All,
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Twenty four year old female with a chronic perineal tendonitis R/F following injury sustained during a period of reasonably active running with minimalist shoes. I saw her shortly after the original injury and an ultrasound scan revealed peroneal tendonitis, retrocalcaneal bursitis and mild to moderate plantar fasciitis but no tear or disruption to the lateral ankle ligaments. Initially immobilisation in an air cast boot then a short course of strapping with lateral shoe wedging and regular icing appeared to settle the acute lateral pain, however I saw her again last weekend when she was home from London and the problem persists. She still runs - mostly on treadmills at her gym in regular Nike trainers, but experiences moderate lateral ankle and lower leg pain and stiffness for a few days afterwards. She has provided an excellent history which I have simply copied below together with some photograph of her current trainers (Nike) and her original shoes at the time of injury. I will upload some video of her running later which shows a forefoot strike pattern. Unfortunately, she lives in London and only visits her parents infrequently so I was unable to follow her up as I would have liked. From her description of her injury, it sounds like a classic inversion/supination sprain with secondary tendonitis which should have settled after a few months. She is a compliant, fit and healthy young lass and with a good understanding of her foot mechanics. My question is whether her forefoot strike pattern may be contributing to the chronic peroneal tendonitis, which is proving quite debilitating. If so, what might be the best approach - gait retraining (if such a thing can be achieved) or orthotic management? If the latter, what limitations are there with the usual rear foot devices and how can I modify this for a forefoot striker? All foot & ankle RoM ok - unremarkable gait and feet and aside from the tight hamstring she mentions, no other issues. I am a little concerned she is developing similar symptoms in the other foot and ankle but there is no significant family history and it may well be a secondary compensatory issue - or is peroneal tendonitis more common in FFS and if so, why?
Many thanks.
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Influence of Dorsiflexion Shoes on Jump Performance
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APTA Practice Guidelines for heel Pain-Plantar Fasciitis
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Perhaps you should consider unloading the Peroneals with valgus posting, orthoses etc. Also I would ask for the assistance of a competent Physio to probably apply the Continuum Paradigm to the Tendonopathy and investigate the core/lumbar issues. This combined approach will likely yield results.
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I blogged about peroneal tendonitis and comments on forefoot striking and minimalist shoes here:
http://www.runresearchjunkie.com/peroneal-tendonitis-in-runners/
...I have got >20 emails from runners using minimalist running shoes with this problem!!!! -
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Mark:
The peroneals are also ankle plantarflexors so they will likely be recruited more heavily, along with the gastrocnemius and soleus muscles, by the central nervous system in those runners who run in minimalist shoes, those runners who run barefoot or in those runners attempting to become, for some reason, more of a forefoot/midfoot striker and less of a rearfoot striker. From my clinical experience over half the peroneal tendinitis injuries in runners I see are forefoot/midfoot strikers or are running in minimalist shoes. In my patients, only 15% of the runners are FF/MF/minimalist shoe runners. In other words, I consider FF/MF striking and minimalist shoes to be a cause of peroneal tendinitis in many runners.
An MRI scan would be appropriate for your patient along with valgus wedging on the affected side and soft 1/4" (6 mm) neoprene heel lifts bilaterally to see it this helps along with some physical therapy.
Good case!:drinks -
When I was teaching gait analysis back at CCPM, there was one student who had one of the most lateral axes that I had ever seen. He often would forefoot strike when walking. Sometimes he wouldn't and sometimes he would. So, it was a choice he subconsciously made. My explanation was that the point on his foot that was most lateral to the axis was his lateral forefoot and that is what hit the ground first when he forefoot struck. Forefoot striking was a behavioral adaptation to decrease the supination moment from the ground.
So, if this woman is choosing to forefoot strike because she has a lateral axis, she might still get peroneal tendonitis because of the lateral axis and not because she is forefoot striking. Regardless, some of the same treatments that have been suggested should still help. Wide lateral flare on the shoe, valgus heel and forefoot wedge.
