When to Consider Surgery for a Chronic Running Injury

Stay the Course[Author’s Note: This article is intended to guide a runner experiencing chronic running-injury pain, which is defined as persistent pain lasting for at least six months. Acute, traumatic injuries do not fall under consideration in this piece.]

Endurance runners are problem-solvers. Mountain runners and ultrarunners, in particular, thrive on the myriad challenges presented by terrain and distance. Some even welcome the seemingly inevitable problems that trail races and ultramarathons provide. This is because most running problems have solutions, if only we’re willing to dig deeply and creatively enough to find them. Often, these perseverance finishes can be more memorable than a faster and easier victory.

But not all problems have a simple solution, or one that’s within our personal reach. Chronic-injury pain is a substantial challenge that strains many of our greatest efforts and abilities to problem-solve. Seeking skilled, professional medical care can be a challenge, with many disciplines ranging from medical doctors, physiotherapists, massage therapists, chiropractors, and other body workers. Where do you go? And if Dr. A is good for X, are they also the best for Y and Z? What happens, then, if you’ve seen Doctors A, B, C and D, and still have pain? Most runners needn’t travel too far through the doctor alphabet before the S-word is mentioned. That’s surgery.

Why surgery? The simple answer is that the sport of running is stressful. High-intensity and long-duration loads can cause tissue strain. Damage is common and, accordingly, can easily be found using modern medical imaging technology.

But does pain plus evidence of damage equal the cause of pain? And does the amelioration of that damage automatically resolve chronic pain? Hardly. Numerous studies have shown poor or no correlation between tissue damage and pain. Namely, many people often have abnormal (“damaged”) tissue, yet they have no pain. The converse is also true in that one can have severe pain with normal imaging. Let’s say that you have chronic pain, and you may or may not have damaged tissue. When, then, might a frustrated runner consider surgery?

Possible Risks and Costs of Surgery

First, let’s consider the possible risks and costs of surgery:

  • Time. Most surgeries involve cutting tissue to some degree. Some more minor surgeries will remove excessive or unhealthy tissue. In these cases, healing time is the least, yet is still between three and four weeks of full rest from running. Reconstructive surgeries involving repairing pieces of tissue, including implantations, take much longer to heal, upward of 12 to 16 weeks. Surgery is a commitment to near-total rest.
  • Money. Surgery can be very expensive, depending on where you live and your access to both health care and health insurance.
  • Complications. Most surgeries turn out fine, but some do not. Complications include myriad possibilities ranging from infection to even death. These are rare, but possible.
  • “Subtraction by Addition by Subtraction!” Even the most minor surgical procedures can create a powerful ripple effect in our anatomy and physiological function. The pain of surgical incision alone can change neuromuscular movement patterns either through pain avoidance or by impairing efficient core-stability activation. These changes may result in altered movement patterns (corrupting “Run.xls”) even after healing is complete. But the real rub? Sometimes taking something out can put more back in! Anatomically, surgeries–even small arthroscopies that involve only a couple small cuts–can create pervasive, underlying scar tissue that gums up the surrounding area by sticking to muscle and fascia and impairing normal movement. It is in these cases that runners often emerge with more pain and less function than before the surgery.

In conclusion, the worst-case scenario for a failed surgery is steep: lost time, a huge price tag, serious complications, and/or more pain. Thus, any decision toward surgery deserves heavy deliberation and an earnest effort to problem-solve first.

