Six Signs That Your Running Injury Is Nerve Pain

Stay the CourseOne challenge I come across as a practicing physiotherapist is the vast number of possible sources of pain and dysfunction. A foot may be a foot, but often–because the foot is connected to the lower leg, knee, and hip–a foot problem may arise from a hip issue. Moreover, because the nerve that supplies the foot runs the entire length of the body, literally from head to toe, foot pain may come from the spine! Indeed, a full 10 to 20% of runners with foot pain have an issue stemming from a nerve.

Nerve pain is far more common than we, as runners or medical professionals, realize. While it’s more common to overuse or strain a muscle or tendon, or if we fall, possibly break a bone, irritating a nerve is not only possible but perhaps even commonplace amongst trail and ultramarathon runners. This may be because of the extreme demands we place on our bodies and also because of our propensity for falling. Falling might bruise a muscle or bone, but it can also irritate a nerve.

This article outlines the signs and symptoms of nerve pain: how and why it happens, and how we can go about properly treating it.

What is Nerve Pain?

Nerve pain, or neurogenic (of nerve origin) pain, can arise any time a nerve is sensitized. Under normal circumstances, a nerve is quite robust and asymptomatic when exposed to mild to moderate pressure and/or stretch. However, once a nerve is irritated, it can be very sensitive to any compression, stretch, or chemical changes (even our own, internal stress hormones). This often results in neurogenic pain.

There are generally two types of nerve sensitization, mechanical and chemical sensitization:

Mechanical Sensitization 

This occurs any time the normal motion and position of the nerve is restricted. While this could be a severe pinch (say, from a vertebral disc), the vast majority of mechanical restrictions are far more subtle and related to stiffness of surrounding muscles, tendons, joints, and fascial (connective) tissues.

Moreover, mechanical stress may involve overstretching a nerve. In general, nerves are very sensitive and resistant to stretching (and under normal circumstances, have enough length so they, themselves, don’t need to actually stretch). Thus, any force (whether accidental or intentional) that overstretches a muscle, tendon, or joint might also overstretch–or even strain–a nerve!

Chemical Sensitization 

This occurs from some sort of inflammatory chemicals that come in contact with a nerve, possibly from an injury adjacent to a nerve (like a strained muscle or broken bone).

Where and Why Nerve Pain Occurs

There are two other important things to note about neurogenic pain.

First, the nerve can create pain anywhere along its length. It may surprise even the educated runner to know that a sensory nerve unit in the foot has but three parts: the peripheral nerve (which in a tall male could be four feet long), a tiny interneuron in the spinal cord, and the upper nerve (which runs the length of the spinal column and into the brain). As such, any sensitivity anywhere along that sensory (or motor) unit can cause pain anywhere above or below that nerve! It may be mind blowing to consider that a stiff neck could be causing your foot pain, but it is both possible and far more common than anyone (including the sports-medicine professional) may realize.

Second, nerve sensitivity is cumulative. Because a nerve runs the length of the body, there are countless areas where the nerve might come under irritation. A good analogy for this is a garden hose: a single small crimp in the hose may result in no perceptible difference in flow. But two or three crimps anywhere along the length of the hose often results in major interruption. The nerve functions in the same way: sensitivities anywhere along its length–at the neck, mid-back, low back, or pelvis–can cause a mild compression at the foot and ankle to result in severe pain.

Signs That Your Running Injury is Nerve Pain

Here are six signs that your running injury is actually nerve pain:

1. Your Pain Fails to Respond to Conventional Treatment.

If conventional sports medicine treats injuries to muscles, ligaments and tendons, and bone, then conventional treatment often includes RICE: Rest, Ice, Compression, Elevation. This is the standard treatment for acute injuries; however, it (at least the RI) is often used for chronic injury as well. Resting and icing chronic plantar-foot and Achilles pain continues to be prudent and useful for prolonged, subacute issues.

Sports physical-therapy treatment for orthopedic injuries also includes stretching and strengthening. For healing soft tissues, this stress-and-rest cycle, when patiently and progressively applied, nearly always results in progressive improvements–if the injury in quest is muscle, tendon, or bone!

However, if your pain is neurogenic, then conventional treatment rarely, if ever, is effective, for two reasons:

  1. There is no soft-tissue injury (to rest, ice, stretch, and strengthen).
  2. The sensitive nerve needs very specific (and often very gentle) treatment.

Not only that, but conventional orthopedic treatment–namely aggressive stretching, massage, icing, and compression–could make nerve pain worse by overstretching, compressing, or otherwise irritating an already sensitive nerve.  

