Utilization of Nutritional Supplements by South African Chiropractors in the Management of Musculoskeletal Conditions in Runners: A Qualitative Exploration

Abstract

Objective

The purpose of this study was to explore chiropractors’ utilization methods, types of supplements advised, and their influence in managing musculoskeletal conditions in runners.

Methodology

This was a qualitative, exploratory descriptive study. Fifteen South African chiropractors with a minimum of 3 years' experience, who treat runners and recommend nutritional supplements, were interviewed. Data collection took place over about 5 weeks, between July and September 2023. Data were analyzed using Tesch's method for themes and sub-themes.

Results

Four main themes emerged, revealing chiropractors' active use of supplements for runners, diverse supplement recommendations, improved treatment outcomes, enhanced recovery and performance, and reduced injury rates. Holistic management of runners was evident.

Conclusion

This study offered insights into South African chiropractors' selection, prescription, and dispensation of supplements for runners, revealing recommendations for both musculoskeletal and nonmusculoskeletal conditions.

Introduction

Chiropractic is a health profession that specializes in the diagnosis, treatment and prevention of neuromusculoskeletal disorders.¹ The South African chiropractic scope of practice includes adjustments, electrotherapy, exercise therapy and advice, thermal therapy, massage, traction, immobilization, dry-needling, as well as dietary advice or supplementation.² The Allied Health Professions Council of South Africa (AHPCSA) permits for the recommendation, prescription and dispensing of nutritional supplements to patients. Furthermore, clinical nutrition is included as an integral module in the chiropractic curriculum in South Africa.³

Nutritional supplements include a variety of substances which aid the diet to maintain healthy physiological states and prevent nutritional deficiencies.⁴ A study on South African chiropractors noted that while adjustments were the most commonly used treatment technique, lifestyle advice was the second most frequently employed for patient management.² Another South African study found chiropractors to view nutritional supplementation as an effective adjunct for managing MSK conditions. Studies in Australia, the United States, and Canada, found that most chiropractors offer nutritional advice to patients, with practitioners in the latter 2 countries most commonly recommending supplements, primarily for musculoskeletal (MSK) conditions.5, 6, 7 The mentioned studies did not investigate the chiropractic recommendation of supplements to a specific population, nor was the impact of supplementation described.

Chiropractors treat many different types of athletes at varying levels, including runners.⁸ There is variation in the types of running and the classification of runners based on factors such as distance, duration, speed, and surfaces (example trail, track and road).⁹ Many people participate in running for recreational, health or competitive reasons.¹⁰ Running is a popular sport in low-income countries like South Africa due to its cost-effectiveness, accessibility, and minimal equipment requirements.^11,12

Runners are at a high risk of developing MSK conditions due to the high intensity nature of the sport, as well as various intrinsic and extrinsic risk factors.^11,13 The common interpretations of MSK conditions in runners include a complaint, injury, pain or disorder of the MSK system from running. Running is associated with the highest rate of overuse injuries than any other aerobic sport.¹⁴ Each year, 50% of runners and 90% of marathon runners are reported to sustain an injury.^11,15 A high prevalence (18.2% to 94.2%) of MSK injuries has been noted in South African runners.¹² Musculoskeletal conditions may inhibit a runner’s training and performance,⁹ adversely affecting their physical, mental, emotional and psychosocial wellbeing.¹⁶ Low-income runners cannot “afford” conditions that may jeopardize their daily income, making effective treatment and prevention strategies of running conditions necessary.¹¹

