Q & A from Injury Clinic on Thursday 5th September 2013:


Question:  I have recently started running, only 2-3 miles and slow… but I am getting a pain on the side of my right knee.  I spoke to a friend and they originally thought it was ITB issues, but because whenever you push the painful area it doesn’t make it worse, they ruled this out.  Any idea what it could be? I have had my gait analysed and new shoes etc.

Apex Physio Belfast Clinic:  It sounds like, from the description of your pain, there are 2 likely causes.  It may be the beginning of a change in your joint surfaces (wear and tear or meniscus) an x-ray of your knee (via your GP) is an easy way to assess this.  Secondary your symptoms may be referred pain coming from your lower back due to the impact on your spine from running.  For treatment a thorough assessment of your condition from a specialist physiotherapist would be recommended to get to the root cause of your problem and allow you to continue to exercise!

Question:  I have been waking up in the middle of the night with cramp in my foot and toes. This occurs on nights where I have completed either a long run or a hard training session. Are these cramps happening because of sore muscles?

Apex Physio Belfast Clinic:  There are a few things that could be causing your night cramps.  Firstly, as your symptoms are related to a post-run make sure you are well hydrated, including isotonic drinks, not just water as there may be an imbalance in your sodium levels.  We have also treated these symptoms with physiotherapy focusing on manual therapy to the spine to increase the flexibility of your neural tissue.  As the nerve that travels down the back of the leg may be getting irritated during the run and causing a cramp-like feeling in your feet. If this is the case we recommend you try and sleep on your side with a pillow between the legs to stop your spine twisting during the night. We are sorry not to be any more help than this, if the above tips do not help please do not hesitate to contact us. Good luck!

Question:  I have occasionally had tight gluts that required needling etc probably due to overtraining or being inflexible, is it possible that my foot on the relevant side could be over-pronating whilst my gluts are tight. If so could I be misdiagnosed as being an overpronator and possibly be running in the wrong shoe type when fit again?

Apex Physio Belfast Clinic:  We are not clear from your message whether you have had your feet assessed by a specialist podiatrist, if not this would be advised in order to properly diagnose your foot-type.  In our opinion tight gluts will not have an effect on your foot biomechanics and vice-versa.  Due to the reoccurring nature of your glut problem we wonder has it been thoroughly assessed?

Question:  I often suffer lower back pain after a longer run. It becomes achey and stiff and makes standing or sitting uncomfortable.  I have good flexibility and warm up/down well.

Apex Physio Belfast Clinic:  As all our physios are Spinal Specialists at Apex Clinic, this is our bread and butter! Our spine is made up of vertebrae bones with a spongy-disc in-between, creating a space which allows for shock absorption through the spine when we run.  If there is any dysfunction, ie a tightening in a level of the spine, repetitive running especially uphill and on hard surfaces causes this area to become aggravated. This usually results in a dull ache in the lower back and associated stiffness.  An indication of this problem are these symptoms occurring after exercise.  We recommend a thorough physiotherapy assessment from a spinal specialist to identify your problem and to stop your symptoms progressing.  For now the best advice is to reduce your mileage, keep to soft surfaces and flat roads. Thanks for your question.

Question:  I’ve started training again after spraining my ankle just over 3 weeks ago. I’ve been back on the roads gradually with no ill effect.  I am however, apprehensive about going off road again.  What is your advice regarding strapping/ankle supports etc? Worth trying or just go without them and take it easy?

Apex Physio Belfast Clinic:  Firstly, you are doing really well running back on the roads in 3 weeks. In our professional opinion we advise that for the following 2 weeks you keep to the roads and in the meantime concentrate on strengthening your ankle for off-road running. It is important to focus on progressive balance exercises eg… 1 legged standing (eyes open and closed), 1 legged squats, heel-raises, lunges etc. After 2 weeks of intense conditioning your ankle you will be more stable to run off road, thus reducing the risk of re-injury. The ankle support is not necessary if you are running without pain and can be counter-productive in the long term. Wishing you luck with your rehab!

