When Can I Start Running Again? Key Considerations Before Returning to Running After Injury

A friend of mine recently sought orthopedic consultation for recalcitrant left knee pain, which set in this past June after completing a half ironman. The orthopedist diagnosed him with patellar tendonitis and advised him to refrain from running until he was able to climb stairs pain-free. Following this advice, my friend took a break from running and diligently iced his knee. After a few weeks, he found that his knee was actually feeling better to the point where he was able to negotiate stairs without issue. He was excited because this apparently meant that he was ready to run. I remember speaking with him before his first outing and immediately grew wary of the situation when he told me that he was going to “try” running. Anytime someone uses the phrase “try running” after injury, I know disaster is imminent. Inevitably, his knee pain resurfaced landing him back at square one while further prolonging his recovery. Knowing that I am a physical therapist, who specializes in the care of endurance athletes, he asked me how I know when an injured runner is able to return to training.

“When can I start running again?” is perhaps the most common question I receive as a physical therapist. Rather than roll the dice, I thought that I’d share with you my criteria to return an individual back to running following injury. These criteria have been developed based on the medical literature, my experience as a physical therapist and triathlon coach, as well as my background as a competitive runner and triathlete.

1. ARE THERE ANY SIGNS OR SYMPTOMS OF INFLAMMATION? – Running in the context of inflammation is a recipe for DISASTER! This will not only result in further injury but will also prolong your recovery. Resolving inflammation is the first step in setting the stage for a safe return to running. Initially Protecting the injury through Rest coupled with proper Icing (360 degrees around the affected region, 15 min, 3-4x/day), Compression, and Elevation will facilitate resolution of any swelling and inflammation. Once the inflammation has subsided, you are still not ready to run, so avoid the temptation of resorting to non-steroidal anti-inflammatories or opting for a corticosteroid injection as these interventions will mask your symptoms while failing to address the underlying problem(s).

2. HAVE YOU NORMALIZED YOUR LOWER EXTREMITY FLEXIBILITY? - The bottom line is that running involves exercising our muscles in a lengthened position. While running does not requires a tremendous amount of flexibility, stretching key lower extremity running musculature plays an important role in the rehabilitation setting. Since there is a certain amount of microtrauma associated with running, soft tissue adhesions often form and bind tissues together. These adhesions can restrict movement of the nerves in the lower extremity (extra neural adhesions) while creating soft tissue dysfunction. Neural mobilization (see video below) and static stretching can be used to restore mobility of the nerves and viscoelastic properties of the musculotendinous unit, respectively. The key lower extremity musculature worthy of consideration include the following: hip flexors, gluteals, tensor fascia late, hamstrings, quadriceps (esp. rectus femoris), triceps surae, pretibial muscles, and flexor hallucis longs (FHL).

3. ARE THERE ANY OUTSTANDING JOINT RESTRICTIONS? – Since joint/arthrokinematic movement is not under voluntary control, assessing for and treating joint restrictions is a critical part of any formal rehabilitation program. Anecdotally, the two most common joints that I find to be restricted/hypomobile are the 1st MTP joint and talocrural joint. Ensuring adequate ventral and posterior glide of the 1st MTP joint and talocrural joint, respectively, is critical to minimize compensatory motion upstream. From a rehabilitation standpoint, establishing at least 40-45 degrees of 1st MTP dorsiflexion, and 15 degrees of ankle dorsiflexion with the knee flexed 90 degrees is a good target. I have attached a simple ankle mobilization that I often use clinically to restore ankle dorsiflexion. I hope you find it as effective as I have.

4. IS THERE ANY HIP WEAKNESS PRESENT?  - By now, most runners are getting hip to the role of the hip. In addition to inflexibilities about the lumbo-pelvic-hip complex, hip weakness can also lead to injury, especially among recreational runners. Ensuring adequate strength of the hip musculature, especially the hip flexors, abductors, external rotators, and extensors is critical given the affect of hip strength on knee kinematics. While open chain hip strengthening exercises are appropriate during the early stages of a rehabilitation program, runners and rehab professionals should strive to incorporate more closed chain strengthening exercises once they are tolerated since running is predominantly a closed chain activity.

4. ARE YOU ABLE TO BALANCE ON EACH LEG WOBBLE-FREE? - Perhaps the most common denominator among injured runners seeking my services is the observation that they lack stability when balancing on the affected lower extremity. Since running is unique in that both feet are never in contact with the ground simultaneously, establishing stability in single limb stance is critical to prevent recurrent injury. Failure to address what I like to refer to as the “runner’s wobble” is a sure shot for recurrent injury. If the runner is unable to stabilize themselves on level ground in a static manner, how can they be expected to stabilize themselves dynamically when landing with 2.2-5x body weight? From my experience, this is probably the most overlooked impairment when it comes to evaluating injured runners yet it only takes ~30 seconds to assess.

5. ARE YOU ABLE TO PROGRESS THROUGH YOUR BIG TOE? - Regardless of your foot striking pattern, the one thing that we can all agree on is that you must be able to load the first ray and progress through your great toe. This is an integral part of running as progressing through the great toe will engage the windlass mechanism, which serves to stiffen the plantar tissues and improve propulsion. Off axis loading will inevitably lead to abnormal and potentially deleterious forces particularly at the level of the 1st MTP joint as well as further upstream at the level of the ankle, knee, hip, and even low back and trunk. Once the runner is able to properly stabilize themselves on the affected lower extremity with the foot straight, they can progress to simple stepping exercises that are centered on pushing off through the great toe in a balanced manner. An example of such as exercise is simply stepping over a cone or beam. I never cease to be amazed how difficult this is for the vast majority of injured runners seeking my services.