Lastly, rest alone seldom improves nerve pain. The reason is simple: if there is a mechanical restriction of the nerve (either in the painful area or anywhere along its length), passive rest will not free the restriction and restore motion. Pain may subside with rest, but nearly always returns with the resumption of running or other activity.

2. Your Pain Includes a Dull Ache, Pins and Needles, Tingling, or Numbness.

Orthopedic pain is nearly always tied to activity, and symptoms will be experienced during activity (such as running, hiking, walking, or standing), and the symptoms are fairly consistent, ranging from tightness and stiffness, to a dull ache or sharp, stabbing pain.

Conversely, nerve pain–which can replicate those aches and stabs–often includes other abnormal symptoms. Pins and needles, tingling, and numbness are classic neurogenic symptoms, and seldom (if ever) arise from an orthopedic injury. That said, nerves can also replicate dull-ache, tight, or stabbing symptoms. What differentiates a painful nerve from the muscle and tendon is outlined below.

3. Your Pain is Extremely Variable and Disproportionate to Activity Level.

Another sign of neurogenic pain is inconsistency in pain behavior. Soft tissue pain–both acute and chronic–has a predictable pattern:

  • Stiff and sore with initial activity (first thing in the morning, after prolonged rest)
  • Generally warms up with small amounts of activity
  • At some point, will worsen with too much activity 

This is the classic pattern for muscle and tendon pain, such as Achilles or plantar-fascial irritation.

However, nerve pain can be maddeningly variable and difficult to predict: a 30-minute jog may feel fine one day, then another day, the same jog (route, pace) may result in a major flareup. Or, aggressive (but variable activity) such as a technical trail run (or a multi-directional running sport, such as ultimate frisbee) may feel okay, but a half-hour flat walk could be quite painful.

Additionally, another hallmark of nerve pain is variable location. Whereas something like plantar fasciitis has extremely focal symptoms (often at the base of the heel, near the anterior/medial aspect), nerve pain can wildly vary in location, often hopping around from one end or side of a bone or joint to the other. This is likely due to the nerve referring symptoms to the various locations of its innervation.

4. It is Difficult (or not Possible) to ‘Feel’ Your Pain.

Another hallmark of most orthopedic injuries is the ability to palpate (touch, massage, or otherwise locate) the precise area of sensitive tissue. Again, with classic Achilles and plantar-foot pain, there is nearly always a precise area of sensitivity: the location of strained, sensitive, and healing tissue that, when touched, often results in significant pain replication, sensitivity, or, when hotly acute, might send you jumping!

Nerve pain is often elusive. Regardless of how sharp, stabbing, or severe its intensity, many runners may be unable to find the precise area of injury or irritation. They themselves may poke or massage the area, or even get soft-tissue mobilization from a physio or massage therapist, but no one is able to actually pinpoint the sensitive area. This is likely because the pain in question is being referred to the area, from a sensitive area farther away. For nerve pain, this could be anywhere along the length of that nerve: farther up the leg, or in the hip, pelvis, back, or even in the neck.

5. You Have Pain at Rest.

If there is one hallmark sign of neurogenic pain, it is pain at rest. Unless extremely acute, orthopedic injury will not be painful at rest: namely sitting or lying down. Indeed, only if a runner has incurred a severe hamstring strain (resulting in swelling and bruising–which is rare) will they experience pain with sitting.

Conversely, a sensitive nerve often refers pain at rest. Why this occurs is variable (and not completely known); suffice to say that when a nerve is sensitized, several factors can create pain at rest, including:

  • Compression stress (in sitting, on the sciatic or obturator nerves)
  • Postural stress (usually sitting, but any position, due to nerve stress related to spinal position)
  • Restorative healing (as nerves will often try to heal themselves at times of rest)

Symptoms at rest is major red flag for nerve pain and should be considered a strong sign that your running pain is not a simple orthopedic injury.

6. Diagnostic Imaging Fails to Find Any Pathology.

When an injury fails to improve, most runners (and their sports-medicine professionals) will seek out diagnostic imaging in order to help identify the source of the injury and (ideally) why it fails to improve. So it can be a crushing blow to both runner and doctor when that imaging–often an MRI–fails to find any pathology at all. Especially in the case of severe, unremitting pain, how can that be?

Nerve sensitivity very often fails to show anything on diagnostic imaging because:

  • A sensitized nerve will not demonstrate any visual abnormality. Sometimes, mild swelling may occur around the sensitive nerve, but so long as the nerve is intact (not severed), no abnormality will be seen and the painful area often looks perfectly normal.
  • Pain may be referred from far away, out of the view of the imaging. An impinged nerve in the low back may not even appear in a lumbar scan, and certainly won’t appear in imaging studies of a foot and ankle, yet the low back is a common location of nerve sensitivity for the foot nerves.