Nutrition is an extrinsic risk factor for MSK conditions in runners. Certain dietary preferences such as veganism or vegetarianism, inadequate dietary intake or lack of supplementation, may result in nutrient or energy deficiencies in runners.¹⁷ Runners are prone to developing relative energy deficiency in sport (REDS), increasing their risk of developing a MSK condition.¹⁷ REDS can result from the high nutritional demands of running or from runners consuming insufficient nutrition due to aesthetic reasons or ideal performance body mass.¹⁸ Furthermore, running stresses metabolic pathways that require micronutrients, therefore, increasing a runner’s need for nutritional supplementation.¹⁹ Additional factors increasing nutrient requirements in runners include high sweat rates, menstruation, altitude training, extreme environments (hot and humid), indoor or winter sports, increased training regimes and a diagnosed deficiency.¹⁷ If diet and supplementation are not adapted to support training, then a nutrient deficiency may lead to the development of clinical conditions.20, 21, 22 Thus, runners frequently use supplements to prevent MSK conditions, enhance healing and rehabilitation of injuries, speed up recovery postruns, and enhance performance.²¹

Chiropractic treatment is often utilized to manage MSK conditions in runners.²³ A study on sports chiropractors with postgraduate qualifications from the Federation of International Sports Chiropractors (FICS), highlighted their multimodal approach to athlete management, including nutritional education and supplement recommendations.⁸ Previous studies on chiropractors’ nutritional advice did not look at the management of a specific population. Thus, limited literature exists on how chiropractors use supplements to manage runners, including recommended supplements for specific conditions and their impact on recovery, performance, or injury rates. Additionally, the motives and protocols for prescribing supplementation or providing nutritional education to runners have not been investigated. This study aimed to explore chiropractors’ utilization methods, types of supplements advised and its influence in managing MSK conditions in runners.

Methods

The study employed a qualitative, exploratory descriptive design to investigate how chiropractors utilize nutritional supplementation in the management of MSK conditions in runners. Purposive sampling and snowball sampling strategies were employed to recruit participants. An advertisement was emailed to South African chiropractors via the AHPCSA, shared on social media platforms, and distributed as flyers among colleagues. Inclusion criteria required participants to be registered with the AHPCSA, practice for at least 3 years, regularly treat runners, and recommend nutritional supplements to runners. The authors created an interview guide aligned with the study's objectives, featuring 4 predetermined open-ended questions in a semi-structured format, ensuring consistency and enabling further probing questions (see Supplementary File). Research questions focused on how chiropractors use nutritional supplementation when managing MSK conditions in runners, the types of supplements advised, the conditions for which they are recommended, and the influence of supplementation in the management of runners.

A pilot study was conducted with 2 chiropractors who met the inclusion criteria; after which minor adjustments to the interview guide were made. A total of 15 participants were included in this study. Interviews were conducted both online (using Microsoft Teams online meeting platform) and in person, recorded with a digital device, and then transcribed verbatim. Participants were assigned an alphabetical letter to maintain confidentiality. The data were analyzed to identify themes and sub-themes, using Tesch’s method.^24,25 Data collection took place over about 5 weeks, between July and September 2023. All electronic data were transferred onto a password protected storage device belonging to the primary researcher. Data on the audio recorder was deleted afterwards.

Ethics

This study was approved by the Institutional Research Ethics Committee (IREC) from the Durban University of Technology. The 4 dimensions of trustworthiness (credibility, dependability, confirmability and transferability²⁶) were used throughout the study. Participants could refuse or withdraw from the study at any given time or choose not to answer all questions. Prior to the interviews, participants received an information letter and informed consent. The researcher explained the study's purpose, and interviews began once consent and recording permissions were obtained. To ensure ethical compliance, approval from the IREC was secured before data collection, and gatekeeper permission was granted by the AHPCSA prior to participant communication.

Results

The demographic data of 15 participants is detailed in Table 1. Themes and sub-themes were identified from the data, regarding the utilization of nutritional supplements by chiropractors to manage MSK conditions in runners.

Table 1.

