Tuesday, 9 March 2021

Shoes, toe and knee

 This post has been pending for six months and two weeks. Without answers, I haven't known quite what to write and how to write it. 

I have not been running - like proper running - for six months and two weeks. I have never had such a long 'time off' in my 28 years of running. 

I can count the number of injuries that I've had in the past - that have limited my running - on one hand:

  • 2000 - lower shin stress fracture caused by old shoes. Took me out for a few weeks. I didn't know what the issue was or what caused it. I rested (took up more mtb instead) and replaced road and trail shoes - problem solved.
  • 2002 - A bad step on a round rock at a race, suspected fracture in a small bone on top of my foot. Two weeks in a cast, six weeks of rehab and stability exercises and months to regain full confidence and proprioception.
  • 2003 - groin 'injury / niggle' caused by brand new shoes worn for a weekend (lots of running and hiking) - same brand and model as I'd been wearing. Caused a sore limp. Multiple physio sessions offered no relief nor solution. They couldn't find anything wrong with me. As I recall, I took a break from running was wearing summer sandals while away for work. One day, I pulled on the shoes, ran across the road to the shops and minutes later I was limping. I never wore those shoes again. I replaced them with the same brand and model and had no issue with the replacement.
  • Odd niggles - as far as I can recall, any niggles that have cropped up have gone in a day or two. Not many of them - fortunately. Very few have prevented me from running for more than a few days.
  • Other incidents - like dropping a table on my foot (badly injured nail bed) have taken me out of action for a few days. 
I read trail runner Nicolette Griffioen's 'The Injured Runner' blog post last night. 

If you'd told me six months ago that I wouldn't be running for six months, I'd have crumbled. But, six months have passed in a blur and I'm fine, well and functional. Of the six month, I actually had four months of no running - only walking. In early January (month 5) I started with light trotting - uphills only. And then a bit more and a bit more. I was feeling reasonable. 

In early Feb (the 9th) I went to see a biokineticist here in George. I wanted to gauge where I was in my recovery process. A few minutes on the treadmill set me back. I spent a few days on Genpayne and ice. The session was too hard and too fast but the video of me running was useful in identifying issues to correct. This week is my fourth week with the bio and I'm doing ok.

So, what is my injury, you ask.

I've had a sore right knee.

On Sunday, 23 August 2020, I woke up to a swollen - not sore - knee. I'd been out on trails the day before. Nothing different to usual. I was alarmed! I did icing and went to see the physio the next morning. She didn't find anything structurally wrong. I stopped all running and took to only walking the dogs. I was on anti-inflams, ice and Transact patches to reduce inflammation. Initially my range of motion was not affected but this changed along the line to become discomfort with reduced mobility.

August into September is a blur. In late Sept I enjoyed a gentle run with my friend. Wasn't right, wasn't wrong either. I stuck to walking. A month or so after seeing the physio I bumped into her at paddling. She asked how I was. "Not right," I replied. My knee was generally sore all the time by this stage and I was still limping. She said I should see our local GP in Parys, who is more than just a regular GP (he is an athlete - running and cycling - himself). The physio's assistant tried to get me an appointment. Nothing available for a few weeks. I left my name on their waiting list. My mom had a hip replacement in August and I was taking her to see her orthopedic surgeon. I figured I may as well see him. 

So, 6 October, I saw him. X-rays showed bursitis 'water on the knee' (I read this in the radiologists report after the appointment) and confirmed both of my knees to be in excellent condition. He moved my hips and knees around. No problem. He didn't offer any solution or explanation. I asked him what I should do as I couldn't run. I literally couldn't run. I left there in exactly the same place I'd arrived there but knew only that there was nothing structurally wrong with my knee. So why was it sore? Why could I not run? 

From above

From the side

From the back

I made an appointment with our local GP and got to see him two weeks later. He removed 5ml of fluid from my knee (instant relief!) and injected cortisone and ozone to treat the tissue and inflamed nerves running over my knee. He confirmed that it was a really good thing that I'd stopped running immediately the morning I woke up with a swollen knee - it was the best thing to limit the chance of any long-term damage. A week later I saw the physio (twice) and biokineticist (twice - assessment and programme). We then packed homes and factory and moved to George.

