Mark:  Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada. He's the Clinical Director at the Physiotherapy Clinic and we're talking about running. How you doing, Iyad? 

Iyad: Doing well, Mark. How are you? 

Mark: I’m all right. Adaptation to running. So what's, isn't it just your legs?

Iyad: Yeah, it's a really good question. Well, it could be just your legs, but also we want to think about what's in your legs. So most people we see in the clinic that come in, who just started a running program. They tend to focus a little too much on too many things, basically, like, how they're, let's call it their cardiovascular systems adapting, like your heart, how well that's doing, and then your lungs you're breathing.

So I think we measure exertion purely by those means sometimes, and then, you know, new runners will notice that the first run you do, your abs are going to be sore, your back's going to be a little tight, your calves and your probably quads and hamstrings are going to feel a little bit of tension depending on how fast you went and how long you went.

And I feel like we tend to kind of leave it there as far as most of us are aware of, like, these are the systems that are at play for running. I wanted to just draw a bit of attention to some other things that maybe people neglect when we think about the running. So we do have a cartilage in our joints and cartilage does love weight bearing.

So, you know, there's a bit of a misnomer out there that running is bad for your cartilage, and I think those are probably borne out by some of the extreme examples, maybe. So, yeah, if you're putting a lot of mileage, I'm talking like a huge amount, like, well, over 50 to 60 kilometres a week. Yeah, you could potentially tip the scale in the negative direction. But what we see is actually that recreational runners have healthier cartilage than sedentary people. 

So I kind of really want to highlight that. And there's been like, huge reviews where they've sampled millions of people in the big studies, and then we find that actually could be argued that it's good for you and protective against these cartilage related issues like knee osteoarthritis.

Obviously, the key thing to keep in mind is that this is somebody who's adapted to that run over a period of time and not just somebody who got off the couch and started running 10, 12, 15 kilometres at a time. 

The other piece that is often neglected is bones, you know, like our bones experience impact. And when we impact or stress bones the reaction to them is that after a while, they too tend to adapt and get stronger. You have examples of this all over your body. 

So, for example, if your shoe has a bit of a heel cup, that bone in the back of your heel gets a little thicker due to the stress. And that's not always a bad thing. You know, people call these bone spurs. Sometimes the bone spurs just, well, it's adapting to the force you put it on, so it has to lay down bone to kind of help shore up the area.

And we see this, for example, with lifting. If you're lifting weights, we know bone loves load, and that actually is very protective to your bones and to your system.

Where I think people neglect this in running is you just add mileage because your aerobic system, you're like cardiovascular systems adapting really nicely. And you're like, oh, my God, I can run another 2K now. And then we tend to progress a little too fast. 

So then things that might be a little slower to adapt than our muscles and our heart, like our tendons, for example, people get Achilles tendon pain quite often, or like our bones, so people will get small reactions in the bone that could be anywhere from a tiny bit of inflammation to a stress fracture to a complete fracture, so it's a bit of a huge spectrum. There's about five stages of bone injury that you go through as you're repeatedly loading it. 

So, just things to keep in mind when you're considering the running plan and considering starting running, especially if you are not a usual runner, and you haven't had a long training history with running.

Mark: So when somebody comes into the clinic and says, okay, I want to start running, I imagine that's not that often, but maybe it does happen. How do you prescribe what sort of routine program that maximizes their adaptation to running? 

Iyad: So we actually do get quite a few people who do this. And a lot of our therapists are involved in different sports. So then, you know, depending on like, which sport environment you're involved in, you'll see people from that. So, we do see quite a few of these, and then what we end up doing is do a pretty thorough history. And the history is not just like taking into account injury history, because that's a huge factor, obviously.

So, if you've come and seen me after you've had a surgery 2 weeks ago, or 2 months ago, that's a different story. We're going to have to kind of address that piece 1st and try to figure out what's happening. But then the other thing that we really kind of want to dive into is their training history.

We want to get a really good idea of how experienced this person is with running. How experienced this person is exercise. Are there other comorbidities? So, for example, if you have someone who is training with hypertension, which is high blood pressure or any form of diabetes or other metabolic issues, and they're on medications. Well, that's going to really change how we draft that training plan up. 

So, for example, if you have blood pressure, which is controlled with medication, well, that's going to change the way your heart rate is going to change with exercise. Because part of that control to blood pressure is to try to lower some of these things.

So, I've seen people who follow heart rate on their watches, for example, and they're running and they're like, oh, I'm still really under my 120, 130, but I'm freaking tired. What's going on here? And I think that's 1 of the things that it's really important for them to be aware of that. Like, you know, that's going to cause a bit of a change and you're going to just need to maybe do things a little differently.

