Understanding the multiple factors and clinical reasoning process involved in return to running in an injured runner
Recognise the importance of achieving and assessing load tolerance and improving plyometric ability, in preparation to return to running
Explore various clinical criteria and rehab options to be utilised in the process of return to returning
Optimise the return to running process, based on individual risk factors and type of injury
5.1.1 Introduction
Many recreational runners fail on return to running, following rehabilitation, since they have been cleared to progress based on time-lines rather than clear functional achievements in terms of strength, functional capacity and pain levels. Further, many runners attempt to resume running at a level that they had run previously and are unable to sustain or progress secondary to increasing pain levels.
This program was developed due to the high rate of recurrent pain or disability seen in our clinic, shortly after attempting to return to running. Furthermore, it has been our experience that many patients fail upon return to activity because they had been cleared to progress based on healing guidelines, rather than functional achievements in terms of strength, gait, or pain. Most runners attempt to resume running at a level they had run previously, and are therefore unable to sustain or progress secondary to pain in joints, muscles, or compensating tissues.
Disclaimer: This program builds up on multiple published protocols and is should be taken as a Guidance, since there is a huge variability in the return to running rates in various running injuries and the experience of the runner.
Patient should be able to walk at least 30-minutes pain-free at a reasonable pace (at least 3-4 miles per hour). It is important to start on a flat terrain outdoors or on a treadmill without incline. In addition to walking for 30 minutes, other criteria which are necessary to be meet, prior progression to the next phase are:
No or minimal pain (VAS <2/10) with daily activities
No Night pain or Swelling in symptomatic region (especially in the morning)
Walking without limp
Body-weight Strength Markers (Pain-free and without increased symptoms)
Single-leg Sit to Stand with Chair – 15 reps on each side
Single-leg Calf Raise – 20 reps on each side
Single-leg Hamstring Bridge on Chair – 10 reps on each side
Single-leg Hip Abduction – 15 reps on each side
Basic Strength maintenance exercises
Along with the regular walking, it is important to continue with basic strengthening exercises as provided by the therapist for the specific injury. Find below, a general body-weight routine, which can be done by the runner at home with minimal equipment, to supplement their return to running programme. This routine or a similar routine should be done for a minimum of 3 times a week. These exercises are useful for training endurance and body stabilization during running.
For certain running injuries, an additional gym-based programme for additional external load, may be necessary.
Running is a plyometric activity and therefore incorporating fast response training is essential, before return to running. Low level plyometrics are initiated in this phase, progressing to about 500– 600 foot contacts between one and two legs. Thus, if a runner has an average turnover of 170–180 strides/min, then running for 5–7 min would be required to reach the necessary 500–600 single-foot contacts.
Plyometric training has been shown to reduce the energy cost of running when compared with dynamic weight training (Berryman et al. 2010). Therefore, successful completion of this phase is a good indicator that an athlete is ready to initiate the running program. Find below a sample low-level plyometric session which should be completed for a minimum of 8 sessions (done in 2-3 weeks), before progressing to the next phase.
Exercise
Reps
Video
Forward and backward SKIPS
3 sets of 60-90 seconds
High Knees
3 sets of 30-60 seconds
2 foot line jumps Front/back with bounce
3 x 12
Alternating Hop/Hold
3 x 10 total jumps
Note: All plyometric exercises must be pain-free. It is normal to feel mild feel soreness after the routine; However, the symptoms should settle within 24 hours. If it is persistent, try reducing the reps or go back to phase 1 strengthening exercises.
5.1.4 Phase 3: Walk/Jog program
Upon completion of the low-level plyometric program, such as outlined in the phase above, a walk/jog progression may be initiated.
The goal of this program is for the patient to start and gradually progress their running volume and expose their bodies to impact loads, without an increase in symptoms. There are multiple walk-jog programmes available with varying distances from 5k, 10K to half-marathon. The author’s personal preference is the couch to 5k programme which is outlined in detail here. The NHS Couch to 5K is a progressive walk/jog programme, which guides a runner to 5K in 9 weeks. For runners with mild symptoms or low irritability, you can start the programme from week 4 or 5, rather than week 1, depending on running experience. Alternatively, you can also follow this 5-week programme, which might be suitable for an experienced runner or if recovering from a minor injury.
Stage
Walk
Jog
Repeat for
Stage 1
5 minutes
1 minute
5 times (30 min)
Stage 2
4 minutes
2 minutes
5 times (30 min)
Stage 3
3 minutes
3 minutes
5 times (30 min)
Stage 4
2 minutes
4 minutes
5 times (30 min)
Stage 5
Jog every other day with a goal of reaching 30 minutes. Begin with five minutes of walking, gradually increasing the speed. End the run with five minutes of walking, gradually decreasing the pace to a comfortable walk.
It is necessary to remind the runners of certain key aspects of the walk/jog programme, which are outlined below, to avoid flare-ups or over-training.
