Pain underneath the Achilles Tendon

A new injury, or should I say pesky set back, has been pain on the back of my calf, above the ankle about 4 inches and seemingly on either side of my Achilles tendon.  I've had this happen twice now within the last 2 months, so I thought it was worthy to write a blurb on it by chance others are suffering with this issue.

I first noticed a mild pain during a run--I was running outside and I ran across someone's gravel driveway that had some large rocks--like river rocks.  My right ankle wobbled naturally as I navigated across and I noticed a little strain on the outside, back of my right leg.  It was uncomfortable for a minute or so and then seemed to ease up.  I was at mile 1.25 when that happened.  At mile 5.7, I should have stopped but 6 was so close!  I shouldn't have pushed it, because when I hit 6 and walked I was hobbling a little.  Shame on me, I know.  The pain was more like an ache on the outer lower calf of my right leg.  At one point I thought I felt pain going up the back from the heel and worried if it was an Achilles issue.   

When I got home and did some googling trying to figure out what muscle was really bothering me, it turned out to be my soleus muscle.  The pain up the calf from my ankle was really just faking me out--it was really the soleus as it is located under the Achilles tendon. 

I remember a visit to my PT within the past 8 months or so where he gave me an exercise to strengthen this muscle.  I can't actually remember what pain I was having then, only that he gave me an exercise to strengthen the soleus.  I do remember him saying that the job of the soleus is to provide stability or stabilize the leg you are standing on for that brief moment when you alternate feet during running.  He said that sometimes when you increase your mileage, that other muscles develop or strengthen faster than the soleus, and since the soleus is weaker it eventually gives you some pain.  I did the exercises and the pain went away.  

The exercise was to sit on the floor with the affected leg out in front of you, loop a small exercise band (about 6") around the top of your foot, and attach the loop to something (I put mine under the couch leg) and use only the top of your foot to stretch the band away.  Then change positions so that you can have the band looped around the same foot but this time rotate in.  I'm sure there is a name for this exercise, but I don't know it's official name.  Just make sure the loop is around the ball of your foot, not the arch.  And GO SLOW! 

It made sense when I thought about how it came on when I ran across the river rock--it took a lot more effort to stabilize me on uneven ground and my lower leg just pooped out.  I also cut back my mileage a little and made sure that I didn't drastically increase my milage after--like no more than 10% per week so that my soleus could have time to adjust.  My PT also said no running hills until it got better.  Hope this helps!

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Top of Foot/Ankle Joint Pain

I've been running (after recovering from ITBS injury) for a couple months now, but only recently have I been increasing my miles.  The most recent injury or issue I've encounted is this pain on the top of my foot, but in the nook of my ankle if that makes sense, right below the knobby ankle bone.  When I would run, it almost felt like something was being pinched in that area.  When it first started coming on, I thought I had my shoes laced up too tight.

I went to see my PT, who solves all my running issues of course--seriously!  After checking to make sure that my tendons were all okay, he said that most running injuries have to do with range of motion, or lack thereof.  In my case, with the build-up of miles I was running, my calves were getting really tight and cranking down on my ankle.  Thus the pinching feeling.  All I did to get rid of the ankle pain was do 2 stretches he recommended to start stretching my calves--not necessarily my whole hamstring (which probably wouldn't hurt to do but wasn't the main issue).  Specifically, he had me stand, facing the wall, put my hands on the wall in front of my with one foot forward and bent at the knee with the back leg stretched back.  He told me to turn my back foot in slightly in order to get at all the muscles in my calves, then just bend the front leg forward to stretch. 

The second stretch was the same thing, only bring the back foot closer to the wall (so the distance is less between the front and back feet) and then bend the back knee so you are stretching your calf but bending at the ankle.  It feels really weird, but it totally works.  I also stretched my calves by hanging my foot off a step (or a curb works fine).  My PT said that the hanging off the curb stretch is pretty hard core and the other ones should be fine, but what can I say--a bit of an overachiever and I wanted that range of motion back! 

Now I don't have any pinching in my ankle or any top of foot pain.  I also ditched my orthotics at his suggestion; I thought long and hard about this, and I determined that the orthotics could be restricting the range of motion my ankle needs while running.  So far my runs have just been getting better, even without the orthitics, and I've continued to increase my distance.

