I have a problem: Mostly after a long bike, I am fine on the transition run at first, but then after a mile or so, the lower legs get so hard that they seem about to burst. As a result, the feet & lower legs go numb. This does not happen on long Sunday runs. My bike position & training has not changed. No new shoes, Not compartment syndrome. In IMTX it happened and I was numb for 8 miles, then it was just the left leg for 8 miles and the last 10 I was fine. My regular doc says the heart is fine and tells me not to run. I’ve been doing IM for 25 years and have not ever seen anything like this - has anybody had this problem? It is getting worse. It is severely limiting my running which used to be my strength…any advice on who to turn to would be appreciated.
Also do a search on the forum for iliac artery compression. Lots of good discussions in the past.
Wow. Super interesting to read this given I am going through what seems like the exact same thing, only for me, it is my left leg. I have generally tight calves, but during training (even intense workouts) I don’t have any significant problems, but in my past few 70.3 races, about 2 miles into the run my lower leg cramps up and eventually the outside of my foot goes numb/pins and needles, and eventually spreads toward my whole forefoot. Interestingly, much like you have explained, I tend to regain feeling after about 20-30 minutes (e.g., for the back half of these half marathons of the bike). A few things to investigate that could be at play.
- CECS (which you say you don’t have…I am actually signed up for the pressure test during an off-season break)
- Popliteal Artery/Vein Entrapment (could be you are losing blood flow, and then eventually enough collateral flow explaining regaining feeling)
- Nerve damage somewhere up above (would explain only racing as even if your position is the same, odds are you don’t stay down aero nearly as much during training rides as you do in a race)
- Change in bio-mechanics: Goes along with nerve damage, but perhaps something has changed in the way your foot is falling, etc
- Actual nervous system issues: Vitamin B deficiency, etc.
I completely feel your pain as I am going through the exact same thing right now. I have fully committed (and followed through pretty well) to doing everything possible before my next race in mid July on the conservative side of things, so massage, stretching, cutting caffeine, Varus wedge in the cycling shoe to take pressure off soleous, etc.
Keep me posted on your progress and I will do the same.
Thanks - I have seen that thread and unfortunately, it is not IAC…I had a friend that had that, however…it has been ruled out - appreciate your post!
Thank you - I’m sorry that you have the same issue…I figure somebody somewhere has had this and they can fix it…I’m not getting anywhere with doctors but if there was a doctor that has worked IM races, perhaps they have seen this before? I appreciate your thoughts on the matter & will keep you posted as to any remedies I find… You may be on the right track with a change in biomechanics…I have found it is not an electrolyte imbalance, not cramps. I too had tight calves prior to this development, so that might also be something to look into. One doc said that it may be vascular, but so far we have not been able to replicate the symptoms…please stay in touch
Bilateral symptoms like yours suggest lumbar spinal stenosis. Biking is fine because flexing forward opens spinal canal. Running with back straight would decrease canal, pinching nerve roots.
The same thing happened to me at IM Raleigh 70.3 – felt fine on the bike, and within 1/2 mile of the run my lower right leg felt tight, then painfully tight, then burningly tight, then my entire foot went numb. I flopped along on it for several miles, debating whether I should stop, and then the numbness receded and the leg was fine. I felt some minimal tightness in my next two runs, but so far no recurrence. But… I haven’t run off the bike again (I usually have to do split bricks thanks to those pesky children) and I am REALLY worried about my upcoming IM. I’ll follow this thread for use with the orthos after the race if it happens again 
Good luck to you… it was an awful experience!
Could some sort of nerve issue in the lower back also be the case if symptoms are only manifesting on one side? I ask because, as I mentioned above in the thread, I’ve been experiencing something very similar, albeit at the HIM distance. Here is what I’ve heard in terms of the differential diagnosis and why I (along with many of the physicians I have seen) are puzzled.
