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602 Views 3 Replies Latest reply: Jan 18, 2013 12:49 PM by JamesJohnsonLMT RSS
CourtneyMoriarta Rookie 1 posts since
Nov 11, 2011
Currently Being Moderated

Jan 14, 2013 12:38 PM

Ankle/Heel Pain!

I've been an on again, off again runner for the past ten years.  Worked my way up to 20+ miles per week last year and have stuck to it for over 6 months.  Two weeks ago, out of nowhere, ankle pain flared up in the middle of a 9 mile run.  Pain started on inside of my ankle from ankle bone to heel and got worse as I ran the last few miles.  I elevated it when I got home and could barely walk by bedtime. In the past two weeks, I've only attempted running once, managed 1.5 miles and quit.  The pain seems to migrate around, sometimes on the inside of my ankle, sometimes on the outside of my ankle, sometimes with swelling.  I can pedal a bike pain free and this seems to help get the swelling down and ease the pain (go figure?).  Standing, walking, and running send pain up through the bottom of my heel.  The area from my ankle bone to heel is tender on the inside and outside of my ankle if I apply pressure.  The heel doesn't hurt at all with pressure from my fingers, only when I stand on it.   I have almost full range of motion (it's a little tight when I try to turn my foot out.)  I saw the doc, got an x-ray, and there was no obvious stress fracture.  Other than that the diagnosis was inconclusive.  He said to come back in 3 weeks for an MRI if it doesn't get any better!  Meanwhile, I'm going crazy.  Anybody have any clue what this is?  It doesn't seem to be Planter Fasciatis -- the pain is contained to the area directly below my ankle bone (not along the arch or anywhere else in my foot other than the heel) -- it just moves from one side to the other.  I haven't done anything new -- same old mix of road and treadmill running, I've been wearing the same shoes for 8-9 weeks with less than 200 miles on them, same weekly mileage, etc.





"I can, I will, and I do." -- Maureen O'Hara, The Quiet Man

  • Haselsmasher Legend 507 posts since
    May 25, 2009
    Currently Being Moderated
    1. Jan 14, 2013 7:02 PM (in response to CourtneyMoriarta)
    Ankle/Heel Pain!

    I had something similar a number of years back.  The pain moved around and I couldn't figure out what was wrong.  I went to a Physical Therapist and it turned out my hips weren't working well.  In some when that happens it just causes a chain reaction down the look.  Basically everything else has to take up the slack for something above that isn't working right.  Depending on your particualr physiology that might cause the weakest link in the chain to yell 'I've had enough!" - and start complaining.  In my case, just by getting the hips working correctly the leg/ankle issues just went away.  I'm not saying that's your  issue per se - but rather there may be something going on away from the ankle that is the root cause of your problem.  (Although from what you describe it also sounds like you've got to heal some tendons or something by your ankle.)

     

    I'd get to a good PT - along with making sure your doc says there are not major acute issues.  I believe the classic heel stress fracture test is to squeeze the heel - with the fleshy part of the palm at the base of the thumb on one side of the heel and fingers on the other side.  Depending on the length you've had the pain a stress fracture may not show up on an x-ray.  A stress fracture that has been healing for a while will - but an active/current one - in most cases I believe - will not.

     

    Good luck.

     

    Jim





    http://jimhaselmaier.blogspot.com/


    "Kick off your high heel sneakers, it's party time."

    -- From the song FM by Steely Dan

  • BOSNPM We're Not Worthy 2,482 posts since
    Nov 20, 2007
    Currently Being Moderated
    2. Jan 15, 2013 5:47 AM (in response to CourtneyMoriarta)
    Ankle/Heel Pain!


    Do a search for Pergneal Tendonitis, might be it.

  • JamesJohnsonLMT Legend 1,150 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Jan 18, 2013 12:49 PM (in response to CourtneyMoriarta)
    Re: Ankle/Heel Pain!

    I'll take my turn here with respect to the chronology of your account, which is fairly complete.

     

    A lot of us do on-off running due to injuries, or because life gets in the way. It's OK to have gaps in our running for any reason, because we can always get back whatever we lose when we're willing to go through the growing pains all over again. The problem with down-time is that rest comes at a price. Our bodies tend to take away what they do not need to match the demands of activity.

     

    There are cross-training and dietary interventions that can limit the atrophy, but it still takes time and effort. After any layoff, it is still wise to scale back on training goals to allow for reconditioning. The general rule of thumb is to allow two months for every month off, to regain lost fitness, even if it is not felt right away, even when the rest is refreshing enough to lure us into a false sense of readiness.

     

    My guess, from your account, is that you increased your demands to the 20+ level when it might have worked better to settle for an earlier goal, at least long enough to work off any losses after the last dip in your schedule. In that case, it would not be unusual to experience your kind of pain after 6 months of an advanced schedule takes its toll.

     

    Your description of pain is good enough to hazard another guess about the cause. The usual approach, even among professionals, is to take pain at its word for pinpointing the location of an injury. This is often a mistake when overworked muscles are involved, since we are "set up" to feel pain remote to the muscles involved. Otherwise, every stride would hurt. When tension or damage builds to a certain point, vague pains start moving around the way you describe, because they are often not caused in any of the apparent locations of the pain. In this case, one or more calf muscles appear to be jacked up enough to refer pain to the general vicinity of the ankle, which is of course operated from those muscles above the ankle, as are the heel, arch, toes, etc.

