One of the areas that physical therapists often report feeling a lack of confidence is building a return to running program after an injury or surgery.
There are a few things to consider, such as the type of athlete and what their goals are in the long run. But in general, a slow and gradual progression is often best.
Here are the factors we consider and how we build our return to running programs.
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#AskMikeReinold Episode 340: Return to Running After an Injury
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Show Notes
• When is it Safe to Start Running After a Hamstring Strain?
• The 7 RunWell Pillars of Resilient Running
• Running Injuries with Scott Greenberg
Transcript
Libby McCann:
Yeah, I have a question from Katie from New Mexico. One area that she seems to struggle with the most is developing a return to running program for athletes. So how does Champion develop a return to running program after an injury or surgery?
Mike Reinold:
Awesome. Good one, Libby. Wow. We got one. I think we just entered the Kevin Coughlin wheelhouse.
Dave Tilley:
I’m going to sit here and listen to Kevin give a masterclass on running.
Mike Reinold:
Kevin, how many marathons you’re running this year? What’s the plan?
Kevin Coughlin:
I just finished one and I got one planned for the fall in Dublin, so that should be fun.
Mike Reinold:
Wow. Just two this year? Taking it easy?
Kevin Coughlin:
Just two. Yep.
Mike Reinold:
That’s amazing. Good stuff. So I like this question. I think Dan and Dave and I, we started our online mentorship a little bit, and I feel like one of the areas that a lot of people are saying they feel the least comfortable with is this return to sport progression, this late progression. And I think running’s a big one for that, right? Sure, there’s lots of easy ways you can start doing running, but I think unless this is something that you excel at, it’s probably not something that I’d say we’re optimizing as best we can. So I think this is a good question, Kev. In terms of the way it’s phrased from Katie here too, is that it’s not necessarily getting to run your first 5K or a marathon type thing, but you have an athlete, field sport trying to get back, running program, any injury, ACL, knee, whatever it may be. What’s running through your head, Kev? How do you work somebody through that?
Kevin Coughlin:
Yeah, I like the way you frame that because there’s so many different types of return to running programs, and I think the first big piece of information that you need to get as a therapist from your patient is what type of running are they trying to get back to? Is this a track and field athlete or cross country athlete trying to get back to running high volume, high distance running, or is this a field sport athlete like a soccer player trying to get back to soccer? Because those two types of return to run programs will definitely look different. So that’s the first piece of information I think you need to get. What I would ask the patient is if you weren’t injured right now at this point in your season, or off season, what types of running are you doing and how many days per week?
Because a good way to think about this is just starting with the end in mind. So if you have a soccer player who’s in an off season, maybe for conditioning, he’s running three times a week. So that’s something you want to think about when you’re about to develop your program, versus if you have a long distance runner, cross country runner, or master’s level adult who’s training for longer distance. They might be running six days per week and that program’s definitely going to look differently. So I think the first thing is figure out what type of running they need to do, and then figure out how many days per week that they’re usually doing that type of running, and then from there you can kind of start plugging things in. So as an example, recently I worked with a kid with a bone stress injury, a cross country runner.
So that’s kind of straightforward in the sense that he needs to be running six days a week about 50 miles per week. So bone stress injury, you’re really building from the ground up, so you kind of have full control from the very beginning. And usually what I’ll do is I’ll try to get those six days as quickly as possible, but it’s going to be a lot of cross-training. And I think cross-training is a good way to think about building return to run programs because you’re able to build some of that volume with a little bit less impact. So perhaps those six days, maybe three of them are cross-training and then on non-consecutive days, I’d start a walking program. And it’s really that simple of, “Okay, so you’re usually running anywhere from 40 to 60 minutes on these days. Let’s start walking 40 to 60 minutes and make sure that’s tolerated well.” And then we’ll start building in kind of walk, run progressions.
And then conversely, if it’s not a distance runner who’s actually building that much volume and it’s more of a soccer player who’s running a few days a week, I would think about they need to be doing some type of conditioning. So maybe at this point with their injury, that longer, zone two effort stuff might be better off on a bike if the impact of running is bothering them. And then maybe we can focus on some quick sprint sessions that they need to be doing and some tempo type sessions that they need to be doing. So there’s a lot of ways we could work through this, but I think getting that baseline information is super important. Then obviously understanding what type of injury they’re dealing with. So if this is a bone stress injury, our progressions are going to be a lot different, and what type of pain they’re able to run through is going to be a lot different than if this is a soft tissue injury, right?
