Why rest is not best
Got a niggly knee, a tetchy tendon or a bad back? For decades, the accepted wisdom has been that rest is best. But the voice of dissent is growing louder, amid research and clinical experience showing that not only is rest – as in, doing nothing – ineffective, it could actually make things worse.
In 2004, a review of 49 studies compared the effects of rest versus early mobilisation on acute limb injuries. Not a single one found that rest worked better, and the reported benefits of mobilisation included decreased pain, swelling and stiffness; and a greater preserved range of joint motion. ‘Rest appears to be overused as a treatment,’ wrote the researchers.
Then in 2007, Dr Karin Silbernagel, an associate professor at the University of Delaware, led a landmark study challenging the idea that injured athletes must stop their sport during healing. For the study, published in the American Journal of Sports Medicine, athletes with Achilles tendinopathy were divided into two groups. One group followed a strength-based rehab programme for the Achilles and calf muscles while the other group followed the rehab programme and continued their sport, even if it involved tendon-loading activities such as running and jumping. The rules were that their pain should not exceed a score of 5 out of 10 (see How Much Pain Is OK?) and should have settled by the next morning. After six weeks, improvement in function and reduction in pain level were the same in both groups. ‘Our study suggested that resting from sporting activities – including running and jumping – may not be necessary,’ Dr Silbernagel tells me.
Ten years later, Canadian research on running and knee pain came to a similar conclusion. Runners suffering with knee pain were advised how to modify their running to keep it within acceptable pain levels, while also performing either strength exercises or individualised gait retraining. They gained as much symptom relief and functional improvement over an eight-week period as did those who were just given the gait retraining or strength exercises.
But old habits die hard. The NHS website still recommends rest – two to three weeks of it (as well as ice and stretching, two other questionable actions) – for a range of running injuries including shin pain, heel pain, Achilles pain and runner’s knee. As for muscle strains, it says: ‘the time taken for a muscle strain to heal and for you to start running again varies from two weeks to around six months, depending on how severe the muscle strain is.’ Yet a recent Portuguese study found that loading damaged muscle tissue increased muscle stem cell activity, vital for muscle repair and regeneration.
Tom Goom, a chartered physiotherapist based in Brighton who specialises in running, believes there is still far too much reliance on rest among many health professionals when dealing with sports injuries. ‘The go-to advice runners so often receive is “stop running” – but this doesn’t take into consideration the risks involved.’
Such as? ‘On a physical level, a loss of cardiovascular fitness, tissue deconditioning and weight gain. We lose the adaptations we’ve gained from regular running,’ says Goom. ‘And the longer we’re out for, the lower the level we need to go back to when we restart. If we don’t, we risk re-injury.’ The downsides of stopping running aren’t just physical, either. ‘There could be a loss of identity, social isolation and a negative impact on mental health and mood. We need to recognise just how important running is to people and the impact it has when they stop. Of the injured runners I see in my clinic, I aim to keep around 80 per cent of them running.’
Paul Hobrough, a physiotherapist and author of Running Free of Injuries, agrees. ‘I vehemently oppose patients being told simply to rest,’ he says. ‘It makes movement seem scary and takes all that person’s power away. Movement is the best therapy. There is always a way to keep a patient active – it’s about how you adapt their training so that it does not make things worse.’
In the case of an Achilles problem, that could mean avoiding faster running, softer surfaces and hills. ‘I might advise a patient to run only on the flat and take 48 hours between each run to check that the pain level isn’t escalating,’ says Hobrough. ‘And at the same time, we’ll identify where their biomechanical inefficiency or weakness is so that we can work on that too.’
But surely avoiding running altogether wouldn’t be a bad thing – allowing the overstressed tissues some time to recover?
‘With some injuries, such as stress fractures and those requiring surgical procedures, there is a healing process that must be respected,’ says Goom. ‘We’d be looking for minimal pain, good range of motion and minimal swelling before reintroducing running. But the majority of running injuries don’t fall into this category. A runner is getting pain in a particular area, but it’s been given a scary label, like patellofemoral syndrome or plantar fasciitis. Terms like ‘degenerative’ ‘wear and tear’ and ‘damage’ are often used, which simply add to the negative and alarming mental image. No wonder people feel as if running has become damaging to their body overnight – and that any form of movement is going to damage it more!’
