Leg Pain While Marathon Training — Free SCA Practice Case
Sight-impaired man with leg pain while marathon training
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Ben Carter
Age
28 years
Consultation Type
VideoAge
28
Situation
Video Consultation.
Reason for Encounter
"Patient is complaining of worsening right lower leg pain. Currently in high-volume training for a marathon."
Medical Records
- ●PMH: Retinitis Pigmentosa (Registered Severely Sight Impaired / Blind).
- ●Medications: None.
- ●Allergies: NKDA.
Recent Notes
- ●Last Year: Certificate of Visual Impairment (CVI) updated. Patient uses a guide dog for daily mobility.
Patient Script
For the friend playing the patient role
Character Overview: You are Ben. You are 28 and legally blind due to Retinitis Pigmentosa (you have very narrow tunnel vision and cannot see in dim light). You are fiercely independent. You are currently training for the London Marathon, running with a tether and a sighted guide runner. Over the last month, you've developed pain in your right shin. Initially, it was just an ache after a long run, but over the last week, it has become a sharp, localized, agonizing pain that hurts with every single step, and it even throbs at night when you are resting. You are terrified of having to withdraw from the race. You are running to raise money for Guide Dogs UK, the charity that gave you your independence back. You feel a massive weight of responsibility to your guide runner, who has sacrificed six months to train with you. You will not volunteer the charity aspect or your fear of letting people down unless the doctor explicitly asks why this marathon is so important to you or explores your reluctance to rest. Consultation Flow & Responses:
- ●The Opening
- ●If the doctor asks an open question: "Hi Doctor. Thanks for fitting me in. I'm hoping you can just give me some strong painkillers or maybe some strapping for my right leg. I'm running the marathon in six weeks and I've got this nagging pain in my shin that's getting quite bad."
- ●Data Gathering (The Layers)
- ●Layer 1: The Mechanism & Overuse:
- ●"I'm running about 40 miles a week right now. I ramped up the mileage quite quickly last month because I felt like I was falling behind schedule."
- ●"I run mostly on the pavements and roads with my guide runner."
- ●Layer 2: Differentiating the Pain (The Clinical Clue):
- ●"It started off just aching after a run. But now, it's a sharp, stabbing pain the second my foot hits the floor."
- ●"It's not my whole calf. It's right on the bone, about halfway down the inside of my shin. If I press that one specific spot, it makes me wince."
- ●"It aches at night, too. It kept me awake a bit last night."
- ●Layer 3: Systemic/Red Flag Screen:
- ●"No, my calf isn't swollen, red, or hot." (Rules out DVT).
- ●"No numbness, no pins and needles in my foot." (Rules out Compartment Syndrome).
If Asked — Associated Symptoms
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If asked about swelling at the shin: "Now you mention it, there is a slight puffiness right over that sore spot. It's not massive, but I can feel a little bump there."
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If asked about pain when hopping on the affected leg: "Oh god, no — I tried hopping at the gym and it was absolute agony. I couldn't do it."
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If asked about pain at rest or first thing in the morning: "Yeah, it aches when I'm just sitting still. First thing in the morning, those first few steps are really sore before it eases slightly."
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If asked about back pain or hip pain: "No, nothing like that. It's just this one spot on the shin."
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If asked about knee pain: "No, my knee's fine. It's all lower down."
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If asked about ankle pain or stiffness: "No, the ankle feels normal. It's just that one patch on the bone."
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If asked about fever or feeling generally unwell: "No, I feel fine in myself. It's just the leg."
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If asked about previous fractures or bone injuries: "No, I've never broken anything before."
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If asked about diet or calcium intake: "I eat fairly well, I think. I have milk with cereal and I eat cheese. I don't take any supplements though."
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If asked about periods / menstrual history: Not applicable — male patient.
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If asked about weight loss: "No, my weight's been steady. If anything, I've been eating more because of the training."
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If asked about bruising easily or bleeding problems: "No, nothing like that."
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If asked about footwear: "I've been running in the same trainers for about fifteen months now. My guide runner picked them for me — I can't really tell if they're worn out by looking at them."
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Layer 4: ICE & The Core Revelation (The Hidden Emotional Weight) - ONLY REVEAL IF ASKED:
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If the doctor asks: "What are you worried about?" or "Why are you pushing yourself through this much pain?"
