Monday, November 8, 2010

Cortisone Shots and Ankle Rockers

This morning I had a cortisone shot in my hip gently delivered by my physiatrist. Just a tiny pinch and I was good to go. I guess the idea is if the hip pain goes away, it could be a labral tear, as this is for diagnostic purposes. If the hip stays the same, then he has to keep looking for the problem. The interesting thing is that he watches the hip through x-rays as he puts the needle in. He showed my some freezes of the hip x-rays and he said it looks like the dye they used shows what could be a small tear on the outside of the hip joint. I could see it. We didn't talk about this, as I have a follow-up next week, but if that is a tear that needs repair it sounds good as it doesn't appear to be in the joint. It will be interesting so see the effect of the cortisone on my hip, although it shouldn't fully work for a couple of days. I may run a bit tonight on the treadmill. It feels fine walking around. I have seen reports that a cortisone shot can permanently fix the labral tear pain. It is not suppposed to fix it, but some people have been fine after the shot. Others get a few weeks pain-free. Others get many months. Sometimes it doesn't work at all. I see it as a major problem keeping me from running right now, but I really have to seek out the cause of the hip pain. I don't really think the cause is found in the hip as this is mainly the effect of my poor biomechanics.

I was scanning some pictures for my parents at the Cape this weekend and found some pictures they had taken back in about 1986 or 1987. One picture shows my lovely girlfriend Sarah, who is now my wife. This shows me with someone really pretty. The other picture shows me at the same time with something really ugly: my running stride. This is me finishing the Falmouth in the Fall Road Race (same course as the Falmouth Road Race. Ughh! There is that terrible twisting of my leg that I keep seeing in more recent photos. No wonder I am so messed up. I have been running and racing like this for years.

Beauty and

the Beast

See the left leg twists out and the knee and hip twists in. I was still into Ironman and triathlon racing and training at this time, despite a horrible left lower back pain that made it hard to sit and move comfortably just about all the time. Yet, the last three of my five Ironman distance races run in 1983-1987 were completed in 10 hours 20 minutes to 10 hours 23 minutes. You can also see the contortions that my body has to do to compensate. No wonder I have so much pain throughout my body for many years.

I am fairly convinced the hip pain comes from my left foot and toe. So I really want some answers to this. I think the complications from the hip comes from using the new insoles this summer to correct the Functional Hallux Limitis. I felt better stability in my foot and immediately ran way too many miles too quickly and this may have impacted the motion in the hip bringing the pain.

What I have to consider is that the best my running has felt all year was the times a physical therapist manipulated my foot back in the winter and then again after my first visit with the Dr. Dananbergwhere he fitted me to the first insoles and again manipulated my feet and leg. Things in my foot and leg felt so much better those times when the freed up my joints. I know I have told I have tibial torsion in my left leg, but I wonder if there is something else going on instead or in addition and the picture above shows exactly what I feel 20 something years later.

If I walk forward onto my left foot and try to shift my body and weight over it, the tibia will not move straight over the top of the foot like my right leg does. I feel a stickiness or stoppage of movement over the top of the ankle where the tibia isi supposed to go. Instead it halts and finds an easier movement by sliding to the forward to the right, throwing the knee to the inside and pushing the foot to the outside and then rotating my hip to the inside too. Is this because of tibial torsion or because of jammed joints or a combination.

Seeing the photo above this weekend, almost convinced me to throw in the towel forever. This will never be fixed! But I always had a strange stride in high school and college, but not like this. I think it really got messed up when I did triathlons and adjusted my pedals so my left foot pointed out due to my leg problems and this just started the severe chain reactions that I have since had.

Then I remembered the manipulations helped me and that once I used these new insoles on my bike this summer, for the first time I had no pain biking and I much better cycling motion than I ever had without pointing my left foot out.

I went back to reading the few and limited things I have found online on twisted tibia and foot mechanics and found one runner in  Sydney, Australia. This guys right foot does exactly what I think my left foot does (I have never seen how I look from behind). We are like a matching pair.

I wrote in some questions under the video last night and the folks at Sydney Sports Podiatry so nicely replied today:
This is what my left leg does. I have been running for 35+ years (50 marathons), and have been fighting the imbalances and strange stride (tibial torsion-left leg points out-knee knocks in- hip and lower back imbalances and pain) for years but can't fix things. What should the orthotics be doing? I just got a pair from one of the best podiatrist in the states (Dananberg) but he is treating "functional hallux limitis" and hasn't addressed the tibial torsion.

