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

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Question:   I have hip misalignment, which is giving me occasional left sided sciatic pain, especially when I am racing or doing the x trainer. One hip appears to sit higher than the other giving the illusion that one leg is longer than the other. What is the best advice in this situation?

Answer:   From what you have described your leg length discrepancy could be due to one of two things:

  1. A true leg length discrepancy – which is measured in a lying down position. If this is the case you may need a slight heel raise in your shoe on the affected side to level the pelvis. This type of leg length discrepancy never changes day to day.
  2. An apparent leg length discrepancy – which is due to muscle spasm resulting from irritation of the nerve tissue in your back. This is a reflex which protects sensitive nerve tissue which is coming from your spine. If this is the case, it is important that the affected segment in your spine is identified by an experienced physio, and then mobilized or loosened to reduce the nerve irritation and hence the resulting muscle spasm. This type of leg length discrepancy is totally clearable, with the correct treatment.

We would advise at this stage, that you seek a thorough physiotherapy assessment from a physiotherapist experienced in treating spinal problems in runners, to identify the type of leg length discrepancy which you have and then get it corrected. Hope this helps and feel free to give us a shout if you need any help.

Question:   After having crawled round the Dublin Marathon at the weekend I have pain in the top of my foot when I walk. My calves and knee are also sore but I expected this. The pain on the top of the foot is a new one for me. Do you have any ideas on what could be causing this?

Answer:   Firstly, congratulations on completing the Dublin marathon, a fantastic achievement!  With regards to this pain, it is hard to say without a thorough physiotherapy assessment.   However, we would firstly suggest an x-ray to rule out a stress fracture. Stress fractures are reasonably common in runners and are caused by overuse and repetitive loading on hard ground. If there is no stress fracture found, from the information you’ve given us, the pain on the top of your foot could be due to 2 main things-

  1. The most likely cause is due to overloading of the joints in your foot. With high load and pavement pounding, especially after the marathon, the joints in your foot can be overloaded and can get inflamed which then in turn will cause pain. This is an overuse injury of the foot.
  2. Poor movement of the nerves in the top of your foot. This is often triggered by a tight shoe or shoe laces which are tied too tightly, or alternatively, faster or longer runs can also trigger this pain.

From the information that you’ve given, we can’t tell which of the 2 causes of pain you are likely to have.  At this stage, we recommend that you stop running until you can walk good distances with no pain, and reduce your walking mileage where possible.  Also, at the moment, wear shoes which are loose, and not compressing the top of your foot.   Your foot must be unloaded as much as possible to aid recovery.

There is more information on top of the foot pain in one of the articles written by our Director of Physiotherapy, Rebecca Nelson, which you can find on the NI running website, under the Physio section, called: ‘Laces too tight? Or, is there another reason for pain on the top of your foot?”

If after 2-4 weeks of relative rest the pain in your foot hasn’t cleared, or is still present when you try to resume running, then you really need to see a physio who’s experienced in running injuries and nerve pain, to get a proper diagnosis for your pain and then undergo a tailored treatment plan to clear it. Best wishes.

Question:   I have been having issues with my lower leg/ankle for the last couple of months. A cramp or stiffness kicks in on both legs at about 2km into my run, which goes away within 30 seconds or so if I stop, but it will come back as soon as I start running again. If I persevere, it will finally go away at about 5 or 6km in. It feels like compression or tightness in the lower leg. It’s not really painful but very uncomfortable and it doesn’t happen on every run.

Answer:   From the information provided, the cramping and stiffness which you have described could be due to a number of different things:

1) Referred symptoms of cramping/ stiffness from your lower back. This could be coming from the joints or discs in the lower back which leak inflammatory chemicals and thereby irritate the nerves as they leave your spine and travel to your lower legs. This can cause intermittent symptoms and would account for why you feel your symptoms in both legs, as the spine is a central structure, and one problem in your spine can cause symptoms in both of your legs. This is the most likely cause of your cramps/ stiffness.

2) Nerve irritation of the nerves running downwards in the area that you have described in your lower legs (the tibial nerve and the deep and superficial peroneal nerves). This can occur if you have previously torn some muscle fibres in the area where the nerves are passing by, and scar tissue has formed which has irritated the nerves as they pass through.

It’s really important to find the correct diagnosis for the pain. In each of the above 2 cases, the physiotherapy treatment is completely different:

For number 1) manual mobilisation of the affected segment of the lower back is needed to loosen the stiffened segment and stop the referred symptoms.

For scenario 2) specific movements of the nerve tissue are needed to be done by a physiotherapist who is experienced in treating nerve pain, to restore free movement of the nerve tissue again.

Unfortunately, there are no self-help strategies which we can suggest to help you.

