Top 10 tips on managing running injuries

It’s odd really it’s taken me around 8 posts before I got round to a general advice article. The reason for that is that there are so many out there. I wanted some specific stuff first.


That said, a lot of people may benefit from some more general advice…so here goes…in no particular order


  1. Train Smart and include rest – learning when to rest is a key part of running, especially when training for an event. Sometimes it’s harder to rest than to run but it’s essential for your body to repair. A lot of conditions, especially tendon problems, require around 24 hours post run to strengthen the tissue. The body is in a constant balance of tissue breakdown and tissue strengthening, if you run without allowing adequate rest it tips this balance towards breakdown. Remember we train to race, not the other way round, there are no prizes for the quickest time in training. Think about the bigger picture, sure running your long run 30 seconds per minute faster may be a better workout at the time, but how will it affect the remaining runs that week? Have one focus for each run, working speed, endurance etc individually , not together. A long slow run is just that, don’t be tempted to run it fast, you should be able to chat comfortably the whole way. Add new workouts gradually, especially hills and speed work where the risk of injury is higher.
  2. Find the cause of your injury – most websites are excellent at helping you settle symptoms and giving you generic advice on rehab. The idea on RunningPhysio is to help you identify the cause and deal with it appropriately. This helps to stop problems returning again and again.
  3. Settle the symptoms – the old acronym of RICE often proves useful here. Rest. Ice. Compression. Elevation. It has become PRICE, with the P standing for protect and more recently it’s been suggested to change it to POLICE. The R from rest is replaced by OL for Optimal Loading. More on this here, we also have details on what to avoid, sub-acute injuries and the use of anti-inflammatories. Other things can also be used to settle symptoms like offload taping and self massage. Once symptoms are settled and you’ve identified the cause of your problem then you can start rehabbing it.
  4. Strengthen – the most effective way of strengthening is to identify specific weaknesses and work on them. Common areas are calf, glutes and quads. Strong muscles will absorb impact more effectively and help improve running economy (how efficiently a runner uses oxygen while running at a certain pace). Strength and movement control are intimately linked. It is difficult to control movement without adequate strength. After injury it’s important to strengthen weak areas before returning to running. A classic with this is a calf tear, lots of people post on the RW forums about “recurrent calf tears”. When you probe a little deeper you discover they didn’t do enough rehab and returned to running with a weak calf leaving them vulnerable to reinjury.
  5. Stabilise – control and stability of movement is very important for runners. If you have poor control then you are likely to have excessive movement during the impact part of running. This can place a lot of stress on certain structures (like the ITB, Achilles tendon etc.) and lead to inflammation and pain. Assess your single leg balance and single knee dip. Is your balance good? Can you maintain balance without movement of the pelvis, ankle or knee? When you do a single knee dip can you do so without the hip adducting (which makes the knee move inward)? If you find one side is worse than the other or you struggle to control a movement practice it regularly and it will improve. Details on control and stability work here, including videos of tests and exercises, but you have to promise not to laugh at my skinny legs!
  6. Stretch – runners often complain of muscle tightness or joint stiffness. We tend to use generic stretches but it’s best to identity specific tight areas and work on those. Common problem muscles include calf, quads, hip flexors, ITB and hamstrings.
  7. Modify – in many situations you may be able to run pain free by modifying your running. This is a short term strategy but can be very effective in helping something settle. It’s a case of seeing what you can change that allows you to run pain free. It can simply be reducing distance or speed, or avoiding hills or interval training. It might be decreasing your stride length, regularly changing your running surface or starting slower and building up. Changing footwear, trying taping or a gel heel insert can all be ways of modifying your running to keep it pain free. Then when symptoms settle you can gradually return to your normal running.
  8. Plan a gradual return to running – so many people expect a rapid return to where they left off as soon as symptoms have settled. Unfortunately the body needs time to adapt to running again and any long break from running requires a gradual return. One way to do this is to plan it like you might a race. Set your goal as your normal weekly mileage and plan your running building up to this. Start by finding where your new level is – the maximum distance you can run without causing pain (during or after). Build up from there and but don’t increase your weekly mileage by more than 10% per week.
  9. Footwear – having appropriate footwear is an important part of your running. Old, worn out shoes will offer little support and it’s recommended you change your running shoes after approx. 350-500 miles. Choose the right shoe for your foot shape, generally this means a stability or motion control shoe for over pronators and a well cushioned shoe for people with high arches. A growing number of runners are now moving away from supportive footwear towards minimalist shoes. The theory is that with a gradual introduction to these shoes the muscles in the foot and ankle will strengthen and provide the support. The key though is to make the change gradually. If you are unsure about what footwear is best then arranging gait analysis can be very helpful or take advice from a podiatrist who can make custom built insoles.
  10. Ask for help – runners often seem reluctant to ask for help from their GP, Physio or Health Professional. There are several reasons for this, one is they worry they will be told not to run, the other is that some health professionals seem to know very little about running or have a very negative attitude towards it. That said sometimes you need help, injury management isn’t simple are can’t all be managed through advice online. Find a Physio or GP who understands running and has experience of managing runners and use them whenever you can’t manage an injury yourself. The better they get to know you and your training, the easier it will be for them to help you manage any injuries.


