Return to Running After Injury: A Physio Guide to Getting Back to Running
By Lachlan Gillies | Physiotherapist & Founder of Rebuild Physio Glenelg
Returning to running after an injury can be surprisingly difficult.
Rest too long and you may lose fitness, strength and confidence. Return too quickly and you can flare your symptoms and feel like you are back at square one.
At Rebuild Physio Glenelg, we generally approach return to running as a progressive loading process rather than a single test that determines whether someone is ready.
The goal is to understand what your body can currently tolerate, establish a manageable starting point and progressively rebuild towards your normal running.
Importantly, there is no single return to running program that suits every runner or every injury.
Returning after Achilles pain is different from returning after a bone stress injury. Returning after a calf injury, knee pain or ankle sprain can be different again.
This is why a good return to running program should consider the injury, your current capacity, your previous running and what you are actually trying to get back to.
When Are You Ready to Start Running Again?
One of the first things we consider is the injury itself.
Some injuries can tolerate a degree of discomfort as running is gradually reintroduced. Others require a more conservative approach and may need appropriate healing before running begins.
There is therefore no single test that tells every runner they are ready.
Depending on the injury, we may assess things such as:
Pain during normal daily activities
Walking tolerance
Strength of the injured area
Single leg strength and control
Calf or quadriceps endurance where relevant
Hopping and landing ability
Plyometric tolerance
Previous running volume
How symptoms respond to loading over the following 24 hours
For many runners, skipping, hopping and other plyometric exercises can provide an important bridge between strength training and running.
Running involves repeated impact forces. If someone is not yet able to tolerate appropriate lower level impact exercises, we may need to build this capacity before asking them to tolerate repeated running.
The criteria we use will depend on the injury and the individual runner.
Finding Your Current Running Tolerance
Once it is appropriate to start running, one of the most useful questions becomes:
How much running can you currently tolerate without significantly aggravating your symptoms?
This gives us a starting point.
For example, imagine a runner attempts 5 kilometres but consistently develops increasing symptoms towards the end of the run.
Rather than continuing to test the same 5 kilometre distance and repeatedly aggravating the problem, we can establish what amount of running is currently manageable.
If approximately 4 kilometres appears tolerable, I may reduce the initial running distance slightly further to provide some margin for error.
In practice, I will sometimes take a runner’s demonstrated tolerance and reduce it by approximately 10% to establish a starting point they are highly likely to succeed with.
From there, we can build.
That first successful period of running is important.
Instead of constantly bouncing between doing too much and resting, we want to establish a level of running that can be completed consistently before asking the body to tolerate more.
How Much Pain Is Acceptable When Returning to Running?
A common concern for injured runners is whether they need to be completely pain free before they run.
The answer depends on the injury.
For many running related injuries, a small amount of discomfort during rehabilitation and running may be acceptable.
As a general guide, we may be comfortable with symptoms around 0 to 2 or 3 out of 10 during a run, provided the symptoms remain stable rather than progressively worsening.
We also look at what happens afterwards.
Ideally, symptoms settle relatively quickly after the run, often within approximately an hour, and importantly, you should not be noticeably worse the following day.
The next day response gives us valuable information about whether the current running load is appropriate.
If pain continues to increase throughout a run, remains elevated afterwards, morning symptoms are noticeably worse, or each running session progressively aggravates the problem, the current running load may be exceeding your capacity.
This does not necessarily mean that running needs to stop completely.
It may mean that we need to modify the amount or type of running and build from a more manageable level.
Importantly, these pain guidelines are not appropriate for every injury. Certain injuries, including some bone stress injuries and acute injuries, require different criteria.
This is why establishing what you are actually dealing with matters.
Building Your Running Volume
Once we have established a successful baseline, we can progressively increase running.
A commonly used starting principle is to avoid making large, sudden increases in training.
You may have heard of the 10% rule, where running volume is increased by no more than approximately 10% at a time.
I sometimes use this as a practical guide, but it is not a universal rule.
A runner’s previous training history, injury, current capacity, running frequency and goals all influence how quickly they can progress.
Someone who has been running consistently for years may tolerate a different progression from someone who has recently started running.
The important principle is avoiding sudden increases in workload that your body has not recently been prepared for.
We want your running demands and your physical capacity to progressively rise together.
This is also why strength training for runners can remain an important part of rehabilitation even after someone has started running again.
Don’t Increase Everything at Once
Running load is not just the number of kilometres you complete.
