Can I Run During an Injury and if not, When can I Return to Running After Injury or Surgery?
These are million-dollar questions! My answer is, "It depends."
A patient with patellar tendonitis, whom I instructed not to run, came into his appointment and said, "I feel great, and I ran seven miles two times last week." I lifted my head from my laptop, peered at him through my glasses, and gave him a grin and head nod of understanding while at the same time resisting the urge to roll my eyes back in my head.
As a runner who has experienced many injuries and surgeries, I empathized personally, but as a physical therapist, it is cringeworthy when a patient goes rogue.
Why rest from running or manage your return to running after an injury or surgery?
The musculoskeletal system, which includes bone, takes time to heal and strengthen progressively. When running, the structures must tolerate repetitively loading at least three times your body weight.
Several factors determine whether you can run during an injury or when you can return to running after an injury or surgery.
When and whether or not you should run depends on an injury's nature, severity, and chronicity. Does the injury involve bone or soft tissue like a tendon? Is the injury mild or severe? How long has it been present? Six months, three years, or two weeks?
Nature of the injury or Surgery.
If the injury involves tendons and ligaments, it can sometimes take longer than a fracture to heal. The rule of thumb for tissue repair is at least six weeks if you do all the right things! Some surgeries require six weeks of rest from running and high-impact sports, and others require six months or more. Runners undergoing surgery should always have post-operative physical therapy if they want to return to sport.
Severity of an Injury.
The more severe the injury, the longer it will take to return to running. For example, a grade III calf injury may need months of rest, while a grade I calf injury may only require a week of rest from running. Check out my article on Calf Strain and Pain.
Chronicity of an injury.
The longer an injury has festered, the longer it will take to return to running. This is a rule of thumb, and I find it is usually accurate. And why all runners should seek professional help if an injury does not subside within a week of rest and modification.
Signs, symptoms, and issues that indicate you need to rest from running or wait to return to running after an injury or surgery.
Poor biomechanics due to lack of stability, strength, or range of motion
Swelling/inflammation
Pain greater than a 3/10 during or after running
Poor Biomechanics
Many runners can feel when their run gait is “off” or when weakness or lack of mobility is present. Weakness and/or loss of range of motion is your body’s way of telling you that something is off - they are protective mechanisms. Pushing through a run in these circumstances will delay healing, worsen the injury, or even cause another injury!
Swelling and Inflammation
Swelling is a sign that the body is not okay. It is a red flag, a warning to stop running. Intermittent, mild swelling may be permitted with a return to run, but it means that you’ve done too much. Ensure you are working with a physical therapist to help you manage your back to run the program. Check out my article on Aiding and Controlling Inflammation.
Pain
Once again, it is a warning sign that something is not right. If unmedicated, your pain is greater than a 3/10 on a pain scale where 0 is no pain, and 10 is emergency room pain, then you should not run. Do not take pain medication to run. Pain is a fascinating and multi-faceted topic, and your physical therapist can help you navigate when it is okay to have some pain. Check out my article: Pain and Injury Doesn’t Mean You Have to Quit.
Resting from running impacts our mental health. Acknowledging and addressing our mental headspace is just as important.
Following my patient’s admission to running, an explanation ensued, "I don't drink, I don't smoke, and I don't do drugs. I run." Running releases serotonin, which makes us feel good, and it is a mental escape, a muse. Taking it away from us for too long can mess with us physically, emotionally, and mentally. Fear of losing fitness comes at a close second to the effect on our headspace.
Acknowledge this aspect and work with your physical therapist to manage it with modifications and alternatives for running.
Modifications in running during injury and returning to running programs after injury are not one size fits all! It is personal and individual.
With mild injuries, sometimes running can continue, albeit modified in volume, intensity, and perhaps surface, while you heal. When it comes to a back-to-run program or continuing to run while managing an injury, finding the right recipe can be complicated: it takes practice, finesse, and patience. It's an art as much as a science, and an experienced physical therapist specializing in running can help.
