulb globe thermometer accounting for ambient and radiant heat and humidity.[2,3,5] Medical directors should pay attention to the American College of Sports Medicine's (ACSM's) Heat and Humidity Guidelines for Races.

The most common conditions that will present to medical tents are musculoskeletal and dermal injuries, which should be treated with the usual ED care. The next most common complaints are heat-related injuries, which have a unique assessment.[1,2] Surprisingly, respiratory and cardiac problems, such as chronic obstructive pulmonary disease, angina, and myocardial infarction, are not frequently seen at marathons.[1,2] This may be because patients presenting to medical tents are skewed toward the 20- to 40-year-old age range.[2]

Here are some of the common running-related conditions to look out for.

Heat Edema

Heat edema may look like congestive heart failure or renal failure. However, it is usually localized to the hands or feet. It is thought to be due to vasodilation and gravity.[6] This condition does not require any care in the medical tent other than advising elevation of the body parts and use of compression stockings. Further testing, such as lab work and imaging, is not needed.

Patients with heat edema can be released from the medical tent but should not continue to race, because the edema will probably increase. Edema does not place them at risk for more severe forms of heat illness.

Heat Rash

Heat rash is commonly seen, especially in runners wearing tight racing garments. It is usually present on clothing-covered skin. It can appear similar to urticaria, because it is erythematous, maculopapular, and pruritic. It is thought to be caused by blocked and ruptured sweat glands, with localized secondary inflammation. Runners may use antihistamines for pruritus. The rash is self-limited.

Runners with heat rash may be released and return to the race, but they may be uncomfortable. They are not at risk for more severe forms of heat illness. Heat rash can be prevented with loose-fitting, moisture-wicking clothing.[5]

Heat Cramps

Heat cramps are painful but not life-threatening and do not indicate a major electrolyte imbalance, renal failure, or rhabdoymyolysis. They are sustained muscle spasms localized to muscle groups involved in the exertional activity.[5,6,7] There is no need to test creatine phosphokinase or electrolyte levels or get an EKG to assess for hyperkalemia.[5,7] This condition is common. It can be very difficult for runners to walk owing to pain, and they may need wheelchairs to prevent falls.

Patients with heat cramps require rest and oral hydration with water or electrolyte solution. Stretching and massage may help and can be performed by physical therapists or massage therapists. After a short period of recovery, these patients can be released from the medical tent. They may return to the race after the spasms have subsided.

Heat Syncope

Heat syncope is another mild form of heat illness that can appear very concerning. However, it is not associated with structural heart disease, hypertrophic cardiomyopathy, aortic stenosis, arrhythmia, myocardial infarction, pulmonary embolism, or aortic dissection. Unless risk factors for other causes of syncope are present, these patients typically do not need EKGs, cardiac monitoring, or lab work.[5,6,7] A finger-stick glucose test is reasonable.

These patients usually present in the walk-off corral, because syncope occurs after they stop running. Owing to the sudden decrease in heart rate and increase in venous pooling from cessation of muscle contraction, as well as vasodilation from heat radiation and dehydration from the race, cardiac output can drop precipitously after running stops.

Syncope can be prevented with proper prerace and in-race hydration and postrace walk-off. Runner education and training is key to preventing this condition. The biggest risk to these patients is injury from a ground-level fall after syncope.[5] After a brief observation in the medical tent with rest (supine, legs elevated) and oral hydration, these runners can be released and do not need further ED evaluation. They should avoid exertional activity for the next 24-48 hours.[5] It is important to remember that syncope that occurs during exertion is a red flag indicating that the cause of syncope was not heat syncope but rather from structural heart disease, arrhythmia, or even cardiac arrest.

Heat Exhaustion

Heat exhaustion presents as confusion, wide-based gait, nausea, emesis, diaphoresis, and cool or hot skin. These patients may be lightheaded or have brief loss of consciousness.[5,6,7] They appear weak and are usually tachycardic, but blood pressure is variable. Their core temperature is less than 104°F.[5,7] These patients may look sick. However, most of them simply need to rest in a supine position with legs elevated, and receive oral rehydration solution and possibly sublingual ondansetron. A finger-stick glucose check is reasonable.

