Returning to Running after Pregnancy - What You Need to Know.

As Physiotherapists, we are often asked “When can I return to running after having my baby?”  While our goal is to get you back to running and other impact activities as quickly as possible, it is important that this is done safely.

This blog has been written with that goal in mind.

High impact activity such as running may be associated with sudden increases in intra-abdominal pressure (Leitner et al 2018). It also has been reported that ground reaction forces of between 1.6 and 2.5-times a woman’s body weight can occur when running at a moderate speed of 11 km/hr (Gottschall and Kram 2005).

Pelvic floor muscle strength and speed is required to counteract high intra-abdominal pressure which occurs during high impact activities like running. Strong pelvic floor muscles will ensure good pelvic organ support and continence (no leaking) during running and other high impact activities (Leitner et al 2016). Lack of strength and poor coordination in these muscles, which is common following pregnancy, is the reason that many women may not achieve the level of function needed, and struggle with issues of incontinence, when returning to high impact sport too quickly. Pelvic Health Physiotherapy can help ensure you regain your function and return to activities safely and more quickly.

Research supports the effectiveness of Pelvic Health Rehabilitation. There is Level 1 (highest level) Evidence that:

“Postnatal women can benefit from individualised assessment and guided pelvic floor rehab for the prevention and management of pelvic organ prolapse, the management of urinary incontinence and for improved sexual function.”(Goom 2019)

We know that, following childbirth, women need adequate time to heal and regain strength, especially in the abdominal and pelvic floor muscles, which are impacted during pregnancy and delivery. The region around the birth canal (called the Levator Hiatus) is naturally stretched during pregnancy and vaginal delivery and can take up to 12 months to recover to its prenatal condition (Staer-Jensen et al 2015). Pelvic floor muscles, as well as the surrounding connective tissue and nerves, may also be stretched/injured during pregnancy and childbirth, and generally recover by approximately 4-6 months after giving birth (Shek et al 2010).

While caesarean section does not impact the birth canal and pelvic floor muscles like a vaginal delivery, consideration should be given to the impact of healing and remodeling of the surgical scar and surrounding abdominal fascia following caesarean. Ultrasound imaging shows that abdominal fascia regains only approximately 51-59% of its original tensile strength by 6 months post caesarian section while it has been shown to gain and 73-93% of its original tensile strength at 6-7 months post vaginal birth. (Ceydeli et al 2005)

It is important that women understand the key signs and symptoms of pelvic floor and/or abdominal wall disfunction which may include:

• Urinary and /or fecal incontinence 

• Heaviness/pressure/bulging/dragging in the pelvic area and/or rectal area

• Pain with intercourse

• Constipation

• Low back or pelvic pain 

• Pelvic pain during activities

• Diastasis Recti (separated abdominal muscles)

• Reduced function and strength

Risk for potential injury when returning to running or impact activity after giving birth may increase with:

• Returning to impact sport less than 3 months postnatal

• Pre-existing hypermobility conditions

• Pre-existing pelvic floor, low back or pelvic disfunction

• Psychological factors that may predispose a postnatal mother to inappropriate intensity/duration of running as a coping strategy

• Obesity 

• Caesarean section or perineal scaring 

• RED's (Relative Energy Deficiency Syndrome)

Given all of this, how do we know when it is safe to return to impact sport after giving birth?

Guidelines for returning to running following pregnancy:

1.      Seek out a Pelvic Health Physiotherapist who can evaluate strength, function and coordination of the abdominal and pelvic floor muscles following childbirth.

It is recommended that all women regardless of how they deliver seek out a pelvic health assessment with a Pelvic Health Physiotherapist who can assess the ability of the pelvic floor muscles to activate and relax, test for any pelvic organ prolapse or diastasis recti, help treat any underlying lumbopelvic dysfunction, and develop an individual progressive program with the goal of returning to athletic performance safely.

2.      Start with low impact activities like walking before progressing to running 3-6 months postpartum.

Running and other impact sports place a lot of demand on your body. To be impact sport ready your body needs time to heal and regain its strength after having a baby. For these reasons, it is recommended women start with low impact exercises for at least 3 months prior to progressing to high impact.

3.      After 3-4 months post partum, progress through a graduated return to running program (Goom 2019).

The ability to perform the following exercises with no symptoms of pelvic pain, pelvic heaviness, pelvic prolapse or incontinence supports readiness for returning to running. Progress to the next level if symptom free:  

1. Walk for 30 min 

2. Single leg balance for 10 s on each side

3. Single leg squat for 10 repetitions on each side

4. Jog on the spot for 1 min 

5. Forward bounds 10 repetitions (see this youtube video for demonstration https://youtu.be/dbGdZooNHFI)

6. Single leg hop in place for 10 repetitions each leg

7. Single leg "running man" for 10 repetitions on each side (see this youtube video for demonstration https://youtu.be/OufNfxJjMZE)

4.      If able to complete program in #3 with no symptoms, return to running, building slowly.

It is recommended that women slowly increase training volume (running distance and time) prior to increasing training intensity (speed of running). Injury risk is lessened if the total weekly running distance/time is not increased by more than 10% per week. Any increase or recurrence of pelvic symptoms requires modification of your running program and/or reassessment by a Pelvic Health Physiotherapist.

5.      Finally, take your baby with you when you run, but not until your baby is 6-9 months old.

Running with a stroller has been shown to be more challenging than running without a stroller so will help a woman gain strength more quickly. That said, it is important that a baby has sufficient neck strength to tolerate the activity as well, usually around 6-9 months of age.