Running Injuries Recovery Time Lines

Picture from Interplay

I feel that we live in an instantaneous society now where you snap your fingers and you want things done. Fast food, fast internet and fast access to pretty much everything. 

I have many patients who are new to running and want to be a great runner, fast. Many runners expect to improve their times with short periods of training and end up doing too much too soon.

Then there are those who are injured and try to accelerate rehabilitation and recovery beyond normal time lines. I would like to caution that effective recovery will take time and cannot be rushed or forced. 

The 2 times that I fractured my spine, I too hoped to heal faster. However, I cannot accelerate healing and rehabilitation beyond what biology will allow. I can only optimize it.

Back to running injuries. I looked at a study that studied average recovery times for common running injuries. When you look at the study the numbers may surprise you and many of the healthcare professionals that read this.

140 runners out of 839 sustained a running injury in this 24 week study (Mulvad et al, 2018). Runners in the study reported levels of pain in different body parts on a weekly basis. The injured runners attended a physical examination by a physiotherapist who provided a diagnosis. Examples are medial tibial stress syndrome (MTSS or shin splints), Achilles tendinopathy (AT), patellofemoral pain (PFP), Iliotibial band syndrome (ITBS) and plantar fascia pain (PF).

The median time to recovery for ALL types of injuries was 56 days. Yes, you read correctly. Actually let me show you the average recovery times the study found.

Plantar fascia - 35 days

Calf injury - 49 days

PFP - 49 days

AT - 56 days

ITB - 56 days

Gluteus medius tendinopathy - 56 days

Shin splints - 70 days

Hamstring - 74 days

Medial meniscus - 89 days

Surprised or shocked? You should know that effective recovery takes time. Tendons, cartilage, muscle  and especially bone will nor respond to any "magic recovery hacks" or when you try do more. They will respond to patience and appropriate loading. 

When you try to rush your rehab, it usually does not shorten the time line. It will increase the risk of flare ups, setbacks and recurrence.

Now please take note that good and correct rehab is not slow, just appropriately paced. Not everyone will take the same time to recover like those quoted in the study. Recovery is not passive, you can still train. Can't run, stationary cycling should be fine. The healthcare professional treating you should be able to give you alternatives, otherwise you should find another. It is definitely not one size fits all. 

The devil is always in the details. Only 140 out of 839 runners got injured. "Recovery" was self reported by the runners based on return to running without symptoms not performance goals.

The study did not review load management, rehab quality or whether the injuries presented early or late. Neither was training age, sleep, stress levels, nutrition nor psychology taken into account.

The goal is to work within and with the time line, not to beat it. You want the recovery to be boring but steady.

Do not believe anyone who tells you they can give you a short cut.

Reference

Mulvad B, Nielsen RO, Lind M et al (2018). Diagnoses And Time To Recovery Among Injured Recreational Runners In The RUN CLEVER Trial. PLoS One. 13(10): e0204742. DOI: 10.1371/journal.pone.0204742

Our Words Affect Pain

Picture from Coregymball

It may be just words you think. Perhaps not. Recently published fascinating research suggest that how healthcare providers describe an injury can have a direct impact on a patient's pain. 

Not only were the patients blinded (a technique used to minimise bias), the patients also did not know they were part of a study.

Picture from article

50 recreational runners with Achilles tedinopathy took part in the radomized trial (pictured above). They ran 3 times a week. Runners in the experimental group received diagnostic information of tendon pain that highlighted reversible changes in muscle function as their primary problem. They did not hear any reference to tendon pathology.

The control group received an explanation of tendon pain that prioritised irreversible structural tendon pathology as the cause of pain.

The primary outcome measure was how much pain the runners had during a standardised hopping task measured on a scale of 0-100. Secondary outcomes were how stiff the lower limbs were hopping and time in seconds for pain to ease after completing the hopping task.

The diagnostic information immediately affected pain intensity during the hopping task. The average pain score was 25.4 in the experimental group versus 36.7 in the control group.

Time to ease (no pain) after hopping was near identical in both groups. Lower limb stiffness was higher in the experimental group. Note that higher leg stiffness is better for leg hopping because increased leg stiffness allows for greater force production and more efficient energy transfer. This leads to higher jump heights and faster movement.

This is a really intriguing area of research. We now have data showing that information from healthcare providers during the first visit has an immediate effect on pain. The language we use during clinical interactions can be powerful, shaping our perceptions and pain responses. This knowledge should change how we interact with our patients. 

However, we need to also be able to do this in our clinics without compromising the accuracy and necessary medical information.

Reference

Travers NJ, Travers MJ, Gibson W et al (2025). The Content Of Diagnostic Information Has An Immediate Effect On Pain With Loading In People With Morportion Achilles Tendinopathy: A Randomized Clinical Experiment. Bra J PT. 29(5). DOI: 10.1016/j.bjbt.2025.101244

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

Patient With Plantar Fasciitis Who Saw Me 3 Days Ago Won 100 km Race

My patient who had been having plantar fasciitis came to see me 3 days ago in the clinic just won the 100  km Cameron Ultra-Trail race.