Question:  I posted before regarding an achilles injury I had, and was able to have sports massage, stretch it , ice it  and rest it for a week, to a stage where it was Ok to run on – I  have carried on marathon training now including hills but cutting out anything like 5k pace or faster, so it doesn’t hurt to run – but it is still tight and sore first thing in the morning to walk on and the pain is in the same area, right where the achilles meets the foot – is this something that I will just have to manage while running, or is extended rest after the marathon the solution?

Apex Physio Belfast Clinic:  An achilles problem (like a tennis elbow) can be one of the most stubborn problems in the body to clear. I presume your marathon is coming up quite soon. At this stage with you increasing your mileage and gradient it will be hard to settle your symptoms so we advise you to continue with your current management and try to run little and often so as not to exacerbate the achilles. The most important advice that we can give for now is to get a thorough assessment after the marathon to make sure you get the correct diagnosis and treatment so that you can complete the next marathon pain free!! In the majority of cases, Achilles problems can be cleared completely. Good Luck!

Question:  Would you recommend any pre or post run exercises for knee strength?

Apex Physio Belfast Clinic:  If you are pain free, here are a few exercises to help build up the muscles surrounding your knee:  Squats, Lunges, Step up/down, One Legged balance and Calf/Heel Raises.  We recommend that you incorporate these exercises as part of your pre-run warm up and don’t forget the stretching after the run.

Q & A from Injury Clinic on Thursday 1st August 2013:

Question:  I have been running for about 3 years now and after returning from a stress fracture in January 2013 I find that my legs feel tired quite alot. Overall muscle tiredness if that makes sense.  Not a specific injury I know but is concerning as I do alternate running days.

Apex Physio Belfast Clinic:  Muscle tiredness within the first few months of returning to running after a break is within normal parameters, however… if this muscle tiredness has been going on for more than 8-12 weeks then you need to take action.  Try a few of these stretches after your run, Quads, Hamstring, calf and hip flexors, doing 3 on each side holding each one for 20 secs.  Along with these stretches it would be advisable to attend for deep soft tissue massage once weekly for a few weeks, and this combination should help to clear your symptoms.  If this regime doesn’t we recommend a full physiotherapy assessment to get to the origin of your symptoms as something will be causing them.

Question:  Pain in my knee…. Like a numbing pain can’t pinpoint it exactly but hurts all over but mainly outside and under it.  Hurts more if it bent, this has been happening for nearly a year now.

Apex Physio Belfast Clinic:   Based on the info you’ve given, you really do need a proper physiotherapy assessment to get to the root of your problem.  The two most likely causes are either general arthritic changes in your knee, but this will depend on your age, any past trauma and the amount of running you have done to date…. or generalised “numbing” knee pain could be referred pain from your lower back in combination with local knee injury.  Sorry there is no more advice we can give as you definitely need an assessment.

Question:  I have been upping the miles and doing some hilly runs to get ready for a September marathon and have felt a pain in my achillies, just where it joins the heel – quite a sharp pain while walking, a lot of tightness as well – in the main it isn’t so bad when running but I have rested it today but have a 5 mile race tomorrow night – is there anything I can do in terms of icing / heat for this to help it tomorrow night?

Apex Physio Belfast Clinic:  Regarding your Achilles, which just feels tight more than injured, if the race is important you could run but you must be aware that there is an element of risk of tearing the achilles tendon or injuring it further.  If your achilles condition is stable you will probably be ok to run, but really you should get it treated properly after the race tomorrow, or else it will almost definitely stop you in your tracks completely in the future.

Question:  I have recently read that ice has little on no benefits…any thoughts?

Apex Physio Belfast Clinic:  This is a very controversial subject in sports medicine literature.  From our experience, icing is only really helpful in the acute stages of any injury (4-6 weeks maximum) but after this time it is our opinion that it has little or no benefit…. In sports medicine research the jury is out!!!

Question:  I have been changing from heel strike to fore foot and am finding the ball of my foot is very tender, should I change back or carry on? I’ve also started wearing new brooks GT12 and have just read they might also be a problem.

