Decision-making for injured runners

1. How long can you currently run without pain?

Start with that for a couple weeks and slowly increase the time. For example, if you can only run for 5mins before pain starts, try a 3min run, walk for 30s then do another 3min run. If things feel okay, do another 1-2mins.

You could also manipulate intensity instead of time. So, keep reducing your speed until you can run for 6mins straight. This may be frustratingly slow! That’s okay.

It’s just about finding a starting point to build from.

The point is: don’t stop running. Just modify things. Continue to move. And remember, the body responds positively to stress. What will accelerate your recovery process is finding the appropriate level of physical stress (the goldilocks amount of stress for your system).

2. How long have you had pain?

Short-term pain and long-term pain usually need different approaches. Short term pain (~2 weeks or less) often just needs a temporary reduction in training volume. In clinic we might start with a 50% reduction (eg., total mins of running per week divided by 2). If this feels good, slowly build back up. If it still hurts, reduce by 50% again. This way of dealing with pain errs on protection.

If your pain is long-term (~months) and you’ve already tried backing off (ie., protection), we might start doing the opposite! Namely, exposing to load and discomfort in an effort to build a tolerance to running. So, you will actually start to push into discomfort with your runs. The rationale is that we’ve tried backing off and this hasn’t worked. Now we’re thinking you don’t have an issue in the tissue, but rather a sensitive nervous system. We don’t need to protect your tissues, we need to expose your nervous system to build capacity and resilience over time.

We respect pain, but we don’t fear it!

3. What type of training pisses it off?

If you’ve identified that every time you do hills or speed work your short-term pain flares up, we might temporarily avoid those things and replace them with brisk walking or slow jogging on the flat. Or if your long Sunday run starts to hurt at the halfway point, we might break that run up into two shorter runs. Personally, I’ll often simply play with my pace, slow everything right down but keep the distance the same. Find what works for you.

4.  Have you been avoiding running for months or years, yet when you return your symptoms are the same?

I hear this all the time: “I stopped running because my knees hurt.” Or, “I stopped running because my low back hurt.” This is common and very frustrating for the individual. But, I’m a big believer that everyone can find a starting point that works for them. You may not like where that starting point is.

It may involve a pitiful amount of running at a speed where grandmas with 4 wheel walkers are overtaking you.

You may be doubled over out of breath after 10s of “running”. But have patience here – the body is wonderfully designed (yes, even yours!) and 10s of running quickly turns into 5mins, then 15mins, then 30mins and so on. Just monitor pain during (pain score of less than ~4/10), pain after (no flare-ups) and the trend over time (pain trend over a longer timeframe gradually decreasing) and build up accordingly. Again, even if it hurts when doing this, I’d still encourage you to continue if it goes back to normal for you the next day. I’ll often add in walking before and after these return to running sessions so that you get in a good ~30min workout and changing your clothes feels worth your while. However, I’ve had a couple patients present with stress fractures and this is a time where pushing into pain is not appropriate.

5. Pushing into pain

Basically, if I were to summarise the research it would be not too much, not too little, but just right. Sometimes therapists will say things like “you can poke the bear but don’t kick it and piss it off!” I often see a few of these presentations below (and I’ve had a number of them myself):

You have pain at the start of the run sometime in the first 10mins but when you push through it it goes away. No flare-ups the following day.

Great! Keep running. Ignore it.

Decent pain comes on during the run and gets worse when you try to push through it. You may limp or hobble. It is present the next day.

Not great. I usually try to change my gait mid-run (wider/narrower/shorter/longer strides, slow down, run as though I’m in tall grass etc. – just play around with gait). If this does not help I will stop, walk home and try again in a couple days with reduced volume and speed. I’ll try to find the “edge” of pain and just keep pushing my tolerance over several weeks.

A mild pain comes on when you run and it hangs around the whole time. It doesn’t get better or worse. You aren’t limping or hobbling. It’s not flared up the next day.

Basically, you have to make a call – do I push into it or back off. Sometimes it’s a coin toss. If my client has a race or some competition coming up, I’ll remind them that they’re safe to push into pain if they need to. If my client does not have anything pressing coming up, I’ll often get them to back off a bit and perform some other mode of exercise to improve cardiovascular fitness and burn some kcals.

These presentations can be tricky!

I’ll also usually start to look at the rest of my life (eg., sleep, diet, general activity, other exercise I’m doing, stress, mental health etc.) and try to improve anything I think might be contributing.

6. Do you feel safe to run?

Pain is complex. Stress, poor sleep, fear etc. can all contribute. There are lots of things that can modify pain, for good or bad. We know:

• Pain is an alarm system not a damage report
• Pain is poorly related to damage: either can exist without the other!
• Pain is poorly related to “altered functioning”: there is no perfect way to move, you have options for moving – be a movement optimist!
• Pain is context-dependent: lots of things influence pain – not just the “usual” things we think of (tissue damage, poor posture, asymmetry etc.). Worry, unhelpful beliefs, relational conflict and a million other things can all influence our pain for good or bad.

Our alarm system can become too sensitive: sometimes it’s too good, goes off too soon, too easily, too much and for too long!

You are stronger than you think! If you’re alive and breathing, you can adapt positively – it’s not over for you! You built yourself up to run in the past and you can do it again.