Can I Run On This Injury?
Avoiding the Abyss: When runners should seek professional help

I’ve seen runners crippled by running on injuries. An injury that cripples you, that’s the Abyss. It prevents you from running, sometimes temporarily – sometimes permanently. That should be a wakeup call for all runners.

Here’s an example: While training for a marathon in Miami, I was running with an acquaintance who mentioned that her foot was bothering her. At the time, I didn’t pay it much mind. Later, during the marathon, she complained again and I paid attention. When I spoke to her the next morning, she was crippled with pain – she couldn’t even walk.

What happened? I discovered that she had been getting cortisone shots throughout the course of her training program. She had gone to a sports medicine doctor, a podiatrist, who repeatedly injected her with cortisone and told her it was okay to run.

At the time, she thought she was doing the right thing. She knew the foot wasn’t getting better, but she ran on it anyway. She got her last cortisone shot on a Thursday, ran the marathon on Sunday, and ripped her plantar fascia. It took her four weeks to walk without crutches, six weeks before she could work or exercise – and she never ran again. She fell into the Abyss.

Why do runners run on an injury? They don’t perceive that it’s going to cripple them. This woman would not have continued running if she thought she was going to wake up one day and be unable to care for her children, unable to walk, unable to fulfill her responsibilities. No adult would do that. They don’t know they can risk everything by taking pain medication in order to race. They don’t know they can fall into the Abyss.

It doesn’t have to end up that way. You can avoid the Abyss by understanding and following a few basic guidelines for identifying the severity of an injury, knowing when it’s okay to run, and when to seek qualified professional help.

How Bad Is My Injury?

Running injuries can be complicated. There are over 20 different types of running injures, including plantar fasciitis, shin splints, Achilles tendinitis, runner’s knee, and iliotibial band syndrome. Most are caused by training errors that can be corrected.
When it comes to deciding whether or not to seek professional help, however, the type of injury doesn’t really matter – what matters is the severity.

Unfortunately, most runners don’t know how to rate the severity of running injuries. So, over the years, I’ve developed my own practical scale of factors, increasing in severity from stage 1 to stage 5.

Stage 1 is pain upon exertion. It might be a pain that comes after 10 miles, or after one mile, and continues as long as you are running, but stops when you stop running – this is the first warning sign of an injury.

Stage 2 is pain at rest. The pain is there after you stop running, and it does not go away – this is the time to start self managing.

Stage 3 is pain that persists during normal daily activities, like walking to the car, or walking up steps. You may be sitting at your desk and have some ache or nagging pain that bothers you. Pay attention, if it doesn’t improve in a few days, or worsens as you do your self management, seek professional help.

Stage 4 is pain that you take medication for. This is a very important factor. Medication masks the severity of an injury and allows it to get worse if you keep on running. If you are taking medication, you must cease running until it is out of your system. At this stage, you’re on the edge of the Abyss. You must stop running.

Stage 5 is pain that cripples you. It stops you from running, or maybe even walking. That’s the Abyss.

Any type of running injury can be staged this way. When a patient calls me with an injury, I start to stage it over the phone. For example, the patient might say, “Bruce, I’m training for a marathon, and at ten miles my foot is killing me – I can’t get past ten miles.” I ask him, do you have pain when you stop? He says, no, it’s okay. I ask him if he’s having pain that interferes with daily activities. He says no, when he stops it’s okay. I ask if he’s taking any medications, and he says no, he’s not taking anything. That’s stage 1.

Note that, even if a runner is at stage 1, pain-wise, if they’re taking any medication for it – suddenly they’re at stage 4, which is one stage from crippling. Say you take Advil, and keep taking Advil, you need to address that. With pharmaceuticals or injections, if one keeps running, the medication could mask the pain just enough to cripple you.

I want to make it very clear that at stage 4, if a patient insists on taking medication to keep on running, including prescribed oral or injected, I can’t help them. In my professional practice, that’s a deal breaker. I have patients who say “Oh, it was prescribed, my doctor said it was okay.” Well, if you’re going to run on cortisone shots, I say you’re out of here. I don’t want anything to do with it. You’re not going to stage 5 on my watch.

