2002 |   
 
Scand J Med Sci Sports. 2021;31:2002–2009.
wileyonlinelibrary.com/journal/sms
Received: 26 April 2021 | Revised: 20 June 2021 | Accepted: 30 June 2021
DOI: 10.1111/sms.14016  
O R I G I N A L  A R T I C L E
The socio- economic impact of running- related injuries: A large 
prospective cohort study
Tjerk S. O. Sleeswijk Visser1,2
 |   Marienke van Middelkoop3
 |   Tryntsje Fokkema2,4
 |   
Robert- Jan de Vos1
This is an open access article under the terms of the Creat ive Commo ns Attri bution License, which permits use, distribution and reproduction in any medium, provided the original 
work is properly cited.
© 2021 The Authors. Scandinavian Journal of Medicine & Science In Sports published by John Wiley & Sons Ltd.
Trial registration number: NTR number: NL5843 
1Department of Orthopedic Surgery 
and Sports Medicine, Erasmus MC 
University Medical Center, Rotterdam, 
The Netherlands
2Leiden University Medical Center, 
Leiden, The Netherlands
3Department of General Practice, 
Erasmus MC University Medical Center, 
Rotterdam, The Netherlands
4Department of General Practice and 
Elderly Care Medicine, University 
Medical Centre Groningen, University of 
Groningen, Groningen, The Netherlands
Correspondence
Robert- Jan de Vos, Department of 
Orthopedic Surgery and Sports Medicine, 
Erasmus MC University Medical Centre, 
Dr. Molewaterplein 40, 3015 GD 
Rotterdam, The Netherlands.
Email: r.devos@erasmusmc.nl
Funding information
The INSPIRE trial was funded by the 
Netherlands Organization for Health 
Research and Development (ZonMW), 
grant number 536001001
Objectives: To evaluate the impact of running- related injuries (RRIs) on activities of 
daily living (ADL), work, healthcare utilization, and estimated costs.
Design: Prospective cohort study with data from a randomized controlled trial.
Methods: Adult recreational runners who registered for a running event (distances 
5 to 42 km) were included in this study. Minimum follow- up duration was 3 months 
(preparation, event participation, and post- race period). Injuries were registered using 
a standardized definition. Primary outcome measure was a standardized 5- item sur-
vey on limitations in ADL. The survey data were categorized to the number of injured 
runners with complete/moderate/no limitations. This outcome was expressed as the 
percentage of injured runners with any limitation (complete or moderate limitations 
amalgamated). Secondary outcomes were work absenteeism, the number of health-
care visits per injured runner, and estimated direct medical and indirect costs per 
participant and per RRI.
Results: 1929 runners (mean [SD] age 41 [12] years, 53% men) were included in 
this study and 883 runners (46%) sustained a RRI during the course of the study. 
Injured runners reported the highest limitations (% with any limitation) of RRIs dur-
ing the first week of injury on sports and leisure activities (70%) and transportation 
activities (23%). 39% of the injured runners visited a healthcare professional. Work 
absenteeism due to the RRI was reported in 5% of the injured runners. The total mean 
estimated costs were €74 per RRI and €35 per participant.
Conclusions: Injured runners are mainly limited in their transportation activities and 
during sports and leisure. While the estimated costs of RRIs are not high when ex-
pressed per participant, the absolute costs may be substantial due to the popularity of 
running.
K E Y W O R D S
activities of daily living, epidemiology, running, work
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SLEESWIJK VISSER Et aL.
1 | INTRODUCTION
Physical activity has proven to be a cost- effective way to en-
hance overall health and reduce morbidity and mortality.1- 4 
Running is an increasingly popular way to improve physical 
and mental well- being.5- 7 In 2019, close to 2 million people 
(11% of the Dutch population) performed weekly running ac-
tivities in the Netherlands.8
Musculoskeletal injuries are a prominent disadvantage of 
running, with training errors being frequently suggested to 
be a major cause of injury.9,10 Most running injuries are due 
to overuse and are located at the knee, lower leg, ankle, and 
foot.11,12 The incidence of running- related injuries (RRIs) 
varies among different populations (eg, cross- country run-
ners, novice runners, and long- distance runners) of runners 
and can be up to 85% in novice runners training for an event.9 
Even though RRIs are frequent, not much is known about 
the impact of these injuries on socio- economic outcome mea-
sures. The impact of RRIs on activities of daily living (ADL) 
has, for example, never been described in literature.
