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Bone stress injuries in runners

5 Risk factors leading to Bone stress injuries in runners.

Doug James, Physiotherapist, Podiatrist, Marathoner.

A bone stress injury (BSI) is a painful and debilitating problem that affects runners and athletes. It usually occurs as a result of surges in training loads which often coincides with preparing for a competition or a race. Additionally, we’re finding athletes who had to take time off due to Covid-19 quarantine are at greater risk due to a marked reduction in loading during their isolation, and then an overcompensation when returning to running. Depending on the severity of the BSI, the injury may be season ending, or even career ending. The following article will discuss how BSIs develop and the risk factors associated with them.

How they develop

Bone stress injuries occur when the capacity of a bone is unable to deal with the amount of stress it is subjected to [5]. In runners, stress is most commonly generated from running training loads, but any and all physical activity can contribute. If the amount of stress and load is not adequately managed, this can lead to painful fractures developing within the bone. With impact exercises such as running, the bones in our feet, legs, hips and spine undergo stress from compression (jarring from impact when landing), and tension (from muscles absorbing impact, stabilising the body, and creating propulsion). When a healthy bone undergoes sufficient stress that is still within a tolerable level, a process is triggered within the bone to make it stronger. This process involves the removal of part of the bone’s support structure that is then replaced with remodelled and stronger bone.

Symptoms to watch for

In early-stage BSI, symptoms are usually mild – perhaps felt as an ache or light bruising sensation, and might only be felt at the start of physical activity, and/or after the athlete has cooled down. It is thought that at this stage of the injury there is usually only mild damage and a small amount of swelling around the exterior lining of the bone may be evident on MRI. At this stage, the bone’s capacity for loading and stress may be slightly reduced, so caution is needed with any higher risk activities (high-intensity sessions e.g. hills or intervals, or very long runs). If the training load (or other physical activity) continues to stress the bone in its weakened state, swelling within the marrow of the bone begins to develop. At this stage, the injury becomes more uncomfortable during running, but symptoms may still ‘warm up’ as the session continues.

If stress to the bone isn’t reduced sufficiently, the cortical or hard part of the bone begins to degrade and fractures can form within it. By this stage, the injury would be very uncomfortable to run on and is often accompanied by an aching sensation even at rest.

Common BSI sites

80-95% of all stress fractures occur in the lower limbs[1]. The majority of these lower limb BSI are found in the tibia (shin bone) 33[2]-55%[3], metatarsals (long toe bones in the forefoot) 20%[2], and the remainder in the hindfoot and femur (thigh bone).

Who is at risk

Bone Stress Injuries can account for 50% of injuries sustained by runners and military recruits [3]. Female runners are twice as likely as their male counterparts to develop a bone stress injury [3]. Aside from being female, there are a number of factors that have been identified as risks for developing a bone stress injury.

Risk factor: Training load

By their nature, a BSI requires stress to develop [3]. A rapid increase in training load, particularly in poorly conditioned athletes or those new to running will likely bring about sufficient stress to develop a bone injury. A long history of physical activity is protective [6] as this tends to improve bone density over time. Total training volume needs to be monitored over the course of weeks and months to ensure adequate recovery occurs in order for bones to strengthen. For runners that have taken more than 2 weeks off training due to illness and/or quarantine, a gradual return to pre-break levels is advised. Those that are new to running need to be careful if mirroring the training of more experienced runners.

Risk factor: Running technique

Running technique can play a part in the development and likely location of a BSI. Distance runners who land on their heels are more likely to develop a BSI in the tibia. In contrast, sprinters, and runners who land on their forefoot are more likely to develop a metatarsal (toe bones) BSI.

Runners that produce high ground reaction force (impact)[2,3,4] and had increased rearfoot eversion [4] (rolling in) were more likely to suffer tibial stress fractures. Gait retraining can be beneficial in cases of recurrent BSI but needs to be done carefully due to the risk of injury developing from an unaccustomed running style [6].

Risk factor: Footwear

Shoes can play a role in the development of a BSI. It was found that running in old or worn-out shoes increases the risk of BSI[8]. General footwear industry advice is to replace shoes within 600km of running, but keep in mind that shoes will also degrade over time irrespective of use.

A recent study has proposed that running in maximalist (thickly cushioned shoes such as HokaTM) may reduce the risk of tibial stress fractures in female (but not male) runners. By comparison, minimalist (thinly cushioned) shoes were linked to metatarsal stress fractures(10). The use of foot orthotics was found to help reduce the risk of developing BSI in military recruits[9].

Risk factor: Low energy availability

Tracking the amount of energy you consume compared to your daily energy expenditure can help determine if your body is in an energy deficit. This is where the amount of energy consumed is less than the amount expended. Low energy availability reduces the ability of bone to resist load and/or impairs its ability to repair micro-damage [6]. Sustained periods of energy deficit can have negative effects on the body and will compromise performance and recovery. In females, this can lead to disorders in their menstruation cycle [6,7].  

Assessing your attitude towards food can help to identify eating behaviours that may result in low energy availability. The Eating Attitudes Test (EAT-26) questionnaire is a simple screening tool that can help flag problematic eating behaviours [7]. Athletes that score 20 or higher on this test would benefit from professional guidance. The questionnaire can be found easily on google.

Risk factors: Vitamin D and calcium deficiency

Low vitamin D [1] and calcium levels were common findings in athletes that develop BSI [4,5,6]. Ensuring adequate levels via dietary intake or supplementation is an important factor, and a fairly easily achieved goal to help reduce BSI risk. 

  • 600 IU of vitamin D daily is suggested for ages 9 to 70 years
  • 800 IU of vitamin D daily is recommended for > 71 years or older
  • 1300 mg of calcium daily for ages between 9 to 18 years[11].


Bone Stress Injuries are painful injuries that are best avoided. It is important to be aware of the signs and symptoms of a BSI – particularly if you are new to running, have increased your training (especially after taking more than two weeks off running), and/or are at risk of any of the factors listed above. Developing a considered plan for your training load and recovery is crucial for avoiding this potentially season-ending injury.  If you suspect you have a bone stress injury or have had one in the past, contact the intraining running injury clinic for an assessment and to develop a plan on how best to avoid them in future.

By Doug James – Physiotherapist and Podiatrist at intraining running injury clinic.

Doug James Colour 2020



Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes through to elite athletes.

Bachelor of Podiatry (Honours), Master of Physiotherapy Studies.

Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment.

Doug is also a keen runner having completed the New York Marathon.


  1. Alexandra Abbott, Mackenzie L. Bird, Emily Wild, Symone M. Brown, Greg Stewart & Mary K. Mulcahey (2020) Part I: epidemiology and risk factors for stress fractures in female athletes, The Physician and Sportsmedicine, 48:1, 17-24, DOI: 10.1080/00913847.2019.1632158
  2. Tavares, J., Jost, T., Drewelow, G., & Rylander, J. (2020). Do maximalist shoes mitigate risk factors for tibial stress fractures better than stability or flexible (marketed as minimalist) shoes? Footwear Science, 12(1), 63–74.
  3. Milner, C. E., Ferber, R. D., Pollard, C. S., Hamill, J., & Davis, I. (2006). Biomechanical Factors Associated with Tibial Stress Fracture in Female Runners. Medicine & Science in Sports & Exercise, 38(2), 323–328.
  4. Song SH, Koo JH.   Bone Stress Injuries in Runners: a Review for Raising Interest in Stress Fractures in Korea.   J Korean Med Sci. 2020 Mar;35(8):e38.
  5. Miller, T. L., Kaeding, C. C., & Rodeo, S. A. (2020). Emerging Options for Biologic Enhancement of Stress Fracture Healing in Athletes. Journal of the American Academy of Orthopaedic Surgeons, 28(1), 1–9.
  6. Warden A, Davis I, Fredericson M. Management and prevention of bone stress injuries in long-distance runners. J Orthop Sports Phys Ther. 2014;44(10):749e765. jospt.2014.5334.
  7.  Sanderson, S., Raab, S., & Moch, P. (2012). BMI and EAT-26, Predictors for Low BMD? SAGE Open, 2(1), 1–5.
  8. Gardner LI, Jr., Dziados JE, , Jones BH, , et al.. Prevention of lower extremity stress fractures: a controlled trial of a shock absorbent insole. Am J Public Health. 1988; 78: 1563– 1567.
  9. Snyder RA, , DeAngelis JP, , Koester MC, , Spindler KP, , Dunn WR. and Does shoe insole modification prevent stress fractures? A systematic review. HSS J. 2009; 5: 92– 98.
  10.   Salzler, M. J., Bluman, E. M., Noonan, S., Chiodo, C. P., & de Asla, R. J. (2012). Injuries Observed in Minimalist Runners. Foot & Ankle International, 33(4), 262–266.
  11. Institute of Medicine (US) Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Dietary reference intakes. Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride. 1997.

3 Reasons To Get Your Orthotics Checked Now

3 Reasons to get your orthotics checked now

Reason 1  Make the most of your health fund

You may only have until December 31st to use up your remaining extras cover.  If you have podiatry cover, then you are usually eligible for a new orthotic each year.  This gives you the chance to leave a pair in your running shoes, and even have one made for your dress shoes. 