We also need to consider:
Distance
Frequency
Speed
Hills
Surface
Duration
Intensity
Imagine a runner increases their weekly kilometres, adds another running day, introduces hills and starts doing intervals in the same week.
Even if each individual change seems reasonable, together they can represent a substantial increase in overall demand.
It also becomes difficult to determine which change has aggravated symptoms if something goes wrong.
For this reason, I generally prefer changing one major training variable at a time.
For someone returning to distance running, that may mean rebuilding comfortable running volume first before progressively introducing faster running, hills or harder sessions.
For some runners, we may also assess running technique if aspects of their running could be contributing to their symptoms or influencing where load is being distributed.
Returning to Running After a Bone Stress Injury
Bone stress injuries in runners need to be approached differently from many other running injuries.
Bone needs adequate time and appropriate loading to recover.
Before returning to running, we want to ensure the injury has progressed appropriately and that the runner can tolerate the strength and impact demands required before repeated running is introduced.
Depending on the injury and stage of rehabilitation, this may involve progressively introducing:
Strength training
Calf raises and lower limb strengthening
Hopping
Skipping
Landing exercises
Other appropriate plyometric exercises
These exercises can provide a bridge between gym based rehabilitation and the repeated impacts experienced during running.
Once the runner is ready for running exposure, a run walk progression can be useful.
Rather than immediately returning to a continuous 20 or 30 minute run, we may alternate periods of running and walking.
For example, a runner may initially complete several short running intervals separated by walking recovery.
As this becomes well tolerated, the running intervals can progressively increase and the walking periods can reduce until continuous running is appropriate.
The exact progression should reflect the location and severity of the bone stress injury, healing, symptoms, previous training and the individual runner.
Returning After a Calf Injury
The calf plays an enormous role in running.
Someone returning from calf pain or a calf injury may be comfortable walking well before their calf is ready to tolerate the repeated demands of running.
This is why rehabilitation may involve progressively rebuilding calf strength, endurance and eventually the ability to produce and absorb force quickly.
Skipping, hopping and other plyometric exercises can help bridge the gap between slower strength exercises and running.
Once running begins, we can then gradually rebuild volume and eventually speed depending on the runner’s goals.
Returning After Achilles Pain
A runner with Achilles pain or Achilles tendinopathy may also need to progressively rebuild the capacity of the calf and Achilles complex.
Strength and endurance can be important, but we also consider the amount of running the athlete is currently doing and how the tendon responds to that load.
In some runners we may also consider footwear, hills, running speed and aspects of running technique depending on the presentation.
The goal is generally not simply to rest until the tendon feels better.
It is to progressively rebuild the capacity required to tolerate running again.
Returning After a Hamstring Injury
Returning from a hamstring injury in runners brings another consideration.
Running faster places different demands on the hamstrings compared with easy running.
A runner may therefore be able to comfortably complete slower running before they are ready for faster sessions.
Depending on the injury and the runner’s goals, rehabilitation may progressively move from strength exercises into running, before gradually exposing the hamstring to faster running.
For someone returning to sprinting or field sport, this progression becomes particularly important.
Returning to Running With Knee Pain
Knee pain when running is another common reason runners reduce or stop their training.
The appropriate return depends on what is causing the knee pain.
For someone with patellofemoral pain, for example, we may consider current running volume, strength, hills, speed, running technique and how symptoms respond during and after running.
Rather than automatically stopping all running, it may be possible to identify a manageable running dose and progressively rebuild from there.
You can read more about patellofemoral pain in runners and ITB pain in runners, including how we assess and manage these common running related knee problems. If you are concerned about the effect running may have on your knees over time, we have also looked at the evidence around whether running is bad for your knees.
Returning to Running With Hip Pain
Hip pain can affect runners in different ways depending on the cause of their symptoms and the demands of their training.
When helping someone return to running with hip pain, we may consider their current running volume, strength and capacity, hills, speed, running technique and how symptoms respond during and after running.
Rather than simply waiting until all symptoms disappear, the goal is often to identify an appropriate level of running, continue rebuilding strength and progressively increase running as capacity improves.
You can read more about hip pain in runners and how we assess and manage common running related hip problems.
Returning to Running After an Acute Sporting Injury
Return to running following an acute sporting injury can look different again.
For someone returning to football, basketball, netball or another field or court sport, being able to jog comfortably in a straight line is only one step in the process.
Sport involves much more than jogging.
