When disaster strikes, follow our roadmap to recovery – a step-by-step guide to exactly what you need to do in the hours, days, weeks and months following an injury to ensure you come back faster and stronger than ever
Surefire shortcuts for those tough times when injury strikes
Acute injuries You probably already know about acute injuries: they feature brutal, instant scythes of pain and include muscle tears, fractures and breakages. If you suffer an acute injury, the action you take in the immediate aftermath is key, so head directly to STEP 2.
Chronic injuries can be trickier to diagnose, as we runners are constantly dealing with niggles that may not develop into full-blown injury. But you’re far more likely to experience chronic, overuse injury than the acute variety, according to research at Hanover Medical School in Germany. The researchers found runners were 10 times more likely to have suffered an Achilles tendon overuse injury than an acute Achilles tendon rupture.
‘Chronic injuries are essentially overuse injuries,’ explains Graeme Everard of Coach House Sports Physiotherapy Clinic. ‘The most common tend to be issues with the Achilles tendon and smaller tendons around the foot and ankle.’ You can also add the usual suspects, such as ITB syndrome and patellofemoral syndrome (aka Runner’s Knee).
According to Everard, failing to recover from one run to the next could be a sign of overuse. Matt Shepherd, of Bath-based Physio Impulse, puts it this way: ‘Use a pain scale, where three out of 10 is your normal, post-tough run benchmark. That’s tolerable and you can keep running. But if you’re at five, six or more, there could be a problem.’
Being honest with yourself is key to diagnosing chronic injury. Many runners try to struggle through, but in the long run that will mean more time out. You won’t need the same swift plan to speed recovery as you will with acute injuries, but seeking expert help early will have you back to fitness faster (see STEP 3).
Taking the appropriate steps in the immediate aftermath of an acute injury is crucial in reducing recovery time. And research published in the Britishjournalofsportsmedicine recently proposed an update to the RICE (Rest, Ice, Compression, Elevation) acronym. ‘For acute injuries, we use POLICE,’ says Tom Goom, head physio at Brighton’s Physio Rooms. That means:
Protection ‘This might be crutches, a brace or even a cast in serious injuries,’ says Goom. ‘This could be for as little as a few days until symptoms settle or around six weeks in a cast/ brace for a fracture.’
Optimal Loading ‘O and L stand for optimal loading,’ says Goom. ‘They’re the major changes. With RICE you were advised to rest but it’s been proven that if you can keep a certain amount of movement you can reduce injury time. Always stay within comfortable pain limits.’
‘Optimal loading should come quite soon after an injury,’ says physio Paul Savage. ‘After two days for a relatively minor injury and around a week if it’s more serious. The load needs to be appropriate for the severity of the injury and this is best directed by a physio.’
Ice, Compression, Elevation The familiar trio are grouped together, as they’re all designed to reduce swelling in the first 48 hours. However, there is some debate over whether suppressing this natural
response is a good idea: ‘It is part of the healing process and the benefit is that swelling brings chemicals that accelerate healing,’ says Goom. ‘The downside is swelling reduces activity around the joint, so it leads to temporary muscle weakness and instability. It also makes the joint painful and stiff. If we can reduce that, you’ll get movement and feeling back much quicker.’
‘I find compression very useful in managing swelling,’ says Goom. He recommends a simple Tubigrip bandage, especially for ankles and knees. ‘The area should feel compressed but not uncomfortable, and ensure there’s good circulation.’ Goom recommends removing compression at night for comfort ‘and because swelling is usually well controlled when we’re lying down’.
Ice? Ice? Maybe… ‘There’s debate over whether you should apply ice or simply compress and elevate,’ says Shepherd. ‘It’s down to recent work by researcher and sports therapist Peter Thain.’ He argues that while ice reduces local pain, there’s no human research to show it reduces swelling. For effective reduction in swelling, tissue-temperature reduction must be achieved at depth rather than on the surface and no study has proved that ice reduces temperature at 2cm below the adipose tissue (the fat that lies beneath the skin).