Reason 2   Make your life easier

It is so handy to have a second pair of orthotics – one for your long run shoes, and one for trail shoes or your speedwork shoes.  Keeping a pair in each shoe stops the frustration of changing it around, and reduces the wear and tear as you move it from shoe to shoe.

Reason 3  Refresh your current pair

Most orthotics will last up to 18 months. If you have used them a lot in the year, you can refresh that pair by simply replacing the covers.  This is a low-cost way to create a fresh feel for your orthotics and to give a little more life to them. 


Stay running happily … Make the most of your Health care funds and

BOOK in to our podiatrists at intraining Running Injury Clinic BEFORE December 31st to make the most of your health fund.  


07 3367 3088 | [email protected] | Book an appointment

Come and see us at 535 Milton Road, Toowong

How to recover after a marathon?

Most marathon training programs take you up to race day and then leave you to fend for yourselves during one of the most vital training phases. Optimum recovery from the marathon is important because what you do can have long-term consequences for both your health and future performance. During a marathon you push your body beyond your limits causing massive muscle and connective tissue destruction. If left untreated the physiological effects can lead to injury, illness and even depression.

This can affect your normal life activities as well as your running ability. On the upside, improvements in fitness come from overloading your body and then recovering properly. There are not too many things you can do more challenging then a marathon. Because of this the marathon represents a great opportunity to improve your fitness. The key to achieving this improvement is recovery. What you do after the marathon will help you gain the fitness benefits from having completed such a hard long run.

How soon?

The main difficulty during recovery is knowing how soon you can run again. This is complicated by the varied amount of damage that is inflicted for different runners and different races and conditions. It takes less time to recover from a fast marathon where you finished strong then a slow marathon where you hit the wall and had to stagger into the finish. Hot weather conditions or hills will increase recovery time. What you do just after you finish can decrease your recovery time. Your recovery should be flexible and managed based on how you respond both physically and mentally.

How hard should I run?

An easy way to understand training theory is to examine it based on three major components of Intensity, Quantity and Frequency. Regardless of what phase you are in, or what theories you believe, all training is founded upon these three components. It is how the intensity, quantity and frequency vary during each phase that describes what you are doing to try to achieve progression, periodisation and success. During recovery training intensity and quantity will initially be very low and gradually increase as your body gets stronger. If you try to run hard or long too soon you can delay full recovery. Because you only improve while recovering from hard efforts you will also lose any benefits you could have gained from running the marathon if you start hard training too soon.

How often?

Frequency is the only thing that should be maintained during the recovery phase. Normal intense training and racing damages some muscle fibres. The scope of destruction after a marathon includes the macrostructure of the muscles and connective tissue. If you run at least every second day you will break the muscles down a little bit each time. This will allow the macrostructure of the muscle to be rebuilt in the right way. The cellular microstructure will not recover any quicker if you do no running in the first week or if you run every second day. But the advantage of easy running is that the muscles will have less scar tissue that can lead to injury further down the track.

How long till a long run?

An old theory for recovery used to recommend that you give yourself one day of recovery for every mile of the race. For a marathon of 26.2 miles this would be about four weeks of recovery before you try to train properly again or run another race. However it is dangerous to lump everyone and every experience into one simple calculation. How long it takes to recover depends on the difficulty of your race experience and what you have done to try to recover.

Rather than think of an arbitrary number to calculate how long it takes to recover you should listen to your body. Train easy and avoid building up mileage until you get that zip back in your stride. It can be easy to tell that you are not recovered because even easy runs are a struggle. You may be sore after running and can’t maintain any speed for very long. I usually recommend to wait one until I feel fully recovered and can push the pace along. I then feel it is safe to commence the build up of long runs back.

How to help recovery?

What you do after you finish a race can have a drastic effect on your recovery time. In fact recovery training starts before you even finish your marathon. The most important factor of this immediate recovery involves re-hydration and nutrition. While you might think that drinking in the last few kilometres is not necessary to improve your performance in that particular race, it will have an affect on your recovery. During a marathon you can sweat out nearly ten percent of your body weight. This is significant for your performance but also affects the amount of damage that occurs. Fluid helps to transport resources used to rebuild damaged muscle to where it is needed.

It is also important to remove heat from the location of the damage to release it from the skin. Muscles and the liver are completely depleted of glycogen at the end of a marathon. This source of energy is more effective at rebuilding muscles so you must replace glycogen as soon as possible after you finish. The best way to do this is by drinking a sports drink or soft drink within the first few minutes of finishing. This helps to re-hydrate at the same time as replacing some glycogen. In fact if you drink just water it will not stay in your system as well as if you drink something with some sugar and salt in it. Within the first ten minutes you should begin to eat some carbohydrate rich solid foods. Fruit is easy to get down and has high levels of fluid as well as important vitamins to help you recover. After the first half-hour you have missed your opportunity to replace water and glycogen optimally.

Massage is often available at the end of races. Because of the major cellular destruction that has occurred mechanical manipulation of this damaged tissue will just cause greater damage. You should avoid any massage until the initial inflammation has subsided. This can take a few days. After the inflammation has gone down then massage can be very beneficial to proper recovery.

How to race again?

You know you are recovered from a marathon when you are able to race well again. But what do you do if you want to run two marathons within a few weeks or months of each other? The key to frequent marathons is to train sensibly between them. Do not think that you have to get in some good quality training in between. It is more important that you recover properly from the first marathon and are rested for the second one. There is no better training for a marathon then running another marathon. A marathon race exactly simulates what will be required for running a marathon. As long as you recover properly you will gain the benefits from the first marathon and will be able to run even better at the next one.

No matter how well you have planned your recovery program things may not work out the way you wanted. You might be taking longer to get over the pain of the marathon or picked up a niggling injury from the race. This will force you to rethink what you should do. Blindly sticking to your plan will lead to poor recovery, overtraining and probable injury or illness. A responsive recovery program will have the capability of changing based on how you are coping with the recovery. It will have contingencies built in so you can change sessions around and increase your recovery time if needed. Intensity is not fixed at a certain level but responds to how you are feeling without any major failure of the program. By responding to how the recovery is going you can optimise the benefits you have gained from running a marathon and take your performances to another level in the future.


Article written by podiatrist, level 4 athletics coach and 2hr30 marathon runner, Steve Manning.

If you need help with recovery training, an injury or post-race niggle contact intraining Running Centre at 3367 3088 or book an appointment online.




By Margot Manning – intraining Running Injury Clinic podiatrist, coach and runner

Black toenails, blisters and calluses are a common hazard of running, but with a few simple changes, you can usually prevent them from occurring. The main reason that they occur is from the pressure of the shoe in different ways onto your feet and toes as they move across the ground.

BLACK TOENAILSblack toenail edit squareszie

The dreaded black toenail is nearly always caused by shoes that are too small or the fabric upper too shallow where your toes are located. This lack of depth in the shoe puts a lot of pressure on the tips of the toes, particularly when running longer distances. The repetitive movement of running can make the toes move like mini hammers – for a very long time.

TIP: Buy a larger shoe, wider shoe  or one with a deeper toe box 


Blistering usually occurs when the foot is moving against the shoe rather than with the shoe. This creates a rubbing of the skin against the material creating friction and blistering. There are three typical places for blistering.blisters on feet edit squaresize

1. Tips of your toes: Toe blisters occur when the shoe is too small or too tight and the freely moving toes continuously rub.

TIP: Longer and squarer shoes can help (Look for D width for women or 2E / 4E in mens)

2. Arch of foot: Arch blisters occur when the arch flattens at an angle or with more pressure on the arch of the shoe. Flat feet and flexible feet are more prone to arch blisters.

TIP: It may be as easy a minor modification to your shoe insole to take the pressure off the arch. Visit one of the intraining Running Injury Clinic podiatrists who can help.

3. Back of heel: Heel blisters occur if your foot is mismatched to the stability type of the shoe. Usually, the shoe is too stable and your foot fights this structure. Sometimes it can be a mismatch between your heel and the heel counter.  The newer designs in shoes have worked to improve this.  

TIP: Check your shoe is the right type for you. Ask one of our running footwear specialists at intraining Running Centre to watch you run on our in-store track.  


Calluses usually occur from the thickening of the skin at a place where there is excessive rubbing. These are usuallycalluses editsquaresize related to the way you run.

Top four common locations of calluses on runners

  1. Along the edge of the big toe
  2. Under the fifth toe joint (little toe)
  3. The tips of the toes
  4. On the inside of the heel

TIP: Calluses can often be easily remedied, either through minor modification to existing insoles or alternatively a more comprehensive orthotic may be required.

If you are having any troubles with blisters, black toenails or calluses, Book an appointment with our podiatry and physiotherapy team at intraining.  A simple footwear modification can make a pain free run.

Book an appointment

Get the most extensive range of choice and expert advice on your next pair of running shoes. Visit us at intraining Running Centre and chat with our footwear specialists.

We’re located at 535 Milton Road Toowong

CALL  (07) 3367 3088 | EMAIL [email protected] 

Don’t let your summer sprain ruin your new season of running 

Ankle Sprains:  the long term risks

  …   and why you need to have it checked ASAP!

By Doug James, Physiotherapist and Podiatrist, intraining Running Centre

Ankle sprains are one of the most common acute injuries in the world, accounting for up to 5% of cases at Emergency departments in hospitals [5]. The injuries can be seemingly harmless in that the pain from most minor sprains tends to settle quickly, however, all ankle sprains should be assessed.

