Q & A from Injury Clinic on Thursday 5th March 2015:

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Question:  I’ve just had a cortisone injection on a bulging disc which was touching a nerve and causing bad leg pain. The injection seems to have worked.  What exercises should I do next? I’ve started swimming and cycling. Should I try yoga next week?

Answer:  A lumbar steroid injection works by delivering a potent anti-inflammatory agent (corticosteroid) directly to the site of the injury/pathology in the spine which is causing the pain and discomfort. It is used in order to reduce the inflammation in that region. In addition to relieving pain, the process of natural healing can occur more quickly once the inflammation has reduced.  It is important to realise that a steroid injection should not be considered a cure for back and/or leg pain, rather, the goal is to help patients get enough pain relief in order to progress with a rehabilitation programme.

We recommend that for 3 weeks after the injection you only perform low load exercises, ie exercises that will not put much impact through your lower back, this may be walking, swimming, cycling, x-training.  From weeks 3-6, if you remain pain-free, you may gradually increase the load through your lower back by alternating short periods of running with walking and gradually building it up. During this time continue with the unloaded exercise also.  If your condition remains improved from your injection, during 6-12 weeks post injection then you may gradually build up running to your previous level.  It is important that you do not run too soon as overloading your lower back will increase the inflammatory response which will counteract the response of the injection.  Please let us know if we can offer any further advice.

Question:  Hi. I feel pain when I press near my shin on the inside of my leg and also when I try to run. Not the actual shin bone but right beside it. Any ideas? It eases after a rest day or two but keeps coming back.

Answer:  Really, you need a thorough physiotherapy assessment to get to the root of your problem and establish a correct diagnosis for your pain. This will include an assessment of your foot biomechanics to see if any insoles are needed or not.  Virtually all shin pain can be cleared with the correct treatment and in nearly all cases, the person can return to running pain free. There are many causes of shin pain and each is treated differently:

1. A stress fracture – which can be diagnosed with an x-ray or bone scan (organised through your GP).

2. Tenoperiostitis (inflammation of a muscle attaching into the shin bone).

3. Nerve pain of the nerve running through the front of the leg alongside the shin bone.

4. Much less likely, compartment syndrome.

Rebecca Nelson, Director of Physio at Apex Clinic has written an article on shin pain, which you can read on the NiRunning website under the physio section, and it will give you more information behind the different causes of shin pain. Shin pain which continues for more than a few weeks should definitely be assessed by an experienced physio who treats a lot of running injuries; as if it’s wrongly managed it can continue for months and even years!  If correctly treated it should be able to be cleared and you should be able to return to running pain free.  If you are determined to continue running, in the meantime we recommend you stick with shorter runs on the flat and consider softer surfaces such as sand, grass, bark and treadmill. Make sure you have a decent pair of trainers also.  Good luck!

Question:  For the last 6-8 months I have been getting a pain on the outside of my right knee. This is straight across from the middle of my kneecap and the pain is usually a dull ache and after a long run it gets very stiff, to a point where I can hardly straighten my leg without being in agony.

Answer:  From what you have described the likelihood is that your problem is coming from the cartilage inside your knee. The role of the cartilage in the knee is to help absorb shock through the joint and reduce friction on the joint surfaces.  Researchers estimate that running increases the load through the knees by up to 5.5 times versus walking. When the cartilage has been injured this can cause pain and stiffness around the joint lines which will increase during and after running. It is important that your knee is assessed by an experienced physiotherapist in order to determine the extent of your injury.  If there is a concern that the extent of injury is marked, the physio could then refer you for an MRI scan of your knee.  This problem is often treated successfully with conservative physio treatment alone whereby the physio will manually work on your knee and guide you through an appropriate rehabilitation programme.

In the meantime, we recommend that you reduce your running as without an assessment of your knee you will potentially worsen your condition causing a possible deterioration of your joint surfaces.  Generally we advise that any injury which has not resolved within 3 weeks warrants a professional opinion.  Since your condition has been present now for 6-8 months it is unlikely to resolve by itself, unfortunately.

Question:  I have a stress fracture in my right foot.  Is there a faster healing process or is it just going to take a lot of time to heal? I haven’t rnn in about 4/5 weeks as it is still sore but my stress levels are building!

Answer:  We do not recommend that you attempt to run at all at this stage, as you will jeopardise the healing process! This is due to the transmission of forces coming upwards from the impact of running. This type of force, if introduced too early, can cause malunion of the bone and definitely lead to further problems down the line.  The general healing time frame for a stress fracture in the foot is 6-8 weeks and so we do not recommend you run until 8-10 weeks post stress fracture at the earliest. I’m afraid you are going to have to be patient with this one! Some orthopaedic consultants recommend taking calcium supplements as a way to help the strength of the healing bone but not as a way of speeding up the healing.

