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!
I am trying to strengthen my hips and straighten out my stride and mechanics after surgery for a labral tear in my hip. I have been doing PT and hearing and working on the same dysfunctions that I previously had (inward rotating knee and outward flared foot as well as post run glute medius problems), I have returned to The Gait Guys (they have moved their website) to find some interesting videos.
The first shows how to do a single leg squat as well as how not to do one (that collapsing hip and knee!).
How to (and how not to) do a single leg squat, CORRECTLY ! Here Dr. Allen has one of his elite marathon and triathletes demonstrate how to correctly and incorrectly do a single leg squat. The single leg squat can show many of the pathologic movement patterns that occur in a lunge. The single leg squat is more difficult however because it requires balance and more strength. Many people do not do the single leg squat correctly as you will see in this video. Many drop the opposite hip which means that there is an inability to control the frontal plane pelvis via the stance leg gluteus medius and the entire orchestrated abdominal core. Most folks will drop the suspended hip and pelvis and thus collapse the stance phase knee medially. This can lead to medial knee pain (tracking disorder in the beginning) , a driving of the foot arch into collapse and impingement at the hip labrum. We know that when the knee moves medially that the foot arch is under duress. This problem is often the subliminal cause of all things foot arch collapse in nature, such as plantar fascitis to name a common one. Remember, optimal gluteus medius is necessary here. And the gluteus maximus is working to eccentrically lower the pelvis through hip flexion. So, if you do not consider the gluteus maximus a hip flexor then you are mistaken. Everyone thinks of it as a powerful hip extensor and external rotator. But do not be mistaken, in the closed chain it is a powerful eccentric controller of hip flexion and internal hip rotation. We are The Gait Guys, Shawn and Ivo (visit our blog daily at http://www.thegaitguys.tumblr.com)is/ some more information that they added:
Now, Lets take another look from a little different perspective....
Watch carefully. Did you pick up the bunion forming on both feet (Hallux Abducto Valgus)? This tells us that this individual has a faulty foot tripod, and is not able to get the base of the first metatarsal to the ground (remember the tripod is the base of the 1st metatarsal (big toe), the base of the 5th metatarsal (little toe) and the center of the heel). As a result, the muscles which are supposed to be assisting in forming the longitudinal and transverse arches are pulling the big toe (hallux) laterally. This also means that the medial side of the tripod is collapsing and unstable. This can be seen at :05 as she descends into the squat. You will also notice that this drives the knee medially and is causing some collapse of the arch. You also see the big toe flexing to try and create some arch stability through the flexor hallucis brevis.
As Dr Allen Points out, keeping the arch stable requires core stability, muscular strength and good proprioception. It also requires adequate flexibility (ie Range of Motion) of the 1st ray complex (the proximal and distal phalynx of the great toe and the 1st metatarsal). This range of motion can be seen from :12 to :20 and again from :42 to :51
Dr. Shawn Allen of The Gait Guys discusses Gait Biomechanics again, this time pure hip biomechanics and how it applies to gait and running and compensation patterns. This is Part 1 of the Hip Biomechanics. This is essentially applied biomechanics.
In this second installment of applied hip biomechanics, Dr. Allen of The Gait Guys delves deeper into a complex topic and attempts to bring it to a level that everyone can understand and implement. Here he talks about the hip mechanics in relation to pelvic stability and gait. It is our goal to share as much of our collective 37 years of clinical experience as we can in a medium that is usable, friendly and understandable to all viewers. Thanks for taking time out of your busy lives to care about watching our videos. Shawn & Ivo, ....... The Gait Guys
I have read a lot about the mechanics of the hip, but these videos are starting to give me a clearer picture of exactly what is going on. Dr. Allen helps demonstrate the workings of the hip in an easier to understand way. Here is another set of three videos showing you how to engage your glute medius and abdominal muscles to create a pattern for correcting form patterns.