Healthcare utilization, direct medical costs, and indirect 
costs due to absenteeism from work are outcome measures to 
estimate the impact of a disease.13 A few studies have reported 
the economic burden of RRIs, which varies between €83 and 
€174 per RRI and €13 and €105 per participant training for 
an event.14- 16 These ranges are large and this may be due to 
the fact that these results were based on small study samples 
or only novice runners were included.14,15 This makes it dif-
ficult to extrapolate these findings to the general recreational 
running population.16,17 Therefore, it is relevant to evaluate 
the economic burden of RRIs in a large heterogeneous run-
ning population. Knowledge of the social impact, the specific 
areas affected by RRIs, and the experienced pain and disabil-
ity could aid in the design of tailored treatment practices. The 
magnitude of the economic burden of RRIs is important to 
know, as it affects the urgency of RRIs in scientific agendas.
Therefore, the primary objective of this study is to assess 
the impact of RRIs on activities of daily living in runners 
training for an event. Secondary objectives are to evaluate the 
experienced pain and the effect of RRIs on work absentee-
ism, healthcare utilization, and estimated direct and indirect 
costs.
2 | METHODS
2.1 | Study design
The study was designed at the Erasmus MC University 
Medical Centre (Rotterdam, the Netherlands) and was part 
of a randomized control trial (The INSPIRE trial), which 
evaluated the effect of an online prevention program on 
the number of RRIs among recreational runners. A detailed 
study protocol has been published elsewhere.18 The Medical 
Ethics Committee of the Erasmus MC University Medical 
Centre Rotterdam, the Netherlands, approved the study pro-
tocol (MEC 2016– 292). The trial was registered before com-
mencement (NTR number: NL5843).
For the randomized trial, patients in the intervention 
group had access to an online injury prevention program, 
whereas the control group did not receive this information. 
There were no differences in injury proportion between both 
groups, and therefore, we regarded this study population as a 
large cohort. The results of this randomized controlled trial 
have been published elsewhere.19
In the RCT and the current study, an RRI was defined 
as an injury of the muscles, joints, tendons, and/or bones in 
the lower back or lower extremities that was caused by run-
ning with at least one of the following criteria: (1) the injury 
caused a reduction in running distance, speed, duration, or 
frequency for at least 1 week; (2) the injury led to a visit to 
a medical specialist and/or physiotherapist; and/or (3) med-
ication was necessary to reduce symptoms as a result of the 
injury.
2.2 | Participants
Potentially eligible participants were runners of 18 years or 
older who registered for one of 3 running events in 2017. 
These running events included the LadiesRun Rotterdam 
(5, 7.5 or 10  km), the NN Marathon Rotterdam (10.6 or 
42.2 km), and the NN City Pier City The Hague (5, 10 or 
21.1  km). If runners expressed their interest to participate 
during online registration for the event, they were provided 
with more information, and if still interested, they were as-
sessed for eligibility. Participants were included if they met 
the inclusion criteria (18 years or older, registration at least 
2 months before the running event, knowledge of the Dutch 
language, and access to email). After providing digital in-
formed consent, participants could immediately complete the 
baseline survey.
2.3 | Procedures
Patients were asked to complete an online survey (using the 
secure application LimeSurvey) on 4 different time points; (i) 
at baseline (≥2 months before the running event, (ii) 2 weeks 
before the running event, (iii) 1 day after the running event, 
and (iv) 1 month after the running event. At baseline, runners 
were asked to complete questions on demographics (sex, age, 
length, and weight), training characteristics during the past 
year (running frequency, duration, and speed), and lifestyle 
(smoking, alcohol use). The baseline survey also inquired 
whether the runner had suffered an RRI in the past 12 months. 
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SLEESWIJK VISSER Et aL.
The 3 follow- up survey consisted of questions about the cur-
rent state of previously reported RRIs, the occurrence of new 
RRIs, the impact of new RRIs on ADL, and work absentee-
ism and health care utilization due to the RRI. Injured run-
ners were asked to specify injury location (back, buttock, hip, 
groin, upper leg, knee, shin, calf, Achilles, ankle, foot, or toe) 
and injury onset (gradual or acute).