Assessment can differentiate the sprain type and severity which can help to determine the necessary recovery period [3,4] as returning to sport and exercise too soon comes with the risk of long-term consequences [2].

What is an ankle sprain?

Ankle sprains occur when your foot rolls excessively and strains (or ruptures) the fibres in the ligaments that attach your ankle to the side of your foot. This can happen on either or both sides of your foot, however, the inner (medial) side of the ankle has much stronger ligaments. The ligaments on the outer (lateral) side of the ankle are generally more prone to injury when the ankle rolls over the outside of the foot [2] (which happens far more frequently). This tends to happen commonly in stop-start sports such as basketball or soccer [2], but runners – particularly trail runners are susceptible to this injury.

Damage that occurs to the ligaments is graded on a 3-point scale from mild to severe based on injury history and clinical tests, with diagnostic imaging used occasionally to provide further insight into the extent of the injury.

Mild sprains (Grade 1)

In mild cases (Grade 1) ankle ligaments may be stretched or slightly damaged, some pain is felt usually at the time of the injury and usually improves over the course of a few days. Some swelling is expected and bruising to the foot, ankle or lower leg may or may not occur during this time.

Moderate sprains (Grade 2)

Moderate, or Grade 2 injuries are generally painful for longer as there is a larger degree of damage to one or more ligaments. Walking can prove difficult due to pain, and the ankle will likely be swollen with bruising that may last for up to a couple of weeks.

Severe sprains (Grade 3)

Grade 3 (severe) injuries can sometimes actually be less painful than Grade 2 injuries as the completely ruptured ligament(s) tend to stop hurting after a couple of days. The ankle is significantly less stable though due to the lack of supporting ligament support, and can progress on to long term injury if not properly treated.

Complex sprains and Long-term complications

Unfortunately, some ankle sprains are complex and severe and require greater care and time to heal.

Here are FOUR examples of more complicated injuries that can occur with ankle sprains.

#1 Avulsion Fractures

In cases of ankle sprains where standing is unbearable, fractures may have occurred to bones in the foot, ankle or lower leg. When the ankle rolls during a sprain there is often a forceful muscle contraction that can pull the bone away from the muscle insertion (a process known as “avulsion”). This tends to occur on the lumpy part of the side of the foot (styloid process and/or fifth metatarsal shaft), the tip of the ankle bone (malleolus), or less commonly just below the knee (fibula head).

Detection of the fracture is usually done with X-ray around the time of the injury but maybe repeated 2 weeks later if the initial scan is inconclusive (evidence of bone healing is more easily detected at this time and is indicative of a recent fracture). Depending on the location and severity of these fractures, treatment may involve immobilisation with a fracture (moon) boot with crutches, or surgery to reattach the bone.

#2 High Ankle Sprains

High Ankle Sprains are a more serious type of sprain that tends to involve a twisting movement of the lower leg (which may happen if the foot is caught while the body twists away from it) [4]. With this injury, pain tends to be felt higher above the ankle joint as the fibres the hold the two shin bones together are damaged.

In addition to specific clinical tests, diagnosis of this injury usually includes a standing X-ray, and Diagnostic Ultrasound or MRI. Return to the sport can occur in as little as two weeks for mild cases [4], though severe cases (where the shin bones have separated considerably), surgery is required to stabilise the leg and ankle.

#3 Osteochondral Talar Dome Lesions

Osteochondral Talar Dome Lesions (TDL) involve damage to the cartilage and bone on the top of the talus bone (where the foot joins to the shin). There are several different grades of this injury depending on the severity of damage to the cartilage and bone. It is not well understood how these injuries develop, though chronically unstable ankles (i.e. those that do not regain sufficient ligament strength after a strain) are at a greater risk [1]. There is evidence that bone bruising is often present in the Talus after some ankle injuries which may lead to the develop of TDLs [7]. This bone bruising can be present for over 9 months [7]

Osteochondral TDLs may involve compression of the bone and cartilage, or have a chip of bone dislodge within the cartilage. Diagnosis is made via MRI or CT scans, and will usually involve a period of immobilisation (fracture boot), and to a year of recovery. In recurrent TDL injuries, or where the ankle is chronically unstable surgical reconstruction of the ankle joint may be necessary.

#4 Post Traumatic Osteo-Arthritis (PTOA)

A further complication that can develop from lateral ankle sprains is Post Traumatic Osteo-Arthritis (PTOA) [6]. Osteo-Arthritis is the world’s most common joint disorder in the western world [5] and having a traumatic injury can increase its likelihood [6]. When it occurs in the ankle, the cartilage lining of the joint becomes thin and can result in pain, stiffness and inflammation in the ankle joint making walking and running uncomfortable. Proper management of acute ankle injuries is an important step to help minimise the amount of inflammatory change which may contribute to PTOA later occurring.

Early treatment for Ankle Sprains

Initial treatment should begin as soon as possible. 

This involves protecting the injury from further damage. If the ankle is significantly sore, it is best not to run with the injury as pain and the resultant reduction in reflexes will force changes in gait and may make the injury more severe and/or create additional injuries. While the use of ice packs in ankle sprain management has been challenged more recently (arguments suggest that this can slow the healing rate) they can be useful for reducing pain which might help reduce long term complications. Compression and elevation are accepted treatments to reduce swelling and should be administered ASAP. Early mobilisation (walking) is useful in most cases as it encourages faster healing and less strength loss, but should be done in moderation over the first couple of days.

X-rays are generally only required if you are unable to stand on that foot due to pain and there is tenderness on the bony parts of the side of the foot or ankle. Pain in these locations can be indicative of a fracture and should be treated with additional care with a fracture boot, plaster cast or in some cases – surgery.

Return to sport rehabilitation

It’s been shown that all grades of ankle sprains result in reduced strength and stability in the injured ankle [2]. Failure to address these deficits results in a greater chance of a more severe grade ankle sprain, a higher than average likelihood of re-injury, and possible complications such as a long-term ankle injury. A good rehabilitation plan will include a personalised program aimed at addressing your particular deficits and restrictions present at assessment. This should be reviewed through the course of the rehabilitation process to ensure the exercises are suitably challenging and are being performed correctly.

Returning to running (or sport) can sometimes safely happen as early as one-week post sprain for lower grade injuries, though this should be done at an easy intensity and for a short amount of time. In cases where the initially diagnosed Lateral Ankle Sprain is persistently painful, or not responding to a rehabilitation program, suspicion a more complex ankle sprain should be raised. These types of injuries are discussed below and may require further imaging [7].

Remember… EARLY assessment and treatment is key

Runners can be their own worst enemies when it comes to stoically (or stupidly) ignoring injuries. Ankle sprains are an injury that deserves respect. Early assessment and treatment are essential to help guide you through the recovery and rehabilitation process while helping reduce the risk of it developing into a potentially more serious, long-term injury. If you’ve recently sprained your ankle, or have a recurrent history of this injury contact the intraining running injury clinic to discuss how best to manage your injury.

Book an appointment

Ph:  3367 3088 or  [email protected]

Doug James Colour 2020



Doug James is a qualified physiotherapist and podiatrist with a special interest in running and sports injuries. He combines the two treatment approaches to achieve successful outcomes for clients of all abilities from non-athletes through to elite athletes.

Bachelor of Podiatry (Honours), Master of Physiotherapy Studies.

Doug has undertaken further training in dry needling, Pilates, and Rocktape and may incorporate these as necessary during treatment.

Doug is also a keen runner having completed the New York Marathon.

Book an appointment

Ph:  3367 3088 or  [email protected]


(1) Gregush, R. V., & Ferkel, R. D. (2010). Treatment of the Unstable Ankle with an Osteochondral Lesion: Results and Long-term Follow-up. The American Journal of Sports Medicine, 38(4), 782–790.

(2) Kobayashi, T., & Gamada, K. (2014). Lateral Ankle Sprain and Chronic Ankle Instability: A Critical Review. Foot & Ankle Specialist, 7(4), 298–326.

(3) Mauntel, T. C., Wikstrom, E. A., Roos, K. G., Djoko, A., Dompier, T. P., & Kerr, Z. Y. (2017). The Epidemiology of High Ankle Sprains in National Collegiate Athletic Association Sports. The American Journal of Sports Medicine, 45(9), 2156–2163.

(4) Miller, B. S., Downie, B. K., Johnson, P. D., Schmidt, P. W., Nordwall, S. J., Kijek, T. G., … Carpenter, J. E. (2012). Time to Return to Play After High Ankle Sprains in Collegiate Football Players: A Prediction Model. Sports Health, 4(6), 504–509.

(5) O’Connor SR, Bleakley CM, Tully MA, McDonough SM (2013) Predicting Functional Recovery after Acute Ankle Sprain. PLoS ONE 8(8): e72124.

(6) Palmer-Green, D.S, Batt, M.E, & Scammell, B.E. (2016). Simple advice for a simple ankle sprain? The not so benign ankle injury. Osteoarthritis and Cartilage, 24(6), 947–948.

(7) Wang, X. (2017). The Significance of MRI in Process Change of Osteochondral Lesion of Talus. Foot & Ankle Orthopaedics.

High Risk vs Low Risk Stress Fractures

High Risk vs Low Risk Stress Fractures

By Steve Manning – intraining podiatrist and coach 

Not all stress fractures are equal.  Low Risk Stress fractures are much more common but they heal quicker and have much fewer complications.  High Risk stress fractures in comparison are at risk of non-union and delayed healing and are much more likely to develop into a complete fracture.


