THE CLINIC

Surprised By Stroke, Seeking a Way Back to Running

Three months ago, I suddenly developed a stroke, as a result of a spontaneous internal carotid artery dissection (ICAD). It was a mystery how it occurred as I have none of the usual risk factors for an ICAD.

I'm neither diabetic nor hypertensive, I weigh 140 lbs, my lipid profile is almost ideal, and I have not suffered any traumatic event. The stroke affected my vision, speech, and locomotion. I am presently recovering very well, and am feeling much better. I am being treated and monitored by a neurologist, a radiologist, an interventional cardiologist, and a vascular surgeon. I am currently on oral anticoagulation medication (325 mg aspirin daily). Although my speech, vision, and locomotion have returned to normal pre-stroke levels, there is still evidence of a partial blockage in the internal carotid, as well as in a more distal vessel in the brain.
 
Here's my problem: I'm feeling so well that I wish to return to running. My physicians have cleared me to return to normal daily activities, but have cautioned me not to engage in any activity that would appreciably raise my heart rate or elevate my blood pressure. Their concern is that a small piece of the clot could break off, form an embolus, and travel further "downstream," affecting a vital center in my brain, and producing a permanent deficit. Admittedly, none of them has encountered many ICAD patients, and none of those patients that they have seen were engaged in an endurance-training lifestyle.
 
I am desirous of returning to my 44-year running habit, but am also concerned with preserving my neurological status. What would you advise an ICAD patient who is also a daily runner with regard to the safety of returning to running after a stroke?

Sean Chaisson
Groveland, MA
 
That is pretty nebulous advice—not to exercise to get your heart rate or blood pressure up. This leaves you in a quandary about where to draw the line, e.g., is sexual activity beyond the limit?  Furthermore, unless there is unstable plaque, it would serve you well to gradually increase exercise so your brain will respond with endothelial growth factor and stimulate formation of collateral blood vessels. Usually after three months, the clot is considered to be matured and not at risk to embolus, especially if the patient is on aspirin. That would be the advice for someone having a usual stroke. Doctors are often overly conservative in their recommendations, more for their own protection, especially if their practices are not oriented toward athletes.

Do note that even though you are doing well, you have lost some of your neurological brain reserve and will need to gradually reintroduce running to stimulate the production of new neurons and synapses over the course of several months.

I do not have specific experience with an athlete with a carotid dissection that is lucky enough to return to running. However, I spoke to a highly renowned vascular surgeon here in Tacoma who said that he does not believe that any evidence exists that beginning an exercise program to include running three months after a carotid dissection and stroke is going to cause further emboli or further stroke injury. It is also important to keep in mind not to deny a person what is a passion to them, since that is a quality of life issue.

Ask your doctors if they know of any evidence that exertion could worsen your condition. Do also consult a rehabilitation/physical medicine doctor for guidance on steadily reestablishing a running program. The dissection should be healed before rigorous activity is started. But as noted, after three months, that is typically the case and the idea is to engage in a slowly progressive exercise program until more sustained running can be implemented in the months ahead.

Patrick J. Hogan, DO
Tacoma, WA

I am with the Cardiovascular Medicine Division at Massachusetts General Hospital in Boston. It is very difficult to comment without seeing your imaging, as I obviously cannot tell from your description alone if your dissection is fully healed. Usually, the recommendation post ICAD is not to engage in isometric or heavy lifting exercise, or anything causing a rapid increase in blood pressure and thus shear stress on the blood vessel. Light cardio activity in a healed dissection may be okay. I agree with the concern of your treating physicians as it is impossible to predict how the carotid will respond to the demands of say, marathon training. In a very functional patient, a repeat stroke could be devastating.

Alice Perlowski, MD
Boston, MA

Long-Running Toe Pain

Nothing relieves the pain I've had between my third and fourth toes. I've iced, heated, taken over-the-counter analgesics, etc. but the pain continues as it has for a year and a half. What is causing the pain, and what solutions might be available beyond the usual suspects?

Kevin L. Borg
College Park, GA

Though it sounds very much like Morton's neuroma, you may in fact have metatarsalgia, which mimics it. This condition is caused by a metatarsal head which is a little lower than the other four heads and receives more "banging" when running. A true Morton's neuroma is painful with tight shoes and relief is obtained almost immediately by removing the shoe and rubbing the affected area. If your shoes are not tight, think metatarsalgia. If the forefoot is tight, get a wider pair of shoes. A good pair of orthotics may help. A cortisone injection may help. A precise diagnosis will help the most.

George Tsatsos, DPM
Elmhurst, IL

If you have pain between the third and fourth toes, you most likely have a Morton's neuroma. This is swelling or scarring of the nerve. Symptoms can be cramping, burning, and/or feeling like an ice pick is being pushed between the toes. Usually, relief is obtained by removing the shoe and massaging the
area. Other possible diagnoses include metatarsalgia, bursitis, capsulitis, ganglion cyst, or even a stress fracture. After 18 months, this should be looked at by a podiatrist or foot and ankle orthopedist.
 
