The Economics Of Injury Recovery

Stay the CourseIn last month’s column, we outlined four fundamentals of injury rehabilitation and recovery. In order to have an expedient and sustainable recovery from injury, all four of these dimensions must be addressed and maintained:

  • Mobility
  • Strength and stability
  • Efficiency
  • Tissue tolerance

A major roadblock toward swift and full recovery is a ‘halfway approach,’ wherein the runner and his or her medical team only address one or two of the factors. (For sports-medicine folks, it’s predominantly mobility and strength.)

Addressing gait efficiency is a challenge. But balancing tissue tolerance–mastering just how much the tissue can handle at any given time in the healing process, without overdoing (or under-doing)–is even tougher, namely because both tissue tolerance and task demands are dynamic and ever changing.

When I describe this balance to a patient or client, I find it useful to invoke economics: that the tissue in question has a finite ability or resourcefulness, while each activity we do has a cost. Accepting this model, then striking balance is simply a matter of balancing revenue and expenses.

Injury rehabilitation and recovery toward desired running, therefore, is a matter of judicious spending and investment to grow revenue (tissue’s ability to handle load) and minimize expenses (the cost of each activity) while maximizing output (increasing one’s ability to run!).

In the rest of this article, we continue the analogy, assigning figurative revenues and expenses to exercise and other aspects of life to show how they all contribute to our health economics. Please note that dollar values are assigned relatively to demonstrate this concept. In real life, each of our specific revenue and expenses for various actions would vary.

Revenues and Expenses: Activity Stress and Tissue Tolerance Dynamicity

We live in world of economics, so balancing black and red is a simple concept for most. In the health realm, we commonly utilize in the economic model of ‘calories in, calories out’ for weight management. While overly simplistic for both, the same concept can be applied to tissue tolerance. Each and every activity has its cost, and is deducted from the tissue’s fitness ability, or revenue.

For the ensuing example, we will use plantar foot pain as our tissue model.

Before talking about revenues–or the specific tissue tolerance of the foot–let’s outline a model of expenses for normal daily activities (Again, these values are purely speculative and only loosely based on physiological stress models in a rehab setting):

Foot Expenses for Various Activities
-$1 — Bed rest
-$10 — Weekend rest day (around the house, no walking)
-$100 — Typical work day (sedentary)
-$500 — Typical work day (rigorous, on feet)
-$1,000 — One-hour easy run
-$1,500 — Hard one-hour interval or tempo run, or two-hour easy run
-$5,000 — Three- to five-hour long run
-$10,000 — 50k to 50-mile ultramarathon
-$100,000 — 100-mile ultramarathon

As you can see, foot expenses vary based on the degree of weight-bearing, active use (pushing off and landing), and degree of impact stress.

Of course, countless other activities all incur an expense to the tissue in question, and they all add up: this would include extra errands or projects at home (on feet), or even socializing (out for drinks, and especially dancing).

The point is, all aspects of activity–namely anything involving weight-bearing–incurs a cost on tissue, whether you are healthy or not.

Tissue Revenue and a Dynamic Income Model

Like our holistic selves, our individual tissues have ‘fitness,’ defined as ‘the quality of being suitable to fulfill a particular role or task.’ In other words, can the person–or individual muscles, tendons, and joints–safely handle a particular activity, and still bounce back the next day?

Developing fitness is based on the ‘Super-Compensation Principle,’ which states that when a load is placed on the body (or tissues), it will incur stress and strain, recover from and repair that strain, then (a finite time later) possess a higher capacity for load and performance.

Super-compensation is the whole idea behind adaptive training: farther and faster. This represents how increased activity creates greater revenue. Based on the activities we do, we ‘invest’ more to create more ability tomorrow.

Therefore, on any given day, tissue tolerance is dynamic.

Other factors besides training impact revenue, including age, general health, and years of training and racing. Here is a general example of various tissue-tolerance revenue values, based on various factors:

Foot-Fitness Revenue for Various Abilities
+$500 — Normal sedentary person (no fitness exercise)
+$1,000 — Sedentary job plus walks 30 minutes a day
+$1,500 — Physically active job (on feet all day)
+$2,000 — Normal sedentary job plus 60 miles/week running after three months regular training
+$2,500 — Normal sedentary job plus 60 miles/week running after one year regular training
+$5,000 — General marathon to 50k fitness*
+$10,000 — 50-mile fitness*
+$100,000 — 100-mile fitness*
(*consistent block of six to 12 months steady training, with specific long runs, etc.)

In addition, everyone has a savings account, in which there is extra money saved up in the event that we ‘dip too deeply’ into checking during a given day or period of time. Those who have been most consistent in training and health tend to have more robust savings accounts.

