‘The right advice’: a qualitative study examining enablers and barriers to recreational running and beliefs about knee health following knee surgery

Study design

A qualitative study, underpinned by an interpretive phenomenological paradigm,16 was conducted and reported in line with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.17 The study was approved by the La Trobe University Ethics Committee (HEC-19524) and written informed consent was obtained prior to participation.

Participant recruitment and eligibility

Eligible participants (table 1) were recruited from the Trajectory of Knee Health in Runners (TRAIL) study, a prospective cohort study evaluating the trajectory of knee health in runners. Comprehensive details of the TRAIL study are published elsewhere.18 For the current project, potential participants were invited via email to participate in an interview. Those who failed to respond to the initial invitation were again contacted via email on a further two occasions at fortnightly intervals. Recruitment was initially stratified by sex and age groups (online supplemental file 1), as these are two factors that influence the risk of development and progression of knee osteoarthritis.19–21 A random number generator selected the first participant from each of the six stratified groups. To enhance our likelihood of capturing a range of diverse experiences and beliefs, remaining participants were sampled purposively22 based on variation in their surgical procedure history and time since surgery.

Reflexivity

All authors are physiotherapists with clinical experience in managing patients following knee injury and surgery and are experienced in conducting research on running-related knee injuries. AE and CB are trained and experienced in conducting qualitative research. All authors are recreational runners with between 5 and 33 years of running experience. Two authors (CB, JFE) facilitate running-related injury professional development courses for physiotherapists. DOS has a lived experience of an acute ACL rupture, and following non-surgical management was able to return to running.

Data collection

The lead author (JA) conducted all interviews. He did not have any established relationships with participants. Participant demographics, running characteristics, and injury and surgical history were collected at their enrolment in the TRAIL study. Interviews were conducted remotely using video communication software (Zoom 5.0, 2020). Interviews followed a prestructured topic guide of open-ended questions (online supplemental file 2) developed by the research team and informed by a literature review of studies relating to the research topic.9 10 23 24 The topic guide was iteratively refined through feedback from recreational runners, research team discussions and early interviews. Interviews were audio recorded and transcribed verbatim. As data collection and analysis occurred concurrently, recruitment ceased when the research team decided that no new ideas (commonly termed data saturation or sufficiency) could be identified from the data.

Data analysis

Interview data were analysed inductively using a six-phase reflexive thematic analysis approach (online supplemental file 3).15 25 Interview transcripts and data were organised in NVivo qualitative data analysis software (QSR International, 2020). Transcripts were read multiple times for familiarisation and generation of preliminary ideas (JA, AE). Initial insights were discussed at meetings before beginning in-depth analysis (JA, AE, CB). JA and AE independently inductively coded six transcripts and met regularly over 6 months to compare insights and generate initial themes and subthemes. JA then independently coded the remainder of the dataset over two rounds. During further discussions, themes and subthemes were reviewed, refined, and a detailed description of each theme was generated (JA, AE, CB, JFE). Participant validation26 was performed in the final stages of analysis. Transcripts were returned to interview participants to review and edit their responses prior to analysis. Also, the main themes were shared with participants during the final data analysis to obtain their perspectives. Throughout data collection and analysis, feedback on interview technique, coding and theme development was provided to JA by experienced qualitative researchers (AE, CB).

Patient and public involvement

Initial interview topic guides were informed by constructive feedback from two recreational runners with a history of knee surgery who participated in pilot interviews. Participants also had the opportunity to review the transcripts and edit their responses as appropriate prior to analysis, and provide feedback (participant validation) on themes during the final stages of data analysis.

Equity, diversity and inclusion statement

Our author team was gender diverse and included graduate level through to senior researchers from Australia, Brazil and Canada. All members of the author group are from the same discipline (physiotherapy). Our study population included a variety of ages (18–50 years) and included males and females. Socioeconomic status of participants was not considered during recruitment or analysis.

Enablers and barriers to running participation following knee surgery

Knowledge and beliefs about the association between running and knee joint health (3 themes, 10 subthemes)

Participants had variable perceptions about running and knee joint health (theme 10). Although most participants believed that running had benefits for knee symptoms and long-term joint health (subtheme 1), a few participants expressed concerns that their ongoing running participation may be detrimental to knee joint health in the longer term (subtheme 2); however, this did not deter their current running habits.