The neuroma diagnosis is confirmed by pinching the space between the third and fourth toes while squeezing the foot from side to side. If your symptoms are reproduced, that pretty much confirms it. It can be further confirmed by ultrasound or MRI, but MRI is unnecessary in my opinion.
 
Treatment after this long is usually by cortisone injection to reduce the size and scarring of the nerve. If you get some relief from the first, then we may do up to three injections in the same area. We then try to prolong that relief with an orthotic to lessen the pinching of that nerve. However, orthotics do not always work to help neuromas. If the cortisone shot(s) do not help, then I have used 4% dehydrated alcohol injections to chemically kill the nerve. This is a great way to treat this without the disability of surgery. Surgery should be the last resort to treat a painful neuroma.
 
Gene Mirkin, DPM, FACFAS
Kensington, MD

Going Shoeless Should Be Gradual

I have run for 35-plus years and have completed six marathons (the last being New York in 2003). I also do strength training, ride my bike, and kayak but running is my consistent companion. I tend to race shorter distances now (10K to half-marathon).

I have switched to a barefoot style of running for about the last year. I started with Nike Frees and have evolved to primarily using the even less cushioned Vibram FiveFinger Bikila shoes. I even have done some straight barefoot running. I have really enjoyed this style of running because of the lessened impact, the ground feedback, and the ability to make adjustments during a run. Any knee or hip problems of the past have disappeared. But, there is no doubt that being flexed and on the balls of the feet puts more stress on the foot itself. I have developed Achilles tendon/heel pain, particularly after I race (push my pace).

The pain is worse upon awakening and I try to stretch it out and see if it will relax enough for a run. Lately, I have returned to wearing Nike Frees which are a flexible shoe but have some heel lift so the Achilles doesn’t have to stretch quite so much. This has helped a lot but these shoes don’t quite insist that I land on the balls of my feet. I don’t want to lose the minimal/forefoot running style. Do you think that an in-between shoe with only slight heel protection (e.g., New Balance Minimus T20) might be a good compromise by reducing the Achilles stretch while still promoting a balls-of-the-feet running style? Is it that the Bikilas may just be inappropriate for long distances? I haven’t used them for distances greater than 10K, but would like to.

In the meantime, in addition to including the Nike Frees into my rotation, I have been making sure to do a lot of stretching of my Achilles tendons. I even broke out an old rocker style stretching device that I have. My office shoe is a minimal heel boat shoe. I did get a "barefoot" office shoe but the pant cuffs drag on the floor, so I stopped using them instead of getting them tailored.

Would it help to try to wear zero-heel shoes as much as possible to stretch the Achilles tendons? I am always barefoot when walking around the house—should I look into “barefoot” office shoes as well? I just want to continue my 16 to 20 miles per week as pain-free as possible. I’m a 54-year-old male, 6 feet, 220 lbs, and run at 8- to 10-minute pace.

Bill Winskey
Rohnert Park, CA

I commend you on your acquired knowledge and insight on the topic, especially as it applies to your work shoes. The closer you get to functioning barefoot all day, the better. You can even try a stand-up desk too.
 
To adapt into pure barefoot you need to be really progressive and easy. This takes months. I do a lot of barefoot running, almost all of my 50 to 60 miles a week barefoot on pavement. I do not run "hard" or race barefoot. It is all about getting strong, having the feedback, and developing a relaxed stride. It has taken me the good part of a year to feel comfortable to run barefoot for these distances on a variety of surfaces. I was running minimal four years before this, so I had already adapted quite a bit.
 
Run easy and comfortable, and alternate barefoot running with shod running. “Get flat” in your daily activities, and most importantly, listen to what your feet tell you.
 
Mark Cucuzzella, MD, FAAFP
Morgantown, WV

You flared up your Achilles because you pushed beyond the intensity it was ready for. Remember that we were designed to run barefoot, but when you prop up your heel for your entire life, it takes more time than many of us are willing to take to provide the tissues adequate time to adjust.

Our research has shown that running in the Frees still encourages a heel strike. That is because there is enough cushioning in them to make it comfortable to do so. However, they do not offer any heel or arch support—which is a plus. You absolutely should be in minimal shoes or barefoot as much as possible during walking to help condition your feet as long as it does not hurt. Then you need to gradually develop your running with small increments of increased intensity.

There is no reason why you cannot run a half-marathon barefoot or in minimal shoes, if you give yourself enough time to adapt. It is a fine line you walk/run between strengthening the foot and putting too much stress on it. You have to pay close attention to pain and unload the tendon (i.e., with a slightly elevated heel) temporarily until the discomfort calms down.

