Background: I’ve had a slightly sore posterior tibial tendon for a few months now. It doesn’t get worse, but doesn’t get better. I’ve tried backing off the running (including a few weeks of zero running). I’ve tried ice. I’ve tried some strengthening exercises. I just can’t quite shake the soreness, which appears after 2-4 miles of running. It’s not so bad that I have to stop running, and I don’t notice it at all when just walking around. But I can feel where it hurts if I really press against the inside of my right ankle. On the plus side, I feel like the strengthening exercises have helped some. My lower legs and feet definitely feel stronger than they used to, and I no longer feel like I want to stand on the outsides of my feet when I’m standing for a long time, as I used to sometimes. But I want to get rid of this soreness before I start to ramp up mileage this fall/winter.
So, the other day I had an appointment with a podiatrist. I picked him because he’s a runner and because his patients seem to like him. He looked at my feet while standing still, and he did some x-rays. He said that my feet are unstable, especially the one where I have had some PTT pain. I’m too pronated when just standing, and my PTT therefore works too hard when running. He went on to say that 90% of people have unstable feet and need some stability in their shoes. He prescribed some naproxen, some shoe inserts, and continued icing to get rid of the inflammation. But he said that if I want to avoid a career-ending injury, going forward (indefinitely) I’ll need orthotics and very stiff running shoes with a lot of stability. I told him that I felt like I ran more comfortably in less shoe than that (e.g., Mizuno Wave Elixirs or Mushas vs. the Wave Inspire or the Asics 21xx). He was adamant that the minimum shoe was the Inspire or 21xx with orthotics (replacing shoes every 200 miles), and that I might need more shoe than that even. I asked whether there were any strengthening exercises or physical therapy I could do to improve the situation, and he said that I’m stuck with the feet I have and that there’s nothing I can do to avoid stability shoes with orthotics unless I want to get so badly injured that I can never run again.
I understand that no one can diagnose me over the internet. But does this sound like a reasonable outlook for someone who has some mild inflammation of the PTT and no other significant running injuries previously? It sounds a lot more dire than I was expecting, and I was hoping that once I got rid of the inflammation, I could continue with strengthening and resume running in lightweight shoes (even if I might need an insert like the green Superfeet). I don’t want to risk major injury, but I also don’t want to be stuck with orthotics and heavy shoes forever. I’m not suggesting that I should become a barefoot runner overnight, but is there room for any middle ground here? I think I probably need a second opinion, but I’m not sure if I’m just over-reacting because I didn’t hear what I wanted to hear. And if I get a second opinion, do I try to find another podiatrist or do I try an orthopod or something different to get a different perspective?
Sounds in my opinion like he is more interested in selling you orthotics than finding the source of the injury and telling you how to correct it. However, it does sound like you are continually inflaming it when you run. Is it on your dominant gait side?
Strengthening the part of the structure that is weak and causing the PTT to be overused is a better choice long term than just putting support in and never fixing the actual problem itself. But that’s just my opinion.
Without my custom orthotics, I would not be a runner today. But you will know right away. I waited until I could barely walk unti I went to the doc. I felt better just walking to the Subway after, two blocks away. It will not be a gradual thing. That’s good. Hurts to walk a block or two, get the treatment and a couple of days later, you’re running 5 miles.
Just had a re-ocurrence. My orthotics had flattened out gradually. All of a sudden, I had it back. Got new orthos and I’m gonna run a marathon. Really good I went to the Pod right away. Didn’t lose my conditioning while I hoped it went away.
I’ve been battling a similar sore PTT for over a year now. Just like you, I tried taking a break from running and everything but nothing seems to solve the problem. I’ve found that the strengthening helps alot, especially calf raises, atleast in my case. I’ve also tried just about every shoe and orthotic combination from minimal to the heaviest stabilty and in my experience, there is no magic bullet that is going to make it just go away. The best luck I’ve had so far is with neutral trainers with the orthotics. I’m currently running in the Saucony Fasttwtich 5 shoes with the orthotics, and while I have occasional flare ups (such as right now!) I’ve managed do keep up 50mpw or so for cross country season. Let me know what works for you, and all of us battling PTT can help each other find a solution!.
