CHAPTER 11
Rehabilitation Principles of the Injured
Runner
ELLIOT JAMES O’CONNOR, DPT, OCS
Increasing running load is the foundation of every pro-
gressive training plan. Through this process of stressing
the body, and then resting to allow the tissues to
remodel and adapt, higher levels of fitness are
achieved.1 At the same time, this process, when done
incorrectly, can lead to injury. Runners become injured
when the load capacity of a specific structure is exceeded
during a running bout or as a cumulative result of mul-
tiple bouts without adequate recovery.1,2 This is
commonly referred to as “training error” and is respon-
sible for the majority of running injuries.3 Running
injury is not just a result of balancing stress and adapta-
tion though. The load capacity of individual structures
is influenced by the magnitude of load per stride as
well as the distribution of that load applied per stride.2
This is referred to as the runner’s “form” or
biomechanics.
When rehabilitating an injured runner, the goal is
to restore their tolerance for running load to the point
where they can return to a progressive training plan.
In this chapter, we will examine two different strate-
gies to achieve this. The first section will examine
restoring and improving the injured tissue’s tolerance
for load. This will be discussed from acute injury
through return to run. The second section will discuss
retraining the runner to decrease the magnitude of
load and/or transfer the load to other tissues. This sec-
tion will examine the role of gait retraining in clinical
treatment of injured runners who can still run. It will
also look at alternative forms of treatment when the
patient cannot run. It is important to point out that
these two strategies are not mutually exclusive. An
astute clinician blends them together during the
course of rehabilitation, but for clarity we will discuss
them separately.
At the end of the chapter, the clinician should be
able to determine the load sensitivity of a running pa-
tient. They should also be able to identify running
Clinical Care of the Runner. https://doi.org/10.1016/B978-0-323-67949-7.00011-2
Copyright © 2020 Elsevier Inc. All rights reserved.
mechanics that could lead to maladaptation to load.
Finally, the clinician should be able to develop a reha-
bilitation program that returns the injured runner
back to a progressive training plan that will help them
reach their running goals.
RESTORING INJURED TISSUE TOLERANCE
FOR LOAD
Running load is unique and poorly reproduced with ac-
tivities that are not running. Therefore, the best way to
get better at running is to run. Unfortunately, this may
not be possible for an injured runner. While some in-
juries will allow for some amount of running, it is
more likely that an injured runner presents in the clinic
with a tissue tolerance so low that they cannot run.
When a runner presents in this state, alternative loading
activities must be used to return their tissue tolerance to
a level that allows them to return to running. Rehabili-
tation is creating the bridge between injury and return-
ing to run.
The exact progression of activities used to accom-
plish this goal must be individualized to the patient.
It will differ based on the injured tissue in question,
the specific tolerance of the tissue, and the goal of the
runner. Different tissues respond differently to different
loads; however, all tissues respond positively to moder-
ate progressive loads.4e6
Acute Painful Phase
Patients often present in clinic unable to run due to the
acute nature of their symptoms. They may be so sensi-
tive that even basic movements of daily life, e.g.,
walking or sitting down in a chair, are painful. This
amount of sensitivity can lead the injured runner to
conclude that these low load activities are causing dam-
age and they may become fearful of activity as a result.
In these cases, initial loading may need to be isometric.
101
102 SECTION II Biomechanics and Rehabilitation
There are a myriad of physiological reasons why iso-
metric loading can be beneficial to recovery. Isometric
contractions can slow muscle atrophy and decrease
edema. More importantly though, isometric loading,
specifically of tendons, has been shown to be anal-
gesic.7,8 This can be incredibly helpful to the clinician
who needs to break the patient’s association between
activity and pain.
In addition to breaking the pain cycle, isometrics
have an important role in restoring normal muscle
recruitment. When a tissue is painful, its use is
inhibited, and alternative motor recruitment strategies
are used to accomplish functional activities. It is there-
fore necessary to restore normal motor recruitment
before more loading can be commenced. Isometrics
serve as the tool to restore this normal motor
recruitment.
