"There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they're falling in."

-Bishop Desmond Tutu

Early last month, Julie and I competed in a 50K trail race near Ann Arbor, MI. This was our second race of the summer and added to what is the most consistent racing I’ve done since 2021, after nearly 20 years of regular racing from April until sometimes as late as November. It goes a bit against the grain for me to openly discuss my training and racing, and while I’m not going to write a race recap, I do feel the need to open a lens into my world as it pertains to sport and more importantly, the road to recovery after a chronic injury.

Since 2001, when I first began competing in endurance events, I have always prided myself on the ability, luck, or whatever you want to call it, to steer clear of the injury bug. I lost little time training and absolutely no time racing due to injury for nearly two decades. Part of me attributed this to the many years I spent NOT participating in endurance sports, but instead preparing my body for sports that required explosive speed, multi-directional loading, and placed a greater emphasis on muscular strength than endurance. Another part of me thought that the lifestyle choices I made with respect to my sleep habits and my diet were acting as safeguards. (If you recall my August newsletter, you’ll remember this was perhaps an error in judgment.) Despite this self-assurance, I knew deep down that my sometimes foolhardy approach to training would sooner or later require me to take a significant step back. I simply couldn’t predict when and for what reason.

Fast forward to the summer of 2021. The world was starting to get a handle on the COVID-19 pandemic, which meant that endurance races were finally taking place again. One of Julie’s childhood friends and her husband put on a great 50K that begins in her hometown every October. This seemed like a great way for us to parlay a race and a long weekend visiting my in-laws all in one trip to Canada. While I hadn’t been training in earnest for anything specific leading up to the race, as there had been nothing to prepare for since late 2019, I was continually running six to seven days per week, logging anywhere from 50-65 miles/week. Pretty standard fare since I stopped racing triathlon back in 2018 and focused solely on running. When a more organized form of training commenced in prep for our October race, including longer miles and structured workouts, I noticed spells of Achilles tendon pain that had started to build in frequency, intensity, and duration. I’d had a few brief encounters with pain in this area many years back, but only in my left leg. After a few weeks of reduced running and a consistent diet of eccentric calf exercises, I’d normally be right back to training and racing pain-free. This time around, however, the usual modalities yielded little to no benefit. Worse yet, I was now having pain in both of my Achilles tendons. I was experiencing discomfort with everyday activities including walking, which was not reminiscent of my previous experiences.

Being stubborn by nature, I was not about to let this derail our return to racing after a two-year layoff. Not to mention, after 30 minutes or so, the pain would often completely subside. I knew this was a common operating procedure for this particular malady, and I continued to hold out hope that eventually, my body would respond the way it had years ago to the same plan of care (if you’re even willing to call it that). Long story short, it did not. In fact, the pain became more consistent, and more intense, and was noticeable later and later into my runs, as well as for many hours afterward. So, instead of doing all the things I would encourage a patient in my office who was suffering my same fate, I continued to plow forward, training plan unchanged, determined to start racing again.

I ultimately completed the race, but what ensued for the next three to four weeks was virtually unrelenting pain that would vacillate between a 3/10, progressing to an 8/10. At this point in the game, I knew I needed to take a significant period of time off from running and come up with a legitimate plan of care to address what had grown into the most significant running-related injury I’d ever faced.

Not only had running become immensely painful, but I could no longer so much as walk without pain. I would routinely feel jolts of pain upon standing if I had been off of my feet for even a few minutes. I had to allot additional time to complete the three-block walk from my office to the train station at the end of my workday, as even a brisk walk became extremely painful. Julie started walking Brucie on her own because if I was in tow, as soon as we were half a block away from home I’d already be in pain, growing grumpier with every step. This was no longer an injury getting in the way of sport, it had significantly impacted my everyday life.