Without my custom orthotics, I would not be a runner today. But you will know right away. I waited until I could barely walk unti I went to the doc. I felt better just walking to the Subway after, two blocks away. It will not be a gradual thing. That’s good. Hurts to walk a block or two, get the treatment and a couple of days later, you’re running 5 miles.
Just had a re-ocurrence. My orthotics had flattened out gradually. All of a sudden, I had it back. Got new orthos and I’m gonna run a marathon. Really good I went to the Pod right away. Didn’t lose my conditioning while I hoped it went away.
I will back this up. Had/have a forefoot issue called metatarsalgia (that I documented well here on ST- look up “frankenfeet”). Went to two different podiatrists. The “runner” specialty podiatrist prescribed orthotics. I was able to continue running high mileage with less pain than before the orthotics. I used them for nearly a year and have just gone back to running without orthotics. Still have some residual pain at times, but nothing like it was. I will credit the orthotics and wearing Crocs sandals with the improvement, but it could just be that it healed.
I found your “frankenfeet” thread when I searched the forum earlier. My eyes still burn from the pictures! Just kidding.
For those of you with orthotics, are you able to use them in lightweight shoes (lightweight trainers, racing flats, etc.)? Or do you have to use them in shoes with a lot of posting/support? The guy I saw told me that if I use shoes that are any kind of flexible, then the orthotic doesn’t have anything to push against. He said, for instance, that my Elixirs are “way too flexible” to use with inserts or orthotics. I don’t think of those are particularly minimal shoes. I’m not necessarily opposed to inserts or orthotics if that’s what I really need, but I do wonder whether I should give up on improving my situation with strengthening and I really hate the thought of never using lightweight shoes. I just run more comfortably in lighter shoes, and I was even starting to think of going with a little less than the Elixir, at least in terms of weight and heel height. Those new Brooks Pure Flow look pretty sweet, for example.
The orthotics I have are basically very rigid from midway along to the heel cup, but completely “floppy” in the forefoot and toe. So, as long as the midfoot/heel area of the shoe doesn’t flex too much, I don’t see why they wouldn’t work with any shoe.
Like I posted earlier, I’ve been having sucess using them with the Saucony Fast twitch 5’s, which are in the light trainer/ racing flat range. I slightly stiffer shoe might work a bit better though. That being said, one of my friends (Ben Kanute, 13th at ITU junior worlds) has a similair issue and trains with Kinvara’s with orthotics, so I guess it can be done! Might just need to experiment a bit.
As far as what shoes you can wear with them, …not sure. I have had them for 7 years. Mine are the whole foot $400 a pair. I can only wear shoes the orthotics fit…ie, matching up the arches. For example I have Aisics 3030’s. My ortho do not fit properly in the kayano’s. In the right shoe I do not feel them. In the wrong shoe it feels like somehting is jammed in my arch. I forgot which shoes, but in another pair the inside of the ortho was pushing into the shoe to the point of weaking the fabric. …Hope this helps
I was running with a heavier more supportive Kayano and went with a lighter Nimbus 12. Took a little getting used to. I had to allow the shoes to slightly modify my running form. A tad further back. Then they were fine. My sense is, the hardness of the orthotic gives you a lot of stability.
Of course you should take your shoes into the Podiatrist. Let him look at the whole setup you’ll be running with. I had a slight chafing on my instep. Developed into a blister on a 8 mile run in pouring rain. Doc told me to vaseline the soles of my feet. Works like a charm. 15 M LTR Saturday, and no hot spots.
Have to say, I was very happy I’d zipped into the Doc at the first sign of trouble. Didn’t lose my conditioning. Doc gave me lots of good info and advice. Punched out a HM the day after getting my new orthotics, in them.