An Outline of the Participant’s Demographic Data

Participant	Age	Race	Institute of Chiropractic Qualification	Number of Years in Practice	Province of Chiropractic Practice
A	43	White	DUT	19	KwaZulu-Natal
B	30	White	DUT	3	KwaZulu-Natal
C	31	White	DUT	6	Western Cape
D	35	White	UJ	10	Gauteng
E	47	White	DUT	7	KwaZulu-Natal
F	38	Coloured	DUT	7	KwaZulu-Natal
G	51	White	DUT	21	KwaZulu-Natal
H	48	White	DUT	24	KwaZulu-Natal
I	33	White	DUT	7	KwaZulu-Natal
J	31	Black	UJ	3	Gauteng
K	32	White	UJ	6	Gauteng
L	28	Indian	DUT	3	KwaZulu-Natal
M	28	White	UJ	4	Gauteng
N	46	White	UJ	20	Western Cape
O	46	White	DUT	20	Western Cape

DUT, Durban University of Technology; UJ, University of Johannesburg.

Theme 1: The Active Utilization of Nutritional Supplements in Clinical Practice by Chiropractors for the Management of MSK Conditions in Runners

It was evident amongst the participants that a common theme of active utilization of nutritional supplements existed when managing runners. Nutritional education was also provided alongside the supplement recommendations. Nutritional advice was used in adjunct with other treatment protocols for MSK conditions, and supplement recommendations were tailored to each runner. The following extracts highlight this active approach:

“… My main line of treatment is obviously chiropractic but I would advise on basic stuff like magnesium, vitamins, any supplements depending of course what sort of uh runner they are.” (Participant G)

“… if they’ve come in with a certain complaint, for example, and I see that nutritionally, they’re kind of deficit, that’s when I would generally recommend like, have you taken this? Have you seen a nutritionist? Have you considered this supplementation?” (Participant I)

Sub-theme 1: Factors and reasoning surrounding supplement recommendations by chiropractors to runners.

Supplement recommendations were based on clinical evaluations and discussions with patients. Factors influencing these recommendations included the type of runner; investigation results; preference for natural alternatives; patient feedback; preventative protocols; and the participant’s personal experience with nutritional supplements. Key factors from the clinical assessment included the runner’s presented condition; clinical features; recurring chronic or acute injuries; slow healing injuries; fatigue; exclusion diets; inadequate replenishment during and after runs; and insufficient nutrients and supplements in the diet. Supplement recommendations were further influenced by the runner’s goals, such as increasing distance, improving race times, improving strength, performance, avoiding illness or boosting immunity, and increasing training intensity and mileage. Additional goals included pain relief and faster healing rates. Participants prescribed supplements more frequently to elite runners, long distance endurance runners, older runners, females, and menopausal runners. The following data extracts illustrate common trends in supplement recommendations by chiropractors for runners:

“… so I look at like an acute injury or chronic condition uh they may be battling with, and then look at the signs and symptoms…” (Participant E)

“Yeah, depends on the runner. You know, whether they are weekend warriors, amateurs or elite runners… I do “DNAlysis” tests actually… Obviously blood tests, you know if there is some chronic fatigue going on, you know if they are vegetarian or they seem pale or malnourished…” (Participant C)

“… if they are in pain, I prefer to bring the pain down naturally as opposed to going the cortisone route…” (Participant N)

“… I take a lot of the advice that I give them from not only my educational experience, but I’ve also fortunately been fortunate enough to compete to quite a, quite a high international level in a number of different sports. Obviously, a lot of things that I’ve learned along the way, um that have contributed towards better performance, quicker recovery, injury prevention, that kind of stuff.” (Participant H)

Sub-theme 2: Dispensing methods employed by chiropractors.

Most participants did not dispense supplements from their practice. Some directed patients to source them externally, while others sold them at their practice or worked in multidisciplinary centers where other practitioners dispensed.

“I’ll give them the name to get them, to go source somewhere else. I don’t dispense.” (Participant B)

“So anything that isn’t already available in the practice from the homoeopath is then sourced from wherever.” (Participant M)

Sub-Theme 3: Education provided in addition to the supplement recommendation.