I spent the next 15 months treating my injury with the same care and focus I approach the aches and pains of those who entrust their physical health to me. An ad hoc approach was not going to cut it this time around. On top of intensive rehab, it was clear that I would be well served to audit my approach to training, which led to a complete and total overhaul. During this period of introspection, I came to the conclusion that regardless of how much I had developed a guttural disdain for the weight room, strength training was going to have to become a mainstay of my weekly preparation if I was going to have any chance at longevity with regard to running, let alone racing. This journey was filled with frustration, sometimes bordering on disbelief, and what were once race-centered goals, were reduced to literal baby steps such as being able to get up off of the couch and walk the first 10 steps without sharp and shooting pain. Slowly, but surely, my symptoms improved, and the diligent months of work I put in began yielding lasting and measurable results. Now, nearly two years later, I’m confident that if I’m diligent in sticking to the program I’ve grown to thoroughly enjoy, there’s hope I can keep this up for at least a few more decades.

While formal knowledge of anatomy and physiology is not required to understand the basics of this injury, I think a little knowledge goes a long way when it comes to understanding one of the most common, and recalcitrant running-related injuries that plague thousands of runners each year. Achilles tendinopathy. As the two largest muscles of the lower leg known as the gastrocnemius and the soleus, (often referred to as the calf muscle complex) course down the back of our leg towards the ankle, they merge to form the Achilles tendon. The tendon ultimately anchors itself into our calcaneus, otherwise known as our heel. As the calf muscle complex contracts, the muscular forces are transmitted through the Achilles tendon, resulting in the raising of our heel off of the ground and/or the pointing of our foot and toes, depending on our position when these muscles contract.

One of the main functions of any tendon is its ability to store and release energy, similar to the action of a spring. The elastic properties of tendons allow them to stretch, thereby storing energy. This action is followed by a recoil effect where the movement of the adjacent joint(s) is produced. The propulsive forces transmitted through the Achilles tendon by the contraction of the calf muscle complex are extremely significant for walking, running, and jumping.

It is these same motions that can produce tensile forces of up to 10 times our body weight. That said, the Achilles tendon is the largest and strongest tendon in the body. Read that again…the largest and strongest tendon in the body. I emphasize this for anyone who has fallen victim to an Achilles injury and worries that continued running is going to result in complete and total rupture of the tendon. The preponderance of research shows that a history of pain in the Achilles tendon does not put you at any greater risk for tendon rupture versus someone who has largely remained asymptomatic. Incomplete rehabilitation of a past Achilles injury on the other hand, results in a far greater amount of time spent on the sidelines for the vast majority of runners and athletes compared to recovering from tendon rupture.

The Achilles tendon is susceptible to damage due to repetitive use and overloading of the tendon’s capacity, especially in athletes. Achilles tendinopathy is the umbrella diagnosis for both acute and chronic pain associated with the Achilles tendon. In recreational runners, it can account for nearly 20% of all running-related injuries, and among competitive runners, the lifetime incidence of this injury can be as high as 50%. For male masters level runners, which is anyone over the age of 35, this is the single most common running-related injury sustained. I guess I've been diminished to a mere statistic.

While Achilles tendinopathy can appear to be a bit of a catch-all diagnosis, it is broken down into a few subgroups depending on the location of symptoms. The first is known as paratendinopathy, which is an acute or chronic inflammation of the connective tissue sleeve surrounding the Achilles tendon, known as the paratenon. This membrane is similar to the insulation surrounding the hot water pipes in your home. The function of the paratenon is to protect the Achilles tendon from friction due to movement of the tendon between the many surrounding structures. Irritation of this tendon sheath can result in diffuse pain and swelling and can often result in audible crepitus (creaking) with toes up/down movement of the foot. The most common cause of paratendinopathy is consistent trauma resulting from tendon overloading. That said, something as simple as wearing ill-fitting shoes, which can put excessive pressure on the back of the foot where the Achilles tendon inserts into the heel, can also cause, or contribute to this injury.

The next category is known as mid-portion Achilles tendinopathy. This includes pathology of the main body of the Achilles tendon approximately 2-6 cm above the insertion into the calcaneus. This category of Achilles pain usually results in morning stiffness and pain in the tendon upon walking after getting out of bed. Tenderness is often felt when pinching the tendon and visual thickening is sometimes noticed. The mechanism of this category of Achilles pathology is frequently tendon overloading. Anywhere from 55-65% of Achilles tendon issues are of this variety.

