Half past five in the morning, and the rubber track around the stadium is still wet with dew. The watch on your wrist buzzes once: four minutes of walking are up. You start to run, slowly, like someone jogging a few steps to catch a bus. That minute passes smoothly. Your left shin does not hurt.
Three weeks ago, at kilometer seventeen of a 21 km race, going down the slope of a bridge, that shin stabbed with every step. You pulled up, walked the last four kilometers, and watched group after group pass you. A doctor examined you, ruled out a stress fracture (a tiny crack in the bone from repeated loading) and told you to rest. For the past few days you have walked for half an hour without feeling anything.
On the third running round, you notice something odd. Your left foot comes down very softly, as if stepping on a freshly mopped floor. Each time it touches the ground, your shoulders lift and your breath stops for half a beat. Nothing hurts. The leg just doesn’t dare yet, that’s all.
That one minute of running is the first stage of the whole return plan. Every stage after it is small, and neither friends inviting you on a long run nor a morning when your legs feel strong is a reason to move up to the next one. The hesitation in the third round, though, deserves attention.
Thirty minutes of walking before one minute of running
The walk–run plan in this article comes from Sahrmann’s book on movement impairments of the lower limb. She wrote it for people who had to stop because of shin pain; the clinic uses it as a general framework whenever a runner returns after an injury. The entry point is very clear: you must be able to walk for 30 minutes without the pain increasing (Sahrmann, p. 392–393). If you cannot yet walk for half an hour, you do not run yet, not even for one minute.
Stress fractures follow a different path. At sites where bone heals poorly, Joyce and Lewindon (2016) only allow a return to running once imaging confirms the bone has healed (p. 230). So before the first walk, the painful spot needs to be examined to find out which kind of problem it is.
Four–one, three–two, two–three
Once you are through the entry point, Sahrmann’s plan has three stages:
| Stage | Each round |
|---|---|
| 1 | Walk 4 minutes, run 1 minute |
| 2 | Walk 3 minutes, run 2 minutes |
| 3 | Walk 2 minutes, run 3 minutes |
The first session repeats stage one four times, 20 minutes in all. Leave a rest day between sessions. The starting surface should be soft, such as an athletics track or a wood-chip path, and concrete comes later (Sahrmann, p. 393). Joyce and Lewindon record a plan with the same rhythm of walking first, then running (p. 356).
The walking minutes break the session into small portions of load that the newly healed spot can handle, and after each portion you can read how it responds. The book stops at the walk 2 – run 3 stage and does not say how many sessions to stay at each stage. For the later stages, with the running part gradually longer and the walking part gradually shorter, the doctor sets them for each person using the same measure as in the section below.
New shoes or an unfamiliar route both make the leg take a different kind of load (Joyce and Lewindon, p. 213, 232). For these few weeks, keep to your old shoes and your old route.
A three-line notebook
Feeling fine today is very easy to be fooled by. The clinic advises writing down three lines after each session, each line a number from 0 to 10:
- During the session: how much the old spot hurts while running;
- The next morning: how much the old spot hurts as you get out of bed and go down the stairs;
- After 48 hours: how sore the old spot still is, and if there is swelling, add the word swollen.
The way to read those three lines comes from two books. Sahrmann sets two markers: a sharp pain during the session means stop; pain or swelling lasting more than 48 hours means reduce the level, that is, go back one stage. The Grieve physiotherapy textbook, discussing patellofemoral pain (pain around the kneecap at the front of the knee), accepts a pain level of 0–2 out of 10 during exercise, and up to 5 out of 10 if it is only brief and does not carry over to the next morning (p. 573). Grieve was writing about the knee. Using that scale as a general measure for the first two lines is how the clinic applies it.
Reading the notebook that way, the current stage counts as passed when the first line is no more than 2, or only touches 5 for a moment. The second line has to return to where it was before the run. The third line is back to 0, with no swelling. Only when all three pass do you try the next stage at the following session; if the third line still has a number or still says swollen, go back one stage. If you feel a sharp pain while running, stop that session, write the word sharp next to line one and tell the doctor.
The day your legs feel light
There will be a cool morning when your legs are light and the minute of running goes by so fast that you feel cheated. People coming back tend to skip stages on exactly those mornings. Joyce and Lewindon advise avoiding sudden increases in load, especially after a break or after an injury (p. 213, 232). That morning, feeling strong tells you something about your sleep and the weather. Whether the newly healed tissue can take more is something you only find out the next morning and two days later.
