Returning to running postnatal is often a goal of many a post-natal client. It can feel very daunting after giving birth especially with a minefield of do’s and don’ts on the internet. The fear of doing damage and confusion about what they ‘should be doing’ are often clients main concerns. So I have put together the current research and guidance to give you all you need to know when returning to running after having a baby…
When returning to running after pregnancy and birth It is common for women to experience pain, urinary incontinence, abdominal separation and pelvic organ prolapse (POP). But whilst these are common they are not normal. These conditions are treatable and even better, preventable. The normalisation and/or taboo with such conditions mean that most do not seek support and end up coping, living with and covering up. Meaning that 1 in 3 women suffer urinary incontinence, 1 In 7 live with bowel incontinence, and 1 in 2 will experience prolapse. But with the right treatment, support and education this does not need to be the case!
Why does this happen?
The pelvic floor is stretched and weakened through the process of carrying and birthing a baby (whether vaginally or via c-section).
On-top of this there could be trauma and injury from the birth in the form of muscle tears/ cuts and the layers of skin and muscle need to heal and grow stronger. New mums need to heal and rehabilitate and either one or both of these steps are often missed out. On top of this you have a new baby to lift, carry, feed and nurse in the night. There is not much time for rest, recovery and rehabilitation. So often we women understandably jump straight back into exercise without following the early rehab guidelines and measures.
But when we run there is a sharp increase in abdominal pressure with forces of between 1.6-2.5x our body weight. This means that the pelvic floor needs to have enough strength and speed to tolerate more than twice it’s normal daily load in order to maintain their role of pelvic organ support and continence whilst running. If we start running before completing pelvic floor rehabilitation we may learn the hard way that the muscles are not quite ready!
A women’s health physiotherapist can assess and rehabilitate your pelvic floor to the point that it is able to withstand these loads and prevent or manage any dysfunction.
Abdominal separation (Diastasis rectus abdominus-DRA)
During pregnancy, your abdominals have to stretch to make space for the growing baby. After giving birth it takes time for the connective tissues and muscles to heal. One third of women will have DRA at six months postpartum. This can impact on the functional strength of the abdominal wall especially the six pack muscles (rectus abdominus). We know core strength is important in order to manage the abdominal pressures and the impact of running and support the pelvic floor. Therefore, in our postnatal MOT’s we always assess your abdominals in regard to their strength and recovery.
Overall deconditioning from pregnancy and birth
As we discussed with the pelvic floor and abdominals, a lot of force goes through your body when you run and so running requires global strength. It is imperative for injury avoidance and performance that the key muscle groups are strengthened before and during your return to running. Key muscle groups to target:
- Quadriceps – We strengthen these with squats, knee extensions, lunges…
- Calves – My favourite exercise for these are calf raises – single leg is best and try with both a bent and straight knee.
- Glutes – If you’ve been to one of our Pilates classes you probably don’t need me to tell you that you can strengthen these with side lying leg lifts, side planks, squats etc…
- Hamstrings – We work on these a lot in S&C classes with deadlifts, hamstring curls and bridges.
Scar tissue
Both c-section and perineal scars (tears and episiotomy’s) can result in pain, restricted movement and alter how surrounding structures function. Scar mobilisation at the appropriate time in its healing reduces inflammation, thickening, and improves tissue healing preparing you well for your return to running. This involves massage to the scars and specific exercise rehab working the tissues around the scars which should be directed by a qualified women’s health physiotherapist.
Breastfeeding
It is recognised that breastfeeding prolongs the presence of altered hormones for up to 3 months after you stop. Overall it is not fully understood, but we know that the altered hormones may influence joint laxity which increases injury risk including to the pelvic floor. Please note this does not mean you cannot breastfeed while running. Look at the famous picture of ultra-runner Sophie Power breastfeeding during a 106mile ultra marathon. Breastfeeding is simply another factor on evaluating the process of retuning to running. Consideration needs to be made to the time of feeds(i.e. making sure breasts are not overly full/uncomfortable while running) and it is also important to consider hydration. It is also important to note that moderate to vigorous exercise during lactation does not affect the quality or composition of breast milk.
Sleep deprivation
I mentioned this in my blog about running smart – sleep is essential for recovery. Postnatal sleep is disrupted and mothers are often sleep deprived. Sleep deprivation increases the injury risk of athletes and impairs maximal muscle strength. Day naps can be a good way to catch up and reduce these risks. Never underestimate the power of good sleep hygiene and the effort involved in running! You will need more rest time.
Where to start after giving birth:
No matter when you start it is important to start at the beginning. Work through the phases starting with phase 1…
Phase 1 (weeks 0-6) recovery
Pelvic floor exercises, from day 1 post-partum (or just as soon as you can!)
Ideally a women’s health physio would have seen you prenatally to teach you how to do pelvic floor contractions, but if not, check out Megan’s video on what and how here.
The recommended amount is up to 10sec holds x 10 and 10 fast contractions 3 times a day. But think of this as the “gold standard” something to build up to in those first few weeks.
I recommend using the squeezy app for reminders and frequency : Home Page – Squeezy (squeezyapp.com).
Postural exercises
Let’s face it pregnancy and birth hits our posture hard. So spending time gently stretching and lengthening is key before returning to structured exercises.
