The popliteus muscle and functional hallux limitus

This is just a quick post for myself before I go for a new and welcome appointment tomorrow. I think I have clarified a lot of my thinking lately and I want to see how right I am. The really really good news is that in the last post I wrote about a doctor who I was told I should go see. I got an appointment, but he is so busy that my appointment wasn't going to be until the end of April. Well he found my blog post and emailed me to offer me an appointment this Saturday as he was going to be in the office doing paper work. Well, isn't that the greatest? I also had a running friend email me as he has been a patient and he also says that he is the best and definitely who I should see! I can only say that I am very fortunate to find a doctor who is very eager to fix problems and to make time to see a new patient. That is quite exciting. The rest of this is more boring stuff, and mostly for my reference, but you never know who may read this and offer some insight or get some ideas to help figure out their own biomechanical problems!
So my hip has been fixed and an MRI ruled out a back or nerve problem so what is up? And what is the etiology, or cause, of my messed up mechanics and problems running. I am going to write what I now think and I then want to compare it to what the doctor says tomorrow, but most important for me is what to do about it all and I think I have found the right doctor to do that!

Last week (after a month of feeling my left lower leg was pointing out more to the side and creating instability on my whole left side) I did some massage on the back of the knee and upper calf. It started feeling better and lining up better. I asked my PT about this and she said it is the popliteus muscle and that muscle can rotate the lower leg out. She then did Graston and deep tissue massage on this and the surrounding muscles. My leg felt better than it had in over a month. I also noticed, however, that when I stand or walk, my big toe really doesn't touch the ground and when I walk or run that left foot awkwardly shifts from from the outside to the inside rotating my foot and lower leg out to the side to try to get that toe on the ground. I also noticed that I have no foot tripod on my left foot (I was aware of this before) as when I  pronate forward the 1st MTP joint gives way and collapses without supporting my foot. The joint and toe is there, but it is almost like it is cut-off and doesn't do what is supposed to do and just gives way.There is a name for this phenonena and it is called functional hallux limitis and I do have orthotics for this, but they seem not to work correctly anymore. So I took out the orthotics ( a cutout under the 1st MTP joint is supposed to preload the joint so this doesn't happen) and instead put a wedge under the big toe which is supposed to do the same thing for the toe joint but in a slightly different way. It is called a cluffy wedge and I bought a set before I got the orthotics made, but I never really used them as I had orthotics. I used them and had a great 8 mile run on Saturday (my only run of the week) and my foot felt much better (of course I got sore muscles from going so far with a change in what I had inserted in my shoe and using a regular insole instead of an orthotic).

So I think that my big toe is the source of my problem.s With functional hallux limitis the big toe joint doesn't work and the foot can't propel itself over the toe, so it finds an new way to do this through pronation. Over time the pronation then forced my foot to point out and that created havoc with my knee (the poplietius muscle). This created the inward rotation at my hip which caused the hip not to work correctly which led to the back pain on the left side for the past 25+ year and the labral tear in the hip. In other words I think the problems start in my toe. Now the question is can we finally fix it and retrain my muscles to work properly. I will be most interested to see what the doctor says tomorrow.

I was also supposed to see the podiatrist who is renowned for his work with functional hallux limitis and made my orthotics this week. I somehow got lost and missed the appointment, which is too bad, because I was looking forward to his thoughts and to get the manipulations on my feet. I have an appointment next week if I need it.

This is my podiatrist showing one of his manipulations for the popliteus:



soft tissue treatment of the popliteus



more on the popliteus and its role as a knee rotator- also ways to strengthen the popliteus



how the cluffy wedge works



My current orthotic works like this with a first ray cutout:



Here is my PT showing a big toe mobilization that I have started doing:




Here is a TRX guy showing some toe joint manipulations:



Here is his explanations for the big toe joint and if I am right explains a lot of the compensations my body has created over the years:

