Return to running postnatal

In 2019, three renowned women’s health and running physiotherapists developed the first
ever Return to Running Postnatal guidelines. (1)

The guidelines were the first of its kind, and were developed to give healthcare professionals and postnatal women advice with regard to returning to higher impact exercise, like running, after pregnancy. The ‘take home’ message from the guidelines was that it is not a ‘one size fits all’ recovery, and that each return to running program varies depending on the individual. Furthermore, it highlighted
the lack of research that has been carried out in this area. No studies to date, specific to the
postnatal population have been carried out to evaluate return to running after pregnancy.

• It is recommended that every woman undergo a postnatal assessment with a
  qualified Women’s Health physiotherapist, regardless of method of delivery or
  whether or not they have had a perineal tear.

• Women can benefit from an individualized assessment and guided pelvic floor
  rehabilitation for the prevention and management of pelvic organ prolapse, the
  management of urinary incontinence, and for improved sexual function.

• Return to running is not advisable prior to three months postnatal or beyond if any
  symptoms of pelvic floor dysfunction are identified prior to, during or after
  attempting return to running.

• Healthcare professionals should assess pelvic health, load impact management and
  strength testing in order to evaluate readiness to running postnatal.

• Additional factors such as body weight, breastfeeding, sleep, fitness and
  psychological status should be considered prior to return to running postnatal.

Below is a list of activities that you can do in the first six weeks postpartum. It is important
to remember to listen to the body, starting slowly before gradually building up your
tolerance and advancing exercises. If you are unsure of an exercise or how to progress, it is
important to consult with a physiotherapist or a fitness professional trained in postnatal
rehabilitation.

• Gentle walking, building up to cross trainer, stationary bike or swimming.

• Pelvic floor exercises.

• Gentle abdominal exercises such as pelvic tilting or knee rolls (ensure tissue healing
  prior to starting abdominal exercises if after caesarean section)

• Gentle resistance exercises such as squats without additional weights.

Longer recovery times (beyond the six-week checkup) are recommended for those who
have had a caesarean section delivery, to allow for the healing and remodeling of the
uterine scar. Increased uterine scar thickness (heaviness) has been found to be present at
six weeks postnatal, and that just over half of abdominal fascia tensile strength has been
regained at this point. The first few weeks after a c-section, you should let the body rest and
recover, taking care of yourself, while you take care of your baby. Pelvic floor exercises can
be started immediately, while gentle abdominal exercises should only be started once the
scar has healed. Focus on a ‘belly breathing’ pattern, along with gentle scar tissue massage.
Gentle walking is encouraged. It is important to work closely with your physiotherapist post
caesarean section for optimal physical and functional recovery.
When is too soon to start running?

It is recommended that you go and get a pelvic health checkup prior to returning to running.
As a rule of thumb, it is advisable not to run prior to three months postnatal or beyond this
if experiencing any symptoms of pelvic floor dysfunction, however, if your pelvic health
physiotherapist can help assess.

Running is considered a high impact activity and places a high demand on the body. During
moderate running, the force going through the legs and pelvic floor is more than doubled,
therefore, it is important to ensure the body is strong enough to tolerate this load.
Returning to running too soon, before the body is ready, may lead to pelvic floor
dysfunction and musculoskeletal injury. High impact exercise has been found to have an almost three times increased risk of pelvic floor dysfunction. (2)

Further medical advice include:

• Urinary or faecal incontinence prior to or on commencement of running.

• Heaviness or dragging in the vagina on commencement of running.

• Musculoskeletal pain prior to or on commencement of running.

• Decreased abdominal strength or function/ pendular abdomen – this may indicate
  diastasis recti abdominis (DRA).

• Ongoing vaginal bleeding not related to menstrual cycle.

• Anyone experiencing these symptoms should be evaluated by their women’s health
  physiotherapist or GP prior to returning to running.

• Body Weight: Being overweight increases the load through the pelvic floor, and
  women with a BMI > 30 are at higher risk of pelvic floor symptoms and
  musculoskeletal injury. Low impact exercise is advisable until BMI is within
  targeted range.

• Fitness: Levels of fitness pre pregnancy, during pregnancy and birth experience
  and issues should be considered.

• Psychological Status: Women should use other coping mechanisms as well as
  running for management of psychological issues like postnatal depression.

• Diastasis Recti Abdominis (DRA): DRA may indicate reduce abdominal strength
  and control, which leads to a higher risk of musculoskeletal injury.

• Breastfeeding: Breast feeding prolongs the presence of hormonally altered
  environment postnatal which can impact joint and ligament laxity. This, in turn
  may increase the risk of developing injury or dysfunction. It is also important to
  consider timing of runs around feeds, to ensure that breasts are not too full or
  likely to become uncomfortable.

• Uterine Scar Healing: Ensure healing of scar and scar tissue mobilization prior to
  running to reduce pain and restriction.

• Supportive Clothing: A good supportive (rather than compressive) sports bra can
  help reduce stress on the body during running. As shoe size can often change
  during pregnancy, ensure that your shoes are correctly fitted.

• Sleep: Sleep is key for recovery both mentally and physically, and can often be
  impaired postnatally. Sleep deprivation has shown to have an increased risk of
  injury in athletes. It is important to optimize sleep routines as much as possible.

• Running with a buggy: Involves increased energy expenditure and altered
  biomechanics. It is advisable to start running alone first before introducing the
  buggy

Your women’s health physiotherapist will carry out a detailed examination to determine
your fitness for return to running, from doing a pelvic floor examination to checking for
diastasis rectus abdominis. From there, we can formulate a treatment plan and advise you
on how to prevent and manage any issues you might be experiencing and how best to begin
your return to running.

The return to running process is an extremely different experience for everyone, and there
is no one size fits all approach. Every postnatal woman should have the opportunity to have
a consultation with a women’s health physiotherapist, and with guidance, you can ensure
that you return to running at a time and pace that suits you, your body and your
rehabilitation. Engaging in physical activity is well established to provide a variety of health
benefits. However, for many women, issues developed during pregnancy or delivery such as
pelvic floor dysfunction or musculoskeletal pain, act as a barrier to returning to an activity
that they once enjoyed. (3)

While these issues are common, they should not be considered
normal, and if you are experiencing any of the symptoms mentioned in the article above,
you should consult with your women’s health physiotherapist to begin your recovery.

1 Goom, T., Donnelly, G. and Brockwell, E. (2019) Returning to running postnatal – guideline
for medical, health and fitness professionals managing this population.
[https://mailchi.mp/38feb9423b2d/returning-to-running-postnatal-guideline]

2 De Mattos Lourenco T, Matsuoka P, Baracat C, Haddad J (2018) Urinary incontinence in
female athletes: a systematic review. International Urogynecology Journal

3 Nygaard, I., Girst, T., Fultx, N. H., et al. (2005) Is Urinary Incontinence a Barrier to Exercise
in Women? Obstetrics & Gynaecology 106(2), 307-314.

By Mary Wrixon,
Physiotherapist
The Moving Body Group