I recently picked up the book, Injury-Free Running: How to Build Strength, Improve Form, and Treat/Prevent Injuriesby Dr. Thomas Michaud and I have enjoyed glancing through it. It looks like a good book for understanding the injury process and rehabilitation. Dr. Michaud also drew the detailing drawings throughout the book. I would recommend this book to someone who wants to delve deeper into the biomechanics of running and solve running related injuries. No, I have not read it all, nor tried his remedies as presented in the book, but I found he addressed some issues that I have such as femoral anteversion, that I rarely seen written about in other running injury books and I look forward to delving deeper into it.
I will also say that three years ago and a few months after I had hip surgery for a labral tear, that I visited Dr. Michaud in his Newton, Ma office. I have visited a great many professionals in my quest to recover my stride and get back to the business of running pain-free. Of all the people that I have met, Dr. Michaud was definitely the most enthusiastic. He spent the the time measuring all sorts of angles on my body and seemed thrilled to be finding all the things that he did (read my blog post So Not Born to Run here). My visit was really a one-shot deal. I never went back and I didn't receive some miracle cure like I had been desperately hoping for. I was only given a few exercises to try and they didn't do much for me when I had so many things going on throughout my body that needed fixing at that time. Since that meeting, I have slowly cleared up a lot of the pain/discomfort issues I had and really the only thing I can't do is run pain free (or be pain-free post run). I am still slowly working on things on my own and I have not seen even any type of specialist since November. I am doing little long term experiments and finding out what works for me over time and I feel like each week I am slowly progressing a fragment more toward being a runner again. I can basically stretch my hip in all directions without problems and I don't think my hip joint is the problem. I started using my orthotics again over a month ago and they seem to help as well as I have started slowly with a small heel lift back in my right shoe. I am also doing some stretches and strength work to better balance my body and learning how to get my hips forward.
From my perspective and I few other people I know who have worked with him, Dr. Michaud is a student of the sport and the science of running. He really loves his work. I think he is someone who can bring his research and understanding and present what he has learned to others. I have heard about all the world class runners that make it a point to visit him from all corners of the world. I like the reflections he makes in the books as he talks about athletes like Rob Decastella and Tegla Loroupe that he worked with. I wish I had been an athlete of that level who could have received more direct treatment from him, but I was unable to be a full-time patient. Maybe this book will give me a few extra tidbits of knowledge as I continue my slow drive to being a runner again.
One interesting thing about this book is that there are plenty of yellow highlights throughout the book for the main points that the author is trying to make. I have never seen this done before, but I guess it makes sense fr when you are browsing the book.
Dr. Tom Michauds recent article on Competitor.com "Are We Really Born To Run?" This is pretty funny, because the post I made after meeting Dr. Michaud was titled "So Not Born to Run."
Other articles on Competitor.com by Dr. Michaud can be found here.
I had the privilege to go visit Dr. Thomas Michaud yesterday. It was actually more than a privilege as he emailed me earlier in the week inviting me in, after he saw my blog post and a question I had over at the gait guys Facebook page. He is a busy man and the earliest scheduled appointment I could previosly get was next April, so it was nice of him to offer a time to fit me in. He also wrote the book on gait related disorders called Human Locomotion, so I was an eager patient.
I think he was just as excited to delve into the mysteries of my running stride as it is quite a puzzle as I was to hear what he would say. He spent a long time measuring angles, testing muscles, and watching me run. He was giving me a running commentary of all the specifics (I couldn' t hold them all in my head) and was very much interested in what he found.
Basically, I should not be a runner! These are not muscular problems, but structural. He was able to give me a clear overview of what was going on in my body. I have heard parts of it all before, but this is the first time someone has put it all together for me. Basically, I have tibial torsion. I forget some of the numbers for what is normal, but I think he said my right foot is pointed out 10 degrees. I don't really notice this one, but my left foot is pointed out to the side at about 40 degrees! You can't fix that!
