OT....question for WendyBG

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It’s feet…again.

Did you/are you finding with this PTTD that your road to recovery was full of apparent setbacks that came out of left field. Much improved now but after quite an extended period of relative comfort, I had a flare up that lasted close to a week. Seemingly unrelated to anything I can think of…even the obvious of “too much, too soon” (unless I’m missing something)

Thinking of it in the context of @intercst and his mention of getting back to running (and the questions … did you run before your surgery/do you need to now) I have a follow up visit with my cardiologist coming up and a topic of conversation has been (me) “I’m still not able to run”…and (him) “you don’t need to run”.

Well, for me and for very specific reasons, I think I do…and I’m now wondering if it’s even on my bingo card for the future :thinking:

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My understanding is that it’s beneficial for amputees to learn how to run (or otherwise move quickly) in case they need to escape a house fire or avoid an oncoming vehicle.

I could run prior to the amputation, and the Robo-Leg is certified for running distances of up to 400 meters. If you’re doing more than that, you need a specially made “running leg”, which Medicare doesn’t cover.

intercst

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@VeeEnn
Going back to 2017 (age 63) I used to do Zumba twice a week, wearing Vibram 5-finger shoes (barefoot style, minimal support) and jumping around like a crazy woman.

When my right instep/ medial ankle began to hurt I thought it was just a minor muscle strain and kept my usual schedule. Over the course of 3 weeks the ankle weakened until I found that I was in real pain. Nothing sudden, but I was limping seriously and couldn’t dance.

It was so painful that I went to the clinic thinking I had a broken ankle. The X-ray showed normal bones. My PCP (nurse practitioner) shrugged her shoulders.

I had been planning a cruise with my breast cancer support group over Facebook. I had to cancel since I could hardly walk, let alone dance. I gave my ticket to one of the members who couldn’t afford to buy one.

The Facebook computer recommended that I join the Posterior Tibial Tendon Disorder (PTTD) group. I was stunned. How did the FB computer know? But as soon as I saw the group’s photo showing the ankle with a red stripe exactly where my pain was, I knew that this was the right place.

I did some research and learned that I had Stage 2 PTTD. I couldn’t lift my heel even 1/4".
The very nice people posted X-rays of their surgeries with 2" screws sunk into their bones. No thank you! I decided to let my body heal itself.
Atrophy is the enemy. I did deep-water aerobics 4 days a week and Zumba with hand weights seated in a chair.

After a year, eating 2 tablespoons of collagen per day, my tendon gradually healed. I didn’t go to physical therapy but I stretched my tendon lengthwise every day using my own two hands.

After couple of years or so, I looked at the PTTD group. One of the women showed Physical Therapy exercises that involved rising to stand on tiptoes. I thought I’d try it in a doorway balancing myself with both hands. I did 10 careful tiptoe raises.

BAM!

My left PTT went out! Then I had to go through the same pain, limping and gradual healing for another 6 months.

That is why I still wear custom orthotics, Ace Deluxe ankle braces and strong-sided shoes. I can’t take the chance of blowing out my weakened PTTs again.

However, I do Zumba twice a week. I carefully avoid high impact and jumps. I also have to monitor my heart with my Fitbit watch. I try to keep my heart rate between 120 - 130 although it sometimes goes over 140. (My cardiologist recommended 109 but that’s for people who haven’t done aerobics for decades like I have.)

My advice to you is: don’t run. It’s high impact. You are risking a tendon tear.

You can get plenty of leg and heart exercise doing Zumba simply by using faster music and light hand weights (1 to 2 pounds to avoid tearing your shoulders).

Deep water aerobics is also good BUT it doesn’t provide the bone-jarring impact needed to prevent osteoporosis. (Witness my younger sister who swims like a fish and has severe osteoporosis.)

Your bingo card says, “Zumba.” No running. Sorry. It’s too risky. Zumba also has the benefit of tuning up your brain and nervous system.

Try these videos. I guarantee you will find them more challenging than running.