September and October were madness months. I don't remember too much and I certainly had no capacity to focus on healing. November and December were much the same. Work and daily walkies with Rusty were all I could manage.

Most of the exercises from the bio I could not do because they put too much strain on my knee. I walked with Rusty daily and did some stretches everyday that I found to give me a lot of relief. Some days were good, some days were not as good. Daily walks started at one or two kilometres and progressed to maybe 4km. By mid December I was walking longer (60-90 minutes a day on trails) and harder. Daily stretching still made all the difference. 

In early January I began adding in bits of running - only uphills. I progressed to gently running uphills, flats and easy downhills with walks in between on most days.

Wanting to know where I was, in early February I went to see a local biokineticist who came highly recommended. Her assessment identified imbalances in quad, glute and hammie strength and functionality - and also between left and right. I was aware of most of this - I could feel it. I'd spent a good month of more limping and in the process lost muscle in the right quad and had my left side working too hard, all the time, because I favoured the left to go easy on my right knee. We needed to fix this. 

I've been in the bio programme now for three weeks. I see the bio's assistant (also a bio) twice a week for 30 minutes. Each session she does exercise tests to see how I fare in the activities and keeps a check on my prescribed homework exercises which are there primarily to activate and strengthen quads, glutes and hammies and to achieve the correct balance between these. I can feel the difference but it will probably be another few weeks until I'm running - like real running - again.

By now you may be wondering what caused this injury?

I didn't trip or fall or slip or slide. I didn't bash my knee or land on my knee. Instead, my sore knee has resulted from some kind of referred injury. I have two theories.

The Toe
Maybe in mid to late June last year, I whacked my big right toe into a rock while running. It was a total head-on collision that affected the big joint. I remember hitting my toe, I remember it being really sore but I don't remember it bothering me at all. At the time I was wearing really light, tactile shoes that offered little more than some sole protection from rocks and thorns. No cushioning. I'd like to think that if the toe was a problem, that I would surely remember it?

I do remember the joint being more sore around the time I first saw the physio in late August. The x-ray in October confirmed a narrowing of the joint space - which explained the toe's reduced range of motion - and early signs of arthritis. The orthopod said the arthritis on the x-ray could have been cause by the impact.

Both feet to compare joints

Right - "Degenerative changes in the first metatarsophalangeal joint, narrowing of joint space and widening of metatarsal joint"

This injured joint may very well have seen me changing the way my foot lands, which would have affected knee alignment, muscle function and, over time and with repeated motions, created the knee pain. So while my knee has no structural problems, the supporting tendons, ligaments and nerves were taking strain with inflammation and pain resulting.

The Shoes
I bought new shoes on 28 July 2020. Same brand I've been wearing for years, different model. 4mm drop. Great fit. I felt at home from the first. Wore them for mostly short (4-6km) runs for the three weeks until the morning in August when I woke up to a swollen knee.

I still wore the shoes daily for the next two months - to work, errands and walks. It did not even cross my mind that the shoes could be responsible. 


On the first Sunday morning of October I was doing housework - cleaning and vacuuming floors. I'd woken up with my knee feeling better than usual, the weather was great and my home was good for a clean. I remember pulling on my new running shoes to take Rusty to my mom's house and within minutes I was limping. I took off the shoes and didn't wear them again until mid-November.

I told the ortho, GP, bio and physio about the toe and shoes. They suspected the toe to be the cause. The GP acknowledged the likelihood of the shoes too.

I took to wearing my old road shoes as my old trail shoes were completely trashed. There was little chance that I was going to put on the new shoes. While my knee wasn't right, I made steady progress with my short dog walks and daily stretching. I progressed from limping to no limping and from short walks to longer, more challenging walks. I went from always feeling my knee to sometimes not being aware of it.

And then I took a chance. I decided to wear the shoes. Buying this new pair of shoes had burned a big hole in my small pocket. And there they were just sitting in my cupboard. I needed to know whether it was the shoes.

In mid November I pulled on the shoes for a walk I'd done a few times at a place I walked a few times a week. Nothing new, nothing different to what I was used to. I started to feel sore on the walk and I spent the next two weeks on anti-inflammatories and Transact patches and regular icing. That walk easily put my progress back a good 3-4 weeks! 

