Q & A from Injury Clinic on Thursday 12th February 2015:

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Question:  Over the last 2-3 weeks, I have been getting a dull pain in the area just below my left ankle on the outside of my foot. The pain is manageable but gets worse as I increase my mileage which is worrying as I am training for the Omagh half marathon.  Any suggestions?

Answer:  This is hard to diagnose accurately without assessing you in person, as gradual pain (ie there has been no direct trauma) on the outside of the ankle from running can be due to a number of different causes-

1. Overuse injury to the lateral ligaments in the ankle: a gradual pain from this can occur from high running loads (particularly rapid changes of direction, uneven surfaces or inappropriate footwear) causing the ligaments on the outside of the ankle to be overstretched and microtears to occur. Usually with this you will notice swelling around the area and there could be soreness when walking and on certain ankle movements.

2. Referred pain from the lumbar spine (lower back): The spine is made up of vertebrae (bones) with spongy discs in between, creating a space which allows for shock absorption through the spine when we run. If there is any dysfunction (ie stiffening of 1 or more levels of the spine) the compression and repetitiveness of running, especially up hill, on hard surfaces and over long distances will further load these segments. This can lead to irritation of the nerves leaving the spine and can refer pain into the leg and foot.

3. Nerve pain from a lack of nerve movement specifically of the Superficial Peroneal nerve on the outside of your ankle. This is best known as altered neurodynamics and occurs where the normal slide and glide of the nerve around the ankle with movement is no longer able to occur normally. This injury is often worse when running down hill with a longer stride length or when running faster.

Each of the above causes are managed differently so it is important that the source of your symptoms is correctly diagnosed so that an effective treatment regime can be commenced ASAP.   Feel free to get in touch.  For now, the best advice is to reduce mileage and to keep to soft, flat surfaces. Make sure you are in appropriate running shoes and are warming up effectively.

Question:  I injured my left knee on Sunday, climbing over a wall trying to escape from a dog! The pain is on the outside of my knee, on the top of the tibia. There is no swelling, just pain. I’m limping, especially when going downhill. It isn’t as bad when walking uphill or on the flat. I’m unable to run at all and the knee feels at times that it’s going to give way. How long will I need to rest and is it too early to start a little cross training/strengthening exercises. I appreciate your advice.

Answer:  From what you have described there is a distinct possibility that you have injured the lateral meniscus in your knee (cartilage) as this is most common by an impacted twist through your knee.  In order to diagnose this correctly an experienced physio can perform tests on your knee to differentiate between a cartilage injury and a ligament injury and therefore start the correct treatment.  There are varying degrees of cartilage injury and in order to not cause yourself any further harm, an assessment is recommended.

In the mean time we recommend that you rest and do not attempt to run. Due to the fact that your symptoms are easily aggravated we do not feel you are ready to use a X-trainer but would suggest a low resistance bike. As for strengthening exercises, it’s too early as pain will cause inhibition of the muscles.

Question:  I’m currently running on average 18 miles per week which I plan to increase over the coming weeks. I went for a 5 mile run tonight and right from the start my left calf was quite tight and I had to go at an easy pace just to finish the run. I warmed up properly.  I was wondering what the cause is likely to be? Poor form, worn out trainers or tired legs (training in gym every lunchtime)? Thanks.

Answer:  If you are doing a lot of running each week (and are continuing to build up) you may not be giving your calf muscles enough time to recover between runs ie your runs may be too close together and any repeated micro-trauma has not been given enough time to recover. The first 2-3 days following a long distance run are the most crucial to a good recovery and these are the days to take relatively easily and consider replacing running with X-training or swimming which will allow you to maintain fitness.

Have you had a previous calf injury? If so you will have scar tissue which will cause the muscle to shorten reducing the tensile strength and leaving you more at risk of recurrent microtrauma and tightness. We recommend that any runners who run 2-3 times weekly or more should have a monthly sports massage to break down scar tissue and adhesions and help maintain general muscle well being.  Of course shoes are extremely important and any unaddressed biomechanical issues will cause imbalance through the calf muscles and again leave you susceptible to injury.  If you have any queries about your foot biomechanics get in touch with our podiatrist or a local podiatrist.

In the meantime, make sure your warm-up is based around dynamic stretches followed by static stretches after your run. At this stage you should perform calf stretches- 3x 20 second holds, twice daily (Look up specific Soleus and Gastroc stretches as the calf is made up of both of these muscles).  If your problem persists, one of our specialised physios would be delighted to assess you, to get to the root cause of your calf pain.

Question:  I have been having knee pain since early January which was diagnosed by a physio as due to the IT-band. I took a week off and am back running now. I have less pain and am doing regular hip stretches and strength work. However; there is still a bit of pain present. Is running through ITB knee pain (training for a marathon) a good idea? Or can there be any lasting damage from it?

Answer:  If this is a true ITB (Iliotibial Band) friction syndrome and you only took 1 week off from running it may well be that the band is still inflamed and you need further treatment with deep tissue massage, stretches of both the ITB and glutes, rest and strengthening of the hip abductors and hip external rotators. 1 week of rest is not long enough to reduce the inflammatory response and without a ‘graded return’ to running, you may have stressed the ITB too soon.  Alternatively, if you have exhausted the above treatment options and your pain remains, there is a possibility it may be due to poor nerve movement at the side of the knee (altered neurodynamics) which is very common in runners, especially those building up mileage. If this is the case there are no self management strategies but it can be effectively treated and cleared with the appropriate physiotherapy regime.  As with any injury we do not recommend you continue to ‘run through it’ as your condition is likely to gradually worsen and may result in compensatory changes and further injury elsewhere.  Best wishes.