So unless there is a blatant source of nerve impingement (where a tendon or other tissue may be seen, compressing a nerve), diagnostic imaging will fail to find the source.

More scary, therefore, is the prevalence of ‘false positives.’ These occur when a runner is experiencing neurogenic pain (either locally or peripherally from a sensitized nerve), but the imagining shows “mild arthritis,” “degenerative changes,” or other rather mild tissue wear and tear, which is falsely interpreted as the source of the pain. This often leads runners and doctors alike to rush into surgery to repair or clean up the area. Unfortunately, not only do these procedures fail to improve the symptoms, but they can often worsen them by creating additional scar tissue, mobility loss, or general post-operative sensitivity.

Common Running Pains and Possible Nerve Sources

Here is a short (but hardly exhaustive) list of common running-injury areas and the possible origin of neurogenic pain:

Injury/AreaPossible Nerve Involvement
Posterior pelvis, hip (butt)Cluneal, sciatic, obturator nerves
Anterior and lateral hip and thighCluneal, sciatic, lateral femoral cutaneous nerves
Medial thigh and kneeFemoral, obturator nerve
Lateral shinSuperficial fibular nerve
Medial shinTibial nerve
Lateral ankleSural nerve
Medial ankleTibial nerve
Plantar footMedial and lateral plantar nerves
Dorsal (top of the) foot and toesSuperficial, deep fibular nerves

How to Treat a Nerve-Pain Issue

This can be complicated–and is best left to highly trained professionals–but it is possible to treat a sensitive nerve. And when done carefully and skillfully, neurogenic pain can often improve rapidly. Some recommendations:

Think Like a Plumber (or Electrician).

While this somehow is baffling to an orthopedic professional, it is common sense a plumber: you must address the full length of the ‘cord’ (or pipe). Normal, healthy ‘flow’ requires the entire length of the nerve be free and clear from restriction or stress. This may include treatment of the spine (or even cranium) to get full resolution of pain.

Be Patient.

Sensitive nerves even when freed may still be sensitive. Once a nerve is even mildly irritated, it can take a very long time for that irritation to heal. Some texts believe that it could take a week per centimeter of nerve length for a severe nerve injury to heal (which is often why severe nerve compression from neck and back injuries can take a year to fully heal).

For severe nerve pain, be very patient in return to activity. The goal should not necessarily be a full abolishment of pain, rather a progressive decrease in frequency, intensity, and duration of symptoms.

Be Progressive.

Sensitive nerves heal best with gentle, frequent mobility and lots of blood flow. It is said that the nervous system is only 20% of the body’s mass, yet it ‘consumes’ 80% of its blood flow. Thus, gentle, frequent activity will not only help gently move the nerve, but also supply vital restorative blood flow–both factors that will result in the fastest possible healing.

In conclusion, just because you’re a runner doesn’t mean your injuries will only occur with muscles, tendons, and bones! Be aware of the importance of healthy and mobile nerves, know the possible causes and symptoms of nerve sensitivity, and, if you think you could have nerve pain, seek out comprehensive treatment from a ‘systems professional’–preferably one who thinks like a plumber or electrician!

Call for Comments (from Meghan)

Have you been diagnosed with a nerve injury? If so, what was the diagnosis? And where did you actually feel pain?

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 96 comments

  1. Gav Pierce

    Hello Joe,

    Really a great article and still reading alot of the comments and advise to find the right remedy for my problem.

    About 3 months ago after a moderately paced 10 mile run, I started to get lower back pains, there was no radiation to the limbs. Visits to the Physio seemed to work and I slowly started running again. After about 1 or 2 runs, I got super tight hamstrings and glutes. Hamstrings seemed to get better (with Physio) after a few days but a deep muscle pain was still in my left glute and I felt a strange sensation (like sock is double) in my left heel and outer side of my foot. Chiropractor tested for strength this was good but I was missing a reflex in my heel. He thought that problem arised from my back.
    I have had treatment for my back for the last 2 months from Physio and the Chiropractor but still regular pain in my left glute and then strange sensation in my foot. It doesn’t seen to matter if I train or rest, sitting or standing. 1 day its there constantly, the other day it comes and goes.
    Tried the slump test and no pain shoots.

    Keep up the good work.
    regards

  2. Guy

    Hi Gav,

    My guess is that Joe is going to tell you to think like a plumber : ) I kid!

