Northern Ireland Running

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NiRunning 'Injury Clinic' Questions and Answers:

Our popular NiRunning live 'Injury Clinic', in association with Apex Clinic takes place on the first Thursday of each month on our facebook page (search NiRunning - Northern Ireland Running).  During the 90 minute live chat, physiotherapy experts Apex Clinic answer questions put to them by our followers. Recently we have had numerous requests to have common questions put onto a page; so, based on this feedback, we will use this page to list the questions and answers from each 'Injury Clinic'.  

Our next LIVE Injury Clinic will take place on Thursday 2nd February 2017, from 7.45pm to 9.15pm (on our NiRunning facebook page)

Q & A from Injury Clinic on Thursday 1st December 2016:

Question:  I've been doing a lot of pavement pounding recently and have managed to run 5 miles without stopping, but I've started to get a pain on the right side of my right foot, which then moves up towards my ankle.  The pain doesn't start at the beginning of the run, but I have noticed that it happens when I go down a steep hill, which is at the end of my usual runs.  I haven't run on grass for a while and I don`t know if that would make a difference. I've got the correct trainers for my feet and have been running for about 7 months now. Is this something which I should worry about or is it one of the little things which comes on with running?


Answer:  Sorry to hear that you’ve developed this pain, and many runners do think that foot pain is a normal thing to experience when running, but it certainly isn’t and should be cleared before it stops you running!  From the information that you’ve given us, your pain could be due to a number of different things. The most likely cause however would be due to overloading of the joints on the outside of your foot, as there are a lot of joints in our feet. With high load and pavement pounding, especially with uphill and downhill running the joints in your foot can be overloaded and get inflamed which then in turn causes pain. This is an overuse injury of the foot. The best thing to do at this stage is to reduce your running mileage, slow your pace and run on softer surfaces only ( ie grass, bark or treadmill) and keep to the flat alone (ie no hills). The fact that your shoes are great biomechanically is one less thing to be concerned about. 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 and hence a tailored treatment plan to clear your pain.  Hope this helps.


Question:  I have a question regarding my knee. I have been having trouble with it swelling for the past couple of years.  I have been to physio and have done a lot of rehab work on my hip and quads etc. to increase my knee stability but my knee still swells up. What could be causing this?


Answer:  If it is generalised swelling of your knee you are experiencing, the most likely cause of this would be wear and tear or osteoarthritis in the knee joint.  This is very common in runners in middle age and older but it doesn’t necessarily mean that it’s the end of the road for your running.   At this stage we recommend that an x-ray of your knee joint should be taken through your GP as this will show the health of the joint surfaces of the knee. If osteoarthritis is confirmed on x-ray, then it would be best to seek professional help from a physio along with your x-ray results for him/her to read.  A physio who is experienced in running injuries should know how to manage osteoarthritis in knees of runners, and with the correct management regime you are likely to be able to continue running. 


If you have a knee x-ray and the joint surfaces are healthy, then it is more than likely that you may have a cartilage tear. Here, we would recommend a knee MRI scan to see if there are any cartilage tears and to look at all the other structures of the knee joint.  Your treatment/management would then be decided from here.   If you need any help organising an MRI scan, we would certainly do this for you at no charge.  


Question:  I've recently been getting mild pain in my groin/inner thigh area which feels quite deep. I also have a very pronounced click in the same area when I raise my knee up while standing. I've stopped running altogether for the last 4 days.

Could you please give me any advice or help? 


Answer:  From the information you have given us, there could be a number of reasons for the pain and clicking that you are experiencing. The most likely cause of your pain is due to one of the following reasons-

 

1) Depending on your age, this could be the beginning of the onset of osteoarthritis  (ie OA) in the hip joint.  OA of the hip joint normally begins with discomfort in the inner groin area and can cause pain to radiate down into the inner thigh. We would recommend an x-ray of your hip joint through your GP as this will show the health of the joint surfaces of your hip joint.  If osteoarthritis is confirmed on x-ray, it would be best to seek professional help from a physio experienced in running injuries along with your x-ray results to hand,  With the correct management regime, you may still be able to continue running.


2) If the pain is not caused by the above, then it could be referred pain coming from your lower back. If you haven’t had a trauma and the pain appeared suddenly for no reason, then this is the more likely cause of the pain, and is a very common complaint in runners. The clicking you are experiencing in this case, is due to maltracking of the hip joint, due to muscle spasm which is associated with the pain.   If the pain you are experiencing is referred pain from your lower back, then the best advice at this stage would be to reduce your running mileage and stick to flat surfaces only (ie no hills).   If with this regime in 3-4 weeks time  the pain hasn’t cleared then we would advise that you seek help from a physiotherapist trained in spinal problems and nerve pain.   If treated correctly, then you should certainly be able to return to full pain free running.  


Question:  I was hoping that you would be able to give me an idea of what's going on with my knee pain. It started just over a week ago, and came on so gradually that I didn't even notice it. It's kind of a dull ache above the knee joint.  It's not hugely painful, but there’s enough discomfort to be constantly reminded of it. It seems to be the same whether I'm sitting or standing.   A 5km run at the weekend didn't seem to make it any better or worse and I didn't notice it at all when running.  I've occasionally had a painful hip during colder months, so I'm wondering if it's something new along the same lines.  Any thoughts? I don't want to be accidentally doing anything that's making it worse.


Answer:  From the information you’ve given us, the most likely cause of your pain is referred pain from your lower back region. The fact that the pain started for no apparent reason, with no injury and no trauma and also the fact that it is easier when running and doesn’t change on sitting or standing, all suggest together that it’s extremely likely for this to be referred pain. The fact that running was pain free would certainly suggest that the pain is not coming from your knee. The hip pain which you are describing is likely to be coming from the same source in your lower back, where the pain is referring to both your hip and your knee along the line of a nerve. Usually the onset of the pain that you have described follows some sort of heavy loading/lifting or bent over postures which has stressed your lower back, a few days or weeks earlier.  Alternatively, a lot of uphill running is very stressful for the lower back.

 

In terms of self help there is very little unfortunately that you can do yourself. The fact that the pain is there all of the time means that it is really time to seek help from a physio who’s experienced in spinal treatment and nerve pain, as it will most likely need treatment to clear it. The physio will identify the segment in your spine from which the pain is originating from and then mobilise or loosen it, followed by strengthening exercises to help prevent recurrence in the future.   In most cases this pain can be totally cleared with a full return to running. In the mean time try to avoid bending, lifting or twisting where possible and avoid walking uphill. To carry on running without seeking treatment will very likely end up in disaster! Feel free to give us a shout if needed as our physios here at Apex Clinic all specialise in spinal problem, nerve pain and sports injuries.

Q & A from Injury Clinic on Thursday 3rd November 2016:

Question:  I ran the Dublin Marathon last Sunday (in just under 3 hours). My legs are not as sore as they have been after previous marathons. I’d like to get back to running but I know my body needs rest. Any advice on how long I should rest for? I don’t want to get injured.


Answer:  Congratulations! What a fantastic achievement. The answer to your question is that there is no exact timeline with regards to post-marathon training.  The good news is that ‘rest’ in your case does not mean no running at all, but rather a decrease in training intensity, so there’s no need to become a couch potato. We recommend you take around 3-7 days completely off from running, but return to active recovery following this. This involves running at a slower pace and lower aerobic capacity with a reduced time of your training session. Light activity will actually help you recover faster than inactivity because it promotes circulation. Good circulation delivers fresh oxygen and nutrients to muscles and carries away metabolic waste and therefore aids healing and recovery. 


A deep soft tissue massage would also help aid recovery as this can increase the circulation following any micro tears of the muscle fibres.  Minimal soreness is normal after such a high intensity event and this is due to the onset of DOMS (delayed onset of muscle soreness). However, the more pain you have, the longer the recovery will be.  The recovery period is a good time to let your body heal, so enjoy this time off and plan your next running goals. All the best.


Question:  I’m doing a bit of running (maximum 5 miles) but I have a sore knee the day after the run, with pain around the back of it. It isn’t sore to run on, just afterwards. I’m not sure if I should take some rest or keep training. Any advice?


Answer: The pain you are experiencing could be one of two things. The first, and most likely cause of the pain, could be due to poor nerve movement of the tibial nerve (ie. altered neurodynamics) which is the nerve at the back of the knee. Poor nerve movement can result from scar tissue (caused by previous torn muscle fibres) attaching to neighbouring nerve tissue in the local area. This then reduces the ability of the nerve to naturally slide and glide with movement. This injury is often worse when running downhill (with a longer stride length) or when running faster. The fact that the pain comes on the next day is a classic sign of nerve pain as it often displays a delayed onset of pain.


The second cause could be due to a Baker’s cyst at the back of the knee. This is very common in runners and is associated with wear and tear in the knee joint (osteoarthritis). It occurs where the joint is overloaded on arthritic joint surfaces causing pain and usually slight swelling at the back of the knee.  The good news is, that if your pain is from the first cause, then it can be cleared easily by a physiotherapist who specialises in nerve pain and running injuries. If it’s from the second cause, we would recommend a knee x-ray through your GP to look at the health of the joint surfaces to see if there is in fact any arthritis, and if there is, to check what stage it is at. After having an x-ray, if it is a Baker’s cyst, then physio should help to some degree. Make sure to shorten your runs and try to run on softer surfaces like grass, treadmill or bark. You should check your foot biomechanics to see if insoles are needed or not. If you need any further help, please feel free to give us a call.


Question:  Whilst trail running approximately 6 weeks ago, I placed the outside of my foot on a sharp rock. It was sore at the time but I was able to continue. However, it has ached since. There is no restriction in the movement of the foot, no swelling and no noticeable bruising. Will this just go away with time?


Answer:  From the information you have given us it sounds most likely that the sharp object your foot has hit against, may have injured nerve tissue inside your foot. Unlike muscle tendons, when nerve tissue is injured, it often causes cyclic pain (ie. pain which goes round and round, continuing on, despite the passage of time). We would expect if it was a tendon or muscular injury, it would have well improved since the injury 6 weeks ago but the fact that it hasn’t improved with time sounds very likely that you have injured a nerve trunk in your foot. Unfortunately, there are no self management tips to help this other than relative rest and adding insoles if needed. A physiotherapist who is experienced in treating nerve pain should be able to clear this for you with similar treatments used to treat altered nerve movement (i.e. altered neurodynamics). This will usually completely clear ongoing cyclic nerve pain.  Avoid wearing anything tight, such as tubigrip around your foot and ankle as this will aggravate the nerve pain further. Please feel free to get in touch if any further help or advice is needed.

Q & A from Injury Clinic on Thursday 6th October 2016:

Question:   I have been getting a pain, which I think may be shin splints recently. The pain is just to the right hand side of my shin on the right leg. I stopped running completely 2 weeks ago and the pain hasn’t subsided any. I would like to start running again but don’t want to aggravate it.


Answer:  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 several different causes of shin pain and they are mostly treated differently. Rebecca Nelson, who is our Director of Physiotherapy here at Apex Clinic, Belfast, wrote an article on shin pain, which you can find on the physio section of the NI running website. This gives lots of information on the different causes of shin pain. 


At the moment if your pain has not gone away, try hopping on the affected leg as a test. If it is not significantly painful on hopping, it is unlikely to be a stress fracture. Other causes of your shin pain could be 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.  In your case it will almost definitely not be compartment syndrome because the pain has not eased with resting. 


At this stage, the fact that you have rested for two weeks and the pain remains, means that it should definitely be assessed by a physio who is experienced in running injuries. We would be happy to help. In terms of any self help, it is limited. You are doing the correct thing by not running at this stage. You should get the biomechanics of your feet assessed to see if you need insoles (orthoses) and should also check that your running shoes are currently giving you adequate support and control.  At the moment, we recommend aqua jogging to maintain your running fitness in the water and keep any walking to a maximum of 20 minutes on the flat at one time.  Unfortunately, we can’t offer anymore self-help tips as really, you need a thorough physiotherapy assessment to establish the correct diagnosis for your shin pain and subsequently the correct treatment plan to clear it. 


Question:  When I start a training session, I feel a sharp pain in my heel, which generally disappears quite quickly. The next morning, however, the pain is back as soon as I get out of bed, but it disappears after a short time. The pain is sharp and I have tried massaging the area after running, but it doesn’t seem to help.

 

Answer:  This sounds like the beginning of an early onset of plantar fasciitis. At this stage you should not have to stop running, but try the following self help methods:


1) Check that your running shoes are in good condition with a good arch support

2) Reduce your mileage and always keep your running to the flat – no hills

3) Don’t run on two consecutive days

4) Keep your walking times to a maximum of 20 minutes on the flat only

5) Avoid walking barefoot at all times

6) Try these stretches: a) Calf stretches with the knee bent and the knee straight, five of each stretch holding each one for 20 seconds twice daily; b) Plantar fascia stretches (which you’ll find online). Hold this stretch for 20 seconds and repeat 5 times, twice daily. Try this regime for 2-4 weeks and if the pain does not improve, you will need a proper physiotherapy assessment.  With this pain, you may find it interesting to read an article written by Rebecca Nelson our Director of Physiotherapy here at Apex Clinic. This is called: “Is Heel Pain Ruining Your Stride?” and can be found on the physio section of the NI running website. This will give you a bit more information on the possible causes. Hope this helps.


Question:   A couple of hours after I finish my run, I get an ache on my right hip, just towards the front and outside of it. I’ve been gradually increasing my mileage but nothing drastic and I changed my trainers three months ago. The pain has arisen in the last two weeks.


Answer:   Thanks for your enquiry. The fact that you haven’t mentioned any inner groin pain and that the pain is isolated to the front  and outside of the hip would suggest that this pain is likely to be one of two things; 1) Referred pain from the lower back. With this, the location of your pain is extremely likely to be worse with uphill running as a pose to running on the flat; 2) It could be overuse of the hip flexor muscles, following the change in your running shoes, as this will have an effect on all of your lower limb muscles and may have been a predisposing factor to getting an overuse injury of the hip flexors.


For both of these causes for your hip pain, we suggest you reduce your running mileage, only running on flat ground and avoiding hills; reduce running frequency to twice weekly; reduce walking time to 20 minutes maximum and feel free to aqua jog (or swim) to maintain your running fitness. You can also try performing hip flexor stretches (which can be found online) twice daily, 5 stretches, holding each stretch for 20 seconds. If after 2-4 weeks of this regime, the pain does not improve, you will need a proper physiotherapy assessment by a physio who is experienced in running injuries. Best wishes.


Question:  Any tips for strengthening Achilles tendons?


Answer:  A good strengthening program for the Achilles tendon is an eccentric training program (lowering the body program). We recommend the following two exercises, performing both twice daily:


1) Standing on a step, go up onto your toes of both feet fully, then move your pelvis over to above your affected foot taking your unaffected foot off the step and then lower your heel slowly (with the knee of the affected foot straight) until your heel is fully down, lower than the level of the step. Next, put your unaffected foot back on the step and raise up to the full toe up position, using both feet equally and repeat the same action. Repeat this exercise 2-3 sets of 15 reps on the affected leg or on alternate legs if required.


2) Repeat exactly the same exercise but keep both knees bent at about (an approximate) 35 degrees angle throughout the exercise. Keep to the same reps and sets.  It is essential that you do these exercises with no pain, or with very mild pain. If these exercises cause pain after performing them, the pain must clear within 1-2 hours after finishing the exercises. If it does not settle within this time, reduce the reps accordingly. Hope this helps.

Q & A from Injury Clinic on Thursday 1st September 2016:

Question:   The top of my right foot is concerning me. When I run I get pain in it and if I continue, the pain becomes more severe. I have had to abandon my last two runs because of this. Due to work, I am finding it hard to get to see someone about this so any advice would be appreciated.


Answer:   From the information that you’ve given us, the most likely cause of your pain is poor movement of the nerve in the top of the 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 the pain. At this stage, we recommend that you reduce your running mileage and keep the laces of your shoes loose, to reduce compression of the nerve 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? This problem can nearly always be fully cleared with the correct physiotherapy treatment by a physiotherapist who is experienced in treating nerve pain. In the meantime, we recommend you run for shorter periods and on the flat only. Hope this helps. 


Question:   My back, just below the middle of my neck, has been giving me problems recently. My neck is also a bit stiff and it is sore on turning to the right and left.  This tends to worsen during heavy training periods. Is it related to running?


Answer:   It is extremely likely that running isn’t causing the problem, however it may be bringing out or exacerbating the problem.  If you have stiffness in your neck joints, the most common place to have this is in the lower part of the neck. Running is a high impact exercise so when pounding the pavements there will be a lot of force coming up from your feet through your whole spine and into your neck and shoulders. Any stiff areas of your spine will tend to be overloaded by this force and this can result in pain. It is likely that you have stiffness in the lower neck area as a result of a previous injury or prolonged poor posture, such as from leaning over a desk or doing computer work or paperwork. We suggest, as a start, to run only on softer surfaces such as grass, bark or the treadmill and be mindful of your running posture. There is more information on running posture in one of the articles written by our Director of Physiotherapy, Rebecca Nelson, which you can find on the Physio section of the NI Running website. If these two changes do not help you, we recommend that you seek physiotherapy treatment from a physio who is experienced in treating spinal problems. Your problem should be relatively straightforward to clear with the correct manual mobilisation techniques applied to the affected areas of your spine, along with a few home exercises to maintain the mobility.


Question:   I’m training for a marathon at present and after 10 to 12 miles the bone below my knee cap starts to ache on both legs and it feels like I need to straighten my leg out to get a bit of relief from the ache. Is this just to be expected or is it something of concern?


Answer:  From your question, if you are an adult as a pose to a teenager, the most likely diagnosis for your knee pain is patellar tendinitis, which is an injury of the tendon connecting your knee cap (patella) to your shin bone. It’s an overuse injury and is very common in runners. It is the result of your patella tendon being overstressed or overloaded. Due to both knees being affected, it is important that the biomechanics of your feet are assessed, along with an assessment of your running shoes to see if insoles/orthoses are needed. To improve the biomechanics of your knee, and therefore help recovery, it is helpful to do a simple exercise called step downs on each leg (you can find this exercise detailed on one of our most recent top tips for runners on the Physio section of the NI running website). 


You should do this exercise twice daily, 2-3 sets of 20 reps on each leg, short of your knee pain if possible. We also recommend for you to stretch your quads and hamstrings on both legs, twice daily, performing 3-5 of each stretch and holding each stretch for 20 seconds.  At this stage, you also need to reduce your running mileage and run on softer surfaces such as grass, bark or treadmill.  If there is no improvement within 4 to 6 weeks with the advice given, then we recommend that you seek professional help from a physiotherapist who is experienced in treating running injuries.  Best wishes.

Q & A from Injury Clinic on Thursday 4th August 2016:

Question:   Lately, I have been getting some twinges in my back on the lower right side after longer runs. I’ll be stiff that night, but then it’ll be fine the next day, until I run again. Is there anything I can do to prevent this? I was considering some core work.


Answer:   Thanks for your enquiry. As a first step we recommend that you avoid any hill running (or incline running) as this will minimise the pressure on the lower back discs. If the pain is no better with this, then really there is no alternative other than seeking help from an experienced physiotherapist, who will mobilise the tight segment of your lumbar spine which is causing the lower back pain. Once this pain has cleared (and this should only take a few sessions of manual mobilisation techniques), it is then that core exercises will be of great benefit to help strengthen the lumbar spine and therefore help prevent reoccurrences in the future. Strengthening the lumbar spine and core as a first step however, is not appropriate as if there is a tight segment in the lower back from which the pain is originating from, then strengthening the muscles may certainly strengthen, but the pain itself is unlikely to improve.  The timing of core work is key here.  Hope this helps.


Question:   My left hamstring has been achy recently.  I don’t think I have pulled it and I can run on it, but I feel the ache after a run and sometimes during long runs. I’ve upped my miles for Dublin Marathon over the last month.  


Answer:   From the information that you’ve given us, the most likely cause of your hamstring ache may be altered neurodynamics (i.e. poor movement of the sciatic nerve up and down the back of the thigh). There is an article on the NI Running website written by our Director of Physiotherapy, Rebecca Nelson on hamstring pain, “Don’t let recurrent hamstring trouble stop you in your tracks” which will give you more information on this subject.


As a starter, try to avoid hills and keep your stride length shorter.  Also, reduce your running speed slightly.  This should lessen the intensity of the hamstring ache.  Treatment for this should be fairly straightforward for a physiotherapist who’s experienced in treating nerve pain.   It involves moving the nerve tissue in a controlled fashion so that it moves more freely in the back of the thigh when running.  Unfortunately, there are no self-help techniques to clear this ache, however there is a very specific home exercise that you can do once the pain has cleared to help to prevent a recurrence of the problem. Feel free to give us a shout for help if needed, as the physios here at Apex Clinic all specialise in spinal problems, nerve pain and sports injuries. 


Question:   I have a set of twinges which I think are to do with tightness in my hip. Regular stretching seems to be somewhat helpful. The location of the twinges are in my hamstring, inner knee and ball of my big toe, all on the same side.  I feel them after running rather than during running, except occasionally the hamstring twinge.


Answer:  From the information that you’ve provided, it sounds like you have a nerve irritation in your lower back which is causing the three areas of your twinges. There is also the possibility that you have tightness (scar tissue) in your hamstring muscle too. Stretching could be helpful in the short term, however there is likely to be no long term improvement with stretching. Other than stretching your hamstrings, there are no other self-help exercises to clear the twinges in your knee or toe.   You really need to get help from an experienced physiotherapist who specialises in the spine, as your symptoms should clear nicely with the correct manual mobilisation techniques to your spine, once the stiff segments of your spine from which the pain is originating from, have been identified. You may also benefit from deep soft tissue massage to the hamstring area, if scar tissue here has been identified.  In the meantime, we advise you to avoid running uphill and reduce your mileage.  You should also avoid any exercises that may irritate your back such as using a rowing machine, sit-ups and planks. Hope this helps. 


Question:   I have torn ankle ligaments and broken (fractured) the tip of my fibula nine days ago. I am currently on crutches and unable to put my foot down to weight bear. I was just wondering what are the best ways to recover/rehab this injury please? Also, this is the third time I have torn the lateral (outside) ligaments of my ankle. What can I do to prevent this injury in the future? 


Answer:  The number one cause of recurrent ankle sprains is the lack of ankle proprioception (i.e. your brain’s perception of where your foot and ankle are in space) following the first lateral ligament ankle sprain that you suffered.


This is the key factor in rehab here ie that your ankle proprioception is fully restored in your rehab program (these exercises can be found online).  As for rehab for the rest of your condition, usually you will be on crutches for up to 6-12 weeks depending on the severity of the fracture. After the fracture is healed (8-12 weeks), intensive rehabilitation is really important to focus on the following-


1. Regaining full ankle and foot range of movement, to break up and clear any excessive scar tissue which may have formed in the joints of the ankle and foot.

2. Soft tissue work on the lateral ligament of the ankle to get rid of any excessive scar tissue here.

3. As already stated above, a progressive program of ankle and foot exercises to make the proprioception of your injured ankle EXCELLENT for the future, to help prevent further ankle sprains.

4. A progressive strengthening program for your ankle, knee and hip muscles

5. An experienced physiotherapist should also assess your foot biomechanics to see whether insoles (orthoses) are required or not.


Please feel free to phone us for advice if needed.


Question:   I have had plantar fasciitis in my left foot for nearly 2 years. I run on trails and mountains. I wear orthoses, which have been modified and I also stretch.  I use foam rollers also. I have been able to run through it since last autumn until now, but recently it’s been getting the better of me. Any advice?


Answer:   Plantar fasciitis can be extremely stubborn to clear unless the predisposing factors for it have been identified. You may find it helpful to read an article written on the NI Running website by our Director of Physiotherapy, Rebecca Nelson on this subject for a bit more information.  The article is called, “Is heel pain ruining your stride?”


From the information you’ve provided, it sounds like you have tried every self-help regime that is recommended. It’s very likely at this stage of your injury that you have one of two factors contributing to your symptoms:

1. Poor nerve movement (altered neurodynamics) of the nerve passing through the heel (the tibial nerve)

2. An element of nerve irritation in your lower back contributing to your symptoms


At this point we recommend that you see a physiotherapist who is experienced in the treatment of nerve pain to assess if either of these two pathologies are involved in your condition. Our team of physiotherapists here at Apex Clinic treat long standing plantar fasciitis on a regular basis and we certainly find that in most cases it can be cleared if the correct treatment is given to address ALL of the factors that are causing the pain.


As our physio team here at Apex Clinic specialises in spinal problems, nerve pain and sports injuries, one of our team would be delighted to asses you, even as a one off to give you a treatment plan to clear it. Hope this helps.


Question:   I’m a very amateur runner and I always have problems with my calves. I concentrate on them before runs, which are usually 10ks, but they always give me bother afterwards. Any advice?