So we'll do a bit of an assessment with that. We will probably get them running to just see how comfortable they are. Their initial impressions. And then what we would do is like, if somebody is a complete newbie starting on a run walk program, and depending on the experience again, if they're completely new on the conservative side. If they're pretty experienced, but just went through a period of absence, maybe like a big family event or a vacation or travel or moving that kept them away from training that we would drop something a little more appropriate. And then the 2nd stage would be to actually have good load tracking. 

So we would ask everybody to track the distance or time that they ran, how they felt, what was it like? What are the things they noticed? What was aching? What was sore? All kinds of different things. Or if they felt really good, because sometimes that's really, really important. And then part of that running program, we would also want to train different systems. 

So your energy systems, the way you use fuel, let's talk about that. So we would kind of try to buy us a bit more of that slower pace running, maybe at 1st, just to get them more used to the idea of being out there and impacting. And then we can kind of ramp up and put a bit more of the fast workouts in their program. And as part of that, obviously, we'll also build them a resistance exercise program, which really will help complement that training and kind of also provide them with some adequate protection.

It tends to really help with things like, you know, people get knee pain when they run, especially pain at the kneecap or at the IT band. We really kind of want to supplement a good running program with a good resistance program. So that cross training is super valuable. 

Mark: If you're looking to get started running, or you have some issues with pain, get in to see the experts at Insync Physio, they have an office in North Burnaby. You can reach them online at insyncphysio.com to book. They also have an office in Vancouver as well. North Burnaby office, you can call them to book at (604) 298-4878. Thanks Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark Bossert. I'm here with Iyad Salloum of Insync Physio in North Burnaby, BC, Canada, and we're going to talk about aching bone pain today. How are you doing, Iyad? 

Iyad: I'm doing well, Mark. How are you? 

Mark: Good, good. So can I just ignore it when my bones ache?

Iyad: I mean, it depends what that means. So let's talk about examples that we see in the clinic. So somebody who started running and they've been putting on some miles and they've been loving it and getting really good at it. And after about a month to 6 weeks of stuff, they start to feel, for example, pain in their shins. 

So, most often what I see is then people kind of go online, try to find some stretches and exercises, and then they try them. They don't really move the needle in either direction. They start to look up a little more on WebMD. They try to figure out what else it is, and then they're like, Oh, look at this, the bone could be one of the causes. So then they'll consult their family doctor, they get an x ray, x ray is negative, and then, well, the x ray is fine, it's probably not my bone.

So then they just go and run again, and then they're still sore, and then eventually after that whole circle of life, they end up in our office trying to find a better solution because most people think it's due to the way they run. Maybe it's like a control issue. Maybe their knees are caving in. They're just not sure. 

So, what I would say the short answer is no, they can't ignore that. Especially if you feel some aching of the bone and you have a negative X ray, that's not enough for us to say that your bone's not affected. 

Mark: So is this like shin splints or like a stress fracture that won't necessarily show up on an x ray?

Iyad: Yeah, so the shin splints a very broad term because there's a lot of different contributors to that. So you could have anywhere from a limb threatening injury that could be in the compartment in front or it could be the bone reacting like you said, like in a stress reaction, not even a stress fracture yet.

So it could be like the early phases of that. Because there's 5 phases of injury for the bone from stress, and only, I think, stages 4 sometimes will show up on x ray, but stages 5 is for sure when they'll show up on x ray when it's completely fractured. You could easily have that, but there's some other muscular components that are also at play. 

So, shin splint is a general term. So, yeah, for sure. It could be all kinds of stuff like that. And that's where if we just assess with the x ray, it might not give us the full picture. So we would need to kind of do a proper clinical exam. And the clinical exam isn't just physically touching things, but also taking in that history of how it started, what it felt like, what's the pattern like? Does it start from the beginning of the run? Does it start continuously throughout the run? So all of those factors really help us figure out what it is. 

And then sometimes based on that, we can recommend better, let's call it diagnostic testing and then also better care. Do you persist with running or do you just have to take a break and do something else for it? And I think all of these options exist, depending on what the injury is, how severe it is and where it is too. 

Mark: So, if I've been feeling shin pain for a week. I guess my question is when's the ideal time? How long am I experiencing it when it's the best time to come in and see a physio so that I can get on a proper program to have this go away?

Iyad: So, I feel like if you notice it more than on 1 occasion, and it's been pretty consistent in terms of pattern. I feel like that's definitely a good time to come in. Even if you had it once or twice, and you're just curious, I think just coming in for an assessment, at least you can understand what it's not. Feel like that's just as important as knowing what it is. Because if it's not any of the, let's say, more dangerous long term recovery related issues and we can at least give proper advice on how to continue running with the injury. 

