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Injury/pain management for runners

Running, in my opinion, is one of the greatest sports out there to compete in. Training can be suited to your ability, and you are able to train whenever suits you. As I am an extremely busy person (to say the least) I love how I can fit my runs into any time of the day, thus still keeping me fit and healthy.

With pros like these, there are also some serious downsides to running. One of them being that it has the highest injury rates compared to other sports. A systematic review and meta-analysis conducted by Videbæk et. al (2015) on the incidence of running injuries showed that novice runners sustained a whopping 17.8 running-related injuries for every 1000 hours of training, and 7.7 per 1000 hours for recreational runners.

These numbers, in my opinion, are way too high, and as a coach, one of my goals would be to minimise the chances of injury whilst attaining peak performance. I can say that I am unfortunately a part of this statistic, I am not immune to injuries having a stress fracture in my third metatarsal last year and a couple of niggles also throughout my career. However, not all injuries are avoidable and can occur when we least expect them. One example is tearing a ligament in your ankle from rolling it during a training session; or tearing your calf during a track race.

One thing that is common with (most) injuries is the way we manage them. All injuries won't follow the same exercise regiment, for obvious reasons. However, the steps that are taken to manage injuries are the same across the board. In this blog, I am going to go through the 5 key steps that a person goes through whilst injured, providing advice/tips & using a case study to illustrate these steps.


Before we dive into these 5 steps I want to discuss a new concept with some of you... a pain scale. I like to use this one I have found online as it not only has emoji's but some description and a colour scale. To best describe the safe zones of pain and exercise, I'll be using the colour scheme.

The safest range to undertake exercise in (as a general consensus) is 0-3 because this is where we are less likely to exacerbate an injury. Even in overuse injuries, it usually takes multiple factors to start an injury and the pain will onset at any stage. This is not to say that if you are experiencing pain within this range it's ok to push through. There are some instances where this might be a red or yellow flag for you. For many bone stress injuries, the pain can be very localised

You know your body better than anyone else, so be sure to monitor any changes/pain closely.

Then let us say you are experiencing some form of pain. Is there an optimal range for you to be exercising in? There is no optimal range for exercising during pain, however, during exercise, I would either want to see a drop OR no more than an increase of 2 on the scale. So if you came to training and the pain was a 3/10, I would ask you to stop once the pain became higher than 5/10. There is also a limit for this scale. If the pain becomes greater than 6 I would ask that you cease exercise and perform light mobility/stretching drills that won't further aggravate the area.

There is also a contraindication to exercise based on this pain scale. If your perceived pain is greater than or equal to 7/10, then DO NOT exercise!! Instead seek medical attention from either a GP, physio, podiatrist, etc. Whoever you might need to see to get this sorted out.

Now that we understand the pain scale, time to talk about the five steps to injury management:

Step 1 - find out what it is

This is one of the least favourite steps during a pain management assessment. As a runner, you'd probably need to see someone who specialises in sport or musculoskeletal pains. Physiotherapists and podiatrists (for feet problems) are probably your best bet... but remember to talk to your coach about this first, keep them in the loop so they know what is going on and can help you out with programs and returning to running if needed.

After your initial consult, you might need certain tests done. Again this will depend on your injury, it might be exercise testing or you might be recommended to get a scan done in & around the area to figure out what the problem is. From here you'll get some form of diagnosis, and a treatment plan will be set out for you, which leads into step 2.

Step 2 - reducing pain, inflammation & load, potential immobilisation

With all musculoskeletal injuries, the first thing we should try to do is to reduce any swelling and allow the bone/tissue to heal properly. Depending on the severity of the injury this can last anywhere from a couple of weeks to possibly three months. Your training load will need to be reduced as well, to reduce the chance of the stress you normally would place on your body causing further damage to the site or other injury. For example, if diagnosed with Illiotibial Band Syndrome (ITBS) you can usually still run, but need to reduce your running load and increase time improving glute/hip strength & mobility. If we compare this to an ACL injury, where you'll probably be spending up to 3 months (sometimes even more) in this stage.

