The Clinic.

Q Painful Bump on Heel

I'm 49 years old, six feet tall, have been running for about four years, and racing for the last three years. I ran five marathons last year compiling over 2,000 miles, with a personal best of 3:34. Over that period I went from 245 pounds down to 172. About two years ago I started having pain in the lower back of my heel near the bottom of the Achilles tendon after long runs of 12 to 25 miles. Sometimes the pain would get so severe after sitting for a while that I could hardly walk when I first got up. I have always had a small bump on the back of each heel, slightly to the outside. Now, there is a large, sore protuberance on both feet. I'm assuming it is Haglund's Deformity.

I have basically stopped all running since the last marathon about eight months ago--I've run maybe 150 miles during that time. Unfortunately, my weight is creeping back up and my heels hurt all the time, even though I've cut my running back to almost nothing.

Please tell me anything you can about Haglund's and anything I can do to stop the swelling and ease the pain. I have higher than average arches. My shoes show wear along the outside edge. I have started running somewhat toe-heel instead of heel-toe because it feels a little better. What are my prospects for rehabilitation and return to running? I would sure love to get back to running, lose weight again, and get rid of this miserable pain.

Curt Welch

Ocala, FL

A I would agree that you have Haglund's Deformity What appears as an enlarged protuberance of the outer pordon of the back of the heel bone is usually associated with a retrocalcaneal bursitis. This is an inflamed bursal sac located between the Achilles tendon and the bony prominence on the calcaneus. Although often hereditary, it can also result from the accumulative effects of biomechanical imbalances, particularly of a supinated foot structure. This problem can stop a runner in his tracks.

Fortunately, most cases of Haglund's Deformity respond well to conservative treatment. Patients usually benefit from an intensive physical therapy program with a sports-minded physical therapist and stretching of the posterior muscle group (hamstrings, calves, and Achilles complex), ice, and NSAIDs. Selecting shoes with heel counters (the back of the heel portion of the shoe) that do not irritate the protuberance is also helpful. In some cases, orthotic therapy may help.

The judicious use of injecting corticosteroid into the retrocalcaneal bursa, avoiding the Achilles tendon, can be very helpful in controlling pain. If the first injection improved your symptoms, total of three injections over a period of six to eight weeks would be used. Certain risks are associated with this treatment. First, corticosteroids can damage tendons. Extreme care needs to be taken to be sure to inject only into the bursal sac. There is also a risk of losing fat close to the skin if the injection is given too close to the surface. In the heel area this can be a serious complication by thinning the skin where the friction of shoes can cause damage. Finally, the procedure can be painful whether it is successful or not in improving the condition. As a last resort, (in a very small percentage of cases), surgery to remove the bony prominence is necessary

Stuart Weinstein, MD.

Seattle, WA

Q Intense Groin Pain on Runs

I am a 37-year-old female, 5'4" and 115 pounds. I have been running for 17 years and was averaging about 50 miles of road running a week. I was diagnosed recently with osteids pubis of my left leg/groin after experiencing intense pain while running for the last five weeks. I have stopped running completely, because of the pain. This is the first dine in 17 years that I've been unable to run. I am in physical therapy mainly doing strengthening exercises for my legs. Physical therapy has enabled me to do light running on a soft surface for about 20 minutes. Can you give me any advice? I understand that this is a relatively rare injury.

Lisa Shelley

Wilmington, DE

A Osteitis pubis is a painful, inflammatory condition involving the junction or joint between. the front portion of the two halves of the pelvis, also called the pubic symphysis. It most often occurs as a result of cumulative trauma or overuse, rather than a specific injury incident. Unfortunately, it is not unusual for symptoms from this condition to be difficult to control in the face of continued running. Perpetuating factors include shear forces between your right and left pubic bones, impact forces, and muscular imbalances. The continuous back and forth motion of your legs with respect to your pelvis, and the repetitive loading and unloading of your legs during running, produces shear forces at the site of inflammation (midline of the pubic area, or pubic symphysis) which are unavoidable.

Cycling--stationary or outdoor--would have some of the back and forth action, but minimal impact forces, and would be a good way to maintain fitness for now. Your symptoms must be your guide to your level and type of exercise. You should have either minimal or no symptoms, and then advance your regimen--keeping things that way. Running despite pain will only worsen and prolong your condition.

