"There's only one hard and fast rule in running: sometimes you have to run one hard and fast."

Thursday, August 1, 2013

Running with Haglund's

Haglund's deformity is a common problem for runners; if you've never heard of it, you probably don't have it (it's genetic). I've run more than 80,000 miles with an advanced case of it and I think the medical advice available on the web only makes sense if you've just found a pea-to-marble sized bump on your heel, not if you've had it for a long time and your heels look like mine:

Legal disclaimer: I'm not a doctor. If you believe you have a medical condition, you should see a physician and follow doctor's orders.

Here's the common advice and my take on it:

1) Take anti-inflammatories.

If you've had the problem for more than 6 months, it's no longer an inflammatory response and you've progressed from tendinitis to tendinosus. Taking painkillers may cause you to run on an injury when you shouldn't.

2) Use heel lifts.

The idea is that raising the heel may change the angle between the calcaneus and tendon and avoid the two rubbing against each other. Heel lifts decrease the range of motion of the ankle and thus limit the speed with which one can run; it also causes the tendon and calf muscles to shorten, which exacerbates the problem.

3) Don't run hills.

If running up a hill hurts, try modifying your stride or slowing down. If there's no way to eliminate the pain, then avoid that hill if possible, but continue to run the hills you can do without pain.

4) Wear orthotics.

The idea is that pronation causes the tendon to rub in a twisting fashion against the deformity in the heel, but there has never been evidence that orthotics help that's been published in the scientific literature.

5-7) Always wear new shoes, cut a notch in the material over the bump, wear padded socks or padding with a hole at the bump.

My heels always hurt more with new shoes and running in them causes the material to wear out over the bump, making them more comfortable. Padding just decreases the space in the shoe, making rubbing problems worse.

8) Wear minimalist shoes or go barefoot.

Most minimalist shoes hold tightly against the heel, which is a problem. If you can run comfortably in huaraches, they would be a good choice; here in Minnesota, there's something we call winter, which makes them impossible. When not running, go barefoot or wear flip-flops as much as possible.

What Actually Works

Surgery is the common option. After 30 years, I may have mine this year.

 If surgery's not an option, then there's three things to consider: tendinosus, retrocalcaneal bursitis and sequelae (the things that go wrong because you've changed your running style to minimize pain).

There are two treatments for achilles tendinosus that claim to have 100% success rates and which have helped me: stretching under eccentric load and self-myofascial release.

Stretching the Achilles and calf

The common stretches for the gastrocnemius and soleus muscles - the wall stretches - aren't enough. The proper stretch is done as follows: Find a stairwell, preferably where you can touch walls on either side of the steps, for support when needed. Place one foot on the edge of a step, the other foot held behind the line of the body. Raise onto your toes and lower yourself slowly (about 2 seconds) as far as possible. Then bend the knee of the leg being stretched as much as possible. Raise up again, using your arms and other leg if needed. Do three sets of 15 stretches with each leg, twice a day.

When I first started, I could only do these doing both feet at once. Within a month, there was considerable improvement.

Physical manipulation

Deep tissue massage, active release therapy, whatever you call it, breaking the adhesions on the tendon manually will allow the tendon to heal normally. Start by using a foam roller (there's a ton of videos out there showing how to do this) over the entire length of the tendon. Then press into the tendon with your thumbs at any point that's painful, as hard as possible (you can actually sprain your thumbs if you're not careful). Pinch the cord between thumb and forefinger and rub both side-to-side and up-and-down. To create greater pressure and save your fingers, use a golf ball pressed into the tendon with your palm and roll it over the area. Massage for 15 minutes per day per leg.

The golf ball thing was my idea. At first, the area of attachment at the base of the tendon was excruciating to press on this way and I actually cried while doing it, but within a month it no longer hurt there. The area where the bursae have pushed out laterally from the tendon has been more difficult to treat, but improved over 6 weeks. The area directly over the bump was never the biggest problem for me, but has been slow to improve. Lastly, there have been occasional flare-ups at the narrowest point of the tendon (actual tendinitis!), which improved in a day or two with careful management.

 All the other stuff

When you run, you'll naturally find what causes the least amount of pain. This won't be the most efficient way to run and you'll be forcing parts of your body to take up more of the load than they're designed for, so you'll likely develop problems in other areas. You should do a range of maintenance exercises to protect against: plantar fasciitis, shin splints, peroneal tendinitis, tarsal tendinitis, hamstring tendinitis, iliotibial band syndrome, piriformis syndrome and quadriceps and hip adductor strains. Really - I've had all of them and more.
That's a lot of work to do on top of running and even that seems to be failing me after 30 years. That's why I'm looking at surgery as a last resort.

Update 2/3/2015

I'm rather shocked that this has been viewed thousands of times. I did not have the surgery, because calcification of the tendon meant I'd have to have it replaced with (I think) hallucis flexus digitorum tendon, which would cause me to lose some control over my big toe - that tendon was also calcified beyond being reparable.  


Alene Gone Bad said...

Steve, I think you summed it up better than anyone could in the final part of the post, there are a lot of things you can do to help yourself, and don't always follow conventional advice. Especially medical advice!! (I say that, as a RN!) Surgery as a last resort, only when all else fails. People don't give their bodies enough chance to work properly on their own, we always want a quick fix. At this point I think surgery is a realistic option for you. Someone who has just recently started having this problem needs to do some body work.

Anonymous said...

I am a runner suffering with this exact thing...only one foot. Was wondering if you have tried DMSO? Also, do you find that the therapies you suggest will make the pain much worse before getting better? I.e....the next day is utter hell.

Truly hope theres an answer without the surgery, but am tempted to consider It. This is exhausting.

SteveQ said...