If this is a chronic tendon thing, you can be a little more aggressive with your return to run program. They’re able to run through some pain. I usually tell them, in the case of soft tissue or tendon, unless it’s like an acute muscle strain obviously, but building up to a four or five out of 10 pain, if it’s not changing the way you’re running, is okay. You want to make sure it’s warming up and then you can keep progressing with your program. Versus a bone type pain, we’re comfortable with zero out of 10 pain. So if you’re having issues with that, we definitely have to modify a little bit more. Then I guess the last thing I’d say is just in terms of really specific programs, one of my mentors for this has been Chris Johnson, and he works a lot with endurance runners, so the longer distance type stuff, but he has a lot of good programs that he’s published over the years that really just, you take your chunk of volume that you want to run and maybe it’s 40 minutes. You start with something like walk for four minutes, jog for one minute, then you repeat a certain number of times.
So for that eight times for 40 minutes, they complete that session twice. Make sure that it goes well both times and then that next phase, you’re just adding a minute of running and taking away a minute of walking. So I know that’s a lot, but there is a lot to it depending on the athlete.
Mike Reinold:
Yeah, no, that was great. And I love the way you framed it a little bit here too, where there’s a big difference between a field sport athlete and then a long distance running athlete. You have a return from an injury to running, but then also it becomes a workload progression, right? And I think the other thing I really liked about what you said too is there’s ways to keep up your cardiovascular using other machines, bikes, rowers, whatever it may be, that can keep your cardiovascular up to an extent without the impact that you see. Awesome. What else? Len, I mean ACLs, you’re doing a lot of ACLs…
Lenny Macrina:
Mm-hmm.
Mike Reinold:
…And those sorts of things. You have somebody cleared by the doctor to get back to running, what do you do?
Lenny Macrina:
Yeah, I clear them as well, making sure that they’re hitting the metrics.
Mike Reinold:
That’s a good point, right? Let’s assume that we agree with the doctor that they’re ready to run.
Lenny Macrina:
Right.
Mike Reinold:
Because sometimes we don’t. I like that.
Lenny Macrina:
I’ve already set the stage, post-op day one. They’re going to clear you at three months and we’re not going to have you start running at three months. They’re just going to say, “All right, you’re good to start running.” But I like to use roughly about a 70 percent limb symmetry index. There was a paper that looked at hamstring autographs that came up with that number. So I’m calculating. I begin my testing around 10-ish weeks, 12 weeks, and then with the goal of having them start a jogging program about five months out of surgery, roughly, depending on what’s going on. I have a kid right now with a big bone bruise and his knee’s still swollen and stuff, so I have to delay things a little with him. But around 4.5, five months, and then if they hit the metrics that I’m looking for with strength and they’re able to do some plyometrics, their knee is quiet, I just tend to use the Delaware program.
Lynn and her group out of Delaware have a nice program that they wrote up in JOSPT that is a walk jog program that I’ve been using for a few years now, or more than that. And it’s easy. They have a treadmill program and they have a track program, and depending on what the goal is of the person, it’s a walk jog program and it slowly increases volume of runs and takes away the walking portion. And it seems to be a nice, easy program that people can do over, I think it’s about six weeks or something like that, and gets them back, depending on the sport. Then it depends on the sport after that, what they’re trying to get back to. I typically see the soccer, lacrosse, the “run a sprint and then jog” kind of athlete, and so you tailor it to them. But like Kevin said, they’re doing a bunch of cardio otherwise with bike sprints and sled push pulls and stuff like that. And then you supplement their running program with that. I use that Delaware program and maintain that quiet knee hopefully. So that’s kind of my insight into that.
Mike Reinold:
Yeah, I love it. I think a big part of what Lenny said there too is don’t forget that… Well, I actually like how you said you delay it, right? Because you’re right. Physicians a lot of times will say week 12, and then you talk about four or five months to not start running. There’s so much progress we can make between month three and month five in the gym.
Lenny Macrina:
Yeah.
Mike Reinold:
Right, with strength and force development and plyometrics and keeping that in mind too. If you start at week 12, man, you haven’t gotten to a lot of the good stuff and you’re starting to do some pounding to an extent, like with running. That’s some pounding. That’s increases in your percentage of weight. But yeah, I think that’s a good tip. And if you’re an early career professional, you’re reading a protocol, it says week 12. I think a lot of people might kind of start that, but wow, we’d love to use those two months to get them in the gym and get some strength, get some power, do some plyometrics. So that way then the running progression is kind of easy, right?
Lenny Macrina:
Yeah, it really is.
Mike Reinold:
I think that’s the goal, right? You don’t want to flare them up week 12 to week 16. You don’t want to flare them up because they start doing it and then you’re not making strength gains from month three to five.