When putting this idea into practice, gym equipment
can be a useful tool because it allows for very specific
loading that can be adjusted right up to the edge of a pa-
tient’s tissue tolerance. If the patient does not have ac-
cess to gym equipment, body weight variations can be
utilized to produce the desired load. Researchers have
classically used five sets of 45 second isometric holds
at 70% of one repetition maximum.9 This should be
adjusted based on the patient’s response. Since the
goal of the exercise is to diminish symptoms, the pa-
tient experiencing those symptoms will be able to direct
the load much better than the clinician. Autonomy
should be granted to the patient to progress the load
as tolerated once they have demonstrated understand-
ing of the purpose of this exercise prescription.
Clinically, exercise choice will be dependent on the
sensitivity of the patient and the tissue that needs to
be loaded. That said, it can be beneficial to recreate
running specific positions with the exercise prescribed.
Conceptually, this loads the tissue similarly to actual
running. It also provides a mental benefit for the patient
who can start to extrapolate the exercise out to their
eventual return to normal running.
Regardless of which tissue is injured, exercise of
some type should be prescribed if only to start to restore
the patient’s confidence in their body. It is at this stage
that a patient is most psychologically fragile. If the mes-
sage that exercise is damaging is promoted, they will
struggle to progress.
During this acute phase, modalities such as tape and
cryotherapy, as well as massage and manual therapy,
could be used to help decrease the reactivity of the
tissue.10.11 It is up to the experience of the practitioner,
taking into account the beliefs of the patient, to deter-
mine the best use of these. Decreasing a patient’s
reactivity to load can help to facilitate their progression
out of the acute painful phase and onto the progressive
loading phase. Care should be taken to ensure that the
application of these does not diminish the self-efficacy
of the patient. Pain is a complex phenomenon, and ul-
timately, a patient must feel that they have control of
their symptoms if they are going to confidently return
to running.12 If they have to rely on external modalities
consistently, they are not demonstrating faith that their
body is robust enough to tolerate external stresses,
which will, in turn, create a struggle to move forward
to the next phase of loading.
Subacute Progressive Loading Phase
Once tissue sensitivity has diminished, progressive
loading should be initiated to increase the tissue toler-
ance. At first, running load may still be too great to
apply to the injured tissue. Therefore alternative loading
strategies need to be used to progress the patient back to
running.
Different loading protocols have been advocated by
different groups.13 Specifically with tendons, the differ-
ence between concentric and eccentric load has been
debated. Initially, eccentric exercise was advocated
because of the “lengthening” strain on the tendon.
This lengthening strain was hypothesized to encourage
reorganization of damaged tendinous tissue and help
return it to its preinjury structure. More recently, this
idea has been called into question. In vivo studies of
tendon mechanics have shown that the actual excursion
of the tendon is not different based on the load placed
on it.14 It is still true that higher loads can be produced
with eccentric exercises.15 However, in a rehabilitation
setting, these higher loads are rarely used; thus the clin-
ical utility of eccentric exercise may be more limited
than previously understood. Ultimately, the benefit of
the load may not even be structural. Limited evidence
supports the reversibility of pathological tissue changes;
however, loading has still been shown to be benefi-
cial.16 This is possibly due to improvements in cortical
control and decreased muscular inhibition, which can
help improve transmission of load through the injured
tissue.17
No matter what type of load is used, progression is
dictated by the symptoms of the patient. Classic loading
recommendations start with body weight and three sets
of 15 repetitions. The weight is increased when the total
volume of sets and reps can be tolerated without
“disabling” pain.18. It is liberating to both the patient
and the clinician to know that exercise need not be
pain free for it to be beneficial to the patient and that
there is some evidence that suggests that painful exercise
 CHAPTER 11
BOX 11.1
Rules for Acceptable Pain in Rehabilitation and
Return to Sport
1) A change in pain of no greater than 2 points on a 0e10
visual analog scale.