Don't let your kids sit like this or they could get tibial torsion!
Coupled with that, my left hip has femoral anteversion. That means my hip, femur and knee want to rotate inwards (hello knock-knees). So while my upper left leg rotates in, my lower left rotates out. They both meet at the knee, which collapses down. He said that my body was doing some interesting things on its own, trying to make the whole structural mess work and these things aren't bad, my body just had to find a way to work. He also said my left hip doesn't' rotate out (well it does at about 5 degrees when most people get 60 degrees).
He said I also do have the functional hallux limitis, but actually my right foot has it more than the left. One thing that surprised him when I ran was that my left foot suppinates upon landing (trying to hold everything in line) before pronating sharply over. I wasn't correct in the last post that FHL was my main problem. In fact my orthotics are very good. They were made by Dr. Michaud's brother up in New Hampshire.
Well, there is no easy fix. He gave me some exercises to do and the reasons for doing them. Some are based on very recent research. They are nothing new, but now I know which exercises to do and why. I also bought a copy of his book, which is going to keep me busy for a long time. Flipping through, there are many references to conditions like mine.
I was thrilled with the visit and the time I got to spend with Dr, Michaud. It clarified a lot of things for me. I hope to do his exercises and my goal is to just run a little bit each day (1 mile on the treadmill/day) as I try to strengthen and reeducate my brain into doing better movement patterns. Yes, he confirmed what I had read on the Gait Guys website: the brain's mental map needs to be changed. One key exercise he wants me to do is a dyna-disc lunge. I am to hold the lunge for 3 seconds. They wiggling I will feel as my foot tries to balance and for my knee to provide stability is the way that my brain is to rewire itself.
One final thing: he said my muscles were very strong on all the testing. The popliteus was strong too. I am wondering if it is going into spasm when I have difficulty with it?
I was very overwhelmed after the appointment. I finally found a doctor who could look at the whole picture, explain it to me (although I forgot so much), and be excited to work with my at the same time. I think he found my mechanics very interesting. Unfortunately, as I left, I had to come to the conclusion that there are some things I just can't fix! You can't fix twisted bones that rotate the wrong way. It left me a bit sad that there is no quick and magic fix. I will do what I can to see if I can run how I would like run, but I am stuck with the body that I have. My body did work somewhat decently years ago when I was younger, so I need to reverse a few of the compensations and take things slowly.
I read somewhere this weekend some saying that goes something like this. " Do what you should and not what you can." I am going to take things slowly and see if the exercises work. That is what I should do. I have to get rid of the "can" part. I can run 8 miles, but I probably shouldn't at this point until I get things under better control. That will be hard for me as I like to push things, but it is time to do what I should.
And sadly, biking is not and was not the best thing for to do with a tibial torsion and the femoral anteversion. He confirmed that that is what probably really messed up my hip, although in the 1980s when I did triathlons it was my back that felt the pain. He said that the glutes have a mass five times greater than the back muscles which take over the work when my hip isn't working right (or jammed in the joint) and that is why it could not handle the stress. It is also why I have to keep working on my glutes, particulary the glute medius.
1987 Cape Cod Endurance Triathlon: It looks like I was trying to keep the foot straight, but the hip then was jammed. This was my fifth and final Ironman distance triathlon.
Dr. Michaud did say that when running and biking I should keep the knees straight ahead and let the foot do its own thing off to the side.
I had planned on chickening out on the Thanksgiving morning Great Gobbler 5k in Nashua, but woke up and decided to endure it as I haven't raced a full race since last years Great Gobbler ( I did do a leg in the Mill Cities Relay last December and did the first loop of a snowshoe race -2.5 miles last January). It didn't go well, but it went as expected. I set an all-time personal worst over the 5k distance. I was huffing and puffing, but my stride was way off and was very discouraging to realize how far out of shape I now am. The only good thing was that I looked at all the results printed from previous editions of the race on the side of the shed and realized I have raced in all editions of this race. It is now my only annual racing streak left. Listing the results show a huge decline in recent years in my times. I hope it goes on the upswing starting next year as I don't like running like a turkey!
