Monday, November 30, 2009

Taking a Closer Look at the Ankle Joint: Dorsiflexion and Mobility

For over 20 years, I have been looking at my hips and back trying to figure out the pain and imbalance problems that I can't get rid of. My left lower back and my left front hip have always been the two areas that I can never seem to fix. I have been told not to run anymore by many doctors and even physical therapists have said it must be something wrong with my hip. But they are never sure what! I have actually helped my back, this past year, to feel the best that is has since the mid 1980s when triathlons just killed my back (or as I now suspect- a faulty bike set up and fit caused the problems).

I have always looked at my hip for a solution, but what if the hip is just the symptom and the problem can be found somewhere else. I have started looking somewhere else and I think I may be able to pinpoint the problem. Is there a solution? I don't' fully know, but if I could run marathons prior to my excursion into triathlons without the problems I have now, then why can't I get my body back to that point.

About a month ago, after much work with Feldenkrais, I started realizing that my hips and back seemed to work just fine (at least while lying on the ground). My left hip could do the same movements as my right hip. I then wondered if Feldenkrais would work on lower body parts, particularly my left foot and ankle. My left ankle does not work like my right ankle. The foot twists out to the side and the inside half of the foot is higher than the outside part. It is sort of like a twisted foot. If I point my left knee forward, the left foot points to the outside. If I straighten my left foot on the ground, my left knee knocks into the right knee. This has been a long-standing problem. In high school, I was jokingly given an award for being knock-kneed. When I started triathlons and fit myself to my bike, I knew my left foot pointed out, so I locked them into that position with my pedals. I did five intense years of triathlons (including five Ironman distance races) with this toed-out position on my left foot. After one year of triathlons, I was trying to figure out the pain in my back (I didn't do stretching or know anything about chiropractic back in those days 1983-1987). By 1987, I honestly thought I would be in a wheelchair by my mid-thirties as I couldn't do much of anything without trying to relieve the pain by cracking my back every 15 minutes all day long. I was a mess! I have improved a lot since then and have kept myself out of a wheelchair, but I have yet to fully straighten out my body again. I went to get physical therapy for the first time in 1988 right before my marriage, because I wasn’t sure that I could stand up long enough during the ceremony without needing to crack my back! This was less than one year after my fifth and final Ironman distance race.

Here I am back in 1985 winning a triathlon in Lakeville, Ma. The ankle-knee-hip thing isn't so bad. Same with this photo from  the Falmouth Road Race in 2004.

But look at what is happening at this year's Applefest 1/2 Marathon. It is painful to look at. I have to straighten things out starting somewhere.

So I started thinking again! What if the problem isn't my lower back (first problem area) or hips (a later problem)? What if it has to do with my feet. I have experimented with Morton's Foot remedies, but that doesn't fully address my misaligned foot. Could it be that my weird stride is because of my foot? When I run the left foot splays out to the side and then my foot rolls over the arch, sending my left knee in the opposite direction so that it knocks into my right knee. Then my femur sticks up into my hip socket at a weird angle causing the hip, butt, and back problems. My body has learned to compensate by getting all out of alignment and running with all sorts of twists and imbalances that somehow work (but is very ugly). I started wondering if I could fix my foot and ankle, thus creating a fix for my hip and back. I found a Feldenkrais ATM lesson for the ankles and used it the night before the Cape Cod Marathon in October. It was an hour-long practice with the ankle and I noticed something right off the bat, well I already knew this, but never really thought much about it. Part of the lesson was done lying on my belly. From this position, you have to leave your knees on the ground together and lift up your lower legs to a ninety-degree angle, bottoms of the feet pointed to the ceiling. With you feet together, you had to do slow movements: toes out-ankles together, toes together-heels out. I could move my right heel out, but the left would go nowhere. Doing these and other movements I was able after an hour to get my left heel to move less than an inch, but there was some improvement.

