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1599 Views 5 Replies Latest reply: Feb 9, 2013 9:25 PM by QincyNL
JonDM Rookie 3 posts since
Jul 18, 2011
Currently Being Moderated

Jan 22, 2013 7:02 PM

Question re: a stubborn ankle injury

Hello,

A few months ago I injured my left ankle attempting to transition (gradually) to minimalist running sneakers. It didn’t go away after a few weeks, so I consulted a doctor. Long story short:an MRI revealed tthat I have a type one (mildest form) hypotrophic tear in the tibialis posterior in my left ankle.

Despite some setbacks initially, it seemed like I was steadily improving with physical therapy and acupuncture. After I month I was able to train on an elliptical machine, do aerobics, and ride my bike. By Christmas, I was 75% improved. Then I visited my parents and decided to run a few miles since I didn’t have access to an elliptical machine. I ran four days in a row, and didn’t feel that bad. But then as I was travelling back to DC, I noticed pain in my ankle. It got even worse after Igot back to the city and helped pack up my office for our renovation. Between the running and the packing, I reinjured my ankle. That was 3 weeks ago, and there doesn’t seem to be any sign of improvement. I can’t even do my physical therapy stretches because they aggravate it. Forget about any kind of cardio, let alone running. And the acupuncture isn’t working as well as last time either. All I can do seemingly is sit on my couch with my leg elevated. Even sitting with my feet on the floor irritates it after a while. My doctor had orthotics custom made for my feet (my flatfootedness/pronation was apparently the main cause of the injury). I’ve been wearing them for the past two and a half weeks when I have to walk anywhere, but they don’t seem to be doing much of anything to heal my ankle (although they do keep the pain down somewhat).

Has anyone had an injury like this before? Can you please give me some insight? I’d like to know: how long it typically takes to heal; what the most effective treatments are; and the names of good doctors or physical therapists in the DC area. This injury has been incredibly frustrating, and I’d love to get some guidance from runners who have been through it before. I NEED to get back to running ASAP.

I’m male, 29 years old, 6’1’,and weigh about 185 lbs when I’m running (its closer to 190-195 lbs now). When I’m healthy I run 25 miles per week.

Thanks.

Cheers,

Jon

  • Haselsmasher Legend 518 posts since
    May 25, 2009
    Currently Being Moderated
    1. Jan 24, 2013 4:50 AM (in response to JonDM)
    Question re: a stubborn ankle injury

    I'll offer a few thoughts - but be aware I'm not a medical professional.  So take it all with a grain of salt.

     

    I think it's significant if the tear is in the (Posterior Tibialis) muscle or the tendon.  If in the tendon it can take relatively longer to heel because tendons get little blood flow.  Often what causes Post Tib tendon pain and if that escalates, tendonitis, is a short/tight Post Tib muscle.  Since that tendon wraps behind and below the ankle bone if the muscle is short it can cause the tendon to rub.

     

    While I'm very much not in favor of orthotics for long term use I think with Post Tib issues they can be helpful if used temporarily.  The orthotic is preventing the foot from collapsing, which means the tendon is not moving as much as it would without the orthotic.  So that should be helping in giving it a chance to rest and recover.  Hopefully your orthotics are of the style that they offer a little bit of movement and aren't totally rigid.  My understanding is a little movement is better than total immobilization.

     

    I've found a major help for this can be massaging the Post Tib muscle to loosen it up.  Cross your leg such that the injured ankle is on the opposite knee.  You'll be looking down on the inside of your lower leg.  Take your thumbs and dig into the fleshy part right behind the shin.  Massage deeply all the way from the ankle to the knee.  If it's tender, IMHO, that's a good thing - because that may mean you're onto something.  The first time I did this I was confirmed the next morning that that muscle really needed work.  It was quite sore.  James Johnson who hangs hear likely has other ideas on how to loosen this up.

     

    Jim





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

    -- From the song FM by Steely Dan

  • JamesJohnsonLMT Legend 1,162 posts since
    Aug 23, 2009
    Currently Being Moderated
    2. Jan 24, 2013 2:10 PM (in response to Haselsmasher)
    Re: Question re: a stubborn ankle injury

    Thanks, Jim. I can't think of anything important to add to the accumulated wisdom in your post. It truly covers all the bases. You are careful, tactful, and comprehensive enough that you should be a medical professional!

