My post on 4th September was motivated largely by Ewen’s recent question about my plans for running a half marathon this year. My running has been disrupted by several health problems and now these have receded into the background, I am trying to build up training volume. However, I am struggling against the re-emergence of several long standing musculo-skeletal problems. Currently my most troublesome problem is metatarsalgia.
By way of introduction to the topic, I had devoted most of my post on 4th September to the rather tortuous history of Dathan Ritzenhein’s metatarsals. Despite a very bright career as a high school athlete and many subsequent major achievements, including a brief tenure as the 5,000m US record holder, and a bronze medal in the world half-marathon championships in 2009, his potential has frequently been hampered by metatarsal fractures. Most dramatically, metatarsal pain led him to drop out halfway through the 10,000m at the Athens Olympics in 2004.
He is currently a member of the elite team of US distance runners participating in the Nike Oregon project. Under the guidance of his coach Alberto Salazar he has made three major adjustments to deal with his metatarsal problems. First, he moved from the beautiful but austere environment of Boulder Colorado, where the trails are rock-hard, to the soft moist terrain of Portland, Oregon. Secondly, Nike’s head of biomechanics, George Valiant, deigned some shoe inserts which relieve the pressure on the downward protruding head of the third metatarsal of his right foot. Finally, and in my opinion, most controversially, he has, abandoned heel-striking for something approaching a mid-foot landing. I presented my reasons for questioning the wisdom of third of these changes in my post on 4th September. Now it is time to describe the history of my own metatarsals.
The history of my metatarsals
Although by nature a forefoot runner, I have always had problems with my metatarsal heads. Since birth, the second metatarsal head in both my right and left feet has protruded downwards. In childhood , I used to wear out my shoes from the inside. By the time I reached my teens, a few months after I obtained a new pair of shoes, a hole appeared in the insole as a result of abrasion by the callous on the underside of my forefoot. Perhaps surprisingly, my feet scarcely suffered at all. I ran all of my marathons in the same pair of Onitsuka Tigers – the fore runner of today’s minimalist shoes. Although I had to take special precautions to deal with my congenitally peculiar toes, I suffered no pain in the vicinity of the metatarsal heads. I think that in those days my body’s ability to repair itself far outstripped the rate of tissue damage. I simply developed thicker callous. However, that has changed as the fat pads between the metatarsal heads and the callous have disappeared with age, and my capacity for tissue regeneration has waned.
About a decade ago, I went shopping for a new pair of street shoes and was frustrated by the fact that every pair I tried caused pain in my forefoot. I was puzzled as to why I had not had such a problem before. Even the worn old shoes that I had worn into the shop were quite comfortable. At first I failed to draw the obvious conclusion but later when I started to suffer serious metatarsalgia (pain beneath the metatarsal heads) while running, the answer came to me. My old shoes were comfortable because the insole have been hollowed out by the abrasive action of my foot.
I therefore hollowed out the insole of my running shoes, in a similar manner to the way George Valiant created inserts for Ritz eight years later. The pain diminished substantially, though unfortunately did not resolve entirely. Perhaps I lacked George’s engineering skills but I suspect the main problem was that I had developed inflammation of the fascia on the underside of the forefoot. Although the hollowed-out insole shifted the pressure away from the metatarsal head, stress was transferred to a different region of the fascia, which continued to tug on the inflamed area. I think that is why orthotics rarely provide full relief from plantar fasciitis.
However as the inflammation settled, I found that I could run without pain. Nonetheless, as an extra precaution, I avoided running on hard surfaces as much as possible. In addition I embarked on regular exercising of the intrinsic muscles of my feet – mainly variations on toe curling – with the expectation that strengthening these muscles would improve their ability to help distribute the load at foot strike thereby controlling the rise in in the tension in the fascia. Together these precautions proved quite effective. Since taking up running again three years ago, I have had minimal trouble from metatarsalgia.