Answer:   From the information you’ve given us, it’s most probable that you have a build up of scar tissue in both calf muscles which has accumulated over the recent number of months.  You are particularly prone to this happening if you are new to running. Scar tissue may be the cause of your symptoms and the way to clear this, is to go to a physiotherapist for deep soft tissue massage and soft tissue techniques to work on the scar tissue once it’s been identified, and then clear it.


Once the scar tissue in your calves is cleared using soft tissue techniques, then this should be followed by a home exercise program of calf stretching and strengthening. It’s good to get this problem sorted out quickly as it may lead to muscle strain in one or both calf muscles if you don’t.  Best wishes. 

Q & A from Injury Clinic on Thursday 2nd June 2016:

Question:   I suffer from really bad shin splints. I have only been running for the past two years and during this time I have been injured with a stress fracture, as well as shin splints. I would love to be able to run without feeling the effects of these injuries. Any advice you can offer me would be greatly appreciated.


Answer:   Thanks for your enquiry. First of all, you need a thorough assessment to get to the root of your problem. This will include assessment of your foot biomechanics to see if any insoles are needed and should also establish a correct diagnosis for the shin pain. 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 from your question we see you have also experienced)

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

3. Nerve pain from the nerve running through the front of the shin

4. Less likely, compartment syndrome


Rebecca Nelson (our Director of Physiotherapy at Apex Clinic) wrote an article on shin pain, which you can read on the Physio section of the NI Running website, and this will give you more information behind the different causes of shin pain. Shin pain which continues for more than 3 months should definitely be assessed by an experienced physiotherapist who treats a lot of running injuries, as if it’s poorly managed it can continue for months and even years! If correctly treated the pain should be able to be cleared and you should be able to return to running pain free. In the meantime we advise you to run only on softer surfaces, such as grass, bark or treadmill. 


Question:   I’m not sure if this is running related, but it is certainly affecting my recovery. I have a sore neck, which restricts how far I can tilt my head to the left. My left shoulder is also achy. In particular, I find it hard to put my head on the pillow when lying on my left side.


Answer:   It is extremely likely that running isn’t causing your neck problem. However, running may be bringing out or exacerbating the problem. If you have stiffness in your neck joints, the most common place to have this is in the lower part of the neck, specifically in one or two of the joints. Running is a high impact exercise, so when pounding the pavements, there will be a lot of force coming up from your feet through your whole spine and into your neck and shoulders. Any stiff areas of your spine will tend to be overloaded by this force and this can result in pain. It is likely that you have stiffness in the lower neck area as a result of a previous injury or prolonged high loaded postures, such as leaning over a desk or doing computer/desk work. We would suggest as a start, to run only on softer surfaces such as grass, bark or the treadmill and be mindful of your running posture. There is more information on running posture 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, “Is running a pain in your neck?’


If these two changes do not help you, we recommend that you seek physiotherapy treatment from a physio who has experience in treating spinal problems. We see this problem on a daily basis within the clinic, which can cause restriction of neck movements. This problem should be relatively straight forward to clear with the correct manual mobilisation techniques applied to the affected areas of your spine along with a few home exercises to maintain the mobility. Sleeping posture is also very important, so make sure your pillow is providing the right amount of support for your neck, ensuring that it’s not too flat or too soft, allowing your neck to have sufficient support during the night. Feel free to give us a shout. 


Question:   Recently, my hamstrings have been getting very tight. I am currently training for a marathon and upping my miles (sensibly). They aren’t sore, just tight. I have tried sports massage before and it seemed to work initially but then I seemed to become reliant on it to resolve the problem, which comes back quickly. Do you have any idea what is causing this or is it something that just comes with big mileage?


Answer:   There could be a few different reasons causing this feeling of tightness, however, the most likely by far would be due to a lack of nerve movement of the sciatic nerve in the hamstring area, also called altered neurodynamics. This means that the nerve tissue in the back of the thigh, which should move freely and slide between all the muscles that surround it, is not moving freely. In this case, unfortunately there is no self help or amount of stretching of the hamstrings that will help, but we recommend a specific physiotherapy regime of mobilisation or movement of the nerve tissue as it passes through the back of the thigh. This will be followed by tailored home exercises to maintain the improved nerve mobility. 


The key to beating hamstring tightness lies in finding the correct diagnosis of the origin of the problem and then treating it at its source. Rebecca Nelson (Director of Physiotherapy at Apex Clinic) wrote an article on hamstring problems, which you can read on the physio section of the NI Running website, and it will give you more information.  All our physiotherapists here at Apex Clinic are very experienced in treating nerve pain and we treat this complaint on a daily basis. We’d be delighted to help if needed. 

Q & A from Injury Clinic on Thursday 7th April 2016:

Question:   I have been experiencing a sharp pain on the right side of my shin on my right leg recently. This is worse during the early part of my runs and then disappears. It is also sore after runs. Any help would be appreciated.


Answer:  Thanks for your enquiry. The good news is that nearly all shin pain can be cleared with the correct treatment regime 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 all treated differently. Rebecca Nelson, our Director of Physiotherapy here at Apex Clinic Belfast wrote an article on tackling shin splints which you may find helpful to read and it can be accessed on the NI running website, under the Physio section. 


From the information that you’ve given us, the shin pain that you’ve described is likely to be from either, poor or altered nerve movement (altered neural dynamics) of the nerve which runs down the shin or secondly, due to referred pain coming from the lower back region which occurs as a sharp pain in the shin.  If your shin pain is worse going uphill, then it’s more likely to be referred pain from the lower back whereas if your pain is worse going downhill or during faster runs, then it’s more likely to be altered neural dynamics.  The other common causes of shin pain are unlikely in your case, but a thorough examination by an experienced physio would definitely be needed to rule out- a stress fracture, inflammation of the tibialis posterior muscle on the inside border of the shin bone and compartment syndrome.  An accurate diagnosis is essential in order for your pain to be cleared.  With the correct treatment regime, you should certainly be able to return to painfree running (maybe with a few softer surfaces thrown into your training regime!) Feel free to give us a call if needed.


Question:   During longer runs I have been developing a pain on the underside of my right foot, around the ball of my foot. Any advice would be appreciated.


Answer:   From the information that you’ve given, your pain is likely to be due to overloading of the joints in the forefoot, namely the MTP joints (metatarsophalangeal joints) and once this overloading is addressed, the pain should clear. This will either result from- poor foot biomechanics alone, where insoles/ orthoses will be needed to improve this or from stiffness in one or more of the MTP joints from overuse of these joints.  In either case an experienced physio would need to assess your foot biomechanics to see if you need over the counter orthoses or referral to a podiatrist for custom made orthoses.  If there is stiffness of the MTP joints the physio would need to manually mobilise the affected joints to restore their full mobility.  At this stage you need to reduce your run length and only run on softer surfaces (grass, bark, or treadmill).  In both of the scenarios mentioned above, you should also stretch the plantar fascia (the soft tissues on the sole of your foot, these stretches can be found online)  and the two calf muscles- gastroc and soleus, which can also be found online. Perform these stretches twice daily for 5 repetitions each time, holding each stretch for 20 seconds.  Hope this helps. 

Q & A from Injury Clinic on Thursday 3rd March 2016:

Question:  I broke my collarbone after falling off my bike about a year ago. The injury is healed but when I’m running I find that it aches, a dull annoying pain. It's mainly on longer runs but also on some faster intervals. Any help or advice would be great.


Answer:  From the information provided, it’s likely that your pain should be able to be cleared or helped considerably with the correct physiotherapy treatment. There is a good chance you have one of two things-


1) Scar tissue from the injury which is surrounding the fracture site (where the bone has been broken)

2) Scar tissue on either joint at the end of the collarbone which is causing pain, ie from either the acromioclavicular joint or the sternoclavicular joint.


At this stage, as you are one year on from the initial injury, the fracture site should be well healed so it is unlikely that the pain you are experiencing is from the broken bone. Therefore, if it is scenario 1), strong deep soft tissue massage techniques around the fracture site should clear the surrounding scar tissue and hence the pain. 


If it is scenario 2), manual mobilisation of the joint on either end of the collar bone should again, clear the scar tissue in those relevant joints, allowing the pain to clear. 


The key is to find the correct diagnosis for the pain.  In the vast majority of cases the pain which you’re describing can be cleared with the correct treatment.  Hope this helps. 


Question:  Over the past 2 years I have had a pain in my right hip when running. It is not an impact injury but feels like it is deep. The morning after running it would be very sore when walking, or even getting up off my seat.


Answer:  From what you have described, it’s unlikely that the pain is coming from your hip. As all of our physios here at Apex Clinic have undertaken extensive post-graduate training in spinal and nerve pain, we are very familiar with referral patterns from both the hips and from the lower back. The symptoms that you are describing sound as though they are originating from, and being referred from your lower back, due to a stiff segment in your spine at an area where the nerves run to the hip. There could well be secondary muscle spasm also over the hip itself.  Until the stiff segment in your spine is mobilised or loosened, it is unlikely that your symptoms will clear on their own.  With the correct physiotherapy treatment it is likely that your pain can be resolved. 


Question:  I am getting a shooting pain in the area just below my calf, on the back of my leg, specifically the area between the top of my achilles and the bottom of my calf. Any advice?


Answer:  From the information provided, the pain you have described could be due to a number of different things- 


1) Nerve pain coming from the nerve running downwards in the area that you have described (tibial nerve). This can occur if you have torn some muscle fibres in that area and scar tissue has formed which has irritated the nerve passing through. 

2) Referred pain from the lower back. This could be coming from the joints or discs in the lower back. In this case the pain is often worse when running uphill or running upstairs. 

3) Local scar tissue itself in the soleus muscle (which is the lower calf muscle). This can occur following a strain of this muscle. 


It is extremely important to find the correct diagnosis for the pain. In each of the above cases, the physiotherapy treatment is different depending on the diagnosis. 


For scenario 1), movement of the nerve tissue needs to be done by a physio who is experienced in treating nerve pain.

For scenario 2), manual mobilisation of the affected segment of the lower back is needed to loosen the stiffened segment and stop the referred pain. 

For scenario 3), local deep soft tissue techniques need to be applied to the painful area to break up any excessive scar tissue. 


As you described your pain as shooting, it is most likely to be case 1) or 2). All of our physios here at Apex Clinic are experienced in spinal pain, nerve pain and sports injuries, so feel free to give us a shout if needed. Best wishes.


Question:  My neck and shoulders are very tense while running. My neck is also stiff sometimes. Is running causing this, or is it something else I’m doing?


Answer:  It is extremely likely that running isn’t causing the problem, however running may be bringing out or exacerbating the problem. If you have stiffness in your neck joints, the most common place to have this is in the lower part of the neck.  Running is a high impact exercise, so when pounding the pavements there will be a lot of force coming up from your feet through your whole spine and into your neck and shoulders.  Any stiff areas of your spine will tend to be overloaded by this force and this can result in pain. 


It is likely that you have stiffness in the lower neck area as a result of a previous injury or prolonged poor postures, such as leaning over a desk or doing computer/paper work. We would suggest as a start, to run only on softer surfaces such as grass, bark or the treadmill and be mindful of your running posture. (There is more information on running posture 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.) If these two changes do not help you, we recommend that you should seek physiotherapy treatment from a physio who has experience in treating spinal problems. This problem should be relatively straight forward to clear with the correct manual mobilisation techniques applied to the affected areas of your spine along with a few home exercises to maintain the mobility. Hope this helps.


Question:  I’m just wondering if you have any advice for breathlessness associated with pernicious anaemia and B12 deficiency? I'm struggling to do any running.


Answer:  Unfortunately, we cannot help you as this is out of the realms of our expertise in musculoskeletal problems. We would however strongly recommend you see a Consultant in Sports Medicine who should hopefully be able to help you. There is a Sports Medicine Consultant that we would definitely recommend and we will happily pass their details on to you if you private message us or contact Apex Clinic, Belfast tomorrow. With best wishes.

Q & A from Injury Clinic on Thursday 4th February 2016:

Question:  During my recent longer runs over the last two weeks I have been getting aching shoulders, right across the top of my back just below my neck. I haven't increased my mileage too much but I’m currently training for the Omagh Half Marathon in March. Any help or advice would be appreciated.


Answer:  The pain in your shoulders sounds as though it could be caused from stiffness in a segment or segments of your neck/upper back region. This then refers the pain to your shoulders. This is often aggravated by running alone, or by poor running posture, increased running distance or by hill running. Usually, the muscles on either side of the spine will be stiff and painful around the area where there is joint stiffness. Initially, we would suggest a deep soft tissue massage. If this does not relieve your shoulder pain then you should have a thorough physiotherapy assessment by a physio who specialises in the spine, as your symptoms should be straight forward to clear with the correct manual mobilisation techniques once the stiff segments of your spine have been identified. Hope this helps. Good luck for your half marathon.


Question:  I would like to know what is wrong with my hip. I have a pain which is right on the bone. When I push it, it’s sore. After speed work it gets a bit sore then after 2 days of rest, it dies off again. Any ideas?


Answer:  From the information you have given us, the pain that you’ve described is unlikely to be originating from your hip. As our team of physios here at Apex Clinic, Belfast specialise in the spine and sports injuries, we are very familiar with referral patterns of pain which originate from the spine. It is much more likely that your symptoms are being referred from your lower back due to a stiff segment or segments in your spine, at an area where the nerves travel out to the hip region. These symptoms are likely to be aggravated by running, particularly speed work as you have described. There could well be secondary muscle spasm which is why you feel tender to touch. Until the specific stiff segments in your spine are identified and then mobilised, it is unlikely that your symptoms will fully resolve by themselves. With the correct treatment regime, the pain should clear nicely and you should be able to return to running painfree. In the meantime, you should reduce your speed work and keep to flat ground when running. Hope this helps.


Question:  What do you recommend is the best method to clear plantar fasciitis? My pain eases after a few days of rest but comes back with any exertion. I have not run for 6 weeks and am currently aqua jogging and icing the sole regularly. The pain flares up with very little movement.


Answer:  As you may know, plantar fasciitis, is an overuse condition of the connective tissue on the sole of the foot which causes pain. Typically, symptoms are felt in the middle of the heel and/or along the arch of the foot. The pain is usually worse for the first few steps of walking in the morning. In the case of a true plantar fasciitis, we recommend the following treatment- 1. Relative rest - no running or prolonged walking for a few weeks. Aqua jogging is perfect to maintain running fitness; 2. Stretching - Stretch your two calf muscles and the plantar fascia 3 times each stretch, holding each stretch for 20 seconds, twice daily; 3. A strengthening program- to improve the proprioception (awareness of where your ankle is in space) and stability of the foot and ankle; 4. Get a biomechanical assessment of your feet and legs by an experienced physio to find the cause of the plantar fasciitis, and to decide whether insoles (orthoses) are needed or not. In some cases, if the runner has recently been wearing hard orthoses, these in fact may be aggravating the plantar fascia and contributing to the pain; 5. Wear supportive footwear- make sure you are in supportive shoes all the time and never barefoot or in flip flops; 6. Massage – attend an experienced physio for deep soft tissue massage applied to the plantar fascia and calf muscles.


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 pain and that it continues to flare up, indicates that you really need to get a thorough assessment in order to get a tailored treatment plan for you, and to establish the reason as to why you developed plantar fasciitis in the first place. With 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 fully return to running. It may be helpful for you to read an article which our Director of Physiotherapy, Rebecca Nelson wrote on plantar fasciitis, called, Is Heel Pain Ruining your Stride? You can find this article on the NI running website, under the physio section. I hope this helps and feel free to contact us if your pain persists.


Question:  Some mornings when I get up, I have an excruciating pain on the bone of my left big toe. I can hardly put any weight on the ball of my foot without it being painful. It then goes away after about 10 minutes. Do you know what would be causing this?


Answer:  We presume from the information that you’ve given, that there was no specific trauma (or injury) to your big toe. If this is the case, the pain you are describing is most likely to be referred pain (nerve pain) coming from your lower back. As the discs in the lower back are fattest and fullest first thing in the morning, this type of pain which occurs first thing in the morning on walking is extremely common and usually does disappear, as you say, with gentle movement within 30 mins to one hour. If this pain is left untreated however, then it will usually occur more frequently throughout the day also. To clear your pain the best thing to do is to attend a physio who is experienced in treating spinal problems and nerve pain, and once the segment of your back is identified from which the nerve pain is coming from, this segment can be loosened or mobilised effectively and the pain should clear completely. There are no self management strategies to suggest unfortunately. Feel free to get in contact as we’re very experienced in treating nerve pain.

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

Question:  I am getting a dull ache under both my knees when I run. It doesn't physically stop me from running but I am very aware of it whilst training. After the run, it's hard to straighten my legs because of the pain. Any ideas or suggestions would be very helpful?


Answer:  From your question, we presume that the dull ache is at the bottom of your knee caps. If this is the case, then it is most likely to be one of two things: Firstly, it could be patella tendinitis, which is an injury of the tendon connecting your knee cap (patella) to your shin bone. It’s an overuse injury and is very common in runners. It is the result of your patella tendon being overstressed. Due to both knees being affected, your foot biomechanics would also need to be assessed along with an assessment of your running shoes. The reason as to why patella tendinitis occurred would need to be established and then addressed, as well as a progressive treatment plan started to clear the pain.


Secondly, due to the fact that both knees are affected this could be coming from a low level of nerve irritation in your lower back, of the nerves that supply the knee. If this is the case, it is identified by finding the appropriate stiff segment of your spine and manually mobilising or loosing it which will reduce and stop the nerve irritation of the nerves supplying the knees.


In both of these cases, you need to reduce your mileage and keep to the flat and softer ground until you have the problem assessed and properly diagnosed. We see both problems on a regular basis at Apex Clinic and the pain can be cleared in nearly all cases with the correct treatment and rehab programme.


Question:  I am currently a beginner and have been increasing my running mileage. I have noticed that my legs are becoming very heavy and achy more after runs especially above the knees, and my runs are feeling harder after a days rest due to this. Is this body / muscle fatigue or should I look into this further?


Answer:  This could be due to a delayed onset of muscle soreness (DOMS) after starting a new activity and continually increasing your mileage, as your body is getting used to the new activity. The best thing to do is to ensure you have a good dynamic warm up prior to running followed by a cool down (for example, 5 minutes of walking) including static stretches (holding for 20 seconds, 3-5 reps of each muscle group) of your main muscles namely your calves, hamstrings and quadriceps. Simple stretches can easily be found on the internet and they provide some great videos of these stretches. We would also suggest a deep soft tissue massage (sports massage) to help to break down any scar tissue caused by microtrauma of muscle tissue during running. A deep tissue massage can also help to reduce muscle fatigue by increasing the circulation and lengthening the muscles, improving flexibility which can prevent potential muscle injury. If this doesn’t help your symptoms to clear, then we would recommend a detailed physiotherapy assessment to diagnose and then clear your symptoms.


Question:  I have a problem with my foot. The bone on the outside of my foot half way between my toes and heel gets very sore in the morning, however as the day goes on it fades away a lot. I am able to train and race on it but it won’t go away. What could be the problem?


Answer:  Was there any trauma to the foot? Does it swell or get worse after exercise? We would firstly suggest an x-ray to rule out a stress fracture of the 5th metatarsal. Most stress fractures are caused by overuse and repetitive activity, and are common in runners. They often occur when people change their activities, such as- by trying a new exercise, suddenly increasing the intensity of their workouts, or changing the workout surface (jogging on a treadmill vs. jogging outdoors). If there is no stress fracture and no trauma, it could be a local soft tissue injury to the foot, most likely caused by over training or poor foot biomechanics. A full biomechanical assessment of your feet and legs will be required. We would suggest with starting with a physiotherapy assessment (who will also assess your biomechanics) as in most cases with the correct treatment this pain can be cleared and we can have you back to pain-free running.


Question:  I have a pain in my right butt cheek. I have taken a week off running and it’s still there. I stretch, strengthen, foam roll, etc. but it just doesn't go away. It has started to work its way down my hamstring, and into my calf (unless I'm compensating for something). What else can I do?


Answer:  It sounds like you aren’t getting to the root of the problem if it isn’t clearing with stretching and foam rolling. It may be helpful for you to read the article written by our Director of Physiotherapy here at Apex Clinic, Belfast, Rebecca Nelson, called “Is running giving you a pain in the butt”?. This article can be found on the NI Running website under the physio section and covers the most common causes of buttock pain. If it is starting to travel down into the hamstring, we would recommend for you to have a full physio assessment sooner rather than later to get to the root of your problem. It is most likely that the pain you are describing is referred pain coming from your lower back. This is very common and can be treated successfully.


Question:  I seem to be having difficulty lately with tightness /soreness in my calf muscle. Any tips on stretching before and after running?


Answer:  When running or performing any sporting activity, it’s best to ensure that you have a good dynamic warm up prior to exercise followed by a cool down (for example, 5 minutes of walking) including static stretches (holding for 20 seconds, 3-5 reps of each muscle group) of your main muscles namely your calves, hamstrings and quads. Simple stretches can easily be found on the internet. Use of a foam roller after running may reduce the level of tightness and soreness. If this regime doesn’t help then we would suggest a physiotherapy assessment to properly diagnose the cause of your tightness/soreness. It may be that a deep soft tissue massage (sports massage) is needed to break down scar tissue which has accumulated in your calf muscle from repeated microtrauma of the muscle tissue itself during running. This is a very common problem and can be cleared with the correct treatment.


Question:  I have recently developed pain in my inner thighs when I run. I’m worried that I might have torn something. Any ideas?


Answer:  There could be a few reasons for the pain. The fact that the pain is in both inner thighs means that it is not likely that you have pulled a muscle on both legs. It is much more likely that your pain is referred pain from your lower back. If there is any stiffness of 1 or more levels of the joints in your spine, the compression and repetitiveness of running, especially up hill and on hard surfaces will further load these segments. This often causes irritation of the nerves leaving the spine, and in your case it will be the nerves which travel to your inner thighs. You don’t need to have any back pain to experience this. We see many runners with similar symptoms in Apex Clinic, who clear quickly with the correct treatment to the spine. Please feel free to give us a shout.


Question:  I have been running for two years with no injuries and then last week I completed the cross country relays and a duathlon. After the events the arch of my left foot became very tender to walk and touch over the bone and it’s also slightly swollen. I'm not aware of hurting/injuring it at any point. Any ideas?


Answer:  We would firstly suggest an x-ray to rule out a stress fracture. Stress fractures are common in runners and are caused by overuse and repetitive activity. If there is no stress fracture, the pain could be a local injury to the foot for example plantar fasciitis or a local soft tissue injury from poor foot biomechanics. It may be helpful for you to read the article written by Rebecca Nelson, our Director of Physiotherapy here at Apex Clinic called “Is heel pain ruining your stride”. This article can be found on the NI Running website under the physio section and covers plantar fasciitis. 


We would suggest a physiotherapy assessment from an experienced physio as soon as possible to correctly diagnose the cause of your pain. The physiotherapist will also need to assess your foot and leg biomechanics (the way your feet and legs move) to see if insoles are needed or not. In most cases, pain in the arch of the foot can be cleared with the correct treatment and you should then be able to return to pain-free running. Unfortunately, there are no self help strategies which we can recommend, as really you need a professional assessment. If you need any further advice, please contact us here at Apex Clinic.

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

Question:  I tore my calf (gastroc) muscle today, Grade 3. How long am I likely to be out of running for? Can I do anything to speed up my recovery?


Answer:  Unfortunately, a grade 3 tear of the gastrocnemius muscle is the most severe calf strain with a complete tearing or rupture of muscle fibres in the lower leg. Full recovery can take 3-4 months and in some instances, surgery may be needed. It sounds like you have had an assessment so I presume that this diagnosis is correct. As with most soft tissue injuries the initial treatment is RICE - Rest, Ice, Compression and Elevation.  Anti-inflammatory medication is recommended (after checking with your local pharmacist) to help reduce your pain and swelling and can be taken with paracetamol for extra pain relief.  Following this it is important to restore the range of movement of your ankle joint, and then start gentle calf stretching, muscle strength work and then progressing to restoring high speed work, power, proprioception and agility before starting a graded return to running.  We would advise that all the above is done under the guidance of an experienced physiotherapist and is done alongside progressive soft tissue work applied to the calf, to reduce an excessive scar tissue build up in this region.  If you need further advice at any stage, feel free to give us a shout here at Apex Clinic.


Question:  I have been road running all year and have just started back to the track this week. My calves and Achilles tendons feel like they’re going to explode!  Any ideas to help reduce the DOMS (delayed onset of muscle soreness)? 