2) No pain that lasts for greater than 24 hours.
3) Pain that is not worsening with repeated bouts of
similar activity.
may be more beneficial.19 Clinically, it is helpful to set
rules for acceptable levels of pain and pain behavior
(see Box 11.1). These should be discussed with the pa-
tient and agreed upon based on the type of injury, the
stage of healing, and the patient’s past experiences
with pain.
This provides room within a rehab program for
discomfort, without the worry of reinjury. It also allows
for patient autonomy so that they can make confident
decisions about their daily activities and whether or
not they are within their tissue’s load tolerance. This
promotes patient self-efficacy and confident return
from injury.
Because running is a plyometric activity, this type of
loading is the ultimate goal of the exercise progressions
being provided. If a runner cannot tolerate hopping in
the clinic, it is not realistic to expect that running will
be successful. To advance, loaded double-leg exercises
can be progressed to single-leg exercises. Single-leg exer-
cises can be progressed to double-leg plyometric activ-
ities and from there to single-leg plyometric activities
(see Fig. 11.1). By the time patients perform this, they
are likely able to tolerate some volume of running,
Double Leg Squats Single Leg Squats
FIG. 11.1 Example of exercise progression.
Rehabilitation Principles of the Injured Runner 103
and a progressive training plan can commence. Pro-
gressing through these exercises is an ideal time to
work on form and biomechanics, which will be
addressed later in this chapter.
Return to Running Phase
The primary question any injured runner will have is,
“When can I return to running?” This is a complex ques-
tion with very different meanings depending on who is
asking it. One patient may really mean, “When can I run
20 yards if I need to catch a bus?” Another patient might
be asking, “When can I return to my 40þ miles per week
training plan?” Obviously, the answers are different,
but, to the practitioner, the answer to the basic question
needs to be, “As soon as your tissues can tolerate a pro-
gressive return to running plan.” Almost no injured run-
ner gets to jump back into a 40þ mile per week training
plan without a transition period. But, given the choice
of not running at all, or starting with less running
load and a clear path back to their running goals, every
runner will take the latter option.
The challenge to the practitioner is establishing the
initial running load and then learning how quickly
the patient can progress. Many factors will play into
this decision: the type of tissue injured, the chronicity
of it, the psychosocial factors involved, etc. Keeping
all this in mind, it is helpful to have minimum criteria
that every runner should be able to meet prior to initi-
ating a return to running program (see Box 11.2). From
this, further criteria can be added based on the con-
founding factors that the clinician has identified.
If a patient cannot walk for 30 minutes without
symptoms, they cannot expect to tolerate a walk/jog
progression of similar duration. If they cannot single-
leg-squat and hop 10 times without symptoms, they
Double Leg Hops Single Leg Hops
104 SECTION II Biomechanics and Rehabilitation

to the previously tolerated running volume and repeat,

BOX 11.2
Minimum Criteria Prior to Initiating a Return to
Run Program.
1. Walk for 30 minutes without increased symptoms
2. Single-leg squat 10 times without increased
symptoms
3. Single-leg hop 10 times without increased symptoms
cannot expect to tolerate an activity that will demand a
comparable movement 60e90 times per minute. When
runners are managing injuries that have a higher risk of
morbidity, e.g., stress fracture, these criteria can be
adapted to be more stringent.
Once a patient can meet the minimum criteria, the
clinician can feel confident about starting them on a
walk/jog progression. Different progressions have
been proposed based primarily on level III
evidence.20e22 Most progressions start with small
amounts of running, in the order of 3e5 minutes, inter-
mixed with walking so that the total duration of activity
equals 30 minutes. This is then progressed, adding 30
seconds to a minute of running while simultaneously
decreasing the amount of time walking until the patient
is running continuously for 30 minutes. Most programs
advocate running every other day to allow for tissue
adaptation but allow for cross-training on off days. It
is not uncommon for a patient to reach a point in this
progression that they do not tolerate well. To avoid frus-
tration, it is helpful to prepare patients for this plateau
in advance. If the patient fails to tolerate a certain
running volume, they should be instructed to return
progressing forward again when they tolerate the
running volume well. See Table 11.1 for an example
of a walk/jog progression. This can be adapted to the pa-
tient’s injury type and running tolerance.
