Ep 39: Running after injury—how to make a safe return

Michael Dermansky

Hi everyone, welcome to the show that helps you become more confident in your body so you can keep doing the things you love. My name is Michael Dermansky, I’m a Senior Physiotherapist at MD Health. I’ve got a special guest with me today, Loris Berlarci. Loris, welcome to the show.  

Loris

Yeah, hi Michael. Thanks for having me here.

Michael Dermansky

Well, Loris, let’s start a little bit about who you are. we know each other for, I think it’s 20, 22, 23 years now. It’s been a few years now, but a little bit about your background, who you are and what you’ve done with your insanely big career in sports medicine, or sports science, actually.

Loris

Yeah, you could say it’s insane. Yeah, look, I’m an exercise phys with exercise physiologist with SR on ACA strength conditioning. I’ve got qualifications in sports science and I’m registered as a sports scientist through Australia. So pretty broad spectrum of things that I do, which is pretty much how I operate. The last five years I’ve been in China working in their sports systems, which was amazing experience. Very lucky to have done that. Before that, worked in many sports like tennis and volleyball and rehabilitation also. A large chunk of my career was in AFL football. I was a high performance manager for four clubs. And before that I did various jobs in gyms and personal training and things like that. And before that I was a lead athlete, coach, lead athlete in track and field. So yeah, fairly broad. lot of mixture of things.

Michael Dermansky

or we married each other at Geelong Football Club where you were the strength and conditioning high performance manager there and we started working this course stability stuff that was relatively new at the time and then we ended up taking that further to next level as well and that’s how we started working with each other.

Loris 

Yeah.

No, well I’ve certainly been amazed at your career and what you’ve done and how you’ve grown and adapted. Yeah, fantastic. It’s been great to see you, your whole career.

Michael Dermansky

Well, today I wanted to talk about a particular topic you and I started talking about a couple of weeks ago, where return to running and particularly where, you know, where that transition between, okay, you’ve done the strength work in the gym and the strength conditioning work. Now, how do we, you know, to get back to running, you really have to start running as well. So you were telling me about that, you know, can get 85 % up the way at the gym doing strength work and getting yourself body ready, but

Loris

Yeah.

Michael Dermansky

until you start doing running, you’re not going to be ready to do running as well. So what does that look like? So getting back to running after you got an injury, getting back to running, you finished doing as much as you can with a physio EP program, and you’re actually starting to do running training again. What does that look like from your point of view?

Loris

Well, the context is important, okay? And, yeah, first of all, we’ve got to, to answer that question, I’ve probably got to say, well, who am I dealing with and what injured, right? So if it’s, say, somebody who wants to run the marathon and they don’t care if they’re going to walk it and it’s going to take them seven hours because that’s what they want to do, you know, and they’re 55, they’re fairly fit, they’re healthy, but that’s all I want to do and they’ve had an injury. That’s one context. The other context is you’re playing local football or masters football and you’ve done a hamstring and you want to play football. Well, that’s another context, right? Another one is that, you know, you’re a basketball or you’ve had a bone stress injury and how are we going to get back to running? It’s a very broad question because the answer is going to depend on the context of what what the ultimate goal is and what actually happens or you know in terms of physio. So therefore you know if we pick a couple like one of the common things you’ll see is people have calf injuries for instance. Just let’s just forget those bone stress injuries and that’s completely different to somebody who’s had a hamstring injury. because you can get running fairly soon with a hamstring injury. You can mix that with the rehabilitation, right? As in your rehabilitation or the on-site physiotherapy strength work. Whereas with a calf injury, you would need to tick all the boxes from, you know, standing on one leg to single leg squats to calf raises to double leg jumps to single leg jumps to Okay, now we run because calves and to be honest, bone stress injuries, lower bone stress injuries, tend to actually follow the same path. You’ve got to a lot more boxes. So it depends a little bit on the context. And if you want to explore some context or some sort of situations that you’ve found yourself in with clients, that may actually be a good way to go down the pathway of finding out what returns the rank. Because at the end of the day, you have to return to running, right? And generally speaking, the best way to work out how much you can run and how far you can run is actually to run. You know, all the other things are surrogate tests, But ultimately you can fall short if you haven’t ticked the boxes with your tests, surrogate tests or tests that you do in the clinic in transition to running. So I think the context is really interesting and maybe we can explore two or three different things from the person who wants to run one marathon, they don’t care if they walk it, but they’ve got an injury and they’re coming back to somebody who’s got to play local footy and has had a hamstring. They’re quite different, right? Okay, so we’ll go to the elite sport one first because I’m spinning out of my brain pretty quickly, right? I think, I’m not sure if all your viewers are aware,

Michael Dermansky

Let’s talk about those two examples as well. Let’s talk about, yeah.

