Building Proper Posture

Recently I injured my shoulder by exercising poor judgement at the gym. One thing led to another, and I found myself at the mercy of a physical therapist. On my first visit, she explained that shoulder injuries are always treated by first addressing posture deficiencies. . . regardless of age, she hesitantly added. I reminded her that I had sustained my injury exhibiting super-human strength at the gym, not because I was old. She had no reply.

Proper Posture Devolves Over Time

Athletes suffer from the SAID Principle, or Specific Adaptation to Imposed Demands. Any given sport will produce adaptations specific to the activity performed. If you’re a figure skater, you’d adapt to the specific strength demands required for figure skating. For runners to develop the endurance for long distances, we must train by running long distances. Adaptations occur in the muscles and systems that are stressed by that activity.

With repetitive movement (or non-movement such as prolonged sitting), the muscle and soft tissue remodel to become stronger in the direction of stress. This is good as it relates to our sport, but long term repetition can create muscular imbalances that slowly devolve into poor posture. As posture deteriorates, joint movements become restricted allowing muscles to weaken. The joints then try to compensate causing pain, stiffness and loss of mobility.

A quick review of exercises that improve posture yields a variety of core strengthening exercises. Most athletes rely on a strong core, and we already spend a fair amount of time on the effort. However, good posture is not only derived from a strong core, but also from the neck, shoulders and hips. Although my strengthening exercises were effectively targeting the core, they were not targeting these other areas that are also essential to good posture.

The Crossed Syndrome

Photo: Triathlon-Hacks

A cyclist‘s position on the bike causes tightening of some muscles while the opposing muscles lengthen and become weak resulting in upper crossed and lower crossed syndrome. Both have negative effects on posture and efficiency for cyclists.

Pinterest Photo Origin Unknown

Upper Crossed Syndrome occurs when the back muscles of the neck and shoulders (upper trapezius, and levator scapula) become extremely overactive and strained. The muscles in the front of the chest (the major and minor pectoral is muscles) become shortened and tight. Potential injuries include headaches, biceps tendonitis, rotator cuff impingement and thoracic outlet syndrome.

With Lower Crossed Syndrome the gluteals (gluteus maximus, gluteus medius, gluteus minimus) and abdominal muscles become weak or inhibited, and the hip flexors (rectus femoris and iliopsoas) and lumbar erector spinae become tight. Injuries can include hamstring strains, anterior knee pain and low back pain.

One-sided rotational sports (such as tennis, golf, hockey, baseball…) can also cause this type of muscle imbalance, although all athletes are at risk of injury from muscle imbalances regardless of the cause.

Uncovering Posture-Enhancing Movements

Over these past few months of recovery, I’ve formulated a routine that stretches and strengthens those muscles that cause our posture to devolve over time while also targeting the core muscles that are normally part of a runner’s strengthening regimen. The goal was to create a sequence that was easy to remember, could be completed in about 10 minutes, and wouldn’t require equipment.

There’s dozens of exercises that target the neck, shoulders, core and hips, so it’s easy to add or substitute other exercises to more intensely target one area or another. This basic routine provides a good starting point, however, as to the types of exercises you would want to include in a personalized program.

This program hasn’t completely replaced my regular strengthening program, but it’s been an effective way to build core strength in a way that also helps support proper posture. The 10 movements include:

  1. Standing Half Forward Bend
  2. Camel Pose
  3. Child’s Pose
  4. Classic Plank
  5. Side Plank – Left
  6. Push-Up
  7. Side Plank – Right
  8. SpiderMan Stretch w/T-Spine Rotation
  9. Up Dog
  10. Child’s Pose
Disclaimer: If you are just beginning an exercise program, you’re dealing with a back, neck or shoulder issue, suffer from high or low blood pressure or have other health issues, please consult your physician or a physical therapist before performing this or any other exercise regimen.
Hold each position for 30-60 seconds, for 5-10 breaths, or as long as you can. Perform 1-3 complete sets.


Courtesy: Pinterest

Uttanasana: Sanskrit word combination: ‘ut’ means Intense, ‘tan’ means Stretch, and ‘asana’ refers to Posture.

Primary muscles involved: stretches the hamstrings and low back.

Tips: Keep feet shoulder width apart and parallel. Bend at the hips (not the waist). Beginners should bend the knees if necessary, but don’t worry if you can’t touch the ground. Go as far as you can. Don’t forget to breathe.



This pose stretches your hamstrings and low back, while the hand clasp opens the chest and shoulders. Keep a soft bend in your knees and use a strap or towel to make the pose more accessible. If you can, keep your torso long and your knees even.



Primary muscles involved: Shoulders, Chest, Core, Hip Flexors

Tips: Keep the legs vertical, and push the hips in the forward direction. Bend the head and the spine backward without straining, and don’t allow the shoulders to extend past the feet. Relax the muscles and breathe normally.

Variation: an easier variation of this pose is to position the palms on the lower back while slightly bending the head and spine backward. Relax the muscles and breathe normally.


A relaxation and resting pose that normalizes circulation, and gently stretches the hips, thighs, ankles and spine. Leave the arms stretched out in front, or rest palms beside your feet.



