Q & A from Injury Clinic on Thursday 5th October 2017:

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Question:    I have shin splints, but there seems to be so many different views on rest and returning from it. What would your advice be?

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 pain-free. There are a few different causes of shin pain and they are mostly treated differently. That’s why it is essential to get the correct diagnosis for your shin pain or it won’t respond to treatment.

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, Running Articles. This article gives you great information on the different causes of shin pain. Shin pain in runners could be due to a stress fracture. This would tend to present as a sharp pain more commonly than a dull ache. Other causes of shin pain include- tenoperiostitis (inflammation of the tibialis posterior muscle attaching into the shin bone), a nerve dysfunction of the nerve running through the front of the shin and less likely 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. To answer your question, with regards to rest and returning from it, it is very difficult to advise you on this because this advice depends on the exact cause of your shin pain.  If you don’t have a stress fracture, we would advise you to reduce your running mileage, run on flat surfaces only and try sticking to grass, bark or the treadmill if possible. If correctly treated, in 95-98% of cases shin pain can be fully resolved and the person can return to pain-free running again (maybe with a few softer surfaces thrown into their running training regime in the future). Feel free to give us a shout!

Question:   My right hamstring has been troubling me since the start of the summer. Recently, I decided to stop racing and reduced my mileage in the hope that this would help it get better. It still niggles me any time I try to inject any kind of pace into my run and even when I finish a slower run, it just aches! Any help would be appreciated.

Answer:   There are a few different causes for recurrent hamstring problems, each requiring a different treatment approach. If you have already tried slower runs and reducing your mileage, 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 it.

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 faster (as you have described).

3. 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 1 or more levels of the spine) the compression and repetitiveness of running, especially up hill, on hard surfaces and over long distances will further load these segments. This can lead to irritation of the nerves leaving the spine and this can refer pain into the back of the leg.

The most likely cause of your hamstring problem is Number 2, from the information that you’ve given us. There are generally no very effective 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 being present from the summer, sooner rather than later treatment is recommended!

For now, the best advice is to reduce your mileage as you’ve done, and to keep to soft, flat surfaces. You will find an article on Recurrent Hamstring Trouble on the NIRunning website, under the Physio section, which our Director of Physio, Rebecca Nelson wrote on this subject, which will give you further information.

Question:   I have a pain in my left Achilles. It feels ok when I run, but I feel a sharpish pain after I’ve rested it for a while when I go to walk again. It’s especially noticeable the next couple of mornings when getting out of bed. I read that heel drop exercises are good for this. Does this sound the best approach?

Answer:   Many thanks for your enquiry. At this stage, the best things that you should do are:

1. Try eccentric lowering exercises which you will get online and repeat these exercises twice daily, for 2 lots of 20 reps.

2. Reduce the frequency of your running.

3. Reduce your running mileage.

4. Avoid hill running.

5. Make sure your trainers are appropriate with good biomechanical support for your foot type (a specialist running shop will give you advice on this, or a podiatrist if necessary).

6. Avoid running on hard ground for approximately 4 weeks. Run on soft surfaces such as grass, bark or the treadmill and also when you’re not running, make sure you’re not walking any more that 20 minutes at a time.

7. Stretch your left Achilles twice daily, 3-4 times, holding each stretch for 20 seconds.

Follow this regime for 4-5 weeks. If your pain is still present you will need to seek help from a physiotherapist who is experienced in running injuries to get a specific diagnosis for your pain and a tailored treatment plan to treat it. Feel free to phone us for further advice if you need to.

Question:   While training for the Belfast half marathon this year I hurt my foot after my 12-mile training run, which resulted in me having to pull out. My foot had swelling on it, along the top and was painful around my ankle area. I took my miles up slowly, 10% at a time. I had an X-ray as the doctor thought it might be a stress fracture but nothing showed up. It’s now been 5 weeks since then. I tried training on Monday which has resulted in foot pain again. Is there anything you would suggest?

Answer:   Sorry to hear that you’ve developed this pain, and it should be cleared before it stops you running completely!

From the information that you’ve given us, your pain could be due to a number of different things.

  1. The most likely cause however would be due to overloading of the joints in your foot. With high load and pavement pounding, especially with uphill and downhill running, the joints in your foot can be overloaded and can get inflamed which then in turn causes 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 reduce your running mileage and keep the laces of your trainers quite loose, to reduce compression of the nerves in the top of your foot. There is more information on this particular type of 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?”