In the meantime, you can do low load exercise which includes swimming, aquajogging, cycling and x-training as these will help maintain your fitness and get you back to your previous level of running fitness faster.  Consider having a podiatric biomechanical assessment of your feet to make sure that your foot mechanics have not been one of the contributing causes of this stress fracture. This may help reduce the likelihood of a stress fracture in the future. Our podiatrist is very experienced in treating runners.

Question:  I did the English National one week ago.  Three days later I developed a severe pain on my right side, just above my bum.  I am currently using thermacare heat pads for 10 hours a day to help with the pain.  Please help!

Answer:  The pain you describe in your upper buttock area is most likely to be referred from your lower back and is a very common problem we treat in the clinic (as we specialise in the spine and sports injuries, this is our bread and butter at Apex Clinic!).  Our spine is made up of vertebrae (bones) with a spongy disc in between them creating a space which allows for shock absorption through the spine while we run or walk. If there is any dysfunction ie a tightening in a segment of the spine, repetitive running especially uphill, on hard surfaces and over long distances will further aggravate these segments. This usually results in pain in the lower back and often into the buttock area.  There generally are no effective self management techniques to clear these symptoms so we would therefore recommend a thorough assessment from a physio who specialises in the spine to identify and treat the source of your problem.

It is an extremely common but debilitating problem and should be cleared fairly quickly with treatment. For now, the best advice is not to run but to try to keep yourself mobile by reducing periods of sitting to 20-30 mins maximum and taking regular gentle walks on the flat.  Feel free to get in touch so we can get you back on the road again!

Question:  Since starting training for the Belfast Marathon, I have tried different drinks/fluids but I always seem to get a stitch. I have also tried to alter the length of time before the run that I drink and tried not to gulp when drinking during the run. Do you know how I can stop the stitch? At the weekend, it reduced me to a walk as every time I tried to breath in it was very sore.

Answer:  Few things are worse than getting a stitch during a run. Here are a few ways to help prevent the problem:

1. Eat carefully before running. Foods that are higher in fat and fibre take longer to digest so if you eat them within one to two hours before a run, they can increase the likelihood of a stitch. Eat lightly and give yourself plenty of time to digest.

2. Warm-up properly. This is probably the most common reason why people get stitches as their bodies are not prepared for the sudden exertion. Walk briskly for 5 minutes then gradually work into an easy run.

3. Regulate your breathing. Runners can benefit from matching their breathing to their strides ie inhaling for two to four strides and exhaling for the same.

4. Slow down and exhale to release the stitch. If you still get another side stitch, slow your pace and breathe deeply. Some people find raising their hand above their head helps (by increasing their lung expansion).

Hope this helps and all the best for your marathon training!

Question:  I have been in and out of running over the past year initially due to increasing my mileage too soon.  It started off with a calf strain.  I did the RICE regime, took weeks out and then started back running gradually after a few weeks. I then did a bit of hill work and my achilles became very sore so I went back to physio again and did resting and strengthening etc.  I took over 3 months off and then started slowly back again. I ran the Parkrun 5 weeks ago and my achilles pain came back even though I slowly increased my speed. There was no calf pain and my calves seemed fine but I now have a constant ache in my achilles every step, even when running really slowly.

I am trying to run with the ache as it’s not a pain and I’m thinking about increasing the miles gradually and not increasing my speed for a while. I had my gait analysis checked and it’s fine. I’m not sure what I should be trying.  I can spin and do cardio classes, but anytime I run I have what can only be described as similar to a toothache in my achilles the whole duration.  Any advice would be appreciated.

Answer:  It certainly sounds as if you have a reoccurring calf and achilles problem. The real question is, “What is causing these areas to keep giving you pain even after conservative management and rest?” It is likely that one factor or more have been missed from your rehabilitation regime to date. Unless you are returning to running too quickly, the likelihood is that you may have altered neural mechanics (a problem with the mobility of your Tibial nerve travelling down the back of the calf and achilles) which is causing the toothache/ nerve type pain in your lower leg. In order to resolve this condition fully an assessment and treatment of the nerve mobility is required by a physio who is experienced in this type of treatment.  (There are no self management strategies for this, unfortunately).

This is a very common problem we see in runners in Apex Clinic. It usually starts from a previous muscle strain where scar tissue has built up and is consequently irritating the nerve beside it.  In the meantime, we suggest that you do not try to progress your running, keep to the level you are comfortable with at the moment which is not giving you as much discomfort.  It is also important that you run on the flat so as not to irritate the nerve further.

Feel free to get in touch and one of our specialist physiotherapists will be happy to help you clear your calf and achilles pain in the longterm.