What happened with the podiatrist

I had my visit with the orthopaedic podiatrist this morning. It was uneventful and confusing. Now I really liked the doctor. He was friendly, had a sense of humor and amicable to asking all of my questions. He even said I had good questions - score!

Perhaps it was the excellent conversation that left me pleased with the visit in spite of the lack of answers.

When I explain how I went about injuring my foot, I could already see the rueful shake of his head. I later learned that give the "fad" (his word, not mine) of minimalist running, that people were arriving at his doorstep in epic numbers with injuries such as mine. I was, in fact, a statistic. He and some collaborators at Harvard are currently writing a paper on this very observation, to be submitted in the near future to JBJS or JSM.

Now he specifically stated that he neither supports nor discourages minimalist running. However, he did spend quite a bit of time pointing out some rather glaring holes in the few papers published on barefoot running - notably the sample population in the Nature article (all Kenyans who had never worn shoes and grew up running on grass compared to shod American runners who ran on urban surfaces). Or that fact that they measured impact force on the ground as opposed between the heel and shoe. And the obvious lingering question - even if you can steadily show that barefoot runners land with 20% of the force of a shod runner, does this actually lead to lower rates of injury? Even Dr. Lieberman wasn't able to conclusively say that barefoot running resulted in lower risk of injury. The research simply hasn't been done at this stage. Adequate controls and sample populations weren't in place in the published studies.

Beyond the few studies themselves, becomes the most relevant question - one that I asked him: As a heel-striking, shod runner, how can I safely transition to a minimalist, forefoot-landing running style? There is no proven or certified method of doing so at this stage. Current research compares lifetime barefoot runners and lifetime shod runners. As someone who spent the first 30 years of their life wearing shoes, running in shoes with an elevated heel, will I not only be able to transition to a healthy, safe barefoot stride that equals the same efficiency? My body has adapted and is "efficient at running inefficiently" - to quote Danny Abshire. The bottom line: Will this transition reduce my risk of injury? The answer is that no one knows right now. The research hasn't been done.

So after spending 30 minutes talking intently to the orthopaedist about this, we did come to several conclusions.

I have a fairly uncommon foot type where my heels are set inward when I stand with my feet facing straight forward. So if you look at my feet head-on, you can see the insides of my heels. This results in a mild supination of my foot, where my foot settles off to the sides and I land harder on the outside of my foot. This is something that could be corrected with a couple millimeter heel wedge. He said that if I continue to have ITBS problems, to give him a call and we'll look into the heel wedge.

If I stick to a minimalist stride, the ITBS may not be a problem, since it is primarily an overuse injury that is a result of the heel-striking gait and compensations associated with it. Therefore, if I continue to land on my forefoot, I will likely curtail the ITBS.

This sounded great to me. My entire reason to swap to the VFFs and natural running stride was to get rid of the ITBS that was plaguing me with mileage above 6-8 miles. So upon having this route confirmed, I asked, "So how do I safely return to the forefoot striking gait without reinjuring myself?"

That's the million dollar question.

For one thing, the stress fracture repairs itself stronger and healthier than it was originally - so the likelihood of refracturing that exact spot is unlikely. That doesn't mean I won't just fracture at another location. I asked if there was a set program or recommended transition. He laughs in a good natured way "You mean, is there running school or programs that safely transitions runners from shod to barefoot running safely? No. That would be handy. I'm sure you can find some guy claiming to be able to do just that, but its not routed in research or proven safe practices. There is no certified program to transition you. Our PTs wouldn't be able to help with that, and I don't know of any place off hand that offers such a program."

So pretty much, I'm on my own. He did confirm that weak calves were the primary problem. I suggested calf strengthening exercises - something I already do - and slowly easing into running. On grass - not pavement. He didn't really confirm or deny. But I can certainly continue my non-impact weightlifting and cardio.

