Friday, June 1, 2012

Injury Update--Extensor Tendonitis

*Make sure you read my Final Injury Update

I realized that what I've been calling metatarsal tendonitis is incorrect.  It's actually called extensor tendonitis, named after the muscles attached to the tendons, not the bones.  The diagrams below show the basic structure of the muscles, tendons, and bones affected by extensor tendonitis.

*images provided by

To summarize my injury; I experienced pain in the top of my foot between my 1st and 2nd toes, between my 2nd and 3rd toes, and between my 3rd and 4th toes as a result of transitioning to barefoot running too quickly.  This was an inflammation of the extensor hallucis longus tendon and the extensor digitorum longus tendon.  The inflammation was likely caused by the increased strain placed on my calf muscles from barefoot running.  As my calf muscles tightened it made it more difficult for the extensor muscles to raise the toes upward toward the knee.  I saw a podiatrist and had an x-ray to rule out the possibility of a stress fracture in any of the metatarsal bones in my foot.  For anyone experiencing "top of foot pain" I would recommend an x-ray or MRI as a first step rather than self-diagnosing tendonitis over a stress fracture.  Treatment is fairly different.

I've compiled a list of treatments that seem to work well for me.  Keep in mind that some of these may work for you, and they may not.  You'll just have to experiment with them.  Please post any treatment methods that worked for you in the comments section!

  • Ice: I ice the top of my foot 2-3 times per day for about 20 minutes with my foot elevated on a pillow.  This feels amazing, and it keeps the inflamation and swelling down in my foot.
  • Compression:  I wrap my foot with an elastic bandage to provide some added support as my foot expands as it touches the ground with each step.  This also provides a little extra cushion for my forefoot, which also seems to help.
  • Wear Running Shoes:  I've been wearing an old pair of neutral running shoes, in conjunction with the wrap, for walking around in.  The support and cushion seems to really help alleviate the pain.  Another helpful tip is to tie the laces more loosely than usual.  Tying them too tightly will add pressure to the inflamed tendons.
  • Forefoot Padding:  I added two pieces of medical gauze under the sole of my running shoes beneath my forefoot to help cushion the impact.  This actually seems to help a great deal.
  • Stretching:  I've found stretching my calves, ankles, and pretty much anything below my knee to be very helpful.  Here are a couple stretches that I do:
    • While standing, place the tip of your toe on the ground without supporting any of your body weight.  Gently roll your ankle in circles, both clockwise and counterclockwise, while keeping your toe in the same place.  This seems to really help relax the tendons in the top of the foot
    • Classic calf stretches.  I like to place my feet shoulder width apart and do a gentle half squat while relaxing my lower legs.  You may need to support yourself by placing your hands on a wall or piece of furniture.
  • Massage:  I start with extremely gentle pressure on the top of my foot in the areas that hurt.  Gradually I can increase the pressure as my foot begins to loosen up.  The pain on top of my foot decreases dramatically as I massage the area.  It just takes a little time.  After about 10 minutes I can massage my foot with almost as much pressure as I would without any injury.
  • Toe Raises:  While sitting in a chair I lean back to take the majority of weight off my feet.  Begin with your feet flat on the floor and gently raise your toes up off the ground while keeping your heels in place.  You'll feel your extensor muscles (around your shin) contract.  This will help to strengthen the muscles and tendons causing the pain.  This may not be a good idea early on in treatment, but if you can do it without causing any pain it will probably be okay.
  • Running:  I know this one sounds crazy, but about every 2-3 days I go on a very light 1-2 mile jog (I've done two 1-2 mile runs since my appointment).  I run at a pace about 2 minutes per mile slower than my usual pace, and I wrap my foot like I mentioned above.  This actually doesn't cause much pain when I have my foot wrapped, the gauze in place, and, of course, when wearing my running shoes.  I don't recommend this if it causes pain so severe that it alters your running stride (also what my podiatrist said).  I really think that this plays a role in encouraging your body to repair the injured area.  It also seems to loosen up the tendons and muscles in my legs and feet.  Keep in mind that I'm not a doctor and you should ask one if you should run while you're injured.
  • Rest:  Before seeing a podiatrist I took a full week off from running.  I did one 2-mile test run in shoes that really hurt, which prompted me to make the appointment.  I had an additional 4 days off from running before I actually met with the doctor, so I had an almost 2 week rest period with one short, slow run in the middle.  After meeting with the podiatrist and confirming that I didn't have a stress fracture I've tried to stay off my feet a bit more, but I still walk the dog and baby and go about my normal life.  Everything I've read says to rest, rest, REST, but I'm not convinced that laying in bed for 2 more weeks would make much difference in my recovery.  On top of that it's boring!

That about sums up my treatment plan for extensor tendonitis.  I don't know that I could pick any specific treatments that help more than the others.  For me, it seems to be the combination of all of the above that is driving my recovery.  As of now, I only have pain between my 2nd and 3rd toes so I think that I'm well on my way to being able to train for the marathon in October.  My podiatrist did say to expect a 2-4 week recovery time for the tendonitis (Today is 3 days after our meeting).  If there is not significant improvement after 4 weeks, or if at any point it starts to get worse, I should get an MRI to definitively rule out stress fractures.  I hope this helps someone!

Happy Running!