Your physical therapist will continually test you to ensure you meet benchmarks for return to run and, when you meet them, will set you up with a back-to-run protocol. That protocol will consider how much time you’ve rested from running, your specific injury or surgery, your running experience, and your tolerance.
Invest in your running future.
My patellar tendonitis patient was lucky. Most runners that do this rouge testing don't fare as well and end up setting back their healing and their return to run. Pay attention to the signs and symptoms that should stop your run, and seek professional help for managing your rest, modification from, and return to run; it is an investment in your running future!
Stop injuries before they occur!
Learn the top five training errors that lead to injuries in runners in this blog post.
Massage Guns: Do or Don't?
"Should I use a percussion device or massage gun?"
That is an excellent question; unfortunately, many patients and athletes assume devices they see at race expos, post-race recovery tents, or in magazine articles are safe and don't question it.
My answer is no; you should not use a percussive device or massage gun. Before you discard yours or ignore my answer and go ahead and use it anyway - yes, I know who you are - please hear me out.
The reason I do not recommend the use of percussive devices or massage guns is that the risks outweigh the benefits. Unlike vibrating massage heads or foam rollers, these devices create a downward force into the body's tissue like a jackhammer, and the smaller the head(s), the more concentrated the power. This hammering force can cause damage, sometimes severe.
Unfortunately, athletes, in particular, associate "pain" with stretching or massage as beneficial. "It hurts, so it must be working." That is rarely the case. It is difficult for injured or sore athletes to discern when it is acceptable to feel discomfort with a self-treatment method like a massage gun.
Risks of using a massage gun
Safely using a percussive or massage gun requires a thorough command of human anatomy. Besides a general knowledge of where the claves, glutes, and hamstrings reside, most athletes and patients are unaware of the location of nerves, blood vessels, lymph nodes, bursae, organs, tendons, or ligaments. Improper device placement over these structures can cause severe damage.
Massage guns on injured and inflamed connective tissue can further damage the structure and increase inflammation. For example, use on a torn ligament, like an ankle sprain, could injure it further.
There are many examples of patients in my clinic who improperly used a massage gun to treat their soreness, pain, or injury. Below are four cases.
Case #1
A patient attempted to treat his groin pain, in this case, psoas tendonitis, and placed the gun in the area where the femoral nerve, artery, and vein reside. Not only is it contraindicated to use the device on the injured, inflamed psoas tendon, but the risk for vessel and nerve damage was high in this area.
Case #2
A patient tried to treat his pectoral muscle strain and aimed the device in his armpit on a large bundle of nerves called the brachial plexus. Damage to these nerves could cause temporary or permanent disability to the entire arm/hand.
Case #3
A patient attempted to treat her knee pain and aimed the device at the painful spot but didn't realize that what "hurt so good" was the peroneal nerve. Damage to this nerve could cause foot drop - or lack of the ability to lift the foot.
Case #4
A patient tried to treat her sore "glute" with the massage gun but didn't realize she aimed it at a bursa (a fluid-like sack) in the same area. Because this was my initial visit with her, it is hard to know if she was suffering from bursitis before using the gun or afterward, but in either case, her injury and pain were worse.
Dangers and contraindications for massage gun use
While rare, a percussive massage tool can sometimes cause severe or life-threatening injuries, including fractures or joint damage, deep vein thrombosis, and rhabdomyolysis.
Using a percussive massage gun can cause a fracture in persons with osteopenia or osteoporosis. Never use a massage gun at the site of a fracture - even a stress fracture. If you suspect a fracture go to the emergency room or an orthopedic urgent care center.
Deep vein thrombosis is a rare but life-threatening condition, especially for post-surgical patients. It tends to show up as calf pain and soreness. A massage gun on that sore calf could dislodge the blood clot and cause a pulmonary embolism and death. If you are experiencing symptoms consistent with a blood clot, go to the emergency room.