Okay, let’s go for that.

Loris within the context of AFL, know, English Premier League, the Spanish La Liga, local football, it’s the number one injury, right? Statistically, it’s the number one injury hamstrings, right? And the recurrence rate’s quite high. So therefore, I was talking to somebody the other day, one of the things with young athletes, any athlete, They’re going to occur, it’s an injury that will occur, right? The important thing is in a rehabilitation program is to get it right the first time. So therefore, the transition from the gymnasium slash physiotherapy clinic rehab program to running becomes critical in that context. It’s almost like there’s not a lot of margin for error, right? Which is why we see a lot of injury, re-injury, recurrence, even at the alert level when you’ve got… people on $150,000 a year doing rehab in the club. So one of the things that needs to be done before we talk about rehab running, people that been through your system have been screened, you’re looking at all the different things that you need to work on individually. And then if it’s a hamstring injury, then you have some hamstrings tests with your dynamics, everything you push, know, with the league, different angles. You need to work through that, need to make sure that glutes are firing properly or are strong and then supportive structures are working properly. Okay, so if you’ve kicked all those boxes, one of the things you can do very, very early, it’s been proven in research and I could cough up the research, you can start running at day five or six with a hamstring, but that might be… a shuffle where you might actually still feel one out of ten. A weiner’s not three out of ten, And you might just go out to the park and jog a hundred, walk a hundred, jog a hundred, and it stays at one, it goes to zero after warm up. And that’s quite important because you’re actually starting to get ground contact and you’re forced on the ground and you’re starting to sort of get some specificity about

Michael Dermansky

Yeah.

Loris

So we go back to strength still. So before you run too much, you do need to tick some boxes in the gym. Now I’m not sure what do you do in terms of return to play as a measure for calf strength? Is it 25 calf raises each leg? What do you use Michael?

Michael Dermansky

you want to do a couple things as well. mean, ideally about 20 to 25 calf raises as well, but also you want to be able to get them to hop forward as well. So some of those more explosive movements that puts more pressure on the area. They want to do side to side hobby movements as well. Can they do have side to side control? Because they’re going to roll it going side to side, not going forwards and backwards. So these are the things they need to able to control before they’re really comfortable doing and above the line, above the chain as well. So what’s a but need control when they like to single it squats. You these things you want to see them ready. Often they’ll realistically start running before they’re technically ready. But these are the things I want to see before they really start running, particularly the start training for marathon again.

Loris

Well yeah, so then we can further divide, subdivide, right? If there was a calf strain, if there was a calf strain, you’ve diagnosed there’s a calf strain, then you need to those boxes before you run, right? You don’t run, you don’t run before you tick those boxes, right? It’s totally different with hamstrings, right? Because I’ve had that experience where, because you’re actually impacting the ground with your calf as it gets the hamstrings, it’s just part of the whole complex, right?

Michael Dermansky

Yeah.

Loris

you can really have problems. So that’s if you’ve had a calf strain, you need to make sure that the strength’s right. In the segue into that, if some people are lucky, if they have a unweighted treadmill where you actually put the thing and drops the anti-gravity through, difficult to have access to, right? One little cheat code you can do is go into the pool at the first transition.

Michael Dermansky

Yep.

Loris

and going to a swimming pool and run at chest deep, is going to be below walking impact chest deep. When then the next day you might run in the pool at waist deep, which is the same forces. You might run 10 by 10 meters at waist deep and then you might run a little bit below waist deep, which is starting to move away from walking force impact to running. So you want to segue from even. you’ve had a cast strain through there and you know to be honest with both, seems to be somewhat similar. it’s a little bit different if you’ve just got diffuse cast soreness and you’re weak right and it’s just you know there’s an imbalance or whatever. It’s good to actually then work interactively with the physio and I think one of the things that it becomes very subjective right because okay you say to them, listen you need to be able to do 25 cast raises to be able hop.

Michael Dermansky

Yep.