As far as somebody who's had it for, let's say, more than a week, and it's been consistent and it's same in the morning the 1st, few steps feel like you know, a slow burn, like, very painful. I mean, that's a very appropriate assessment that needs to come in. And then 1 of the other things we could do as part of that, besides doing the bed exam is to actually get somebody on the treadmill and see what they're doing potentially that could be contributing to this. 

And part of that's also assessing the training program, because it might not be appropriate for that person. 

Mark: Generally sooner you get in the better and faster your recovery is going to be?

Iyad: Yes think about this, five stages of bone injury as per one of the main classifications that we use. If we have five grades, if I catch you on grade one, which is basically just inflammation of the outer covering of the bone. I would say, there's how much less there is to heal from than if we catch you at a complete fracture or stress fracture line. You know what I mean?

So that in itself kind of informs that, yes. If I intervened early, I also have less time missed from training. I see this mostly now with people starting to do their marathon training for the spring. You have to start about six months away sometimes, especially if you're not a consistent runner.

Well, that's exactly where we'll start to see this kind of big spike in runners getting injured. And then they kind of try to dilly dally for two months. I've seen way too many runners in the month of the race, where it might just be a bit too late. Because, you know, even with all the gate modifications and the footwear modifications and the corrective exercises. Well, your tissue still needs to heal because, you know, we're doing 42 kilometres of like regular impact. So that's in itself something that you have to adapt to.

Mark: You're having aching bone pain in your legs. You started a running program. Get in to see the physiotherapists at Insync Physio. You can book online at insyncphysio.com, or you can call the North Burnaby office at (604) 298-4878. There's also a Vancouver office at (604) 566-9716. Get help sooner and get back training faster. Thanks, Iyad. 

Iyad: Thank you.

Mark: Hi, it's Mark from Remarkable Speaking. I'm here with Iyad Salloum of Insync Physio in North Burnaby, British Columbia, Canada, and one of the top physiotherapy clinics in North Burnaby. We were talking about inner thigh groin pain. How you doing Iyad? 

Iyad: Good, Mark. How are you today? 

Mark: Good. So I know we're gonna label this as inner thigh groin pain from soccer, but this really bridges a lot of different sports that have a lot of cutting and moving in different directions. Does it not? 

Iyad: Yeah, basically, the inner thigh muscles, they're called the adductors. So you know, we can have adductor related groin pain from multiple different, let's say exposures. Typically we see it in like, let's say the more sprinty type sports where you have a lot of change of direction because you are putting lots of tension and strain through those musculatures, especially when you're trying to cut and change direction really quick.

You need to kind of put a high amount of force in a short period of time and then pivot and continue going at that same speed. So that's kind of where we see this a lot in hockey potentially, or soccer. And then in other times we'll see it, let's say more traumatic reasons.

So we had a skier who, as you were talking earlier, caught an edge and thigh got pulled up to the side, so suffered an injury to the inner thigh, and that caused quite a bit of groin pain from him. So you could have that as well. It could happen over, let's say a repetitive pattern where you're just doing too much all at once and, you know, maybe not adequately recovering from it, or maybe you're overloading your current capacity. So if your tolerance level is this arbitrary number here and we're doing this a bit too much without adequate recovery, that could do it too. 

Or you have the big force all at once case, which, you know, those tend to be pretty hard to miss for most people, and they don't kind of sneak up on you. They come in all at once. And then we kind of would look at addressing that in as many ways as we can. 

Mark: So let's just define this adductor. What movement does the adductor actually do? 

Iyad: So that's a really good question because I think the muscle suffers from a bad name because it's called the adductor. And adduction is usually when your thigh is, let's say, in your thigh coming towards midline, it's called adduction. So that's basically it, so basically moving inwards it's either left or right. So that inwards movement is one of the things that the adductors will do, but the adductors also can help us rotate our hips so they can actually help us twist.

They can also help us if most of you know, like the time when you haven't done squats in a while and you do a bunch of squats and next morning your inner thigh is really sore. So the adductors can also extend the hip. So they can push us up basically. They can work with the glutes, and then there's some abductors that also will help the hamstring do their job.

So we're looking at quite a big repertoire. And then in our front, we have some abductors that also can flex the hip. So some of them are hip flexors too. So this is where I think the challenge comes in. You have people who can try to do, let's say abduction based exercise only, and you know, just trying to do a lot of squeezing type exercises and where you're missing out, basically. Yeah the thigh master. And it's not a bad exercise to do sometimes. It could be quite useful, actually. Quite neglected muscle group. But, you're not probably addressing the total function of the muscle.

Like, you know, you think about the muscle that it has multiple fibres that go in different planes, in different directions, and then it's really key for us to try and address the function instead of just specifically training the tissue only. So there's some theories out there that because the muscle does so much of the different tasks that maybe you can have a deficit, for example, in your hip flexors, and your adductor starts to potentially try to help out because when we move, we don't think of specific muscles. We think of global movements. 