It was quite a last minute request and I could only fit her in for a 30 minute session during my lunch break (new cases usually have an hour's appointment in our clinic).

Have a look at our WhatsApp exchange.

Not bad for half an hour's work. Now at least I get a full hour to sort it out properly next week. What did I do to treat her? Let me review her case when I next see her and I'll do a follow up post if I find something interesting.

Tendon Damage Linked To Antibiotics

Picture by Oliver.Dodd from Flickr

I thought my patient was kidding when he mentioned that his ruptured Achilles was due to his antibiotic medication. He had to have surgery repair his ruptured Achilles tendon and came to our clinic for treatment and rehabilitation.

I did a quick search and found that the US Food and Drug Administration (FDA) has (since 2008) made it compulsory for drug companies to put a warning label on the side effects of ingesting fluoroquinolone (FQ).

Now if you have taken antibiotics (especially fluoroquinolone), regardless of whether you're active or not, you might want to read on.

FQ are a popular class of broad spectrum antibiotics. They are able to kill a wide range of harmful bacteria and will often work against infections that are resistant to other drugs.They are commonly prescribed for sinus, chest, stomach, kidney and urinary tract infections.

Levaquin (levofloxacin) and Cipro (ciprofloxaxin) are the more commonly prescribed medications. Basically, beware of any antibiotic medications that end with floxacin.

FQ's are also ideal for joint and bone infections and Achilles tendinopathy (or wear and tear in the tendon) or rupture is among the most serious side effects associated with FQ use.

The average person taking FQ has a 70 percent greater risk of tendinopathy and a 30 percent greater risk for a full blown rupture compared to another person taking a different antibiotic. As the Achilles tendon has very little blood supply, it is more prone to injury. It is also the tendon most affected by FQ. The risk of Achilles tendon rupture is quadrupled with FQ. Other serious side effects include nerve damage, confusion and hallucinations.

I found enough data to suggest that FQ's should be used cautiously in a selected group of patients. Older male runners (> 60 years), people with kidney disease, those taking corticosteroid medications (commonly used to treat asthma) are the most vulnerable.

The higher your dosage and the longer you take the medication the greater the danger. The risk does not go away when you stop taking the medication. Tendon problems linked to FQ can appear weeks, months or even years later.

My take is if you're active and if you have sinusitis, bronchitis or a urinary infection, try and ask your doctor if you can take another class of antibiotics instead. This is another good reason to find a doctor/ physiotherapist who understands athletes and knows about your training. Personally I would avoid these medications if at all possible.

In instances where your infection does not respond to other medication and treatment you may still have to take FQ's. You may then have to adjust your training during and after the medication. You may have to cut back your mileage, hill running, intensity for up to nine months after taking FQ's.

Watch out for new pain in any of your lower limb tendons, especially your Achilles (although quadriceps, peroneal, hamstring and rotator cuff tendons have also been reported).

Remember to rest sufficiently after training to avoid picking up any colds that may lead to sinus and chest infections.


Reference

Kim GK (2010). The Risk Of Fluroquinolone-induced Tendinopathy And Tendon Rupture. What Does The Clinician Need To Know? J Clin Aesthet Dermatol. 3(4): 49-54. PMCID: PMC2921747.

Picture by Thirteen Of Cubs from Flickr

Running Injuries? Blame Your Genes?

Chromosome by Hey Paul Studios from Flickr

All right, it's finally been proven, some people are more prone to injury than others. So says a newly published article from the British Journal of Sports Medicine.

The researchers found evidence from family and genetic studies that DNA sequence variants (together with non-genetic factors) can increase your risk for tendon and ligament injuries. This is for both exercise-associated and occupational-associated acute and chronic injuries to tendons and ligaments.

Although research at this stage is still preliminary, there have been specific gene variants found (COL5A1 gene) that are less likely (58 percent less) to cause Achilles tendinopathy (degenerative change in the tendon).

A different gene (COL1A1) is associated with ACL (anterior cruciate ligament) and Achilles tendon ruptures (September et al, 2009).

In fact, several other genes have been associated with injuries ranging from carpal tunnel to tennis elbow.

The common link among these genes is that they affect collagen fibrils structure. Collagen fibrils are the basic structural building block for tendons, ligaments and other connective tissue including fascia. In simple terms, some Achilles tendons are built better than others.

So what do you do with this information then? Athletes and coaches beware, especially when there are now many genetic tests marketed for self testing promising to reveal potential injury susceptibilities.

The researchers reported that such tests should be requested by an appropriately qualified healthcare professional since results need to be interpreted together with certain clinical indicators and other lifestyle factors.

Personally I'm fairly sceptical about such over the counter/ online genetic tests that you can purchase to do a self test on whether you're more prone to injury.