     

    I'm gonna write about it anyway, though, because I love to write! I'm also going to add some red meat to add to Jon's intensity... RG3!!!  If he can come back from injury, anybody can!  Speaking of coming back, the editing code for the Community portion of Active.com was down for a while, and I could not fix all the mistakes in my post. It's back, so I can tidy it up.

     

    JonDM: in your post, you probably meant hypertrophy instead of "hypotrophy," the medical term for the enlargement of a group of cells without increasing their number. Basically, the Doc is saying there's a lump there. While the rest of us have no way of knowing exactly what and where the doc felt in the Tib P to come up with that diagnosis, we can take him at his/her word.

     

    If the lump is in the muscle, we can't say for sure that it represents a persistent myofascial trigger point, but such a problem could be described that way, especially if there are biomechanical explanations for why such a condition might be likely.  In that case we often share our methods for disarming MTPs, but professional therapists tend to guard their methods, even package and sell them .. not necessarily a bad thing in our free enterprise system, but frustrating and expensive for the average recreational athlete.

     

    Scar tissue could be another explanation for apparent hypertrophy, and would be visible on an MRI, as evidence of a tear. In this case a DC (doctor of chiropractic) trained in ART (active release technique) might be worth pursuing in DC (district of columbia). Just be aware that the techniques for releasing MTPs and scar tissue overlap somewhat, may produce a similar effect for either pathology, but also hold the risk of making things worse, along with wasting time and money. Know your causes before picking your solutions!

     

    If, on the other hand, the MRI image was used to diagnose the enlargement, and it is found instead near the ankle, the common diagnosis of hypertrophy of the PTT (posterior tibialis tendon), due to irritation, inflammation, swelling or the accumulation of fluid (tenosynovitis ), tendon involvement is more likely. Having flat feet could lead to excess motion to achieve stability (usually hyperpronation), which would stress the Tib P and its tendon with repeated eccentric contractions during pronation phase, and excess movement during the return (supination). Even if there was no pronation at all, excess use of the Tib P for stabilization could produce similar results.

     

    Technically, hypertrophy is what happens to body builders' muscles when they enlarge due to training and supplements. Not necessarily a bad thing, but a condition, a "snapshot in time," used to describe things the way they are right now. A look at the Governator shows that this kind of hypertrophy can take years to build up, and years to lose:

    http://0.tqn.com/d/politicalhumor/1/0/N/9/arnold_then_now.jpg

    Other types of hypertrophy, such as tenosynovitis from an overuse injury, can build up more quickly during training, and disappear even faster with ice and drugs.

     

    Faster still, can be the dramatic appearance of a myofascial trigger point, which often takes the form of a lump or thickening as a small portion of muscle contracts, but does not release with the rest of the muscle. As the ad above suggests, an MTP can be shut down in seconds after an appropriate amount of carefully targeted pressure, resulting in release of pressure and the associated pain. The method Jim cites is an example of self-massage for this purpose. It can work if you do it right and MTPs are the only problem. It can help, even when MTPs are only part of the problem, a contributing factor. However, it may not resolve everything that is wrong at this time, including pain during exercise.

     

    I'm willing to bet that you may have at least some of everything discussed so far. 25 miles a week can enlarge your muscles naturally over those seen in sedentary patients. It can also lead to MTPs when those muscles are unprepared for the demands of your training. MTPs, or simple overuse due to excess motion (even excess training) can lead to scar tissue build-up (the collagen adhesions addressed by ART, commonly seen in endurance athletes), or the hypertrophy of swelling and irritation, as in tenosynovitis. The doc simply said there is enlargement of tissue, but the diagnosis rendered does not have to include the etiology or causes leading up to the diagnosis. It is important to know why there is enlargement before planning your comeback.

     

    The why is important, and more the domain of Physical Therapists and exercise physiologists. The flat foot is important, because it can not only be the cause of a biomechanical problem, but the result of one or more such problems, even a viscious circle, as discussed above about the common Morton's Foot. If one or more of the above problems are not solved, 25 miles a week is not a realistic goal at this time. As Jim says, the orthotic is not a magic bullet. It is literally a crutch to stop the proverbial bleeding. Since your arch was not meant to directly bear your weight, but to absorb shock on its own, the object during wear should be to address the Tib P problem, whether it be inherent weakness from atrophy (perhaps during downtime before your recent push), MTPs (similar etiology, but sudden onset during training), overuse symptoms (whether MTPs, scar tissue, or tendon breakdown/irritation), or perhaps some other pathology the MRI could reveal on closer examination, such as stretched ligaments or tarpal bone abnormalities.