Wendy

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Well, I think what rescued me from as severe as problem as yours is that I called my orthopedist’s office as soon as the pain started, thinking it was my lapiplasty taken a turn south. Got an appointment with his PA within a couple of days and the radiographs showed the same well healed surgery but she had me walk across the floor barefoot and the cause stuck out a mile, my feet flattened out and both ankles rolled in seriously. Recommended orthotics and a brace…showed me a couple of examples both of what to try and what not (rigid) and physical therapy. Taking it slow and steady the pain subsided and both feet became stronger. However, the rehab period of a reduction in activity b put my road to recovery into reverse.

I was shocked at just how much muscle mass I lost in my legs after the time off my feet with the surgery. Specifically the fast twitch fibres that go so easily in the Chronologically Enriched (it was a rude awakening to get proof that physiology applies to me)…it’s even more irksome to realise how much hard work is needed to maintain muscle, let alone rebuild. My personal trainer is probably a bit more objective than I and routinely points out that I’m comparing myself too much with the old me and that I probably had enough spare capacity to still be a long way from sarcopenia even with the loss.

Hence, being able to run would be a measure of some semblance of power and reactivity gained. Running is a simple, uncomplicated (for me, usually) and natural method of locomotion. Although it’s high (ish) impact…well, higher than walking… it’s not inherently worse or better than any substitute. I suspect that the bad rap comes from the number of injuries sustained by runners… oftentimes earned by poor training practices. I’ve managed to avoid running related injuries for 5+ decades, so it’s particularly irksome that my tendency to lax tendons that supposedly led to my bunion formation has come back to haunt me.

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Try recovering after open-heart surgery, partially-collapsed lungs, 9 days in the hospital and months of weakness so extreme that I needed a chair in the shower.

Wendy

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Well, you nailed it there. Another reason for wanting to get back to my former level of activity (including the specific activities) is that I’m aiming to prevent the need for such surgery.

Given that my lifestyle choices weren’t adequate to compensate for my genetic predisposition to ASCVD, and given that my severe coronary artery occlusion has remained symptom free, there presumably must be something that has actually triggered a significant collateral circulation build over the years (decades)

This is the incongruity of my conversations with my cardiologist (which are really pretty much tongue in cheek) since he admits that there isn’t a tremendous amount of research into what the ideal exercise might be to effect this (specifically the collateral/micro circulation , not general cardiovascular fitness…although the two might be the same) The obvious thing would be to say “keep doing what you’ve always done”… and then the response would be “what I’ve always done has included running” … and then it becomes a bit circuitous.

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Wendy,

Thanks for discussing PTTD and barefoot shoes. I just switched over to barefoot shoes. I have been doing exercises for my legs for a year. So that is not so bad. Plus I have been in less support for the year. I subranate by nature. In barefoot shoes I stop subranating. This means I am far from pronating. That is the first cause of PTTD in barefoots.

Barefoot (minimalist) shoes do not directly cause Posterior Tibial Tendon Dysfunction (PTTD), but a rapid transition to them is a very common trigger. If your feet are accustomed to the built-in support of traditional shoes, suddenly forcing them to do all the work can overload and inflame the tendon. [1, 2, 3, 4]

Why Barefoot Shoes Can Trigger PTTD

  • Increased Tendon Load: The posterior tibial tendon runs down your inner ankle and is responsible for holding up your foot’s arch. Traditional shoes artificially prop up this arch. When you remove that support, the tendon has to work significantly harder to prevent your foot from excessively rolling inward (pronating).
  • Transition Shock: If your foot and calf muscles are weak from years of wearing supportive footwear, they cannot immediately handle the sudden jump in biomechanical demand. This leads to micro-tears and inflammation. [1, 5, 6, 7]

Safe Transition Strategy

If you are transitioning to barefoot shoes, you can prevent this overuse by taking a few precautions:

  • Start Slow: Wear them for just an hour or two a day, gradually increasing duration over several weeks or months.
  • Build Strength: Actively strengthen your feet and calves. Exercises like single-leg calf raises, ankle inversions with resistance bands, and “foot doming” help prepare the tendon for its new workload.
  • Pause if Pain Occurs: Do not attempt to run or work out in minimalist shoes if you are already experiencing inner ankle pain or active PTTD symptoms. [2]

For more specific guidance, are you currently experiencing arch or ankle pain, or are you just planning a transition to barefoot shoes?

