Member questions from oneslowdoc

I am coming back to triathlon after a year off due to an ankle injury.  My left ankle started to bother me in May of 2007 when I was training for the Chicago Marathon.  I didn't think much of it at the time - just typical Achilles tendinitis that I have battled since I started running in 2001 and a new pain on my anterior ankle.  I then had a stress fracture of my right calcaneous in September of that year so I figured my left ankle would heal during the 10 week rehab, but I was wrong.  

I trained through the pain in 2008 until August/September when I was having too much pain to kick a soccer ball with my kids.  I started to limit my activity (missing my fall races) and self rehabed my ankle (without a real clear diagnosis).  After a few months I self referred to a local physical therapist and had ultrasound and ASTYM of my Achilles, peroneal tendon, and extensor digitorum longus muscle and tendon, and the superior extensor retinaculum.  I did stretches, exercises, eccentric calf raises, ice and Voltaren gel.  After a couple of months of that I got an MRI (which was normal) and went to an ankle orthopedist.  He did more xrays under stress and found nothing.  He decided he could decompress the anterior nerve (intermediate dorsal cutaneous nerve and superficial peroneal nerve) and shave off the talus.  This would have been a long recovery and only helped one of the three problems.  I decided to not go that route and finally ended up at my friendly sports med doc.  He put my back in physical therapy with a different physical therapist (who did the same ASTYM treatment) and was a little more knowledgeable about runners.  

I did more therapy, more stretches, more exercises and stopped running for over six months.  I even stopped biking for several months because that even seems to bother it.  If fact pushing of the wall while swimming seems to bother it.  Any dorsiflexion  hurts my anterior ankle. I am getting better currently doing band exercises 3 - 4 days a week, stretching multiple times a day, and moderating my exercise.  I am back to triathlon, but I noticed my old pains are starting to come back.  I have used custom orthotics, OTC orthotics, and even Vibram Five Finger shoes.  I have changed running shoes, biking shoes, and pedals.  I really think both running and biking hurt my ankle.  

Any other ideas?

Answer by Andrew Getzin, MD
Member AMSSM

Wow.  It sounds like you have been struggling with your ankle for almost three years.  After reading your history, I am impressed by how much energy you have put into getting your ankle better so that you can get back to your triathlon goals.  Based on your name, "oneslowdoc," and your self referring to PT, I am suspecting that you are a physician or a clinician.  I am fortunate in that I often see my medical colleagues when they develop exercise related injuries.  I have found that having medical knowledge can often cloud the picture. What I try to do as a clinician when I see medical people with extensive histories like yours is to step back and have a clean look.

You describe some reassuring information in that the MRI was normal.  In addition, your ankle seems to be getting better currently with the band work and stretching.  Instead of focusing on a possibly elusive diagnosis, let me present some common sense suggestions.

The first thing that crossed my mind is that I really don't know why you are having this problem.  What is your running form like?  Perhaps your center of gravity is too far behind your foot strike and you are loading your ankle too much.  You may benefit by working with somebody who has skills in evaluating running gait; video with feedback can be very helpful.  The second thing to look at is your training load. When I had a recent bout of Achilles tendinosis, I realized that I could train for the run as aggressively as I wanted, but that would exacerbate my injury.  Instead, I took my foot off the gas pedal and accepted my fate.  My run time might be a bit slower this year, but I will still be able to compete.  I would encourage you to look at the forces you are applying and possibly back off a little in your running training.  Finally, keeping a good training log is essential.  I ask my patients to include what they did for the day and their pain level from 0-10.  If their pain is climbing they need to modify what they are doing.

Hang in there!

Andrew Getzin, MD
Clinical Director Sports Medicine and Athletic Performance
Cayuga Medical Center
www.cayugamed.org/sportsmedicine