Rhabdomyolysis is a severe and potentially life-threatening condition. Endurance sports athletes are particularly at risk of acute exercise-induced rhabdomyolysis (AER), which can occur after profound overexertion, such as after a long run, ride, or race. Endurance athletes using percussion massage to treat delayed onset muscle soreness after an endurance event or training session may be at a higher risk.
There is a case in the literature of a patient who suffered a case of severe rhabdomyolysis after percussion massage: Chen, J., Zhang, F., Chen, H., & Pan, H. (2021). Rhabdomyolysis After the Use of Percussion Massage Gun: A Case Report. Physical Therapy, 101(1). https://doi.org/10.1093/ptj/pzaa199
Not ready to throw your massage gun in the trash?
Limited research supports that a percussion device can help with increased mobility when used on healthy tissue and when operated by a healthcare professional. The risks outweigh the benefits, but if patients and athletes insist on using them, I recommend scheduling an appointment with a physical therapist to learn how to use them safely.
While your health is serious business, we can also take a minute to laugh about the massage gun. Check out comedian Tom Papa’s bit about these “weapons-grade jackhammer massage guns.” Tom Papa: What A Day!
Alternatives to achieve mobility
Physical therapists, patients, and athletes have many safer alternatives to achieve mobility. Subscribe to Coach Amy Says to receive upcoming posts on how to achieve mobility and why Coach Amy does not recommend stretching as well as other tips on injury prevention, wellness, and performance.
Coach Amy discusses massage guns and all things endurance sport with Coach Liz in their podcast, The Coach Amy and Coach Liz Show. Coming soon to Apple Podcasts, Google Podcasts, and Spotify.
Fall Leaf Clean Up Without Pain: Tips from Coach Amy
“During an easy, after-school run one Friday, my fellow cross country teammates and I came across an elderly lady who was outside raking her yard. Seeing that her yard was carpeted in leaves, the whole team stopped, grabbed rakes and bags, and cleaned up her yard in under 30 minutes. This is one of my fondest memories. ”
Fall leaves are beautiful to behold. Removing them from the yard can be a fun form of exercise in the crisp fall outdoors. Unfortunately, raking can also lead to overuse injuries, such as back strain, shoulder impingement and pinched nerves.
Maintaining strength and physical fitness throughout the year is always a good idea, but even with a solid foundation, the risk of injury with seasonal tasks is high. When it comes to fall leaf clean up in the midwest, most of us are as prepared for it as we are for snow skiing. We don’t rake or blow leaves all year long, nor do we gradually train for the event, so our bodies are not adapted to the the unique, repetitive movements.
Our tendency to use one favored position over another for an extended period of time contributes to acute stress on the body. This is confounded further by our propensity to pack the work into two full days on a weekend.
REPETITIVE MOTION + POOR FORM + EXTENDED TIME = PAIN & INJURY
Follow these tips from Coach Amy to prevent pain and injury with fall leaf clean up.
Warm Up is Worth It
Move dynamically for 5-10 minutes with an activity that you are familiar with, such as yoga, walking, elliptical or stationary bike before starting your leaf clean up.
Variety is Virtuous
Switch arms every 10 pulls of the rake or swings of the leaf blower.
Alternate the leg that is forward every 10 pulls of the rake.
Position is Power
Bend at your knees to scoop up leaves.
Use your whole body when making sweeps and pulls - not just your arms. Your ankles, knees, hips should all move together.
Pick up your feet and move your whole body when you turn directions to avoid repetitive twisting.
Hold leaf blower or wear a strap to keep it close to your body. The further away it is from your body, the more force it transfers to your spine/shoulder.
Relative Rest Rules
Take a break every 20-30 min to drink some water, rest or perform a different task that doesn’t use the same motions or uses the opposite motions.
Plan your lawn work over several weekends. Avoid cramming it all in.
Get help! There are many teenagers who would love to earn a few bucks helping you out by either doing the whole job or working alongside you.
As with many activities, we do not always feel the helpful pain that can tell us to stop or slow down a harmful motion during the activity. Instead, that pain sometimes doesn’t come until after we’ve stopped for the day. Follow Coach Amy’s tips, and you are more likely to be successful, have fun and get a good workout doing it!
