Injury – extricate.org

Beating Insertional Achilles Tendonitis

It has now been one month since I turned a corner in conquering my Insertional Achilles Tendonitis. Having struggled with it since February, to the degree that it made me not want to run and certainly not enjoy it in any way if I did, I made rapid improvements within days once I started using Superfeet for extra support.

I also got some new footwear, as I felt that the running shoes and football boots I was using were a size too small. While increasing the size did reduce any pressure on the back of the heel, and probably did help in the soothing of any aggravation going on, for actually running around it just made me prone to blisters. I ended up going back to my original size and without any ill-effect.

With the Superfeet in use, I have been able to gradually build up my running with zero achilles pain. The difference is remarkable. Prior to using them, I could not even run about in the garden with my daughter without the achilles playing up in an annoying and sore way. Very quickly, I was able to do a full football match with the achilles not even being noticeable. However, because of my lack of training over recent months, everything else hurt!

I have had a lot of fitness to build up again. I’m not back at pre-injury levels yet but am noticing strong gains all the time. However, I don’t really mind that, as I can run around and enjoy it with a smile on my face again! I think a strong indicator of being over an injury is when you just look forward to getting out there and training again, and the idea does not worry you.

Now, while using the support of the Superfeet to get over the injury has been great, I don’t want to become reliant on them forever. I have therefore been transitioning to removing them over time. As an example, doing one half of a football match without them, then doing the second half with them in. When they are not in use, I ‘feel’ my achilles more, so it is a case of being careful.

This has gone really well. For the last two days in a row, I did two 5k training runs in minimalist (inov-8) footwear and without the Superfeet. The achilles was noticeable but not painful. More importantly, after the run and the next morning it was absolutely fine. I have had to build up to this point and may now go back to using the Superfeet for a few sessions just to avoid doing Too Much Too Soon.

My key learning points to being successful in dealing with this horrifically stubborn injury are:

SEE A SPECIALIST, GET A SCAN: In my case, nothing scary was revealed by getting this done. I feel a scan is important to rule out any complicating factors which could be present. Perhaps it is bursitis, and not the achilles? Is there a severe tear that needs immobilisation and/or surgery?
REST: This is important to a degree. Certainly rest is required until any obvious acute pain is gone, and you should NOT RUN THROUGH PAIN. You know the difference between pain and soreness. Don’t be stupid. Rest on its own did not help me though: I took 3-4 weeks off running and when I went back to it, it was just the same as before. The problem is that you are not truly resting the achilles anyway if you are still walking around. Which leads me to…
SORT OUT PAIN ON WALKING: This was the key for me. If the achilles is sore as you are walking around, it is not getting the chance to heal. This is where the Superfeet added enough support for comfort during the day, and gave the achilles that chance! Heel raises, orthotics… find out what you need. Some specialists may immobilise the achilles for a week or two to force this issue.
CHECK FOOTWEAR: In my case, I went up a size, even if on a temporary basis. This added extra space around the heel so there was no tightness causing aggravation of the heel area. Those new shoes were not suitable for running and led to blisters, but for walking around during the day, they were absolutely perfect. If you can get away with ultra-cushioned running shoes at work then even better. Yes, such cushioning is a crutch, but that’s fine because you are injured!
TAKE YOUR TIME: Depending on the extent of our lay-off, you will have lost fitness. Both in terms of cardio but also muscle strength and stability. Come back slowly. Take rest days as you need them. Enjoy the runs you are having pain-free and remember that you want to preserve that. There is no rush! Avoid hill running and sprint training to begin with and introduce over time as your confidence comes back.
REMOVE TEMPORARY SOLUTIONS WHEN READY: As stated earlier in this article, I do not believe in using orthotics long-term. For helping an injury heal, sure, and I feel the same way about heel-raises, lots of cushioning and so on. Once everything is feeling good, work on removing those temporary fixes. Again, take your time. Mix it up a bit.

I hope you find this guide helpful, and please let me know your own stories!

