Return to Running - A Guide for Therapists

Picture this, you have four runners under your care all keen to return to running. They all have
different injuries and different needs. How will you plan their return? This guide is designed to help
you get a runner back to their sport and help them achieve their goals. We’re going to talk about
these four runners as case studies at the end of this guide to illustrate the process in action.

Three things are key in return to running; REASONING, RISK and REWARD.

And lets be clear from the start there are NO RECIPES here!

Reasoning

Let’s begin by delving into reasoning. Here I really want to give you an insight in to what my
thinking will be when planning return to running with an athlete. Below we’ll explore key areas that
inform my reasoning process;

1. Pathology and stage of condition

Some pathologies and presentations don’t respond well with continued running or early return to
impact. The obvious example is a stress fracture and bone stress injuries in general don’t appear
to react well to running with pain. Acutely painful tendons and plantar heel pain also don’t usually
respond positively to continuing running and often benefit from a period of rest prior to a gradual
return.

2. Irritability

Knowing how irritable a patient’s symptoms are can go a long way in guiding their return to sport.
As a simple guide those with pain with low load day to day activities such as walking short
distances, climbing the stairs etc may be too irritable for a return to running at that point.
Conversely those with minimal day to day symptoms will often respond better.

3. Readiness to run

Testing readiness to run with subjective questions and objective tests can guide us with return to
sport, we’ll explore this more shortly. It’s important to remember though that a) there’s very little
evidence in this area and b) we need to be wary of rigid rules as they can sometimes serve as a
needless barrier to return to sport

4. Response to running and ‘run tolerance’

How does this athlete respond if they run? What are their symptoms during running? How long do
they last after? Is there a distance they can manage with minimal pain and without lasting
reaction? If so this distance can often form the starting point to a return to running programme.

Severe pain during running, pain that lasts beyond 24 hours or significant increases in other
symptoms (such as swelling) suggest excessive loading. Running should be decreased to a
manageable level or stopped if a manageable level can’t be found.

5. Athlete’s goals

Know your athlete and their goals. A runner who just wants to ‘get round’ a marathon will have
very different training needs from one who wants finish it in under 3 hours. This must be factored
into our reasoning with return to running. In fact a runner’s goal may be a key driving factor in
return to running decisions. In many cases the process is less about working with pre-determined
rules (such as increasing by 10% per week) and more about considering the best way to safely
train to achieve these goals.

6. Stage of competitive season

There are points during the season when you and the athlete may be more prepared to take risks.
For example, imagine developing an injury just before the key race of the year. We may be more
inclined to manage that injury to allow an athlete to compete than we would be in the off-season
when there’s far less need to take such risks

7. Address injury impairments

Alongside planning return to running key impairments in strength, range of motion, control,
muscle mass, power and plyometric ability should be addressed. A lot can be achieved through
careful selection of 3 or 4 key exercises tailored to the individual’s need.

Risk v reward

A HUGE part of return to sport is balancing risk (of increase in symptoms or injury) with reward (in
terms of performance and achieving goals).

We can go for super low risk - “you can run 1 minute this week and build up to 2 minutes next
week” but this may also mean low reward, it’ll take forever to reach your training goals!

We can go for super high risk - “Just keep pushing harder, you’ll be fine!” And while this may
mean better performance it’s also more likely to flare symptoms and could stop the athlete
running altogether if pain worsens significantly.

A skilled therapist looks for ways to minimise risk and maximise reward.

Cross-training is a good example of this. We can use it to reduce risk by replacing some running
with a less provocative form of training and it can increase reward by maintaining or improving
cardiovascular performance. Win, win!

Return to running - 4 key steps

What we’ve discussed so far establishes some considerations in the return to run process we
now need to implement these with the following key steps;

1. Assess readiness to run

2. Determine current ‘run tolerance’

3. Plan graded return to achieve patient’s goals

4. 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;

1. 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%)

2. 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

3. Restore training volume prior to intensity

4. Plan recovery time into the weekly schedule and consider recovery weeks with reduced
volume where needed. Factor psychological and emotional stress into this - where there is
greater stress (physical or psychological) their needs to be greater recovery.

5. 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%.

6. Change one thing at a time

7. Base majority of training around what is manageable for the patient (i.e. doesn’t lead to lasting
increases in symptoms)

8. Allow longer recovery after challenging sessions especially if they increase symptoms

9. 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)

10. 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).

A return to running programme like couch to 5km or pre-made schedules can be useful,
especially if the athlete prefers a structured approach. Where possible create an individualised
plan that incorporates rehab and recovery and is tailored to their goals.

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. Advise the patient on monitoring both
their training load and how they are responding to it. Discuss 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).

Case studies

Below are 4 case studies to illustrate the different approaches we may use in the return to run
process. For an excellent additional case study read top physio Brad Scanes’ example;

From Shin Splints to Marathon in 30 days.

1. Achilles pain, low irritability. PLAN: continue running based on ‘run tolerance’

Our first case study is a gentleman in his 50’s with left sided achilles pain which we’ve diagnosed
as insertional achilles tendinopathy. He’s non-irritable and has minimal pain with day to day
activity including walking distances. His ‘run tolerance’ is 6 miles on the flat at a slow to moderate
pace. If he exceeds this distance, increases his pace or runs uphill it leads to symptoms the
following day including early morning stiffness.

This gentleman represents many runners that we see in that he can tolerate some running and we
can keep him running with some training modifications and rehab. Our advice might be to start
with training at a slow to moderate pace with a maximum distance of around 6 miles. He can then
progress by changing one thing at a time, for example increasing distance, pace or adding hills.
Changing more than one thing at a time increases the likelihood of aggravating symptoms.

