The clinic.

Q. Late Night Leg Cramps

I'm a 65-year-old runner averaging about 24 miles per week. I run almost every day, taking one day off every two to three weeks. My pace is about a nine-minute mile. I have been experiencing painful seizures of leg cramping in my right thigh at night when sitting and even at times when sleeping, waking up in excruciating pain.

I take vitamins including an extra dosage of vitamin E. My doctor has suggested quinine water, which I have been drinking after my run. My left leg is shorter than my right by 5/16 of an inch. I have placed inserts in my left shoe to compensate. Still I'm suffering these horrible cramps.

Lionel Wolpert

Beach Haven, NJ

A. You seem to be a very dedicated runner, but remember, we all need to have adequate time for recovery in our training schedule (particularly as we get older). Only two to three days of rest a month may not be enough. Overly fatigued muscles can definitely develop painful cramps.

Make sure you are stretching before and after your runs. You may need to stretch additional times throughout your day, especially before going to bed at night. Also, be sure to get adequate fluid intake before and during your run. Your climate is hot in the summer, so its a good idea to use a sports drink to replace minerals lost in sweat. As we are all health conscious, it is a common mistake to excessively limit salt intake in our diets. Unless you have a specific reason to limit your salt intake, such as hypertension or kidney problems, you should probably be a bit more liberal with your salt use.

Be careful not to overcompensate for your small leg length discrepancy. If you have had this difference in leg length all your life, it is likely that your body has already compensated and acclimated to this difference. You may be causing more trouble for yourself by using a shoe lift that forces your body to readjust. If you do use a shoe lift, start with a partial correction first of about one half the difference and make any additional changes gradually.

Finally, if your cramps do not subside, see your physician so that other medical or spinal problems can be appropriately investigated. At times, muscle cramps are a reflection of an irritated nerve in the lower back.

Stuart Weinstein, MD.

Seattle, WA

A. Often with lots of fluid loss and replacement with water, a salt (sodium) deficit develops. For that type of leg cramping try a salt tablet-as long as your doctor has not put you on a low salt diet for other reasons. It sells over the counter in one-gram tablets (100 tablets for less than ten dollars). Try replacing lost sodium and see if your cramps improve. If not, see sports medicine doctor to have a complete evaluation.

Marvin Bloom, MD.

Burlingame, CA

Q. Down with Shin Splints 

I'm 37 years old and have been running competitively for about ten years. I have experience in training, injury prevention, and racing. I've completed nine marathons, one 50-miler, and many half marathons, 5Ks and 10Ks.

My problem is shin splints. Twice in the last two years I've injured my shin, and it's taken three to four months to recover. The pain is in the inner portion of the lower part of my shins, usually after speed work or long runs.

I've tried "listening to my body" and taking some time off when I feel the soreness in hopes of preventing a full-blown injury. But even with minimal running and days off, before I know it, the deep, severe pain sets in and I'm down with shin splints again. I always wear well-cushioned shoes and try ice and rest with the first hint of pain. Still, I suffer this injury and have to limit my running.

Krisi Harmon

Bakersfield, CA

A. I don't know your height and weight or your hormonal status, but you are a very high mileage runner, and therefore at risk for the Female Athlete Triad in which estrogen levels are lower than normal and bone density can suffer as a result. Female runners who fall into this category can be at very high risk for stress fractures.

Did you make the diagnosis of shin splints on your own, or did you see a doctor? There are other conditions that can cause pain in this area of the leg, including post tibial tendinitis, periostitis, compartment syndrome, as well as a true stress fracture. Plain X-rays will not completely rule out a stress fracture. Often a bone scan is needed. Compartment syndrome may require compartmental pressure measurements to make the diagnosis.

Although the interventions that you have tried so far have all been appropriate in treating anterior tibial pain, I would strongly recommend that you see a sports medicine physician to make sure of your diagnosis and your bone density status. A precise diagnosis is needed to determine the cause of your shin pain and the necessary treatment. Orthotics may be needed to reduce the amount of pronation in your gait, which can increase the possibility of shin splints. Check shoes for problems, always stretch, and add strengthening exercises to your routine.

Again, a sports medicine physician can help you with the appropriate interventions. It is very frustrating to train at your level of intensity only to be leveled by injury. Good luck.

Russell C. Cantrell, M.D.

Kirkwood, MO

Q. Achilles Tendon Troubles

I am a 58-year-old competitive runner -- 5Ks to Half Marathons. I have been running for almost 23 years and have one recurring injury. The injury has been diagnosed as microscopic tears in my Achilles tendon. I get a tightening at the point where the Achilles connects with the calf muscle. Depending on the severity, it can take from six to ten weeks before I can start running again.