     

    I'll also bet that a chronic flat foot has stretched the plantar fascia, which though not necessarily painful in itself, can explain why the foot needs to be propped up. Ah, here's the rub: when you hold up the arch with an orthotic, along with banging out the miles and further stretching the fascia with each footstrike, it's not going to get any tighter. This means the arch will remain collapsed unless the Tib P alone keeps it tensioned, which the muscle was not meant to do by itself. The body is full of redundant support systems, and that one is very important, since it bears all of your weight minus the weight of the feet themselves, or in your case 200 pounds times the momentum of impact, or roughly 600 pounds per footstrike.. Ouch.

     

    Speaking of weight, while most people know that diet and exercise are both important for losing pounds, it is commonly thought that exercise is more important than it really is. Diet is by far more important, so you don't have to gain weight in your down time, just down-regulate your carb consumption and/or alter the timing to change your metabolism in a positive way. Too much emphasis on exercise, particularly vigorous exercise, can backfire by increasing your appetite for carbs. Don't get trapped between an athlete's appetite and the downtime of an injury.

     

    In your case, if you want to heal, you are going to have to continue productive cross-training, like the elliptical you are using, and avoid the temptation to load that injury prematurely. Less impact and more targeted strengthening of the Tib P (without engendering more MTPs in the process), perhaps some therapies to tighten the plantar fascia (pro-inflammatory strategies such as needling techniques or prolotherapy /PRP are examples), maybe rest from impact alone, could allow those dogs to return to their intended condition naturally. Bottom line, it's gonna take more than temporary fixes and a return to the road to accomplish this. You Need A Plan. Maybe these guys are a good place to start:

     

    http://starclinic.net/

     

    http://www.prosportscare.com/

     

    http://www.theorthocentermd.com/physical-therapy

     

    http://www.mdbonedocs.com/OurServices/PhysicalTherapy/tabid/20182/Default.aspx

     

    http://www.quistmd.com/

     

    http://thejacksonclinics2.reachlocal.net/ci/the-jackson-clinics/home/locations/

     

    Message was edited by: James Johnson LMT

  • Haselsmasher Legend 518 posts since
    May 25, 2009
    Currently Being Moderated
    4. Feb 5, 2013 6:48 PM (in response to JonDM)
    Question re: a stubborn ankle injury

    Returning to jump in a bit late..............

     

    James:  Wow.  Really helpful information.  Thanks for putting it together.  You think *I* should be a medical professional?  I think you should look in the mirror. 

     

    Jon:  If you haven't aleady gotten a cortisone injection I'd be *really* careful with that.  It'll mask the pain - but may not do much for long term resolution of the problem.  There are exceptions of course - I'm just relaying what I've heard as well as seen reported on the boards.

     

    Jim





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

    -- From the song FM by Steely Dan

  • QincyNL Amateur 10 posts since
    Aug 31, 2009
    Currently Being Moderated
    5. Feb 9, 2013 9:25 PM (in response to JonDM)
    Question re: a stubborn ankle injury

    Tears to the tibialis posterior are nothing to mess around with... I'm sure you have seen PTTD boots and surgeries etc and the only thing I would recommend looking into before possible arch collapse occurs is eccentric exercises on the area... it has not been tested much in the area but it has been on other injuries (HS, Patellar tendon, Achilles and more) but what it should come down to either way is...

     

    http://www.p2sportscare.com/2012/03/11/how-to-treat-tibialis-posterior-tendon-dysfunction-huntington-beach-orange-county/

     

    1st you need to make the muscle/ tendon function the best it can (release scar tissue etc ) ART is a great option http://www.p2sportscare.com/for-skeptics-only/what-is-active-release-technique/

    2nd strengthen areas of weakness (Look at Pubmed)

    3rd slowly build into your normal activity

     

    You should be seen by a medical professional though... I would not try to tackle this on your own

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