The final category is insertional Achilles tendinopathy. The symptoms of this category of Achilles pain are similar to the mid-portion variety, but the location and mechanism of pain provocation are considerably different. As we discussed previously, while mid-portion tendinopathy affects the middle of the tendon itself, insertional Achilles tendinopathy occurs at the insertion site of the Achilles tendon into the calcaneus. While mid-portion tendinopathy is often resultant of tendon overloading, compression of the Achilles tendon against the calcaneus is considered to be the key factor in insertional tendinopathy.

Hallmarks of Achilles tendinopathy:

• Pain with palpation of the achilles from origin to insertion
• Swelling and potential thickening of the tendon itself
• The onset of pain is often gradual and increases with time
• Symptoms will often wax and wane between more significant, and sometimes non-existent
• The tendon often experiences a "warm-up" phenomenon when running where the pain at the outset of running diminishes after a few miles
• Walking barefoot is often more provocative than wearing shoes, especially those with an elevated heel

As you can see, not only is the location of symptoms between the subgroups of Achilles tendinopathy quite different, but so is the mechanism of injury. Next month, I’m going to discuss some of the basic principles of rehabilitation and recovery, as well as some of the frequently utilized modalities that should be avoided when dealing with Achilles tendon pain. You may be unpleasantly surprised to find that what you thought were the right things to do, could potentially be leading to more pain and irritability, thereby interfering with your recovery and increasing your time away from sport.

Nothing But Good News

​Nation's Largest No-Kill Shelter Opens in Alabama to Save 5,000 Dogs a Year​

​Dog Repeatedly Escapes Animal Shelter, Sneaks Into Nursing Home, is Adopted by Residents​

​First Study to Show Dogs Cry "Happy Tears" When Reunited With Their Owners​

Recipe of the Month

​Vegan Lentil Nut Meatloaf​

Every year when Julie asks me what I want for dinner on my birthday, this is the answer. At first, she made it into the shape of a heart, and over the last few years, it morphed into my age.

The round-up

FERTILIZE, FERTILIZE, FERTILIZE!

With the recent passing of the autumnal equinox, it's officially fall. You've worked long and hard all year to give your lawn the best chance it has to succeed. If you live in the Chicagoland area, where the temperatures have been relatively mild and the rain has been fairly consistent, this has been one of the better years for lawn growth in recent times.

While Thanksgiving may be here before we know it, there's still a handful of weeks where you can really put your lawn in a position to hit the ground running come next spring. A little bit of planning this time of year can go a long way.

If you look at the chart below, you'll notice that there are two main growing seasons for lawns in the northern part of the country, spring and fall. Temperate weather and ample rainfall encourage significant growth of your lawn during these two seasons. Come summer, when the temps are typically higher and rainfall is less plentiful, your lawn enters a bit of a holding pattern. As we approach winter, when grass growth is halted altogether, it becomes ever more important to bulk up your lawn as much as possible to withstand what can be a long and stressful period. The number one piece of advice I can give you is to fertilize your lawn from now until the first hard frost, perhaps every two to three weeks.

If you've ever had your lawn serviced by a company that provides fertilizer and weed control services, the last application of the year will often contain "winter fertilizer." While this may seem like a special concoction of nutrients to feed your lawn during the winter, it is nothing of the sort. It is the same high-nitrogen fertilizer that you spent all spring, and hopefully, all fall, spreading on your lawn. The only difference is when you apply it. By spreading one more application of fertilizer right before your lawn goes dormant for the winter, this round of fertilizer lies in wait for warmer temperatures in the spring, readying your lawn for growth as soon as the ground is warm enough. By the time April rolls around you'll already be cooking with gas. Just as you've done throughout the entire year, try to time your fertilizer applications with rainfall, and for the final round, snowfall. If rain is not in the forecast, you'll have to run the sprinkler to make sure the nutrients make their way into the soil, instead of sitting on the surface.

Thanks for reading! Reply any time.

~Dana

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