I have no idea if my left ankle-foot arrangement is something I was born with or something I developed through misuse or poor movement patterns (or locking myself into an unnatural pedal position). I decided to try to find out more information, and am still looking, and I am not sure it is something I can fully fix, but I am willing to see what I can do to improve my movement patterns. I am no expert, but unless my bones are formed improperly or worn down, (can that happen?) then it might be my muscles and ligaments that are holding things in bad positions and alignment and maybe that can be fixed. There are 26 bones, plus the tibia and fibula, in the lower leg, ankle, and foot so there are many places where "something" can go wrong.

In a well-written article called The Ankle Paradox: Building Indestructible Ankles for, Jimmy Smith writes:

Some of my colleagues may want to slap me around a bit, but I'm convinced that the ankle is the primary cause of abnormal gait.... Pain or improper movement will cause the individual to compensate for the dysfunction.

I never have pain in that ankle, but I certainly have dysfunction and an "abnormal gait." So maybe the ankle is where I really should be looking and it looks like a very complicated joint complex. Here is a wonderful video of how the ankle joint complex works:

I still don't know how or if I can fix things. I do know this. Once I start running forward and put weight on my left foot rather than moving straight ahead over my foot, it feels "stuck" as my leg moves over my ankle (that part right in front of the angle-sort of like the vertex where the foot and leg meet).. Rather than move straight over the foot, the front of my ankle rolls to the inside, everting the foot out to the side, and rolling down towards the arch. Could this movement be throwing off my stride? Could this habit be the cause of my funky left foot positioning?

What if I could roll forward over my ankle in a straight line?There are many ankle mobilization videos that show how to test and work on this dorsiflexion. Bill Hartman shows how it is done in this video, as well as a tennis ball trick to work on the soleus muscle, calf muscle, and plantar muscles. I have been working on this mobility work to see if I can get a better sense of moving properly and gaining better dorsiflexion.

Here are other videos that take the ankle mobilizations further into a kneeling position. It helps you line up the knee and ankle with a long dowel or broomstick. The blurb for the first video states
Great warm up for walkers and runners, especially if you have suffered from a previous ankle sprain. Improves ankle and opposite hip flexibility, but more importantly helps to re-wire the front knee on how it is supposed to move and keep it from caving in during walking and running.

Here is another take on that mobilization:

I was also wondering a bit about something that chiropractor, Brian Bigelow, told me many years ago. He mentioned something about my tibia or fibula being out of position. I really didn't realize that these bones move in a small way as your ankle flexes. Bill Hartman shows a technique he developed to mobilize the ankle when the fibula is stuck in the forward position. I used a regular belt when I tried this and it seemed to do something the first time I did it. This stopped some of the pressure I was feeling in my left peroneals and knee. I used it again twice more in the following week when I had the same pressure. It seems to do something positive with my leg, so it is something I am trying to learn more about.

Bill Hartman together with Eric Cressey (I have a couple of his books, plus the Magnificent Mobility DVD), and Mike Robertson have recently come out with a new DVD called "Assess and Correct". I do not have this yet, but it looks very interesting. I am wondering if it gives any more information on ankle mobility techniques.

Here is an article with more videos called Alleviating Ailing Ankles by Carson Boddicker with many exercises to increase dorsiflexion. Carson writes:

All the issues can be both joint mobility restrictions and muscular tightness; achieving proper dorsiflexion should be addressed with a multifaceted approach including altering tissue lengths, joint mobility, and other modifiable lifestyle factors.
Here is a good blog post. It is for frisbee player, but they run too!
I am also looking again at the joint mobility work through the Z-Health exercises. I am paying proper attention to foot placements when doing them.

Many ankle mobility mobilizations require an expert to evaluate and practice. Here is an overview and then some other more complicated videos that I just want to keep track of.

Who knows if doing the simple mobilizations will improve my stride. I am willing to try. Like anything, I assume it will take some time to alter the tightness and alignment issues and then to let the body adjust.