Primary muscles involved: biceps, neck, and shoulders

Secondary muscles involved: arms, biceps, core, thighs and gluteus.

Tips: Keep your torso straight and rigid, the body in a straight line from ears to toes with no sagging or bending. This is the neutral spine position. Ensure your shoulders are down, not creeping up toward your ears. Your heels should be over the balls of your feet.

Variation: TALL PLANK

Courtesy: wikihow


Courtesy: bodybuilding-wizard

Lean on your left elbow and forearm in a side-lying position, with your shoulders and hips parallel to the floor. Raise your hips until your body forms a straight line from your ankles to your shoulders. Brace your core by contracting your abs forcefully as if you were about to be punched in the gut. Place your right hand on the hip. Hold the position without letting your hips drop.

Primary muscles involved: deep abdominal muscles (obliques, transverse abdominis), quadratus lumborum (muscle in the lower back)

Secondary muscles involved: erector spinae, adductors, gluteus medius, gluteus minimus.


Courtesy: bodybuilding-wizard

6. PUSH-UP (perform up to 30 reps, or as many as you can)


The New York Times says, As a symbol of health and wellness, nothing surpasses the simple push-up. The push-up is the ultimate barometer of fitness.

Starting from the tall plank position, keep the pelvis tucked in and the neck neutral with palms directly under the shoulders. Keep the back flat while lowering the body by bending the elbows until the chest barely grazes the floor. Extend the elbows and repeat as many reps as possible.

Primary muscles involved: chest muscles/pectorals, shoulders/deltoids, back of your arms/triceps, abdominals, the “wing” muscles directly under your armpit, called the serratus anterior.

Variations: bend your legs at the knees to make the pushup easier. If necessary, start out doing the exercise against the wall instead of the floor or from the edge of the kitchen counter.

To make the pushup harder, adjust the position of the hands either wider or more narrow, use the fingertips instead of the palms, or place your feet on a high surface such as a bench to increase resistance.

Advanced: The Hundred Pushups Training Program (a 6-week program)


Courtesy: plankexerciseroutine

8. SPIDER-MAN STRETCH W/T-SPINE ROTATION (perform 10 reps each side, or as desired)


According to the renowned strength coach Mike Boyle, the Spider-Man is extraordinary because performing it to one side simultaneously develops mobility in both hips. The movement requires you to tilt your pelvis backward, which prevents your back from arching and forces you to stretch the opposite side’s hip flexors, Boyle says.

Take a long lunge forward. Place fingertips or palms on the ground in line with the front foot. Make sure the knee is on the outside of the arms, not between them. Keep back knee off the ground. Look up and create a neutral spine. Step through and repeat with other leg. After attaining a neutral spine, lift the outside arm towards the sky. Watch your hand as your lift the arm.Attempt to create a straight line between your arms.


Courtesy: yogabycandace

Stretches the chest and abdominal muscles while strengthening the shoulders, triceps, forearms, and low back.

The palms should be aligned under the shoulders, the shoulder blades engaged and pulling the shoulders down and away from the ears, the chest open, and the eyes looking forward.

Only the palms of your hands and the tops of your feet should be touching the floor. Push strongly into both.

Primary muscles involved: Chest, shoulders, abdominals, triceps, forearms, low back

10. End with CHILD POSE

Read More:

Yoga For Runners,

8 Neck and Shoulder Stretches to Relieve Pain: Work and play both stress the neck and shoulders. Here’s how to recover; OutsideOnline

5 exercises to correct lower cross syndrome in cyclists, Canadian Cycling Magazine

The Anatomy of a Runner: Phalanges Maintenance

The Runner’s Pedicure in 3 Easy Steps:

  1. Choose the Proper Equipment
    A large nail clipper works well. Avoid scissors or knives. An emery board is important for filing down thick nails or smoothing rough nail edges, and a pumice will aid in reducing calluses.img_4113
  2. Wet or Dry?
    Trim your toenails when they are dry. Dry toenails are less likely to bend or tear when you cut them. For thicker toenails, cutting is easier after a shower.
  3. Use a Straight Cut

Trim the nail straight across using two cuts – the first cut should be with the clippers slightly off the side of the nail to create the straight edge; the second cut removes the rest of the nail following the line of the straight cut. Smooth the edges with an emery board.

img_4108Don’t cut in a curved pattern or cut too short, as this may lead to ingrown toenails.

A good standard is that you should be able to run your finger across the top edge of your toe and barely feel the toenail. Trim often to maintain this length; approximately every 4-5 weeks in cool weather, and every 2-3 weeks in warmer weather.


Why it hurts.

Black Toenails: A subungual hematoma (bruising) under the nail that is generally caused by trauma resulting in a collection of blood underneath the nail. This collection not only causes the nail to become discolored, it also generates a tremendous amount of pressure, and can cause intense pain.

Black toenails may eventually lead to the loss of the entire nail (it will grow back). If there is pain or a foul smell (indicating an infection), seek medical treatment right away.

Fix it: the easy answer is to keep toenails short. Trauma occurs from the toenail hitting the end of the shoe.

