Return to Running with your Newcastle Podiatrist
Basic Return to Running
Running is one of the most forms of physical activity world wide. Owing to its ease of access and low barriers of entry, it has been shown to be associated with lower all causes mortality, weight, improved cardiovascular fitness and mental health.
Due to the high demands it places on the body, running related injuries are common. Up to 79% of runners over a 6 month period have been reported to suffer some form of injury. This means along with adequate rehab and treatment, an evidence based approach is required when returning to running.
Return to running - 4 key steps
Assess readiness to run
Determine current ‘run tolerance’
Plan graded return to achieve patient’s goals
Monitor response to training and modify where needed
Assessing readiness to run
Subjective and objective tests can give us an indication of a patient’s readiness to run. Can they do the following with minimal pain (ideally pain free but a pain score of 2 or less out of 10 may be acceptable)?
- Perform usual activities of daily living - Walk 30 minutes
- Single leg stand (10 secs)
- Single leg squat (10 reps)
- Jog on spot (1 minute)
- Jump squats (10 to 15 reps)
- Bounding (10 to 15 reps each leg)
- Hop in place (10 to 15 reps or aim for 30 seconds)
There’s little evidence to guide us with readiness to run but Silbernagel et al. (2015) suggest a pain score of 2 or less (out of 10) prior to return to running and plyometric activity in achilles tendinopathy and Rambaud et al. (2018) suggest a pain score of less than 2 amongst their return to run criteria post ACL reconstruction.
If a runner is managing the activities above with minimal or no pain it suggests they may be ready to run and we need to determine their ‘run tolerance’.
Run tolerance
I define run tolerance as the distance (or time) someone can run for with minimal pain (and no lasting provocation of symptoms into the next day).
We can often determine this through careful subjective questioning such as “how far can you run without pain?”
It may well vary at different speeds and on different surfaces so it can help to explore this with an athlete to determine what’s manageable and what’s provocative for them.
Many injured runners will be able to identify a distance they can manage with no pain and this can then form the basis of a training programme providing there’s no increase in symptoms the following day.
When a runner has had a short break from running due to injury (e.g. 2 to 4 weeks) and it isn’t clear what their running tolerance is we may need to try and test it objectively. Assuming their readiness to run tests are well tolerated we would then try a short, easy run of up to around 5 minutes to assess response. Providing there is minimal pain during and no reaction after we might then ask the runner to try a longer run and see at what point their symptoms begin. This can be used to approximate their run tolerance (as discussed in case study 3 below) but as with all approaches needs to be used judiciously depending on individual need and presentation.
With longer breaks (for example post ACL surgery) a rehab ladder approach is often needed - firstly addressing key impairments then gradually introducing impact, developing a readiness to run before starting with very short runs (1 or 2 minutes) at an appropriate stage of the injury.
Planning return to running - training structure and progression
There are no rigid rules when it comes to training structure and progression after injury and very little research to guides us. The following are suggestions we might implement to reduce risk where possible;
- Limit weekly increases in total training volume to approximately 10% (large increases of 20 to 30% may be tolerated in non-irritable cases with low starting distances. Those with irritable/ recurrent symptoms and athletes already at high volumes may need smaller increases of less than 10%)
- Consider chronic training load (e.g. last 4 to 6 weeks) in acute training changes - those with higher chronic load may tolerate higher training load during return to running
- Restore training volume prior to intensity
- Plan recovery time into the weekly schedule and consider recovery weeks with reducedvolume where needed. Factor psychological and emotional stress into this - where there isgreater stress (physical or psychological) their needs to be greater recovery.
- For endurance events low intensity training makes up roughly 80% of training time (i.e.minutes rather than miles), high intensity takes up the remaining 20%.
- Change one thing at a time
- Base majority of training around what is manageable for the patient (i.e. doesn’t lead to lastingincreases in symptoms)
- Allow longer recovery after challenging sessions especially if they increase symptoms
- Don’t be a slave to the sheet - allow flexibility in training depending on how the athlete feels (credit Greg Lehman for suggesting ‘Cognitive Flexibility’ with training)
- Plan training based on current capacity and athlete’s goals and consider weekly schedule, medium term (e.g. next 4 weeks) and longer term (beyond 4 weeks)
Monitoring the return to running phase
The return to running phase is an important one and commonly a time when runners encounter flare ups or secondary injuries which need to be managed. Monitoring both training load and response to it is important. Think about what symptoms are expected and acceptable (e.g. mild pain during running providing it returns to baseline within 24 hours) and what is too much (severe pain during or symptoms that last beyond 24 hours).
Blake Withers
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