Stretching of the inner thigh muscles and hamstrings, and strengthening the abdominal muscles are important physical therapy techniques because tight hip adductor (inner thigh) muscles and hamstrings, along with weak abdominal muscles are possible underlying causes of osteitis pubis. Other treatments include ultrasound therapy to deeply heat the attached muscles, NSAIDs like ibuprofen, and ice. As a last resort, cortisone injections into the site of injury can be considered. If you have not had a biomechanical evaluation to determine whether conditions such as a leg length discrepancy have contributed to your problem, it would be wise to do so. Sometimes simple adjustments such as a heel lift can make a huge difference. In any case, you need a thorough evaluation by a sports medicine physician.

Brian L. Bowyer, M.D.

Columbus, OH

Q. Running and Fertility

I am a 30-year-old female runner, 5"3", 129 pounds, and have 15% body fat. I've been running for about two years. I am training to run my first marathon and am now running 35 to 40 miles a week I am going to stop taking birth control pills in a few months in order to try to get pregnant. I have been on the pill for the last 13 years without interruption. Do you think I'm at risk for amenorrhea and subsequent infertility due to my body fat percentage, training schedule, and history on the pill? I eat about 2,000 to 2,400 calories a day, which includes 300 to 500 grains of carbohydrates, 70 to 120 grams of protein, and 20 to 45 grams of fat.

I would like to continue with my marathon training and racing when I can, and continue running at reduced mileage even when pregnant. Is it too much stress on my body? I would appreciate some advice.

Kendra Thomas

Rockville, MD

A. Congratulations on your running progress over the past two years. I hope your first marathon goes well. Based upon the information provided, you do not appear to be at risk for the development of chronic amenorrhea once you discontinue birth control pills. However, both elite athletes and long distance runners tend to have fewer ovulatory cycles than those not involved in strenuous physical activity. This means it may take you longer to conceive, but otherwise should have no affect on a pregnancy.

If you do develop amenorrhea off the birth control pill, then you may have to reduce your mileage and increase your calorie intake, in order to allow for ovulation and subsequent conception. With supervision, I see no reason why you should not continue to run during your pregnancy General guidelines include keeping well-hydrated during any activity, keeping your heart rate at 70% maximum or less, and avoiding continuous, prolonged exercise for greater than 45 minutes without a short rest and return of heart rate to normal range.

Michael W. Method, MD., MPH.

Biloxi, MS

Q. Major Sweats with Medication

I recently had a right hemi-thyroidectomy due to a large thyroid nodule. Following surgery I was placed on 100 micrograms of Synthroid with the dose adjusted after blood testing a month later to 88 micrograms. In order to take the medication on an empty stomach, as instructed, I take it before my six-mile morning run. The result has been extreme sweating, which I understand can be a symptom of Synthroid toxicity. Having trained for marathons for the past 20 years, dealing with summer heat and humidity in Florida, I know that what I'm experiencing now is abnormal. I have a fine doctor, but I doubt that he is accustomed to treating marathoners, and I'm worried that I may be doing long-term harm.

Ed Rutkowski

Tequesta, FL

A. Your increased sweating may indicate that you are taking too much thyroid hormone. The dose you are currently taking (88 micrograms) appears to be appropriate; however, I do not know your weight or values of recent thyroid function tests while on this medication. I can only judge by your symptoms.

I suspect that your doctor has you on the thyroid hormone to prevent further nodule formation in the left lobe of your thyroid. If this is the case, then the goal of the thyroid hormone therapy is to give enough thyroid hormone to "suppress" the remaining thyroid, but not so much that you will have symptoms

of hyperthyroidism, which include excessive sweating. Therefore, the goal should be to aim for a serum TSH concentration in the low-normal range. Thyroid Stimulating Hormone, or TSH, is the pituitary hormone that senses the serum thyroid hormone concentration and increases or decreases to control thyroid activity. There should be enough to suppress the thyroid, but not enough to cause symptoms of hyperthyroidism.

It is not absolutely necessary that you take your Synthroid first thing in the morning. It is important not to take it with things that may prevent its absorption, such as iron (sometimes in vitamins), some antacids, and some cholesterol lowering drugs (cholestyramine). You may want to try taking it before dinner if you find that taking it in the morning interferes with your run. If you are taking the correct amount of thyroid hormone, you should not be experiencing excessive sweating during your run.

Have a serum TSH measurement on your current dose of Synthroid. Be sure that measurement of TSH is done six to eight weeks after any adjustment of dosage so that a steady state has been achieved, and results actually reflect hormone levels. If it is below the normal range, you are probably on too much and need to decrease the dose. That should solve your problems and you should be able to resume comfortable running.

Theresa A. Guise, M.D.

San Antonio, TX

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