Tuesday, January 4, 2011

Achilles' Ankle

My running plan for 2010 was to join the New York Road Runners, run nine races and volunteer for one, and qualify for the New York Marathon for 2011. 

I'd had miscellaneous issues with my right ankle and my knees over the course of getting into barefoot-style running in 2009 and early 2010, but I thought I had sorted all that out.

Then I ran the Brooklyn Half Marathon: I finished, and started limping.  I'd done a 20k prior to this race, and my foot was fine, although I had runner's knee from running in my MT100s prior to and during the race.  But running the half in my new Bikilas left me with an injured metatarsal-cuboid joint, a joint I wasn't aware I'd possessed.  After attempting a few more runs, including a 5k race the following weekend, I realized that I had a problem.  The New York Marathon was obviously not a reasonable goal if I couldn't even finish a half-marathon without a six-week recovery window.  I'll note that this injury felt far better when walking around barefoot than it did even in Vibrams.

So I started analyzing the situation.  I recalled that when I started running in Vibrams, I'd had a number of issues with my right ankle, but through form adaptations I'd managed to make the acute pain disappear.  But I continued to have issues at longer distances, and when trail running over rocky terrain.  I began to realize that I had been compensating for the injury, but that this compensation fell apart at longer distances and rougher terrain.  I also recalled that 3-4 months before reading Born to Run and recommitting to running in Vibrams I had severely sprained my ankle while mountain biking.  The ankle didn't bother me while wearing shoes, though.  Apparently I just didn't use those muscles while wearing shoes.  I was able to compensate by holding the ankle rigid while running: this worked, but put stress on the metatarsal-cuboid joint (hence the pain in the Brooklyn Half), and stressed the Achilles' tendon on rough surfaces (hence the pain while trail running).

So I decided to attempt to resolve the issue in two ways:  First, since the metatarsal-cuboid joint pain basically went away when barefoot, so I started running barefoot and not just in Vibrams.  After getting nasty blisters on the 4th and 5th metatarsal heads (just before the toes) on the second run, this seemed to work pretty well.  The supination that lead to those blisters was also the motion that was causing the metatarsal cuboid pain (putting weight on that joint in the wrong way).  But the movement was too subtle to be conciously apparent.  I needed a mechanism to auto-correct the movement, and barefoot running provided the feedback.

Second, I noticed that when doing the potty squat (or Asian squat) my right ankle was less mobile, and my right foot over-pronated compared to the left.  So I commenced doing regular potty squats to try to improve this.  I also made a conscious effort to keep from holding my right ankle rigid using my Achilles' tendon.  This was problematic, as I kept reverting back when I stopped thinking about it, but it did improve things.

My reward from these efforts was shooting pains on the inside of my ankle.  I regard this as a good thing: I was now bypassing my compensations, and was actually stressing the weakened and injured parts of my ankle. The metatarsal-cuboid joint pain disappeared, and the Achilles' tendinosis improved when running on rough surfaces.  The ankle did get stronger, and while I had these pains running in Colorado and when running the Reach the Beach Relay, they didn't seriously impede me. 

I managed a 20-mile round-trip run/walk up Pikes Peak, did another 7.2-mile run up Waldo Canyon, and did 16 miles in 24 hours during the relay, and so figured I had slain the beast.

So with high expectations I entered the Paine to Pain Half Marathon.  I decided to wear my New Balance MT100s, and then when they came out, the very similar MT101s.  Unfortunately, around the 5-mile mark for the training run, and the 6-mile mark for the actual race, I started getting IT band pains.  Serious IT band pains.  While I was able to manage a somewhat decent time (for a guy who limped the second half of the race) it was not fun and left me with a six-week recovery window.

And unfortunately, unlike my prior injuries which went away almost immediately when I reverted to Vibrams or barefoot, this was a real injury, apparently, and I had to wait it out.

So I continued to work on my ankle, do the potty squats, and try to use both feet in a symmetrical fashion.  The ankle seemed to improve.  Then "the jerm" posted this on Barefoot Ted's Google group:

"and the winner is! Posterial Tibial Tendonitis/ dysfuntion. x rays showed no signs of fracture or bone degeneration or abnormalities. ultra sound is next week sometime to check for inflammation and/or edema. the doctor complemented me on my complete lack or arch, and really thinks i need orthotics, i will give him some props he did mention the study on custom vs. store bought and how they showed no difference, but then said each persons foot is different and need them made to fit properly. sooooo i guess i'll be cross training and p90xing for a a while and elipticaling and swimming. any other suggestions to keep my cardio up and impact down?"
I replied:

"Cool! That sounds very similar to the issue I'm having!
http://orthopedics.about.com/cs/footproblems/a/posteriortibial.htm

"Especially the bit about the sprain, the flattening arch (especially obvious when doing the potty squat), and being unable to stand on the tip-toes on the affected foot. My right foot also points out more than my left, just as described.

"Thanks for posting!"