Here Dr. Shawn Allen of The Gait Guys works with elite athlete Jack Driggs to reduce a power leak in his running form. The Cross-over gait is a product of gluteus medius and abdominal weakness and leaves the runner with much frontal plane hip movement, very little separation of the knees and a "cross over" of the feet, rendering a near "tight rope" running appearance where the feet seem to land on a straight line path. In Part 2, Dr. Allen will discuss a more detailed specific method to fix this. You will see this problem in well over 50% of runners. This problem leads to injury at the hip, knee and foot levels quite frequently. To date we have not met anyone who had a good grasp on this clinical issue or a remedy quite like ours. Help us make this video go viral so we can help more runners with this problem. Forward it to your coaches, your friends, everyone. Thanks for watching our video, thanks for your time. -Dr. Shawn Allen, The Gait Guys
Here Dr. Shawn Allen of The Gait Guys further discusses this gait problem in running form. The Cross-over gait is a product of gluteus medius and abdominal weakness and leaves the runner with much frontal plane hip movement, very little separation of the knees and a "cross over" of the feet, rendering a near "tight rope" running appearance where the feet seem to land on a straight line path. In Part 2, Dr. Allen will discuss a more detailed specific method to fix this. You will see this problem in well over 50% of runners. This problem leads to injury at the hip, knee and foot levels quite frequently. To date we have not met anyone who had a good grasp on this clinical issue or a remedy quite like ours. Help us make this video go viral so we can help more runners with this problem. Forward it to your coaches, your friends, everyone.
Here Dr. Shawn Allen of The Gait Guys summarizes this gait problem in running form. The Cross-over gait is a product of gluteus medius and abdominal weakness and leaves the runner with much frontal plane hip movement, very little separation of the knees and a "cross over" of the feet, rendering a near "tight rope" running appearance where the feet seem to land on a straight line path. In Part 3, Dr. Allen will discuss a more detailed specific method to fix this. You will see this problem in well over 50% of runners. This problem leads to injury at the hip, knee and foot levels quite frequently. To date we have not met anyone who had a good grasp on this clinical issue or a remedy quite like ours. Help us make this video go viral so we can help more runners with this problem. Forward it to your coaches, your friends, everyone. Thanks for watching our video -Shawn and Ivo......The Gait Guys
Just be careful about how much work you do!
Update:
This new book from the author of The Entrepreneurial Patient blog is a must read book for anyone with hip problems and is thinking about about arthroscopic hip surgery or has had arthroscopic hip surgery for a labral tear or FAI.
As soon as Dr Baroody mentioned that I had a condition called Hallux Functional Limitis and an inverted heel, I went online to find out everything that I could. One place that I went to was "The Gait Guys" website.
THE source for progressive and innovative gait analysis, performance and rehabilitation information.
I embedded one of their videos on my post on inverted heels, but I had a question, so I asked it in their forums. Dr. Ivo Waerlop, one of the Gait Guys, was kind enough to repsond and gave a pretty thorough and technical observation of what he saw going on with my feet and legs based on my videos. It is nice to give names to what I sensed was going on, even though I didn't know what it was called that made my feet and legs "not the norm". I guess it all started going awry as I was developing before I was born. Thanks Mom! He then goes on with more descriptions after observing pictures of my feet. I guess my feet and stride are even curious enough that they may make a teaching case from my videos and photos.
I do know one saying that I really dislike and I have heard it constantly in one form or another from my earliest days of running. It goes something like this, "Running is 10% physical and 90% mental." I always think that this quote is very wrong in implying that good running is basically a case of who is the strongest mentally. I would disagree, you need to be born with a good set of wheels if you want to be good! Everyone does not start out on equal footing (or with equal feet). It is what you do with your wheels that forms the mental part.
I appreciate Dr. Ivo's responses and look forward to seeing what I can still do to improve my mechanics and functioning. That along with the quality care I am now getting from Dr. Baroody and the insoles from Dr. Dananberg might mean I may be able to get a few more years out of these legs, and hopefully do so with an improved economy and efficiency.