My first supply league middle

Following on from my first game of the season (in a 4th official role), it was time to grab my whistle and have my first ‘middle’ of the season too. This was on my local supply league now that I am eligible to do those games following my promotion to Level 4.

The warm-up from the previous game had given me confidence that my achilles was going to behave, and I’m very happy to report that it stayed rock solid throughout the 90 minutes. However, the first game back is always a shock to the system, so the end result was that everything else hurt instead! Thankfully, just the usual DOMS after the game rather than anything more sinister.

The game itself went well although I am aware that I have a lot of work to do to get my fitness back to my peak level. That’s to be expected following the injury. I’ve resumed training runs again with the achilles remaining stable but I am being careful with how I am ramping up the activity to avoid anything else going ‘ping’.

It was a great moment to start that training run yesterday, as I was very much aware that I was able to run along pain free so had a big smile on my face!

It’s a busy week though: Another supply league middle coming up, then my first outing as Assistant Referee on the contrib, then refereeing an U18s Premier League Academy match!

Tentatively back on the Treadmill

I’ve been noticing a dramatic improvement in the achilles over the last few days, now that I’m wearing appropriate footwear and tackling my severe overpronation head-on. The best way of explaining this is that I am just not really noticing my achilles during the day and there is much reduced morning soreness.

As a result, it was time to do a controlled treadmill run to see where I was. For reference, the last time I did one of these a few weeks ago, I managed about 30 seconds before I needed to stop because I could tell it wasn’t doing me any good at all.

I did 17 minutes, broken down as follows:

3 minutes – Warm-up to 8.5 km/h.
7 minutes – Run at 13.5 km/h.
4 minutes – Run at 8.5 km/h.
30 seconds – Run at 12.5 km/h.
30 seconds – Run at 15.5 km/h.
2 minutes – Cool-down.

I was amazed at how strong the achilles felt. There was a slight twinge when starting which faded very quickly, and the same when there was an increase in speed. Again, it went away pretty quickly. This was one of those situations where I could have just kept running but I wanted to avoid ‘Too Much Too Soon’, so kept it short and sweet.

Remember, I lasted just 30 seconds last time. The improvement in just a matter of days is wonderful and has given me a LOT of confidence. I actually enjoyed running! The footwear change and Superfeet are doing the business so far, and this is after months of struggling to deal with rehabilitating the injury.

Of course, an important indicator is how I felt after the treadmill session. There was no additional soreness, and when feeling around the achilles and foot it again struck me how much it has improved this week. If anything, it felt a lot more opened up. The ‘Morning After’ test was also a positive: The achilles felt better than the previous morning, and I hadn’t done any exercise then!

I did a quick bent-knee calf-stretch this morning. This has always been the stretch which really aggravated the injury before. Now I can reach my full range of motion with only a tiny feeling of discomfort, as opposed to the ‘Argh, I should NOT be doing this!’ sensation of before.

I need to stay disciplined with this, but this week has been a major step forward. I’m happy!

Achilles Ultrasound – All clear to referee (carefully!)

I had the follow-up with my consultant this evening, now that the ultrasound on my achilles had been performed. I had been feeling pretty nervous about this as I’ve been looking forward to getting cracking on with the start of the season, and did not want any upsets!

This was the report:

No plantaris tendon was identified separate to the Achilles tendon. There is unremarkable retro-Achilles bursa measuring maximum 1mm depth. There is a strand of low and less linear reflectivity within the Achilles insertion onto the calcaneum centrally and medially, each measuring approximately 1mm deep and up to 2cm length. No increased perfusion is detected. The mid and proximal Achilles tendon and musculotendinous junction look normal. No retrocalcaneal bursitis is detected. No paratenonitis is detected. No erosion of the calcaneum at the Achilles insertion is detected. No calcification in the Achilles tendon is detected.”

CONCLUSION:

Subtle features suggestive of a couple of fine strands of tendinopathy insertional within the medial and central insertion of Achilles tendon.

Essentially, there is a tiny little tear in there which looks like it has been healing well. ‘Healing well’ is indicated by the fact that no evil calcification or other knock-on effects such as aggravation to the bursa have been happening.