AI responses may include mistakes.

[1] Why transition slowly into barefoot shoes?⁣ ⁣ 🦶🏽 The Posterior Tibialis Muscle wraps around the inside of the foot to lift up the medial longitudinal arch. ⁣ ⁣ 🖐🏽 I used a sticky hand on a string to represent the Posterior Tibialis muscle, because that’s how it really works! It branches out like the little fingers to grip onto the inside and bottom of the foot bones then the long tendon wraps around the medial maleolus of the ankle and up to insert on the back of the tibia and fibula. ⁣ ⁣ 👞 When your foot pronates, the medial arch of the foot moves down toward the ground. This is neither good nor bad, but it does put the posterior tib tendon on stretch. ⁣ ⁣ 🤷🏽‍♂️ If you’ve been pronating your entire life, the posterior tib has adapted. There’s a good chance there is no associated pain.⁣ ⁣ 🤔 If you start running barefoot all of a sudden however, you are likely to place a demand on the post. tib tendon that it hasn’t had time to accommodate to. ⁣ ⁣ ⭐️ This can present as pain, tenderness, and bruising along the post. tib tendon (often near the top of the medial arch or the inside of the lower leg). ⁣ ⁣ 👉🏽 The post. tib is one of the only muscles that is on throughout the entire gait cycle. It is one of the first to take a beating when you make a quick change in footwear. ⁣ ⁣ 👇🏽 So, here’s what to do:⁣ ⁣ 1️⃣ Transition SLOWLY to minimalist shoes. ⁣ ⁣ 2️⃣ Strengthen the Post. Tib with Single leg calf raises, Ankle inversion, Single leg stability exercises, Foot Tenting exercises, etc. ⁣ ⁣ 🧠 Share with someone who thinks they have Plantar Fasciatis | The Movement System, LLC

[2] Reddit - Please wait for verification

[3] https://yourfootclinic.com.au/minimalist-shoes-pros-cons-foot-types/

[4] https://www.michiganfootdoctors.com/best-shoes-for-posterior-tibial-tendonitis/

[5] Barefoot Walking: Is It Healthy or Harmful? | Gotham Footcare

[6] https://michiganpodiatry.com/blog/fat-pad-atrophy-foot/

[7] https://ubiehealth.com/doctors-note/foot-pain-why-foot-anatomy-failing-medical-steps-523e4

[8] https://www.upstep.com/a/blog/barefoot-shoes-plantar-fasciitis

[9] https://sixmillionsteps.eu/en/the-best-shoes-for-a-blister-free-hike/

[10] Foot Fight: A minimalist runner's road to recovery | Tri for Les

[11] Posterior Tibial Tendonitis Exercises: Do’s and Don’ts - Upswing Health

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We must be related. Lp(a) problems. . . . PTTD problems. . . .

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@VeeEnn let’s stop the circle.

  1. You (and I) both need vigorous exercise to stimulate heart rate. You, because of ASCVD and the need for collateral circulation. Me, because I want to maintain fitness now that my aortic valve has been fixed. Both of us have decades of aerobic exercise so raising heart rate requires really vigorous exercise. Heart rate is the cardiologist’s ballpark. He doesn’t do ankles so he can’t credibly advise you on running.

  2. Both of us have PTTD. This is where we have to break the circle of the cardiologists’ conversations. I can tell you from sad experience that high impact will disrupt the PTT in vulnerable people. That’s definitely me since my father had flat feet and my sister’s feet are so flat that her footprint is oval. I tore my first PTT by high-impact Zumba and the second one by doing tiptoe lifts which wouldn’t harm a normal person.

