The most successful return to run programs are individualized, not cookie cutter.
If you follow my running journey at all, you probably know I took my first DNF at Chicago Marathon. I experienced some hamstring tightness leading up to the race and felt a very slight pull during some strides the day before. On race day, I was more concerned about the heat than my actual hamstring. The tightness in my hamstring worsened throughout the first part of the race. By mile 14, it was painful with each step and I knew I had strained it.
It was frustrating because my aerobic system was not taxed, but my body could not keep up with the pace. I often get asked what it’s like to be a physical therapist AND a runner. Most of the time, I have to separate the two and ask myself, “what would I tell my patients to do?” I knew if I had finished that it would not be an enjoyable race, I would worsen my hamstring strain to a grade 2 or 3, and it would cost me a lengthy rehab and potential complications in the future.
I took the bus ride of shame back to the start and the pain was intense. It hurt to walk. I went back to my hotel and had pain lying in bed. That night, I noticed swelling in the back of my left thigh but no bruising. Luckily I had the company of my friend Nicole who has experienced all of the highs and lows of running to let me know things were going to be alright. The next morning, I still had a lot of pain 6-7/10. For those who are curious about my symptoms: I physically could not straighten my knee when walking. Stairs were killer. Sitting down for long periods of time was painful. I couldn’t lift my heel to my butt.
Like most injuries - you’ll have a better idea of the degree of damage in the first 4-5 days. Here’s how the hamstring strain unraveled for me:
Day 0-3: I walked for 30 minutes for exercise and around work. I tried not to sit too much as the hamstring would feel extremely stiff. No rolling or stretching. Only glute band exercises.
Day 4: I learned to walk normally “heel to toe” cues to get my leg to straighten. We set up the bike trainer and I rode 45 minutes with light resistance. No pain, but I did have discomfort swinging my leg on to the bike. Range of motion was still limited, but improving.
Day 5-7: Initiated strength training. I was able to bring my heel to my butt in a standing position. Light plyometrics were tolerable. I was able to do every strength exercise with low resistance, aside from isolated hamstring exercises (hamstring curls, reverse plank, RDL’s)
Day 7-9: initiated a walk /jog program. Started with a 6 x 1min, 1min walk. Then 6 x 2 min jog, 1 min walk. I was happy to run 9:30/mile pace. It honestly felt better with light running that I progressed myself to 25 min continuous easy.
Day 10-14: able to run continuously pain free. 5 miles one day, then 6 miles, then 8 miles. Nothing faster than 8:45 pace.
Day 15: able to incorporate some form of speed training, no strides. 8 x 1 min jog, 1 min walk. Achieved close to marathon pace without pain.
Day 21: Able to run a 17 mile long run and close out 57 miles for the week. No hamstring pain. Lots of PT exercises daily.
Day 23: 100% back to training. Speedwork (with caution), tempos, and strides.
Day 28: Able to run 70 miles/week, no hamstring issues. Continuing aggressive rehab program
Now according to most return to run programs out there, I should probably still be doing a walk/jog for the next 5 weeks or running no more than 35 minutes. If your physical therapist hands you a return to run program, question whether that’s appropriate for you and specific to your injury because returning to running from a stress fracture is MUCH different than returning after a muscle strain. I always recommend patients find a physical therapist that specializes in management of running injuries or is a runner and has experience running injuries because you know that every athlete is different and the individual’s experience needs to be considered.
Luckily for me, I built my return to run program as I went along in the rehab process. This made me think, are physical therapists holding their runners back when they’re fully ready to advance? Consider how often you see your typical physical therapist in an insurance based practice (1-2x/week for 30 minutes?). They hand you a return to run protocol for the next 8 weeks, but you have no way of communicating with them in between if you feel good, bad, or what is normal to feel? They tell you to schedule a follow up if anything comes up.
Half the job of being a physical therapist for runners is treating the physical ailments, but also patient education and coaching the runner on how to return to running safely and how to develop good judgement. The runner needs to be able to make the call when they’re out there running on their own. It’s not necessarily true that you need to have 0/10 pain in order to run. In fact, most elites are always dealing with some sort of ache or pain (mostly <3/10 pain). My point is, there should be clear and frequent communication between the physical therapist and runner to get the athlete back to running as soon as possible.
While some may analyze my return to run process and think I may have returned too quickly with a big long run after 3 weeks of injury, consider this: I only had to take 6 days off from running, I regularly run 60-75 miles throughout the year, I didn’t have pain with running (except with strides), and I was being aggressive with my physical therapy exercises. I was also fortunate that my hamstring strain occurred in the mid portion of the hamstring and not the proximal hamstring.
All runners are different and your return to run program should not be cookie cutter. Go see a physical therapist that specializes in running injuries to get the best treatment and guidance on how to return to running safely and minimize risk of re-injury.
Here are my key things to consider when returning to running:
Need to be able to walk pain free
Easy running should be no more than 3/10 pain, and not worsen
Normalized range of motion
Maintain normal running gait
Able to do 20 single leg step downs pain free with good mechanics
For physical therapists, utilize return to run programs as a “framework” for your treatment and guidance. One of my favorites is from Ohio State Medical Center as they have a beginners AND advanced program with clear directions on how to progress the athlete. Listen to your running patients and help them identify pain patterns (hurts with speed? hills? worse in the morning?) and come up with a strategy to help them minimize time away from sport.
Side note: Runners returning from stress fractures should go on a structured return to run program to monitor the increase in load/stress on the bones. Female runners have a high rate of repeated stress fractures and it’s important to ensure a steady return to running.