You should also know which group you are in. Saragiotto and colleagues (2014) pooled the studies on risk factors in recreational runners, and the factor that came up most consistently in those who got injured was this: they had been injured in the previous 12 months. People who are coming back belong to exactly that group, so they have all the more reason to keep to the stages.
On the other hand, on days when you have slept badly, the weather is hot or your legs feel heavy, stay at your current stage, or just walk. The walk–run plan is expert experience recorded in rehabilitation books, not the result of comparative trials. For stress fractures in particular, the sources we could find have no study that defines when runners can return.
A bird once struck by an arrow fears a bent branch
A child who fell off a bicycle at the pothole at the end of the lane still squeezes the brakes when reaching that spot a few days later. Seeing this, Grandma laughs and says that a bird once struck by an arrow fears a bent branch. Adults who run are the same. The left leg has healed, yet the step still holds back.
Applied Kinesiology (AK), a way of testing muscle strength by hand to read the state of the body, looks at that holding back from the side of the nervous system. Walther, who wrote the foundational AK textbooks, notes that the memory of an injury, for example after an accident, can be held both in the physical part and in the emotional part. When almost every muscle tests weak at once, the examiner has to consider the emotional side (Synopsis, p. 187). The clinic looks one step further: the body stores memories in many areas, not only in the brain, including in a shin that once hurt.
In the clinic’s experience, the fear of pain can keep the muscles that cross the once-painful spot working below threshold, meaning they become weak when muscle tested. In the lower leg, these are the tibialis anterior, tibialis posterior, gastrocnemius (calf muscle) and soleus. On the track, it shows up exactly in the third round: the left foot touches down softly, the shoulders lift, the breath falls half a beat short.
The bridge slope on the examination table
This examination is done once the painful spot has been confirmed not to need further imaging and you can already walk for half an hour. The doctor tests each muscle of your left lower leg while you lie down, then while you stand on that leg. Every muscle is solid.
Then the doctor asks you to close your eyes and think about the downhill stretch of the bridge at kilometer seventeen. You do not need to say anything. An indicator muscle (a muscle the doctor uses to read the body’s response) that was holding firm now lets go. Walther uses the emotional neurovascular reflex, located on the two frontal eminences of the forehead, for exactly this kind of thing: a specific event the patient has not yet gotten over, such as the memory of an accident, and the examiner does not need to know what it was (Synopsis, p. 433–434). While you keep thinking about the slope, the doctor lightly touches the two frontal eminences for a while. Afterward you think about it again, and that muscle is retested.
The physical part comes next. You stand on a low step and step down with your left foot, stopping at the exact moment the foot touches the floor, your body leaning slightly forward, close to your posture on the slope that day. Palomar, who developed P-DTR (Proprioceptive Deep Tendon Reflex, a method that works with the sensors in muscles, tendons and joints through deep tendon reflexes), calls the moment of injury “The Event”. He notes that putting the patient back into exactly that position can make every muscle weak at once, and that a deep tendon reflex (like the leg jerk when a small hammer taps the tendon below the knee) can clear that imprint, including in cases the Injury Recall Technique (IRT) had not resolved (ICAK 2008–2009, p. 195; ICAK 2009–2010, p. 225–227). The doctor triggers a tendon reflex in that position, then has you step down again and tests the muscles.
After treatment, you step down from that step a few times and jog slowly on the spot for about one minute, then the muscles of your left lower leg are retested while you stand on that leg. Cuthbert advises that, for the knee, a correction only counts if it holds while the patient is moving (p. 99). The clinic checks this way for every area, and does not test muscles on a treadmill.
AK cannot change how quickly or slowly tissue heals. The examination only targets the neurological brake that is holding the leg back, while moving up a stage is still decided by the three lines in your notebook.
When to stop the plan and see a doctor
The plan is for a painful spot that is healing. Stop running and see a doctor if you have any of these signs:
- Pain concentrated at one point on a bone, tender to press, getting worse from session to session, or hurting even at rest or when lying down at night, even if earlier imaging was normal;
- Hip or groin pain when you put your weight on one leg;
- You have had to stop a session because of sharp pain, or you have gone back a stage and the pain still returns at the lower stage;
- After a knock, the lower leg swells tight very quickly: go to the emergency department right away, and do not raise the leg.