Lenny Macrina:
Yeah.
Mike Reinold:
That would be terrible, right?
Lenny Macrina:
You’re right.
Mike Reinold:
Kevin, you want to jump in on that? Then I know Dan and Dave want to jump in too, but…
Kevin Coughlin:
Yeah, one thing I just wanted to say on that I was thinking about when Lenny was talking is that I think a lot of these people early on in their running program, we have to make clear that the goal of the running isn’t to build cardio right away. It’s probably more to get impacts on the leg and get it used to running. So monitoring intensity for them is really important. I think a lot of our field sport athletes are used to just doing higher intensity running. It’s more like the distance runners that are used to doing slow jogging type running. So I think being clear about what the intensity should feel like, whether you want to use an RPE scale and they’re doing something for their easy running, even a two or three out of 10 maximal, they should be able to hold a full conversation type thing.
And I know that there’s that equation of arbitrary units for a session RPE where you can just multiply the length of time of the run by how hard it was, and it gives you some idea. So say it was like a 40-minute run at a two RPE, that’s only 80 units, and you want to make sure that that’s kind of where they’re sitting week to week and session to session. They’re not doing a 10-minute run at a nine RPE and they’re not feeling good running and it’s probably an intensity issue. So I think communicating that with the patient is really important.
Mike Reinold:
Yeah, and we use that in all our return to sports, right? Our interval throwing program. You’re not pitching day one, we’re just building load to your healing tissue. It’s not about throwing it as hard as you can. It’s about building progressive load. Dan, what do you got?
Dan Pope:
Yeah, I think one of the big elephants in the room, depending on the sport, Lenny kind of mentioned ACL, is that a lot of these sports are not kind of straight plane running for long periods of time. They have very different demands, like a soccer player obviously can be sprinting, walking, changing direction, so on, so forth. So I think the place where physical therapists have some trouble is mostly how to have a good workload starting from an easy level of exercise to the harder level of exercises. I love all that Kevin said. Usually what I’ll do with my athletes, and it really depends on their sport, I’m thinking about this from the very beginning… But once they get to the point where they’re tolerating some impact and doing well, I want to incorporate some more impact outside of that sagittal plane. So thinking about more kind of frontal plane, side to side, a little bit of rotation.
Usually I start folks off with things like ladder drills, which is, I think you’ll see this a lot if you’re in a standard PT clinic, if you see ladder drills, those are advanced, but in my mind, they’re kind of like the start of a change of direction program. And once someone’s tolerating that well, we might do more shuttle work and I do a combination of different types of runs. So we’re going to be shuffling, which is probably more important for something like basketball, not as important for something like soccer. And we do forward and backward runs. We do more lateral running. Over the course of time, we have more space between the shuttles, running faster. And then eventually I think you just get more sport-specific. One of the things you can do, because I’m not an expert in every sport, but when I get someone to these end stages of rehab, you can actually see some of the GPS data of what these high-level athletes are doing.
So an elite soccer player is going to be doing somewhere between five and eight miles in a game and they’ll actually tell you how much time they spent sprinting versus walking, so on and so forth. You can set up a whole session that tries to get a similar amount of volume and a similar amount of work to rest ratio with a soccer ball. You can get really, really specific if you want to. So I think for physical therapists, think about the sport you’re trying to get back to. When is it safe to start these things? How do we start to get outside of that sagittal plane and then eventually just trying to bridge that gap between what do they need to be, where do they need to be, and where are they currently?
Mike Reinold:
Awesome. Yeah, that’s great stuff, Dan. So Katie, hope that helps. I mean, I think we covered a lot of spectrums here. How to figure out where to get started, how to progress them through it, how to incorporate some of that agility stuff like Dan was saying. To be honest, that’s a whole other episode. We’re talking about return to running, but then it’s return to agility. So we’ll see. Maybe we’ll put that in the queue for the next batch of podcasts. We’ll talk about a return to agility thing. But you see this, it’s a complex question, Katie, and I think that’s why people think this is a daunting subject. Then you break it down, you look at the Delaware running program like Lenny mentioned, and you’re like, “Oh, that’s pretty simple. It’s pretty straightforward.” It’s not rocket science, but it’s about a controlled application of force, and I think that’s the neat part of it.
So awesome. Hope that helped, Katie. Thanks so much. If you’re enjoying this podcast, I don’t know, what are we close to… I don’t know. We’re way over 300 episodes, so I probably don’t have to keep saying this every episode, but head to Spotify, head to Apple podcast, rate, review, subscribe, all those fun things, and we will see you on the next episode. Thanks so much.