A simple diagram showing the balance between doing too much and overloading the tissues and doing too little and not improving strength and fitness. Some tissue overload is needed to improve strength but keep working too hard, for too long with too little rest and it’s likely you’ll pick up an injury.



Assessment and rehab of movement control and balance

I’ve mentioned movement control and balance in most of my blogs on injury management. It’s one of what I think of as the Big Three; Movement control, range of movement and strength. If you have all three you’re onto a winner and less likely to struggle with injury. It’s also likely to improve your running economy, making you run more efficiently with less energy expenditure.

When assessing balance it’s best to start with the basics; single leg balance and single knee dip. When you can manage these, and their variations with ease and good control then you can progress on to more advanced work, including multidirectional exercises and impact control. So let’s start with assessing single leg balance;

Then single knee dip;

Use a mirror and assess yourself with these 2 tests. If you struggle to maintain balance or to do the dip without excessive trunk, knee or ankle movement then you can rehab this with some of the suggestions in the next videos. To improve single leg balance pick 2 or 3 of the exercises that you find challenging and aim to maintain your balance with good leg alignment for 10-20 seconds. Repeat roughly 10-15 times or stop if you start to fatigue and lose movement control.

If you struggle with single knee dip, try some of the following exercises and again focus on good control. This is a dynamic exercise rather than a static one so we aren’t focussing on a hold, rather aiming at 10-15 good quality reps, you can increase or decrease this if you want but it’s usually a good place to start.

If you really struggle with balance you may have a strength or range of movement issue that needs addressing too. For example, it’s very hard to balance with very weak glutes or if your ankle range of movement is limited. In the third video note how much my ankle has to move initially when I use the rockerboard on 1 leg, without that flexibility the ankle can’t change position to help maintain balance.

People may point out that these 2 exercises are a little basic and they’re right. There are a lot more advanced control exercises that challenge in multiple directions and at higher speed but a good grounding of basic balance and movement control is needed before progressing to these.

Shin Pain – Part Two – Exertional Compartment Syndrome

In Part Two of this blog we look at Chronic Exertional Compartment Syndrome (CECS)



There are several muscle “compartments” in the lower leg, each includes muscles, blood vessels and nerves enclosed within soft tissue called fascia. During running the pressure gradually increases in the compartment until you start to experience pain. Symptoms often start at a predictable time during a run then gradually increase, reducing somewhat when you finish. It usually feels tight, tense and sore and can cover most of the shin area depending on what compartment is affected. If the pressure in the compartment is significantly raised it may affect the nerve, causing pins and needles, numbness or muscle weakness.


Adapted from Fraipont and Adamson 2003

Symptoms will depend on what compartment is affected. The anterior compartment is most commonly affected, accounting for around 45% of cases, the deep posterior compartment is second most common at around 40%. Lateral compartment makes up 10% with the superficial posterior compartment around 5%.

The anterior compartment contains 4 muscles (Tibialis Anterior, Extensor Hallucis Longus, Extensor Digitorum Longus and Peroneus Tertius) the tibial artery and the deep peroneal nerve. Symptoms are usually felt within the belly of the Tibialis Anterior muscle. There may be weakness in dorsiflexion (lifting the foot) or toe extension. If the nerve is affected there can be pins and needles or numbness in the top of the foot and the first web space. In severe cases all power to dorsiflexion may be lost and a temporary or persistent “foot drop” can develop.

