The clinic.

PAIN THAT NAGS AFTER YOU STOP

? Several hours after running, I have been experiencing pain on the inside of my upper right leg or groin area. I usually run five times a week, totaling 25 or 30 miles. I'm a 62-year-old male, 155 pounds, 5' 11", and have been running for 25 years. I usually run on asphalt. I'm a slight pronator with a heavy heel strike. The pain is usually gone by the next day. Distance appears to cause more discomfort than intensity does. Though my left leg is not affected, the right leg has nagged me for several years, and lately seems to be getting worse.

Bob Bond, Vero Beach, FL

The pain you describe sounds like it may be a thinning of the cartilage that protects the ball and socket in the hip. A thorough evaluation, either by a certified chiropractic sports provider or an orthopedic surgeon, is called for. In addition to a physical evaluation, I would have them take x-rays of both hips; you can get a pretty comprehensive understanding of your hip health with these assessment tools. You and your doctor can then decide what is the best fitness plan for you going forward, including shoe and running surface changes, crosstraining, and gentle flexibility work.

Chris Sorenson, DC, CCSP, St. Cloud, MN

Groin pain is not very common among runners, but it can be due to stress fractures of the pelvis, which in this area can be caused by excessive tension on a muscle. Your complaint of long-standing pain in the area might be due to excessive tension on the muscle, and only now as you are getting older has this become a problem for the bone. However, stress fractures usually cause increasing pain on the run that resolves afterward.

The increasing symptoms after the run are more suggestive to me of muscle strain. Again, this is not common in runners, but here are a few scenarios that might cause it. When running, the groin muscles of the leg that is swinging through the air contract to help elevate the pelvis as the leg swings. Facing traffic, the right side of the road is higher than the left. If you always run facing traffic, your right groin muscles (and left hip muscles) will have to work harder to lift your pelvis enough for your right leg to clear the road. A second scenario is that you turn your right leg either inward or outward too much. In either case, the abnormal orientation of the leg forces the muscles to take on slightly different functions than they were designed for. Try running facing the other direction on the road if you've been running against traffic. In the other scenario, you can try to consciously rotate your leg inward or outward--or try a corrective shoe--to counteract the undesired rotation.

Stephen Perle, DC, Bridgeport, CT

NOCTURNAL LEG CRAMPS

? I have been experiencing foot and leg spasms (charley horses) at night. I'm 63 and exercise regularly, about five times a week. I lift weights and use a glider two to three times a week and jog five to eight miles on the other days. I started the South Beach Diet in early February and have since lost 25 pounds. I drink water, coffee, tea or diet drinks during the day and sometimes milk or wine in the evening. I take a senior multivitamin, a calcium supplement, plus vitamins E, C, B6 and B12 (my mother had troubles due to B vitamin deficiencies). Any advice about the spasms would be greatly appreciated.

Nicholas J. Wirt, Boca Raton, FL

Nocturnal leg cramps, as this condition is formally known, are sometimes the result of low potassium. There is a fair amount of potassium in several of the foods that are decreased on the South Beach Diet--bananas in particular, at least in its early phase. If you also happen to take a diuretic such as furosemide (Lasix) or hydrocholorothiazide, the problem may be exacerbated. Sometimes nocturnal leg cramps can occur when recently-exercised muscles that aren't accustomed to physical activity are at rest, but it doesn't sound like you've changed your activity levels as of late. If it isn't new activity or low potassium causing these cramps, a trial of 325 mg of quinine at bedtime may help, even if the cause remains unknown.

William M. Simpson, Jr., MD, Charleston, SC

Congratulations on the terrific commitment to improved health. I wish I had more patients come to me with leg cramps after exercising five days a week. I hope your active lifestyle infects a few friends; keep up the good work.

A person in a catabolic state such as yourself, i.e., one who is losing weight or breaking themselves down as opposed to gaining weight, can sometimes experience subtle electrolyte aberrations. (I can't recall ever seeing a patient who suffered muscle spasms and at the same time was gaining weight.) Also, when people diet they often drink more, and since you mentioned tea, soda and coffee, it may be that you are now consuming too much caffeine, which can cause muscle spasms.

I recommend, then, that you try limiting your caffeine intake and substitute several glasses of electrolyte-rich sports drink per day. If these steps don't help, have your doctor check your electrolytes and thyroid. You may also try exercising every other day for longer periods at a time. Quinine sulfate is indeed a well-known (and ancient) remedy for nocturnal leg cramps, and it is relatively benign, though it can (infrequently) cause blood-related side effects. People with liver problems or those who are pregnant should avoid quinine.

Peter Mendel, MD, Fairfax, VA

Another possible source of the cramps could be stain drugs, if you happen to be taking them. In any case, I have often seen results with 600 to 1,200 mg daily of calcium (without phosphorus), in split doses.

Sarah Harding Laidlaw, MS, RD, MPA, Mesquite, NV

SHOCKWAVE THERAPY AND ACHILLES TENDINOSIS

? Since my marathon in September, I have been experiencing left heel pain. After an MRI, my orthopedic sports physician diagnosed degenerative tendinosis of the left Achilles tendon. His advice was to limit activity, continue with NSAIDs, ice after exercising and regularly stretch the calf. He did not recommend surgery for now.

Can you expand on this diagnosis and also offer me advice about surgery as well as shockwave treatments? Are you aware of any clinical trials for shockwave treatment of Achilles tendinosis? Would physical therapy help me return to running? What are the consequences of trying to continue my normal training?

Noreen Driscoll, Medford, OR

Achilles tendinosis is a much more serious problem than Achilles tendinitis (inflammation of the sheath surrounding the tendon). Tendinosis causes a thickened heel cord and is a pathologic degeneration of the collagen fibers within the tendon. This may be a precursor to partial or complete rupture. Cutting back on your mileage is essential--avoid speedwork and hills until you can jog pain-free. Deep water run to keep up your cardiovascular fitness. Ice massage three times a day and ultrasound have both been shown to be effective treatments. You can decrease strain by adding a 1/4" to 1/2" heel lift to your running shoes. Shockwave therapy is an exciting new option, but it is not yet FDA-approved for any injuries beyond chronic plantar fasciitis and tennis elbow. Initial results have been excellent, but some clinicians are concerned that it may predispose the tendon to rupture. Long-term studies are needed. Surgery is sometimes necessary and is usually successful, but it may require a prolonged recovery period.

Matt Werd, DPM, Lakeland, FL

Modified rest, stretching and ice are all good treatments, but probably insufficient. NSAID use is questionable as there is a good deal of controversy over whether this condition is inflammatory. I would definitely add intensive physical therapy to your treatment regimen. Most patients respond well to it and resume their previous level of running. Surgery is rarely necessary, as the danger of spontaneous tendon rupture with this condition, while real, is low. Shockwave therapy is non-invasive and done on an outpatient basis. If you do not respond to physical therapy, it is an option worth considering. While it is not yet approved for Achilles tendinosis, many doctors perform the procedure anyway and it is safe thus far, with the patient able to walk immediately afterward. In Europe, the procedure is approved for many more conditions than in the U.S., and you can read the results at www.shockwavedoc.com. If you do explore this route, look for a doctor who uses the Ossatron (made by Health Tronics); this is the best of the available machines.

Richard Wilson, DPM, Melbourne, FL

Please note that Clinic responses frequently appear as excerpts of longer answers, especially when the inclusion of two full answers would result in redundant information.

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