I went through my recent improvements with the consultant (including the new footwear). This included the findings on my severe overpronation and the Superfeet orthotic. The good news is that he approved of all this, and in particular that the orthotic was the appropriate type. In his own words, “You seem to be fixing yourself!”.

He is happy for me to carefully resume refereeing. I have also been referred to a recommended physio (my consultant used them for his ACL tear) to work on continued strength and flexibility training.

Achilles injuries are SLOW to heal (poor blood supply), so I feel there is still a bit of a journey ahead of me with this. It will be good to get back to running and other physical training, as getting the weight down will help with all this too!

Bring it on!

Taking on my severe overpronation with Superfeet

Recent video gait analysis (and hey, the same sort of thing done years ago) has confirmed that I am severely overpronating. Just looking at the video made me wince, and it has made all the puzzle pieces fit together regarding my achilles tendonitis.

I picked up some properly fitted running shoes at the weekend (in the correct size too, which might help, huh?), and the extra support for my achilles is immediately obvious. I got new football boots too, again in the correct size, but football boots are traditionally very neutral and do not give much, if any, support. I would be continuing to overpronate and send my achilles into oblivion.

What to do?

Well, orthotics can help with this, and my online research had turned up many positive comments about Superfeet. As a result, I popped along to Alexandra Sports to be fitted out (You can just grab them online but the personal touch is always good!).

The fitting

The customer care at Alexandra Sports was excellent. I took along my new boots so the Superfeet insoles could be fully tested. I tried both the blue and black versions. Both are designed for footwear where there isn’t a great amount of free space, even after taking out the original insoles. Football boots fit into this category!

My preference was the blue. Everything fitted nicely (the lady serving trimmed them as required) and they were really comfortable. The blue give more support so it was a done deal.

And here they are (well, one of them!):

I also have the option of putting these in my running shoes if required. We’ll see.

I performed a quick run on the treadmill with the Superfeet fitted. Wow. NO DISCOMFORT AT ALL. This is a major win for me. Even when the achilles was feeling in a ‘good mood’ I would always be aware of it. During this test, including ramping up the speed to 15 km/h or so (which in itself demonstrated my confidence) everything felt stable. The video replay showed my overpronation had been solved to a huge degree, with my right leg looking pretty normal, although the left leg is still not ideal (it was always the worst, which is ironic considering the right leg was the one that got injured).

Next Steps

As with any shoe change, there has to be a break-in period. I’m wearing one pair of my new boots around with the Superfeet fitted: They are turf shoes (Adidas Mundial Team) which means this doesn’t look weird! I have a 4th official appointment this Friday and then an actual game Saturday.

This is all positive news to take to my consultant tomorrow evening. I just hope he agrees it is positive enough…

New season. New Boots. New Shoe Size!

The new season started today! I had the day closed due to holiday plans, so my first game is next week. However, it was time to take a look at my footwear to make sure everything was all set.

I have suspected for a while that I have not been wearing the right size football boots. I’ve had the classic sign of ‘Black Toenail Death’ in both feet. There has never been any pain involved with this but clearly it can’t be too healthy, particularly when the toenail just falls off due to a new one growing underneath it! It has always felt a bit like a scene from ‘The Fly’.

When I went to try on my boots from last season the tightness was particularly noticeable. Perhaps the lay-off in more flexible shoes has been a factor here? Feeling around the toe box confirmed my suspicions, and I could feel the shoes pushing down on my toes without doing this too. Besides, I’m a bit more sensitive to this sort of thing at the moment due to my ongoing achilles tendonitis issues, which interestingly can be caused / exasperated by, you guessed it, shoes that don’t fit properly!

It is also important to leave a bit of extra space as your feet will swell with exercise.

A shopping trip was required…

Mizuno Wave Inspire 8

I popped along to Alton Sports. First up, I had my running gait video-analysed to see how that looked. I last had this done a couple of years ago, and the results were the same: I very obviously over-pronate. It’s quite scary looking at the slow-motion video as it made me think my ankles were going to snap off at some points!