If you do want to ice, Thain recommends applying wet ice through a fabric bag, as wet ice cools more effectively than dry, and the porous bag ‘provides a barrier to stop potential ice burn. However, if it’s a significant trauma, add ice to a plastic bag and compress with tape.’
‘Apply ice for 10 minutes, then remove for 10 minutes, reapplying the compression bandage in the rest period,’ says Thain. ‘Continue the 10/10 cycle for as long as possible, then place the compression wrap back on the area.’
Take the pain Popping an ibuprofen is often recommended to reduce inflammation, but it’s not necessarily a good plan, says Andrea Jackson of Physiofit in Cheshire. ‘One study showed that the use of NSAIDS [non-steroidal antiinflammatory drugs] after exercise slowed the healing of muscles, tissues, ligaments and bones. Antiinflammatory medication has also been shown to delay fracture healing. But most doctors agree that if the pain is severe, it’s worth taking them for the first few days.’
Avoid further ‘HARM’ In the first 48 hours after acute injury, it’s not just your training diary you need to steer clear of. ‘Avoid HARM,’ says Shepherd. ‘That’s Heat, Alcohol, Running and Massage.’ Jackson adds: ‘Heating acutely inflamed tissue in the first few days after an injury may increase swelling,’ she says. ‘However, during the healing phases, which begin 48 hours after injury, applying heat to the injured area can facilitate the healing process.’
In this period, heat can inhibit pain receptors and help you regain movement patterns that aid recovery. Jackson recommends a warm bath with Epsom salts daily to reduce pain in soft-tissue injuries, and some research also suggests heat can help increase flexibility post-injury.
‘The sooner you can get the injury assessed by a physiotherapist who specialises in treating runners, the better,’ says Savage. ‘I might see someone with runner’s knee but think this is an issue you could still run with if you add something to
your programme, such as foam rolling. Or I might see someone and say no, that looks so inflamed that it needs a period of rest.’
There are excellent NHS physios, but waiting lists can mean long periods out of action, or the injury worsening before you’re seen. Going privately can be pricey, so you won’t want to use that option until you know it’s necessary. There’s no onesize-fits-all rule as to when that may be, but, in general, ‘if after three or four days of resting and icing the pain continues, see an expert’, says Savage. That’s particularly relevant to acute injuries. And if it’s truly traumatic, you should seek expert help immediately. Chronic injuries can be trickier, as pain might come and go. Be honest with yourself and remember the cost of a physio can pay huge dividends in the long run. Once inflammation’s eased, massage can also play a role in your recovery.
Your physio will give you a rehab programme to reduce swelling and inflammation, increase range of movement and address underlying issues such as weakness or imbalance. Of course, you then have to actually do the exercises. If you struggle with motivation, stay focused on the goal and accept that there will be psychological hurdles along the way (See Rehabyourmind, below). ‘Recovery isn’t a smooth journey but keep with it,’ says Shepherd.
Shepherd says adding load comes first. ‘It might risk poor early range of movement, but it will pay off,’ he says. ‘Then we’d introduce isometric exercises, progressing to isotonic exercises, where you move through a range of movement and build things up. Then comes strength and proprioception work.’
Time for low-impact activity. ‘Cross-training is invaluable for recovery,’ says Goom. A turbo trainer is great, as you can exercise free from injury-aggravating dangers, like stopping abruptly at traffic lights. If you have access to a pool or gym, aqua running and elliptical trainers are good options.
‘Make sure any pain during crosstraining is tolerable,’ says Everard.
As for session content, Shepherd suggests mirroring. Instead of a long, slow run, do a long, slow bike or swim. In time, you can also mirror more intense sessions to help regain fitness before your injury is fully healed. ‘Most recreational runners should focus on the lower-intensity stuff initially,’ says Shepherd. ‘You can add speedwork after about six weeks. ‘Just ensure you intersperse with rest and recovery days.’