Progress gradually, giving adequate time for tissue and joints to adapt and recover
Start running on firm surfaces (either outdoors or treadmill). Avoid soft surfaces, sand training, or uneven surfaces in this phase.
Avoid Running on consecutive days and not more than 3 days in a week. Cross-train with low-impact exercises like cycling or swimming is recommended on non-running days, if possible.
Avoid Speed training and Hills during this phase (minimum of 8 weeks, maybe more in certain injuries)
Monitor both your training volume (either distance or duration) and response to training sessions (e.g. RPE score 1-10)
Further, it is important that patients continue to monitor their discomfort level throughout the training progress as shown in Table 1.
Table 1: Monitor discomfort level throughout the training progress
Acceptable (Progress training)
Unacceptable (Reduce Training)
General muscle soreness after run/walk session
Pain that lasts for > 48 hours after a run/walk session
Slight muscle or joint discomfort after a workout or next day that resolves within 24 hours
Pain that is evident at the beginning of a run/walk then becomes worse as run/walk continues
Slight stiffness at beginning of run or walk that dissipates after first 10 minutes
Pain that is keeping the patient awake at night
Persistent swelling or signs of inflammation in a joint (e.g. knee, ankle)
Sharp pain in areas of tendon insertion to the bone (Achilles, Hamstrings)
The purpose of the warm-up is to ensure that the muscles involved in running are warmed up and activated and that the mobility necessary to run is available. Neuromuscular warm-up activities have been shown to prevent lower extremity injuries (Herman et al, 2012) and therefore it is very important for this warm-up or similar routine to be performed prior to each workout or run
Find below a dynamic warm-up routine, which can be incorporated prior a running session.
Most runners must have heard that training mileage should not exceed 10% each week. Although rapid changes in training load correspond with increased risk of injury, this 10% rule should be interpreted as more of a guideline, than a RULE. There are a number of factors to take into consideration, including the type of training performed (type of running, strength, plyometric training, etc.), injury history, your current level (novice vs experience runners), and your emotional or lifestyle stressors. It’s important to use some common sense when making training progressions. For example, if you have a low chronic load (e.g. you run 5 km per week), your body would most likely tolerate larger increases in loading, at least in the short-term. When increasing training load, 10% increases per week can be used as a guide, but context (e.g. chronic load, training phase, period of de-training) is still important. Consider changing to a training model that includes “down weeks” every 4-6 weeks or an “equilibrium” model that maintains new levels of mileage for longer before increasing again.
5.1.7 Conclusion
Rather than specifying when patients can return to running, the proposed guidance allows for graded activity progression based upon the pain levels and the ability for the runners to accomplish specific markers, prior to a full return to pre-injury running levels. The challenge to the treating therapist is to establish the initial running load and then modify/progress, based on the runner’s response. The aim of this module is to facilitate the therapist in the decision-making process in returning a runner back to running and also to minimise the chances for recurrence of the injury.
Please check the assignment at the bottom of the page!
5.1.1 Introduction
Many recreational runners fail on return to running, following rehabilitation, since they have been cleared to progress based on time-lines rather than clear functional achievements in terms of strength, functional capacity and pain levels. Further, many runners attempt to resume running at a level that they had run previously and are unable to sustain or progress secondary to increasing pain levels.
This program was developed due to the high rate of recurrent pain or disability seen in our clinic, shortly after attempting to return to running. Furthermore, it has been our experience that many patients fail upon return to activity because they had been cleared to progress based on healing guidelines, rather than functional achievements in terms of strength, gait, or pain. Most runners attempt to resume running at a level they had run previously, and are therefore unable to sustain or progress secondary to pain in joints, muscles, or compensating tissues.
Disclaimer: This program builds up on multiple published protocols and is should be taken as a Guidance, since there is a huge variability in the return to running rates in various running injuries and the experience of the runner.
There are three key steps involved in successful return to running in an injured runner.
5.1.2 Phase 1: Achieve and Assess Load Tolerance
Patient should be able to walk at least 30-minutes pain-free at a reasonable pace (at least 3-4 miles per hour). It is important to start on a flat terrain outdoors or on a treadmill without incline. In addition to walking for 30 minutes, other criteria which are necessary to be meet, prior progression to the next phase are:
Body-weight Strength Markers (Pain-free and without increased symptoms)
Basic Strength maintenance exercises
Along with the regular walking, it is important to continue with basic strengthening exercises as provided by the therapist for the specific injury. Find below, a general body-weight routine, which can be done by the runner at home with minimal equipment, to supplement their return to running programme. This routine or a similar routine should be done for a minimum of 3 times a week. These exercises are useful for training endurance and body stabilization during running.
For certain running injuries, an additional gym-based programme for additional external load, may be necessary.