Leave No Stone Unturned: Pre-Surgical Considerations

To decide on surgery is a serious decision. Before considering surgery, a runner with chronic pain should explore as many treatment options as possible. This could be compared with the dedicated and full-spectrum preparation they’d have before a focus race. With whom in the doctor alphabet this is done is less important than the importance of covering all four dimensions of injury treatment:

  1. Mobility. Full mobility should be restored to the whole athletic system, not just the tissue or area in question. A systems-based treatment professional will work with you to restore optimal mobility to your entire running system.
  2. Strength and Stability. The same goes for neuromuscular strength and core stability. As with mobility, whole-runner strength and stability is a lot more than working on the painful spot.
  3. Pacing (Rest). This can be both under- and over-emphasized. I often encounter runners with chronic pain who are contemplating surgery, yet they’ve never taken full rest from running. Complete rest from physical loading is often required, not simply for full healing, but sometimes to initiate a healing response. Conversely, too often rest is over-relied upon as a treatment strategy. Complete rest, in the absence of other treatment dimensions, seldom results in full recovery and sustained pain relief. In the presence of mobility, strength, and/or efficiency deficits, rest tends to only temporarily dampen symptoms that, once running is restarted, quickly recur.
  4. Efficiency. Efficient running mechanics as well as basic movement patterns are paramount for the comprehensive treatment of and full recovery from a chronic running injury. Inefficiency puts abnormal loads on tissue. Given enough abnormal load, tissue or other, more complex pain systems reach a pain threshold. Once that is met, only by changing the abnormal loading pattern will pain subside.

Most rehabilitation professionals do great work on the first two dimensions. But often the multi-dimensional treatment ends at this point, so be sure to advocate for all four dimensions.

The greatest failures in conservative care come from a failure to fully address movement efficiency. Comprehensive running-stride assessment and efficiency training–in combination with mobility, strength, and rest (including progressive tissue loading)–must occur before surgery is considered for chronic running-injury pain.

Indications for Surgery

What if you’ve covered all the bases and your pain persists? Here are some signs that it is time to consider surgery:

  • Significant Imaging or Exam Findings. In order to consider surgery, you and your doctor should have a clear idea of the offending structures, how and why they may be causing pain, and how a surgical intervention should resolve the injury or pain. (The converse would be an “exploratory” or “arthroscopy” surgery that endeavors to “clean up” the area without a clear objective.)
  • Four Dimensions Failure. Even with significant anatomical findings, conservative treatment using the four dimensions is warranted first. A failure in this realm means that either efficiency is improved with no reduction in pain, or efficiency cannot be attained due to pain or anatomically limited deficits in mobility and strength. Thorough four-dimensions treatment is a high threshold. But even the most valiant efforts there sometimes come up empty. Little to no tolerance to running even after such conservative care is a strong indicator that surgery is warranted, especially when coupled with compelling anatomical findings.
  • Impaired Life Function. In addition to running, other aspects of daily life are impaired such as sitting, standing, walking, and other normal activities.

Final Cautions on Surgery

Finally, here are a few more considerations before deciding to have surgery:

  • Be Patient. Stable, persistent, and treatment-resistant chronic pain may be an indicator for surgical intervention. But more recent injury pain–issues only a couple months old–coupled with chronic, degenerative imaging findings are much less likely to respond to surgery. Knee pain for one month’s duration paired with an x-ray showing arthritis is far less likely to be caused by the arthritis. That’s because arthritis takes many years to develop. Good candidates for joint resurfacing or replacement usually have chronic joint pain for many years. Shorter-duration pain will be more responsive to a multi-dimensional conservative approach first.
  • Avoid Hubris and Gurus. Among my favorite sayings is, “When you’re a hammer, everything’s a nail.” Similarly, some orthopedic surgeons believe that any chronic injury or poor anatomical finding can be improved with surgery. They’re often right, but sometimes wrong. Ask for your options, and who they recommend for initial and post-operative rehabilitative care. Also, be wary of gurus and miracle cures. In the modern age of medicine and knowledge, there is no single cure held by a single doctor. If you are interested in a specific strategy or treatment technique, do your homework to seek out and consult with reputable clinicians in your area.
  • Healing Just Begins After Surgery. Returning to the four dimensions after a surgical intervention is vitally important. As previously noted, even a wildly successful surgery has collateral issues that may impede full recovery. Re-addressing mobility, strength, efficiency, and pacing should be a part of every post-operative plan–regardless of whether or not your surgeon recommends them–in order to ensure the best possible outcome for full pain relief and optimal running.