2.4 | Outcome measures
2.4.1 | Primary outcome measure
Impact of RRIs on activities of daily living (ADL) was meas-
ured at all 3 follow- up time points (2 weeks before the run-
ning event, 1 day after, and 1 month after the running event), 
using a 5- item survey. Only participants who sustained one 
or multiple new RRIs were asked to complete this survey. 
Injured runners completed this survey only once per follow-
 up time point, independently of the number of RRIs they 
sustained. This survey has not been validated but has been 
used in previous studies on RRIs.20,21 The survey consists 
of 5 questions on the following dimensions: (1) daily activi-
ties (eg, getting up, washing, getting dressed), (2) household 
activities (eg, cleaning, vacuuming), (3) activities at work/
school, (4) transportation activities (eg, driving, cycling, 
walking), and (5) sports and leisure activities. Each domain 
consists of 3 response options: no limitations, moderate limi-
tations, and complete limitations. Injured runners were asked 
to indicate their ability to perform activities of daily living in 
the first week after the injury. For every follow- up time point, 
injured runners completed this survey, resulting in an expres-
sion of the number (%) of injured runners with complete, 
moderate, or no limitations per domain. The results of these 
three separate follow- up time points were combined and ex-
pressed as the total number (%) of injured runners with com-
plete, moderate, or no limitations per domain. Results were 
also expressed as the number of injured runners with any 
limitation (complete or moderate limitations amalgamated). 
We also compared the impact on ADL in the first week after 
the injury between RRIs with an acute and gradual onset.
2.4.2 | Secondary outcome measures
Impact on ADL per RRI location
We compared the impact on ADL between different injury 
locations by subdividing the RRIs in 5 clustered injury loca-
tions: (1) lower back, (2) buttock/hip/groin, (3) upper leg/
knee, (4) lower leg (shin/Achilles/ankle), and (5) foot/toe.19 
If injured runners sustained more than 1 RRI, which origi-
nated from different clustered injury locations (eg, if a runner 
sustained an RRI to the groin and an RRI to the ankle), they 
were excluded from this part of the analysis. This is because 
in these cases, it was not possible to adequately assess which 
RRI specifically led to an impact on ADL. If injured runners 
sustained multiple RRIs, but these injuries were all located in 
the same clustered injury location, they were included in this 
part of the analysis. For every follow- up time point, injured 
runners completed this survey, resulting in an expression of 
the number (%) of injured runners with any limitation (com-
plete or moderate limitations amalgamated). Injured runners 
were asked to indicate the amount of pain (on a visual ana-
logue scale; VAS 0– 10) during rest and running in the week 
preceding the completion of the survey. We also compared 
the mean pain during rest and running between the clustered 
injury locations and between acute injuries and gradual onset 
RRIs.
Work absenteeism
Work absenteeism was assessed by the number of lost days at 
work/school due to an RRI and was measured at all 3 follow-
 up time points. Only injured runners were asked to complete 
this part of the survey. Work absenteeism was expressed as 
the mean number of days of absence from work per injured 
runner.
Healthcare utilization
Injured runners were asked whether they had used health care 
due to an RRI. Healthcare utilization was assessed by asking 
the total number of healthcare visits per type of healthcare 
provider. Healthcare utilization was expressed as the mean 
healthcare consumption (number of visits) and mean medical 
costs per injured runner, per type of healthcare provider.
Costs
The estimated costs were divided into 2 categories: costs from 
healthcare utilization (direct costs) and costs as a result of ab-
senteeism from work (indirect costs). We established produc-
tivity costs per hour and the costs per treatment/visit based on 
a guideline for economic evaluations in health care, published 
by the Dutch Healthcare Authority.22,23 We determined the di-
rect costs by multiplying the total number of visits/treatments 
with the estimated medical costs for those visits/treatments. 
The specific costs used for the economic evaluation are pre-
sented in Appendix S1. Mean direct and indirect costs due to 
an RRI were calculated per RRI and per participant (the mean 
of all participants and not only injured runners).
2.5 | Statistical analysis
Presence of a normal distribution of data was assessed using 
the Shapiro- Wilk test. Normally distributed data are presented 
as mean with standard deviation (SD) and non- normally dis-
tributed data as median with interquartile range (IQR). We 
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SLEESWIJK VISSER Et aL.
presented costs (in €) as mean with standard deviation (SD). 