Some suggested remedies include wearing larger shoes. While it is important that your shoes aren’t too short or small, shoes that are too large will cause other problems, such as blisters. Shoes that feature a larger toe box may help alleviate trauma to the nails, but the best place to start is to simply keep nails short.

If there are no underlying conditions, such as an infection, the nail will eventually fall off, a new nail emerges, and the injury heals without intervention.

It is possible to have a black toenail that is relatively painless. However, if pain is persistent, the hematoma can be drained to relieve the pain and pressure. Visit the doctor earlier rather than later to ensure the new nail regrows normally.

Brave runners may choose to drain the hematoma themselves. Jeff Galloway’s website contains step-by-step instructions for this procedure.

Some runners, such as ultra trail runners, may continue to be plagued by painful black toenails even after taking every precaution. Occasionally these runners will have their toenails surgically removed.

Note: black toenails can also be caused by a fungal infection, common in immuno-compromised patients, or they may indicate underlying melanoma (a malignant tumor consisting of dark-pigmented cells called melanocytes). In the case of an underlying infection, there may be pain associated with redness, swelling, foul odor, and discharge.

Thick toenails: nails can thicken with age, because of a fungus, infection, or trauma. Any alteration to the nail plate, nail bed, or root of the nail can result in thickening. This damage may be temporary or permanent, depending on the cause.

Runners may experience thickening of a nail from the repetitive pressure or continual striking of the nail against the shoe (trauma) causing it to separate from the nail bed.

Thickened toenails may or may not be painful, but they are difficult to cut, and they can increase one’s susceptibility to infection.

Fix it: use an emery board or nail file to immediately reduce the thickness of the toenail. This is the first and easiest thing to do. File the thickened nail each time you trim your nails, or as needed.

  • Soak your nails for at least ten minutes in warm, soapy water.
  • Completely dry your toenails.
  • Use the emery board or file to reduce the thickness of the nail.
  • Keep the nail trimmed, starting at one corner and continuing straight across to the other corner. Smaller cuts with the trimmer will prevent splitting or chipping thick nails.

One important note:  do not use cuticle pushers, which disturb the natural barrier that prevents the introduction of potential pathogens.

Prevention: A shoe with a larger toe box may help by giving the toes more room inside the shoe. Consult a physician if you suspect the problem is caused by an infection or other trauma.

Ingrown toenail: occurs when the edge of the nail irritates and eventually breaks the skin. Ingrown toenails are caused by several conditions, including genetics, trauma, infection, repetitive stress (usually in sports that require sudden stops), improper footwear, or improper trimming (too short or not straight across). The most common digit to become ingrown is the big toe, but ingrowth can occur on any nail.

Fix it: consider seeking immediate medical attention, or consult a nail specialist who will understand how to resolve the ingrown nail. In other words, treat yourself to a pedicure, or two.

A mild ingrown nail can be removed with careful clipping, but if it is deep or painful, consider a trip to the podiatrist. An unresolved ingrown toenail can lead to infection.

Prevention: proper cutting leaves the leading edge of the nail free of the flesh, precluding it from growing into the toe.

Never cut a V shape into the middle of your nail. Many people believe this technique is useful for preventing ingrown toenails, although it has been proven ineffective.

Footwear that is too small or too narrow, or a too shallow toe box, will exacerbate any underlying problem with a toenail.

Callus: areas of thickened skin caused by repetitive friction, or by abnormalities of the bony structure of the foot. Usually painless, calluses are a natural protective reaction of the skin over pressure sites.

Fix it: when a callus first develops, file it with an emery board or a pumice stone after bathing, and apply petroleum jelly, lanolin or other moisturizer to soften the area. Repeat this process as often as necessary. If a thicker callus has formed, you could use a peeling and softening agent such as Ultramide 25 lotion.

Runners may not want to totally remove calluses since they provide protection at pressure sites. However, if a callus becomes too big, it can crack, become tender, and it will be painful.

Calluses can also become tender on long runs or races from prolonged exposure to moisture from sweat. Blisters may also form under calluses. Resolve what is causing the callus, and it will go away on its own.

It’s good to regularly moisturize the feet (even for men). Consider products that contain tea tree oil since they are naturally antifungal.

Blisters: are small pockets of fluid under the skin caused by friction that can be a result of shoes that fit too tightly or too loosely. As your feet get wet with sweat the skin softens and leaves you at even greater risk.

Fix it: always leave a blister intact since an open blister can become infected. Cover the blister with an adhesive bandage/moleskin to protect it while it heals.

If it is particularly painful or uncomfortable, it may be necessary to drain the blister:

  • Wash your hands with warm water and antibacterial soap.
  • Using a cotton swab, disinfect a needle with rubbing alcohol.
  • Clean the blister with antiseptic.
  • Take the needle and make a small puncture in the blister.
  • Allow fluid to completely drain from the blister.
  • Apply antibacterial ointment or cream to the blister.
  • Cover the blister with a bandage, moleskin, or gauze.
  • Clean and reapply antibacterial ointment daily. Keep the blister covered until it heals.

You should visit a doctor if fever, nausea, or chills accompany a foot blister. This can be a sign of an infection.

Prevention: the most important step in preventing blisters is to identify the underlying cause.