How are the new insoles going? I got them Tuesday and wore them all day. I ran the Lowell 5K about 20 seconds slower than the previous week, but once I started running my left sacrum started seizing up. Wednesday I wore them again all day and at the track my left glutes were really stressed and sore. The workout was a struggle as I think my left glutes were starting to do work for a change. This is the side that the PT said my glute medius was very week on, as well as my hip flexor being tight and weak, and so I was using my TFL to compensate. Well these muscles were getting really sore, particularly the glutes. This morning it was again tight and sore. I ran 8 miles slowly. I almost turned home after 100 yards as it was difficult to move. Halfway through the run, things loosened up a bit. My feet seem to be very stable on the ground and my toes appear to point straight ahead. I don't have as much twisting and turning. I noticed that my feet roll across the ground and after awhile I realized that I was extending my leg behind me more and actually getting a push-off. I had another ART treatment today that worked on the muscles that had tightened up in the hips, back, and noticeably the hamstrings, so I hope things start settling down and working together for an improved stride.
I do like this video, "What Can The Single Leg Deadlift do for you?" that Frank Snideman posted here. The forum discussion where I found it is here. I think it can be very important for my strengthening at this time and I find it much easier to do these types of moves with the balance that is restored to my feet with the new insoles.
I am putting up a few posts basically for myself as I try to figure out things I am learning about my feet. In this way I can check back and see what works and doesn't work and keep track of my thinking. Please skip over if you are not interested, but sometimes people find my stuff on the web and offer really good suggestions or are also looking for similar answers to biomechanical issues.
Last night I posted what I am learning from the Active Release doctor who I am currently working with. My left foot is a problem foot and he gave words to the strange things that my foot does that affects my stride, hip, and back.
Basically he said the left foot has an inverted heel, which causes the foot to suppinate and then I have something called functional hallux limitus which means the forefoot goes into a severe pronation because the bog toe and metatarsal do not work and contact the ground correctly. Thus I have problems.
Here is what I have found on inverted heels (besides some crazy dance step). It comes from Carson Boddicker, whose blog I have been reading for the past few months (see "My Blog List" to the left). He gives some exercises and drills (some using a wedge that I have not tried as I am relying on the therapy I am undergoing now).
Following ankle injury, a positional fault is often observed in subtalar joint position, which is locked into inversion known as rear foot or subtalar vars Rear foot vars is when the position of the foot is inverted relative to the ground in subtalar neutral.
Given the body’s remarkable ability to adapt, it can attempt to shift the position of the talus to compensate for an inverted calcaneus. In observing the rear foot, a compensated rear foot vars will appear perpendicular in subtalar neutral but averted in standing (left). Uncompensated, it will appear inverted in both ranges of motion (right).
With the subtalar joint in inversion, the foot must pronate more to clear the heel from the ground. Once clear, the foot is forced to rapidly supinate to be effective in propulsion, creating a whip-like effect, which has been implicated in Achilles’ tendonopathies. Additionally, the first ray of metatarsals becomes an inadequately stable base for propulsion (remember the joint by joint approach) and the big toe begins to lose mobility.
Finally, remember that the subtalar joint translates this rotation (pronation) to the tibia and the tibia translates rotation higher in the body. Excessive relative internal rotation of the foot, tibia, and subsequently femur can cause femoral head position changes and scarring of the deep hip rotators. This can ultimately lead to a grab bag of pain and pathology of the knee, hip, and low back.
I don't know if this is an accurate description of half of my foot's problems, but it sounds right.
Next up is an excellent descriptive video from "The Gait Guys" which descibes rearfoot varus, which I think is the same thing as an inverted heel.
Finally, I am putting up (hate to do this) some videos the chiropractor wanted of me running. It shows my stride Tuesday (after one day of ART treatment) and after an 8 mile run. It shows the weird things my left foot and leg does even at a slow jog. I would guess it looks much worse at a faster pace.
Now you can see why running is so much fun for me!
Here's a link to the stretches for my feet and ankle that the chiropractor says I should do. The first is pretty much a Z-Health Toe Pull. I now have better informed instruction on how to do it. The tops of my toes are really stiff.
Now about jammed joints and how I seem to get relief from hip problems when the joints in my feet are mobilized. Here is a video on the arthokinetic response showing how a jammed foot joint affects the glute medius muscle (the muscle that the postural restoration therapist said was one of my weakest muscles on the left side).
I also posted about Z-Health and jammed joints here, where Dr. Eric Cobb (Z-Health) demonstrates the affect of jammed joints here. Mike T. Nelson of Extreme Human Performance (blog on my list to the left) wrote about jammed joints here.