All of our physios here at Apex Clinic are highly trained in treating spinal pain, nerve pain and sports injuries, so feel free to give us a shout if needed!

Question:   I have had knee pain that has stopped me from running altogether for a few weeks. This was diagnosed as pes anserine tendonitis. With orthoses I’m able to run again, having just completed the Dublin Marathon, but I always have discomfort in the area below the knee cap now when running. This is worse when I’ve just stopped after a long run and I feel it even after 3 to 4 rest days if I try a one leg lunge. Any advice?

Answer:   Congratulations from all of us at Apex Clinic on a great achievement!

From the information that you’ve given us, the most likely cause of your pain is patellar tendinitis, which is an injury of the patella tendon which connects your knee cap (patella) to your shin bone. It’s an overuse injury and is one of the most common running injuries. It is the result of your patella tendon being overstressed or over loaded.

Often it can result from the following-

  • Poor foot biomechanics, which is unlikely in your case as you have orthoses already.
  • A change in your training routine, such as increased mileage or more sprinting.
  • Not enough rest days in your training routine.
  • Kneeling on your knees which can aggravate the patella tendon.

Unfortunately, patella tendinitis doesn’t usually get better on its own.

You really need to seek physio treatment for it, from a physio who’s experienced in running injuries.

It may be helpful for you to read about the treatment of it in an article written by our Director of Physiotherapy, Rebecca Nelson, on the NI Running website, under the physio section, under Running Articles.  This article is entitled, Is patella tendinitis getting the better of you?

Your foot biomechanics would need to be reassessed along with an assessment of your running shoes to ensure that they are correct for your orthoses. The reason as to why the patella tendinitis occurred in the first place would also need to be established and then addressed, as well as progressive treatment implemented to clear the pain.

At the moment, you should stop running and consider aquajogging, to maintain your running fitness until you get the pain treated and cleared.   We see this injury on a regular basis at Apex Clinic and in the vast majority of cases, the pain can be cleared completely with the correct treatment regime. Good luck!

Question:   8 weeks into my London Marathon schedule, I had to stop running due to problems and pain with my glute, hip and inner groin area. For several months I have visited physios, had MRI scans and a cortisone injection into my SI joint. I have followed a S+C plan to try and strengthen the area but every time I try and run, within two miles I have to stop with the pain. Any advice?

Answer:   From the information that you’ve given us, the pain that you’ve described is unlikely to be originating from your hip. It is most likely that the pain in your glute, hip and inner groin region is referred pain from your lower back. As our team of physios here at Apex Clinic are very specialised in the spine, nerve pain and sports injuries, we are very familiar with the referral patterns coming from the spine i.e. exactly where in the spine we would expect your set of symptoms to be coming from.  It is a very specific area of your spine which could cause your set of symptoms.

It is very likely that you have a stiff segment or segments in your spine, which is causing the disc or facet joint to leak inflammatory chemicals, which in turn annoy the nerve tissue in the area and then this refers pain to the regions that you have described.  An MRI scan of your back often won’t show this up, as inflammatory changes aren’t shown up well on an MRI scan, whereas disc prolapses are detailed well on a scan.

The fact that your pain has been there for months already, suggests to us that you really should have a full physiotherapy reassessment of your condition from a physiotherapist who is specialised in the spine and nerve pain.  It’s very likely that your problems can be cleared by mobilisation of the area of your spine from where the symptoms are originating from, followed by a gentle strengthening program once the pain has cleared.  Feel free to call us for help or guidance if needed.

Question:   I’ve had problems running.  For as long as I can remember my knees get extremely sore the next day and I can barely move, no matter how many times I go running along the Portstewart Strand. I always get so red faced when people see me limping about my caravan the next day. Any suggestions?

Answer:   Many thanks for your enquiry. From the information you’ve given us your pain could be due to a number of thing:

  • Biomechanical overloading of your knee joints. If you have poor foot biomechanics or poor biomechanics of your legs and hips, this can cause overloading of your knees, which in turn can cause generalised pain which can sometimes be quite severe.  To establish if this is the problem, you would need to have a biomechanical assessment of your feet and legs by an experienced physio or a podiatrist and they will determine if you need insoles and / or a change in your running trainers to improve your biomechanics.  If this is the case, with correction of your biomechanics followed by a few gentle strengthening exercises, you should do very well and the pain after running should clear.
  • Patellofemoral dysfunction in both knees.

This is when the knee cap isn’t quite moving up and down in the correct alignment, and therefore it moves up and down out of alignment which causes pain. One in four of the sporting population will experience this in their lifetime.

