Posterior Tibialis Tendonitis

In 18+ years of running, I certainly have made the rounds of all the different types of tendonitis!

Patellar Tendonitis: Spring of 2008
Peroneal Tendonitis: Fall of 2009
High Hamstring Tendonitis: Summer 2013
Achilles Tendinitis: Fall of 2017

I can now add to the list Posterior Tibialis Tendonitis. Here's how it happened.

December 8: CIM

Before CIM. No tendonitis!

Upon completion of the marathon I noticed a pain in my arch. It hurt as I walked back to the hotel, and when I took the Vaporfly Next% off of my foot- OUCH. It was a burning pain of about 6 out of 10 on the pain scale. It seemed as if the shoe had been rubbing against my foot in a certain way to cause this arch pain. It bothered me for the rest of the day and and into the following day.

December 9 - 15: Marathon recovery
The pain went away completely two days post marathon. So much so that I forgot about it.

December 16 - 20: Easing back into running
I resumed running with short, easy runs of 30-50 minutes. I didn't have any pain in my foot.

December 21: First post-marathon symptoms
I did an 11-mile long run and the arch of my foot started to hurt about halfway through. It was maybe about a 2 on the pain scale, so I wasn't concerned. As I walked around on it for the rest of the day, I noticed that it felt off, kind of like a tight muscle.

December 22 - January 9: Blissful Ignorance (or denial)
I continued to train, doing hard workouts on the track and long runs of 10-13 miles. I even ran a 5K on New Year's Day without any problems. My foot would bother me a little, but it was more of an annoyance than anything else, never getting above a 2 on the pain scale.

After my long run on January 4th, my foot hurt more than normal, which caused concern. It was mostly okay during the run, but afterwards it was about a 3.5 to 4 on the pain scale for the rest of the day. Very tender to the touch and I could feel it with each step. That's when I realized I would probably have to address it. I continued with my training plan and track workouts until I could get in to see my physical therapist on January 9.

Diagnosis!
It didn't take long for my PT to diagnose me with posterior tibialis tendonitis; I had classic symptoms. The two areas of pain were on the bottom of my foot, where the tendon connected, and on the side of the foot, about one inch forward from the ankle bone, and one inch below. He told me I would need to take some time off running to let it heal. Not the news I wanted.

Area of pain - feels like a sore ache

This issue wasn't caused by "overuse"-- it was caused by my shoe rubbing the wrong way during the race. So how does that result in tendonitis?!  My PT had a theory that it could have been because the shoe had an 8mm drop (as opposed to the 10mm I normally wear) and it was extra bouncy, causing my foot to pronate, where it normally does not pronate. Or, it could have been rubbing against my arch the wrong way, which irritated the tendon, and now it's going to take a while to calm down.

So. . . couldn't I just train through it like I trained through Achilles tendonitis? He said that this was different and I needed to ease up to give it time to heal. Of course, in addition to doing exercises. He was concerned that I took a week off post marathon and it came back. And he said that this is a nagging injury and tends to come back unless you treat it with the exercises over several months.

January 10 - 13: No running; pool workouts only
I took four full days off of running, but I went to the pool every day. I mainly did deep water running with a floatation belt, but I also added in some swimming to save myself from boredom. And I simply enjoy swimming. I would do it all the time if it were more convenient.

January 14 - now
After my four days off, I started running again, but only 3-4 miles per day. And that's where I am at now-- I just finished a 3.5 mile run in the snow. And of course, I have been religious about my exercises. Rest alone won't heal this; I need to load the tendon with weight.

I'm now at a point where I don't feel any symptoms while walking around during the day, which is a big improvement. However, after about two miles of running, I do start to feel some soreness on the bottom of my foot. Since I'm only running 3-4 mile easy runs, this pain has been about a 1.5 to 2 on the pain scale, and I am back to being symptom free five minutes after stopping.

I also bought a pair of the Mizuno Wave Inspire-- a shoe I stopped wearing over a year ago when I was told I was a neutral runner. I am a neutral runner, but the added stability will reduce the load on the tendon as I recover and the firmness of the shoe will help too. My PT told me that cushiony, bouncy shoes were bad for this injury.

Looking ahead
I'm trying not to look ahead and take this one day at a time. I have no idea how bad this is going to be. Once I start increasing my mileage (next week) will the pain come back while walking around during the day? Will it become more painful so that I can't run? My PT said that I can let it get to a "3" on the pain scale. But anything above that and I need to stop running and go back to a reduced load. Thankfully, I haven't felt a 3 or above since the day of my long run two weekends ago, and I want to keep it that way.

If this had happened a month out from Boston, I probably would have continued to train through it at full intensity and waited until after the race to rehab it. But since Boston is still over 12 weeks away, I feel like I can get away with easing up on the mileage now and still run a strong race.

