Q & A from Injury Clinic on Thursday 3rd September 2015:

Question:  For the last 2 weeks the inside of my right shin has been giving me problems. It is a dull ache and I am able to run on, but it is frustrating. Any advice would be appreciated.
Answer:  Thanks for your enquiry.  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 painfree. There are a few different causes of shin pain and they are mostly treated differently. 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, and this article gives you great information on the different causes of shin pain.  The most unlikely cause of shin pain in runners is a stress fracture.  This would tend to present as a sharp pain rather than the dull ache which you describe.  Other causes include- tenoperiostitis (inflammation of a muscle attaching into the shin bone), a nerve dysfunction of the nerve running through the front of the shin and less likely again would be compartment syndrome.
If your shin pain continues for more than a couple of weeks it should definitely be assessed by an experienced physio, as if it’s poorly managed it could continue for months and even years.  I would advise you to run on flat surfaces and try sticking to grass, bark or the treadmill if possible.  If correctly treated, in 95-98% of cases it should be able to be fully resolved and the person should return to painfree running (maybe with a few softer surfaces thrown into your running training regime in the future).  Feel free to give us a shout!
Question:  I’ve been plagued with plantar fasciitis since running the Belfast marathon in May.  I’ve managed a few runs since then but every time I think it’s on the mend it seems to flare up again. What advice would you give me for relief from this? I’ve been stretching and massaging etc but am struggling to get rid of it completely.
Answer:  As you know, plantarfasciitis, is irritation of the connective tissues on the sole of the foot which causes pain.  Typically, symptoms are felt at the bottom of the heel and sometimes in the arch and are usually worse for the first few steps of walking in the morning.  In the case of a true plantarfasciitis, we would recommend the following conservative treatment-
1. Rest – No running or prolonged walking for a few weeks.
2. Stretch – Stretch your calf muscles and sole of your foot 3 times each, twice daily, holding each stretch for 20secs.
3. Wear supportive footwear.  Make sure you are in supportive shoes all the time and never barefoot or in flipflops.
4. Massage – deep soft tissue massage in the arch of the foot, ideally by an experienced physio and by yourself by rolling a golf ball along the foot for a few minutes twice daily.
From the information you have given us, it sounds as though you have already tried some of the above recommendations. The fact that you are unable to completely clear your symptoms and that it continues to flare up indicates that you need to get a thorough assessment in order to provide you with a tailored treatment plan, and to establish the reason as to why you have plantarfasciitis.  A biomechanical (the way your body moves) assessment may need to be done from your lower back downwards.   In our experience in Apex Clinic, nearly all sole of the foot pain, even if it’s longstanding can be cleared with the correct treatment regime and the person should be able to return fully back to running.   Best wishes.
Question:  I have recently increased my mileage in preparation for my first marathon in Dublin in October 2015. My Achilles tendon has given me pain for 2 weeks. Following RICE guidelines and stretching/foam rolling and ibuprofen gel. I am noticing improvement. . However, I went back to running 10 days into the 2 weeks as the pain seemed to have gone and after 4 miles my achilles gave me sharp pain and I also had hip pain on the same side.  These pains have gone now over the last 48 hours and I have just started eccentric strengthening exercises today. I’m keen to return to training and would appreciate any feedback.
Answer:  Thank you for your enquiry.  We’re sorry to hear that your symptoms were exacerbated by your recent run, I’m sure this is frustrating as the marathon is fast approaching. It sounds as though to date you have been managing your Achilles pain exactly as we would recommend. However, the fact that you are now experiencing pain into your hip may indicate that there is something else which could be contributing to your achilles symptoms. It may actually be referred pain from an area in your lower back which can refer to both the hip region and the Achilles region.
As all of our physiotherapists are spinal and nerve pain specialists at Apex Clinic, treating these symptoms is our bread and butter.  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. a stiffening up of one or more levels of the spine, repetitive running; especially uphill, on hard surfaces and over long distances as in your case, will further load these stiff segments.  These stiff segments can then commonly refer into the buttock, hip, lower leg and/or down into the Achilles region. There are generally no effective self management techniques to clear these symptoms, so we therefore recommend a thorough physiotherapy assessment from a spinal specialist to identify the source of your problem and stop your symptoms progressing.  For now, the best advice is to reduce your mileage on land and keep to soft, flat surfaces e.g. grass, treadmill, bark or sand.  It would be great to introduce aquajogging in a pool that’s deep enough to maintain and build your running mileage at this stage.
Question:  I’ve had a bit of pain in the inside of my ankle recently. When I’ve warmed up, its fine but when it’s not in motion it can be quite painful, especially in the morning. Any advice would be greatly appreciated.
