Running Injury Recovery
Running injury recovery used to be focused on RICE: Rest, Ice, Compression and Elevation. RICE has been shown to actually slow recovery from injury and healing. After a running injury there is a natural and beneficial inflammatory process around the injured tissues that we want to allow to happen. Inflammation around the injured area creates a natural brace that limits movement (think sprained ankle) to allow injured tissues to heal. The inflammatory fluid also contains many substances that help with the pain and healing including neutrophils, macrophages, and satellite cells. If we ice, compress, or elevate the injured area we are decreasing this natural and helpful inflammation which will slow healing.
PRICE is another common acronym where the P which stands for Protect was added to RICE. Protecting the injured area to prevent further injury in a good idea for a limited period of time, but the body will naturally do this with pain messages and natural inflammation. We want to use braces, wraps, tapes, orthotics, etc. as little as possible because they all weaken the body and allow movement before the body is ready which can lead to re-injury.
PEACE is third acronym used for running injuries. PEACE stands for Protect, Elevate, Avoid anti-inflammatories, Compress, and Educate. Protect, Elevation, and Compression I already talked about above. Avoiding anti-inflammatories is a good idea because as I stated above, we want to allow the neutrophils, macrophages, and satellite cells to surround the injured tissues to help it heal faster. We also don't want to take any drugs that decrease the feelings of pain because pain signals are there to tell us whether or not we are ready to start loading the injured tissues. If it hurts, it's not healed and too early to start running again. When the area is naturally pain free, then it's our body telling us we can slowly are carefully start running. Education is always a good thing (you’re educating yourself right now!).
LOVE is the newest acronym used when talking about running injuries and stands for Load, Optimism, Vascularization, and Exercise. The acronym LOVE is great: we want to slowly start Loading the injured joint in most cases (as long as the pain is not increased by loading). Optimism creates both physical and mental/emotional changes associated with faster healing and better health. Pessimism creates physical and mental/emotional changes associated with slower healing and worse health. The choice seems clear. Vascularization means getting pain free cardiovascular exercise because it boosts blood flow, keeps muscles and joints moving, and boosts motivation and mindset. Exercise is referencing specific therapeutic exercises to restore strength, mobility, and proprioception to the injured joint and other affected joints.
Let's summarize what slows recovery from running injuries and what helps healing happen faster:
Bad: Ice, Compression, Elevation, Anti-inflammatories, prolonged external Protection and anything that reduces your body's natural inflammation or numbs your pain.
Good: Load, Optimism, Vascularization, Exercise, limited Protection and anything that allows your body to heal itself naturally and any pain free movement and therapeutic exercise to restore function.
Myth 1: Injuries are the result of bad luck.
Truth: Scientifically there is no such thing as bad luck, thus that can't be the cause of running injuries. All running injuries are caused by something concrete and with enough investigation the underlying cause can be found and fixed or eliminated, which will help that injury heal faster and more completely and help prevent future running injuries.
Myth 2: Injuries are from overuse.
Truth: Most running injuries are not from overuse (running too much etc.) but caused by posture imbalances, especially left to right imbalances in your body. You don’t get right Achilles tendon pain (save the tendonitis vs tendinosis debate for another time) because you are running too many miles, but because your right foot strike is compromised. Why is it compromised? There could be many reasons, but some examples are: your right shoulder blade is locked up and out of position; or your right hip is not flexing and extending from the hip joint correctly; or your left hip is unstable and you’re overloading your right leg; or your right ankle lacks dorsiflexion; or…The point is, it is not an overuse issue like running too many miles, running too fast, running too much vert., it is a posture imbalance issue that needs to be addressed.
Myth 3: Most running injuries are caused by inflammation.
Truth: Most running injuries RESULT in inflammation but are not caused by inflammation. If you sprain your ankle, either straining or tearing ligaments, your body senses the damage and instability created by the sprain and inflames the area for several reasons. The inflammation creates a natural brace to limit movement at the ankle until the ligaments have healed – brilliant! The inflammatory fluid also contains many substances that help with the pain and healing including neutrophils, macrophages, and satellite cells. The last thing we want to do is reduce this inflammation after an acute injury. The inflammation is actually helping us in multiple ways to heal faster. Running injuries are not caused by inflammation but result in inflammation.
Myth 4: Running injuries are caused by a weak core.
Truth: Most running injuries are not caused by a weak core. Most running injuries are caused by posture imbalances. Most running injuries are one sided. Think about it: you injure your right knee, or left ankle, or right foot, or left hip. Most injuries are not to both feet at the same time or both knees - it's either your right or left side. Why? Because you have posture imbalances left to right in your body. Yes most physical therapists will immediately tell you your core is weak and give you exercises to strengthen it, but that is doing nothing to fix the underlying cause of your running injury.