Savings-Account Balances for Different Kinds of People
+$500 — Active person, but just started training
+$1,000 — One year of consistent, healthy running
+$5,000 — Three years of consistent, healthy running
+$25,000 — Periodized training (with rest periods) for five-plus years
+$50,000 — Periodized training (with rest periods) for 10-plus years

The savings account is extremely useful as a safety net. It allows people to be more aggressive in training and racing, to cover additional costs incurred, and speed up recovery. However, it takes a wise runner to only occasionally dip into savings, then re-invest to restore these ‘rainy-day funds!’

In summary, the abilities of tissues–to a specific area, or the person, in general–are highly dynamic. They can be trained to increase ability (revenue potential), but like fitness can be quickly lost.

Optimizing fitness and avoiding injury is about accurately gauging this ability at any given time, then knowing how much activity is tolerable to stay balanced!

The Balance Sheet: A Healthy Runner’s Typical Week

Below is a rough outline of a runner and his estimated fitness and activity levels, each monetized to highlight activity balance:

Demographics: 30-year-old runner, sedentary job, runs 70 miles a week, consistently running without injury for over three years
Daily-fitness revenue: +$2,500 per day
Savings account: +$5,000

Weekly Balance Sheet
Daily fitness (+$2,500) x 7 revenue: +$17,500
Seven runs* (easy runs at -$1,000, two hard workouts at -$1,500, one long trail run at -$5,000) Expenses: -$12,000
Net income: +$5,500
(*For simplicity, we choose not to include non-running activities–such as home or family life–in expenses for this example.)

As you can see, this runner ended the week in the black: his tissues could cover the cost of his activity, so there was no excess in tissue stress (expenses) incurred.

So where does the extra income go? In part, the extra is re-invested, such that next week, his revenue might rise from +$2500 a day to… +$2501. Such is the gradual return on fitness investment!

There are limitations to this analogy: extra revenue isn’t pocketed. Often, we use it or lose it: where if we continually do less than our capability, our income will actually decrease (de-training). This is as if our ‘boss’ sees we don’t need that extra income, and docks our pay!

Indeed, human-exercise physiology is far too complicated to accurately apply this model, so let’s stick to injury prevention and recovery. The key to both is to balance the sheet: use our resources wisely, neither excessively over- or under-loading.

In the Red: Expenses > Revenue = Injury

Mechanical injury results when the strain of an activity outweighs the tissue’s ability to absorb the cost. This can happen suddenly–with a major stress event–or gradually over time.

When we incur a sudden-onset injury, such as a fall, the tissue is injured: strained, broken, or torn. Suddenly, our nest egg is gone. For someone with a serious fracture or ligament rupture, the stock market has crashed, or they’ve been robbed blind. They’re left penniless.

Rehabilitation is a total shutdown. Recovery commences with total rest (and/or surgical intervention) we must start saving from scratch. Revenue building is extremely gradual, and expenses must be equally minute (e.g. crutches). Over time, tissues heal and strengthen, and activity can slowly increase.

Most running injuries are insidious. They represent a more prolonged disturbance of the balance sheet: expenses gradually out-strip revenue. This can occur for a variety of reasons:

  • Too much volume (expense)
  • Too much intensity (expense)
  • Insufficient recovery (revenue)
  • Lack of fitness development (stagnation of revenue building)
  • Stride inefficiency (expense–see below for further explanation)

Whatever the factor, expenses start to outstrip revenue, and the bank balance dwindles. This explains how an athlete might initially perform very well on an aggressive training plan–with high-cost workouts and volumes–yet, eventually break down. The resources gradually decrease until a breaking point is reached: the bank account runs dry. Strain. Pain. Bankrupt.

Initial Rehabilitation: Cut Costs, Save Capital, Spend Wisely

After a significant injury, the smart runner does the right things:

  • They rest, cutting mileage or stopping, entirely (cut cost)
  • They see a medical professional to work on mobility, strength, and stability (cut cost, generate revenue)
  • They take anti-inflammatories and ice (create revenue)

But after a period of rest and restructuring, they resume running… and the pain returns. Why? More often than not, it is not due to a more serious, sinister pathology. Instead, stress and rest remain imbalanced.

‘Why Aren’t I Getting Better?’

Part 1: Too much, too soon
The most-common reason runners have a pain relapse is a failure to conservatively resume running. They fail to grasp the true cost of running, versus their current tissue tolerance–or present revenue level. Simply, they try to put a normal load on abnormal (still sensitive, still weakened) tissue.

