From Bad to Good Enough: Running an Ultra After Injury

Stay the CourseEight years ago, I was a month out from running my first Western States 100. The only problem was, I hadn’t been able to run at all for nearly two months. Memorial Day weekend and its annual training-camp runs were fast approaching, and I’d been hobbled by a knee injury from the American River 50 Mile in early April. For two full months–arguably the most crucial period in an ultramarathon build-up–I couldn’t run. No long runs, no ‘quad seasoning’ hill training, no workouts. I could cross train, but that was also limited.

Like any logical runner (let alone medical professional), it was plain to see that I was quite screwed. However, the mantra of our local band of Eugene, Oregon ultrarunners (led by then-resident and future-Western States race director, Craig Thornley, a valuable early mentor of mine) was simple: “Fix your problems.” So that’s what I did. Or at least I didn’t quit trying to get better and I didn’t pull the plug on the race.

But it really didn’t look good. The pain got severe enough that one day in early May, I put myself on the kind of cane that old folks use. I even emailed my entire 12-person crew, all with airfare and hotels booked and paid for, telling them I probably wasn’t running. Probably.

Then something strange happened. I got better. I ran. I finished the race.

There’s nothing extraordinary about my story. The only noteworthy aspect is that I refused to give up. I did my best to fix my problems, get better, and prepare for the race to the best of my ability. I got lucky enough to recover and finish. But without the will to solve problems, it never would have happened.

If you’re in a place like I was, read the rest of this article before you throw in the towel on your goal race. It offers a step-by-step process for healing your injury and getting to the starting line with enough preparation to finish your race.

Step 1: Accept the Situation

Acceptance is the first step to overcoming an injury before a major race. Acknowledge that you’re injured, that you cannot train, and that you have injured tissues which are painful and require healing. To stop training and start healing are crucial to your recovery.

Beyond that, you must also let go. We all have grand visions of how we think our goal race and its build-up will play out. But with a major injury, we must let go of that vision. It’s now gone. In doing so, you allow space for a new plan and vision. I cannot overstate how important it is to let go of your previous vision. Along with that, allow yourself to grieve for that loss with anger, sadness, frustration, or whatever emotion it incites. But do it fast, because you must get to work!

Scott Jurek talks about this in his autobiography Eat and Run: My Unlikely Journey to Ultramarathon Greatness. When he encountered major obstacles, he allowed himself to pass through three stages: acceptance, grief, and action. This played a central role in helping him overcome seemingly insurmountable challenges, and it will work for you, too.

Step 2: Make a Decision

Before going further, it’s important to decide if your upcoming race is worth the fight. Not all races are equal, and neither are all injuries. Thus, a decision must be made weighing the costs of potentially worsening an injury (or creating a new one) versus the cost of not racing.

Is this race a fun run or a true bucket-list race? Highly sought-after­ events like Western States and the Hardrock 100 may weigh much differently than a local race.

For injuries, this decision is best made in consultation with a medical professional, weighing any potential risks of worsening the injury. Just as important is weighing the second-order effects, such as compensatory injuries or even systemic he­­­alth risks (such as rhabdomyolysis due to insufficient preparation) that might occur through racing without adequate preparation.

If you’ve decided that the risk is worth it and the reward (or cost of missing out) is big enough, then proceed with caution and courage.

Step 3: Heal

Before you can train, you must heal. Too often, injured runners get greedy, trying to work out while injured. In doing so, they often delay healing. Why this important has to do with the non-linear, geometric relationship between tissue integrity and its tolerance to load.

Consider setting concrete: how much weight can completely wet concrete support? None. Twenty percent dry? Slightly more than zero. Fifty percent? A modest load. What about 90% dried? A ton!

Collagen fiber and bone have similar, highly geometric strength-to-integrity ratios. At 10% healed you might not be able to walk to the bathroom without pain. Fifty percent healing might only allow for cross training. But once you’re at 80 or 90%? That could be a 30-mile run. Even more, the duration between 50 and 90% healed might be only two to three weeks.

Paradoxically, what we tend to lose more slowly–over the course of many weeks and months–is aerobic and neuromuscular capacity. Yet we act as if it’s the opposite and that we must exercise or our fitness will quickly evaporate.

Showing up to race morning nearly fully healed but undertrained gives you a much better chance of finishing the race with minimal pain and less chance of reinjury. Resist the urge to rush back to training. Your base fitness and strength will still be there. Instead, bank the healing and get to the start line as close to 100% as possible. Let the concrete set. Only when that foundation is strong should you attempt aggressive training.