Differences in direct, indirect, and total costs between men 
and women and between acute and gradual onset RRIs were 
compared using a Mann- Whitney U test. Missing data (par-
ticipants who did not complete at least one follow- up sur-
vey) were excluded from the analyses for the study purposes 
described in this manuscript. For the analyses, a p value of 
<0.05 was considered statistically significant. We used SPSS 
software (V.24.0.0.1; SPSS) for statistical analysis.
3 | RESULTS
3.1 | Participants
In total, 2378 participants were included in the randomized 
control trial of whom 1929 participants (81%) completed at 
least one follow- up survey and were included in this study. 
The mean (SD) age was 4212 years with the majority being 
male (53%). 883 (46%) participants reported at least one RRI 
during the course of this study. Most injuries (61%) had an 
acute origin. 714 of the 883 (81%) injured runners completed 
the surveys for our primary and secondary outcome meas-
ures. The participant characteristics are displayed in Table 1.
3.2 | Primary outcome— Activities of 
daily living
Injured runners reported the highest limitations (any limita-
tion) of RRIs during the first week of their injury on sports 
and leisure activities (70%) and transportation activities 
(23%). Lower frequencies of limitations were reported for 
daily activities (10%), household activities (12%), and activi-
ties at work/school (9%).
Injured runners with acute onset RRIs reported higher 
limitations (any limitation) of RRIs during the first week of 
their injury compared to injured runners with gradual onset 
RRIs on daily activities (11% vs. 6%), household activities 
(16% vs. 7%), activities at work/school (12% % vs 5%), trans-
portation activities (25% vs. 18%), and sports and leisure ac-
tivities (75% vs 60%). Figure 1 shows the impact on ADL of 
acute and gradual onset RRIs.
3.3 | Secondary outcomes
3.3.1 | Impact on ADL per RRI location
Injured runners with RRIs located at the lower back and 
lower leg reported higher limitations (any limitation) of RRIs 
during the first week of their injury compared to the over-
all average on household activities (42% and 13% vs. 12%), 
activities at work/school (25% and 10% vs 9%), transporta-
tion activities (42% and 26% vs. 23%), and sports and leisure 
activities (71% and 75% vs 67%).
The impact on ADL per clustered injury location is shown 
in Figure 2. Mean (SD) pain (VAS 0– 10) score during rest 
was higher in lower back (4.8 [2.8]) injuries compared to but-
tock/hip/groin (3.7 [2.4]), upper leg (3.5 [2.4]), lower leg (3.3 
[2.9]), and foot injuries (3.2 [2.4]). Mean pain (VAS 0– 10) 
score during running was lower in lower back injuries (5.1 
[3.1]) compared to buttock/hip/groin (6.0 [2.7]), upper leg 
(5.9 [2.7]), lower leg (6.0 [2.9]), and foot injuries (6.4 [2.7]). 
Mean (SD) pain (VAS 0– 10) scores during rest and running 
were similar for acute injuries (3.7 [2.4] and 5.7 [2.7]) and 
gradual onset RRIs (3.4 [2.4]) and 6.0 [3.0]).
3.4 | Work absenteeism
Work absenteeism due to an RRI was reported in 5% of the 
injured runners. Within this group of injured runners, the 
mean (SD) number of days of absence from work due to an 
RRI was 3.5 (3.5).
3.5 | Healthcare utilization
39% of the injured runners visited a healthcare profes-
sional and 8% initiated self- care. The mean (SD) number of 
TABLE 1 Descriptive statistics of participants
Characteristics (n = 1929)
Mean (SD)
Personal characteristics
Age (years)
41.9 (12.1)
Sex (Male/Female)
1020/909
BMI (kg/m2)
23.6 (2.9)
Injury- related factors
Injury proportion
883 (45.8%)
Injury mechanism (acute/gradual onset); %
61/39
Previous RRI (preceding 12 months) n (%)
994 (51.5%)
Reported RRI at baseline (yes)
415 (21.5%)
Sports- related factors
Running duration (hours/week)
3.1 (3.7)
Running experience (years)
6.8 (8.1)
Lifestyle- related factors
Smoking (yes) (%)
76 (3.9%)
Alcohol use (glasses per week)
4.2 (4.8)
Days with >30 mins of physical activity (days/
week)
5.8 (2.0)
Note: Values are displayed in frequency means (standard deviation).
