Q & A from Injury Clinic on Thursday 1st February 2018:

Question:   4 weeks ago I got a pain in my shin. I have been to the doctors, physio and hospital and everyone is saying there’s no injury. There’s no swelling or bruising. There’s constant pain in my shin so something is wrong. Is this shin splints? And what’s the treatment?

Answer:   There are a few different causes of shin pain and they are mostly treated differently.  To answer your question, yes, it could be called shin splints, as the term shin splints is really a dustbin diagnosis for pain in the area of the shin, but this term doesn’t tell you the actual cause of the shin pain.

The common causes of shin pain are outlined below and each needs to be treated differently in order to clear the pain:

1. A stress fracture – which can be diagnosed by an x-ray or a bone scan (organised through your GP).
2. Tenoperiostitis (inflammation of the tibialis posterior muscle attaching into the inside border of the shin bone).
3. Compartment syndrome- a swelling of muscles within a closed compartment.
4. The most likely cause of your shin pain, which is commonly overlooked as a cause of shin pain, is poor nerve movement of the nerve which runs down the front of your shin (the deep peroneal nerve).  This is called altered neurodynamics and most commonly there is no swelling or bruising associated with it. The pain is from the nerve itself. This can occur if you have previously torn some muscle fibres in that area of your shin, and scar tissue has formed which has irritated the movement of the nerve passing through the area.

Treatment of altered neurodynamics here involves specific movements of the leg in such a way as to restore the normal slide and glide of the nerve and therefore clear your pain.  You really need to see a physiotherapist who is experienced in treating nerve pain to get this treated successfully.

Rebecca Nelson, who is the Director of Physiotherapy here at Apex Clinic, Belfast wrote an article on shin pain, which you can read on the NI running website under the physio section, under running articles, and this article gives you great information on the different causes of shin pain. Feel free to give us a shout if you need help, as all the physios here at Apex Clinic specialise in the spine, nerve pain and sports injuries.

Question:   I have reason to suspect I may have Achilles tendon bursitis on my left Achilles and it has stopped me running on and off over the past 6/7 months. I am just back running in the past week or so after a two month break, but feel it’s still not right. I still have a small lump sitting out of my Achilles. Do you have any suggestions?

Answer:   Achilles tendon bursitis is an overuse injury and often occurs if the person has poor foot or leg biomechanics. At this stage we would recommend that you have your feet and legs assessed by an experienced physiotherapist or podiatrist to see whether you need insoles or a different trainer to suit your foot type. At this stage, we recommend that you do stretches of the gastroc and soleus muscles twice daily, holding each stretch for 20 seconds and repeating each stretch 3 times. You can find these stretches online. It is also possible to cut 2 slits in the heel counter of your shoe to take any direct pressure off the achilles, which may help your recovery as well.

You should also significantly reduce your running mileage and frequency at the moment, to give the above measures a chance of working in terms of clearing the pain, and keep any running to flat ground.  If after 6-8 weeks, the pain is still present despite the above measures, then you really need to have a thorough physiotherapy assessment to establish all the underlying causes of your condition and then get them treated. There are other factors which may have a part to play in this condition such as muscle imbalance or tightness elsewhere and this may need to be addressed in order to get you back on the road painfree.

Question:    I stopped running for around 6/8 weeks due to calf pain, as suggested by my GP while taking Naproxen. I’ve just started again in the last 2/3 weeks. I’m still getting very bad calf pain as soon as I start running. Any help is greatly appreciated.

Answer:    From the information provided, it is unfortunately not surprising that you still have calf pain despite resting for 6-8 weeks with anti-inflammatories.  The reason why it is unlikely to have cleared with these measures, is that most calf pain in runners is due to a mechanical problem, so therefore if you rest for a month or two and then resume running, the mechanics of your problem will be no different at all, so the pain is very likely to be the same as soon as you start running again.  It is like parking your car in your garage because there was a problem when you drove it, and then leaving it for 2 months and then when you drove it again after this time, the problem was no different!

The calf pain which you have described when you run could be due to a number of different things:

1) A build up of local scar tissue in either of the 2 main calf muscles. This can occur following a strain of the muscle which may have gone unnoticed at the time.
2) Nerve pain coming from the nerve running downwards in the calf area (the tibial nerve). This can occur if you have torn some muscle fibres in that area and scar tissue has formed which irritates the nerve passing through.
3) Referred pain from the lower back area. This could be coming from the joints or discs in the lower back as soon as you load your back when you start to run. In this case the pain is often worse when running uphill or when running first thing in the morning.

It’s extremely important to get the correct diagnosis for the pain. In each of the above cases, the physiotherapy treatment is different depending on the diagnosis-

For scenario 1); Local deep soft tissue techniques need to be applied to the painful area to break up any excessive scar tissue which is present.
For scenario 2); Movement of the nerve tissue needs to be done by a physio who is experienced in treating nerve pain, to free up the normal slide and glide of the nerve which occurs when running.
For scenario 3); Manual mobilisation of the affected segment of the lower back is needed to loosen the stiffened segment and therefore stop the referred pain to the calf.

