[reply]We were taught that high ankle sprains can cause pain and discomfort for up to 6 months. Sounds like you are functioning pretty well if you are doing all the runs you listed from recovery to sprints. How long is the pain lingering after you run?

Doesn't sound like RSD. One of the hallmarks that I look for is pain out of proportion to the injury. If you are running speed work and long runs, I would highly doubt that you truly have RSD.

If you have doubts, definitely request the MRI, at the very least it will give you peace of mind. Joint manipulation, as mentioned by cerveloguy and others may of benefit. Just read a case series on calcaneocuboid syndrome, fairly uncommon, but responds well to manipulation.[/reply]

Pain out of proportion to the injury is not the only hallmark of an RSD. RSD can be relatively (or completely) painless but have other manifestations. (I once saved the finger of a marine whose trigger finger was constantly blue from poor circulation with no obvious etiology and no pain. They were going to amputate it and I "cured" it with two sympathetic blocks in a "just to make sure" move before it was lopped off). Another manifestation is a movement disorder which, again, can occur without much pain.

The other "hallmark" of RSD is something that lasts out of proportion to the "injury" (the inciting trauma can be so minor as to not even be remembered by the patient). Something lasting for 6 months, or 2 or 10 years without explanation or response to treatment is almost certainly out of proportion to almost every trauma. I always think of it as a possibility in these situation. Failure to think of it can sentence the patient to years of pain, especially when the diagnostic test is so easy to perform, at least in the right hands.

In my role as a specialist in treating chronic pain I saw everyone else's failures and I can tell you the most common reason for chronic pain is a missed diagnosis and the most common missed diagnosis is RSD.

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Frank,
An original Ironman and the Inventor of PowerCranks

true pain is not the ONLY sign of RSD, but in this situation, doesn't sound like RSD, he is not reporting any other symptoms other than pain. Remember he had a high ankle sprain, actually he said he had a "severe" high ankle sprain. Pain after activity, especially high-impact activity is not out of proportion for this type of injury. Even though 22 weeks sounds like a long time, it's par for the course for this type of injury.

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Dan Hollingsworth

Nobody grows old by merely living a number of years. People grow old only by deserting their ideals. Years may wrinkle the skin, but to give up interest wrinkles the soul." - Douglas MacArthur

[reply]true pain is not the ONLY sign of RSD, but in this situation, doesn't sound like RSD, he is not reporting any other symptoms other than pain. Remember he had a high ankle sprain, actually he said he had a "severe" high ankle sprain. Pain after activity, especially high-impact activity is not out of proportion for this type of injury. Even though 22 weeks sounds like a long time, it's par for the course for this type of injury.[/reply]

Fine. I didn't say she had it, only that is is a possibility (a strong possibility in my experience). But when it continues to persist how long would you wait before you even looked? 9 months, a year? 5 years? Never? Regardless of what her doctors think, she has been made aware. She will know when it is time to consider the diagnosis and to find someone skilled at diagnosing and treating it (they are few and far between I am afraid). At least now she is aware of the possibility, which is probably more than her doctor knows until she shows him this thread.

And, BTW, what on earth is "true pain"? I had 5 different categories (etiologies) of pain complaints (all of which required a somewhat different approach usually and figuring out what was going on was the key to successful treatment). True pain was not one of them.

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Frank,
An original Ironman and the Inventor of PowerCranks

sorry forgot my punctuation. That should have read "True, pain is not the ONLY sign..."

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Dan Hollingsworth

Nobody grows old by merely living a number of years. People grow old only by deserting their ideals. Years may wrinkle the skin, but to give up interest wrinkles the soul." - Douglas MacArthur

[reply]sorry forgot my punctuation. That should have read "True, pain is not the ONLY sign..."[/reply]

That is cool. In my mind she has all the symptoms (don't know about signs as none of us have done a PE) she needs for me to consider it a strong possibility.

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Frank,
An original Ironman and the Inventor of PowerCranks

Here's what the MRI showed: (1) moderate effusion at posterior ankle joint and (2) nonspecific mild bone marrow edema mid/superior calcaneus inferior to subtalar joint. Tendons looked fine.

