The St. George runner's guide to the ache that is not going away

There is a particular kind of injury that never quite earns a day off. It does not stop you running. It shows up at mile two, fades once you are warm, and comes back that evening on the stairs. You have been managing it for six weeks. You have a theory about your shoes.

St. George produces a lot of these, and the reason is geography rather than bad luck. The trails are hard, uneven and steep, the road is unforgiving asphalt, the training year has a marathon and a Senior Games in it, and a lot of people here mix trail, road and bike in the same week. That is a great life and a broad set of loads for one set of tissues to absorb.

Runner's knee: pain at the front, worse downhill

Patellofemoral pain, or runner's knee, is an ache around or behind the kneecap that is worse going downhill, worse on stairs, and worse after sitting still for a long stretch. On red rock descents it is loud.

The knee is usually where the symptom is, not where the problem is. Frequently the hip is not controlling position under load, so the femur rotates in slightly with each step and the mechanics at the kneecap change. That is why hip and glute strength work often resolves a knee complaint that no amount of knee-focused treatment touched, and it is why an assessment watches you move rather than only pressing on the sore bit.

IT band syndrome is a related regular, felt on the outside of the knee rather than the front, and it responds to a similar line of investigation.

Shin splints, and the version of them that is not shin splints

Aching along the inner shin after a jump in mileage, on a new surface, or in new shoes is the common presentation. It usually settles with load management, calf and foot strength, and some patience about the training progression that caused it.

The important distinction is a stress fracture, which can start out feeling similar and does not behave similarly at all. The pattern that should stop you self-managing is pain in one small, specific spot on the bone that you can cover with a fingertip, pain that has started arriving during rather than after running, or pain that persists at rest and at night. That is a get-it-looked-at situation, not a stretch-more situation.

Plantar fasciitis: the first ten steps of the morning

The signature is unmistakable. The first ten steps out of bed are the worst of the day, it eases as you move, and it returns after you have been sitting. Heel pain, sometimes reaching along the arch.

It is stubborn, it responds well to the right work, and it responds slowly to anything. Calf and foot loading matters, so does how much you have suddenly increased, and so does what you are standing on for eight hours at work. Dry needling is used for it at Fortify, generally alongside the loading programme rather than instead of one.

The first two weeks, before anyone else is involved

• Cut volume rather than stopping dead. Complete rest deconditions the tissue you need, and most of these respond better to a reduced, tolerable load.
• Change one variable at a time. New shoes, new surface and a new interval session in the same fortnight makes it impossible to know what did it.
• Take the hills out temporarily, particularly the descents, which is where a knee complains loudest.
• Note when it hurts, not just that it hurts. During, after, next morning, on stairs. That pattern is the most useful thing you will bring to an appointment.
• Keep loading what does not hurt. Strength in the hip, calf and foot is the long-term answer for most of this, and there is rarely a reason to stop it.

When to stop self-managing

Four weeks of an unchanged or worsening ache, pain that has started arriving earlier in each run, a specific point on a bone, swelling, giving way, or numbness and pins and needles. Any of those, book it.

The other trigger is more boring and more common: it is not getting worse, but you have quietly stopped entering things. Half the value of a sports physical therapy assessment is that it turns a vague ongoing negotiation with your own leg into a specific problem with a plan and an end date.

Why an endurance athlete would rather see an endurance athlete

Colbie Jorgensen, PT, DPT, has raced triathlon since 2006 and has ridden 200-plus-mile events in a single day. He is also trained in bike fitting, which is not on most physical therapy menus and is quite often the actual answer for a cyclist's knee.

His own description of the job is the least salesy thing on the clinic's website: most people do not need fancy exercises or miracle treatments, they need someone to listen, focus on the basics, and coach them along the way. For a runner who has been managing something for six weeks and has a theory about their shoes, that is usually exactly the correct amount of intervention.

Fortify is at 792 S 3000 E, Unit 104 in St. George. You can ask for a specific therapist when you book.