The lateral compartment contains 2 muscles (Peroneus Longus and Brevis) and the superficial peroneal nerve. Symptoms tend to be felt more along the outside of the shin in the muscles affected. If the nerve is affected there can be pins and needles or numbness in the front and outside of the shin and weakness in ankle eversion (turning the ankle out). I had this during my marathon training. I had a dull ache and pins and needles over the outside of the shin and eversion was weak. My symptoms were there for around 3 weeks then completely resolved with 3 treatments of acupuncture and a change of running shoes.

The deep posterior compartment contains 3 muscles (Flexor Hallucis Longus, Flexor Digitorum Longus and Tibialis Posterior) and the posterior tibial nerve. Symptoms are usually felt around the inside of the shin or back of the lower leg. If the nerves is affected there may be pins and needles or numbness in the sole of the foot and weakness of toe flexion and ankle inversion (turning the foot into).

The superficial posterior compartment contains 2 large muscles (Gastrocnemius and Soleus) and the sural nerve. If the nerve is affected there may be pins and needle or numbness on the top of the foot, on the outside and weakness in plantarflexion (pointing the foot down).

Diagnosis and Investigation

The gold standard for diagnosing compartment syndrome is intracomparmental pressure measurement. This is an invasive procedure and tends to be done after exercise to monitor pressure changes. MRI and Near Infrared Spectroscopy have also been used.

Something to consider with CECS is that if you are symptom free at rest then your doctor or Physio may find very little when examining you. There may be some signs, such as fascial hernias which are quite common in people with CECS but unless you exercise as part of the assessment they may find little else. This can lead to misdiagnosis and it is a condition that is commonly missed.

Causes of compartment syndrome

We know that muscles tend to swell during strenuous exercise and that the compartments in the leg are enclosed within fairly inflexible fascia. So why is it that some people develop a compartment syndrome and some don’t?

I think much of it comes down to overloading one particular muscle group while we run. The muscle responds by strengthening and hypertrophy – an increase in muscle size – think Arnie! If the muscle is already enlarged before you start running, the added expansion during a run is too much for the limited space in the compartment. The result is that blood flow into the compartment becomes restricted, the tissues within the compartment become ischaemic (the reduction in blood supply leads to a shortage of oxygen and glucose which is essential for tissue to function). Tissue ischaemic causes pain. When you stop running the pressure in the compartment decreases and normal blood supply can return and symptoms settle.

So why is one muscle group being overloaded? And can you change it?

It’s worth remembering at this stage that compartment syndrome comes in varying levels of severity. Also for many, their symptoms may well just be muscle tightness in response to being overloaded and not a fully developed case of compartment syndrome. Up until fairly recently it was thought that compartment syndrome responded poorly to non-surgical treatment and needed surgery but there is growing evidence that it can be treated without going under the knife. One study took 10 runners who were awaiting a fasciotomy surgery and changed their running style to forefoot running. All 10 avoided surgery and returned to running with reduced symptoms. Another smaller study by the same authors similar affects. Forefoot running isn’t the only potential solution, a small study showed excellent results for anterior compartment syndrome just with change of footwear. Now, it’s worth baring in mind that these are only very small studies and only on patients with anterior compartment syndrome. There are also a number of limitations with study design but at least they suggest that this condition can be changed non-operatively.

Address the causes

In part one of this blog we looked at how certain factors can place greater stress on parts of the bone leading to stress reaction and eventually, if continued, stress fracture. The principles here are similar. Like bony stress I do think it’s also a “continuum”, that is it’s a gradual increase in stress on tissues and not a sudden switch (like you either have compartment syndrome or don’t). Earlier signs may be just tightening and discomfort in the muscle, something many runners experience and probably describe as “shin splints”.

Potential causes are;

  • Training error
  • Poor biomechanics
  • Inappropriate or old footwear
  • Poor running form
  • Excessive running on solid surfaces
  • Poor movement control
  • Muscle weakness
  • Reduced foot and ankle movement
  • Tissue tightness

Symptom management

With compartment syndrome it may be pain free at rest, despite that it can be worth trying these measures to see if they reduce pain when you actually run.