Great Gobbler race results: 2003 19:59 16th originally called a Nashua High School Alumni race. 2004 19:38 15th 2005 19:19 7th (Awesome snowstorm during the race!) 2006 18:16 13th 2007 18:09 18th 2008 20:10 28th 2009 20:46 31st 2010 22:00 77th (off the fumes of summer training) 2011 24:45 170th (Ouch- even got passed by a guy dresses as a turkey!)
Last week I only ran twice: this race and 8 miles on Saturday. My body isn't working right, so I don't feel like running.
I know something is off with my body and I am still working on figuring it out. The last few days have been helpful. I had an MRI for my lower back about 10 days ago. Yesterday, I went for the result. I was expecting to hear something about my disks and nerve problems. I was stunned when I was told my back looks really good. I have had left lower back problems since the mid 1980s so this was a weird result. It is good news to have a good back, but what next?
The following is more to clarify my current thinking and keeping it for future reference, so don't bother to read if you have even gotten this far. I tell my students that they should enjoy solving math problems as it is like detective work and they are going to be solving problems all their lives. I feel like I have spent half a life trying to solve the problem of my back and hip. So it is back to asking questions and looking for answers.
I was absolutely floored that my back looked fine and I realised that I forgot to ask more probing questions about the MRI results. They did sign me up for another appointment with another doctor for the week before Christmas. This is another physiatrist at The Spine Center in Newton-Wellesley. This doctor will be looking more a musculoskeletal problems. I was told they made look to do things like trigger-point injections if they find a problem. I would guess they they might find a problem in the piriformis area.
I had a couple of valuable internet interactions over the weekend that were very pertinent and thought provoking. The limiting factor in my running now is my left foot/ankle "tibial torsion" or rotation outwards. The Gait Guys commented on this in 2010 for me- although their response was on their previous website and is now gone. My foot seems to be stuck and angling out more, the left side of my knee is also "stuck" and has a twisty feel to it, and because of this my femur doesn't feel right in my hip (where I was operated on), and my lower back gets tight. I have been stuck in this position for over a month now and nothing I do gets me out of it. The Gait Guys had a post last week on an external rotation in the foot. I couldn't answer on their blog, but I did have a Facebook conversation with them on this post. It was an interesting post as the externally rotated foot was seen as a "brain issue" where the brain maps out what is the best position in space for a body part to work in it's perceived "best position".
It is quite possible and reasonable to assume that a motor pattern is a natural mechanism for joint and multi-joint protection. Consciously trying to alter a motor pattern is likely to drive an improper pattern or one that is deemed unstable by the brain.
Scenario: client has right foot spun externally into the frontal plane by 15 degrees more than the opposite side.
In this scenario, this could be the reason why merely attempting to turn inwards a right foot that has drifted its way in time outwards does not hold even though it is clearly a deviation from symmetry. It is likely the fact that the brain, in such a scenario, has calculated that there is not sufficient stability in a more neutral symmetrical foot progression angle and thus has found the necessary stability in a more turned out position. As we have always said, subconsciously turning the foot outwards helps to cheat into the frontal plane, likely because that plane is less stable with a neutral foot and with the foot “kickstand” turned out, stability is achieved. Thus, engaging the foot better in that plane gives the brain and body the perceived and actual stability that it feels it needs to more naturally provide joint or multi-joint stability. (read more)
So I wanted to know "what to do about this"... and I was told firstly that,
"The labral tear does not surprise us and the "wanting to turn the foot out more" is most likely a compensation to avoid internal rotation of the hip and impinging on a labrum that isn't there. The fix depends on the etiology: does it start at the foot or is it from above down?"