DMSO has nothing but drawbacks, from weakening the tendon to giving unplanned tattoos (it'll carry the dye from your socks into your skin!) - the self-myofascial release hurts horribly when you do it and for a bit afterward, but I don't think it makes the pain worse the next day and the stretching seems to lessen pain the next day (for me).

Anonymous said...

Thanks for the blog and answer. I ran for 12 years with a slightly enlarged heel..never ever gave me one moment of pain. This all began, i believe, 3 years ago when i decided to switch to a 4mm drop shoe and threw away my orthotics...minimal did me in. I am in Hokas (cushioned and 6mm) now and just ordered presc.orthotics which, along with your suggestions, will be my last line of defense against this POS condition.

Best of luck to you.

Heidi said...

Very interesting to read all your posts. I have struggled with the very same thing for about 7 yrs. now, but I find that using orthotics with a heel lift is worse that the minimalts approach. I have not run in true minimalist , zero drop shoes though. Tried everything from crazy expensive ESWT (x2) to Graston and Dry needling to loosen knots in the calf muscle (ouch) to conventional physio and chiro tx. Had orthotics for quite a few years after the first ESWT tx and ran well and fast for 2 years in Brooks adrenaline, a support shoe. Then started running hills and trails - which is so fun- and the trouble started again. Had the ESWT again (another 750 bucks) and this time it did not do much. Started cycling instead of running and reading whatever I could find about this condition. Ordered the Osmo Patch on line and found that it actually does reduce the bursitis, but as soon as you irritate the area again it swells up again. So not a cure. Used a night brace to keep the calf from contracting. Can't sleep with that. tried apple cider vinegar patches , where in the world did i find that piece of advise? lol. The acid just eats your skin away. It' supposed to dissolve calcium deposits. Came across a website called sockdoc.com and followed his advise to work on trigger points, stopped wearing the orthotics and using nike frees run3.0. Those are not a true minimalist shoe which I id not know at the time. The heel is soft (no hard heel counter). I did cut a slit in the back to make room for the bump.
I am walking barefoot at home al the time and wear Merrell barefoot flats at work. I work in a dental office so thankfully it's not a dressy environment.
Running is about every other day. Pain free. But I still get quite a bit of pain as the day goes on after a run due to stiffness, I believe. I alternate running with cycling, which actually is a great solution for me.The guy from sockdoc also talks a lot about nutrition and bursitis, which is the toughest part to change. But after reading a lot about bursitis and natural cures, I believe there definitely is a correlation between nutrition, calcium metabolism and inflammation. so i am working on that. I have visited 2 different surgeons for opinions and both told me that if I can run 10k pain free than surgery is not an option. And also that the surgery is no garantie. So , having said all that, my conclusion first of all is that running with othotics in the first place with a heel lift contributed greatly to this problem. It shortens the whole back of your legs. So when Ii started running hills, there was absolutely no give in the back, causing huge stress on the achilles insertion point. I also did not eat right, always rushing to get another run in an not compensating properly for energy used. My whole metabolism was not healthy causing all kinds of other issues. Getting my nutrient intake in order is prime. I do work on trigger points a lot and massage my calf and achilles myself/ Keeping things loose is key. Sometimes I am so sick and tired of it, but then to be out of comission for months on end with no garantie of success I just can't do. Maybe after 30 years of this I will ...but then when you are 80somthing, who knows. It would be great to still be running then. lol, How did we get ourselves into this predicament that we can't stop?:)

Hope my experience helps someone.

spermy02 said...

Thanks that is great info...I have had this for 10 years or so after a very long professional Australian football career I assumed it was from tight leather football boots and a lot of hard grounds but my family have it so I guess it is genetic as well. I am into Triathlon now and doing Ironman in May and am having some issues with both heels...they are pretty ugly and give a fair bit of grief. I agree with all of your advice....Deep tissue work and trigger point works wel for me...Also the strength work is very important...I was amazed when my physio did some strength testing on me how weak I was in full flex especially with the knee bent. The Nike Free are good I am currently trying the Hoka...

Mariann said...

Hi Steve, great blog, thanks. I'm a 55-yr old female running addict. Love to race and pretty decent - can still win small races outright. Experienced tightness on outer foot in June 2014 a few days after a hilly 10k race. Have since learned it's the Peroneal Tendons. Also discovered I have Haglunds (who knew?). No running the whole summer, endured 4 wks of PT, 30 days anti-inflamms, and it was mostly gone. Had 2 mos of good Fall running and even a few races. Then it returned. Can't run more than 7 miles or even 2 consec days w/out the tightening. Never had Achilles pain but doc confirmed Bursa swollen. SO: 8 mos and still not back to my normal routine. Went to a new doc and finally got an MRI. Just today the doc reviewed the MRI which showed extensive damage. He recommends surgery to shave the bump and remove the Bursa. I am terrified but will do anything to get my normal running life back. Thoughts?

SteveQ said...

Mariann, you don't need the bursa; apparently I haven't had any for 30 years. "Extensive damage" could mean a lot of things - if there's no calcification of the tendon like I have, they go in, clean it out, shave the bump and you're back in business in a few months. Get a second opinion from a doctor who deals with runners.

Jean-Serge Cardinal said...

Hi mariann, don't let the doctors foul you, I had the same problem as you have, I fixed it with a change of gait.

Anonymous said...

Steve, can you give us another update? I have been struggling with a very similar Haglunds situation and am wondering what has happened with you. Are you still running? I have run exclusively barefoot for the past 5 years (I am in a warmer climate than you) and am now wondering whether some sort of shoe might help. I agree with you about the trouble with heel lifts. I can walk and ride my bike without any real issues but once I switch to running the strain on my heel causes real problems...