The Secret to Smarter Return-to-Running Plans

Most physios have been there – treating a runner with an overuse injury who has a big race on the horizon.

Whether it’s an elite athlete or someone completely new to running, balancing return-to-run progressions to maximise race performance while protecting fitness, preventing flare-ups, supporting confidence, and maintaining overall motivation often feels like a tricky maths problem.

In his Case Study, expert physio Jason Tuori takes us through the rehab journey of one such patient with Achilles tendinopathy. This blog highlights some of the key resources Jason uses to guide his return-to-running decisions – these are tools you can apply with your own patients to simplify decision-making and improve outcomes for running-related injuries.

If you want to see exactly how an expert physio assesses and manages a patient with Achilles tendinopathy, watch Jason Tuori’s full Case Study HERE. With Case Studies you can step inside the mind of experts and apply their strategies to get better results with their patients. Learn more here.

Background

Jason’s case involves a 33-year-old male with left-sided Achilles tendinopathy, preparing for his seventh marathon in seven months’ time. While this scenario will feel familiar to many physios, the great thing about these strategies is that they can be adapted to a wide range of patients, goals, and performance levels.

First, watch Jason explain the special tests he performed to confirm his diagnosis in this video from his Case Study:

Based on these assessments, Jason diagnosed Achilles tendinopathy and built a treatment plan around the findings. The key elements included:

• Calf raise program: a cornerstone of Achilles rehab, targeting deficits in soleus and gastrocnemius, Jason recommends starting at the highest tolerable load.
• Strength & conditioning program: at minimum, this included a squat, a deadlift, and calf raises. Jason shows the exact program he prescribed in his Case Study, so be sure to check it out!
• Cross-training program: essential for maintaining fitness while reducing tendon load. Whether cycling, swimming, or another activity, Jason ensures training volume and intensity match the patient’s running plan to keep fitness on track.

Return to running decisions

This is a challenging stage of rehab – the patient is often feeling a lot stronger and ready to put on their running shoes and hit the pavement.

Our job as physios is to make objective, level decisions based on a range of patient factors, thoughtfully balancing the patient’s motivation with their tissue capacity and long-term goals. While there’s no one correct answer, there are some really useful strategies you can implement into practice to make these decisions more systematic.

First of all, Jason explains how he implements the strategic Assessment of Risk and Risk Tolerance (stARRT) framework in his decision-making – watch this clip from his Case Study:

He also further breaks this concept down into six key components he considers on a sliding scale, leaning more conservative or accelerated depending on the patient, they are:

1. Tissue type: e.g., tendons may allow faster progression, while bone stress requires more caution.
2. Symptom irritability: how easily symptoms are reproduced and how likely flare-ups are.
3. Time away from running: longer breaks generally mean a more conservative return to running.
4. Competitive level: elite athletes may require a faster progression despite higher risks.
5. Timing and season: e.g., if the marathon is soon and there’s no immediate follow-up goal, you might accelerate the plan.
6. Mental health: consider the patient’s wellbeing – are they better off returning despite risks, or could setbacks be more mentally harmful?

Considering these factors can really help guide your clinical reasoning for return to running (or activity). Weighing these, Jason set up a return to running plan for his patient, watch him explain in this video from his Case Study:

It’s also important to know that it’s more than likely there will be set-backs, and return to activity is often trial and error. For example, Jason’s patient experienced a flare up from this initial program. Instead of stopping the plan, Jason simply looked at the whole picture and tweaked the program by reducing the jumping/plyometrics in the program, and slightly shortening the interval lengths in the running progressions.

Wrapping up

Most physios have experienced the challenge of balancing a runner’s eagerness to return against the realities of potential flare-ups and the need for gradual progress.

Using structured approaches like the stARRT framework and Jason’s six-factor tool can make those decisions clearer and more consistent, not only making our lives easier, but most importantly leading to better outcomes for our patients.

If you want to see more tangible strategies you can apply today, watch Jason’s full Case Study HERE.