Participants perceived several important factors related to running which could positively influence their knee pain and joint health (theme 11). These included managing training load and prioritising recovery (subtheme 1); maintaining consistent strength training (subtheme 2); considering footwear fit, cushioning and age (subtheme 3); and varying running terrain and surfaces (subtheme 4). If diagnosed with knee osteoarthritis, participants said they would seek guidance from a health professional with expertise in running (subtheme 5).

Participants had variable knowledge about knee osteoarthritis, its risk factors, prevention and management (theme 12). Most participants had a pathoanatomical focus when attempting to define knee osteoarthritis, using terms such as chronic knee pain, inflammation, degeneration; bone on bone; wear and tear; and loss of cartilage (subtheme 1). Most participants were aware of established knee osteoarthritis risk factors, including previous acute injury and surgery (subtheme 2). There was significant variability in participants understanding of how to prevent and manage knee osteoarthritis, with the overall perception that staying active and strong would be helpful (subtheme 3).

Motivations and perceived benefits of running following knee surgery (2 themes, 4 subthemes)

Almost all participants reported the psychosocial benefits of running as their main motivator (theme 13). Running was perceived important to maintain and improve mental health, cope with stress, relax, and ‘switch off’ (subtheme 1). Participants said they ran for enjoyment (subtheme 2), with social connections obtained considered an important benefit and motivator for some (subtheme 3). Most discussed the psychological benefits of setting and achieving running-related goals and how they were motivated by the competitive aspect of running (subtheme 4). While participants spoke about the physical health benefits of running (theme 14) and saw this as a positive outcome, it was not typically their primary motivator for running.

Enablers to running participation following knee surgery

Health professional support was commonly considered by participants as a key enabler facilitating a successful commencement or return to running following surgery. Consistent with evidence in patellofemoral pain,27 adults with knee pain28 and chronic musculoskeletal pain,29 the relationship between patient and clinician, built on clear education, trust and honesty, was considered important. Therefore, providing constructive education and nurturing a strong therapeutic alliance should be prioritised by clinicians when working with runners following knee surgery.

Reflecting the recommended best-practice management after ACLR,30 almost all participants described undertaking some form of clinician prescribed exercise rehabilitation following knee surgery, but specific prescription and dosage varied substantially.31 Participants described exercise as important to restore strength and confidence in their knee to run again. These perceived improvements are important considering reduced knee confidence23 and fear of movement are common following traumatic knee injury and surgery.32

Consistent strength training was discussed as an important factor to maintaining running consistency and reducing injury risk by our participants, yet they did not always adhere to a regular strength training programme. It may be that runners do not adhere to strength training due to lack of time and/or that they prioritise activities that are more meaningful to them, factors that have been reported in low back pain literature.33 Regarding running-related knee injuries, the potential for strength training to reduce running-related knee injury risk is unclear34. an appropriately dosed strengthening programme may significantly improve running performance,35 which may be motivating for runners. Clinicians should educate runners so that they are aware of these potential benefits, alongside other possible benefits for knee joint health.36 37 Based on our findings, future research may seek to understand why runners do not adhere to strength training to assist in developing strategies to promote its adoption.

Progressive return-to-run programmes were frequently a feature of participants’ rehabilitation. Although there is a lack of research to guide such programmes following knee surgery,38 associated principles of gradually increasing running loads (ie, frequency, volume, speed) may be important to allow tissue remodelling and adaptation to the demands of running.39 Our finding, that monitoring and effectively managing running loads was perceived to reduce injury risk, is consistent with previous qualitative studies in recreational running populations.40 41 While training load errors, such as a significant and rapid increase in running speed, distance or frequency may be a risk factor for injury, current evidence is conflicting,42–44 and there is a paucity of evidence supporting load management education to prevent or manage running-related knee injuries.34 45 Considering the conflict between runners in this study valuing load management education, and current evidence to support this as an intervention, further work to develop and test load management education interventions is encouraged.

Barriers to running participation following knee surgery

Some participants shared experiences of receiving unhelpful advice and management from health professionals. Examples included being told they should not run following knee surgery, without a clear explanation why; a lack of structured rehabilitation; a lack of advice on load management and pain monitoring; and being rushed to return to running too early. Subsequent failure for knee pain and function (including running) to improve led participants to seek out other health professionals, often guided by recommendations from running friends. Some participants expressed a preference to work with clinicians who were runners themselves and had expertise in working with runners.