The dr. said he might be able to tell more about what's amiss with a CT scan, and that it might be a good idea not to run for awhile. I negotiated him out of that position--or as my coach said when I related the story to him, I "browbeat" him out of it--since I usually have only discomfort-not-rising-to-the-level-of-pain when I run on it now, and I am tired of being convalescent. (I have had a really bad year for injury--broke my collarbone in a bike wreck last August and had shoulder 'scoped to fix torn labrum in February.)

The eventual compromise was I run on it to the extent it doesn't hurt, even including speed work, see what happens over the next 2 months, and then come back for a CT scan if it's no better.

I asked specifically about the possibility of RSD, and the dr. said he didn't think so. But did he say that because the presentation really is inconsistent with RSD, or did he say that because he himself has simply never seen RSD present like this?

[reply]Here's what the MRI showed: (1) moderate effusion at posterior ankle joint and (2) nonspecific mild bone marrow edema mid/superior calcaneus inferior to subtalar joint. Tendons looked fine.

The dr. said he might be able to tell more about what's amiss with a CT scan, and that it might be a good idea not to run for awhile. I negotiated him out of that position--or as my coach said when I related the story to him, I "browbeat" him out of it--since I usually have only discomfort-not-rising-to-the-level-of-pain when I run on it now, and I am tired of being convalescent. (I have had a really bad year for injury--broke my collarbone in a bike wreck last August and had shoulder 'scoped to fix torn labrum in February.)

The eventual compromise was I run on it to the extent it doesn't hurt, even including speed work, see what happens over the next 2 months, and then come back for a CT scan if it's no better.

I asked specifically about the possibility of RSD, and the dr. said he didn't think so. But did he say that because the presentation really is inconsistent with RSD, or did he say that because he himself has simply never seen RSD present like this?[/reply]

The effusion suggests there is an ongoing instability or inflammation in the joint. CT is better at looking at bone than an MRI but not sure it will tell you much and there is no reason to do any test unless one will change what they are going to do based upon the result. I am not sure if this result is consistent with an RSD as I NEVER got an MRI (or CT or anything else) to confirm the diagnosis and rarely did I ever see a patient at the 6 month stage, I usually saw them at the 2 to 10 year stage (yes it can last that long - longer, even though I don't think it will in you even if you do have it, you are too mild). RSD, in my opinion, is a clinical diagnosis, there is not an XRay or any other "test" (with the possible exception of a thermogram, checking for a temperature difference between the legs/feet) helpful in making the diagnosis. In the acute stage RSD can present with some clinical swelling so it is not necessarily inconsistent. Your doctor said "he didn't think so" because he doesn't know squat about this diagnosis I suspect. However, that doesn't mean I object to the plan. It is ok. At least he knows there really is something wrong and this isn't all in your head.

If I were you I would stop the pounding of this joint to give this a fair shot at healing (as you are clearly not going to get the diagnostic block I would propose if you came to me). That means one of three things. 1. Stop running (already vetoed by you) 2. Pool running only. 3. Biking only (perhaps with PowerCranks if you want to maintain your running skills). Otherwise, when this problem is still there in 2 months, what have you learned?

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Frank,
An original Ironman and the Inventor of PowerCranks

OK, I'm rethinking my immediate veto of the "stop running" idea. The ortho guy I saw today suggested it, you're suggesting it--maybe there's something to it. My knee-jerk reaction was due to already having not run at all for the first 4 months (December - April) after the injury.

Maybe I'll stop running for 2 months, which is the time frame I already agreed to before going back for something else. I'll think it over this afternoon while I run. In any case, I appreciate how generous you've been with helpful information, clinical experience, and advice.

Re: Powercranks. My coach is about to buy some. I'm impressed that you invented them.

Susan

[reply]OK, I'm rethinking my immediate veto of the "stop running" idea. The ortho guy I saw today suggested it, you're suggesting it--maybe there's something to it. My knee-jerk reaction was due to already having not run at all for the first 4 months (December - April) after the injury.

Maybe I'll stop running for 2 months, which is the time frame I already agreed to before going back for something else. I'll think it over this afternoon while I run. In any case, I appreciate how generous you've been with helpful information, clinical experience, and advice.

