The dark days of injury are fading into the past and you feel ready to hit the road again, how do you return from injury without once again ending up on the Physio's couch? First you need to find out are you ready to start running again? And then plan a graded return. It's all about finding a level your healing tissue can manage and progressing at a speed that allows the body to strengthen and adapt. Remember stressing tissue the right amount (I.e. not excessively) promotes healing.

How you plan your return will depend on the nature and severity of your injury and the length of time you've been out for. If you're just returning from a slight niggle, or have had less than 2 weeks out with a minor injury you may not need to be so cautious with your return. That said, even in that situation, returning straight to pre-injury level is a common mistake that can cause more serious injury.

Are you ready?

When an athlete wants to return to sport I like to test them out first and see how their body responds to tell me if they are ready. I will check you have full range of movement in the joints surrounding the affected area. There should be no swelling and ideally you should be pain free. I say ideally because this isn't always feasible. Sometimes you can return to running with some residual symptoms if you can keep the running pain free. I'll give you an example, if you have back pain and it hurts to bend forward but running is totally pain free during and after, you can often return to running before the back pain completely goes.

There should be no instability in the injured area – no giving way or locking of the joint. If you are under the treatment of a doctor or physiotherapist follow their guidance . This is especially important with any type of fracture, ligament injury or after surgery.

Before you hit the road again see if you can do the following pain free;

Walk briskly for 30 minutes

Balance on one leg for 30 seconds

Perform 15-20 controlled single knee dips

Do 20-30 single leg calf raises

Try the 100 up and 100 up “major” – this is a great introduction to impact and practicing running form. It'll give you an idea of how your body will respond to running. If 100up is painful, then it's likely running will be. Video from http://www.naturalrunningstore.com

Jump, bound and hop pain free – do this on a soft, flat surface like a gym mat, start by jumping forward onto both feet. Aim to land quietly, in a controlled manner. Repeat 3-4 times, if this is pain free try “bounding”. Bounding is jumping forward from your stronger foot onto your weaker foot. Start with a small jump, again aim to land quietly and pain free. This allows you to test your impact without your weaker leg having to be involved in the “take off” part – that comes in when you hop. Again aim to do 3-4 times, quietly, pain free and with good control. Next try small hops forward on the weaker leg. Start one hop at a time, just a small distance. If pain free increase the distance a little then try consecutive hops (I.e. hop, hop, hop not stopping between each). You're aim is to do 10 consecutive pain free hops before returning to running. Impact is often painful following fractures, your Physio may want you to do as much as 50 hops pain free before you return to running.

If you can't manage this yet then be patient, cross train if possible and continue your rehab until you can manage it. If you decide to run anyway, keep it light, slow and pain free – you may manage a few minutes on the treadmill. The list above is a guidance, not set in stone. It always comes down to your choice but if you can manage everything above it's less likely you'll aggravate your injury or pick up a new one. It's a good idea to see a Physio/ health professional to help your return. They can test more accurately and assess your muscle power and areas to focus your rehab. Return to sport can be a complex area, as this research piece discusses.

Graded return

Use a graded return to running. It's easy to say isn't it? Not so easy to do. I try to be as scientific as possible and, as discussed here and here, there is no established formula on how to return to sport. The research in this area is fairly sparce. I use 4 principles;

Work below your 'break point' Allow a rest day between each run and after a rehab day. Change 1 thing at a time Progress gradually when comfortable to do so.

Your first step then is to find your baseline – this is the distance you can run at long run speed without pain both during the run, and for 48 hours after. in the majority of cases an injury will hurt during a run, but sometimes it can take up to 48 hours for inflammation to develop. When finding your baseline go for less if there is any doubt. The easiest way to find your baseline is on a treadmill. You have much more control over speed and distance and there is usually less impact. Start up with a brisk walk for 5 minutes to warm up then slow and stop the treadmill. The point of this is it resets distance and time and makes it much easier to workout your baseline. Start the treadmill again and gradually increase the speed to a pace you could easily talk at. Run for as long as comfortable, stop if painful and note distance, time and pace. Your aim is to identify a distance and speed you can do without increasing your symptoms. You don't have to run until it hurts, just find a level you know you can manage, that's the aim here. If you don't have access to a treadmill, run on a soft surface and use a GPS or watch to estimate your baseline.