  • If the blister is caused by friction, check your shoes to see if they are rubbing your foot in that area. Sometimes a seam or another design of the shoe can be the culprit.
  • If moisture seems to be the issue, apply foot powder to reduce sweating, (Dry Goods Athletic Spray Powder or Jack Black Dry Down Friction-Free Powder are two examples).
  • Wear moisture-wicking socks specifically designed for athletes. Socks with individual toes in the sock helps reduce friction between the toes that may cause blisters in some runners.
  • Over-striding can also cause blisters. This stride causes the foot to land in front of the body, absorbing the energy of the stride with a braking force that allows the foot to slide inside the shoe. Keep the stride short enough that the foot lands beneath the body rather than in front.

Bunions: a bunion is an (often unsightly) protuberance at the base of the big toe that forms when the metatarsophalangeal joint (MTP for short) is stressed over a prolonged period of time, causing the first metatarsal to turn outward and the big toe to point inward. (Bunions can also occur on the pinky toe.)

Fix it: the most important first step is to change your shoes.

High heels and pointy-toed shoes should be eliminated since they force the body’s weight forward, forcing the toes into the front of the shoe. Choose running shoes with a wide toe box, and consider shoes that have a lower heel drop (the height difference between the heel and forefoot often measured in millimeters).

Apply ice, use acetaminophen/ibuprofen, or visit your doctor for a cortisone injection for temporary pain relief. Using moleskin, gel-filled pads, or shoe inserts for arch support may also help.


Wear a toe spacer, starting with no more than 30 minutes a day. Two options are Correct Toes and  Yoga Toes.

Try shoes that are wider at the end of the toes than at the ball of the foot and that do not have an elevated heel—what is known as “zero drop.” (This website has more info and specific shoe suggestions.)

Do a bunion massage – a bunion massage stretches the adductor hallucis.

Read this article in Runners World.

Numbness or tingling sensation: numbness in the toes (unrelated to the cold weather) is often caused by shoes that are too tight or from tying your shoelaces too tight, but can also be caused by Morton’s Neuroma. This condition is caused when the tissue inside the foot becomes thicker next to a nerve that leads to a toe. The pressure against the nerve causes irritation and pain, usually between the third and fourth toes.

Morton’s Neuroma symptoms include:

  • tingling in the toes that may get stronger with time;
  • a burning sensation or numbness;
  • feeling like a pebble may be in your shoe, or that the sock is bunched up;
  • there may also be a shooting pain around the ball of the foot, or the base of the toes. 

Fix it: 

Choose shoes with a larger toe box.

Over-the-counter metatarsal pads can relieve the pressure, or your doctor may prescribe orthotics that are custom fit.

Some people find relief with cold therapy, which involves applying extremely cold temperatures to the irritated nerve to kill some of the nerve cells. There are also permanent surgical options, or a doctor may prescribe a corticosteroid shot.

Some runners have had success in resolving Morton’s Neuroma symptoms with a daily supplement of Vitamin B12.

Prevention: wearing high heels or shoes that are too tight can cause the tissues in the forefoot to thicken over time causing the neuroma. Be sure shoes fit correctly and that there’s plenty of room for the toes to move around inside the toe box. Women suffer from Morton’s Neuroma more often than men.

Read More:

Common Running Foot Injuries and Issues; Very Well fit

Thick Toenails (Onychomycosis); Healthline

Ultrarunning Problem, Solved for Good; The New York Times

Blister Prevention;

Don’t Ring The Bell

This was the week that we learned Washington Wizards’ point guard and five-time All-Star John Wall will have season-ending surgery to address bone spurs in his left heel. Wall had secretly suffered through several seasons in pain before consulting with a specialist who recommended surgery. I’ve been following Wall’s condition closely since a bony heel protrusion showed up on my own right foot this past summer.

It’s called Haglund’s deformity. Mine and John Wall’s. A bony englargement on the back of the heel, or essentially a bone spur on the heel. I will only say that if you’ve got one, you’ll feel it every day forever. The last thing the doctor told me was that it would never go away. Given John Wall’s level of play, his doctor warned that the stress from the spur could eventually rupture the Achilles’ tendon. Thus the surgery, and six to eight months’ recovery.

In retrospect, I can see that I floundered a bit during the second half of 2018. Previous injuries could always be resolved with rest. Give it enough time, and whatever ailed me would get better. This time the injury turned out to be permanent, and it changed everything in life as I knew it.

Running has defined nearly half my life. Years before I even acknowledged myself to be a runner, I ran five miles every day. I didn’t take rest days because I didn’t realize you needed rest days. Memories of every place I’ve lived revolve around the running routes associated with that city. Life revolved around running, and I’ve loved every minute.

Once your mind and body have adapted to not working out, however, it’s pretty easy to convince yourself to give up on your previous level of exercise altogether. It has taken me awhile to come up with a plan.

The most common thread among athletes of all rank is injury, but it’s a short list of athletes that make a come-back from catastrophic injury. Peyton Manning had multiple neck surgeries, Serena Williams had pregnancy complications, Kobe Bryant’s shredded knees, and Ben Hogan’s serious car accident. Then there’s Tiger.

