Returning to running after injury

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Running after injury

It may surprise you to know that, running places relatively low demand on the knee and is a great way to get and stay fit, as well as helping to maintain good mental health and sleep habits. But many people fear running after injury will either damage their knees and that they shouldn’t run if they’re in pain. This is simply not the case according to the best research. You can run, and its good for you.

Two of the most common injuries that typically stop you from running because of pain and fear of worsening injury are Achilles tendon pain and anterior cruciate ligament (ACL) surgery.

In an excellent single-blinded randomised controlled trial, by Silbernagel et al., runners aged 20-60 years with Achilles tendinopathy (defined as Achilles pain for more than 2 months) were divided into two groups. One group was told to stop any exercise that loaded the tendon e.g. walking, running and jumping (but were allowed other non-loading exercise such as cycling and swimming) and the other group continued to run as long as their pain reached no more than 5/10 during exercise and must have subsided by the following day.

Both groups were given the same rehab programme that increased and strengthened Achilles tendon-loading over 12 weeks to 6 months involving 2-legged, 1-legged, eccentric and fast-rebounding toe raises gradually increasing range of motion, repetitions, load and finally plyometrics.

There was no difference in pain, rate of improvement, or function between the two groups at 6 weeks, 3-, 6- and 12-month evaluation and ultrasound of the tendons in the two groups were similar.

So its good news if you’re a runner with Achilles tendinopathy – keep running as long as your pain doesn’t increase over 5/10 during your run, and subsides over 24 hours, and use progressive loading to rehabilitate the tendon!

If you’ve had an ACL tear and reconstruction, its important that you rehabilitate your knee before you start running. You’ll have experienced significant loss of muscle bulk in your thigh and lower leg muscle groups and need to start building this back up. Premature return to sport increases the risk of reinjury and delay in rehab can hinder your motivation and readiness to exercise. So what are the criteria that you should assess to make sure your knee can take the strain?

According to Rambaud et al. who in 2018 conducted a massive review of the literature, the median average time for return to running was 12 weeks (the full range was 5 to 39 weeks post-surgery). Ability to return to running was based on any of the following three categories.

  1. Time (all 201 studies used a time criterion)
  2. Strength and performance testing (31 studies used this measure for RTR -return to running)
  3. Clinical findings (fewer than 1 in 5 studies used this measure)

The authors of the study recommend ‘non-negotiable’ clinical milestones to ensure functional loading allowing your knee to cope with activities of daily living and rehabilitation before higher level tasks such as running.

An increase in pain, swelling or movement restrictions after walking, strengthening and/or sensorimotor control exercises suggests poor load management and mean you should probably wait before running, irrespective of the postoperative time.

Non-negotiable clinical milestones

  • pain <2 on visual analogue scale (subjective rating scale)
  • 95% knee flexion RoM
  • full extension RoM (0° knee extension)
  • no effusion/trace of effusion

Strength and frequent functional testing, using a range of different tests, that starts early in the rehabilitation process characterises high-quality rehabilitation.

Information gained from these tests gives your clinician feedback that can be subsequently used to target specific deficits and make changes, as necessary, in a timely way.

Clinicians are not clairvoyants—without regular assessment, it is impossible to know whether the planned rehabilitation is high quality and appropriate for the individual patient.

The authors of the study suggest the following strength and performance-based criteria: hamstring and quadriceps LSI (limb symmetry index)>70% evaluated by isometric assessments, and hop test LSI>70%. The addition of a single-leg squat or step-up assessment performed without increase in knee valgus may also be considered.

Further functional tests that replicate some of the physical requirements for running include

  • hop tests performed with a controlled and balanced landing
  • single-limb squats at 45° knee flexion, performed without loss of balance and without dynamic knee valgus
  • step-up-and-holds
  • Y-balance test and
  • modified Star Excursion Balance Test

Your physiotherapist or your osteopath will be able to guide you through the different stages of a safe return to physical activity so If you have any queries about whether you’re ready to start running again, call us on 020 7735 6813 and ask to speak to one of our physiotherapists or osteopaths!


Silbernagel et al. (2007) Achilles Tendinopathy: A Randomized Controlled Study Continued Sports Activity, Using a Pain-Monitoring Model, During Rehabilitation in Patients With Achilles Tendionpathy: A Randomised Controlled Study, American Journal of Sports Medicine

Rambaud et al (2018) Criteria for return to running after anterior cruciate ligament reconstruction: a scoping review, British Journal of Sports Medicine


If you’re not sure whether we can help, please give us a call on 02077356813 or email