THE CLINIC

Unraveling SI Joint and Hamstring Trouble

I am 35 years old, weigh 128 lbs, and am 5'5" tall. I started running in November 2012, but really started running consistently in the spring of 2013. At that time, I was running three times a week and never more than four miles at a time. Prior to taking up running, I did one-hour aerobic classes and spinning regularly three to four times per week.

I pulled my hamstring when I tried out a CrossFit class but continued running for over a month before seeking help because I thought the pain would go away. Physical therapy focused on strengthening and stretching, and reintroducing me back to running. When I started running again, I reinjured my hamstring and it was then determined that I also have a left anterior pelvic tilt. PT then also focused on hip, core and glute exercises.

I fell during PT and had significant pain for a few days in my left glute which hindered me from doing lunges for about a week. I also had pain in my left hip and left SI joint. I have tried stretches for my SI joint and took a break from running for over three months. I began doing spinning classes again pain-free, but it’s hard to tell at this point what is causing what pain.

Heat helps my SI joint pain. Laying on my left side seems to aggravate it, as well as sitting sometimes. I have no pain in my back or hamstring while running, but all tingling sensations and pain occur afterward and stay with me. I also now experience this randomly sometimes. The pain and tingling comes and goes, but after running seems to linger longer.

Janice Bellifiore
Eastchester, NY

The pelvis is a tough area when injuries occur. The SI joints connect the lower back (sacrum) and pelvis posteriorly. In the front, the pelvic bones meet in the pubic region (symphysis pubis). The sockets of the hip joints are part of the pelvis. Numerous muscles attach to the pelvis—trunk muscles and muscles that originate on the pelvis and act on the legs and the gluteal muscles.

When you strained your hamstrings but continued running, you most likely altered your running gait; this will often cause you to shorten your stride on the affected side, which can impact other muscles and joints in the pelvis. The fact that you re-injured your hamstrings when you returned to running leads me to question whether there was a persistent strength deficit and/or gait abnormality. The pelvic tilt suggests muscle imbalance. The PT focused on the appropriate muscle groups. 

The fall threw a major monkey wrench into your recovery. Not knowing how you fell and landed, it's impossible to say exactly what was injured in the fall. Your SI joints certainly could be inflamed due to the hamstring injury; a fall could aggravate this issue. It is also possible that there is an occult fracture of the sacrum or pelvis that is causing your pain. The tingling that you are experiencing is most likely due to irritation of the sciatic nerve as it passes through the buttocks. Activities and sitting will irritate the nerve, causing symptoms you describe in the leg. 

At this point, you need a thorough evaluation of your back and hips. Further evaluation with x-rays and possibly an MRI or ultrasound may be indicated. Alignment, strength and flexibility must be assessed and deficits corrected.  Treatment may include rehabilitation exercises, manipulation and possible treatment injections. Any injuries to the pelvic joints and muscles can be difficult to treat, with a slow recovery. Once you have recovered from this problem, a gait analysis may help correct any biomechanical issues that may be impacting your running. 

Be patient. Hopefully the physician can identify the issue(s) causing your symptoms and an appropriate treatment plan can be initiated. Good luck!

Cathy Fieseler, MD
Tyler, TX

Tibia Stress That Just Wonít Heal

I’m a 40-year-old female with a six-year competitive racing history, plus bike races and triathlons. I weight train weekly as well. Within three years, I have had four stress fractures in the right tibia. I’ve been to an orthopedic surgeon, a podiatrist, a physical therapist, a sports medicine doctor and two chiropractors. I have tried the following solutions: I run on a rubberized track once a week; I run on a treadmill once a week; I run on trails once a week; I take Fosomax, isoflavones and hydro-calcium supplements; I have had orthotics; I wear arch supports; after no impact exercise for six weeks, I had pain immediately while trying to run on grass. Two bone scans revealed some bone thinning, but in my back only. I weigh 110 pounds. I’m running out of ideas.

Karen West
Fort Lee, NJ

If you are a highly competitive athlete with the kind of heavy training schedule you indicate, I would ask if you have irregular menstrual cycles, and whether this has been evaluated. Menstrual irregularity affects progesterone/estrogen cycles, which can have a significant and direct impact on your bone mass.
You might want to see an endocrinologist for a work up. I am a board-certified orthopedic surgeon with
a sub-specialty in foot and ankle. I have also been running for about 35 years. My experience has been that when you run into this problem there is something else going on that may be endocrine related. You are doing everything right: seeing a number of physicians, trying to crosstrain and running on easier surfaces. You have already addressed the biomechanical possibilities with orthotics, arch supports and altered training. Your underlying problem may be metabolic.

