This is my shoe strategy for Achilles tendonopathy recovery

So, actually, I don’t really have a shoe strategy any more..I don’t even have a shoe tactic.  In fact, all I have is a disorganized pile of  unsubstantiated ideas representing completely different directions, that I try arbitrarially at various times depending on how I feel at the time.  So, for a while, I was back to using the old “stability shoes” with the podiatrist-fashioned orthotics, (yes, the foot-coffins!), on the theory that my AT is fragile so I should keep from stretching it in any way  while running.  This resulted rather quickly in the return of my ancient hip ‘bursitis’ and bunion aggravation.  Then I tried going back to the 4mm-drop New Balance WT10, which is what I was wearing when I first got injured.   Almost immediately I had ankle pain while running.  So then, I cast cuteness to the wind and bought a pair of men’s Nike’s.  I don’t know what the heel drop is, but I bought them because they seemed wide enough and were lighter than the Mizunos.  They weren’t very flexible.  My latest are Merrells with vibram soles, which I found on sale and bought a size too large so I could put orthotics in them if I needed a break, on the theory that flexible flat shoes with a wide toe box will help keep my feet from getting any weaker and throwing my whole body even further out of whack, but that occasionally I might need some extra support.  I seem to like them best, because they put me into that barefoot pose that with a midfoot strike that is so much easier on my body as a whole.  I haven’t been wearing them with orthotics but sometimes I do use a rigid plastic heel cup in them.  The jury is still out on what they do to my AT, and, well.. they are turquoise.  I’m not a fan of turquoise.  And I’m pretty sure that’s why they were on sale.

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One year post injury

It has now been one year since I injured my AT.
I have more pain than I had a year ago.  I’m sure that I have lost cardiovascular fitness  and I am not yet back to my pre-injury running routine; the most frustrating thing being the lack of improvement over time and the constant setbacks.  I can now run 5 miles  at about a 10 minute pace without pain, but I can not do it two days back to back.  I  seem to need 2 days for the tendon to recover from each run.  I have an exercise routine that feels like it is helpful so I am sticking with it for a while longer.

Twice daily:

• eccentric heel lifts 20 X 2 with 10 LB

Once Daily:

• bridge marches 30,
• rear leg extensions 15 X 2,
• single leg squat  1- X 2,
• isometric toe exercise 30s,
• calf stretch 30s,
• single leg stand eyes closed or heel-toe eyes closed 30s X 2

3 times per week: 

• Side step with the red Theraband on the feet – down the hall and back,
• 5 mile run @10 minute pace with orthotics OR 40 minutes elliptical OR 1 hour stationary bike
• Kneeling hip flexor stretch 3 minutes

Once weekly:

• pool running 20 – 30 minutes,
• thigh, calf and foot stretches in the whirlpool,
• hip abduction (Nautilus) 12
• Seated Leg extensions (Nautilus) 12

I also foam roll and massage the ankle and gastroc whenever I have time.  My goal is to run a 10K race in January, a 5M in February, and a 10K in March. 

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What was I thinking?

I had my 6-week follow-up with the orthopedist.  She did a follow-up ultrasound and opined that the tendon was less heterogeneous in appearance..not as many “dark patches” as she called them.  OK.  That seems good, I guess.  And yet, I am in much more pain now, still, at 6-weeks post-procedure, than I was prior to the procedure.  So, it’s hard to think of this as a success.  In fact, it seems pretty clear to me that I made things worse by undergoing the needle tenotomy and I probably shouldn’t have done it.   The magic healing response hasn’t materialized. Did that ever make sense..the idea that inflicting more damage would stimulate a beneficial response in the tissues?  I have no idea.. Anyway, maybe it is the lack of endorphins talking but I’m not a happy camper.   I’ve started back on the nitro patch and am still not supposed to run.  So, I’ve decided to try an acupuncturist.  Clearly at this point, it can’t make things any worse.  I’ve found one right up the street, and made an appointment for two weeks from now.

In PT,  we started eccentric exercises.  Actually I started the a couple of days ago on my own.  We also tried a hop on one leg test, which I did OK with until she told me to land on my forefoot instead of my heel and then it got very hard very fast.  The PT and I discussed my latest theory (brought on by re-reading Jay Dicharry’s Anatomy for Runners), that inability to effectively recruit the glutes is a major contributor to my chronic Achilles tendon issues, and asked about exercises for that.    I have noticed, that when I do exercises purportedly for the glutes, like bridges for example, I never feel it in my glutes, I feel it in my quads or in my lower back, or somewhere in my calves.  So we tried a bunch of things until she hit upon something that I actually felt in my hips, and now I have standing hip abduction and standing kickbacks added to my exercise regimen.   I feel like the PT is helping me in a general way, but I don’t feel as though it is doing much for my AT pain.  But at least I like my PT this time, so I’ll stick it out for another couple of weeks.  I can feel my interest in it waning, though.