  • Ice – 10 to 15 minutes over the affected area
  • Self massage
  • Compression – many people find wearing compression socks very effective in reducing symptoms when they run
  • Taping – tape can be used to help support the muscles to reduce overloading. It also tends to compress the area. RW have a nice technique here for anterior shin pain.
  • Stretch the affected area
  • Foam roller – be gentle and start in the pain free surrounding areas first
  • Acupuncture – not something you can do on yourself obviously but I found it very effective.

Returning to running

One of the frustrating issues with compartment syndrome is that often symptoms return when running even after a prolonged period of rest. The challenge is to find a way to return to running without symptoms. With my lateral compartment syndrome I noticed some clear patterns. If I started a run too quickly I’d get symptoms, if I gradually built up speed it was far less. If I warmed up well symptoms improved. If symptoms developed when running I could usually reduce them immediately by switching from the road onto grass and slowing just a little. Speed work on concrete was the most aggravating and caused tightness and pins and needles in my leg. I ran Brighton Half Marathon when my symptoms were near their worst. The tightness kicked in around mile 3 and my ankle felt weak. I changed my position on the road regulary so I was running on slightly different cambers. By mile 5 I was symptom free again.

My point here is modify and overcome. See what you can change that allows you to run without your symptoms. It may be speed, distance, running surface, stride length, running shoes, pre-run warm up or training type (hills/ endurance/ interval work etc). In this way you can continue to run and by addressing the causes (as detailed above) your body will adapt to stop overloading one muscle group and then you can gradually return to full training. Bright Half Marathon was February 19th, I ran Brighton Marathon on April 15th completely symptom free.

Like all my posts on here this comes with a message; if in any doubt get checked out. It’s always a good idea to have injuries assessed especially if they involve pins and needles, numbness or muscle weakness.

Gluteus Medius – evidence based rehab

This is in part advice for runners and in part something else….

…you’ve heard of a “dance off” and probably a “sing off” this my friends is a geek off!

It’s come about after I’ve heard lots of people being advised not to bother with sidelying exercises for glutes because they “aren’t functional”. Several well-meaning websites even describe them as harmful and more likely to cause “regression” than rehab. I say in my home page for this site that I appreciate everyone’s opinion and I do. I also agree that sidelying work isn’t functional, but I feel it still has a valuable place in glutes rehab and it shouldn’t be treated as ineffective quackery! My point here isn’t that sidelying work is the best, but simply that it has it’s value in rehabbing glutes and should be used as part of a comprehensive programme including weight bearing exercises.

So let’s examine some glutes exercises you can do and some research behind them. All pictures are reproduced from research articles freely available on the web and will be referenced and linked.

Sidelying abduction – reproduced from Distefano et al. 2009 (below). There is also a video although it doesn’t work on the iPad. This page contains links to videos for all the exercises in this article (links may take you to a “mobile page” if using iPad or iPhone. Use the search box and you can locate the full article without signing in).

Distefano et al. 2009 used an EMG study to determine which exercises produced most activation of Gluteus Medius. EMG (Electromyography) uses electrodes to examine muscle activation. They compared a number of exercises including hip clam, single limb squat, single limb deadlift, lateral band walks, multiplanar lunges and multiplanar hops. They concluded that,

“The best exercise for Gluteus Medius was side-lying abduction”

They found single limb squat to produce the second most EMG activity and lateral band walk the third.

Now you may be wondering does this translate to changes that I can feel and see? Will it improve my symptoms? It’s fair to question this, EMG change is all good in theory but what about in practice?

Fredericson, who’s written quite widely on ITB problems and their treatments did a study on runners in 2000. They found that,

“Long distance runners with ITBS have weaker hip abduction strength in the affected leg compared with their unaffected leg and unaffected long-distance runners….symptom improvement with a successful return to the pre injury training program parallels improvement in hip abduction strength.”

So hip abduction, one of the roles of Gluteus Medius, is weaker on the side runners have ITBS. No great surprise there. What exercises did they use to rehab it and return people to running?…..

… guessed it side lying abduction and pelvic drops.