So whatever's available, we'll try to help out sometimes. And then we can kind of build these, let's say patterns that strain one area a bit more than the other. And then that's kind of where, for example, if we're treating an adductor, we wouldn't just treat the adductor or we'll just see where's there a deficit in those surrounding musculature and try to kind of address that too. Because the last thing we'd want is somebody to rehab their adductor, feel really good, and then go back into play and then pull up with another injury somewhere else, for example. 

Mark: So, as always complicated to diagnose. What are you looking for? You mentioned this a little bit, but I'd like to emphasize it. What are you actually looking for? 

Iyad: So, in cases where there's trauma, we wanna look to see if there's potentially any like major injury to the structure. So the muscle or the tendon attachment to see if there's like any, you know, big injury there. So we would look at from bruising to strength to range. We can do palpation, it's a good test too. It's not the most comfortable area to have someone poking around for sure. But it can have some clinical use to do that because in the latest criteria to diagnose it, we'd look at those three things. 

So you'd have to have pain in that region, and then you'd have to have like tenderness to touch and then some kind of, let's say, weakness in one of the tests that we would use to assess the strength of it. And then you'd probably lose a bit of range just because that's typically what tends to happen.

I can't move my hip too much when I'm really, really sore there. So it could be protective, let's say restriction of movement or it could be that sometimes the swelling could be there and it kind of limits my movement and sometimes it could be just weakness that I just feel like I can't move because I just don't have that ability to leverage properly, you know, to push off of things properly.

So I feel like I'm stiff, when reality I just don't have the ability to move, full stop. So that's how we would try to, you know, see that. We would try to see if it's the only thing we're dealing with too. And there's really been a lot of recent studies on this where we look at not just rehabbing the local area, but we also look at rehabbing the trunk.

So for example, how you control your low back, your pelvis in conjunction with the adductors because control issues there can also spill downstream. There's a big study cohort out of Ireland that looked at this and they did some really cool stuff with like, even 3D measurements and stuff, and they found that, yeah, an intervention even to the, to the like, you know, to what we classify as the core musculature, especially in running and sprinting can also help the adductor related groin pain.

Mark: Hip bones connected to the thighbone , in other words.

Iyad: Yeah, like that song says, exactly. 

Mark: So how much has it changed the course of treatment, depending on what you actually see and which adductor positioning or fibres are causing the issue? 

Iyad: Yeah. So I wanna just clarify. The abductors themselves, it's a group of muscle, it's not a singular muscle. So I have a couple in the front, couple in the back. They're quite big as a group. 

Yeah obviously like the more widespread, like if you have a very focal injury, it's gonna be a little easier potentially to come back from than if you have multiple little things all over the place.

The good news is, a lot of the times, our clients are surprised by how much we get them to do right off the bat. They think we have to rest and avoid, and avoid, and actually we can push in like a loading program without affecting them negatively.

If anything, like we speed up the recovery a bit more cuz they're able to kind of get started on something a bit more meaningful for them. And you know, the toughest thing on athletes is when you tell 'em, Hey, you're gonna sit down and do nothing, for example, right? And this is anywhere from like a university level varsity athlete you know, to a pro all the way to the weekend warrior. Sports can be a nice outlet for a lot of people and just having them completely withdraw from that could be, you know, negative in other areas beyond the hip pain and the groin pain. 

So yeah, we would get people started quite early and it's really just about tolerance. Is it appropriate to get this person started more aggressively? We wanna make sure that they're safe to do that, obviously. Like, so this is where, I guess it depends on is it just a single spot? Is it multiple things that we're dealing with? You know, multiple different things. Because sometimes, like, you know, there's nothing that says you can't have your low back and your adductor hurting at the same time. And maybe that's more limiting to them than the adductor injury. So it just depends on what you're dealing with.

And then obviously, the timeline depends on your target. What are you trying to get back to? What's the level of like, what's the capacity, what's the max? Let's say torture you should be able to handle with your hip muscles and with your leg and with movement. Because a lot of the times you'll see people who test normally on the bed because the load's not the same as sprinting for 90 minutes in the soccer game. So that's where you'd wanna kind of match the intervention to the level that they're trying to get back to. 

Mark: If you've got some kind of inner thigh groin pain happening. You wanna see the experts at Insync Physio in North Burnaby. They will diagnose exactly what's going on so that your recovery will happen more efficiently and effectively. And you can book online at insyncphysio.com. There's two locations, one in Vancouver, one in North Burnaby. Of course you can call the North Burnaby office, (604) 298-4878 to book. You have to call and book ahead. They're always busy. And thank you so much for watching and listening. Thanks Iyad. 

Iyad: Thank you.