Popliteal Artery/Venous Entrapment Syndrome: I’ve actually been diagnosed with this (biliterially) via MRA, but it was explained to me that this was likely an incidental finding for the following reasons. First off, it is ‘functional’ meaning my vascular structures only become compressed by my Gastroc (a third muscle head is the cause of the issue) when my foot is in plantar flexion, which I guess isn’t so uncommon. Second, and more telling, although I get numbness in my foot, I don’t get calf pain at all and have been told that if i was experiencing a significant reduction in blood-flow through the popliteal artery/vein I would notice all kinds of things with my calves themselves, starting with bad cramps. Third, and what they said was most telling, is that if it was PA/VES causing my problems, there would be no difference between long hard training bricks and racing, and the issue would present itself during open runs (currently it only acts up after running off the bike) since that is when the most plantar flexion occurs (I’ve also had my bike fit tweaked to eliminate plantar flexion as much as possible)
**CECS: **They actually think this could be at play, so I am signed up for the pressure-test during my mid-season break, which looks terribly un-fun. Anyways, they want to rule it out, but said if it was CECS, doubtful that the pressure would go down (e.g., the numbness seems to come on strong from miles 3-8, then kind of go away toward the back half of the run)
**Tarsal Tunnel Syndrome: **My numbness and pins in needles begins on the outside of my foot and then kind of travels across the top of my foot from there. Was told TTS begins on inside of foot, arch, big-toe first.
**Hydration/Nutrition: **Been over this with a dietitian and everything looks fine, even if it wasn’t, was told symptoms would be more systematic symptoms if this were a cause (e.g., not just one foot)
******Where I’m At Right Now: **I do have very tight calves, but nothing unusual for a more serious triathlete (not trying to sneak in a brag, simply stating I train often). My next 70.3 is Vineman, and in the past month, I’ve committed to taking all conservative measures to try and address this issue because 1) that pressure tests looks awful and 2) based on my symptoms, I’m not convinced it’s CECS. What this means is more stretching, rolling, massage, cutting caffeine, slight change in cleat position plus Varus Wedge.
Curious to hear if anyone has additional insight for me. The only thing that I can think of that is different on race day versus training bricks that could be in effect (e.g., many things are different, but most would cause systematic symptoms, not just one side) is the fact that in a race I am in the aero position non-stop and more aggressively than I ever am in training (nerve issue?) and even during my best transitions outside of racing, there is a time lag to put the bike in the trunk, etc. (pressure comes down if it’s CECS?). I also make sure to loosen my timing chip so it basically flops around on my ankle after the swim to eliminate that as an outside chance cause.
To the OP, if I can tell you anything from my experience, it is be careful with a differential diagnosis. I work in healthcare and the modern medical system can do amazing things, but we also have such a full-gambit of imaging and what not, incidental findings in situations of uncertainty (e.g., this) happen all the time. Be careful not to sign up for anything until you are positive it is causing your symptoms. For example, with PA/VES, there is a surgical fix (and was recommended by some for me) but it involves 2 major incisions in the back of the knee, which outside of your undercarriage, has some of the most nerve endings in your body. Looked more into risks and decided odds are, I could come out worse than better from that surgery, so I said no thank you (also got medical advice from a second opinion that it probably wasn’t the cause of my symptoms and given it was functional entrapment, no need to worry about a blood-clot). Anyways, point being, just be careful to not “find something to treat” but to find “what is causing your issues and treat.”
GREAT post Brad!
I have had the same problem since I started triathlon. I always thought it maybe had to do with a high instep in my foot and went to a 2E width shoe. This made no difference. I do bricks a fair bit all year and it happens whether I’m in aero or on a road bike just the same. I find the numbness positively correlates with longer rides, harder rides and heat. The longer, harder and hotter the worse the condition. In the winter if I do a 4hr base ride and go for a base run I have no problems, in the summer if I got for a 2hr hard ride and a race pace run it’s brutal, lasts for 20-30mins and then goes away.
