Ouch, my ankle!
I have had chronic ankle and foot pain for a number of months now.
In medical school fashion, let’s do a ‘SOCRATES’ history to characterise the pain further.
Site
I have pain in the ‘big toe joint’ of my right foot, AKA the ‘first metatarso-phalangeal joint’. The pain is both within the joint and within the dorsal ‘top of the foot’ aspect of the joint.
Onset, Character, Radiation.
It crept on insidiously, causing intermittent discomfort after I’d been walking or running a lot. On quiet days the pain was completely silent and I easily forgot about it. When I pushed myself, extending my running mileage or adventuring up hills with friends, the pain would come back to bite me – sometimes mid-way through activity, but mostly as an aching discomfort when the running shoes were off and feet put up at the end of the day. Luckily, the pain doesn’t radiate to other joints in my lower limb. The extend of the ache increases, but is localised to the foot and ankle.
Alleviating factors:
Rest, swimming, activity that doesn’t promote lower limb weight bearing.
Timing:
Short twinges lasting seconds to persistent aches and pain lasting hours.
Exacerbating factors:
Any activity that has a high ‘eccentric contraction’ component of plantarflexion, for example, when the foot strikes the ground during the ‘heel strike’ or ‘foot strike’ phase of walking or running – the activity of the lower limb muscles to decelerate my velocity and control my movement. The main movement that does this with high loads is running, and worse when
Severity:
Pain in foot: 5/10 Pain in my mind when I feel my life is limited by discomfort: 10/10
What could it be? A scary connective tissue disease? A trauma after falling off my mountain bike? Gout?!?!
All possible, but unlikely.
It’s probably due to my own ignorance and pig-headed type-A tendencies which together create a perpetual mismatch between my current perceived and actual abilities against the outcomes I desire.
Fuelled by a short memory for the feeling of pain and a hatred of feeling like I suck, I think I probably ran my right foot into the ground.
A burst of activity earlier this year, training for the St Polten Half-Ironman, was probably a significant factor. A history of use and abuse of my lower limbs during running and biking excursions, or during contact sports, also probably contributed a less-than-concrete foundation on which to build my training.
The nature of the insult – a chronic, insidious worsening of function of the joints – is scary to me. It highlights multiple areas of neglect; poor connective tissue health, poor training, inadequate nutrition and recovery. It suggests suboptimal biomechanics. Importantly, it also suggests poor insight and self-awareness.
I think it’s time to set out to try to change this.
The Barefoot Not-Running Experiment 17/9/2019
I want to restore the health of my feet and ankle to a healthier, pain-free state.
To achieve this, what actually should I aim for?
We live in a world where ‘optimal’ is sought by adding things on. When chasing a pain-free, functional ankle, some people might choose to support the foot with cushioned shoes or engineered insoles that prevent excessive pronation or supination of the foot. While this might restore functionality for some individuals, just as a crutch allows an injured person to ambulate, it also creates a dependency on those items. What would I do if I wanted to go out for a run and I hadn’t packed my go-go-gadget shoes? This doesn’t seem like the right solution for me.
What I am seeking is to restore my foot to a level of strength and mobility where it can function without a reliance on shoes that alter motion or intervene with support. To have independent feet. Dogs and cats don’t wear shoes, right? You don’t see sheep pulling on hiking shoes to support their hairy ankles before they traverse a steep hillside.
I am hoping to ‘get back to nature’ – a controversial concept of eschewing modern footwear technology to let my naked feet function as they were evolutionarily designed. Research and material came out of Harvard and made it’s way to be published in Nature – so hey, it must be kosher.
To be honest, I’ve been interested in ‘barefoot running’ since I was in school, when I electively wrote an essay on the biomechanics of barefoot running. During medical school I organised an educational evening for students interested in sports medicine named ‘The Barefoot Medicine Clinic’. I even have done some running courses with a shoe company called Vivobarefoot and I own an assortment of barefoot shoes from different brands. This past relationship with barefootedness complicates things somewhat – if I’m so practised and knowledgeable about being barefoot, why am I injured? In answer to this I’ll use the coarse example of my respiratory physiologist at medical school who smoked outside of the lecture theatre, or the numerous healthcare staff who are carrying too many extra pounds. I’m not a perfect role model and haven’t got all the answers, but I’ll give finding a solution a good go.
What I don’t intend to do is to shed the shoes to go out for a ten mile run in the hope that along my painful journey I will miraculously morph into Abebe Bikila or Eliud Kipchoge.
Rather, it means employing theoretical and practical approaches –
1. Extinguishing inflammation
I know that by continuing to run I will continue to cause damage and pain. This means I will stop running, for 4 weeks, and re-assess during those 4 weeks how I think I’m doing. Maybe I will keep a diary.
I don’t want to be inactive or sedentary, so I’ll keep doing sports and activities I know don’t trigger the pain – like going to the gym and swimming. I’ll have to do some things such as cycling, because I’ve got to get to work… If I start a new sport (considering BJJ or Muay Thai) I have got to be cognisant of my smouldering foot.
The pain isn’t bad enough to use analgesics or an antiinflammatory. I’m reluctant to use a NSAID as I don’t know enough about the effect on the recently discovered chemical mediators involved in healing, such as ‘specialised pro-resolving mediators’. More on these another time, but worth a Google search in the interim.
2. Analysing the anatomy – where actually is the pain?
The 1st MTP joint is surprisingly complicated for such a small bit of the body. The pain I experience is in the joint and dorsal to the joint. Perhaps the deep pain corresponds with the intrarticular sesamoid bones or ligaments. Perhaps there is osteoarthritic change. There are also extensor tendons, adjoining muscles in the foot and leg with the big toe, that run across the 1st MTP joint. These might also be inflamed with overuse.