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An Update

I signed up to run a 5k.  The next week, I got the flu--the nasty kind.  My whole body was tight from the puking, even a rib out of place.  Yuck.  I began to get a little nervous about this 5k and my training since I was sidelined for a week.  As you know by now, I've been recovering from ITBS and running again, so far, without pain.  My PT has had me on a limited training schedule where I could only run every 2-3 days so as to not irritate my knee.  Also, I could only run 2 minutes on, 1 minute off.  I bet you are wondering how I was going to run a 5k!  Well, so far I've been doing fine, until this flu hit.  I ran yesterday after a week off, and I decided that if I was going to run this 5k, then I needed to run at least 6 minutes on.  After completing my 5k circuit, my knee was inflamed and irritated.  I even stretched well before I ran, but when stretched I could feel tight hips and some tightness around my knee.  Oh well, I thought, it will loosen up.

I took some anti-inflamatories and I can walk up and down stairs without any issue.  I am convinced that the tightness in my whole body, and especially in my hips from sitting a lot while I was sick, contributed to my latest relapse.  Also, I was reading on a site about ITBS and how when runners suddenly increase their milage that ITBS can surface.  I didn't increase my milage, but I did increase how long I was running.  Anyway, that's where I'm at today.  Hopefully the ITBS will go away with the right hip and knee stretches so I can run this crazy 5k!

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Getting Caught Up in the Big Picture

During my journey of looking for a solution to my injury, I began to classify doctors (PTs, MDs, etc) into one of two categories:  those who looked at the area of injury and those who look at the whole body.  I found that after visiting several (20+) medical professionals, that MDs looked only at the area of injury, PTs were more likely to look globally, and that as you get more holistic (chiropractor, acupuncturist, homeopath) they look most globally.  Take orthopaedic surgeons for example--I saw several who, after examining my knee and found nothing "wrong," were flummoxed at my pain and inability to run.  Shouldn't these Docs be able to offer more than surgery, meds, or nothing at all?  PTs on the other hand were way more likely to check out how the neck, back, pelvis, and body in general was working or not working together.  Still, I wondered how so many people could miss correctly diagnosing my relatively common injury of ITBS (see My History).

When my knee seemed to be classified as "fine" according to all the doctors I went to see, I started looking globally.  I started searching the internet to find out how my diagnoses anteriorly rotated pelvis could be causing knee pain and how I could fix it on my own.  Then I started looking at my posture and researching how possibly bad posture was effecting other parts of my body, contributing to knee pain.  I thought I was on the right track, in fact I was really critical of medical professionals who weren't looking at the big picture and taking into account my/the body working together as a whole.  I got so caught up in this that when my PT (who helped me be able to run again) said we should go back to the knee and investigate the source of the pain, I was really surprised.  I had gotten so caught up in "in order to fix my knee, 5 other things had to be fixed first," that I was almost shocked when we went back to basics.  The kicker was that my PT knew how to properly treat ITBS.  None of this "jump on a strengthening regime right" away when he knew that would make my knee worse.  One of the things I remember him staying, especially when I sighted different stretches I had done over the course of a decade, was, "you've tried those exercises and they haven't fixed things for you, right?"  Right, I replied.  "Then let's try something else."

All I'm saying here is that while the big picture is totally true, the body does work together and one thing does effect another, that sometimes solutions can be simpler than we make them.  At least that was the case for me.  I figured that if 20+ medical professionals couldn't figure out the problem, then it must be really complex.  So I started looking for a solution that would take into account what I believed to be correct diagnoses along the way.  And since I wasn't getting the same diagnosis from all these professionals, I was basically on my own to figure out my injury.  I guess my last words on this are to the source of the pain--if I could go back in time, I should have spent more time investigating/researching the roles of ligaments in my knee, etc. 

Also, I came across ITBS sites, but the symptoms and treatment didn't exactly fit my situation.  For example, the foam roller did bubkiss for me.  According to some, the foam roller is one of the main ways to get rid of ITBS.  When I asked my PT about the foam roller, he said that my ITBS was so severe that using the foam roller would actually make my situation worse.  See!  Who knew that?  I never found that information once on any site detailing ITBS.  My PT did say that the Stanford xcountry team had far fewer incidents of ITBS if they started using the foam roller before and after their runs, reducing the occurrence of ITBS among runners dramatically.  That's great for those who are proactive, but for those of us who already had ITBS we were hosed.

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Returning to running after Injury = Different Injuries?

Today I came across a site titled Thoughts of an Experienced Physical Therapist.  He said that the purpose of his blog was to share his thoughts about issues and injuries that athletes and others encounter in their return to sports after injury.  I thought, this is me!

I have been running for about a month an a half after not running at all for 13 years because of injury.  Just when you think you are free of injury, here comes more, should I say especially with runners?  I posted the links to his old blog and new blog (the old one has great stuff) because I intend to check into it to hopefully avoid more injuries.