Many participants emphasized the importance of patient education to enhance compliance. Nutritional guidance was tailored to the patient, type of supplement, injury presented, and their goals. The participants explained to the runners the need for supplementation, benefits, potential side effects, and usage directions, advising runners to consume them for a given period to yield results. Participants emphasized the importance of runners to train on the nutrition and supplementation, avoiding first time use on race day. Most participants advised runners to maintain supplementation after injury recovery to prevent recurrence. However, the dosage may alter with continuation based on the supplement type, condition, and type of runner. Participants further educated patients to be cautious of unwanted substances and ingredients in supplements. Some provided journal articles and online links for runners seeking more information. The following extracts illustrate the nutritional education provided:

“… it’s not an instant result thing. So that’s, you know, managing patient expectations is is a very important thing. Um, and getting patients to actually read about what they’re putting in their body is is also important… go and read up why you would, why you need the vitamin D, and why you need this and and that… Um getting them to understand the benefits of it… they can’t take a supplement for a week and then their symptoms suddenly feel better. Um, it’s a it’s a lifestyle thing, it’s a long-term thing, and and you really just have to kind of push that point through.” (Participant K)

“Um, I do put a lot of emphasis on whatever nutrition they’re using, and supplementation they’re using, they need to use during training so that they’re not um going into a race and kind of using it um, ‘unexperienced’ so to speak.” (Participant H)

“Possibly depending on if I’ve suggested like maybe a slightly higher dose of magnesium roll that back a little bit to just one a day.” (Participant B)

Theme 2: Commonality in Nutritional Supplements Utilized by Chiropractors in the Management of MSK and non-MSK Conditions in Runners

The participants reported on the common nutritional supplements which were recommended to manage both MSK and non-MSK conditions in runners. All of the participants recommended magnesium to runners. Majority of the participants recommended the following supplements to runners: vitamin D3, omega 3, electrolytes (sodium, potassium and chloride), chondroitin, glucosamine, vitamin B, collagen, calcium, iron and whey protein. Many participants also advised on homeopathic remedies, herbal products, Traumeel and proteolytic enzymes. Less frequently recommended supplements were: a multivitamin, zinc, MSM, vitamin C, phosphorous, creatine, curcumin, probiotics, caffeine, carbohydrate supplements, vitamin K, folic acid, selenium, and hyaluronic acid.

“… magnesium is a big one, um potassium and then just a general um multivitamin is what I put most people on …” (Participant G)

Participants discussed the supplements frequently recommended for MSK conditions in runners. These responses are detailed in Table 2.

Table 2.

Nutritional Supplements Recommended by Chiropractors for Musculoskeletal Conditions in Runners

Musculoskeletal Condition	Nutritional Supplement
Bone support	Vitamin D, calcium, vitamin K
Cramping	Magnesium, electrolytes, water, vitamin B, iron, calcium, bicarbonate of soda, zinc
General Inflammation	“Anti-inflammatory supplements”: Omega 3, proteolytic enzymes, curcumin, homeopathic remedies, Traumeel, MSM, alkalizing powders, Septogard
Joint pathology	Glucosamine, chondroitin sulphate, boswellia, MSM, omega 3, proteolytic enzymes, Traumeel, vitamin D, bone broth, collagen, hyaluronic acid, magnesium
Joint support and arthritic change prevention	Collagen, glucosamine, chondroitin sulphate, boswellia, omega 3, hyaluronic acid, Arnica supplements
Ligament laxity	Collagen
Ligament tears or sprain	Whey protein, creatine, collagen, magnesium, Traumeel, anti-inflammatory supplements, homeopathic remedies
Lower back pain	Joint support supplements, magnesium
Muscle aches, pain and stiffness	Magnesium, phosphorous, calcium, electrolytes, water, whey protein, vitamin B, vitamin K, multivitamin, Omega 3, zinc
Muscle atrophy	Omega 3, electrolytes, water
Muscular tears or strain	Whey protein, creatine, collagen, magnesium, Traumeel, anti-inflammatory supplements, homeopathic remedies
Osteoporosis	Vitamin D, calcium, vitamin K
Stress fracture	Vitamin D, calcium, vitamin K
Tendon injuries	Whey protein, creatine, collagen, magnesium, Traumeel, anti-inflammatory supplements, homeopathic remedies