6. DO YOU TOLERATE ECCENTRIC CONTRACTIONS? – Tolerance to eccentric contractions (AKA negative contractions) is prerequisite to returning to running. Examples of some appropriate closed chain exercises for runners include but are not limited to the following: step ups/downs, lunges, squats and deadlifts (progressing from double to single leg). Once the runner is able to tolerate eccentric contractions, they are one step closer to plyometric activities. Always remember to focus on proper form and technique when performing eccentric contractions to ensure that the runner is balanced and loading the tissues in an optimal manner. The most common mistake during lower extremity eccentric contractions is for the runner to fall in to excessive femoral internal rotation or exhibit an ipsilateral trunk lean in compensation (see video below), both of which indicate poor stability and neuromuscular control.

7. ARE YOU SHOED PROPERLY AND TOLERANT OF A WALKING PROGRAM? – Ensuring that the runner tolerates a progressive walking program is perhaps one of the most neglected components of a rehabilitation program. I often attribute this to impatience on the part of the runner along with the rehabilitation professional succumbing to pressure placed on them by the runner. Since walking is a heel to toe activity, ensuring that the runner is prescribed appropriate footwear is critical to avoid overstressing healing tissues. Proper shoes should control for abnormal motion while affording adequate shock absorption and cushioning for heelstrike and toe-off, respectively. Once the runner is in appropriate shoes, they are ready to initiate a walking program. I generally make sure that a runner is able to tolerate a 50 minute walking program at ~3.5 mph without issue before progressing them to a walk-glide program.

8. DO YOU TOLERATE ACCELERATIONS & HILLS? - Once a runner successfully completes a progressive walk-glide program, they can be progressed to more strenuous exercises involving accelerations, hills, and plyometrics. These drills are designed to get you stronger and running better than you were pre-injury. Accelerations (progressively running faster) are important whether you are a fitness runner or a racer. As a runner ramps up their speed they will start to use less of their foot and adopt a forefoot striking pattern. Being able to perform accelerations while maintaining a balanced and upright posture will ensure the previously injured region can tolerate greater forces while safeguarding against re-injury upon resuming regular training. Preparing the runner for hills is also essential as the runner will have be forced to find different balance points depending on the grade of the hill and the speed at which they are running. Uphill drills should focus on moving your balance point forward by using a more forward arm swing while downhill drills should emphasize lowering your center of gravity, keeping your elbows out, and increasing your stride.

9. DO YOU TOLERATE PLYOMETRICS? - The bottom line is that running is basically hopping in a balanced manner from one leg to the next. Therefore, exposing the injured runner to hopping activities is critical during the late stages of a rehabilitation program. It is important that the runner loads through the previously injured region when performing plyometrics to ensure that the tissues can withstand such forces. A few examples of plyometric exercises that I routinely incorporate in to my programs include but are not limited to the following: skipping, high knees, and bounding.

10. DO YOU KNOW HOW TO IDENTIFY & GRADE RUNNING INJURIES? - I always place a huge emphasis on patient education, especially when it comes to treating runners since they are notorious for getting injured. A key education component relates to being able to identify when you are injured. The injury grading system that is listed below was originally developed by Bruce Wilk and has proved to be invaluable in identifying the severity of an injury while also fostering communication between medical professionals. If you are in search of an injury grading system to

Stage 1 – unfamiliar disconcerting pain that is present while running

Stage 2 – pain at rest following running

Stage 3 – pain while performing activities of daily living (ADLs)

Stage 4 – pain that is managed through medication (NSAIDs, narcotic painkillers, corticosteroid injections)

Stage 5 – crippling pain that makes it very difficult to get through the day.

11. PECTORALIS MINOR TIGHTNESS AND THORACIC EXTENSION - While running injuries predominantly involve the lower extremity, we must always consider impairments in the upper quadrant that can negatively impact running form/technique and lower extremity function. Two impairments that I frequently document in runners are pectoralis minor tightness and poor thoracic extension. These impairments will not only compromise a runner’s ability to assume an upright position but can also lead to poor arm mechanics (see video below) and greater shearing forces at the cervicothoracic junction. Trying to resolve or minimize these impairments is critical to decrease strain on the posterior chain while fostering a more upright posture.

As you can see, determining when an injured runner is able to return to training is not as simple as being able to climb stairs pain-free. The sport of running is a complex activity that involves an integrated set of movements from head to toe. My goal in working with injured runners is never to simply get them back to training as fast as possible, but rather, to return them to running better than they were pre-injury . WISHING YOU HAPPY, HEALTHY, & STRONG RUNNING. SEE YOU ON THE STREETS!

Tagged as: Eccentric Contractions in Running, Graded Walking Program, Great Toe Dorsiflexion, Hip Strenth, Inflammation, Neuromuscular Control, Plyometrics, Running Advice, Running Rehab, Talocrural Joint, Windlass Mechanism