Answer:  If you haven’t had any trauma to your ankle ie. no known accidents or sprains, then from the information that you’ve given us, this pain may be due to poor nerve movement of the nerve which runs down that area of your ankle (the tibial nerve).
If this is the case, you need to see a physio who is experienced in treating nerve pain and will therefore know how to treat it. They would also need to assess your foot biomechanics to see if any insoles are required or not. There are no self-help strategies for this problem unfortunately, but the good news is, that if the pain is due to poor nerve movement, then in nearly all cases this pain can be cleared completely. As all of our physios here at Apex Clinic are experienced in treating running injuries, nerve pain and spinal problems we would be delighted to help you.
Question:  I completed a 100k race last week and in the last 15k I started to get a stiff overuse feeling in my left hip. Mostly when I lifted the leg (there was a lot of vertical in the race). With this sort of injury should I just rest totally, or are there exercises I should be doing? What about ice or heat?
Answer:  Thank you for your enquiry. It sounds as though the origin of your symptoms are similar to that of one of the above questions.  As you have said that your race contained a lot of vertical running, this loads certain segments of your spine and can cause nerve irritation at an area where the nerves supply the hip region.
If there is any dysfunction ie a tightening up in a segment of your spine, repetitive running especially uphill, on hard surfaces and over long distances will further aggravate these segments. Although we agree that currently you should take a rest from running in order to reduce your symptoms, this alone unfortunately won’t be enough to clear your symptoms once you return to running again, because the segment in your lower back from which your symptoms are coming from, hasn’t been mobilised or loosened by specialised physiotherapy treatment, so when you return to running the mechanics of your spine won’t have changed and the pain is very likely to be exactly as before.  Therefore, we recommend a thorough assessment from a physio who specialises in the spine and running to identify and treat the source of your problem and enable you to return to running under the guidance of your physiotherapist.  Goodluck.
Question:  I injured my knee during a half marathon back in June. It’s a lot better now but I still get the odd twinge especially if I go over 8 miles. I couldn’t run for about 2 weeks after I injured it and I tried to rest it and just applied deep heat lotion which helped.  When it’s at its worst now, it feels like a stiffness right down the outside of my leg from my knee to my ankle. I never got it looked at but I just worry because I occasionally get a twinge in the same place, and I’m doing my first marathon on 26th October and don’t want it to play up then. Have you any idea what I might have done to it and are there any specific exercises I could do to help it?
Answer:  Congratulations on your half marathon. From the information you have given us regarding the location and the features of the pain you are experiencing, it does not sound as though you have injured any ligaments or meniscus. The fact that the pain is exacerbated by running for more than 8 miles and radiates from the knee to the ankle may indicate that you have a nerve dysfunction or nerve pain. We would recommend that you get a physiotherapy assessment ASAP to establish a diagnosis for your pain so that you can return to training for your marathon pain free as it is a race against the clock now.  There are no home exercises to suggest which could help.  For the meantime I would recommend that you stick to cross-training or aqua jogging in order to keep your fitness up and avoid running on hard surfaces such as the road, as you may be continuing to irritate the problem.  Hope this helps.
Question:  What are the best strengthening and stretching exercises for hamstring trouble? I’ve had it on and off for the past while and when I run fast, all the hamstring niggles return.  I’m doing a lot of foam rolling currently.
Answer:  There are a few different causes for recurrent hamstring problems, each requiring a different treatment approach. If you have already tried general stretching and strengthening exercises, then it is likely that the source of your niggles are due to one of the following-
1. A build up of scar tissue in your hamstring muscle which will require deep soft tissue massage to clear.
2. Nerve pain from a lack of nerve movement in the back of your thigh. This is commonly caused by previous torn muscle fibres of the hamstrings attaching to neighbouring nerve tissue in the back of the thigh. This then reduces the ability of the nerve (the sciatic nerve) to normally slide and glide with movement. This is best known as altered neurodynamics. This injury is often worse when running down hill with a longer stride length or when running faster (as you have described).
3. Referred pain from the lumbar spine (lower back) which has already been mentioned a few times this evening – see above posts.
There are generally no self management strategies to clear these problems and only a thorough physiotherapy assessment to distinguish where the source of your pain is coming from, is required to clear your condition. As you describe the symptoms as recurring, sooner rather than later treatment is recommended.  Rebecca Nelson, who is the Director of Physiotherapy here at Apex Clinic, Belfast wrote an article on recurrent hamstring pain which you can read on the NI running website under the physio section, and you may find this interesting in view of your symptoms.