after my half marathon, i was feeling a minor ache on the medial side of my left ankle. i was still able to walk fine immediately following the run, but once my adrenaline came down i noticed i was walking with a slight limp. initially, i chalked this up to just having very tired legs, but a day later it was clear that it wasn’t the same type of soreness i was experiencing in other parts of my body. i had a hard time going up and down stairs and noticed myself avoiding any sort of flexion (plantar/dorsi) on my left foot. uh oh.
so i googled “medial ankle pain runner” and one of the first results that came up was posterior tibial tendonopathy. the tibialis posterior muscle is as the name suggests in the posterior of the tibia – the muscle lies deep in the calf and it is connected to various parts of the inner food (navicular bone, cuneiforms, and some of the phalanges) through a long tendon called the posterior tibial tendon. even before trying the diagnostic exercises, i had a sense this was likely my injury because i was experience pain in my medial malleolus. turns out, the posterior tibial tendon actually passes right under the medial malleolus and its common to experience pain & inflammation of the tendon in that area as pain directly from the malleolus!
to diagnose, i have to understand the muscle function. the tibialis posterior muscle is responsible for
- plantar flexion (the muscle in the back of tibia near claf contracts and pulls the heel of the foot up)
- foot inversion (pulling foot in towards medial side) and adduction
- arch control of foot. tibialis posterior dysfunction (not what i have) leads to a collapsed arch. arch control is a big part of foot stability – if you cant control the height of your arches, you will have a tough time standing on one leg
two main diagnostic exercises are single leg stands and single leg calf raises
even on tired legs, i easily did a calf raise on my right leg but i could not perform a single calf raise on my left. earlier that day, i also took a yoga class and could not hold a stable tree pose on my left leg. so basically, i’ve failed both tests. i cannot stabilize and i cannot plantar flex under weight. i don’t think i ruptured a tendon, because theres almost no inflammation and its not like im unable to walk. it’s likely just strained, but i want to give it a couple of weeks before getting professional opinion. the recommended protocol for recovery is pretty standard: RICE (rest, ice, compress, elevate) until the pain is gone and then gradually begin to re-introduce strength training. the recovery period for tendon injuries is in weeks to months – so its likely im going to have to cancel my upcoming april races. it’s day 4 since my half and i’m starting to feel much better (i can plantar flex now without weight with no pain). i can also initiate a calf raise but not without pain, so im going to avoid anything to aggravate it.
one of my big questions is – how the heck did this happen? i felt pretty well trained. i had done a 12 mile long run at the peak of my training block and have incorporated some hill training as well in the final weeks. one of the clues came from photos taken of me during the race – here’s an interesting one taken at the final 2 miles of the race. i annotated it with lines that highlight a form breakdown
there’s two problems i notice here…
the first is a pelvic drop where my right pelvis was dropping. this tilt towards the right tends to happen with weak or fatigued gluteus medius muscles. in the diagram below, the highlighted green muscle is the glute med. that muscle is primarily responsible for abduction and it plays a major role in keeping your hips stable when you walk. if you look at how it attaches to the greater trochanter, imagine if that muscle isnt able to contract – what happens? the opposite side will collapse. thats exactly whats happening in my photo. my left glue med was fatigued and i was experiencing a drop on the right.
pelvic drops are not great in any running situation because it triggers an entire chain of movements that create injury. i’ve had to deal with IT band syndrome two years ago as a result of having a pelvic drop. another interesting consequence of pelvic drop is over pronation, which i annotated in my running photo. im excessively pronating in that photo on my left leg. excessive pronation is sort of the smoking gun for why i have posterior tibial tendonopathy. i’m basically straining that tendon over and over again, because remember – that tendon is there to invert/pull the ankle inwards. pronation is the exact opposite of that!
take a look at this left foot. the very right photo is what my left foot was doing.
turns out, one of the ways your body compensates pelvic drops is to overpronate. the way it works is this – the drop of the pelvis (in this case, my right pelvis) shifts the center of mass slightly to the right. this causes the knee on the left to move more inwards to try to stabilize the body which causes the excessive pronation. even worse, ground contact time is increased because the body needs more time to recover from the pelvic tilt.
understanding the forces at play here really helps, because this gives me a lot of ideas on what i need to work on during strength training and what to pay attention to during long distance races like the half. ill likely want to strengthen all the muscles to contribute to excessive pronation as well as targeting all muscles like the glue med that contribute to pelvic stability. i might also need to work on increasing my easy long runs to improve my overall endurance so i don’t start fatiguing as early when im putting in max effort
anyway im thankful for the internet and im hopeful about recovery. will post updates here like i did with my knee pain from november of last year. weirdly .. i consider one of the blessings of having minor-ish injuries is that it teaches me so much about my body and anatomy. before this i had no clue about the muscles other than the gastrocnemus and soleus in my calf! it’s a lot of fun for me to learn about running mechanics and get better at troubleshooting issues that will inevitably come up in this very repetitive activity.