    I’ve had very similar issues with a deep muscle pain in my glute (kind of a cramping feeling), hamstring irritation, and some weird spasming in my toes on occasion (but not much). This has been going on since August 2018. I’ve tried 30-50 different types of physio exercises, back treatment (2 shots, chiro adjustments – I think we’ve all ruled out the back). Also tried shost in my piriformis and SI joint. 3 MRIs on my back, pelvis and knee – showed nothing.

    Out of frustration – after doing all these exercises and going to 100 docs/physio appointments, I finally shut it down. Total rest and relaxation – no PT exercises, stretches, cross training. Only when I did this, did I start making (slow, but regular) progress. I started playing a lot of Mario Kart. Now, the pain in my hamstring and weird toe sensation are gone. I still have some deep glute pain, but it seems to be improving as well. Tried to do some walk/jogging this weekend and it felt pretty good.

    Probably not what you want to hear, but it’s the only thing that’s helped me so far. Maybe you could nip yours in the bud quickly with some total rest (and a little Mario Kart).

    1. Joe Uhan

      The both of you guys could have your primary (remaining) dysfunction at the *neck*.

      Runners blow off neck pain more than anything else, because they don’t think it’s relevant to a current leg injury, or directly stops them from running.

      Neck dysfunction can cause pervaisive nerve tension and pain/dysfunction in the leg. Thus, if you haven’t had anyone assess your neck, it would be a worthwhile exploration.

      1. Gav Pierce

        Hi Joe,

        Thanks for your answer. My Physio has only been concentrating aroung my lower back area.
        During my regular (8 weekly) visits to the Chiropractor he starts with a check and corrects my neck, also whilst knuckling the top of my glute he was elbowing around my shoulder area, wasn’t the nicest feeling I ever had.
        He didn’t mention that the neck could be related to my injury. I will ask him to check this out next week.

    2. Gav Pierce

      Hi Guy

      Thanks for your reply and advice, changed my training schedule about 8 weeks ago to see if it would help.
      So instead of running for about 5 hours a week, I visited the gym for weight training, intensity of the training is about the same just different type of training. Dont get so tight hamstrings anymore but the pain/tightness in the glute area and tingling in the foot are still there. Maybe I have to back this off as well and steal my son’s Xbox.
      I have an appointment with the neurosurgeon today to discuss the recently made MRI scan. I hope that he can give me a clear area to focus the treatment on.

      1. Gav Pierce

        Just a update, had a MRI and consultation with a neurologist, I have a bulging a L5/S1 level, left side more prominent than right. According to the doctor this perfectly explains my symtooms and has advised me to keep seeing a Chiropractor. Absolutely no running as the shocking is bad for the recovery, only biking and a bit of weight training. If no improvemnets within 8 weeks than I ahve to get back in touch.
        What I found strange is that he told me to stop making a hollow back (mackenzie therapy) and start to exercise with a rounded back. This is totally different to what my chiroprator advises me.

  3. Martyn

    I’ve recently come back to running after 5 weeks off with high outer pelvic pain above my hip. Always just on my right side. I’ve been to physio last year and am regularly carrying out the exercises she gave me to strengthen up. I started back on Jan 1st with just 2, gentle miles, slowly building it back up, no speed work or ‘efforts’ either. As I’ve returned to running so has the pain in my hip / pelvis and once again a very sore soleus muscle and very tight calf on my right side. My massage lady called it ‘hypertonic’. I’m at my wits end. I’ve had my gait checked and am supposedly in the right shoes, fitted by a running shoe shop and I’m always being told the my ‘form’ is great so I give up! What is wrong with me? ‍♂️

    1. Joe Uhan

      Martyn-

      It certainly could be nerve pain. Unhappy (tensioned, irritated-by-running) nerves can cause those symptoms. Have a skilled manual therapy practitioner look at you (links to those affiliations posted numerous times, above). Sorry, and good luck!

  4. Manuelle

    Hey. Thank you for the article. I’m an ultra trail runner and everything was fine until one day I just woke up and had a ver weird pain close to my lateral right meniscus. We tried everything and it wouldn’t stop. They even found that because of that pain I had broken the meniscus for which they performed a surgery. I’m recovered from the surgery but the pain is still there. I’ve been having neural therapy but I feel it’s not helping at all. I don’t know what else to do anymore. Can you give me better tips to heal it?
    Thank you

    1. Joe Uhan

      Manuelle-

      Thanks for the message.

      Based on your symptoms description/location, it’s less likely this is a nerve pain issue; rather, a knee (mechanical/alignment) issue. (If knee bones aren’t properly aligned and moving, pain will persist, even if the meniscus is repaired).

