Can I Run During an Injury and if not, When can I Return to Running After Injury or Surgery?
These are million-dollar questions! My answer is, "It depends."
A patient with patellar tendonitis, whom I instructed not to run, came into his appointment and said, "I feel great, and I ran seven miles two times last week." I lifted my head from my laptop, peered at him through my glasses, and gave him a grin and head nod of understanding while at the same time resisting the urge to roll my eyes back in my head.
As a runner who has experienced many injuries and surgeries, I empathized personally, but as a physical therapist, it is cringeworthy when a patient goes rogue.
Why rest from running or manage your return to running after an injury or surgery?
The musculoskeletal system, which includes bone, takes time to heal and strengthen progressively. When running, the structures must tolerate repetitively loading at least three times your body weight.
Several factors determine whether you can run during an injury or when you can return to running after an injury or surgery.
When and whether or not you should run depends on an injury's nature, severity, and chronicity. Does the injury involve bone or soft tissue like a tendon? Is the injury mild or severe? How long has it been present? Six months, three years, or two weeks?
Nature of the injury or Surgery.
If the injury involves tendons and ligaments, it can sometimes take longer than a fracture to heal. The rule of thumb for tissue repair is at least six weeks if you do all the right things! Some surgeries require six weeks of rest from running and high-impact sports, and others require six months or more. Runners undergoing surgery should always have post-operative physical therapy if they want to return to sport.
Severity of an Injury.
The more severe the injury, the longer it will take to return to running. For example, a grade III calf injury may need months of rest, while a grade I calf injury may only require a week of rest from running. Check out my article on Calf Strain and Pain.
Chronicity of an injury.
The longer an injury has festered, the longer it will take to return to running. This is a rule of thumb, and I find it is usually accurate. And why all runners should seek professional help if an injury does not subside within a week of rest and modification.
Signs, symptoms, and issues that indicate you need to rest from running or wait to return to running after an injury or surgery.
Poor biomechanics due to lack of stability, strength, or range of motion
Swelling/inflammation
Pain greater than a 3/10 during or after running
Poor Biomechanics
Many runners can feel when their run gait is “off” or when weakness or lack of mobility is present. Weakness and/or loss of range of motion is your body’s way of telling you that something is off - they are protective mechanisms. Pushing through a run in these circumstances will delay healing, worsen the injury, or even cause another injury!
Swelling and Inflammation
Swelling is a sign that the body is not okay. It is a red flag, a warning to stop running. Intermittent, mild swelling may be permitted with a return to run, but it means that you’ve done too much. Ensure you are working with a physical therapist to help you manage your back to run the program. Check out my article on Aiding and Controlling Inflammation.
Pain
Once again, it is a warning sign that something is not right. If unmedicated, your pain is greater than a 3/10 on a pain scale where 0 is no pain, and 10 is emergency room pain, then you should not run. Do not take pain medication to run. Pain is a fascinating and multi-faceted topic, and your physical therapist can help you navigate when it is okay to have some pain. Check out my article: Pain and Injury Doesn’t Mean You Have to Quit.
Resting from running impacts our mental health. Acknowledging and addressing our mental headspace is just as important.
Following my patient’s admission to running, an explanation ensued, "I don't drink, I don't smoke, and I don't do drugs. I run." Running releases serotonin, which makes us feel good, and it is a mental escape, a muse. Taking it away from us for too long can mess with us physically, emotionally, and mentally. Fear of losing fitness comes at a close second to the effect on our headspace.
Acknowledge this aspect and work with your physical therapist to manage it with modifications and alternatives for running.
Modifications in running during injury and returning to running programs after injury are not one size fits all! It is personal and individual.
With mild injuries, sometimes running can continue, albeit modified in volume, intensity, and perhaps surface, while you heal. When it comes to a back-to-run program or continuing to run while managing an injury, finding the right recipe can be complicated: it takes practice, finesse, and patience. It's an art as much as a science, and an experienced physical therapist specializing in running can help.
Your physical therapist will continually test you to ensure you meet benchmarks for return to run and, when you meet them, will set you up with a back-to-run protocol. That protocol will consider how much time you’ve rested from running, your specific injury or surgery, your running experience, and your tolerance.
Invest in your running future.
My patellar tendonitis patient was lucky. Most runners that do this rouge testing don't fare as well and end up setting back their healing and their return to run. Pay attention to the signs and symptoms that should stop your run, and seek professional help for managing your rest, modification from, and return to run; it is an investment in your running future!
Stop injuries before they occur!
Learn the top five training errors that lead to injuries in runners in this blog post.
Massage Guns: Do or Don't?
"Should I use a percussion device or massage gun?"
That is an excellent question; unfortunately, many patients and athletes assume devices they see at race expos, post-race recovery tents, or in magazine articles are safe and don't question it.