Re: Powercranks. My coach is about to buy some. I'm impressed that you invented them.

Susan[/reply]

That advice is based upon the obviously abnormal MRI but it is not necessarily to stop running or exercising, only to stop the pounding on the ankle. Something must be going on. If it is mechanical the only hope is to let it heal. I am surprised some of the others here did not come back and state how your MRI fit in with their theories. I would be interested in knowing. Good luck.

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Frank,
An original Ironman and the Inventor of PowerCranks

Well - the radiologists interpretation doesn't help much. Marrow edema in the calcaneus beneath the subtalar joint can indicate a healing stress fracture though. Probably the reason he would "like" to see a fine CT scan to more definitively rule out a stress fx.

In all fairness to Frank - I actually do treat patients exactly like this all day. And I have made several RSD/complex regional pain syndrome diagnoses and have a good buddy who I refer them to for treatment (yes, usually a stellate ganlion/sympathetic block).

I just saw a patient almost exactly like you today - about a 4 month history, only hurts when she is running and is fine with walking. MRI was similar as well - basically treating as a stress fx as she want to run - I have her in a CAM boot/Fracture walker right now to eliminate stress as much I can without casting her. This is not at all unusual.

I treat my runners (or triathletes) a bit different than other patients since I know they want to get back into it ASAP and rarely listen to the "stay off it" rec. Obviously not running/pounding will help, but for how long? It would be virtually impossible to answer. If you are otherwise perfectly healthy, an ESR (sed rate) should be elevated with the "stress reaction" marrow edema. This simple blood test could be repeated in say, 1 month, and it should be lower. Problem is, ANY inflammatory condition in the body can elevate this. It is very sensitive, but non-specific. BUT, if it is very low after a month and was high - that would likely point to no further bone inflammation and could be your "go ahead" signal to run.

Best of luck to 'ya!

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

[reply]In all fairness to Frank - I actually do treat patients exactly like this all day. And I have made several RSD/complex regional pain syndrome diagnoses and have a good buddy who I refer them to for treatment (yes, usually a stellate ganlion/sympathetic block).[/reply]

Stellate ganglion sympathetic block? Not for the foot I hope :-)

I agree a stress fracture is a possibility and the CT could be used to diagnose this for sure. If the CT was normal though I can't think of much to explain what is going on in the MRI other than possibly RSD, and that is a stretch. Let's assume this is a stress fracture. I agree, the ESR would be a cost-effective way to follow her as to when it would be safe to start "real" running again (assuming it is elevated now, which it should be, but maybe not, then all bets are off. And it could be used to follow her after she starts running to make sure it isn't coming back. The most important thing is to allow healing to occur and then to prevent reinjury. Nothing slows the athlete down more than an injury.

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Frank,
An original Ironman and the Inventor of PowerCranks

The orthopedist did say a stress fracture was a possibility and that he'd had a detailed conversation with the radiologist about it. All I remember about the discussion he had with me is that he doesn't think it's a stress fracture. I don't think it's a stress fracture either. I haven't done anything to get a stress fracture. I didn't have any pain before I sprained my ankle in December, I didn't run on it at all til April, and I have been running on it only intermittently and usually for less than an hour at a time since then.

And for sure, I'm not going to be running on it at all for the next 2 months. After warming up for a mile, I did 10 minutes all-out on the track this afternoon, just to see what would happen. It didn't hurt during, but it began to hurt shortly after--diffuse pain extending up into my tibia, even. It's better now, some 3 hours later. But if 10 minutes all-out is all it took to make it hurt that much, I figure I can't manage anything more intense than the "convalescent workouts" I've been doing, which are accomplishing exactly zero in terms of training. I'd be better off spending that time on my bike and in the pool.

I like your idea of getting a baseline ESR. I had already begun to think about how I will know when it's OK to run again. I just called my best friend, who's a rheumatologist, and she said her office could do it for me Monday morning. However, I do have one other inflammatory condition going on. I apparently hurt a finger in the same bike wreck in which I broke my collarbone in August. I didn't even notice the finger injury til a few months later, when it began to swell and hurt at the middle joint. My rheumatologist friend injected it with something, which fixed it for awhile, but now it hurts again and is twice the size of the joints in my other fingers. Do you think this finger issue would skew the sed rate?