Prescribing rest misses a critical point: that the injury itself is a signal that the tissues were not strong enough to deal with the load they were being placed under. ‘Removing the load might stop the pain, but it also further lowers the tissue’s capacity to cope, by allowing it to decondition,’ says Goom.
Silbernagel agrees. ‘We do harm by being afraid of doing too much,’ she says. ‘All tissues – tendons, bone, muscles – need load to be healthy. No load is just as problematic as overload. It creates stagnation, like water in a pond with no movement. You’re not going to get healing in that environment, you’re going to get disorganised tissue and a slow decline in tissue health.’
In other words, doing nothing isn’t the passive strategy it might seem – it’s actually detrimental. ‘When you return to your sport, the same problem (weakness or inefficiency) exists, but now your body is in a worse position to deal with it because you’ve reduced blood flow - which brings oxygen and removes metabolic waste - reduced range of motion and allowed the body as a whole to decondition,’ adds Hobrough.
So how does movement actually help – other than keeping us from going crazy – while we overcome injuries and niggles? It’s a complex process with a fancy name – mechanotransduction. This refers to the actual physical deformation of tissue by mechanical load – say, the shortening of the calf muscles as you rise up on to your toes. ‘Mechanical loading prompts cellular responses that promote structural change to strengthen the healing tissue,’ explains sports physiotherapist Samuel Dunn (livelyphysiotherapy.com.au). What’s more, load helps these newly forming muscle cells align in neat parallel lines; picture hair that has been combed, compared to tangled, knotty strands. ‘When we tear a muscle, inflammatory cells flood the area to seal it off and clean away dead tissue,’ says Dunn. ‘Then cells called fibroblasts start laying down scar tissue to mend the muscle. But this scar tissue is very ‘disorganised’ – loading helps to align it in a parallel fashion in the appropriate direction of pull for maximal tensile strength, making it less likely to re-tear.’ The term ‘mechanotherapy’ is now being used to describe movement specifically prescribed to treat injuries.
For a regular exerciser, continued activity also helps to maintain ‘normality’ for the musculoskeletal system. ‘The body hates change,’ says Hobrough. ‘Tendons in particular are like your most boring friend. If they are accustomed to loading through running, then being able to maintain that to an appropriate degree is much more beneficial than stopping.’
We have as much to lose in terms of mental wellbeing as we do in terms of physical health, as runner Lorna Watts found in 2019 when she developed a hamstring injury while training for the London Marathon.
‘I was told to stop running until I was "better",’ she says. ‘I was given about an hour’s worth of strengthening exercises to do every day - it was unrealistic and exhausting, and most of the exercises made the pain worse. Within a couple of weeks of stopping running, I had a new pain, which the physio diagnosed as sciatica. Driving and sitting at home was agony. I was then given a different set of exercises to do. This was a mental blow - I had been expecting improvements but instead I was going backwards. Depression started to take hold, affecting my work and personal relationships. Over the forthcoming weeks, my condition did not improve. I was in pain; depression was ruling my life and yet I was being told not to do the one thing I knew would help. I was told that if I ran, I would make my recovery take even longer.
After six weeks I reached a tipping point with my mental health – sorting my head out felt more important than my physical health. I started with a mile. Yes, it hurt... but I was on cloud nine for the rest of the day. Over the next few weeks I slowly increased my distance and found both the original pain and the sciatica starting to improve. I changed physios, this time to someone who had a completely different diagnosis and recovery plan, and who never once told me not to run. I am now almost back to where I was and my depression is back in its box!’
We runners can be a single-minded and passionate bunch. In writing this article, I’m aware that there is a risk that some may view it as a green light to limp on in the face of injury. However, stresses Goom, the shift in attitude isn’t from rest to blindly ignoring pain: ‘It’s from rest to modifying your training to a level that preserves physical and mental health, does not make your injury worsen and increases your capacity to cope with the load that brought you down better in the future so that injury doesn’t recur.’