Therefore, during this stage, I recommend CROSS TRAINING! Again, this will be dependant on the type of injury, as some injuries will prevent you from completing certain exercises. Ask your health professional/coach what you CAN DO, and together create a program that can maintain your fitness throughout the duration of your injury. Depending on how severe the injury is, also make sure to still keep in touch with your training mates and help out where you can! It will help keep your mind off your injury and stay motivated within the sport!

Step 3 - regaining ROM/strength/pain management

This stage I commonly refer to as the rehab stage. This is where we start implementing S&C programs, targeting the muscle groups that have been affected whilst in stage 2. The goal here is to help you get back to running, and again, will depend on the severity of the injury and the time spent in step 2. A stress fracture may mean you spend up to 3 months in this stage, with an ACL injury it would be at least 6 months (more if you play a contact sport as well). With these types of injuries, you'd need to prescribe low intensity lower limb exercises as a priority (during the first weeks), before slowly increasing the intensity and progression of exercises. If we look at something less extreme, let's say a hamstring strain, you might only spend around 2-4 weeks depending on the grade of strain.

Towards the end of this step, there will most likely be an integration of some form of walking/Kenyan shuffle → jog, as this will make it easier to get into the next step and reduce the potential risk of further injury. However, DO NOT take this for granted! Just because you have been given an inch does not mean you take a mile! Keep it slow and steady to reduce further risk of injury!

The big note here is that your rehab will not always improve linearly. There might be some days that you go backwards, other days you'll feel like you are the king of the world. You should be keeping close contact with your coach/physio/any other health professional you are seeing. Also, keep a close eye on that pain scale... pain does not always mean there is associated damage, but it does mean that we might need to be extra careful when being in this stage. If you've completed step 2 properly (not by your standards, but by your coach & health professionals), any pain you might experience could be because your danger receptors around the area might be still firing. I can remember my first time starting weight-bearing resistance exercises and I'd get pain around my stress fracture whenever I'd complete SL exercises within the first couple of weeks. However, after a couple of sessions, I got no pain whatsoever and was able to continue without any concern. This might be different for everyone, so you need to make sure you are paying attention to yourself, not others.

Step 4 - returning to running

Once we have successfully completed our rehab stage, and we have been given the all-clear, it is time to return to running. I stress again, don't overdo it! Otherwise, you'll be going back to stage 1/2, which is sub-optimal. Start off slow and work your way up. When I had my stress fracture, I spent 4 months in this stage, or 16 weeks. That's a very long time, but it has paid off! So be sure to follow your running program as best as possible so you can get to the next step as best as possible. You might not have a lot of running to begin with, but your load will increase the more you get through this stage (as long as the progression is gradual)!. I have seen many runners come back too fast too soon, and they have either re-injured the area or picked up another niggle.

By this time, you should be spending less time with physios/doctors as such, only checking in with them so they can see your progress. But I can't say that for every MSK injury. Some injuries might require more checking up than others.

Step 5 - return to competition and management post-process

The final stage of the pain management process is returning to competition. This step is basically the end-stage where you'll most likely see the treating medical professional after the first couple of competitions, as long as they are happy with how you are managing it all. It's important when first returning to comps that you may not be as you were pre-injury, and that is ok. You should feel pretty happy to just be out there competing rather than sitting on the side of the track.

Your initial goal in this stage should be to return to pre-injury fitness. From there, you can set your sights on attaining PB's or qualifying times. This is because (in my opinion) when you first return to competition, chances are you aren't going to be in the shape you were pre-injury. Your times will probably be slower and it would be harder for you to make the splits you used to in training. Remember, don't feel too hard upon yourself when you first start out, trust the process and you'll get there!

Keep up the running!


Intermediate coach


Videbæk, S., Bueno, A. M., Nielsen, R. O., & Rasmussen, S. (2015). Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports medicine, 45(7), 1017-1026.

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