Part one of our post-natal Pilates program is called “stretch and release”. It can be done as soon after birth as you feel able. It will teach you some stretches that you can spread through your days and some key tips and tools to work on your posture.
Gradual walking
Walking is not as “low load” as you may first think. Compared to your normal level of exercise it may seem like no big deal but bear in mind the feat your body has just achieved! Start slowly, keep track of how far / how long you are walking and take care not to suddenly increase the time you spend in this activity. Build it up gradually.
Phase 2 (6-12 weeks): rebuilding
Progression of your pelvic floor rehabilitation
This can be directed by a women’s health physio or you can use Megan’s book Stronger; the honest guide to healing and rebuilding after pregnancy and birth to tailor yourself a program. We are all different as are our goals. So the level to which we train our pelvic floor to will also vary.
Increasing your walking distance/time and intensity
Speed, distance and load (hand weights work really well) are all good ways of gradually increasing the effort of walking before running.
Global strengthening
The most important muscle group is your “deep core”. Part 2 of our online program “Activation” is all about re-setting the foundations and switching this on in all other exercises. This not only protects us from injury and pelvic floor dysfunction but also ensure we are training all of our muscles equally, including the ones most stretched by pregnancy and birth. Parts 3 and 4 target the lower body in “Pelvic ring closure” and “core abdominals” and you should build up to being able to complete these with ease before progressing from this phase.
We can also start with body weight strengthening and the key muscle groups we target are:
Glutes e.g. glute bridge, clams, side lying leg lifts, functional exercises in line with daily function
Core abdominals – appropriate abdominal exercises depending on your abdominal muscle healing – e.g. breathing, deep abdominal activation exercises, rectus abdominis strengthening
Back e.g. superman’s, dead lifts, cobras
Calves and quads e.g. squats, lunges, single leg step ups
Reformer Pilates, Mat Pilates and Barre are good examples of classes that meet the goals of this phase.
Scar mobilisation
Pelvic floor or abdominal scar massage, exercises and stretches e.g. cat-cow, overhead arm reaches, perineal massage.
Phase 3 (from 12 weeks at the earliest) : returning to running
Here we can add some resistance load. Adding weights to the exercises above, joining an S+C for mums class or buggy fit are all examples of progressive strength training.
When you are ready here is a short test to see if you are ready to start running:
- Single leg balance 10 seconds
- Single leg squat 10 repetitions each side
- Jog on the spot 1 minute
- Forward bounds 10 repetitions
- Hop in place 10 repetitions each leg
- Single leg ‘running man’: opposite arm and hip flexion/extension (bent knee) 10 repetitions each side
- 20 repetitions of each test. ⁃ Single leg calf raise ⁃ Single leg bridge ⁃ Single leg sit to stand ⁃ Side lying leg lift
All these tests should be performed without any discomfort, leaking or feeling of heaviness. If any of these occur you should:
- Stop and see a women’s health physio if you haven’t already.
- Work on these with a “co-contraction” of your pelvic floor. Meaning you contract your pelvic floor before you bound, hop or jog on the spot. The idea being you build your strength here so that when you come to running you don’t have to try and contract your pelvic floor the whole run!
Phase 4 from 12 weeks at the earliest: running
If you are confident with the tests above then this is the time to start a couch to 5km program! Couch to 5km is a great guide of how to gradually progress your training, no matter what level you were at pre-pregnancy. It will take you through a walk-run program, gradually progressing your running time and distance as your tolerance improves.
Don’t forget to keep up with strength and pelvic floor training along side your running and progressing the exercises as you get stronger.
There are also supportive clothing that can help support the pelvic floor in your return to running and reduce stress urinary incontinence. EVB shorts are great examples of the supportive underwear: EVB Shorts – Support for Prolapse, Leakage and Pelvic Issues (evbsport.com)
What you need to look out for
- Heaviness, dragging, or pain down below that may be indicative of pelvic organ prolapse.
- Incontinence, urgency or staining in the underwear.
- Joint or muscle pain (more than 3/10 intensity on a pain scale).
No matter how postnatal you are it is important to start you return to running program from phase 1.
It goes without saying, no woman is the same, no birth is the same! Everyone’s journey is different and that is why it is so important that your rehabilitation is guided by a professional and created just for you. Be patient, doing too much too soon is when preventable injuries happen and makes the return to running process so much longer.
Myself and the rest of the four sides team are here to help get you back to activities after giving birth whether it was 6 weeks ago or years ago! It is very too late, and it brings us so much joy to get women to their goals.
By Natasha Hughes Physiotherapist & Women’s Health Specialist
References
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Relationship between diastasis rectus abdominis muscle (DRAM) and musculoskeletal
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6. Dumoulin, C., Cacciari, L. and Hay-Smith, E.C. (2018) Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews Issue 10 [Accessed online 24/02/19] doi: 10.1002/14651858.CD005654.pub4.
7. Hills, N. F., Graham, R. B., and McLean, L. (2018) Comparison of trunk muscle function
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supportive underwear versus pelvic floor muscle training or no treatment in women with
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Urogynecol J [Accessed online 24/02/19] https://doi.org/10.1007/s00192-018-03855-z
9. Price, N., Dawood, R. and Jackson, S.R. (2010) Pelvic floor exercise for urinary
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10. returning-to-running-postnatal-guidelines.pdf (absolute.physio) written by Tom Goom, Gráinne Donnelly and Emma Brockwell, March 2019