Answer:  The best thing to do is to ensure you have a good dynamic warm up prior to running followed by a cool down (for example, 5 minutes of walking) including static stretches (holding for 20 seconds, 3-5 reps of each muscle group) of your main muscles namely your calves, hamstrings and quads.  Simple stretches can easily be found on the internet and they provide some great videos of these stretches. Use of a foam roller after running may also reduce the level of DOMS.  If your calves and achilles feel like they are going to explode, we would suggest a deep soft tissue massage (sports massage).  This helps to break down any scar tissue caused by microtrauma of muscle tissue during running and lengths the muscle also, which can help to improve flexibility and prevent future muscle injury. Hope this helps.


Question:  Recently, both of my knees have been sore during and after running. The pain is at the bottom of my knee cap and started with the left one, then a few weeks later the right one started to get sore also. The day after running the pain makes them very restless, I can't keep them still for too long and when I move them they are sore. Any help would be great.


Answer:  Pain at the bottom of your knee cap is most likely to be one of two things: Firstly, it could be patella tendinitis, which is an injury of the tendon connecting your knee cap (patella) to your shin bone.  It’s an overuse injury and is very common in runners.  It is the result of your patella tendon being overstressed.  Due to both knees being affected, your foot biomechanics would also need to be assessed and an assessment of your running shoes performed.  The reason as to why patella tendinitis occurred would need to be established and then addressed as well as a progressive treatment plan to clear the pain.  


Secondly, due to the fact that both knees are sore and they feel ‘restless’ the day after running, this could be coming from a low level of nerve irritation in the lower back, of the nerves that supply the knee. If this is the case it is identified by finding the appropriate stiff segment of your spine and manually mobilising or loosing it which will reduce and stop the nerve irritation of the nerves supplying the knees. We see both problems on a regular basis in runners and it can be cleared in nearly all cases with the correct rehab problem.


Question:  I keep getting a recurrent strain in and around my calf which was diagnosed by a physio as posterior tibialis tendinitis. It got to the point where I had to stop running for 2 months as I was limping after each run. I tried road running again recently and the niggle was back almost instantly albeit not to the same extent as it was before. Any tips on how to manage this without having to stop running again for a lengthy period?


Answer:  We see a lot of recurrent calf problems at Apex Clinic. If you’ve had local treatment to the area and have followed a graded approach to return to running and it has still returned, then it sounds as though your symptoms may be due to a lack of nerve movement (altered neurodynamics) of the nerve (tibial nerve) that passes through the calf muscles. This could be due to scar tissue within the calf muscle itself following a microtrauma of the muscle.  Unfortunately, however there are generally no self management strategies to clear this problem and only a thorough physiotherapy assessment to establish exactly where the source of your pain is, and a subsequent treatment plan is essential to clear it.  As you describe the symptoms as recurring, it sounds like a mechanical problem, therefore resting alone is unlikely to clear it, because as soon as you begin running again the problem will recur unless the mechanics of your problem are addressed.  Feel free to contact us for a second opinion.  We’d be happy to help.


Question:  I was out running 10km last night and I managed to hurt my hip.  It’s a shooting pain and ever since then it’s been quite annoying. I went to see my doctor and he said it’s a hip bursitis.  He gave me anti-inflammatory tablets to take.  Are there any other natural things I can try to help? Should I still try to train, or rest and recover?  Is taking supplements beneficial? What would you recommend that I do?


Answer:  Initially, you should rest from any activity or movement that causes the pain.  The rule of thumb is - don't do anything that reproduces your pain for the first three or four days.  After that, you need to get it moving to prevent other problems from developing.  Ice can be applied for the initial two or three days post-injury if you feel there is any ‘heat’ around the injury.  Apply ice for 20 minutes each time, every 3-4 hours where possible during the day for the first few days.  Ice should also help to reduce your pain and swelling.  If it is a true hip bursitis, this is an inflammation of the bursa (a small sac of fluid), we would advise a physiotherapy assessment to establish why this has happened in the first place. The anti-inflammatories the GP has prescribed should also help the pain, but not the cause of the problem. If the pain doesn’t settle within a week, we would advise a thorough physiotherapy assessment to get to the source of the problem and clear your pain.  There is no medical literature to suggest that taking dietary supplements in this case will help.

Q & A from Injury Clinic on Thursday 1st October 2015:

Question:  I have been suffering from pain in the buttock (gluteal) area. The pain seems deep and appears to be connected to the upper hamstring. I would describe the pain as an achy feeling both in the buttock area and hamstring area. It affects the length of my stride. The symptoms sound similar to a high hamstring tendinopathy.  I am considering having an MRI scan to identify the exact cause of this pain, because the injury has lasted so long (12-18 months) and treatment, although it has loosened the area, has not cured the problem.  From a physio perspective, would this help in the treatment of this type of problem? Would a consultant need to report on the scan, or can a physiotherapist read them just as well? Thank you.


Answer:  From what you have described it sounds like the pain in your buttock could be referred from your lower back, due to a stiff segment in your spine, at an area where the nerves supply the hip/gluteal region, which is often aggravated when running. There could well be secondary muscle spasm over the hamstring area, but if local treatment hasn’t resolved the problem and it has been on-going for 12-18 months, it is more likely that the pain is referred from your lower back. Until the specific stiff segments in your spine are manually mobilised, it is unlikely that your symptoms will fully resolve.  An MRI scan of your gluteal region may certainly be helpful. These are usually read by a consultant radiologist and a report is then sent to the physiotherapist who is treating you. However, we treat a lot of runners with similar symptoms whose symptoms clear completely with the correct treatment without a scan being needed.  At this stage, we would advise a full assessment of your condition including your lower back prior to having an MRI scan. If you would like any more advice please feel free to get in touch with us here at Apex clinic. 


Question:  After long marathon training runs of 2.5hrs and more, can you recommend any simple exercises to release a tension build up in my shoulders? I try to run relaxed but tension can still gather in my shoulders.  This is not such a problem when the runs are off road. 


Answer:  This is a common problem with runners. Concentrate only on running in a relaxed manner. Don't hunch up your shoulders while running. Deliberately let your shoulders drop if they rise upwards. Concentrate on holding your arms more loosely, keeping your elbows at 90 degrees bent or slightly less bent than this.  Since you are running for longer periods, let your arms swing a little from your abdomen periodically.  Keep your wrists limp.  There are some simple shoulder exercises on the Runner’s World Website (HERE) that you may find useful on the link below.  Also, a hot shower allowing it to run over the shoulders or a deep soft tissue massage every 4-6 weeks can also be of benefit . Hope this helps. 


Question:  I've had a pain in my right knee for a few months, below the patella. It happened after the Ards half marathon. I have rested it and tried strengthening but it can still be a bit sore. There is also a nip when straightening the knee.


Answer:  This is hard to diagnose accurately without assessing your knee fully, however it sounds like it could be patellofemoral pain.   This is caused by a tightness of the structures on the outside of the knee along with weakness of the muscle on the inside of the knee, which doesn’t allow the knee cap to glide properly. This can be caused by an increased running mileage, increased hill work or generally overloading the area.  The good news is that with the correct treatment regime including specific stretches of the patella inwards and strengthening of the muscle on the inside of the knee, usually the pain can be completely cleared.  An assessment of your foot biomechanics (the way in which your feet move) would also need to be done, to assess whether insoles need to be added in or not.  At this point, we would advise a physiotherapy assessment by a physiotherapist who is experienced in treating runners and currently don’t do any strengthening exercises in the presence of pain.  All exercises which are done need to be done in a painfree manner, as the muscle on the inside of the knee will not strengthen effectively in the presence of pain.  Hope this helps. 


Question:  I've been running for nearly 2 years now. During training for a half marathon earlier this year I developed a lump on the top of my foot, about where my laces would tie. The lump is always there but it's not always sore. Sometime it is sore after a hard training session or after more than 10 miles of running, when it gets agitated, more swollen and has a dull pain in it. I thought the issue may have came about from tying my laces too tightly but I have adjusted them and changed trainers several times and now my other foot is starting to have the same issue. Is this a common thing to have as a runner?


Answer:  Yes, this is quite a common problem we see and treat here at Apex Clinic. Rebecca Nelson our Director of Physiotherapy here at Apex, wrote an informative article called “Laces too tight? Or is there another reason for pain on the top of your foot.”  This article can be found on the NI running website under the physio section and covers the most common causes of this pain.  The treatment for this pain purely depends on the diagnosis for it.  From what you have described, your pain on the top of your foot/feet may be due to altered neurodynamics, but really a thorough assessment would need to be done to be certain of the correct diagnosis and subsequent treatment.  Unfortunately there are no self management strategies to suggest to help you.  Feel free to give us a shout. 


Question:  I have anterior knee pain and I’m attending a physio.  It is so painful on walking and up and down stairs. I’m just worried that I'll never be able to run again!?


Answer:  It is hard to diagnose what is causing your pain with the limited information we have, but the most likely cause of this pain is due to patellofemoral pain. We’ve seen many severe cases of this which can be cleared completely and the patient is put on a pathway to a graded return to running. In some cases, the person may have to adapt the surfaces they run on or cut out hill running or add more rest days into their training regime. But in the vast majority of cases, this pain can be cleared with a full return to running.  It is hard to comment on your specific case without knowing your history and treatment progress. I would advise you to discuss your concerns with your physiotherapist and if you don’t make a full recovery or would like a second opinion please feel free to give us a shout here at Apex Clinic. 


Question:  I have had a bit of pain in the left buttock area this week. What’s the best way to help to get rid of it.  Are there any stretches? Foam rolling? I have been running but the pain isn't during running, it just comes and goes from time to time. I’ve been doing a lot of bridging to help to strengthen my hamstrings, would that be why?


Answer:  Stretching can sometimes help to relieve buttock pain.  A simple stretch for your gluteal (buttock) muscles is: 


1. Begin seated on the ground with your legs straight out in front of you.

2. Bend your left knee and place your left heel as close to your right sit-bone as you can.

3. Reach your left arm behind you, and plant your palm or fingertips on the floor. Place your right hand or elbow on your left knee or thigh, and gently pull your knee to the right until you feel the stretch in your buttock.

4. Hold for 30 seconds, then release and straighten your legs again.  Repeat 3-5 times twice daily. 


We do not advise foam rolling for buttock pain as really this is not addressing the root cause of the problem.  It may be helpful for you to read the article written by Rebecca Nelson, our Director of Physiotherapy here at Apex Clinic called “Is running giving you a pain in the butt”.  This article can be found on the NI running website under the physio section and covers the most common causes of buttock pain. 


We also advise you to reduce the bridging exercises in case that this exercise did trigger the pain, as this is a possibility.  If the pain persists for longer than 2-3 weeks despite stretching, we would advise a physiotherapy assessment to accurately diagnose the cause of your pain and subsequent design a treatment plan to clear it.  Hope this helps to get you back to pain-free running.

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.  

Q & A from Injury Clinic on Thursday 6th August 2015:

Question:  In the last 6-7 months, I have been having cramps in my right calf any time I participate in speed sessions at my local running club. Have you any ideas?


Answer:  It sounds like it could be due to one of two things. Firstly, the cramps could be due to a build up of scar tissue due to micro trauma of the calf muscle fibres (tearing of these fibres), which becomes more apparent when you stress the muscle during speed work.


Secondly, your symptoms could be coming from the tibial nerve (the nerve that runs down the back of the calf muscles) which isn’t moving freely within your calf muscle. This again could be due to scar tissue within the calf muscle following a micro trauma of the muscle itself. During speed sessions the tibial nerve has to move more due to the increased stride length involved, and this then could cause symptoms as the nerve is aggravated by the scar tissue. 


In nearly all cases, your symptoms should be able to be cleared completely with the correct physiotherapy treatment. If this has been going on for the past 6-7 months I would advise you seek a specialised physiotherapy assessment sooner rather than later to get you back to pain-free sprint sessions. Good luck.


Question:  Six weeks ago I fell during a run, hitting my knee off the ground. The swelling has now gone and the cut has healed, however now when I run it feels like the knee cap is actually moving. Do I need to rest it more?


Answer:  The most likely cause of the feeling that your knee cap is moving during a run is due to the swelling following the fall which will have caused the muscle in the inner knee area (the VMO muscle) to switch off temporarily. The research has shown that this occurs with only 5mls (a teaspoon) of fluid around the knee. This is likely to have caused patella instability (a feeling of more movement occurring at the knee cap). Physiotherapy treatment is normally very successful and in most cases this can be completely resolved with the correct regime, which includes a strengthening program for the VMO muscle and specific patella (knee cap) stretches in different positions of the knee, performed by the physiotherapist.  Hope this helps.


Question:  I've recently had a trapped nerve in my back and am still getting some pain in my upper and lower arm when running. Have you any advice on how to strengthen this to stop the pain? It gets worse the longer I run.


Answer:  Thank-you for your enquiry. From what you have told us it certainly sounds as if you still have a nerve irritation problem in your neck/upper back which is causing the symptoms of pain into your arm. Unfortunately, there are no self-management strategies or strengthening exercises to improve your symptoms at present and in our experience if it is left untreated it may eventually lead to weakness and possibly altered sensation into your arm. This is more serious and can take longer to cure.  At this stage we recommend that you get a specialised physiotherapy assessment of your neck, upper back and arm in order to correctly diagnose and tailor a specific treatment plan to suit your needs.  Here, at Apex Clinic we specialise in the spine, nerve pain and sports injuries, so we would be delighted to see you as we specialise in this area of treatment.  At present, you should rest from longer runs as the repetitive action of your arms is causing further neural irritation and hence increasing the pain you are experiencing.  Best wishes.


Question:  I hurt my back deadlifting 11 weeks ago. The injury is a bulging L5/S1 disc. It has taken this long to get enough flexion to touch my feet. I tried a test run after the pins and needles went 3-4 weeks ago. After 1km it felt like I was running with a wooden peg leg! There was zero push off. I've been cycling since about week 2 following the injury. My power feels nearly there on the left leg when cycling. I've not had an MRI scan and it has appeared always to be improving, however the last 20% has taken 4 weeks. 


I've seen a physio and that has helped a bit. I’m also doing my own daily program of foam rolling and resistance band exercises that has helped a really good amount. The question is, how long best-case-scenario, would it take to get back to my 50 mile running weeks? Is there normally a rehabilitation process with running? Thank-you very much for you valued opinion.


Answer:  Thank-you for your enquiry. From the information you have given us, it sounds as though there may be more than one level or segment of your spine which has been affected from the injury. As your injury occurred from deadlifting, this exercise puts the thoracic region under a lot of stress as well as your lumbar region.


L4/L5 and L5/S1 are the most common levels of your spine to be involved in a disc prolapse (bulging disc), however from our experience in Apex Clinic, we see many similar weight lifting injuries which also caused an irritation higher up in the spine in your lower thoracic region.  A common symptom of this can be a heavy, dead or weak feeling in the whole leg or as you described running on a ‘wooden peg leg’. It is great that you are using self management strategies such as the foam rolling and resistance work, however without treatment of all the involved segments of your spine (spinal mobilisation) you may not clear that last 20% of symptoms.  In terms of getting you back to running your 50 mile week, it is very difficult to put a time frame on this without seeing a specialised spinal physiotherapist to assess all possible involved levels in your spine, (and subsequent treatment), and also knowing exactly where you are up to with your training currently. Feel free to get in touch as here at Apex Clinic we specialise in the spine, nerve pain and sports injuries and would love to help.


Question:  Hi Apex Clinic.  I'm a keen runner but have been getting pain right behind my left hip bone.  It is tender to the touch but seems to get worse after I’ve been sitting a while or driving. I've had this for months now and I can’t seem to shift it. Have you any ideas?


Answer:  The pain that you’ve described is unlikely to be originating from your hip. As our team of physios here at Apex Clinic are specialised in the spine, we are very familiar with referral patterns coming from the spine i.e. which symptoms sound like they are originating from the lower back or from other areas of the body and from which level of the spine they are originating from. From what you have described it is much more likely that your symptoms are being referred from your lower back, due to a stiff segment in your spine, at an area where the nerves supply the hip region, which would be aggravated by sitting or driving as you described. There could well be secondary muscle spasm which is why you may feel tender to touch.  Until the specific stiff segments in your spine are mobilised, it is unlikely that your symptoms will fully resolve. The fact that your pain has been there for months already, suggests to us that you really should have a full physiotherapy assessment and treatment to clear the pain once and for all.  With the correct regime of treatment, the pain should clear nicely.  


Question:  Hi Apex Clinic.  I had to stop running 6 weeks ago due to Achilles pain. I rested it and did my first 10 minute run 3 days ago.  It was fine at the time but sore for the following two mornings. Any advice would be much appreciated.


Answer:  Tendoachilles (TA) problems can be one of the most stubborn injuries for runners if managed incorrectly. The first line of treatment is usually rest as you said, also ensuring your trainers are biomechanically supportive and then progressive stretching of the 2 calf muscles, twice daily. If this has not decreased your pain, then we would strongly advise you see an experienced physio for an assessment to establish the correct cause of the Achilles pain and subsequent treatment plan.  It sounds as though your symptoms may be due to a lack of nerve movement (altered neural dynamics) of the nerve (tibial nerve) that passes through the calf muscles and Achilles tendon.  Your foot biomechanics will also need to be assessed to establish if any insoles are needed or not and a strengthening program will need to be added, which includes heel dip exercises off a step.  The good news is that this problem can usually be cleared completely with the correct physiotherapy treatment.  

Q & A from Injury Clinic on Thursday 4th June 2015:

Question:  I was diagnosed with ITB (iliotibial band) syndrome five weeks ago. I've had anti-inflammatories and been resting since. I'm also using a foam roller, stretching, strengthening and had a massage. I really need to get back running but I don't know how long to rest or if I should run or what to do now! I'm struggling to get past 4 miles which is very frustrating as a marathon runner. Help!


Answer:  At this stage, to get the problem cleared you really should not resume running until you are pain-free walking, fast walking and using the cross trainer.  It may be helpful for you to read the article on ITB problems by our Director of Physiotherapy, Rebecca Nelson which is on the NI running website under the physio section and this will give you more detail on the best exercises to do to gain hip stability and therefore less pain as part of the rehab program. Your foot biomechanics will also need to be checked, to assess if you need either over the counter insoles or custom made insoles to improve your foot biomechanics.


Since your symptoms have been persistent for 5 weeks, really at the moment you should seek an assessment by a physiotherapist experienced in running injuries, as you may need some hands on deep soft tissue release techniques to the appropriate hip muscle groups as detailed in the article above. The longer you have this problem the harder it will be to clear so please take action now. Thank you.


Question:  Recently I have developed soreness on the inside of my right ankle, just above the actual ankle. It gets worse the longer I run and when I do speed work the pain becomes sharper. Last week I made the decision to rest and I am also seeking treatment, although I haven't had any answers as yet. Have you any ideas?


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) and this would fit in with your symptoms being worse with speed work (and it also is often worsened by down hill running).


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. 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 to get you back to pain free running. If you need any more advice, feel free to give us a call. Thanks.


Question:  I think I have a stress fracture of my little toe. It is sore when I put pressure on the outside of my foot, close to the base of the toe and is especially sore when running. I have a doctor’s appointment booked for next week. I have run through it for a month, but realistically how long can I wait before I start training again? Is there anything that can be done to speed up the process?


Answer:  It is great that you are seeing your GP next week, as really you definitely need an x-ray of the toe to confirm if it’s actually broken (fractured) or not. As, if it’s painful, but not broken, then the time frames for returning to running will be different than if it’s broken.  If it is fractured, then you must not run for approximately 8 weeks, but can maintain your running fitness by aqua jogging, and you could use the cross trainer to maintain your general fitness after 4 weeks. To speed up the bone healing, all you can do is- eat a healthy diet, plenty of diary products and fruit and vegetables; don’t smoke; take calcium supplements from a local chemist or health food shop (this isn’t proven, but many folk swear that it speeds up bone healing); and don’t overload the toe too early ie. don’t run on it too early or else you will delay healing by causing micro motion at the fracture site. Hope this helps and good luck!


Question:  I'm getting pain in my calf (soleus) after running in both legs. I've recently got orthotics but it still seems to be occurring. I am only running about 25-30 miles a week. There is a dull type of pain in the morning when I get up.


Answer:  That’s great that you have had your foot biomechanics checked however the dull pain you reported in the morning is unlikely to be coming from the muscles as they have been at rest overnight and is more likely to be referred pain from your lower back. This is a very common problem we treat 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, it can cause referred pain into the calf muscle. There is a common misconception that you need to have lower back pain to have pain referred from the lower back, but this is definitely not the case. The reason the pain is present in the morning is because overnight, the discs absorb fluid and are slightly bigger, which makes the discs more likely to leak and irritate surrounding nerve tissue causing pain in the legs.  We recommend a thorough assessment from a physio who specialises in spinal problems to identify and treat the source of your problem, by gently loosening the tight segments and enabling you to return to pain-free running under their guidance.


Question:  Hi. I'm getting pain on the outside of my knee. It initially started on a hilly 10k run, about 4 miles in the pain started but I kept going. It was worse going up hill. I rested for a week but then I only managed 1 mile of running before I had to stop with the same pain. I rested it for another week and then I did 5 miles last night but I had the same pain after 2.5 miles. Any ideas?


Answer:  From the description of your pain, there are 2 likely causes. It may be due to the ITB (iliotibial band) rubbing at the outside of your knee (ITB Friction Syndrome) and if so, there is usually tenderness to touch the ITB at the outside of the knee. It may be helpful for you to read the article on ITB problems by our Director of Physiotherapy, Rebecca Nelson which is on the NI running website under the physio section, which will give you more detail on the best exercises to do to gain hip stability and therefore less pain as part of the rehab program. If this is the case, try the exercises for a few weeks and hopefully the pain will clear.


Alternatively, the pain may be referred pain from your lower back due to the increased impact on your spine during running and especially up hill running. If this is the case, it is usually easily cleared with the correct physiotherapy treatment. Unfortunately, there are no self-management strategies to clear this alone. Hope this helps!


Question:  When I put pressure on my foot, I have a pain which shoots into my middle toes. What would this be, and am I doing damage by running on it?


Answer:  Firstly, we would advise resting from running at present. The pain is there for a reason and running through it could cause more damage/injury. It sounds like it could be either a strain on the capsule of the metatarsals (toe joints) or a Morton’s Neuroma.

In either of the above cases, we would advise a biomechanical assessment by a podiatrist who’s experienced in running injuries, to see if you need either over the counter insoles or custom made insoles to improve your foot biomechanics. You also need a thorough assessment by an experienced physiotherapist to confirm the possible diagnosis mentioned above and to treat it accordingly. Hope this helps.


Question:  Recently, I completed my first marathon in London. However, at 16 miles I had a horrific pain on the outside of my knee. From this, I haven't been able to surpass 6 miles without it flaring up again. I have been reading up on this and it seems to be the ITB (iliotibial band). I have been resting and stretching. Is there a fixed time for recovery or how do you know when it becomes injury free?


Answer:  For this injury to become pain-free on running, you should only resume running once you are pain-free walking, fast walking and using the cross trainer. If this is the case, then a graded approach to returning to running is advised. The graded approach that we recommend is to reduce your mileage by 50% prior to injury, allow a rest day between each run and avoid hills and speed work until you are back running at 75-80% of your mileage prior to your injury. Always increase one thing at a time, either your distance or your speed.


It may be helpful for you to read the article on ITB problems by our Director of Physiotherapy, Rebecca Nelson which is on the NI running website under the physio section, which will give you more detail on the best exercises to do to gain hip stability and therefore less pain as part of the rehab program. Your foot biomechanics will also need to be assessed to see if either over the counter insoles or custom made insoles to improve your foot biomechanics are required. Due to the level of running you have been doing, you may need some hands on deep soft tissue release techniques to the appropriate hip muscle groups as detailed in the article above. Hope this helps.


Question:  I have a pain deep in the crease of my groin. Initially (about 6 weeks ago) it hurt when I coughed/sneezed and after I ran. I checked with my doctor to rule out appendix issues. His opinion was that it may develop into a hernia if it continues to get worse, but didn't offer any advice.

I have rested and after doing a training run, there is always a pain there. It doesn't seem to get worse but doesn't improve with time. Because of where it is I don't really know how to address it, by stretching or massage?


Answer:  It’s good that you have had the pain checked by your GP to rule out a current hernia. The pain in your groin sounds like it could be coming from your lower back (discogenic- ie. the disc of origin). This groin pain, is a common problem from the discs in the upper part of your lower back region and is caused by nerve irritation in that area. Sneezing and coughing increases the groin pain because it increases the pressure within the discs, causing pain.


At present, we would advise you to take a short break from running in order to reduce your symptoms and the load on your lower back. During this break, physiotherapy treatment is also required to mobilise or loosen the area of the spine from which the pain may be coming from, to completely clear your symptoms. We recommend a thorough assessment from a physio who specialises in the spine to identify and treat the correct source of your problem, and get you back on the road running painfree.

