Running is Rehab: The doing is the fixing when it comes to recovery from injury and pain
Part 1: Running is Rehab: why running is part of the “fixing”
In Lehman’s Terms: When you are injured a primary component of recovery should be the activity you love.
It can be that simple some time. Running is one of the stressors that catalyzes your healing and your preparation to return to full time running.
One way to look at pain and injury is that all of the stressors we place on ourselves exceed our ability to adapt. For some reason, our current stressors might exceed our current capacity. If you want to run a marathon you know that you have to slowly build your tolerance to running and physical capacities by…RUNNING.
Running got you into this mess and running can get you out
Returning from an injury is the same thing. You heal yourself and build your tolerance to the demands of running again by…RUNNING.
But just like you don’t run 100km in your first week of running you slowly build a tolerance to running. Your tissues, your nervous system and cardiovascular system adapt and before long you are running 20k when before 3k was unthinkable.
If you are injured how do you know if you can run?
Simple, go try and run. That’s it. That is the test. There are no physical tests that you must pass to running - at least, no tests that tell you if you are ready. Running is the test. You don’t have to be able to do 50 calf raises, 12 single leg squats, front planks or some arbitrary number of pushups to see if you are capable of running. Running is its own task and its own test. You don’t need to “perfect” your squat based on more made up rules about the “correct” way for your knee to move. You don’t need to teach your knee to stop moving inside your toes. You don’t need to teach your glutes to fire again. You don’t need correct some imaginary patellar maltracking. You need to find the right stimulus for you to adapt.
That is not to say that part of your recovery won't involve calf raises, planks and single leg squats. These can all help with injury recovery as well. But those are supplemental exercises that you can do WITH your running.
But…don’t be stupid
Running got you into this mess and running can get you out. But, that means you can’t keep doing whatever type of training caused your pain and injury. This is where the art (e.g guesswork) and science comes into play. To get back to 100% of running you need to start at somewhere less than 100%. Something needs to change and then you need to build back up.
WARNING: There are exceptions where you probably want to back off. High risk stress fractures are good examples. A future blog will explore this. Please work with a health professional in these areas or any time you are not sure.
Evidence? Rehab research is hard. What we rarely in exercise studies are control groups that just do physical activity with good advice and education. But the two studies that I know of show that people who just modify their training loads and physical activity do equally well as groups who do specific exercises (Hott et al HERE) or gait retraining (Esculier et al HERE)
Clinical decision making when using Running as Rehab.
1. How many minutes can you run currently without pain?
OK, do that for a 2 weeks and then slowly build up. If you can only run 10 minutes then try running for 5 minutes, do a 1 minute walk and run another 5 minutes. If things feel good do another 2-5 minutes. Other tips to maintain your running volume is to run at your pain threshold 2x/day. Or instead of running 3x/week you now run daily. But each run might be only 12 minutes long. And then, to make it worth your while you add in a hard fitness walk (as suggested by many great coaches like Chris Johnson). Essentially, don’t stop your running routine. Just modify things. Stay active. And remember, the body responds positively to stress. The right amount of physical stress is what is going to catalyze your healing.
2. How long have you had pain?
When pain is pretty short term (less than 3 weeks) then often its a good idea just to drop your volume by 50% and skip your speed workouts for a week or two. This is just a temporary change when we got those bothersome niggles. Your therapist or coach should be able to help you find what the aggravating parts of your training were/are (or something else in your life) and make simple modifications to just temporarily avoid those things. This is essentially a case of “Hey, it hurts more when I do this” so we say “OK, don’t do that”…Temporarily. :)
When you’ve been dealing with pain for months then that requires different thinking and instead of taking an avoidance approach we actually start to run into some discomfort. This assumes you have been backing off for the past few months. What we are trying to take advantage of here is our amazing ability to adapt. The thought process is that sometimes the pain you feel is much more about a sensitive nervous system and much less about some tissue damage. We think there might be a disconnect between the symptoms you feel and “problems” in the tissue. Thus, we respect pain but we just don’t bow down to it. But remember this, even if there is tissue “damage” the stimulus to heal that tissue is quite often physical load. Its just finding the right amount of stress to cause that positive change.
3. What type of training bothers you the most?
Again, with acute pain we typically take an avoidance strategy. If speedwork is bothersome then we replace that with an easy run. If its long run then maybe we trade your long run for two medium runs. Or we decrease the pace of your long run and just run for the same time. So, in the short term we avoid but then after a break we start to add back in the aggravating activity slowly. This is what catalyzes adaptation and prepares you tolerate the loads of running again.