Whichever of the above scenarios that you have, the good news is that in nearly all cases the calf pain can be cleared completely and you can return to painfree running. You really need to get treatment now from an experienced physio. Best wishes.

Question:   I think I’ve got a stress fracture in my foot. It started like a bruised feeling on top of my foot. I didn’t realise it was due to running until after a long run of 1.5 hours. It became more sore and the top of my foot swoll up. I haven’t run for 2 weeks now. The swelling has gone but there is a small bump and the bruised feeling is still there, but it’s not very sore. I’m just wondering when I’m likely to be able to run again? Is this something I could run through or should it be rested?

Answer:   Yes, we agree, it sounds as if you have a stress fracture.  At this stage though, it’s important to confirm if you do have one or not, because this will determine how you manage the condition.  We recommend that you go to your GP and ask him or her for an x-ray of your foot which should show a stress fracture if it’s present.  Occasionally, further clarification is needed by having a bone scan, but it’s less likely that you’ll need this.

If x-rays of your foot do reveal a stress fracture, then you certainly should not run on it, or else you will hinder healing significantly!  Continuing to run with a stress fracture could lead to further problems down the line so it’s definitely not recommended.   We recommend that you should avoid running on land for approximately 6-8 weeks, but this time frame will depend on the severity of the stress fracture.  During healing, many folk recommend taking calcium supplements to aid healing of the bone, but there is no definite evidence as to whether this helps or not.

During your rest period from running on land, the best thing that you can do to maintain your running fitness is aquajogging in a local swimming pool.  It is perfect to allow bone healing in an unloaded environment whilst you maintain your running fitness.   Before you return to running on land, it is important that you see an experienced physio or podiatrist to have your foot and lower limb biomechanics assessed to see if you need insoles or not, and to check that your current trainers are suitable for your foot type.  Poor foot and leg biomechanics is often a contributing cause of stress fractures. Improving your foot and/or leg biomechanics may help reduce the likelihood of a stress fracture occurring in the future.  Also, introduce some running on soft surfaces when you return to running, such as grass, bark or the treadmill.

Question:   I’ve got an achilles tendon injury at the minute and I was wondering what is the best treatment and how long it could be to get back running again as it seems to flare up every time I attempt to run again? I had rested for a month, then possibly attempted too much and it came back with a vengeance.

Answer:   At this stage, you should only attempt to run if you have no pain when walking during the day.  Achilles tendon injuries are overuse injuries which often occur in the presence of poor biomechanics of the feet and/or legs.  Resting alone isn’t recommended, because after you’ve finished resting, when you return to running, whatever the biomechanical factor was that triggered the achilles injury will still be unchanged and therefore the pain will return as before.

If you have pain when walking, then really you should seek treatment from an experienced physiotherapist now rather than delaying it.

Otherwise, we recommend that you reduce your running distance, frequency, speed and stick to running on a flat, soft (grass, bark or treadmill) surface. Stretch the two main calf muscles – gastroc and soleus twice daily, holding each stretch for 20 seconds and repeating each stretch 3 times (these stretches can easily be found on the internet).  You also need to see a physio or a podiatrist to have your foot and leg biomechanics assessed, to see if you need insoles or not and to ensure that your trainers are correct for your foot type.   Also, you must ensure that your trainers aren’t too tight, and aren’t rubbing at the back of your heel. You could try this regime for around 4 weeks and if the symptoms are still present, then you really need to seek professional help.  Leaving this problem untreated could invite a possible tendon tear to occur, which is bigger trouble!

As for the best treatment for achilles tendon injuries, we can’t include all this info in this answer because the treatment for this condition depends on which biomechanical issues triggered it in the first place, and these biomechanical factors are numerous.  Unfortunately, we can’t tell you the time frame either, because this depends on multiple factors….sorry!   What we can say, is that most achilles tendon injuries can be cleared 100 per cent with the correct treatment and the person can return to painfree running as before.  Feel free to call us if you need any help as we treat and beat achilles problems in runners every day of our working lives!

Question:   I have a hard lump the size of a small marble on the arch of my foot, which looks very like photos I’ve seen of plantar fibroma, (hopefully my GP will give me an official diagnosis next week). It isn’t painful at the moment. If it is a fibroma, is there anything physio can do to help it? I already wear orthoses for over pronation of my feet.

Answer:    From the information you’ve given us, it may certainly be a plantar fibroma but our advice would be to go to your GP and get him to organise an ultrasound scan of it, as you can’t be sure from clinical examination alone, so a scan is needed to be 100 per cent sure.

Unfortunately, physiotherapy treatment has no place in the management of plantar fibromas but most importantly we believe that you should have an ultrasound scan to make sure the proper diagnoses is achieved, and that there is nothing more serious in its pathology.  Following a scan, it can then be managed by medical intervention.