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Reaction (The Reveal): You look incredibly stressed. "Doctor, I can't stop training. I'm running for Guide Dogs UK. When I lost the rest of my sight two years ago, I fell into a massive depression. That charity, and my dog, gave me my life back. And my guide runner has trained for six months just for me. If I pull out now, I let the charity down, I let him down, and I let myself down. I just need to push through it. Isn't there an injection or something?"
ICE — Ideas, Concerns, Expectations
Actor guidance: Do not volunteer any of the following unprompted. These responses surface only when the candidate directly explores the patient's perspective.
- ●Ideas: Ben doesn't have a specific medical theory. He thinks it's probably "shin splints" from running too much too quickly — something his guide runner mentioned. He assumes it will settle on its own if he manages it with painkillers and strapping. He has no concept that the bone itself could be at risk.
- ●Concerns: His deepest fear is having to withdraw from the marathon and letting down Guide Dogs UK, his guide runner, and the donors who have sponsored him. Beyond the race, he is terrified of anything that could threaten his hard-won independence — if he can't walk, he can't work his guide dog, can't get to the office, and is back to being dependent on others. He will not voice these fears unless directly asked.
- ●Expectations: He wants the doctor to give him something practical — strong painkillers, strapping, an injection — that lets him keep running. He is not expecting to be told to stop. He wants permission to continue, not a diagnosis that forces him to rest.
If Asked — Medical History and Medications
Actor guidance: Respond naturally if the candidate asks about your medical history or medications. Do not volunteer this information unprompted.
- ●If asked about the Retinitis Pigmentosa / eyesight: "I was diagnosed as a teenager. It got gradually worse through my twenties and about two years ago I lost most of the rest of my peripheral vision. I've got a tiny bit of central tunnel vision left, but I can't see in dim light at all. I'm registered severely sight impaired — legally blind, basically."
- ●If asked about the guide dog: "I've had my dog for about eighteen months. She's a Labrador called Juno. She completely changed my life — before I got her I was barely leaving the house."
- ●If asked about the CVI (Certificate of Visual Impairment): "Yeah, that was updated last year. My ophthalmologist at the hospital sorts all that out."
- ●If asked about medications: "I'm not on anything. No tablets, no eye drops, nothing."
- ●If asked about allergies: "No, no allergies to anything that I know of."
- ●If asked about mental health / previous depression: "When I lost most of my sight two years ago, I went through a really rough patch. I was barely eating, not sleeping, didn't want to leave the flat. My GP referred me for counselling and that helped, along with getting Juno. I'm in a much better place now — the running has been a massive part of that."
Social History and Lifestyle Impact
Actor guidance: The following details can be woven into conversation naturally when the candidate explores your daily life, work, or how the leg pain is affecting you.
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Occupation and daily life: Ben works as an audio content editor for a podcast production company. He works from home three days a week and commutes to the office in central London two days a week with Juno. He is proud of his independence and his routine — getting to work, going to the gym, doing his long training runs at the weekend with his guide runner.
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Lifestyle impact of the condition: "The leg is starting to mess everything up. I can't take Juno for her normal walks properly because it hurts too much — I'm hobbling along and she doesn't understand why we're going so slowly. My guide runner drove us to a track session last week and I had to stop after two laps because the pain was so sharp. I haven't told anyone on the fundraising page that I might not make it — I've raised over four thousand pounds already and people keep messaging me saying how inspiring it is. And honestly, the training was keeping my head straight. If I can't run, I don't know what I'll do with myself."
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Negotiation & Collaborative Management Plan
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If the Doctor just says "You have shin splints, take paracetamol and keep running":
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Reaction: "Okay, great. I'll just dose up on Nurofen before my 18-miler this Sunday." (Note: Candidate fails for missing a high-risk stress fracture and enabling a catastrophic injury).
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If the Doctor bluntly tells you "You have to stop running, race is over":
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Reaction: Defensive and upset. "You can't just say that! You don't understand what this means to me. I'm not giving up. There has to be another way!"
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If the Doctor explains it's a suspected stress fracture and the bone could snap:
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Reaction: "Snap completely? Like, a full break? ... Oh god. If my leg breaks, I won't be able to walk my dog or get to work. I'd lose all my independence." (This realization helps him accept the rest).
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If the Doctor discusses safe cross-training (e.g., swimming, stationary bike):
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Reaction: "So I could use a stationary bike at the gym to keep my cardio fitness up without hurting the bone? I can do that. My guide runner could come to the gym with me."
