Too Much Too Soon Syndrome FAQ: A Look at Inside Ankle Pain

The most frequent question that barefoot runners ask me is, “Why does the top of my foot hurt?” Second, “Why do the insides of my ankles hurt?”  I will go a bit backward with my posts, because I’ve gotten two inside ankle pain questions in the past two weeks. I will try to address top of the foot pain in my next one.  First of all, what is Too Much Too Soon Syndrome (TMTS)?  TMTS is very common among us newly converted barefoot or minimalist runners.  Many of us have tried for years to run in traditional shoes and failed to run injury free, or failed to meet our goals, or just failed to run happy!  Running happy is the most important thing of all.  So, that being said, when we start running barefoot or even in Vibrams, something funny happens to us.  The first time, it’s a little weird, and we may even vow to never do it again.  All it takes is that second time.  Two barefoot runs, and you may find yourself addicted.  THIS IS FUN!! WHEEE!!!  All of the sudden, running is fun again, and it feels like play.  Sensation is on overload, your awareness is heightened, and you think to yourself, this is great!  I’m going to run my usual five mile route!  Now it’s very difficult for a barefoot runner to do their normal five mile route because their soles will force them to turn around, but this is where many Vibram Five Finger runners get in trouble.  We have a false sense of security from the rubber on the shoe, and we do not pick up the feedback that’s telling us to stop for the day. And that’s when I get an email, or a message on Facebook…

They usually go something like this: Leigh, I tried those stupid shoes (and yes I ignored you when you said to go barefoot first) and I started really slow by walking in them, and then I ran 4 miles.  Or 6 miles.  Or 8 miles.  Now, I can’t walk!  The top of my foot hurts, or my calves are dying a slow death, or the insides of my ankles hurt, or my whole body hates you Leigh, and I can’t even sit on the toilet correctly.  I broke myself.  These are all things that I’ve heard!  And guess what?  I’ve experienced all these things, because I too, am an impatient runner and ignore my own advice.  It’s true, PTs make the worst patients!

Anyway, what am I talking about? Right, TMTS.  So as new barefoot runners, we truly need to appreciate the amount of time it takes to build strength in the lower legs.  Not only that, but the mobility of our foot must be enough to accommodate our new running style which is decidedly different than say, running in a shoe with an 1.5 inch heel.  It is known that it takes about 8 weeks to gain strength and mass in a muscle.  While we may feel stronger after only a few sessions of weight training or barefoot running, this is only due to neurological factors, i.e. the signal from the brain to the muscle to tell it to contract is getting faster.  This is the common phenomenon that may happen when you’re trying to bench press for the first time.  The first time you try it in the gym, the bar wobbles around like a noodle, and everyone laughs.  Yes, it’s happened to me.  But after a few days of persistence, that bar is steady and you get to show off your mad skills.  Are you stronger?  Well, in a way.  You have better control.  But you won’t be maxing out on the bench press with the big boys and girls until you practice for a long time.  And so, there is the parallel to barefoot running. Just because you’ve been a runner, doesn’t mean that you can max out (run 5 miles barefoot) the second time you try.  We are learning to turn on muscles that have been off for a long, long time.

In the past couple of weeks, I’ve gotten questions from two different people about inside ankle pain after ramping up mileage in Vibram Five Fingers.  In both scenarios, the individual ramped up mileage very quickly. Because they were both runners before, they likely assumed they could do this.  Let me start out by saying that if you’re experiencing persistent pain after trying minimalist or barefoot running, please see a physical therapist who specializes in running.  If possible, seek an open minded, knowledgeable PT who has experience in minimalist running.  Physical therapists are movement and musculoskeletal experts, and they can evaluate and treat the specific problem.  While primary care doctors are a good starting point to get a referral to see a PT, they might not necessarily know exactly what’s going on or be open minded to a form of running that’s still considered to be “alternative” or “different.”

So let’s get back to inside ankle pain.  Inside ankle pain is not uncommon because the muscles that support the arch and muscles of the lower leg are usually atrophied from wearing regular shoes or running shoes with an arch support.  The arches including the intrinsic muscles of the feet need to learn to come alive again, but until then, sometimes certain muscles will try to do all the work to hold up and support the arch.  One such muscle that may become overworked while trying to control the arch, is a muscle called the posterior tibialis.  This muscle originates deep in the calf area and its tendon wraps underneath the inside ankle bone (medial malleolus) and connects to a small bone in the arch called navicular, and then attaches by fibrous expansion to many other small bones in the foot.  When this muscle is overworked, one could develop posterior tibialis tendonitis.  The action of that muscle inverts or brings the foot in towards the midline, plantarflexes the foot (points it like a ballerina)  supinates the foot (helps it roll out during running) and helps to control pronation (arch rolling in during running.)

Good Picture of Posterior Tibialis

So what can you do for this ailment? Well, for starters, RICE.  Rest, ice, compression, elevation.  Yes, it works!  Then, it will be necessary to restore normal mobility and strength in the feet and lower legs.  This is important for anyone who is considering barefoot/minimalist running!  So the question is, is there anything that could cause inside ankle pain other than the posterior tibialis tendon?  Of course! That’s why it’s important to talk to your PT.  But, these exercises below will be beneficial to ANYONE who is considering minimalist running, so you really can’t go wrong with them.

Stretch!

1. Gastroc/Soleus Stretch: Please perform this with knee straight and then bent to stretch both gastroc and soles muscles.  Soleus (knee bent) is of utmost importance as you will be eccentrically loading this guy with your barefoot running.  I like to hold this one for up to 1-2 minutes and repeat 3 times to really change the tissue and increase the dorsiflexion range of motion. Additionally, I like to use a slant board to obtain even more of a stretch. It is necessary for barefoot runners to have lots of dorsiflexion range of motion!

2.Ballerina Stretch: This will ensure the top of the foot has sufficient range of motion so that the muscles/tendons in back of the leg are not overworking. 

3. Roll Out!  Roll your calves out on a foam roller.  Get in there!  Also, roll out the arch of your foot on a golf ball.  Get in there! This should be a “good hurt” and the area should feel looser and freer afterward, not damaged and painful. The muscles/tendons need to be free of adhesions, rolling out can help bring circulation to the area.  Increased circulation means increased blood flow and oxygen, which brings the good stuff we need to repair tissue.

Strengthen!

1. Direct Isolated Posterior Tibialis Eccentric Strengthening: Tendonitis and eccentrics are enemies.  This one is a great addition to your toolbox! 

2. Short Foot Exercise: Janda’s genius idea.  This one is fantastic for intrinsic strength, so that posterior tibialis does not have to compensate for intrinsic weakness. Sanatan calls this the invisible arch support exercise:

3. Calf Raises with Eccentric Lower: Great strength exercise for minimalist runners, as we must have eccentric control via the muscles of the lower leg and foot to decelerate upon landing on the forefoot.  Please be sure that your weight is focused over the big toe.  In other words, do not allow the foot to roll out when lowering down. I use this daily! 

4. Calf Raise 100’s: Love this! 

5. Functional Posterior Tib Exercises: During the second video, you can stop watching at about 3:30, unless you want to know about the navicular drop test.  

These exercises are just a few things to put in your toolbox for minimalist barefoot running.  The most important thing to remember is that patience is key to success in your transition, and the reward in the end is well worth your time.  Run happy and run strong!

Have you experienced any TMTS injuries? What are/were they?