Eric -
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Many thanks
Mark -
The peroneus brevis and longus are weak plantarflexors of the ankle joint, they are not dorsiflexors of the ankle joint. As far as the central nervous system is considered, the peroneals will be recruited when extra plantarflexion power is necessary in some patients, especially those with normal to lateral subtalar joint axis position. It is for this reason, I believe, that we see peroneal tendinopathy/peroneal tendon muscle pain more commonly in runners with a midfoot/forefoot striking pattern or in runners wearing running shoes with a low heel height differential.
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I have been asking the same question now for the past 30 years. In the thousands of runners I have examined during that time, there does seem to be one thing that correlates to someone being naturally more of a forefoot striker rather than a rearfoot striker: natural forefoot strikers nearly always have a lack of ankle joint dorsiflexion with their knee flexed while being examined in a non-weightbearing position.
My hypothesis is that in those runners that have a tighter soleus and/or bony ankle joint dorsiflexion restriction, they need to use significant anterior muscle group power to get 10 degrees of ankle joint dorsiflexion with the knee flexed (the knee is flexed at footstrike during running). Therefore, they will choose, by central nervous system control, to footstrike on their forefoot, rather than their rearfoot since it is more metabolically efficient to run as a forefoot striker when the runner has restricted ankle joint dorsiflexion when the knee is flexed.
However, the gastrocnemius does not seem to be involved in causing a natural forefoot striker since there are many runners with "tight" gastrocnemius muscles that rearfoot strike. In my three decades of observation and examination of runners, the only runners who naturally choose to forefoot strike at recreational running speeds (5:00 minute mile pace or slower) have a lack of 10 degrees of ankle joint dorsiflexion with their knees flexed while being examined in a non-weightbearing position.
Now, if I could just get someone to do the research study to see if my observations can be confirmed, I would be grateful, since I have been talking about these observations and hypothesis of mine for at least the past 5 years but no one seems to take me seriously or is paying any attention.:bang: -
It would be hard to do a study on them, because you can often see tension in the medial and lateral ankle tendons around the time of heel contact. You would think that they would need to be pre loaded in case of unexpected surface variations that could lead to sprained ankles. It would make sense that the pre load could also happen in forefoot strikers.
Eric -
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Eric -
Mark
Firstly a couple of obversations from the video and pictures, her right tib ant is firing in stance and the left one is not. Her left foot appears to pronate more than the right - heel and knee valgus. Difficult to see from the video but her knees appear to be flexed at toe off, heel lift is low for a forefoot style, she is overstriding (contact infront of hips and knee), dropping onto contact foot rather than drawing foot back underneath her, leaning forward at hips and sitting back at contact. Right also appears to show no heel contact whereas left foot does.
So she would appear to be more lateral on her right foot with less pronation, blocked at ankle or 1st MTPJ as restricted into propulsion, therefore not using her hamstrings / gluts correctly and hence low heel lift and overuse of hip flexors to pull her foot throught swing phase and so overstriding.
So I would say the lateral position of her COM during stance and poor posterior biomechanics is causing overuse of the peroneals.
I personally would not use any rearfoot posting with this patient unless she is prepared to change to a rearfoot strike (but why should she?) Need to work on posture of upper body, dynamic core strength - related to running motion, arm swing, pelvis position - reduce sitting back just after contact, working on 'pushing' with hamstrings and gluts to ensure power is coming from behind her and not pulling herself forward with her hip flexors/quads.
Right foot needs to pronate more not be held laterally but she has to improve posture, dynamic strength and may need a bit more under her feet in the short term with regards to Nike over Vivo. Have the confidence to let her foot go and load it through the stance phase, power onto 1st MTPJ into propulsion. Will likely need ankle, 1st ray and midtarsal mobs to allow this weight transfer lateral to medial.
A different approach maybe but one I am using more and more.
Colin -
I'll say it now a fourth time: natural forefoot strikers nearly always have a lack of ankle joint dorsiflexion with their knee flexed while being examined in a non-weightbearing position.
Does everyone agree, disagree or simply aren't interested enough to comment?? -
You might find this reply I received over the weekend from my patient interesting.
