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?  

My Journey to Becoming a Barefoot Runner, Part 3: The How to Begin

When I started this journey, I’m pretty sure I started a little backwards.  I ended up with the best possible outcome, but that’s not to say I didn’t encounter some major speedbumps.  So, I believe a cautionary tale is in order:  If you think that you can go out and run the same distance barefoot or in minimalist shoes as you do in your conventional running shoes right away, you better check yourself before you wreck yourself  For real!   Thanks, Ice Cube, for that throwback to the early 90’s.

First, (after I sprained my ankle again) I went out and bought a pair of Vibram Treksports.  Here’s a picture of my muddy feet in them:

  When I first bought them, I didn’t try to run in them right away.  I’d been wearing cushioned shoes for so long, that I couldn’t even stand barefoot in my bathroom to get ready for work without pain, so I knew running in these was pretty much a death wish.  I walked around most of the day in them and realized, oh, I have a pinky toe!!  Apparently that appendage is actually a separate entity from the rest of the foot.  It blended in for so long, I was surprised to hear it screaming at me from the ground.  OUCH! You’re stretching me out!  But I was excited to see that I could walk around pretty well in them despite recovering from an ankle sprain.

A couple of days later, I finally got up the nerve to go for a quick run in them.  I strapped them on, and stepped onto the sidewalk feeling like an alien.  Awkwardly, I began slowly running down the sidewalk.  I imagine I looked something like one of these guys, this absolutely cracks me up: 

That day, I ran 2 minutes in one direction away from my house, then 2 minutes the other direction away from my house, so I was never far from home in case of a disaster.  I ran for a total of 4 minutes, and oddly enough, my ankle didn’t hurt.  A few hours later, the calf soreness set in…

The next day, walking was a chore.  I was having trouble with stairs, and thought about borrowing a cane from a patient.  Over the course of the next couple of months, I slowly built up to running 3 miles, then 5 miles.  My first 5 mile day, I was ecstatic.  My this time, alien running was really feeling good.  I was light, energetic, and best of all, no ankle pain.  I felt so good, that the next day I went out and did it again, the same 5 mile route despite the lingering soreness in my calves.  This is where the problem resurfaced, the problem of being both a runner and a PT.  There’s that deranged runner on one shoulder shrieking, “WHEEEE!!!  This is fun, do it again, again!!”  And then the sensible PT on the other shoulder saying, “Come on, you know better than to do this, you’re not ready!”  It seems that the runner always wins the first round.

The next day, walking was not even an option.  I had successfully acquired my first too much too soon injury from minimalist running, also known as TMTS in running lingo.  Retrocalcaneal bursitis, welcome to your new home in my ankle for the next few weeks.  Oops, I got a little too excited and and ran two back to back 5 mile days.  You see, the reason for most injuries resulting from minimalist running are due to user error.  It’s not the shoe’s fault.  Or your foot’s fault.  It’s your own damn fault, you deranged runner.  🙂  I spent plenty of time icing the golf ball on my heel over the next couple of weeks and realized that I needed to listen to my body.  Afterall, this was something brand new, and you have to respect that.

The easiest way to avoid the TMTS injuries is to take the shoes off.  That’s right, nudey foot time.  Strip down to your bare soles.  Even if the Vibrams or other “barefoot shoes” feel like nothing on your feet compared to what you’re acquainted with, they still disguise the precious feedback coming in from the sensory nerves in your feet.  Have you ever tried to find something in your purse or your pocket when you’re wearing thin liner gloves?  It’s like being blind!  I always end up getting frustrated and taking the things off to find my chapstick.

That being said, when we first introduce our bare feet to the ground, it’s like waking up and seeing the sun for the first time.  Holy hell, that thing is bright!!  We will be using muscles that have been sleeping for years in your shoes, heck I’d be sleeping too if I didn’t have anything else to do.  A good rule of thumb that I’ve used when we begin running this way is this:  If it hurts, acknowledge the pain and where it is.  Continue running for another 10 seconds or so, and if it still hurts, head home.  Preferably, stay close enough to home so that you can get there easily.  More importantly, Michael Sandler, author of one of my favorite books Barefoot Running, says, “Stop barefoot running when you stop having fun.”

If we begin barefoot, we won’t get  far because our soles won’t be tough enough to get the job done.  If we begin in minimalist shoes, we have more chance of being injured because we will not get the sensory communication from our feet, leading to overdoing early on.  Beginning barefoot for short distances allows our skin on the bottom of our feet to toughen up, while simultaneously strengthening the muscles and tendons.  Strengthening the muscles and tendons gradually will facilitate the gentle tugging on the bones they are connected to, in turn strengthening those bones and preparing them for the increased weightbearing load that they were originally designed to hold.  Have you ever heard that resistance training (lifting weights) can help to prevent osteoporosis?  Bingo!  The bones respond to the gentle tugging from the muscles and tendons by building stronger bones, resulting in a stronger overall body and increased bone density.

Now don’t misunderstand, we can begin this journey in minimalist shoes instead of totally barefoot, but know that injury/soreness is more likely, and we have to learn to rein in our deranged runner tendencies.  Heck, I did it, but I’m a physical therapist who still was dumb enough to go through 2 separate but short episodes of retrocalcaneal bursitis (“WHEEEE!!!”) and some killer top of the foot pain for a week or two.  While these brief discomforts were nothing compared to the chain of injuries I had before, they were still discouraging.  But in my case, I really didn’t have the option to go back to shoes, so I stuck with the alien running.  Lucky for me, because I’ve been totally injury free for a year and a half.  All of my TMTS injuries (3)  were in the first 5 months of running inVibrams and lasted 2 or 3 weeks at most.  All my fault, I might add.  1. Back to back 5 mile runs in the first month or so.  2. Half marathon followed by launching into full blown marathon training the next week (top of foot pain coupled with retrocalcaneal bursitis on the other foot)

In the case of minimalist running, it’s no secret that there is a new crop of injured runners experiencing ugly things like stress fractures and the above injuries.  But on the bright side, this is easy to prevent as long as we educate ourselves and retrain our bodies to run properly by giving ourselves enough time to build strength in the muscles that have been napping for a while in our cushy shoes.  In my next post, I would like to go into preparation, form, and progression of barefoot/minimalist running.  In the meantime, a great book to read is Michael Sandler’s Barefoot Running.  The book along with the DVD, which I also highly recommend, can be found on his website, http://www.runbare.com/.  Here is a picture of my copy of the DVD!  It’s filled with great philosophies and instructions on form as well as preparation exercises.  Also, visit Minimalist Mondays You Tube channel which is a program hosted by local PT, Sanatan Golden and local podiatrist,  Dr. Ray McClanahan.  They are doing a fantastic service for the community, and I will certainly reference several of their exercises next time when I talk about preparation.

In closing, here is a funny video about us barefooters: