Is PTT curable? Help convince me not to quit running!

Triathlon Forum
1

Hello,

This post may end up being quite long, but after a year of constant post-tibial injury, Im starting to wonder if I just wasn’t meant to run

Heres a little background:

Im 19 years old and I am 5’10 150, so not at all overweight, although I’ve been thinking that hitting 145 may help. I have swam for most of my life, and always excelled as a breaststroke swimmer. I have a medium size arch in my foot if I hold it in a neutral position, but it is somewhat flat if I relax and let it pronate. I also have what I would describe as somewhat “duck feet”, where my feet go out, but I think it is a result of the way they look when pronated, because If I stand my arch up they are somewhat normal. I have noticed that many of my fellow breaststroke swimmers seem to also have highly flexible ankles and are somewhat flat footed, so I wonder if there is some correlation. Anyways, I started triathlon about two years ago, and for the past year I have been constantly injured with what the doctor says is Post-Tibial Tendinitis in my right ankle. I find It interesting that its in my right ankle, as my left ankle is somewhat worse from a pronation standpoint.

In the last year, I have litterally tried almost everything possible to get rid of this injury. I did physical therapy, and since then Ive made calf stretching, calf rasies, and PT strengthening activities a daily ritual. At this point, it seems I have a very strong PT tendon, to the point where, when walking, I no longer have flat feet because I can constantly hold my arch up as I walk. But if I take a sort of running step on it, it does pronate. I’ve also put a huge emphasis on technique. I train with running phenom Lukas Verzbicas and have worked on my stride with him and his coach. Both say I have very good technique, I run from my hips, with a fast cadence and a perfectly mid-foot strike. In an effort to reduce impact I only run on flat dirt trails and grass. Ive also taken many 1-2 month breaks. After every break, I manage to get 4-5 good runs in before I am injured.

I have also tried tons of different types of shoes. Stability shoes, heavy stability shoes, heavy stability shoes and orthotics, minimalist shoes, and lightweight trainers with orthotics. None of the shoes seem to help the problem, in fact, the amount of injury free running I got in with the heavy stability shoes and orthotic was almost the same as the minimalist shoe. My runs have consisted of only 10 minute easy runs, trying to easy back into running, but after like 6-7 miles per week I am injured again.
Currently I am running in Saucony Fastwitch 5 shoes with a superfeet blue orthotic. I like this combination because it has some stability and still has a low heel to toe drop which I like. There isn’t much pronation movement in these shoes, but it seems my ankle is so flexible that I pronate no matter what stability or orthotics I have.

During this entire process, I have never stopped swimming or cycling, so there is a chance that one of these activities could be irritating it, but I never have pain after either. I did notice that I do pronate massively when cycling, but I have never been sore during or after riding.

At this point I have been asking myself if maybe I was not meant to be a runner, maybe I should look for some aqua bikes or take up cycling. There just seems to be no way I can run without injury.

If anyone can think of anything that I havn’t tried, I’m all ears! This injury has gone on too long!

2

Hey Fender,

I have suffered thru PTT similar to yours. I would strongly suggest a leg length x-ray be done. I found that my right leg was 4mm shorter. That’s not a big deal by most standards. However, I added the 4mm lift to my running shoes. It helped tremendously! I would also suggest that you have a bike fit by someone with training from Specialized or Bike Fit (Paul Swift method) to evaluate your shoe cleats and their placement. You may need some correction there as well. I still continue with my foot and leg exercises to keep these tendons and feet strong. There is no substitute for that. I also wear orthotics and a stability (light weight) shoe. Hope this helps you out.

Jacqueline

3

Wow, train with Lukas? Cool.

No, you weren’t meant to be a gifted sub 4 min/miler like him. Contrary to a popular new book, we were not all “born to run”. However, you are only 19 and have a lot of options still from changing sports to surgery. Seems like you have done a lot in between already, so I’ll move on. I’d seek out a specialist near you that can discuss more aggressive measures if you are so inclined (for example, google MBA implant to start). You can then proceed to read about the more aggressive procedures like a medial displacement calcaneal osteotomy with FDL tendon transfer for more severe PT tendon dysfunction (not likely you based on your description).

