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Hi, it is Tom here from Running Physio. Today, I want to talk to you about a topic which is really important to me and many runners out there which is, when we should perhaps suggest someone considered permanently stopping running. So not just a small break to let an injury settle, but actually hanging up their running shoes and deciding that they're no longer gonna run again.

Now, this is really important to talk about because there are a lot of runners out there that are actually told to stop running, I think unnecessarily. Some of the reasons are frankly quite ridiculous. One example someone shared recently on social media was a runner was told to stop running because he was too tall at six foot three to continue to run. I've seen examples of various different injuries, some hallux rigidus, great toe pain, arthritis in the knee, following various different surgeries like hip replacements. All told not to run. Even after things like ACL surgery, which usually actually is used to help people get back into sport, I've heard people told that they shouldn't run anymore.

I want to cover in this video when is it actually appropriate to suggest that to someone and when is it not? What might we be able to do instead. And we've also got an example someone shared just yesterday on social media, they've literally just been told that they need to stop. And I'm gonna talk through how we would assess and manage that example.

If you'd like to learn more about running injuries, I have put a link to our new shin pain series. This includes a runner that was really struggling to do any running consistently for about two years because of shin pain. And we were able to get them successfully back to a marathon. So, visit the link. Check out that video series to find out how we did that.

Okay, so let's think about when should we suggest to someone that they might permanently stop running? And I think it is a suggestion, and I think what we're trying to do is help someone make an informed choice, but we are not trying to choose for them. And I think that's really important. This is not us telling them what to do, it's giving them all the information, so they should decide.

I think when we might suggest someone to stop is gonna be a very specific set of circumstances. Firstly, I feel like we need to have explored all the options available to them, both conservative options in terms of their rehab, and that needs to have been followed fairly diligently for a period of time.

And also, perhaps surgical or other options as well. We really want to explore all the options first. It shouldn't be our first answer. We shouldn't go straight to, “Stop running”. Let's say we've explored all those options. We've given it plenty of time, we've nothing more that we can offer. It might be then appropriate to suggest that someone does stop permanently if either:

A. They're still unable to run, they just can't manage it, or

B. We feel it would be unsafe for them to do so. We think there's significant risk of long-term harm if they continue to run.

These situations actually are relatively rare. When I was preparing for this, I was trying to come up with some examples and thinking, what patients have we said that running is completely out of the question and it is really rare.

One example that I did remember was an example of someone unable to run, someone who had a really complicated tibial plateau fracture. It required lots of surgery to address it, and even two years down the line from that person was struggling to walk any distance they couldn't tolerate any impact, even despite being really diligent with their rehab. That person, best will in the world, they just weren't able to run. That would come in that category. They tried everything they could, but they just weren't able to get back into it.

And then, in terms of examples where someone might be unsafe to run, one would be someone who's had a total hip replacement and perhaps has a past medical history of osteoporosis. And they've then gone on to have a periprosthetic fracture following the hip replacement. We might think in that person because of their osteoporosis, because of their fracture history, because of the surgery, it may be unsafe for them to return to running because there'd be a real risk of further fracture and there might not be lots of surgical options available to them if that happens.

So, you can see in these quite extreme examples, hopefully they illustrate when someone's either unable despite everything or it's unsafe for them to run and all options have been considered, then it might be appropriate to suggest that actually they replace running with some other sport, typically a non-impact sport that they can tolerate well.

But it will still be their choice, not ours. And I think that's really important. For some runners, running is a vital part of their life. It's so important for them. They may be prepared to take those risks and that is their choice to make. But as I said, it does need to be an informed choice.

One of the key things with this is, it should be specific to the individual, not the diagnosis. This isn't about saying you've had a hip replacement, therefore you can't run. But that seems to be what's happening out there in some clinics. It's based just purely on the injury they've had or the surgery they've had. It needs to be about the individual and their ability. For example, I know there are lots of runners out there that have successfully come back to running after total hip replacements.

There are some that have gone on to win ultramarathons on their new hip. Assuming that all people that have a total hip replacement can't return to running afterwards isn't really well founded. People have returned successfully to run every day after ankle fusions, osteoarthritis in the hip or the knee, with multiple different conditions.

