Issues Around Returning To Running After Injury
We get a lot of questions about time frames and strategies for returning to sport for running knee pain. While there is no single answer for all people and conditions, there are some concepts that we find effective for many of our running physio patients.
As the days get longer and warmer, the parks and pavements of Randwick become busier with runners of all ages and abilities. Ramping up the volume (whether it is distance or number of running sessions a week), changing the intensity, or changing the type of running can load our muscles, tendons and joints in new and challenging ways.
Running Loads
- Volume: Volume of running refers to the amount of distance we are covering. This is impacted by the kilometres run, and the number of days we run – usually assessed as a weekly output.
- Intensity can be harder to assess. This usually refers to the speed or overall effort of the session. This can be impacted by other variables such as hills, beach/sand running, sprints, intervals and cross-training. Heart rate monitoring and running apps like Strava can give us an insight into intensity but tracking heart rate and speed. Otherwise, we can use a simple subjective measure like Rating of Perceived Exertion (RPE) – a number from 0-10 indicating the level of intensity of the workout.
- For a simple metric we use to analyse our running knee pain athletes return to sport, we take the number of minutes or kilometres of running in a session and multiply that by the RPE. An example for a session may be 25minutes x 8RPE = 200*. By then adding the overall intensity minutes over a week we can track an athlete’s output. This then allows us to work out a rough guide to increase their overall loading in a safe and consistent manner.
Type of running training is also an important factor to consider.
- Base running is training at a slow steady pace, that you can sustain for long runs without fatigue. This type of training often makes up the bulk of a normal runners training program.
- Tempo running is training at a faster pace, taking the body closer to the anaerobic threshold for sustained periods. This type of running better simulates race pace.
- Interval training involves performing repetitions of time or distance with rest periods in between. These sessions can involve a variety of work and rest periods of differing times and distances. Importantly the rest period needs to be a focus of the session to ensure that the energy systems and muscles are given adequate recovery.
Environment and surface are also variables to consider with running knee pain. This is especially important when considering a return to running from injury. Tarmac, running track, turf and sand all have different requirements of our muscles. Often tarmac is seen as problematic, as the surface is so hard, however the flat and even surface can provide a much kinder surface for running than softer surfaces like turf and sand.
Common knee complaints seen by a running physio
This isn’t an exhaustive list, or a guide to diagnosing knee pain from running. This is just to provide a rough guide of some of the conditions that may benefit from an understanding of the rehab concepts that we look at.
- Patello-femoral joint syndrome (PFJS) – this is a pain that can arise from irritation between the undersurface of the patella and the femoral surface. This can result from biomechanical issues at the knee that create irritation and tension around the kneecap – particularly with repetitive up and down hill running.
- Ilio-tibial Band Syndrome (ITBS) – The ITB is a tendinous band of tissue that runs from the lateral hip to the lateral knee. Pain can arise at the lateral knee due to irritation of soft-tissue structures underneath the ITB at the knee. As with PFJS, this pain can be brought on by repetitive up and down hill work, particularly as the muscles of the lateral hip fatigue and more tension is put through the lateral thigh with medial deviation of the knee in stance phase.
- Fat pad irritation – The fat pad is a tissue that sits directly inferior to the distal patella. Repetitive running and extension of the knee can result in irritation to this tissue. This is often more pronounced with downhill running; and often as a result of reduced quadriceps range of motion.
- Patella tendinopathy – The patella tendon connects the base of the kneecap with the tibial tuberosity. Patella tendinopathy is a condition in which the tendon undergoes a disordered healing process – often as a result of increase in loading of the quadriceps in deep flexion – particularly jumping, hopping and hill running.
Training strategies for a return to running with knee pain running
The above list is not exhaustive for running knee pain conditions, and the brief descriptions cannot be used to diagnose or treat your condition. Nor is the following advice intended for use in place of personal medical advice from a physio.
- Book in to see a running physio: Come and see one of the physios at Movement Centre if you are experiencing running knee pain. This is the best place to start to get an understanding of the condition and create a plan.
- Understand the condition and the causes of running knee pain:Our first message for athletes with knee pain who are returning to running is to understand what their condition is, and what are the drivers of their condition. This involves having an understanding of the biomechanical and anatomical aspects, and any underlying changes to the tissue that may be causing the pain.
- Understand and monitor running load: One of the first places we look is at overall running load (distance and intensity) in the months leading up to the onset of the running knee pain. This helps us understand why the pain commenced and gives us an idea of an appropriate load to return to.
- Change up the running training: Returning to sport after experiencing running knee pain presents us with a bit of a paradox. Strangely, we often recommend faster running, in short flat intervals as a starting point for a return to running. Running faster when safe to do so generally allows for a much quicker ground contact time with each step. It allows muscles controlling the knee, hip and torso to perform their roles without fatigue. Often a return to running plan involves 2-3 interval sessions a week, consisting of 4-10 reps of 200-500m running, with 60-120seconds rest between each interval. As fatigue, fitness and pain allow, we try to lengthen out the working intervals, and shorten the rest. As pain allows, we put an emphasis on returning to base running. This helps to restore aerobic fitness and build up relevant running load for our patients to return to their distance goals. With the base running, we will often encourage a light, faster cadence, shorter step length style of running, which is often favourable for a return to pain free running.
- Gradual increases in load: Returning to the focus on load, we then look at ramping up the running load gradually. We aim for about a 10-20% increase per week, to get our patients back to the running they love.
If you are experiencing knee pain with running, our team at Movement Centre Randwick has running physio solutions for all ages and abilities.