My foot seems a bit better in alignment and as it straightens out. I notice more arch in my left foot. Mywhole foot seems to do its own wiggling and rotations that are not normal. I assume this is also a neurological problem and hope that if things fix in my foot, I can retrain the brain for proper movement patterns. Like everything else I try, I never know if it will work, but I think it is another step on the way to recovering my stride.

Yesterday was another warm and beautiful November day for running. I was stiff, particularly in the hamstrings, as I spent most of the week doing lots of additional things, Z-Health, resistance stretching, yoga, and a return to kettlebells. I think the kettlebell swings tightened up my hamstrings, but I wanted to get back to a consistent use of the kettlebells.

It took a few miles to warm up, but I ended up doing 11 miles and my stride was shifting after a while to a different position as I tried to keep the left foot straight. It really affects the rotations in both hips and the imbalances in my back. By the end of the run (which went very well), I was very stiff over my entire back. I will just take that as a sign that my balance is shifting and my body is readjusting. After a month, I can now rotate my left heel out about two inches when I do the Feldenkrais exercise I wrote about earlier.

The ankle joint is something I have to learn a whole lot more about. I would really like to know if it is possible to get that left foot to rotate back into position. If it is doable then I may really be onto something!


Anita said...

I teach Feldenkrais Awareness Through Movement(R) classes and last night I taught the very lesson you described - I call it "Foot Circles." During the lesson I was struck by the huge variation in people's ability to move their ankles.

Kudos to you for exploring, and believing in your ability to improve your movement. I hope you will continue with the Feldenkrais work. The new, improved movement pattern can become your way of moving.

Jim Hansen said...

Hi Anita,
I am doing tons of ATMs and really enjoy doing them. I found some free ones online, but have bought a few series that I find very useful and "informative".

Yes, that is what I was doing: foot circles, heels adn toes in and out, and inverting and everting the foot. Great stuff! I hope it even takes me further out of stiffness.

Thanks for the response and encouragement. Why give up? There is always something new to learn and strangly enough, it all goes back to the basics that we "knew" when we were kids!

Cospielman said...

Hi Jim, I just discovered your blog after you posted the link on the RW forums. I was just scrolling down, thinking oh, this is interesting - when I saw your post about your foot splaying out. Mine does the same thing! And I've also been running over 35 years, and I know it's done that the whole time - although my high school coach once told me as I sprint it straightens out. I've also had all sorts of hip overuse injuries throughout the years, and have been getting ART for the last year for a piriformis issue - which I'm now wondering if it's related to my ankle. Thanks for all this info - I def. need to read more and try some of the exercises.

Jim Hansen said...

Hi Cospielman,
That is interesting that you run in a similar way and have kept at it too! I haven't' figured out if I can change things, but if I can keep it together as I get older and be able to continue running I'll be happy. I do think that what the foot does follows through to the hip. Maybe something in the hip messes up the foot. Somehow it is all connected and I'd love to find the right practitioner that can figure it all out and set me on the proper path, until then I have to read and figure out all I can. I'll have to see about running fast to straighten it out! It is just not as easy anymore!

Adam said...

Hi Jim,

I'm 28 years old, I have the exact same muscle imbalance problems as you do, and I'm pretty sure that I finally got the root of the problem!
I hope I'm right and that it helps you as well.

I've been studying this newly-found problem of mine for about 9 months and all signs keep pointing to fallen arches. My right foot is nearly flat now and that is where this chain reaction starts. When the inside arch falls, the long bone from the top of the foot pushes into the base of the big toe bone at an angle that points the big toward outwards towards the other toes, creating a bunion or the appearance thereof. It also causes the knee to rotate inward and the leg to rotate in the hip socket.

After that, the way we compensate for it when driving, standing, walking, and sitting, creates the muscle imbalance we're seeing. I have no idea if these imbalances vary from person to person just yet.

