Sunday, July 13, 2014

Ultrarunning and High Hamstring Tendionopathy

Tagwords - Piriformis Syndrome, Sciatic, Osteoarthritis (I put these in here because at one time or another over the years I though I had suffered from some of these other ailments before only recently discovering what I believe is the proper diagnosis.)

(written July 2014)
I really hope that the following information will be of some help to a fellow ultrarunner (or of course any runner or athlete).  There is very little information out there on this diagnosis and it appears to be quite rare and easily misdiagnosed.  The information that is out there is often contradictory and confusing so I will add this blog to that jumbled mix.

First, I should discuss a brief history of running background and my experiences with this ailment to see if it is similar to your experiences.  I'm 43 and have ran for over 15 years.  The last 12 of those I've done ultra marathons.  My mileage has always been quite high.  I usually would average 60-70 miles a week during racing seasons and then often would have 90 to even 120 mile weeks when training for a specific ultra.  I often ran twice a day, especially in the summer.  I'll admit that I was never very good at taking time off and ran throughout the year.  (I think now that this was a mistake and I think that a month off each year going forward will be of great benefit to prevent this injury from recurring after I am healed.)

I usually run about 12 marathons and ultras each year.  More often in the fall and winter when I would race about every three weeks and less often in the heat of the summer.

I've had what I always thought was sciatic pain for over a decade.  I believe now that is was high hamstring tendinopathy all along.  But it would always come and go and I would always run through it and it would always get better.  Up until 2010, I was running great and had tons of great races and ran very consistent times.  Marathons and ultras were fun because I got the feeling that every runner gets that you ran as hard as you could.

About three years ago, I noticed that I would have more bad races, more days with long stretches that the 'sciatic' did not feel right.  I raced the Little Rock Marathon in 2011 intending to have a great time and really struggled. Houston Marathon in 2012, same thing.  When I say struggled, I mean not like the struggle where your pace is 20 or 30 seconds off your goal pace.  I mean struggle where I start fast and over time each mile is slower and slower and I am a minute to 90 seconds off goal pace and pain wants me to drop out.  Boston in 2013, I ran my worst time in a road marathon since my first marathon, shuffling after mile two.  In between there were many ultras and trail runs where I just did not run well and really struggled.

Now of course, I like everyone have had my share of bad races but that was always a different feeling.  Heat or humidity would slow me down or I would go out and then bonk and have a bad patch etc. These more recent bad races were different - my legs would just not go.  I would get a mile or two into the race and it's as though my legs would not fire, would not want to stride.  I could not run with my normal gait.  There would be pain in the butt and it would get worse as the race went on.

At both Little Rock and Houston this happened about mile 5 or 6.  At Boston it happened at mile 2.  I ran the 20 plus additional mileage but it was not pretty.  I struggled and suffered and shuffled my way to the finish line and I would want to drop out of the race really bad.  Shuffled is the key word because I just could not run with the normal gait.

I think this symptom is key to the diagnosis of HHT - you can still run at a daily, slow pace without much if any discomfort but just as soon as you try to increase the effort, the hamstring will not allow a normal gait.

At this point, I began to seek help.  I went to two different chiropractors, I had stretched religiously, done yoga routines, had active release technique done.  Dry needling was done in May of 2012 and that seemed to have the most benefit as I was able to complete Leadville 100 three months later in August of 2012.   Though I  definitely did not do as well as I think I am capable of and was quite a bit slower from two years earlier.  I'm unsure of how much if any benefit the dry needling had.

In addition to the finish at Leadville, I would have enough good races that I would believe that this too would get better because all the other previous aches and pains had always gotten better.  I ran some decent 50ks and trail marathons (though never at the level I was previously at) and my daily runs were comfortable with occasional mild discomfort.  Then about 18 months ago, it really went downhill.  Boston 2013 as I've mentioned was disastrous.  That summer I began to have more pain on my daily runs.  I ran a marathon in early September and did just well enough (3:10 on a hot and hilly course at a medium effort) to think that maybe I would be okay.

