Holiday wishes and Happy Thanksgiving to everyone. This is just a quick note.

I’ve added some new material and updated some older material. The topics and pages are:

Injuries To the Hallucal Sesamoid Bones: Sesamoidopathy and Sesamoiditis

Hallux Rigidus and Hallux Limitus

Turf Toe

These can all be challenging problems for athletes. They are less common than certain other problems, but they still occur very often. Hallux rigidus, sesamoid area pain and sesamoid injury, hallux limitus and turf toe are inter-related problems. The articles review the conditions, classification, and treatment. The tone of the articles is fairly hardcore science, but hopefully they are still accessible enough for everyone to understand.

OCD is not always in your mind. It could be in your knee, elbow or ankle. And it can certainly be a pain to have. In many cases the injury is missed initially and under treated. What we are talking about is osteochondritis dissecans, also known as osteochondral fracture, defect, or  osteochondral injury. It is an injury to the cartilage and subchondral bone which happens most often in the knee, ankle or elbow. In the athlete, who has had an inversion injury, even a minor one, it happens most often on the lateral (outer) ankle. In some

cases the forces are not large. The injury is staged from a compression or contusion to a fully displaced fragment of varying size. With under treatment it can progress from an early stage to a much worse stage. For simple injuries, Stage 1 especially, the treatment is most often what we’ve mentioned for severe ankle sprains “put a cast (or pneumatic walker) on it”.

More detailed information and classification systems including the Berndt-Harty classification and modifications of that system are in a new article: Dr. Pribut on OCD of the Ankle (Osteochondritis Dissecans and Osteochondral Injuries)

Point / Counter Point: The Truth is Out There Somewhere (or maybe here)

Every now and then the “Fear Factor” comes to the Internet. And if you travel the running blogosphere, you’ll discover that sometimes it takes the form of a red alert for heel lifts for Achilles tendonitis. It seems that some would rather have you run in pain or give up because of the pain for fear that a 1/8″, 1/4″ or 3/8″ lift which alleviates the pain could cause a tendon to “pop”. There is evidence that the sound of a tendon popping may come after an indiscriminate intratendinous injection of steroid though. 

The truth is one should pay attention to what your body is telling you. Running in pain which causes an alteration in form is not good. It will most likely lead to both your original injury not improving, and a few additional injuries because of your altered gait.   

With the knowledge that medicine is an art and a science, it is probably best to avoid dogmatic opinions such as  ”no, no ,no” to a heel lift. While some will be helped with shoe and surface corrections, orthotics, stretching and strengthening alone, the addition of a 1/8 – 3/8″ heel lift can often make the difference in both comfort and eventual healing of this condition. The lift is used on both sides to avoid creating a longer leg and altering the gait in such a manner that could create low back pain, hip pain or other problems in the absence of the affected leg being a short limb. The lift is best made of a non-compressible material. It is extremely important to avoid compressible materials which will lead to continued slow stretch movement which could add to either activating the stretch reflex of the achilles tendon or allow for eccentric contraction of the muscle-tendinous complex. This may work to inhibit the healing of the tendon, and stop the individual from being able to run without pain. We certainly, and the ladies among us, especially, will vary our heels by much more than this over the course of a week. A slight change in the heel contact and foot angle should not put your Achilles tendon at greater risk of injury. 

While there are flaws in evidence based medicine and in the ability of us to accurately predict those most likely to become injured, there is  no evidence that 1/8 to 3/8 ” lifts cause ruptured Achilles tendons. Not even the slightest hint that muscles and tendons would be ruined by such a lift or adapted so much that you’ll never be the same. I do not know of any study that shows a 1/4″ lift used for a limited amount of time each day could shorten the muscle/tendon complex. There is adequate time spent in other shoes, barefoot, and even doing stretching exercises. 

Running in pain without a heel lift, or more dramatically running on a soft surfacer with a mushy, over cushioned shoe or a racing flat is far more likely to lead to chronic pain and disability. Proper orthotics are a must, along with avoiding over cushioned running shoes to prevent the tendon while functioning from being over stretched and causing eccentric working of the muscle-tendon complex . There seems to be no reason to avoid a heel lift, but it is not the be all and end all of a program to treat Achilles tendonitis. 

