People who love to run, hate it when they can't run... So it is very common for me to hear the following three questions from an injured runner- Why did I get injured? How do I fix it? When can I start running again? Answering the first of these questions is often very difficult. The reasons for why any type of injury occur are many and most often, I would argue that we can't ever know for sure why an injury happens. The good news is that such uncertainty doesn't prevent us from building well reasoned hypotheses to explain an injury. And from there we can piece together useful strategies for treatment and rehabilitation. Importantly, if managed well, you shouldn't need to stop running. Very often we can simply change aspects of your training. Occasionally however, symptoms are severe enough to warrant a short break from running. We need to consider five key parameters to reach a hypothesis for the cause of an injury. Those parameters are technique, baseline level of strength, flexibility and fitness, task intensity, task duration and task frequency. That is to say-

  1. how you run

  2. how strong, flexible and fit you are

  3. how hard you push yourself when running

  4. how long you run for

  5. how often you run

All of these factors will influence the adaptive potential of your muscles, joints, nerves and other body tissues. Your adaptive potential describes your body's capacity to withstand and adapt to load, in this case, the load of your running routine. So if you are a regular runner and have no injuries or problems to speak of, we can say that you are operating within your adaptive potential. We can say that you have reached your adaptive threshold when an injury occurs (e.g. muscle tear, cartilage tear) or the onset of symptoms occurs (e.g. pain). Usually pain will accompany an injury, but pain is also likely to emerge as a kind of warning signal before a gross structural injury occurs. So although we could argue that the presence of a structural injury is a sign that the adaptive threshold has been breached, the presence of performance limiting symptoms such as pain, stiffness or tightness are perhaps a more useful indicator of whether or not you are operating within your body's adaptive potential. So if your adaptive potential is being breached, which load parameter is to blame?

Is running technique the Problem?

The most tempting one of these five parameters to blame for your running injury or symptoms is the first one- technique. If there was a technical adjustment that could be made that would make an injury or symptoms go away and allow you to keep running it would be great, right? It's attractive because if it were true, there would be no need to alter the other parameters i.e. there would be no need to think about changing for example, how often or far or hard you run. Unfortunately, I very rarely see a treatment plan pan out this way. For most people, and when I say people, I am referring to the novice, average joe, recreational running population that I tend to see, running technique is not the problem. For those who do appear to have an "unusual" looking technique, making a judgment about whether or not that unusual technique is the cause of an injury is fraught with potential for error, as we don't have good research or data that establishes exactly what a "normal" or "optimal" technique for running is. Complicating issues is the fact that if you have pain you probably aren't using your "normal" running pattern anyway. Pain tends to muck around with our motor patterns and outputs, so it is difficult to know if your running style is a cause or a product of your symptoms.

I prefer not to jump to conclusions about the role of running style or technique when assessing a running injury. Doing so creates a massive burden of proof on me as a Physio, one that I simply cannot meet with evidence. We do have options for adjusting or altering aspects of running technique, and very often these bring about a reduction in symptoms. But generally, it is an error to frame these changes to technique and observed reductions in symptoms as a technique "correction", since no one knows what "correct" running looks like. A more reasonable explanation is that by adjusting or changing an aspect of how one runs, we have unloaded tissues that were otherwise being irritated. So is "technique" the cause of running injuries? I would argue that the answer is no, but with the caveat that some changes to how you run, for example, altering stride length or attempting to run more "softly" might have a positive impact on symptoms. Such changes alone however, are unlikely to help in the long term if the other parameters are not considered.

Is Strength or Flexibility the Problem?

The next most tempting parameter to blame your running injury on is your strength and flexibility. If only there was stretch you could do that could sort out your symptoms so that you could run pain free again. If only you were stronger through the glutes or hamstrings, then maybe you wouldn't have had that calf strain. Again, these are attractive propositions because it means avoiding making changes to how often, far or hard you run. And it isn't necessarily wishful thinking. Increasing your strength and flexibility may well increase your adaptive potential for your running routine such that you can overcome an injury or pain without having change anything else. I would argue though that this occurs infrequently. Usually, if someone has symptoms that are prominent enough for them to take the step to see me in the clinic, there is enough of an injury or irritation of tissues to warrant some sort of adjusting of the remaining parameters on the list above- those being load frequency, load duration and load intensity. This could be as drastic as stopping all running altogether for a period of time, or it could be a selective reduction in how far, fast or often you run.

Strength and flexibility training probably also helps from an injury prevention perspective, in that both can increase the adaptive potential of your tissues such that an injury is less likely. This is speculative however, as it is very difficult to test these ideas in controlled research settings. Incorporating a lot of prescriptive strengthening exercises into the treatment plans for injured runners is probably unnecessary- at least in the early stages anyway. In my view, the initial focus should be on reducing sensitivity to load and regaining any losses in mobility and capacity for performance of everyday activities. This means that it is nearly always more useful to direct treatment towards activity modification as the first line treatment option, and to follow up with strength interventions and stretching once you are approaching a symptom free baseline. Depending on the severity of symptoms, I think it is reasonable to commence strengthening activities in parallel with activity modifications, but I don't think it is reasonable to skip past a consideration of running load parameters and assume that you will be able to simply stretch or strengthen your way out of a running injury. We need to make sure we look at how far, often and hard you are running, and how these factors might be influencing your symptoms.

Altering Load Parameters

We don't have a solid research data to direct us when it comes to deciding which load parameters to alter. Should we attempt to restore normal sensitivity to load by first reducing frequency, duration or intensity? In my experience the simplest way to make a positive impact is to reduce intensity first. Basically, this means asking a runner to reduce how hard they push themselves when they run... to run within themselves as opposed to working near a maximum effort. I think it is reasonable to argue that maximum, or near maximum running efforts are more likely to lead to symptoms than sub-maximal efforts. Runners who try to reduce overall load by reducing running distance or frequency while maintaining intensity, in my experience, eventually end having to reduce intensity anyway. So I tend to suggest a reduction in intensity first.

If reducing the intensity of your running efforts does not bring about a reduction in symptoms, I suggest reducing the duration (distance) next. This means shortening how far you run. That one is pretty simple. The next option, if symptoms are still hanging around is to reduce how often you are running. Generally, those who run 5-6 times per week have a higher risk of injury than those exercising less than four times per week. Some runners prefer to reduce the frequency before reducing distance, which I think is reasonable, provided there has already been an attempt to reduce intensity. Really, the adjusting of these load parameters is trial and error. I can't provide solid data to say that one way is better than the other. I can only offer my opinion based on my experience as a Physio and the argument that a sensitized system is not likely to calm down if we keep making it work at high intensity for sustained periods of time.

Building Up Again

Once we have struck the right balance of adjustments to load parameters, and symptoms have resolved to a steady baseline, we can begin to increase load parameters again, with a view to returning to your preferred running routine. There are hundreds of approaches for progressing a return to running, and if you examine the ones that tend to be successful, the common feature between them is the application of the graded exposure principle. It's my view that this phase of a recovery from a running injury can very easily be over-complicated, especially for novice, average and recreational runners. The temptation is to replicate training programs designed for elite athletes, which have very specific progression pathways and are designed to get a runner back to training / performing as quickly as possible. They are designed to push the athlete as much as they can be pushed, without causing re-injury or a flare up in symptoms. These programs are structured this way because for elite athletes, time is of the essence- they need to get back to performing. If these programs could be described in terms of a risk-benefit analysis, there is a leaning towards greater risk in order to get the benefit of a return to performing earlier.

For most of us however, who run for general health fitness, enjoyment and fun, there is no rush to get back to running. This extra risk is arguably unnecessary. This is an important point to consider as what I tend to see quite often is that recreational runners can lose sight of the reasons why they run, in favour of for example, a secondary goal such as hitting a personal best time for a 5km run. If the main purpose for running is enjoyment, health and fitness, it makes sense to me to shelve these secondary goals when injury strikes and simply take your time getting well again. And if there is no rush to get back to running, there is no need to design elaborate, periodized training programs. What is important, in my view is that the return to running involves a progression of loading that is;

  • sub-maximal

  • systematic

  • progressive

There really are many many ways to progressively load up the key parameters of frequency, duration and intensity. Generally, I take the approach that we should begin by increasing duration first, followed by frequency and intensity. But there aren't really any hard and fast rules. Returning to running after an injury is all about gradually exposing your body to the load of running again, in a manner that at worst, stops short of re-sensitizing the injure area and at best, increases your adaptive potential so that you are less likely to get injured again. The programs I put together for the runners I see tend to be very collaborative. They always emerge from a negotiation of sorts with the runner so that they incorporate the runner's primary goal without unnecessarily risking re-injury. If you are a Eastern Suburbs local, and have a running injury, or symptoms that are affecting your running, feel free to call me on 9665 9667 to discuss your options for treatment and rehabilitation.