     

    The mention of peroneal tendinitis might cover some injuries to the lateral lower leg, but does not explain the pain inside the ankle where there is very little tissue involved. Moving pains are a search by the brain to produce an accurate image of an injury based on input from sensory neurons. It's just a guess based on input, and not an accurate self-diagnosis in many cases. Do not be surprised if, when running the symptoms past a professional for differential diagnosis, it "turns out" that they also think it's one thing or another based on such bogus symptoms. It takes more work to tease out the real cause, but you do not have to wait for that.

     

    You have already noted that there is tightness when you turn your foot out. This motion is involved in pronation, and stretches the muscles which supinate and/or invert the foot, essentially returning it from pronation. The more exaggerated this movement becomes, the more likely a repetitive-motion injury will be. Such injuries are most likely to become evident in soft tissue such as muscle, before moving into tendonopathy and fracture. It is common for runners to ignore these early signs, and continue to train beyond the integrity of soft tissue to more serious injuries to tendon, tendon sheath, ligaments, and bone. It is still possible for your injury to be in soft tissue, evidenced by the movement of pain symptoms in a pain-referral pattern. I hope you are acting in time to prevent more serious injury.

     

    Before I proceed, you should read the following report (PDF file, needs Adobe Reader) on ankle and foot pain by two doctors involved in sports medicine and orthopedics at the University of Minnesota: http://www.ithaca.edu/hshp/ess/AT/Articles%20&%20Documents/SMAT%20Journal%20Articles/LE%20Injuries%20Eval/Hyperpronation%20and%20Foot%20Pain.PDF

     

    You can see from the above article that foot pain and the many possible diagnoses appear to be quite complicated, but boil down to two main interactive causes - Structure and Function. No matter what snapshot in time a given diagnosis represents, these two main causes pose a "chicken and egg" question: Does structure influence function or vice-versa? The answer, like the egg, is "both." As many PTs will note, (Jim's experience is an example), The use of the hips can result in damage to the lower extremities (see article, about halfway down). It is also possible the other way around. Issues in the feet can work their way up to the hips, back, and beyond in a vicious cycle.

     

    Hallux Valgus, or bunions, are a very good example. Jim's success with barefoot running goes well with the article's mention of Hallux Valgus being present mostly in shoe-wearing societies. Bunions are also seen in shoeless cultures though, so it invites more scrutiny than the effect of shoes alone. I have often mentioned how important foot structure is to the action of the foot, and eventual effects on the rest of the body. One problem I find with the doctors' article is that there is little mention of this. I consider it to be very important, since there is great variety in foot structure, evidenced by the differing results individuals get with/without various shoes. The structure of your foot is very critical to determining the nature of your injury, your biomechanics, and what you can do to optimize these things.

     

    Not to overshadow the biomechanics above, especially in the hips, another problem associated with modern culture is the effect of just sitting in chairs, car seats, etc., on the shortening of intrapelvic and hip-flexor muscles, which translates into lower leg and back dysfunction, even causing neck and shoulder pain, including headaches (but that's another story). Bottom line, it's a good idea to have a good look at how you are built, and how you use what you have. This is where an expert analysis of your treadmill running, via slo-mo video, can reveal a lot. Many PTs with sports experience can do this. Running stores do it too, but with a motive to match you with a particular shoe type. As Jim says, sometimes you just need to "kick off your high-heeled sneakers" and figure out how your foot moves naturally. The sensitivity in your ankle area is a good indication that your nervous system is in high-alert mode. Whether this is actual injury, biomechanical faults, or simply overworked/unprepared muscles (my choice), you need to find out why.

     

    As you recounted above, MRIs have been taken to look for advanced pathologies with no results, so it's time to do the hard work that MDs often have little time for. Two docs that have grappled with this issue wrote the article above with that in mind. Of the many possible diagnoses based on symptom, function can perform as an effective filter to rule out false positives. This is the realm of the PT, but your role in accurately observing and reporting is just as important. I would start by examining the muscles of your rear calf at various locations and depth to find out why some motions seem tighter than others.

     

    The involvement of the PTT tendon can point to supinator Posterior Tibialis (center rear calf, deep to the Soleus/lower Gastroc), and its associated pain referral pattern around the ankle. It would be strained by countering excess pronation, which could in turn be influenced by foot structure and/or hip function. You may have already found tightness and a resulting pain pattern, but may not find sensitivity in the muscle itself. This does not matter as much as it may seem. Just make an attempt to influence the tone of the muscle with as much deep pressure as necessary to cause it to relax.

     

    Relaxing an overworked muscle can result in temporary relief or remission of symptoms, but by no means is a cure to whatever caused the problem in the first place. Once again, I think you may have  bitten off more than you could chew with your schedule, but hyperpronation, foot structure, and hip dysfunction would create the problem anyway at a certain level of training, with no overtraining required. Ruling these factors out is your next step. Good luck, Courtney!

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