Wednesday, September 22, 2010

The year of running injuriously

Cynthia’s Experience

Ok, silly title, but apt, as you will see. As of late summer of 2009, after running the SF Marathon and wondering why I was so much slower than expected, I intended to increase my mileage and see if I couldn’t improve my running ability. That did not happen as planned obviously, or I would have been happily blogging about my triumphs attempts. For running friends wondering what has happened, here is the sad story of the last year in running.

May 2009 at Quicksilver 50K, I landed badly while jumping across a creek—the embankment was at a steep angle, which I failed to notice until midair. Afterwards, I had swelling and pain in that foot off and on for a couple of months. It never hurt particularly badly and I mostly ignored it, continuing to run on it, even completing Diablo 50K a month later without problem, with my foot at least. Anyone who has done an event at Mt. Diablo knows it will take a lot out of you one way or another. I mentioned this in blog entries in June 2009 and July 2009. I thought I was babying it enough by taking it easy and mostly running uphill, where the foot falls are softer and more controlled. It did feel like there was some structural weakness for a couple of months when I’d try standing on the ball of that foot with my full body weight, but I figured it would pass. Mostly I just congratulated myself on having good recuperative powers, and continued to run as much as I pleased, and never bothered to get any x-ray or medical opinion.

In summer 2009 while training for the SF Marathon, I ran more track workouts and harder road runs, not the varied and softer surfaces of trails. A glimmer of foot pain began, but remained sporadic and mysterious until by August, after the marathon when I got the bright idea to up my mileage, I developed the dreaded plantar fasciitis. I scoured the web for information on treating and training with PF. One of the more useful references I found is from the Sports Medicine Institute, complete with physical therapy recommendations. My symptoms matched those of textbook PF, and I began to treat it as recommended—icing, using arch supports, keeping the fascia stretched, reduced running, using ibuprofen, etc.

When September came around, it was time for Steven’s Creek 50K. This is another charming local race on trails that we often train on, put on by Steve Patt of Steven’s Creek Software, with proceeds to benefit the Audubon Society. In 2008, the first year I ran this event and only my second 50K, I had such a poor time that I was determined to come back and vindicate myself, hurt foot or no. In 2009, the weather was cooperative, cool and even a few sprinkles, and I managed to improve my time by over 2 hours even with the injury! This tells you how terrible I am in the heat. I found myself running slower and scouring the trail ahead for the softest surfaces to run on, but my foot seemed all right afterwards.

So without too much fear, I signed up for a second running of Dick Collins Firetrails 50 Mile. I thought I would be faster since I was fresh from marathon training and significant hillwork and was lighter compared to 2008. Instead, I was slower by 40 minutes (almost a minute per mile slower!). It turned out to be a truly miserable experience, with me fantasizing about using crutches for much of the race, wincing down the long descent to the turnaround and just generally having the motivation sucked out of me by pain. I vowed not to run any other races until it didn’t hurt so much to run.

For the rest of the Fall/early 2010, I was reduced to easy running/rigorous icing, stretching and physical therapy. I could run, but not fast, and not far (nothing new really, but I didn’t enjoy being even slower than usual). There was almost no pain running uphill—this is of course without any kind of energetic bounding, which would likely negate the pain-free aspects. But of course, there is the downhill part to every run, where I would cringe and whimper my way back down. The strange part is how much more it hurt after running than before or during, and more than in the mornings when it is supposed to hurt the most (“first step” pain). On bad days, the arch and entire heel blazed with heat from the resulting inflammation (icing certainly helps with that), and even tingling or buzzing sensations from nerve irritation and entrapment. I also noticed occasional toe numbness and neuroma-like symptoms, but it seemed to be specific to going uphill, and was helped by walking on rocks that would put the pressure on the arch and not the ball of the foot.

During this time, I compared my feet and realized that my injured foot was now noticeably longer than the right (before, the right was larger), and the right calf musculature was better developed. Whatever injury I had sustained caused the foot structure to attempt to adapt and compensate for the weakness. The bone structure in the arch is now noticeably thicker as well, and presumably is stronger. This picture shows the two feet aligned heel to heel (excuse the post-Rio blisters). The plantar fascia can be easily seen when the toes are stretched back, revealing the tautness of the fascia. Unfortunately, the left fascia is still much tauter than the right due to the relative fast growth of the foot. The tautness can be more readily felt than seen, and the right is springier, with more give to it, than the left. Whenever I strain the fascia, such as landing on the toes going downstairs, skipping, running fast, I can feel it yanking on the calcaneus as if it was trying to pull free. In the acute phase, it felt like an ice pick or broken glass in my heel. Now it is merely a dull but persistent pain.