A list of Woods’ surgeries prior to his second microdiscectomy operation in Sept. 2015. 
photo courtesy: abcnews.

It’s easy to quit. It takes courage – and a plan – to stay in the game. And if you’re not moving forward, you’re losing ground.

How you plan forward momentum is dictated by your present condition, but your present condition should never prevent you from moving forward.

My husband and I have researched my injury from every direction. I’ve tried every homeopathic solution ever mentioned – he discovered a new one just yesterday that’s already on order. He also bought me a pair of minimalist shoes with the thought that they would help strengthen the muscles and tendons of my foot and ankle over time. So far so good.

I stopped running (again) in November in favor of walking. Since then I’ve focused on a strengthening routine and increased my walks to an hour, six days a week – roughly 4 miles each. By February, I hope to incorporate a few days of running, and plan my next steps from there. Surgery may still be in my future, but we’ll try every other avenue first. It’s a process.

I’m reminded of my first lessons in Kung Fu and Wing Chun. The translation of Kung Fu is time and effort. There are no short cuts. The foundation of Wing Chun is to always move forward and aim for the center.

Naval Admiral William H. McRaven, ninth commander of U.S. Special Operations Command, gave an amazing and powerful 20-minute commencement speech at the University-wide Commencement of The University of Texas at Austin in 2014. The speech was about the lessons McRaven had learned from Navy Seal training, “To me basic SEAL training was a life time of challenges crammed into six months.” A few of the key points from his speech seem to provide a nice conclusion to my thoughts. (Read the full transcript here.)

Don’t Be Afraid of the Circus. Every day during training you were challenged with multiple physical events—long runs, long swims, obstacle courses, hours of calisthenics—something designed to test your mettle. Every event had standards—times you had to meet. If you failed to meet those standards your name was posted on a list and at the end of the day those on the list were invited to—a “circus”. A circus was two hours of additional calisthenics—designed to wear you down, to break your spirit, to force you to quit. No one wanted a circus.

But an interesting thing happened to those who were constantly on the list.  Over time those students-—who did two hours of extra calisthenics—got stronger and stronger. The pain of the circuses built inner strength-built physical resiliency. Life is filled with circuses.

Get Over Being A Sugar Cookie And Keep Moving Forward. Several times a week, the instructors would line up the class and do a uniform inspection.  It was exceptionally thorough. Your hat had to be perfectly starched, your uniform immaculately pressed and your belt buckle shiny and void of any smudges. But it seemed that no matter how much effort you put into starching your hat, or pressing your uniform or polishing your belt buckle—- it just wasn’t good enough. The instructors would find “something” wrong. For failing the uniform inspection, the student had to run, fully clothed into the surf and then, wet from head to toe, roll around on the beach until every part of your body was covered with sand. The effect was known as a “sugar cookie.” You stayed in that uniform the rest of the day—cold, wet and sandy.

There were many a student who just couldn’t accept the fact that all their effort was in vain.  That no matter how hard they tried to get the uniform right—it was unappreciated. Those students didn’t make it through training. Those students didn’t understand the purpose of the drill.  You were never going to succeed.  You were never going to have a perfect uniform. Sometimes no matter how well you prepare or how well you perform you still end up as a sugar cookie. It’s just the way life is sometimes.

If You Want To Change The World Don’t Ever, Ever Ring The Bell. Finally, in SEAL training there is a bell.  A brass bell that hangs in the center of the compound for all the students to see. All you have to do to quit—is ring the bell.  Ring the bell and you no longer have to wake up at 5 o’clock.  Ring the bell and you no longer have to do the freezing cold swims. Ring the bell and you no longer have to do the runs, the obstacle course, the PT—and you no longer have to endure the hardships of training. Just ring the bell. If you want to change the world don’t ever, ever ring the bell.

The Pump Bump and Achilles Tendinitis

She was the goddess of water in Greek mythology. Both Zeus and Poseidon loved her and did their best to win her hand in marriage until Prometheus warned them of a prophecy that her son would become greater than his father. She married a mortal king instead, and dropped their son into the river Styx to make him immortal – holding him by the heel of his foot.

I had exercised patience regarding the time required to recover from a dislodged peroneal tendon, but when the swelling subsided and I could no longer move the tendon around with my finger there was still a hard bump on the back of my heel. Even relatively easy exercise made it sore. It was time to visit the doctor.

My husband and I sat quietly while the doctor examined my heel. As he left to order the x-ray he mumbled something about a pump-bump. My husband immediately took to his phone and by the time the good doctor returned we had discovered everything there was to know about Haglund’s Heel.

Dr. Haglund was a friend of Dr. Roentgen, the inventor of the x-ray. Haglund began researching the boney anatomy of humans for his dear friend, and came up with a fairly common deviation of the heel bone, which became known as Haglund’s Heel (also Hagulund’s Syndrome or Deformity).


This deviation is associated with decreased range of motion of the ankle and increasing age, typically hitting women in their 40s, 50s, and 60s after years of wearing high heel shoes. Jumping, running and navigating stairs can exacerbate the condition making inflammation and heel pain worse. It develops gradually, but we usually take notice when the tendon becomes inflamed. In many cases, especially with runners, Haglund’s Heel evolves into Achilles tendinitis.