4. Have you been avoiding running for months and your symptoms are the same?
This is quite common. We stop running and ours knees still hurt. You can still do your regularly rehab but maybe it’s time to start doing the thing you love again. If it’s been months since you ran you are going to have to swallow your pride here and start over or start at a greatly reduced amount. But don’t worry, 10 SECONDS of running quickly turns into 20 minutes and then you are running 40 minutes. Have patience here. A very simple return to run program for someone who has been off for 3 months could be:
1. 3-5 minutes of jogging
2. 5-8 minutes of skipping, shuffling, A skips, B skips, lunges etc (i.e a dynamic warm up)
3. Ten minutes of very hard walking
4. 3-4 minutes of a dynamic warm up
The amount of jogging you start with will probably depend on your mileage before you were injured. If you were running more than 50km/week before then we might start with 10-15 minutes of jogging. We never know for sure. We give that a try, see how you respond and build accordingly.
You might still have pain doing this. Even during the run. But if that pain goes back to its normal levels the next day and it doesn’t get in the way of your life that is a success. In general we suggest if the pain is 2-4/10 (please note: there are exceptions to this - SOMETIMES NO PAIN POKING - and a future blog will go into that). Now you need to slowly progress. A simple progression here is to add 2 minutes, to each run per week. So that in 5 weeks you are now running 20 minutes. But, be flexible here. If things flare up then we know your threshold. Go back to running a little less.
The idea behind the warm up drills and hard walking is to make this worth your while. You don’t have to do those things but now you can get out there for thirty to forty minutes. Let’s make your run worth changing your clothes.
5. Its OK to poke into pain
Poke the bear but don’t hump the shit out of it is what the science suggests. Meaning some discomfort is OK. But you can’t get “better” at having pain. We often see a few presentations:
a. Pain is 5-10 minutes at the start of the run but goes away with more time and you never feel it later in the day or the next day
Awesome, keep running. Don’t worry about it.
b. Pain comes on at a certain point and gets worse during the run. You feel it the next day
Less awesome. Very reasonably to back off here. Change something. Perhaps speed, environment, your running style and your distance. Try to just running to the edge of pain onset. Over time we might have you start to poke into the pain for a time-contingent amount. We often do this when you have had pain for months and things are not improving. Remember, successful rehab often involves doing more of the things you love despite pain. But again, this is not always the easiest decision to make.
c. Pain comes at a certain time in the run and just stays mildly uncomfortable. Nobody knows you are in pain until you tell them. The pain is pretty much gone once you stop running and you don’t feel it the next day.
These scenarios are tough. Sometimes this is pretty normal and resolves over a few weeks. Sometimes it sticks around. Depending on your training goals you can keep training with this discomfort (e.g. you have a race in two months). But, it could also be the start of the season and maybe it’s worth backing off or changing something about your training. These are often scenarios where your supplemental rehabilitation (e.g gait retraining, strength exercises, load management, more sleep, more hobbies, less hobbies) can be helpful.
d. You’ve back off your running and there is point where you start to feel some discomfort.
If you’ve been running but not poking into pain then sometimes its time to start poking. This is where you might run 15-20 minutes pain free and then consciously choose to run 2-3 minutes INTO discomfort. The idea is that we can habituate and adapt. And we can push that threshold of pain farther away.
6. What do you think will happen if you start to run? What have you been told your injury is? Do you think it’s safe to run?
Pain is complex. Pain is multidimensional. It’s not just what is going on with your muscles, tendons and joints. Stress, poor sleep, worries and fear can all influence how much pain you feel. The fear of reinjury, worries about your injury and all sorts of life stressors can influence your recovery. Understanding that you are safe, that you are built for running and running can positively influence your pain and injury are important for recovery. Don’t let someone tell you that you need to fix yourself before you start running. I bet you will hear that you have patellar “maltracking”, weak glutes, faulty firing of your VMO, fallen arches or other things that are poorly related to injury pain. You might be told you need to fix those things. Poppycock! Take a look at all the happy runners you see. You will see “weak” glutes, knock knees, “wonky” form and these people are doing great and running. You can run.
And although someone like me can tell you that running is good the best way for you to truly know that is to start running again. It won’t be easy. When you lose fitness and start again it sucks. I know :). But you can adapt. You built yourself up to run in the past and you can do it again.
A quick summary
1. Find what you can currently do and do that
2. Slowly progress this.
3. Avoid aggravating types of runs temporarily (speed, hills, very slow jogging) but then add them back in slowly when your symptoms are stable or getting better
4. Be flexible. Progression is not always linear. Its OK to take plateau weeks and easy days
5. Add in other types of training to make it worthwhile (speed walks, hill walks, shuffling, skipping, dynamic warm ups etc)
6. Know that its OK to poke into pain but sometimes it is worth backing off. i.e. Don’t be stupid
Related links:
1. Running Injury Prevention
2. Gait Modifications to influence symptoms.
3. Clinical decision making for running gait modifications
3. Tom Goom’s return to running guide
Coming Soon
Part 2: Running is rehab Case Study: Poking into pain for a high hamstring tendinopathy
A framework for running injury management
When to back off. Using specific examples of avoidance to create principles for practice