Frank loves to run. He’s been running for many years and sometime last year discovered an area of discomfort near the bottom of his leg, right at the Achilles tendon. Frank did what most normal males do. He ignored it. But one day he rolled out of bed, placed his foot on the floor and stood up. The tendon felt like it was made of concrete and the pain was hot, searing and extreme. He sat down immediately and took a breath. “Maybe I’m dreaming,” he thought. Then he stood and realized he was very much awake.

Frank hobbled around for a few weeks and to his surprise the pain went away. So he started running again. First slowly with short periods of running then gradually increasing his time. He thought he was over the problem until he noticed some tightness and a little pain. This continued until his wife couldn’t tolerate the moaning and frequent complaining any longer. Upon the verbal pummeling and persistent urging of his wife (some of us might call it nagging), he came to see me.

It seems Frank has no clue why his symptoms returned. He believes his return to running was slow, reasonable and well planned. He did not suddenly increase the intensity or the volume of running. He is quite perplexed.

At 55 years of age Frank is in excellent health and has remarkable flexibility, strength and balance. About the only unusual configuration is a slightly pronated left foot he has had for many years. Now I am nearly as perplexed as Frank.

“Frank, the only thing so far I have found that could be related to your problem is your pronated left foot. But considering you have been pronated for many years and have run for many years and from what you describe, have resumed running in a very reasonable way, I am wondering how have you managed this pronation in the past?” I asked.

“I know. I wear shoes to correct it – Asics. They have really good pronation control and I’ve never had any trouble,” replied Frank.

“I see.” I was wondering if perhaps Frank had changed his shoes to some other brand recently although surely he would have mentioned it. My wife Ellen has a great expression she uses when you are looking for something that is right in front of you. She yells “SNAKE!” as if you are about to get a nasty bite. I happened to glance around the room and tucked back way under the chair were two additional pairs of running shoes sitting innocently begging me to ask them a question. I thought “SNAKE!” to myself. So I decided to ask the question this way. “Frank, when was the last time you changed running shoe brands?”

Frank replied quickly, “Well, I changed to Reebok a while ago. They were a lot cheaper but I don’t think it’s related to my problem.”

“Why is that?” I asked.

The tone of Frank’s voice sharpened and the volume went up a few notches like I had hit a nerve. “Well… are shoes aren’t they? What difference do they make?” said Frank.

“Right. You seem a little bit angry here. Am I sensing that correctly? Are you upset?” I asked.

Frank sighed deeply. Then he said, “When I bought those shoes I wondered if it was a smart thing to do. But they were so much less money and my leg felt fine. I guess I’m a little mad at myself for being so stupid.”

“You know Frank, I think stupid is when you do something twice when you know you shouldn’t. Doing it the first time is just a bad choice – not stupid. Now, those shoes on the floor – are those yours?” I asked

“Yeah, they are. I thought you might want to see them. I don’t know why I didn’t bring it up sooner,” said Frank.

“Let’s look at them,” I said as I picked up the left shoe of each brand and set them on the table. Frank suddenly exclaimed, “Whoa – I can’t believe how different these shoes are. Look at how far in the heel leans on the Reebok. They can’t be good.”

Frank was right. The Reebok shoe leaned inward at the heel 26 degrees while the Asics was a steady 0 degrees.

“Frank – I think we found one of the sources of your problem. Go back to the Asics and follow my running program and you should be fine. You body should adapt once your rearfoot is under control. The Reebok shoe permitted too much pronation. The excessive pronation increases the strain on the tendon. I think once you correct the position, the strain levels will match the tissue capacity and the symptoms will go away,” I explained.

This story has several learning points for me. First, it’s a good example of the subtle interplay between physical loads, biologic tissue health and biomechanics. When the physical loads exceed tissue capacity, symptoms often follow. Interventions can be focused on tissue health, reduction of physical force, altering biomechanics or all three. Second, is the concept of the pivot. The pivot in this story occurs when I ask Frank when he had last changed shoe brands and then followed with an observation of what I perceived to be anger. By reflecting back to him what I sensed I gave him room to vent his own frustration and get the real issue out for discussion. Together we were able to converge the facts into a resolving storyline and diffuse Frank’s festering self-directed anger.

Sometimes the solution and pivot are right in front of you. Look for the SNAKE.

Make Today Count.

Doug Kelsey