Insertional Achilles Tendinitis is a common overuse injury among athletes causing stiffness in the heel especially in the morning, pain along the tendon that increases with activity and possibly swelling. A bone spur gradually develops around the tendon that can cause irritation (bone tends to generate new bone in an attempt to heal itself), and eventually the tendon may calcify and harden.

7A184A2D-7D55-4E29-9737-E6D2D4A2A7B6Note: Insertional Achilles tendinitis affects the back of the heel where the Achilles tendon inserts into the heel bone. Non-insertional Achilles Tendinitis causes pain in the lower calf, where the Achilles tendon and calf muscle meet.


Male and female athletes alike can develop insertional Achilles tendinitis with or without the underlying Haglund’s Heel, but in many cases Haglund’s Heel will trigger or evolve into insertional Achilles tendinitis.

Why it hurts: When a healthy tendon experiences an increased load, it responds by increasing its stiffness to handle the greater demand as it also increases the production of collagen cells. Researchers propose that this non-inflammatory cell response is an attempt by the tendon to increase the cross-sectional area to better handle the load. This short-term adaptation is reversible if the load is diminished or the tendon has a chance to rest before the next stress is applied. Over time a healthy tendon adapts to the stress by growing larger and stronger. An overused or diseased tendon does not recover from the stress and the injury progressively worsens.

The Progression:

Tendinitis is inflammation of the tendon (the suffix “itis” indicates inflammation), in this case of the Achilles. The condition lasts about six weeks although most practitioners view tendinitis as the first in a continuum of tendon injuries that subsequently increase in severity (you’ll also see it spelled tendonitis). If you feel pain in your heel, this is the time to take action.

Tendinosis is a non-inflammatory degeneration of a tendon that can include changes to its structure or composition. These changes often result from repetitive micro-traumas or failure of the tissue to heal and will likely require several months of treatment.

The suffix “pathy” is derived from Greek and indicates a disease or disorder. Tendinopathy is the term also applied to a chronic condition that fails to heal. For example, a runner who has suffered a hamstring tendon rupture that does not heal properly may be diagnosed with tendinopathy.

Insertional Achilles Tendinopathy is inflammation, and later, degeneration of the tendon fibers that insert on the back of the heel bone. Since the Achilles tendon connects the calf’s gastrocnemius and soleus muscles to the calcaneus, or heel bone, by the time you’ve reached the Achilles tendinopathy stage you will likely also notice reduced strength in the calf muscles.

Treatment: The Achilles’ tendon is exposed to greater amounts of strain in the dorsiflexed or upward position where the forward section of the tendon is exposed to low loads. Researchers suggest the lack of stress on this forward aspect of the tendon may cause that section to weaken and eventually fail. The treatment goal of insertional Achilles tendinitis is to strengthen the forward-most aspect of the tendon, which is accomplished through a series of eccentric exercises.

The Alfredson Protocol: The story goes that Hakan Alfredson, an orthopedic surgeon and professor of sports medicine in Sweden, developed Achilles tendon problems in the mid-1990s. When his boss refused his request for surgery because the injury was not yet advanced enough, Dr. Alfredson attempted to deliberately aggravate the injury with a series of exercises. Instead of getting worse, however, his injury disappeared.

These exercises, now known as the “Alfredson protocol” are considered the most effective first line of treatment for Achilles tendinopathy. The eccentric movements are designed to physically stimulate the cells in the tendon as they move relative to each other, causing the cells to initiate a tissue repair process.


Stand on your toes at the edge of a step (holding onto something for balance). Slowly lower the injured foot until the heel drops below the edge of the step. Return to the starting position (on your toes) by using the non-injured foot. The injured foot should never be used to raise onto your toes.

Perform 2 sets of 20 reps with the knee straight, which strengthens the gastrocnemius muscle, and another 2 sets of 20 with the knee bent to strengthen the soleus muscle. Repeat the exercises twice daily for 12 weeks. If the effort become too easy, add weight to increase the load.


(The original protocol called for 3 sets of 15 reps with the knee straight and another 3 sets with the knee bent for a total of 180 reps daily.)

Note: as with everything science, there is a corresponding study that found no difference when performing the heel drop using a straight knee only, and performing the exercise from both the straight and bent knee position.

Compression tack and flossing along with lacrosse ball massage to treat chronic Achilles tendinopathy

Another study published last year involves a 3-prong approach combining the eccentric exercises mentioned above with compression band therapy, or CBT, and Lacrosse Ball Management (basically massaging the tendon using a lacrosse ball).

LBM: Once daily apply firm but comfortable pressure with the lacrosse ball while rotating the ball over the tendon.

The CBT process: Firmly wrap a floss tape around the Achilles tendon as well as the gastrocnemius and soleus muscles starting at the heel (using a 75-90% stretch) and finishing just below the knee. (In the referenced study, a black Theraband© was used.) Perform a ‘flossing motion by slightly shifting weight forward and backwards over the back foot and ankle in a standard soleus stretch position. Perform 3 sets of 10 reps daily.