The good news is that this problem responds extremely well to a specific regime of physio treatment and specific exercises. It normally only takes a short course of treatment to clear it and it’s managed mostly with a combination of strong stretches of the knee cap inwards and home exercises to strengthen the muscle which pulls your knee cap inwards. You should also have your footwear (trainers) assessed as well as your foot biomechanics, as this could be contributing to the problem if you need better trainers or insoles.

Because your pain sounds quite severe the day after running, really we would definitely recommend a proper assessment of your condition by a physio who’s experienced in treating running injuries, followed by a tailored treatment plan to clear the pain.  It’s very unlikely that any self-help strategies will help you in this case, but it is likely that the pain can be cleared.  So, don’t give up on running just yet!

Question:   I’ve had pain on the outside of my right foot for the past 12 weeks, which seems to run along the peroneal longus and around the cuboid and up the back of the lower leg. My calf is very tight too. An x-ray showed no damage to the bone. I think I may have gone over on it on ramps when doing speed work in August.

A podiatrist has tried a heel lift in the left shoe and insoles for more support. Any advice on what I should do please

Answer:   We see a lot of foot problems in runners at Apex Clinic. If you’ve had an x-ray and ruled out a stress fracture or damage to the bone, then from the information that you’ve given us, it sounds as though your symptoms may be due to a lack of nerve movement (called altered neurodynamics) of the nerve, the superficial peroneal nerve that passes through the outside of the ankle in the area that you’ve described. This often occurs after a microtrauma, in which the muscles in the area were tugged, and scar tissue formed within the muscle itself.  This scar tissue can then hinder or impede the normal smooth movement on the nerve tissue in that area.  This in turn causes pain.

Unfortunately, however there are no really effective self-management strategies to clear this problem and a thorough physiotherapy assessment is essential to confirm or disprove the above diagnosis.  If it is altered neurodynamics as mentioned above, it can nearly always be cleared with the correct treatment regime to restore normal, free movement to the nerve tissue along with a few, gentle home exercises.  Feel free to contact us if needed.

Question:   I have IT band issues. Should I use a foam roller or not? I’ve seen a few different suggestions about this. Also, should I keep running when suffering from this?

Answer:  Here at Apex Clinic we believe that foam rollers should be used sparingly in general for all areas of the body.  The sports medicine literature is very controversial about them, as to whether they help or not.  As such, to date there is no conclusive evidence of the benefits of foam rolling, especially beyond the short term.

For IT band issues, it is our belief here at Apex Clinic, from years of experience of treating running injuries, that foam rollers should not be used with IT band issues.  The reason for this is that foam rolling doesn’t address the underlying issues and doesn’t appear to give any long lasting results.  The other reason we feel that it shouldn’t be used with IT band issues is that often, prolonged or repeated foam rolling can aggravate the local nerve tissue in the outer aspect of the thigh, such that over time, the foam rolling can slowly and slowly sensitize the local area and actually aggravate the pain from about 24-48 hours after foam rolling.

To answer your second question, in the early stages of suffering with IT band issues your running distance should be reduced or modified, but if you have been suffering with IT band issues for longer than 3 months, then we recommend for you to temporarily stop running during the course of physiotherapy treatment and then gradually do a phased return to running after the course of physio treatment has been completed.

For more information on IT band issues, you may find it helpful to read an article which our Director of Physiotherapy, Rebecca Nelson wrote, which is on the NI Running website, under the Physio section, under Running Articles.  This article is entitled, ITB Friction Syndrome in Runners.

Question:   I’ve been running with sciatic pain for the last month or so. I’ve done all the stretches but it still hurts. After running the Bobby Rea last Saturday, I ran on Sunday and I felt like both my glutes were on fire.

Answer:   From the information that you’ve given us, it sounds most likely that your sciatic pain and the feeling that both of your glutes were on fire, are both referred symptoms from your lower back region.  A “burning” pain, is an extremely common adjective used to describe nerve pain.  It is very likely that you have a stiff segment or segments in your lower back, which is causing the joints or disc in the area to become inflamed, and thus irritate the nerves in that area, which in turn will refer the burning and sciatic pain to your glutes and leg.

This is a very common problem in runners, particularly in those who do hill work.

Specific stretches will not help this problem in the longterm unfortunately, and there are no specific self-management techniques which could help significantly.  We recommend for you to see a physio who’s experienced in treating running injuries and they will identify the stiff segment/s in your lower back from where the nerve irritation is originating from.  These stiff segments will need to be mobilised or loosened to stop the nerve irritation occuring and then you’ll be given a few gentle home exercises to strengthen, once the pain and burning has stopped.  The correct physio treatment and management is extremely likely to clear all of your symptoms.

In the meantime, you should reduce your running mileage and speed, and only run on flat, soft surfaces such as grass, bark or the treadmill.

Here, at Apex Clinic we specialise in spinal problems, nerve pain and sports injuries so feel free to call us if you need any help.