Case 002 — 11 miles, then nothing.

Encounter summary

Member is a 38-year-old IT operations engineer, two prior marathons (Grandma's 2023 at 3:42, Twin Cities 2024 at 3:33), training for a sub-3:30 attempt at Grandma's 2026. Presented in mid-October 2025 with new medial-arch pain that came on consistently at 11 to 11.5 miles into the long run, across three Saturdays running. No acute injury. Pain was 4–6/10 at onset, resolved within 24 hours, no residual at rest. Training had ramped to 52 mpw including a 16-mile peak. Shoes (Brooks Glycerin 21) at roughly 320 miles.

Office exam: tenderness over the tibialis posterior tendon distal to the medial malleolus, single-leg heel-rise weakness on the affected side (could complete 12 reps versus 22 on the unaffected), no swelling, no medial-arch collapse on weight-bearing. POCUS in office showed mild thickening of the tib-post tendon distal to the malleolus with no discrete tear and no tenosynovial fluid. Working diagnosis: tibialis-posterior insertional tendinopathy, stage 1.

Splits

Split	Week	Event	Pain (loaded)	VISA-A
00:00	2025-W42	Initial visit, exam, POCUS	5/10	—
00:00	2025-W42	Volume reduced to 60% MPW; long run capped at 8 mi	5/10	—
02:00	2025-W44	Heavy-slow-resistance program begins (Hjelmtvedt PT)	4/10	—
06:00	2025-W48	Single-leg heel-rise progresses; long run 10 mi cleared	2/10	—
10:00	2026-W04	16 mi long run, no pain	1/10	—
14:00	2026-W08	20 mi peak, slight tightness, no pain	1/10	—
18:00	2026-W12	Taper begins	0/10	—
22:00	2026-W16	Grandma's Marathon, 3:09:42, BQ	0/10	—

Debrief — what was tracking

The graded loading program followed the pattern that the BJSM consensus on tendinopathy management¹ describes: heavy slow resistance work three days a week, eccentric calf raises with a tibialis-posterior bias (the "calf raise off a step with adduction" cue), isometric loading on bad-pain days as a pain modulator. The Duluth Physical Therapy team (Hjelmtvedt) ran the loading; Vass tracked the rehab arc in office every four weeks; the member did the work.

The key clinical decision was not a particular exercise. It was the decision not to image past the in-office POCUS. The pre-test probability of a tear given the exam findings and the tendon's appearance on ultrasound was low; the cost of an MRI was real (member is on a $6,000-deductible HSA plan); and the post-MRI finding most likely to be reported — incidental tendon thickening — would not have changed management. We decided, with the member, to proceed without imaging. We documented the decision and the reasoning. It was the right call, but only because we were prepared to revisit it if the rehab arc stalled.

What didn't track

Sleep got worse for about three weeks in mid-program when the member was managing both reduced training volume and a project deadline at work. We didn't intervene; we noted it. Sleep recovered when the long-run mileage came back. We also discussed shoe rotation (the member had been running every run in the same pair); they added a second pair (Saucony Endorphin Speed) for shorter sessions. Whether that helped at the margins is unknowable. They thought it did.

Plan, T+0

• Member transitions to a post-marathon recovery block.
• Continue heavy-slow-resistance program at 2×/week for 8 weeks before any return to volume training.
• Re-imaging with POCUS at six months; consider release from active management at that point if asymptomatic.
• Pre-Boston (April 2027) consult booked for late September 2026 if member confirms entry.

What this case is and isn't

This is a clean case of a stage-1 tendinopathy treated with the published evidence-based protocol. It is not a case for the proposition that all medial-arch pain in a marathoner is tib-post tendinopathy and not, say, a navicular stress reaction — and the way we know that is that we did the exam, ran the POCUS, and revisited the decision tree at week six. If the loading program had not begun to bend the pain curve by week six, we would have gone to MRI.