Pre-injury revenue: +$2,500
Current revenue: +$800
‘Normal run’ (one hour, easy) expenses: -$1,000
Net loss: -$200

In the red again! Within a few days, the runner has flared his foot. “I’m just running my usual!” they claim. “There must be something really wrong, why is the pain back?” They fail to recognize that, while the foot feels healed (e.g. they no longer have a negative bank account), their tissue tolerance is still quite low: they have yet to build up the capital to afford a ‘normal’ run! It’s simple economics. Even though it’s your ‘normal,’ easy run, it’s too costly! You can’t afford it yet.

Another common tale is how a runner will feel good for a day or two, running short three milers. The third day, they feel great and decide to be ‘normal’ and run 10 miles! They got their paycheck cashed… and blew it all in a day! Nothing is leftover, and they went overdrawn. Again.

Part 2: Nickel and Dimed, Hidden Fees Increase Tissue Cost
Most non-professional ultrarunners must balance running life with work, family, and other pursuits. Yet we often like to think that we have separate accounts for each. They are not. All activities dip from the same fund.

When injuries occur, it is usually that the aggregate cost of all activity is higher than revenue. But since most runners are diligent about tracking running expenses (mileage, workouts), it is usually the hidden fees that bite them:

  • increased work stress (more hours, more pressure)
  • increased family demands (time, energy)
  • relationship stress
  • other activities (home-improvement tasks, volunteer work, travel)

These costs individually are small, but they can quickly add up. So even when a runner is easing back into running with shorter, easier runs, they continue to experience flare-ups:

Current revenue: +$1,000
Short, easy run (30 minutes) expense: -$500
Work stress (extra hour of work, stressful meetings, traveling) expenses: -$350
Family activity (home-improvement tasks, running errands, playing with kids) expenses: -$350
Net loss: -$200

It all comes from the same fund! Just because you’re doing a short run does not mean you’re not overloading the foot. Do not discount the physical and chemical effect that increased time-on-feet and/or psychological stress can have on tissue healing.

Part 3: Beware the Hidden Costs of Cross Training
This is another area of error for injured runners: excessive cross training, or cross training with hidden tissue stress. Injured runners will frequently bike, elliptical, swim, or pool run, hoping to maintain fitness while resting. Too often, they fail to realize there are mechanical and chemical stressors that keep tissue sensitive and slow recovery.

Non-impact but ‘partial-weight-bearing’ cross training such as elliptical and even cycling still puts load through stressed tissue (particularly the foot). Recognize its cost, and don’t believe that a two-hour spin session is ‘free!’

Chemically, cross training too hard adds a metabolic stress to sensitive tissue. So even a runner doing a deep-water (completely non-weight-bearing) workout–if it is of grueling intensity–may be exacting a steep chemically inflammatory cost.

Part 4: Taxation Without Representation, Stride Inefficiency Cuts Deepest
So a runner gets injured, and they do all the right things: they rest (cut expenses), heal well (increase revenue), do their PT stretches and strength work (more revenue), and manage stress to the utmost (cut more expenses).

It’s time to return to running. They go short and easy… but experience pain. Their PT or coach advises them to run even shorter and easier. Still pain! Full-on runner freak out ensues: “I’m running beyond easy! There must be something really wrong, why is the pain back?”

The number-one hidden cost for runners is stride inefficiency. When we run efficient, the cost per mile is low. However, stride efficiency is extremely dynamic and subject to change, so when we develop a stride hitch, the cost per mile can increase, even skyrocket, especially when there is a stride imbalance that creates a one-sided overload.

Since stride inefficiency is a major factor in cost, a failure to address and correct inefficiency keeps the cost per mile high. In fact, after an injury, many runners become even more inefficient! Inefficiency extends beyond running, into daily life. Limping or compensating–just standing and walking funny–creates abnormal stresses and can weaken sensitive tissue, causing a slow bleed of healing, keeping revenue low, and subsequent costs high.

Let’s look at the numbers again, first for the ‘healthy, efficient runner.’ This runner is both strong and efficient, and can handle high mileage without breaking down.

Revenue (+$2,000 x 7): +$14,000
Expenses (-$150 per mile x 80 miles): -$12,000
Net income: +$2,000

And now the numbers for the ‘inefficient (but healthy and cautious) runner.’ This runner is resilient, but rather inefficient; thus he cannot handle high mileage without injury.