During January, we cut back running in favor of some weight and cross training, but ran the Fremont Fatass 50K anyway. This is a local event organized by Catra Corbett and Mike Palmer, a friendly (mostly) flat run on bike trails between Quarry Lakes and Coyote Hills. My foot wasn’t too bad on the trail part, though the pavement portions were painful. Then we ran the Second Saratoga Fatass 50K in February (where we got lost and only did a marathon) and Adam Blum’s Overgrown Fatass Marathon, where I was feeling better (and won the women’s event—Yea me! I think there were only two of us!). With the rainy winter, the trails were often soft and squishy, and this helped a great deal to soften the impact for my hurt foot.

By March, I was just starting to feel normal again, until I pushed too hard one day. I could feel something in the fascia “ping” and was back to pain and rigorous icing again. It was clear I wasn’t going to race anytime soon. We volunteered at Skyline-to-the-Sea in April, but my foot was killing me just from standing around all day. I went back to track workouts, thinking the soft springy surface would help. I also did running drills, not realizing these would exacerbate the problems. With more PF pain and weird associated pains and numbness, I finally broke down and went to see a podiatrist in an attempt to find out what the heck had happened and whether I had a stress fracture or something serious. Several x-rays and CT scans later, he informed me I had dislocated a bone in my foot nearly a year before! As a consequence, the foot joints had been trying to compensate for the injury by growing larger and stronger, hence the longer left foot. He also said it looked like I was getting some arthritis too. He instructed me to ration my running, run on soft surfaces, use an insole and to take glucosamine/chondroitin sulfate pills. (As an aside, he was also appalled at the looseness of my left ankle ligaments and advised me to run with an ankle brace, which I do- it has saved me from further injuring the ankle at least). So for the next month, I stuck with trails, the softest I could find and ran gently—no more “speed” work!

By May, it was time for Quicksilver 50K again, the scene of the original injury. I was determined to run it again, not sure if it would be the last ultra for a long time. I wanted to look for the offending stream crossing and this time cross it sensibly, but never did find it (I think they put up a bridge). This race was slower than last year by 23 minutes, but my foot didn’t hurt until after 15 miles. The after effects were fine too—less pain if anything. Encouraged, I signed up for the famous and popular Ohlone 50K two weeks later (I got lucky on the wait list), which involved a lot of slow trudging up hills and fast downhills trying to make up time, and I was pleased that my foot wasn’t a limiter, not seriously. We got lucky with a cool spell of weather on this one too. My lack of ability to run those hills was by far the biggest limiter. And again, the after effects were minimal. I was so excited to get through Ohlone without further injury that I went out and injured something else by running too hard (one of the little gemellis or something in the butt—the little bugger still hurts).

David and his son Ethan decided to run the SF Marathon this year. I played “coach,” leading them through a 30 minute time trial to assess training paces, long runs, hills runs, and mile repeats and Yasso 800s on the track. I couldn’t keep up with their pace, but tagged along behind. We did short trail runs at first to keep the impact lighter to help Ethan work up to longer distances without injury, but quickly escalated to 17–25 mile runs (I only did 20 miles that day) when it was clear he was weathering the distance without his previous injuries reappearing. Being injured yet again, I took it pretty slow and used this as a build phase. By marathon day, they were both primed and ready (though as it turns out, David had pushed too hard already and had some limiting injuries), and gave 3:37 and 4:12 performances.

So by August 1st, I was eager for another race, this time Skyline 50K. This race was extremely well organized and fun, with friendly volunteers positioned at trail junctions pointing the right direction frequently during the race, it was not possible to get lost. The course was harder than I expected, even though it is ostensibly completely runnable (just not for me), because some sections are very steep and rugged. I was amazed to read Jean Pommier’s account of running 7 minute miles through the parts that had me picking my way carefully over roots and rocks, averaging 15 minute miles!

Two weeks later marked the August 2010 (instead of September or March) running of the Steven’s Creek 50K. The event was well run this year as well, though our weather was not as considerate and became hot, while last year was unseasonably cool. I met Roger Jensen (“the yo-yo guy”) and Gordy Ansleigh here. Roger planted the seed for running Rio del Lago, saying that he and Barbara Elia would be there. I ended up finishing a little ahead of Roger, and thought Hmmm…

For these races as well, my foot just wasn’t the main limitation—it still hurt sometimes and made me run cautiously and tentatively at times, but after the races seemed better than before, if anything. But by the time the next weekend came around, I had put in 61 miles for the week and everything started to rebel. I had aches at the Achilles insertion into the calcaneus, peroneal brevis (or longus) tendonitis (maybe) in addition to PF (but the buzzing and tingling of nerve entrapment has finally gone for good I think). I blamed running with extra weight for aggravating the ligaments, but I certainly don’t understand what causes it to flare up on occasion still. So, a couple of easy cutback weeks were in order. I watched and pampered the foot during these weeks and then on the last possible day signed up for my first 100 mile race. Stay tuned for this next misadventure!

