Can I Run On This Injury?

Avoiding the Abyss: When runners should seek professional help

"Medication Can Never Treat the Cause of an Injury"

Orthopedic Rehabilitation Specialist
Bruce R. Wilk, P.T., O.C.S. Individualized coaching
Running Injury Management

Iíve seen runners crippled by running on injuries. An injury that cripples you, thatís the Abyss. It prevents you from running, sometimes temporarily Ė sometimes permanently. That should be a wakeup call for all runners.

Hereís 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 didnít 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 Ė she couldnít 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 wasnít 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 Ė and she never ran again. She fell into the Abyss.

Why do runners run on an injury? They donít perceive that itís 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 donít know they can risk everything by taking pain medication in order to race. They donít know they can fall into the Abyss.

It doesnít 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 itís 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, runnerís 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 doesnít really matter Ė what matters is the severity.

Unfortunately, most runners donít know how to rate the severity of running injuries. So, over the years, Iíve 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 Ė 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 Ė 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 doesnít 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, youíre 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. Thatís 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, ďBruce, Iím training for a marathon, and at ten miles my foot is killing me Ė I canít get past ten miles.Ē I ask him, do you have pain when you stop? He says, no, itís okay. I ask him if heís having pain that interferes with daily activities. He says no, when he stops itís okay. I ask if heís taking any medications, and he says no, heís not taking anything. Thatís stage 1.

Note that, even if a runner is at stage 1, pain-wise, if theyíre taking any medication for it Ė suddenly theyíre 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 canít help them. In my professional practice, thatís a deal breaker. I have patients who say ďOh, it was prescribed, my doctor said it was okay.Ē Well, if youíre going to run on cortisone shots, I say youíre out of here. I donít want anything to do with it. Youíre 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, itís just muscular shin splints; thatís 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 Ė and when one is crippled, one is risking not coming back. Youíve 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 itís moving back. Massage could be part of it. Rest could be part of it. Modifying your training could be part of it. But itís actively working to regain the normal function of the structure Ė not passive.

Medication can be a part of recovery if oneís sleep is disturbed and medication is necessary for rest Ė but there must be no running until the medication is out of your system. Youíre at stage 4 now, and you donít compete.

Ice means cold compresses. Thereís 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. Itís okay to run some, but we have to keep our eyes open. My rule of thumb is, if youíre concerned, you should come in, even at stage one. 

Remember, the first rule of management is protection. Itís 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 youíre having pain thatís interfering with normal activities Ė if youíre having trouble walking, if you canít take the stairs Ė 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 arenít trained in running injuries Ė and finding a professional with specialized knowledge isnít easy.

If you are going to a doctor who prescribes medication, or injects medication, and tells you its okay to run, thatís not professional help. In my world, thatís 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 youíre 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 donít, 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. Weíre not talking about post-marathon sore Ė weíre talking about the inability to live your responsibilities or meet your commitments. It doesnít matter if itís plantar fasciitis or a stress fracture, if it cripples you, you might not come back. Itís not worth the risk. Even if youíre crippled for a week, who wants to be crippled?

Crippling doesnít necessarily mean you wonít 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.


About the Author: 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.


cid:image002.jpg@01C9AE3D.EC0098F0SIDEBAR 1:

The Wilk Scale: Five Stages of Severity in Running Injuries

Stage 1: Pain upon exertion

Stage 2: Pain at rest

Stage 3: Pain that persists during normal daily activities

Stage 4: Pain that you take medication for

Stage 5: Pain that cripples you



Q: How would you treat a patient with stage 3 injury differently than with stage 1?

A: If pain is disturbing their sleep, Iím probably going to tell them to cease running until they improve Ė you know, get some rest for a couple of days.

Q: Do you tell all your patients to stop running?

A: No! Weíre telling them itís okay to run as long as they are following their specific instructions for protecting the structure and recovery. For example, changing the shoes, doing less mileage, toning it down, going slower Ė if they make the changes, thatís okay, theyíre protecting it.

And during recovery, if theyíre doing their stretching exercises and improving (going in the other direction on the scale), weíre telling them itís okay. Weíre telling them itís okay as long as itís not disturbing their sleep, theyíre not progressively having to modify or reduce daily activities, and theyíre not using medication.

Runners_High.jpgSIDEBAR 3:

Running Shoes and Running Injuries

Running brought me to physical therapy, physical therapy brought me to triathlons, and running injury brought me into studying running shoes.

Shoe problems are an avoidable cause of running injuries. Around 1998 I got a pair of running shoes that were defective and picked up an injury (plantar fasciitis) while doing a race. Because I was really able to identify a very specific injury in my mind with a very specific source, and a very specific pattern of shoe defect, I did the research and started publishing articles on running injuries and defective athletic shoes.

As I researched it I learned about the running shoe industry Ė thatís when I opened up a shoe shop for runners called The Runnerís High, where runners can come in and get expert advice on the right shoe for them.

You can learn more about athletic shoes on my website

Contact Info:

Bruce R. Wilk, P.T., O.C.S.,

Orthopedic Rehabilitation Specialists

8720 N. Kendall Drive

Suite 206

Miami, FL 33176



Copyright 2009 by Florida East Coast Runners and Bruce Wilk.Reproduction or reprinting without written permission is illegal.

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