Participants recommended supplements most frequently for muscle cramping. Most of the chiropractors advised supplements for joint pathology (pain, inflammation, arthritic changes), joint support, general inflammation, bone support, muscle pain and stiffness, muscular tears or strain, ligament tears or sprain, osteoporosis, and tendon issues (tendonitis, tendinopathy, tendon tear). Very few participants recommended supplements for stress fractures, ligament laxity, lower back pain and muscle atrophy.

“… So most of the time, people are dealing with cramp, that’s like our biggest issue on a on a day to day basis. So magnesium is is really the best solution for that… when you’re looking more to stress fractures, or potential stress fractures, any bone density issues … obviously your calcium and that, but you know, if you if you’re lacking vitamin D, there’s no absorption happening. So that’s, that’s really, that’s quite important there” (Participant K)

“… um protein, general sort of injury and then creatine if someone is struggling to recover … something that affects the muscle… tendinopathy, any sort of overuse, repetitive strain or acute, yeah, even an ankle sprain… Vitamin D um, obviously, you know, if you’re seeing stress fractures, that is the first one that you’d go to.” (Participant C)

“… I look particularly into the joint space. So, recommendations around for lubrication et cetera around your, for example, your omegas, inflammation MSM, the actual structure of the cartilage and joint so chondroitin sulphate, um glucosamine… hyaluronic acid… I look at then like collagen, so I look at the connective tissue make up and then… I’ll add on herbal and naturopathic kind of things. Um so we’ll have a look if there’s tears into tendons or ligaments et cetera, and add on various herbal remedies…” (Participant E)

Participants recommended supplements for both acute and chronic injuries, noting that acute injuries required supplements for inflammation, pain and healing, while chronic injuries required supplements to address nutrient deficiencies and prevent injury recurrence.

“Um it depends on how acute the condition is … so I utilized quite a lot of proteolytic enzymes to get the inflammation down.” (Participant N)

“… in the acute injury phases like musculotendinous injuries, um I do use a lot of Traumeel…” (Participant H)

“… But if it’s something I feel like it’s a chronic condition or something that is preventative then they will, I recommend that they carry on using it.” (Participant E)

Participants additionally recommended supplements to runners for non-MSK conditions, detailed in Table 3, including energy support, immune support, menstrual irregularities and support, and iron deficiency anemia. Fewer participants addressed gut health, menopause, and sleep related issues with supplementation.

“… when it comes to like your female athletes and your runners, iron is a is significant thing that I I often suggest. If they are more focused on doing your longer distance stuff, then then iron is certainly something that I recommend… you get that, you know, that breakdown in, in kind of the haemolysis process and all of that. So, um and again, females, especially with menstruation … if you’ve got more your long-distance athletes, especially in females, um a lot of the time they they can you know become amenorrhoeic… If you’re looking at your older female athletes, menopause, things like that, so I would say iron is is a big one. Um obviously, calcium…” (Participant K)

“… immunity is a very big thing when they’re running that amount of distance per week… So then we need to ensure that the immune system is sufficiently supplemented if it’s not coming from food um with some supplementation to maintain that they don’t fall sick, because if they fall sick then they can’t run … ensure that they’re getting sufficient vitamin C, vitamin B12, Neurobion, and then um zinc … immune boosting vitamins, especially during winter… getting closer to competition” (Participant O)

Table 3.