It was also around this time in the Fall that I began to notice that my right leg would splay out while running.  My footstrike would have my foot landing to the right.  I thought it was odd and asked my wife and friends about it and they said they noticed it too.  But I could still run at a slow pace on a daily basis with little or no pain and so I tried not worry about it.

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This is approximately the extent to which my foot was splaying out.

 I definitely should have been worried about this because in hindsight, this was definitely a sign that something was seriously wrong from which I would not be able to just "run through it". I also noticed that I  now had a heel strike while running and I had always been a forefoot strike person.  This was also evidenced from the wear on my running shoes.  But these changes in my stride were so subtle and happened slowly that I did not notice it.

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The wear on these shoes shows how much I had begun to run as a heel striker.  During races or speed workouts I would start running back on my forefoot but pain would inevitably lead me back on my heals.  These changes were subtle and at first imperceptible.  I was just running as comfortably as I could.  But as my condition worsened, it became much more noticeable.

Then I went to the Arkansas Traveler 100 mile race in early October.  I was hoping I would have a good day despite all the negatives leading up to it.  The mediocre marathon should have been a warning but instead, it wasn't horrible and so I thought I might be okay.

It was terrible.  Ran okay to mile 20 but was not pushing the pace (it was a 100 so the pace was very conservative).  This is probably why I was able to do the first 20 without much pain.  But then after mile 20, it just started to really hurt.  The pain in the butt came on strong, the shuffling, the inability to stride at a normal gait.  I shuffled to near the 50K mark and dropped.  I was at a point where all I could do was walk.  It was terrible because 50K in a 100 mile race should be the point where you're just getting warmed up.

Then in later in October, I did a 5K.  I had not done speedwork in months because anytime I tried to do 5K pace, the symptoms would come back.  So this was a test.  Maybe under race conditions I could muscle through it.  Maybe I would still be okay.  I was 90 seconds slower than my usual time (in a 5K!) and I suffered.  The first kilometer I hit my normal split  and then the rest was a shuffle.  In hindsight, it has been at least 18 months since I last ran a 5K and it felt good and my time was reflective of my ability.

At that point, I knew I needed to see a doctor.  I believe that was November of 2013 (last year) and after explaining all of the above, the doctor kept telling me what he would try to do for my back pain.  I was convinced that it was Piriformis Sydnrome.  That the Pirformis muscle was compressing the sciatic nerve and thus creating this pain in my butt and the back of my leg.

I now know that HHT (high hamstring tendinopathy) is a similar pain to sciatic/piriformis but is different.  It's more of a dull ache that gets stronger as I would run and really seems to only extend to about the back of the knee.  Sciatic apparently is more of a pulsing sharp pain that extend to the toes.

The doctor then ordered anti-infammatory Meloxicam.  He also said that there really was nothing more that could be done and we might just have to consider "a change in lifestyle".  I was furious when I got home.  "A change in lifestyle!!" - I will remain active the rest of my life.  I want to get better, not change my lifestyle!   In addition, he's always talking about my back and I told him my back feels fine.  There is nothing wrong with my back.  But I went with this advice because I was told and I am sure it is true that the lower back can lead to all sorts of referral pain.

So I struggled some more for several more months and several more bad ultras.  (Though I did run comfortably at my own race - Ouachita Switchbacks 50K - but then again, I never pushed the pace.  But it was good to run almost pain free.  Then a bad race at Sylamore 50K convinced me that I needed to go back to the doctor.

I did.  He was nice.  But he talked about my back.  Ordered an MRI.  Got the MRI done.  Then went back to my appointment with the Doctor and the MRI was basically negative but he thought a lumbar steroidal injection might be of benefit.  If that doesn't work, he said, there is really nothing further we can do.  I was really not connecting with this doctor because I am not ever going to give up on this.  He was not going to do surgery because the MRI was negative and of course I would not want him to.