Strategies: Lately I considered it maybe had to do with the amount of blood and fluids in my legs after the bike. I also tend to pedal at a lower cadence which makes the problem worse. In my last half ironman in the last 5 minutes I upped the cadence to over 95, lowered the power 10% and spent a bit of time stretching my achilles, calf, and hamstring. I then sat down at T2 to put on my shoes. When I started running I made sure the first couple km’s were slower (4:35/k) till all my legs muscles loosened up and my stride was normal and it naturally dropped down to the 4:10-4:15 range on it’s own. It still happened this time but it was not as bad and didn’t last as long, but it seems to work better.
I will also try a quick back stretch on the bike as well now as I didn’t consider the issue was that far up the chain.
Could some sort of nerve issue in the lower back also be the case if symptoms are only manifesting on one side?
You are a textbook example of the well-informed patient assisting with a difficult dx!
I don’t think it’s your foot. So, if you have not already, it’s worth getting X-rays of the lumbar spine to rule out lumbosacral radiculopathy. If any suspicion arises, a MRI might be recommended.
Thanks for the suggestion. Have not had any imaging studies of the spine, but now will discuss this with my physician. Also, and more generally, a big thanks to you and Rod for constantly offering your expert guidance (but never actually practicing medicene!!) on the forum. I feel like the advice I’ve gotten here would have taken me countless DOVs and hassle to find (and that’s a big maybe) elsewhere.
It really speaks to the potential of virtual medicine and consults. Likely a huge opportunity for niche sub-sub specialties like Endurance Athletes. Not sure what the regs are toward that sort of thing, but certainly an opportunity.
Anyways, I will keep this thread posted and appreciate any further insight, even if anectdotal.
B
Thanks for the suggestion. Have not had any imaging studies of the spine, but now will discuss this with my physician.
OK, your compliment (thx!) got me thinking more about your case… and here’s a related suggestion:
My suggestion about X-rays to investigate lumbosacral radiculopathy concerned the sciatic nerve roots. The peroneal nerve is a component of the sciatic and its distribution goes to the area of your symptoms. Because of your unusual gastrocnemius anatomy, the peroneal nerve might be getting compressed behind the knee. The common peroneal nerve divides into the deep and superficial. I think the superficial might be the source of your symptoms. A nerve conduction study could rule out this idea, but you might have to reproduce symptoms.
I had something similar two years ago where the outside of my right foot went numb at the heel, my calf would tighten after about 30 minutes on the bike or running for more than a mile, and stretching did not seem to relieve it. Every now and then I would have a pain behind my right knee as well. After trips to PT, orthopedic, and a negative MRI, I spent most of last year not running more than a mile at a time or biking for longer than 30 minutes. It progressively got better over the year, and after about 4.5 to 5 months of zero activity (Oct-Feb), I’m back running and biking more now than I did before it all started. I still don’t know what the issue is, but I assume it’s a nerve issue from my back. I do get my back adjusted and stretched once a week, and that does seem to help after a long training week. But as far as the numbness in the foot and tightness in the calf, both of those are now gone.
Wanted to give quick update to thread. Ironically just a few days after this thread became active, I bumped into local Sports-Med foot/ankle ‘legend’ Amol Saxena at a race, and he was kind enough to let me pick his brain. Sure enough, he shared ST wisdom to start with Lumbar Spine in terms of a differential, and work my way ‘down’ from there. Called up my KP Sports-Med doctor (who happens to be very open to mutual problem solving) and was completely honest about my thinking (e.g., spoke with friends that are experts in this kind of stuff, and explained in a bit further detail the difference between even a 4-5 hour training ride and 2.5 hours spent as aero as possible) and he agreed to start with the Lumbar Spine. Really like this guy because he is very pragmatic, and basically said I am going to end up on the MRI table anyways, so might as well save the time, hassle, radiation of an X-ray and start with an MRI (yup, that’s right for all you that thought KP was the big bad HMO) so I’ve got one scheduled for Sunday. He mentioned disc issues, and speculation that if it was my Lumbar Spine, likely in the L4/L5 area. Will report back when I have results. Hoping something may be found since I understand the ‘what to do about it’ is significantly less invasive/risky than CECS and certainly vascular issues.
Good luck chasing down the cause of your symptoms with MRI.