Top Five Training Errors That Lead to Injury in Runners
Two months into 2020 and many runners are deep into training for Spring and Summer races while others are running to get in shape, to decrease stress or even just for the fun of it. Regardless of goals and experience runners can fall victim to injury. Running injuries are usually the result of several issues combining to create the perfect storm. Frequently a part of that storm includes training mistakes. Today we summarize the top five training errors that can lead to injury. Are you making any of these mistakes?
“Getting to the bottom of a runner’s injury is like solving a puzzle; the four corners are strength, mobility, biomechanics and training.”
Here are the top five training errors that Coach Amy finds lead to injuries:
Increasing total weekly mileage and long run mileage too quickly.
Lack of recovery between training runs within the building phase, after races and between seasons.
Not enough, too much or the wrong kind of cross training.
Lack of varying intensity of hard and easy runs.
Changing running form, surface, or shoe type without a slow, gradual introduction and without professional guidance.
Personalized coaching can help create a individual training plan just for you to prevent these errors. If injury does occur, physical therapy with a therapist that specializes in running can speed up and improve success with recovery.
Completing the Trifecta to Pain-Free Function and Injury Prevention: Proprioception
Welcome to the third installment of our trifecta to pain-free function and injury prevention! While there are many components to injury prevention and healthy movement, our trifecta covers mobility, stability, and, in this installment, proprioception.
Proprioception incorporates agility, balance, and coordination.
You know about the five senses: hearing, taste, sight, touch and smell. Proprioception is your sixth sense. It is your unconscious and conscious ability to know where a given body part is in space. For example, if you close your eyes and your friend moves your thumb, you can report, without looking, that it is pointed up or down, left or right.
Your sense of proprioception provides approximately 70% of your ability to react to your environment. That's a lot more than the mere 10% provided by sight and 20% provided by hearing! Your muscles and joints relay information to your brain. Your brain uses that information to decide what action to take and relays it to your muscles and joints.
If the proprioceptive system is damaged or out of practice, connections are disrupted. Your muscles can’t fire at the right time to make use of the strength, even with you have strong muscles around your joints. This can lead to poor balance, lack of coordination and decreased agility. These deficits can cause and/or contribute to injury and negatively affect sports performance.
Proprioception can be disrupted with injury, surgery and declines with age. We all depend upon this sense operating at capacity for daily activities such as using stairs, standing and putting on shoes and socks. We require it for work-related functions, hobbies, and sports. Imagine a quarterback with a recent knee injury that has disrupted proprioception. If his brain cannot interpret which direction the knee is moving and adjust, he is at risk for injury when trying to pivot on one foot to throw the ball.
The great thing about proprioception and balance is that we can restore it! I use a combination of progressively challenging dynamic and functional exercises that stimulate the proprioceptive system. I balance proven exercises with exercises that I create and personalize to each unique patient and case. In some cases, neurological dry needling is helpful to facilitate the function of the proprioceptive pathway.
About Physical Therapy. Physical Therapy addresses function in daily lives, whether it’s our ability to unload the dishwasher, walk without a limp, or run an ultra marathon. Physical therapists work not only with injured patients but also preemptively with patients to prevent injury. This can prevent long periods of pain and time off of sports and work. Periodic PT visits focusing on prevention save time and money on the higher frequency therapy appointments required with chronic injuries.
Stability: Another Key to Pain-Free Function and Injury Prevention
Just because we can, doesn’t mean we should! We may have the ability to lift the laundry basket and carry it up a flight of stairs or run ten miles, but without proper body mechanics and stability, injury can ensue.
Prevention and rehabilitation from injury involve addressing mobility, strength, and balance. We discussed mobility last week. Achieving proper mobility of the tissues doesn’t ensure safety. In fact, some people have too much mobility but can’t support the joints or get power from their muscles. This causes them to compensate elsewhere and/or fail to support the joints. This is when injury can occur.
