Sports Medicine

, Volume 47, Issue 5, pp 869–886 | Cite as

Risk and Protective Factors for Middle- and Long-Distance Running-Related Injury

  • Adam HulmeEmail author
  • Rasmus Oestergaard Nielsen
  • Toomas Timpka
  • Evert Verhagen
  • Caroline Finch
Systematic Review



Despite a rapidly growing body of research, a systematic evidence compilation of the risk and protective factors for middle- and long-distance running-related injury (RRI) was lacking.


Our objective was to compile the evidence about modifiable and non-modifiable training-related and behavioral risk and protective factors for middle- and long-distance RRI.


We searched five databases (PubMed, CINAHL, MEDLINE, SPORTDiscus, and PsycINFO) for the dates 1 January 1970 to 31 December 2015, inclusive, for original peer-reviewed articles. The eligible designs were cross-sectional, case–control, longitudinal observational studies, and randomized controlled trials involving runners competing at distances from ≥800 m to ≤42.2 km. Outcomes were any specific and/or general RRI, and exposures included training-related and behavioral factors. We extracted authors and date, study design, injury type(s), descriptors and comparators for each exposure, and results and measures of association from the selected studies. Methodological quality was independently appraised using two separate checklists: a modified checklist for observational study designs and the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials.


Among 73 articles eligible for inclusion, 19 (26.0%) and 30 (41.0%) were of high or satisfactory methodological quality, respectively. As a non-modifiable exposure, a history of previous injury was found to be associated with an increased risk of both general and specific RRI. In terms of modifiable exposures, irregular and/or absent menstruation was found to be associated with an increased risk of stress fracture development, whereas the use of oral contraceptives was found to be associated with a decreased risk. High clinical, methodological, and statistical heterogeneity meant it was not feasible to estimate a pooled effect size across similar studies.


A history of previous injury was associated with an increased risk of both general and specific RRI. The use of oral contraceptives was found to be associated with a decreased risk of skeletal stress fracture. Conversely, irregular and/or absent menstruation was associated with an increased risk. The varied effect directions and/or a number of statistically insignificant results associated with the majority of factors hindered our ability to draw any definitive conclusions about their relationship to RRI risk.


Stress Fracture Electronic Supplementary Material Table Previous Injury Female Runner Patellofemoral Pain Syndrome 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with Ethical Standards


Adam Hulme was supported in this research by Federation University Australia via the ‘FedUni Postgraduate Research Scholarship’ scheme. Caroline Finch was supported by a National Health and Medical Research Council (of Australia) Principal Research Fellowship (ID: 1058737). No other/specific sources of funding were used to assist in the preparation of this article.

Conflict of interest

Adam Hulme, Rasmus Nielsen, Toomas Timpka, Evert Verhagen, and Caroline Finch have no conflicts of interest relevant to the content of this review.

Author information

Adam Hulme undertook this work as part of his PhD studies under the supervision of Caroline Finch. Caroline Finch is the Director of the Australian Collaboration for Research into Injury in Sport and its Prevention (ACRISP). ACRISP is one of nine research centers worldwide to be selected by the International Olympic Committee (IOC) as a member of the IOC Medical Research Network.

Supplementary material

40279_2016_636_MOESM1_ESM.docx (128 kb)
Supplementary material 1 (DOCX 127 kb)


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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Australian Collaboration for Research into Injury in Sports and its Prevention (ACRISP)Federation University AustraliaBallaratAustralia
  2. 2.Department of Public HealthAarhus UniversityAarhusDenmark
  3. 3.Department of Medical and Health SciencesLinköping UniversityLinköpingSweden
  4. 4.Department of Public and Occupational HealthEMGO+ Institute for Health and Care Research, Vrije University Medical CentreAmsterdamThe Netherlands

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