I also told him that my foot was going outward while running and he just dismissed it stating that I probably always ran like that and just never noticed.  I thought to myself - Hell no, I've never run like that!  Remember the pictures up above.  It was a deformed style of running.  It was nothing like I've ever run!  I always felt like I had a nice stride with a forefoot strike.  This was not a normal stride, this was survival running.  And this is what upset me because I mentioned this to him and it was just dismissed out of hand.

But now I know it is because he was looking in the wrong place.  He refused to believe that it was anything other than my back.  I have found from reading on the internet that many doctors find it unlikely that the piriformis, which is such a small muscle could cause so much trouble.

Nonetheless, we went ahead and scheduled the injection.  But he scheduled a different doctor to perform the injection and as it would turn out, this would be a godsend.

When I went in for the Lumbar injection, Dr. Brian Goodman came for the pre-procedure consultation.  And low and behold, he actually listened to me!  I can't tell you how much I appreciated Dr. Goodman.  He has been wonderful!!  After listening to me, he acknowledged that it could indeed be the Piriformis muscle that is the cause of the problem but he felt that he should go ahead with the lumbar injection.  If it did not benefit me, it would be of benefit as a differential diagnostic tool.   This is pretty standard when trying to identify Piriformis Syndrome.  I really liked that phrase, differential diagnosis, when I read about it.  In other words, we will try this, if it does not work, then it must be something else.  Duh.  But how else could we figure this out.

Needless to say, it did not help my running injury.  So I went back to Dr. Goodman.  We scheduled another injection, this one for the piriformis.  By the way, this all takes a very long time because insurance has to approve the MRI, the first injection, the second injection, etc.  That really makes me angry because it should be my doctor and I that make the decision, not the insurance company.  But that is for another blog.

So Dr. Goodman injected the Piriformis muscle (bilateral - both sides).  This was a very strange procedure.  Not really painful but uncomfortable.  You lay down on a table and there is an x-ray overhead and the doctor is looking for the sciatic nerve so he can locate it and the piriformis.  He is guided by x-ray and when he finds it, you feel the nerve pulse all the way down to your toes.  That's a really strange feeling.  This is as disconcerting as it is painful.  He also numbed the entire back of my legs.

Because my legs were numb, my wife drove me home.  As I got off the table and walked to the car, my legs had the strangest sensation.  They were just numb.  I could not feel the back of my legs.  Like when you go to the dentist and your mouth is still numb so a drink of water spills out of your mouth.  But instead of your mouth, it is your legs.  But the great thing, was that with my legs being numb, I had no pain for the first time in years.  Typically sitting in the car would be uncomfortable and during long drives, it would become excruciating.  I giggled like a little girl not just because of the strange sensation of numb legs but also because I had NO pain.

But of course, the true test would come after the numbness wore off to see if the injection would be successful.  I had high hopes for this Piriformis Injection.  I had read on the internet of some people that had the injection and then wallah - they were healed like Oral Roberts put a hand on them.   So I resumed my running and low and behold I was healed!!  Well, not quite.

I had some pain in the butt but not a lot.  But most importantly, I could stride again.  I no longer had that shuffle.  It had been at least 18 months since I ran like that.  It felt so good to run again with a normal gait and forefoot strike.  I also noticed that my right foot that had been pointing outward, was now back in.  Just like that.  I had tried previously to run with it in but it would never work.  It was strange because it's like the muscles in my legs had adapted to where they were straight and parallel to the other leg only when my right foot was out.  If I brought the toe in, the muscles looked out of align.  Now, the foot strike was back to normal.

But strangely, after the injection, I also noticed that my left foot was pointing in!!  But I was no longer running on my heel.  So at first I thought I should not worry about it.  I have no idea what caused the left foot to come in after the injection but I suspect it may have been because the left high hamstring/piriformis was not nearly as bad as the right and somehow the injection had an overcompensating effect.  I do not know.