How I feel
Of course, this sucks. I'm generally optimistic because as I said above, it wasn't like I was overtraining or anything. It was caused by the Vaporfly during a marathon, so once it calms down it shouldn't come back. I'd be discouraged if my normal running routine caused this.

I basically have some loathing of CIM, though. I tried to be positive about my experience there, but now I just look back on that race with regret. I had a perfect training cycle and I was in the best shape of my life. I went into that race healthy and with no issues. I ended up having a difficult race, missing my goal time, not getting a PR, and ending up with an injury.

My primary positive takeaway from that race was that I had such a great training cycle and it would set me up well for my Boston cycle. But now just the opposite is true. The race set me up to start my training cycle off with an injury. If CIM had been the race I had hoped to run, I wouldn't be as peeved about this. I would have been "worth it." I'm glad CIM is behind me, and I'm never going back there and I'm on the fence about ever putting my foot in a Vaporfly Next% ever again.

Phew! Glad to get that off my chest. I am sour, but I have been distracting myself with my pool workouts and focusing on the healing process. So generally, I am in a good spot mentally. I still think I will be able to run well in Boston, and at least participate (if not run fast) in the races I have signed up for this spring.

Video Gait Analysis

Several of my teammates had their running gait professionally analyzed by Dr. Maggs, a sports chiropractor, and provider of other rehab services, and I thought it would be beneficial for me to have my gait assessed as well. I mainly wanted to understand how I could run more efficiently and reduce injuries.

The process was a quick warmup around the parking lot for about 1/3 mile so that I could get into my natural stride, and then Dr. Maggs would take video of my running from different angles. Here's the video:



And here is another video from a different angle. I feel like the camera is adding 10 pounds here. I swear I don't look that heavy in person!!!



I know this isn't supposed to be a vanity video, but I can't help thinking that it highlights my extra energy stores.

Anyway, after the video was recorded we watched the play back in slow motion, frequently pausing the video. The main area for improvement was my hips. I'm lacking in hip flexor and glute strength so when I land, my opposite hip droops down out of alignment. He said that this is a moderate problem and that it's more noticeable in other runners, but it's definitely something that should be addressed. I do it more when I land on my left foot, resulting in my left foot pronating more than my right foot. He told me I looked completely neutral in my right foot and that the Brooks Adrenalines are probably too much stability for me.

His theory on my peroneal tendon issue is that I don't pronate on the right foot so my stability shoe is causing supination (the opposite of pronation). While I can see how this might be contributing, I ran far more miles in 2010 in the Adrenaline than I am currently running with no injuries. I think my foot slapping correction is the more direct cause, although eventually I might move away from the Adrenaline.

Dr. Maggs gave me a series of strengthening exercises for my glutes and hip flexors that specifically mimic running motion. He said that you cannot consciously change this gait issue-- you simply need more strength and targeted exercises. This is good because the last time I consciously changed my gait I ended up with Peroneal issues! Eventually he thinks I can move to a more minimalist shoe once I correct the hip weakness. I started the exercises last week and will continue to do them. I just worry about overdoing it and being sore for a run.

The good news is that overall I have good running form. He says that my cadence is close to perfect and my posture is excellent (thank you ballet!) He said if he had to nit-pick, I was over-striding very slightly, but it was barely noticeable. I was really expecting there to be all sorts of problems, but I was happy to learn that I only have one real area for improvement.

Here is a link to the gait analysis results for Katie, Amy, and Cristina.

Update on the foot. I took six full days off of running (I did pool running, swimming and the elliptical instead). On Thursday, I ran 4 easy miles near my gym so I could hop on the elliptical immediately after for a "tempo".  I was 100% pain free during the run and for the rest of the day. Today, I did feel a hint of "something's there" when I woke up, but now it's silent. In fact, it's been the trend that I feel "something there" every morning, but it vanishes completely by noon. So as I write this, there isn't even a hint of anything in my leg or my foot. I am planning on running 18 miles tomorrow, but I am fully prepared to cut that run short at the first hint of anything.

Injury Sleuthing

One of the worst things about being an injured runner is the guilt that comes with knowing that you ignored the early warning signs and are now sidelined because of it. I refuse to let that happen to me.

Warning Signs
About a week ago, as I was laying in bed before going to sleep, I noticed something very faint in a small area of my foot. When I went to go feel for the area, I immediately recognized it as the same area that I used to massage when I had Peroneal Tendonitis back in August of 2009. That was a horrible injury. I ended up having to take five weeks off of running and I missed my fall marathon because of it. I didn't know about pool running back then so when I returned to running, my fitness had gone out the window.

I wouldn't describe what I felt last week as a pain-- more of just a sensation. Throughout the week I continued to run, but I iced the area just to be on the safe side. I didn't feel a thing while running or walking. But when I was completely at rest and trying to fall asleep, there was that nagging little feeling in my foot.

