Q & A from Injury Clinic on Thursday 2nd March 2017:


Question:   My question is in relation to my left Achilles tendon. I developed pain on running a few months ago. I now have pain on walking. It is very localised. I can pin point the exact spot where the pain is greatest, beside the ankle bone, inner aspect. After circuit training involving pushing off with the foot, the Achilles is less sore but not totally pain free. How can I go about rectifying this problem?

Answer:   Your pain could be due to a number of different reasons:

  1. An overuse injury of the Achilles tendon, which used to be called Achilles tendinitis, but more recently has been renamed Achilles tendinopathy. This however, is less likely, because pain from Achilles tendinopathy tends to be very much localised within a few mm of the tendon itself, and it wouldn’t be that likely that the pain would be beside the ankle bone.
  2. An overuse injury of the medial (inner) ligament of the ankle: a gradual pain from this can occur from high training loads (particularly rapid changes of direction, uneven surfaces or inappropriate footwear) causing the ligament on the inside of the ankle to be overstretched and micro-tears could occur. Usually with this you will notice mild swelling around the area and there could be soreness when walking and on certain ankle movements.
  3. Nerve pain from a lack of nerve movement, specifically of the tibial nerve on the inside of your ankle. This is best known are 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 and therefore pain occurs.

At the moment, self-management should consist of regular stretching of the gastroc and soleus muscles. Appropriate stretches for these calf muscles may be found online. Remember that stretches need to be held for at least 20 seconds and repeated three times, twice daily. You could also consider if simple over the counter insoles are needed if you have high arches or are flat footed to improve your foot biomechanics and/or shock absorption of your feet. Ensure your trainers aren’t too tight or old, and aren’t rubbing at the back/inside of your ankle and heel.  You should also significantly reduce or stop running at this time, until the pain is significantly better or has cleared completely.  We recommend that you try this regime for a few weeks and if the symptoms don’t ease, then it’s definitely time to seek physiotherapy treatment with a physiotherapist who is specialised in treating running injuries.  With each of the 3 possibilities of the diagnosis for your pain, the physiotherapy treatment of each of them is different and the management advice which goes with the treatment is also different.  Unfortunately, there are no other self-help strategies that we can recommend.  Feel free to give us a shout if needed.

Question:   After enjoying many years of competitive sport (water sports, football etc), I took up running. I am getting bad front of the knee pain during, but especially after running. Last week, I was barely able to walk the day after a longer run. Any advice would be great.

Answer:  This is hard to diagnose accurately without assessing your knee fully in person, however it could most likely be due to one of three things:

  1. Firstly, it could be patellar tendinitis or patellar tendinopathy as it’s more recently been called. This is an injury of the tendon connecting your knee cap (patella) to your shin bone. It’s an overuse injury and is very common in runners. It is the result of your patella tendon being overstressed. With this injury, it is important to have your foot biomechanics and running shoes assessed, as you may need orthoses (insoles) to help improve your foot biomechanics, which in term will help to unload the patella tendon. The reason as to why patellar tendinitis occurred would need to be established and then addressed, as well as a progressive treatment plan started to clear the pain.
  2. Another more common injury in runners which could be causing your pain, could be patellofemoral pain. This is caused by a tightness of the structures on the outside of the knee along with weakness of the muscle on the inside of the knee, which doesn’t allow the knee cap to glide or move smoothly. This can be caused by an increased running mileage, increased hill work or generally overloading the area.
  3. Thirdly, due to the fact that your pain is worse after running, it may suggest a low level of nerve irritation coming from your lower back. This would cause an irritation of the nerves travelling to your knee. If this is the case, it is identified by an experienced physiotherapist finding the appropriate stiff segment of your spine and manually mobilising or loosening it, which will reduce and stop the nerve irritation of the nerves travelling to your knee.In each of these cases, you need to reduce your running mileage and keep to the flat and softer ground (grass, bark or treadmill) until you have the problem assessed and properly treated. We see all of these problems on a regular basis at Apex Clinic and the pain can be cleared in nearly all cases with the correct treatment and rehab programme.

Question:    I badly strained a calf last October 2016.  I had one physio appointment and then recovered gradually. I ran painfree until January 2017, when the same calf went again. I have been getting dry needling from a physio for 5 weeks now and making little progress. Can you advise me regarding dry needling versus deep tissue massage for my calf strain?

Answer:  From the information you’ve given us, in our professional opinion we do not feel that dry needling would be the best course of treatment to clear your pain.
We do not believe that dry needling would get to the root or cause of your problem because it is likely that you have a mechanical problem, that will not be cleared, until the mechanics of your problem are treated and improved. Any other treatment which does not improve the mechanics of your problem is unlikely to help you.

The most likely cause of your pain is one of two things:

  1. A build up of scar tissue within the calf muscle that needs to be broken down using a number of manual deep soft tissue techniques with the calf muscle positioned in a gradually more stretched position during each treatment. This should clear or significantly reduce the scar tissue build up nicely.
  2. Nerve pain from the nerve that runs through the calf muscle (ie the tibial nerve). This is called altered neurodynamics or poor nerve movement. In your case, this can occur when there are torn muscle fibres within the calf muscle itself, which then heal but in the healing process there are tiny bits of scar tissue within the calf muscle which also get attached to the neighbouring nerve passing by this area. When this nerve has to move during running, this lack of nerve movement can then cause pain. This is treated very specifically by repeated movements of the leg performed by a specialist physiotherapist in a way which restores normal nerve movement of the nerve which is involved, to stretch or break this scar tissue. With this particular problem, it is usually worse with downhill running or downhill walking or during faster runs.

Unfortunately, with both of these scenarios there are no self-help strategies which we could recommend to help you. We really recommend that you seek physiotherapy treatment from a physio who is experienced in treating the above 2 scenarios.  Feel free to ask us for help if you need to, as we treat your problem here at Apex Clinic on a regular basis.