Running & Pregnancy 
Pregnancy and childbirth create multiple changes to the core and lower extremities. Stress incontinence is observed in about 19% of runners post-partum. Many runners are free to start running as soon as they are released from their doctor (2 weeks to 2 months post-partum) with little to no guidance on how to safely return and not excessively stress the healing pelvic floor tissue. The purpose of this article is to share a new four-step return to the running process with all of our runners.
Physical Therapy Evaluation
Getting a physical therapy evaluation and screens for pelvic health, impact readiness, physiological variables, and a running-gait analysis is paramount to a safe and seamless return. A physical therapy evaluation is key to establishing the post-partum versus the pre-pregnancy function. The therapist will discuss the pre-pregnancy or concurrent running training schedule, past medical history, medication usage, and current post-partum recovery experience. They will also do a musculoskeletal exam including the pelvic floor, abdominal region, and the lower extremities (hips, knees, and feet).
A pelvic health screening will consist of a questionnaire requesting information regarding any type of pain since giving birth, any issues with bowel or bladder function, including leaking with activity (stress incontinence) or an increase in leaking with the urge to urinate or urination frequency (urge incontinence).
Running is a high-impact activity and places a high amount of stress on the healing abdominal and pelvic floor tissue. This stress can lead to leaking of urine and dropping of other organs such as the bladder or colon into the vaginal space, causing more dysfunction and a sensation of heaviness or pressure in the vagina or pelvis. A thorough pelvic evaluation should occur to determine running readiness.
Return to Running
While the focus in this article is on post-partum return to running, the following screens are appropriate for any biological female to minimize running-related injuries to the pelvic floor and the lower extremities across the spectrum of their running career:
- Tolerance and response to the ground reaction forces, jostling of joints and soft tissue that occurs during running to determine if pelvic symptoms are present with increased load and impact
- Running gait to determine the risk factors on the pelvic floor and the lower extremities
- Physiological issues
Decreased sleep, increased fatigue, and poor nutrition can all contribute to running-related injuries.
Once screened, released by a practitioner overseeing the pregnancy, and feel ready to start training, the following framework should be used to assist each post-partum individual meet their running goals. The information gleaned from the screens will determine which phase of training is an appropriate starting point.
If there is an increase in fatigue or musculoskeletal symptoms, then the individual should regress to the previous phase until symptoms subside. The four targeted muscle groups for strengthening include the abdominals, pelvic floor, gluteus medius (important hip muscle), and the foot muscles. Strengthening exercises should be performed after running on run-specific training days.
Frequency, Intensity, and Rest: General Guidelines 
Frequency of exercises: Strength exercises should be performed 2-3 nonconsecutive (not back-to-back) days a week, unless they are isometric (static, no movement during muscle contraction) or very low intensity exercises in phase I, which can be performed 3 to 7 days a week.
Rest between sets: The athlete should rest 2-3 min between each set of each particular exercise in order to recover in the muscles used. You may continue with exercise of other muscle groups while waiting for the 2-3 min recovery of the muscle group just targeted.
For example, in order to save time and keep heart rate elevated during strengthening, if you are performing squats, after the first set, switch to heel raises to continue exercises while allowing for recovery of the glutes and thighs. If the muscle group is still fatigued after 2-3 minutes, a rest up to 5 min may be needed for each muscle group.
Intensity of exercise: To build strength, the patient should perform 8 to 15 repetitions of high load. Proper form must be able to be maintained. On a 1 to 20 scale, with 1 being very low intensity and 20 being extremely high intensity, the patient should be scoring themselves at a 7 to 12 in phase I and 13 to 16 in phases II, II, and IV.
Strengthening exercises: The physical therapist will assign exercises to address individual hip, foot, pelvic floor, and abdominal strengthening needs. Strengthening activities do not need to be synchronously progressed with the running exercises.
For example, a runner can be performing phase III strengthening exercises and run phase 2 distances. Most likely, the running phases will not progress faster than the strengthening phases due to strength and endurance needs in each phase to maintain proper form.
Four Phases of Exercise and Running Progression
Phase I: Strengthening exercises assigned by the therapist for the abdominals, pelvic floor, glutes, and feet will be performed in a seated and supine (on your back) positions. Evaluation by physical therapists determined patient is not ready to ready and therefore, phase I exercises are initiated!