More than a third of distance runners will experience a bone stress injury.  Stress Fractures are thought to make up around 20% of injuries in runners.
The most common stress fractures are in the forefoot (Metatarsals) and the leg bones (Tibia and Fibula).  Less often are stress fractures in the midfoot and heel (Tarsals), the thigh bone (Femur), the kneecap (Patella) and even in the big toe (Hallux).


Bone Stress injuries are usually the result of repetitive chronic overuse.  When you stress your body at a level to which it is unaccustomed, the tissue response is to adapt and remodel so that the body is better able to cope with the same stress in the future.  In your bones, this triggers special cells called osteoclasts to go in and eat away the bone so that other cells called osteoblasts can then lay down new stronger bone with a higher bone density and alignment towards the direction of the force.
This process takes around 5 to 6 weeks to occur.  If the stress increases or continues without recovery weeks then the result is that you are stressing a bone that is weaker while it is remodelling.
That is why stress fractures usually occur around 6 weeks after there has been an increase or change in training.  It is also possible to have a stress fracture from a single traumatic like a sprain, fall or contusion but that is rarer. 


We can often make a clinical diagnosis of a stress fracture from history and palpation.  If the patient is just willing to do the time then we can review it before they return to running.  If it is not clear and the patient has a race they want to do then we will refer for an MRI.  There is an MRI classification system for bone stress injuries that classify by the depth of the swelling and findings on T2 and T1 images.  If the fracture has not healed in the normal time then we will suspect a high-risk fracture and refer to an MRI immediately.  All stress fractures in someone with low bone density or osteoporosis should be considered to be high risk.


The location of the stress fracture determines the risk classification. When weight bearing different bones or parts of bones undergo either compression or tension.
Compression vs Tension in the leg bone (Tibia)
Compression forces are much more likely to lead to a stress fracture especially in long bones.  
In the Tibia the lower half of the inside border undergoes compression during weight bearing so that is where most of the tibial stress fractures occur.
The front or anterior border experiences Tension with normal weight bearing. For this reason, normal weight bearing pushes the medial border stress fracture edges together encouraging healing while the anterior border stress fracture is pulled apart leading to non-union.
Compression vs Tension in the metatarsal bones  (The long bones of the feet)
The same thing occurs in the metatarsal bones which make up the front part of the arch and foot. 
Stress Fracture Risk by Location cropped scaled 
On normal weight bearing the top of the bone has compression and the bottom of the bone has tension. The vast majority of metatarsal stress fractures occur in the midshaft area.  The treatment for these common low risk fractures is to cease running and jumping activities.  Normal weight bearing with walking will help the healing process so the use of a boot is not indicated.  Long periods in a boot will lead to a loss of bone density, delayed healing and a much longer return to sport.
However, if the stress fracture is in the base of the second metatarsal then this is a high risk fracture.  Normal weight bearing will prevent the union of the fracture and a boot is critical to healing despite the loss of bone density.  In some cases even a boot may not be enough and surgery will be required to have a resolution of the fracture.  A recent study found that low running mileage was a factor linked to a greater risk of a high risk fracture in the base of the second metatarsal.
Some bones like the navicular, fifth metatarsal and femur are always high risk fractures.  They require a reduction of weight bearing for an extended period with either a boot or crutches.  


The size of the bone determines the duration of the recovery time.  Metatarsals take the least amount of time – between 4 and 6 weeks off running.  The Tibia and the Calcaneus will take 6 to 8 weeks and the femur will be 12 weeks.  If the fracture is at a high risk location then the recovery period should be at the high end of the range and may take even longer.


Stress Fractures are an injury that needs you to stop running.  You can do any activity which does not hurt but be careful of not getting another injury from your cross training.  Only high risk fractures should be immobilised.  There are no treatments or exercises that have been shown to make any significant difference in your recovery time.  However, maintaining some non-running activity will help your return to running.  
Once you have recovered you should get a review of your training and a return to running training plan.  It also might be worthwhile to investigate other contributing factors like your foot structure and biomechanics, your running shoes and your diet.  
At the Intraining Running Injury Clinic, we can help you diagnose your running injuries and create a treatment plan.  We are running coaches as well as being Podiatrists or Physios.  We have extensive experience in helping runners get back on the road as soon as possible.

Steve’s Tips for Stress Fractures:

1.   Suspect a stress fracture at a high risk location then an MRI must be done.
2.  Do not run or jump during the required recovery phase.
3.  Maintain fitness and activity with cross training.
4.  You can do any activity that does not cause pain.
5.  Avoid the use of crutches or a boot at a low risk location to reduce recovery time and the rehab period.

Come and see us at 535 Milton Road, Toowong 

Your Running Injury Helpline

(07) 3367 3088 | [email protected] | Book an appointment 

Calcaneal Apophysitis


That painful growth injury that makes your child limp on and off the field.

with Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist

READ Doug’s article below to give you and your child a quick guide to help you tackle Heel Pain in kids.

Calcaneal Apophysitis  (formerly known as “Sever’s Disease”)

Calcaneal Apophysitis is one of the most common injuries in early adolescents, though its name is probably unfamiliar to most who would refer to it as “Sever’s Disease”, or more simply “Sever’s”. It is pain felt on the back of the heel bone (calcaneus) around the base of the Achilles tendon in some young people sometime between the age of 7-15 years old [1-5] (the age ranges vary by source but usually falls within 1-2 years of the upper and lower limits). This injury was first identified in 1912 by Dr James Sever, after whom the injury was named[2].

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What’s in a name?

While the term “Sever’s Disease” is commonly used today, it is falling out of favour with the medical world. In the past, a medical condition or disease would often be named after the person that studied and identified it. Injury names become increasingly difficult to pronounce when a team of people lay claim to the identification of a condition such as the wordy “Sinding-Larsen-Johansson Syndrome” (a knee pain condition in teenagers), or Klippel–Trénaunay–Weber Syndrome (a blood vessel disorder).

The favoured and current approach is to refer to these “diseases” with a more accurate pathophysiology (problematic process) title so as to better describe the “where and what” of the condition. This move also aims to replace using inaccurate and vague terms such as “syndrome” and “disease” as these names can carry a certain stigma.

So, what is a Calcaneal Apophysitis?

The individual components within the name “Calcaneal Apophysitis” gives a clue as to its nature and location. The Calcaneus is the heel bone. An Apophysis is a bone protuberance or small lump formed on the bone where tendons or ligaments attach, in this case, it is on the back part of the bone where the Achilles tendon attaches. Lastly, the term “-itis” refers to an irritation or inflammation of an attachment site on the heel bone. Put together, these terms describe irritation of the back of the heel bone.  

How does it develop?

There are a few theories about the factors that lead to how and why Calcaneal Apophysitis develops and what the actual source of pain is. One theory is that the Apophysis becomes painful from the Achilles tendon applying repeated or continuous tension to it [5].

Another thought is that the underlying Calcaneus bone (not simply the apophysis) that may be the source of pain. The human skeleton grows primarily from ossification centres. These are the foundations from which bones lengthen and expand making us taller (and wider). The calcaneus has two ossification centres that are located in the middle and rear of the bone, which eventually disappears once the bone has finished growing – usually in the early teenage years.  The rear ossification centre is thought to become painful as it undergoes stress from tension. Clinically, it’s not uncommon to observe tenderness in the lower part of the Achilles tendon as a standalone presentation, or along with the bony heel pain, again possibly due to tension, or possibly trauma. In more severe cases the growth plate can become fragmented (see image 1).

What is the source of the tension?

Calcaneal Apophysitis is often observed in young people that have had a recent growth spurt (but not always). When the shin bones grow (resulting in increased overall height), the muscles and tendons need time to elongate to the optimum length for the newly lengthened legs. In the weeks (and sometimes months) following a growth spurt, adolescents may complain of calf muscle tightness due to the relative shortness of their calf muscles. This muscle tightness can exert a constant strain on the Achilles tendon and the Calcaneal Apophysis which serves as its anchor point and may irritate the Calcaneal Ossification Centre [5].

The Achilles tendon is also subjected to increased tension in flat-soled, and low heel drop shoes. Adolescents with heel pain should be encouraged to avoid walking around in flat shoes, thongs, or bare feet. Calcaneal Apophysitis is fairly common in active young people [1-5]– notably those playing one of the football codes. Many football boots have a low heel drop (minimal height difference between heel and forefoot) which increases pressure on the calf muscle, Achilles tendon and heel. Playing football involves bursts of sprinting which is another activity known to irritate the injury.

Management of the injury

Just as there is little consensus as to the exact nature of the injury, there is no agreement on a universal fix. This may be due to the fact that there are a number of different contributing factors in each individual presentation. As such, each case needs to be assessed and managed uniquely. The most common theme in management strategies is finding a balance of rest and sport/running within an acceptable level of discomfort, as rest alone doesn’t lead to faster improvement [5]. In cases where pain levels are severe, abstaining from any pain provoking activity becomes necessary, though this is thankfully usually rare.