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Safety Netting / Follow-up
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If the Doctor sets a plan for an X-ray/MRI and a review:
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Reaction: "Alright. I'll stop the running for now. I'll get the scan and we'll see exactly what's going on with the bone. Thank you for being straight with me."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Distinguishing Tibial Stress Fracture from Medial Tibial Stress Syndrome
Lower leg pain in runners is common, but the distinction between soft-tissue overuse and bone failure has direct management consequences and must not be missed.
- ●Medial tibial stress syndrome (MTSS / 'shin splints'): Periosteal and fascial microtrauma along the posteromedial tibial border. Pain is diffuse (typically >5 cm), tends to 'warm up' during a run, and resolves with rest. Point tenderness is absent or mild.
- ●Tibial stress fracture: Repetitive loading outstrips the bone's remodelling capacity, producing cortical microdamage. Pain is focal and point-tender on the bone (typically <3 cm), sharp on first impact, worsens throughout a run, and — crucially — persists at rest and at night. A palpable periosteal bump or swelling over the site is a corroborating finding.
- ●The single-leg hop test is a sensitive bedside pointer: agonising pain on hopping strongly supports a bony rather than soft-tissue injury and should prompt urgent imaging.
- ●The clinical triad of focal point tenderness + pain on impact loading + night/rest pain is sufficient to treat as a stress fracture pending imaging, regardless of X-ray result.
Risk Factors for Tibial Stress Fracture
Identifying modifiable risk factors matters both for acute management and for prevention of recurrence.
- ●Training load and ramp rate: The single most common cause is a rapid increase in mileage. A ramp rate exceeding 10% per week is an established risk factor. Ben increased volume abruptly over one month — this is the primary mechanism in this case.
- ●Running surface: Hard, non-compliant surfaces (road, pavement) amplify repetitive impact forces compared with softer terrain.
- ●Footwear: Running shoes lose approximately 30–50% of their shock-absorbing capacity after 300–500 miles. Fifteen months in the same trainers almost certainly exceeds this threshold.
- ●Bone health: Insufficient calcium and vitamin D intake impairs bone remodelling under load. In patients with visual impairment, limited outdoor sun exposure may compound dietary vitamin D insufficiency — this is a directly relevant consideration in this case.
- ●Relative Energy Deficiency in Sport (RED-S): In male athletes, RED-S (low energy availability relative to training load) should be considered when stress fractures occur — it is not confined to female athletes or the classic 'Female Athlete Triad.' Ask about dietary adequacy in the context of training volume.
Investigations
- ●Plain X-ray (tibia and fibula, weight-bearing): The appropriate first-line investigation. Candidates must know that X-ray sensitivity for stress fractures is approximately 10–20% in the first 2–3 weeks — a normal result does not exclude the diagnosis.
- ●MRI: The gold standard. Detects bone marrow oedema before any cortical change is visible on X-ray. If clinical suspicion is high and X-ray is negative, manage as a stress fracture and arrange MRI or refer to an MSK/sports medicine physician — do not discharge on the basis of a normal film.
- ●Bone scintigraphy (isotope bone scan) is an alternative if MRI is contraindicated, but MRI is preferred for anatomical localisation and grading of severity.
Clinical Management
Immediate management
- ●Immediate cessation of all high-impact activity (running, jumping, hopping) is non-negotiable. Continuing to run risks propagation to a complete, displaced fracture — potentially requiring intramedullary nailing and many months of immobility. This must be communicated clearly and with appropriate urgency.
- ●If pain is present with normal walking, a pneumatic walking boot (e.g., Aircast) with or without crutches is appropriate until the patient is pain-free on level walking.
- ●Do not provide strapping, corticosteroid injections, or any pain-masking intervention that would allow the patient to continue loading the bone. A corticosteroid injection at a stress fracture site is contraindicated — it masks pain and facilitates complete cortical failure.
Analgesia
- ●Paracetamol is the preferred analgesic. Use at standard doses as required.
- ●NSAIDs (ibuprofen, naproxen, diclofenac): There is evidence that prolonged NSAID use impairs fracture healing by inhibiting prostaglandin-mediated bone remodelling and callus formation. Avoid regular, high-dose NSAID use. If used at all, restrict to the lowest effective dose for the shortest necessary duration.
Cross-training
- ●Non-weight-bearing cardiovascular exercise — stationary cycling or swimming — allows the patient to maintain aerobic fitness without loading the tibia. This is a critical management point for a motivated endurance athlete and significantly improves compliance with rest advice.
- ●For a patient with visual impairment, practical access to cross-training should be explored: a guide runner or trusted companion can assist with gym-based cycling.