Is it you? If you already have PTTD the answer is probably yes. Therefore, you must avoid high impact exercise. Unless you have a very soft way of running in very well-supported shoes, sadly, that means you must give up running.
Fortunately, there are many forms of exercise which will raise heart rate while still being low impact and ankle-sparing. These include low-impact Zumba (no jumping), deep-water aerobics and HIIT (weight lifting to fast music).

Sorry. We are both old ladies. We have to adjust to avoid injuring ourselves.

Wendy

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To everyone here, if you are falling let your doctor know.

My Dad, a doctor himself, did not know the importance of this.

If you are lucky you get to fall a few times with no repercusions. But you will fall on your head and it probably will kill you. Please let the doctors know if you fall.

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In fairness, @WendyBG , it’s my cardiologist who keeps reminding me that I don’t need to run… knowing, as he does that I have multiple outlets for higher intensity challenges (including, but not limited to my Peloton [bike] in addition to our treadmill at home). Plus, he’s a runner so is also aware of rational training strategies and contraindications to running etc (presumably why he doesn’t listen to my griping)

Interestingly, there isn’t the overwhelming consensus on whether or not running is completely contraindicated with PTTD, that mightseem obvious …although I’m sure an intrepid Googlier will come up with an AI overview and string of unread sources to contradict that statement of fact. As is oftentimes the case, it all depends…

Obviously, absolutely NOT during the acute phase…that pretty much goes without saying for anyone who’s actually experienced this. Even after apparent full recovery (as assessed by an appropriate evaluator) caution is advised and a rational, well structured and individually tailored training program necessary. During the worst of my initial problem, I didn’t even feel like walking, let alone running but, as things eased and I did start to develop muscle strength, I had a hypothetical discussion with my physical therapist and, her opinion was that my acute issues were likely secondary to the lapiplasty, as opposed to an inherent predisposition. Looking at the before and after radiographs, the degree of correction required to fix the problem might well have overtaxed the capacity of the ligaments and tendons (always the slow responders) to adjust. Also, I don’t have flat feet…a natural, passive high arch, in fact. So, in someone younger, it might be totally doable. I’d already told her that, like any good many of my running buddies of the same age, running wasn’t such an imperative for us as, to quote a common runner’s adage…“The older I get, the faster I was” … and the slower times have started to become a frustration. My rationale for being able to run with a biologically sound gait, rather than actually doing it, was that it represented a measurable sign for me that there was enough strength, power, reaction speed returning to provide some insulation against frailty related falls.

What we did start doing just prior to me finishing up my sessions was introduce some plyometric exercises to provide for controlled build back of power production, and to reintroduce some ground force reaction and management…which, by definition cannot be provided easily any other way.

Looking at the pathophysiology and it’s ultimate management is actually an interesting exercise in and of itself (a bit like ASCVD, really) Not so interesting that I’d recommend either to someone looking for such a challenge, mind. I guess it’s necessary to have some skin in the game to be motivated enough to scamper down these rabbit holes, I guess.

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Steep hill walking at a vigorous pace and/or stairmaster?

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Under normal circumstances, I do a fair amount of hill walking (I live on the side of a mountain) but that’s my regular, organic exercise and I have to focus on staying upright, avoiding rattlers this time of year, enjoying the views etc rather than ground force reactions or intensity. Our treadmill, though, has 15% elevation as a choice, so enough to provide for an appropriate cardiovascular challenge…and at a walk. Stairmaster at the gym is another story. It’s torture and even a podcast doesn’t relieve the sheer monotony. I am normally disciplined enough to be able to do what I don’t want if I perceive that it’s beneficial (witness strength training and maintaining a lean bodyweight) but that device I cannot hack…I don’t need that much character building.

In reality, I imagine that I’m “majoring in the minors” here and…under normal circumstances…my exercise routine/training regimen has been/is enough to provide for adequate challenge.

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This is a huge issue for all seniors. I felt it keenly when I got home after my open-heart surgery and literally was so weak I could hardly stand up from a chair by myself.

