1. Structured Return To Endurance Sports
Marion “ Moose” Herring
Advanced Orthopaedics Sports Medicine Center

2. Who has pain when they run , bike or swim?

3. Who has had to stop or alter training because of an injury or pain?

4. Who has continued to train despite an injury ---- knowing you were doing damage or digging a deeper hole to recover from?

5. Suppose you are having that magical day
Suppose you are having that magical day. You have trained months to get ready. You have sacrificed diet, family time, and rest to train. You had to buy a plane ticket and hotel. Your race fees and tribike transport was paid. You start having a pain you know is bad. You are on PR pace.
Do you stop?

6. Suppose you are racing and having that magical PR day
Suppose you are racing and having that magical PR day. You suddenly feel chest pain. You know if you continue, the consequences could be really bad.
Would you continue?

7. General Principals of Treatment
Understand the mechanism of injury
Athlete Rationalization: A break from activity causes disorganization of the strength and flexibility of muscles
2-3 weeks off leads to significant losses of fitness especially the endurance components
Return takes twice as long as the down time

8. When can I run/ride/train again ?
The Question Becomes:
When can I run/ride/train again ?
Not
When will I be healed?

9. Integration: Athlete-SportsMed-Chiro-PT-Coaching
Race
Normal prep for racing
Build phase
Increased Workout
Begin workout
Modified
Injury phase

10. Healthy Progression Very Individual
You can kill a career by going to fast
Make a Goal for the End of Each Phase
“You are lucky-You get to do this for fun“
Conrad Stoltz

11. Initial Treatment Phase I (3-6 weeks)
Goal : to eliminate the pain or stimulus for pain
***Stopping the activity
Get the correct diagnosis !!!
NSAIDS ( oral or topical), injections ?
Ice
Active or inactive rest
Gentle stretching or Range of motion
Deep tissue massage
Chiropractic Treatment
Set Your Phase 1 Goals: More time with family, Learn about nutrition, Swim technique or speed, read books, learn Spanish

12. Initial Treatment Phase I
Rest ----Ice------hydration

13. Initial Treatment Phase I
Avoid Temptation to Not Rest

14. Initial Treatment Phase I
Active Rest
Cross training, walking, swimming that does not cause pain
**If cross training causes pain, you need complete rest!
Chiropractor: Active Release and modalities
Physical Therapy (with dry needling)
Core Strengthening
Yoga, pilates are great for flexibility and strengthening
Hot yoga is incredible for flexibility, core, balance, heat acclimatization
Stretching
***All that does not cause pain*****

15. Integration: Athlete-SportsMed-Chiro-PT-Coaching
Race
Normal prep for racing
Build phase
Increased Workout
Begin workout
Modified
Injury phase
*Pain or injury is better

16. Initial Treatment Phase II (? weeks): Assume pain is absent
We are beginning our sports specific motion (train coordination of joint and muscle)
****be aware of the pain******
Set Your Phase 2 Goals: Time with family, continue nutrition , Yoga, Core strength, swim , better run or bike technique

17. Proper Weight Too much Too little Just Right ?
4 x body weight each step across your hip , knees and feet
Too little
Not enough nutritional ability to train
Bone density decline
Just Right ?

18. Phase 2 How do I avoid the abnormal stress that led to injury ?
Form and Technique
Mechanics of repetitive load
Orthotics/Shoes
Bike fit
General and Specific Strengthening

19. Form and Technique Gait Analysis Drill Work Shoe Wear
Crucial is determining repetitive stress
Cadence (Metronome)
Specific exercises to address these issues
Drill Work
Striding ON
Fitness Goals Limited
Shoe Wear
General and Specific Training

20. Aquatic Based Return to Running
Deep Well running
*Zero gravity
*Good cardio with high cadence
*Work hip flexion and careful of extension, straight back, arm swing
*Use as a return from injury or supplement
**Pete Pfitzinger 9 week plan
Under water treadmill
Up to 30%
Alter G treadmill
-50-90% weight bear
Running

21. Form and Technique Bike Fit
This must fit your flexibility and your race plans
**Not everyone should be “nose down”
Cleat Position

22. Integration: Athlete-SportsMed-Chiro-PT-Coaching
Race
Normal prep for racing
Build phase
Increased Workout
Begin workout
Modified
**understand mechanism
**gait and bike fit
**proper strength /balance
Injury phase

23. Phase 3 : Increased Volume
Use of a Coach
Develop a Long term and short term plan
Training
Racing
Recovery
Journal
Develop An Aerobic Base to build volume and intensity
BALANCE

24. Run Progression in Phase 3
Track/grass
walking
gravel
jogging
Hilly or uneven
running
Cutting
Fitness Challenge to set zones

25. Phase 3: Increased Run Volume
Use of Run/ Walk Program
***Rules of progression
*Each stage should last 1 week. You can obviously progress the total time by increasing the interval . In stages 1-8 do not increase the interval by more than one.
*If you have pain-skip a run ( 3 days ) and return to the previous stage. If you still have pain at that lower stage please notify your doctor

26. Run Walk
Stage 4-7 are jogging steady or zone 2 ( no intensity); the walk is good form good arm swing . This should be done no more than 4 times per week.
Stage 4: 4 min run / 1min walk x ___
Stage 5: 6 min run/ 1 min walk x ____
Stage 6: 7 min run/ 1 min walk x _____
Stage 7: 8 min run/ 1 min walk x _______
Stage 8: 9 min run/ 1 min walk x______

27. Run WALK
Stages 8-10 : the run pace intensity can increase by adding strides focusing on perfect form and, terrain can vary. This should be % of normal pace prior to injury. The walk is same as above. You may want to do a shorter steady run without breaks on other training days.
Stage 8 7 min run/ 45 sec walk x______ with ____ x strides @____________
Stage 9 8 min run/ 45 sec walk x _______ with ____ x strides @____________
Stage 10 9 min run / 45 sec. walk x _____ with ____ x strides @____________

28. Run -Walk
Stages 11-14: This progression is meant to realize longer race pace with scheduled rest. This would be normal run walk training for, marathon, half marathon, Ironman or half iron man
Stage min run/ 45 second walk x ____
Stage min run/ 45 sec walk x_____
Stage min run / 45 sec walk x ______
Stages 14 and 15: the athlete should decide where they want their nutrition and interval to match that plan. Build the time to match the event .
Example1 : I plan on running 730/ mile marathon pace and I want to walk for nutrition every 2 miles. That would give 15 min run/ 1 min walk.
Example 2: I plan on running 9 min/ mile for Ironman and walk 30 seconds through the aid stations. This would we 9 min run/ 30 second walk.
Stage min run / 1 min walk x ______

29. Bike Progression Fitness Challenge To Set Zones Trainer
Recumbant
Trainer
On the road or trails
Fitness Challenge
To Set Zones

30. Integration: Athlete-SportsMed-Chiro-PT-Coaching
Race
Normal prep for racing
Build phase
Increased Workout
*increase run volume
*increase bike volume
*Strength/core/yoga
*Test to set zones/aerobic base
Begin workout
Modified
Injury phase

31. Our favorite step!

32. Race Day

33. Suffer So Good !

34. Recover !!!! Enjoy What You Do !

35. Marion M. Herring, MD mherring@advancedortho.me
Race
Normal prep for racing
Marion M. Herring, MD
Build phase
Increased Workout
RECOVER
Begin workout
Modified
Injury phase

36. Thanks