My answer is no; you should not use a percussive device or massage gun. Before you discard yours or ignore my answer and go ahead and use it anyway - yes, I know who you are - please hear me out.
The reason I do not recommend the use of percussive devices or massage guns is that the risks outweigh the benefits. Unlike vibrating massage heads or foam rollers, these devices create a downward force into the body's tissue like a jackhammer, and the smaller the head(s), the more concentrated the power. This hammering force can cause damage, sometimes severe.
Unfortunately, athletes, in particular, associate "pain" with stretching or massage as beneficial. "It hurts, so it must be working." That is rarely the case. It is difficult for injured or sore athletes to discern when it is acceptable to feel discomfort with a self-treatment method like a massage gun.
Risks of using a massage gun
Safely using a percussive or massage gun requires a thorough command of human anatomy. Besides a general knowledge of where the claves, glutes, and hamstrings reside, most athletes and patients are unaware of the location of nerves, blood vessels, lymph nodes, bursae, organs, tendons, or ligaments. Improper device placement over these structures can cause severe damage.
Massage guns on injured and inflamed connective tissue can further damage the structure and increase inflammation. For example, use on a torn ligament, like an ankle sprain, could injure it further.
There are many examples of patients in my clinic who improperly used a massage gun to treat their soreness, pain, or injury. Below are four cases.
Case #1
A patient attempted to treat his groin pain, in this case, psoas tendonitis, and placed the gun in the area where the femoral nerve, artery, and vein reside. Not only is it contraindicated to use the device on the injured, inflamed psoas tendon, but the risk for vessel and nerve damage was high in this area.
Case #2
A patient tried to treat his pectoral muscle strain and aimed the device in his armpit on a large bundle of nerves called the brachial plexus. Damage to these nerves could cause temporary or permanent disability to the entire arm/hand.
Case #3
A patient attempted to treat her knee pain and aimed the device at the painful spot but didn't realize that what "hurt so good" was the peroneal nerve. Damage to this nerve could cause foot drop - or lack of the ability to lift the foot.
Case #4
A patient tried to treat her sore "glute" with the massage gun but didn't realize she aimed it at a bursa (a fluid-like sack) in the same area. Because this was my initial visit with her, it is hard to know if she was suffering from bursitis before using the gun or afterward, but in either case, her injury and pain were worse.
Dangers and contraindications for massage gun use
While rare, a percussive massage tool can sometimes cause severe or life-threatening injuries, including fractures or joint damage, deep vein thrombosis, and rhabdomyolysis.
Using a percussive massage gun can cause a fracture in persons with osteopenia or osteoporosis. Never use a massage gun at the site of a fracture - even a stress fracture. If you suspect a fracture go to the emergency room or an orthopedic urgent care center.
Deep vein thrombosis is a rare but life-threatening condition, especially for post-surgical patients. It tends to show up as calf pain and soreness. A massage gun on that sore calf could dislodge the blood clot and cause a pulmonary embolism and death. If you are experiencing symptoms consistent with a blood clot, go to the emergency room.
Rhabdomyolysis is a severe and potentially life-threatening condition. Endurance sports athletes are particularly at risk of acute exercise-induced rhabdomyolysis (AER), which can occur after profound overexertion, such as after a long run, ride, or race. Endurance athletes using percussion massage to treat delayed onset muscle soreness after an endurance event or training session may be at a higher risk.
There is a case in the literature of a patient who suffered a case of severe rhabdomyolysis after percussion massage: Chen, J., Zhang, F., Chen, H., & Pan, H. (2021). Rhabdomyolysis After the Use of Percussion Massage Gun: A Case Report. Physical Therapy, 101(1). https://doi.org/10.1093/ptj/pzaa199
Not ready to throw your massage gun in the trash?
Limited research supports that a percussion device can help with increased mobility when used on healthy tissue and when operated by a healthcare professional. The risks outweigh the benefits, but if patients and athletes insist on using them, I recommend scheduling an appointment with a physical therapist to learn how to use them safely.
While your health is serious business, we can also take a minute to laugh about the massage gun. Check out comedian Tom Papa’s bit about these “weapons-grade jackhammer massage guns.” Tom Papa: What A Day!
Alternatives to achieve mobility
Physical therapists, patients, and athletes have many safer alternatives to achieve mobility. Subscribe to Coach Amy Says to receive upcoming posts on how to achieve mobility and why Coach Amy does not recommend stretching as well as other tips on injury prevention, wellness, and performance.
Coach Amy discusses massage guns and all things endurance sport with Coach Liz in their podcast, The Coach Amy and Coach Liz Show. Coming soon to Apple Podcasts, Google Podcasts, and Spotify.