Revenue (+$2,000 x 7): +$14,000
Expenses (-$250 per mile x 48 miles): -$12,000
Net income: +$2,000

When rehabbing from injury, the ‘inefficient runner’ will be burdened by the high cost of even an easy run relative to the decreased tolerance (revenue) of a healing foot:

Current revenue: +$800
Short, easy run (-$250 per mile x 4) expenses = -$1,000
Net loss: -$200

Should they compensate further, the cost per mile may rise even higher! Inefficiency represents an exorbitant taxation of each mile (or step) run. In fact, with severe compensations, it often makes even a single mile of running painful and intolerable. Thus, even though they’re ‘doing all the right things’ in the rehab setting, the runner who fails to adequately address efficiency often finds themselves still in the hole and unable to climb out, experiencing prolonged pain and protracted recovery time.

Interpreting Revenue and Expenses: Listening to the Body

There is no exact science to revenues and expenses: of what the tissue can handle versus the cost of activities. In orthopedic physical therapy, the bulk of research is based on injury-healing timelines, and how to progressively and precisely load tissue, without under- or overdoing it. The parameters are based on basic physiology (cellular healing) and patient feedback and outcomes.

Tips for the injured runner:

  • Find a skilled sports-medicine professional with know-how and experience in injury rehabilitation. By properly evaluating and diagnosing your issue, they will have the best idea of gauging both your tissue ability and loading progression, which are often based on clinical and research-based guidelines.
  • Listen to your body. Your body will tell you what is enough and what is too much. The keys are to tune in and accurately interpret the message.
  • Pain during activity is not necessarily bad. Often, it is stiff tissue that needs (and does better with) activity. Feel out the trends. If it starts painful, then gradually improves, you’re in the clear. The same load tomorrow will likely feel better.
  • Pain after activity is also okay… as long as it goes away. Any pain that dissipates within an hour or two of that activity is an appropriate, affordable load.
  • Pain the rest of the day and the next is a definite overdraft. While it doesn’t necessarily mean you’ve re-injured yourself, you have definitely overdone it and will have to be more restful the next day to overcome the cost.

The most challenging scenario is when one is pain-free during an activity, then is very painful several hours later. This delayed-onset pain also represents an overdraft. Lesson: even though it feels good while doing it, know the true cost of your activity!

Swiftly and successfully overcoming injury takes many skills:

  • Wisdom and skill to thoroughly and constantly address the Four Fundamentals, and to accurately gauge the abilities and costs of the person and their life activities.
  • Discipline to stick to a budget and progress gradually.
  • Courage to push through discomfort. Pain does not always mean damage. As with training, we often must endure some pain in order to progress beyond injury. Watch for the big picture.
  • Consistency. Once your running is on stable ground, be consistent and patient. Bank healing time and develop a savings account of physical resiliency that will help you avoid further setbacks!

Emerging from Bankruptcy: Sustainable Recovery from Running Injury

The key to the fastest-possible recovery time is the delicate balance of crucial savings and wise spending:

  • Resting irritable tissues
  • Restoration of mobility and strength
  • Efficiency
  • Progressive loading stress (reinvestment) to enhance tolerance

It represents substantial cost cutting and thrifty spending up front, intensive labor–in restorative exercise and efficiency work–then judicious investment in your precious income in order to increase revenue for the future.

Here’s an example of what this may look like, with a person with plantar foot pain:

Week 1
Revenue: +$200/day
Work only (at a sedentary job) expenses: -$175/day
Net income: +$25/day

The plantar fascia is moderately (but not severely) strained. It hurts to stand and walk on, so its weight-bearing abilities (revenue) are quite low. With revenue this poor, there is absolutely no running. In fact, normal weight-bearing is limited. You’re trying to stay off your feet. Extra errands or activities are cut out. And by doing so, the saved-up income can be re-invested in greater healing and tissue strength.

Week 2
Revenue: +$500/day
Work, 30-minute exercise biking, short walks expenses: -$400/day
Net income: +$100/day

By the second week, wise spending and investment has resulted in nice healing: the foot is more tolerable to weight-bearing, and short bouts of non-impact activity are well tolerated. However, as you approach your upper limit of budgeted activity, it does feel sore and sensitive. Costs continue to be curtailed, and ‘healing time’ (leftover income) is re-invested toward a more resilient, revenue-generating tissue!

Week 4
Revenue: +$1,200/day
Work, home tasks, 40-minute easy jog daily expenses: -$1,000/day
Net income: +$200/day

By Week 4, the runner has resumed running… but still not at 100% normal volume. Healing revenue is continuing to be banked and re-invested. Aches and pains are minimal and, by and large, the runner is banking healing and feeling a little better every day. Following a progressive plan, the runner gradually adds minutes to his daily run.

Week 6
Revenue: +$2,000/day
Work , home tasks, one-hour easy run daily expenses: -$1,500/day
Net income: +$500

By Week 6, the runner is doing great! Back to normal… right? Normal run volume, normal revenue… almost.