His goal is to run a flat road marathon in 4 months time and he just wants to finish (rather than get
a certain time). We might suggest he focusses on building distance as a priority to achieve this
rather than focussing on speed/ hills.

Most marathon programs are approximately 16 weeks with peak mileage occurring at around
weeks 10 to 13 prior to a taper period where training volume is decreased to reduce fatigue.
Runners typically aim to reach somewhere between 18 and 22 miles for their longest run in
preparation for racing 26.2 miles. These details do vary though, and they do matter as they will
inform our training goals and progression.

In this gentleman’s case he’s currently managing 6 miles and his goal is to reach 18 for his longest
run. He could add a mile a week for the next 12 weeks while monitoring response and reach this
target plus hit peak mileage prior to tapering.

2. MTSS, moderate irritability. PLAN: settle symptoms, period of pain free impact and then
graded return

Our second case study is an 18 year old runner with Medial Tibial Stress Syndrome (MTSS) which
is moderately irritable. MTSS is considered to be a bone stress injury and doesn’t tend to respond
well to running with pain. It’s a recurrent issue associated with rapid increase in training volume.

The patient is frustrated by this and now wants to focus on a gradual return to allow consistent
training. Her goal is to return to competing over 1500m and 3000m. Her longest run in training is
5km.

The patient reports mild pain towards the end of a 30 minute walk and impact testing reveals
medial shin pain immediately with jogging on the spot, bounding and hopping. Cycling, swimming
and using the cross-trainer are all symptom free.

In this case we could recommend 2 weeks of pain free cross-training to allow symptoms to settle
and avoiding painful impact.

The patient returns in 2 weeks and symptoms have settled significantly, she can now jog on the
spot for at least 1 minute pain free and manage bounding and hopping for 30 seconds. We decide
to try a short run on the treadmill (2 to 3 minutes) to gauge response and this too is pain free.

Considering the history and irritability a gradual progression is sensible so we recommend running
for 2 to 3 minutes every other day with a rest day in between to assess next day response. We
may progress in this case by adding a minute or 2 to these runs each week, favouring a slower
return to build run tolerance and reduce likelihood of recurrence.

3. Calf pain, low irritability but unclear run tolerance and race coming soon PLAN: run
tolerance test and build from there

Our 3rd case is a 38 year old male runner who developed calf pain when running 6 weeks ago and
hasn’t run at all for the last month. He has a marathon in 8 weeks time and has consulted for the
first time today. History and examination suggest symptoms were fatigue related calf pain
following an increase in training intensity and possibly as a result of reduced calf strength on the
affected side.

His symptoms are non-irritable, he has no pain day to day and can walk for over 30 minutes pain
free. All readiness to run tests are symptom free including repeated hopping. Within the session
we try a short test run of 5 minutes at an easy pace which is symptom free both during and after.

A gradual progression in running starting from just a few minutes will not be enough to reach this
patient’s goal of completing a marathon in 8 weeks time. We don’t currently know what his ‘run
tolerance’ is as he hasn’t run recently but we can find out by doing a run tolerance test. This
involves the athlete running at a comfortable pace until they start to notice some symptoms and
then stopping. They need to be sensible and not push too far (i.e. don’t keep going for 20 miles
on the first attempt!) as we don’t know how it will react the next day. If symptoms start they note
how far they’ve run and for how long and use this to form the basis of their training.

In this runner he finds he can manage 8 miles until the calf starts to feel a little tight but there’s no
lasting reaction. We can then form a training plan around this - where the longest run is 8 miles
and build up from there while monitoring response.

4. High risk Tibial stress fracture PLAN: rehab ladder and graded return

Our final case is a 23 year old female runner who had a left anterior tibial stress fracture about 7
weeks ago. She’s been non-weight-bearing on the advice of her consultant who has recently
reviewed her and advised to weight-bear as tolerated. At present she’s generally symptom free
but the leg aches a little if she’s on it too much.

On examination there is atrophy of the left calf and quadriceps muscles. Single leg balance and
single leg squat control are reduced on the left side and there is a significant loss of weight-
bearing dorsiflexion (likely due to non-weight-bearing).

In this case we need to consider a more ‘rehab ladder’ approach to address impairments in
strength, control or range of movement and begin impact and return to running at an appropriate
time frame and stage of healing. In addition we should consider the multi-factorial nature of bone
stress injuries and bone health including diet, energy availability, sleep and recovery, mental
wellbeing and menstrual function.

We would consider the end goals of the athlete from the start and progress through a rehab
ladder first to restore equal strength, control and range of movement (for example Limb Symmetry
Index >80% of non-injured leg) and potentially progress further if the demands of the sport were
high.

Once these goals are achieved we can begin introducing impact with a focus on controlled, pain
free technique starting with light impact and progressing to include single leg hopping and multi-
directional work. This should be considered at the appropriate stage post injury when there has
been sufficient bony healing and irritability is low.

From this stage onwards the return process is similar to what’s been discussed above -
considering the athletes goals, assessing readiness to run and irritability and then beginning a
gradual return to running.

We may utilise a run - walk pattern initially to reduce the effects of fatigue which is thought to
increase bone loading. Gradually the walk breaks are reduced and continuous low intensity
running is increased prior to increasing intensity:

Run - walk pattern

Reduce walk periods

Increase continuous low intensity running

Graded increase in intensity