It was then a case of picking out some shoes, and I went with the Mizuno Wave Inspire 8. Predictably, I did need a whole size higher than I had previously been wearing. They are very comfortable and a treadmill session felt very good. Certainly any achilles discomfort was minimal to zero. The whole twisting inwards motion of over-pronation is a real killer for me, and perhaps is showing another contribution as to why this happened in the first place: If I deliberately go completely the other way, i.e. only use the outside of my foot for a bit, there is no achilles discomfort at all. That’s a strong link I will be keeping an eye on!

Adidas Copa Mundial

These boots are a real classic. The leather makes them incredibly comfortable and I’ve used them for some time. However, they were the primary cause of my beloved black toenails. I’ve also gone up a size and they feel a lot better now. Plus, mmm, shiny new leather!

These are the ones I will use when turf shoes just can’t cut it. Oh, talking of which…

Adidas Team Mundial

Essentially, the Copa Mundials but designed for astroturf. The reality is, however, that they are suitable for most firm ground, which certainly covers football pitches at this time of year. As with the other shoes mentioned here, I needed to go up to size 12, and I was previously a size 11.

What about the Minimalism?

I’m a big fan of minimalist running: It got me over a knee injury. However, I need to do whatever I can now to get my form in good order, and achilles well supported, as part of my continued refereeing and rehabilitation. This was really the reason of getting, dare I say it, a more ‘traditional’ running shoe. The replacement football boots needed to be done anyway for the sizing reasons! I also considered trail shoes for refereeing but struggled to find any that were an appropriate colour. That’s a tricky one.

It is possible that I will require orthotics to aid with support when in my football boots, but that’s a pretty open question at the moment: My follow-up with my consultant is this week. Fingers crossed!

End of Season Review 2012/2013

It’s that time again! This follows on from the End of Season Review that I wrote last season. It’s a chance to reflect before moving onwards.

THE GOOD:

I GOT LEVEL 4: This was my primary goal for the season. I went into the season requiring another four assessments, as although the first one was good, it wasn’t good enough! Thankfully, they all went well to the extent that I knew that for the final assessed game I was home free provided I didn’t really screw it up. There was then a waiting game until I found out whether The FA would take me, and thankfully they did.
CUP FINALS: As the promotion indicates, I performed well during the season, and was awarded with a total of five cup finals, including a county cup. That’s certainly something I am very happy with, although I know not to expect the same sort of thing next season, mainly due to the consequences of refereeing at the next level.
KNEE ISSUES SOLVED: I transitioned to minimalist running before the season started. This worked much better than I imagined, and I took the preliminary fitness test in that style too. The ligament issues I was suffering with in my leg knee healed up pretty quickly. The knee was probably being shot to pieces with all the heel-striking. I felt I was my fittest yet going into the season.
FITNESS TEST PASSED: A requirement for Level 4. Technically this happens between seasons, but hey, it’s happened! I passed the fitness test with no issues despite the achilles issue mentioned below. In fact, I ran the same distance as last year, which was pretty surprising to me.

THE NOT SO GOOD:

ACHILLES PROBLEMS: In February, some form of achilles tendonitis crept up on me in my right leg. I suspect an overuse injury following the lay-off over Christmas, increased in scope with the terrible weather! Oh, and my lazyness in not keeping up the supplementary training. It’s never been awful but has put me off training for fun, and is still not resolved at the time of writing. As a result, I’m pretty fed up with it and in the early stages of having a consultant involved (X-Rays, Ultrasound and so on).
FITNESS LOSS: Perhaps a bit harsh to put this, but I would consider my fitness levels to have dropped due to not wanting to train with the persistent achilles issue. It didn’t cause any issues towards the end of the season, and of course the fitness test I mentioned earlier went well.
WEIGHT GAIN: The achilles is my excuse here. Limited exercise = Weight gain. However, it’s a poor excuse as there is nothing stopping me from eating healthily! I have put on about a stone compared to my best weight. I need to pull together the discipline and get that sorted.