Very interesting case! Typically, lumbar disc disease would produce symptoms more on the bike than running, but vice versa for lumbar stenosis.
I remain intrigued by your comment, “First off, it is ‘functional’ meaning my vascular structures only become compressed by my Gastroc (a third muscle head is the cause of the issue).” Still wondering if the compression might involve the nerve as well.
Update. Raced Vineman 70.3 on July 14, couldn’t feel my foot for 90% of the run. Same very predictable onset of symptoms; about 10 minutes into run, calf felt like a balloon about to explode, worst when running up hill, then calf pain kind of subsides everywhere but lower back part of calf, but front half of foot goes pins/needles/asleep numb.
Lumbar spine MRI more-or-less normal. Although there were some slight deviations, doc explained nothing out of the ordinary for someone training 15-20 hours a week. Just yesterday, lugged by trainer into the physical medicine department, road it at just about 70.3 watts for 2 hours (at least I got a good workout out of the deal) and then hopped on the treadmill, setting the incline to 5. Sure enough, at the 7-10 minute point of the run, usual symptoms came on, and by minute 12, foot was numb. OK, go time!!
About 5-7 minutes later leg was numbed up with Lidocane and Stryker device needle (the F-ing huge one) was going in. Somewhere between 8-10 minutes after getting off the treadmill my readings for Anterior/Lateral/Superficial Posterior compartments were all between 25-27 and my Deep Posterior Compartment was at 32 (measured last, a good 10 minutes post exercise). It is my understanding that these are supposed to be down around 20 at this point…
Got in touch with is the nation’s expert in the differential diagnosis between Popliteal Entrapment and CECS, a Vascular Surgeon named William Turnipseed at U-Wisco Madison. Incredibly, he took my call same day and spent a good 30 minutes on the phone with me, unbelievable! Based on my presentation and symptoms, he is confident the Deep Posterior Compartment is causing my problems, and wants to release it. Whether/not to release the other compartments is still a question. Orthopedic docs here at Kaiser haven’t seen this (and I guess not so any in CA period), so it looks like it is off to Wisconsin for me.
Was told I could continue this year to train/race to tolerance, but that the pins/needles are not a good thing and that IMAZ is out of the question, which i was pretty prepared to hear. After processing all of this, I also think Vegas 70.3 is going to be nixed. 1) Just not worth the risk, 2) no sense IMO in toeing the line at a WC knowing you won’t be able to give it your all and 3) all compounded by the fact that the course is so hilly and that seems to really aggravate things most. Will likely try and race a few OLYs and then have the surgery in October/November. Lots of good information on CECS here on ST, and threads like JSAs have been super-helpful.
Medicine is full of uncertainty, so I need to accept there is a chance I go through all this and still have problems caused by the popliteal entrapment, but it was nice to hear Turnipseed’s confidence in the CECS being the cause of my problems.
So that’s where I’m at…OP, any news on your end?
Textbook case study of chronic exertional CS, if release is the cure! Best wishes for full recovery after seeing Turnipseed. I think you are being very sensible about not training heard or racing. The more times you have the symptoms, your risk of muscle and nerve damage increases.
I’ve had both compartments released on my left leg about three years ago. After a couple of years of training and racing there is a slight pain back in the same leg, with pain in the calf / behind the shin but the numbness in the foot has not come up like before. Running with the pins and needles has not yet occurred. Could this be the start of the same symptoms or possibly a stress fracture? I’ve been foam rolling and icing as a precaution but have just started training for my first IM (IMTX) and hoping I won’t have to derail my training.
Should I take time off running for now and just focus on swimming and cycling?
I wish I could offer you some concrete advice, but that’s a huge question. You need to know your body and listen to it, and seek out a good sports med doc for extra help if you need it. It could be anything from popliteal artery entrapment, to scar tissue being irritated from your prior surgeries, to a stress fracture, to your calves just being sore from a return to training after the off-season. You’d need to provide a lot more detail of what’s going on to get advice from the armchair forum docs, or, just go see one in person.