After a baseline of 30 minutes of continuous running
is established, the classic “10% rule” can be applied to
the patient’s running volume to help guide them back
to their ultimate running goals (see Box 11.3).20
It is still important for runners to take a full day off
between runs to allow for tissue adaptation. Therefore,
due to the odd number of days in a week, it becomes
more practical to divide time into 2-week blocks so
that an equal number of running days is compared. A
widely used example of a return to running program
that follows these rules is shown in Table 11.2.
The far-right column includes extra data on the Acute
to Chronic Workload Ratio (ACWR). This is another
measure of injury risk that compares the average
(chronic) amount of work done over 4 weeks to the
(acute) amount of work done over the past week.
Dividing these two numbers results in a single metric
that has been correlated with risk of injury.23 Research
using this metric has found that athletes who have
too high of a ratio, greater than 1.5 (referred to as a
workload peak), have an increased risk of injury. This
idea, running more than usual can lead to increased
risk of injury, is not surprising. However, what is sur-
prising is that research has found that having an
ACWR that is too low, less than 0.7, also increases risk
of injury. This has been referred to as a workload trough
and can be thought of as an acute bout of
detraining.23,24

TABLE 11.1
Three Week Walk-Jog Progression of an Initial Return to Run Program.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
9 minutes - 8 minutes 7 minutes 6 minutes
walk/1 minute walk/ walk/ walk/
jog 3 2 minutes jog 3 minutes jog 4 minutes jog
3 3 3
5 minutes 4 minutes 3 minutes
walk/ walk/ walk/
4 minutes jog 6 minutes jog 7 minutes jog
3 3 3
2 minutes 1 minutes 30 minutes jog
walk/ walk/
8 minutes jog 9 minutes jog
3 3
 CHAPTER 11 Rehabilitation Principles of the Injured Runner 105

own personal running goals. The patient should be

BOX 11.3
The 10% Rule
This is a classic idea of run training that dictates a runner
should not increase their running volume or intensity by
more than 10% a week. While the scientific reasoning
for this rule may be lacking, it serves as a conservative
guide to keep eager runners in check as they return
from injury. More aggressive training plans could be
used if the patient’s tissue tolerance is greater and their
risk of reinjury is lower. Increases in running volume up
to 30% per week have been shown to be just as safe as
smaller increases in healthy novice runners.8 However,
when dealing with runners who are injured, it may be
beneficial to take the more conservative path back to
running.
This novel way of quantifying injury risk emphasizes
consistent workloads to maintain tissue health. It also
allows for quantification of intensity. The problem
with most measurements of load is that they do not
take into account how hard the work was. The above
workout plan could be ran at any intensity and still
not violate the 10% rule or the ACWR rules. However,
if an intensity modifier is added to the minutes, a
commonly used modifier is session rating of perceived
exertion (sRPE); you can manage changes in intensity
without increasing risk of injury unnecessarily (see
Box 11.4).25 This additional metric is not always neces-
sary for safe progression; however, the clinician may
find it helpful for higher level or more complex patients.
After a return to running program has been
completed, many runners will still need to progress
their running load tolerance if they are to reach their
educated throughout the process so that they will be
able to apply the structure of their return to run pro-
gram to their own progressive training plan. Just as it
is with avoiding injury in the first place, to prevent rein-
jury, avoiding training errors is the most important
factor.