Often overlooked, the big toe is not a big joint (metatarsophalangeal joint) but vital for performance and non dysfunctional movements. Mobility is key in locomotion and reciprocal patterns with the feet like the lunges in all planes of motion. Compensations will happen when motion can't occur in this part, which can give other dysfunctions higher up in the chain, muscle or joints or both. Proper gait pattern requires ability to flex the knee to 40 degrees, the dorsiflex the ankle at minimum of 20 degrees, and to be able to extend the first MTP joint to a minimum of 65 degrees (Oatis, 2004). The inability to extend the first MTP joint due to joint degeneration, structural change, or general restriction is commonly known as hallux limitus and is often seen in running athletes who wear traditional running shoes (not all but many of them). This range of motion is very important in the grand scheme of the "Windlass Mechanism" , which is a passive loading mechanism that occurs as the calcaneus clears the ground in late stance and the weight transfers over the heads of the metatarsals. Combined, these motions load the plantar fascia and intrinsics of the foot that help to transform the foot into a stable lever off of which to push (Fuller, 2000). As demonstrated by Carlson, there seems to be an incremental, linear relationship between hallux dorsiflexion and increased tensile strength of the plantar fascia (Carlson, 2000). As you know, the plantar fascia and Medial Longitudinal Arch are capable of producing a great deal of elastic return in running, so imagine the detrimental effects when this mechanism cannot function well. Those with reduced hallux extension and pronated feet often have diminished effects of this mechanism and ultimately less efficient (Dananberg, 1986). When the big toe does not extend well during late stance, plantar flexion torque decreases and occurs in a delayed fashion (Hall, 2004), knee flexion increases (potentially as a result of tension from the distal end as the calcaneus raises early), and hip extension decreases. To compenstate, there must be an increased drive of the hip flexors to advance the leg. When the foot is fixed upon the ground, this contraction creates potential for lumbar rotation and lateral flexion can occur stressing the intervetebral disks and potentially leading to low back pain and dysfunction (Kapandji, 1974). Add to that the possibility of the body compensating with an anterior tilt to facilitate hip flexion and you have a gamut of issues that sounds a lot like the makings of Janda's lower crossed syndrome with excessively toned hip flexors, inadequate gluteal strength, and possibly an increased full body anterior tilt placing the plantar flexors under excessive load. It is very common in the running world. Additionally, the early knee joint flexion and limited extension of the hips can beget a loss of transverse plane stability possibly as a result of ineffective use of the "screw home mechanism" at the tibiofemoral joint and ineffective activation of the hip extensors. Put all of the above together and you have a recipe for increased forces at the PFJ, shearing across the iliotibial band, potentially increased contact pressures at the anterior hip capsule, excessive activation of the deep hip rotators forcing the hip into a hyperextended position causing decreased sacral rotation during gait, low back pain, and SIJ instability. Clearly, limited hallux extension/flexion/abduction is not something to be ignored.

Jay Johnston's General Strength Progression

Coach Jay Johnston has 5 videos online which detail his general strength progression for runners. They originally appeared in Running Times magazine. Jay says, "The General Strength progression below is the content that I most frequently forward when answering questions on how to improve your running." You can find his post with all 5 videos here. The Colorado mountains in the background are just magnificent. Here is the first routine




These directions are pretty simple and I wish I knew and practiced this stuff years ago. The short routines that Jay presents are certainly worth the effiort and he suggests doing them post run. I have worked through the first routine a couple of times now. His lunge matrix is another valuable routine that I hope to be able to start again soon with my hip. Jay recommends doing these before running or any other work.




Coach Jay also put together two DVDs in his Building a Better Runner series. I did a little bit of proofreading work for Jay on them, so I hope you don't find any spelling or grammar mistakes if you watch them! Here I reviewed the DVD a bit. I found that the DVD had tons of good information, but knowing what to do and sorting through the DVD to figure it out was too much for me. If you want to work on your building yourself up using Jay's methods, the general strength progression posted above is an excellent way to start. He has posted a lot of other worthy stuff online. I would recommend the DVDs to a coach, a trainer, or to an athlete how wants to dig a bit deeper into building up their body for running so that they can keep injuries at bay and fun faster.

Detective Work

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):

I enjoyed the video and have a question. You said this about the piriformis: “Piriformis – this muscle extends from under the front side of the sacrum and attaches to the greater trochanter in the upper leg. The major action is to laterally rotate the hip as well as turn the foot out.” I am a long time competitive runner and my left foot turns out so it is not pointing the same direction as the knee. Could this be related to the pirifomis? I do have a lot of problems on the left side including a pain in the butt post runs, I had arthroscopic surgery to repair a torn labrum in the hip this summer, but the foot twisting out is always there (sometimes worse than others). I am curious about the pirifrmis’ effect on this or does the twist create the pain in the butt?