When my feet are lined up, my right knee is a little lower then the left, my whole ribcage is visibily twisted clockwise (no wonder i have Asthma!), my hips are twisted to a lesser extent, and my right shoulder pulls forward and asymmetrically close to my neck, causing cold hands, and both carpal tunnel and ulnar nerve pain. I've also noticed that my face and neck have actually become less symmetrical, as the right side is somehow larger or more muscular than the left though my wife says it's completely unnoticeable. Back exercises helped the nerve pain in my wrists and cold hands, but I've just started exercising my feet and arch muscles and the bones at the arch of my feet have actually started to temporarily pop back into the correct position when I flex my foot arch muscles, so I have hope that the dysfunction is not yet beyond non-surgical repair.

It seems as though we will always struggle with muscular imbalance until we restore the arches of our feet. I think there are is a lot of research indicating that bunions, flat feet, hernias, Inflammatory Bowel Diseases, and maybe back/spinal/nerve disorders to possibly be hereditary but I think that it's specifically long-term fallen arches and postural problems, and we have the ability to control this hereditary fate. I also think that "Ghetto Booty" is a product of flat feet, too. It's just a hunch, but all the dots seems to connect, don't they?

With the advice I found here on improving dorsiflexion, I hope to be able to rehab my foot in a couple of months and I hope that my little theory may be helpful to you all in reaching the muscle balance you are looking for.

Jim Hansen said...

Thank you for your response Adam,

A lot of what you say does ring true. I have noticed that when "things" feel good to me that my foot "stands" better on the floor and there seems to be a stronger lifted arch under the foot. One thing that I am noticing is that I also need to loosen and strengthen the muscles of the lower foot: the peroneals and the tibealis anterior. I have started doing this with the TPMassage products (here is a video that shows this: )but you can also do this with self treatment similar to ART (active release technique). I just got this book this week and it shows you how to do this with angled pressure from your fingers. The foot circles and pointing using either of these techniques are really hitting the muscles in the right spots. In fact they the only muscles in my body that when targeted bring exibit extreme tightness, then a tingling, and then a bit of release.

When you talk about the arch and big toe, this article shows how these muscles of the lower leg connect to the bottom of the foot. I haven't fully studied it all yet, but I this is all intriguing me currently. Maybe you have seen and figured this out already, but it certainly is interesting stuff.

I have been wearing minimalistic shoes for years, but I am now realizing that without more specific work on my lower legs and feet that shoes alone will not fix the feet.

When you wrote about how we sit and stand, I was reminded of this article on left-leg drivers syndrome:

Good luck with your rehab and thanks for the great reply.


Markus said...

I have the same problems. I tried these mobility drills and alot of calf stretches. The problem i run into is that i cant stretch my calves very well cause there is always pain and blockage in front of my foot were the tibia meets the foot. It feels like i jam something in there. I got orthodics in my shoes and its a little bit better now. I have this problem for years and tried PT, stretching, Z-Health, those mobilisations by Hartman/Boyle, i tried traction with bands like shown on jumpstretch. The thing i didn´t try was prolonged static stretching with those casts you can put on over night that keeps your foot dorsiflexed. I had op on this foot to reconstruct a band in there and maybe clean it up a little in there. The band was fixed and there was not much to clean up. I hoped maybe after the op there was more rom. I was wrong. There was no difference in rom at all but a more stable feeling so it was not useless. My doc just told me that dorsiflexion rom is hard or in some cases even impossible to get back. I´m not satisfied with his opinion and maybe one day i or somebody else will find a solution to my/our problem.

P.S.: Sorry for my bad english. I don´t use it that often ;)

Jim Hansen said...

Hi Markus,
Thanks for sharing your your struggle with this dorsiflexion problem. It seems like we have traveled on similar journeys, minus your operation and using the jumpstretch band (I have read about those for use with back problems). I went to a physical therapist yesterday and it seems she does something called postural restoration. She was very curious about my ankle and measured and tested things like she knew what she was looking for. I did not recieve any exercises for the ankle yet but she made notes on my calves too. I did get exercises for my hips so I will be curious to see where this goes.
If you get it figured out, let me know! And your English skills are great.