Footwear factors can play a major role in the successful management of the injury, and being able to modify aspects such a heel drop by using firm heel lifts, or cushioned heel cups can be beneficial. Research has also examined whether orthotics play a role in managing Calcaneal Apophysitis though the results are inconclusive [2] (possibly due to the limitations of research that requires a standardised orthotic be used in all patients). Addressing muscle tightness issues when present is also important for managing pain levels, and expediting recovery time. This can take the form of calf muscle massage, ankle mobilisation, and where appropriate – a targeted stretching program.

How long does the injury last?

It can be difficult to predict how long Calcaneal Apophysitis will last. In a majority of cases, there is a resolution of symptoms soon after the sporting season finishes. In a smaller number of cases, the pain can persist for up to a year, or longer in an unlucky few.

Imaging such as X-rays are not always necessary, but in more severe cases can be helpful to assess any derangement of the Calcaneal growth plate which is often associated with greater pain and longer recovery times.

When to seek treatment?

It is useful to have an assessment when heel pain symptoms first present (which is often in the first few weeks of a new sports season or following a significant growth spurt). Learning ways to manage the pain is crucial to helping settle the symptoms and improve quality of life, while hopefully allowing a continuation of physical activity. An assessment of the patient’s footwear, walking and running biomechanics, and muscle testing can help to develop a personalised treatment and successful treatment approach.

For a thorough assessment of adolescent heel pain, contact the intraining running injury clinic for an appointment to see a Podiatrist or Physiotherapist who can assess the injury and design a custom management plan.

Doug James – intraining Running Injury Clinic Physiotherapist & Podiatrist


  1. Uvelli, K. O., Neher, J. O., & Safranek, S. (2017). Treatment for Calcaneal Apophysitis. American Family Physician, 96(2), 126–127.
  2. James, A. M. M., Williams, C. M. P., & Haines, T. P. (2013). “Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (sever’s disease): A systematic review” Journal of Foot and Ankle Research, 6(1), 16.
  3. James, A., Williams, C., & Haines, T. (2013). Contributing factors in children who present with calcaneal apophysitis. Journal of Science and Medicine in Sport, 16, e26–e26. 
  4. James, A. M., Williams, C. M., Luscombe, M., Hunter, R., & Haines, T. P. (2015). Factors Associated with Pain Severity in Children with Calcaneal Apophysitis (Sever Disease). The Journal of Pediatrics, 167(2), 455–459.
  5. Williams, C. (2016). Wait and see, heel raise and eccentric exercise may be equally effective treatments for children with calcaneal apophysitis [commentary]. Journal of Physiotherapy, 62(2), 112–112.

Image 1: Sourced on 07.10.20 from

intraining Running Injury Clinic

Your  Running Injury Helpline


(07) 3367 3088| [email protected] | Book an appointment

3 Signs your shoes are too small

3 Signs your shoes are too small

Your feet should not hurt when you run. 

If they do, then you need to find out why that happens and make some changes.  The most common reasons for uncomfortable feet when running is because your shoes are one or more of these:

  • too short
  • too shallow
  • not the right shape.  

Here are the three signs of shoe not fitting you right:

#1 Numb toes

After running for 8 to 10km, your toes start to go numb or tingly. It’s usually the third and fourth toes that are affected the most and you will get relief when you take off your shoes.  Annoyingly, this will only happen when you are running. 

This numbness is a sign of irritation and pressure on the nerves that run between the toes.  The reason it happens later in your runs is because your foot expands with increased blood flow and muscle use after a while.  If your shoes don’t have enough space  around then (aka too small) then they become squished.  

Feet that are flexible can also develop this numbness.  When you stand on one foot the front of it flattens.  Runners with flexible feet will get even more flattening.  This makes your foot wider than what you would expect.   So when you are buying shoes, make sure you check that the front of your foot does not have bumps showing  or feel too much pressure from the sides…  check the width.  

High arched feet can also be a problem contributing to numb toes.  If you have a high arched foot you need to ensure the middle of the foot is deep enough  to accomodate its height and even lace the shoes differently.  


Even if you have a relatively normal or slightly thin feet, check that it’s not one that flattens to be wider when you stand.  A common sign can be small bumps on your fifth toe.  

What to Change: 

If this is you, you need to go to a wider or deeper shoe.  This can be tricky if the rest of your foot is narrower, but there are a variety of shapes in shoes and ways to customise your shoes to fit and run well.  

#2 Blisters & Black toenails

Black toenails should not be considered ‘normal’ for a runner.  They occur more frequently with long runs and races but can be avoided. The reason they occur is from repetitive rubbing or ‘bumping’ onto the inside of the shoe.  Think about how many steps you take running, and how many times your toes will be hitting the end or top of the shoe.  A lot!!  

There are different reasons black toenails form. 

  • a shoe is too short  (the most common)
  • a shoe is too shallow at the end because the upper is tapered towards the toe
  • you have the wrong shaped shoe for your feet and toes are rubbing
  • your toes move more than they should when inside the shoe because of the way you run – your biomechanics.
  • with a longer or deeper pair of shoes.


Buy a different shoe – size, or shape.  Toes that continually go black from trauma (being beaten constantly in their shoes), eventually can thicken.  This is a permanent damage and will make it even more difficult as an older person to fit into shoes.  


The biggest change is the size and shape of the shoe.  If you have done this and still have problems then you need to see a running podiatrist to review your foot biomechanics.  

#3 Hot feet or a lump under the foot

The feeling of a lump, your sock bunching up or a stone under the ball of the feet is another sign of tight shoes.  This has the same pattern as your numb toes, starting after a while with the foot starting to feel warm or hot. This is not a fun experience at all and can completely ruin the enjoyment of your runs due to the pain.  To compensate for this pain, you may also start to alter how your foot is landing on the ground leading to a secondary tendon injury – a much harder one to resolve.  


Check the fit of the shoe just as you did for the numb toes.  Sometimes this injury starts as numb toes and turns into the stone-like pain.  

Check also the age of your shoes.  This is a common sign when the cushioning in your shoes has worn out.  Remember that the midsole (cushioning) can wear out with no visible signs.  


Larger shoes if they are newer.  New shoes if you have done a lot of exercise of they are old.  


Your feet should be comfortable, especially when you run the longer distances. It is not normal to get these pains and they are often pretty easy to get rid of with the right size and fitted shoe. 

Make sure you take the time to think about the fit and feel of your feet when you are buying new shoes.  Stand in them, run in them and check you don’t have any obvious signs while in the shop suggesting they are too small.  Even a little too small can escalate to larger discomfort on your runs. 

If you have answered yes to any of the above signs come and talk with our running team at intraining Running Centre. They can help you with some tips to modify your shoes or help you find the right pair.  There are so many different shape designs to running shoes that usually we can help you find a pair to suit.

You’ve tried all those changes and still need help?

If it is an ongoing pain, then you should book in to see one of our running podiatrists, because there are other in-shoe management strategies and we can determine if there is another underlying cause, such as neuroma’s, bursitis, nerve impingements, or joint capsule injuries.  

Don’t live with this pain.  Take the steps to make your running more enjoyable again.

Phone us on 07 3367 3088 , or come in and see our running team.  They know what signs to look for and can help you find the right shoe.  

By Margot Manning, Podiatrist, intraining Running Centre CEO, Runner,  and Coach.

Lighter shoes for faster running?

400x640px coachprofile margotmanning
Article by: Margot Manning (intraining podiatrist, runner and coach)

Can lighter shoes really make me run faster?

This is such a common question. You need to know that there is no substitute for consistent training and a great running program… BUT… the correct pair of running shoes for you and a second, lighter weight pair of running shoes can definitely make a difference to how easily you can run.

The four main benefits of a lighter shoe for faster running are

  1. More responsive feedback from the ground
  2. Less cushioning thickness for your foot to work through
  3. Co-ordination – the faster you run the more co-ordinated your body moves, and the less structure you need at your feet.
  4. You feel light, fast and ready to go!

“Put these four factors together with the shoe and you could soon be running new PB’s.”

Choosing your second shoe can be daunting where there are so much to choose from. Every footwear brand has a range of shoes from the long run shoe, lightweight training shoe, down to the racing shoe.

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How do you choose the right shoe?

Most recreational runners would use a lightweight training shoe rather than the racing shoe as their second shoe. When buying your first, second, third or any pair of running shoes it is important to follow these steps to ensure you minimise the chance of injury

  1. Try before you buy: It is good to always try and run in the shoes before buying them to feel the difference between different brands and shoe types and which pair you feel the most comfortable.
  2. Heed the advice of industry professionals: If a shoe is making excessive noise when running, you are over-pronating or simply does not suit your running gait, then take the advise of your local running specialist.
  3. Comfort is key: Ensure you feel comfortable in the shoes before purchasing.

How intraining can help?

At intraining Running Centre, our staff are all runners and have understand how each of the lightweight running shoe alternatives can not only help you run faster, but will also complement your current training shoes.

Our trained footwear experts analyse your running style, outside, in real world conditions, to ensure you are comfortable and the shoes are the best fit for your feet. There is no charge for our comprehensive footwear fitting service with our footwear experts when purchasing shoes. We want you to be comfortable with your choice and enjoy your running.

Whether you are looking for a lightweight alternative to your training shoe or are keen to purchase a second pair of training shoes, let the experts at intraining Running Centre take care of you.

Note: Bookings are not required when visiting the to purchase shoes


How to treat shin pain

How to treat shin pain?

