Pain after Running

Overuse injuries in the lower extremities after running are common.  

• If there has not been a trauma, this pain is usually caused by stress to either bone or muscle-tendon units.  

• Localizing the pain will help determine the probable cause and significance of the pain.  

• In addition to stress fractures and tendonitis, exertional compartment syndrome, although relatively rare, may also cause pain in the legs.  

• A few of the injuries can be significant and have to be specifically ruled out. 

Differential diagnosis of  lower extremity pain after running

• Stress fractures

• Shin splints

• Tendonitis

• Bursitis

• Patellofemoral syndrome

• Exertional compartment syndrome

History and Physical

Determine:

• Location

• Duration

• Radiation

• Aggravating Factors

• Alleviating Factors

Knowing the anatomy of the region will help determine what structures may be involved in producing the pain.  Care must be taken as certain problems may present only with referred pain, such as a femoral shaft stress fracture presenting with achy knee pain.

Stress fractures usually begin with pain following the activity.  If the activity persists, pain will occur during running, and eventually hurt all the time.  A common exception to this is metatarsal stress fractures which may have little antecedent pain before completing.   Femoral neck stress fracture pain may be referred to the hip.  On exam, a painful range of motion of the hip may be the only objective sign of a femoral neck stress fracture.  On the tibia, shin splints are a diffuse tenderness thought to somehow involve the periosteum.  They may evolve into stress fractures that on exam will have a point tenderness localized under one thumb width.

Tendonitis will have pain associated with particular motions and is usually localized.  Palpating the specific tendons and gently resisting active range of motion for the affected muscle will help confirm the diagnosis.  Commonly involved tendons include the hip flexors with tenderness about the anterior inferior iliac spine, the iliotibial band with tenderness at Gurdy’s tubercle on the lateral femur, and pes anserine bursitis on the medial tibial plateau.  Pes anserine bursitis may actually be masking underlying tibial plateau stress fracture and a high clinical suspicion should be maintained. 

Exertional compartment syndrome presents with repeated pain and possible paresthesias which occurring in a similar distribution in the legs often after 20-30 minutes of running.  Feeling the different compartments of the leg after running and finding a very firm compartment suggests the diagnosis.

Look specifically for biomechanical problems that predispose people to overuse injuries.  Leg length, foot form (pes planus and pes cavus) and Q angle should be recorded.

When do I order x-rays

• If a stress fracture is suspected, obtain x-rays.  

• Often, initial x-rays are negative, but repeat x-rays in 2 weeks reveal about 85% of fractures.  

• About 15 % never have x-ray changes.

When do I order bone scans?

• If the repeat x-ray is negative but stress fracture is still highly suspected, obtain a bone scan.  

• If a femoral neck stress fracture is suspected and initial x-rays are negative, a bone scan is usually obtained to definitively rule out this potentially catastrophic lesion.

What about other tests?

• MRI can be used to determine the extent of  a femoral neck stress fracture or used as an alternative to bone scan in diagnosing other stress fractures.  It is sensitive and may be more specific than bone scan

• Exertional compartment measurements are obtained to diagnose exertional compartment syndrome.  After obtaining baseline values, the patient runs until symptoms are reproduced and pressure is remeasured.  If positive, a fasciotomy will eventually need to be done to treat it.

Treatment

Acute treatment follows the guidelines for acute musculoskeletal injuries –PRICEMM

• Protection.  If patient has difficulty ambulating, use crutches or a cane to aid ambulation. Suspected femoral neck stress fractures should be non-weight bearing until there is a definitive diagnosis

• Relative rest.  If the problem is due to overuse- stop overusing and use alternative means such as biking, aqua jogger, or swimming to maintain cardiovascular fitness while allowing the injured part to heal

• Ice 20 minutes three times a day. 

• Elevate if applicable

• Medication- a short course of NSAIDs can provide pain relief.  As more studies show inflammation to not be part of many so called tendonitis, long-term therapy with these medicines may get less prevalent

• Modalities – ice massage, e-stim, US, phonophoresis and iontophoresis may help ease pain and inflammation.

After the acute pain has subsided, gradually return the athlete to activity.  Start with a gradual walking program of a mile or two, then gradually add running minutes in every week until back to full speed.  Recurrence of pain suggest  either reinjury or new injury and should be reevaluated.

What are some dangerous stress fractures?

• Femoral neck stress fractures

• Anterior proximal tibial

• Base of 5^th metatarsal

• Medial malleolus

• Foot navicular

Sample walk run program for recovering from a stress fracture.  Runs are 3 to 4 days a week:

• Week 1  Walk 1 ½ miles

• Week 2  Run 1 minute, walk 4, repeat, for 1 ½ miles

• Week 3  Run 2 minutes, walk 3, repeat, for 1 ½ miles

• Week 4  Run 3 minutes, walk 2, repeat, for 1 ½ miles

• Week 5  Run 4 minutes, walk 1 , repeat, for 1 ½ mile

• Week 6  Run  for 1 ½ miles

• Week 7  Run 2 miles

• Week 8  Run 2 ½ miles

• Week 9  Run 3 miles

Scott D. Flinn, MD

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*This web version is provided by The Brookside Associates, LLC.  It contains original contents from the official US Navy NAVMED P-5139, but has been reformatted for web access and includes advertising and links that were not present in the original version. The medical information presented was reviewed and felt to be accurate in 2001. Medical knowledge and practice methods may have changed since that time. Some links may no longer be active. This web version has not been approved by the Department of the Navy or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. The Brookside Associates is a private organization, not affiliated with the United States Department of Defense.

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