This exercise targets the activation of your gluteus medius muscles of your pelvis and hip. Have the back of your ankle and heel pushing back on the front low side of a big ball against the wall. In side lying, make sure that your torso is not too far back or bent too much forward to avoid your hip being in a flexed position.

With your spine and hip in neutral position push the back of your ankle and heel up to the top part of the ball maintaining contact on the ball the entire time.

A few key things to look for is to keep the toes pointing forward and towards your own nose so that you’re not rotating the hip and the toes upwards while you push the ball upwards. Bring the ball back down and repeat this 10 times for 3 sets on each side.

This is a great exercise to build more functional core and pelvic muscle strength after a running related leg injury. If you have any problems or questions with this exercise consult your local Physiotherapist before continuing. 

Mark: Hi, it's Mark from TLR. I'm here with Simon Kelly. He's a physiotherapist that Insync Physio in Vancouver. They are multiple time, best physios in Vancouver award winners as voted by their customers. And Simon's going to talk about leg nerve irritation. What, what is this all about Simon? 

Simon: Hi Mark, how's it going?. Thanks for having me again. Yeah. Just going to talk a little bit about the leg nerve irritation and you know, a lot of times it's hard to pinpoint where the irritation is actually going from. But most of the time that actually come from the lower back region, somewhere between L1 down to L5 vertebrae.

A lot of times, you know, people get quite worried that it can be something quite serious, like a disc irritation or a disc compression and things like that. And on occasion it actually is those things, but the very, very small percentage of people that actually need to go for surgery. So it's good to be not too scared in the beginning, but of course it's good to get checked my physiotherapist as well.

The other thing just to bring to mind just for some people as well, is when the nerve is already irritated, as it comes out in the lower spinal column, it kind of brings down the threshold of nerve. So we've all heard of the sciatic nerve pain, but you know, it's things that are usually not painful, like sitting and then become painful. 

So I kind of use the analogy, it's like water coming out of a hose and then you step on the hose and the water stays coming out and it doesn't really affect it that much, but then you step on it in another location, irritated in the nerve root and then irritated from sitting. And it's the sitting then can drive the threshold down. And that's when people really come into us reporting lots of tingling, numbness and irritation, referring down to leg. Call it double crush syndrome, which actually sounds pretty scary actually. But a lot of the time it can be really fixed. 

Mark: So if I was experiencing this, I might not necessarily be feeling pain in my lower back, but I might feel it in my legs. Is that why we're kind of referring to leg nerve irritation? 

Simon: Yeah, absolutely Mark. Yeah, like it doesn't always have to be linked with a major nerve, like traumatic back injury. Sometimes it can just be progressive in nature. And, you know, as we get older, we get stenosis, that's like a narrowing in the spine in the lower back as well.

Lower population or lower aged population people usually it's not like a stenosis or degeneration and things like that. But in my experience 99% of the time, once you kind of eliminate the information at the primary source, whether it's the lower back or sometime as it passes through to the bum muscle, aka the sciatica, will eventually go away.

That's where we come in then in the clinic and it's all about the education on what movement somebody can do. And if you know, you can fix the back pain, but if you don't tell someone not to sit for long periods of time on a hard surface, that's going to keep irritating that nerve and it's going to be ongoing for quite a long time.

Mark: So how do you treat it? 

Simon: So that's it yeah, first of all, when the client comes in, we do need to figure out, first of all, where it's coming from if we can. Either the back, usually it is the back or usually as it passes down through the bum muscle and sometimes it is two areas. So we have to treat both. So in clinic we do a lot of hands-on treatment. We do a lot of needling in the lower back just to kind of decrease, it's kind of like the hypertonicity of the muscle, so the muscles get really tight around the nerve. And this is a common mistake that a lot of people make is oh, the muscle must be tight. Let's stretch it, but stretching in this occasion is not really, the muscle is tight because the nerve is sending a signal to the muscle to protect it.

In other words, please, please leave me alone. But what people do then is they kind of throw petrol on fire and by stretching it, and that really really irritates the nerve. So a lot of the stuff we do is actually a nerve flossing or nerve glides, we call them. Where you're actually gliding. You're actually gliding the nerves. You're not actually stretching it. You're actually just moving the nerve as one unit by different movements in the clinic, I can't really show you on the video here now, but that helps desensitized the nerve. And once the nerve becomes desensitized, it stopped sending the signal to the muscle and the muscle relaxes and it's not in spasm. Preventing you from moving or causing pain essentially. 

So by eliminating inflammation around the nerve, obviously you can do ice in a bit of rest for that too. And by doing these nerve glides, especially in the earlier stages of rehab, you can eliminate all that spasm that a lot of people complain about.

Mark: And is that why you use the needling? Is that also help with the relaxation of the nerve? 