Will knowing that really change your training habits? As a previously compulsive competitive athlete, I trained as hard as I could handle and more without getting injured. Knowing I'm say, 10-20 percent more likely to get a tendon injury will not alter my day to day training. On the contrary, because I've been training hard for so long (previously), I know what injuries I'm prone to because I've already had them previously.

Hmmm, maybe from now I'll ask my patients whether they have a family history of tendon or ligament injuries instead. (Standard practice for Physiotherapists is asking patients if they have any family history of hypertension, heart diseases and cancer etc).


Reference

Collins M, September AV and Posthumus M (2015). Biological Variation In Musculoskeletal Injuries: Current Knowledge, Future Research And Practical Limitations. BJSM. DOI: 10.1136/bjsports-2015-095180.

September AV, Cook J et al (2009). Variants Within The COL5A1 Gene Are Associated With Achilles Tendinopathy In Two Populations. BJSM. 43: 357-365. DOI: 10.1136/bjsm.2008.048793.

Achilles Pain Related To Your Glute Strength

I've just had 3 patients in a row today all come and see me with pain in their Achilles. Strangely enough, all 3 had weakness in their gluteus medius muscle despite that side being their dominant (and should be stronger) leg. That was also the leg that had Achilles pain. Hence this write up.

It has been published and I've written before on how your gluteus medius (or buttock muscles) can cause knee pain especially in females. Well guess what, I just found a published paper from Australian researchers that found a link between gluteus medius and maximus weakness and Achilles pain (in male runners). Yet more confirmation on how important your gluteus medius and maximus really are.

The Australian researchers in the published paper compared 2 groups of male runners where one group had Achilles pain while the control group did not. Both groups of  runners did short runs at about 6:40 min per mile pace and the group of runners with Achilles pain were found to activate their gluteus muscles later than the group with no Achilles pain.

And not only that, their gluteal activation was also shorter in duration compared to the pain free group. This is of significance as poorer gluteal muscle activation can cause increased hip internal rotation and adduction (movement towards the midline of the body) leading to Achilles problems.

The authors are suggest retraining and strengthening gluteal muscles be included for runners with Achilles injuries.

The causes of your Achilles pain can be multifactorial, one of which can be due to your weakness in your gluteus medius and maximus as described above. Come see us at Physio and Sports Solutions to treat the cause of your Achilles pain.

Worth a look?

Reference

Smith MM, Honeywill C et al (2013). Neuromotor Control in Runners with Achilles Tendinopathy. Med Sci in Sports Ex. doi: 10.1249/MSS .0000000000000133.

*Pictures from Flickr.com

Do You Need That Cortisone (Steroid) Injection?

Have you got any pain in your elbow, patella or Achilles tendon? I've seen many cases of what used be called tennis elbow or lateral epicondylitis and Achilles tendinitis in our clinics recently. What is now known as tendinopathy (or diseased tendon) of the elbow or Achilles as these cases are actually due to degenerative change rather than inflammation as numerous studies have shown.

Most of the time patients with tendon problems were given a cortisone (or corticosteroid) injection to treat the pain (rather than treating what caused the pain). Cortisone, an anti-inflammatory agent used to be one of the preferred treatments for overuse injuries of tendons (like tennis elbow, patella and Achilles tendinitis) which were notoriously resistant to treatment. Cortisone is often used to treat plantar fasciitis too. 

Pain wise the injections were effective, but as soon as the patients returned to the their sporting activity or even their daily activities, the pain returned. In adverse cases the tendons can even rupture. This happened on a few occasions when I was working at my previous job at the Singapore Sports Council with our national athletes after receiving the corticosteroid injections. They subsequently needed surgery to repair their ruptured tendons resulting in more time off. So for all you athletes out there, think three, four or five times and not just twice about taking that cortisone injection.

A major new review article published in the Lancet just last week raised major doubts on the efficacy (or wisdom) of using cortisone on tendon problems. Yes, the authors found plenty of evidence (in over 4 dozen high quality randomized controlled trials) that corticosteroid injections reduced patients' pain in the short term, but the effects were not great in the intermediate and long term. In fact patients receiving the injections had a much lower rate of recovery than those who did nothing or received physiotherapy (at 6 and 12 months). This was especially true for patients with tennis elbow pain, rotator cuff (swimmer's shoulder) pain and Achilles tendon pain.

There are more evidenced-based treatment for tendinopathy other than cortisone injections, ultrasound, massage, interferential currents etc. We at Physio and Sports Solutions practice evidenced-based physiotherapy (neural stretching, Mulligan MWM's, eccentric muscles strengthening exercises and Maitland joint mobilizations etc) to treat you. Come let us help you with your tendon injuries.

Reference


Coombes BK, Bisset L, Vicenzino B (2010). Efficacy And Safety Of Corticosteroid Injections And Other Injections For Management of Tendinopathy: A Systematic Review of Randomised Controlled Trials. The Lancet. Epub on 22 October 2010.


*Picture by Ballyscanion/Getty Images.