Bone health
- ●Advise adequate dietary calcium (approximately 700 mg/day for adults) and consider vitamin D supplementation (400–800 IU daily), particularly where sun exposure is limited — as it may be for a person with severe sight impairment.
- ●If clinical concern about bone density exists (e.g., recurrent stress fractures, signs of RED-S), consider baseline bloods (25-OH vitamin D, calcium, phosphate, PTH) and DEXA referral.
Footwear
- ●Advise replacement of running shoes that have exceeded their effective lifespan (approximately 300–500 miles). For patients with visual impairment, the practical barrier to assessing shoe wear should be acknowledged — recommend assessment by a guide runner, family member, or a specialist running shop. New shoes should be introduced gradually before return to full training.
Return to running
- ●Recovery from a tibial stress fracture typically requires 6–12 weeks of offloading from impact activity. The wide range reflects fracture grade; higher-grade or cortical fractures at the anterior tibia (a high-risk site due to tensile loading) may require longer.
- ●A graded return follows the principle: pain-free at rest → pain-free walking → pain-free low-impact exercise → progressive running — with each stage confirmed before advancing.
- ●Return to marathon-level training requires structured physiotherapy input; self-directed rapid mileage build-up is what caused this injury.
Red Flags — When to Act Urgently
- ●Complete fracture: If Ben reports sudden onset of severe pain with an audible crack, inability to weight-bear, or visible deformity, this represents a complete cortical fracture — send to ED.
- ●Anterior tibial stress fracture: The anterior cortex is a high-risk site ('the dreaded black line' on X-ray) — tensile forces here impair healing and non-union risk is significant. This requires orthopaedic referral rather than conservative GP management alone.
- ●Neurovascular compromise: Acute severe swelling with calf tightness, pallor, pulselessness, or paraesthesia requires emergency assessment to exclude acute compartment syndrome.
Safety Netting and Follow-up
- ●Review appointment: Arrange follow-up once X-ray results are available. If the X-ray is negative but clinical suspicion remains high, the next step is MRI or orthopaedic/sports medicine referral — not discharge. Make this pathway explicit to the patient.
- ●Symptoms warranting urgent reassessment: Sudden severe worsening of pain (possible complete fracture), new neurological symptoms in the foot (compartment syndrome), or inability to weight-bear.
- ●Mental health: Running has been central to this patient's recovery from depression following sight loss. Enforced rest removes his primary coping mechanism and fundraising purpose. Safety-net explicitly: ask Ben to monitor his mood, provide contact details for the surgery, and offer an earlier review if he notices low mood or anxiety returning. Consider signposting to relevant support (GP counselling, Mind, Guide Dogs UK peer support) proactively.
- ●Accessible formats: Ensure safety-netting information, referral letters, and appointment confirmations are provided in Ben's preferred accessible format (email for screen-reader use, large print, or audio).
Consulting with Patients with Visual Impairment
- ●Direct communication: Speak to the patient, not to any companion, chaperone, or guide dog present.
- ●Do not make assumptions about capability: Severe sight impairment does not preclude high-level athletic performance. A tethered guide-running partnership is a sophisticated and demanding arrangement — treat the patient's athletic identity and concerns with the same clinical rigour as you would an elite sighted athlete.
- ●Accessible information: Safety-netting advice, leaflets, and appointment letters must be offered in the patient's preferred accessible format. Ask directly — do not assume.
Common Candidate Mistakes in This Case
- ●Reassuring the patient on the basis of a negative X-ray: A normal X-ray result in the first 2–3 weeks does not exclude a stress fracture. Discharging Ben after a normal film without MRI or clinical follow-up is a patient safety failure.
- ●Providing a pain-masking 'quick fix': Agreeing to strapping, NSAIDs at loading doses, or a corticosteroid injection to allow Ben to continue running prioritises the patient's stated preference over clinical safety and risks a complete fracture.
- ●Failing to explore the emotional stakes: Ben will not volunteer the Guide Dogs UK charity dimension, his guide runner's sacrifice, or the role of running in his mental health unless directly asked. Candidates who do not explore ICE miss the real barrier to compliance — and miss the opportunity to frame the management plan in a way Ben can actually accept.
- ●Omitting cross-training: Telling a highly motivated marathon runner in peak training to 'do nothing' without offering a safe alternative is both clinically incomplete and practically counterproductive. Stationary cycling and swimming are the key alternatives to offer.
Mapped to the RCGP curriculum topic: Musculoskeletal Health.
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