Abbreviations: BMI, body mass index; RRI, Running- related injury; SD, 
standard deviation.
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SLEESWIJK VISSER Et aL.
healthcare visits was 1.4 (4.5) per injured runner. A visit to 
a physiotherapist was reported by 32% of the injured run-
ners. 4% visited a general practitioner and 2% reported hav-
ing visited a medical specialist. 76% of the total number of 
healthcare visits consisted of physiotherapist visits. Table 2 
demonstrates the frequencies of healthcare visits per type of 
healthcare provider.
3.6 | Estimated direct and indirect costs
The majority (82%) of the estimated total healthcare costs con-
sisted of physiotherapy treatments (Table 2). The estimated 
total healthcare costs were €39 (SD 139) per RRI and €18 (SD 
97) per participant, accounting for the entire study population 
of participants who completed at least one follow- up survey 
FIGURE 1 
Impact on activities of 
daily living (ADL) during first week of 
injury (gradual vs. acute onset injuries). 
Displayed values are percentages of any 
(moderate and severe) limitation
0
10
20
30
40
50
60
70
80
Daily activites
Household activities
Activities at
work/school
Transportation
activities
Sports/Leisure
activities
Impact on activities of daily living (ADL) during the first 
week of injury
Gradual
Acute
FIGURE 2 
Impact on activities of 
daily living (ADL) during first week of 
injury (specified per injury location). 
Displayed values are percentages of any 
(moderate and severe) limitation
0
10
20
30
40
50
60
70
80
Daily activities
Household activities
Activities at
work/school
Transportation
activities
Sports and leisure
activities
Impact on activities of daily living (ADL) during first week 
of injury. 
Lower back
Buttock/hip/groin
Upper leg/knee
Lower leg
Foot/toe
Overall average
TABLE 2 Healthcare utilization and medical costs per injured runner, per type of healthcare provider (n = 714 injured runners)
Healthcare provider
Patients using health 
care, no. (%)
Mean healthcare consumption
(% of all healthcare visits)
Mean (SD)
Medical costs
Primary care (visits)
General practitioner
26 (3.6%)
0.06 (8.6%)
€2.11 (13.0)
Physical therapist
231 (32.4%)
1.2 (76.2%)
€39.88 (141.7)
Othera 
31 (4.3%)
0.1(10.2%)
€3.25 (19.4)
Secondary care (visits)
Medical specialist (eg, Sports medicine 
physician/orthopedic surgeon)
15 (2.1%)
0.04 (5.0%)
€3.48 (27.7)
Total
1.4 (100)
€48.74 (154.6)
Abbreviation: SD, standard deviation.
aAnother healthcare provider (eg, masseur, osteopath, podiatrist, alternative healthcare provider).
   | 2007
SLEESWIJK VISSER Et aL.
(N = 1929). The estimated costs due to absenteeism from work 
were €35 (SD 267) per RRI and €16 (SD 183) per participant. 
Total estimated direct and indirect costs were €74 (SD 329) 
per RRI and €35 (SD 227) per participant (Table 3). Costs 
from work absenteeism accounted for 48% of the total costs.
Estimated direct costs for acute and gradual onset RRIs 
were €41 (SD 166) and €37 (SD 88), respectively. This 
difference was not statistically significant (U  =  96  950.5, 
Z = −0.38, p = 0.71). The estimated indirect costs for acute 
RRIs (mean €59) were significantly higher (U = 92 953.0, 
Z = −4.2, p = 0.00) than for RRIs with a gradual onset (mean 
€2). There was no significant difference in total costs for 
acute RRIs (mean €100) compared to RRIs with a gradual 
onset (mean €39) (U = 97 563.0, Z = −0.17, p = 0.87).
No statistically significant difference in estimated direct and 
indirect costs was found between males and females (Table 3).
4 | DISCUSSION
This study showed that the largest impact of RRIs is on sports 
and leisure (70%) and transportation activities (23%), while the 
impact on other activities of daily living was relatively low. 
