Authors: Dr. Katie McGee, PT, DPT (they/she), with contribution from Kennie Q. Story, MS, ACSM-CPT
If you are a runner thinking about gender affirming bottom surgery, there can be a lot of unknowns.
- How long will it take to get back to running?
- Will I be as good of a runner as I was before?
While these questions can be hard to answer, there are things you can do to optimize your return to running. These are my top suggestions for people of all genders, from a physical therapy perspective.
If assigned bed rest exercises, stick with them!
Bed rest refers to staying in the hospital bed after surgery, with little to no walking time. Not all gender affirming bottom surgeries require bed rest, although some may involve a week or more. In one study of healthy young adults, one week of bed rest caused a loss of three pounds of muscle and a three percent decrease in quadricep muscle cross-sectional area  . What runner wants to try to bounce back from that kind of de-conditioning?
In order to slow the rate of muscle loss, many hospitals will give directions for simple strengthening exercises to be performed in bed, called bed rest exercises. It is important to do exactly the type and amount of bed rest exercises assigned in order to avoid complications with the surgical site.
For reference, some examples of bed rest exercises include ankle pumps, quad sets, and glut squeezes. Sometimes a surgeon may recommend bed rest exercises be continued even after leaving the hospital to maintain muscle bulk while cardiovascular exercise might be more restricted.
As an additional perk, bed rest exercises can also be useful for reducing the risk of a blood clot after a pelvic surgery . Blood clots are clumps of stuck blood that can slow or entirely block the blood flow in our vessels. The loss of blood flow can injure an extremity, such as a leg, or even the lungs. Again, no runner wants to deal with extremity or lung injuries. Be sure to check with your medical team if you have questions about bed rest exercises.
Bonus tip: If you are concerned about muscle loss due to possible bed rest, consider increasing muscle bulk prior to surgery. This way your body has more of a reserve when it comes to muscle loss.
Follow post-op guidelines
For some people, completing a gender affirming surgery can bring on a burst of energy. While it may be tempting to quickly return to previous workouts, it is very important to follow your medical team’s advice on returning to activities. For example, surgical sites both inside the body and outside the body often take two to three weeks to close entirely, but sometimes longer.
More activity than recommended by the medical team could open an incision, leading to excessive bleeding or infection. This could result in complications that further delay a return to running. If given the go ahead for walking, many people will start out at 2,000 steps per day and gradually increase steps when it feels comfortable to do so. (This many steps is about the same as 20 to 30 minutes of walking.) Walking doesn’t have to be all at once; it can be broken into several spurts throughout the day.
Be aware that some surgeons, especially in the case of phalloplasty, may restrict walking due to the very delicate nature of the microsurgery. Expect restrictions on the amount of lifting and exercise that can be done for at least six to eight weeks. Some people may start light jogging as soon as six weeks, while others may be waiting four months or more.
Bonus tip: Some people find it helpful to pick a less demanding activity to focus on after they have surgery. This can help reduce the very real feelings of loss around not getting to exercise at a high intensity.
Nourish your body
As a group, runners are known for limiting food to control body weight. The inactivity of recuperating from surgery causes many runners to want to cut back even more. However, after surgery, the body truly needs an appropriate amount calories and nutrients to heal as well as possible. For some people, eating enough food is hard in general. In these situations, a manageable goal can often be taking a multivitamin daily.
If you or someone you know needs assistance with an eating disorder, there is help! Here are two starting points: National Eating Disorders Associations and Eating Disorders Anonymous. Another resource is the Healthy At Every Size (HAES) list of providers which includes nutritionists, mental health specialists, and other specialists.
It’s worth pointing out that the necessary inactivity after surgery can worsen constipation. Drinking two to three liters of water per day can help combat this issue. Fiber supplements can sometimes worsen constipation when people are not active, so stick to your medical team’s recommendations regarding stool softeners and prune juice.
Optional: Support wear
For the most part, specialized gear is not required for returning to running after gender affirming bottom surgery. For people who developed increased external genitalia after surgery, compression shorts or leggings may be helpful to minimize bothersome jostling. Others prefer a jock strap. Those who received a phalloplasty may find that the penis does not bend downward much for four months or so, and they may require different underwear for support until that time.
What about running after skin grafts?
Some people who undergo gender affirming surgery may have skin taken from another body part. This is called a skin graft. Initially, the area where the skin was taken from will require special care (which often involves avoiding stretching and heavy exercise). When cleared by a surgeon, greater amounts of walking and running can be resumed. If a runner notices restricted movement, especially in a skin graft taken from the lower body, they should bring this up with their surgeon. A physician may propose medical treatment or physical therapy to allow freer movement of the skin graft area.
Ease back into running
Once cleared by a surgeon to resume running, it is recommended that runners gradually reintroduce jogging by alternating it with walking. Some people intuitively find a balance of progressively increasing jogging time while decreasing walking time. Others follow a more structured plan, such as a Couch to 5k program (C25k). It’s not uncommon to have fatigue and soreness when starting out.
If someone hits a roadblock in their return to running, a trainer or physical therapist who is well versed in transgender fitness can be incredibly helpful. Personal trainers who specialize in transgender fitness can often be found through searching on Instagram or on Google. One tool for connecting with the right trainer is the listing page on Non-normative Body Club (based out of Philadelphia but streaming worldwide).
A physical therapist may be more appropriate than a trainer for people who have a medical condition interfering with running. The PT Locator through the American Physical Therapy Association Academy of Pelvic Health has an option to search by transgender health practitioners. Pelvic Rehab is another search tool, but without the ability to screen for gender affirming care providers.
Gender affirming surgery does not mean the end of running! It is possible to enjoy fitness and a new body. If someone is struggling to return to running after gender affirming surgery—whether the operation was a hysterectomy or a phalloplasty—help is available. A friend who has been there, a trainer, a physical therapist, or the medical team can offer support. Every runner deserves more miles!
- Dirks ML, Wall BT, van de Valk B, et al. One week of bed rest leads to substantial muscle atrophy and induces whole-body insulin resistance in the absence of skeletal muscle lipid accumulation. Diabetes. 2016;65(10):2862-2875.
- Guo M, Lu L, Sun Y, Li L, Wu M, Lang J. Comprehensive functional exercises with patient education for the prevention of venous thrombosis after major gynecologic surgery: A randomized controlled study. Thrombosis Research. 2019;178:69-74.