Our articles are not designed to replace medical advice. If you have an injury we recommend seeing a qualified health professional. To book an appointment with Tom Goom (AKA ‘The Running Physio’) visit our clinic page. We offer both in-person assessments and online consultations.
Chris Johnson is a multi-talented guy! He’s a physical therapist, certified triathlon coach, multiple time Kona qualifier and the owner of Zeren PT & Performance. Plus Chris is the CEO of RunCadence, an app we featured recently that helps runners optimise their gait retraining through changing cadence. He also has an extensive Youtube video library for runners and multi-sport athletes and you can follow him on Twitter via @ChrisJohnsonPT.
Chris is joined today by the equally talented Nathan Carlson (@RunningMateKC), a physical therapist, USATF certified coach and founder of RunningMateKC in Kansas City. Sounds like a dream team to me! I’ve been looking forward to their take on returning to running so I’ll hand you over to Chris and Nathan…
“When can I run?” is perhaps the most common question for runners to ask clinicians. Wouldn’t it be nice to provide a clear, succinct answer while delineating a path back to consistent running? For a sport with relatively predictable performance demands, clinicians routinely provide clients with a nebulous response, and invariably lose the runner’s trust from the outset. Our typical response to this question is… “You can return to running when your bones can effectively handle the shock of impact, your muscles can tolerate eccentric contractions, and your tendons can store and release energy in a repetitive manner, all while controlling motion in the sagittal, frontal, and transverse plane.” The focus of this piece is to share a group of exercises that the authors routinely use in working with runners following tissue injury.
The goal of a proper rehab program is not only to help runners build the necessary capacity to get through their daily routine, but to also withstand the performance demands of running; a repetitive plyometric activity that involves bounding from one leg to the next in a balanced manner. This is best accomplished through a “considered, gradual overload by progressing the intensity and complexity of movements specific for that tissue and region” before finally restoring capacity in the entire kinetic chain (Cook & Docking 2015). While every runner must be treated on an individualized basis, let’s make no mistake that all runners must be prepared to withstand a specific set of prerequisites related to running. By taking the time to understand the performance demands of running, we will be in a better position to develop a comprehensive, direct, dynamic, and progressive routine to foster a safe and timely return to consistent training and beyond.
Prerequisites to Return to Running:
- Tolerant of unilateral loading of both lower extremities with good postural stability
- Ability to progress the leg over the foot (ankle dorsiflexion)
- Ability to progress through the forefoot and first ray
- Tolerant of both open & closed chain contractions involving the lower extremity
- Ability to repetitively hop on each leg multiple times
- Tolerant of a progressive walk-run routine
METRONOME MARCHING – to effectively run, one must be able to tolerate unilateral loading of both lower extremities in an upright manner. Therefore, one of the primary goals during the early stages of rehab is to get the performer to fully load the involved extremity while assuming an upright position in single-leg stance. Marching is a great exercise along these lines because it effectively challenges unilateral loading while forcing the runner to progress through the forefoot while synchronizing the contralateral arm and lower extremity. Incorporating the use of a metronome is also encouraged because it serves as a great external cue while reinforcing the rhythm and timing associated with running. It also affords a greater degree of objectivity from an exercise prescription standpoint when it comes to rate of force development. The authors routinely start runners at 30bpm and progress them up to 150bpm, which is roughly when most runners tend to adopt a float phase. It should also be mentioned that the performer should avoid locking the knee of the stance leg into hyper-extension and gripping with the toes. Lastly, I encourage the performer to initiate contact with the forefoot when lowering the non-balancing leg to the ground as a means to reduce their step length and safeguard against over-striding, which has been shown to yield distinct benefits in relation to the running gait (Heiderscheit et al. 2011). Marching can also be progressed through the use of external resistance such as barbells and a weighted vest, which both serve to increase the axial load. With regards to training parameters, I usually have runners perform 3-5, 10yd passes and perform 1-2x daily in conjunction with other exercises.