Shin splints are a generic term that many runners use to broadly cover shin pain. Sports medicine practitioners have needed to develop more specific terms to differentiate conditions and treatments required when addressing shin pain.

These terms try to reflect the tissues affected and their different causes. Whilst some shin pain may present similarly, it is important to correctly identify the pain and provide appropriate treatment. Below are common shin pain issues we see at intraining Running Injury Clinic.

  • Medial tibial stress syndrome
  • Stress fracture
  • Compartment syndrome
  • Nerve entrapment
  • Muscle and tendon strain

Below we briefly describe; how to diagnose shin pain, common symptoms and how to treat the injury appropriately. If you have shin pain that is holding you back from enjoying your running, click the button below to make an appointment to see one of our podiatry or physiotherapy team.

Make an appointment to see Steve
Steve Manning (podiatrist, coach and runner)




The most common cause of shin pain is medial tibial stress syndrome. This pain hurts along the inside of the shin most commonly in the lower half and isolated to the medial border of the shin bone, the tibia. It is an inflammation of the tibial skin, called the periosteum, where the fascia of the leg attaches. The fascia is the stiff layer of tissue that holds all the muscles in place. Little tears occur along this attachment causing inflammation and pain.



The pain can sometimes hurt after waking or rest but most commonly hurts at the beginning of a run before warming up. When bad it can begin to hurt again at the end of a run and will hurt a lot afterwards.


Treatment involves a direct icing technique for a few days with the addition of a gentle distraction massage after that time. Screening for any underlying biomechanical causes may be necessary if continued running aggravates the injury. Extended rest is not recommended as the scar tissue may become more entrenched and harder to resolve in the long run.


Prognosis is generally quite good with a significant (greater than 50%) reduction of pain within a week and complete resolution within a month.



Medial tibial stress syndrome that goes untreated may lead to more severe injuries to the bone like bone stress or stress fractures. Stress fractures are most commonly found on the inside (medial) border of the tibia but may also occur on the front (anterior) border. It is often overtraining that is the culprit, where it has occurred more than a month prior to injury onset.

MTSS Pain1Symptoms

Pain usually occurs at the start of a run and gets worse without going away. It can ache afterwards and sometimes the pain will wake you at night. Pain is usually localised to a spot on the bone and may hurt on both borders and the shaft. Normal x-rays may pick up a stress fracture after 3-4 weeks but an MRI is the best scan to use.


Unfortunately bone injuries are one of the few injuries that require complete rest from activity. If it is bone stress than after a week there will be significant improvement in point tenderness while a stress fracture will take at least three weeks. With bone stress you can return to running when the pain is gone but stress fractures require 6 to 8 weeks of no running. Once the stress fracture has healed adequately there is less chance of recurrence in the same location.



A compartment syndrome can be defined as the increase in pressure within the limited anatomical space of a fascial compartment which compromises the circulation and function of the tissues within that space. If compartment volume is limited or decreased due to tight or thickened fascia then compartment pressures can increase upon normal muscle swelling during exercise. The anterior compartment muscles are most commonly affected in running.


Generally there is no pain at rest or at the start of a run. Pain comes on at a certain distance of each run and is quickly too severe to continue. The muscle feels tight and may be firm to the touch. Within a few minutes of stopping the pain has gone completely. If the anterior compartment is affected, the foot may ‘slap’ excessively when running. This is because the purpose of the anterior compartment muscles are to control ankle movement as the runner lowers the forefoot to the ground after heel strike.


Non-surgical treatment includes changing biomechanics through form modification, change in footwear or orthotics. Avoiding hills or rough surfaces may help as will a reduction of training below the threshold distance of onset of symptoms. Icing and Myofascial release massage techniques can help to release the adhesions between fascia and muscle that may be causing the compartment syndrome.


While immediate improvement can occur complete resolution can take a very long time. In some cases surgical intervention is the only successful treatment.



There are more rare forms of shin pain may mimic some of the more common injuries as described above. Entrapment of the popliteal artery has the same symptoms as compartment syndromes but the onset seems to be more related to intensity of activity rather than duration. Neural entrapments can feel like stress fractures but have less consistent symptoms.


Arterial entrapment will give a lack of pulses at onset which does not occur with chronic exercise induced compartment syndromes. The symptoms of neural entrapment can be reproduced by palpation or percussion of the affected nerve.


Physiotherapy is the best initial treatment however surgery may be required.



The posterioral tibialis muscle is the most common strain in the shin. This muscle acts to control pronation in a similar way that the anterior compartment muscles control ankle motion. The peroneal muscles on the outside of leg, control supination of the foot (roll out), to prevent ankle inversion sprains. Peroneal muscles may also be strained. Pain is usually related to activity and may last for a long time after a run. Pain may occur during other activities of daily living.


Damage may just be normal delayed onset muscle soreness (DOMS) caused by unaccustomed activity or it may be more severe rupture of muscle or tendon. More commonly there was a traumatic event that occurred to cause the injury.


Treatment requires rest and icing for 72 hours. Massage, stretching or heat during this time will make the injury significantly worse. After the 72 hours then a gradual return to activity with massage, stretching and continued icing should see most strains resolve within a week. If the tendon was damaged, or if it was a chronic strain, then a much longer rehab period will be needed.


From these brief descriptions of some of the more common injuries you can see how important correct diagnosis and treatment can affect the outcome and subsequent return to exercise. Incorrect diagnosis can prolong the healing period and can also lead to further injury and increased delay in return to activity.

Steve Manning is the owner and CEO of the intraining Running Centre and works as a podiatrist at the intraining Running Injury Clinic in Milton.

If you have shin soreness and want to get back out and running as soon as possible, visit the intraining Running Injury Clinic. Our podiatry and physiotherapy are all runners and understand how important it is to correctly diagnose and treat your injury to ensure you can return, pain free, to running as quickly as possible.

For bookings, please call us at the intraining Running Injury Clinic on 3367 3088, or book online.


Tools to stay injury free

Emily Donker
Article by: Emily Donker (podiatrist, coach and runner)

Tools and tips to stay injury free

If you’re a runner, chances are you hate being unable to run. Staying injury-free is the best way to maintain consistent training. Getting a regular massage can reduce injury risk, but unfortunately, many runners don’t always have the time to prioritize massage within day to day life.

Thankfully there are some great tools you can use for self-massage which, if used correctly, can reduce the need for a sports massage. Two of the best tools that should be in every runners household are, foam rollers and trigger balls. We have both available at the intraining Running Centre.


When to use a foam roller?

Using a foam roller is great for relieving tension from, and flushing larger muscles – generally longer muscles such as the hamstrings, calves, quadriceps, ITB and through your back. Typically rollers are used on the ground (or against a wall) such that you can move your body and the target muscle across the roller. Foam rollers are available in various sizes and textures (eg. smooth vs bumpy).

Foam rollingHow to use a foam roller?

Using a foam roller is easy to do and can be done in front of the TV without much concentration required. Using your foam roller as ‘resting’ point, gently apply pressure to the area you are targeting by lying on the roller. Use your weight to apply pressure as required. If you need additional support to reduce the pressure, use your hands.


When to use a trigger ball?

ED May18 Trigger Ball

Trigger balls are perfect for releasing muscle knots and tension, particularly in deeper and bulkier muscles. Tight spots within longer muscles, plus the glutes, piriformis, hip flexors, erector spinae (lower back) and muscles around the shoulders all respond well to trigger point therapy.

How to use a trigger ball?

Find a tender spot and keep the pressure on for 30sec – 2min. They’re a great self-release tool, particularly if you travel a lot and are limited for space. Again, trigger balls are available in a range of sizes and textures.

intraining Running Centre has a range of foam rollers and trigger balls on offer. Our staff are all runners and can help guide you in the right direction to determine which tool will be best for your needs.

If you are experiencing pains that feel like they are more than just a niggle, or have an injury that just won’t leave you alone – come see one of our podiatry or physiotherapy team. For bookings, please call us at the intraining Running Injury Clinic on 3367 3088, or book online.

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Science of compression gear

Doug James
Article by: Doug James (podiatrist, physiotherapist and runner)

Science of compression gear

It’s been 20 years since SKINS, the Australian based compression garment company first launched their product range. Since then, SKINS and other brands of compression garments have been worn by athletes from a wide range of sports. Aside from the professional endorsement and anecdotal support of these products – just what scientific support is there to justify their use?

A review of reputable peer reviewed scientific studies released within the past decade shows that compression garments actually offer little to no increase in running performance. So why do people keep wearing them?

Science has been able to prove that Lower Limb Compression Garments (LLCGs) are of most use as a recovery aid. Perceived muscle soreness after endurance running events was less in runners that used LLCGs. Additionally, LLCGs (either calf sleeves or integrated calf sleeve + sock) were found to reduce foot swelling that may be associated with foot pain and numbness during running.

CompressionTightClinically it has been suggested that LLCGs may also offer benefit in reducing muscle vibration that occurs during impact sports such as running, and this in turn could help reduce shin pain and calf muscle injuries.

Remember that recovery is an important part of your training approach. Consider using lower limb compression garments to help maximise your recovery and training.

If you are looking to get that little extra edge on your competition, the intraining Running Centre, Milton and Indooroopilly have a wide range of compression garments from the major brands, including major brands; Skins, 2XU and Compresssport.