Loris

You need to be able to do this, right? Plus we have to fix up a little bit here. But, and then the person says to you, but you know what? I can actually run four Ks and then it starts hurting me. Okay, well let’s just run three Ks and do that, right? And then hopefully build up the strength the next time. actually I ran four Ks, it didn’t hurt me. And then five days later I ran six Ks and I felt that then, okay, well, you know, just build it up gradually, right? So.

Michael Dermansky

Yep.

Loris

I mean, it’s almost like the 2020 for the hamstrings, but totally different context. You’re trying to draw volume up and get feedback from the person on the back of the treatment you’re doing. So that’s sort of, you know, I’ve subdivided a cast strain and diffuse cast soreness because as I said at the start, we can go anywhere with this podcast on the context of the injury and then what you do for return to play, right? We can go anywhere.

Michael Dermansky

Yep.

Loris

So those be the two things. It’s very pure if you’ve a cast rain. Just get strong before you even run because you’ve got to into a lot of trouble, right? Because that’s what you’re impacting on the ground with. With diffuse pay, work on what you can tolerate. And as you know, one out of 10 is quite safe really. Four out of 10 going for run and stop, that’s enough. We’re getting too much, right?

Michael Dermansky

Yep. Yep.

Loris

and build up your volume relative to some subjective sort of feedback. Yeah, how’s that sound?

Michael Dermansky

That sounds, that sounds, there’s some really important things you’ve talked about today as well. If you’re going to physically do is you can make yourself stronger, whether it’s a calf or hamstring tear, the basics of making the complex stronger hamstrings, hamstrings and glutes, calves, quadriceps, all really important calf as well is that because you’re going be using it straight away as initially as you run, needs to be ticked off the boxes of working your strength before you start running. So you’ve got a hamstring injury. You can probably start running relatively early day five, but at a low pace and not not any more than that because the hamstring is not going to really kick in. can do it where calf needs to be strong straight away from the first time you start running. You’re not ready until you’re strong enough because it’s use in that cycle is very different. It starts working straight away. It doesn’t stop working where hamstrings will kick in the highest things. Am I hearing you right, Loris? Am I hearing you right, sorry, hamstrings?

Loris

Yeah.

Michael Dermansky

I’m running early, but you need to start getting it slowly better to that 100 % mark, but only gradually. Today’s 80 % day, you stick to an 80 % day. Today’s 85 % day, you stick to an 85 % day. You don’t go, I feel like I look to 100 % because that’s when things really go wrong.

Loris

Yeah, and I think all rehab, because there’s no cookie cutter approach and there’s no piggy-fock in the video with the rehab, right? It’s like a concertina, right? Even a hamstring, that five days could be eight days if it was a severe hamstring, could be nine days. The same concept is there, but you’re doing the same thing, but you’re just stretching out, know, your thresholds for recovery might be three days after you run, you know, might actually, yeah, so it just depends, right? So everything’s like that, you know. You start here, but you might have to stretch it out a little bit because the recovery is not good or more severe. I mean, that’s the dialogue between the clinician and the athlete or the person that’s involved and the feedback that’s coming back as far as recovery, right? And obviously the best feedback you can get is when you’re actually doing the movement. The only problem

Michael Dermansky

Yeah.

Loris

that occurs with hamstrings, which is as you get to high speed, it becomes a different feedback. You do not want to be running at high speed and saying, still feel it. Where if you’re running 4Ks and you ran the last half a K and you felt it a bit, you probably haven’t re-injured it. It’s just probably reached a threshold and you need to stop. Okay? So it’s quite subtle what happens between in a return to play. I think that we’re talking about ACLs, it’s different again. It’s different again, right? But probably a lot of the markers that I use with the return to play for a marathon are somewhat similar to ACLs. Because obviously with an ACL, you’re not going to run if you’ve got a niggling knee and it’s swelling. you know, it’s getting hot again and all, you know, it’s, so you need to sort of work again hand in hand with the clinician to decide what the progression is going to be. So, you know, as I said, it’s contextual, it’s really return to play running or return to play anything or return to play to do anything. That’s the key thing. We need to be able to run the marathon in four months or we need to play a game of footy or we need to… brought this one to the masters in them you know i think that this question a lot of results in the dot seventy two-year-olds running sixty two seconds before it is you know this that’s inside forces that’s the newtons on the ground assets you know so that’s the exact words to conditioned at that age to to take on huge forces so how do you get there well it’s progressive progressive running programs

Michael Dermansky

Yep. And so, mean, what are the mistakes you see people make? I mean, we’ve already talked about it quite a bit, but any particular two or three specific mistakes people make in their return to running program, as you said, both elite level or that, say, hamstrings for an elite level and a calf strain for the recreational marathon runner.