I’ve followed the exercise and massage protocol for 4 weeks (although I will admit that I have performed the flossing motion without the band). After not running one step for several months (because it hurt), I ran three times last week with no pain during or after the run. My results have been similar to the results achieved by the test subject at this same interval in the study. At the study’s nine month follow-up, the test subject was exercising up to nine hours each week with no pain. It would be premature for me to claim victory over this injury, but I am cautiously optimistic.

Read more:

Athlete’s Edge: Achilles Tendinopathy

For The Love Of Running

There would be no fartlek through the woods. No peaceful run down the mountain, and definitely none of those mind-numbing sprints around the track. In fact, there may be no substantive running at all this year. It’s shocking to the core.

If you’ve ever talked at length to a runner, chances are the discussion evolved into the topic of injuries. There’s not a single memory of an injury from the nearly 20 years of competitive tennis in my earlier years, but I can’t even put a number to all the running injuries.

You’d think it would be discouraging, but it’s not. The goal is to avoid injury, somewhat like the goal is to avoid misjudging your arrival at the airport and never miss a flight. It still happens sometimes.

This latest injury happened within the first two steps of a run when I heard a loud pop. It’s curious that I heard the pop despite music blasting into my ears, which I’ve later realized is because the pop came from inside my body. The peroneal tendon of my right foot had moved out of its groove. If it moved all the way across the ankle bone and snapped back, it‘s called Peroneal Tendon Subluxation. Treatment seems to be the same nonetheless. REST.

One authority on the subject claims this injury is one of the few running injuries that’s not a consequence of overuse. They correctly observe that some athletes experience this ailment even when we’ve followed all the proper training rules. The alternative label appears to be “repetitive use with biomechanical dysfunction” because those of us with high arches that also run excessively are more prone than others to succumb to its ill fate.

Initially it hurt to do everything. The back of my heel was swollen, the tendon was tender to the touch, and would move around slightly. It was during these early weeks that it hurt to walk, run, or even ride my bike. Some weeks I did nothing at all. It was depressing, frustrating, and every other aggravating ‘-ing’ word imaginable.

My husband told me one day that I needed to get out there and do something to exhaustion. We found a new bike route and I went for a long ride. There were the steepest hills I’ve ever climbed, nail-biting descents, and the hairiest of all hair-pin turns. I used every gear in my arsenal that day. It was exhausting.

I’ve learned something. I love running so much.

I love the long runs, and the total exhaustion that comes from a grueling race. I simply adore the daily routine of charging up my watch and following a training plan. I miss all those things that runners learn to endure over years of practice.

The advice I’d want to give to every new runner is to stick with it. It gets better. It doesn’t always hurt. Focus on training your mind, and some day you’ll be pleasantly surprised that you’ve actually enjoyed yourself.

Exactly the conversation I’ve finally had with myself about doing every other exercise besides running.


For more information about a peroneal tendon injury or the dreaded subluxation, click on one of the articles below.



The Runner’s Do-Absolutely-Nothing Approach To Rest

The headline promises that if we know this one thing, we will never, ever stop training. We’ve worked hard to become the super heroes we are today. We can run for hours, outpace a cheetah, or lift a VW Bug. Why on earth would we risk losing this for a few measly rest days we won’t enjoy anyway?

Exercising at least 30 minutes per day, five days a week for just over a week increases our plasma and blood volume. A few weeks later our heart rate no longer spikes, and we get better at dissipating heat through sweat. We feel more comfortable.

Then our heart gets better at pumping blood, capillaries increase so that more oxygen and nutrients reach the muscles, and now we can exercise even longer.

Keep going and we gain muscle mass, strength, and cardiovascular efficiency; after six months of endurance training, it’s possible to increase blood volume by as much as 27 percent.

Take just three days off and you lose that blood volume increase, and now your heart rate increases during exercise. Within two weeks, the amount of oxygen we can process drops by about a half percent each day. The brain’s ability to recruit muscle drops by one to five percent.

Three weeks off and the muscles begin to atrophy. The body increases its reliance on carbs rather than fat for fuel while simultaneously increasing its capacity to store fat. In other words, the body you had trained so efficiently to burn fat during those long runs can no longer burn fat – just as it also becomes easier to get fat. Excellent.

But even super heroes need rest.

Hans Selye first discovered how the body reacts to stress, including a set of responses he called the “general adaption syndrome,” and a pathological state from ongoing, unrelieved stress. Sports training theorists eventually used his ideas to explain why adequate recovery is an essential part of the athlete’s training program.

The General Adaptation Syndrome has three phases: Alarm, Resistance, and Exhaustion.

During a stressful training event, your body alarms you with a sudden jolt of hormonal changes which immediately equip you with sufficient energy to handle the stress. If the stress continues (exercise does not end) or recurs for a period of time, the body resists by making adjustments in its structures or enzyme levels to give it added protection against this specific type of stress. At this point rest must occur for repair/recovery and rebuilding to begin. Rest restores balance.

Problems begin to manifest when you find yourself repeating this process too often with little or no recovery – not enough rest days, time between speed sessions, or even recovery time between races. Ultimately this moves us into the final stage.

