Q & A from Injury Clinic on Thursday 1st June 2017:


Question:   I develop pain on the outside of my left foot under my ankle when running. It clears an hour after a run. There’s no swelling, just a sharp pain as the foot hits the ground. Thanks for any help offered.

Answer:   From the information you’ve given us, this pain could be one of three things:

  • 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 one or more levels of the spine) the compression and repetitiveness of running, especially uphill, 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 foot, even when there’s no back pain.
  • Nerve pain from a lack of nerve movement, specifically the superficial peroneal nerve on the outside of your ankle. This is best known as altered neurodynamics and occurs where the normal side and slide of the nerve around the ankle with movement is no longer able to occur normally. This injury is often worse when running downhill with a longer stride length or when running faster.
  • A less likely cause, because you haven’t injured your ankle and no swelling or bruising is noted, is that it could be coming from your inferior tib/fib joint – sometimes you can get scar tissue here and this can cause pain. The way to clear this is joint mobilisations by an experienced physiotherapist.

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

Question:   I have been suffering from two injuries for the past 18 months. One is that my right leg and foot goes numb and painful when running. The second issue is that my left foot gets very painful after 3-4km and requires me to stop and rub the foot before starting again. These have been treated separately with no success. I am beginning to think they are both linked and coming from my back. What are your thoughts?




Answer:   Thank-you for your question. All the physios here at Apex Clinic specialise in the spine, nerve pain and sports injuries so we are delighted to give you advice on this. From the information you’ve given us, it is certainly extremely likely that the symptoms in both feet/legs that you’ve described are indeed linked.

The spine is a central structure, with nerves travelling out at each level to both legs and feet. It is very likely that a segment in your back is causing nerve irritation, resulting in numbness in your right leg and foot, and it’s the same segment which is causing the pain in your left foot.

The symptoms you’ve described are most likely coming from a disc injury, or leaky disc, where nerve irritation is occurring, with or without compression of the nerves.

At the moment, the best thing to do would be to do aqua jogging to maintain your running fitness and to avoid placing a high load through your spine, and see a physiotherapist who is experienced in treating spinal problems and nerve pain. We would be delighted to give you an opinion if you would like to phone us in the morning and we can sort out an appointment for you. Otherwise, there is no amount of treatment locally to your foot or leg that will clear these symptoms if they are indeed coming from your back.

If you continue running, the injured disc is likely to get more loaded and break down further causing a spread and worsening of all symptoms. Good luck and best wishes.

Question:   Over the last few months I have noticed a cracking/crunching noise in my knee when I’m kneeling on the ground. A friend said it may be loose cartilage. Do I need to get this checked out?

Answer:   The most common cause of a clicking and crunching when kneeling on the ground in the knee, is patellofemoral dysfunction (maltracking of the knee cap – this is when the knee cap isn’t quite moving up and down in the correct alignment, and therefore grates and crunches). One in four sports people will experience this in their lifetime.

This problem responds extremely well to a specific regime of physio treatment. It normally only takes a short course of treatment and is managed mostly with a combination of strong mobilisations of the knee cap and specific exercises. You should also have your footwear (trainers) assessed as well as your foot biomechanics, as this could be contributing to the problem.

To ignore your symptoms at this stage, may speed up the onset of arthritis on the undersurface of your knee cap. It may also be useful for you to have a read of an article on this (patellofemoral pain) written by our Director of Physiotherapy, Rebecca Nelson.  You can find this article on the NI Running website, under the physio section.

Question:   I experience pain in my lower legs, especially along the inner sides of my shine bone. A lump has developed here and it’s very tender. I have pain when I run and I also get extreme tightness in my lower legs and they feel tight and swollen, daily. I stretch after every run. I have been running two or three times a week and in between runs I use the cross trainer. My legs always feel stiff and heavy when running. I can’t seem to increase my runs to four times a week, as I get shin splints pretty quickly. I’ve been in a constant cycle of injury for about two years. As soon as one injury heals and I increase speed or run more frequently, I’m injured again. Any advice would be great!

Answer:   The good news is that virtually all shin pain can be cleared with the correct treatment and in nearly all cases, the person can return to running again pain-free. There are different causes of shin pain and they are mostly treated differently. Rebecca Nelson, who is our 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, and this article gives you great information on the different causes of shin pain. The least likely cause of your shin pain is a stress fracture.

From the information you’ve given us, the most likely cause of your shin symptoms is either:

  • Tenoperiostitis (inflammation of the tibialis posterior muscle attaching into the inside border of the shin bone) OR
  • Altered Neurodynamics of the deep peroneal nerve (nerve pain from the nerve running through the front of the leg alongside the shin bone).
  • Much less likely, compartment syndrome, (which is swelling of the muscles in a closed compartment).

Number two above, is the most likely for your symptoms, as your symptoms are on both sides and the nerves from the spine travel down both legs. Having local inflammation is a result of the nerve trunk leaking inflammatory chemicals and is in keeping with altered neurodynamics. If you have had failed treatment up until now, it is most likely that the correct diagnosis for your shin symptoms has not been established and addressed.

Shin pain which continues for more than 8 weeks should definitely be assessed ASAP by an experienced physio who treats a lot of running injuries, as if it’s wrongly managed it could continue indefinitely. This type of pain is usually worse with faster running versus slower, and downhill running. At the moment, we would advise only to run on softer surfaces, avoid running on hills, especially downhill, and to keep your stride length short in your training regime.

Unfortunately, this pain is very unlikely to clear with time or self management strategies, so feel free to give us a shout for a second opinion if needed.