REDUCING AND REDISTRIBUTING LOAD
PER STRIDE
There are situations when running injuries are not due
to training error alone. These are situations where the
patient’s magnitude of load per stride is too high or
the distribution of the load across specific tissues is
excessive. In these cases, it may be unrealistic to expect
a progressive loading program alone to be enough to re-
turn the patient to running. It may be necessary to
retrain the runner to diminish their load per stride or
redirect it to different tissues in order for them to reach
their running goals. In simpler terms, it may be benefi-
cial to improve the patient’s running form.
Gait Retraining
If the patient is still able to run without excessive symp-
toms, the most efficacious way to improve running me-
chanics is through gait retraining. Exercise alone, while
beneficial in terms of running economy, has not been
shown to be effective at improving running me-
chanics.26,27 Gait retraining is done with the specific
intent of decreasing the magnitude of load per stride
or biasing the running style of the patient away from
the overloaded tissue. These goals are not mutually
exclusive; however, it is helpful to think of them as
different purposes for changing a runner’s gait.

TABLE 11.2
Progressive Running Plan.
Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total minutes ACWR
30 e 30 e 30 e 35 e e
e 30 e 30 e 35 e 220 e
35 e 30 e 35 e 35 e e
e 35 e 40 e 35 e 245 0.95
35 e 40 e 40 e 35 e 1.22
e 40 e 40 e 40 e 270 0.93
45 e 40 e 40 e 45 e 1.24
e 45 e 40 e 45 e 300 0.91

Adapted from program by Steven L. Cole, ATC, CSCS College of William and Mary.
106 SECTION II Biomechanics and Rehabilitation
BOX 11.4
Acute to Chronic Workload Ratio
Acute to Chronic Workload Ratio ¼ ðAcute work  sRPEÞ=ðChronic work  sRPEÞ
Load per stride is a concept that has been researched
in depth as a causative factor of running injury. Magni-
tude of load per stride is measured very specifically us-
ing instrumented treadmills or force plates. When a
runner is examined using these tools, the ground reac-
tions forces (GRFs) can be examined. GRFs are mea-
sures of the force exerted by the ground on the runner
as they come into contact with it. These forces are
exerted in three dimensions: vertical, horizontal, and
mediolateral. In running research, the vertical and, to
a lesser extent, horizontal forces are what have received
the most attention. Specifically, excessive peak vertical
ground reaction force (VGRF), vertical loading rate
(VLR), and peak braking force (PBF) are what have
been most closely examined in relation to running
injury.
VGRF is the vertical component of GRF and is typi-
cally highest at midstance of the running gait. VLR is a
specific part of VGRF. It refers to how rapidly that force
is produced and is usually highest during the transition
from initial contact to midstance. Intuitively, lower
values of both VGRF and VLR are encouraged for
decreasing injury risk.28
PBF is a component of the horizontal ground reac-
tion forces, the forward and backward forces. It is
defined as the maximum posterior force observed dur-
ing the gait cycle, typically at initial contact.29 VGRF
and VLR are associated with stress fracture risk in run-
ners; however, they have not been found to be signifi-
cantly associated with other running-related injuries.28
PBF has been found to be associated with running-
related injuries in general, but not specifically with
any one type.29
Researchers have demonstrated that if visual repre-
sentation of these forces is given in real time to the sub-
ject, the subject can alter their gait to modify the forces
and, over the course of a year, decrease their risk of
injury.30 This is very important as a proof of concept;
however, its utility to the clinical practitioner is limited.
The vast majority of clinics will not have access to
instrumented treadmills and will likely be unable to
provide real-time feedback of specific variables related
to the magnitude of load per stride. Therefore, clinicians
must be able to identify the mechanics that correlate
with these excessive loads and provide useable feedback
to the patient using only the tools available. Typically in
the clinic, this means a tablet computer or a smart
phone with a camera capable of capturing slow motion
video and an application that allows the practitioner to
review the video with the patient. This has been shown
to be a valid and reliable way of measuring gait me-
chanics clinically.31
The mechanics that are most often correlated with
excessive loading variables (VGRF, VLR, and PBF) and
increased risk of injury are overstriding, excessive
adduction of the femur, and/or contralateral hip drop
(see Fig. 11.2).9,32 Overstriding can be defined as a
tibial inclination angle greater than 5 at initial con-
tact.33,34 Excessive adduction of the femur and contra-
lateral hip drop is observed at midstance and is
defined as pelvic drop in the frontal plane greater
than 5e7 degrees.33,34 Males typically have less, females
more, so the upper limits of what is acceptable should
be adjusted accordingly.