Apex Physio Belfast Clinic:  The problem here is that you have changed 2 things simultaneously.  Your new trainers will most likely have changed your biomechanics, and now that you have changed your foot strike, this will also have altered your biomechanics when running.  You would be best to use your new trainers and run with your old running style for a few weeks until comfortable with no symptoms and then add in the new running style.  It is only then, if you still have pain in the ball of your foot that you should come to us for an assessment.

Question:  I have recently purchased a foam roller.  What suggestions do you have for using it, pre/post run?

Apex Physio Belfast Clinic:  In terms of foam rolling, the sports medicine literature is very controversial about them, as to whether they help or not.  In our opinion and experience, they can be mildly useful for some sports people (but not all) after running for the quads, hamstrings and calfs to help to reduce DOMS and the feeling of muscle tightness.  Pre-running we find foam rollers to be of little to no benefit.  Some folks find foam rolling after running speeds up their muscle recovery time and others find it of no help… and even a few find firm foam rolling aggravates the feeling of muscle tightness and soreness.

Question:  I have psoas bursitis in my right hip, started February/March time.  I’ve been to NHS physio who showed some stretches.  It seems to calm down at times but flares up if I do hill work or if I try to increase my miles.  Is it something I will just have to put up with?

Apex Physio Belfast Clinic:  You certainly should NOT have to put up with this problem as it is highly unlikely that it cannot be fully cleared.  In our experience stretches alone will not clear it.  It needs to be actively treated… stretching of the hip flexors alone, is just one component of treating this problem. The muscle length of all your major lower limb muscles should be assessed and any other relevant stretches added, along with local soft tissue work to the painful area, and a screening of your lower back to ensure that it isn’t referring pain to the area (as well as the local problem).  Then a few progressive strengthening exercises should be added in, in a running position etc.  You should not do hill work at the moment until your running on the flat is pain free completely.  Once it is, only then should gentle hills be introduced… We would recommend a second opinion of your problem, as you shouldn’t have to live with it!

Question:  When I run I feel tightness in my left calve only, it doesn’t slow me down or be really sore much more than the right leg after running but it just doesn’t seem to be as smooth a running action as the right leg… ps I’m a mid-foot striker.

Apex Physio Belfast Clinic:  Often, these vague symptoms can be attributed to slightly poor biomechanics and we would recommend a physiotherapy biomechanical assessment of your lower limbs and feet as there may be slight asymmetry (lack of symmetry) on one side which may be making all the muscles on the affected side work harder and feel more sluggish and tight.

Question:  I’m running a half marathon on Monday but have been having some achilles trouble for a while; stiffness in the morning that goes when walking around for a while.  No pain when walking or running, but some very recent tenderness.  Can you give me any advice please?

Apex Physio Belfast Clinic:  This is clearly the beginnings of an achilles tendonopathy (achilles tendon problem) and after your race on Monday you should definitely be addressed before it gets worse, you will probably be ok to run your Half Marathon on Monday as it sounds that it is early days of an achilles problem. Between now and then stretch your achilles twice daily for 20 secs 3 times, with the knee straight and the knee bent.  After your race on Monday, consider looking at your trainers to see if they need to be replaced.  After Monday, if the stretches and assessment/replacement of your trainers doesn’t help then you really should see us for an assessment.

Question:  I’ve had a stress fracture in the second metatarsal for nearly year and a half.  Waiting on appointment for foot surgeon.  Is it true there is no chance after this length if time it will heal on its own? Was told it stops trying to heal itself after a while?

Apex Physio Belfast Clinic:  As you are aware, a DEXA bone scan and an x-ray can be obtained through your GP.  If your stress fracture has not healed by now (after a year and a half) and you have not been running on it, this is unusual and there will be a reason for this eg. your bone density is lower than normal for some reason.  I would recommend going to see a sports medicine consultant privately for a one off appointment who will not only assess the stress fracture, but will also assess your bone density and calcium levels to find the reason for this.  The Stress fracture should still be able to heal after this time.  We can recommend an excellent sports medicine consultant, please phone us if you would like their details.