Let’s use another rubber band analogy. Imagine shooting an older rubber band that is super stretched out, maybe even saggy or brittle. When we pull back on it, the band stretches only a bit. The rubber band has lost power and elasticity, and it will not fly very far. Its mobility is useless because it lacks integrity.
In our mobility article we discussed how people who sit for long periods of time at desk jobs, lose mobility in key muscles on the front of the body with sitting. The opposite is true for the muscles on the backside of the body, namely the glutes (bum muscles). If poor posture is involved, the muscles of the back and the front of the neck elongate as well. These muscles are like the rubber band: they become too long and weak. As a result, they do not provide adequate support (stability) during activities like walking with the dog, kicking the ball with the kids, and playing sports. This is when injury is possible.
Many activities that involve holding a position for a long time can cause muscle imbalance and reduced stability. For example:
Wearing high heels often or for an extended period of time. This creates a long term stretch for the muscles at the bottom of the foot and front of the hip. These lengthened muscles weaken when engaging in activities like walking the dog, running, climbing steps, and attending exercise classes. Injuries such as pain in the lower back or the bottom of the foot can surface.
Participating in triathlons, as mentioned in our mobility article. Being in aero position for 100 miles stretches the back muscles and glutes for hours. These lengthened muscles are needed to support the back, and for power with push off for the 26.2 mile run segment.
Patients recovering from abdominal surgery, such as a cesarean section. It takes time for abdominal muscles and tissues to heal from surgery. Gradual strengthening is required. These weakened muscles cannot support the spine adequately for activities of daily living, including bathing and lifting the baby, or even walking. Injury of the back and hips can occur.
One of the first things I assess when evaluating a patient is how they move. I look for faulty movement patterns that could cause injury or worsen a current injury. Poor mobility or lack of stability (or both) may contribute to the problem. I attack a lack of stability with progressively challenging dynamic and functional exercises within the patient’s tolerance. I like to use a combination of proven exercises, with exercises that I create and personalize to each unique patient and case. When pain is contributing to weakness, neurological dry needling can be helpful. Active Release Technique may also be used to treat injured joints and ligaments that result from lack of stability.
Faulty movement patterns can also be the result of poor proprioception and balance. Stay tuned for more on that in our next post!
About Physical Therapy. Physical Therapy addresses function in daily lives whether it’s our ability to unload the dishwasher, walk without a limp, or run an ultra marathon. Physical therapists work not only with injured patients but also preemptively with patients to prevent injury. This can prevent long periods of pain and time off of sports and work. Periodic PT visits focusing on prevention save time and money on the higher frequency therapy appointments required with chronic injury.
Mobility: A Key to Pain-Free Functional Movement and Injury Prevention
Prevention and rehabilitation from injury involve addressing mobility before strength and balance. Mobility is a prerequisite to strength. When joints, muscles and nerves don’t move properly, we compensate elsewhere. This is when injury can occur.
Imagine trying to shoot a rubber band across the room. If it’s as dense as a tire, it will not go anywhere. It doesn’t have the ability to stretch and load energy. Any strength it has is useless because the structure lacks mobility.
Many people have desk jobs that require sitting for long periods of time. Key muscles shorten throughout the day, namely the muscles in the front of the hip and the back of the thighs. If poor posture is involved, the abs, chest and muscles of the back of the neck shorten as well. These restricted muscles are at risk for injury when they are engaged for other activities like gardening, playing catch with the kids, and playing sports.
Many activities that involve holding a position for a long time can cause muscle imbalance. For example:
Biking in a triathlon. The athlete is in aero position for 100 miles and then moves to an erect posture to run a marathon.
Texting. The front of the neck, elbow, forearm and thumb muscles are held in a shortened position for hours throughout the day.
Carrying a heavy backpack on one arm. This creates long term shortening of muscles on one side of the spine and the hip on the opposite side.
Carrying a baby on the same hip for an extended period of time. As with carrying heavy backpacks, this causes muscles on one side of the spine and the hip on the opposite side to shorten long term.