If you can tolerate cross training, be very careful to minimally disturb the healing process. Recognize the economics of the stress and rest balance, being careful not to ‘overdraw’ from the daily allowance. At the same time, recognize that some amount of pain is okay (and possibly necessary) to remodel healing tissue.

Having a skilled ‘pain manager’ to help you is invaluable in this process. An invested sports-medicine professional is your best bet, but an experienced coach might be good to guide you through the day-to-day balancing act of activity and healing. I was lucky to have my boss, also a physical therapist, help guide me through my own healing progression.

Outside training, optimum healing requires excellence in sleep, nutrition, and life-stress balance. Do your best to stay detail-oriented to these key factors.

Lastly, stay positive! The brain plays a huge role in the healing process. Allow yourself to smile and laugh. Even if it feels like the last thing you want to do, make it happen. I intentionally rented several of my favorite 1980s comedies (including this one, which featured a tinge of sporting triumph) to make me laugh and buoy my spirits.

Step 4: Cross Train

Cross train if you can. The key here is to perform activities that have minimal impact on healing and specific benefit for your goal race. This will vary widely based on your injury and the race.

Most significant lower-body injuries are intolerant of impact activity. Yet ultramarathons and mountain races, in particular, demand that unique combination of both high-impact and eccentric loading of the lower-body musculature. What to do?

While nothing can replace the specificity of actual running, here are two of the best substitutes:

Cycling

Biking might be the best combination of aerobic and muscle-strength training. Where it lacks in eccentric and impact load, it can make up for it in significant muscle strength. Injured runners can cycle for hours at a time if it doesn’t bother their injury. And if you have hills, all the better! Biking long hill climbs (which can often last 10 minutes to an hour or more, if you’re in the foothills or mountains) replicate the demands of mountain ultrarunning better than anything except running or hiking itself. Elliptical training is a close second to cycling, but in my professional experience it tends to be more provocative and less tolerated as a cross-training modality.

Strength Training

Often overlooked, non-aerobic strength training is a terrific cross-training option, if cycling or other options aren’t available. Most runners believe that aerobic fitness is the key to ultra success. This may be true for front-of-the-pack and peak performance, but the key ingredient to finish an ultra is muscle strength. It’s the legs (namely the quadriceps) that cause more DNFs or missed cutoffs than a lack of lungs.

Get and keep the legs strong. Again, this is injury dependent. A foot injury may not allow for weightbearing strength, but a runner with plantar fasciitis (or whatever that foot pain might be) can aggressively train on knee flexion and extension machines. Indeed, eccentric strengthening (albeit without impact) can be well-trained on most weight machines. Don’t fear the gym! Use it to the best of your ability.

Conversely, I am not in favor of a large volume of non-impact aerobic training, such as aqua jogging, because it’s completely non-weightbearing without resistance. And while it might be able to improve some injuries, some others–such as hip, hamstring, or back pain–might get aggravated by the thrashing and splashing.

The reality is, less cross training is more. Do what you can to augment your preparation, but when in doubt, air on the side of doing what will allow the fastest healing.

Step 5: Skills Development

While holed up with an injury, you’ll have time on your hands. Shut down the social media (and the intense fear of missing out it can elicit) and instead go ‘old school.’ Seek out some race-report blogs about your goal event. Read them all, from the winners to the very back of the pack. That said, the most lessons will be found in between, among the mid-packers who like yourself had to overcome adversity to get to the start and finish lines.

Then step into the real world and talk to ultrarunner friends with experience at your goal race. Learn as much as you can about the race and how to best balance your injury with the challenges of the event. Be prepared to adjust your gear, nutrition, aid-station needs. Your Plan B is now your Plan A, so get to work to make it as solid as possible.

Skills development also includes improving mobility and core (abdominal and hip) stability. Use your free time to shore up those areas. Then, consider how you might be able to improve your stride efficiency once you get back on your feet!

Step 6: Progressive Loading

If you’ve made it this far, something cool is about to happen. You’re going to get better. Because of the non-linearity of healing and the mirage of remodeling pain, it can really sneak up on you.

In 2011, I showed up to the Western States Memorial Day Weekend Training Camp with my bike and the hopes of hiking–or perhaps walk-shuffling–some bits of the course. I hadn’t run in several weeks. I knew my knee was better, but it was still occasionally painful so I wasn’t sure what it could handle.

Friday afternoon I did a walk-jog from Michigan Bluff to the top of Volcano Canyon. Specifically, I alternated one to two minutes of running with equal walking rest. My knee was a little sore, but not quite intolerable. Best of all, there was no residual pain that night or the next morning.