I sent an email to the agent - a guy I know. I explained the situation and then sent the shoes back to him by courier. I was (and am) convinced that they have a manufacturing fault. Not something that you can see, but something subtle and structural. Much like my 'injury' experience of 2002 with that brand-new, out-of-the-box pair of shoes. 

He told me that wear pattern was normal, he couldn't see anything and that he wouldn't replace the shoes but that I could by a new pair for half the retail price (his retail price was almost R800 more than what I'd paid in a store!). He recommended another model, which I have had and hated. The thing is, I really liked the model I had bought but I am convinced that this particular pair - not the model - has a flaw. I couriered the shoes back to myself. They're sitting in their box in my cupboard and a team of huskies wouldn't drag me into ever putting them on again.

I continued wearing my old road shoes for another few weeks and in mid-December I bought a pair or Saucony Peregrines -  a model I've had before (two or three editions) and I've enjoyed them. These are serving me well.

Toe and shoes?
Of course, the injured big toe joint and a flaw in the shoes may have been the perfect combination of wrong to cause the knee pain. I must clarify that on a scale of 1-10, I'd peg my sore knee at 1 mostly and occasionally 2 to 3. It has been primarily discomfort more than pain. 

Considering that I've made progress in my rehab and recovery even with a still-affected toe, my money is still on the shoes.

Despite not running for so long, I've been in an OK head space.

The first four months being off running were ridiculous with work, stress and moving. It really is all a blur. I had walking and paddling to get me outdoors. January gave me some light running and lots of walking - plus paddling. February has seen me walking (daily), paddling (once a week) and on the bio programme.

I've lost hard-core cardio fitness, that I only really feel with running. I've missed this. I am living in a trail running mecca. I haven't done any of the peaks. There is also the George Trail Running (GTR) group. I get the messages about social runs and time trials but I haven't done any of them. I have covered most of the lower and mid-elevation trails in the area by walking them on my own with the dogs.

This evening I set off on today's GTR social run route about 30 minutes before the group. I hooked up with them around halfway and learned of a new bundu-bashing trail that I would not have known about otherwise. I saw a few people I knew. As I was with the dogs, I'd planned to take a shortcut on the return, which I did. Rosy would have been up for more distance but not Rusty. Nice to see people but being with the group made me feel, for the first time in these months, that I was missing out and gave me the craving for a really hard run where sweat is running and you feel completely worked over. 

Good things come to those who wait, I tell myself.

I am doing a flatwater kayak race this coming weekend that I am looking forward to. I can push hard on the water with no knee repercussions.

I have had very few injuries of any sort - ever. Multi-discipline participating and cross training have definitely had a hand in injury prevention. 

I've always been quite astounded at how top athletes - like many of our local trail runners - go through serious injury after injury and then get back into the game. Physical and mental fortitude! My injury is not serious by a long stretch. I don't think it would suit me to be injured over and over and over again. I love running but there are other activities to enjoy and to keep on enjoying.

I count myself lucky to have had 28 years of pretty much injury-free running. And I've got great knees. Structurally. 

You may be wondering why I'm not mountain biking considering that there are hundreds of kilometres of riding to be enjoyed here in George? Risk. I can't risk anything happening to me. I single-handedly run two companies that answer to partners and customers. If anything happens to me that puts me out of action, we're in trouble. I can't risk falling off my bicycle. Bicycle injuries can be bad. There is considerably less risk in walking, running and paddling.

My whole injury-and-recovery saga could probably have been sorted out if I'd seen our local GP in the first two weeks of my injury and if I'd had the right biokineticist programme and guidance then. I didn't have the mental or emotional capacity to deal with it back then. I'm only now trying to focus on myself.

In Nicolette Griffioen's blog post she gives great insight into identifying injuries and the injury management process - something that she is going through. It is worth reading.

As far as my knee goes, she nails it.

"It is important to remember that the location of your pain is not necessarily the origin of your pain, even with more localised injuries."

I've probably got another 3-4 weeks of rehab, With six months already gone (WHAT!!!), I'm in no rush. It is worthwhile taking the time now to have running a part of the rest of my life.

Below: Out on the trails this evening

Overcast but with a great view.

Dogs. Long tongues.

My Rusty girl on the railway track.

Dogs leading the way.

Old tunnel built in 1912.

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