With stress fractures, X-rays are often still normal in the first weeks, and magnetic resonance imaging (MRI) is more sensitive (Joyce and Lewindon, p. 229; Magee and Manske). What to image, and when, is for the doctor to decide after the examination.
Herbal pouches that keep pace with you
Some people, after long walk–run sessions, get home with an aching back and knees and legs that feel clearly weak. On days of heavy work, the old spot hurts more. Traditional medicine books call this kind of pain that worsens with exertion “worse with overwork” (劳则加重 / 勞則加重, láo zé jiā zhòng). Such a person may be classed under the pattern of Liver and Kidney deficiency (肝肾虚 / 肝腎虛, gān shèn xū), because the Liver governs the sinews and the Kidney governs the bones (肝主筋、肾主骨 / 肝主筋、腎主骨, gān zhǔ jīn, shèn zhǔ gǔ), that is, the Liver nourishes the tendons and muscles and the Kidney nourishes the bones (Basic Theory of Chinese Medicine, 中医基础理论 / 中醫基礎理論, p. 219, 225). After the four examinations (looking, listening, asking and taking the pulse in traditional medicine), the doctor may prescribe a decoction in ready-to-drink 50 ml pouches, cooked separately for each person, aimed at supplementing the Liver and Kidney so the tendons and bones grow stronger. People who are pregnant or trying to conceive have the herbs that do not suit them left out. If you are about to enter a race with urine sampling for doping control, tell the doctor from the very first prescription.
The fourth running round
The watch buzzes again. The fourth running round of stage one. Tonight, besides the three numbers, you add one small line: left foot touches down softly, shoulders lift. Then you put the notebook next to your shoes, so you take it to the track the morning after next.
If you have passed stage one and the leg still doesn’t dare, or you keep having to go back at the same stage, book an appointment with Dr. Dinh Ngoc Duc (MD, MSc in Traditional Medicine). The doctor will read your notebook, rearrange the stages for the coming weeks, and then look for the old signal that is making your left lower leg hold back. Book a consultation.
Worth keeping
- Only start mixing in running once you can walk 30 minutes straight without the old spot hurting more;
- First session: walk 4 minutes, run 1 minute, repeat 4 rounds, on an athletics track or a soft path, avoiding concrete;
- Leave a rest day between running sessions;
- After each session write down three numbers: pain during the session, the next morning, and after 48 hours;
- Sharp pain during a session means stop; pain or swelling lasting more than 48 hours means go back one stage;
- Only move up a stage when all three lines pass, even on days your legs feel very strong;
- During the weeks of your return, keep the same shoes and the familiar route.
References
Sources in English
- Cuthbert S. 2013. Applied Kinesiology: Clinical Techniques for Lower Body Dysfunctions. Gangasas. p. 99.
- Joyce D, Lewindon D, editors. 2016. Sports Injury Prevention and Rehabilitation: Integrating Medicine and Science for Performance Solutions. London: Routledge. p. 213, 229–234, 356.
- Jull G, Moore A, Falla D, Lewis J, McCarthy C, Sterling M, editors. 2015. Grieve’s Modern Musculoskeletal Physiotherapy. 4th ed. Edinburgh: Elsevier. p. 573.
- Magee DJ, Manske RC. 2021. Orthopedic Physical Assessment. 7th ed. St. Louis (MO): Elsevier. p. 1018.
- Palomar Lever J. 2008–2009. Proprioceptive-Deep Tendon Reflex. ICAK-USA Collected Papers 2008–2009. p. 195.
- Palomar Lever J. 2009–2010. ICAK-USA Collected Papers 2009–2010. p. 225–227.
- Sahrmann S, et al. 2011. Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spines. St. Louis (MO): Elsevier Mosby. p. 392–393, Box 7-1.
- Saragiotto BT, Yamato TP, Hespanhol Junior LC, Rainbow MJ, Davis IS, Lopes AD. 2014. What are the main risk factors for running-related injuries? Sports Med. 44(8):1153-63. doi:10.1007/s40279-014-0194-6. PMID: 24809248.
- Walther DS. 2000. Applied Kinesiology: Synopsis. 2nd ed. Pueblo (CO): Systems DC. p. 187, 433–434.
Sources in Chinese
- 王新华, 主编. 中医药学高级丛书 · 中医基础理论. 第 219、225 页.