Simon: It kind of helps more so the muscles around it Mark, to be honest, so the muscles it does help relax the muscle around it. But the primary objective will be to get that nerve moving normally without, without irritating by fully stretching it, or we all like that feeling of a nice stretch, but in this particular occasion that's really, really, really bad to do. 

But you're right yeah. The muscle spasm, the needles just help release that to give someone a bit more mobility in their back. Again, in the earlier stages. Once that's all the settlement and we have certain tests in clinic we use to kind of see what the nerve mobility is like. We can obviously go back into strengthening it, and a lot of core work, a lot of lower back stability stuff. And obviously depending on what the client does, back to running or higher end plyometric stuff. 

Mark: So what's a typical treatment protocol like this. What does it normally take for somebody to get back to doing some of that stuff? Of course it's individual, but what would be the typical timeframe?

Simon: Yeah, absolutely Mark, it is very individual dependent on a person's circumstances, but you're probably looking at maybe 8 to 10 weeks, like kind of from start to finish and obviously take that with a grain of salt, depending on the population and different ages and different activities. But yeah, 8 to 10 weeks, depending on the irritability and also dependent on when we kind of catch it.

How limited and how what kind of was the mechanism of injury as well, may also have to be taken into account for sure. Was a traumatic or was it more gradual? For example, traumatic can sometimes take a little bit longer. 

Mark: So what's the common cause of this kind of leg irritation referring from the back?

Simon: Yeah. One of the common cause, just lots and lots of excessive sitting even Mark, especially if it comes on gradually and naturally grows, especially in this pandemic or in general. Sitting for long periods of time, sitting on hard surfaces. You know, if you kind of think about it, like older people get a lot of pressure sores because they can really move their body in bed when they get very, very odd.

It's kind of a bit like that. I mean at an extreme level, obviously somebody can move a little bit in the younger population. But you're kind of depriving the nerve of sort of nutrients through blood flow as well. And eventually it hits a certain threshold where it gives you that signal of maybe tingling down the leg, where it's like, wow, you really need to get the pressure off this nerve as it's passing through the bum muscle. 

There is obviously traumatic, more traumatic stuff as well. If you had a fall off a ladder and you injured your lower back, for sure, that obviously you'd have to go for x-rays to make sure you had no fractures or anything like more serious, but once all that's been cleared, you know, it's a matter of really just getting rid of the inflammation. The treatment is not very different. It might take a bit longer though on a traumatic situation. 

Mark: So if you've got tingling in your legs. If you've got pain, that you suspect might be from your back, but it's in your legs, in your sciatica. Get in to see Simon Kelly at Insync Physio. You can book online at insyncphysio.com or you can give them a call (604) 566-9716 to book your appointment, you have to call and book ahead. He's busy, but he'll get you feeling better as fast as possible. Thanks Simon.

 Simon: Cheers Mark, thank you

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver. One of Vancouver's most popular physiotherapy clinics, many time winners of best physiotherapists in Vancouver. And today we're going to talk about a really common issue shin splints. How are you doing Simon?

Simon: How's it going Mark,  thanks for having me today. Yeah, shin splints Mark. I'll talk a little bit generally about the topic and I might relate it to a recent case study, I had a bit as well. We've all heard about shin splints, the layman term, but we call it ATSS, which is anterior tibial stress syndrome, which sounds a bit fancier. 

That's more so pain to the front of the shin and more to the outside of the shin. And then you have MGSS, which is media tibial stress syndrome. That's probably the more common one where you feel it more distally or at the end of your leg sort of on the inside of the shin bone. So a lot of people kind of get this pain when they're kind of increased their running too quickly essentially. A lot of pain down the inside of that shin, or sometimes it can be a change in footwear a change in surface and things like that. So it's important obviously to diagnose, did the person take up running or any sort of activity, like lots of jumping, lots of high-impact activity, that's kind of leading is kind of pain.

And it's also very important not to run through this pain because you can develop stress fractures or another thing called exertional compartment syndrome. So our job would really be deciphering, is it actually true shin splints because that's like an umbrella term or is it one of those other two things. But very important not to run through that pain. Some injury yes, it's okay to run through it a little bit and just kind of monitor it, but certainly if you keep going, you can develop that stress type fracture and the pain is very on the shin. Shin splints is more diffused where you kind of feed it along the shinbone for like three or four inches. That's kind of how we decipher that a little bit as well.

And obviously an x-ray will tell you if you do have a stress fracture and the exertion and compartment syndrome, usually pain just comes on after you start the exercise, because blood is filling into the compartment of the lower leg. And then it expands and there's a mesh around the lower leg and it can expand out actually.

So that's when you know, that's the difference in it. And you might have tingling in your lower leg. It's very important not to continue that because you can create nerve damage and things like that. 

Mark: So how do you diagnose it, just by the pain? 