What are the best type of running shoes? What type of technique training? Do you let the foot do its own thing? or point it forward. Any advice would be appreciated.
Me (marathonnh)
@marathonnh You can't make it point forward without pretty advanced surgery. Also be aware of actual or functional leg length differences which may be stuffing up your back. Your hip/leg will always dictate where your foot points before strike. If orthotics and technique change aren't helping, Dr Dananberg will give you your surgical options, the most radical of which may be getting the torsion fixed. Look up Ilizarov aparatus. It's pretty dramatic and will stop you from running for a long time.
Me-know way I want the Ilizarov aparatus. I get cast claustrophobia (broke leg twice and had cast removed to a softer removeable cast). I can't imagine having that thing around my leg, let alone the surgury.
Hi Marathonnh,

Dr Dananberg is well regarded here. Your hallux limitus is probably from years of overload from the increased velocity and amount of pronation because of the tib torsion. You probably have two very different orthotics already, but if your limitus is advanced, this can have dramatic consequences during propulsion.

A low profile shoe (minimal heel elvation), midfoot strike technique with high cadence can help, as there is slightly less dorsiflexion required from the joint.


That is some great feedback. Thanks! I also went from my years of miniimalistic low-profile running shoes to a heavier structured running shoe this summer trying to see if that would help correct things. Maybe my intution was correct. I had also spent years transitioning from a heel-strike to a more midfoot strike. Maybe I need to work on that higher cadence when I can start running.

I also went back to checking out what the Gait Guys had to say. They were the first to give me a name for the tibial torsion. This is from their podcasts and pretty much descibes what my left leg does: Podcast #7: All about the Glutes (and nothing butt).

This video shows the compensations for a defective ankle rocker that could be the jamming feeling that I feel in my ankle.

This video shows some corrections for a defective ankle rocker.

If you got this far, I commend you. This is basically my thoughts for myself (or therapy) so I can check back, but I hope this certainly helps someone else with similar conditions. There may be only a few of us built like this and running, and so there is little information for runners with tibial torsion. As my 10 year old daughter said to me today, "Dad, you should have become a doctor because you like to find out everything you can about the body." Well, I just can't conceive of giving up. I hope to beat this thing one way or another.

Thinking about manipulations, since I basically stopped running in September, I have had all sorts of pains up my left side (toe, ankle, hip, back) that seem to originate under the left outside ankle bone. Something feels "caught" and it travels up and down my body to various joints.  The left lower leg also gets very tight. I wouldn't know how to adjust the foot, but if this is what remedies things and keeps me running , I need to find someone who can every few weeks or when needed. I certainly had better foot placements after the adjustments this year. One adjustment Dr. Dananburg did was to my upper tibia (Dr. Bigelow also did something like this at times for me). You can see it here (actually he says it is for the popliteus and it keeps the tibia from externally rotating) hmmm!:

I tried this move with my trigger point Quadballer Roller two nights ago (putting it behind my knee and pushing it together against the tibia) and got a little movement or pop and my left foot, ankle, and lower leg and they have felt the best they have in about a week (no constrictions).



Interesting, that photo of you running is a real find, amazing you could run like that.
there is a guy who runs the local races here 37 mins for 10k and he seems to have 2 locked ankles, he kind of runs by lifting his hips from side to side, looks very strange!
But my own photos arn't too handsom either, see my blog cover shot, hip collaping inwards, knees rubbing together and feet pointing in!
Had a lot of progress in the last few weeks doing the trigger point performance workouts and this video is helping build some strength in the hips
Its been a very long journey to try and fix my sciatic problems and just like you I've learned a lot along the way1
Hope at last you will be able to run with free movements.
Sometimes after years of pain you can take it for granted that this is almost normal and part of running and everyday life, so it's very nice when the nagging pains leave for a bit, almost like the sun breaking through the rain clouds, we see a glimpse of what could be!

Jim Hansen said...

I hope that photo is just a more extreme moment- I was sprinting downhill at the end of a race, but I have seen similar shots. IT is great to hear the trigger point stuff is working for you. I'll have to check out the video. Very poetic note at the end, but I know the feeling. I did 8 miles pain-free yesterday from the cortisone shot, I am not sure what this means but at least for a day my hip had better mobility and I got a bit of a glimpse of what could be.

Stephanie Cosgrove said...

It might be useful to consider a chilectomy if you are heavily spurred along the anterior crural mortice. I no longer send patients for Z plasty surgery for equinus as I have found that the tendon sheath (or pseudo-sheath in the case of the Achilles) gets adhesions and doesn't slide normally anymore. Cortisone - infiltrated carefully - and no silly acceleration of activity - can be a good help for the right patient. Cheers from Down Under.