Also, are all these ankle exercises I'm doing in PT helping or hurting this situation (dorsiflexion, inversion, and eversion with weights)?

You and Frank are so kind to spend your time helping a total stranger. Thank you.

Susan

[reply]The orthopedist did say a stress fracture was a possibility and that he'd had a detailed conversation with the radiologist about it. All I remember about the discussion he had with me is that he doesn't think it's a stress fracture. I don't think it's a stress fracture either. I haven't done anything to get a stress fracture. I didn't have any pain before I sprained my ankle in December, I didn't run on it at all til April, and I have been running on it only intermittently and usually for less than an hour at a time since then.

And for sure, I'm not going to be running on it at all for the next 2 months. After warming up for a mile, I did 10 minutes all-out on the track this afternoon, just to see what would happen. It didn't hurt during, but it began to hurt shortly after--diffuse pain extending up into my tibia, even. It's better now, some 3 hours later. But if 10 minutes all-out is all it took to make it hurt that much, I figure I can't manage anything more intense than the "convalescent workouts" I've been doing, which are accomplishing exactly zero in terms of training. I'd be better off spending that time on my bike and in the pool.

I like your idea of getting a baseline ESR. I had already begun to think about how I will know when it's OK to run again. I just called my best friend, who's a rheumatologist, and she said her office could do it for me Monday morning. However, I do have one other inflammatory condition going on. I apparently hurt a finger in the same bike wreck in which I broke my collarbone in August. I didn't even notice the finger injury til a few months later, when it began to swell and hurt at the middle joint. My rheumatologist friend injected it with something, which fixed it for awhile, but now it hurts again and is twice the size of the joints in my other fingers. Do you think this finger issue would skew the sed rate?

Also, are all these ankle exercises I'm doing in PT helping or hurting this situation (dorsiflexion, inversion, and eversion with weights)?

You and Frank are so kind to spend your time helping a total stranger. Thank you.

Susan[/reply]

the finger thing could screw up the ESR and it also could be an RSD. One thing we don't know much about RSD is why some people get them and others don't but it may be that some just are wired differently so they are more prone. Maybe you are one of those.

If the problem you have in your foot is bony structural or an RSD then all those exercises should not hurt. If it is soft tissue or tendon/ligament issue then those exercises could bother things. One thing that bothered me what you said before was water running made things worse before. Not sure what to make of that.

As I said before, the key to correct treatment is a correct diagnosis. It certainly is not clear to me what is going on with you. You are going to have to pay your money and take your chances it seems. Hopefully you will be able to find a way to maintain your general fitness while you heal.

Patients like you are why doctors are paid the big bucks. If only real patients were as easy as medical school. Your doctor is going to earn his money me thinks.

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Frank,
An original Ironman and the Inventor of PowerCranks

[quote]The orthopedist did say a stress fracture was a possibility and that he'd had a detailed conversation with the radiologist about it. All I remember about the discussion he had with me is that he doesn't think it's a stress fracture. I don't think it's a stress fracture either. I haven't done anything to get a stress fracture[/quote]

Well, if he wanted a CT (to see bone better), he thinks the same. Also, you did plenty in just being a distance runner, female, triathlete to get a calcaneal stress fracture. These don't occur with a 1 time, acute injury like many people think. They occur from repetitive microtrauma until the bone fatigues.

Your finger joint capsulitis will likely skew the initial ESR, but you can still monitor the "fall", assuming your finger improves. Rheumatologist are VERY familiar with inflammatory markers (a C-reactive protein may be useful as well).

Best of luck Susan -

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

I like the C-reactive protein test idea. I'll get that, too.

If it's a stress fracture, not running on it should fix it, right? Walking around on it is fine, and riding my bike is fine, right? (PLEASE say riding my bike is fine.)

Susan

Well - textbook answer is below the knee non-weightbearing cast for 6 weeks. Reality answer (especially since yours is questionable anyway): biking should be fine - walking around should be fine, but I would probably do so in a fracture walker/CAM boot to offload the heel as much as possible to that "it" can heal.

