How can you avoid overuse injuries when training? - Interview with Peter Hedström
How can you train smarter, reduce the risk of overuse injury, and understand your body’s signals before it is too late? In this interview, we meet Peter Hedström, a specialist in overuse injuries with more than 40 years of experience in biomechanics, movement science, and rehabilitation. He shares his knowledge about why overuse injuries occur, how to prevent them through proper training and equipment, and what you can do if the injury has already happened.
Who are you and what do you do?
– I currently have two professions, orthopedic technician and specialist in overuse injuries, but with a slightly different focus. I specialize in biomechanics and work a lot with that as an analyst. I look at which injuries you have had and which injuries you may develop, with a focus on movement science.
I have worked with this for over 40 years, traveled all over the world, and helped elite athletes with their injuries. I also work with Science Footwear and research, and I also own clinics. Gå- och löpkliniken has approximately 65,000 patients per year with overuse injuries, and we have a total of 10 clinics.
I also work with Stinaa.J, which is a fashion brand within shoes. The founder, Stina Andersson, wanted to change the shoe industry, especially when it comes to shoes with high heels. That means that the brand has one leg in fashion and one in well being, in the form of super orthopedic heels but also other styles.
Henrik Bunge (CEO of Björn Borg) has invited me to give a lecture to help keep his employees healthy and injury free. Today we will talk about overuse injuries, why they occur, and what can be done about them, but also some focus on physiology and anatomy.
What are the most common causes of overuse injuries?
- First and foremost, it is about anatomy. It can be divided based on the different shapes of the feet. Each foot has three arches that are meant to absorb impact, so that the foot can spring in the best way.
In Sweden, about 60 percent of people are flat footed and hypermobile, and 7 out of 10 end up in the risk zone. You can have high, normal or low arches, which affects load distribution in different ways. In our clinics, we mostly only see low and high arches. These are the ones who suffer unnecessary overuse injuries. Those with normal arches do much better.
The second part concerns foot strike. If you have low arches, instability, and hypermobility, overpronation often occurs. If you have high arches, the foot instead falls outward. Neutral feet are straighter.
Humans can be compared to a car, the wheels need to be properly aligned to function optimally. That is why anatomy becomes a very important factor.
The surface also plays a major role. Asphalt, gravel, and terrain have different levels of shock absorption. If the surface cannot absorb impact, it is important to train on the right type of surface. The surface greatly affects the risk of overuse injuries.
Why shoes, load, and training choices matter
- Shoes and different types of equipment in sports and exercise are another important factor About 30 percent of all overuse injuries are caused by incorrect equipment, such as the wrong shoes.
The flight phase is also crucial. When you walk, you always have one foot on the ground, but when you run, the body is loaded with three to five times body weight. Some training forms have longer flight phases, which increases load.
Age is another factor that needs to be respected. Today, we have a higher average age and we live longer. The cumulative load over time is something that must be taken into account.
Finally, it comes down to training volume and personal responsibility. You need to understand who you are, look down at your stability, and take responsibility for reducing the risk of injury. This can involve the right shoes, orthopedic insoles, and physiological training.
How should you adjust training volume and intensity to avoid overload?
- When it comes to injury prevention, it is important to increase training gradually. The problem we often see is that changes become too drastic. We have the most patients in March, often people who start training after New Year because of New Year's resolutions etc. Usually, it takes 4 to 6 weeks before the first injury appears.
In Sweden, a large part of the population is physically inactive, so called couch sitters. What we see today are patients who either train too little or too much. At the same time, we are moving in the right direction compared to 10 to 15 years ago.
During the pandemic, many people started taking more action to increase their movement, which has led to a positive development. Natural everyday movement is still very important. The most important thing is to increase training gradually and not think in terms of all or nothing.
It is also important to give yourself the best possible conditions by getting the right shoes and equipment fitted before you start. If, for example, you plan to run three times a week, you need to train in order to be able to do that.
When running, it is important to focus on both training volume and intervals, as well as rest and allowing the body to recover before the next session.
What should an effective warm up look like to reduce the risk of injury?
- Raising your heart rate, getting warm, and preparing the body is extremely important. You should not go all out immediately, but warm up gradually, much like a car engine that needs time to warm up.
Preparation is a crucial part. Feel where you are stiff and stretch those muscles.
Warm up should be individualized. It is about finding the right setup for yourself and learning to understand your body.
Warm up is important, but cool down also plays a major role. Cool down helps remove waste products and prepares the body for the next session, from a physiological perspective.
When running, for example, you can start with an easy jog and mobility exercises before the session, and do the same afterwards.
How big a role do the right shoes and training equipment play in reducing the risk of injury?
- The right shoes and equipment play a major role, about 30 percent. It is about finding the right shoes for the right activity. For indoor sports, you need shoes that are stable both laterally and forward and backward, while a running shoe is adapted for forward movement.
Shock absorption systems are placed in different areas in different shoes. You need to find a shoe that works as a foundation and base, and then complement it with insoles to achieve a good combination. It is important to test both shoes and insoles.
