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From time to time I get emails from readers with various types of running injuries. Given that I am not a medical doctor, I generally don’t feel comfortable doing much more than discussing the anatomy and sharing some houghts, and usually my advice is to seek professional help if an injury is of major concern to a runner (in other words, I know and respect my limits!).
Sometimes, however, a particular problem can benefit from advice provided by other runners who might have dealt with a similar issue. My hope in posting the following story is that someone who has experienced or is knowledgeable about what Allan is going through might be able to provide some helpful advice.
Here is Allan’s story:
I have been running regularly since 2004. After a long down time with a hip injury, I decided earlier this year that since I was starting from ground zero, I was going to do all of my running either barefoot or in minimalist footwear, mostly Merrell Trail Gloves, but also Vibram Fivefingers KSOs and Bikilas. Before this year I was mostly running in Asics Nimbus, Nike Air Max 360, and Mizuno Wave Creation. During my minimalist transition, I carefully controlled the mileage and intensity buildup, never increased it more than 10% per week, and cut back 50% every 4th week. Very conservative. I gradually ramped up to where I was doing 1 run a week of 4 to 5 miles barefoot and 2 or 3 recovery runs of 1.5 miles barefoot. The rest of the runs were in minimalist shoes. As my long run got up to about 6 miles I started getting some soreness in my left heel near the Achilles tendon insertion. Longest runs were 11 miles before the pain flared up so bad that I had to stop running.
The heel pain started out gradually, went away as I warmed up, and went away the next day. Pretty typical story. It was always better before the next run and didn't affect my gait so I kept going. But over time it got worse, started swelling, etc. Finally after a 5k on a very hilly course it got so painful and swollen that running was no longer possible. I stopped running and after the pain didn't go away with rest, I went to the doctor and got diagnosed with retrocalcaneal bursitis. A month of PT and anti-inflammatories didn't clear it up, so the doctor took X-rays which revealed a Haglund's defect, which is a large spur of bone extending from the calcaneus just behind the Achilles tendon (see photo below). The doctor recommended surgery to remove it. The spur was apparently digging into the tendon and bursa and causing the inflammation.
Haglund Deformity – note the large, pointed spur extending up from the calcaneus (heel bone)
I have gotten things calmed down enough to start doing very limited running, but it is still uncomfortable. I’m developing a theory of what is going on, so I tested my hypothesis this morning by dusting off my high heeled running shoes. Guess what. Things felt much better. So, what I'm thinking is that over the last several years my heel has remodeled at a particular angle dictated by the footwear I was wearing, which all had traditional raised heels. When I started running exclusively in my bare feet and flat shoes it changed the angle of my foot at mid stance such that the spur was now protruding back into my Achilles tendon and its bursa. I suspect that this wasn't a problem when I was running only occasionally in my bare feet. But once it was full time my Achilles never got a chance to calm down.
I recently went to another orthopedic surgeon who specializes in foot and ankle surgery and he didn't recommend surgery to remove the Haglund structure (he didn't call it a defect). He said that lots of people had it and that it shouldn't be a problem. He noted tightness of my calves and Achilles tendon and recommended continued stretching. I was already working on this but even doing this irritates the bursitis and tendonitis. I again suspect that it is the Haglund structure digging into the inflamed tendon and bursa.
I've learned one thing regarding stretching. I was doing the traditional calf stretch, which stretches the gastrocnemius, and I'm pretty even on both the left and right side and it's not too bad. I didn't know about the soleus stretch that is done with a bent knee. I'm actually very, very tight in the soleus on the injured side so that is what I'm focusing on right now because that seems to be what is limiting my dorsiflexion. So, the Haglunds’ seems to be a contributing factor, but both doctors and my physical therapist would concur that my lack of ankle dorsiflexion (only about 7 degrees) is probably contributing as well. I had ligament (ATFL) reconstruction on the ankle in 2008 and that probably left me with reduced range of motion, although I think we got most of it back. However, with the injury it has tightened back up. I've had other injuries over the last year and tend to be very tight anyway and I suspect that combined with the barefoot running it may have caused the soleus to get very tight. Don't know. But it's very tight and getting things stretched back out is a slow and painful process. So right now the combination of the Haglund’s, tight soleus and AT seems to be a recipe for a really sore heel.
I'm curious about the cause of my Haglund’s - given the size of the spur, I’d guess that it had to have developed prior to me making the minimalist/barefoot transition. When I went for the consult with the foot and ankle specialist he said that a typical cause is repeated rubbing of a stiff heel counter against the heel bone. However, none of the shoes I wear seem to irritate the heel. I'm an engineer so it's pretty casual wear at work and I always wear running shoes. I almost never wear dress shoes. If anything, the raised heel of my running shoes provides relief by taking some stress off the AT, and probably by changing the angle of the AT relative to the Haglund’s structure. For now I'm going to go back to running in traditional running shoes to see if that will keep me out of surgery, and not lead to a recurrence of my past hip issues. If that successfully rehabs my bursitis then I'll return to using barefoot running as a tool and run only once or twice a week and not on my long runs. Maybe over time that spur will remodel and allow a more gradual transition to exclusively minimal footwear.
I'm curious how many runners are affected by this and if runners who switch to minimalist footwear are more prone to this kind of injury.
I’m also curious about what those who have dealt with Haglund’s and retrocalcaneal bursitis have done for therapy. Is surgery the best option, or can I manage just by using my high-heeled footwear? Any thoughts on a potential cause in my case? Any advice on how best to proceed?
And finally, I guess a word of advice to those transitioning to minimalist footwear - high heeled shoes can actually help with insertional Achilles pain.
If you have any thoughts or advice, feel free to leave a comment!
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