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

I will call the orthopedist Monday about the fracture walker/CAM boot. If he wants me to have a CT scan first, I'll do that, too.

Thanks for the good ideas, even though I wish they didn't apply to me. I guess this is the year I will work on my swim.

Susan

[reply]I will call the orthopedist Monday about the fracture walker/CAM boot. If he wants me to have a CT scan first, I'll do that, too.

Thanks for the good ideas, even though I wish they didn't apply to me. I guess this is the year I will work on my swim.

Susan[/reply]

The problem is you can do as much as you can without agravating the problem but no one can tell you what that amount is. Some of the suggestions are things that might make a difference. Only after the fact can you know what was ok or not.

The average patient who the average doctor encounters could care less if the doctor tells them to stay off the leg for 2 months, they do that anyhow except when walking from the house to the car to work and back.

When athletes are involved the equation changes but few doctors have any real experience with what can and cannot be done while in rehabilitation without aggravating the injury (after all, even completely staying off the injured part doesn't result in 100% recovery, even in the sedentary).

I find it hard to believe you cannot or will not be able to continue to swim, run in the pool, and do base work on the bike (with or without PC's), unless you find that any of these activities cause you pain. If you take care in your workouts ordinary activity could be more stress on your "ankle", hence the need for the boot. I would test the waters and see how it goes. your need is to maintain aerobic fitness, not so much maintain specific skills while rehabilitating.

Frank

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Frank,
An original Ironman and the Inventor of PowerCranks

I am paying careful attention here--"base work on the bike" means no tempo work and no pushing big gears?

I'm sorry to ask so many questions, Frank, but it is pointless for me to ask my orthopedist. He's not a cyclist--although he is a runner, and for that I'm thankful. My PT comes from a different universe altogether, though. He's a former "athletic trainer," which as far as I can tell means football. I said something to him once about an easy workout on my trainer--just spinning on the bike. In conversation later, it came out that he thought I had been to a spin class.

I am convinced that pool running made a bad situation much worse the week after my ankle sprain. It hurt then when I ran in the pool, but I didn't interpret the pain to mean "stop," and by the next day my ankle (which bled out pretty considerably in the first few hours after I sprained it) had bled out even more--up the back to my calf and my whole foot (even my toes) were purple. Lots of swelling, too. And it hurt when I first started swimming again--PT had to tape it for weeks, even with a non-overt kick. It's OK when I swim now, which I suppose means it would be OK pool running, but I am still really apprehensive about it.

Susan

[reply]I am paying careful attention here--"base work on the bike" means no tempo work and no pushing big gears?

I'm sorry to ask so many questions, Frank, but it is pointless for me to ask my orthopedist. He's not a cyclist--although he is a runner, and for that I'm thankful. My PT comes from a different universe altogether, though. He's a former "athletic trainer," which as far as I can tell means football. I said something to him once about an easy workout on my trainer--just spinning on the bike. In conversation later, it came out that he thought I had been to a spin class.

I am convinced that pool running made a bad situation much worse the week after my ankle sprain. It hurt then when I ran in the pool, but I didn't interpret the pain to mean "stop," and by the next day my ankle (which bled out pretty considerably in the first few hours after I sprained it) had bled out even more--up the back to my calf and my whole foot (even my toes) were purple. Lots of swelling, too. And it hurt when I first started swimming again--PT had to tape it for weeks, even with a non-overt kick. It's OK when I swim now, which I suppose means it would be OK pool running, but I am still really apprehensive about it.

Susan[/reply]

The big unknown here for me is you have some issues with your calcaneous. Biking could put some stress on it, especially big gear work but then it is all non-impact so you might (and probably will) tolerate it well. I would start easy and if there is no problem with your foot increase the intensity of your workouts and see how it goes. Use the boot to reduce the stress on the bones during ordinary walking/activity. You should probably ice the area after every workout. The key is listen to your body. You are the only one it is talking to. Pain usually means stop or, at least, back off. Next time listen.