My Peroneus Longus is Irritated

After Thursday's tempo run, the area was more tender during the day, so I iced it off and on a few times while at work. On Friday morning, I actually did start to feel something while walking. Still not a pain, but it was in the exact same area of my previous peroneal tendonitis injury so I was particularly attentive. Friday was a scheduled pool running and swimming day, with no planned land running to irritate it. I also coincidentally had an appointment to get my gait professionally analyzed by a sports doctor (more on that in another blog). I told the doctor that I had a sensation in my foot that felt like the beginnings of peroneal tendonitis. He confirmed that the tender spot was the attachment of the peroneal tendon, thankfully not a 5th metatarsal stress fracture.

Emotional Roller Coaster & Denial
Friday can best be described as an emotional roller coaster. For 15 minutes, the area would be 100% silent, but then 15 minutes later, I'd feel something again. I'd walk around without any sensation in the area at all, but then a short while later I would feel something while walking. I kept going back and forth on whether or not I should do my 18-miler the next day. Eventually, I shook myself out of denial: If you are wavering this much, the answer is no long run. How much would it suck to truly injure myself on a long run when my body was giving me warning signs of a previous injury? An injury that sidelined me for five weeks!!!!

I made the sensible decision to spend 2 hours and 40 minutes pool running. Thankfully, I had the company of some of my CAR teammates. Ironically, Tara and I had planned to meet at 6:00 that day to run 18 miles, and when Saturday rolled around, we were both pool-bound. Even though my foot didn't actually hurt-- I definitely felt something in that peroneal tendon attachment area and I was taking it seriously. No denial!

Detective Work
My most important question was why I was getting this injury. My mileage increase has been extremely gradual and I even had a "cutback" week two weeks ago. I'm only running four days a week, as opposed to the six I used to run during typical marathon training cycles. So it's not overtraining. My first question in my sleuthing: what has changed in my training recently?

I can think of three things: core work, hills, no foot slapping. At first, I thought that the side bridges (core work) were the culprit. Putting weight right there on the side of my foot might have been irritating the area. Good theory, but I ultimately didn't think it was the true culprit. I didn't think it was the hills because I only do them once a week, and the hill isn't that steep. So. . . foot slapping?

When I went on my first long run with CAR, my coach told me that I was a "foot slapper" and that I needed to be lighter on my feet to prevent injury and be more efficient. Foot slapping is when the ball of the foot hits the ground and makes a slapping noise, rather than being quiet. When I asked him how to not do it, he told me to just focus on not doing it. And so I did. I found it easy to correct and since that day in late June, there was no more foot slapping.

So, foot slapping was one piece of the puzzle. Question number two: what causes peroneal tendonitis in runners? I consulted Dr. Google and found that a strained peroneus longus muscle is often the culprit. As soon I read that, I remembered back to earlier in the week when I noticed my outer lower leg was sore. This just felt like the standard muscle ache so I didn't pay any special attention to it at all. But suddenly the pieces were coming together. I massaged around the peroneous longus muscle and voila: a tight and tender area.

Question #3: Why is my peroneus longus muscle strained? To answer this one, I had to figure out which motion stresses that muscle. The answer was easy-- plantar flexation of the foot. This would explain why my foot doesn't hurt at all when I walk, but I definitely feel something while driving. My drive to and from the pool hurt my foot more than anything else because my foot was in a flexed position the entire time.

So far, I knew that plantar flexation while running caused me to strain my peroneus longus muscle, which resulted in mild tendon inflammation near the foot-- felt primarily when driving. And I knew that I changed my gait to avoid foot slapping. Well, what muscle do you use to restrain that forefoot from coming down hard? The peroneous longus!!!! I realized that I was flexing my foot ever so slightly to keep it from slapping down, and in doing so, strained the peroneous longus muscle.

I can't be 100% sure that my foot issue was caused by this, but it makes a lot of sense. Changes in gait often lead to injuries, even if they are for the better.

The Solution
I plan to do strengthening exercises for the peroneous longus muscle as well as stretching and massage. I am also wearing my CEP compression sleeve to help speed recovery. I'm icing my foot A LOT. I also scheduled two ART (Active Release Technique) sessions with the sports doctor who did my gait analysis.

My coach told me to wait until my tendon felt 100% to return to running, and I plan to take that advice. My foot already feels much better today than it did yesterday. I have no pain with walking and I only feel it while driving or when pointing and flexing my foot. And even then, I would give it a 1.5 out of 10 on the pain scale. It's very minor and had I not experienced this injury in the past, I wouldn't be reacting this way. The earliest I see myself running again is Thursday (which would be six full days off) and that's only if I am pain free. My hope is to be able to run 18 miles on Saturday, but I won't do it unless I'm completely free and clear of any foot sensations.