The true test was to always go to the track.  I had not done speedwork at the track in nearly a year because it was painful.  Pre-injury I would run a 3 or 4 mile tempo run at a 6 minute pace and it was hard but felt good.  I would do this type of workout about once a week.  Sometimes it would be mile repeats or a 6 mile tempo.  The 6 minute pace would be a 90% percent effort for me.  Definitely pushing the pace hard but feeling I could go faster.  My marathon PR pace is 6:17 so 6 minutes is about right for a tempo run.  For the past year, I struggled just to run a single half mile in 3 minutes (six minute pace).  When I would try to run a six minute mile which normally should be pretty easy, it would just hurt and be impossible.

So my personal track workout would be the ultimate test to find out the effectiveness of the piriformis injection.  I waited five days until I felt the pain from the procedure had worn off and when I felt like I had really very little or no pain in the butt.  I then went to the track and started my workout.  After a two mile warmup, I hit the first half in right at 3:00 minutes.  This is the point when in the past, I would have to stop because of pain but I felt okay.  It was a hot day so the effort felt a little difficult but there was no pain in the butt.  I ran on for the next two laps and it felt like days of old.  It felt good.

The left toe was still pointing in but I ran around the track with a forefoot strike and a full gait!  Awesome.  I was pretty excited though cautiously optimistic.  I ran a rest lap and then thought I will run one more mile just to make sure I was not subconsciously pushing through pain.  The second mile was better than the first and a ran 5:56 at an easier effort than the first.  It was hot and I didn't want to push things and so I stopped the workout and just ran an easy cool down.

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I was so excited that I texted my wife a picture of my watch.  She was anxiously awaiting at home to see if the injection would work.  No doubt she wants this thing to be healed as much as I do if only so she will not have to put up with my misery any longer.  Never before had I been so excited about a sub six minute mile which use to be pretty routine.

But despite this successful track test, I remained only cautiously optimistic.  There remained some remote pain in the butt and we could not be sure if the injection worked until one month later when the steroid wore off.  Dr. Goodman had worried that if it worked at all, the pain may come back after the steroid wore off.

So I ran for another week or so and my pace was strong again, my gait was full, no longer the shuffle that it once was.  But sure enough, things began to go south.  I began struggling more on my daily runs.  I also began to feel more pain in the butt again.  I thought maybe if I straightened that left foot while running, that would solve the problem.  It did not.  And three weeks post injection, things were almost completely back to normal.

Dejected, I went back to the track just before our Disney vacation to Florida and tried the six minute mile test.  I ran one lap in 1:33 and had to abandoned the effort.  I don't think I could have ran a sub 7.  The pain felt even worse than before.

That evening I went back to my friend google and for the first time I came across the condition known as High Hamstring Tendinopathy.  Upon reading the symptoms for HHT I am convinced that this is actually what is causing my suffering.  Not piriformis.  HHT as a diagnosis has only been widely accepted the last 25 years or so.  It is almost exclusively a problem in runners, especially high mileage competitive runners.  Much like tennis elbow for tennis players (which I have as well) though less common.

So why did the piriformis injection have some benefit?  I'm not sure and will have to confirm with my doctor but I suspect that the steroid was able to mask the pain in that general area so that I was able to run at full speed but the damage was still there.

The reason I believe this is the case is because one month post procedure and the pain is worse than before.  I think that is because I aggravated the injury (HHT) unknowningly thinking it was just piriformis.  So I actually did more damage to it.

We left for Disneyworld the next day - a 17 hour drive - not the best for this condition.  Things got worse.  I had signed up for an 8 mile race on July 4th in Montgomery, Alabama and was excited to run that race on the way to Orlando.  That night when we got to Montgomery after 12 hours in the car, the race was out of the question.  That's a pretty big deal for me because for a little 8 mile race, I would always just go and run it.  That's an easy normal morning run for me.  But I was in a lot of discomfort and was very concerned that I had already done quite a bit of damage to the hamstring and should not make it worse.