Loris

look, think everybody, the biggest mistake is people will rob a guy’s. I go to the casino, and I’ll just go into denial and they’ll just say, why are you feeling so nice when I woke up, I’m just going to do what I’ve done in the past, stuff it. So at the elite level that could be, know, Lionel Messi saying to his rehab guy on the ground,

Michael Dermansky

Yeah.

Loris

I don’t want to, I feel all right, I don’t feel any pain. I’m running 90 % cut to tell, you know, I’m just going to go flat out bang, re-injured. And that is a classical problem at the elite level, right? So that becomes very tough. At the other end of the spectrum, it’s not following a progression. if you, we talked about a threshold of awareness, right? So if you’re coming back from diffuse calf, saunas, tightness, achilles, even achilles I suppose tendon saunas right. If you’re getting to three K’s and then you start feeling it you’ve got to stop. Right now as I said before there’s the odd person that’s lucky rolls a dice and their body just adapts by just going through it. Let’s forget those they’re outliers. They’re outliers. If you don’t follow the symptoms or attended the symptoms or the feedback that you’re getting and then report it back. And then if the clinician doesn’t institute a program that’s actually progressive and lines up with the strength they’re seeing and where they’re at with the load they can tolerate, that’s the biggest mistake. So it’s actually like a load management, load tolerance situation and understanding how you’re going to progress, right? And progressing too quickly. So you know, one thing that I can say all the time is the biggest mistake is people plan forward. Now, you always should plan in reverse. If you know where your goal is, if you don’t know where your goal is, well make a goal. And the goal would be, in too much time I want to be able to run properly again. I just want to run, I want to be able to run three times around the block. That’s a goal, right? So make a goal. But generally speaking, people have got a goal. You know, I want to go to, like you said to me, Spain and do this thing, or, you know, I want to run a half marathon, I want to run a fun run, I want to do this, I want to do that. So if you’ve got a goal, work backwards. So I backwards with me, you got a calf problem, you got four months. The biggest mistake, if you walk forwards, you go, oh, two weeks time, I just want to run, I’ve got to run my 18Ks on the weekend. No, well, you’re rolling the dice, you’re going to get really injured, you’re gamed. Symmetry’s out. I saw a guy running at the track the other day at the athletics track. He’s about 40. He’s pretty fit looking guy. He’s knee bandaged and he was just hobbling. He was running quite fast and I thought well, mate, you gotta stop. You hold Gates off. You obviously gotta saw him there. It’s pretty obvious to me. He’s in denial. If you work backwards, then it’s easy. The best thing is getting noticed for it. This is simplest thing. Always do it. probably remember you get a notice board, you don’t even worry about a laptop, you get a notice board, you say, Fun Run, June. Three weeks before I need to 10kms like I’m going to do in the fun run or I need to run a half marathon in training three weeks before. Three weeks before that, well if I run 7kms that’s probably okay if I’m training every second day and yeah so I’ve got a bit of a plan going. Okay, three weeks before that I’m going to just run a k, walk a k, walk the road, okay walk a k. So all of a sudden you go, oh you know what I can do to that goal if I… But it’s much easier to plan in reverse and then you can then see that you’ve got three or four weeks to progressively build up to maybe a 5k run. You know, with 100 meter, walk 100, jog 100, walk 100, jog 200, walk 100, jog 400, walk 100, jog 2k’s, right? And you’re supplementing it with cross training, you you’re doing bike, you’re swimming, and then, okay. So that’s the big thing is in those situations, which is different to hamstrings, Angle quadriceps is if you plan in reverse, you will find you’ll have a lot more objectivity about how you do things. If you plan just forward, like it’s just daily, especially people like me too, when you know, it’s, I’m very emotive if I’m training myself. I will take, you know, you. hard to be objective. So planning in reverse is a really big one because you want to avoid the mistake of doing too much too soon. That’s basically it. And the other mistake is, which is not about return to play, if you haven’t addressed all the strengths deficits to the limit that you can, you’re asking for trouble. You’re asking for trouble. Again, you’re rolling the dice. You might be lucky, but you haven’t addressed all the strength emphasis and you’re up your load before you’re even in a recreational situation, you can’t do six single leg squats, you can’t do some hops, can’t do this, that, the other, you’re asking for trouble. So there’s some of the problems and maybe possible solutions that can be done.

