Marathoners: Could ‘Prehab’ Help You Run Better?

Injuries are so common in runners that some seek medical care before problems even arise. It’s called prehabilitation, or “prehab,” and involves addressing muscle imbalances or weaknesses that, if left unchecked, could increase the risk of injury.

With race season in full swing and runners hitting the roads, trails, and treadmills, now is the time those weaknesses may rear their ugly heads. Roughly 32% of distance runners—and 52% of marathoners—get injured after a year of running, research shows. New runners have it especially hard and are twice as likely to develop a running injury compared to their more seasoned competitors, another study reports.

Yale Medicine’s Leigh Hanke, MD, MS, says she often treats runners who aren’t injured and want to keep it that way. “It might be a marathon runner interested in preventive care,” explains Dr. Hanke, who specializes in physical medicine and rehabilitation (physiatry) with an emphasis on sports medicine. “I would work with a patient to find weak links. It may be that her gluteal muscles aren’t strong or her balance is off. She may not be feeling any pain now, but when she starts her 15- to 20-mile runs, that’s another story."

As many road warriors can attest, having to stop or limit running—especially after experiencing that famous runners’ high—is frustrating, to say the least. So, if you suspect the muscles supporting your right knee aren’t as strong as they should be or want to understand why all of your injuries always occur on one side of your body, consider booking a prehab appointment.

A preventive care or prehab appointment works just like any medical consultation. After reviewing your medical history, including previous athletic injuries and functional goals, Dr. Hanke performs a physical exam to assess your strength, stability, and range of motion and to identify any functional imbalances.

In sports medicine, the body is often described as a “kinetic chain” because movement in one muscle or joint will affect others. A weakness in one part of the chain—such as the hips—might cause inefficiencies in the leg, raising the risk you’ll suffer an injury.

A strong core is important for injury prevention, too. “The focus of preventive care is strengthening and optimizing these weak leaks, such as in your hip musculature, or restricted motion, for example. Or there may be a leg length discrepancy that throws other things off,” explains Dr. Hanke, herself a two-time marathoner and former college lacrosse player. “If you have an asymmetry or weakness from a prior surgery, you may be more likely to injure another link in your chain, like roll an ankle or strain your knee from overuse.”

If, during the physical exam, Dr. Hanke discovers weaknesses and imbalances that are straightforward issues, she may demonstrate a few exercises to do at home. For example, for a weak core she may suggest planks (maintaining a position similar to a push-up for several seconds to several minutes) or pelvic bridges (lying on your back with knees bent, arms at side, and buttocks lifted up).

If the issues require greater attention, she will typically refer you to physical therapy (PT) for a more in-depth evaluation and exercise treatment plan. Some people, she says, may just need one session with a therapist to learn a tailored home exercise program. Others may benefit from a longer course of PT to get more hands-on guidance from a therapist. Once educated, patients can make certain exercises a part of their regular workout routines.

Pain in the hips or knees is among the top complaints Dr. Hanke treats in runners. “The hip joint has more than 20 muscles surrounding it. If you have an issue with one of those muscles, it may go unnoticed during a 10- or 20-minute jog, but when you go on longer runs, internal hip muscular weaknesses, especially in older athletes, can limit your movement and exacerbate underlying degenerative conditions,” she says.

But often, it’s a matter of merely correcting how people are moving. “You can have rock-solid quads and you’re able to do squats for days, but if you are doing them poorly you could be hurting your knees or lower back,” Dr. Hanke says.  

“I try to determine what is wrong, figuring out what is happening and how to optimize all the moving parts. A patient may have the same lateral hip pain as me, but we have it for different reasons. I may be weak, but flexible in my hip, while my patient may be strong but stiff,” Dr. Hanke says. “And those both call for different physical therapy protocols.”   

Some runners are so focused on their legs and feet, they neglect to keep their abdominal muscles strong. “Your core is unbelievably important to running,” Dr. Hanke says, adding that it helps with stability and balance. “When you run, you land on one foot; a strong core is key in keeping you stable. If your core is weak, there is increased risk of muscle strain and joint overload, which can lead to overuse or acute injuries.“

Just doing more crunches, however, is not necessarily the answer. “If you have a history of back pain, crunches can exacerbate that. This is where input from a physician or therapist can better guide an exercise routine. In this case, instead of crunches, I would recommend pelvic bridges, which place less strain on the structures of the lower back,” Dr. Hanke says.

Meanwhile, most runners could benefit from other dynamic stability work, Dr. Hanke notes, such as standing on one foot. “The functional movement of standing on one leg requires engagement from a lot of different muscles, and this is a great drill to work on,” she says.  

Sometimes, home exercises or physical therapy don’t solve problems, or imbalances and weaknesses graduate to pain or an acute injury.

“As a nonoperative physician, I try to manage these problems with conservative care that may include getting diagnostic imaging, as well as using medications or injections, in addition to physical therapy. Diagnostic imaging includes X-rays, MRI, or ultrasound imaging. When to order these tests is determined by many factors surrounding an injury or chronic problem,” Dr. Hanke says. “We sometimes use injections to address pain and optimize function; these can be steroid injections, gel-type injections, or regenerative medicine, like platelet-rich-plasma or stem cells.”

While stem-cell injections are often used for professional athletes, these are not considered a first line of treatment for everyday runners. “We look at the big picture and start small with things you can easily do on your own. If pain or impaired function persist, then we may consider injections or even a surgical referral,” Dr. Hanke explains.

Runners, especially marathoners, are stubborn. They don’t want to be told to run less, or worse, to not run at all. However, simple preventive steps can keep your muscles, tendons, joints, ligaments, and bones in better shape. In the long run, this will prevent more serious injuries that can keep a runner on the sidelines for months.

“Most people can get away with planning their own fitness programs with what they read from 'Dr. Google' and be fine. But when you step up your game to a marathon or other higher levels of competition, you increase the risk of overuse injuries,” Dr. Hanke says. “And that is when you want a more tailored and professional approach.” 

For more information about Yale Medicine Physical Medicine & Rehabilitation, click here.