We had a wonderful time at Disney but I was in constant pain walking around the parks.  Besides the hamstring, I had achilles tendonitis in both ankles and just to top it off, I had bad case of tennis elbow (tendon again!) from playing a lot of tennis and made it worse after playing in a weekend tennis tournament.  Damn you tendons!!!

I did read one report from a fellow runner who also had both HHT and achilles tendonitis and he suspected that they were related.  I'm not sure how that's possible and I think the only relation is that they are both overuse injuries.  But if this is the case with enough runners, it may warrant investigation.

The drive home was just as bad as the drive to Florida and it was just impossible to relieve pressure/stress on the hamstring.

So where does that leave me?  From my research on the internet, it seems as though all the other methods will not work and besides, I have tried nearly all of them.  Massage, massage by rolling on a tennis ball, stretching, yoga, chiropractor, dry needling and the list goes one.  Some people have reported some success with these treatments but either their response was limited or I suspect their condition was far less chronic than mine.  I suspect that those that had the greatest success had addressed the problem early and had taken appropriate rest.  I fear that mine is much worse and only a pelvic MRI can reveal the extent of the damage.

I have not ran since July 2nd and do not intend to run for many months.  The only question is whether my doctor believes that this can heal with complete rest or whether only surgery is going to offer a solution.  Either way, I am out for at least four months, and if I rest and it does not work and then have the surgery, we are looking at a ten month time frame before I can resume running.

It will also be very difficult to retain conditioning because any movement of the hamstring would seem to aggravate this injury and impede the healing process.  But movement of that hamstring is essential to almost all endurance exercise - running, biking, hiking, swimming, elliptical, etc.  I will have to do my best to eat healthy, do some moderate weight training and sit-ups etc to try to retain conditioning and a healthy weight but otherwise, I think it is inevitable that I will lose considerable conditioning.  However, that is okay as I must just accept that.  I believe that once allowed to heal (or once healed with surgery) that I can regain the conditioning rather quickly, keeping in mind that I will have to be very cautious on not re-injuring the high hamstring.

I will finish this race some day.

One final dilemma I face is that it is my dream to run the Hardrock 100.  Hardrock has a lottery but requires a mountain 100 mile as a qualifier race to enter the lottery.  I needed a mountain 100 this year after not gaining entry the past two years and so I entered Run Rabbit Run 100 which is in Colorado in September.  I know what your thinking, why would you enter this race when you are hurting like this.  I signed up back in April during one of my more optimistic moments when I thought I would be able to get through this.

Run Rabbit Run | 50 & 100 Mile Races | Steamboat Springs, CO
Should I attempt this qualifier?  Or just hope to get in to the 2016 Hardrock?

So that race is about 8 weeks away and I admit that I am tempted to stop all training and heal as much as possible in those two months and then just give it a go and see if I can slowly finish under the 30 hour time limit.  I don't have a lot of hope for that being successful.  In May (pre Piriformis injection), I attempted the Jemez Mtn 50 Mile race and had to drop to the 50K and hobbled the last 13 miles to the finish.  If I feel like that, there is no way I can finish a 100 miler.  Only if there was considerable healing would I be able finish Run Rabbit Run and thus secure that qualifier and even then, I would likely be setting myself back quite a bit in the healing process.

But if that were successful, then I could take the rest of the year off and see if it heals.  I think I will know the answer to that once I can review the findings of a pelvic MRI.

So that is where we stand.  I hope this will be of some help or maybe that some of you out there can help me by sharing your experiences and what works for you.  I have yet to find anyone out there was has reported that complete rest for several months effectively healed this condition.  If you are that person, please post here.

I will definitely keep updating this blog with my progress and I have no doubt that one year from now, I will again be posting race reports and this time those report will be on the fun and pain free ultras that I ran in the mountains!

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