One of the first things I assess when evaluating a patient is how they move. I look for faulty movement patterns that could cause injury or contribute to a current injury. Then I determine which structures are preventing that motion such as muscle, nerve, tendon, fascia, ligaments or all of the above. Then we set about restoring mobility. This may involve the use of deep tissue techniques such as Active Release Technique, neurological dry needling, and/or dynamic stretching, both passively and actively.
Strength, balance and coordination also come into play once a healthy amount of mobility is restored. More on this in our next post!
About Physical Therapy. Physical Therapy addresses function in daily lives whether it’s our ability to unload the dishwasher, walk without a limp, or run an ultra marathon. Physical therapists work not only with injured patients but also preemptively with patients to prevent injury. This can prevent long periods of pain and time off of sports and work. Periodic PT visits focusing on prevention save time and money on the higher frequency therapy appointments required with chronic injury.
And This is How We Roll
Most of us have a love-hate relationship with the foam roller. It’s a bit of a sore ride but so worth it. Foam rolling improves circulation and mobility of muscles, tendons and fascia*. It also prevents injury in the back, hip, foot and shoulder, and aids in recovery.
That’s a lot of benefit from a piece of high density foam! However, knowing how and when to use a foam roller is critical. Foam rolling incorrectly, too frequently, or with too much compression can cause bruising and injury to nerves.
Coach Amy’s high level “rolling” tips:
Start WARM. Foam rolling is best with warm muscles. For athletes, this is AFTER a workout. The less active individual should warm-up for 10 minutes prior to foam rolling. A walk is a great way to get the blood flowing a bit first.
Time is MONEY. Conveniently shorter is better. No need to roll for hours. 1-2 minutes per area is long enough.
Go SLOW. Moving too quickly on the foam roller causes the connective tissue to fight back and tighten up: the opposite of what we want.
MEET the tension. Going too deep with too much compression can cause damage. We want to stimulate, not irritate.
Want to know more? Want to see a licensed PT demonstrate the proper technique, and watch you foam roll to ensure proper form? Coach Amy is hosting two foam rolling clinics in October during National Physical Therapy Month. These “one-time” clinics will be FREE in gratitude and enthusiasm for keeping Kansas City active and injury-free. NOTE: classes were held in October of 2019. Subscribe for information about future events.
*what the heck is fascia? It’s a thick and strong spider-web like mesh of connective tissue that wraps around muscles, groups of muscles, blood vessels, nerves and even organs!
A Case for Changing Cadence: Injury Prevention
Caption: Coach Amy evaluating a client’s running form. Video taping the runner is always useful in a personal run evaluation.
If you’re a runner, you’re probably familiar with most running “lingo.” Cadence is a measurement of run gait that we can easily measure with our smart watches, but knowing what do with the data is a mystery to most runners. A quick Google search reveals debate among coaches and scientists creating even more confusion. Avoiding injury is a runner’s number one goal, but what about energy cost and efficiency?
Read the latest Roadrunners of Kansas City blog post to see how Coach Amy solves the case of what to do with Cadence data, with some run coaching clues!
Top Five Training Errors that Lead to Injury in Runners
Inquiring minds want to know…“When Coach Amy speaks at Rockhurst University, what is it about?”
Getting to the bottom of a runner’s injury is like solving a puzzle; the four corners are strength, mobility, biomechanics and training. Coach Amy explains how to evaluate the patient’s training history for potential errors that contribute to injury and how to modify training during treatment.
Here are the top five training errors that Coach Amy finds lead to injuries:
Increasing total weekly mileage and long run mileage too quickly.
Lack of recovery between training runs within the building phase, after races and between seasons.
Not enough, too much or the wrong kind of cross training.
Lack of varying intensity of hard and easy runs.
Changing running form, surface, or shoe type without a slow, gradual introduction and without professional guidance.
Personalized coaching can help prevent these errors. If injury does occur, physical therapy with a therapist that specializes in running can speed up and improve success with recovery.