Insoles have a major advantage because they can be moved from shoe to shoe and are flexible. The more hours per day you use them, the better effect they have in reducing the risk of injury. They play a very important role.
Are there specific strength exercises that everyone should include to prevent or reduce the risk of injury?
- Standing on one leg with your eyes closed is a fantastic stability exercise. It can easily be done both morning and evening, for example while brushing your teeth. The exercise trains the muscles up to just above the knee joint.
Here is a link to eight simple exercises in the form of short videos that everyone can do. They focus on the lower abdomen, lower back, calves, and the rhomboids, which are important for posture and shoulder stability. Posture is a very important part to work on to prevent unnecessary strain injuries.
How do you distinguish between normal muscle soreness and warning signs of an emerging overuse injury?
I classify this based on inflammation. At level one, you experience pain during training. At level two, you have pain after training. Level three involves morning pain, and you may also start limping. When you reach that level, it is a clear signal that the body needs rest.
These are important signals to listen to in order to avoid injury. If you cool down properly, you prepare the body better. By gradually increasing training, using the right equipment, and prioritizing both warm up and cool down, you reduce the risk of overuse injuries.
Do not be afraid to take rest days.
Research also shows that inflammation is linked to sleep. Poor sleep increases the risk of inflammatory conditions, while good sleep is a very important part of recovery.
What are the most common overuse injuries and how can they be treated?
- The most common overuse injuries, and those that are increasing the most right now, are forefoot injuries such as hallux valgus, as well as heel spurs and plantar fasciitis.
After the pandemic, every fifth doctor’s visit was related to back pain, which has increased significantly. This is followed by problems with knees and hips.
The order is often back, knee, and hip. Other common issues include shin splints and Achilles tendon pain.
When it comes to treatment, much is about reducing risk before the injury occurs, which we have already discussed. But once the injury is present, you can get help through clinics, such as Gå- och löpkliniken (link), or work with self treatment in the best possible way.
How do you practically adjust training for common injuries such as runner’s knee, Achilles problems, or shoulder pain?
- All injuries need to be treated differently, and it is difficult to go into detail in general terms. The most important thing is to find out who you are, what your feet look like, and how your foot strike works.
You need to try to find the type of training that best suits your body. If, for example, you have high arches, running may not be the best training form, while downhill skiing or ice hockey often works better.
There are no elite level runners with high arches, which is a sensitive but important issue. Based on anatomy, it is about understanding what suits me best.
How important is physical activity for rehabilitation compared to rest?
They are equally important. Rest is very important, but it is also crucial to get moving again. For example, if you have a heel spur and you get into a wheelchair, you run a high risk of it only getting worse. The body is designed to move and be loaded.
How you should load depends on the sport in question. If you are an active person with an injury and can, for example, walk for an hour without pain, that may be a sign that you are ready to start training carefully. The body’s joints, muscles, and tendons adapt to what you do.
Versatile training is an important part of rehabilitation. For runners, this may involve running in water. Often, you need to avoid the activity that initially caused the injury.
What is the most common mistake people make when trying to train despite an injury?
- The most common mistake is starting too quickly after an injury. Many people have a strong drive and want to return quickly, and that drive is fundamentally good. But it is important to listen to your prescriber and follow the recommendations you receive regarding rehabilitation.
If you do not listen and do not do what you have been told, the outcome is rarely good. It is extremely important to listen to your physiotherapist.
How can you gradually return to normal training after an injury to avoid relapse?
Listening to your body’s signals is number one. When you have completed your rehabilitation, it does not have to end there. If, for example, you have done rehab training every other day, you can then continue with maintenance training, perhaps once a week, to maintain the same level. Those who manage to stick with this over time usually get the best results.
It looks different depending on the injury. Some injuries require more stretching, others more strength training. The most important thing is to listen to the person who gave you your training plan and follow the advice you received for your specific injury.
Heart rate training is also important. The balance between base training and interval training can sometimes become too tight. For a runner who runs a few times a week, both mood and daily form are affected, and sometimes you want to run a little too fast. Then training risks becoming flattened and the risk of injury increases. It is about the balance between catabolic and anabolic states. The goal is for the body to become better and stronger, not the opposite.
Finally, what are your top 3 best tips for reducing the risk of injury when training?
Find out your anatomy, what foot type you have, and review your equipment.
Try to find the right training volume, including rest, based on who you are.
Prepare the body for the training you are going to perform.
- An example is padel, where many people do not warm up properly. The sport includes both eccentric and concentric movements, and therefore injuries often occur. Knees and Achilles tendons are common injury areas, and padel is known for being an activity where warm up is often deprioritized.
Barefoot running works for some people, for example those with high arches, but not as well for others. Warm up also needs to be adapted to the training. Running two laps around a football field may work as a warm up, but running ten kilometers is not as suitable.
Finally, you must consider the total load. You may be active, working, walking, standing, and sitting a lot during the day. All of this is load. When you then go out running, it may feel like a running injury, but the cause may just as well lie in work related load.
Work injuries and sports injuries come from different directions, but the most important thing is to look at who you are and what you do as a whole.