Q & A from Injury Clinic on Thursday 7th May 2015:

Question:  What's the best exercise to strengthen your IT band?


Answer:  The iliotibial (IT) band is a tendon-like length of connective tissue that runs along the outside of the leg from the hip to the knee. Whilst you can’t strengthen the actual IT band you can strengthen the hip abductors and hip external rotators (the muscles on the outside of the leg) which help to stabilise the IT band. Two great exercises for this are- the clam exercise lying on your side and another exercise involving lifting your leg out to the side with a straight knee when lying on your side or when standing.  These exercises can be progressed by using therabands to add resistance to the exercise.  On each exercise complete 3 sets of 20 reps twice daily.  For more information on ITB problems and the rehab of them, you may like to read an article on this, written by Rebecca Nelson, Director of Physio here at Apex Clinic on the NI Running website, under the physio section.


If you are experiencing pain during the exercises or during activity we would strongly advise that you have a physiotherapy assessment to get to the route of the problem, and to ensure that you can complete the exercises pain-free and can progress them as appropriate.   

Hope this helps.


Question:  My right calf has been giving me problems over the past 4-6 weeks. It feels tight and when I do speed work it just feels like it is going to 'pop'. I have tried sports massage.  Do you have any other advice? Thank you.


Answer:  It sounds like it could be one of two things. The tightness could be due to a build up of scar tissue due to micro trauma of the calf muscle fibres, that becomes more apparent when you stress the muscle during speed work giving you the feeling it could ‘pop’ as you don’t have the flexibility in the muscle. You said that you have had a sports massage, if this didn’t work it could be that it wasn’t deep enough into the muscle or did not move through the full range of movement of the muscle, lengthening the muscle during the massage. 


Secondly, your symptoms could be coming from the tibial nerve (the nerve that runs down the back of the calf) which isn’t moving freely within your calf muscle.  This again could be due to scar tissue in the calf muscle following a micro trauma of the muscle itself.  During speed sessions the tibial nerve has to move more due to the increased stride length involved, and this then could cause symptoms as the nerve is aggravated by scar tissue. 


In nearly all cases, your symptoms should be able to be cleared completely with the correct physiotherapy treatment. I would advise that if you have tried a sports massage and this didn’t help, to have a physiotherapy assessment to have your problem correctly diagnosed and get you back to pain-free sprint sessions as soon as possible. Good luck!


Question:  Hi there, I just wanted to enquire about a pain in my back and neck.  It was fine prior to taking up running but since then, I have found that the muscles on the left side of my neck at the base and shoulder are so sore and stiffen up when running. It is only on the left hand side and not the right. On occasions I can't even look down as the pain in my neck and shoulder is so sore.  I've been for sports massages and this has been of limited help. Would you have any suggestions to help me? It makes long distance running incredibly painful.


Answer:  The pain on the left side of your back and neck sounds as though it could be caused from stiffness in a segment of your neck or upper back region. This can be aggravated by running alone, or by poor running posture, increased running distance or hill running.  You said that you have been for a sport massage which hasn’t significantly helped.  Usually, the muscles on either side of the spine will be stiff and painful around the area where there is joint stiffness, therefore a massage may reduce the symptoms however, without mobilizing or loosening the joints, sports massage will only offer short term relief.  The fact that your movement is restricted also, would suggest that a physiotherapy assessment rather than a sports massage at present, is what is needed.  We would also advise you to either stop running at the moment or to reduce your running distance until you get this problem resolved.  Hope this helps.


Question:  I have a dull, sometimes sharp pain high on the outside of my right calf. This seems to occur if I've been sitting at my desk at work for any extended period.  I have tried strengthening and foam rolling to help, but with no luck yet!


Answer:  The pain you describe in the outside of your right calf is most likely to be referred from your lower back and this is a very common problem which we treat here in Apex Clinic (as we specialise in spinal problems and sports injuries, this is our bread and butter!). 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 up in a segment of the spine, poor posture or long periods of sitting at a desk can load the stiff segment of the spine even more, and can cause disc related symptoms. The most common misconception that people often have, is that you have to have back pain to have pain referred from the back into the legs.  This is definitely not the case. When you are sitting, you are not moving the calf muscle so it is very unlikely that stretching or strengthening the calf will work. There generally are no effective self management techniques to clear these symptoms so we would recommend a thorough assessment from a physio who specialises in the spine to identify and treat the source of your problem.  We understand that this is a debilitating problem, but it should be able to be cleared fairly quickly with the correct treatment. For now, the best advice is to take regular standing and walking breaks from sitting at your desk and ensure you are sitting with good posture.


Question:  Hi.  I have a burning pain in the centre of my back and my lower back is very stiff. Also, I’ve been getting pain in my left hip.  I have stopped running altogether. Any ideas?


Answer:  The burning pain you describe in the centre of your back referring into the left hip is most likely all coming from your lower back and is a very common problem we treat. 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. Although we agree that currently you should take a break from running in order to reduce your symptoms, this alone unfortunately won’t be enough to clear your symptoms once you return to running, 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 present exactly as before.   Therefore we recommend a thorough assessment from a physio who specialises in the spine to identify and treat the source of your problem and enable you to return to running under the guidance of your physiotherapist.


Question:  When running, about 3 miles into the run I get weakness in my left knee as if it’s going to give way. I am not running very fast, 7.30 to 8 minute miles. After 10k I am sore but not in severe pain. It is not my cruciate as I had the same problem in my other knee as well. Any ideas? Are there any remedies or type of strapping you would recommend? 


Answer:  If you have had the anterior and posterior cruciate ligaments ruled out as causing the symptoms (because of the excessive gliding of the lower leg which would occur and this in turn would lead to weakness of the knee) then, a feeling of weakness in the leg can result from a low level of nerve irritation in the lower back, of the nerve that supplies the thigh muscles. If this is the case it is identified by finding the appropriate stiff segment of your spine and manually mobilising or loosing it which will reduce and stop the nerve irritation of the nerves which supply the thigh muscles. We see this scenario on many occasions in runners and it can be cleared in the vast majority of cases. Strapping is not recommended here as it is not getting to the route of problem and is unlikely to help. Please feel free to get in touch with us, to get this problem cleared.


Question:  I have been having trouble on my right shin for the last 6-8 weeks.  It started with pain on the shin bone but I was still able to run.  Later, with speed work and training for a 10k run, my shin bone and the muscle around it, and even my calf muscle became sore and the soreness was such that I was only able to run once a week. I have stopped running over the last two weeks to see if this helps but I am wanting to get back to running to prepare for the Dublin marathon.  Any help is greatly appreciated.


Answer:  First of all, you need a thorough physio assessment from a physio who is experienced in treating running injuries, especially if you want to prepare for the marathon! Virtually all shin pain can be cleared with the correct treatment and in nearly all cases, the person can return to running painfree again.  A proper physio assessment involves assessing your foot biomechanics to see if any insoles are needed ONLY if you have poor foot biomechanics and also establishing a correct diagnosis for the shin pain. 


There are many causes of shin pain and they are mostly treated differently.  The most unlikely is a stress fracture and other causes include tenoperiostitis (inflammation of a muscle attaching into the shin bone), nerve pain of the nerve running through the front of the shin, and less likely compartment syndrome.  Rebecca Nelson, Director of Physiotherapy here at Apex Clinic wrote an article on shin pain, which you can read on the NI running website under the physio section, and this article will give you more information on the different causes of shin pain.  Honestly, shin pain which continues for more than a few weeks should definitely be assessed by an experienced physio, as if it's poorly managed it can continue for months and even years.  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!) Feel free to give us a shout.


Question:  Hi.  When doing a long run, over 6 miles I get a pain/stiffness in my right shoulder, going from my shoulder to my ear and down to my elbow.  It will remain for a day after the long run but fades away over the next few days.


Answer:  It is very likely that the pain from your ear to your shoulder and into your elbow is all related and coming from your neck or your upper back.  This can be caused by having a stiff segment of your spine, in the neck region and when you increase your running distance this loads your spine and can stress the stiff segment of your spine, such that the nerves in the area are irritated.  This in turn causes your symptoms.  I would advice that you have a thorough physiotherapy assessment by a physio who specializes in the spine as your symptoms should be straight forward to clear, once the stiff segment or segments of your spine have been correctly identified.  Hope this helps.


Question:  My right hip is constantly painful.  The pain runs down my hamstring and around the knee.  I can find the trigger point deep in the hip. I’m wondering what is causing this and what techniques I could use to help recovery.  I've had this injury for a few months now.


Answer:  Sorry to hear that your injury has continued for a few months now. This pain that you’ve described is unlikely to be originating from your hip. As all of our physios here at Apex Clinic have undertaken extensive post-graduate training in spinal and nerve pain we are very familiar with referral patterns ie which symptoms sound like they are originating from the lower back or from other areas of the body.  From what you have described it is much more likely that your symptoms are being referred from your lower back, due to a stiff segment in your spine, at an area where the nerves supply the hip and knee. There could well be secondary muscle spasm which is why you can feel the trigger points, however unless the stiff segment in your spine is mobilised, it is unlikely that your symptoms will fully resolve.  The fact that your pain has been there for months, suggests to us that you should have a full physiotherapy assessment.   Feel free to get in touch.


Question:  Hi.  I injured my left hip during a 10k run about 3months ago and now I can’t seem to get past 5k without pain.  I’m usually ok for the first 3-4 k then the pain kicks in.  Any ideas? Any hip strengthening exercises you can recommend?


Answer:  Without knowing the exact location of your pain it is difficult to diagnose where your pain is coming from.  But from the information you have given us, without examining you, it is likely that your hip joint has been over loaded from longer runs and as a result, muscle weakness around the hip can occur.  If that is the case, a progressive program of hip stability exercises would be recommended which may help to unload the hip joint to some degree and should in turn lessen or clear the pain.  The latest article on the NiRunning website on IT band friction syndrome (written by Rebecca Nelson, the Director of Physio here at Apex Clinic) provides three exercises that should be appropriate for you and are likely to help.  If these exercises don’t help your pain however, then a thorough physiotherapy assessment would be advised.  Good luck.

Q & A from Injury Clinic on Thursday 2nd April 2015:

Question:  Carrying an injury. Bursitis of the heel. Have you got any advice on how to get rid of it?


Answer:  Yes, we treat bursitis of the heel (calcaneal bursitis) regularly and in most cases it can be cleared completely. The most important thing is to make sure that the diagnosis is correct. With a true calcaneal bursitis, checking the foot biomechanics is essential.  Ensure that your running trainers are in good condition and are still providing adequate support.  Calf stretches for both the gastroc and soleus 2-3 times daily are important, holding each stretch for 20 seconds and performing 5 stretches of each muscle group at a time.  (these stretches can be found on the internet).  Stretching the plantar fascia is also important (again, these can be found on the internet).  Local soft tissue work is recommended by an experienced physio, over and around the area to increase the circulation and speed up the healing process. 


In certain cases it may be helpful to get a felt pad with a circle cut out of it, for the back of the trainer to take the pressure off the bursa. In the vast majority of cases it can be cleared completely with the correct physiotherapy treatment but in rare cases a local steroid injection may be needed into the bursa, if it is resistant to conservative treatment. Hope this helps.


Question:  I started running approximately 6-8 months ago and have gradually increased my mileage. However, recently, whilst working on specific speed sessions I have had problems with my calves. In fast speed work I sometimes get sharp pains in them... then the next day it turns into a dull ache. Is this just because I have started speed work or do you think it is a weakness?


Answer:  It sounds like you could have one of two things going on, causing your symptoms. The first one, is where the tibial nerve (the nerve running down the back of the calf) is not moving freely within the calf muscle… this could be due to scar tissue in the calf muscle itself following micro trauma of the muscle itself.  This scenario often occurs during speed sessions because the stride length increases during speed sessions and the tibial nerve has to move more as a result.  


Secondly, the pain may be due to a build up of scar tissue due to micro trauma of the calf muscle fibres, that only becomes apparent when the muscle is stressed more, with speed work.  The first possibility mentioned above requires treatment from a physio who is experienced in treating nerve pain, to mobilise the nerve tissue. In the second case, the physio would apply local deep soft tissue therapy to the calf muscle itself, with the calf muscle positioned in a stretched position, in order to break down any scar tissue.


In nearly all cases, your symptoms can be cleared completely with the correct treatment. Unfortunately, there are no self management strategies which will help to clear your symptoms. Until you have treatment, we advise to avoid speed sessions and running down hill. Good luck.


Question:  I have knee pain that comes on gradually during a hard running effort. It’s actually behind the knee itself in the upper calf region, close to where tendons from the hamstrings meet at the inner part of knee. I am able to squat, jump, twist and turn. But during running, the knee pain gradually gets worse. This pain only started after a recent half marathon race. I’ve been icing and taking anti-inflammatories.  I would like to know if it’s ok to continue running after a few days off?


Answer:  If the pain is in the centre/inside of the back of the knee there could be a number of causes. If it is more the centre of the back of the knee, it may be due to poor movement of the tibial nerve (as detailed in a question above) and if it is more at the inside of the knee then it may be due to a tear of the posterior (back) horn of the medial meniscus (cartilage). If it is cartilage, then you will do further damage by continuing to run therefore we recommend you seek treatment from a specialist physiotherapist with relative rest from running. If it is altered neurodynamics, (poor nerve movement) continuing to run is more a case of hurt rather than harm, but either way it is very likely that you will need treatment to clear the pain. If there is any visible localised swelling, then it will implicate the cartilage more.  Hope this helps.


Question:  I have had a dull ache in my achilles for approximately 4-6 weeks. I have tried resting for a few days, but it hasn’t helped. Is there anything else I can do?


Answer:  At this stage we recommend that you reduce your running distance, speed and stick to running on a flat, soft (grass, bark or treadmill) surface. Stretch the two calf muscles - gastroc and soleus 2-3 times daily (these stretches can easily be found on the internet), holding each stretch for 20 seconds and performing 5 stretches at a time on each muscle.  Consider if simple over the counter insoles are needed if you have high arches or are flat footed to improve your foot biomechanics and/or shock absorption. Ensure your trainers aren’t too tight, and aren’t rubbing at the back of your heel.  We recommend for you to try this regime for a few weeks and if the symptoms don’t ease, then it’s definitely time to seek physiotherapy treatment.  Leaving this problem untreated could invite a possible tendon tear to occur, which is bigger trouble! Hope this helps.

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

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.

Q & A from Injury Clinic on Thursday 12th February 2015:

Question:  Over the last 2-3 weeks, I have been getting a dull pain in the area just below my left ankle on the outside of my foot. The pain is manageable but gets worse as I increase my mileage which is worrying as I am training for the Omagh half marathon.  Any suggestions?


Answer:  This is hard to diagnose accurately without assessing you in person, as gradual pain (ie there has been no direct trauma) on the outside of the ankle from running can be due to a number of different causes-


1. Overuse injury to the lateral ligaments in the ankle: a gradual pain from this can occur from high running loads (particularly rapid changes of direction, uneven surfaces or inappropriate footwear) causing the ligaments on the outside of the ankle to be overstretched and microtears to occur. Usually with this you will notice swelling around the area and there could be soreness when walking and on certain ankle movements.


2. 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 can refer pain into the leg and foot. 


3. Nerve pain from a lack of nerve movement specifically of the Superficial Peroneal nerve on the outside of your ankle. This is best known as altered neurodynamics and occurs where the normal slide and glide of the nerve around the ankle with movement is no longer able to occur normally. This injury is often worse when running down hill with a longer stride length or when running faster.  


Each of the above causes are managed differently so it is important that the source of your symptoms is correctly diagnosed so that an effective treatment regime can be commenced ASAP.   Feel free to get in touch.  For now, the best advice is to reduce mileage and to keep to soft, flat surfaces. Make sure you are in appropriate running shoes and are warming up effectively. 


Question:  I injured my left knee on Sunday, climbing over a wall trying to escape from a dog! The pain is on the outside of my knee, on the top of the tibia. There is no swelling, just pain. I'm limping, especially when going downhill. It isn't as bad when walking uphill or on the flat. I'm unable to run at all and the knee feels at times that it's going to give way. How long will I need to rest and is it too early to start a little cross training/strengthening exercises. I appreciate your advice. 


Answer:  From what you have described there is a distinct possibility that you have injured the lateral meniscus in your knee (cartilage) as this is most common by an impacted twist through your knee.  In order to diagnose this correctly an experienced physio can perform tests on your knee to differentiate between a cartilage injury and a ligament injury and therefore start the correct treatment.  There are varying degrees of cartilage injury and in order to not cause yourself any further harm, an assessment is recommended. 


In the mean time we recommend that you rest and do not attempt to run. Due to the fact that your symptoms are easily aggravated we do not feel you are ready to use a X-trainer but would suggest a low resistance bike. As for strengthening exercises, it’s too early as pain will cause inhibition of the muscles.   


Question:  I'm currently running on average 18 miles per week which I plan to increase over the coming weeks. I went for a 5 mile run tonight and right from the start my left calf was quite tight and I had to go at an easy pace just to finish the run. I warmed up properly.  I was wondering what the cause is likely to be? Poor form, worn out trainers or tired legs (training in gym every lunchtime)? Thanks.


Answer:  If you are doing a lot of running each week (and are continuing to build up) you may not be giving your calf muscles enough time to recover between runs ie your runs may be too close together and any repeated micro-trauma has not been given enough time to recover. The first 2-3 days following a long distance run are the most crucial to a good recovery and these are the days to take relatively easily and consider replacing running with X-training or swimming which will allow you to maintain fitness.


Have you had a previous calf injury? If so you will have scar tissue which will cause the muscle to shorten reducing the tensile strength and leaving you more at risk of recurrent microtrauma and tightness. We recommend that any runners who run 2-3 times weekly or more should have a monthly sports massage to break down scar tissue and adhesions and help maintain general muscle well being.  Of course shoes are extremely important and any unaddressed biomechanical issues will cause imbalance through the calf muscles and again leave you susceptible to injury.  If you have any queries about your foot biomechanics get in touch with our podiatrist or a local podiatrist. 


In the meantime, make sure your warm-up is based around dynamic stretches followed by static stretches after your run. At this stage you should perform calf stretches- 3x 20 second holds, twice daily (Look up specific Soleus and Gastroc stretches as the calf is made up of both of these muscles).  If your problem persists, one of our specialised physios would be delighted to assess you, to get to the root cause of your calf pain.


Question:  I have been having knee pain since early January which was diagnosed by a physio as due to the IT-band. I took a week off and am back running now. I have less pain and am doing regular hip stretches and strength work. However; there is still a bit of pain present. Is running through ITB knee pain (training for a marathon) a good idea? Or can there be any lasting damage from it?


Answer:  If this is a true ITB (Iliotibial Band) friction syndrome and you only took 1 week off from running it may well be that the band is still inflamed and you need further treatment with deep tissue massage, stretches of both the ITB and glutes, rest and strengthening of the hip abductors and hip external rotators. 1 week of rest is not long enough to reduce the inflammatory response and without a ‘graded return’ to running, you may have stressed the ITB too soon.  Alternatively, if you have exhausted the above treatment options and your pain remains, there is a possibility it may be due to poor nerve movement at the side of the knee (altered neurodynamics) which is very common in runners, especially those building up mileage. If this is the case there are no self management strategies but it can be effectively treated and cleared with the appropriate physiotherapy regime.  As with any injury we do not recommend you continue to ‘run through it’ as your condition is likely to gradually worsen and may result in compensatory changes and further injury elsewhere.  Best wishes.

Q & A from Injury Clinic on Thursday 4th December 2014:

Question:   I train regularly, 30-50km per week.  I did my first half marathon and it was pretty painful in the top of my hamstrings and lower glutes and this is quite normal for me with longer runs. I get no doms and stretching isn't overly uncomfortable.  Any ideas to help this?


Answer:  From what you describe your symptoms are unlikely to be a tendinopathy (tendinitis) of the hamstrings or a muscle problem; but rather one of the two following problems: Nerve pain from a lack of nerve movement or referred pain from your lower back.


1) Nerve pain from a lack of nerve movement.  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 which lies in the back of the thigh) 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.


2) 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 refers pain into the back of the leg. This sounds more like what you are describing as your pain tends to be present during longer runs. 


There are generally no self management strategies to clear either of these problems and only a thorough physiotherapy assessment to distinguish where the source of your pain is definitely coming from, is required to resolve your condition. In our experience pain in the lower buttock/ high hamstring area which is left untreated will gradually develop into pain radiating down the back of the leg as you continue to run high mileage.  Once this occurs, it takes longer to clear with treatment so feel free to get in touch with us. 


For now, the best advice is to reduce mileage and to keep to soft, flat surfaces. You will find on the NIRunning website an article about this under the physio section. Feel free to check it out!


Question:  Over the last 2 weeks I have felt a pain on the top of my left foot.  It’s not really sore to touch but it’s painful when I run and tends to get worse the longer I run.  If it was sore to touch I would understand, but I'm confused as it isn't.  What do you think?


Answer:  Due to the fact that you are unable to reproduce your pain by touching your foot, it is unlikely to be bony (a stress fracture) or soft tissue (a ligament strain or tendinopathy) injury.  It is likely to be another underlying structure, such as nerve tissue which is causing your pain.  The nerve may be causing pain due to a problem with poor nerve movement around the top of the foot (known as altered neurodynamics) and this problem needs to be treated otherwise it will remain persistent or get worse.  This problem can be nearly always fully resolved with the correct physio treatment by a physio who is experienced in treating nerve pain.  In the meantime we recommend you run for shorter periods and on the flat only (running down hill is likely to make this worse). I hope this helps.


Question:  I've been running for a couple of years but have been unable to for the last 3 months due to.pain in my glutes, lower back and into my leg. I’ve been attending a physio who.fitted me with orthoses but I’m still getting pain even when I’m standing or sitting.  Any suggestions?


Answer:  As all Apex Clinic physiotherapists have undertaken extensive post graduate training in the spine and nerve pain we are confident, from the information that you’ve given us that your symptoms are likely to be referred from your lower back and you will not get better unless you have the correct diagnosis and are treated accordingly.  We see many people in Apex Clinic who come wanting a second opinion when treatment elsewhere has not cleared their pain.


The spine is made up bones with discs in between which act as shock absorbers.  If, for whatever reason, the discs/ joints are irritated this can annoy the nerve tissue beside it causing referred pain down your leg.  In order to treat this successfully a specialist spinal physiotherapist will diagnose the exact source of your problem and treat it appropriately. It is very likely that your pain can be cleared completely with the correct treatment.  In the mean time we do not advise you to do any running due to the fact that you have pain even when you’re sitting or standing.  Please get in touch.

Q & A from Injury Clinic on Thursday 6th November 2014:

Question:  I have had an on-going issue with my hamstring for over 4 years. The first injury was slight strain while playing football in the upper hamstring near the buttock. I didn’t feel it sore until after I stopped playing that day. I continued to play and carried on training over the next few weeks with a slight bit of discomfort.  However, the niggley pain wouldn’t go away and I eventually rested the leg for one month. After this month of rest I found that even a light jog still caused it to niggle. 


This has been on-going for a few years. Currently I feel the pain mostly when running up hills or sprinting. I have tried every stretch possible and have had regular massages in the area but feel it is difficult to get anywhere near it. I personally feel that this is some sort of tendonitis? Any help would be appreciated


Answer:  At Apex Clinic we have successfully treated many runners with re-occurring hamstring pain. From what you describe your symptoms are unlikely to be a tendinopathy (tendinitis) but rather 1 of the 2 following problems:  Nerve tissue dysfunction or referred pain from your lower back.


1) Nerve tissue dysfunction resulting from scar tissue (caused by previous torn muscle fibres of the hamstrings) attaching to neighbouring nerve tissue in the thigh. This then reduces the ability of the nerve (the sciatic nerve which lies in the back of the thigh) to naturally slide and glide with movement. This is best known as altered neural mechanics. This injury is often worse when running down hill (with a longer stride length) or when running faster.


2) 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 usually irritates the nerve leaving the spine and then refers pain into the back of the leg. This sounds more like what you are describing. 


There are generally no self management strategies to clear either of these problems and you would require a thorough physiotherapy assessment to distinguish where the source of your pain is definitely coming from in order to stop your symptoms progressing and to fully resolve your condition. Feel free to get in touch with us.  For now, the best advice is to reduce mileage and to keep to soft, flat surfaces.  You will find on the NI Running website an article about this, written by ourselves, under the physio section. Feel free to check it out!


Question:  I ran my first marathon in May. I followed a 16 week training schedule and it went well. During the race I was running well, until about 18 miles, when my leg muscles started to tighten up a lot and really slowed me down. I managed to rally somewhat in the last couple of miles and finished in 4 hours 22 minutes.  At the start of July, I started another 16 week training schedule ahead of the Dublin Marathon. On longer runs, after about an hour or so, I would suffer from a severe pain at the top of the outside of my right thigh. The pain was so severe that, during my longest training runs, after about 13-15 miles, I had to stop running and walk/jog home. I visited a sports masseur and used a foam roller and hoped that the problem would ease before the marathon.