First of all, I know that each person is different and that each podiatrist is different. I think correcting what it is that is causing your pain should be your main goal rather than treating it with orthotics. That’s not to say that there’s no place for orthotics, but rather that unless you have very strange feet, you can be healthy and strong without the orthotics. If you’re like most of us in the developed world, your feet have been cushioned and supported in shoes your whole life and are underdeveloped. With my foot injuries, I did what the podiatrists told me for a long time until I realized that the more I listened to them, the worse my problems got. When I started addressing lower leg/ankle flexibility and foot strength and flexibility I experienced drastic reductions in pain. The more regular I am about stretching and strengthening, the less pain I feel. When I get lazy about those, pain returns. There are lots of people on the forum who disagree with the idea that humans evolved to run naturally, but the evolutionary evidence is pretty convincing to me, as is the near absence of most of our common foot problems in unshod populations. I’m not necessarily advocating barefoot running or minimal running, as I don’t think they’re for everybody, but I am advocating strengthening and stretching to address the weaknesses that cause your problem.
I think correcting what it is that is causing your pain should be your main goal…
An orthotic is “a device or support, especially for the foot, used to relieve or correct an orthopedic problem.” (Webster) Orthotics can, and often are, the best way to correct biomechanical issues. Not the only way, but they shouldn’t be ruled out because they’re not “natural”.
Sldo, there was no pavement or concrete throughout the vast majority of human evolution, and very little in the way of hard, flat surface either. Just something to think about.
I had the exact same problem. I’m the proud owner of two flat feet with a severe over pronation.
Background:
I weighed 60 pounds more than I weigh now.
Used to run with stability shoes (Saucony Guide) - low mileage
Suffered from plantar fascaiitis on the same ankle\foot i’d broken a couple of years before.
I’ve tried custom orthotics which haven’t solved me the problem of the PTT inflammation and pain and caused me more pain towards the knee and hip.
After being frustrated with those orthos and haven’t been trying to solve and tweak\tune them I switched to NB 1012 (Brooks Beast equivalent) which solved me the PTT pain.
I weigh 160 pounds so these shoes are way to heavy for my weight. I’m going to put my money on new custom orthotics just to try getting rid of those heavy shoes.
BTW, there are too many opinions about what kind of shoes go the best with orthotics. Some say that you must have a stable platform which gives the orthos stable foundation to work with.
Others say that any neutral show will do fine because the orthos do the stability and the motion control part of this equation.
I think that finding a good podiatrist is like finding a good mechanic for your car. You must believe him and trust him and there’s always a chance he wants to suck money out of your wallet.
I agree that orthotics shouldn’t be ruled out. For some outliers they might be the only solution. In my experience, though, a good number of podiatrists think they’re the only solution for everybody. I think they have a hammer and everything looks like a nail to them. (and, by the way, that hammer makes them a bunch of money, further incentivizing seeing everything as a nail.)
We don’t need to rehash the natural running vs. running in heavily padded and supportive shoes with thick heels here. I understand, but don’t necessarily agree with the hard surface argument. (Even now, when running on hard-packed dirt and roads, unshod populations display almost none of the chronic overuse injuries that people in developed countries wearing our high-tech running shoes do. The difference made by different styles of foot landing is far more significant in terms of shock than the difference between a hard-packed dirt and concrete.) But like I said, I’m not trying to convince people to run barefoot, but rather to recognize that the heavily cushioned and supportive shoes we wear from the time we’re infants affect how the muscles in our feet develop (or don’t) and that working on regaining a naturally strong foot musculature can help significantly in dealing with and preventing overuse injuries.
I do not think orthotics should be used to treat overuse injuries in the absence of structural and biomechanical issues. If you do however have a significant amount of overpronation with a valgus calcaneus, some type of biomechanical correction might be indicated. Whether that is a shoe change, an over the counter insert (like Superfeet or Sole), or a custom orthotic, is really impossible to say over the internet. I do reject the idea somewhat that actively strengthening and acutely inflammed tendon makes any sense. If your foot structure is compromised due to the underlying skeletal support, no amount of exercises will reverse that. For what is is worth, there is a lot of controversy right now about the roles of shoes, arch support, orthotics, etc., so don’t be surprised if you get a lot of contradictory opinions.
