A Practical Post on Running with POTS

how I run without passing out - your mileage may vary!

one of the best running photos ever taken of me - tysm, Em Domingues!

When I was first diagnosed with Postural Orthostatic Tachycardia Syndrome (POTS) in 2019, it felt like every story about POTS was mostly about how no one knew what POTS is. Things are changing now. More people know about POTS (thanks, Covid), and as a result, we’ve got more nuanced narratives. We’re even starting to get more stories about athletes with POTS - and there’s actually a lot of us out there!

These stories matter to me. Even though I’ve got a great running group, being the only one with this condition feels isolating. Knowing that other people like me are out there trying comforts me. It’s nice to be reminded that I’m not alone in this, especially as my training runs get longer and harder.

However, most of these stories don’t actually tell you how people with POTS actually pull these things off, just that they do.¹ The how-to isn’t poetic, but it’s practical. So, for anyone else who’s searching, here’s how I run with POTS. My method is mostly a lot of electrolytes, a die-hard commitment to walking breaks, and compression socks. These things, combined with being comfortable with being pretty slow, successfully helped me run two marathons and a 339-mile team relay race in 2023. I’m on track to do that again in 2024.

If you’re reading this, I’m going to assume that you have a general understanding of how POTS works. But before we begin, I need to make some disclaimers.

• POTS is different for everyone who has it. There’s a lot that affects what this conditions feels like, and it’s largely things that are out of anyone’s control.

• What works for me might not work for someone else. For example, part of the way I manage POTS is by dramatically increasing my salt intake. But, it’s not abnormal for someone with POTS to also have high blood pressure - after all, nearly half of Americans have high blood pressure - and that’s usually managed by eating less salt.

• Running marathons didn’t get rid of my POTS. While I am way less symptomatic now, I still have this damn thing! If you’re looking for a cure, this isn’t it.

  ---

Getting started

I wasn’t a runner before I got POTS, but I didn’t go from never running to running marathons immediately.

In my first year with POTS, I ended up getting bunion surgery (gotta take advantage of hitting that out-of-pocket max!). No surgery that involves breaking your foot is going to be fun, but in hindsight, it was very helpful because the recovery process forced me to spend a lot of time on the recumbent bike. Working out horizontally is *great* for many people with POTS because you can actually do cardio without your orthostatic tachycardia kneecapping you. I don’t think I would have been able to run in my first year with POTS. Getting used to what tachycardia felt like took time.

I started off running a year and a half later by sort of following a built-in 5K training plan that came with my Garmin watch. The plan itself was fine, but being able to see my heart rate while I was exercising was (and is) crucial for me. As I got better at running, I used Peloton’s Walk+Run classes (my favorite instructor for these is Kirsten Ferguson) to increase my mileage.

A lot of people recommend the Couch to 5K plan for people new to running. It’s a hard no for me because its goal is to get you to be able to run a 5K without taking a walking break. This isn’t a bad goal for most people, but it’s one that I can’t meet. My heart rate gets way too high to not take a walking break.

How much do I run?

I use the Galloway plan for beginners to train for my marathons. It’s a 30 week training plan, which is way longer than what’s standard in the world of marathon plans but it makes the build-up much gentler. The plan is built on the assumption that you’re going to run/walk the entire time. I am not exaggerating when I say that taking walking breaks while running changed my life.

I set my Garmin watch up to tell me to take a thirty second walking break every two minutes when I’m running long distances. If it shows me that my heart rate is above 180BPM (which is usually when I start to feel “floaty”), I’ll take a longer break - but I’ll take a longer break if I want to even if my heart rate isn’t that high.

The Galloway beginner plan only has three runs per week. You do two 30-minute runs during the week and then a long run on the weekend. The long runs go up in mileage every couple of weeks, but the majority are under 7 miles. I run less than two and a half hours total most weeks.

Electrolytes

Extra electrolytes make a huge difference for my POTS symptoms. My cardiologists have me on a high-sodium diet², but this alone isn’t enough for running. Before a long run, I’ll have a Liquid IV packet and another one afterward. If I’m running more than 15 miles, I’ll usually have one during the middle of the run.

Electrolyte goos and gels are fun! I’ll have a couple during a long run in addition to my water and Liquid IV. There are a lot of gross ones out there, but my favorites (based on flavor and texture alone) are all from Honey Stinger.

What do I wear?

Compression socks!!!! Compression garments reduce POTS symptoms by making circulation easier on your body. I am sure that there are other great brands out there, but my local running store had these CEP knee-high running compression socks, and I love them so much.

I also do not function without my hydration pack. I need to be able to have water whenever I want, so you’ll see me with my little backpack even if I’m only running for a mile or two. It just makes life easier, and it gives me a place to put all of my snacks. I like this one by Nathan, but there’s nothing that’s uniquely special about it.

me and my beloved lil backpack before our second marathon

Physical Therapy

This is new for me! I’ve done physical therapy before, but never for running. I had some mild knee pain over the winter, and I wanted to be proactive about not making it worse this year. I’m working with a PT who’s both 1) a running specialist and 2) very familiar with Ehlers-Danlos Syndrome (EDS).

EDS is a hypermobility disorder that’s very common in people with POTS. I never considered myself hypermobile, but it turns out I’ve got this too - which probably explains my long history of weird injuries, semi and fully dislocated joints, and chronic pain. Hypermobile bodies require different care than non-hypermobile ones, often in ways that feel counterintuitive. For example, my physical therapist wants me to NOT stretch after running - and so many of my other friends with EDS and other hypermobility disorders have told me their PTs have said the same. I can stretch if my legs feel extremely “tight”, but otherwise, it’s not beneficial and puts my already too-flexible joints at risk.

The rest of my PT mostly involves a lot of lower body lifting with a focus on single leg exercises (e.g. single leg squats) and what feels like five-million different types of calf raises to help build up my ankle and hip stability. I try to do my exercises three times a week, and I continued to be annoyed and delighted that they make a difference.

---

Overall, these adaptations are pretty simple, and most of them aren’t even that POTS specific. Plenty of regular runners wear compression socks, and more and more people are embracing the run/walk strategy each day. I’m still searching for stories of athletes with POTS, but I’m starting to see myself in all sorts of other runners. Hopefully, they’ll see parts of themselves in our experience.

1. Notable exceptions include:

• This interview between Precision Hydration and Sophie Hillyerd, a professional footballer for the London City Lionesses. It’s absolutely a product placement, but it was what introduced me to taking electrolyte packets before AND after exercise as well as during it to manage POTS symptoms.

• Laurie Dupnock’s blog, Better by the Beat, where she posted about how she got back to running with POTS

2. Most things about having POTS suck, but this rules!!