Update 3/6/12:

Thanks to Stuart Palma (a nice bloke despite being a Liverpool fan!) we also have another article to add to the mix. McBeth et al. 2012 compared 3 sidelying exercises sidelying abduction, the clam, and sidelying abduction with external rotation in healthy runners. Unlike previous articles they used a leg weight and a “biofeedback unit” to monitor trunk position. They compared muscle activation in Gluteus Medius, Gluteus Maximus, anterior hip flexors and Tensor Fascia Latae with each exercise. They concluded that,

The sidelying hip abduction exercise was the best for activating Gluteus Medius with little activation of Tensor Fascia Latae and anterior hip flexors”

A few key points here then;

  1. It gives us an indication of specificity – sidelying abduction appears to be able to activate the muscle we are targeting without working the muscles we are not targeting.
  2. Gluteus Medius activation was similar to Distefano’s earlier work at 79.1% of MVIC.
  3. Important to note there is no comparison with weightbearing exercise

Now I could stop there. I’ve made my point – sidelying abduction clearly has a role, but part of this is not about cherry picking a couple of articles to prove a point, it’s about looking at the bigger picture even if that includes research that goes against your theories….

Side plank abduction

This is reproduced from Boren et al. 2011 who did an excellent study and also compared their results with earlier work. Their top 3 exercises for Glute Medius were side plank abduction with dominant leg down, side plank abduction with dominant leg up and single leg squat (in that order). Notice again that these positions, despite being “non-functional” do create a lot of activity in Glute Medius and again more so than weight bearing positions such as single leg squat. Of note too is that they found less activity with side-lying abduction than the previous studies. This raises a good point with research and rehab. Nothing is concrete. You simply cannot say “this exercise has no role” as you will find evidence to support your claim and evidence to refute it. Also they used a slightly different technique which might account for the difference.

The Clam

Again reproduced from Boren et al. 2011 but I’ve modified them with some instructions to clarify (thanks to Debra for the suggestion). The link above also includes detailed descriptions of this exercise and its progressions (it’s all in the appendix at the end of the article). Most people think of the clam as the exercise described in Clam 1 above. In this study 3 progressions of the exercise were included. In many exercises they can be progressed by increasing resistance, this one is progressed by a change in position. The article demonstrated an increase in glutes activity from Clam 1 being lowest to Clam 4 being the highest. Compared to other exercises in the study Clam 4 had a high level of Gluteus Medius activity (77% of MVIC – Maximal Volitional Isometric Contraction) only slightly lower than Single Limb Squat (81% of MVIC). Distefano et al 2009 showed lower levels of activity with the clam but didn’t include the same progressions.

So we’ve seen 3 exercises, all in sidelying, that produce high levels of Gluteus Medius activation, at least comparable to, and in some cases higher than weight bearing exercise. It’s no great surprise then that the English Insitute of Sport uses a selection of sidelying exercises in its “Glutes Circuit”. We were given this by one of their team at a Strength and Conditioning lecture but sadly can’t reproduce it online.

Next we look at weight bearing exercise

Single Limb Squat

Once again from Boren et al. 2011. Single Limb Squat as above showed good Gluteus Medius and Gluteus Maximus contraction with 81% of MVIC for Gluteus Medius and 71% for Gluteus Maximus. Both muscles are hugely useful for runners and so this exercise clearly has its benefits. As a result it’s one I use regularly. The only issue here is the risk of aggravating pain. The deep dip position places greater stress on the ITB and patellofemoral joint. As a result I often start with a shallow knee dip or use this exercise after first rehabbing with sidelying exercises. There is also an issue of control, some patients struggle to even balance on one leg let alone perform a squat.

Distefano et al. 2009 used the slightly different technique shown above, they also reported good activation of both Glute Med and Max. Lateral Band Walk shown below, also showed good Gluteus Medius activation (although less than side lying abduction). This doesn’t appear to have been assessed by Boren et al. 2011.

Wall Press – reproduced from O’Sullivan, Smith and Sainsbury 2010. In the picture below the right Gluteus Medius is being exercised by pushing the left knee, hip and ankle against the wall and maintaining a contraction for 5 seconds.

Wall press was compared to Pelvic Drop and Wall Squat and achieved the highest MVIC of 76%.

Pelvic Drop – picture below reproduced from Bolgla 2005 who found reasonable activation of Glute Medius on pelvic drop of 57% of MVIC and was similar to Boren et al 2011 (58%). In Bolgla’s study it scored the highest of 6 exercises which also included sidelying abduction.