Ahh, the question I have been asking for years! Their suggestion for me was to visit Tom Michaud who is a chiropractor in Newton and who has worked on many runners including those of international stature. It seems Tom Michaud just published a new and well-received book this year called Human Locomotion.
In the course of a year, more than 1.9 million runners will fracture at least one bone and approximately 50% will suffer some form of overuse injury that prevents them from running. Despite the widespread prevalence of gait-related injuries, the majority of health care practitioners continue to rely on outdated and ineffective treatment protocols emphasizing passive interventions, such as anti-inflammatory medications and rest.
If you start here and forward ahead to pages 8-9, that is a picture that pretty much looks like how my left leg works. The book is $100 and is written for doctors, so it is not something I would buy, but the parts online sure look interesting as it addresses abnormal gaits and even has a section on labral tears. Do I think this guy could look at the whole picture of what my body is doing? I sure do. So I called to set up an appointment. His office is just down the road from the Newton-Wellesley Hospital where I had my hip surgery and where I am going now to their Spine Center. I got a call into his office yesterday. He doesn't take my insurance, which stinks, but still I wanted an appointment. Seems he is a busy guy. I got the first available appointment. It is for April 19, 2012. Well. that is a bit of a wait!
This weekend I saw another interesting video on the piriformis. I guess since I don't have a back or nerve problem, according to my MRI, that this video is even more important, as I still have an extremely tight or knotted piriformis that can be aggravated by running. I left this comment on the site, because the doctor talks about a link between the piriformis and a foot turning out (hey, my two problems):
Hi Jim, yes I’d say that is exactly what is happening to you. The left foot would be the tight piriformis (could be your psoas too), with the right side being inhibited (“weak”). The twist is really not what is causing the pain, but the piriformis being too tight is causing both the pain and the lateral rotation – that puts a significant amount of stress on your labrum, hence your surgery.
It is interesting learning about the connection between the piriformis and my left foot as well as the resultant labral tear, But I really don't' want to wait until April to see Dr. Michaud or even the end of the month to have an initial visit at The Spine Center. Will they address the piriformis? Is there where I could get a trigger point injection? Will it help my misaligned left side?
On the way back from the hospital, it suddenly occurred to me what to do short term. Today, I set up an appointment with Dr. Dannanburg, the podiatrist who gave me shoe inserts and later orthotics for my functional hallux limitis in my 1st MPT joints. When I first got the inserts in the summer of 2010, my foot felt great, within a week I was doing a 65 mile week, which I soon bumped up to 85 miles. My leg had a new alignment. However, while I continued to run, my left hip got worse and worse till I had a full blown labral tear in less than two months and I couldn't run at all. My feeling is that my foot and leg were tracking better and my left leg couldn't compensate and "hide from" the torn labrum (which it had been doing for years).
I was thinking about my orthotics post surgery, my leg turn-out and misalignment is getting worse. Then I remembered that it just wasn't orthotics or inserts that Dr. Dannenburg gave me. He adjusted bones in my foot and ankles as well as my fibula. So I think I might need him to adjust my bones again, as several bones in my ankle, foot, and where the fibula joins the knee feel stuck or trapped. He doesn't take my insurance either, but he is a podiatrist who is known throughout the world for his work, so I set up an appointment and will see what he says and does next week. Hopefully, he can get me up and running again with his manipulations.
So it is all about problem solving. I can't tell if there is an end in sight, but I will keep trying to figure out how to get my body out the door and running pain-free again. Never give up!
by Dr. Thomas Michaud and I have enjoyed glancing through it. It looks like a good book for understanding the injury process and rehabilitation. Dr. Michaud also drew the detailing drawings throughout the book. I would recommend this book to someone who wants to delve deeper into the biomechanics of running and solve running related injuries. No, I have not read it all, nor tried his remedies as presented in the book, but I found he addressed some issues that I have such as femoral anteversion, that I rarely seen written about in other running injury books and I look forward to delving deeper into it.