Simon: Yeah, good question Mark. Well, first of all, you'd take the history and you kind of ask them are they doing lots of running. It doesn't have to be running necessarily. It can be like lots and lots of walking even. A lot of people are doing 10,000 steps lately. I don't know why humans have a fixation on it. You do 10,000 steps every day and you're not used to it, you can benefit from walking as well, or even just a combination of running and walking might just throw you over the edge to develop this, too.

 When the person comes in, they usually say, yeah, I feel this at nighttime or sometimes after the walk, you don't always feel it while you're doing the activity actually. So will you feel it at rest and you will feel it when you push along the inside of your shinbone or the outside of your shin bone.

So that's kind of how we diagnose it. As opposed to exertional compartment syndrome is more, you just feel it after a few minutes of getting into the exercises that increased the blood flow, but the minute you stop, there's no pain at rest. There's actually no pain when you push it either.

So there are kind of too big differentiating factors. And you don't want to keep running through it. Like I said, it's very important that you don't. I know it's important that we look at the footwear and the surface, if you're, a lot of the times people run on concrete, which is quite unforgiving under the foot, and it's better to run on maybe grass and some trails are sometimes better if there's not huge amounts of inclines and declines. So we try and alter that as well. 

Usually for the treatment part of it, I just stop them running for maybe a week or two completely, and then just reload it very, very gradually. And we do a lot of stuff here in the clinic, a lot of  massage, some needling of those muscles that join onto of the inside of the shin especially, it usually stays behind the calf muscle that joins in at the back, which is responsible when we come down from running or from the jump.

Just micro tearing on the inside and basically the micro tears aren't getting a chance to heal before somebody goes running again. And then it just develops into this lots of pain. 

Mark: So the treatment protocol is pretty straightforward, but what if I wanted to prevent it? If I'm going to up my mileage, I'm going to engage in a new fitness program. Is there things that I could do that would help it? Would rolling my shins, very unpleasant experience, but would that help? 

Simon: Yeah, you could roll out your shins Mark and honestly it really is just listening to your body a little bit. You know how much you can load, how quick, you know, and there's no real magic answer to that. There's every individual is slightly different on how much, but usually people will come in and say, they might say something like after my fifth kilometre, it starts to come on a little bit and then it's worse afterwards. So you kind of have an idea in relation to that individual, like five kilometres is kind of where we're at right now. So that's your limit, and maybe they might take a day off and back again, or they might do it again the following day. So you'd really have to just, a bit of trial and error there really. Rolling it out, strengthening up your calf muscles in particular are definitely stuff to do to try and prevent it from happening.

Sometimes if it's more chronic or you've tried a few techniques here in physio, you can go maybe to a podiatrist and look at insoles. There is a bit of a link in some of the literature saying like an over-pronated foot or a flat foot, and definitely predispose you as well. So I'd like to try and not give people insoles right off the bat and see if we could get it right but that's something I might come back here with, if we tried everything in our tool bag and it didn't work, that would be something I'd look into. 

Mark: And this is just from a personal interest kind of point. Is there any research around the new kind of movement towards going more towards barefoot shoes? Like the really non-supportive shoes that you wear that strength your foot has to strengthen rather than being over supported? 

Simon: Yeah. There's a lot of research out there, Mark, and even there's, I think it's like everything in the world, you can find 10 research papers that say that for the pros of barefoot running and that's how we were back in the wild, back in the day, running her own hunter and gatherers. Like there was no need for all the support. Why do we have it now? But then there's other arguments saying like, well, we didn't have tarmac and concrete and a lot of hard surfaces that we're running on now.

So that's a very good question. It's a very good question. When I started my physio career, I was sort of told that insoles where to where to go. But as I developed throughout my career, I sort of, it's only from a personal perspective that I don't want someone to have something in their foot, forever. If they really don't need it. But I'm not negating getting an insole or if you've tried everything else, then I kind of go back to the insoles, as I think it is beneficial indefinitely some scenarios, for sure. Especially someone who's an athlete and really want to continue through their running or they're in competition and they can really afford to wait, then we go towards insoles for sure.

Mark: And what kind of length of treatment are we looking at? What's a typical, I know it's individual, of course, maybe this is really individual, but what would be the, is it three weeks? Six weeks. 

Simon: Yeah. And you're on the money there, Mark. You know, some people like literally, if you just stop running for two weeks and you just slow gradually, it could just literally be four, six, eight weeks. It just really depends. Every physio might be slightly different. It might get you to run and just cut down your mileage and you still might be okay. I just like to go for two weeks, just give it a total break, until it's not too tender on to palpation or on touching clinic here. And then we'd obviously do all the strength and exercise in those sessions. And then we'd go back to do more higher impact stuff because it has the higher impact stuff. 

So like running and jogging that really do create a lot of tension on the inside of that shin bone. So yeah, you're probably looking at four, six, eight weeks max, for sure. 