 

Dr. Gangemi wrote this in reply:

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!

Awesome story about getting your legs back!

Well this is an incredible story. It seems a Paralympic cyclist may represent her country in the Olympics after a bike crash miraculously gave her back the use of her legs.

 Monique van der Vorst was paralysed from the waist down and had been confined to a wheelchair for 13 years.

She won two silver medals at the Paralympics by powering a bike with her hands but last year she was knocked off her bike in a crash.

 

What could have led to a serious injury actually did the opposite. Van der Vorst started to feel her feet tingle and within months she was able to walk.

Her recovery was so rapid that she started competing on a regular bicycle - then progressed to a point that has seen her earn one of just 11 places in a top women’s professional cycling team.

Van der Vorst is hoping her form escalates to such a level that she will be able to compete at the 2016 Olympics.

So in one year she has gone from an expectation of competing in the 2012 Paralympics to signing with the Dutch Rabobank's women's cycling team and dreaming about potentially competing in the 2016 Olympics. This is the best story I have ever heard of an athlete recovering his or her stride!

After an accident in 2010 my body started to change and after a long/ hard rehab period I am back on my own feet again! For me a new competition has started now, I don’t know were or when it is gone finish but I will succeed and I will run!

Monique van der Vorst



 

Here is a quick interview where she explains how it felt after the accident.

Dathan Ritzenhein on warming up before a run

I only ran 3 days this week: Friday, Saturday, and Sunday and did 8 miles each run as it was just perfect running weather all weekend. That is 24 miles for the week and the first time I have done 8 miles three days in a row post surgery. I also had an MRI Thursday night for my lower back. It will be interesting to see what the doctor finds. Saturday's run was dicey as I had become a bit lazy about my hip stretches and had not been warming up prior to my runs. Today I warmed up first with my stretches and loosened up a lot more. I also pushed today's run the whole way and took almost another 2 minutes off my best time for the course post surgery, however the time I posted would have been an "easy run" time prior to last year. I guess it is a good reminder to make sure that you warm up prior to your run. Here is a video of Dathan Ritzenhein demonstrating how he warms up his muscles and improves the efficiency of his running form using dynamic flexibility movements and form drills. This is not what I do or am capable of doing, but it is always interesting to see what an elite runner can do.

New York Times Article: Hip Procedure Grows Popular Despite Doubt

There is an interesting article by Gina Kolata in today's New York Times: Hip Procedure Grows Popular Despite Doubt.

It is one of the most popular operations in sports medicine. It comes in various forms, all with the same name: Hip impingement or bone shaving surgery. World-renowned athletes have had the operation — the Yankees’ third baseman Alex Rodriguez had it about two years ago and the sprinter Tyson Gay had it last summer.

Hip arthroscopic surgery is a relatively recent procedure and the doctor's skills and knowledge keeps growing in this field. This summer I had hip arthroscopic surgery for a torn labrum and I was convinced the surgeon would find a hip impingement (cam or pincer) of some sort that contributed to my years of running problems, aches, and imbalances. I choose a prominent surgeon, but one who I later discovered does not treat bone impingements (at least that is what I have heard a few times on the internet). Maybe, my surgeon was a good choice for this very reason. My recovery from surgery was swift and my hip feels solid and is pain free. According to the article some sports medicine researchers are beginning to question if shaving the bone when fixing labral tears is really helpful.

One of the concerns that I had pre-surgery was what the surgeon would find and fix as well as what the recovery would be. There are untold stories of botched surgeries on the internet that would seriously trouble any candidate. As I continue to read forum posts online, so many people still struggle with pain post hip surgery and most of them have had the more invasive bone shaving of hip impingements. This is the group that today's article addresses. I have also read numerous stories of great recoveries from this surgery, where athletes are back up and pain free as they continue to pursue their favorite sport including running. As some of the comments on this article mention, as well as comments on other boards, if the surgery helps you become pain free than it is more than worth it to have it done, even if the long-lasting effects are still unknown or being debated I would recommend getting the best surgeon that you can if you are facing such a surgery. I wish the article had quoted a surgeon like the one I had who will fix the labral tears and other impingements ( I had a synovial  tissue impingement that was debrided during the surgery), but who do not believe in bone impingements as being part of the problem in hips with labral tears. My torn labrum surgery was more than worth it, even though I am just getting running again, it feels good to have a working and pain free hip.