GOING FORWARD:

Firstly, I’m obviously looking forward to my first season as a supply league referee / contributory league assistant referee. It’s going to be a great experience. My goal here will simply be to ‘Do well and enjoy’.

Secondly, I need to get a handle on the achilles issue. That’s in progress but looks like it will be slow. Very slow. It may even result in me missing some of the beginning of the season as part of the rehabilitation. Worth it though, as I want to be enjoying my exercise and therefore refereeing.

Thirdly, I need to get full fitness back. I’m not unfit but I am falling short of my own standards in this area.

Let’s see how it goes!

Battling with Insertional Achilles Tendonitis

I’ve been struggling with Insertional Achilles Tendonitis since around February. I really need to get it sorted now, so am going to start blogging about it to maintain some sort of focus.

The history is fairly typical for this sort of injury: Overuse. I’ve been running regularly for years as a football referee. In a typical game, I will travel 10 km in a variety of ways: Walking, jogging, running, sprinting, running backwards, changes of direction… It’s all going on! When fully fit I would also be engaging in training runs of between 5 and 10 km, and last year I did the Great South Run (10 miles) with no problems at all.

I used to be a classic heel-strike runner, but switched to a minimalist style last year. I managed to transition pretty quickly and was using that style for about eight months before the achilles issues struck. Transitioning also solved the knee ligament issues I was suffering from in my left leg! Due to the long time period before the achilles issues came on, I’m not blaming the minimalist style here, but I do accept that it does load the achilles more than heel-striking — That’s how it saves the knee joints from being shot to pieces!

So what happened?

Well, over the last winter we had atrocious weather in the UK. Lots of games were postponed. I was lazy and did not keep up my supplementary training runs. Then it was the Christmas break and I didn’t do anything then either, but did put on a bit of weight! When the season started again the weather continued to be bad, so it wasn’t really until February that I was back to full-intensity games. And that was the problem. I went from a sustained period of doing nothing to resuming my usual refereeing intensity, and at that point the tendonitis started. As is typical, there was no sudden ‘BANG’ moment: it was more of a dull that came on the following morning. It never really went away and has persisted since then.

I would class the pain as annoying. It doesn’t impact my performance per se: I can still run, sprint and so on, but I just end up paying for it afterwards or the next day. Doing two activities in two days is really asking for trouble. Basically, it makes me not want to or enjoy training, and that has gotten worse over time. Not because the soreness has gotten worse, more that I am just getting completely fed up with it.

At the end of last season I took a bit of a break, but short-lived. About three weeks. That isn’t very much for an achilles tendon injury from the reading I have been doing. I then needed to train for my fitness test (Cooper Test and sprints), which I passed with no problem. Then another four weeks of rest before I got a bit over confident and did two 5k runs in two days, and the soreness came right back. Not as bad as it has been though, I will say, but again the fact I am not healed is getting tiresome.

I’ve had some physio during this time but I am left feeling that in my case, it isn’t helpful without giving the tendon time to rest first. Calf stretches cause pain due to the tugging on the tendon. It isn’t the ‘nice’ sort of pain you get when you know a stretch is doing you good. It’s the ‘Please don’t do this!’ sort of pain. There seem to be various references that the best thing to do is ACTUALLY REST IT, and certainly don’t try stretching and strengthening until that painful acute stage is over. Common sense, I guess?

The latest is that I have seen a consultant who has taken X-Rays and an Ultrasound. I’m awaiting my follow-up. The X-Ray has not shown anything out of the ordinary: Perhaps a very slight Haglund’s Deformity but it seemed very, very small compared to some of the example ones on the Internet. Besides, this did come on in an ‘overuse’ scenario. The Ultrasound confirmed a very small (1mm or less) tear. I don’t know exactly where yet until the follow-up. The optimist in me sees this as a good thing in a way: A tear can heal, even if it will take a while, and I’d rather it be that rather than some structural failure.

The immediate plan is more rest until the follow-up in a week or so. I won’t know then whether I should commence refereeing in the new season when August swings around. If I have to declare myself injured for a month or two (maybe more?!) then so be it. The important thing is to beat this. Much as I will be chomping at the bit as a result!

