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A Sticky Situation: Identifying and Treating Nerve Pain in Runners

Identifying and treating nerve pain in runners.

By on February 12, 2019 | Comments

Stay the CourseSeveral years ago, when I was in heavy training for a marathon, I began to experience pain in my left ankle and heel. My lower leg, heel, and ankle area felt stiff, sore, and achy. I’d experienced an Achilles tendon injury years before, and the prospect of re-injuring it–and having to stop training and endure a long healing process–was both frightening and demoralizing.

As a newly minted physical therapist, I did all the things I had learned from my Doctorate of Physical Therapy degree: I rested, massaged, strengthened, stretched, and iced. But it didn’t seem to help. The heel remained stiff, sore, and achy.

But on top of that, I began to experience some other strange symptoms:

  • Occasional sharp, shooting pain. Despite not running, I would feel unexplained sharp pain in my Achilles area when simply walking around.
  • No palpable tendon soreness. The Achilles itself wasn’t actually sore!
  • Pins-and-needles sensations. I felt some odd tingling sensations around the ankle, but namely on the medial side.
  • Pain at rest. This was the strangest. I was driving in my car, just sitting there, and the inside of my ankle and Achilles began to ache!

Pain at rest was really the kicker. Why would something hurt when I was not moving it? Then I began to put together some pieces:

  • If I changed positions, the pain disappeared. While sitting, if I flexed my leg closer to me, or sat upright, the pain would dissipate. Conversely, I could make it return with a slumped posture and a straight leg.
  • My left low back was sore. In the weeks preceding this Achilles pain, I noticed some increased left lumbar pain. But like any good runner would do, I blew it off.

It only took that, three-and-a-half college degrees, and a year of clinical experience to realize that my ‘Achilles’ was, in fact, nerve pain. And while I cursed my initial stupidity, the self-loathing was short-lived. I worked on my back, did some key nervous-system mobility exercises, and within a day, was back to running normally.

So goes the frustration and folly of nerve-related (or neurogenic) pain. It can be both extremely painful and laughably inconsistent, and it can appear out of nowhere and abolish just as quickly. But for some unlucky runners, nerve pain can stubbornly persist for months if not years, and be impervious to resting, stretching, strengthening, icing, medications, and even surgery.

So what do we do?

Nerve Dynamics: How Nerves ‘Get Stuck’ and How to Get Them Moving Again

We’ve written about nerve pain before. For a full background on nerve dynamics and nerve pain, including common runner aches and pains that could be caused by nerves, consult these articles:

For a crash course on the anatomy and physiology of neurodynamics, here is a primer:

  • The nervous system is a continuous system. All nerves are connected to one another as they flow from the central nervous system (brain and spinal cord) to the periphery.
  • Nerves are real-life, tubular ‘electrical cables’ that must be able to move amidst the surrounding tissues without excessive pressure or stretch. While they require movement, nerves do not like to be stretched!
  • In a healthy state, we have just enough nerve length to move our body and limbs in all directions.
  • Occasionally, nerves lose functional mobility. General stiffness or previous injuries can restrict motion. This most often happens at the vertebral level, where the nerves branch away from the spine.
  • The most common cause of nerve tension is a current (or previous and seemingly healed) neck or back injury. The second most common is inefficiency (poor posture or running-stride inefficiency). The third most common is a previous trauma (falls or surgery that result in insidious scar tissue).
  • While nerves tend to cause pain at the site of restriction, a movement or flow disruption upstream can cause pain downstream, and vice versa–the plumber’s theorem. A dysfunction in the upper body can create a dysfunction in the lower body, and vice versa.

For more detailed discussion and demonstration of nerve mobility and nerve pain, check out this video!

Identifying and Treating Nerve Tension

Identifying whether your pain is neurogenic isn’t always straightforward. Here are two criteria:

  1. Does your pain align with any of the six signs of nerve pain? If your injury satisfies at least two or three signs, nerve involvement is possible; four or more and it’s highly likely.
  2. Test your nerve mobility. Try the nerve-mobility tests in the two videos below. Two questions to ask as you test your nerve mobility are, does the test replicate your pain and/or is the affected limb significantly tighter than the unaffected side?

Treating neurogenic pain related to nerve tension is simple but not easy. It requires four steps:

  1. Normalize motion to the area around the nerve first! Normal nerve mobility requires healthy motion around the vertebral segments. Trying to ‘stretch’ a nerve around a stiff joint can overstress it and may result in a painful flare-up. First get the spinal area moving, then address the nerve itself.
  2. Restore nerve mobility. This requires gentle, repetitive, progressive and often multi-system motions. Do as few as five gentle stretches, but every two to three hours.
  3. Avoid re-accumulating tension! Avoid any position or movement that re-stiffens the nerve or surrounding area.
  4. Be patient! Even after full motion is restored, sensitive nerves still may not tolerate full and aggressive athletic motions. Run up until but not beyond the time or distance that symptoms return.

The good news is, once a nerve dysfunction is identified and appropriately treated, very often the recovery can be rapid, and often pain can resolve much faster than orthopedic sprains and strains. So if you’re suffering with a running injury that simply won’t go away, consider and assess for nerve tension!

[Author’s Note: Reference acknowledgement goes to the Neuro-Orthopaedic Institute for the current promotion of this knowledge, first pioneered by Bob Elvey, PT, nearly 50 years ago. For their full series of videos, click here. Here are specific videos describing and demonstrating nerve mobility in the upper body and lower body.]

Call for Comments (from Meghan)

  • Have you ever been diagnosed with a nerve injury? What were some of your injury’s symptoms and how were you able to heal?
  • Did you take the nerve-mobility tests? If so, what were the results?
Joe Uhan

Joe Uhan is a physical therapist, coach, and ultrarunner in Auburn, California. 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.