So the upshot is that over the last year, an impact injury with dislocation resulted in significant remodeling of foot structure, resulting in PF and other aggravations. It’s possible if I had gone to have it checked out right away, all of these problems could have been avoided, although I’ve heard stories about residual effects of injuries in people who were careful to get everything checked out. I now wonder whether PF is generally the result of minor or unnoticed foot remodeling. After all, the fascia is very inflexible, and changes in bone structure in the foot increasing the length of the foot of only a few mm could result in changes in tension in the fascia, possibly in stretching and tearing injuries. I was able to keep running, but not as fast or as far as I wanted. I had to give up my beloved Inov8’s because my feet seemed to hurt more wearing them than my uber-protective Montrail Continental Divides (sadly, no longer available). I also tried La Sportiva Cascadias and Salomon XTs, which are great shoes, but not as easy on my feet. I got into a routine of easy runs with prophylactic ibuprofen, which seemed to help prevent the majority of the inflammation, then I’d have to sit around for several hours icing my foot. It gradually got better so that it no longer hurt after running most of the time, and did not hurt when getting out of bed in the AM, but still requires a lot of maintenance and pampering. I’ve been able to manage mileage of 20 to 50 miles per week throughout the year, but have to be prepared to cut back at signs of aggravation. At various times, the pain has caused me to run with an awkward running gait, twisting of the knee or ankle (trying to avoid direct pressure on the heel), differences in foot falls (midfoot or forefoot on the left while heel strike on the right), all possibly leading to additional injury if not careful. I can really see the difference on potentially fast downhills, where I find myself holding back for fear of re-injury. I am optimistic, but would not be surprised to have to put up with this for another year or more. It’s looking less and less like I will ever run as fast as even a 6:30 (hilly) 50K again, but at least I can still get out there, and I am grateful for that. Luckily for most PF sufferers, their injuries are more minor and will resolve more quickly.

David’s experience

It has been a rough year for both of us in the running area. David strained his popliteus muscle in May 2009 (sprinting on the track in his new VFFs), and shortly thereafter pinched his meniscus, probably as a result of his knee misbehaving due to his first injury (one injury begets another). He ran with a knee brace for months, and as a result of this knee tenderness was not willing to run Steven’s Creek 50K (he volunteered) or Firetrails in 2009, but instead agreed to be my pacer. Sometime in late Fall 2009/early Winter of 2010, David also developed plantar fasciitis, in the same foot as me. We’re not sure why, or if it was related to some adjustments he made due to knee pain he had from the previous injury, or due to excessive strain when adapting to using VFFs. His PF never became as rabid as mine, and he has managed to recover without suffering too much. It didn’t seem to bother him in the Fremont Fatass 50K or the Second Saratoga Fatass 50K, though he was definitely slower at the Overgrown Fatass Marathon because of it (and also something of a real tenderfoot on that rugged trail with his VFFs). So he has spent some of the past year also icing his foot, along with physical therapy exercises too (lots of ankle work and calf raises).

Then while training for the SF Marathon, he injured a psoas muscle and one or two adductors. Though seemingly minor, these became aggravated during the race so that he was unable to run his best pace. Afterwards, we noticed he had a big lump on his Achilles tendon, so he is treating all of these new injuries with caution and easy running. David is convinced that it was speed work that was problematic and led to injuries; he’s never had any problems from the longer, slower distances. I am reminded of one of Gordo Byrn’s posts about how big men (i.e., ≥ 6 ft tall, > 165 lbs) benefit from easier training (“Small women get fast from intensity, big men get fast from volume.”). This certainly seems to be true for David. He seemed indestructible when he first started running with me, but then he never had to strain very hard to keep up with me and was always able to stay within his body’s limits. Avoiding high intensity training doesn’t seem to have prevented him from running faster than me!


Ewa said...

I cannot believe you ran this much with all those injuries. Totally amazing. Hope your next year will be injury free.
Some problems just don't want to go away easily (especially as I age and I think I do). Like my Achilles tendon. It finally stopped hurting after months and months of pain, but the lump is still there so there must be some scar tissue left.
Good luck to both of you and I am hoping to see more, a lot more of your posts.

Danni said...

Ugh. That's a lot of ouch. For me cross training seems to have helped me avoid injuries, though I've been relatively lucky (except for a SI Joint blowout around 2003).

Methuselah said...

Yikes, my feet were hurting just reading that. I have just come to the end of 2 weeks of rest after two big races (well, big for me, but not for you!) and can't wait to get back out even though one foot is still tender. So I well understand the difficulty in finding that balance. Hope thing improve next year.

chris mcpeake said...

Wow. Now I feel ashamed for complaining about my feet so much.

Drs. Cynthia and David said...

Welcome to our blog, Chris. The point I hope came across is that though injuries suck, you can keep "training" through them and they will eventually get better. Feet are incredibly sensitive though. I once worked on a project involving sustained local anesthesia, and the model they tested it in was post-surgery pain control in feet, apparently a challenging test.