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.
The Unexpected Benefits of Trail Running
I had put off trying trail running because I worried that, with unstable ankles, I’d injure myself. The results were just the opposite: trail running helped strengthen my ankles.
How to Keep Training Amongst COVID-19 and Race Cancellations
Regular physical activity, along with a healthy lifestyle and practicing preventative measures, is one of the best defenses against viral illness, including the current COVID-19 pandemic. Coach Amy encourages athletes who are healthy to remain active and continue training with a few considerations:
While we are being advised to practice social distance during the COVID-19 pandemic, avoid crowded gyms and group classes with shared equipment and/or workouts occurring within 3 feet of other participants. If equipment is shared, make sure it is wiped down between each user with a 70% alcohol solution.
Rest after long runs and intense efforts. Long-distance running (one hour or more) and running at race effort can temporarily weaken the immune system for up to 72 hours. If your plan calls for intense and long efforts, recover fully with rest and hydration. Take extreme caution with regard to exposure to others during the time you are vulnerable.
Consult your coach and adjust your training plan if needed. Many national group races have been canceled or postponed, including the St. Louis and Boston Marathons and Ironman Puerto Rico. You may need help managing your training plan to ensure you still achieve your peak performance.
Take precautions if you attend an organized group run. Check out Coach Amy’s post on Tips for Staying Healthy at Group Runs.
“Many components of the immune system exhibit adverse change after marathon-type exertion...including the mucosal tissue and lung...Of all immune cells, natural killer (NK) cells, neutrophils and macrophages...exhibit the greatest changes in response to marathon competition, both in terms of numbers and function. [During this time] viruses and bacteria may gain a foothold, increasing the risk of infection. ”
As always, exercise regularly and opt for fresh air. It benefits your physical wellness as well as your mental health not only during the COVID-19 pandemic but also during any flu season and all year long!
Psst...Want to Know the Secrets to Sport Performance Enhancement?
One of the secrets to sport performance enhancement is reducing inflammation from the microtrauma of training in a non-pharmacological way. Recall from our article, The Magic of Rest Day in Training:
“The microtrauma created through training causes a low level of inflammation that is typically not seen or felt. There is no observable swelling, redness or pain.”
The faster an athlete heals from microtrauma, the less time they need in recovery. Less recovery time means more time for quality training, which in turn improves performance. For example, the athlete that recovers faster can tolerate adding more volume and intensity to the plan with less risk of injury. Non-pharmacological methods for treating inflammation have far fewer risks and side effects and can be used long term.
The field of physical therapy originally arose to rehabilitate polio survivors and injured soldiers after WWI. Over the years, it has evolved to include injury prevention, and in the past decade or so, it plays a role in sports through performance enhancement.
The same treatment methods PT’s use to treat injured and diseased persons are effective with healthy individuals, like athletes who live in a constant state of low-level inflammation. Coach Amy uses a combination of Neurological Dry Needling (NDN), Active Release Techniques (ART), and Applied Functional Science (AFS) to help non-injured athletes recover faster during training.
““I sought treatment with Coach Amy during the rigors of Ironman training. Her treatments allowed me to return quickly to a very functional level of mobility for training. It was great that competing in my upcoming races wasn’t jeopardized!” ”
Your first performance enhancement visit with Coach Amy includes a thorough evaluation of your training history, current goals, mobility, and stability as it relates to your sport. Typically treatment is started during this initial visit. PT for performance enhancement is not covered by insurance.
To book an appointment for performance enhancement:
Choose NEW Patient Evaluation & Treatment-Self Pay
Athletes who would like an assessment of running form should choose Running Evaluation from the menu (otherwise stick with the first option)
For all subsequent performance-based treatments (after the initial evaluation), choose PT Treatment-Self Pay, or PT Treatment-Self Pay with Dry Needling
Stay tuned for our upcoming articles on just how NDN, ART, and AFS work to speed recovery and improve sports performance.
The Magic of Rest Day in Training
Athletes dread rest days. They believe they are missing out, falling behind their competition and losing strength and fitness.
They are wrong.
Believe it or not, your rest day is the most important aspect of training. On training days, the body is challenged and worked, tested and pushed. On rest days, the body takes it to the next level.
"Rest days are when the magic happens: the body makes biochemical changes at the cellular level. It adapts to the positive stress of training and improves to a better, adapted state. It recovers and reforms.” -Coach Amy
Microtrauma occurs in bone, skeletal muscles and tendons during training. This positive and normal part of training is necessary for the development of strength. It is similar to the formation of a callus on the foot of a ballerina or the hands of a rock climber. The musculoskeletal system changes and provides strength and protection just like a callus. The microtrauma causes a low level of inflammation that is typically not seen or felt. There is no observable swelling, redness or pain.
Without adequate rest days, repetitive microtrauma is left unchecked and can result in poor performance and injury. Learn more about the positive and negative impacts of inflammation in our three-part series:
Rest can entail curling up on the couch with a good book, but usually rest for the athlete is relative and active in some way. Rest is dependent on the training cycle, the sport, and the athlete.
After a marathon race, the best form of relative rest is walking.
For the triathlete in the midst of high volume and high-intensity training, a rest day may be light, restorative yoga or taking the dog for a walk.
A runner who runs 5-6 days per week needs rest from high impact and load on the heart, so a low-intensity swim, spin, pilates or yoga is a great option for reformation day.
A knowledgeable coach can help an athlete determine the best length, frequency, and type of rest.
Finding the delicate balance between load and rest is tricky business. A coach can help, but even with the best of training plans, managing the microtrauma and inflammation is challenging. Over the last few decades, athletes have relied on physical therapists to speed recovery from microtrauma with regular visits during training and tune-ups during the off-season.