If symptoms progress rather than reduce, pay close attention to pain onset, location, a progression from a general area to a more focal one. If you develop a stress fracture, which can be diagnosed through MRI, you need to cease running for a while. You should not run through this type of pain and engage in active rest (pain-free, non-impact activities). I have seen many runners heel strike in minimal shoes, leading to heightened impact forces on the heel than in cushioned shoes. I would recommend having someone videotape you from the side while you run on a treadmill to see what type of foot strike pattern you are truly using in these shoes.

Irene Davis, PhD, PT, FACSM
Cambridge, MA

Knee-Healing Strategies for an Ex-Competitor

I am a 47-year-old, 135-lb female marathon runner with a competitive collegiate past (at shorter distances). A year and a half ago I developed lateral knee pain and soon after was diagnosed with patellofemoral syndrome. I was in physical therapy twice a week in the summer, during which the pain persisted but did not worsen. I continued to train for and race a half-marathon that fall. But by the winter, I had reduced mileage to 15 or 20 miles per week, without hard runs. I had an adjustment to my custom orthotics to no avail.

In January I was diagnosed with “atypical” patellofemoral syndrome and sent for an MRI. That revealed a small joint effusion and thin medial plica. My patella is laterally tilted and slightly laterally subluxed, and there is “moderate to marked” thinning and irregularity of the patellar cartilage, most prominently along the lateral facet. There are “broad areas of subchondral bone marrow edema.” The patellar retinacula are intact, as are my cruciate ligaments, quadriceps, and patellar tendons. They found no meniscal tears.

I have had two orthopedic surgical opinions since, and both say I am an ideal candidate for a lateral release of the retinaculum. Self-research on this arthoscopic procedure does not reveal favorable results to a pain-free return to running. I have taken the past six weeks to evaluate things and during that time, the knee pain has grown worse. Stairs are now a problem, and cycling and most exercise machines are painful.

The surgeons are optimistic but runners I have spoken to are not. The research indicates that certain ideal conditions need to be present in the injured knee for this surgery to be effective and not make things worse. Is surgery my only option? What happens if I push myself to run and pass on the surgery. Am I creating more problems?

Kathleen Thornton
Petersburg, VA

There are innumerable names for problems related to the patella. The basic problem is a loss of the normal muscle balance that controls the patella. This goes under multiple names. The most common is patellar malalignment syndrome or patellar maltracking syndrome. It has also been called an excessive lateral pressure syndrome. It is commonly known as "chondromalacia" in the lay press but that is inaccurate. Chondromalacia is a pathological finding of wear and tear of the articular cartilage and is not a specific diagnosis. Something causes chondromalacia. Chondromalacia is not the problem, it is the result of the problem.

The MRI absolutely confirms your diagnosis. You have subluxation and tilt of the patella which has resulted in excessive pressure on the lateral facet of the patella and has caused premature wear of the articular cartilage. Whether this has crossed the magic line to be called osteoarthritis of the patellofemoral joint or not is probably irrelevant. You have pain and a degenerative process. The initial treatment for this is anti-inflammatory medication, ice, and straight leg raising exercises in an attempt to improve the balance of forces on the patella. A cortisone injection or even a series of hyaluronic acid injections would also be reasonable if one felt that this was truly arthritis. A brace can sometimes improve symptoms but is much less predictable. If nonsurgical care fails, then a subcutaneous lateral release is ordinarily the next step.

However, there is significant disagreement among orthopedic surgeons. While the subcutaneous lateral release would be successful in improving the alignment of the patella, it would also have absolutely no effect on the degenerative changes. It is unclear how much the degenerative changes are contributing to your current symptoms.

You could have perfectly normal x-rays after surgery and still have little if any improvement in your pain. Because of the degenerative changes, some orthopedic surgeons would advocate a tibial tubercle elevation, which has the capability of addressing the degenerative changes because it not only realigns the patella to take pressure off the lateral side, it also redistributes the forces proximal and distal to try to relieve some of the pressure on the worn area.

Therefore, while you are a candidate for subcutaneous lateral release, in my opinion, you are definitely not an ideal candidate. To a certain extent, it gets into philosophies. The arthroscopic subcutaneous lateral release is an outpatient procedure with a very low risk of complications when done properly but there is no question that the tibial tubercle elevation would have a greater chance of symptomatic improvement. However, the tibial tubercle elevation is an open procedure, requires several weeks in a cast, has a higher risk of infection, and the recovery time is longer.

In my opinion, running is not dangerous but certainly may be painful. You can rely upon the intensity of your symptoms. However, I am also not sure that any surgery, including the tibial tubercle elevation, would allow you to return to significant running. Under any circumstances, I would definitely avoid hills and StairMasters as much as possible because going up and down stairs and going up and down hills definitely aggravates patellofemoral pain.

G. Klaud Miller, MD
Evanston, IL

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