Our running experts can help fit you up correctly in the latest compression gear and can also provide recommendations to suit your needs. From calve sleeves and socks, to full length tights and tops we have it all.

If you are experiencing muscle soreness and tightness that needs a little more attention, make an appointment to see our podiatrist and physiotherapist, Doug James. Please call us at the intraining Running Injury Clinic on 3367 3088, or book online.

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When are your shoes too old?

Margot Steve
Article by: Margot Manning (podiatrist, kids coach and runner)

Are your shoes too old?

We are in the middle of the running season and most runner’s shoes will be close to the end of their life. While most injuries occur because of training mistakes it can be easy to neglect the ‘aging’ of your running shoes leading to a usually avoidable injury.

The most common reason for a running shoe causing an injury is because they are too old or the cushioning has compressed from the months of training. This aging process can be difficult to recognise in a shoe because there are usually minimal physical signs of age.

However, there are a few things you should learn to recognise so that you avoid injury and enjoying your running.

The 4 early signs of an aged shoe

  1. Delayed muscle recovery: Do you get excessively sore muscles, bones, ligaments following a run?
  2. Niggles: Are you starting to notice minor injuries that make running uncomfortable?
  3. ‘Hot’ spots: Do your feet feel like they are burning?
  4. Excessive wear on the outsole rubber: Have you worn through the rubber on the sole to the midsole (ie: the soft white part of the shoe)?

ShoeDonationTake the time to update your running shoes. Don’t leave it too late to change your shoes and risk getting an injury. As a general rule of thumb, the lifespan of a running shoe is approximately 600km. Remember, incidental walking around contributes to your running shoes life.

Runners tip: Use your running shoes only for running. Save your old shoes for shopping, walking around, catching up with friends and all the other incidentals. You will find that the lifespan of your shoes will increase – plus it is easier to keep track of distance covered.

If you are unsure if your shoes are on their way out, visit the intraining Running Centre and our footwear specialists will help determine if it is time for a new pair.

If you have been unhappy with your current shoes, book in to see one of our running podiatrists for a more thorough analysis of your biomechanics, running style and training. Don’t let your shoe be the cause of an injury.

Call us at the intraining Running Injury Clinic on 3367 3088, or book online.

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FREE running magazine

The April edition of intraining’s Love2Run Magazine is now available online for download. View and download all magazines online here.

Get your running fix running season with running injury articles, product reviews, ways to keep fit as well as the upcoming Queensland fun run calendar.

Get your FREE running magazine here

Love2RunApril2018This edition includes:

  • How to start running for beginner runners
  • Knee pain – Know when to stop
  • How lightweight shoes can make you faster
  • Coaching kids from tiny to primary
  • Kids and running injuries
  • Healthy Winter recipe for the runner
  • Find out how to look good this running season

To complement our quarterly edition of the intraining Love2Run magazine, we invite you to join our monthly Love2Run e-newsletter, so you can stay up to date with everything running. Click here to join the list.


Heel pain and kids

Don’t let heel pain stop your kids from running

with Margot Manning, Podiatrist, running coach, and a mum.  

Heel pain in children, often called Sever’s Disease, is one of the most common injuries experienced in active kids today. Heel pain usually occurs because of the repetitive loading with active play.   The vertical attachment of the achilles tendon to the back of the heel bone (calcaneus) is right where there is a large bone growth plate.

The growth plate is the area where new bone cells are generated and is present until between the ages of 13-16 when children stop growing, and the bone fuses, to make the completed heel bone. During this time, running, jumping, kicking and rapid changes in direction that children do while playing sport exert an incredible amount of sheer force and pulling onto the growth plate. This pulling can create soreness which can be quite debilitating for children and interfere with their ability to play without pain.   Being aware of this process enables you to take a few steps to minimise the chance of your child developing heel pain.

Early detection of heel pain and being proactive can reduce the severity of heel pain and help your kids get back to being kids and enjoying being active. Below are three of the most successful management strategies for treating heel pain in kids.

HeelPain4 Tips to manage and minimise the onset or severity of Sever’s Disease:

  1. Fit their shoes properly – Get the right size
  2. Teach your kids HOW to put their shoes for play
  3. Match the right shoe for their feet needs
  4. Change their shoes regularly

Get the right size…  Make sure their shoes fit properly   2. Teach your kids HOW to make their shoes fit to play, 3.  Match the right shoe for their feet needs  4.  Change their shoes regularly

If heel pain catches you out, don’t worry come and see us to creating a management plan to help both you and your child know what to do before and after playing sport.

Have you noticed any of the following with your child?

  • Limping when walking or when active
  • Favouring one leg over the other
  • Adversity to activity due to pain in the heel
  • Complaints or comments about soreness in the heel

Kids training groups

If you are unsure whether your child has Sever’s Disease, or have noticed any of the above symptoms it is time to take action. Don’t let your kids suffer in pain any more. Our team of podiatrists and physiotherapist at the intraining Running Injury Clinic can help diagnose, assess and provide management strategies to help your child return to activity – pain free.

Make an appointment to see one of our podiatry team today. Often there is minimal out of pocket expense with private health cover claimable on the spot. We recommend you bring all your child’s shoes with you to the appointment so these can each be assessed and possibly modified to help relieve pain.

To make a booking call intraining Running Injury Clinic on 07 3367 3088 or click the button below to make an appointment online.

Margot image
 Article by Margot Manning (podiatrist, kids coach and runner)


Did I buy the right shoes?

Top 5 signs you have the wrong running shoes

Starting a new year with new running shoes is a good idea. Running in the wrong shoes, however, is a bad idea. With online shopping we now have access to more shoe brands and models than ever before, and it can be difficult to know which shoe will suit your foot and running needs, particularly without the benefit of being able to try the shoe on before purchase.

Top 5 signs you have the wrong shoes

  1. Burning, tingling or numbness in your foot or toes
  2. Pain in your heel or Achilles tendon
  3. Cramping in your arch or calf muscles
  4. Soreness on the inside of your ankles or knees
  5. The shoes make excessive slapping noise when running
Doug James 300x407 1

Article written by: Doug James (podiatrist, physiotherapist and runner)

It may be tempting to save a few dollars buying shoes online, however buying the wrong running shoes may result in wasting hundreds of dollars and worse still – injury! It pays to have your running shoes fitted at a FromtheSole Wrongshoesreputable running store and by knowledgeable staff who take the time to fit you up based on your needs. Trying the shoes on before you purchase them as well as receiving advice from trained experts will help you rest easy and know your next run will be an enjoyable one.

In some cases it may also be worth consulting with a podiatrist to get specialist advice on the best shoe, particularly if you’ve been having problems with injury. At intraining Running Injury Clinic, our podiatry and physiotherapy team have extensive knowledge in footwear and can provide qualified advice to ensure your running shoes are exactly what you need.

At intraining, we are all runners and understand just how important it is to have the right tools for the trade (so to speak), which will help keep you injury free and running at your best.

If you are experiencing any of the symptoms above, or would like to book a footwear fitting appointment with Doug or one of our podiatry team, please call us at the intraining Running Injury Clinic on 3367 3088, or book online.

Runner heel pain

Emily Donker (podiatrist, coach and runner)
Emily Donker (podiatrist, coach and runner)

Runner heel pain

Injuries aren’t always caused by running, even if that’s when you feel the most pain. Your everyday lifestyle and footwear (or lack thereof) contributes significantly to injury risk. Unfortunately, many people (both runners and non-runners) develop heel pain during their down time, particularly during the hot summer months when wearing thongs and being barefoot becomes almost second nature for many Australians.

Footwear choice and injury risk

When barefoot or wearing unsupportive footwear (including thongs, slides, ballet flats and many other casual shoes), the soft tissue structures within your feet and lower limbs work much harder to maintain good foot position and dampen impact forces, because there is no help from footwear.

Think about a typical day. How much time you spend wearing your running shoes or supportive shoes vs unsupportive shoes or barefoot? Balancing this to suit your foot type and strength is important in managing and preventing injuries, particularly heel pain.

Oofos thong
A better option for a thong – Oofos. Made for runners.

Many injuries cause heel pain, with Plantar Fasciopathy, Achilles injuries and fat pad injuries being the most prevalent. Each of these injuries affects a different region of the heel, so can usually be differentiated by determining the primary source of pain.

Which heel injury is holding you back?

What is Plantar Fasciitis?

ED_Image3_Plantar FasciopathyPlantar Fasciitis is one of the most common complaints addressed by podiatrists among both runners and everyday individuals. Fasciitis refers to an acute presentation, whereas Fasciosis refers to more chronic pain. Pain is typically localised to the medial plantar heel (inside of the heel) at the insertion of the plantar fascia, and sometimes also extends through the medial (inside) arch of the foot. Although the plantar fascia is a soft tissue structure, it’s very inflexible and is responsible for containing the muscles of the foot, maintaining arch integrity and stabilising the foot during both stance and gait. The plantar fascia can quite easily become strained and overworked if your footwear is offering insufficient support, because the plantar fascia is working much harder to maintain it’s function.

Plantar Fasciitis and Fasciosis respond very positively to wearing supportive footwear. Your shoes should offer a more structured arch contour and more rigidity through the midfoot. They don’t need to be over-controlling, but more rigidity will help to prevent excessive arch collapse and movement through the midfoot. Arch contour can also be beneficial for providing more proprioceptive feedback (sensitivity to foot position). Supportive thongs and enclosed shoes with an arch contouring insole are more ideal options, whilst sometimes the addition of a specific orthotic or more supportive insole will be necessary for more support.