In Silbernagel’s study, patients used a numerical pain scale – where zero denoted no pain at all and 10 represented the worst pain imaginable. Athletes were allowed to continue with their sport as long as it did not exceed five on this scale. ‘This rating was used during the activity itself, immediately afterwards and the following morning,’ she says. The researchers also applied another scale that many runners will be familiar with – the Borg Scale. This is normally used to rate ‘perception of effort’ – how hard do you feel you are working during exercise? ‘We asked the athletes to apply the Borg Scale specifically to their Achilles,’ explains Silbernagel. ‘What was the intensity of the effort in that area? They were allowed to perform activity that felt ‘light’ daily but activity that they rated as medium intensity required two recovery days and activity they rated as high intensity required three recovery days.’ This combined tool has since been used successfully with everyone from recreational runners to elite marathoners managing Achilles injuries.
Goom uses the term ‘run tolerance’ to define the level of training a patient can achieve during injury rehabilitation with no detrimental effects.
‘There’s nearly always a level of running that can be tolerated,’ he says. ‘It might not be as far, or as fast, but it’s something. For example, let’s say you go for a run and your symptoms flare up after 20 minutes. Next time, you might decide to stop at 15 minutes. If that’s OK, you could try upping it to 17 minutes. It’s easiest to do this under the guidance of a health professional, but the problem is that practitioners often don’t want people to run at all if they have a perceived injury.’
That’s why Silbernagel feels using the numerical pain scale is so helpful. ‘It gives the patient some control over what is too much or too little,’ she says. ‘And pain science has taught us how important having that control and empowerment is. You’re allowed to have some pain. Pain is not synonymous with damage.’ In fact, one study on rehab exercises found that those which caused a bit of pain were more effective than those that were kept pain-free!
There are times, however, when you shouldn’t even try to run. ‘You need to be sensible,’ says Hobrough. ‘If you cannot walk without pain, then don’t run.’ See Ready to Run? checklist, below.
And bear in mind that the path to recovery isn’t always smooth. ‘Any return to running after injury is likely to suffer the odd setback,’ says Goom. ‘But a resurgence of symptoms doesn’t mean you are back at square one.’
With so much evidence to support the idea of continuing to train within a manageable window of pain, why are runners still being told by doctors, osteopaths, physios and sports massage therapists to take time off? ‘It’s the path of least resistance in a litigious society,’ says Hobrough.
Silbernagel believes that it stems from a historic ‘one size fits all’ approach to injuries. ‘There’s a big difference between an acute injury – you fracture a bone or rupture a tendon – and an overuse injury of the type that most runners are more familiar with. They should not be treated the same.’
That said, it’s becoming increasingly evident that appropriate loading is better than complete rest, even in the case of acute injuries. A review of 46 studies published in 2017 on ankle sprains found strong evidence to support early mobilisation (movement). Even Dr Gabe Mirkin, the sports medicine doctor who coined the RICE acronym in 1978, now says that rest should not be the first port of call. ‘It appears that both complete rest and ice may delay healing, instead of helping,’ he says. ‘Don’t increase your pain, but you want to move as soon as you can.’
For Hobrough, the worst-case scenario is to tell a patient to stop doing what they love doing. ‘I might be very prescriptive about how a runner trains while we manage their injury, but it’s very unlikely that I’ll tell them to rest,’ he says. ‘Sure, I will modify your training load, but the likelihood is that you will still be able to maintain the activity you love, while we work on identifying and strengthening the area your body ‘told you about’ via the injury. There’s every chance you’ll come back better than before.’
Ready to Run? Checklist
Tom Goom recommends you can tick all the boxes below before you take a run to establish your run tolerance…
If the above is true for you, you’re in a good position to go for a run and see how you feel. ‘There is always some trial and error involved in trying to find the appropriate amount of running to do,’ says Goom. ‘It’s best to start low – with something that feels really manageable - and build up. If your symptoms kick in during the run, note where you are time- or distance-wise and call it a day. Then wait to see how it responds the next day. If the pain settles, you can run again, but this time, stop a little before the time/distance you were at when symptoms occurred previously. For example, if pain started at 3.5 miles, run 3 miles next time and gradually build from there.’
How Much Pain Is OK?
The pain can score up to ‘5’ on the scale during the activity. But, says Hobrough, be wary of escalating pain. ‘If your pain starts off at a ‘1’ but creeps up to 2, 3, 4… you need to stop. Four might still be within the acceptable limits but it’s pain that is increasing.’
The pain after completion of the activity is allowed to reach 5 on the scale, provided it settles within 24 hours.
Pain and stiffness should not increase from week to week.