Nutritional Supplements Recommended by Chiropractors for Nonmusculoskeletal Conditions in Runners

Nonmusculoskeletal Condition	Nutritional Supplement
Energy and fatigue	Vitamin B, multivitamin, caffeine
Eye and vision related issues	Omega 3
Gut health	Probiotics
Immune support	Vitamin C, multivitamin, vitamin B, zinc, selenium
Iron deficiency anemia	Iron, vitamin B
Menopause	Magnesium, calcium, vitamin D, anti-inflammatory supplements, homeopathic remedies
Menstrual support or irregularities	Iron, calcium, vitamin B, folic acid
Sleep	Magnesium, vitamin B

Theme 3: The Positive Influence of Supplementation in the Management of MSK Conditions in Runners

Participants emphasized the positive impact of supplementation on MSK conditions in runners, reporting improved treatment outcomes such as reduced pain, stiffness, postrun muscle soreness, faster recovery, improved performance, less cramping, decreased joint pain, increased energy, and quicker return to running. Runners reported a stronger immune system which allowed them to maintain training schedules. Most participants observed a decreased injury rate after supplementation, largely linked with the runner’s compliance to supplementation protocols. Runners further reported an improvement in their performance, ability to push harder, and improved race times. The following extracts illustrate these positive outcomes:

“…you notice that there is a gradual, and and I think a quicker progressive improvement to a patient compared to someone who’s just coming to you twice a week or three times a week without supplementation.” (Participant L)

“… cramping, feeling lethargic, just feeling flat during their runs- I’ve noticed an improvement.” (Participant B)

“… only when taken correctly, same time every day and you want it for longer than a month…” (Participant E)

“… you put them on a vitamin B um um supplement…. And um you see now, well they will always tell you that actually, now I can push longer you know…” (Participant J)

Theme 4: Holistic Management of Runners by Chiropractors

Participants emphasized the importance of holistic management for runners, addressing all contributing factors of a condition. The following extract illustrates this approach by chiropractors:

“Okay, so not just with runners, but with everyone, I do believe that we we need to treat the patient as a whole. Um by only adjusting them or by managing the condition that is in front of us, whether it be an acute condition or maintenance, um I believe we are not actually doing our jobs correctly if all we’re doing is adjusting and um mobilising. I believe that we have to discuss lifestyle… give them the whole package and the whole package includes supplementation, because we’d be a miss if we weren’t discussing that.” (Participant N)

Sub-theme 1: Dietary advice.

Some participants attempt to correct a runner’s diet before recommending supplements, however most do not make dietary changes prior to supplement advice. While minimal dietary guidance may be offered alongside supplementation, participants often lack the confidence to suggest significant alterations and refer runners to a dietician when needed. Participants emphasized the importance for runners to replenish nutrients (both supplements and macronutrients) before, during and after runs, to meet the high demands of running.

“Yes. So, if they can get what they need through their diet, I much 100% prefer them to do that first. Um and then, but like if they uh don’t eat specific certain things, say the person is a vegetarian or vegan or something like that, um they can’t eat specific things, then they have to bring in supplementation.” (Participant J)

“I’ll normally ask them a bit about their diet but that’s not my strongest field. We actually have a dietitian here I will sometimes refer to.” (Participant B)

“… So I do push that they at least supplement during race and post um for electrolytes, and then then it all then it all kind of breaks down to kind of your macronutrients whether they to replenish with carbs and protein and that sort of thing.” (Participant D)

Some participants tailored nutritional and supplement advice based on a runner’s socioeconomic status, prioritizing dietary advice for lower-income runners who may not afford supplements. If dietary changes were ineffective, they would recommend supplements or alternative methods.

“…the guy who’s really, really poor… he’s not going to go and buy money on supplements and stuff like … I’ll try and do it by nutrition. So, go eat bananas, eat to, make food make sure you’ve got your starches, eat a balanced diet and try and do it that way first.” (Participant A)

Sub-theme 2: Interdisciplinary management of runners.

All participants collaborated with other practitioners, including dieticians, functional medicine practitioners, and homeopaths, to manage MSK conditions in runners. For complex cases requiring in-depth advice, participants referred runners to a nutritional specialist, recognizing that these professionals offered a higher standard of nutritional care.