Thanks to everyone for the responses so far. I do appear to have some overpronation in the right foot (much less so in the left), but don’t have a totally foot. It’s easy to believe that the right posterior tibial tendon is working harder than the left one, but it’s not clear to me whether I’m beyond fixing without mechanical correction, especially since this is the first time I’ve ever had this sort of injury (in 8+ years of running pretty regularly) and the pain/inflammation is not severe (I could easily push my foot against the doc’s hand in every direction, and I only notice the inflammation during and right after runs). That’s why I’m wondering whether his recommendation was maybe a little extreme for my level of injury. It’s funny…I have done some reading over the past several months about the debate between the “minimalist” school of thought (less is more, strengthen your feet and legs, built-up shoes and orthotics are bad) vs. the more “traditional” school of thought (we are what we are in modern times, and stability/cushioned shoes and orthotics are just a tool to help people run who might not otherwise be able). Mainly I have just been reading that stuff out of a general interest in the debate and not because I felt strongly on one side or the other. But now that I find myself with a bit of an injury, I really feel a little lost in all of that debate and the conflicting recommendations that result. Do I really need orthotics and heavy shoes, or is the guy I saw just telling me that because those are the tools he’s most familiar with? Do I try the minimalist approach, or will that lead to further injury?
For what it’s worth, I think I’m convincing myself of an approach in between the two sides of the debate. Maybe I’m just waffling, but at least it’s a place to start. After a couple days of taking some naproxen, icing more regularly, and reduced running, the inflammation is now barely there even when I press on the tendon pretty hard. That’s promising. I’ll keep doing this until the pain has been totally gone for several days, and then I’ll reassess my plans. But my current thinking is that once I’ve kicked the inflammation, I will resume the strengthening exercises. That seems worth a try, as long as I don’t aggravate the tendon. I will run some of my runs in the more-structured shoes with Superfeet in them, but I’m going to try to do half or so of my mileage in lightweight stability shoes. If the pain and inflammation don’t come back, then I’ll experiment with shifting more mileage toward lightweight shoes. Of course, if the pain does come back, then that’s probably a pretty good indication that I’m being dumb and should go back for the orthotics. However, I figure that the pain and inflammation to date has not been severe or debilitating at all–only slightly annoying during runs. So if I’m cautious, I am probably not risking really serious injury by trying an approach that starts more conservatively and tries to trend in the general direction of minimalism. I don’t want to become a barefoot runner, but I do like the idea of trying to have stronger feet/legs so I can run in lighter shoes. If it doesn’t work, then I’ll probably just be back where I am now.
Anyway, thanks again for the responses, and I’d be happy to hear further input if anyone has any.
I just finished “Born to Run” and have to agree that the Barefoot argument is very compelling. But then I’m 62. I do like to run barefoot on the beach at the waters edge. But elsewhere? I’m sure this has been hashed out extensively on other threads.
My first Podiatrist, taped bandages to my instep padding it up. Felt better walking out of the office. So you could try that. Tape a quarter inch or so (YMMY) of bandages to mimic an orthotic under the instep. You’ll know right away.
Also, I don’t think paying attention to road camber can be overstressed. Something starts screaming during a run, that’s one of the first things I look at.
I do not think orthotics should be used to treat overuse injuries in the absence of structural and biomechanical issues. If you do however have a significant amount of overpronation with a valgus calcaneus, some type of biomechanical correction might be indicated. Whether that is a shoe change, an over the counter insert (like Superfeet or Sole), or a custom orthotic, is really impossible to say over the internet. I do reject the idea somewhat that actively strengthening and acutely inflammed tendon makes any sense. If your foot structure is compromised due to the underlying skeletal support, no amount of exercises will reverse that. For what is is worth, there is a lot of controversy right now about the roles of shoes, arch support, orthotics, etc., so don’t be surprised if you get a lot of contradictory opinions.
Good reply nick. I liked it. Been watching this thread from the sidelines …