Patients with heat exhaustion usually recover in 20-30 minutes and can be released from the medical tent, but they should avoid returning to the race and told not to participate in any exertional activity for the next 24-48 hours.[5] They should also be advised that there is a risk for heat illness in future races.

Heat Stroke

Exertional heat stroke is the most severe form of heat illness and is accompanied by lethargy and diaphoretic and hot skin, with or without loss of consciousness. If untreated, heat stroke causes inflammatory and coagulation abnormalities and multisystem organ failure.[5,6,7] Patients are usually tachycardic, but blood pressure is variable.[8]

Patients with heat stroke must be cooled rapidly. They should have a finger-stick glucose and sodium level checked to rule out hypoglycemia and exercise-associated hyponatremia (EAH). If the sodium level is normal and the patient appears volume-depleted, isotonic intravenous fluids should be started. If the sodium level is low, the patient should be managed as having EAH. A digital continuous rectal thermometer probe should be placed for real-time core temperature monitoring. Oral, axillary, and external rectal thermometers are likely to be inaccurate. A temperature over 104°F is typical, but it may be 108°F or higher.

The most rapid and effective method to cool patients with heat stroke is in a cold-water bath in the medical tent. Do not transport the patient to the ED until he or she is normothermic.[5,8] A cold-water bath can be made with a plastic tub filled with ice water.[8] The patient should be placed on a sheet, and then the patient's torso and legs are immersed (head above water) in the ice water. The patient will regain consciousness as his or her core temperature dips below 104°F. At 102°F, the patient should be removed from the water to prevent hypothermia.[8] He or she will continue to cool once removed.

Most patients require transport to the ED once they are normothermic because they are at risk for inflammatory, coagulation, and tissue abnormalities or organ failure over the next 24-48 hours. These patients should not return to the race and should avoid exertional activity in the near term.[5] They are at risk for heat illness in future events.

Exercise-Associated Hyponatremia

EAH is caused by overhydration with free water either before or during a race, and presents as confusion, sustained loss of consciousness, or seizures during or after a race. It has become less common as runners have been educated on proper hydration, such as drinking according to thirst. Sports drinks and sodium tabs have not been shown to decrease the risk for EAH. Risk factors include exercising for more than 4 hours, having low body weight, drinking more than 1.5 L of water per hour, taking nonsteroidal anti-inflammatory drugs, overhydrating before exercise, and being exposed to an abundance of drinking fluids at the event or to extreme temperatures.[9,10]

Patients presenting to the medical tent with altered mental status, lethargy/coma, or seizures should have a finger-stick glucose and point-of-care sodium level checked. A core rectal thermometer should also be placed to rule out heat stroke. If the sodium level is < 135 mEq/L, and the patient is asymptomatic or minimally symptomatic (dizzy, lightheaded, fatigued), oral rehydration electrolyte solution and free water restriction is appropriate. Saline intravenous fluids run the risk of exacerbating hyponatremia owing to increased antidiuretic hormone. If the sodium level is < 120 mEq/L with or without symptoms, or if the sodium level is < 135 mEq/L and the patient is symptomatic (headache with vomiting, delirium, seizures, agitation), then hypertonic (3%) saline in 100-mL aliquots over 10 minutes, repeated at 10-minute intervals, is needed until symptoms improve. With severe symptoms (coma, decorticate posturing, status epilepticus), larger or more frequent boluses may be necessary. Because this is an acute-onset hyponatremia, there is no risk for osmotic demyelination syndrome (ODS), and no cases of ODS have been reported.

All patients with hyponatremia should be transported to the ED.[9,10] They should avoid returning to the race and avoid exertional activity for the near term.

Prevention

Medical directors should provide guidelines for runner training and preventive education, because patient presentation rates are inversely proportional to runner experience and education.[1,2] Such organizations as the National Athletic Trainers' Association and ACSM have resources available. The New York Road Runners and the Pittsburgh Marathon also have online educational programs. Finally, physicians can refer runners to the USA Track and Field's website to find local running clubs.

Races are generally fun events for physicians and provide a unique setting in which to provide medical care. If you're interested in volunteering, contact your local race organizers.

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