Unfortunately it seems to come back more often as I get older. I only run 30 to 35 miles a week and always try to mix hard days with easy ones, So, although I know this injury can arise from overtraining, I have tried to avoid it.

I have been to orthopedists and podiatrists and have used orthotics to reduce my over-pronation. I stretch and was getting weekly massages, which seemed to be helpful. I do strength training emphasizing leg strength. Is there anything else I can try? I don't want to quit running.

Ron Thomas

Glencoe, IL

A. Your problem of chronic Achilles tendinopathy at the origin of the tendon, is unfortunately a common one in runners your age.

The Achilles tendon has a poor blood supply, which decreases even more as we get into our fourth, fifth, and sixth decades of life. When you add the stresses of running or other athletic activities, chronic mechanical overload of the tendon resulting in partial or even complete tears of the tendon are not uncommon.

You have basically done all the right things to prevent Achilles problems, but given that it keeps returning, you need more intensive treatment, such as physical therapy. I would recommend that you consult with an experienced, sports-minded physical therapist (your podiatrist or orthopedist can give you a referral), and begin an intensive program of physical therapy, which should include corrective stretches and exercises for the entire lower limb, deep friction massage, and formal gait and orthotic assessment. It may take some time to see improvement but this should help you continue to run while minimizing recurrences.

If there is no improvement, your doctor may want to obtain further diagnostic testing. Unfortunately, given the length of time that you have experienced this problem, it may not have an absolute resolution. If the recurrences persist, try to avoid excessive "down time" by doing deep-end pool running while you are healing.

Richard C. Wilson, D.P.M

Melbourne, FL

A. It sounds like you may have to allow this situation to totally cool-out or heal. This may mean abatement from running for a while. Try cross-training activities that do not increase stresses. Once you are pain free for a significant amount of time, a gradual return to running should be okay.

Doug Lentz, C.S.C.S.

Chambersburg, PA

Q. Running with No Place to "Go"

I have an embarrassing, unspeakable running problem. Thank goodness for The Clinic--at least no one can see my mortification.

I have always had a healthy diet and very regular bowel habits. And now, although I use the bathroom everyday before I start my run, when I go out for a long run it doesn't seem to be enough. After several miles I have the overwhelming urge to go again and must try to find a place. Sometimes I haven't been lucky enough to make it and have actually lost control. I don't have this problem under any other circumstances. I really need an effective solution or else I will simply have to forego long runs.

Miserably Anonymous

Chicago, IL

A. Your problem is far more common than you realize. This is a frequent concern for runners and is sometimes related to high fiber intake. Some runners have exercise-related diarrhea and also suffer loss of bowel control. This has happened to famous elite runners while in the spotlight of national television.

I often recommend the use of two to three tablets of Pepto-Bismol prior to running and sometimes the same dose the night before. Adding bananas to your diet can be helpful. I have also recommended one tablet of Imodium before running. Be warned: too much use of this over-the-counter diarrhea remedy can cause constipation, which really won't help solve your problem.

Try using these suggestions and until you have your problem under control, take your long run within a short radius of your house. That way, if you feel trouble coming on, you can head home and not to the bushes. When you find the right combination of diet and over-the-counter remedies, you can take your run truly long again without worry. Meanwhile, rest assured that although no doubt embarrassing, this is a problem you share with many, many runners.

Kim Edward LeBlanc, MD., Ph.D.

Breaux Bridge, IA

A. Some other causes may be eating too much, too late at night if it is an early morning run. Or, the type of food eaten the evening before (high fat or high carbohydrate) may also result in the problem. Consuming alcohol the evening before may also cause a sensitive gastro-intestinal tract to over react in the morning, as may aspirin in the evening or during the hours before the run. Keep a food diary and record everything you eat as well as when the urge occurs. See if you can relate it to particular foods.

Sarah Harding Laidlaw, M.S., R.D., MPA. Glade Park, CO

Ask the Clinic!

Are you bothered by an injury? Do you have a training or diet question? If so, ask The Clinic, in care of American Running Association, 4405 East West Highway, Suite 405, Bethesda, MD 20814, FAX [phone], e-mail run@americanrunning. org. Free personalized sports medicine, training, and diet advice is an exclusive benefit for American Running Association and AMAA Members only. American Running has more than 255 Clinic Advisors representing more than 27 specialities. Include as much relevant information as possible about you (age, weight, etc.) and your injury (type and location of pain), training schedule (typical weekly workouts, pace, surface), athletic and medical history, sole wear, recent changes in training, etc. Type or print your letters. Hand-written FAXed letters will not he accepted. Include your name, address and phone number (even in e-mail). Letters cannot be processed without your name and mailing address. Responses usually take three to four weeks, but can take as long as five.