Clinically, there are multiple strategies that can be
used to change these aspects of running mechanics.
Which strategy is used is dependent upon the specific
injury and how well the injured runner can use the strat-
egy to change their mechanics.32 The most researched
strategies can be divided into two categories. The first
category is made up of strategies that have an external
focus, cued by something from the outside. The second
category comprises strategies that have an internal
focus, using the runner’s own body for feedback.
External Focus Gait Retraining
When retraining a runner’s gait, level III evidence sug-
gests that external cueing may be more effective than in-
ternal cueing in creating meaningful change.32 This idea
has been examined in great detail in other fields of mo-
tor learning and is generally accepted as superior to in-
ternal cuing.35 This is because using an external cue, one
that focuses the mind outside of the body, does not
constrain the body to perform a movement in a specific
way. It allows the body to determine an outcome it
wants to achieve and then use the most efficient pattern
 CHAPTER 11
Over Striding
FIG. 11.2 Common mechanics that correlate with excessive loading variables.
of movement to achieve it. This is opposed to an inter-
nal cue that would dictate the movement be done in a
specific way that may or may not be as efficient for
the individual to perform. Internal cues may still be
beneficial at times as described below, but in general
an external cue is usually more successful due to the
freedom of movement it provides.
In regard to running mechanics, much of the
research in this area focuses on modulating cadence
(the number of strides per minute) because this in
turn decreases step length. This decrease in step length
decreases the lever arms that apply forces on the body
and has been shown to reduce the magnitudes of load
per stride. This is not a new idea;33 however, it has
received more attention due to recent research demon-
strating that small changes in cadence can significantly
decrease the overall forces placed on the joints during
running.36 It is important to note that there is a down-
side of increasing cadence, in the form of decreased
running economy. However, if cadence changes are
limited to 5% or less, this has been shown to not be a
significant issue.37
Clinically, when using cadence to cue gait modifica-
tions, the patient is instructed to run at a self-selected
pace without cues and the preferred cadence is recorded
along with the runner’s biomechanical data. Average
cadence in recreational distance runners is 164 strides
per minute.38 Cadence can then be increased to the
point where running mechanics or symptoms improve.
As stated above, ideally this is less than a 5% change to
Rehabilitation Principles of the Injured Runner 107
Excessive Hip Adduction
maintain efficiency. That said, efficiency may be sacri-
ficed in the short term if the trade-off is that a patient
is able to run with less symptoms.
It is important to remember that cadence is used
only as a means to shorten step length and ultimately
reduce ground reaction force variables. Other strategies
have demonstrated success doing the same. Both cueing
vertical oscillation and cueing to decrease the sound of
the runner’s footfalls have been shown to have positive
effects on ground reaction variables.39,40 In general, a
cue is only as good as the resulting change in the run-
ner’s gait. A clinician who can individualize their cueing
to the patient will be the most successful.
Internal Focus Gait Retraining
External cues have the benefit of allowing a patient to
self-select a motor strategy to match the cue. There is a
freedom for the runner with these cues, which often
leads to a more consistently successful outcome. How-
ever, depending on the specific injury, there are situa-
tions when an internal cue, which dictates the strategy
used, is needed to address their specific injury. Internal
cues focus the runner on themselves for feedback and
encourage them to run in a specific way, which changes
how forces are distributed across their own body.
