5.1 Return to Running following Injury

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:

• 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.

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.

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.

1. Progress gradually, giving adequate time for tissue and joints to adapt and recover
2. Start running on firm surfaces (either outdoors or treadmill). Avoid soft surfaces, sand training, or uneven surfaces in this phase.
3. 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.
4. Avoid Speed training and Hills during this phase (minimum of 8 weeks, maybe more in certain injuries)
5. 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

Adapted from Kraeutler et al. (2020)