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How to train in the pool and look really silly

I’ve now accomplished five weeks of no running.  Usually when I say no running, I mean, no running more than 3 miles.  But this time I really mean no running.  Zero.  I now suspect that the whole reason that needle tenotomies are effective (if they are) is that they cause you so much pain that they force you to really truly not run for eight weeks.  The tendinopathy pain is definitely worse than before the procedure, in that before the procedure I could run a couple of miles with no pain, and now I can’t run more than a couple of steps without experiencing a hot-poker-in-the-tendon feeling.  So, in a probably futile effort to maintain some sort of cardiovascular fitness and keep my legs in shape,  I’ve started aqua-jogging, aka pool running.  I don’t think I quite have the hang of it yet, though.  Basically what I do is clip on my aqua-fitness buoyancy-belt-thingy, hop into the pool and proceed to sink to the bottom while running in place.  I did this for 30 minutes today, feeling very silly, but my PT seemed to think it was a good idea, so I will keep working on my pool running form and maybe eventually I won’t sink.

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PT 3.0

It’s week three post-procedure .  At week two,  I had my follow-up visit with the doctor.  She  seemed mildly surprised but happy that I had not had any significant pain, and wrote me an order for physical therapy, accompanied by stern reminder to do everything gently, gently, gently.   I did not tell her that I had been walking 4 miles a day; no reason to spoil her happy mood.   Both my old PTs were booked up for weeks, so I made an appointment with a new therapist who works out of the gym where I do my work outs.  She listened to my long rambling account of my long rambling injury odyssey, and decided not to put me through another evaluation, but to jump right into therapy.  She had me stand on one foot for her, stand on tiptoes, and twirl my feet around to demonstrate my range of motion, and pronounced me in pretty good shape.  She seemed optimistic, though she might jsut have been an optimistic type of person; it’s hard to say on the first meeting.  But anyway, I liked her better than the infamous “Rick”.  She gave me stretches and exercises with the stretchy-band to do at home.   So now, I have a colorful array of red, blue and green Thera-bands draped on my bedpost.  She told me to do 2 sets of stretches and one set of the resistance exercises daily and not to overdo it.  So of course, I overdid it.  Because that’s who I am.  And today I’m sore.  Lesson learned.

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Getting Needled

Yesterday I had an ultrasound-guided percutaneous needle tenotomy of the Achilles tendon. The theory behind this, according to my doctor, is that it will cause an inflammatory reaction and stimulate the body’s healing response, increasing blood flow and stimulating the release of various healing factors which will go rushing into the tendon and make it all better.   Either that or it won’t help at all, but hey, it’s covered by my insurance.  Here are five important lessons learned, which I offer for anyone contemplating this procedure.

1. This procedure feels like someone is sticking large hypodermic needles repeatedly through your tendon and into your bone with no local anaesthesia. The reason it feels like this is because that is exactly what they are doing. Do not be fooled by any similarity to acupuncture. These are big needles, not little skinny magic needles that you don’t feel. There will be blood.

2. A “walking boot” is a pain in the ass. The boot is about 3 inches off the ground, so unless your other shoe has a three-inch thick sole, you will be completely uneven when you try to walk and will probably end up with some sort of back injury from listing to one side. (I ended up walking on my tip toe to get to the bus stop to go home.) If you are going to get a walking boot, try to find some platform disco pimp shoes from the eighties ..actually you only need one..to wear on the other foot.

3. You absolutely can not drive in a walking boot. They will tell you this, and you will not believe them, but it’s true.

4. You can not sleep in a walking boot, despite what the doctor tells you.

5. Your walking boot will scare your cat.

So, I have two more days after today to be in the boot, and then, the doctor tells me, I will be able to remove it and carry out my “activities of daily living, but no exercise” which is, of course, an oxymoron.  Stay tuned.

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Follow-up

Today is my follow-up visit with the Sports Medicine Doctor.  I know she will ask me if I am better so I consult my blog to find the answer.  Yes!  A month ago, my ankle was hurting when I ran to catch the train, and now it usually only hurts when I run uphill or run more than about 4 miles.  So that’s progress.  In fact, according to my faithful Garmin, I ran 8 miles without having to stop for pain last week.  So, while I don’t feel anywhere near normal, I can’t deny I am improved.