      I do offer remote video consults should you wish to discuss your case more specifically (for that, visit my website uhanperformance.com)

      Good luck,
      -Joe

  5. ANDREW MACLENNAN

    Hi Joe

    I have a good level track and field athlete with chronic bilateral hamstring soreness. We’ve tried all sorts of ways to address it with flossing, glute strengthening etc and nothing has made much difference. Your article seems spot on. We need to find someone who can do some work with neurogenic pain?

    Thanks

    1. Joe Uhan

      Andrew-

      Thanks for the comment/question.

      I’d have to say: it’s pretty rare for nerve pain to be bilateral (/symmetrical) AND only “soreness”. Based on those alone, I have my doubts it’s neurogenic (though an actual evaluation is warranted).

      Given his a T&F athlete, it’s more likely there’s hamstring over-use due to inefficient form (What comes to mind: upright/hyper-extended lumbar, pelvis anterior tilt, excessive heel recovery (heel to butt)).

      You’re welcome to submit a running stride video to my site for a “free estimate”: https://uhanperformance.com/submissions.php

      Good luck,
      -Joe

      1. ANDREW MACLENNAN

        Thanks Joe

        Fair to say I am an absolute stickler for technique and I am always very attentive to if the athlete is holding their pelvis in an undesirable position in particular, as things generally fall apart from there.

        I have submitted a video for your feedback.

        1. Joe Uhan

          Andrew-

          Thanks for the submission. I’ve posted it here: https://www.youtube.com/watch?v=zYdklOGcq0Q&feature=youtu.be

          Assuming your athlete is in “lane 4” (roughly)?

          I’m by no means a sprint form expert, but what I see that I don’t like:

          1. More side to side trunk motion than desire (can only see in first 2 and last 2 seconds of clip) – compare to woman in lane 3

          2. More static AND active (on/off) lumbar extension with stance-push-off

          Both of these issues can:

          A. cause nerve irritation (due to spinal stability deficits in two planes), and
          B. cause hamstring overuse

          Here’s my (relative) gold-standard for short-sprint technique video: https://www.youtube.com/watch?v=8YkngF_kdTc&feature=youtu.be&t=130

          Note the lack of significant trunk rotation/sidebend AND static (and moderate) lumbar lordosis.

            1. Joe Uhan

              Ah, OK, thanks.

              Then it is easier: heel recovery is excessive. That stresses the hamstring on both ends:

              * too much active “curl up”

              contralaterally:

              * leg extends/over-reaches too far (eccentric load)

              A good follow to work on sprint mechanics (and a lot of commentary of excessive heel recovery) is Stuart McMillan from ALTIS:

              https://twitter.com/StuartMcMillan1

              He’s written a lot on the subject.

              (My take: gotta work on the “triple flexion: hip/knee/ankle — straight up, to decrease that extra curl behind and trim the excessive reach, in front)

  6. CJ

    First article that makes sense!
    I’ve got an odd issue.
    Returned to running after extended break and now have weird uncomfortable knee/lower leg sensation when I take a deep breath.
    Any ideas?
    Thanks!

    1. Joe Uhan

      CJ-

      Thanks for the message. Leg pain in response to *neck motions* is a classic sign of neurogenic pain, I’ve never heard of the same symptoms arising from taking a deep breath. It’s certainly possible that there’s some tensioning between the upper quarter nervous system (including even the cranial nerves, which course through the diaphragm to various organs) and the legs.

      I have no advice or ideas, other than consider consulting with the above-posted referral lists. Good luck!

  7. dr wime

    Thanks Joe; Finally some information that hits home! I am a Triathlete (Level 1 Coach also !). I am absolutely on love with this sport and can’t get enough! My body tells me otherwise. Training is at a low volume now with the whole virus think going on. You’ve touched on a number of issues that I am experiencing with the outside of my left foot. Tingling, numbness that won’t go away and won’t respond to conventional treatment of any kind. After a casual run, or after a Tempo bike ride is when I feel the most discomfort/pain/tingling/numbness. My physio does the massaging and my podiatrist has seen me a few times, built custom orthotics, cortisone shot (lasted 5 days) and this pest still comes back. I’m open to suggestions, but not being a Triathlete is not one of them. Thanks so much.

    1. Joe Uhan

      Dr Wime-

      Thanks for the message. Tingling and numbness are certainly hallmarks of a neurogenic issue, but where it could be coming from isn’t an easy answer. As with any nerve pain, the issue could be anywhere (and multiple) from head to (in this case), toe.

      Given your activity level, I’d wager hefty sums that running stride is playing a role, as well.

      Consult with your medical team; you might also consider doing an online consult, which I offer through my clinic page.

      Good luck,
      -Joe

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