For pelvic drop the standing leg (right in this case) stays straight and you lower your other leg by lowering the pelvis on that side.

Krause et al. 2009 (abstract only) studied the effect of doing exercises on a balance cushion and found an increase in Gluteus Medius activity (compared to balancing on normal floor) although it should be noted this difference wasn’t thought to be statistically significant.

Lubahn et al. 2011 looked at the effect of using resistance band to pull the knee more medially (towards the other knee) during weightbearing exercises. The idea behind this is that the medial pull of the band should increase activation of Gluteus Medius. They found it didn’t increase activation during single limb squat or step up and may result in poorer limb alignment during the exercise.


Acknowledging Limitations and closing thoughts

An important part of any theory is acknowledging limitations. Like I’ve mentioned above nothing is concrete. I’ve barely scratched the surface of research in this area and I acknowledge there is more research out there, undoubtedly with different findings. I also realise that the main measure involved in these studies is surface EMG recording of muscle activity in healthy individuals. This measure is only related to Maximal Volitional Isometric Contraction presented in a percentage and has not included people with injuries. Endurance activity such as running rarely needs maximal voluntary contraction. So we can’t conclude that because sidelying abduction has a higher % of MVIC than single limb squat that it is a better exercise for rehab in return to running. Neither can we conclude that certain exercises are better for rehabbing certain conditions as the research above (with the exception of Fredericson et al. 2000) doesn’t examine the effect of exercise on injury. That said I think the research is a useful indication for strength work – Boren et al suggested that an MVIC of greater than 70% was needed for strength work while ealier research suggested a range of at least 40-60%. Sidelying and weightbearing exercises have both achieved greater than this range and should be capable of producing strength changes.

The aim of this blog was not to prove sidelying exercises are more effective but only to show that they create good levels of glutes activation and have a role in rehab. This idea that exercises must be functional is a slightly limited one. The very fact that sidelying work isn’t functional may be its advantage – it is a task that we don’t do as part of our day, a task that can potentially isolate a muscle to gain good activation. If functional tasks were so good at glutes rehab, we’d all have great glutes just from walking around, climbing stairs and running!

The other advantage of sidelying work is that it can often be done without aggravating symptoms if done correctly. For people with painful ITBS or irritable patellofemoral pain a range of weightbearing exercises can make symptoms worse.

Selecting exercises for yourself or a client is very individual and should be based on addressing specific weaknesses. Take sidelying abduction, some people can do 40-50 with good form and minimal glutes fatigue. There is little point asking them to do this as an exercise as it probably won’t overload the glutes to achieve strength changes. Some people get to 9 or 10 reps and start to fatigue or lose control and they are more likely to benefit from it. For some the issue actually isn’t strength at all, some studies show poor correlation with Glute strength and pelvic position, this is because control of movement can be poor even with good strength. In that situation it’s control and form that needs to be addressed and this is where functional weightbearing movements are more important. I think if your control of pelvic position is poor, but Glute strength is good it’s unlikely sidelying work will be of great benefit.


So what to do for your Glutes? The answer is what works for you. If you find sidelying exercises are getting you results without causing symptoms then great. If not try some of the others above and see which ones seem to work your glutes and get results.


What about reps and sets? Assuming we are working endurance roughly speaking people usually start at around 10-15 reps 3 sets in a session with a rest of 1-2 minutes between each set. Then progress up towards 25 reps, you’re aiming to fatigue the muscle so there will be lots of individual variation in the reps needed to do that. That said if you can do more than 30 reps without fatigue maybe you need a harder exercise? These recommendations are based on those by the American College of Sports Medicine research (abstract only) which I’ve summarised in a table below (click to expand). Remember too that form and control are very important and you should feel it in your glutes not the side of your knee or front of the thigh.

Closing thought, from the research I’ve read and patients I’ve seen, a combination of both functional weight bearing and less functional (sidelying) exercises is most likely to be effective in glutes rehab.


Please feel free to comment, I welcome other opinions even if very different from my own. Where possible back up any claims with research evidence.



