Visit to Ortho / Peroneal tendonitis
Saturday, September 21, 2013
I've been eating up running books like they are candy. Why? I suppose because I was born broken and became broken-er and never really liked exercising before. Then I found running. I am still broken. But I am motivated to overcome the issues I can and ignore or tolerate those I can't because running is what I like to do. Despite the fact that I suck at it. I am slow, loping along at a pace my lungs can handle, a 10 minute mile most days, sometimes less.
I haven't signed up for any more races. The last race included many paved and bark path hills and a steep sand dune hill (up and down). The hills did not hurt in the least at the time, but I also was working clinical rotations with 6 hours of standing on my feet. Within two days, I was wondering if the next race would injure me so I couldn't even work. I didn't understand this since leg pain has not been an issue before. Running itself has never hurt, only standing at work. And since I live in Oregon, I run small hills all the time. I even live on a mountain shelf (well, my mother refuses to call it a mountain because it rarely gets more than a dusting of snow but it DOES go almost straight up, dizzyingly) and trudge up it now and then to check fences or just for the peace and quiet of looking down on my ant-sized car and house below.
I knew for years that my right leg was much longer than the left. When it got to be really hot outside, I started running on the treadmill and couldn't stand to listen to myself, so I put a drugstore shoe insert inside my left shoe. It was only 1/8" deep, but I sounded better... and had less lower back and hip pain. Hmmmmm, I thought. This obviously isn't the cause of my upper spinal issues, but maybe my leg length difference is compressing some lumbar nerves. So I got a thicker drugstore orthotic and tried that. The clip CLOP sound was not only gone, but so was about 50% of my lumbar and hip pain - as long as I was wearing those shoes. So I bought more inserts, threw away all the right feet and stuck them in all my left shoes. Now I have to remind myself not to go around barefoot anymore. Pretty soon even my right knee which has a torn meniscus, was feeling better, no doubt because it no longer had to travel so much more than the left leg, because I'd lessened the leg length difference with the shoe inserts.
But that didn't solve the other problems, the ones caused by the combination of sand dune plus clinicals... suddenly my right ankle was severely swollen right ankle by the end of every day. I had inverted (sprained by turning outwards) this ankle repeatedly in the past but not recently. This foot has always been oddly flexible, like a ballerina's. Meanwhile, my left foot has started to creak and crack with arthritis. I had Achilles tendon pain in both legs and IT band pain in my right leg. Where were all these pains coming from?
I used to be an anatomy tutor. So I got running and sports injury and anatomy books wherever I could find them - the thrift store, the library and Amazon. I started putting together a program for recovery.
Basically, I limit impact on my feet. I use an Arc Trainer for warm ups. This is like an elliptical, but you can dial the incline down to zero. I "jog" for 5 minutes, then "run" on it, moving at 150 or more strides per minute for at least 1.6 miles. I usually try to stay un-bored long enough to do 2 or more miles. Then I move to the treadmill or the track to do "speed" work. (A "jog" to other runners, I am sure.) Or I stretch and do strength training.
One book - Running Anatomy by Joe Puleo - really stands out of the literally 2 dozen or so I've gotten for helping me in formulating a training plan. It covers the whole body and shows why certain strength, stretch and plyometric exercises are helpful.
I made an appointment for the only sports podiatrist in Roseburg - Cordell Smith. He is a marathoner and is fabulous. When I said "I have pain from the lateral malleolus to the fifth metatarsal base but am edematous primarily at the calcaneous", he respected my knowledge and listened. He didn't blow me off as someone who memorized something off the internet. We talked about previous history, leg length difference, and that I hoped that orthotics with inversion prevention and that a heel lift for the left shoe would help me with ankle pain and my IT band pain. I brought in an assortment of shoes - my trail runners, my gym shoes and two pairs of walking shoes. My right shoes all show an "under-pronator" wear pattern, bordering on supination. My left shoes show under-pronation, no supination. He measured my leg length difference and came up with 3 cm - more than an inch.
I always knew I was a twisted chick!
We looked at the x-rays together. No broken bones, not even in the past, which somewhat surprised me. A couple of those sprains felt pretty bad. I have a bone spur at the superior edge of each heel, at the insertion for the Achilles tendon - and the spurs are long and sharp, like upholstery tacks. So that is the source of my pain. Why did the pain start suddenly? The sand dune hill, no doubt, because my calf muscles are not balanced in strength. (This is my theory, not his. I think I need to strengthen the soleus.) Bone spurs are surgically removed as a last resort. Also, the sand dune, not being at all firm, encouraged my right ankle to supinate.
He showed me the insertion points for the tendons of the Peroneal Longus and Brevis, which tuck behind the lateral malleolus and insert at the 5th metatarsal - my pain sites exactly. He said that orthotics with extra support on the lateral footbed will help with the ankle roll/supination problem. The x-ray was not clear enough to show if there were any small tears in the tendons.
He pressed my feet into some dusty pink styrofoam stuff to make molds. I frankly doubted it was as accurate as previous casting materials, but he showed me that you could see I had three arches in my right foot - a medial arch, a lateral arch and a metatarsal arch. He said hardly anyone has an lateral arch. Meanwhile, my poor left foot casting looked like a blob. I had to admit the pink dust caught more detail than I thought. The technicians don't need the details of my foot wrinkles. They are not going to read my fortune off these castings.
The diagnosis for insurance? Peroneal tendonitis. The cost of my orthotics? Depends on how much insurance plans to cover. Could be as much as $425 for the first pair.
My personal plans to strengthen the ankle? There are a lot of exercises in the running injury books - mostly using exercise bands and moving the foot around. These are also freely available on the internet. Also recommended are drawing circles with the big toe.
According to Running Anatomy, heel raises with weights (dumbbells or a machine) will exercise the peroneus brevis as one of the secondary muscles. This is the only book I've seen that also gives the recommendation that I remember from my favorite anatomy teacher.
Bryan Nichols at Lane Community College told us that when he was working in sports medicine, he was hired as a consultant to University of Oregon's football team - the Ducks. Everyone in town loves the Ducks so the class listened with rapt attention. The coach was concerned with how many ankle injuries the team was suffering. These fellows were strong and fast from a secret program of explosive plyometric exercises. However, somehow their ankles kept bringing them to the ground. The coach wanted to know what kind of weight training program would strengthen them.
Brian's answer was to have them stand on one leg, hold their arms out to the side and shut their eyes. We giggled because it sounded so easy and he made us stand up and do it. Then he had us switch legs. A lot of us could stand reasonably long on one leg, but not on the other. We wobbled like drunks.
So part of my rehab will be to train my proprioceptive balance. Standing on flat feet, on tiptoes, holding one weight and bringing it down to the floor while simultaneously bringing my other leg up behind me. (I already was doing the latter exercise with a kettlebell. I suck at it while standing on either leg. I wobble and put my foot down all the time.)
I have great hopes for the future. I'm sure I'll have another race by Thanksgiving.
P.S. If anyone reading this is just beginning a running career, is having pain issues and is not receiving much help from the medical profession (ugggh - my previous experiences with PT) - I recommend beginning with the books Running Injury Free and Healthy Runners Handbook.