Some of the best running advice I ever received was "sacrifice a day of training to save a week, sacrifice a week to save a month, sacrifice a month to save a year." So I am sacrificing a week to save a month. I'll continue to do workouts in the pool (today I did 40 minutes of pool running plus 1000yd swim) and hopefully get to the starting line of my marathon both healthy and well trained.

Injured

I am injured.

One week ago, I felt like part of my running shoe was rubbing against the outside of my right foot. It didn't hurt, but it did feel awkward. I forgot about it completely until later that evening when I went down a flight of stairs in flip flops. The same part of my foot started to hurt.

The next day, I went out for a 10 mile run, including speedwork. I wore a different pair of running shoes (a pair that has more cushion and bounce) and I couldn't feel the twinge in my foot at all. I successfully completed the speedwork, and I averaged a 7:35 pace for 39 minutes. I was so excited about this because it was humid and in the upper 60's, which meant I would be even faster in better conditions. After the run, when I took my shoes off, I felt my foot walking around my house. It wasn't painful, but I definitely felt something as I was walking around. I called my physical therapist, who is typically booked up at least one week in advance, and she was able to get me in the next day-- Wednesday.

Meanwhile, I had been experiencing some tightness in my left medial calf, so I decided to get a sports massage on Tuesday night. This was the most painful massage I had ever experienced! She spent 20 minutes on just my calf and said there was a huge knot there. When I went to see my physical therapist the next morning, she was much more concerned with my calf than my foot. She said that there was some mild Peroneal Tendonitis, but that my calf was in bad shape. It was swollen and bruised from the massage and she said that it had probably been just a few days away from tearing. She told me not to run again until my calf felt better.

I took Wednesday and Thursday off as rest days and my calf felt better on Friday morning. Meanwhile, my foot was barely an issue. I decided to run six easy miles on the treadmill. At mile 3.5, I suddenly felt a pain on the outside of my foot. It was much worse than it had been last time. I kept running in the hopes that it would go away, but it didn't, so I stopped after five miles instead of the planned six. I limped my way off of the treadmill, and my foot has been hurting ever since.

I called my coach and she told me how to take care of it. She recommended ice massage, stretching, and foam rolling the Peroneal tendons. I even found a web site that showed me how to stabilize the ankle with taping to prevent lateral motion that would irritate the area. My coach said this was a minor setback--not an injury-- and she thought that I would be able to do my last long run (20 miles) the following weekend. She also thought I would be able to do some light running on Sunday, but given the fact that I was still limping, I didn't attempt to run.

So now it's Monday and it still hurts to walk on my foot. I've been swimming and using the elliptical machine (neither seem to irritate it) but that is no substitution for running. I just want to maintain what I have. At this point, I am not looking to gain more fitness. I just don't want the past 8 weeks of hard training to come undone. I can't predict when it will get better-- all I can do is keep resting my foot and taking care of it. I'll go back to my PT on Friday.

I cried a lot on Saturday. It hurt to walk on my foot, so every step was a reminder that I was injured. I couldn't put it out of my head. My boyfriend actually carried me a few blocks in D.C. on our way to dinner because it hurt with every step, and I could only walk slowly. Maybe it's not meant to be. Maybe I am not meant to qualify for Boston. I always come so close, and then something comes along at the last minute to ruin it. A year ago, I was in the home stretch for the Hartford marathon but I caught a virus and was sick for five weeks. I couldn't run a fall marathon so I attempted Arizona in January. There was an unexpected heat wave, so I bonked at mile 14-- not having been acclimated to the heat. Then, at the New Jersey marathon in April, I was on target for a sub-3:40 based on my recent half marathon. But it was cold and pouring rain, so I ended up in the medical tent with hypothermia. It never works for me, and it's always a matter of bad luck. I do everything in my power to train smart but the "stars" haven't aligned for me. I have been working toward this BQ goal for over a year, and something always gets in my way.

My boyfriend Greg says that if there weren't obstacles then it wouldn't be worth attaining. That's what makes it all the sweeter-- having to overcome obstacles and fight for it. I agree with this but I also feel like I have faced more than my fair share of obstacles. And I see so many people train for one season, run the marathon and get the time they deserve. Heck, I used to do that. My first six marathons were all PRs. And then the injury/illness/weather demons started to show their faces at every marathon.

As of now, I don't really have a "plan of action". I just have to wait. And wait. And wait. I have no idea when my foot will feel better, but I am not going to run on it until I can walk on it. And even then, it will be very easy running. My patellar tendonitis that I had in the spring of 2008 took three months to completely recover from. My biggest fear is that I will have to wait three months to resume normal training, and I will have lost everything I have worked so hard for.