One of the most well-known and researched exam-
ples of internal cueing is changing a rear foot striker
to a forefoot striker. This idea gained significant atten-
tion as it was deemed to be a more natural way to run
and was subsequently shown to decrease VLRs.41e43
108 SECTION II Biomechanics and Rehabilitation
Its benefits are twofold. Similar to increasing cadence,
switching to a forefoot strike tends to decrease stride
length, thus decreasing joint load. Unlike cueing
cadence, cueing foot strike determines how the runner
lands and therefore which body parts they distribute
the load across. Forefoot striking can be used specif-
ically for runners who are experiencing knee pain by
transferring the load that would normally be absorbed
by the knee to the foot and ankle.43 Care should be
taken, as this strategy, while beneficial, can lead to
increased risk for foot and ankle injuries if proper tran-
sitioning is not undertaken. Plus, more recent research
suggests that the improvement in VLR could be related
to the initial vertical loading peak, typically seen with
heel striking runners, actually just being hidden within
the normal curve of the VGRF.44
Forefoot striking is not the only internal cue that can
be given, and other strategies may be useful depending
on the type of injury the runner is experiencing. Another
well-researched cue is forward lean. Research suggests
that cueing increased forward lean during gait can in-
crease load distribution to the hips and thus decrease
load on the knees.45,46 This same idea is what differen-
tiates a squat from a deadlift. Both require an individual
to bend their ankles, knees, and hips; however, the
squat biases the quads and knees to take on more of
the load, while the dead lift encourages the hamstrings
and glutes to do it. This is far from automatic though,
just as a deadlift requires body awareness to perform
correctly, forward lean requires similar skill to ensure
that the runner gets the purported benefits.
These are well-established concepts, but they also
suggest that their inverse could be true. If an individual
were having calf problems and they were a forefoot
striker, transitioning to a heel strike could change the
load and allow them to keep running without overload-
ing the sensitive tissue. Similarly, if a patient were hav-
ing hip pain, adopting a more upright posture could be
helpful to maintaining their ability to run. Again, the
maximum benefit for the patient comes not from the
cue itself but from its application to address the pa-
tient’s specific problems.
Improving Running Form When the Patient
Cannot Run
Runners will often present clinically with a tissue toler-
ance so low that they are unable to run. In these cases,
gait retraining is of little use initially. A progressive
loading plan is the first tool to assist in the return to
running. However, some patients will present with
such poor mechanics that even the most conservative
loading plan will not be enough. These patients may
require concurrent interventions to improve their me-
chanics and help them improve their load distribution.
For clinicians, this is where their creativity and
problem-solving skills are most important. Little to no
research has connected the effects of interventions other
than gait retraining to the loading variables that are
typically correlated with injury. The choice of interven-
tion will vary between practitioners and will be dictated
by the presentation of the patient. Below are two exam-
ples of practical interventions that will be beneficial to a
wide range of running patients.
As stated earlier, there are certain mechanics that are
hypothesized to lead to greater risk of injury. Runners
that demonstrate excessive hip adduction and internal
rotation of their hip are at increased risk of multiple
runningerelated injuries.9,32 If the patient is unable to
run or has failed to change their mechanics with gait
retraining, then it is necessary to work on them in a
simplified form.
A good proxy for addressing running form is the sin-
gle leg squat. While it lacks the plyometric forces of
running, it requires the same ankle, knee, and hip me-
chanics. Observing a patient demonstrate repeated
single-leg squats can help the clinician identify deficits
that may be contributing to the patient's poor running
mechanics and in turn guide intervention. Typical im-
pairments that limit the patient’s ability to single-leg
squat are decreased lower limb strength, specifically of
the gluteals, as well as decreased ankle range of
motion.47e50 All of these can affect a runner’s ability
to control their lower limb mechanics. Thus, it is impor-
tant for the practitioner to have a battery of tests to
determine which could be contributing to the patient’s
inability to perform the basic movement pattern of
running.