I have a patient who's done a hundred marathons and both his great toes are totally fused and he's done successfully, no pain, whatsoever. So, it shouldn't be about the diagnosis, it should be about the individual.

A nice example that we have from this that Dr. James Noake shared recently on Twitter is this amazing runner called Fiona Oakes. Her story is that she actually lost her patella to a tumor as a teenager. She doesn't have a patellar on one side, but she since then has gone on to become the fastest female to run a marathon on each continent and the North Pole, and she holds four different world records. Now, you can imagine after that surgery, perhaps she may have been told, “Of course you can't run again. You don't have a kneecap, you don't have a patella”. But that's not what she's followed. She's gone down her own path and has had a wonderfully successful running career. So, it very much needs to be about the individual and their wants and goals.

Part of the problem with this if we are talking about, is it safe for someone to run, is there's a big gray area here.

There's a big area where we just don't have really much research to tell us who is at risk. What surgeries, what injuries actually may deteriorate significantly with continuing to run? What my knowledge of the research that's out there, for example, in things like cartilage tears, which are very common in asymptomatic runners, about 36% of us have them and osteoarthritis in the knee. The available evidence I've seen would suggest those don't usually worsen with continued running. We can talk about the risk, what we might be concerned about, the knee might become more swollen, might become more sore. There's a possibility that this could get worse. But we won't necessarily know unless you are prepared to test out and see what happens.

We can acknowledge those gray areas. We can discuss the potential risks, and then the person can decide what they want to go on to do. And part of that then needs to be looking at the other risk factors that are gonna increase the likelihood of this injury worsening. This would be things like other past medical history such as diabetes, osteoporosis, potentially obviously being a big factor for bone health.

It might be if they have high BMI, if they're managing obesity for example, that's gonna place more stress on the tissues if they've had previous injuries that may be factored in as well. I think we need to, on an individual basis, weigh up those risk factors, but also consider the impact of not running. And I think this is often really missed when we just say flippantly, stop running. We are not really thinking about what impact will this have on the individual, both physically and mentally. A lot of runners use running to manage their mental health. An example, recently I worked with a guy who had ACL surgery, but he'd been told by the surgeon that he should no longer run, which is quite unusual following ACL surgery, but he'd been told, “That's it. No more running”. I then met him a couple of years down the line. He'd been very diligent with his rehab. He had no pain, no swelling. He had full range. He was really strong. And he shared with me that running was how he was managing his depression and his mental health. And since having the surgery and being told not to run, he'd really struggled with his mental wellbeing.

So, if that surgeon had perhaps thought about it, the risks here are pretty small. Most people can get back to running after ACL surgery, and the impact on this person is if I ask him to stop or suggest he stops, it's gonna have a negative impact on his mental health, hopefully they would've seen that. That really wasn't the best advise to give him.

And I saw this person just once in the end. He was in great shape and we just talked through a graded return to running and he never needed to come back to me again. We really in those situations don't want to be telling people to stop. That's not unsafe for them to do. So, they're not unable to run.

It doesn't follow their criteria. Really important on an individual basis, it's not about the diagnosis, it's about the individual, their goals, their risk factors, and the impact that not running will have.

So, let's have a look at this example that was shared on social media. This is a quote from someone I've kept confidential obviously. But, if they are listening, I hope you find what we're talking about helpful here. They've said after an MRI, I'm told there is moderate arthritis and cartilage damage in the knee and a slight meniscus tear. And the consultant has advised non-operative care, and if it worsens, a partial knee replacement. Oh, and stop running. So, they've then gone on social media to ask any suggestions, which don't involve stopping running.

If this patient then was presenting to me in clinic, and this is quite a common situation actually, they've been told that they need to stop, I'd really want to do a good assessment to find out what's going on.

So, have they been continuing to run and if so, how is that knee responding to it? Is there actually a manageable distance they can do that doesn't flare up their symptoms? perhaps even if they can just manage a kilometer, say, and it feels comfortable on the knee and it doesn't swell and become more painful afterwards because we could use that and see, okay, this is what is tolerable for you. We wanna know about their past medical history, like we've talked about. Have you had previous injuries? Do you have any history of things that will affect healing like diabetes or bone health, like osteoporosis? Do they have general health issues like obesity, high BMI, things that we might look at, modifiable factors. Also, I'd want to reassure them that these findings on the MRI, most of these are common in asymptomatic individuals. There will be lots of people running quite successfully on a slightly arthritic knee without any symptoms, whatsoever. We'd want to drill down into that assessment, identify their rehab needs. Identify their running tolerance if they have some and then discuss with them what would they like to do.