On race-day, I taped the problem area and hoped for the best. Everything was going fine, until about 12-13 miles, when I started feeling a rapidly increasing tightness throughout all of the muscles of both legs (though, strangely, not particularly in the previously problematic right thigh/hip area). I battled on until about mile 18 when I gave up and walked the rest of the course (crossing the line after a disastrous 5 hours 45 minutes).  Can you advise what might be the cause of the deteriorating in my marathon running?


Answer:  Well done on completing your 2 marathons.  From what you are describing your problem sounds very like a nerve irritation originating from your spine. You do NOT need to have accompanying lower back pain for this to occur.  As you have been training for, and have run, 2 marathons this year there has been a lot of mechanical loading through your back. This has likely overloaded a joint or disc in your back which has in turn irritated the neural tissue beside it causing generalised muscle tightness and intermittent episodes of severe pain. The fact that the tightness occurs on both sides further indicates this.


Really you require an appointment with 1 of our specialised physiotherapists who will be able to assess you to diagnose where exactly the source of your problem lies. If you continue to train without treatment you will find that gradually the symptoms (pain and tightness in muscles) will come on quicker and take longer to resolve between training sessions.  In the meantime if you are keen to continue running we recommend shorter, flatter and softer (treadmill, grass, bark etc) runs.  Goodluck!


Question:  I have been told I have mild arthritis in my ankle.  Just wondering about how much I can run on it?  I do a lot of mountain running and indoor cycling, any advice?


Answer:  A diagnosis of arthritis is made from an X-ray which will visually indicate the quality of the joint surfaces of the bones in your ankle joint. You probably know that continued repetitive impact through the ankle joint will gradually worsen your condition as the pressure on the bone surfaces increases leading to further arthritic changes.  Understandably, in order to keep up your mountain running performance you will need to do an element of running training! The best way to do this is by aqua-jogging (running in the swimming pool) and X-training. Neither of these exercises involve high impact but closely resembles the mechanics of running. When you occasionally do choose to go for a run, a softer running surface is best (bark, grass, sand or treadmill). 


Cycling indoors is not a problem and is of benefit in helping to keep the ankle joint mobile.  If your arthritis is causing a loss of your ankle joint movement or any pain then it is advised to seek physiotherapy treatment in order to stop your symptoms progressing and of course to give you relief. Best Wishes.


Question:  I have been suffering with calf pain for almost 4 months. It started as a slight twinge but has now developed into a pain that feels like someone is cutting my calf muscle at the point where it meets my tendon. I have had treatment, needling, rest and stretching. I thought I was getting rid of it but I pulled it again tonight. I’m so frustrated with it!! I have until March to get ready for European masters indoors! Help!


Answer:  It certainly sounds as if you have a reoccurring calf strain, the question is, “What is causing the calf to keep tearing?” Unless you are returning to sport too quickly, the likelihood is that you have altered neural mechanics (a problem with the mobility of your Tibial nerve travelling down the back of the calf) which is causing the calf to tighten and continue to re-strain.  In order to resolve this condition fully the calf tear needs to be completely healed and prior to returning to training an assessment and treatment of the nerve mobility is required (There are no self management strategies for this, unfortunately.)


You may help healing of the calf muscle yourself by:

1 - Stretching gently 3 x 20 second holds, 3 times daily (Look up specific Soleus and Gastroc stretches as the calf is made up of both of these muscles.)

2 - Icing the calf muscle for 20 mins 2xdaily (only if the calf is bruised)

3 - Having an assessment of your foot biomechanics and footwear to ensure this is not the primary source of your problem. 

4 - Continue with your soft tissue massage (we recommend you attend a therapist who is trained in sports massage therapy)


As you have the pressure of the European masters indoors ahead I recommend that one of our specialised physiotherapists assesses and treats you to speed up your recovery.


Question:  Hi.  I really need some advice about my entire left leg, in particular my knee. I have only been running for 2 years now but since training for a half marathon last year (while wearing a knee support) something went in my left hamstring. It felt like a snap and meant I couldn't continue to run at the time.  Now, 14 months later I'm still having so much pain in my knee/hamstring and the pain is even sometimes now into the pelvis.  I can run about 3 miles (if I'm lucky!) and then can't run for weeks again afterwards. I now can’t go running without prophylactic ibuprofen and/or paracetamol.  I have tried resting it completely for several months with no training all to no effect. I feel that the left knee definitely tracks in and out of position during the day; however a local physio checked my knee and said there was nothing wrong with it except maybe an internal bursa of the knee that a weeks rest and anti-inflammatories would sort out. This was wrong.  


I’m really gutted about this knee and the alternating tight sore hamstring probems I’m experiencing. Supports seem to be making it worse now and send shooting pains up the internal side of my knee upwards (they obviously aren't ideal anyway and are just compensating for my weak muscles). Please help. Any advice if possible is much appreciated.


Answer:  Your question is not wholly different from another we have received this evening. It sounds as though your symptoms are coming from either 1 of 2 problems: Nerve tissue dysfunction or referred pain from your lower back.  There may also be a lesser maltracking of your knee cap or patellofemoral dysfunction.


1. Nerve tissue dysfunction results from scar tissue (caused by previous torn muscle fibres of the hamstrings) attaching to neighbouring nerve tissue in the thigh. This then reduces the ability of the nerve (the sciatic nerve which lies in the back of the thigh) to naturally slide and glide with movement. This is best known as altered neural mechanics. This injury is often worse when running down hill (with a longer stride length) or when running faster.


2. 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 usually irritates the nerves leaving the spine referring pain into the back of the leg. 


The maltracking of your knee cap is easily corrected but can certainly be exacerbating you problem further.  A biomechanical assessment is important to identify any issues which need to be corrected here.  There are generally no self management strategies to clear these problems and you really require a thorough physiotherapy assessment to distinguish exactly where the source of your pain is coming from and stop your symptoms progressing.  For now, the best advice is not to run (aquajog alone if you like) until you receive a thorough physiotherapy assessment.

Q & A from Injury Clinic on Thursday 2nd October 2014:

Question:  I am in the final weeks of training for the Dublin Marathon. After my longer runs my calf is cramping really badly. Although it feels as if it is going to cramp whilst running, I can hold it off, but when I stop, it gets really bad, almost like a spasm. Any advice?


Answer:  Muscle cramps are extremely uncomfortable and involve intense contraction of the calf muscle; this usually needs to be held in a stretch in order to resolve the spasm.  There are a number of factors that can lead to muscle cramps. Most common are:


1. Exercise-related cramps, usually caused by muscle fatigue. This is when the muscle fibres fatigue and the nerve input to the muscle is overstimulated causing the muscles to cramp (a basic explanation!).  You may not be giving your calf muscles enough time to recover between runs (i.e. your long runs are too close together and any sustained micro trauma has not been given enough time to settle). The first 2-3 days following a long distance run are the most crucial to a good recovery. These are the days to take relatively easy and consider replacing running with x-training or swimming (which will still allow you to build and maintain fitness). Gentle stretching of the major muscle groups (hammies, calves and quads) holding 20 seconds 3 reps, 3 x daily should be done.

 

2. The other proposed culprit is a potassium/ sodium imbalance and/or dehydration following prolonged exercise with lots of sweating. This can be reduced by good hydration and considering drinks with added electrolytes.


3. Alternatively, another cause of cramping which is commonly overlooked is poor nerve movement in the calf (altered neural dynamics of the Tibial nerve which runs through the calf complex). This is very common in runners building up their mileage. If this is the case no self management strategies are appropriate and  physiotherapy assessment and treatment is required to get to the root of this problem and in nearly every case, it can be cleared completely with the correct treatment.  We see this in Apex frequently.


Many runners we treat at Apex Clinic use regular soft tissue massage as a preventative to maintain their muscles in optimum condition during running season and also as a post-race recovery method. We would be happy to iron out your calves in preparation for the big day!!


Question:  I broke my arm 6 weeks ago and am waiting to go see the consultant for a check up. There is currently no pain in it. The cast covers my elbow but I can move my arm back and forward at the shoulder, do you think it would be ok to run?


Answer:  We do not recommend you run in a cast at all as it is likely to jeopardise the healing process. This is due to the transmission of vibrations coming from the impact of running. This type of vibration if introduced too earlier can contribute to malunion of the bone and lead to further problems down the line. Your consultant will remove the cast when he/she is happy that the bones have properly healed. Generally fractures in the upper limb take between 6-8 weeks to heal.  Be patient- it’s not much longer!


Question:  Occasionally while walking up-stairs if I lead off with my left foot I hear a clicking noise in the Achilles. Having recovered from Achilles trouble in my right leg I'd like to know why is now the left giving that noise? Again it’s not a lot, just now and again.


Answer:  Clicking is usually a warning sign of an early onset of tendinosis (previously called tendinitis). At this point we highly recommend you undergo a specialist physiotherapy assessment as it is vital to determine why the problem is now starting on the opposite foot.  Reasons for this may be muscle imbalance in the lower legs or poor biomechanics. Physiotherapy at this point will almost definitely stop this progressing into a true tendinosis.  In the meantime self management should consist of regular stretching of the Gastroc and Soleus muscles with a reduction in running. Appropriate stretches for these calf muscles may be accessed online, remember that stretches need to be held for at least 20 seconds and repeated 3 times.  Feel free to get in touch with one of our specialist physiotherapists to arrange an appointment. Best of luck!


Questions:  7 weeks ago I injured my left knee, probably from overuse as I've run a lot of marathons (26 this year) so there was no sudden trauma it just gradually became a problem over the space of 2 weeks. I ran 4 marathons in 4 days in August and after day 4 I couldn't even walk. After 6 week’s rest I've tried running but the pain remains.  It feels like there is pain and weakness in behind the back of my knee joint. When I've tried to run those few times I get extreme pain at the back of the knee and afterwards I get some pain and swelling under the knee cap about an inch and to the side a bit towards the inside of the leg. I've no trouble walking or cycling. Could this be a meniscus injury? 


Answer:  This does not sound like a classic meniscus injury as there was no specific trauma and the symptoms you describe are generally too wide-spread to be so. We would seriously question the integrity of the joint surfaces in your knee i.e- there may be wear & tear/ arthritic changes within the knee which have been majorly overloaded with all the recent (and very impressive!) running. These overloads on poor joint surfaces have likely caused a capsular swelling of the knee which is exacerbated now every time you run. 


A proper physiotherapy assessment is certainly required to give a more definite diagnosis and if any doubt remains an MRI scan will be considered before treatment and rehab of this condition is commenced.   After being such an accomplished runner I feel we need to get to the bottom of this one to secure the future of your running career. Feel free to get in touch with us. 


Question:  After I'm out for a long run I get a pain in my buttock. Just wondering what the cause could be and the best way of preventing it?


Answer:  The pain in your buttock is most likely to be referred from your lower back and is a 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 creating a space which allows for shock absorption through the spine while we run. 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 a dull ache in the lower back which commonly refers into the buttocks. 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 problem and should be cleared fairly quickly.  For now the best advice is to reduce your mileage and keep to soft/ flat surfaces for example: grass, treadmill, bark or sand.  Best of Luck!!

Q & A from Injury Clinic on Thursday 4th September 2014:

Question:  What's the best recovery for shin splints? Thanks!


Answer:  First of all, you need a thorough physiotherapy assessment to get to the root of your problem. This will include assessment of your foot biomechanics to see if any insoles are needed and should also establish a correct diagnosis for the shin pain. 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 shin

4. Less likely, compartment syndrome. 


Rebecca Nelson (Director of Physiotherapy at Apex Clinic) wrote 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 3 months 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. In the future we would advice a few softer surface runs in your training regime.  Feel free to give us a shout!


Question:  I have had a pain up the inside of my left leg for some weeks now.  It is approximately 10-15cms up from my ankle. It hurts when I run, but not enough to make me stop. Any ideas on what this could be? Thanks.


Answer:  Often vague calf symptoms can be attributed to slightly poor biomechanics. We would recommend a physiotherapy biomechanical assessment of your lower limbs and feet as there might be asymmetry on 1 side which may be gradually overworking the muscles on the affected side and eventually causing pain in the calf complex.  At present conservative management should consist of: 


- Stretching your calves regularly both the Gastroc and Soleus muscle. Stretches must be held for 20secs repeated X 3, 2 X daily- correct techniques can be accessed online. 

- Icing the sore area after runs for 15-20mins. 

- Deep soft tissue therapy to the calf muscle (Sports massage). 


We would also suggest you keep your runs shorter and on the flat in order to reduce any progression of your pain (i.e.- a tear!) until your pain has settled.  It is also important that all runners establish a good warm-up and cool-down regime to include post-run stretches in order to help prevent these niggles occurring.  If the above management does not improve your condition within the next 2 weeks feel free to give us a shout!


Question:  On my longer runs (over 60 minutes) I sometimes get a sharp pain in my right hip. This would make my leg feel weak and wobbly, but once I stop and stretch it goes away. It might happen 2-3 times during a 2 hour run. Is this something that I should get looked at?


Answer:  By the nature of the pain you describe it sounds unlikely to be originating from your hips.  As all of our physiotherapists are spinal and nerve pain specialists at Apex Clinic, this condition is commonly treated successfully by ourselves!  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- i.e. a stiffening up of one or more levels of the spine, repetitive running; especially uphill, on hard surfaces and over long distances will further load these stiff segments. This usually results in a pain either in the lower back, buttocks or hips and can cause general muscle weakness and pain in these areas.  There are generally no effective self management techniques to clear these symptoms, so we therefore recommend a thorough physiotherapy assessment from a spinal physio specialist to identify the source of your problem and clear your symptoms.  For now, the best advice is to reduce your mileage and keep to soft, flat surfaces e.g. grass, treadmill, bark or sand. Best of luck!


Question:  Hi, any good advice for recurring achilles pain. Thanks.


Answer:  Tendoachilles (TA) problems can be one of the most stubborn injuries with runners if managed incorrectly. The first line of treatment is usually rest, ensuring your trainers are biomechanically supportive, progressive stretching of the calf complex and soft tissue therapy on the lower legs. If this does not decrease your pain, then you need to see an experienced physio.  The symptoms then may be due to a lack of nerve movement (altered neural dynamics) of the nerves that pass through the calf muscles into the Achilles tendon or referred pain into the Achilles and often heel area from the lower back.   Altered neural dynamics is often the answer to a lot of recurring Achilles problems that have not resolved with local Achilles treatment. 


As this problem can usually be cleared completely, our advice to you at this stage is to seek an experienced physio who is familiar with this problem. We are experienced in this treatment if you wish to have it assessed.  In order for you to get back on the road we recommend that you are pain free running on a softer surface ie- treadmill, bark or grass first before progressing to road running. Thanks!


Question:  Hi.  I’ve just been diagnosed with a degenerative knee.  I am an endurance triathlete.  How do I keep some race run pace with limited training on the road?


Answer:  We are glad you are already aware that you are limited in how much road running you may do with a degenerative knee joint. As you already probably know, continued repetitive impact through the knee joint will only worsen your condition possibly leading to a knee replacement in the future.  The positive to this situation however, is that as a triathlete the 2 other sports you do are actually very good for your knee condition as they involve lots of movement without the impact.  Understandably, in order to keep up your performance you will need to do an element of running training. The best way to do this is by aqua-jogging (running in the swimming pool) and x-training. Neither of these exercises involves high impact but imitates the mechanics of running. When you occasionally do chose to go for a run, a softer running surface is best (bark, grass, sand or treadmill.)


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-exercise warm-up.  Glucosamine is a popular supplement amongst people with knee osteoarthritis but there is no firm research to support its use.  If you have any further queries about the management of your condition please feel free to contact us. Thanks.

Q & A from Injury Clinic on Thursday 7th August 2014:

Question:  I'm having problems with my foot when I run. The problem is happening when I run 3-4miles, I get pains in the arch of my foot and if I don't stop running it gets worse and it will remain sore for 3-4 days after.  I'm stretching my calves and have tried arch supports with little improvement.  Any help would be great thanks.


Answer:  It sounds as if you are irritating the soft tissue that makes up the arch of the foot while you are running. We understand you have already trialled an arch support but we recommend you receive a proper Podiatric Biomechanical assessment to ensure you are wearing the correct type of insoles (orthoses) as poor biomechanics may be a major contributing factor to this problem.  In the meantime in order to self treat your symptoms try: deep soft tissue massage in the arch of the foot (by rolling a golf ball or frozen drink can along the foot) for a few minutes twice daily, icing the foot and regularly stretching the plantarfascia (these exercises can be accessed online).  Our podiatrist has a special interest in gait analysis in runners so feel free to get in touch! Best Wishes!


Question:  My left calf has been troubling me for the last 2-3 weeks, particularly when doing speed sessions. I have had it rubbed out a few times which has helped, but it still seems to be lingering. Should I rest?


Answer:  General Calf pains may be helped by:

1- Stretching 3x 20 second holds, 3 times daily ( Look up specific Soleus and Gastroc stretches as the calf is made up of both these muscles.)

2- Having an assessment of your foot biomechanics and footwear to ensure this is not the source of your issue.

3- Continue with your soft tissue massage (we recommend you attend a therapist who is trained in sports massage therapy) 


While doing the above regime, reduce the frequency and distance of your runs and only run on flat and softer surfaces (ie- sand, grass, bark etc). 

If your problem persists, one of our specialised physios would be delighted to assess you, to get to the root cause of your calf pain.


Question:  I am just returning after a stress fracture on the top of my foot (metatarsal). How long should I take it easy before picking training back up? The injury was diagnosed exactly eight weeks ago and I'm not feeling any pain while running. It is still a little tender when I touch it after a run.


Answer:  Metatarsal stress fractures take around 8-10 weeks to heal.  Even though you are not experiencing pain at present (8 weeks post fracture) we do not recommend you run at all for a further 2 weeks to give the recommended healing time for your fracture. During this time to maintain your fitness you may partake in aqua jogging, X-Training, cycling or swimming as all these activities are low impact through the foot.  When it is time to return to running, grass, bark or treadmill is a safe place to start for the softer surface. Hang in there! If you continue to run too soon this will become an on going issue and possibly shorten your running career! Thanks for your question.


Question:  My hips are giving me problems. It used to be the bones that ached down into my pelvis, but now it seems more muscular. I feel like they are so tight I can't move my leg forwards and my buttocks are sore when I run. Also, I have a sore shin for the first 2 miles of running. How to prevent that?


Answer:  The pain you describe is unlikely to be originating from your hips. As all of our physiotherapists are spinal and nerve pain specialists at Apex Clinic, this condition is commonly treated successfully by ourselves! The spine is made up of vertebrae (bones) with spongy discs inbetween, 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 will further load these stiff segments. This usually results in a dull ache in the lower back which commonly refers into the buttocks, hips and pelvis causing general muscle aching and tightness in these areas. 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 clear your symptoms. For now, the best advice is to reduce your mileage and keep to soft, flat surfaces e.g. grass, treadmill, bark or sand. Best of luck!


Question:  I hurt my left ankle 20 years ago.  It was fine for 18 years and then bang, it got sore during a cool down after a 10k run up a slope.  It was really sore for weeks but once I warmed up, it was ok for me to run on. Now it’s fine to run on but when I get up in the morning I have to walk around on the outside of my foot for the first hour and then the pain goes. I do loads of stretches using steps etc but it’s an ongoing problem! Any magical advice?


Answer:  Sorry to hear your ankle has been giving you so much bother.  Are we correct in thinking it has now been ongoing for 2 years? If this is the case, self management is unfortunately not working and physiotherapy intervention may be required now. If you continue to run with this problem you will certainly be making things worse and risk damaging surrounding structures in the ankle.  Please feel free to get in touch with us for a thorough physiotherapy assessment so we can identify the source of your problem and clear it appropriately.


Question:  I have run 2 half marathons in the last 12 weeks. When I run approximately 4/5 miles I get increased pins and needles and numbness in my right foot and my right calf is very tight and has lots of trigger points. I don't have any back pain. Any ideas?  One person mentioned chronic compartment syndrome or just a nerve irritation. It has been going on since March 2014 .


Answer:  Here at Apex Clinic the 2 main areas that we specialise in are sports injuries and spinal problems (which includes nerve pain and headaches).

From our experience this sounds like a nerve irritation originating from your spine. Compartment syndrome does not fit the features of your symptoms.  You do not need to have accompanying lower back pain for this to occur. As you have recently run two 1/2 marathons (very impressive!) there has been a lot of mechanical loading through your back. In order to treat this problem you require a physiotherapy assessment to establish where the origin of this is coming from in your spine and treat it at its source (as well as a thorough assessment of your foot and calf also). It is very unlikely to clear with self management or rest alone. In the meantime if you are keen to continue running we recommend shorter, flatter and softer runs! Good luck!


Question:  I've been having a twinge at the top of both legs during and after running. It goes over the top of my thighs into my groins. I’ve only been running for a few months.  Any advice?


Answer:  The origin of your problem sounds very similar to our previous answer.  The fact that your pain is on both sides and refers from the top of your thighs into your groins implicates referred pain from the lower back.  Again, continuing to run with this problem will certainly cause it to worsen.  It is best treated by a spinal physiotherapy specialist who will assess your back to find the origin of the pain.  Best of luck!


Question:  I’ve been struggling with a sore heel for ages.  I've tried cushioned shoes and gait analysis.  Any ideas?


Answer:  There are a number of sources from which your heel pain may be coming from, but the most likely (especially for runners) is plantarfasciitis, which is irritation of the connective tissues on the sole of the foot causing pain.  Pain is felt at the bottom of the heel and sometimes in the arch and is usually worse for the first few steps of walking in the morning.  It may only occur in milder cases after running or after another activity.   Plantarfasciitis may start as a result of running or walking in a worn-out pair of shoes, training on a new surface or adding hills into a running or walking routine.  It may also start for no apparent reason.


At this stage, we recommend for you to try the following, only for a 3-4 week period:

1. Rest- No running or prolonged walking. 

2. Stretch. Stretch your calf and sole of your foot 3 times, twice daily, holding each stretch for 20secs.

3. Wear Shoes. Make sure you are in supportive shoes all the time and never barefoot. 


If there is no significant improvement in the heel pain after 3-4 weeks of performing the above, then you really need to see an experienced physio to get a proper diagnosis for the pain and a proper treatment plan started.  In our experience in Apex Clinic, nearly all heel pain, even if it’s long standing can be cleared with the correct treatment regime and the person should be able to return fully back to running.  The fact that you’ve had your heel pain for “ages”, really tells us that it is most likely that you’ll need proper physio treatment on it to get it cleared completely.  Feel free to give us a shout.  Best wishes.

Q & A from Injury Clinic on Thursday 4th July 2014:

Question:  My left hamstring is constantly tight when I run. It's not strikingly sore, more of a dull ache?


Answer:  There could be a few different reasons for tightness in your hamstring when you run. It may be that the hamstring muscle itself has been injured causing it to tighten, in which case a gentle stretching programme while resting from running (consider cross-training and aqua jogging to maintain fitness) in combination with a sports massage should help ease these symptoms. Alternatively, this tightness could be due to a lack of nerve movement of the sciatic nerve in the back of your thigh. This means that the nerve tissue which should move freely and slide between all the muscles which surround it, has now become restricted. In this case we recommend a specific physiotherapy regime of mobilising/moving the nerve tissue through the back of the thigh. This would be followed by a tailored home exercise program, specifically to maintain the nerve mobility in the long term.  Hamstring tightness is a common complaint in runners and the key thing to beating it, is finding the correct diagnosis for it and treating it at it’s source.   If your symptoms do not seem to be clearing with self management (stretching and massage) then see an experienced physio and make unhappy hammies a thing of the past!


Question:  I have pain in my hips and lower back after long runs.  The hip pain is in the sides of the hips and centre of the buttocks and sometimes I will also have what feels like movement/clicking in the sides of the hips after a long run (10+ miles).  It clears after a few days of rest but returns 1/2 mile into the next run.  Thanks.


Answer:  The pain you describe is unlikely to be originating from your hips. As all of our physiotherapists are spinal and nerve pain specialists at Apex Clinic, this condition 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 of one or more levels of the spine, repetitive running; especially uphill, on hard surfaces and over long distances will further load these stiff segments. This usually results in a dull ache in the lower back which commonly refers into the buttocks and hips. 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 and keep to soft, flat surfaces e.g. grass, treadmill, bark or sand. Best of luck.


Question:  How long should sciatic nerve pain in the leg last?  I've had this from March and every time it seems to be away, I try running again and it keeps coming back?


