Calf Overload Can Come from the Back

I am a 62-year-old male who has been running for over 40 years, and over the past two years I have been experiencing calf strain, mostly on the left side. I had to cancel a half-marathon last week due to this. I'm running around 20 to 25 miles a week and I also work with a trainer three days a week; I lift weights, do Pilates, and stretch. I wear orthotics, work with a sports doctor who does Active Release, and change my shoes at 200 miles—nothing works. I'm fine for a few months and then out on a simple run, suddenly the calf starts to go. What should I try next?
 
Mauricio Fermange
Carlsbad, CA

I have seen your problem before. I would ask you to consider a couple of different angles given your age and perhaps your running style. I am sure you have been through the usual suggestions for calf cramping and calf strain.

Possibility #1: I agree with the notion that this may be coming from your back. You are 62 years old and in a typical age group to have a back that does not move like it once did. Do you have pain with sitting or transitions from sitting? Do you have calf cramps at night or tingling in your toes at times? These, in addition to your frequent strains, may be the result of nerve compression occurring in your lower back. This may be present even if you have an MRI of your back that does not support this hypothesis.

Often posture that does not support extension of the spine can contribute to functional narrowing of the outlets of nerve roots from the back. These supply the muscles of your legs. If they are not putting out optimal current under high demand, the muscles may be unable to support that demand. The result is recurrent strain.

Try this exercise: lay on your stomach, feet dangling off the edge of a bed or mat. Place your hands in a position as if you were going to do a push-up. Arch your head backward (up), then your upper back, then your mid-back, and finally your lower back. Your arms should be fully extended. Ideally your pelvis would stay flat on the mat or bed, but it may lift some. Try to do most of the work with your arms and let your back passively extend. Exhale at the end of the extension and let your belly sag downward, then return in reverse sequence to the mat. You may be quite stiff at first. Try doing a set of ten of these several times per day. Also, whenever you sit, place a towel roll or pad in the small of your back, especially in the car. Even if this does not solve your calf problem, doing the press-ups two times per day is a great preventive exercise for your back. If it seems to make your back hurt or creates other symptoms, stop doing them and see a specialist to help modify the exercise.

Possibility #2: What pace do you run? If it is slower than 9 minutes per mile or if you tend to develop slumped posture, you may be overloading your calf muscles differently than you think. When you land and load your foot and leg most of the weight bearing should be up in your hip, particularly by the time your foot is flat on the ground. This posture will allow you to load your hip and proceed to hip extension as you toe off and drive forward. This is where your stride length and your power come from. If you tend to sink into your knee when you land on your foot such that you have a bent knee and your hip is sitting back behind your knee, you will not load your hip properly and most of your body weight will remain loaded in your lower leg and calf.

When this occurs over and over again it can cause eccentric fatigue in your calf and result in recurrent strains. The solution is to make sure your gluteal muscles are strong and that they are loaded properly when your foot hits the ground. Simply said, practice running tall, as if there is a string tied to your chest pulling your upward. This assumes your gluteals are strong. If they are not, you will need to strengthen them first.

You also may want to work on the eccentric strength of your calf muscles. Stand on a low step with your heels hanging off the edge, using a handhold to remain steady. Raise up on both toes so your heels rise off the step. Next, lift one foot off the step so you are supported only on one foot. Slowly lower your heel below the edge of the step to a five count. Repeat this in a set of 15 reps once per day for each calf. You may not be able to do 15 right away, so work up to it and keep the repetitions clean and in good form. This is great therapy for your Achilles tendon as well.

John Cianca, MD
Houston, TX

It appears you are doing everything appropriately for prevention and wellness. One of the missing puzzle pieces is diagnostic testing for your spine. Often etiology of lower extremity problems can be found in our lower back or lumbar spine. So, I would recommend an MRI of the lumbar spine. If this test fails to provide reasonable cause then dynamic view x-ray (standing lateral, flexion, and extension) should be ordered to rule-out instability.

Brian Kim, MD
Germantown, MD

Foot Drop: a Gait Abnormality Not to Take Lightly

I am a 46-year-old male, 5' 11" and 170 lbs. I have been running 23 years and run one or two marathons a year for a lifetime total of 26 marathon. The most recent was two months ago. In the last month, I have developed “right foot drop” after running only two miles. As I run, I develop fatigue and soreness in the lower front leg and the have difficulty with pulling the toes toward the front of the leg. I can walk normally minutes after I complete the run.