Saturday was an ambitious day. With my friend and pacer Sam Jurek, we walked from Michigan Bluff to a mile past Last Chance: 14 miles! I’d never been in the canyons before, and although that hike took several hours, it seemed to fly by. But once we got a mile past Last Chance and turned back, I guess you could say I got a little impatient. On the gradual downhill from Last Chance to Deadwood Canyon, I ran. Like a catcher careful not to jinx a no-hitter, Sam said nothing as we ran nearly the entire way back to Michigan Bluff. The knee was nearly symptom-free.

Boom. I suddenly had a 28-mile day in the books.

Best of all? No residual pain. So the next day? We ran from Michigan Bluff to the river crossing, which was 25 miles of straight running. It was officially ‘on’ again.

Is that a miracle? I don’t think so. Rather, it demonstrated the extreme non-linearity of healing. Injured, dysfunctional tissue will tolerate hardly any load while healed tissue, though potentially stiff and sore, can tolerate massive loads.

So that’s what I did. All the while, I was mindful to listen to my knee and how it felt during and after exercise, in the night, and the next day. As long as I followed those injury economics and remodeling rules, things were good.

That’s how progressive loading works. Take only what the tissue will take, but at the same time, gently push on the door of your limits. And if there is no push back, continue to press forward.

Step 7: Experiential Training

Once you’re back to running, there will likely be precious little time to prepare. How do you prioritize training among the limitations of time and energy?

While it may be tempting to try to do it all–daily runs, interval workouts, hills, long runs, overall high mileage–instead, focus on experiential training. Ask yourself what key experiences you need to practice in order to finish your goal race.

For me at Western States, it was two things: big vertical and one more long day. After Memorial Day weekend, I had just over a month before race day, and at most a few weeks left to train. I ran a couple short but vertical-heavy runs, and one long run locally.

But that didn’t seem to be enough. Having never run a 100 miler, I felt I needed one more experience. Fifteen days pre-race, I drove back down to Placer County, California. With the help of my then-new friend (and future pacer and best man) Jacob Rydman, I left a car above the river crossing and got a ride to Michigan Bluff. From there I ran to Last Chance, back to Michigan Bluff, and then all the way to the river. Fifty miles. It was a long day, mostly because I went very slowly while hiking or slow jogging.

This brings up another important point, and that is to keep the intensity low. Chemical stress weakens tissue (namely that freshly healed tissue) and makes it more susceptible to mechanical failure. Moreover, it takes longer to recover, and is more difficult to absorb when undertrained. Keep the training easy, and instead focus on time on feet and strength development.

Step 8: Have Faith

Once race day arrives, it’s out of your hands. You’ve done everything possible. You’ve rested, healed, cross trained, slept, ate well, stretched, strengthened, and trained to the best of your ability. And yet you’ll feel like it’s not enough. The funny thing is that most people on the starting line feel the same way! Rest assured, the chances are great that you’re as ready as you need to be.

Trust your body, and trust your intrinsic strength and ability honed from your years of running and racing. I like to say that our best races are borne from the training and experiences going back over years. While it’s easy to focus on what’s missing, remember where you came from. Have faith that the depth and breadth of your intrinsic ability is more than enough to get you through the day.

Step 9: Be Positive and Grateful

Once race day arrives, be positive and grateful. You made it! Smile, chat, take it all in. Thank people at every opportunity. Beyond its logic, gratitude boosts the release of the chemical dopamine in your body which will keep at bay any lingering injury pain and stave off the inevitable ultra ache. Lastly, remember why you do it. You’re here for the challenge, the chance to prove to yourself that you can go farther, faster, and stronger than before. Best of all, having overcome what you have to get to the start line, you’re already ahead of the pack.

Good luck!

Call for Comments (from Meghan)

  • Do you have a story of becoming injured a couple months out from an important-to-you race where you were able to overcome your injury and get to the start line after all?
  • If so, do any of Joe’s tips ring particularly true for your recovery and last-minute preparation process?
  • Do you have additional tips to add to this ultra-preparation crash course?
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 3 comments

  1. Pete W

    Damn Joe this article could hardly be more timely. I’m 2 months out from my first 100km, and about 3/4 weeks into an unspecified hip injury. Been watching my mileage drop and the weeks melt away. Think it’s time to stop running on it, heal and do what I can to get to the start line fresh and injury-free. Thanks!

  2. Gregory

    As Pete said above your awesome post hit my box as I prepare to get ankle debridement surgery tomorrow morning. I have tried to deny the need to rectify the ankle issues for some time and finally decided that it is too important to continue to ignore the adverse effects that the ankle has had on the rest of my body, spirit, and running as a whole. Thank you so much for sharing your story and first hand knowledge Joe!

  3. SK

    I would also highly recommend that anyone cross training on a bike should get a proper bike fit. It can make all the difference.

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