You should also slow your pace and run only on softer surfaces (ie grass, bark or the treadmill) and keep to the flat alone (ie no hills). If with this regime in 3-4 weeks’ time,  the pain has not gone completely then you would really need to seek help from a physio who’s experienced in running injuries to get a proper diagnosis for your pain and hence a tailored treatment plan to clear it. Best wishes.

Question:   I had a sudden onset of ITBS in August, having never suffered from this before (although I do have tight hamstrings/glutes). I took it easy for a few weeks and then tried to follow the general recovery methods I found online – finding the distance I could run without pain (4K) and stopping as soon as I felt anything. Things slightly improved and I was able to complete 5K of running. I then decided to take a full week off again in late September, hoping to give myself a bit more time to heal before starting to rebuild my mileage. Instead of getting better, things got worse. I was forced to abandon the next 5K at 3K and the pain was worse and lasted longer. I have no idea what to do now. Any advice would be gratefully received!

(If it matters, I do Pilates at least once per week, but I hadn’t been doing it due to the instructor’s summer break in the month before the pain hit.)

Answer:   From the information you have given us, the pain that you’ve described is unlikely to be originating from ITSB as it worsened following a rest period. The pain which you are experiencing is most likely to be originating from your lower back. Referred pain from your lower back is commonly referred to the outside of the thigh and the outside of the knee.

As our team of physios here at Apex Clinic, Belfast specialise in the spine, nerve problems and sports injuries, we are very familiar with referral patterns of pain which originates from the spine. It is likely that the pain you’re experiencing is due to a stiff segment or segments in your spine, at an area where the nerves travel out to the outside aspect of the thigh and knee. These symptoms would certainly be aggravated by running, are could certainly be no better and even worse following a rest period.

To treat this problem, unfortunately there are no self-help tips which we could advise to clear it. If you see a physiotherapist who is experienced in both running injuries and spinal problems, they will identify the specific stiff segment/s in your spine from where the pain is coming from, and will then mobilise this segment/s so that pain should then clear.

It’s very unlikely, unfortunately, that your symptoms will fully clear by themselves. The physiotherapist will also need to assess the biomechanics of your feet to see if insoles are needed and to ensure that you’re in the correct trainers for your foot type. With the correct treatment regime, the pain should clear and you should be able to return to running pain-free. In the meantime, you should reduce your running speed and distance and also keep to flat ground when running. It’s important to only run on soft surfaces at the moment, such as grass, bark or the treadmill if possible. Hope this helps.

Question:   I’ve got a bit of a niggle in my left knee. It’s not stopping me running but I’m conscious about not letting it get any worse. I get what I can only describe as a crunching noise when I go downstairs. I don’t seem to have the crunching sound at any other times. There is no pain, just an awful noise. I’ve been stretching my quads and hamstrings and foam rolling my glutes etc but it seems to be quite persistent. Any other advice or things I should be trying out?

Answer:   This is hard to diagnose accurately without assessing your knee fully, however it sounds very likely that it is due to patellofemoral dysfunction.

The most common cause of a clicking and crunching in the knee, especially when going downstairs as you have described is patellofemoral dysfunction (ie maltracking of the knee cap).  This is when the knee cap isn’t quite moving up and down in the correct alignment, and therefore it grates and crunches as it moves. One in four of the sporting population will experience this in their lifetime.

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 is 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.

An exercise which may help you at this stage, if you’re not keen to see a physio yet, is to do step downs, standing on your left leg.  Stand on this leg, on a step, such as your stairs, and slowly bend your knee such that your knee is moving over your 2nd toe, but always move short of the crunching occurring.  Only bend about ¼ of the way down and then come up again.  You can find this exercise online for a further explanation of it.  This exercise must be done with no pain and no crunching occurring, and twice daily, performing 2 or 3 sets of 20 reps each time.

To ignore your symptoms at this stage, may speed up the onset of pain at the front of your knee so take action now!  It may also be useful for you to have a read of an article on this, entitled Treat and Beat Runner’s Knee,  written by our Director of Physiotherapy, Rebecca Nelson on the NI Running Website, under the physio section, Running Articles for more information. If you’ve any further questions or need help,  feel free to give us a shout!