As I noted in my that thread, the treatments they prescribed at about.com for that problem were absurd.  I did the rest part inadvertently, but wearing sneakers.  But I had clearly had no improvement in function, the initial injury was 1 year, 9 months ago, at today's date.

I started doing some exercises to strain the affected area: sort of like doing eccentric heel drops for Achilles' tendinosis, if it hurt me, I figured it was doing some good.  And things seemed to be improving, albeit slowly.  I was able to do nine-mile trail runs in my favorite local park with little pain, and the Achilles was doing much better than before.

When ski season started, I also noticed that I was using my right ankle and foot differently.  I was getting ankle pains, but was also jamming my right big toe against the front of the  ski boot.

I mentioned all this to my trainer, who's been hugely helpful to my progress through this, and he stated that he didn't think the problem was the in the ankle at all.  He thought that the problem was likely in the hip, and the ankle was just showing strain as a result of a problem elsewhere in the system.  I scoffed, but agreed to do the exercises that he said would demonstrate the weakness.  Well damned if he wasn't right.  By having me lie on my side and lift my legs, and then attempt to resist his downward pressure on my legs, he conclusively demonstrated that my gluteus medius and minimus (more bits I wasn't aware I had) were much weaker in the right leg than in the left.  He also had me attempt to balance on a bent knee (you know, the way you do when you're running) on both legs, and while I was rock-stable on the left leg, I wasn't able to do it well on the the right.  The gluteus muscles terminate in the IT band, and this would explain why I had the IT band issues while running the Paine to Pain race.  The combination of the cushioned shoes and a leg that was too weak to stabilize itself effectively on the cushioned shoe was a double-whammy. 

I'd managed to improve my ankle enough to get to the next weakest point in the chain.

So the next time I went skiing, I worked on the right leg, forcing myself to use both legs evenly.  I hadn't even realized how asymetrically I had been skiing, especially in the moguls.  I noticed that my right foot had changed quite a bit from the prior season. (Nothing like stuffing your feet into a block of hard plastic to draw your attention to how your feet have changed!) A bunch of settings that I had done to my right foot needed to be undone, as my right foot seemed to be becoming more like my left. This was on a six-year old pair of boots, btw.  So clearly, as my trainer sugested, the issue was a preexisting one.  He thought that the sprain 18 months ago was probably due to the weakness of the leg, not the other way around. 

I was explaining all this to my wife with my eight-year-old daughter listening, and she piped in and showed me an exercise that her dance teacher had taught her.  The exercise was specific to all the muscles I was discussing (and hurt me like heck to do in my right foot!).  My daughter explained to me that most people have one leg weaker than the other, and that this exercise was specifically designed to address that.  From the mouths of babes!  I'm adding this exercise in, it was more effective at hitting the weak area than anything my trainer showed me!

I also noticed that the attachment point of my posterior tibial tendon (under the arch) was bothering me a bit after the latest bout of skiing.  I want to stress it, but I need to be careful about not over-doing it.  I also had a fair bit of itchiness there, inside my foot.  A weird feeling, but not a bad one.  Perhaps this indicates healing, as itchiness generally does, or maybe some scar tissue breaking free?  A short run on the treadmill in Vibrams cleared this up.

So between skiing evenly and doing a bunch of new exercises to address the weak gluteal muscles, I think I'm well on the way to defeating this.  I can already start to feel the strain in my knees as the next-weakest part of the link becomes stressed.

One other thing that I noticed was that when I stood at rest, I bear most of the weight on my left leg.  As my trainer observed, "That'll do it.  20 years of standing primarily on one leg and you're left with a big imbalance."  So I now try to balance on both legs, and this is part of the exercises I'm doing.

For 2011 I'm back to the plan for 2010, hopefully this time the legs are both strong enough to get me through it.

None of this would have been possible without barefoot-style running.  I never even realized that my ankle didn't heal properly after the sprain.  In sneakers I used the muscles in my foot and ankle so little that it didn't matter that they were injured and weak!  No doubt I was set up for worse sprains and injuries in the right ankle as time went on.

I hope that this is useful for you folks.  Unravelling this took a lot of patience, a lot of attention to minute signs from my body (some of which, like the initial ankle pain upon running in Vibrams I should have been more attentive to), and being very open-minded.  I thought my trainer was nuts when he told me the problem was likely, at least in part, in my hip, but sure enough, he was right.

P.S. One other useful tidbit of information that helped me figure out what was going on was from Robb Wolf's interview of Tim Ferriss.  Tim Ferriss mentioned that one of the things that helped him deal with some of his niggling little problem was to divide his body into quarters, and address the weakest quarter, to equalize the strength, and therefore the stress, on the body.  He mentioned that this alone caused a lot of annoying aches and pains to go away.  It makes perfect sense, and as I was already doing this with my right arm versus my left (I'm left-handed), opened me up to the same idea concerning my legs.

P.P.S. Exercises here and here.

P.P.P.S. Achilles' Ankle and Lee Saxby, a follow-up post.