I don't want this to be a sales pitch for my product (I assume some will think so but there are only about 10 people following this thread it looks like) but if you were on PC's and tolerated the biking well then you could delay going back to running even longer, until you were certain things were ok, and still see running benefit from these workouts. In addition, when you went back to running you could cut back on your mileage and reduce your riskof reinjury. You would lose almost nothing (and some get faster) during this period, assuming you tolerate the bike well.

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Frank,
An original Ironman and the Inventor of PowerCranks

Re: PCs. I am on the fence. After having read the downloadable owner's manual and so many posts here that my eyes glazed over, here is what I have concluded so far:

Pros:

1. Will help my run during this time I'm not running--a huge plus for me, since even at my best, I am not good at running.
2. Will help my coordination--another huge plus. I wouldn't go as far as to say I'm clumsy, but I'm not a natural athlete either.
3. My coach is talking about buying some, so I know they must be good. (This point is probably #1, actually.)

Cons:

1. Not being mechanically inclined, I will need to get my LBS to install the PCs, so practically speaking, once they're on, they're on. There won't be any changing back to regular cranks on a Sunday morning whim.
2. I probably won't be able to keep up on group rides. I really need to be able to ride with the group right now, because there's a century ride on my calendar in 2 months, and I don't feel safe on long rides by myself.
3. Given that I'm not very coordinated, I'm concerned about surviving the learning curve without falling. The last thing I need right now is a bike wreck.
4. I don't want to give up the option of standing out of the saddle. I do most climbs seated, but sometimes standing is what it takes for me to crest a steep hill.

Your thoughts about the points in the "con" column?

Susan

Not to "pitch" his product either (I don't have them), but being a foot and ankle surgeon and biomechanist familiar with your condition and cycling, they actually would be a very good idea for you and your current condition. Really. Will keep you cycling/spinning without "mashing" the pedals while training and working some running muscles (since you can't run). The only downside to the whole process would be the cost of the cranks. You may even end up "faster" for the whole experience with the extra swimming and cadence work.

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____________________________________
Fatigue is biochemical, not biomechanical.
- Andrew Coggan, PhD

 
Cons:

1. Not being mechanically inclined, I will need to get my LBS to install the PCs, so practically speaking, once they're on, they're on. There won't be any changing back to regular cranks on a Sunday morning whim.

That would probably be a good thing from the long-term perspective but, that being said, they are not that hard to put on and take off and if you watched your bike shop put them on you would probably have no trouble learning how to change them if you wanted to.

2. I probably won't be able to keep up on group rides. I really need to be able to ride with the group right now, because there's a century ride on my calendar in 2 months, and I don't feel safe on long rides by myself.

You definitely won't be able to keep up on group rides for awhile. I suspect you could find a new, slower group, though for this transistion so you wouldn't have to ride alone and this period usually lasts less than a month for most people. After that you will probably be able to ride with your previous group, and lead it, not just hang in. the alternative is to do the initial rides on a trainer or stay close to home until ready to venture out with your group.

3. Given that I'm not very coordinated, I'm concerned about surviving the learning curve without falling. The last thing I need right now is a bike wreck.

While I can't guarantee you won't fall, the likelyhood is quite small. We just want you to be careful on them for those first few rides until you feel comfortable with them. After a couple of days your risk of falling will return to "normal".

4. I don't want to give up the option of standing out of the saddle. I do most climbs seated, but sometimes standing is what it takes for me to crest a steep hill.

90% of all new users are riding them out of the saddle in about 3 weeks so you don't have to give up anything. 99% are out of the saddle in 2 months.

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Frank,
An original Ironman and the Inventor of PowerCranks

I can feel myself falling off the fence. You should know that rroof's endorsement as a disinterested third party is a strong nudge. I've left voice mail for my coach to see if there's some reason he sees that I shouldn't buy these.

Meanwhile, please tell me what I need to get. All the tech talk on the website is Greek to me. The bike on which I would install the PCs has a triple crankset--Shimano Tiagra Triple: 30/42/52, with 165 mm arm. The bottom bracket is a Shimano Tiagra cartridge.

This bike is an entry-level WSD Terry to which I am emotionally attached, and I do all group rides and off-season training on it. However, I plan to upgrade sometime this winter. My TT/triathlon bike is a P2K.

Susan

So . . . if they're so good, how come you don't have some? ;)

Susan