Answer:  As all physio's at Apex Clinic specialise in spinal problems and nerve pain, as well as sports injuries, this is an extremely common problem that we treat.   Although the symptoms seem to ease between runs, it is clear that the source of the problem has not been corrected due to the fact that it keeps recurring.  The key to treating "sciatica" is for a physio who specialises in the spine, to identify the correct origin of the problem and treat it at it's source. This is a condition which in most cases is easily cleared which the correct physio treatment but cannot be successfully cleared with self-management.   


There is no definitive time as to when sciatic pain should clear.  It can last indefinitely if it’s allowed to continue without the correct treatment.  We are confident that your symptoms should resolve on receiving the correct treatment, however, the length of time it will take will depend on; how long you have had the problem, how severe it is and how far down your leg it travels. In the meantime we do not recommend that you continue to run as it will exacerbate your condition. We would love to help. Thanks for your question.


Question:  I do a lot of long distance running and developed severe shin splints 3 months ago. Each time I've rested until the pain has disappeared and when I do my first run the pain comes back again, in the same place but more severely.


Answer:  First of all, you need a thorough physio assessment to get to the root of your problem. This will include assessment of your foot biomechanics to see if any insoles are needed, and this physio assessment should establish a correct diagnosis for the shin pain. 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 shin

4. Less likely, compartment syndrome. 


Rebecca Nelson (Director of Physiotherapy) wrote an article on shin pain, which you can read on the NiRunning website under the physio section, and it will give you more information on the different causes of shin pain. Shin pain which continues for more than 3 months 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 painfree (but maybe with a few softer surface runs thrown into your training regime in the future). Feel free to give us a shout!


Question:  I have run 7 marathons in 4 years but last year I noticed my calf getting tight (cramping) when I ran about a mile. I stopped and massaged it and I could feel it release and then I ran on the rest of the race (10k) with no problems. In my last race last summer, again at about 1 mile in, it cramped up badly and I had to walk back to the start as I couldn't get it to release.  I then rested for a few months and have been to multiple physio’s, sport massage therapists, foot clinics and although the sports massage seemed to help, I still feel my leg getting uncomfortable after about a mile and now it also seems to be painful in the front of the thigh just above my knee. I am trying to get back running again slowly but it is getting disheartening when I feel it tightening.  Please can you give me any advice or things to try? Thanks.


Answer:  Please don't be disheartened as it does not sound like you have a local calf problem as the primary source of your pain.  You most likely have 1 of 2 things going on and causing your symptoms. The first one, is where the tibial nerve (the nerve running down the back of the calf) is not moving freely as its movement is limited by scar tissue from the calf muscle.  Secondly, you may be getting pain which is referred from your lower back to the calf in response to the high loading involved with running. The nerves which go to the calf area (somatic referred pain) can also refer to the front of the thigh area too. So, it is very likely that the front of the thigh pain you have developed is a result of worsening of the original calf problem.  Despite insoles which may be perfect for you and all the physio in the world to your calf and thigh regions, these pains will not clear with this approach. We recommend you come to Apex Clinic for a second opinion and we will assess your spine and nerve mobility going to these regions.  We hope this has been helpful.


Question:  I have had pain in my right foot since March.  At first I assumed it was a 5th metatarsal stress fracture but two x-rays later they have not shown anything.  I have pain most of the time but more so when weight bearing, along the right hand side of my foot to the base of my toe. My foot swells to a haggis like state, including a pale grey mottled look.  Any ideas?


Answer:  In summary to an unusual question; if you have already had X-rays to rule out stress fractures your next step needs to involve going to your GP and getting blood tests to check for infective and inflammatory markers.  If these come back clear, it may be useful to have a foot biomechanical assessment. Unfortunately we cannot comment any further without seeing you. Hope this is useful.


Question:   After a hard run tonight, up the inside of my right leg, along the length of my shin is sore to walk and touch. Any help would be appreciated?


Answer:  A previous question regarding shin pain was answered just prior to your post please check it out.  Since your condition is more acute (i.e just started this evening) we would recommend you manage your current symptoms with icing, and stretching (see the web for appropriate stretches) and rest.  You may need to consider a biomechanical assessment of your feet to prevent this reoccurring in the future, along with intermittent runs on a softer surface.  Do not allow your symptoms to persist.  Best wishes.

Q & A from Injury Clinic on Thursday 5th June 2014:

Question:  I have only recently started running (very slowly), but I am experiencing soreness around my knee's. It’s not a sharp pain, more like a dull pain.


Answer:  If the knee pain that you're experiencing is very generalised, all around the knee, then it is most likely soreness as a result of force or impact coming up from the ground to your knee joints. If this is the case, then running more frequently on softer surfaces is important, such as grass, bark tracks or the treadmill to reduce the impact passing through your knees. Alternatively, a generalised knee pain all around the knees may be due to poor foot biomechanics which in turn will lead to overloading of the knees and resultant soreness. A podiatrist or good physio would be able to tell you if this is the case, and over the counter, or less likely custom made insoles may be needed to resolve this problem. Which ever the case, ensure you have good trainers with a good arch support and good shock absorption as this is vital. Hope this helps!


Question:  Can you advise as to the best way to deal with a groin strain?


Answer:  If you have had a recent groin strain, then it's important to gently stretch the adductor muscles (inner thigh muscles) twice daily, approximately 3 reps of 20 second holds with the knee straight, standing up for example and then 3 reps of 20 second holds with the knee bent, for example sitting down with the soles of your feet together and pushing gently downwards with your elbows towards the floor and holding. Just perform each stretch to the point of the beginning of discomfort. 


Relative rest also is important if running is painful, ie reduce the mileage and pace if the pain is mild, but if it's severe then stop running for a few weeks. Gradually, when back into running building up the speed and mileage slowly. If the groin pain has been longstanding, then a physio assessment is definitely needed to get a proper diagnosis and resultant tailor made treatment plan started, as not all pain in the groin is from a muscular groin strain, there are many other causes for this, which we see daily in the clinic and until the correct diagnosis is found, the pain will usually continue! Good luck!


Question:  I'm doing my first 10k in two weeks and training was going well. But I've aggravated my plantar fasciitis. I've bought sole inserts and I am taping/stretching but it still hurts. Please advise. Thanks


Answer:  Well with 2 weeks to go, we understand that you don't want to waste all your valuable training up till now, by not doing it! So, using soft over the counter FULL length insoles can certainly be helpful, just ensure they aren't hard and digging into the plantarfascia to annoy it further. If you're not sure if they are the correct ones to have for your condition, feel free to phone us at the clinic tomorrow and we'll tell you the ones that we recommend. Taping is OK as a symptom relieving help, but it isn't going to help you in the long term, so only use taping if it's giving effective pain relief and not otherwise. 


As for stretching, ensure you're stretching your 2 calf muscles, with your knee straight and knee bend, 3 of each for 20 secs twice daily and do plantarfascia stretches, as seen on the internet twice daily, the same quantity also. Then the decision remains whether to run through it and complete the 10k or whether to stop and get it treated and not continue training. It all depends on the severity of the pain. If you continue through moderate pain just to complete the marathon then that is fine if you are dead set on completing it, then after you've done it, you definitely need a proper physio assessment to get it cleared fully with the correct treatment. Best wishes!


Question:  I was wondering could you give me some advice. I was at A&E and they told me I’ve pulled a stomach muscle. They didn’t tell me too much else except rest for up to 10 days. I don’t know what strain it is, my symptoms are if I stand up, sit, bend, sneeze etc.  I’ve a sharp burning stabbing pain in my stomach. Is there any way I can speed the healing process up and is there any exercise I can do that wouldn’t hurt my stomach muscles once the severe pain settles?


Answer:  The advice we give, really depends on whether you actually have an abdominal muscular strain or not, as from the information that you've given us, we're not so sure that you do!  Without assessing you, we can't say for sure but from what you've said, the sharp pain in your abdominal region on the actions you described, may in fact be referred pain from the spine at the bra strap level in a woman, or equivalent area in a man and this referred pain certainly feels commonly sharp and stabbing and is often worse on coughing/ sneezing etc. I think if the pain is still sharp and stabbing after 2 weeks, you really need a proper assessment to diagnosis what's causing it. If it is your spine, then it is usually straight forward to clear with the correct treatment and resting it often doesn't help. If it is muscular, then it should progressively improve fairly rapidly with rest and would only need treatment in rare cases. Don't let the pain drag on unnecessarily, best wishes


Question:  I have a shin injury, I think either I've torn a muscle or it's shin splints. Fine for cycling but too sore to run on. Rested it for 10 days & only marginally better. After a short trial run, it's much worse. I'm taping, bandaging, stretching, iceing etc. I'm a regular runner, 3-4 times a week, anything from 5k-1/2 marathon. Feeling very frustrated!


Answer:  First of all, you need a thorough physio assessment! As virtually all shin pain can be cleared and in nearly all cases the person can return to running painfree with the correct treatment! Where to start. Taping, stretching willy-nilly is really going in blind and firing anything at it!  Which shows that you're keen to clear it, but usually won't result in success! A proper physio assessment involves assessing your foot biomechanics to see if any insoles are needed ONLY if you have poor foot biomechanics and also establishing a correct diagnosis for the shin pain. 


There are many causes of shin pain and they are mostly treated differently, most unlikley a stress fracture, or tenoperiostitis (inflammation of a muscle attaching into a bone), nerve pain of the nerve running through the front of the shin, and less likely compartment syndrome. We wrote an article on shin pain, which you can read on the NI running website under the physio section, articles which will give you more information on the different causes of shin pain. Honestly, 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, in 95-98% of cases it should be able to be fully resolved and back to running (maybe with a few softer surface runs thrown into your training regime!) Feel free to give us a shout!


Question:  For the past year and half I have been suffering from pain which is best described as being on the inside of the leg between the shin bone and calf, I have been told that this is untreatable only rest for several months will help, as we are now in mid season, resting is a big no, so any help would be graciously accepted. Darren


Answer:  Unfortunately, we don't agree with the advice that you've been given elsewhere..that you've had this pain for 18 months and that only further rest will resolve it...The only time that this would be the case would be if you had malunion (not healing) of a confirmed stress fracture in the painful area!! When you've had a problem for 18 months which isn't clearing or hasn't cleared with a treatment regime, then it's time for a second opinion as to the cause of the pain and the correct treatment plan! Resting at this stage is certainly NOT recommended as you will have a mechanical problem which needs to be treated and cleared. Resting just reinforces the problem and just delays getting back to running painfree! Please refer to Bryony May's response from us as to likely causes, and if you'd like a second opinion, feel free to give us a shout! It is very likely that your pain should be able to be resolved from the information that you've given.... Best wishes


Question:  My achilles has been causing me pain. When I rub it there's a crunching/creaking sound/feeling! I don't run much or very fast but I'm doing Lisburn 10km on 18th June.


Answer:  Hi Fiona, The creaking, crunching feel that you describe, means that you have a tendonopathy (which is a new, updated word for tendinitis) in your achilles tendon!! Unlike some injuries which cause hurt and not harm, running through an achilles tendonopathy can increase the risk of tearing it, which can be a long, slow process to recover from! So, beware with running through it. It is your call whether to run through it, but there is a risk involved here! In the meantime, try stretching the calf muscles with the knee straight and knee bent, twice daily , 3 x 20 sec holds and avoid hill running, and reduce the mileage if you do plan to complete the 10K...if you REALLY want to complete it , the best regime would be to aquajog all the running sessions in a pool that's deep enough, right up until you do the 10K, as this will be the kindest possible on the tendon until the big day! If sense prevails and you don't do the 10K then get it treated now so you'll be fighting fit in 8- 12 weeks for further races! Best wishes


Question:  I am having problems with my periformis muscle, very tight which is causing problems down my leg into my foot. What are good stretches for this?


Answer:  From the information you've given us, this is not in fact a piriformis problem as the piriformis muscle can cause muscular pain up to cm's away from the actual muscle and not down the whole leg into the foot. Also the current literature is actually debating whether piriformis syndrome actually exists or not! It sounds that you have referred pain (or nerve pain) referred or coming from your lower back, and in fact by stretching the piriformis muscle this more often than not, worsens the referred pain or nerve pain because the nerve is tugged or tensed when the piriformis muscle is stretched. 


The piriformis muscle often will become tight secondary to the referred pain or nerve pain and it is a secondary protective response and not the primary problem. Once your pain has cleared then it is the time to stretch the piriform muscle if it's tight. Really, you need a good physio assessment to establish where your leg and foot symptoms are coming from and then the appropriate treatment regime can be implemented. It's a very common symptom that you're describing which is usually straight forward to clear with the correct manual treatment. Best wishes.

Q & A from Injury Clinic on Thursday 1st May 2014:

Question:  Thank you for doing this before the Marathon. I have had a slight hamstring strain for the past two weeks, I am due to run in a relay team on Monday. I was thinking about still running, but taking it easy. Is there anything you would recommend I do or try in order to reduce the risk of worsening the strain?


Answer:  As physiotherapists we do not encourage running with a muscle strain as in most cases it will worsen the problem.  However, to reduce the impact on the hamstring during the marathon we recommend you run the shortest and flattest leg.  Gentle stretching of all major leg muscle groups and good water intake are recommended between now and Monday.  Following the marathon we would highly recommend a sports massage or if the problem persists a physiotherapy assessment to diagnose the problem and return you to the running field ASAP.  Good Luck for Monday!


Question:  Hi - I have recurring Achilles issues – the last flare-up in my right Achilles was over 2 weeks ago, and since then I have been cross-training, doing lots of heel drops and strength exercises for my legs BUT no running! I overpronate slightly, wear orthotics, have newish shoes and have been trying to run with a higher cadence. Any advice on how to minimise achilles niggles would be great, as well as advice of when I can get back on the road. Many thanks.


Answer:  Tendoachilles problems are one of the most stubborn injuries with runners. The first line of treatment is usually rest, having your feet biomechanically assessed, progressive stretching and strengthening (eccentric) and soft tissue therapy on the lower legs. If this does not decrease your pain, the symptoms may be due to a lack of nerve movement (altered neural dynamics) of the nerves that pass through the calf muscles into the achilles tendon. 


This requires specialist diagnosis and is usually the answer to a lot of recurring achilles problems that have not resolved with local achilles treatment. As this can be usually cleared completely our advise to you at this stage is to seek a specialist physio who is familiar with this problem. We are experienced in this treatment if you wish to have it assessed. In order for you to get back on the road we recommend that you are pain free running on a softer surface ie- treadmill, bark or grass first before progressing to road running.  Thanks!


Question:  I have an issue with damage on the arch of my right foot.  Could you tell me what would fix this issue please?


Answer:  We recommend you initially can try to self manage your condition by deep soft tissue massage on the arch of the foot (by rolling a golf ball or frozen water bottle along your foot), icing the foot and stretching the plantarfascia (check the web for specific stretches). If your condition persists or has not been the result of an injury we would recommend a physiotherapy assessment to get to the root of the problem and a podiatric biomechanical assessment may also be needed.

Best of luck!!


Question:  During longer runs (approx 6+ miles) my left hamstring seems to tighten a lot. I can still run, but it feels uncomfortable. What could cause this?


Answer:   There could be a few different reasons causing this feeling of tightness. It may be the hamstring muscle itself has been injured causing it to tighten. If it was a local hamstring problem you would usually feel the tightness earlier than 6 miles and gentle stretching would ease the symptoms. Alternatively this feeling of tightness may be due to a lack of nerve movement of the sciatic nerve in the hamstring area. This means that the nerve tissue in the back of the thigh, which should move freely and slide between all the muscles that surround it, is now restricted in its movement.  In this case we recommend a specific physiotherapy regime of mobilisation or movement of the nerve tissue as it passes through the back of the thigh. This will be followed by tailored home exercise to maintain nerve mobility.  The key to beating hamstring tightness lies in finding the correct diagnosis of the origin of the problem and then treating it at its source.  If your symptoms don’t seem to be clearing, seek a second opinion, and make unhappy hammies a thing of the past!


Question:  I wonder could you help me?  I’m currently being treated for severe pains in my right hip.  I’ve had lots of physio elsewhere but it didn’t help me. I just got my MRI results back and they came back normal (I haven’t had a follow up appointment yet) so I started back to running, entering races and upping my mileage slowly. I still have severe pain and it is now affecting my left hip and my back, the pain is worse when I’m not running, any ideas?...


Answer:  Sorry to hear of your ordeal. This pain you describe is unlikely to be originating from your hips. As all Apex Clinic physiotherapists have undertaken extensive post-graduate training in spinal and nerve pain (alongside sports medicine) we are confident that your symptoms are being referred from the spine and you will not get better unless you have the correct diagnosis and are treated appropriately. Your MRI clearly indicates there is no local hip problem. The fact that your pain is beginning to spread indicates the problem is worsening. In the meantime we do not recommend you continue to run, you are making the condition worse. We would love to help you as this is our bread and butter! 


Question:  Hi, after doing a long run (marathon distance) the inside of my right foot is very sore. I think it's my arch? It is very painful to walk with no shoes or in flat shoes. The only relief is wearing heels.  Any advice? Thanks


Answer:  We recommend a podiatric biomechanical assessment of your feet as the preference to wearing heels following a run indicates an issue with the arch of your foot. We would encourage you to do lots of lower leg stretching, especially of the plantarfascia (look up online for specific stretches for this area) and to ice the area following long runs. If this regime does not help please feel free to contact us directly.

Many thanks


Question:  Around my knee got stiff following a more energetic run, any suggestions?  It has been a week or so and it's still stiff.

Answer:  Stiffness around your knee could be due to a number of different problems.


1) Muscle imbalance causing mal-tracking of the knee cap/patella. 

2) Poor biomechanics

3) Cartilage wear and tear due to repetitive impact.


If rest and gentle stretching does not resolve your symptoms or you find in the future your symptoms become reoccurring then you should have a thorough physiotherapy assessment to diagnose the origin of the problem.  At present on returning to running, keep your distances short, hills to a minimum and keep to soft surfaces.  Best of luck!!

Q & A from Injury Clinic on Thursday 3rd April 2014:

Q.  Private Message (PH1):  Hi, I have recently got back into running after 6-8 months of very little training. I find that I am constantly aggravating my right calf when I run. On Tuesday night I was doing a tempo run and it just went. I was able to finish, but when I woke on Wednesday morning it was very tight. I am warming up. Do you know why this would be happening? Thank you.


A. Apex Physio Belfast Clinic:  Hi PH1, the best place to start is to look at your footwear and see if your trainers need to be replaced, as being flat footed can very commonly predispose to this problem.  Ensure you are gently stretching the calf muscles (hold stretches for minimum 20 seconds x 3 each leg) regularly.  There may also be a build up of scar tissue contributing to your symptoms.  The only way to remove scar tissue and clear the pain is by deep soft tissue massage combined with the above recommended stretching of the affected muscle. This pain can't be cleared with self management alone. 


If on examination scar tissue can not be felt inside the calf muscle, then it is likely that the nerve which travels down the back of the calf is being restricted in its movement.  With the correct treatment by a physiotherapist, this can be identified and easily cleared.  In both of the above cases getting diagnosis and treatment ASAP is very likely to clear it.  Many thanks.


Q.  Prviate Message (TMcK 1):  I am having trouble with what I think is a groin strain on longer runs. It doesn’t seem to flare up on shorter runs, but I have found that when doing long Sunday runs, it starts to cause me problems later on in the run?


A.  Apex Physio Belfast Clinic:  Hi TMcK1,  a local muscular groin strain is a common injury in sports that involves sudden changes of direction and pain will always be present during the entire run.  In our experience, pain that presents during longer runs (when otherwise pain free) may be due to the lengthy impact on your spine causing referred pain into the groin area.  This needs to be identified and treated.  In the meantime, keep to shorter, flatter distances and softer surfaces (eg grass, sand, trail).  If these symptoms are not treated soon, you may find that the groin pain starts developing sooner.  I hope this helps!


Q.  Quigs:  What is the best way to remove scar tissue from the vastus lateralis muscle?


A.  Apex Physio Belfast Clinic:  Hi Quigs, the best way to remove scar tissue in any muscle is deep soft tissue massage (we recommend one deep soft tissue massage per month for regular or competitive runners).  Stretching regularly especially quads, hamstrings, calves and gluts after running (3x 20secs each leg) should help reduce and prevent build-up of scar tissue. Thanks.


Q.  Quigs:  Would dynamic or static stretching make a difference?


A.  Apex Physio Belfast Clinic:  It is generally recommended to do dynamic stretching prior to your run as part of a warm-up and static stretching following your run after a sufficient cool-down.


Q.  Prvate Message (MMcE 1):  Hi, any ideas? I have recurring knee pain mainly going down stairs. I’ve been out of running for 8 months and every time I try a wee light jog the pain comes straight back. MRI clear. I tried rest, ice and ibuprofen on and off for nearly a year. No joy.  Constant clicking/crunching in my knee. it has been suggested that it may be radiating from my lower back.  So far nothing has helped and I have been resting now 3 months.


A.  Apex Physio Belfast Clinic:  Hi MMcE, we will try to answer your question with the information you've given.  The most common cause of constant clicking and crunching when bending the knee is patellofemoral dysfunction (maltracking of the knee cap.) 1 in 4 sports people will experience this in their life time.  This problem responds extremely well to a specific regime of treatment. It normally only takes a few treatment sessions and is managed mostly with a combination of intense mobilisations of the patella and specific exercises.  You should also have your footwear (trainers) assessed as this could be contributing to the problem.  Again, a thorough assessment should be carried out to identify the true cause of the problem.  Clearly rest has not been effective and therefore an active approach is necessary now!  We hope this helps.


Q.  Derek Goodfellow:  I was out running two weeks past Monday on an 8 mile run and at mile 7 I had excruciating pain in the side of my left foot.  I went to A&E and there was no break; they said it was the ligaments.  However, the pain is not around my ankle, it is mid way towards my wee toe (metatarsals?).  I rested and iced for two weeks, went out training on Tuesday and it started to hurt again after 20 mins light jogging and a short sprint or two, any suggestions?


A.  Apex Physio Belfast Clinic:  Hi Derek, if the pain is focused around the base of the small toe, and a fracture has been ruled out by an x-ray, it could be either a local tendinosis, joint impingement or nerve pain. 


1. The treatment for a local tendinosis is rest for 2-3 weeks and to wear supportive footwear.  As you are still experiencing pain after 2 weeks rest, we can rule this out at present.


2. If a joint impingement is the diagnosis, treatment involves specialised and specific joint mobilisation techniques carried out by a specialist physio, in combination with a biomechanical assessment of your feet. 


3. The other possibility is that you are suffering from referred pain from the spine. When you increase the running distance, the load throughout the spine is increased significantly, which is also the case when you increase running speed. Specialist treatment to your spine would most likely clear these symptoms (which we very commonly treat at Apex Clinic).


In summary, the origin or root of the problem really needs to be established through a physio assessment. Feel free to give one of our specialist physio's a shout!

Q & A from Injury Clinic on Thursday 6th March 2014:

Q.  Private Message (AS1) - I have only started running about 6 weeks. I run 5k every Saturday at parkrun and have built up to a 10k run during the week as well as spinning Pilates and gym. Last Saturday after I had stretched and cooled down I took this dull pain and a stiffness on the outside of one of my knees. I applied a cold patch which eased it a bit but I still felt a dull ache for a few days. Is this likely to be a normal occurrence or as a result of running at my fastest pace ever. Please note I had no pain whilst running. Any advice on this would be appreciated. Thanks.


A.  Apex Physio Belfast Clinic - Hi AS1, This pain you described is unlikely to be originating from the knee joint, namely cartilage/ ligament/ joint surfaces, because you had no pain at the time of running. It may be due to the ITB rubbing at the side of your knee (ITB Friction Syndrome) and if so there is usually tenderness to touch the ITB at the side of the knee. If this is the case, ITB stretches should be tried for 1 week or 2 and if it clears GREAT! If not, you need a proper assessment and treatment. Alternatively the pain may be due to poor nerve movement at the side of the knee (altered neural mechanics) which is very common in new runners who are building up their mileage. If this is the case it is easily cleared with the correct physio treatment, but can't be cleared with self management. Hope this helps!


Q.  John Apperley - Hello, I broke the base of 5th metatarsal at Dublin marathon 18 weeks past on Monday. I was put in plaster for 4 weeks. I then went privately and was put in a fracture boot for approx 3 weeks. Got xrayed early Jan and the bone hadn't healed, doc advised no running but to come back in 8 weeks and should be ok to run by then, got X-ray last week and no real change in 8 weeks, bone hasn't fused and doc now saying 50/50 chance I’ll be able to complete another marathon. Is this normal? Should I have had a screw inserted at beginning? Any advice appreciated. I have tried running on treadmill but getting some discomfort.