My appointment is before work.  I talk with the doc and she seems upbeat.  She pinches, er, palpates my tendon and it is still really sore,  but I think that problem can be solved by not pinching it.  It is also still enlarged compared to the other one, but I personally feel that symmetry is overrated.  She says  she doesn’t think we need to do to the thing where they stick needles in your tendon down to the bone until it bleeds.  She says she doesn’t think I need an MRI.  Neither do I.  She asks if I want to renew the nitro prescription and I think about it..hmmm…is there any reason I want to squirrel away some nitro patches for some illicit use?  I can’t actually think of any illicit use for nitro patches, because as far as I can tell they just give you a headache, so I say no.  The doctor thinks I should go back to the PT again and get more advanced exercises.  I agree to do this providing I can find a time when “Rick” isn’t triple booked.  And actually I want to go back,because I want validation that my self-prescribed exercise regime is beneficial.

I stop at the PT counter and ask for a copy of my evaluation from last time I was here.  I scan it hastily and determine that I will need to do lots of googling to get through it, as it is laced with more jargon and initialisms than anything I’ve ever seen before.  I see the term “inadequate flexibility” in about 12 places.  And lots of stuff about rotation and compensation.  In other words, I’m a mess!  But I knew that already. Then I spy a part that really perturbs me.  It’s  the section on ” factors impacting prognosis” and it says:  “low motivation”.  Low motivation!  Me?  Now I really want to go back..just to prove “Rick” wrong in his stinging assessment of my motivation.   In fact, I would say I am highly motivated to go back.  And I plan to demonstrate a stunning improvement in strength and stretchiness.  So there.

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attitude adjustment

I am trying to rid myself of the ‘more is better’ mindset.  This is hard.    This week, life intruded on my Tuesday run so I got in only 14.5 miles for the week, spread across Thursday Saturday and Sunday.  I feel bad about this.  I feel that the running gods are judging me.    I feel a strong urge to double up next week to make up for it.  But I know I should get over these feelings and focus not on running more, but on running better.  Otherwise, my Achilles tendon will never get better and I’ll be hobbling around for the rest of my life.  So, since I am tracking both my heart rate and my pace with my Wahoo-Garmin combination anyway, I have decided to take on the goal of to increasing my pace while keeping my heart rate the same.  To this end, I am calculating the ratio of pace to heart rate, and tracking that variable over time, hoping to see it increase.  This enables me to (1) have an achievable goal that doesn’t involve more mileage (2) increase my cardiovascular health and (3) create a spreadsheet!  and graphs!  I love graphs!

Meanwhile, pictures from this weekend’s runs:  Wissahickon and Pastorius Park.

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PT 2.0

“Rick” has triple-booked today, so he is working with three clients at the same time.  This means he gives me an exercise to do, and I do it, and then I have a 10 minute interval while waiting for him to come back to me, during which I  read my email on my phone and start thinking about other things.  Eventually he comes back and asks me about the exercise I’d just done and by this time I can’t remember how many reps I did or how it felt.  He has me run on the treadmill.  Yay, I get to run!  He tells me that my right knee is collapsing in and I need to strengthen my right hip.  I’m on it!

OK,  this is now my current nightly exercise routine:

back extensions

plank

side-lying quad stretch

pigeon pose

some sort of back stretch thing that I can’t even describe (I’m not so sure this is good for my back anyway)

lateral leg raises against the wall

bridges

clamshells

squats

single leg stand

rear-elevated lunges

monster walks with theraband

hip hikes

figure 4 stretch

bendy foot exercises with the theraband (no idea what these are called)

concentric heel lifts

eccentric heel drops

calf stretches, gastroc

calf stretches, soleus

Sigh…this is a lot of stuff to do…

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Good News and Bad News from Sweat Science

A few posts ago, I mentioned feeling better when I run in the Wisshickon as compared with around the neighborhood.  Alex Hutchinson provides an explanation in Sweat Science, called This is Your Brain on Nature.

And now for more depressing news.  A study that tested the levels of carbon-14 in the Achilles tendons of people who were around during above-ground nuclear testing in the fifties show that the AT just doesn’t regenerate.

Today’s run was 5 miles on the trails, 900 feet of elevation gain, but I walked up all the hills and ran down them so as to not anger my Achilles.  Sadly, I couldn’t manage to get my heart rate above 110 with this routine.  Oh well.

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