Then what?

The Rainy-Day Insurance Fund: Restore the Savings Account!

Once the runner is pain-free and normal, they are not yet in the clear. Most runners get back to normal running, yet (both the runner and their medical person) believe they’re 100%. But not quite.

The savings account–the ability to develop resiliency and protection from more aggressive activity–must be restored! This can be done a variety of ways:

  • Continue to keep expenses (activity) well below daily revenue
  • Continue to make wise re-investments (stretching, strength, and cross training)
  • Continue to keep taxes and fees (stride efficiency) at a bare minimum!

Over the next three to six weeks, any extra income should go directly back into the savings account so that the tissue can truly handle a higher-expense activity like a track workout, hill session, or long run–and any unexpected stresses that come along. Without it, the runner risks once again going in the red, having a pain flare, and compromising tissue integrity (revenue ability).

Call for Comments (from Meghan)

  • What do your health economics look like right now? Are you generating enough revenue to tolerate the expenses of all of life’s demands, including your running?
  • The last time you were injured, what were the expenses you had to cut?
  • And, were you able to find any extra means of generating revenue in your recovery?
Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master’s Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 9 comments

    1. OOJoeuhan

      They are completely arbitrary and should not be taken literally (in any sense).

      That said, research-based injury and surgical rehab protocols are based on this same economics:

      – tissue healing parameters
      – various “costs” for each exercise

      For example, someone with knee surgery:

      – is on crutches for 2 weeks
      – is in a brace for 4 weeks
      – can do strength exercises at 6 weeks
      – can resume impact/running at 12 weeks

      Across the board, nearly every soft tissue* follow this model, based on the physiological “economic” of tissue.

      (*with a few exceptions)

      Strains and non-surgical injuries are the same, but less cut-and-dry, because it’s much more difficult to:

      – accurately gauge precise tissue injury
      – accurately itemize “costs” of daily activities

      Conclusion: arbitrary numbers, but the step-wise approach is **extremely applicable** to injury recovery

  1. Markus

    Wow, that is a great model to explain “Listen to your body”.

    I always thought I fell short with explaining how I train with saying: I am just listening to my body. This capitalist model explains it so much better.

    There is a “cost” to a long ultra and I always gave myself enough time to recover. Joe’s capitalist model explains it so well why so many ultrarunners go “bankrupt”.

    1. OOJoeuhan

      That is an interesting application – with respect to training and racing. It gets even more complicated, in that case.

      “Listen to your body” is very vague – especially in the injury rehab realm – because we as ultrarunners train ourselves to block out certain information or to “gut through the pain”. As such, we’re more likely to blow off low-level aches/pains.

      In this model – especially coming back from injury – the nature (frequency, duration and timing) of aches/pains – is vital information on that economic balancing act, and needs our attention.

      1. Markus

        Joe, I always say: “Pain is information”.
        There is a difference between having blister pain and real pain. Unfortunately a lot of runners try to mask the pain with pain killers and that’s where the problems start.

  2. Julien

    Great post and economic metaphor. Injured myself for now, I definitively recognized myself in this post and being in the red for too long. Thanks for sharing this, it explains the dynamics for recovery!

    Julien.

  3. Lisa

    I really enjoy this metaphor, and I like how it can be extended to demonstrate why “But I’m feeling good, so why not?” isn’t necessarily appropriate reasoning. If you have $100 in the account, you may feel like you could tack on an extra couple miles, but you’re not necessarily doing yourself any favors by fully exhausting those resources. Keeping a couple bucks in the account at the end of the day, when possible, can add to tomorrow’s potential.

  4. Lauren

    Last season ended with what I thought was a simple ITBand issue from SIJ dysfxn. Turns out it is more complicated than that. Weak gluteus maximus/medius causing overtime, over pronation on just the R foot. Problem identified 4 months ago and I have been diligently working on strengthening of glut max/med and recently (last 4 wks) strengthen arch of foot and simply working on foot mechanics in standing/etc. At work (physical therapist) I do use superfeet heel control insert along with short/sweet foot exercises throughout the day. Believe it or not my SIJ has stabilized after years of dysfxn (B hip labrum repairs), glut max/med are now firing, and foot is beginning to come around. Occasional distal ITBand discomfort which is resolved with foam rolling/dry needling of vastus lat and rectus fem. Mileage is short 3 miles 3x/wk with a longer wknd run of 5-7 miles (base building). Running in the morning allows for gym work after work to attend weak areas in order to continue increasing miles to eventually ultra distance once again. It takes diligence, commitment, routine to tend to deficiencies. But once you are on the uphill, boy is it nice!

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