Consistent with research on the outcomes following ACLR,46 47 return to running following surgery was hindered by persistent symptoms (eg, pain) and impairments (eg, muscle strength), and fear of reinjury. A small proportion of participants felt that ignoring their pain and pushing through due to frustration with a lack of progress with their rehabilitation contributed to their persistent pain. Persistent knee pain and sustaining other running-related injuries were barriers to maintain running participation, resulting in short- to long-term interruptions to running for some participants. These findings are consistent with evidence reporting that persistent knee problems are common following surgery,47 along with the high rates of knee injuries reported in recreational runners.48 Our participants also reported social barriers to running participation similar to those reported by females who have undergone ACLR49 and older adults with knee pain,28 including lack of time and ability to juggle other work and life commitments. This highlights the common inter-related and complex interplay for multiple socioecological barriers to regular physical activity participation.50

Knowledge and beliefs about running and knee joint health

Most participants in our study believed that regular running benefited their knee joint health, which is consistent with a recent large international survey.10 There was some uncertainty from a few participants about the longer-term implications of continuing to run, although this did not deter their current running habits. Considering the paucity of prospective longitudinal evidence regarding the impact of running on knee joint health following knee surgery,8 our findings highlight the need to address this evidence gap and guide clinical decision making as to suitability and ideal dosage of running following knee surgery.

Participants shared beliefs about factors that they thought could positively impact their knee pain and optimise joint health with running, including carefully managing training loads by listening to their body, prioritising recovery to avoid overloading their knee, and strength training. Self-regulating training loads have been identified in other qualitative studies as an important aspect in how runners avoid and deal with injury.40 41 51 The effectiveness of maintaining consistent strength training to reduce running-related knee injury risk remains unclear.34 However, evidence of its beneficial effect in reducing pain and improving function in runners with knee pain conditions,34 and those with knee osteoarthritis,37 is well established. Based on our findings, if runners perceive a benefit from strength training, they should be encouraged by clinicians to implement it regularly into their training routine to help manage knee symptoms.

Footwear considerations including fit, cushioning and age were identified by our participants as factors which influenced their knee symptoms. Although this finding is consistent with qualitative research reporting that women runners perceive running footwear to play a key role in injury prevention,52 it contrasts to current evidence that footwear prescription or alteration is not effective in prevention or management of running-related knee pain.34 53 Consistent with recent survey findings,10 our participants perceived running repetitively on hard surfaces can negatively influence knee joint health. However, this link is not substantiated in the literature. These findings highlight the need for better research dissemination and educational resources to assist clinicians in educating runners to make evidence-informed decisions about running and knee joint health. For example, a freely available online evidence-based education resource54 was recently reported to be associated with changes to more positive perceptions about recreational running and knee health in the general population and healthcare professionals.54 However, its effects on behaviour change and running participation remain unknown, and further development and testing of resources like this is encouraged.

Despite being at an increased risk of knee osteoarthritis, our participants had varying levels of knowledge about the condition, which aligns with previous research on experience of living with osteoarthritis.55 Similar to people with established knee osteoarthritis,55 most participants had a pathoanotomical focus describing structural deterioration of the joint using language such as ‘bone on bone’ and ‘loss of cartilage’. Participants’ knowledge of risk factors, including that previous acute injury and surgery, and that ‘staying active and strong’ will assist to prevent and manage knee osteoarthritis, aligns with current evidence and guideline recommendations.56 57

Motivations to run

Despite the majority of our participants’ believing running was beneficial for their knee joint health, this was not considered as a motivating factor. Similar to previous research,41 58 59 our participants had various motivations to run, with psychosocial benefits by far the most common. Our findings add to the growing body of evidence reporting the important psychological benefits of running,60 61 and highlight the importance of developing and implementing effective rehabilitation interventions to maximise participation for those who wish to run following knee surgery.

Limitations

Our study recruited participants who had successfully returned to running. However, not all people do so following knee surgery.4 Our findings may not reflect the same barriers faced, or perceptions about running and knee joint health, as people who fail to return to running following knee surgery. Our participants had a minimum of 1 year running experience, with most having greater than 3 years’ experience. Additionally, almost 50% of participants had a 5-km personal best run time of less than 20 min, meaning findings may not be generalisable to less experienced or non-competitive runners. Interviews took place online, which may have affected personal interactions and rapport between interviewer and participants. The interviewer and research team are all physiotherapists and active recreational runners, which, along with past experiences, may have influenced their perspectives during development of the interview topic guide, data collection, analysis and interpretation of findings. However, participants were actively involved throughout the research process including the opportunity to review and provide feedback on themes, to improve confirmability and trustworthiness of results. However, although all participants were offered the opportunity to provide feedback on the themes and subthemes developed, only 2/17 provided any response.