As rehabilitation progresses, we may introduce:
Faster running
Acceleration
Deceleration
Lateral movement
Change of direction
Cutting
Reactive movements
Sport specific drills
The progression should gradually become more representative of what the athlete will actually experience when they return to training and competition.
This helps bridge the gap between being able to run and being ready for sport.
What Happens If Your Pain Flares When You Start Running?
A flare does not automatically mean that you have reinjured yourself or that you need to return to complete rest.
Sometimes it simply tells us that the progression was greater than your current capacity.
The next step is working out what changed.
Did you run further?
Did you add another running day?
Did you introduce hills?
Did you run faster?
Did you change shoes?
Did your overall activity increase?
Did you have less recovery between sessions?
Identifying what changed can help us adjust the program.
Instead of repeatedly cycling between doing too much and stopping completely, we can often return to the last manageable level and progressively rebuild again.
However, significant or unexpected changes in symptoms should be assessed rather than simply pushed through.
Strength Training Should Continue as You Return to Running
One mistake runners can make is stopping rehabilitation as soon as they are able to run again.
Being able to complete a run does not necessarily mean the rehabilitation process is finished.
Running itself can gradually rebuild running specific capacity, but strength training can continue developing the physical qualities required to tolerate training.
Depending on the injury, this may include calf strength, quadriceps strength, hamstring strength, hip strength and plyometric capacity.
Our article on strength training for runners explains this in more detail.
The goal is not simply to survive your first few runs.
We want to build enough capacity that running becomes consistent again.
A Successful Return to Running Should Be Individual
There is no universal return to running program.
A runner returning from Achilles pain may need a different progression from someone recovering from patellofemoral pain, a calf injury, a hamstring injury or a bone stress injury.
Your previous running history matters too.
Someone who previously ran 70 kilometres per week has a very different starting point and end goal from someone trying to complete their first 5 kilometre run.
Your goals matter.
Your injury matters.
Your current strength and capacity matter.
And importantly, how your body responds as running is progressively reintroduced matters.
That is why a return to running plan should be individual rather than simply following a generic online program.
Do You Need a Physio to Help You Return to Running?
Not every runner needs physiotherapy to return from an injury.
However, if you repeatedly try to return to running and your symptoms keep coming back, you are unsure how much running is appropriate, or you cannot progress beyond the same point, an assessment can help identify what is limiting you.
At Rebuild Physio Glenelg, our running injury physiotherapy looks at the injury itself as well as the strength, capacity and running demands that may be contributing to the problem.
From there, we can establish an appropriate starting point and progressively rebuild your running and rehabilitation around your individual goals.
Whether you are trying to get back to your local 5 kilometre run, recreational running, a half marathon, marathon or competitive sport, the aim is the same.
Build enough capacity to run consistently again rather than repeatedly stopping and restarting because of injury.
Book an appointment at Rebuild Physio Glenelg
If a running injury is stopping you from training or performing at your best, our Running Injury Physiotherapy in Glenelg service is designed to help runners understand their injury, rebuild capacity and return to running.
Book a physiotherapy appointment at Rebuild Physio Glenelg and we can assess the problem and develop an individual plan to help you return to running.
About the Author
Lachlan Gillies
Founder, Director and Physiotherapist
Rebuild Physio Glenelg
Lachlan has a particular interest in running injuries, sports physiotherapy and strength-based rehabilitation. As a two-time marathon runner and physiotherapist with a strength and conditioning background, he enjoys helping runners understand their injuries, rebuild their physical capacity and return to running and training.
References and Further Reading
Ardern CL, Glasgow P, Schneiders A, et al. 2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern. British Journal of Sports Medicine. 2016
George SZ, et al. Criteria and Guidelines for Returning to Running Following a Tibial Bone Stress Injury: A Scoping Review. Sports Medicine. 2024.
Gabbett TJ. The training injury prevention paradox: should athletes be training smarter and harder? British Journal of Sports Medicine. 2016
Pollock N, et al. London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport. British Journal of Sports Medicine. 2023
Lorenz D, Domzalski S. Criteria Based Return to Sprinting Progression Following Lower Extremity Injury. International Journal of Sports Physical Therapy. 2020
Cushman DM, Rho ME. Comparison of Conservative Interventions for Proximal Hamstring Tendinopathy: A Systematic Review and Recommendations for Rehabilitation. International Journal of Sports Physical Therapy. 2023.