The price of complacency
Eventually I became a little complacent. I stopped doing the exercises to maintain strength in the intrinsic foot muscles and I became lackadaisical about hollowing out the insole when I obtained new shoes. There were slowly evolving signs that all was not well: since the episode of acute arthritis in the early months of this year, I had been aware of an increase in forefoot pain, but in the setting of the various other aches and pains that afflicted me, it appeared trivial and I ignored it. However, I suffered a rude awakening two weeks ago when I set out for my ill fated tempo run. Because I had been late home from work, I ran along a paved sidewalk rather than risk the uneven riverside path in the dark. I am not sure what was the main culprit: lack of hollowed insole; the hard surface; the alteration of gait due to my knee problems; the effect of lingering systemic inflammation or the accumulation of stress due to my recent return to running. Whatever the cause, the outcome was a sharp pain in the forefoot. The metatarsalgia had returned with a vengeance. The following morning I could scarcely bear to put my foot on the ground. Hollowing-out the insole of my street shoes provided only slight relief. I was amazed at the ferocity of the sudden exacerbation. I wondered whether or not it might be a stress fracture. Focal tenderness of the second metatarsal head added weight to this possible diagnosis, though my experience of similar pain in the past indicated that it would be unwise to jump to a rapid conclusion.
An abrupt drop in high frequency Heart Rate Variability that morning confirmed that I was markedly stressed, no doubt mainly due to the widespread minor musculoskeletal trauma arising from my tempo run, to which the metatarsalgia was only one contributor. As shown in the figure presented in my post of 30 August, HRV remained depressed for two days, but then returned to a healthy level, indicating that my recovery mechanisms had risen to the challenge and dealt with the systemic stress level. The focal pain in my forefoot was also substantially reduced but nonetheless, still quite appreciable. Even with a hollowed-out insole, I could not bear to take my weight on my forefoot while standing. Running was unthinkable.
Becoming a heel-striker
Gradually the pain in my forefoot diminished and by the fourth morning after the tempo run I decided it was time to try to run. However it was clear that landing on my forefoot was out of the question. Circumstances dictated that I should become a heel-striker. To minimise the force at each foot fall, I adopted a quite high cadence and short stride. To my delight, I found this high cadence, heel-striking style was actually less painful than walking. After a few Km, the pain in my forefoot had disappeared entirely, a time course typical of pain due to chronically inflamed connective tissue, which tends to feel better once recently formed local adhesions have been remodelled and local blood flow has increased. This is not the usual time course of pain from a fracture, which tends to increase as the distance run increases. So I was relived to realise that stress fracture was unlikley.
I was feeling very relaxed at a pace between 5:30 and 6 min per Km. There was no sign of the discomfort in my knee that had plagued me in recent weeks. I had intended to run about 6Km. but was feeling so relaxed that I extended this to almost 14 Km. Although I still felt comfortable, I stopped simply because this was several Km further than I had run in the preceding two months, and I feared that accumulating tiredness would increase the risk of further injury. My average pace was 5:45 Km/min and average heart rate 120, confirming the previous evidence that my loss of aerobic fitness has not been severe. Later in the day I suffered the expected aches in knee and forefoot, but on the whole, my body had coped well.
In subsequent days my forefoot has remained tender. When I stand-up from a sitting position pain from the patella-femoral joint and also from the point where the ITB rubs against the lateral femoral condyle confirms that I still have lingering irritation of tissues in these areas, but provided I run with a mild degree of heel-strike and a high cadence, both my forefoot and my knees are comfortable when running.
What the next few weeks will bring remains uncertain, but I have growing optimism that conversion from forefoot striking to slight heel striking, at least during low-aerobic training runs, might be the key to building up to an adequate volume of training. If I can achieve a reasonable volume of running, I would like to run a half-marathon before the end of the year. Currently, I have the Worksop Halloween half marathon pencilled into my diary. However that is less than two months away, and in the intervening period I will be doing some travelling. I am scheduled to deliver talks at conferences in both Germany and China in October. Unfortunately attending conferences does not diminish the load of routine work, so October will be a busy month. Therefore, it is far from clear that I will be able to get my legs adequately conditioned for a half marathon by the end of October, and it would be foolish to race if my legs are seriously ill-prepared.
Whatever happens with my own race preparations, I am of course looking forward eagerly to the outcome of Dathan Ritzhenhiem’s experiment with the transition from heel-striking to mid-foot striking. I hope that on 7th November in New York he at least improves upon his previous best marathon time even if he does not win what promises to be a great race. But even if his experiment has a successful outcome, I am dubious about Alberto Salazar’s belief that there is one ‘best way’ to run. I am increasingly inclined to think that while there are indeed rational principles that govern running mechanics, each individual needs to discover how best to apply those principles to his or her own situation. The heel-strike debate is probably one of the least important issues for most marathon runners, but for Ritz, I think that it is potentially an important issue, and that in abandoning heel-striking he is taking a risk.