Metronome Marching
Marching Drills for the Ages
LATERAL TOE TAPS –for such a simple exercise, lateral toe taps yield a myriad of benefits through effectively challenging runners in all three planes. This is a particularly effective drill for training the lateral hip musculature and gluteus medius while reducing TFL activity when compared to performing the exercise in a more upright posture (Berry et al 2015). This is perhaps the most common exercise that we prescribe to female runners during the early phase of rehab once the runner is able to tolerate unilateral loading. Research by Noehren and colleagues has prospectively shown that increased hip adduction during the stance phase of running is predictive of females who go on to develop patellofemoral pain (Noehren et al 2013). Additionally, the peak force of the gluteus medius during loading response is significantly greater than any other hip muscle (Lenhart et al. 2014). Focused training of the posterolateral hip musculature, therefore, deserves keen attention. Lateral toe taps also serve as a reasonable entry point to challenge ankle dorsiflexion, lateral hip strength, quadriceps strength and trunk control. While several clinicians tend to prescribe crabwalks right off the bat, it has been the experience of the authors that runners routinely employ a wide array of compensatory motions. When instructing this drill, challenge the runner to position their foot such that the great toe is pointed towards 12 o’clock unless they exhibit a bony torsion in one or both lower extremities. Once runners master the lateral toe-tap drill, they can progress to lateral and cross-body toe taps to further train the lateral hip musculature in an eccentric manner. From there, feel free to move on to resisted sidestepping and quick crabwalks. Another great drill combo is the “Sidestep to lateral hop progression.”
Simple Frontal Plane Progression for Runners
Sidestep to Lateral Hop Progression
STEP UPS – the step-up drill is a staple in nearly all lower extremity rehab and sports performance programs, yet also happens to be one of the most bastardized exercises. Considering that the motion of the knee primarily occurs between 20-45 degrees of knee flexion (Dicharry 2010), the step-up is a great drill to challenge the runner in this range. The step-up also demands ankle dorsiflexion, lateral hip strength, quadriceps strength, and lumbopelvic control all while challenging the runner in a unilateral manner. Here is practical step-up progression that can be used in both the clinic as well as for home programs. Once a runner masters this progression, they can focus on “Step up and overs” to further challenge the performer to progress through the first ray while incorporating a retro step to take them out of their typical pattern. Yet another progression of the step-up is to combine a few different motions into one drill series. A great example of this would be the “Four-way step series.”
Simple step-up progression
Step up and over
Four way step series
JUMPING DRILLS – perhaps one of the greatest pitfalls to most running rehab programs is that they fail to expose the runner to plyometric activities during the late stages of rehab. Failure to incorporate some form of plyometric training can lead to incomplete rehab and a potential relapse when attempting to return to running. While the exercises featured above promote muscle recruitment, strength, and endurance; they fail to simulate the speed and forces that runners encounter during training racing. Plyometric exercises and drills, therefore, serve as a means to bridge the gap between traditional rehab exercises and sport-specific activities (Chmielewski et al. 2006). While a wide range of plyometric drills can be incorporated into the rehab process, we selected relatively simple baseline drills that can pave the way for more advanced training. By no means do runners need to master all of the drills listed below. Rather, these are just a handful of exercises to consider pending the level of runner that is in need of your care.
Four Square Hopping Basic
Quick Tap Variations
Repetitive Box Jumps
Four Square Hopping Advanced
Advanced Platform Jump Series
SKIPPING DRILLS – one of the many mantras that you we use in working with runners is that “if you can skip, you can run.” Being able to tolerate single-leg, plyometric activity is a key component to progressing a runner back to training. Single leg hopping is an excellent drill to implement in late-stage rehab in order to facilitate the elastic loading that happens during running. The runner should attempt to maintain their “springiness” throughout the drills and focus on their foot staying on the ground for a very short amount of time. One verbal cue you can use is “Imagine there is a pane of glass above your head, and that you are trying to break it with every repetition.” Adding an incline to hopping activities further increases the demand on the lower extremity musculature.
Lateral Skipping Over Hurdles
Sample Skipping Variations
Single Leg Hopping for Runners
