It has now been 5 weeks and 1 day since I last went out for a run.

I had always planned to take a full two week break after running the Virtual New York City Marathon on the 18th October. I like to have a break at the end of each year to give the body some time to recover before starting to chase new goals the following year. Also having a mental break from the grind of training for a race really helps me to re-focus on the next target.

Anyway, as you now know, that two week break has been a little longer than first planned.

I have tendonitis in my left knee.

Something that I was in denial about for a number of weeks. Just a niggle and a small pain that will go away with a few weeks off. I am sure you have had similar niggles and continued to train through it.

The Injury

I first started to notice some knee pain towards the end of August as I was tapering for the Virtual Boston Marathon on the 5th September. At first, it would only crop up slightly when walking up & down the stairs, I could run pain-free, walk pain-free and bike pain-free.

I carried on with the taper and ran the virtual 26.2 miles on 5th September. I continued to train for the next 26.2 “races”, the Virtual London Marathon on 4th October and Virtual Chicago Marathon on 11th October.

I still had the pain on the stairs but was still able to run without any pain so I thought I would get through this series of four virtual marathons over a six week period and give the knee a bit of rest to calm it down. These first three virtual marathons had actually been my second, third and fourth fastest times over 26.2 miles, so the knee can’t be that bad right?

It wasn’t until the week between the Chicago and New York virtual marathons, where I started to notice the pain during the warm up or first few miles of a run. As the pain went away I did carry on with those runs. I only had to get through this last week but did take two rest days that week.

The Recovery:

My plan for recovery from this tendonitis is going to be in three steps. Firstly to reduce the swelling and pain, Secondly to increase flexibility in the muscles around the knee, such as calf, quad and hip flexors. Thirdly, once pain-free, gradually begin to strengthen the knee-tendon.

I am not going to set any time frame on this, it will take as long as it takes and let’s face it. Now is as good a time as any to be out injured with no races on the near horizon due to the COVID-19 pandemic.

Step 1: Rest

The main part of this recovery is resting. Not doing any of the activities that impact the knee-tendon. Mainly jumping, squatting or running. Over time the pain will decrease and hopefully go all together. One thing I learned was for every week you put off the injury recovery/rest, it is potentially a further week added to the recovery. So those six weeks where I ran on through the pain have possibly added a further 6 weeks to this injury.

During the “two week” break which eventually turned into “being out injured”, I started RICE. Rest, Ice, Compression and Elevation. During the Ice phase, I would alternate between the ice pack and a hot water bottle. The cold to reduce swelling and the heat to flush out the tendon.

Step 2: Flexibility

I added quad and hip flexor stretches into my three times daily calf stretching routine very early on alongside the Icing and Compression. The hope is this stretching will reduce the tension in the quad and calf muscles. Over time this should reduce the potential of any reoccurrence and it’s just good practice to be stretching more anyway. Stretching has always been one of those things that I know I should do more of but for some reason, I put it off. I would happily go out for a 3 hour run but 10 minutes of stretching gets put off.

I had a sports massage to loosen the calf and quad muscles which may have been pulling on the knee-tendon.

Step 3: Strengthening

Once pain-free I can move to the strengthing phase. After 5 weeks of resting I am not yet at the pain-free stage but my plan once I get there is to add some knee specific exercises to the routine. Starting slowly and not a large number of reps but gradually build them up and not risk damaging the knee-tendon and heading straight back to step 1.

I am planning on starting off with simple knee extensions, stepping up and down and slow squats. If I can get through them and still stay pain free I will add in squats on my slant board.

Then I will be able to add in running again.

The return to running will be very slow and steady and following the same routine, I used when returning from a grade 2 calf strain in 2019. Starting off with one 1 mile run to test the knee, the move on to two 2 mile runs in week 2, three 2 mile runs in week 3, three 5k runs in week 4, same in week 5 but run on two consecutive days. All run at a very easy pace on flat ground.

From day 1 (19th October), I have been doing a 40 minute Legs, Hips, & Glutes strength training session each day. My aim here is to really build up my hip and glute muscles to a level that can sustain 40 – 50 mile weeks and form the routine of doing this daily without having to think about it.

The Root Cause?

What caused this knee tendonitis?

I am thinking it is the combination of increased mileage, reduced strength training and insufficient stretching.

From April through to October I, like most people, started to run more miles with no races to taper for. I was focusing on hitting quality sessions and building up a solid base to launch off of for 2021. I ran 16 weeks of 50+ miles, 5 of which were over 60 miles. In previous years I had only hit 50 miles on three occasions.

It was a calculated decision to increase the mileage, I had been averaging around 48 miles per week between November 2019 and April 2020 so it wasn’t a massive jump to go past 50.

Whilst increasing the miles I forgot or put off the Legs, Hips & Glutes strength training. By October 18th I had done four 30 minute session in 2020. This is a session I would plan to do two or three times per week so you can see that I was way behind with that.

Running more miles and doing less strength work is what I feel has caused this injury.