Stay tuned for our series on how Neurological Dry Needling (NDN), Active Release Techniques (ART) and/or Applied Functional Science (AFS) help speed recovery and enhance performance.
Big Benefits of Running with Buddies
It’s no secret that working out in a group produces better results than flying solo. Research shows that the healthy actions of others rub off on us. Benefits of working out with other people include improving consistency, and increasing the intensity and duration of exercise. The same rings true for running.
Tackling runs or a lengthy training plan with a run group not only improves individual accountability but also allows athletes to: increase mileage safely, avoid injury and mental burn-out, and gain moral support and stamina.
Roadrunners of Kansas City (formerly known as Personal Best) has been hosting group runs filled with positive support for over 25 years. We invite you to try out some group runs for free every Saturday in October to see for yourself the benefits of running with friends (and water stops)! Also check out our short promo video for a glimpse of the spirit of our group.
Coach Amy Parkerson-Mitchell as the owner and operator of this run club adds unmatched expertise. Amy is a certified Garmin Coach, has recently been featured in Runner’s World, and is a licensed physical therapist. Although run leads may fluctuate, Coach Amy creates all of the training plans and provides a world of knowledge for her runners.
Whether you’re a first-timer, a seasoned runner, or anything in between, there is a place for everyone at RRKC. Ready to try something new? Join us for the month of October. It could transform your year.
“Before I joined RRKC, I struggled to train consistently, battled injuries, and couldn't find my community of people that made me fall in love with running in the first place. RRKC has changed all of that for me. I train more consistently, have kept injuries at bay, and because of that managed to get faster, all while making great friends!” -Melody
Stinky Shoes!?
Running shoes got the funk after a muddy, sweaty or rainy work out? Read these quick and simple tricks of the trade to dry them out, freshen them up, and get them ready for the next run.
This works for drying out any athletic shoes. So if you packed lightly for vacation, and need to restore wet shoes for the next day’s adventures, these tips could save the day!
Such a Pain in the Knee Cap!
My first serious running injury was a pain in the knee cap! I was 17 years old running my fastest mile times during the indoor track season. This came to a halt with patellofemoral pain syndrome AKA Runner’s Knee.
Back in the 80’s the advice from the orthopedic specialist was, “Stop running.” Sadly, some physicians still give that same advice. But I say, no! Don’t hang up your run shoes. Seek an alternative. I wish I’d known back then that physical therapy was an option.
With early intervention, physical therapy can prevent or decrease time off. In chronic cases, modification or a break from training may be necessary, but physical therapy can help return runners back to sport earlier and healthier.
My battle with Runner’s Knee was thirty years ago; now I regularly treat athletes suffering from the same condition. CoachAmyPT patient, Alyssa, suffered from Runner’s Knee and writes, “I’ve been doing the stretches you showed me, squatting properly and taking my pace slow.... excited to report that I ran my first pain-free three miles [in months].” Alyssa went on to run a half marathon this Spring.
The first sign of Runner’s Knee is usually mild pain behind the knee cap after running. As it worsens, pain can become severe and occur after AND during running. A hallmark sign of this condition is pain in the knee while standing after sitting for long periods of time. Climbing up and down stairs can also be uncomfortable.
There are many causes of Runner’s Knee including training errors and poor bio-mechanics.
The pain in the knee is a result of altered positioning of the knee cap on the lower part of the thigh bone. This altered position means that forces are not evenly distributed on the underside of the knee cap; wear and tear and irritation result as it glides over the thigh bone improperly. Over time this can result in tears of the cartilage surface.
What is causing this altered position? Weakness of the hips, imbalances in mobility such as tight Achilles and hamstrings, and poor dynamics at the foot with running are some of the possible culprits. A physical therapist that specializes in running injuries can accurately determine the contributing factors, and provide treatment that addresses them specifically. Proper diagnosis and treatment can also help prevent the injury from coming back.
Most running injuries are caused by a combination of things, and training errors typically do play a part in Runner’s Knee. Common errors include increasing volume and intensity too quickly, and lack of recovery between and within training seasons. A physical therapist with a background in run coaching and training can be helpful in assessing if training error is part of the puzzle, and work with you to make necessary changes.
So what to do if you suspect you have Runner’s Knee? At the first sign of a problem, it is best to rest for a few days, take NSAIDS (nonsteroidal anti-inflammatory drugs), and apply moist heat (soak in Epsom salts). After a few days, resume activity gradually. If symptoms continue, seek evaluation and treatment as soon as possible. The longer this problem persists, the greater the potential for more damage, and the longer the rehabilitation process will take. Not all knee pain associated with running is due to Runner’s Knee, so an evaluation by a professional is important.
Note: Running while taking NSAIDS is not recommended.
Alyssa listened to her body, sought treatment, put in the work, and went on to run a half marathon this Spring. “I missed running so much and I feel more like myself than I have in months... thank you so much for helping me get back in the game.” -Alyssa. Don’t let a pain in the knee cap put an end to your running game either.
Personalized Coaching Makes Doing the Hardest Thing You’ve Ever Done Stress Free and Fun
My favorite part of coaching is helping people achieve goals they previously thought impossible. Through Personalized Training Plans and Individual Coaching, I work with athletes to develop short-term and long-term goals. Each plan considers your personal lifestyle, and your running history including prior injuries.
Individual coaching is designed to help runners reach their performance peak, while taking the stress and guess work out of training. Following is a Q&A with Kathryn, a CoachAmyPT client. Her motivational journey outlines the logistics of how individual coaching works, as well as the benefits.
Read on, dream on, and reach out to Coach Amy to personalize YOUR plan.