After an injury, it is important to employ a gradual return to function. For lower limb injuries, this will often involve a return to running and then progressing to sport-specific activities. It is important to start at a gentle level and to not rush the progression. The aim is to gradually increase the load that is being applied to the body at a rate that allows for all tissues to adapt to the load without deterioration. The risk of going too fast is generating or re-aggravating stress-related injury by upsetting the balance between microdamage formation and its repair. Above applies for returning from stress injuries as well as from acute injuries, such as ACL reconstructions.

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Once determined safe to return to running, including regaining of adequate lumbopelvic and core strength and balance, a requirement is 2 episodes of 30-40 mins of pain-free walking in the first instance prior to walk-jog programme.

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There is no universal algorithm for how much an individual can modify their training programme before excessively heightening their re-injury risk. A common rule of thumb has been a training capacity being increased by no more than 10% per week. This is a good rule that clinicians often use.

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There are other variations. A programme I often use for my patients is Dr Dan Exeter’s, which has the following progression:

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A 30min block and divide it into 6 lots of 5 min units

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For each of the 5 minute units, divide that into a walk and jog component. The stages are as follows:

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1. 1 min run : 4 min walk x 6 = 30 mins
2. 2 min run : 3 min walk x 6 = 30 mins
3. 3 min run : 2 min walk x 6 = 30 mins
4. 4 min run : 1 min walk x 6 = 30 mins

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Programme is employed with a day of active rest in between the jogging days, where floor-based exercises and alternate exercises such as biking/swimming is used. 2 runs of each stage must be completed prior to progression to the next level. I personally used this programme to return myself to running capacity after my ACL surgery.

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Another programme was discussed at the recent BJSM podcast by Dr. Blaise Williams, which is starts with a 1:1 split of jog and walk load, and weekly increasing the run portion by twofold. So, the progression a week later is 2:1 split, then 4:1 split, so on, until working up to 30 minutes. Another variation is gradual progression using lamp-posts.

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Once 30 mins of jogging is reached, then increase in speed/intensity can be introduced at a shorter time (e.g. 15 mins) and gradually increased weekly (e.g. 5 mins)

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The messages that are consistently stressed for all these programmes are:

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1. Importance of good biomechanics prior to running and maintenance of good techniques while returning to run.
2. Self-awareness and recognition of pain (particularly pain lasting after ceasing activity, delayed onset of pain) and returning to prior level.
3. Gradual progression for tissue to adapt at a safe rate.

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Individualised approach is important when returning your patient to running. Often a subtle change to running style, such as shortening his/her stride for “over-striders” by increasing the cadence, can be quite helpful in reducing the load through the lower limb joints.