Gluteal weakness is often implicated in a runner’s
physical examination. During their single-leg squat,
lack of gluteal strength is responsible for contralateral
hip drop and/or increased adduction and internal rota-
tion of the femur, leading to knee valgus. During the
running gait, the force on the gluteus medius is esti-
mated at three to five times body weight. Only the
patellar tendon and soleus need to absorb more.36
While it is difficult to argue that the gluteus medius
should be strong enough to lift five times body weight,
it is reasonable to think that increased control and
strength of the gluteals will greatly aide in lower limb
mechanics. Clinically, it is difficult to give hard goals
for strength. Even measuring strength in a reliable and
comparable fashion is challenging without expensive
equipment. Limited research has found that a cutoff
of 35% of body weight measured using a handheld
 CHAPTER 11 Rehabilitation Principles of the Injured Runner 109

Hip Abduction Side Lying Side Plank Clam Shell Side Plank Hip Abduction Full Side Plank Hip Abduction

FIG. 11.3 Progressive hip strengthening exercises.

dynamometer is protective for risk of anterior cruciate

ligament tear, but this has questionable application to
runners.51 Without reliable objective measures, it is
best to examine this functionally. Side bridges/planks
are a good functional test that relies heavily on gluteal
strength but also incorporates other frontal plane stabi-
lizers into a functional task that can be measured objec-
tively for time or repetitions. To address gluteal
weakness, a progressive strengthening program such as
that pictured in Fig. 11.3 should be used. In the past,
runners have been discouraged from strength training
for fear of “bulking up” and hurting their running abil-
ities. Research has dispelled these myths, and more
modern thought sees strength training as important
for injury prevention as well as performance
enhancing.27,52,53
The range of motion (ROM) necessary for running is
not large.33 Most running patients will not present with
deficiencies in joint motion or muscle length that truly
restrict their running gait. The one major exception to
this is the ankle. Ankle dorsiflexion during running FIG. 11.4 Weight-bearing lunge test.
gait is measured as high as 30 degrees.33 If a patient
lacks this, they are forced into faulty mechanics to
compensate.47,54 Classic goniometric measurements If a patient demonstrates faulty mechanics when
put normal ranges of motion at 10e15 degrees. These single-leg squatting with their heel on the ground, but
measurements are performed noneweight bearing, their mechanics improve when their heel is elevated,
and therefore, their applicability to running mechanics then it can be concluded that the deficits are due to
is questionable. A more useful test for determining if a ankle restriction and not gluteal weakness. If the me-
running patient has the necessary dorsiflexion range of chanics do not improve, then they could still be the
motion is the weight-bearing lunge test (see result of either impairment.
Fig. 11.4).55
Its reproducibility and carryover to the single-leg Conclusion
squat make it very helpful in determining if a patient Ultimately, running injuries are unique to the individ-
has the requisite ROM. Level III evidence suggests that ual patient. A clinician must treat them as such. Any
a measure of 10 cm correlates with 35e38 degrees of number of variables may lead to the injury of a patient;
ankle dorsiflexion and that 10e12.5 cm is a range, however, it is helpful to use a foundational outline for
which running patients should be able to achieve.56 what a clinician is trying to accomplish to return them
Clinically, a heel-elevated single-leg squat test can to running. Like any good training plan, you must start
also help a clinician differentiate whether faulty me- at a level that the runner can tolerate and build up
chanics are the result of gluteal weakness or ankle tolerance for load progressively. For some patients,
ROM restriction (see Fig. 11.5). this will actually be achieved with running, whereas
110 SECTION II Biomechanics and Rehabilitation
Heel elevated single leg squat demonstrating glute weakness
FIG. 11.5 Heel-elevated single-leg squat.
for those that are too sensitive, this will need to be
alternative activities until they can return to a level
where running is tolerable. During this process of
reloading the patient, improvements in mechanics
can be made so that forces are transferred appropri-
ately and load is absorbed safely and efficiently. The
ultimate goal is to help the patient return to their
desired running load with a better understanding of
how to manage it with less risk of reinjury.
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