Shin Pain – Part One

Shin pain often gets described as the dreaded “Shin Splints”, the bane of many runners and an ongoing topic of discussion on the RW forums. The thing is shin splints isn’t really a diagnosis, it’s a collection of several potential diagnoses. Shin pain can be divided into 4 broad categories, bony, muscular, vascular and neural pain. As this is a complex area I’ve spread it across three blogs. In Part One we’ll look at bony pain and “shin splints”, Part Two compartment syndrome and Part Three tendonopathy and the rarer stuff – vascular and neural.

Bony Pain

The surface of bone is covered in a layer called periosteum (see picture below, this link has details on ankle anatomy and terms like “medial” and “lateral”). This layer has a good blood and nerve supply – as a result it’s very capable of creating pain. Bone tends to respond to stress by strengthening, but, as you see from the diagram below, if the stress on the bone is too great then a “stress reaction” occurs. If this process continues without the bone having adequate rest to strengthen then a stress fracture can occur. There appear to be 3 stages to the development of a stress fracture;

  1. Bone marrow oedema
  2. Inflammation of the periosteum
  3. Stress fracture.

The early stages of this can be pain free. In fact some research has found stress fractures with no symptoms that then resolved spontaneously without intervention. During the second stage where the periosteum of the bone is inflamed, a diffuse (spread out) pain is often described. Sometimes runners find this is present at the start of a run but reduces as they continue. If this progresses to an actual stress fracture a more focal, more specific pain is expected. Usually this gets progressively worse when running, forcing a runner to stop.

Picture from Ruohola 2007

The medial border of the tibia (on the inside) is a common area for stress fractures. They can also occur in the fibula and the anterior part of the tibia (the front of the shin) although this is more rare.

A medial tibial stress fracture is a non-critical stress fracture, this means it usually heals well as it has a good blood supply. It normally takes 4-8 weeks for symptoms to settle enough to start a gradual return to running but on average 8-12 weeks for full return to sport.

An anterior tibial stress fracture is a bit more complex and comes under a the “critical” banner. This means it takes longer to heal and has more complications. However people can often return to running after around 4-6 months depending on how well they heal.

Symptoms of a stress fracture include pain on palpating the bone (feeling along the length of the bone) and pain on any impact. You may also have swelling or bruising over the fracture site. The problem is it’s quite hard to diagnose a stress fracture without any scans/ X-rays. It’s a bit more straight forward to rule one out. If you can tolerate impact e.g. Repeated hops are pain free and palpating the bone is not tender, there is a good chance you don’t have a stress fracture. But if impact hurts and there is bony tenderness, that doesn’t mean you definitely have a stress fracture. The only way to tell would be through either an X-ray, MRI or bone scan. X-rays often miss stress fractures and so a second X-ray is done around 4 weeks later and you look for signs of bony healing. Even then it’s easy to miss. MRI or bone scan are better but harder to get on the NHS. This site has some excellent X-ray and scan results for several types of stress fractures, well worth a look. More info on stress fractures here from the American Orthopaedic Society for Sports Medicine.

Medial Tibial Stress Syndrome (MTSS) and Anterior Tibial Periostitis

Just to confuse you (and me) there are several other terms used to describe bony stress reaction. Some people see these as part of the stress reaction spectrum i.e. a stage on the path to stress fracture, and others see them as a separate condition.

MTSS is considered by some to be the medical term for Shin Splints. It refers to diffuse inflammation of the periosteum on the medial part of the tibia. Pain is expected to be diffuse and linear (along the bone) rather than focal (at one particular point). Some have theorised that MTSS occurs as a result of stress caused by the pull of deep fibres of the soleus muscle (in the calf) on the tibia.

Tibial Periostitis is another term for inflammation of the periosteum, when it occurs at the front of the tibia it can be termed Anterior Tibial Periostitis. One of the main muscles in the shin is Tibialis Anerior. It attaches to the front of the tibia. In theory the pull of this muscle on this area can cause the periosteum to become inflamed.

Management of Stress Fractures and Bony Stress Reaction

The first stage is to work out a likely diagnosis. If there is any question of a stress fracture then get it properly assessed! My old favourite if in doubt get it checked out!.