Kind regards
Mark -
That is the question, is anyone else looking at this, or has everyone else not doing these measurements on runners anymore? -
Kevin
Nope I didn't and even if I did I would have probably missed its significance, to be honest. Can you offer a suggestion why this and the loading from forefoot striking might be contributing towards her tendonitis?
Mark -
As I said earlier, forefoot strikers will tend to use their peroneals more than in rearfoot strikers to decelerate ankle dorsiflexion since they are landing on their forefoot during running, not their rearfoot. In rearfoot strikers, at foot strike, the anterior muscle group needs to be active and create an internal ankle joint dorsiflexion moment to decelerate ankle joint plantarflexion. However, in forefoot strikers, the posterior calf muscles (including the gastroc-soleus, peroneus brevis and longus and deep posterior group) all probably contribute toward decelerating ankle joint dorsiflexion by exerting an internal ankle joint plantarflexion moment.
In watching your runner's video, she looks like she is artificially placing her foot into a plantarflexed position at the ankle before footstrike since most runners running at this pace will rearfoot strike and even those that naturally tend to forefoot strike are not this plantarflexed at the ankle at footstrike. Ask her next time you see her if she has been coached by someone or read somewhere that "good running form" includes forefoot striking, not rearfoot striking. If she changed her running form to being a forefoot striker a few months before the injury, you have just found the etiology of her injury.
By the way, a change to forefoot striking from rearfoot striking causing peroneal tendon injury is more common than you think in runners. In the last few years, I have seen almost one runner a month with peroneal tendinitis/tendinopathy with this exact same history. This is why I now include a history on footstrike pattern in all runners I see in my office. -
Hi Mark:
Unilateral, Hx of acute onset.
Although the US was neg for tear, you know that linear tears are very difficult to see either on US or MRI.
If she fails to respond to your various Biomechanical treatments I would not rule out a linear tear of one or both Peroneals.
Good luck
Steve -
Best wishes
Mark -
Heres my 'pennorth, for what it's worth. In my 'umble opinion, her running gait is decelerative in every foot strike due to an inadequate knee lift, (video 2) thereby not allowing an adequate swing phase that will ensure that the foot clears the ground during swing and is moving rearwards at 1st contact which kinda fits in with the peroneals having to cope with a decelerative force at every foot strike. To achieve adequate ground clearance there is therefore an abductory swing, (video 1 on treadmill) the knees are internally rotated and the contact phase is all pronated. All her running is coming from below the knee (see video 2).
Running is nothing more than controlled falling over, should be as sagitall as possible and if you dont get the front foot forward fast enough, together with the foot moving backwards at 1st hit then you will get deceleration at every footfall, and subsequent tissue stress and injury.
It doesn't matter whether there is a fore, mid or rearfoot strike as long as there is minimal decelerataive force at 1st contact. See any elite runner to see what I mean (Mo Farrah in Quorn advert!) -
I'm reviewing this girl in a couple of weeks time and would welcome your comments. The consensus would suggest offloading the tendon with lateral wedging - however, as she is a forefoot striker, rearfoot posting on any device would, I assume, have limited benefit. However I am still not sure that simply fitting a forefoot varus insert to her running shoes will change the dynamics sufficiently to offload the tendon - if she continues to forefoot strike. Is their any merit in having her try to change her running style - gait retraining - if it works?
Many thanks -
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http://en.wikipedia.org/wiki/Running
Kind regards -
Mark:
Instead of using the wikipedia reference which seems to be written by someone who actually hasn't reviewed the literature correctly, why don't you start with these three sources for learning about running footstrike.
https://www.youtube.com/watch?v=hDo_kny7czM
http://www.podiatrytoday.com/emerging-evidence-footstrike-patterns-running
http://pursuitathleticperformance.com/2014/047-an-interview-with-dr-kevin-kirby-dpm-podcast/ -
Very kind, Kevin. Clearly a subject close to heart.
Best wishes
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Influence of Dorsiflexion Shoes on Jump Performance
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APTA Practice Guidelines for heel Pain-Plantar Fasciitis
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