Since the marathon, I have soreness on the top of the foot around the first two toes and on the side of the ankle. This occurs when I first get out of bed, but it dissipates after walking a few minutes. Are there any conservative stretegies I can try at home prior to seeing a professional for the foot drop?

Sal Demarco
Concord, NH

I would strongly recommend you not try to manage drop foot yourself. Drop foot can be caused by peroneal nerve injury and/or nerve root compression originating in the lumbar level of the back.  It is a condition that needs to be addressed by a physician before permanent nerve damage occurs.  Please see a physician at your earliest
convenience.

Paul Langer, DPM
Minneapolis, MN

You may be developing a foot drop caused by an abnormality in your lower back. The region of your soreness is with the "L5" disk. I would seek out a physiatrist that deals with runners and a physical therapist or chiropractor as needed. Do not run with a foot drop, as you could fall and injure other things.

Amol Saxena, DPM
Palo Alto, CA

Understanding Post-exercise Sugar Spikes

I'm diabetic, 62 years old, 4' 10", and weigh 95 lbs. For three years without medication I’ve been able to consistently keep my morning blood sugar readings below 110. I've noticed after high-intensity tennis or running, though, that my blood sugar count is often in the 200 range. An hour or so later, the level is back down to around 120.

My tennis games are very competitive, and I play four or five times a week. Am I harming my body? In addition to tennis, I try to speedwalk or jog 20 miles a week, and I've noticed my blood sugar level does not spike on days when I just speedwalk. By comparison, my last run was a 5K at 9:15 mile pace, and my blood sugar level was 240 ten minutes after the race. My diet consists mainly of vegetables, oil and protein.

Mary Testa
Trumbull, CT

Exercise typically lowers blood sugar level in type 2 diabetics during the event and for one to two days following, which is one reason why exercise is recommended for diabetics. Therefore, I suspect you are not as well controlled as you think you are. Check your glycohemoglobin with your doctor. This is a measure of long-term blood glucose control. It is reflective of the last three months of blood sugar levels, and more meaningful than individual blood sugars. I think you may need some type of once-a-day medicine that will make you more sensitive to the insulin your body makes. Another consideration is how much glucose loading you are doing in the meals before (and during) exercise. On a side note, I recommend having a stress test or heart scan, since diabetes is a major risk factor for coronary artery disease, which is often asymptomatic.

Peter Mendel, MD
Woodbridge, VA

I emphatically urge you to continue your exercise regimen—the benefits, both physical and psychological, are just too great to give up. That said, please know that it is very common for diabetics to progress over time from managing their disease with diet and exercise, then to taking one or more oral medications, and finally to insulin.

It's good that you test regularly. I would keep your doctor informed about your blood glucose response to the vigorous workouts, as he/she may one day feel the need to prescribe medication to help you manage; this is not a bad thing. You should continue your workouts. Your body's response to them is not unusual, and may be related to catecholamine release. This is a stress hormone that causes the liver to produce glucose. You seem to follow a low-carb diet. Your age at diagnosis suggests that you may have overt type 2 diabetes, which is well controlled with diet and exercise. Remember, however, that diabetes can be a progressive disease and so medications may become necessary down the line.

Kevin Foley, MS
Dayton, OH

Fighting Nausea on the Race Course

I'm a 33-year-old female weighing about 118 pound. My recent Ironman competition went well for the first two legs, but by mile six of the run my stomach began cramping and that continued for the next hour and a half. I vomited during miles 19 through 24.

I've been running for almost 20 years, but when participating in endurance events, I often have trouble with my stomach. At about the three-hour mark during a marathon, I am no longer able to ingest a gel or other food without feeling nauseated. What can I do to alleviate this problem?

Wendy Suarez
Cornwall, NY

The fact that these symptoms occur well into these extended events suggests that dehydration or electrolyte imbalance is affecting peristalsis. When peristalsis, the muscle contractions that propel food along the digestive tract, is interrupted, nausea and vomiting can result. There is a normal reduction of blood flow to the digestive tract during exercise, but this occurs early and remains so throughout the exercise, so it would not be the cause of a problem this late in the event.

You should prehydrate with sports drink containing sodium, and continue to hydrate throughout the exercise period. Peristalsis is very sensitive to salt and water imbalance in the intestinal tract. Many runners restrict their nutrient intake late in the race to fluid-only. Be sure to experiment on long training runs with various foods—your intestinal tract needs to be trained for an endurance event in the same way your other muscles and organs do.

Dennis D. Daly, MD

Camillus, NY

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