4

Thanks for the replys.

I really wish I could avoid surgery, but if its an option I may look into it. I would just love to be able to run because I have a strong swim and bike and a fast run (when I can) and I really enjoy the sport of triathlon. Even If I could find a solution just limit me to sprints for my entire life, I’d be happy. I’m also somewhat curious about the leg length descripency, as I find it odd that only my right left gets hurt, even though my left leg pronates as bad (or worse). Luckily, if I let it heal, I have no pain while walking, so if running isnt an option, I can continue to cycle and swim. It just wont be the same without tri!

Also training with LV and the team is quite an experiance! I can tell you that he will be ready for worlds this September!

5

I’d examine your pelvic tilt. Males should have 4-7 degrees of anterior pelvic tilt. Among endurance athletes, swimmers are notorious for excessive anterior tilt. If you haven’t had your pelvic tilt measured by any of the other medical practitioners you’ve seen, then their “treatments” may be of no benefit to you. From my book Holistic Strength Training for Triathlon:

Anterior pelvic tilt is associated with femoral anteversion which predisposes the athlete to a host of pronation injuries. Shin splints, iliotibial band syndrome, and patellofemoral syndromeare all prime examples of preventable injuries which ruin the seasons of countless promising triathletes. During the first half of the support phase of running, the increased load on the
subtalar joint causes it to pronate faster and with greater magnitude than that which normally occurs with walking. This leads to increased tibial internal rotation which is transmitted to the knee, forcing the knee to collapse medially. Couple that with the increased femoral anteversion caused by excessive anterior pelvic tilt and you have a hip, or a knee, or an ankle in a position in which it was never meant to be.

There is an indisputable fact that force is transmitted best through a straight line. So as you run all catawampus with a knee over here and a hip way over there, not only are you losing potential speed—with every stride you’re hastening the demise of your athletic career. You are tearing your body up. Think about what you learned in high-school physics class: For every action there is an equal and opposite reaction. Thus, pushing on the ground results in the ground pushing back at you. Yet your body is not aligned properly. So just like when you fail to hammer a nail straight down and the nail bends, each misaligned step you take not only robs you of propulsive force. It also brings you that much closer to the breaking point. And if you just came home with a sweet new pair of motion-control shoes from your local running store to eliminate this problem, sneakers aren’t the only thing they
sold you. You just bought into what the shoe companies have been selling to the running community for years: the idea that pronation is an evil word. Yet pronation (a combination of dorsiflexion, calcaneal eversion, and internal rotation is how the body absorbs shock. And its opposite motion, supination (plantar flexion, calcaneal inversion, and external rotation is how the foot acts as a rigid lever for forward propulsion. Too little pronation not only forces the knee to endure rotational stresses it was not designed to handle (after all, the decreased motion of the foot must be made up somewhere); it also transfers too much of the landing impact to the rear of the foot. Try the followingexperiment I learned at one of Joe Friel’s Endurance Coaching seminars in Boulder, Colorado:

Stand up and begin hopping on the balls of your feet with your legs straight. Feel the springiness in your feet and calves. It’s effortless. Given a good Tour de France video, some power bars, and perhaps a dare you accepted while in a drunken
stupor and you could jump like this all day. Continue jumping. But, now, switch to landing on your heels. Do you feel the
difference? The impact forces can literally be felt all the way up to your skull. Can you imagine landing like this for 26.2 miles? But if you’ve been told you over-pronate and should wear special, beefed-up shoes or even orthotics to control excess
motion in your feet, you’re not allowing the natural shock absorbers of your body to work.

Why are you treating the symptom? Why not treat the source of the problem?

Let’s examine how the position of the pelvis influences the movements of the lower leg. Stand up and tilt your pelvis forward or anteriorly and you’ll feel your weight shift forward and to the insides of your feet (pronation). Now tilt your pelvis backward or
posteriorly and you’ll feel your weight shift backwards and to the outsides of your feet (supination).

Martin and Coe, the authors of Training Distance Runners, say that “although it is the foot that strikes the ground, the actual pivot point for the lever system that provides movement is really the lumbar spine and pelvis.”