Watch this space…

Natural Running: Too Much Too Soon?

I recently took my first steps in natural running. About 5k on a treadmill, to be precise, in order to get a feel for the mid-foot/toe motion as opposed to my usual (very) heavy heel-strike technique. It felt great and so much lighter.

However, the very nature of this style is that the calf muscles and Achilles tendons are having to do more work. They are partly protected in a traditional running shoe as the shoe is taking over! Despite only doing 5k at a gentle pace, I suffered from some bad calf soreness over the weekend which ruled out any further running. Thankfully, it is pretty much back to normal today.

By contrast, my Achilles is just fine and I’m not surprised by this: When I first started football refereeing, I had major problems in that area, even though running was not new to me. Why? Changes of direction and speed. It’s one thing to go out for a jog where your tempo rarely changes. When refereeing, your speed and direction is constantly changing, and my Achilles did not know what hit them! It took a while to settle down, although I did not help particularly by refusing to rest properly. The end result: Strong Achilles.

I need to be more careful with the transition. Today, I intend to do a simple 5k on the treadmill (The weather outside is awful!), but most of it will be in my usual running shoes, with a bit of natural running in the my new Inov8 shoes at the end. A safe mixture. After all, I didn’t get any pain during the previous run: The DOMS came afterwards!

My calf muscles are getting more of a load in other ways too: I’m working on learning jump-rope for conditioning (via CrossFit) and being light on your toes for that necessitates calf-loading!

My End of Season Review

My football refereeing season of 2011/2012 is at an end. Now is the time for self-analysis in order to see how well I did, especially in comparison with my goals, and decide where I would like to go in terms of moving forwards.

THE GOOD

I GOT MY PROMOTION: I succeeded in going from level 7 to level 5 (a ‘double jump’ promotion) in one season. This required a great deal of commitment and I’m pleased that there was no drama along the way.
CUP FINALS: I was very pleased to be selected for a total of five cup finals. This was nearly six but unfortunately I was away on holiday for the last one. It is always a honour to be considered for a cup final and they were a great way of rounding off the season.
I DIDN’T GET INJURED: Well, kinda. I will touch on this more in the next section. Essentially, I got through the season without any major problems, which was important considering how many games I needed to get in for the promotion.
I ENJOYED IT! Isn’t this the most important thing? I enjoyed my games, the challenges that they presented, and the various people that I met during the season: Players, officials and fellow referees. Some early advice I received was “Enjoy your refereeing” and how true that is!

THE NOT SO GOOD

MY WEIGHT: Despite being so active, I managed to to put on about 10 kilograms during the season. This was down to eating very badly. It started to have an impact on my joints plus how generally nimble I felt when refereeing (twisting and turning, changes of direction and so on). Not only that, I’m not happy with how I was looking towards the end of the season!
INJURY: Linked to my weight. My knees started to play up a bit towards the end of the season due to the repeated impact of the stop/start running. Essentially, a case of Runner’s Knee. Nothing serious as rest abates it but those extra 10 kilograms were hardly helping! Oh, and having an ‘out of balance’ body, but I will come to that later.
LEVEL 4: I’m now going for promotion again, to level 4. I’ve had my first assessment and while it is a commendable result for my first assessment at my new level, it is not as high a mark as I would like.

GOING FORWARD…

WEIGHT LOSS: This is already going very well, and I’ve lost over 5 kilograms so far. I’m sticking to a 2000 kcal diet, with exercise allowing extra calories! MyFitnessPal is an excellent site for tracking this.
FITNESS: The off-season allows me to be more stuctured in my routine. I’ve been working on a combination of normal running, interval and speed training. This has included working towards my fitness test which needs to be done in August/September (I am well on track for this). I’ve also started CrossFit in order to keep my body in good balance, to aid in flexibility and injury prevention. I’m really enjoying this.
I’M LOOKING FORWARD TO 2012/2013: I’m really looking forward to the new season. I feel like I’m going to be great physical shape when it comes around, and I have a level 4 to earn!

Bring it on 🙂