Attention all you calf-dominant runners: Frieberg’s Infraction

Sounds like some one broke a law or something, doesn’t it? Well, it’s almost like that, but also much like a foot rebelling against itself. Insidious, slowly painful, destructive… AKA: avascular necrosis of the metatarsal head.

Essentially, what happens is that the metatarsal head is destroyed from the top down, either by trauma from some outside source, or repetitively through the joint itself, and it’s slow to heal. Vascular supply in this area is sparse, so healing takes longer. MUCH longer. Longer than any typical runner takes between workouts.

Here’s the interesting part – this condition usually occurs in young women. Most medical literature says that the causes aren’t clear, but from what I’ve seen of my own issues (after I started paying attention due to having it surgically corrected in my left foot and starting to see the same symptoms in my right), I think some of the causes could be linked to high-heel shoes. Not that I’ve been walking around in pumps or anything…

Here’s a picture of me from my last tri in 2007 (the last one I did before the surgery in 2008, photo by Image Arts Photography, September 2007), and you can see that I’m VERY calf-dominant. Pushing off the ball of my foot hard. I did this no matter what shoes I was in. Racing flats, training shoes, whatever. The pain started just at he base of my 2nd toe, but it wasn’t bad, wasn’t constant, and went away by my next run. It took about 4 months, but eventually it wasn’t going away, and then became constant. Funny thing is, it didn’t hurt WHILE I was running. Well, not for quite a while anyway. Once it started to hurt while I ran, I knew it was time to seek medical help.

So I went to see a local podiatrist. He poked, prodded, took x-rays, sent me for MRIs, and put me in a boot to immobilize my foot. After 6 weeks, he took more x-rays, poked and prodded more, with the pain still there… He admitted he had no clue, suggested another podiatrist, and said I should consult with him and come back (yeah, like I was interested in coming back).

Trip to the guy who knows something, and in 5 minutes I have my options, and the only one that has a good long-term outlook is surgery. At least this guy said that it really doesn’t matter if I wear the boot or not – I can’t do any more damage, basically. Here’s what it looked like, and was the “clincher”:

See that notch on the upper side of the metatarsal? That’s the bone getting eaten away by my toe bones. That huge white thing above my foot is an almond taped to the top of my foot so they knew they were in the right area.

Surgery consisted of taking a wedge out of the top of the joint and then rotating the articular surface backwards, and screwing it in place (I have hardware now!). Rehab felt like it took forever. Finally trying to start running again, my ankles were blowing up on me. My 2nd toe now doesn’t sit all the way on the floor…

So anyway, back to the symptoms happening on my right foot – I’d finally gotten to running at a slow pace early this year, built up some distance, did a sprint tri on Memorial Day… I was balancing my training, building up the strength in my ankles, but I also had to moderate my pace so that my right foot didn’t start feeling the same symptoms as my left did before surgery. I went for a couple months thinking that my running days would be numbered, even with just the limited run training I was doing.

I did another tri, an Olympic distance this time, in September, and then went towards a more minimal shoe after that race. But the thing that was different about them was that the heel height was much lower, and the upper was flexible enough to allow my forefoot to spread out. What was the difference to my foot? Less toe flex, meaning my joint was staying straighter. My foot was landing flatter. And I was re-making my stride into something more hip- and hamstring-dominant, instead of calf-dominant. This went even further when I switched to Sacony Kinvaras. Since those changes, I haven’t had any symptoms in my right foot at all (where’s the wood to knock on?).

It comes down to not having the toes flex so much, landing the foot as close to flat as possible, and keeping it that way.

Will I get back down below 6 minute pace again? I don’t know. And really I don’t care. I’m glad to be running again at all. I’ve dropped from 10’s in January to between 7:45-8:15’s in training now. No idea what I’d do in a race now, but my Oly tri I averaged 7:45’s.

That warning at the top? Yeah, I’d just say to the calf-dominant runners out there, maybe you’d want to rethink that stride, especially if you start feeling any pain at the base of your 2nd toe.