The assessment should then clarify the nature and location of the problem and aid you in managing it. This isn’t something that should be managed solely through advice from this or other sites. As you’ll see above a period of rest is often required to allow the bone to heal. This period is governed by the location and nature of the fracture you have. The help of a health professional is needed to decide how long this rest period should be and what other management is needed. It’s also likely you’ll need an X-ray, MRI or bone scan. The rest period is usually between 4 and 12 weeks but this can vary and will be longer for a “critical” stress fracture (such as the anterior tibia). Medial Tibial Stress Syndrome or Anterior Tibial Periostitis may require less rest but symptoms need to be closely monitored. The causes below are relevant to MTSS as well, as they all aim to address any factors that might place extra stress on the bones in the lower leg.

Use your rest period to help you identify the cause of the problem. This is where Physio can be very helpful. Most often it’s training error – excessive mileage, change in intensity or running surface, but other factors play a part;

Running shoes – Footwear that is too old will lose it’s ability to support your foot. Replace your shoes when you start to feel they have lost their spring or if the sole of the shoe loses it’s rigidity and becomes bendy. There is no definite figure in terms of mileage but a general guide seems to be to replace shoes every 300-500 miles. It depends a lot on you, your running and the shoe you have. Ensure you have the correct running shoe for your foot type, a running gait assessment may help this.

Altered biomechanics – over pronation, high arches and leg length difference have all been connected with stress fractures. Assessment from a podiatrist might help identify and treat these factors.

Poor running form – running form and biomechanics are intimately linked in running. Excessive hip adduction (the hip moving in towards the other leg during running) and over pronation during running have been linked with stress fractures in the research. Poor control of impact on landing could also lead to increased bony stress. Again, having your gait analysed could help identify this but bare in mind a 5 minute jog on a treadmill may not see how your gait changes when you’re fatigued after running a distance.

Poor movement control – again linked with biomechanics, running form and muscle strength, your control of movement will affect how your legs deal with impact. With good movement control the ground reaction force is dissipated throughout the leg (I.e. a number of muscles, tendons, ligaments, bones and joints deal with the impact of running). If movement control is poor this can place greater stress on certain areas. Check your single leg balance and single leg dip and compare left and right. Once you can tolerate impact you can also ask your Physio to assess your impact control – here they will look for excess movement in the ankle, knee, hip or trunk and help identify how to improve your control.

Muscle Tightness – tightness in the calf muscles or tibialis anterior can place increased stress on the tibia during running. Compare your flexibility on each leg. You can then add stretches to your rehab when guided to do so by your health professional. Stretching too early in the recovery process can be painful as it places stress on healing bone.

Ankle Joint range of movement – if your ankle is stiffer on one side this can have an affect on running gait and biomechanics. For example, ankle dorsiflexion (upward movement) is essential during impact, if the ankle is stiff in this movement it often compensates by over pronating. This can increase bone load in the tibia or fibula. One way to test ankle dorsiflexion is the knee to wall test, this is linked to calf muscle tightness as well as joint stiffness. Inward and outward movement of the ankle is also important (inversion and eversion), again compare left and right and work on it to correct the difference.

Muscle Weakness – strong muscles help to absorb the impact involved in running. Those muscles need not only strength, but also the endurance to keep working mile after mile. Look for any areas of muscle weakness in the leg. Compare both sides, check the calf (with repeated single leg calf raises) the quads (repeated single knee dips) the glutes (repeated clam, side lying leg lift, or single leg bridge) and the hamstrings (repeated hamstring curls in standing). You can also compare using weight machines for a more accurate measure.

General Health – in some cases (more commonly in women than men) a runner may have reduced bone density leaving them more at risk of stress fracture. This can occur through changes in diet, with conditions affecting the gut or bowel (e.g. Celiac disease, Crohn’s disease), with prolonged steroid useage and with menstrual irregularities.


Rehab following a stress fracture can be a frustrating and slow process. Once you’ve grown to love running it’s very hard to stop doing it! Despite this, it’s vital you listen to your GP/ Physio/ health professional during your rehab. They can guide you in returning to running and when to start strength or flexibility work. You can usually cross train when not running as long as no impact is involved and it remains pain free. Swimming and cycling are commonly recommended, but again be guided by your health professional. I have heard people on forums saying “I’ve been told not to run but….” it’s not worth the risk of running before a fracture is healed – you could face a much longer lay off if you do.

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