Myth 5: Your knee hurts, so it must be a knee problem.
Truth: Knee injuries are almost never caused by a knee problem, just as foot injuries are almost never caused by a foot problem. Knee injuries and foot injuries are related to your ankles, knees, hips, spine, and shoulders because your body is a unit and everything works together. If you injure your right knee it could very well be because your left hip is weak causing you to overload your right knee. If you injure your lower back it is probably because your hips and upper back have lost mobility and function, putting increased stress on your lower back. Again the key is finding and fixing the underlying cause of your injury, not just treating the injury itself.
Myth 6: Once you injure a joint, it will always be prone to re-injury.
Truth: It is true re-injury rates are alarming: ACL up to 60%, disc herniation up to 20%, rotator cuff up to 80%, ankle sprain up to 30%, etc. The reason re-injury rates are so high is because most people treat the injury, but never fix the underlying cause of the injury. It's like this: You spilled a box of nails on your driveway and you drive over them and your car gets a flat tire. You repair your tire and then get another flat the next day as you drive over the nails again. It's no surprise you got another flat tire! You forgot to pick up the spilled nails on your driveway! When we correct or fix the cause of the running injury we can prevent future re-injury.
Myth 7: It’s important to RICE or PRICE after an injury.
Truth: RICE which stands for Rest, Ice, Compression, and Elevation or PRICE which adds Protect to the start, do not help running injuries heal faster and research is showing they most likely slow healing. Why? Post injury inflammation is helpful to healing. We want to allow the body’s natural inflammation to remain to allow faster healing of the damaged tissues. Ice, compression, and elevation were all designed to decrease inflammation, which is what we now know is the opposite of what we want to do. What about Rest? Resting the injured area is a good idea initially but once the initial pain has decreased it’s important to start slowly and carefully moving the injured area. Movement helps improve blood and lymphatic flow which is important to remove waste products from the injured area and to bring more nutrients and healing cells to the injured area. Movement can decrease scar tissue from forming which can lead to future problems. The key is keeping movement gentle, slow, easy, and as pain free as possible.
Myth 8: A stress fracture is caused by RED-S or low energy availability.
Truth: Stress fractures are caused by imbalances in your posture and gait not low energy availability. Why? The stress fracture almost always happens on one side of the body – like one tibia, or one femur, or one side of the pelvis. Pure nutritional issues wouldn’t show up on one side of the body. Posture imbalances left to right in the body have caused increased load and stress on one side of the body and one part of the body causing the stress fracture. Fix the imbalances and the stress fracture wouldn’t happen. (Don’t take this to mean that RED-S and low energy availability isn’t a big problem in sports and especially ultra-endurance running – it is. And I encourage everyone to eat enough and not restrict eating at all. Food is vitally important for health and performance. It’s just not the cause of injuries like this.)
Myth 9: After a running injury we should always take anti-inflammatory drugs (NSAIDS) like Ibuprofen, Aspirin, or Naproxen.
Truth: NSAIDS slow healing because they decrease natural and positive inflammatory cells around the injury site. Those inflammatory cells (like neutrophils, macrophages, and satellite cells) play an important role in tissue healing after injury. It’s also important to remember pain plays an important role after injury – it keeps us from using/loading the injured tissues before they are healed and ready to be loaded. NSAIDS decrease pain which might encourage someone to start using the injured area too soon which could lead to more injury.
Myth 10: Running injuries are genetic.
Truth: Genetics determine our hair color and how tall we are, but not whether we get running injuries or not. Just because your father and two brothers have had plantar fasciitis, it does not mean you are going to get plantar fasciitis.
If you'd like to discuss your injury and learn what's really causing your injury and how you can fix it and get back to running pain free, contact me and let's have a conversation about it.
Matt's first trail race win!
Many people start running later in life, and what a great thing to discover running in your 40s, after your kids go to college, or after you retire. There's nothing like the joy that comes from trail running in beautiful places, the peace of early morning runs, and the sense of accomplishment that comes from finishing your first ultra or a premier 100 miler like UTMB or Western States. Matt however, discovered running and his love of trail racing quite a bit earlier than that...(cue the flashback music)
Matt's first race was a 4th of July kids fun run in Council Idaho in 1981 at the age of 2. As seen below, Matt was so fast he not only won the race, but had time to be talked into "breaking the tape" before the other runners finished. Matt had learned at an early age not to break things, so he didn't want to "break the tape" at the finish line.
After this race, Matt had a love of running and never stopped running, even though he didn't always win the race.
Trail and ultra running thoughts, advice, and research.