When I started running again after finally getting rid of the ITBS, I started to have pain on the inner part of both of my knees.  My PT said this was tendonitis, and usually goes away with hip exercises.  I have been using the green theraband he gave me to do simple 4-point resistance exercises.  My tendonitius stays away when I do them, but wants to come back when I get lazy.  I only spend part of my day sitting, but that seems enough to want to weaken my hips.  I can't find a picture to post of the 4-point exercises, but essentially you make a loop in the band, put it around your ankle (wear a sock so it doesn't rubber burn your skin) and 1. face away from the band and kick forward slowly 2. face toward the band and kick your leg back 3. stand sideways to the band and pull your leg away from the band 4.  stand sideways to the band but pull the band across your other foot as you lift your leg out to the side.  I will keep looking for some images to clarify that. 

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Stretching with Pain

One of the reasons I didn't do several stretches while injured was that the stretches hurt, and we all know that stretching should not hurt, right?  Well, actually wrong; this was the key to me getting better.  Michael, my PT, had me start doing standing quad stretches.  Having ITBS, I felt pain on the outside of my knee when I did these and I got nervous.  I know what a healthy stretch feels like, and I was feeling specific pain in my knee.  He asked me the pivotal question, "When you stop doing the stretch does your knee still hurt?"  My answer was no, it didn't.  He said that as long as it didn't still hurt when I stretched that I was okay.  He said that the insertion point of all the ligaments attaching on my knee/tibia were what I was feeling. 

I continued to stretch with his rule: if the pain didn't continue I had stopped the stretch, then I was good to go.  For years I hadn't done the quad stretch because it "hurt."  Little did I know that this stretch, besides my PT assisted stretching, was the key to me getting running again.  The kind of pain I am talking about is not a 9 on a scale of 1-10, but more like a 6 or 7--it hurts.

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The Mysterious Leg Length Discrepancy (LLD)

After I was incorrectly diagnosed (unaware at the time obviously) with a severe leg length discrepancy (LLD) based on standing x-ray that was taken, I had a few main issues with this diagnosis even though I went ahead with it because at the time I thought my doctor had finally discover the cause of my inability to run.  But how could an x-ray be refuted,  not to mention that the lift prescribed to me was 1 1/2 inches high--substantial (For more see My History tab)?  If you have been told you need to wear a lift and it isn't working for you, maybe these will help you too.  Here were some of my issue with the diagnosis: 

1.  I still couldn't run, hike, swim, or ride a stationary bike without pain, even once I started wearing the lift.  If the lift was the end-all-be-all solution, why couldn't I still run?  Even after 4 years of giving my body time to "adjust" to the lift, I still couldn't run, etc.

2.  I had run in high school, college, even a major relay race (Portland to Coast) with no problems whatsoever.  If I really had that big of a LLD, why hadn't it shown up before now?  They told me that LLDs of this size were there since birth.  If that was so, why had I been able to clock serious milage over several years without it manifesting? The answers I found on the net left me unsatisfied--they said that you can get away with it until you are in your 30s or 40s, at which point the body just can't take it anymore.

3.  Doctors were not in agreement on the actual LLD measurement, despite the x-ray.  One doctor said that I had an LLD, but not substantial enough to need a lift.  Another doctor told me that I did have an LLD, that he was more sure of it than anything in his whole life (seriously), and that he could give me a lift right now that would solve my problem immediately.  Other doctors said I had an LLD, but that much of the population has a slight LLD between both legs and that he wouldn't recommend wearing one.  Here was my issue:  how could 5+ doctors all be at odds?  This was a main factor in me vowing to never wear a lift again.  I would not let the one doctor who practically swore on his life (and was seriously upset that I wouldn't accept his recommendation) talk me into wearing another lift. 

This was the same doctor who, knowing I had a knee issue and pain with activity, would tell me to go warm-up on the stationary bike before each session with him.  Anyone who knows ANYTHING, you think, would be wiser than this with their patients.  Needless to say, he achieved no results, but instead agravated my knee with his prescribed strengthening exercises.  If you are suffering from ITBS, exercises designed to strengthen your quad are only going to make your condition worse.  My favorite (joking of course) was the 4-point standing single leg squats that I was told I should do twice a day.  Imagine my frustrating when the more I did them, the more my knee hurt.  At the time, I got really discouraged, thinking "how am I even going to be able to get better/run again when the exercises that are supposidly the solution are actually making my knee worse.  Great recipe for depression right there.

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