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RETURNING TO RUNNING AFTER A STRESS FRACTURE
OR OTHER MAJOR INJURY

In another Lab Report, we looked at how to stay fit and sane when a stress fracture or other serious injury prevents you from running. Over the past few months, several readers have asked about the next step. How should you start back when your doctor (finally) gives you the green light to begin running after a major injury?

The answer to that question depends on the site and severity of the injury, how long you were off running, and your overall health status. On average, it takes 90 days for a stress fracture to heal completely. So, while you may be able to resume running 6 to 8 weeks after the initial diagnosis, it is critical to start back slowly and increase your mileage gradually to allow the final healing to take place. Let’s investigate how to get back into training after an injury.

How far, how fast, and how often?

Before you can run you must be able to walk briskly without pain. During walking, your body absorbs forces of about 2 times your bodyweight. This is a stepping stone for determining when the injured bone will be able to handle the greater impact forces of running. When you can walk briskly for an hour without pain, you should be able to try a small dose of running. The impact forces of running, however, are over twice as great as for walking, so the only way to know whether your body is ready to handle running is to run.

During the first few runs you will just be getting your body used to the running motion again. You may feel as though you have never run before. Rest assured, this feeling will go away after a few runs. If you have pain in the area that was injured then you have not healed sufficiently to run. You may, however, experience some normal soft tissue discomfort as your muscles get used to running again. If running is painful, stop right away and consult your doctor. Trying to “run through” the pain could severely set back your recovery.

Your re-introduction to running will start out by alternating walking and running. Walking will warm up your muscles and walking breaks will give you time to evaluate how you feel. There is a danger during the first few weeks back of releasing your pent-up physical and emotional energy and overdoing it. Alternating walking and running will help keep your demons in check. The running segments will gradually become longer and the walking breaks shorter until you are back to continuous running.

The amount of time required to return to full training generally ranges from 6 weeks to 4 months, but in extreme cases can require as much as a year. The main training variables that you can adjust are the distance, frequency (number of runs per week), and intensity of your runs. After a stress fracture, you need to increase the workload slowly and allow enough rest for the bone to adapt. The key is to continue with alternative activities such as water running and cycling while re-introducing running. It will take several weeks before you are running far enough or hard enough to actually improve your cardiovascular fitness. Your running for the first few weeks, therefore, is not really training. Your hard sessions will have to remain in the pool or on the bike for a while.

It is important not to increase the distance, frequency, and intensity of your running all at the same time. In any given week, you can increase one or two, but not all three of these training variables. For the first several weeks, it is best to increase the distance and frequency of your runs, but to keep the intensity moderate. After a month or two of this base work, you can gradually add higher intensity workouts such as tempo runs and long intervals to your program.

Initially, you should run every 3rd day or every other day. This will give your bones, ligaments, tendons, and muscles time to adapt to the stresses of running. You can then progress to two days running and one day off, then three days running and one day off, etc. During this time it is important to avoid the factors that caused the injury in the first place, such as worn out shoes, running on concrete, too much downhill running, or increasing your mileage too quickly.

A Sample Program

Each runner’s recovery from injury is unique. This sample program is based on several runners’ stress fractures of the tibia and metatarsals. Time off from running for these runners varied from 4 to 8 weeks. This seven-week schedule is devoted to regaining fitness while avoiding re-injury. Your own situation may differ substantially, so your training may need to progress at a different rate. In planning your return to full training follow the principles discussed and listen to your body’s feedback.

Seven-Week Schedule for Returning from Injury

Week
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
1
Walk 10 min, Run 5 min, Walk 5 min, Run 5 min Run in water or other training Run in water or other training Walk 5 min,Run 5 min,Walk 5 min,Run 5 min,Walk 5 min,Run 5 min Run in water or other training Run in water or other training Walk 3 min, Run 7 min, Walk 3 min, Run 7 min, Walk 3 min, Run 7 min
2
Run in water or other training Walk 2 min, Run 8 min, Walk 2 min, Run 8 min, Walk 2 min, Run 8 min Run in water or other training Run 10 min, Walk 2 min,Run 10 min, Walk 2 min,Run 10 min Run in water or other training Run 12 min, Walk 2 min, Run 12 min, Walk 2 min, Run 10 min Run in water or other training
3
Run 15 min, Walk 2 min, Run 15 min Run in water or other training Run 20 min, Walk 2 min, Run 10 min Run in water or other training Run 25 min Run in water or other training Run 30 min
4
Run in water or other training Run 25 min Run 30 min Run in water or other training Run 25 min Run 35 min Run in water or other training
5
Run 30 min Run 35 min Run in water or other training Run 30 min plus 6 x 100 meter stridouts Run 30 min Run 40 min Run in water or other training
6
Tempo Run (15 min warm-up, 15 min @ 15 km race pace) Run 30 min Run 45 min Run in water or other training Run 40 min plus 6 x 100 meter strideouts Run 30 min Run 50 min
7
Run in water or other training Run 35 min Tempo Run (15 min warm-up, 20 min @ 15 km race pace) Run 35 min Run in water or other training Run 40 min plus 6 x 100 meter strideouts Run 55 min

Why do runners get stress fractures?

According to a 1996 review in Sports Medicine, stress fractures “result from repetitive, cyclic loading of bone which overwhelms the reparative ability of the skeletal system.” Stress fractures can occur from either increasing the load on the bone (e.g. adding speedwork, switching from trail running to sidewalks, or wearing less supportive shoes), or from increasing the number of times the bone is stressed (i.e. increasing your mileage). Running causes more stress fractures than any other sport because we tend to run on hard surfaces and land with forces of 4 to 6 times bodyweight.

The impact forces of running make our bones stronger, however, our bones can only adapt at a gradual rate. That is why you may get a stress fracture from increasing your mileage too quickly from 20 to 40 miles per week, but a few years later may handle 60 miles per week with no problems.

(This column originally appeared in Running Times Magazine.)