ED_Image4_AchillesPosterior heel pain (Achilles injury)

Posterior heel pain (back of the heel) is most commonly caused by Achilles Tendinopathy and related injuries such as Achilles Bursitis. Tendinopathy is a generalised term encompassing both acute (tendonitis) and chronic (tendinosis) pain. Pain may affect the mid-potion of the tendon and/or the tendon insertion lower on the back of the heel bone. Symptoms, including the type of pain and palpable feel of the tendon, vary between these injury presentations.

The Achilles is a common tendon for the calf muscles, and is responsible for pointing the toes and pushing off the ground during walking and running gait. Compared to wearing high heels or conventional running shoes (10-12mm heel pitch), being barefoot or in flat shoes places significantly more stretch and strain on the calf muscles. There is subsequently also more strain through the Achilles tendon. Injury occurs when loading and strain is greater that what the tendon can withstand, either from inappropriate footwear choices, excessive running, or a combination of both factors.

Footwear’s role in Achilles injuries?

Tightshoes_TinglingtoesFootwear again plays a significant role in resolving Achilles injuries. Structure and support are important, but targeting shoes with a higher heel pitch (difference in height/cushioning under the foot between the heel and forefoot) is most important. Increased heel pitch will reduce strain and stretch on the calves and Achilles, and promote active recovery during every day walking and standing without excessive load. Sometimes the opposite approach can be employed.

Wearing shoes with lower heel pitch is suggested to help by passively stretching the calves and Achilles to developing strength. However, with this approach most people are more likely to suffer in the short term due to overload and increased strain. It depends how your body responds. The most suitable approach will be dependent on your specific symptoms and injury presentation.

Plantar heel pain (fat pad injuries)

Injury of the fat padPlantar heel pain (underneath the central heel) can be caused by a number of injuries, with most being related to the calcaneal (heel) Fat Pad. The fat pad is designed to dampen impact forces and work as the body’s self-defence cushioning system. Fat Pad injury causes structural damage and jeopardises function, meaning that the heel bone is subjected to much larger impact forces in stance and during gait. Contusion (partial damage) or complete rupture may occur, with the later typically resulting from a sudden traumatic event such as landing very heavily (usually from a significant height) on a hard surface. Excessive load on the fat pad from long periods of standing or repetitive landings on an unforgiving surface can lead to contusion, particularly if footwear is not providing additional protection.

Fat pad injuries respond best to plenty of cushioning underneath the foot, so again barefoot and unsupportive footwear should be avoided. Your shoes are required to work for the fat pad and prevent excessive force to the heel. Having a structured heel counter can also be beneficial in helping to contain the fat pad soft tissue underneath the heel.

IRIC17_RehabLogoV2So how do you avoid runner heel pain?

Whilst the presentation and treatment required for each of these injuries is different, wearing more sensible and supportive footwear is an essential part of the treatment plan. Being barefoot or wearing unsupportive shoes can be a primary contributor to injury in each case, so whether you’re trying to prevent injury or resolve heel pain, think about your footwear choices and make changes to ensure you are comfortable in your running shoes and your everyday shoes.

If you need assistance to overcome your heel pain, or would like footwear advice, click the button below to book an appointment with a podiatrist at intraining Running Injury Clinic.

Make appointment

School shoes vs running shoes?

Article by Emily Donker. Podiatrist, coach and triathlete
Article by Emily Donker.
Podiatrist, coach and triathlete

School shoes vs running shoes. They are different!

There are a few things that you just shouldn’t do (for various reasons – not explored in this article), such as:
–    Eat soup with a fork
–    Go 4WD and beach driving in a beetle
–    Use a time trial bike for mountain biking
–    Swim whilst fully clothed
–    Go for a run in business shoes

… and you also should not send your children to school in running shoes, or out for a run wearing school shoes.


Just as it does for adults, footwear plays a significant role in preventing and managing children’s injuries. Wearing shoes that are appropriate for the task at hand will reduce injury risk, ensure better comfort and prolong shoe life.

BacktoschoolWearing the same pair of shoes day in and day out can cause significant and excessive wear, and inappropriate wear patterns to develop – especially when young, active children are the culprits. Children’s shoes are renowned for taking a beating in the schoolyard, and running shoes in particular are not designed to withstand the rigours of lunch-time play. Scuffing to the outsole and midsole can easily result from rough games and change of direction, whilst the lightweight, breathable upper is also easily damaged and does not provide sufficient support. Specific ‘school’ shoes will offer a more sturdy and hard-wearing outsole, and ideally a leather upper.

Wearing shoes that are excessively worn, or that are not designed specifically for running can increase the risk of injury. So, if your child is running regularly, they should be treated to a pair of running shoes, which are to be used only for running. These will be lightweight, more breathable and more flexible than their school shoes and therefore encourage a more comfortable and natural running stride.

You should encourage your child to stay active, and ensure they remain healthy and injury-free by wearing suitable shoes, by having specific shoes that are used exclusively for their various different activities.

Want to your kids to stay injury free? Visit the intraining Running Centre for expert advice and get your children fitted correctly.

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Sore ball of foot?

Margot Manning
Article by: Margot Manning podiatrist and running coach

Sore ball of your foot?

It could be a plantar plate tear

What is plantar plate tear?

Plantar plate tears occur when there is trauma from over-extension or bending of the joint. Swelling in the ball of foot is a common sign you may have a plantar plate tear. Common incidents that we see contribute to plantar plate tears are:

  • Slipping on loose rocks whilst trail running
  • Climbing stairs
  • Running steep hill repetitions
  • Repetitive burpies
  • Skipping

Tinglingtoes2Each of these activities can hyper-extend the forefoot and can lead to plantar plate tear. Whilst not the sole cause, bio-mechanical issues are often a contributing factor to plantar plate tears, usually as a result of:

  • Instability of the foot
  • Excess force placed at the ball of the foot during toe of

How to diagnose a plantar plate tear?

Diagnosis for plantar plate tears is best seen on MRI. The MRI will determine the presence of the tear and can help differentiate this injury with those listed above and any other possible diagnoses.

PlantarPlatetearHow to treat a plantar plate tear

Treatment for plantar plate tears needs to be done with a podiatrist initially to offload the injured plate and to correct bio-mechanical issues. Runners need to stay off hills until there is no pain. If there is no resolution, the next step is surgical repair.

If you have swelling in the ball of your foot and feel you may have a plantar plate tear, we recommend making an appointment to see one of the podiatrists at the intraining Running Injury Clinic. The sooner you are able to receive a correct diagnosis and treatment the sooner you will be back running pain free.

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Why do my toes tingle?

Margot Manning
Article by: Margot Manning podiatrist and running coach

Why do my toes tingle?

5 causes of tingling in the toes

Tingling toes are a common sensation experienced by some when running as well when wearing day to day shoes. The main reason for tingling to occur is from pressure on a nerve.  Running can cause continual pressure on nerves from long term repetitive motion and the resultant swelling of feet. Tingling occurs if either shoes are too small, or there is an underlying injury. Don’t think it is your shoes – what do you need to look out for?

Five common tingling toes injuries

  1. Neuritis: Inflammation of the nerves that run between the


    bones at the ball of the feet. This is usually resolved by changing footwear and lacing.

  2. Neuroma: Thickening of the nerve at the ball of the foot where it fills up the available space and hurts even when not active. Both footwear, podiatry and sometimes surgery are necessary depending on the progression of the symptoms.
  3. Bursitis: Fluid filled sacs become enlarged due to pressure between the heads of the metatarsals (long bone of the feet). These fill the space between the bones and put added pressure on the nerves. Footwear, podiatry and if no resolution, a visit to a sports doctor for cortisone injections may be needed.
  4. Synovitis or joint capsulitis: Inflammation of the fluid within the toe joint, usually from trauma (e.g. landing badly on a rock) or when the head of the metatarsals are driven into the ground. The latter is a biomechanical problem that needs to be addressed with podiatry care. Like bursitis, the increase in size of the joint can put pressure on the adjacent nerve creating tingling as a secondary symptom.
  5. Plantar plate tear: The plantar plate is a strong fibrous structure that sits beneath each of the joints at the ball of the foot. Its role is to withstand the high loads at these joints and to create stability. If the toes are over extended repetitively or with excessive force (e.g. running up hills), thickening or a small tear can develop in the plantar plate. Over time, the affected toe can drift apart from its adjacent toe, and develop both synovitis and a claw toe. These changes to the joint integrity can lead to subtle tingling of the toes.

Tightshoes_TinglingtoesOf the five injuries, plantar plate tears are the least common, but the most misdiagnosed. This is because there can be a combination of symptoms from the other four injuries above.  This can lead to unsuccessful treatment plans and ongoing frustration for the runner.

Don’t ignore tingling toes. Whilst it is often a footwear isolated issue that can be relieved by; wearing thinner socks, specific lacing techniques or changing the shoe itself. If your tingling toes are not relieved by these adjustments there may be an underlying injury that is the cause. Book in to see one of our podiatrists at intraining Running Injury Clinic for accurate diagnosis and treatment.

Our podiatry team are all runners and understand how frustrating an injury can be. We know you want to get back out and run injury free as quickly as possible.

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