For more details:

Website article: Dr. Pribut on Achilles Tendon Injuries

 Previous Blog entry on Achilles Tendon and stretching

Quick Search of Textbook Comments On Heel Lifts:

I wasn’t sure what I’d find in the texts, but thought it would be interesting to see what other minds have come up with on this issue. I did not think that Noakes would agree with the heel lift, but he did. I do not know what is the scientific basis or aggregate clinical experience to imply that heel lifts are the worst possible therapy for this problem. 

Alfredson, H. and Cook, J. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 32 “Pain in the Achilles Region” p.  606 “A heel lift worn inside both shoes (0.5 – 1.0 cm, .25-0.5 “) is a good practical way of unloading the region. 

Alfredson is famous for his self termed “painful” eccentric stretching for non-insertional Achilles tendinopathy. He has published numerous articles on Achilles tendon problems and on the treatment of them. I am not convinced that eccentric stretching is appropriate in as many cases it is recommended. If you find something isn’t working, including the eccentric work is not helping, you need to change the approach. Measurements have shown that the calf is often weak in eccentric strength when one has Achilles tendonitis. One approach is to work on strengthening that (which can be painful). The other is to diminish the pain by lessening stresses which add to the eccentric contraction strength required. Both approaches and sometimes a combination may be appropriate for different patients and at different times for a specific patient.  I continue  to read Alfredson’s  articles with interest. 

Bradshaw, C. and Hislop, M. in Clinical Sports Medicine, 3rd Edition eds. Bruckner et. al. McGraw Hill 2006, reprinted 2007. Chapter 31 “Calf Pain” Since the calf includes the muscles which create the Achilles tendon, we’ll look at comments in this chapter also. “A heel raise should be used on the injured and uninjured side”. 

Title, C. and Schon, L. “Achilles tendon disorders including tendinosis and tears” in Baxter’s The Foot and Ankle In Sport, Second Edition. Mosby Elsevier. Eds. Porter, D. and Schon, L. 2008. “The initial treatment for Achilles tendinitis is nonoperative. The majority of symptoms respond to rest; activity modification; improved training techniques; stretching and at times, shoe modifications and heel lifts. Initial treatment should include …At times, a heel lift (one fourth to three eights inch)….”

Noakes “The Lore of Running, Fourth Edition”  Human Kinetics Press. 2003. Noakes feels a shoe with a heel height of higher than 12 – 15 mm and says “most authorities agree that a 7 to 15 mm heel-raise should be added to the running shoes”.

Drifting around the web, I came across a description of pain in a runner’s foot which, summarized, was essentially:

“I began having tenderness in my foot, on the top outside at the row of bones and tendons that connect with the baby toe (at about the middle of my foot).  I was also sore all the way up my shin on the outer side of the same leg… so this made me think it was a tendon or muscle issue..(praying its not a stress fracture)”

The answer to this problem follows:

The part of your foot that is indicated as hurt, on the outer part of the foot, includes the 5th metatarsal bone and the peroneus brevis tendon. Right in the middle is certainly the fifth metatarsal bone.

These parts are usually hurt when you invert or turn in your foot. This can happen when you “twist” your ankle in and sometimes ends up as an ankle sprain.

The muscle that the tendon starts at begins up in your leg on the outer side, that’s why it hurts up there. When the ankle turns in, the peroneus longus and brevis tendons are placed under stress and can become injured. The base and sometimes the shaft of the 5th metatarsal bone can become fractured because of the tendon pull. So, this problem could be either an injury to the tendon – (tendonitis, partial tear) and/or an injury to the 5th metatarsal bone – all the way up to a fracture of the 5th metatarsal bone, along with the tendonitis.

Ice, rest, an ankle brace, and possibly a visit to a local sports podiatrist, along with an xray would be a good idea.

Note: Occasionally the cuboid bone is also injured from forces created by the peroneus longus tendon. Additional information on related injuries to the peroneal tendons and to the bottom of the foot are in an article on the “zone of confusion of the midfoot“.

Best of luck with a speedy recovery!