Question:  I had back problems around February time and had quite a few sessions of traction which seemed to help and I am currently waiting for an MRI back scan.  I’ve done 3 runs on grass in the last two weeks and it seemed fine but today I have woken with sharp pain running down my legs (these pains come and go) and pain and stiffness in my lower back for the first time again in over 8 weeks.  I’m really tempted to try and run anyway but do you think this would be a really silly thing to do? The problem used to be on the right side, but today it seems to be on the right, left and lower back… As well as traction, I have also tried acupuncture and physio sessions.  These seemed to work initially, but now the pain is back. Any advice would be great?

Apex Physio Belfast Clinic:  Here at Apex Clinic, the two main areas which we specialise in are sports injuries and spinal problems (which includes nerve pain and headaches).  To answer your question, you should definitely not run at the moment as it has a high risk of making your back problem worse.  In our experience, traction alone to treat a lower back problem is not nearly as effective as traction combined with manual mobilisation of the affected area in the lower back.  Traction alone is a very generalised treatment in that it stretches your whole lower back and does not target the specific level of your spine which is involved.  As your pain has returned fairly quickly now that you have returned to running, it may be worth a second opinion, to ensure that the origin of your problem in your spine has been identified as your spinal problem will be mechanical, in that the pain will only clear when the segment that is causing the problem has been treated.

Question:  I have mild pain just below the ankle bone on the inside of my right foot.  Not too much pain running, but the morning after it’s very tender.  I think I may have injured it on holiday in the pool playing with my young son, and running has been aggravating it.  I have now stopped running since last week as I am afraid it will worsen.

Apex Physio Belfast Clinic:  There are a few things that could be causing the pain here in your ankle, one likely cause is a problem with tibialis posterior (tib post) tendon which often gets overused significantly on holidays by the person wearing flip flops or very loose sandles, or by walking barefoot!! It’s less commonly injured in the pool! If this tendon was injured by the change in footwear as stated, then you should rest it for 2-3 weeks, wear supportive trainers as much as possible (no barefoot walking or flip flops) and walk only moderate distances..and then return gradually to running. This may clear the pain, if not, you need a proper assessment and treatment to clear it!

Question:  I have pain just below my right knee on the inside almost at very top of shin bone, any ideas/advice?

Apex Physio Belfast Clinic:  This area that you have described to have pain in, is really a no-mans land, in terms of local structures which may be involved… as it’s below the knee joint line etc… so it is most likely to be referred pain from another area or source, which we see commonly with pain in this area.  We’re sorry to not be any more help than this, but you really need an assessment to get a diagnosis of this pain.

Question:  I’ve Piriformis syndrome, what is the best way to rehab it?

Apex Physio Belfast Clinic:  The recent literature on piriformis syndrome suggests that true piriformis syndrome is actually extremely uncommon, and that it is often given as a diagnosis too readily! Amongst sports folk, it is most common in hockey players and extremely uncommon in runners… in our experience we have seen only a handfull at the most of runners with this problem between 6 physios over the last 15 years, yet we have seen many, many runners with pain in the piriformis area which has cleared completely with a nerve (sciatic nerve) mobilisation treatment regime and a lower back manual treatment regime along with relevant stretches.  So the million dollar question is… do you actually have true piriformis syndrome? If it is, stretching combined with local soft tissue work and then a progressive strengthening program again progressing to a running position would be advised.  Please consider an assessment with us if it isn’t clearing as pain in this area nearly always can be cleared.

Question:  Myself and several other runners I know regularly get a problem where the spinal alignment goes out and requires physio work to realign.  What in a runner do you think would cause this or what would you recommend to counteract this?

Apex Physio Belfast Clinic:  The 2 most common reasons for this are, a slight biomechanical problem with the lower limbs eg a poor foot posture on one side which may require orthoses (insoles) to correct it… this could be identified by a physio or podiatry assessment, or the second reason – if your foot biomechanics are within normal parameters then in our experience there may be one segment of your lower back or lower thoracic region (middle back) on one side which may be tight or jammed (one or 2 joints), which should be able to be mobilised to restore normal movement and this should stop the spinal malalignment problem. An assessment is required to identify which is the case.