Want to know if you are be able to return to running now that your injury is improving?

What should you do if pain returns as you start running?

How much running should you start with and how should you progress this?

Pain and swelling has gone and you are feeling much more confident in your ability since you became injured. You have been working hard on your strength and you feel ready to take yourself out for that first run but are you ready? It is so important that you avoid overloading the damaged tissues too soon as this will soon lead to a setback in recovery.  Ensure you listen to your physiotherapist and follow the appropriate steps for a progressive return to impact.

FACTORS TO CONSIDER BEFORE YOU RETURN TO RUNNING.

Patients are always desperate to know when they can start to run. It is at this stage we start to feel less ‘injured’ and closer to our long- term goals but firstly we must ensure that the healing tissues are ready to cope with the increase stress. Only then will we see adaptation and progression in recovery.

The severity of injury will be one of the main factors that will affect when you can return to running and I will consider the following before we hit this stage:

1: Range of movement: full range must be restored in the affected joint or soft tissue as well as those surrounding the effected area. Failure to do so will lead to altered load distribution across the joint both locally and in the joints above and below it. This can increase lead to altered muscle patterns and movement control and will also increase risk of future joint problems.

2: Pain and swelling: pain has a significant effect on how we move and swelling can effect joint range of motion and muscle activation. Both will gradually ease with time through your rehabilitation programme. Ultimately, running should be pain free. You may find that there are certain activities that you still struggle to do pain free for example: sitting on your heels or deep squatting but if running is comfortable and all other boxes are ticked then I tend to be happy with my patients running.

3: Stability: there must be no feeling of instability, giving way or locking in the affected joint. A solid, stable joint is essential to tolerate the loads imposed by running.

4: Strength and control: early to mid- stage rehabilitation will tend to look at improving or restoring strength and control around the affected area. How long you work on this will depend on the severity and nature of the injury sustained. As you run the biggest load is sustained when we land so it makes sense that rehabilitation needs to take you through a jumping and landing phase before you return to running. If you feel pain when hopping it is likely you are going to feel pain when you run, right? So why try it?

Taking into account the above factors I aim for the below exercises to be pain free:

Calf raises and hamstring bridges: looking for good activation through the calf complex as the heel is raised off the edge of a step through full ankle range. Good eccentric control (as the heel lowers) is essential and there must be sufficient load tolerance. The same pattern is expected as you perform a single leg hamstring bridge off the edge of a bench or step. As a very rough rule I tend to expect my patients that run to do at least 3 sets of 15-20 reps of single leg calf raises and the same amount in hamstring bridges. This may vary slightly depending on the individual, their presenting problem and how much running you want to do.

Single leg Squats: good movement control maintaining trunk, pelvic and knee control. Screening this movement can be a strong indicator for how a patient moves and absorbs load when running. 3 sets of 15-20 reps are ideal.

Double leg jumps to double leg land: looking for good landing control with soft knees a light landing and control through the knees.

Double leg jump to single leg land on injured side: as stated above. Good control through the trunk, pelvis and knee to foot is essential. Those that lack this control land heavily and tend to loose balance. Heavy compensatory strategies are used to account for poor control e.g wide arms or collapse of the trunk forwards.

Single leg jumps/ hops: the factors stated above are carried forward into this stage. I also look for a soft landing and good proprioception (the ability for you to jump and land in the same place each time without looking down at the floor) over at least a 1 minute period and repeated 3-4 times.

In addition to the above you should be able to perform a brisk walk for at least 30 minutes pain free.

All of this may seem a lot but you have to understand how much stress you put your joints and soft tissues under if you wish to run. Poor tissue capacity (the ability for a muscle, tendon or bone to tolerate load) is the most common factor I highlight in runners that are injured.  If you struggle to do any of the above then I would strongly recommend that you spend a little more time on these areas. Though it may be frustrating do remember that returning too soon will increase risk of damaging the recovering tissue leading to any even longer delay in your attempt to run.

HOW TO RETURN TO RUNNING

When your physio is happy that all boxes have been ticked a return to running programme will ensue. This will be PROGRESSIVE. You can not go from 0K-10K straight away. As with all the other work you have done there will be small steps taken over time. Research and various studies on this stage of recovery do not give an exact protocol for us to follow so my graded return is based on experience! Trust in the process.

POST OP/ LONGER STANDING INJURIES (3 MONTHS +)
  1. Start on a treadmill as more factors are easier to control. Start at a brisk walk and on a slight incline (1.0-1.5).
  2. When ready take your speed up until you are running at a comfortable speed. You should be able to hold a conversation if talking.
  3. Run at this speed for about a minute (it does not have to be exact) and then take yourself back to a walk.
  4. Alternate between a run/ walk over a 10-15 minute period but stop if you get any pain.
  5. Ensure you have a rest day on the following day and monitor symptoms.
  6. If you have had no issues you can start to remove the walking stages but this starts from the end of the programme going forward i.e. stage 2 will involve: 1 min walk, 1 min run, 1 min walk, 1 min run,  1 min walk, 1 min run, 1 min walk, 1 min run, 2 mins run.

** When running for a full 10-15 mins pain free I look to increase this by 5-10% at a time. I recognise this may seem very slow but I see good results with it. In some cases it can be accelerated and others slowed down even further but I always prefer to reach each stage with a happy and pain free patient rather than pushing things too hard too fast, causing aggravation and upset!

DO NOT FORGET THE FOLLOWING:

1: Leave a rest day between runs

2: Change 1 variable at a time i.e. moving from treadmill to road, speed, distance or adding hills. When adding speed start with 100-200m bursts at a pace that you can maintain and introduce 3-4 rounds within 1 of your shorter runs. Be mindful, monitor how you feel and progress slowly. Do the same with hills but be aware that running downhill will often be more difficult and more likely to cause problems.

3: Progress SLOWLY.

4: Keep at least 2-3 rehabilitation sessions going during your training week. Return to running does not mean you can stop all the strength and conditioning work. In fact it is now even more important!

WHAT TO DO IF YOU GET PAIN WHEN RUNNING.

When you first start running it is common for patients to report some form of discomfort or the feeling that the injured area doesn’t feel ‘right’. Now we need to be aware that the affected area is not going to feel the same as the unaffected side. In fact it will probably feel very odd when you first start running. BUT. There is a clear difference between acute, sharp uncomfortable pain and a ‘feeling that the area doesn’t feel right’. Listen to your body. You know when things are not right. If the discomfort is building the more that you run then stop. Symptoms can flare further over the next 48hours so is it really worth it?

You are always better to run a shorter distance pain free then to push into pain.

BE AWARE you are almost guaranteed to suffer a setback in your recovery at some point during this rehabilitation phase. It will most likely be related to tissue overload and microtrauma. (Microtrauma refers to the small injuries that effect tissues that are no possible detect). They will cause some pain and inflammation, maybe a little swelling but this will settle with load modification within a few days to a week. To not be disheartened. The road to a full recovery is never a straight line. There will be ups and downs but eventually you WILL get there.

 

SO IN SUMMARY……….

  • Majority of patients return to running too soon after an injury. This leads to a protracted recovery.
  • Your tissues must have the capacity to tolerate the loads you aim to subject them to. GET STRONG.
  • Ensure a steady progression in your return to running programme and get some help. Different injuries in different individuals require different treatment programmes!
Davina Sherwood
Specialist Musculoskeletal Physiotherapist