Michael Dermansky

Yeah.

One last question before we finish up as well. And I think it’s a great conversation. mean, she just had is that, you know, don’t rush the load progressively increase the load, but don’t rush it. Cause that’s where the problem will occur as well. It’s like, with the marathon going three months, three weeks, like I better upload and then wonder why it’s not getting, you know, getting the account you want. What? What’s the difference between running for rehabilitation after injury and performance training? Because it’s a very, very blurred line depending on where you’re starting off at.

Loris

Okay, really good question and we can quickly go hamstring ACL Achilles rehab, all the same. because where the line’s blurred is in all those three cases, whether you’re an elite athlete playing at the highest level or you’re a recreational runner who just wants to get back to running, the principles are the same. The running you do in rehab is performance training, but it’s performance training at a very, very low level. It’s about getting the body used to the loads and the mechanics of running again.

So, initially, that running might be very slow, very short distances, with lots of walking breaks. The “performance” goal at that stage is simply to be able to run without pain or any adverse reaction (like swelling or increased soreness that lasts for more than a day).

As you progress, the performance goals of your rehab running will gradually increase. You might aim to run for longer durations, at a slightly faster pace, or with fewer walking breaks. You’re essentially training your body to tolerate more running load.

Now, the point where rehab running transitions into what we typically think of as “performance training” is when you’ve built a solid base of pain-free running and you start to focus on things like increasing speed, improving endurance, or preparing for a specific event with time goals.

However, even in advanced performance training, the principles of gradual progression and listening to your body (which are crucial in rehab) still apply to prevent injury. So, in a way, all running is a form of “training” your body to perform at a certain level, whether that level is just getting back to jogging or running a personal best in a marathon. The intensity and the specific goals just change along the continuum.

Does that make sense? It’s more about a gradual shift in emphasis from simply tolerating running to actively trying to improve specific running abilities.

Michael Dermansky

Yeah, that makes a lot of sense. It’s almost like the initial running is just to get your body used to the impact and the movement again, and then you slowly build up the intensity and the volume as your body adapts and gets stronger.

Loris

Exactly! You’ve nailed it. Think of it like building a house. The initial rehab running is laying the foundation. You can’t start putting up the walls and the roof (high-intensity training) if the foundation isn’t solid. You need to make sure the ground is stable and you’ve got a good base to work from.

And just like with building, if you rush the foundation, the whole structure is at risk. That’s why that gradual progression and not pushing through pain is so critical in the early stages of return to running.

Michael Dermansky

That’s a great analogy, Loris. So, if someone is listening to this and they’re in that early stage of returning to running, what would be your top one or two pieces of advice?

Loris

Okay, if you’re just starting to run again after an injury, my biggest piece of advice is listen to your body, and be patient.

That sounds simple, but it’s where most people go wrong. Your body will give you feedback. A little bit of muscle soreness the next day is usually okay, but sharp pain during or after running, or increased swelling, or pain that lasts for more than 24 hours is a sign that you’ve likely done too much, too soon.

Be patient with the process. Returning to running isn’t a race. It takes time for your tissues to heal and adapt to the demands of running. Follow the guidance of your physiotherapist or exercise physiologist, and don’t try to jump ahead of their recommendations, even if you feel good on a particular day. Consistency and gradual progression are key to a successful and sustainable return to running.

If I could add a second piece of advice, it would be to focus on the quality of your running, not just the quantity. In the early stages, it’s more important to run with good form, even if it’s just for short periods. This helps to retrain your body’s movement patterns and reduces the risk of re-injury. Think about things like your posture, your cadence (how many steps you take per minute), and trying to land lightly.

Michael Dermansky

That’s fantastic advice, Loris. Quality over quantity, and really tuning into what your body is telling you. I think that’s applicable to so many aspects of recovery and training.

Loris

Absolutely. It’s a fundamental principle that underpins all successful rehabilitation and performance training.

Michael Dermansky

Well, Loris, thank you so much for sharing your expertise with us today. It’s been incredibly insightful, and I think our listeners will get a lot out of this discussion on returning to running safely and effectively.

Loris

My pleasure, Michael. Thanks for having me on the show. It’s always great to chat with you.

Michael Dermansky

And that brings us to the end of another episode. Remember, if you’re dealing with an injury and looking to get back to running, always seek guidance from a qualified healthcare professional. They can help you develop a safe and personalized return-to-running program.

Thanks for tuning in, and we’ll catch you on the next episode!