A.  Apex Physio Belfast Clinic - Hi John Apperley, It is unwise to run on this injury until it is either healed or stabilised as it is more likely to lead to malunion, and annoy healing. If you are not happy with the orthopaedic opinion you have received (and certainly the fact that giving up running was suggested!) we would advise a second opinion from a different orthopaedic consultant. Also, although not entirely supported by literature we have seen many patients in Apex who have taken calcium supplements, we don’t sell them, but can recommend them, and these folk have sworn that it speeded up their slow to heal fractures or malunion recovery. We will gladly recommend an orthopaedic consultant who specialises in feet if you ring the clinic or private message our facebook tomorrow.  Don't resign to hanging up your trainers yet!


Q.  Private Message (DJ1) - I am training for the Omagh Half Marathon and I'm finding that as I reach the peak of my training plan I am getting very tired or sore (not injury sore), so much so that it is affecting my sessions the next day... Do you have any advice? A friend told me to get a massage but would this not leave me sore the next day as well?


A.  Apex Physio Belfast Clinic - Hi DJ1,  Certainly from the information you've given us a sports massage should significantly help. Also remember to have at least 1 rest day per week on the build up to the half marathon. Intersperse running on the road with bark, sand, aquajogging and/ or treadmill.  A sports massage will help to get rid of a build up of lactic acid from your fatigued lower limb muscles, which is very likely to be the reason why you are feeling so weary and achey.  On the day after a good sports massage you may feel a bit worked on but not significantly sore. It is recommended to have a sports massage 3 days before a big event, and obviously more frequently leading up the race.  Our sports massage therapists treat many competitive runners who swear that it is that that keeps them going in terms of injury prevention. Thanks.


Q.  Private Message (DS1) – Hi, I have a pain in my left calf, it is in the upper outer calf. When seated, if I place my foot flat on the floor and turn my leg out there is no pain but if I turn it in there is. When running it can come on at anytime either long or short runs, sometimes it clears but on a few occasions I've had to stop due to almost limping.  I have entered the Larne Half on the 22nd of this month.  Many thanks


A.  Apex Physio Belfast Clinic - Hi DS1,  From what you've told us there may be a build up of scar tissue (muscle fibrosis) in the lateral/ outside gastroc muscle and the only way to remove it and clear the pain is by deep soft tissue massage combined with home stretching of the affected muscle. If it is fibrosis an experienced physio will definitely be able to feel it and consequently break it up with soft tissue work. This pain can’t be cleared with self management alone.  If on examination scar tissue can't be felt within the calf muscle then it is very likely that the nerve which travels through the outside of the calf is being restricted in it's movement by local scar tissue. With the correct treatment this can be cleared easily. In both of the above cases getting treatment ASAP is very likely to clear it/significantly reduce it in time for your half marathon. Thanks!


Q.  Private Message (PMcA1) - Since last week, I have had a sharp pain on my right foot, just above my toes. This seems to only come on during longer runs?


A.  Apex Physio Belfast Clinic - Hi PMcA1, the first thing to ensure is that your foot biomechanics are good and that your trainers are suitable for your foot type and aren't past their best! If you already have an insole or orthoses ensure you have a neutral trainer.  We recommend a physio assessment to diagnose what exactly is causing this pain. The least likely is a stress fracture and the most likely is that it is pain resulting from poor foot biomechanics. An experienced physio will be able to diagnose it properly and will know whether you need to see a podiatrist or whether over the counter insoles will be enough to make a difference.  There is no self management we can suggest as you need a proper diagnosis to clear this pain. Thanks.


Q.  Kate Pell - Hi, I was diagnosed by a physio as having shin splints. It's only on my left inner shin and it's like a sting. I went for a sports massage and was told it was a pocket of inflammation that had to be iced and massaged. It eased for a short time but always niggled... It's back again sorer than ever now.. What do you think it is and how do I get rid of it?


A.  Apex Physio Belfast Clinic - Hi Kate Pell, shin splints is only a dust bin diagnosis and really just means pain in the shin area!  Your pain could be due to a number of things:


1) A stress fracture, which can only be diagnosed by an isotopic bone scan. However, the quality of your pain ie- stingy is less likely to be due to stress fracture.

2) Compartment syndrome, again less likely due to the quality of your pain.

3) Tenoperiostitis, this is what the physio you saw probably thought that it was. If it is this it usually responds to local soft tissue work, stretches and ensuring that your foot biomechanics are good with the correct trainers +/- insoles if they are needed.

4) Altered Neural mechanics, see our running article on this on the NIRunning website. This pain is commonly misdiagnosed and with the correct treatment is nearly always cleared. This type of pain is usually worse with faster running versus slower, longer stride running and down hill running. It will never clear with massage.  We would recommend you come to us for a second opinion as it should be able to be cleared. Thanks!


Q.  Wayne Morrow - Hi, just a quick query. In Dec last year I started getting a pain on the bottom of my left foot, just behind my 3rd/4th toes on the padded part of the sole of my foot. I have been nursing it ever since with limited training but it has neither gotten worse or better? Any idea??? I have done the usual Google diagnosis and came up with 'Morton's Neuroma'!!!? Can you recommend any self treatment or a good sports podiatrist? Thanks.


A.  Apex Physio Belfast Clinic - Hi Wayne Morrow, your Google searching has actually come up with a likely diagnosis for your pain!  It may indeed be a Morton's neuroma which is relatively common. And yes, insoles either custom-made or over the counter in this case would be recommended.  Here at Apex Clinic our podiatrist treats many many sports folk and a high percentage of runners. We would recommend that you see her and she will tell you if insoles are appropriate and which type, custom made or over the counter.  However... Not every pain in the location you've described is a Morton's Neuroma! I think to see a podiatrist as the first port of call is recommended as if it isn't a Morton's Neuroma the podiatrist will certainly know and will recommend a physio assessment to clear it. Thanks!


Q.  Eóin J. Lennon -  I tend to feel pain in both feet (stronger in the right) for a minute or two when I get up out of bed and walking around in the morning. Tends to be midfoot, sometimes feels like it's 'pulling' the heel. It generally ceases within a few minutes although it may crop up throughout the day, and is strangely never an issue when running. I had tried massaging with a golf ball for a day or two but it seemed to make it worse. It's manageable certainly, as are all the other niggles, but would you reckon there is something underlying that maybe needs attention? Thanks


A.  Apex Physio Belfast Clinic - Hi Eoin, The pain you have described does Not sound like a local foot problem, such as plantar fasciitis, as it is not painful during or after running.  It is most likely, from what you have described, to be somatic referred pain from your lower back, even though you may have no back or leg pain whatsoever. If this is the cause the pain is usually worse 1st thing in the morning (when the pressure within the discs is high) and is also worse after prolonged sitting or prolonged driving on the first few steps of walking. If you run uphill you may find that your foot pain is present during or afterwards as this also loads the lower back discs.  The way to treat this pain is to see a physio who is experienced in treating nerve pain and referred pain (such as 1 of our team!) and they will assess your back and feet to confirm or disprove this likely diagnosis. It also goes without saying that your foot biomechanics need to be good as poor foot biomechanics can predispose to this problem. Best wishes!


Q.  Tom Purves - I dislocated my left kneecap 5 years ago. If I squat, on the way back up it crunches / grinds, stops when my thighs are parallel to the ground, it doesn't cause me any pain at all, even when jogging, but can feel warm after a run, more concerned of lasting damage I may do when pounding the tarmac. I only used to jog 3-4 miles, 3 times a week, and still could but I’am reluctant due to my concern. Thanks in advance for any advice you can offer !!!!


A.  Apex Physio Belfast Clinic - Hi Tom, in view of your dislocation history it is likely from what you have described of the warmth feeling following a run combined with the knee cap crunching, that you have a little bit of patella maltracking (where the knee cap isn't quite moving up and down in the correct alignment) which is very commonly leftover as a remnant of your knee cap dislocation.  This is easily corrected with the correct treatment regime (see an article on this written by ourselves on the NiRunning website). A physio assessment to confirm this is needed but the likelihood is extremely high that the above diagnosis is correct and also that you will get back to your full desired running regime. To ignore your symptoms may speed up the onset of arthritis on the under surface of your knee-cap.  Hope this helps!


Q.  Private Message (SA1) - On some runs I get a real shooting pain in my right knee. This usually happens just as I start my run and is very sore, so much so that it makes me stop, it doesn't happen all the time but I would like to know why it happens?


A.  Apex Physio Belfast Clinic – Hi SA1, we will try to answer your question as best we can as we don't know the location of your knee pain.  Your sharp knee pain may be due to a floating body (a fragment of broken off cartilage) within the knee joint which is causing sharp pain sporadically, but not all the time as it can float out of the way of the joint surfaces. This really needs a physio assessment to diagnose.  If the sharp pain is at the front of the knee it may be due to maltracking of the knee cap, as mentioned in a previous answer tonight. This can easily be cleared with the correct treatment. 


If there has been no knee injury another likelihood of sharp knee pain which is very intermittent and can sometimes be severe and other times be not present, is referred pain from the lower back. If it is this, this pain will almost certainly be worse with uphill running, but the good news is that in most cases can be cleared with back mobilisation techniques.  In summary a physio assessment is needed to ensure the sharp pain does not become more frequent and stop you running completely. Best wishes!

Q & A from Injury Clinic on Thursday 7th February 2014:

Question:  My achilles has been niggling since the start of the year.  If I use the cross-trainer or run (treadmill or road) it feels like someone is poking the area with small pins.  It is ok when I walk however?


Apex Physio Belfast Clinic:  This sounds like the beginnings of an Achilles Tendinopathy. The best place to start is to look at your footwear and see if your trainers need to be replaced. You may also benefit from seeing a podiatrist who could assess your feet and see if you need insoles, as over pronation is the most common problem to predispose this injury. This problem can be stubborn to clear therefore it is advisable to get it assessed and treated as soon as possible. In the meantime ensure you are gently stretching your calf muscles twice daily 3 x 20 sec holds. I hope this helps.  If you have any further queries do not hesitate to contact us directly, thanks.


Question:  I am training for a 50k in Paris in March but am struggling with a very tight lower calf Achilles problem with also some discomfort on the bottom of the same foot the day after.  It doesn't bother me running until  my calf tightens up.  Any help is appreciated, thanks.


Apex Physio Belfast Clinic:  As you have probably noticed, we have just replied to a similar type of injury from a question above, so the advice there is also relevant to you. However, your pain in the sole of your foot could also be the onset of plantarfasciitis.  With the training you are doing we would expect that you have had your feet and footwear assessed (if not this is your first port of call). There are special foot stretching and strengthening exercises you will need to do if plantarfasciitis is starting. As your race is coming up in 6 weeks we would strongly recommend that you get a physiotherapy assessment to give you a proper diagnosis and commence the appropriate rehab ASAP.  Good Luck!


Question:  I have recently upped my long run miles for the Larne and Omagh Half Marathons, but I find that when I am nearing the last few miles, my hamstrings are getting very heavy and tight.  Are there any exercises I could do for this?


Apex Physio Belfast Clinic:  It’s very important that you are stretching your hamstring after the warm up and before the run. Current literature recommends that you hold your stretches for at least 20 sec (which most of us don't do!). It may be beneficial to add in some strength and conditioning for your legs throughout the week on your non running days. This could include mini-lunges, half squats, step ups and bridging. If your symptoms persist, our specialised physiotherapists at Apex Clinic would be delighted to help.


Question:  I am training for the Paris marathon in April.  I am having problems with my IT band , the outside of my right knee and the front inner of my calf . I hadn't run in 3 weeks and got physio but after a 20 minute run/ walk yesterday,  it just felt the same with the pain starting in my calf and  then my knee.  Any ideas as I am running out of time ? I have been rolling and stretching.


Apex Physio Belfast Clinic:  It sounds like you have been doing everything right if your problem is an ITB dysfunction. The only other recommendation would be to avoid downhill running.  In our experience ITB dysfunction would not cause pain in your inner calf.  Your problem sounds very much like nerve pain. Nerve tissue is the most likely structure that would present with pain in this distribution. We have seen this type of problem many times being misdiagnosed and as we specialise in nerve pain and sports injuries, we would love to see you in Apex Clinic for a second opinion.  You need the correct diagnosis to resolve your symptoms as quickly as possible. Hope to see you soon.


Question:  I have a pain on my forefoot leading into my middle toe and it hurts when I run. It's slightly swollen on the top of the foot at the base of the toe also. Is this a stress fracture, or something else? And apart from rest is there any way to treat it, like use of kinesiology tape?


Apex Physio Belfast Clinic:  Stress fractures are commonly caused by overtraining and an x ray is the only way that you can diagnose a stress fracture. Another cause of this problem could be Morton's interdigital neuroma, which is a swelling of nerve and scar tissue arising from compression of the interdigital nerve. Treatment consists of ice for acute tenderness and a podiatry assessment to provide plantar metatarsal padding to help spread the load over the metatarsals. An experienced physio would also give you foot strengthening exercises.


Question:  I experience sharp pain in my knee, behind the knee cap when running, but on the bike I’m fine.  I am a new runner of 9 months and did my first 10 mile run on Sunday (slow and steady). I have got a 10k on Saturday and really want to do it. Any suggestions?


Apex Physio Belfast Clinic:  We treat many knee injuries in the clinic. The symptoms you describe sound like you may have patellofemoral pain.  This is pain coming from under your knee cap from a muscular imbalance of your quadriceps muscles, which places an abnormal load through the knee cap joint. Your inner quads muscle (VMO) is the only muscle used to move the patella or knee cap inwards. If this muscle is not firing correctly it will cause a mal-tracking of your patella which will cause pain. The treatment of this common condition is specific exercises to rebalance the quads muscles especially working on VMO along with an experienced physio performing stretches of your knee cap. The success rate of clearing this pain is extremely high with the correct treatment. Unfortunately, this is not a quick fix problem as with any strengthening of a muscle it will take at least 6 weeks of a progressive exercise program to resolve this problem. If you need any help with clearing this pain, you know where to find us!


Question:  I have been running long distances for a couple of years but over the last few months I've been getting very tight hamstrings on longer runs and tightness and discomfort has been focused on the area behind the knees. My usual self treatment of ignoring it isn't working this time!


Apex Physio Belfast Clinic:  We must highlight that your normal treatment plan of ignoring the problem is not what we would recommend here at Apex Clinic!!!!! On a serious note, we discussed hamstring rehab earlier in tonight's live chat. So we suggest that you should start a stretching and strengthening rehab program and in 4 - 6 weeks if your symptoms have not resolved or improved within this time frame, that you contact us via phone or email and we can discuss the issues and arrange a thorough assessment.  All the best.


Question:  I broke my big toe just four weeks ago.  The A&E doctor told me that I should wait at least 8-12 weeks before considering a run (as long as it felt ok), but it feels a lot better now.  Do you think it would be ok to try a run on grass?


Apex Physio Belfast Clinic:  Fractures can take weeks to heal. Although you feel much better and painfree we would still recommend that you do not run for another four weeks, to give the minimal recommended healing time for this fracture. During this time you can do some bike training, swimming & cross training as all of these are minimal load on your toes. Grass is certainly a good place to start when you return to running.   Hang in there!


Question:  Is there anything else I should be doing other than stretching and using  a foam roller for hip bursitis?  I have been able to run the past 6 months pain free, but it’s returning.  Is there anyway to help prevent this recurring?


Apex Physio Belfast Clinic:  Has this been diagnosed by a medical professional as hip bursitis? We would certainly not recommend foam rolling for this problem. If this is true bursitis the recommended management would be to rest, gentle stretching of your glut medius, physio applied soft tissue work over the area to increase the circulation and a course of anti-inflammatory medication in the short term.  Prevention of this problem returning would include monitoring/reducing your mileage, checking your lower limb biomechanics and strengthening the hip muscles. If the pain still returns despite this approach, please contact us for help to clear it.


Question:  I am training for the Belfast city marathon but have a problem with my calf getting tight. Have you any ideas?


Apex Physio Belfast Clinic:  General calf tightness can be managed by -

1) stretching 3 x 20 sec holds twice a day

2) assessing your foot biomechanics and footwear

3) adding in a strength and conditioning program on your non running days.


If this doesn’t resolve the problem, a physio assessment should be your next port of call to get it cleared.  Hope this helps.

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

Question:  I was wondering if you had any advice on how to deal with persistent calf injuries and tightness of the calves in general.  I have always had this problem with my calves which sometimes leads  to achillies issues but the persistent issue appears to be tightness in both calves, despite pre and post run stretches.  Would foam rolling help or heat etc?


Apex Physio Belfast Clinic:  The best place to start is to look at your footwear and see if your trainers need to be replaced as being flat footed can very commonly predispose to this problem. Ensure you are gently stretching the calf muscles by doing this set of exercises twice DAILY:-

 

1.  Stand with one leg in front of the other with both feet pointed forward.  Place hands on a wall or similar for support.  Keep the back knee bent, with the heel pressed to the floor.  Push your hips forward, whilst pressing your back heel to the ground. Hold the stretch for 20 seconds and repeat on the other leg. Do this 3 times.

2.  Stand with one leg in front of the other, with both feet pointed forward.  Place hands on a wall or similar for support.  This time keep the back knee straight, with the heel pressed to the floor.  Push your hips forward, whilst pressing your back heel to the ground.  Hold the stretch for 20 seconds and repeat on the other leg.  Do this 3 times. 


In terms of foam rolling, the literature is very controversial as to whether they help or not. In our opinion and experience they can be mildly useful for some sports people (but not all) to reduce feelings of muscle tightness. Heat increases the blood flow to the soft tissues which may feel beneficial but may not necessarily solve your longstanding problem. 


Your pain may also have a neurogenic origin, especially as the pain is a longstanding issue. Nerve pain can present in many ways and not just pain eg feelings of cramping and tightness etc. This can be quickly diagnosed with a thorough specialised physiotherapy assessment. I hope this is of some help.  Please do not hesitate to contact us if you would like any more information.


Question:  I have a problem with a click in my hip.  Every time I lift my legs when in a standing position or lying on my back I get this clicking noise coming from my back along with pain in my buttocks. Also, when I run at a higher tempo or a race I take cramp in my right side under my rib cage (which makes me slow down). Any help welcome.


Apex Physio Belfast Clinic:  The rule of thumb with clicking joints is if they are not painful then we leave them alone and focus our attention on any area that is causing pain or discomfort. The pain in your buttock may be stemming from one of two sources. 


1.  A muscle imbalance between your three glute muscles, and... 

2.  A referred pain from your spine which may fit in with the symptoms you have described in your back. 


We recommend a specific assessment by a physiotherapist to assess your gait, biomechanics and spinal mobility to get to the root of your symptoms. Hope this helps.


Remember: Apex Physio Belfast Clinic contributes lots of useful running advice and tips on staying pain and injury free on the 'Physio' page on NiRunning's website where you can also find our contact details.  We will be back on 9th January 2014 with another live 'injury clinic' and we look forward to seeing your questions then.  Merry Christmas and have a pain free running New Year!

Q & A from Injury Clinic on Thursday 7th November 2013:

Question:  Following a hill session on Monday night, my calves were sore on Tuesday, and then even worse on Wednesday. This is not an injury pain, but more soreness from working hard. How long would you recommend leaving it before running again? Is it ok to run even when my muscles are sore?


Apex Physio Belfast Clinic:  This certainly sounds like it is a typical DOMS (Delayed Onset of Muscle Soreness) which is often at its peak 2 days post exercise. Usually on the days of DOMS we recommend that you stretch the affected muscles, twice daily 5 X 20sec holds on each muscle group. In terms of resuming running you could certainly run again gently on Thursday (today) low mileage and on a flat surface only. A gentle run again on Saturday could be done and then resume your normal running routine. Never resume hills until the calf muscles feel fully recovered or you run the risk of a tear.  Sports massage is great for DOMS and for competitive / serious runners it is recommended once monthly. Most runners who receive it usually swear that it significantly reduces any DOMS they feel.  Best Wishes!


Question:  At the moment I am having a bad pain in the arch of my left foot. It has been diagnosed as Plantar fasciitis and treated by both injections and physio but I need some advice on how to prevent this becoming long term as it has happened on both feet and I don’t want it to be a recurring thing


Apex Physio Belfast Clinic:  In most cases a Plantar fasciitis which doesn’t fully clear or keeps recurring suggests that something in the rehab programme has been missed, as in most cases this condition is treatable and clearable if treated correctly. I am assuming the biomechanics of your feet have been fully assessed, and orthoses (insoles) have been provided if needed.  From here we recommend testing the muscle length of all relevant lower limb (leg) muscles and adding any appropriate stretches from any muscle imbalances that are found.  Also, if the arch pain has not fully cleared we recommend assessing if the nerve tissue is involved in the sole of the foot from potential scar tissue that has formed over time from the plantar fascia and finally, we would assess if the lower back is involved in referring pain to the arch of the foot, as well as any local foot involvement.  So, really rehab of PF is multifactorial, and if any of the factors which contribute to it are missed, rehab is often not fully successful.  If you are not fully cleared of it soon please feel free to contact us regarding a reassessment.  Thanks!


Question:  I am training for a marathon and during long runs my right shoulder gets very sore. Any idea what this could be? Is it running related?


Apex Physio Belfast Clinic:  This kind of pain in your shoulder does not sound like a local shoulder problem. If there has been no specific shoulder injury this pain is extremely likely to be referred pain coming from the lower neck/ upper back region of the spine due to stiffness of a few levels of the spine in this area. Running is often a trigger for this pain as it is a high impact sport in terms of the spine as the spine is loaded and jarred throughout running. Often this pain is less severe when running on a softer surface.  There is no real way for you to treat this yourself, you really need a thorough assessment to identify where these symptoms are coming from and treatment will mobilise/ loosen the affected segments. At Apex we treat this problem on a daily basis with great success.  In the meantime stick to softer surfaces (grass, bark or treadmill) for running.  Thanks.


Question:  Is there any treatment for pain in the inside of the left knee when running?  It is a burning pain.  I always wear a cloth support which helps a bit.


Apex Physio Belfast Clinic:  There are many causes of inside of the knee pain such as a torn cartilage, arthritis in the inside compartment of the knee (in older folk), medial ligament overstrain etc. But in your case, the fact that you used the word "burning" may suggest that your pain has a nerve component to it, as irritation of nerve tissue classically causes burning and most of the other causes of inside of the knee pain don't cause a burning pain.  In order to get to the root of your problem, a detailed assessment would really be needed.  In the meantime, it's important to have your foot biomechanics assessed to ensure that poor foot function when running isn't contributing to your pain. If it is, then insoles may be needed.  Sorry that we can't be of any more help, as an assessment is the only real answer! Thanks!


Question:  I had a bit of tightness in my IT band during Causeway Ultra.  It was no big deal but got very sore in the subsequent weeks.  I ran Dublin last week and it came on very sore after 3 miles.  I ran today for the first time in a week and a half and the pain in my knee was unbearable. I could also feel it tight through the hip flexor. How do I get rid of this quickly? Can I run through it? I need to run!


Apex Physio Belfast Clinic:  Firstly, the fact that you described the pain as unbearable when you ran today, means that yes, you should definitely get a thorough physio assessment ASAP as something could go bang, rip or tear if you don't!!  It isn't recommended that you run through unbearable pain as this suggests that you will do damage by continuing.  After a physio assessment has been done to establish the correct diagnosis, such as a possible ITB friction syndrome with maybe some local knee involvement also, there is a good likelihood that you may be able to continue gentle, low mileage running while you receive physio treatment, so you're not actually stopping running, just backing off slightly while you get it sorted.  The longer that you continue running through unbearable pain, the longer it's likely to take to get it cleared! Again, having your foot biomechanics assessed is vital to see if insoles are needed or not.  Think about the longevity of your running life and get it sorted quickly, thanks.


Question:  I've an ITB problem, mainly sore going down hill. Should I stop running until it's better or can I run and do ITBF syndrome exercises? Any advice is appreciated. Is there a strap I can wear while running to ease the pain?


Apex Physio Belfast Clinic:  As a starting point, you could try - doing ITB stretches twice daily, 10 times 20 sec holds.  You can find these on the net.  You could continue running but reducing your mileage and avoiding hills completely and seeing if this helps. It's also vital that the biomechanics of your feet are assessed to see if insoles are needed or not, and to ensure that your running trainers are correct for your foot type.  Try this regime for approximately 3-4 weeks.  If it doesn't clear you will need a proper physio assessment to get the correct treatment regime started. It is extremely likely that you'll make a complete recovery and full return to running.  Best wishes!


Question:  I’ve been suffering an Achilles injury over the last few weeks.. I’ve been having physio sessions for this along with no training.  I’ve been off training now for 4 full weeks!  The physio has also said that the soleus muscle is a bit tight.  I’ve been doing exercises throughout the day to try to help. What would be the best training recommendations for starting back? Maybe grass work? etc.  I’m currently using my bike, trying to keep my fitness up.