The percentage of injured runners with any limitation in ADL 
was higher in RRIs located at the lower back and lower leg 
compared to the other clustered injury locations. Work absen-
teeism due to an RRI was reported in 5% of the injured run-
ners. The total mean number of healthcare visits was 1.4 per 
injured runner, and the total mean estimated costs were €74 
per RRI and €35 per participant. Acute injuries initially led to 
more limitations in ADL and higher estimated total costs.
4.1 | Activities of daily living
Activities of daily living were mainly affected in the domains 
sports and leisure activities and transportation activities. Still 
approximately 1 in 10 injured runners experienced limita-
tions in daily and household activities or activities in work/
school. To better understand the impact of RRIs on activi-
ties of daily living, we evaluated this impact for both acute 
and gradual onset RRIs and for different injury locations. We 
found that acute onset RRIs and lower back and lower leg in-
juries in particular led more frequently to limitations in daily 
life. This limiting effect only partly correlated with pain score 
during rest, which was relatively high in lower back injuries. 
The restricting effect of lower back pain on ADL has been 
demonstrated in previous studies.24,25 For lower leg injuries 
such as shin bone, Achilles tendon, and ankle joint injuries, 
this has never been described using this approach. Healthcare 
providers can take this into account when educating injured 
runners with lower back or lower leg injuries about the poten-
tial consequences of their injury. This information can also 
be used by healthcare policy makers in the design of tailored 
management plans or preventive measures.
4.2 | Healthcare utilization, work 
absenteeism, and costs
Healthcare utilization mainly consisted of physiotherapy 
visits, which is in line with existing literature.13- 16 The total 
costs of RRIs were estimated at €35 per participant and €74 
per RRI. We compared these costs to other studies describing 
the economic burden of RRIs in runners preparing for and 
participating in a running event. Two studies estimated the 
economic burden to be around €173 per RRI.14,15 In contrast 
to our study, only small and selected (trailrunners and run-
ners participating in events ≤10 miles) running populations 
were included. This could have led to a less accurate estima-
tion of the economic burden of RRIs in these studies and less 
generalizability to the overall running population. A large 
prospective cohort study estimated the cost of RRIs to be €13 
per participant.16 However, this study had a follow- up of only 
Overall
Mean (SD) 
medical costs
Mean (SD) indirect costs 
(absenteeism from paid 
work)
Cost per RRI, total 
(n = 898)
€74.29 (328.6)
€38.99 (138.5)
€35.29 (266.7)
Acute onset (n = 523)
€99.75 (420.6)
€40.74 (165.6)
€59.00 (346.6)
Gradual onset (n = 375)
€38.78 (100.0)
€36.56 (88.0)
€2.22 (32.1)
p Value
0.87
0.71
0.0
Cost per participant, total 
(n = 1929)
€34.58 (227.7)
€18.15 (96.9)
€16.43 (182.8)
Males (n = 1020)
€33.98 (225.7)
€20.35 (120.0)
€13.63 (169.2)
Females (n = 909)
€35.25 (230.3)
€15.68 (59.3)
€19.57 (196.9)
p Value
0.48
0.45
0.49
Note: Mann- Whitney U test values comparing costs between acute and gradual onset RRIs and males and 
females.
TABLE 3 Direct and indirect costs 
per RRI (n = 901) and per participant 
(n = 1929)
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6 weeks. This could explain why the estimated costs in the 
current study are higher as long- standing injuries will have 
had more impact on our study.16,26,27 Expressed per partici-
pant the total costs of RRIs appear to be relatively low. When 
considering the popularity of running, which is practiced by 
close to 2  million people in the Netherlands, the absolute 
costs of RRIs may be substantial. This underlines the need 
for optimized preventive measures.