Walking progression only:
- Level 1 - Walk 10 min
- Level 2 - Walk 15 min
- Level 3 - Walk 20 min
- Level 4 - Walk 30 min
Goal: Patient is able to walk 30-minutes at a perceived exertion level of no more than an 11 (fairly light) on a 20 scale without any symptoms and pass a running readiness screen before initiating phase II. The runner will demonstrate good control and strength of the hip, trunk, pelvic floor, and lower extremity muscles.
Phase II: Assigned strengthening exercises are performed against gravity in all positions while lying down (stomach, sides, and back) and in standing, as well as on hands and knees.
Running progression with a RPE of 11 to 13:
- Level 1 - 0.25 walk, 0.25 run, 0.25 run (weekly running mileage 1.5 mi. This does not include walking mileage.)
- Level 2 - 0.25 walk, 0.28 run, 0.25 walk, 0.28 run (weekly running mileage 1.65 mi)
- Level 3 - 0.25 walk, 0.30 run, 0.25 walk, 0.30 run (weekly running mileage 1.82 mi)
- Level 4 - 0.25 walk, 0.33 run, 0.25 walk, 0.33 run (weekly running mileage 2.0 mi)
- Level 5 - 0.25 walk, 0.36 run, 0.25 walk, 0.36 run (weekly running mileage 2.2 mi)
Each level must be performed 3 times, symptom free, and with proper form before progressing to the next level with 48 hours of rest required between running sessions, a perceived exertion level of
Goal: The runner will be able to run 2.2 miles per week symptom free with good form with exercises and proper mechanics with running.
Phase III: Strengthening exercises are a combination of lying down, standing, on all fours, and the addition of light plyometrics (double leg jumping).
Running progression:
- Level 6 - 0.25 walk, 0.40 run, 0.25 walk, 0.40 run (weekly mileage 2.4 mi)
- Level 7: 0.25 walk, 0.44 run, 0.25 walk, 0.44 run (weekly mileage 2.65 mi)
- Level 8: 0.25 walk, 0.48 run, 0.25 walk, 0.48 run (weekly mileage 2.90 mi)
- Level 9: 0.25 walk, 0.53 run, 0.25 walk, 0.53 run (weekly mileage 3.20 mi)
- Level 10: 0.25 walk, 0.58 run, 0.25 walk, 0.58 run (weekly mileage 3.5 mi)
Each level must be performed 3 times, symptom free, and with proper form before progressing to the next level with 48 hours of rest required between running sessions, a perceived exertion level of
Goals: Running a total of 3.5 miles per week with proper form and mechanics.
Phase IV: High level strengthening exercises in various positions and including plyometrics (hopping and box jumps).
Running progression:
- Level 11: 0.25 walk, 0.63 run, 0.25 walk, 0.63 run (weekly mileage 3.80 mi)
- Level 12: 0.25 walk, 0.70 run, 0.25 walk, 0.70 run (weekly mileage 4.20 mi)
- Level 13: 0.25 walk, 0.77 run, 0.25 walk, 0.77 run (weekly mileage 4.62 mi)
- Level 14: 0.25 walk, 0.83 run, 0.25 walk, 0.83 run (weekly mileage 5.00 mi)
- Level 15: 0.25 walk, 0.92 run, 0.25 walk, 0.92 run (weekly mileage 5.50 mi)
- Level 16: 0.25 walk, 1.02 run, 0.25 walk, 1.02 run (weekly mileage 6.10 mi)
- Level 17: 0.25 walk, 1.12 run, 0.25 walk, 1.12 run (weekly mileage 6.70 mi)
- Level 18: 0.25 walk, 1.50 run, 0.25 walk, 0.75 run (weekly mileage 6.75 mi)
- Level 19: 0.25 walk, 1.75 run, 0.25 walk, 0.50 run (weekly mileage 6.75 mi)
- Level 20: 0.25 walk, 2.0 run, 0.25 walk, 0.25 run (weekly mileage 6.75 mi)
- Level 21: 0.25 walk, 2.25 run, 0.25 walk (weekly mileage 6.75 mi)
- Level 22: 0.25 walk, 2.48 run, 0.25 walk (weekly mileage 7.43 mi)
Goals: Running a total of 7.48 miles per week, symptom free, with proper form and mechanics.
Summary 
Intermittent visits to the physical therapist are appropriate to monitor and progress each level as well as an opportunity to update the strengthening activities. Symptoms of pain, incontinence, swelling, prolapse, and muscle stiffness must be monitored and communicated by the runner to the health practitioner in charge of their program. Running progression may be quicker than written above for a more elite athlete or runner who was able to continue running through the majority of their pregnancy.
We hope this article provides some guidance and appropriate timelines for safe and symptom-free return to the exercise you love.