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 he 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).

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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.

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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.

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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.

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(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.

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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