Mark: So there you go. If you got shin splints, the guy to see is Simon Kelly. You can reach him at Insync Physio in Vancouver. You can book your appointment at (604) 566-9716 or check out the website insyncphysio.com. You can book online there. Or if you're in North Burnaby or the Burnaby area, they have a clinic there as well. You can reach them at (604) 298-4878 or again, book online at insyncphysio.com. Thanks Simon. 

Simon: Cheers Mark. Thank you.

Mark: Hi, it's Mark from Top Local. I'm here with Simon Kelly of Insync Physio in Vancouver, BC. He's a physiotherapist at one of the top rated physiotherapy clinics. Many time winners of best physiotherapists in Vancouver as voted by their customers. Today we're going to talk about something that I'm sure a lot of people run into. Especially if they're very active with walking or running it's lower leg tendonitis. Pain in your lower leg. What's the deal going on here, Simon? 

Simon: I'm Mark, thanks for having me. Yeah, I just going to talk through a case study that I had there during the week. A guy who had something called peroneal tendonitis.

Basically it's a tendon that runs down the outside of the leg. A lot of walkers aggravate this tendon and it can be due to a number of different factors really. Sometimes it's maybe they changed their footwear. Might've changed the surface they're running on. Or they just might've increased their workload. And then a little bit too quickly, which I know a lot of people do this. That's the most common thing as well. So it can be debilitating and a little bit scary to someone who hasn't had it before. 

So this guy was 25 years old. He actually had a spontaneous pneumothorax, which means his lung spontaneously collapsed on occasion. So he had a long period of time out from running. And he was just trying to get back into running, I think a month after this collapse and he was starting to do two to four kilometres running. Where he was running, they had made a new path where he usually runs and it was an uneven surface because of COVID, they wanted to keep the paths kind of socially distance.

So that was kind of the angle, I kind of thought maybe he went a bit too quick and maybe to surface he's running on a bit of a camber. And no roads we run on are actually truly flat. If you want to be honest about it, they're all a little bit slightly at an angle, not incline decline, but more of an angle of the foot so it would be turned sideways.

So he came into clinic. That was his kind of background story. We did a few tests to prove it was this peroneal tendonitis, where you kind of evert the foot out against resistance and that creates pain in the foot. Sometimes going up onto your toes can also create a little bit of discomfort because it does what the calf must've does as well.

So that was kind of a the general diagnosis and how we diagnosed him initially. 

Mark: So what was the course of treatment? 

Simon: The course of treatment Mark, there's four reasons really peroneal tendinitis can go up. If you're running on a surface, like I said, like a camber, we really needed to tell him to stop running. But eventually we would add back in running, but on a flatter surface as possible. Usually it's tight calf muscles as well. So not just the pernoneal itself, but all the calf muscles in the back are usually a bit tight that can predispose you to excessive use of this tendon. And like a lot of volleyball players and dancers, if you can imagine them up on their toes. 

He wasn't in this case up on his toes, but that was one of the reasons that you can get peroneal tendonitis. So initially stop all the aggravating factors, stop running and let's load this tendon progressively. Isometrically is how we load it first. Isometrics are where you move the tendon against the resistance, but you're not moving through range.

So that just helps decrease the pain, settle down all the inflammation. And then we got him back in running, into a running program, but a little bit slower. Would footwear, because sometimes it can be from over pronation as well. I meant to mention that earlier on, actually. Just good footwear or good support.

And then we told him to stop running. When he does go back running to run on a flat surface, not running the track that he was running on. And to just go a little bit slower, maybe just try a couple of hundred metres in a straight line, and then we just took it from there, Mark. That's how he presented over the coming weeks.

Mark: And so after the of course of treatment, what was the result? 

Simon: Absolutely Mark, so obviously when his lung was re-inflated at this point, that was another thing I meant to say, for his endurance. We had to keep an eye on his breathing and his endurance. So that was actually fine. I asked him that every time he came in. He went back into proper pairs of shoes. His calf was relaxed and he was back running, you know, five to six kilometres every other day, without any pain. Just best afterwards, few adjustments that we made. 

Now he doesn't have to not run in that path ever again. But I told him that he'd have to start adding in uneven surfaces just towards the end. So he'd just run on that path again, and he had no problems whatsoever. So he's back up and running and back into action. 

There you go. If you need some help with your lower leg, if you're having some issues with a change in your fitness program, that's causing you some pain or any part of your body, give Simon Kelly a call. You can reach him at the Vancouver office of Insync Physio. You can book there at insyncphysio.com either in Vancouver or Burnaby. The Vancouver office number is (604) 566-9716. Burnaby is (604) 298-4878. Give him a call. Simon will get you straightened right out. Thanks Simon.

Cheers, Mark. Thanks very much.