Again, the type of running injury is not a factor when deciding whether or not to seek professional help. Any running injury can go from stage 1 to stage 5. Sometimes runners think oh, it’s just muscular shin splints; that’s not so bad. Then they start taking Advil and keep running on it, or go to a doctor and get cortisone shots and keep running on it. That injury can go to stage 5 – and when one is crippled, one is risking not coming back. You’ve fallen into the Abyss.

Self Management

The self management for running injuries is PRICE; protection, recovery, ice, compression, and elevation.

Protection means identifying and modifying, as well as you can, the reason for your injury. The main cause is usually training error, which is a broad area and hard to define. The first thing you do is protect the injury and allow it to recover. That could mean a change in footwear, or modifying your exercise program, or resting.Recovery is about moving from later stages on the Wilk Scale back to earlier stages, regaining the movement, strength, and function of the injured structure. One can still train, working to regain movement and strength, as long as it’s moving back. Massage could be part of it. Rest could be part of it. Modifying your training could be part of it. But it’s actively working to regain the normal function of the structure – not passive.

Medication can be a part of recovery if one’s sleep is disturbed and medication is necessary for rest – but there must be no running until the medication is out of your system. You’re at stage 4 now, and you don’t compete.

Ice means cold compresses. There’s a lot of discussion about applying ice packs. We go 360 degrees around the structure whenever possible.

Compression: We compress the ice pack. We put toweling around the ice pack and put pressure on the injured structure (basically ankle, shin, knee, or hip) using Ace bandages or Velcro straps.
We then elevate the injured structure above the heart, so ice, compression and elevation are combined.

When to Seek Professional Help

When you are a runner, pain upon exertion is kind of always there, to a greater or lesser degree. It’s okay to run some, but we have to keep our eyes open. My rule of thumb is, if you’re concerned, you should come in, even at stage one.
Remember, the first rule of management is protection. It’s better to put a management system in place early (such as the right shoes, exercises, or training routine) that can correct the problem before it progresses to higher stages.
Seek professional help immediately if you encounter any of the following warning signs:

  • If you are taking medication and continuing to run.

  • If you are being prescribed, or injected medication and being told you are allowed to run.

  • If you are consistently having pain at rest or pain disturbs your sleep.

  • If you’re having pain that’s interfering with normal activities

  • If you’re having trouble walking, if you can’t take the stairs and it continues for more than a day a two, or is worsening and not getting better.

Professional help often means knowledgeable help by a runner with licensed medical credentials. Most doctors and physical therapists aren’t trained in running injuries – and finding a professional with specialized knowledge isn’t easy.

If you are going to a doctor who prescribes medication, or injects medication, and tells you its okay to run, that’s not professional help. In my world, that’s just wrong. Medication can never treat the cause of a running injury; it only masks it and allows it to get worse if you continue to run. You can be crippled. Even if you’re only taking Advil, it may mask it enough for you to lose daily function.
Most adults are going to limit their running and employ self-management techniques early enough to prevent loss of daily function. When they don’t, the things to worry about are pain during daily activity, taking medication, and becoming crippled.

Staying Safe

Left to itself, any running injury could be crippling. We’re not talking about post-marathon sore – we’re talking abut the inability to live your responsibilities or meet your commitments. It doesn’t matter if it’s plantar fasciitis or a stress fracture, if it cripples you, you might not come back. It’s not worth the risk. Even if you’re crippled for a week, who wants to be crippled?
Crippling doesn’t necessarily mean you won’t run any more. One could still recover from stage 5. But one may not recover from stage 5. You do not want to be at stage 5. Please seek specialized professional help early, and avoid the Abyss.

Bruce Wilk is a board-certified physical therapist, a certified running coach, and director of Orthopedic Rehabilitation Specialists in Miami, Florida, where he has managed running injuries for 27 years. He is also an experienced runner who has been running for 35 years, including 22 marathons, four Ironman competitions, and many triathlons.