“…when it’s bit more niche, often someone who specialises in that over and above me.” (Participant B)

“Yeah, functional nutritionist or a dietitian or a coach, depending on the athlete and what they’re looking for.” (Participant C)

Discussion

This study may assist chiropractors in creating protocols for preventing and managing MSK conditions in runners, reduce injury risk, improve healing times, and enhance performance. Insights gained could lower financial costs and income loss from injuries, benefiting all runners, especially those from lower socioeconomic backgrounds.

Previous literature has revealed the chiropractic utilization of nutritional advice and supplement recommendations to patients of the general population.^1,6,7,27,28 The South African chiropractors in this study offered nutritional education and supplement recommendations to runners for both MSK and non-MSK conditions, revealing a variation in how supplements are utilized. Some chiropractors recommended supplements to all runners to ensure holistic patient management and to prevent injuries arising from the increased demands of running. This is supported by studies indicating an increased need for micronutrients in runners¹⁹ and that inadequate nutrient intake can lead to clinical conditions.²¹ Some chiropractors recommended supplements only to specific runners, such as long distance, elite, female runners, or those at risk of nutrient deficiencies or MSK conditions. However, some runners already followed a nutritional and supplement program and did not require additional advice.

Previous studies have highlighted the need for runners to increase supplementation if they have a history of MSK conditions or require enhanced injury healing.^21,29 This study identified key factors influencing chiropractors’ supplement recommendations to runners, including case history and clinical assessment. Chiropractors emphasized the importance of dietary discussions to identify lifestyle risk factors contributing to MSK conditions. The literature has identified such factors as underweight or overweight, lack of supplementation, inadequate nutritional intake, nutrient or energy deficiencies, poor hydration, and veganism or vegetarianism.^{9,15,17,22,30} Chiropractors in this study primarily base supplement recommendations on the type of runner, which informs supplement dosage and usage directions. Nutritional advice was tailored for long distance endurance runners, sprinters, elite and recreational runners, as well as female, male, young, and older runners. Research indicates that supplement recommendations vary among runners due to differing nutritional needs based on individual training regimens, mileage, intensity, and duration of running.^20,21 The chiropractors recommended supplements more to endurance runners due to a greater challenge of energy availability compared to shorter distance sprinters, track and field runners. Elite and recreational runners have differing nutritional requirements.²¹ Elite runners experience more MSK injuries due to higher training volumes,³¹ leading chiropractors in this study to recommend supplements more frequently to elite runners than to recreational ones. A previous study indicated that higher levels of running may increase the risk of arthritis.³² Similarly, chiropractors in this study more frequently provided joint support supplement advice to endurance and elite runners. Nutritional recommendations were further tailored for long-distance runners based on their personal goals, experience, and performance levels. The chiropractors recommended supplements to support Comrades runners in their training, performance, immunity, recovery, and to prevent conditions like cramping, iron deficiency anemia, joint pathology, and bone pathology.

Previous studies have shown that supplementation in runners varies by sex and age.²⁹ Similarly, chiropractors in this study offered different supplement recommendations based on a runner’s age and gender. They advised older runners on supplements to manage and prevent arthritic changes, while younger runners received general joint support, with supplements recommended for those with serious or recurring joint injuries.

A study which looked at nutrition in collage distance runners, highlighted the need for supplementation in female runners with menstrual irregularities or low energy availability to prevent the female athlete triad.¹⁹ Accordingly, chiropractors in this study recommended supplements more frequently to female runners to prevent the triad, iron deficiency anemia, and to support ligaments, with iron being commonly advised for long-distance female runners. Female runners have a higher risk of stress fractures than male runners.³⁰ Thus, this study's recommendation for bone support supplements in female runners is supported. Chiropractors also advised supplements for older menopausal runners to address bone health, fatigue, and inflammation.