The key to protecting ourselves from falls is muscle strength and practicing reaction time in unbalanced motions. Speaking from experience, recovering from a trip/ almost fall situation takes lightning reaction for the nervous system to recognize !something’s wrong! and fast muscle strength to instantly pull back into balance, which takes much more force than normal walking. The trip/ fall may be at an unusual angle or during a turn.

I do fitness training with a Native American trainer I have been following for 20 years. She plans every session ahead of time and brings 15 sheets of paper so every session is different and flows smoothly. The motions aren’t simple straight lifts.

An example from Monday was
Squat left with a curl > stand straight > left side leg lift with a shoulder press > stand straight > squat right with a curl > stand straight > right side leg lift with a shoulder press > stand straight > repeat 15 times to fast music.

A different variation is to do the same routine except substituting a diagonal toe touch for the squat but keeping the side leg lift/ shoulder press.

I do this with a 5 pound weight in each hand. This brings my heart rate up to 140 even though the move is low impact.

These moves are fast and inherently unbalanced. They build strength in core and side hip/ leg muscles that would be needed for recovery from a trip.

Shelley charges $5 per class and teaches 5 days a week at 8 AM Pacific time over Zoom. She happens to be on vacation this week but would be delighted to add a student - that’s you - when she returns. That’s the great thing about Zoom. I would be more than happy to share the Zoom code and password if you want to join.

I do Shelley’s class twice a week plus a Zumba class twice a week.

The biomechanist Katy Bowman (founder of “Nutritious Movement” and author of several books on biomechanics) has pointed out that machinery that develops muscles in a single, planar orientation (such as bicycles and stair masters) inherently prevent the body from developing the non-oriented muscles that are so important in preventing a fall coming from an unexpected direction.

As I have mentioned several times, most of the muscle-oriented exercise programs neglect the nervous system. Fall prevention requires nerves that react quickly and decisively from long and regular practice.

This is where Zumba excels as an exercise. It’s the reason I combine strength training with Zumba, which uses fast music to force quick footwork including forward, backward, to the side, crossing feet in front and behind and also doing turns. It’s also a lot of fun. I can’t stand boring exercise without mental challenge and music.

It occurred to me that your bunion surgery might have changed the orientation of your foot bones and caused the PTTD by stressing the tendon.

But whatever the cause, your safety (and mine) depend upon fast reaction to the unexpected. I have a chore today to write a get-well card to an acquaintance who is in rehab after breaking a hip bone in a fall.

Wendy

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Another thing that my surgery did, I think, is almost reproduce symptoms of peripheral neuropathy. Husband put a name to it just recently.

After surgery on each foot, I had a longish spell of parts of the foot being totally numb and the parts that weren’t were really painful. The physical therapists both times confirmed what I thought in that, just like can happen following orthognathic surgery…even just plain third molar surgical extraction…surrounding nerves at the site are unavoidably traumatized. Usually resolves with time (I can’t recall ever having a patient with permanent parasthesia). Now, with both feet, it hasn’t resolved totally and I have the really weird situation of parts of the foot still numb and others hypersensitive. Hard to describe but, for instance, my toes can all feel each other!! It makes a big difference to balance and my trainer is really excellent at spotting when I’m slightly off and alerting me straight away … as muchto enable me to spot the feeling of “off” vs “on”. For instance, I can’t actually feel if I have that big toe, little toe, heel three-point-contact. I wear minimalist shoes for lifting (only time I wear them) and it’s getting easier to discern other foot cues. It’s really strange but, until my kinesthetic awareness on that issue improves, I’m putting any new skill acquisition on hold.

Re Zumba. At my old gym gig down on LI, the group fitness director for the LI branches of NYSC was very keen on all the group ex instructors to be cross-trained in both group ex and personal training…both for our benefit and for customer service in providing subs. Yes, I’ve done Zumba workshops (more to show willingness as a team player and the CE credits than anything) She informed me that I was probably too “white” for Zumba …and to please not jump to provide class coverage unless absolutely necessary. Fair enough.

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I admire your tenacity.