EXHAUSTION STAGE: At this phase, the stress has continued for some time. Your body’s ability to resist is lost because its adaptation energy supply is gone. Often referred to as overload, burnout, adrenal fatigue, maladaptation or dysfunction. Stress levels go up and stay up resulting in injury and/or illness.

The problem is that we don’t always completely recover between workouts. Some of the fatigue stays with us, accumulating slowly over time. A 2005 study of Olympic swimmers found fatigue markers still present in the rested athletes six months after their season ended.

In sport science, fatigue is the term used to describe the inhibition of maximal performance that comes about as a result of stressors imposed on the athlete. Although acute fatigue lets us know we’ve trained hard, cumulative fatigue is problematic.

It is generally believed the primary cause of training-induced fatigue is the total volume of a training program, and not nearly as much its intensity. This is likely because volume represents the amount of physical work being done, and thus energy expended and damage sustained by the body.

At the time of this writing, I’ve been working through an injury for several weeks. I had done everything by the book: a slow build-up in mileage, low intensity, adequate rest days, and I still got injured. I think cumulative, unresolved fatigue was the culprit.

For more than a decade, I’ve included a few days off from running here or there, but any extended time off was always spent cross-training to avoid losing fitness. That way I could easily transition back into marathon training. I had wanted to take time off at the end of last year, but maintained a minimum effort instead so I wouldn’t lose time in reaching this year’s goal. Executing years of back-to-back training plans (without complete rest breaks) takes a toll.

Dr. Tim Noakes wrote in his book, Lore of Running, “The body only has a finite capacity to adapt to the demands of intensive training and competition. Runners must choose, early in their careers, whether to spread that capacity over a long career, as did Bruce Fordyce and Ironman triathlete Mark Allen, or to use it up in a spectacular but short career, as did Buddy Edelen, Ron Hill, Alberto Salazar, and Steve Jones. This is the reality that both elite and non elite athletes must confront every day that they run.”

I’ve taken a fresh look at the value of the do-absolutely-nothing type of rest. If the point of rest is to restore homeostasis – a stable condition of equilibrium or stability – how is this accomplished if we rest from our primary sport only to spend that time cross-training hard in another sport.

Professional athletes take time off; sometimes a week or two of no exercise followed by a week or two of cross training. This provides the time needed for the body to completely heal without so much time off that detraining begins.

That article that claimed we’d never, ever stop training? The great takeaway was: you should never, ever stop training. . . for more than two weeks, if you can help it. My takeaway is that we should do what’s right for us – whether that’s two weeks or two months depends on your level of fatigue.

Read more: General Adaptation Syndrome: the Athlete’s Response to Stress

A-Kills-Me Tendon and a Peroneal Mess

The best laid plans often go awry, and I still don’t understand why it needs to be that way. My husband always advised that we should prepare a good plan, and work the plan. If you have a good plan and stick with it, according to his playbook, success is inevitable. My training plans could surely challenge that theory, or perhaps I’ve yet to establish a good plan?

Twenty-eighteen appeared to be the first year we would not be remodeling a house, and I was going to put the extra stress-free time to good use. I spent several weeks researching the most effective way to design a full-year training program, and documented my plan on this blog. Enter the awry part.

It was late February when I noticed my calves were tight. I even mentioned it to my husband. But life gets busy. We forget to stretch. Muscles get tighter, and they take other major body parts down with them.

My Achilles’ tendon got all out of sorts, and finally I started stretching. Except this irritable tendon became inflamed by the sudden attention and swole in disgust.

Not one to give in to a rant from Achilles, I ran through the pain until it settled down and left me alone. It’s a known fact we will almost always lose a battle with overuse injuries. ”Overuse” is not the true source of our ailments anyway. Training error accounts for most of our problems, which makes the question from the first paragraph all the more apt.

Of course, I continued to train through the pain. If I could just survive a minute or two of being uncomfortable, I could run for as long as I wanted pain free.  But the damage was still being done, and it should come as no surprise that eventually things went from bad to worse.

Achilles’ tendon issues will usually diminish when tight calves are resolved. Even if the tendon settles down, it will flare up again if running is resumed when the calf muscles remain tight. The key is to stretch the calves without over-stretching the Achilles.

Courtesy: (includes Achilles’ tendon stretches for recovery)

In my case, the peroneal muscles also became tight. This caused pain in the peroneal tendons that run behind the outer ankle bone. Injury of these tendons include tendonitis, tears and subluxation – the latter of which is not pretty in the least.


Peroneal injuries are caused by injury/trauma to the ankle, such as a sprain, or from overuse of the tendon (training that does not include sufficient periods of rest). Having high arches also puts you at greater risk for peroneal injury, and could lead to developing a degenerative tear.


My full-year training plan has been re-worked. Running has been replaced with long walks, and the strengthening phase began last week instead of next month. I have succumbed to a massage that helped relax the calves and the peroneal muscles – something my husband had suggested in early March. The swelling is slowly subsiding, but the tendons remain tender to the touch. This has clearly been a peroneal mess of my own making.

Follow-up: when the swelling was gone and the peroneal tendon had fully healed, it became obvious there was another underlying issue with my heel: a ‘pump bump.’

The Pump Bump and Achilles Tendinitis