Previous studies reported contradictory findings on the 
difference in costs between males and females and between 
acute and gradual onset RRIs.14- 16 The costs per RRI in the 
current study were substantially higher for injuries with an 
acute onset than injuries with a gradual beginning. This dif-
ference can be explained by the difference in costs from ab-
senteeism from work. The finding of higher indirect costs for 
acute RRIs is in line with a large study on RRIs among nov-
ice runners but in contrast with other studies.14- 16 Overuse 
injuries are supposed to have more impact over time, which 
was demonstrated in several studies.16,26,27 If we would have 
followed the runners for a longer time, costs of overuse inju-
ries may have increased. It could be hypothesized that RRIs 
with an acute onset are accompanied with higher absenteeism 
from work because the severity of symptoms is higher in the 
initial phase of the injury, while the severity of injuries with 
a gradual onset is spread out over time. This might lead to 
less people being absent from work. We found that injured 
runners with acute onset RRIs experience more limitations 
on ADL in the first week of injury, which could support this 
hypothesis. The difference between both injury groups could 
also originate from the way we measured indirect costs in this 
study, as we only included costs from absenteeism from work 
and did not ask participants about a decrease in work pro-
ductivity. A decrease in work productivity could lead to sub-
stantial costs, which has been shown in several studies on the 
impact of overuse injuries.28- 30 It could be that— while acute 
onset injuries lead to higher absenteeism in the short term— 
once back at work the work productivity in people who suf-
fered this type of injury is back to normal. Subsequently, 
indirect costs could be similar in both injury groups if they 
were measured over a longer period of time and measured 
more accurately (including work productivity measures).
4.3 | Strengths and limitations
This is the first study to report the impact of RRIs on ADL. 
We were able to show this impact for different injury loca-
tions. Furthermore, this prospective cohort study included a 
large heterogeneous running population, which increases the 
generalizability of these findings. There are also some limi-
tations to this study. We assessed our primary outcome by 
using a non- validated survey, which could decrease the reli-
ability of the results. However, we used an online survey with 
limited response options, which was completed in the same 
way by all injured runners at all 3 follow- up time points. This 
guaranteed the internal consistency of the survey, and it is 
therefore likely that these results are reliable. Secondly, we 
asked patients about their limitations in daily life during the 
first week of injury retrospectively. This could have induced 
recall bias and may have led to inaccuracy of the results on 
this specific outcome measure.
4.4 | Recommendations for future research
Future research could focus on the impact of RRIs on qual-
ity of life, hereby using validated questionnaires (eg, the 
EuroQol questionnaire [EQ- 5D]). This will provide more 
information on the social impact of RRIs and the specific do-
mains which are affected. In addition, it would be interesting 
to perform an economic evaluation of RRIs with the addi-
tion of work productivity and a longer follow- up period in 
order to evaluate if this affects the direct and indirect costs 
of overuse injuries. Next to this, it would be helpful if more 
economic evaluations per type of sports are performed to be 
able to adequately compare the costs of RRIs with different 
sports.
5 | PERSPECTIVE
This study showed that runners suffering from an RRI are 
mainly limited in their sports and leisure and transportation 
activities and these limitations are particularly substantial in 
lower back and lower leg injuries. The total costs for run-
ners training for an event were €74 per RRI and €35 per 
participant. Even though the estimated costs of RRIs are 
not high when expressed per participant, the absolute costs 
may be substantial due to the popularity of running and be-
cause long- standing RRIs may further increase the costs with 
longer follow- up time. Consequently, this study emphasizes 
the need for optimized preventive measures.
CONFLICT OF INTEREST
The authors declare there is no conflict of interest.
DATA AVAILABILITY STATEMENT
The authors can confirm that all relevant data are included in 
the article and/or its Supplementary Information Files.
ORCID
Tjerk S. O. Sleeswijk Visser 
 https://orcid.
org/0000-0002-4483-1936 
Marienke van Middelkoop 
 https://orcid.
org/0000-0001-6926-0618 
Tryntsje Fokkema 
 https://orcid.org/0000-0002-3767-2770 
   | 2009
SLEESWIJK VISSER Et aL.
Robert- Jan de Vos 
 https://orcid.
org/0000-0003-0372-0188 
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SUPPORTING INFORMATION
Additional supporting information may be found online in 
the Supporting Information section.
How to cite this article: Sleeswijk Visser TSO, van 
Middelkoop M, Fokkema T, de Vos R- J. The socio- 
economic impact of running- related injuries: A large 
prospective cohort study. Scand J Med Sci Sports. 
2021;31:2002– 2009. https://doi.org/10.1111/sms.14016

The socio-economic impact of running-related injuries: A large prospective cohort study.
Sleeswijk Visser, Tjerk S O,van Middelkoop, Marienke,Fokkema, Tryntsje,de Vos, Robert-Jan