Chiropractors in this study recommended supplements based on runners' goals, such as improving race times, increasing mileage, strength, or training intensity. A study noted that runners' goals and training intensity will influence the type and dosage of supplements.²¹ The chiropractors advised runners on nutrition to prevent MSK conditions, supporting their training and goal accomplishments. They also recommended supplements to runners with goals of pain relief, faster healing, improved immunity, and reduced fatigue. Runners face an increased risk of infection and immune suppression,¹⁹ validating the recommendation for immune support supplementation. The chiropractors recommended supplements to aid injury healing, as supplementation has been shown to accelerate rehabilitation in runners.²¹ They also recommended supplements for post-training recovery and injury prevention, including creatine, recovery drinks, electrolytes, whey protein, and amino acids.

Supplements were recommended for inflammation control, pain relief, and injury healing, particularly for runners seeking a natural, long-term alternative to medication, aligning with chiropractic's conservative approach.

Previous literature has not investigated the type of supplements recommended by chiropractors to runners. However, a limited amount of literature has noted chiropractic supplement recommendations in the general population. Nutritional supplements frequently recommended by South African chiropractors to runners was noted in this study for MSK and non-MSK conditions. This study found that magnesium was the most commonly recommended supplement by chiropractors, aligning with previous findings that it is the most frequently consumed mineral supplement among runners.^20,21

This study found that nutritional supplements had a positive impact on runners when recommended by South African chiropractors, resulting in both objective and subjective improvements in treatment outcomes. However, these chiropractors emphasized that the positive results stemmed from a combination of management protocols rather than supplements alone. Overall, South African chiropractors adopted a holistic approach to managing MSK concerns in runners. Previous studies have shown that supplementation can enhance a runner's performance.^20,21 While some participants in this study noted performance improvements from supplements, many chiropractors indicated that supplementation primarily helps maintain performance through injury prevention rather than enhancement. The chiropractors reported decreased injury rates in runners following supplementation. Appropriate nutrition can lower the risk of injuries during marathons, and certain supplements may help prevent tendon and ligament injuries.^33,34 Thus, the literature supports this study’s findings that runners experience fewer injuries after chiropractors recommend supplements.

Most chiropractors in this study prescribed supplements without first correcting runners' diets, as many patients preferred taking a tablet. However, they offered minor nutritional advice when necessary, especially to lower socioeconomic runners, often suggesting budget-friendly dietary options. One chiropractor mentioned using “Steri Stumpie,” a local flavored milk, as an affordable postrun recovery drink. If dietary changes were insufficient, chiropractors then advised supplements. In contrast, higher socioeconomic runners could afford a wider variety of recovery and nutritional products, allowing for a variety of recommendations.

Chiropractors in this study utilized interdisciplinary care to manage runners, referring them to nutritional experts for specialized dietary advice if required. Previous research in South Africa indicated that chiropractors also refer patients to nutritionists, homeopaths, naturopaths, and other health professionals.^1,27 Additionally, some chiropractors referred runners to general practitioners when a condition exceeded their scope of practice or to prevent potential interactions between chronic medications and supplements.

Limitations

This study involved a small, context-specific sample of South African chiropractors, limiting generalizability to other regions or populations. Participant self-selection may have introduced bias, as those with interest in supplementation were more likely to participate. Furthermore, a wide variation in chiropractor training, knowledge, and scope may exist among the sample of study participants. Some may have additional training and thus be more nutrition-oriented in their management protocols compared to others. This adds variability and makes standardization difficult. In addition, data relied on self-reports, which may be affected by recall or social desirability bias. The small study sample did not capture the full diversity of chiropractic practice in South Africa. Findings are context-dependent and cannot establish causality regarding the effectiveness of supplementation.

Conclusion

This exploratory qualitative study examined how chiropractors utilize nutritional supplements to manage MSK conditions in runners. While prior research reported on this practice in a nonspecified population, this study provided new insights into how chiropractors select, prescribe, and dispense supplements to runners. It identified specific supplements recommended for certain conditions and highlighted the positive impact of supplementation on runners' health.