Apex Physio Belfast Clinic:  You should only resume running when your TA (tendoachilles) pain has gone completely ie no pain first thing in the morning, on walking after prolonged sitting, on any prolonged walking for more than half an hour to 1 hour.  Once you are pain free eccentric strengthening exercises should be started ie toe ups on a step with both feet then lower slowly with the affected foot only, doing approx 15-20 reps twice daily. This is then progressed to include the same exercises with a bent knee on both sides for soleus.  Dynamic exercises should then be added.  In terms of running, once you are fully pain free you can start a very gentle walk- jog- walk etc routine, such as 5mins of each walk and each jog, starting from 10mins in total and gradually building it up from there. Gently… as a remodelling or repairing tendon likes a bit of stress while healing.   Always start the jogging and then running on a soft surface (grass, bark, treadmill).  Do not add hills until you can run 45mins on the flat symptom free.  Best Wishes!


Question:  I’ve had a tibialis anterior tightness for a few weeks.  It’s an annoying pain that I can’t seem to shake.  I’ve seen a physio and had a number of massages.  I’ve even rested for a week.  The numbing pain still exists if I run the next morning after running the day before, which can hinder running 2 days in a row.  I always ice and use compression guards for support.  I ran the Dublin marathon recently with it.  Any advice would be great.  Thanks in advance. 


Apex Physio Belfast Clinic:  This most likely sounds like it is something which is called, 'altered nerve dynamics'. which means that the nerve which runs down the front of your shin (the deep peroneal nerve) is not moving freely. This certainly will cause a numbing feeling, which is often indicative of nerve problems, tightness and even pain. In most cases, compression socks will actually make it worse as it squashes the nerve and reduces its movement further. Also ice usually worsens the problem too, as the nerve tissue will get more irritated by ice.  We specialise in nerve problems at Apex and advise you to book in for an assessment as this problem clears in nearly all cases. Sports massage will not help this problem in the long term and is not recommended as it may even worsen the symptoms by annoying the nerve tissue even more!  Many thanks.


Question:  Can I ask how long a stress fracture (metatarsal) takes to heal? I was told not to run for 8 weeks but that seems to be the standard overcautious medical advice - could I start again gradually once the pain has gone? Thanks for your help.


Apex Physio Belfast Clinic:  The answer is definitely NO! Even with mother nature working at her fastest your stress fracture can't heal in less time than 8-12 weeks!! You should definitely not start running before 8-12 weeks.  If you do, you will delay bone healing and could end up with malunion problems.  We promise!  We would recommend that in order to prevent this happening again you should have a thorough biomechanical assessment of your feet with the prescription of orthoses if required as really the key thing here is to identify WHY this stress fracture happened in the first place.. and prevent it from ever recurring in the future.  Many thanks.


Question:  I have had a pain in my left foot running from my heel down to the ball of my foot. If I try running, I can't strike the ground properly and afterwards it's hard to put my foot on the floor.


Apex Physio Belfast Clinic:  This sounds like it could be due to, again, from a previous question tonight, a lack of nerve movement of the nerve in the sole of the foot, called altered neural dynamics of the tibial nerve.  It means that this nerve is not moving freely and doesn't like being tugged, i.e. it doesn't like being tugged as you heel strike when running, therefore flat foot running is often less painful. With this problem you may find that running down hill is more painful and running faster is also more painful.  You will need to have your foot biomechanics checked to see if insoles are required or not and otherwise you really need a thorough assessment and the correct treatment regime started to clear the pain and restore the mobility of the nerve.  The beauty about this treatment regime is that it includes a few specific home exercises for the person to do themselves to help to clear the problem, and in private practice this will reduce the number of sessions needed to clear it, in most cases!  Best wishes!


Question:  What is the quickest way to get a soleus strain back on track?


Apex Physio Belfast Clinic:  To start with, you should do twice daily stretches of the soleus muscle (knee bent)-you'll find these easily on the net if needed, and do 5 times 20 second holds on each session.  It's also advisable to stretch the gastroc (knee straight) too, so that you don't get any scar tissue between the two muscles. Don't run in the early stages, but you could keep up your running fitness by aqua jogging or just keep up your cardiovascular training by using the x trainer for example.  Depending on the severity of the strain, once you are mostly pain free when walking then start eccentric strengthening of the soleus, which is done on a step, by doing toe ups on both feet, knees bent but then lowering on the affected leg only , slowly and do 2-3 sets of 15-20 reps twice daily.  The only thing about doing all this yourself, is that if you have a significant amount of scar tissue in the soleus muscle then when you return to running, it may tear again. So, if it’s a bad strain, you should see a good physio for soft tissue work to supplement your stretching and strengthening program.  Best wishes with your rehab!


Question:  I keep getting blue toenails and they are very painful but eventually they fall off after a few weeks. I have tried everything, bigger trainers, trainers with larger toe box and specially made insoles. I seem to claw my toes when running.  Do you have any advice?


Apex Physio Belfast Clinic:  We recommend that you see our chiropodist/podiatrist who specialises in running related foot, nail and skin conditions. You certainly sound like you've tried most things but I wonder if a soft, custom-made toe splint may be appropriate here. I think that it would definitely be worth a reassessment as there is likely to be a solution.  Best wishes!

Q & A from Injury Clinic on Thursday 3rd October 2013:

Question:  Sometimes when I run I get a sudden very sharp pain on the outside of my knee and this causes me to stop. However, it seems to only happen when I wear lighter trainers (like racers) and not when I wear my more cushioned trainers.  Do you think this is an underlying injury or do I just need to wear more cushioned trainers all the time?


Apex Physio Belfast Clinic:  It's good news that your pain is not always present when you run. This sounds like it may be a biomechanical issue and your lighter trainers are not giving you enough support. This may be causing a tug on the lateral (outside) ligaments in your knee while you are running which will result in an injury if you continue in these shoes. If you wish to continue running in lighter trainers we suggest you look into getting a thorough podiatric biomechanical assessment.


Question:  I recently started taking my running more seriously and have found that I am having awful problems with my toenails.  They keep falling off!  Any ideas on how to stop this?


Apex Physio Belfast Clinic:  When you are running regularly, this is a very common problem to experience and if not managed properly can be extremely painful. Attending a chiropodist once every 4-8 weeks is essential if you plan on taking your running seriously. Another essential factor is to have your foot biomechanics assessed by a podiatrist who is experienced with runners. At Apex Physio Belfast Clinic our senior podiatrist/ chiropodist deals with these issues regularly... so you're not alone!


Question:  Hi I am suffering from bursitis in both heels, I have had treatments from dry needling to shock treatment for suspected Achilles tendonitis but nothing has worked. My heels are constantly inflamed and if I run they burn like hell after I have finished. The worst is when I get up in the morning out of bed, my legs are stiff and I have no flexibility in my legs for the first few steps!!!!!


Apex Physio Belfast Clinic:  It sounds like you have exhausted many of the local treatments for this condition. There may be one other element that has not been addressed yet and this is the nerve component. Nerve pain can exhibit as a burning sensation, stiffness and a feeling of being inflexible. Nerve pain can arise from a problem originating in your spine or simply due to a lack of mobility along the nerve. This definitely would need a thorough assessment to get to the bottom of it by a physiotherapist that specializes in nerve pain. Please feel free to contact us via phone or email to get to the root of your problem by speaking with one of our specialist physiotherapists. All the best!


Question:  Good evening! I run regularly 3-4 times per week and have picked up a wee niggle at the top of my right calf, near the knee on the outside, very close to the bone at the knee. Is this a nerve problem or ligament do u think? It seems to persist after an hour of running. I had a deep tissue massage yesterday and she said there was a little knot in the same area. How do I get rid of it? Foam roller doesn't really help either. Many thanks.


Apex Physio Belfast Clinic:  We agree with you that this sounds like it may be a nerve problem. Usually deep soft tissue massage and foam rolling should reduce the symptoms if it was a local muscle/tendon problem and there are no ligaments in the area you describe. Also usually a local 'niggle' will ease once you have stopped running. Nerve pain on the other hand can continue to impose problems long after exercise. It is very important, even though it is a niggle, to get this treated by a physiotherapist that is experienced in treating nerve pain, otherwise you risk the pain spreading . Good luck!


Question:  Hi I strained my glut 5 weeks ago. I was in severe pain but it has now died down to a slight niggle. I haven't run since but have been doing some cross training which doesn't seem to affect it. I am doing a marathon in 4 weeks.  What's best to get me to the start line?


Apex Physio Belfast Clinic:  I understand you are going to be under pressure to safely increase your mileage over the next 4 weeks. The most important element at this point is not to over-do it. The Cross-training will help keep your cardio-vascular fitness stable, however you need to re-introduce gentle running on a FLAT, SOFT (eg- grass/ treadmill) surface and do not forget a good warm up and cool down. At this point aqua jogging could be beneficial for you. All the best with your marathon!


Question:  Hi, 6 weeks ago while on a 16 mile run, I got a severe pain in the side of my right knee. I rested it for 3 weeks and then ran a half marathon. At 12 miles the pain came back ten times worse and it was painful to even walk. I tried 3 miles last night and the pain came back. What is this pain? I have a marathon in less than 4 weeks. Will I be able to compete?


Apex Physio Belfast Clinic:  This is hard to diagnose accurately from the information given. Pain in the outside of the knee could be due to a number of different causes. 


1) it could be due to a cartilage tear in the side compartment of the knee due to wear and tear or the repetitive impact through your knee or 


2) Nerve pain- If you have never had this pain before and it came on that sudden and sharp, not healing with rest and worsening, it is most likely to be nerve pain.


I strongly recommend you get a thorough physiotherapy assessment ASAP to assess, diagnose and treat this problem. The physiotherapist will be able to give you advice regarding your upcoming marathon. Looking forward to hearing from you.


Question:  I hurt my foot over 3 weeks ago (soft tissue damage) and have not been able to run ever since. I get pain when I walk or when I stand on my tip toes. Running is totally out of the question at the minute. No pain while resting. It has gotten slightly better but isn't healing as fast as what I would like. I've tried physio and compression.  Any advice for a speedier recovery? 


Apex Physio Belfast Clinic:  Have you had a recent physiotherapy assessment? Could you please clarify where in your foot/ankle you are experiencing pain? Many thanks.


Question/Response to above Apex Clinic reply:  In response to your reply Apex Clinic... I had a private physio assessment two weeks ago. I was recommended not to run on it and try some ankle strengthening exercises. I've had an x ray to eliminate a stress fracture and also had acupuncture which seemed to give me the most pain relief. The pain is on my left foot just under my ankle bone on the outer side just where it connects to my foot.  It started as a niggle which I ignored and kept running on, until on a longer run I pretty much had to stop as the pain was bad. I've been exercising in the pool and some light biking in the gym which has not been aggravating it. Thanks.


Apex Physio Belfast Clinic:  Thanks for getting back to us.  If you've had a physiotherapy assessment and received treatment to the local soft tissue in the lateral ankle and it is not responding as expected there may be another underlying structure contributing to your pain. This structure may be the superficial peroneal nerve which lies in the area you are describing. The nerve maybe causing pain due to a problem in the spine or due to poor nerve mobility around the ankle. Either way, a nerve problem needs to be treated otherwise it will remain persistent or get worse. Please contact us for a thorough assessment of your ankle. I hope this helps.


Question:  Hello, I am having great intermittent severe periods of pain from the back of the ball of my foot. I have been treated for plantar fasciitis and a few other things. I have had new orthotics made which have greatly helped and I have had a steroid injection for Morton's neuroma on 3 occasions. Up until 20months ago, when these problems started, I was running every day and loving it.  Any advise would be appreciated.


Apex Physio Belfast Clinic:  Morton's Neuroma is a condition that affects one of the nerves between the toes as the nerve becomes irritated and compressed. A steroid injection can certainly help the symptoms in the short term, but we would be more interested in diagnosing where the origin of nerve irritation is coming from. Finding the source of nerve pain is one of our specialities at Apex Physio Belfast Clinic! We have treated many runners who have complained of similar symptoms and have successfully returned to the road- when they didn't think it was possible.  It is worth exploring this avenue as it sounds like you have exhausted local foot treatments. Best of luck!


Question:  Why do I get pain in my knees just after 8 miles or so


Apex Physio Belfast Clinic:  Many runners suffer from knee pain. There are 2 likely causes of your symptoms.


1 - Depending on your age, and past running road regimes, the symptoms may be the beginning of wear and tear (arthritis) of the joint surfaces of the knees, but if you're young this is unlikely. An X-ray of your knees (via your GP) is an easy way of assessing any wear and tear. If there is wear and tear of the joint surfaces your running mileage will need to be reduced with consideration given to the surface you are running on.


2 - It May be due to poor lower limb biomechanics causing increased load and therefore discomfort through your knee joints.  Either way an assessment is needed to correctly diagnose your knee pain to manage appropriately. Good luck!

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.

Q & A from Injury Clinic on Thursday 4th July 2013:

Question:  After about 2/3 miles I get very sore calf pain, then after the run the day after feels as if gonna cramp badly wots up?


Apex Physio Belfast Clinic:  This doesn't like a local calf problem in our experience.  As you are aware a local calf problem would occur immediately with running and would most likely ease once you have stopped.  A characteristic of nerve pain is that it has a latency (delayed) effect which means the pain gets worse after activity, which sounds like what your experiencing.  We can assume you are warming up and cooling down (stretching etc) appropriately therefore it would be worth while coming to Apex Clinic for a proper diagnosis as this is an area that we specialise in. Hope this helps.


Question:  On the front/inner aspect of my left knee, I have what feels like a clicking motion.  This normally happens when I am walking but causes no real problems when running.  Does it sound like something to worry about? Ps... I have been aware of it for a 15/18 months.


Apex Physio Belfast Clinic:  This sounds like it could be a slight mal-tracking of your patella (knee cap) which can arise from a muscle imbalance in the quadriceps muscles.  Although is it not painful at present it would be advisable to have this problem addressed with specific exercises as prolonged mal-tracking of the patella could lead to further problems in the future.


Question:  I went running on Sunday and pulled up with my calf muscle about 3 miles in. I thought it was torn but it feels more comfortable to walk on now with no pain.  When do you think I should start running again (Ps... I'm doing 10k regularly so it isn't an injury from just beginning)?


Apex Physio Belfast Clinic:  At this stage it would be advisable to regularly stretch your calf muscles throughout the day holding for 20secs each time.  If you can walk on your tip toes pain free then on Sunday you could start a gentle interval running program on a bark/grass surface ensuring you have correctly warmed up and don't forget the cool down.  If you are not pain free with this gentle running it would be advisable to get you calf muscle treated with soft tissue massage. 


Question:  I have just been diagnosed with my second stress fracture on metatarsals in a year, is it over training? or should new orthotics prevent loading?


Apex Physio Belfast Clinic:  The most common cause of stress fractures is over training! Although orthotics can reduce loading in the foot during running, if you continue to over train you are still putting too much force through these small bones.  Aquajogging is an ideal way to maintain your running fitness while your injury heals as there is no loading/pressure going through any joints.  Patience is a virtue!


Question:  I have been struggling with tight right hamstring and pain at back of knee when i stretch,seems to hve spread to inner leg between groin and knee also ?


Apex Physio Belfast Clinic:  There could be a few different reasons causing this pain.  It could be the hamstring muscle itself that has been damaged.  It could also be arising from a neurogenic origin as the pain is spreading.  If it was a muscle tear it should be healed by now therefore we would advise that you have this problem thoroughly assessed so it can be managed correctly.  Sorry we cannot give you a more definitive diagnosis at this time.


Question:  Limping with sore left foot, felt like coming from below the ankle towards the bottom of the small toe however it's not sore to touch, it's sore when I touch the top of the foot towards the bottom of the toes, feeling a bit weird at the side of my calf now, I do get tight calfs I think because I don't drink enough water , the pain started the day after a 9 mile easy run 2 days after a PB in ards half marathon, too sore to run now.


Apex Physio Belfast Clinic:  Congratulations on your PB! If the pain is focused around the base of the small toe it could be either be a local tendonosis or joint impingement. The pain at the side of your calf could be due to a biomechanical problem or overcompensation from the foot pain. I'm sure you are wanting to get back to running as soon as possible therefore we would advise you to see a physiotherapist to help you get there as quickly as possible.


Question:  Another calf question if you don't mind.  After an hour or so training, which involves running, circuit type activity, etc, my calves cramp up and feel as if sometimes they are going to literally detach from my legs. Is it weak calves and if so, what can be done to prevent this? 


Apex Physio Belfast Clinic:  This does not sound like a case of weak calfs.  This may be coming from incorrect footwear (poor support or poor shock absorption), or as discussed earlier the latency effect of pain is most likely due to a neurogenic component.  Nerve pain can present in many ways, not just pain eg feelings of cramping, tightness etc.  Again this would be quickly diagnosed with a thorough physiotherapy assessment. 


Question:   How should I treat my recurring calf injury?


Apex Physio Belfast Clinic:  If this is a reoccurring injury the correct diagnosis and treatment has not been identified.  There are two main causes of recurrent pain in the calf area these are nerve tissue dysfunction and referred pain from the spine.  At Apex Clinic we specialise in the assessment and treatment of nerve pain or nerve symptoms so please feel free to give us a shout. 


Question:  Pain in glutes and hamstrings for past few months, cannot maintain speed over long distances but long and slow is manageable.  I am doing constant stretching and strengthening.  Have most pain when sitting... any suggestions? Have reduced mileage but should I take a complete break?


Apex Physio Belfast Clinic:  This could be either a problem with the insertion of the hamstring muscles however you would have most likely felt an improvement with regular stretching.  The other reason behind this problem could be a referring pain from the spine.  When you sit, the load throughout the spine increases significantly and when you increase the running speed this also happens.  This is a very commonly misdiagnosed problem we see in the clinic and believe a correct assessment and diagnosis is key to solving your problem. 

Q & A from Injury Clinic on Thursday 20th June 2013:

Question:  I’ve never had trouble with my achilles, but recently in the morning when I get out of bed the area around my achilles and ankle is tender. After hobbling around for around five minutes it returns to normal, then when out running again after five minutes all pain and tightness that may remains has disappeared..... any ideas of the best way forward?


Apex Physio Belfast Clinic:  This sounds very much like the beginings of an Achillies Tendonopathy (What used to be called Achillies tendinitis).  The best place to start is to look at your footwear and see if your trainers need to be replaced as being flat footed can very commonly predispose to this injury.  If this is the case, advice from a specialist running shop on whether you need an anti pronation shoe or not could be helpful.  If your trainers are in good shape and there is no need for a change, I would recommend a thorough assessment with ourselves to find out the origin of this problem.  As an achillies problem (like a tennis elbow pain) can be one of the most stubborn problems in the body to clear.  Therefore early action is advised. In the meantime, ensure you are gently stretching your calf muscles twice daily.  3x 20sec holds with the knee straight and your knee bent, also reduce your running millage until the morning pain clears.  Hope this helps!.


Question:  This months Irish Runner magazine totally debunks the idea of ice treatment saying that markers have show that it is actually bad for the user.  I swore by them during my marathon training, was this just a placebo?


Apex Physio Belfast Clinic:  If you are talking about ice baths, we would tend not to favor these, in our experience deep tissue massage has most effectiveness pre and post event.  Ice treatment performed as part of PRICE (protection, rest, ice, compression and elevation) is evidenced based first aid treatment to and injured soft tissue, here icing is recommended.  As for your ice treatments possibly being a placebo while marathon training...we can only say, what works for one, doesn't work for another.  As long as it got you through your marathon, you cant argue with that!!


Question:  Any advice for on going calve problems, severe stiffness after longer runs.  I am wearing compression socks and using the foam roller before and after, is there anything else i could be doing? Could it be a hydration issue?


Apex Physio Belfast Clinic:  From what you've told us, it certainly doesn't sound like its a hydration issue, this is unlikely.  Compression socks wouldn't usually help with this problem either, but we understand that it was good to try.  The fact that foam rolling hasn't helped with the calf stiffness, it is unwise to continue, as the origin or root of the problem really needs to be established.  In our experience, the most likely reason for your symptoms, from what you've described is either - a build up of scar tissue (fibrosis) in the calf muscles which can be reduced and the symptoms cleared usually by deep soft tissue massage (which we offer).  Secondly, the symptoms could be due to a lack of nerve movement (altered neural dynamics) of the nerves that pass through the calf muscles, by scar tissue which has occured in the past in the neighbouring calf muscles.  This can also be usually cleared completely by a specialist physio who is familar with this problem, but it needs properly diagnosed.  We would be experienced in this treatment if you wish to have it assessed.


Question:  Recently every time I get above five miles both my knees become incredibly stiff round the sides resulting in me not being able to bend them and its really painful to run. I was just wondering what could be causing this? 


Apex Physio Belfast Clinic:  It sounds from what you've said that there are two likely causes of your pain and stiffness; firstly, depending on your age, and past running road regimes, the symptoms may be the beginnings of wear and tear (arthritis) of the joint surfaces of the knees, but if you're young (watch out,some of us here feel young!) this is unlikely, an x-ray of your knees (via your GP) is an easy way of assessing any potential wear and tear.  The second reason, is that your symptoms may be referred pain coming from your lower back, especially if your symptoms are worse when or after running UP hill.  For treatment, in the first instance, if there is wear and tear of the joint surfaces your running mileage will need to be reduced, and your footwear assessed to consider more shock absorption in them.  In the second case, specialist treatment to your lower back would be very likely to clear these symptoms (which we see very commonly at Apex) in conjuction with over the counter shock absorption insoles for your shoes.  Either way, an assessment is needed.


Question:  I'm suffering from numb toes after about 5 miles into my run or when I'm running hard.  Have you any advice or heard of this before? My trainors are not too small or tight.


Apex Physio Belfast Clinic:  It's great that you've considered your trainers, as this could have been a causative factor, so you've eliminated that.  We have seen many, many runners and other sports folks with similar symptoms and nearly all of them have recovered fully from treatment.  The most common cause of this, is irritation of nerve tissue (as numbness is a common symptom of nerve irritation) originating in the back (this does not mean that you need to have back pain to be experiencing this).  A full assessment is required to identify where exactly the nerve tissue is being irritated and then that area can be treated by mobilisation of the affected area, and then a few exercises to keep that area loose.  At the risk of sounding like we're blowing our own trumpet, one of our specialist areas in Apex is the assessment and treatment of nerve pain or nerve symptoms, so feel free to give us a shout.


Question:  When your legs feel stiff/heavy and sore after a tough long distance race, how long would you leave it before getting a good 'deep' tissue massage?


Apex Physio Belfast Clinic:  We recommend that a good, deep soft tissue massage should be given the day after a long distance run, largely to prevent/ reduce the onset of DOMS and also to optimise the muscle recovery (and increase the circulation following any micro tears of the muscle fibers).  For regular runners, a deep soft tissue massage is recommended once monthly to reduce the risk of a build up of scar tissue in the leg muscles.


Question:  If you were restricted to only doing the one same simple stretch each and every day.  Which one would you recommend and why? 


Apex Physio Belfast Clinic:  To answer your question, the best option if you're restricted for time, which we understand, is to do one stretch for 30secs to 1 minute (and no less) once daily on each leg - alternating between the quadriceps muscles on one day, the hamstring muscles the next day, and calf muscles (with your knees bent) the next day, and your calf muscles with your knees straight the next day, hip flexors and adductor muscles etc these are the most important muscle groups for runners to stretch.... why not stretch each muscle group twice, instead of once, that'd be even better!


Question:  How long would it be best to wait to complete a quality/high intensity session following a vigorous deep tissue massage? 


Apex Physio Belfast Clinic:  We would recommend that you wait until two days after a deep tissue massage before commencing a high intensity session.  This will ensure you get the full benefit of the effectiveness of the massage, and will be in optimal condition for your next session.


Quesion:  I hurt my knee while traing for Belfast, inner part of knee cap, I've reduced my running to about 3/4miles 2 or 3 times a week with some cycling. While the pain is reduced, should I stop running totally to help it clear?


Apex Physio Belfast Clinic:  The most common cause of knee pain on the inner part of the knee cap is Patellofemoral dysfunction (maltracking of the knee cap).  One in four sports people will experience this in their lifetime. T his problem responds extremely well to a specific regime of treatment.  It normally only takes a few treatment sessions and is managed mostly with specific exercises.  You should also have your footwear (trainers) assessed as this could be contributing to the problem.  Again a thorough assessment should be carried out to identify the true cause of the problem.


Question:  Whilst performing hill sprints, my calves tend to cramp up badly.  I keep hydrated and stretch adequately but after an hour or so, I struggle to even jog with the calf cramps.  Is it a lack of sodium?


Apex Physio Belfast Clinic:  It is unlikely that the problem would be caused by low sodium levels, as your symptoms would not be worse when running up hill, you would most likely feel your symptoms at other times.  It is most likely to be coming form a build up of scar tissue or the neural tissue not moving well in the calf muscle.