They've clearly said here, is there a solution that doesn't involve stopping? They're obviously motivated to continue to run. So, we would talk to them about that and say we'd like to get you to come back to running comfortably if we can. The concern here is it may irritate the knee, but we would aim to find a manageable level for you and help them make an informed choice.

And then, we might go through some phases to try and get them back into the running that they'd want to do. Typically something that looks maybe a little bit like this. First of all, let's assume this runner isn't doing any running at the moment. First of all, we might have a strengthening phase where we are looking to really address their rehab needs particularly strengthening up those key muscles that are gonna provide support around the knee, the quads, the hamstrings, the glutes and the calf. Addressing their range. It might be they're bit stiff into extension. So perhaps looking at that, perhaps doing some treatment to help settle swelling and pain. So that first phase, preparing them for building up towards running.

Then we might work on some weight-bearing cardio to try and get their knee used to weight-bearing activity. So here it might be simple things like walking and increasing walking distance, brisk walking, cross train, a stepper in the gym just to get that knee used to weight-bearing activity again.

And then the next phase would be perhaps introducing some light impact or plyometrics. And you wanna start small here. It might be a little bit of skipping, a little bit of jogging on the spot, shallow range, jumps in place, et cetera. Typically, really short duration, so we might be looking at as little as 30 seconds of one exercise initially and gradually building them up with that.

Now, what I'll often the aim to do is use this as a way of building some impact tolerance and try and gradually build up so they're managing around about three or four minutes of impact within an exercise session and monitoring their response throughout. Particularly here, we want to know, is this response acceptable to them? They might be happy to have a little bit of pain and discomfort if it means they can get back into running. But is it acceptable to them? What we don't wanna see is this knee becomes really swollen, really stiff, really uncomfortable afterwards, or has symptoms of locking or instability, any lasting effects that you don't wanna see.

We introduce some plyometrics, perhaps we get them up to three or four minutes of impact tolerance, and then we start with a graded return to running. My reasoning process there is I quite often start with a short run of around about three minutes in total, often with walk, breaks every minute. We are working on building some impact tolerance for a few minutes. As a way of introducing that first run.

And then, we gradually increase that running again and monitor their response to it. What we are aiming for here is a gradual increase with consistency. Consistency is often the key factor here, if you're coming back from an injury where perhaps you've struggled to come back in the past, quite often what we see is we build really rapidly and then things get irritated so we stop all together.

What we want to see here is probably a slower, gradual build, and if things hurt, we come down a little bit and then we progress on again. Hopefully, this is an alternative to just saying stop altogether. And in many cases with runners, if we do a similar process to this, we build their strength, we build their load tolerance, we introduce some low level plyometrics and we do a graded return, many people can return to running despite the underlying diagnosis.

If we follow that approach and we give it enough time, it may well take some months to get there, but if running's really important to a runner and it really is to me, certainly is to me, I'd be well prepared to take that time and get them back in.

Okay, so I hope that's given you some food for thought. Just to summarise what we've said here, we asked this question of when should a runner permanently stop running? Short answer is really, we want that to be a rare occasion. It's not something we should be giving as the first bit of advice when someone sees as following injury.

It may well be appropriate for them to stop if all treatment options have been tried and they're still unable to manage to run, or we feel it's actually gonna be unsafe for them to do so. There's significant risk of lasting harm if they continue, but in many cases, there isn't likely to be harm if we're prepared to do this graded return and monitor their response. It's gotta be down to the individual and not just their diagnosis, you include that obviously. It's gotta be down to the individual, their risk factors, the negative effects of not running as well. And then hopefully we can help them make an informed choice about whether they want to continue to run or not and support them as they work back towards that.

Thanks everyone for listening in today. As I said, I've put a link to our free shin pain video series. Do check that out. That goes into loads more detail about how we took someone from not really able to run consistently for two years back to completing a marathon without shin pain.

So, I'd give that a little bit of a watch. Okay, thanks again for listening. Bye for now.