Anonymous said...

have you looked at a structural leg length discrepancy? A friend has it and his longer legs foot splays out just like yours. he also has tightness and pain in the hip and back on that area. Just a thought..

Jim Hansen said...

Yes, before I was a runner back in junior high school, I was told I had a leg-length discrepency of about 3/8" and Children's Hospital in Boston wanted to operate on my leg to stop the growth in one leg to let the other catch up. They wanted to do it before I reached my anticipated height of 5'8". By that time I already grown to 5'10" and never had the surgery. That was fortunate, too, I grew to 6'0". They did do the operation on my brother. At times the left leg seems longer, but a lift makes things worse. I think it is a more a functional discrepency. This summer one doctor and a PT said that my left leg was slightly shorter and then after some work they pretty much balanced again. Right now it doesn't matter too much as I am waiting for surgery for a labral tear in the left hip which may have been part of the problem too.

Unknown said...

I have the same issue, but with my right leg. I've been reading your blog from the beginning. I'm hoping by the time I get to the end you will have figured out the solution to this problem. I try to run, but by 2 or 3 miles in, my IT band is flaring up and my hip starts to hurt. I'm amazed at the number of miles you are able to run.

I'm reading Egoscue books now and I hope to find some answers in there. I know that posture is my issue, I just need to find the best way to fix it.
-My right foot goes out more than the left, with a higher arch. My right shoulder goes forward, I think to help compensate for my right hip being elevated. So far I think the hips are the key to fixing the other problems. I've noticed that after a few days of doing the Egoscue exercises, my right foot is in better alignment. If you found the answer to this thing, please let me know. Thanks!

Jim Hansen said...

If the Egoscue works, keep at it. If you think it is from the hip (my theory too) try Somatics as change will come much quicker than Egoscue as it is movement based. Does you knee point out along with the hip? Sometimes my foot points out more and I am learning that means that the fibula is getting stuck and I try to release that bone some. Keep me posted-particulary if you find an answer. Martha Peterson's Somatics site has some releases for the IT band. Check out her site for lots of good exercises that work on loosening up chronically tight muscles.

DonDraper1963/Anonymous said...

Hey Jim,

Same poster as above. My foot definitely points out more than my knee. My knee goes straight ahead if my foot everts as it seems to naturally. If i put my feet together and face straight ahead, my knees point inward. If I push my hips forward in this position though, everything seems to line up pretty well.

I want to work on strengthening my abs and gluteus maximus muscles, as these are the muscles I am contracting to tilt my hip back to normal when I am able to all be in line. Do you have an anteverted pelvis too? If I stand with my back to the wall, I can probably but a wine bottle between my lower back and the wall. That by itself is probably my biggest problem I think. I have also been going through the egoscue condition II exercises, and the inward knees exercises in Pain Free. I feel like I am seeing a little progress. I notice occasionally my footstrike feels differently recently, and its cause I am hitting the back on my heel when I walk like I am supposed to, instead of rolling off the side of my foot.

I recently picked up Martha Peterson and Thomas Hanna's book. They are definitely fascinating and I plan on working in some of their exercises into my routine as well. It is amazing to me that the conditions in Health Through Motion are identical to the 3 types of reflexes described by Thomas Hanna.

Jim Hansen said...

Interesting observations. I am not sure if I have an anteverted pelvis. I do have femoral anteversion on my left (bad) side. I am glad the Egoscue seems to be working and I will have to check out the similarities that you mention and give it more thought. One thing I think that makes my foot rotate more out is either a stuck fibula or cuboid muscle in the foot. A podiatrist has done manipulations for me on those bones that seem to work real well for a period of time. I think I need to go back to see him. He used to have videos on youtube, but they were recently removed.