Exercise
Video Link
Half Side Plank with Leg Lifts
Gym-ball Hamstring Curls
https://youtu.be/XkESHgkTdFw
Band Walks
Single-leg Dead-lift
https://youtu.be/84hrdsHgDuQ
https://youtu.be/RCWkvwz7DoU
5.1.3 Phase 2: Plyometric Loading Phase
Running is a plyometric activity and therefore incorporating fast response training is essential, before return to running. Low level plyometrics are initiated in this phase, progressing to about 500– 600 foot contacts between one and two legs. Thus, if a runner has an average turnover of 170–180 strides/min, then running for 5–7 min would be required to reach the necessary 500–600 single-foot contacts.
Plyometric training has been shown to reduce the energy cost of running when compared with dynamic weight training (Berryman et al. 2010). Therefore, successful completion of this phase is a good indicator that an athlete is ready to initiate the running program. Find below a sample low-level plyometric session which should be completed for a minimum of 8 sessions (done in 2-3 weeks), before progressing to the next phase.
Exercise
Video
Forward and backward SKIPS
High Knees
3 sets of 30-60 seconds
2 foot line jumps Front/back with bounce
3 x 12
Alternating Hop/Hold
Note: All plyometric exercises must be pain-free. It is normal to feel mild feel soreness after the routine; However, the symptoms should settle within 24 hours. If it is persistent, try reducing the reps or go back to phase 1 strengthening exercises.
5.1.4 Phase 3: Walk/Jog program
Upon completion of the low-level plyometric program, such as outlined in the phase above, a walk/jog progression may be initiated.
The goal of this program is for the patient to start and gradually progress their running volume and expose their bodies to impact loads, without an increase in symptoms. There are multiple walk-jog programmes available with varying distances from 5k, 10K to half-marathon. The author’s personal preference is the couch to 5k programme which is outlined in detail here. The NHS Couch to 5K is a progressive walk/jog programme, which guides a runner to 5K in 9 weeks. For runners with mild symptoms or low irritability, you can start the programme from week 4 or 5, rather than week 1, depending on running experience. Alternatively, you can also follow this 5-week programme, which might be suitable for an experienced runner or if recovering from a minor injury.
It is necessary to remind the runners of certain key aspects of the walk/jog programme, which are outlined below, to avoid flare-ups or over-training.
Further, it is important that patients continue to monitor their discomfort level throughout the training progress as shown in Table 1.
Table 1: Monitor discomfort level throughout the training progress
Acceptable (Progress training)
Unacceptable (Reduce Training)
General muscle soreness after run/walk session
Pain that lasts for > 48 hours after a run/walk session
Slight muscle or joint discomfort after a workout or next day that resolves within 24 hours
Pain that is evident at the beginning of a run/walk then becomes worse as run/walk continues
Slight stiffness at beginning of run or walk that dissipates after first 10 minutes
Adapted from Kraeutler et al. (2020)
5.1.5 Dynamic warm-up
The purpose of the warm-up is to ensure that the muscles involved in running are warmed up and activated and that the mobility necessary to run is available. Neuromuscular warm-up activities have been shown to prevent lower extremity injuries (Herman et al, 2012) and therefore it is very important for this warm-up or similar routine to be performed prior to each workout or run
Find below a dynamic warm-up routine, which can be incorporated prior a running session.
DYNAMIC WARM-UP ROUTINE
Exercise
Video Links
Knee hug to calf raise
In/out heel taps
2 × 20 steps
Soldier walks
2 × 20 steps
Walking lunges with reach and rotation
2 × 10 steps
Quick steps
20 in place then forward 20 feet
20 in place then backward 20 feet
× 12 each leg
Source: Kraeutler et al. (2020)
5.1.6 The 10% ‘Rule’
5.1.7 Conclusion
Rather than specifying when patients can return to running, the proposed guidance allows for graded activity progression based upon the pain levels and the ability for the runners to accomplish specific markers, prior to a full return to pre-injury running levels. The challenge to the treating therapist is to establish the initial running load and then modify/progress, based on the runner’s response. The aim of this module is to facilitate the therapist in the decision-making process in returning a runner back to running and also to minimise the chances for recurrence of the injury.
References
Berryman N, Maurel D, Bosquet L. Effect of plyometric vs. dynamic weight training on the energy cost of running. The Journal of Strength & Conditioning Research. 2010 Jul 1;24(7):1818-25.
Herman K, Barton C, Malliaras P, Morrissey D. The effectiveness of neuromuscular warm-up strategies, that require no additional equipment, for preventing lower limb injuries during sports participation: a systematic review. BMC medicine. 2012 Dec 1;10(1):75.
Kraeutler MJ, Anderson J, Chahla J, Mitchell JJ, Thompson-Etzel R, Mei-Dan O, Pascual-Garrido C. Return to running after arthroscopic hip surgery: literature review and proposal of a physical therapy protocol. Journal of Hip Preservation Surgery. 2017 Jul 1;4(2):121-30.
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ASSIGNMENT : Return to Running in Achilles Injury Case Study MARKS : 10 DURATION : Unlimited
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