Next I usually advise taking 10-20% off this distance and using that as your baseline. It means you're starting well below your breaking point and allows for natural variations as well as any difference between running on a treadmill vs outside. So for example you managed 5km pain free running at 6 minutes per km your baseline would be 4.5km at the that same speed. (5km – 10% = 4.5km)

Obviously you can do the same using miles rather than km if you prefer. Note that we aren't changing speed. Increasing speed usually increases injury risk, our priority is comfort. Also be aware of your running form look out for any tendency to favour one side, this might include the feeling of the leg giving on that side or just feeling uneven as you run. More on form from RW here.

Now you have your baseline there are a host of ways you can use it but I would keep to the 4 principles above. How you use it will depend on your injury, your fitness and experience as a runner. This approach can be a little restrictive but it is very useful when returning from a more serious injury or long lay-off.

You could go with a cautious approach; 2-3 runs a week, always separated by a rest day with 2 shorter runs (approx 50-60% of your baseline) and 1 long run at baseline level. Stick with this for 2 weeks and if managing well increase your baseline by 5-10%.

Or more adventurous; 3 runs, again separated with a rest day, all at baseline level increasing each week by 10%. A schedule is useful but only progress if comfortable to do so. If you start with a baseline of 5km you could reach 10km in about 8 weeks. I can imagine a few of you thinking, “that's good” and others “Man alive! I'm not waiting that long to run 10k!”. It's up to you! If you think that is slow, I saw an online schedule that took 6 weeks to return to running for 5 minutes!

A variable baseline programme can help a more rapid return. Review you baseline every 2 weeks and change your distances accordingly. This is a slightly higher risk strategy and can result in large climbs in mileage but for more experienced runners or less serious injuries, it's a good option as long as you stick to keeping running comfortable.

What if your baseline is tiny ?

You've got on the treadmill and 2 minutes later your pain has started, your baseline stands at 300 metres. Using the 10% rule it'll be 18 years before you reach your target distance! There are a few options;

Stick with this baseline but focuss more on rehab and review your baseline again in a week or two Try an offloading strategy to reduce stress on the painful area. What you use depends on the injury but it might be taping, orthotics or a gel heel pad. See if it helps you reach a more useful baseline. Use a little and often approach. A baseline of just a few minutes will often allow you to do it regularly if you keep it pain free. You might find you can run once or twice a day and soon pick up your distance. Use a run/ walk pattern to achieve a larger baseline. Gradually reduce the amount of time spent walking until you can run continuously pain free. Try aqua running to build up strength and CV fitness and return to running once you're fitter

Even with very small baselines people can do well. I'll always rember a patient of mine who was desperate to return to cycling. Initially he could only manage 90 seconds on a bike before his pain became too severe. He started with 1 minute and did it regularly and gradually built up. A year later he did the London to Brighton bike ride. The same applies to running, be patient, you'll get there.

Return to running schedules

I've had a look at several return to running schedules available online and I have to admit, I've not found many I like. They seem to range from incredibly cautious to overly prescriptive. I think it needs to be based on your baseline, rather than a specific distance. One approach that I do like is using a couch to 5k or couch to 10k programme. They are specifically designed to allow a gradual return to running and are useful when recovering from a serious injury. I've designed a potential programme based on a 5km baseline with a weekly 10% increase in baseline, using 3 runs a week. Note I've also included a “rehab day” more on that in a mo. The 8 week programme takes you from 5 to 10km;

This is just a sample schedule, you can build one of your own using your baseline or consult your Physio or running coach. The total weekly distance never increases by more than 10% and the long run increases by close to 10% each week (in some weeks it may be a small amount more but that's mainly for sake of practicality – in theory week 7 you should run 8.8578km if you're being strict!) I've chosen an 8 week programme because you can achieve strength gains in 6-8 weeks also muscle tissue takes roughly 6-8 weeks to heal.

The rehab day

A once or twice weekly rehab day allows you to keep working at the cause of your injury, be it strength, balance or flexibility. The rest day after allows you to recover so you aren't running on legs that are tired after strength work. Our specific articles on ITB, Achilles Tendinopathy, Plantar Fasciitis and Patellofemoral Pain Syndrome all have suggestions on rehab. Ideally you have a programme from your Physio or health professional to work with.

Modify and overcome

You want to be able to run further without pain and there are a number of ways to modify your running to help you achieve this. We've talked about this in many of our articles on RunningPhysio, a few subtle changes can reduce load on healing tissue and allow you to do more. The idea is these are temporary strategies and can be gradually eliminated. You may only need them for your longer runs. Try changing running surface, stride length, avoiding the camber on the road or a change of running shoes. Use offload strategies mentioned above. Use a longer warm up, with dynamic stretching or break your run up with walk breaks. Sometimes even the time of day you run helps – you might be fresher before work than after a long day on your feet.