I have pain in the area at the front of my ankle, where the tendons from the shin run down towards the foot. The anterior ankle contains a number of structures, such as the mortice-like articulation between the distal ends of the tibia and fibula with the talus of the foot, the tendons of the shin muscles that wiggle the toes and raise the foot, and a band of fascia called the ‘extensor retinaculum’ that wraps around the front of the ankle like a strap to keep these tendons flattened down.
I haven’t got an ultrasound or MRI machine to scan my foot, so I’m left with testing, palpating and thinking about the anatomy instead. A common structure between my toe and ankle pain is the extensor hallucis longus ‘EHL’ tendon, running from its muscle in the leg, under the retinaculum and across the foot to bind at the base of the big toe. Despite all this guesswork, the anatomy remains complicated and it’s hard to narrow down to a single structure. Even if the EHL is the one to blame, I think that this detective work to pin it as a lone criminal is likely futile – in a multi directional, multi structure joint, it’s likely that the pain is due to multiple processes. I’ll hit it all with a blanket cover treatment of… Rest.
3. Promoting better biomechanics when using the foot.
I will try to wear ‘barefoot friendly’ footwear, with wide toe-boxes and flat and flexible soles. The pair of vivobarefoots I own can be worn at work and in life. I also have a pair of flat and wide shoes for the gym.
4. Addressing limitations in mobility, at rest and while moving.
After the initial inflammation has settled, say, after a week with no pain, I’ll start to address any mobility issues. I can do this with static stretches, dynamic stretches and massage directed at the painful areas.
Because the anatomy of the foot is so complicated, I think it’s also a good investment to address some of the large structures – the plantar fascia on the bottom of the foot, the calf and Achilles tendon posteriorly and the muscles in the front of the lower leg. I’ve got to stretch out the toes too, in plantar- and dorsi-flexion.
5. A gradual increase in loading.
I guess I have a month to think about this – but at an initial glance, I expect I’ll have to start with very baby steps.
The first activities might be to do some ‘Toe-ga’, clenching and stretching the feet to strengthen the intrinsic muscles of the foot.
Eccentric training programmes focused on the calf and achilles tendon complex are useful for people with tendinopathy, restoring function and potentially providing a benefit to tendon architecture.
In terms of dynamically loading the foot, I’ll start this by walking daily, for at least 30 minutes, in minimal barefoot shoes.
When a month of de-load is up, I’ll consider a return to running. My expectation is that I’ll have to run for only 30 seconds to a minute at a time, for only a few reps. I’ll then pack it in, assess how the muscles feel the next day, then subsequently modify the loading of the foot in the future.
I am excited to get stuck into these online modules, produced with help by Dr Mark Cucuzella and the National Running Centre for the USA Air Force.
A lot of my rehab plans rest on:
- Hold off running for now.
- Walk and move more, slowly.
In this way this injury is reminiscent of the back pain I experienced that I have written about before. Having just come off an intensive exam period, I’d spent the previous weeks sitting too much and walking too little. In an attempt to quickly shed my exam stress and get back to my normal self, I went to the gym and racked up a back squat too quickly and at too heavy a weight. In my attempt to move fast, while neglecting ‘moving slow’, I caused myself a back injury. I continued to train in the same way for the next few months. Eventually, Time and I fixed the injury by stopping lifting weights and walking more, while focussing on engaging the small stabilising muscles. Re-reading that blog, there is a lot I can learn from (again).
At work, I tell my MSK back pain patients that there is a spectrum of activity that we all fall onto. It originates when lying down in bed or when sitting, and progresses to active movements such as standing and walking. This is followed by intense activities such as jogging and running, until the spectrum culminates with sprinting and lifting heavy weights with compound movements (such as the squat or deadlift).
The theory is that our bodies are nourished by regularly being in the standing, walking and moving zones. On the other hand, prolonged rest breaks the body down. Likewise, running hard or lifting weights can easily push the body too far. What I see is that people flip from one side of the spectrum like a light switch – spending the majority of the time lying in bed or sitting at a desk, or compensating for their inactivity by pounding a treadmill, hitting a HIIT class or by lifting heavy in the gym. What is neglected is the middle section of the spectrum – walking, moving and easy running – that trains the slow-twitch postural muscles and engages aerobic metabolism to build robust and healthy physical and metabolic systems.
An Early Reflection 1/10/2019.
- Walking in barefoot shoes is fun. I have a reason to get up and outside during my lunchbreak, spending 30 minutes exploring the neighbourhood and local park.
- I feel my stride is shorter and more staccato. No loping or long strides – they really bang up my heel. Smaller strides and a quicker transition from heel to forefoot seems to soften the impact of each step.
- Wide toe-boxes are great! I can wiggle my toes in my shoes when I’m at my desk which is a huge novelty. While I am walking I can also feel my foot flattening out more too, like this video of an elephant’s foot during the gait cycle.
- I’m more aware of the silly postural habits I have picked up, such as rocking on the outside borders of my feet when standing – when I am not in a padded shoe, these weird movements feel uncomfortable! Perhaps this is a simple example of better proprioception and biomechanics given by a minimalist shoe.
I guess that’s all for now.
The finished product of my blogs always end up longer than I had envisioned in my mind. There might be more to come – I haven’t got my thoughts sorted regarding connective tissue health, different rehabilitation approaches or dietary modifications such as protein intake or collagen supplementation.
Any advice for helping, or letting, an injury heal?
Any experience with foot and ankle biomechanics?
Anything else for anything more?
Let me know.
Dr Rory Heath 
[…] you read my previous blog on my barefoot-not-running experiment, you will have learned that my right foot and ankle have caused me persistent […]