‘You should also walk,’ adds Savage. ‘You’re loading the same tissues, muscles and joints as you would when running.’ He says there’s also a psychological boost to a spot of ambulation. ‘You’ll be advised to hit the gym but many runners love running because it gets them outdoors. Drive somewhere nice and have a walk in the hills. It’s better for the psyche than many options.’
When you’re ready to run, go easy. Stick with a cross-training session or two each week, gradually replacing them with runs, and ‘start at around 10 per cent of your pre-injury weekly volume and build up steadily week by week’, says Shepherd.
These sessions should be of a light or moderate intensity; speedwork can come later in your recovery. It can take six to eight weeks to recover from many soft-tissue injuries, but time will depend on severity (see Howbad?howlong? p55).
Shepherd also suggests doing some drills – such as 30 minutes of brisk walking, 30 seconds of balancing on one leg, 15-20 single-knee dips, and 20-30 single-leg calf raises – before you begin running again and at the start of each run rehab session. ‘This gets the muscle and joint moving in a less taxing way, just to give it a tester. Then build up the impact.’
Your rehab should also focus on what caused the injury in the first place and what action you can take to reduce the chances of it recurring. With many acute injuries, the cause may have been external, such as landing on an uneven surface. There’s not much you can do about these triggers except perhaps be more attentive, or ensure you wear suitable footwear for the surface. ‘ Wearing racing flats on a technical trail, for example, will leave you lacking traction, and, therefore, more vulnerable to injury,’ says RW Gear Editor Kerry Mccarthy.
With chronic injuries, identifying the underlying cause is vital. ‘Many are simply down to sudden increases in training,’ says Everard. ‘People often take on too much, too soon. Then there’s another set of runners who are guilty of “cramming”. One common story is that a runner will reach around six miles in their long run, get injured and then pick their programme back up at the 18-mile mark. Inevitably it breaks them.’
When you’re fit, Everard advocates the classic rule of increasing training volume by no more than 10 per cent each week, with a recovery week every four weeks, where you cut back by around five per cent. This covers both volume and intensity, which could be key, says Goom. ‘There’s research that shows knee problems, such as patellofemoral pain, and ITB problems, are linked to training volume, whereas Achilles, calf and foot problems are more likely down to training intensity.’
‘Running is a linear sport that puts a great strain on the knees, especially if you’re slightly misaligned,’ adds Goom. ‘The greater the volume, the more stress, the greater the potential for injury. Running faster is heavily down to the calf muscles, which increases the load on the Achilles tendons.’
But there’s a school of thought that running faster might be better for your knees, due to reduced ground contact time, which means, in theory, your knee is loaded for less time.
Think about surfaces, too. Running on concrete has long been linked with increased risk, and treadmills, which are more forgiving, with lessening impact, placing less stress on the tibia and reducing the chances of conditions such as shin splints. ‘But this might not be the answer,’ says Shepherd. ‘Recent research suggests ground reaction forces are actually greater on a treadmill than on the road.’
Many athletes, such as RW’S own five-time Olympian, Jo Pavey, cite clocking miles outside on softer surfaces, such as grass, as key in protecting the body. So, varying your surfaces and limiting your miles on the road is good advice.
Then there’s your biomechanics: it’s worth investigating whether your technique may be contributing to chronic injury. Patellofemoral pain syndrome, for example, develops when you’re not strong enough to keep yourself in good, straight alignment, which puts undue stress on the kneecap. Focusing on glute strengthening and correct leg alignment will pay dividends.
A good running-specialist physio, or podiatrist, will assess your body and biomechanics as a whole and offer corrective advice. ‘Knee problems might stem from a difference in leg length, for example,’ says Everard. ‘They’d also look at something like shoulder position. This can put rotation through the body, meaning your thoracic spine counter-rotates, which may put the pelvis out of kilter.’
Continuing with strength and conditioning work is important in future-proofing your running body. ‘There’s evidence that it reduces overuse injuries by as much as 50 per cent,’ says Goom. This time of year is ideal for doing strength work in preparation for spring marathons. It could mean dropping mileage, but spending two or three sessions a week building strength will be time well spent.