The source of the problem of excessive pronation may very well be your pelvis. You can control excessive pronation by
controlling excessive anterior pelvic tilt. To do that, you need an exercise program which will strengthen the muscles of the force couple which pull the pelvis up in the front and down in the back. In addition, you may need to stretch the muscles of the force couple which pull the pelvis up in the back and down in the front. Specifically:

STRENGTHEN: lower abdominals, gluteals, and hamstrings.

STRETCH: latissimus dorsi, lumbar erectors, iliopsoas (hip flexors), and quadriceps.

Of course, there are cases when a properly made pair of orthotics is necessary for an athlete, such as when the metatarsal heads have dropped and the athlete does not accept load into the forefoot efficiently. But many of these biomechanical
abnormalities have etiologies which are rooted in core dysfunction or length/ tension imbalances. All too often, these basic faults at the very least hasten the onset of a condition which will ultimately require medical intervention.

Of course, there are many other possible etiologies for what you’re experiencing. I can think of many which are, at least, contributing to your dysfunction. But anterior tilt would be one of the first things I would consider.

Good luck
–Andrew

6

I’d examine your pelvic tilt. Males should have 4-7 degrees of anterior pelvic tilt. Among endurance athletes, swimmers are notorious for excessive anterior tilt. If you haven’t had your pelvic tilt measured by any of the other medical practitioners you’ve seen, then their “treatments” may be of no benefit to you. From my book Holistic Strength Training for Triathlon:

…

STRENGTHEN: lower abdominals, gluteals, and hamstrings.

STRETCH: latissimus dorsi, lumbar erectors, iliopsoas (hip flexors), and quadriceps.

Of course, there are cases when a properly made pair of orthotics is necessary for an athlete, such as when the metatarsal heads have dropped and the athlete does not accept load into the forefoot efficiently. But many of these biomechanical
abnormalities have etiologies which are rooted in core dysfunction or length/ tension imbalances. All too often, these basic faults at the very least hasten the onset of a condition which will ultimately require medical intervention.

Of course, there are many other possible etiologies for what you’re experiencing. I can think of many which are, at least, contributing to your dysfunction. But anterior tilt would be one of the first things I would consider.

Good luck
–Andrew

Do you have suggestions/a link or suggested resource with recommended stretches and strengthening exercises available?

ETA: Other than the one you mention right in your post.

7

just some food for thought:

I’ve got a foot that points out, flat feet, and I pronate. I weigh more than you too.

I put NO emphasis on technique, I don’t try to fight any of these things, I just run, in neutral shoes, and I’ve been fine.

maybe you need to rest for 3 weeks, and then get back to basics, gradually.

8

The stretches and exercises I’d recommend are in my book–that’s one of many reasons I wrote it–to compile the right information in one resource. But you could also study Muscles Testing and Function in Posture and Pain by Kendall. Not necessarily tri specific, but it’s one of the bibles in my field.
–A

9

I have no idea if this will help, but for me the clue is you are a breaststroker. I too was a breaststroker, as a competitive swimmer in my teens. During all of that time I practically gave up running. I had a very strong kick (as was the stroke fashion of those days). My knees were my problem.

The stroke has changed dramatically over the ensuing forty years and I will guess the stroke today will have changed the location of the most stressfull part of the kick. Nevertheless I would suggest that there is a correlation.

I no longer swim breaststroke in races, and have never had a knee problem since.

good luck.

10

after a lifetime of running, at the age of 52, i ruptured(self-inflicted) my right PTT. i had surgery and the doctor removed 4" of it. i was off completely for 17 weeks. i gradually returned to running but also started to cross train and started to do tri’s. that was over 10 years ago. i’m not going to say that my foot was the same, because it wasn’t. my foot landing changed and i lost the ability to push off with my forefoot and i lost speed. because my landing changed my big toe joint lost most of its cartilage and doesn’t move. i cannot rotate my ankle in and very little out. i have also developed some arthritis. still, i have run over 25,000 miles since 2001 and l put in 45-50 miles a week. i wear mizuno wave inspire. now…and take this advice…when my PTT first started to hurt my doctor told me to rest it and it probably would clear up sooner or later. of course i didn’t listen, continued to run, and 2 months later it ruptured…a self inflicted injury…