Raymond F. Lower, DO
Leesburg, VA

I also feel you may have a metabolic bone abnormality. I had another patient like this who ended up having an endocrine problem that is being treated successfully. I suggest seeing an endocrinologist interested in metabolic bone diseases. You may need one of several metabolic tests to see how your body is processing bone matrix information. Also, you will need a pituitary and thyroid work up. Usually, a university center near you will have this type of work up. There is an old adage in medicine, “Diagnosis precedes treatment.” I’m not sure you’ve had a complete diagnosis yet.

Robert C. Erickson, MD
Canton, OH

Pain After Only 10 Minutes of Walking

I’m a runner who had been using weights three days a week to strengthen my chest, back, shoulders and arms until three months ago, when I started experiencing sciatica-like symptoms down my left leg, with no direct pain in the back. The pain was severe enough to cease both my running and my weight training. I began to make good progress with regular back stretching exercises, acupuncture, muscle relaxants, anti-inflammatories and chiropractic adjustments. I see a sports medicine doctor who oversees these treatments. I am a 160-pound, 58-year-old male who usually averages 15 miles a week at 9 or 10 minute pace.

I had reduced my pain considerably in the mornings, with no pain for the rest of the day. I gradually started walking, then walking and running, then running for three miles. I was down to just the anti-inflammatory drug and regular stretching when I had a major setback a month ago, while I was out of town. I was unable to even stand from the terrible pain down my leg. I ran the day before this occurred without any problem. I am back on acupuncture, avoiding the chiropractic, and making progress, though the numbness on the bottom of my left foot continues. I am only taking an anti-inflammatory. I walk as much as I can, which is only for about 10 minutes. How should I go about starting my weight training and running once the nerve heals?

Kevin Spencer
Irvine, CA

I think your spine is a likely source for your symptoms. Even without back pain, sciatica usually arises from the spinal nerve roots. Some practitioners diagnose piriformis syndrome as a sciatica source when back pain is absent. This is a deep muscle in the buttock that lies over or around the sciatic nerve. The notion is that the nerve gets compressed by this muscle when it is tight, spasmed or externally compressed, such as by a wallet. These scenarios are medically possible, but in reality probably very rare. The problem, if it is truly nerve related, is almost always the spine.

A combination of degenerative disc bulging and bony joint enlargement compresses an existing spinal nerve root, usually the lowest lumbar or the first sacral nerve. The majority of sciatica resolves. But your case is unique in that you are 58, you want to get back to running and you may not be getting better. I recommend an MRI study of your lumbar spine; recommendations for activity will be in part based on the results. This can also help the chiropractor determine how best to apply his/her skills.

The initial rehab sounds like it was appropriate. You will have to start from scratch again. When symptoms return like this, you need to see your doctor and work up the problem for a more definitive diagnosis. Generally speaking, return-to-running programs involve starting at a pain-free level and only increasing mileage by 10 percent per week.

Rob Scott, MD
San Diego, CA

Donít Shirk Stretching for a Fractured Calf

I broke my fibula three months ago, and was wondering what I may need to know as I slowly return to running. I am 60 years old and have been running for about two decades.

Gordy Scoseria
Mt. Desert Island, ME

After a trauma such as a break, the time you spend immobilized helps the bone heal, but weakens the ligaments and tendons. The break may be fully healed but it will take some time for the tendons and ligaments to regain their elasticity and strength. I’m assuming your injury has fully healed and your doctor has advised you to begin exercising again.

To increase both range of motion and lateral stability of your ankle, trace the alphabet in the air with your foot. Try both upper case and lower case letters. After several weeks, gradually work the turns back into your workouts.

Establish pain-free walking, before adding running intervals. Gradually increase the time spent running and decrease the walk breaks. Once you are able to run continuously, begin your progression gradually by choosing to increase the intensity or volume of your workouts, not both. Also, do 95% of your training on a smooth, level surface (like a track or a treadmill), running only on the straightaways. Lateral stability is the last to recover, so taking the turns should wait.

Give ample attention to stretching, especially the lower legs. Tightness in those muscles and tendons can put added stress on the bone. Always include rest and recovery between workouts to avoid overuse injury as you return to your previous level of running. Make use of crosstraining modalities like cycling and swimming to help strengthen muscles without leading to re-injury or new overuse injuries. Deep water workouts can also help you maintain fitness and strength without impact.

Greg Tymon, MS 
East Stroudsburg, PA

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