He did tell me that I can go onto the treadmill tonight for a trial run. I am to run 1/2 to 1 mile. If I feel any pain, I should stop. Pain indicates that the fracture isn't healed. I can "only run when there is no pain." This can take any numbers of days or weeks, depending on my day to day activity levels. Every time I feel pain though, I should consider the fact that I'm taking a little away from the healing process.

I asked if I should wear the VFFs or my Landreths for the treadmill trial. He said that was up to me. But suggested if I was going to go the minimalist route in the future, that I should consider alternating in the beginning. That is a wise idea.

So...that's that. You're probably as confused as I am. But I'm not more confused than I was going in. I've just had the confusion over this transition to minimalist running confirmed by one of the leading doctors in the nation. Sweet.

On a side note, I gave myself a mini-pedicure in anticipation of the visit today. My toes are sparkling with fluorescent pink polish. I get giddy just looking at them.

Pre-Appointment Update

Tomorrow is my appointment with the orthopaedist. Last week (April 18th), I had another set of x-rays taken on my foot. I received a note from my doctor stating that it was continuing to heal well and that I should bring along my x-rays to the appointment. Therefore this morning I swung by radiology to grab copies of the x-rays. I will now share them for your viewing pleasure!

As you can see from the periosteal reaction, the stress fracture is located near the head of my second metatarsal of my left foot. These images are at 4 weeks and 7 weeks post-fracture, once healing had begun.





I don't necessarily see dramatic healing in last week's x-rays, but my day to day pain has subsided. I can perform lunges and last week I participated in yoga without much difficulty. I feel comfortable performing knee-dropping dance moves on Dance Central. I get minor pain (3/10) when I walk up a steep incline or hill, but daily activities are unaffected. I'm feeling confident that I'll have permission to start running ASAP.

I will report back after tomorrow's visit!

Confirmation

Nothing has really changed. I got confirmation from the second set of x-rays today that it's a "healing" stress fracture. Which I suppose explains why hurts less now than it did a couple of weeks ago. On a positive note, in my mind at least, this means that I can totally run the 5k in a couple of weeks. If its already healing, then it should be fine by the time of the race. I lightly jogged to the train this morning (mainly because it was arriving and I wasn't at the station) and my foot didn't feel so bad in my Landreths. I guess cushioning and heel-striking tends to lessen the damage on my toe. I'm debating if this means I can run three miles like that. I think that this week I will go for a 1 mile trial run down the park and back. I'll ice it up and if it feels good, then I'll be on for race. Or more like a slow jog, which I know shames people actually racing it. But what can you do? I just love the exhilaration of marathon weekend.

I'm going to try to score the x-rays when I talk to my doctor next time. I really want to see my the bones in my foot.

Anyway, this is what happened:

Image from AAOS website: Here

The Doctor's Appointment

Well, I went in for my yearly physical this morning with my new physician. She's a bit older, but very sweet. I asked if she could look at my foot while I was there, providing a brief history of my running injuries over the past year. I suppose I'm rather long-winded when I describe my running history, but I felt that it was necessary in order to provide proper background to diagnose the issue. Apparently she didn't feel that way.

She rushed me and didn't ask too many questions. Instead, she scolded me for wearing Vibram Five Fingers and made a bold, baffling statement: "Your feet aren't meant to run without lots of cushioning." Something along those lines. She actually referred to the Vibrams as "Extremely dangerous." Seriously. Someone hasn't brushed up on their recent running biomechanics. However, I nodded and smiled because she was referring me to an orthopaedic specialist and wanted me to go to PT once we took some x-rays. Basically, it doesn't matter what her opinion on natural running and Vibrams are once I'm placed into the hands of the specialist. I requested someone from MGH, if possible due to both convenience and the fact that it took over an hour past my appointment start time to see my doctor. I don't think my new health center runs efficiently.

So tomorrow I'm going back for x-rays of the left foot and we'll see if its tendinitis or something more serious.