Cross train

Cross training with swimming, cycling, or gym work can be a great way of maintaining and improving cardiovascular fitness. I often find that better fitness helps runners maintain form longer and therefore prevents excessive stress on healing tissue. One thing to remember though, just because it isn't running doesn't mean it can't aggravate your pain. Approach cross training sensibly, especially if you're new to it and build up gradually.

Managing setbacks

In most injuries people will suffer at least one setback. Your heart sinks and it's hard not to feel you're back to square one. Luckily this is rarely the case. What usually happens with a setback is that you have overloaded healing tissue. Healing tissue is often composed of immature collagen that doesn't manage load very well. Some of this tissue breaks down and as a result you get pain and inflammation. We call this microtrauma. It isn't changes to an entire structure like a complete tear to a ligament – this is macrotrauma. A good way to picture this is with a piece of rope.

Look at the rope. See all the smaller fibres running through it? Imagine a few of those smaller fibres breaking, the rope would still work and be strong enough to pull things along. That's microtrauma. Now look again, the picture shows three larger strands, composed of the smaller ones, if you cut through one of these or the whole rope, that's macrotrauma. Macrotrauma is usually associated with a specific injury and results in pain and swelling. If it's just a flare up of your usual symptoms it's unlikely to be anything serious but as ever on RunningPhysio if in doubt get it checked out!

Luckily microtrauma heals quickly, usually between a couple of days and at most, a couple of weeks. So if you have a setback, stay calm! Often it'll settle again in a few days and you can gently return to your training. Use your acute pain management strategies (ice etc) and consider setting a new baseline once symptoms have settled.

Increasing speed, adding hills or interval training

So far we've focussed mainly on increasing distance at low speeds as this is a low risk strategy. As you progress though you will probably want to improve speed too. The schedule I've created has 2 shorter runs in the week, these can be used to work on speed if pain free and you feel ready. If you are doing speed work it's sensible to keep the weekly mileage the same – change just 1 thing. Then if your symptoms increase you'll know why. So maybe add a speed session but don't increase the length of your long run. Start with short intervals (approx 200 metres or whatever is comfortable) at tempo run pace – a pace that is challenging but you can maintain it. The same applies with hill work, add cautiously and only when you feel ready. Beware the downhill! It's often more aggravating than uphill work.

Don't be afraid to review your baseline

If you're struggling to manage your baseline runs or finding them far too easy then it may be time to review your baseline. This can also be a way of working on speed – try finding your baseline at a more challenging pace but always focus on comfort.

Can I run through pain?

Hmmm here's a debateable one. A sensible answer would be no. A realistic answer, ideally no but sometimes yes and you really have to ask yourself is the risk worth the benefit? During your rehab it's likely you will have twinges and niggles, not only in the injured area but elsewhere as your body gets used to running again. My guidance on this is an occasional brief twinge that isn't severe and settles quickly is usually ok. If you experience pain during a run, you needn't always stop and taxi home. See if you can change it using the modifying strategies above, slow down, head onto the grass, walk or stretch for a bit. If it doesnt go then I'm afraid it may well be best to call that taxi or walk home. With pain it's also worth considering the trend of what's happening. If the trend is that you run, it hurts a little but it's fine after and week by week it's getting better then it may be that you can get away with running with some discomfort. If, however, you're running with pain and making no progress or getting worse each week then you may need to stick more strictly to the pain free plan. What I advise strongly against is the grit your teeth and push through it approach!

More on when to run and when to rest here on general injury management here and on avoid training error here.

And finally…

It's not just running that aggravates pain! It may sound obvious but we often blame running for everything! If your pain is worse but you haven't changed your running or have worked well within your limits, it could be something else. Prolonged sitting often aggravates back pain and patellofemoral knee pain. Kneeling often increases knee pain, as does squatting. ITB issues can be made worse by cycling and knee ligament injuries are often aggravated by swimming breaststroke, while walking barefoot is notoriously painful in plantar fasciitis. My point is that it might not just be running that you need to change. Sometimes you need to pace other activities that hurt too, especially with more persistent injuries. Pacing is a key concept in managing injuries, it's really what this whole piece is based on. Pacing means working within your limits, doing what's comfortable and gradually increasing over time. It may seem a nuisance but with patience you can get good results without the recurrent setbacks you get by just ploughing on with it.

The above Information is not designed to replace medical advice. Serious Injuries should be managed with assistance from your Physio or Health Professional.

As ever on RunningPhysio if in doubt get it checked out