Surgery very well may be a form of a DNF. But like a DNF, sometimes it’s utterly necessary to retool and ultimately live to run again. But don’t take the decision lightly. Do what you can to prevent and prepare for surgery in order to have the best possible result so that you can stand on that future starting line.

Call for Comments

  • Have you labored through the surgery decision for a chronic running injury? If so, can you walk us through your decision-making process?
  • Have you considered but ultimately decided not to have surgery for a chronic running injury? How did your recovery go?
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 5 comments

  1. Nick D.

    I had a Haglund’s deformity removed from my right foot last December after more than five years of heel pain. I had done every conservative treatment possible – countless hours of heel strengthening, heel lifts, removing heel counters from shoes, even running sockless to take the pressure off the bone. Like clockwork, 15 miles into a run, I’d get a progressively stiffer heel until it could barely move. Within 24 hours it would be totally fine. There’s almost nothing more frustrating than an injury that only impacts you when you run.

    I am only just getting back into proper running 10 months later. Would I do it again? Absolutely. But it’s been a difficult journey every step of the way. I had serious nerve dysfunction for six months, both local on my heel and in my toes, probably due to the (still-present) lump of scar tissue. I could not sit down, get up, and walk without limping for the first few steps for eight months. I’ve still got occasional bone swelling, still have reduced range of motion running uphill, and definitely have a hard limit on how much vert I can do.

    Month-to-month, though, I see improvement. Some of that is just time. Some of that is stretching, mobility, and strength building. Some of that is just getting out there and breaking up the scar tissue on a run. The original injury was probably caused by poor hip/trunk alignment. I’ve conceded that I need to run flat trails at least twice per week to keep in good form. But it’s working. Every month I can go a bit farther, a bit harder, and feel a bit more fit than I did when I had the injury.

    Getting surgery simultaneously ruined me, cured me, made me realize what I had been missing, and made me realize everything I still had.

  2. Tim Jordan

    Excellent article. As a surgeon I especially liked the focus on risks v benefits, the importance of exhausting conservative approaches first, and the importance of pre-op and post-op treatment. I also entirely agree that if you go to a specialist they will offer you the treatment that they perform. Some will even offer you a treatment they have never performed before so make sure you find out how many of an operation they have done before and what the outcomes were.
    I had knee meniscus surgery, removal of loose fragments and smoothing of the patella cartilage, some years back after an acute injury in a knee that I had previously been operated on in my teens. Post-op rehab was almost non-existent due to the deterioration of services in the NHS in the UK so it was basically DIY. I am no longer young so all healing and change is slower that it once was but I stuck at it. It took 18 months to 2 years to complete the initial rehab i.e. back to walking and running, going up and down stairs with minor problems. What is taking longer is the correction of the compensations that I adopted to adjust to not being able to straighten my knee fully going all the way back to my teens. This where you need to look at the whole body and how it moves to address dysfunction, and I continue to do soft tissue work and corrective exercises on a daily basis. A little and often is the key.
    I am now able to run 20km off road with a lot of climb on rough rocky trails wearing zero drop minimalist shoes and my running form is better than it has been for 40 years. So mine is a positive result.

  3. AJW

    OOJ, thanks for this great article. I appreciate the perspective. As you know, I got to the point in my running and my life that I had no choice but to succumb to surgery, in fact two surgeries, hip resurfacing in 2015 and 2018. Both times the decision was agonizing but, in the end, it was the right thing to do, at least for me. I am now back to running, 50-60MPW and am pain free. I will always be “abnormal” (although some say I always have been) but that’s OK with me.

  4. nevtrik

    I think a surgery must always be the last option. I had a foot/ankle surgery and only fully recovered after it in two years. Running on not completely healed foot/ankle led to another chronic injury. I had to take a very long time off for it. Maybe stopping running for a long time and focusing on other sports/strength training is what you need instead – it will take the same time, but unlike after surgery you will come back stronger.

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