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.

Happiness is an 8 mile run

Well Charlie Brown, there are lots of things that bring happiness, but if you would ever lace up some running shoes you might just find that a good run makes you feel...happy!

This was not the best week for running. I got in a mile at the YMCA on Monday in between work on the stationary bikes. There are 9 laps to a mile and you have to dodge around walkers, joggers, and the occasional kids who is just bouncing in and out all over the track. The tight corners aren't the best for my hip, but I like that I am a bit more agressive with pace. I got it in at 6:55, but I was huffing and puffing like I was going about a minute faster as I aim so out of shape.

Thursday I got in 2 miles on my treadmill, but the next day I was feeling it. I don't think the treadmill gives me enough variety and after every treadmill run I get a bit achy in my joints the next day. It looked like it was going to be another rough week.

I have one new goal and that is not to run when I feel "off" and I was feeling "off" all week. After PT on Wednesday, when I was told what I think is muscle pain could be a pinched nerve coming from a disc problem, I decided to look that up a bit. I found a few articles pointing to McKenzie exercises that look easy enough. Here is a PDF of simple McKenzie exercises. I tried these and they seemed interesting and they made sense as the Sphinx and Cobra are a similar move to what I have been doing with the Foundations Founder and they are much easier. I also found this video that demonstrates a different take on them.



These are easy enough, but I found after doing them that my back and left leg felt a lot better. Sunday, I decided to give running a shot again as it was such a nice day. For whatever the reason, I felt looser than I have post surgery and a lot more balanced. I did my 8 miler and I felt pretty good and I even felt at times that I was floating down the road. I did not get post run tightness and it was my fastest 8 miler post-surgery by 1 1/.2 minutes and on my last two 8 milers I have dropped my time by 3 minutes without even trying. I really enjoyed the run and it left me feeling very happy! It is good to see some progress for a change and my week and outlook suddenly became much better and brighter.
Thursday, I go in for an MRI of my lower back to see if I do have a nerve and disc problem. I wouldn't doubt it and now that I read about the discs and nerves it makes sense from some of the stufff I have experienced over the past years. I know I sometimes feel a twist in the lower spine, and the pains down my leg come and go mysteriously. I would have hoped the labral tear surgery would have fixed me up good, but I created a bit more problems for myself, it seems, over the years.


Here is Dr. Eric Goodman and a co-author of Foundations talking about getting out of chronic pain and that pain is a product of poor movement patterns. He says that learning where the breakdown is, whether a herniation or bulging disk, is a road map towards learning how to change movement patterns, often brought about through sitting. He says a key movement to learn is the hip-hinge. I wish I was aware of this stuff when I jumped into triathlons in the 1980s as I am convinced that is when I started killing my hip and back. I even recall that near the end of that first summer of triathlons that I couldn’t really bend to make my bed as my lower back would hurt too much - and the was the first signal that things weren't going right. I should have learned the hip-hinge at that time. Because my left foot everts out, I locked my left pedal into that toed-out position, which still caused some pain as I kept changing the right-left orientation of my saddle trying to get comfortable. My hip then was jammed further up the chain and due to the angles it did not work right. Did I start developing the labral tear at that time? Because my hip did not rotate properly, the rotation came from my left lower back and I was in constant pain by year 2 of my triathlon racing and that pain stayed with me for the next 25+ years. I am trying to learn, what I didn’t know then, and that is how to move properly. I get worried that sometimes I have done too much damage, but then I get a nice 8 mile run in and it is pure happiness.
 

Dr. Eric Goodman - TedxAmericanRiviera 2011

And here I am doing the 112 mile bike leg of my fourth Cape Cod Endurance Triathlon (full Ironman) in 1986. I could barely sit or stand without pain at this point during a normal day when not exercising, but I knew of no way to stop the pain and insantiy except by quitting the sport.  I didn't and I did one final year. I guess movement is something that brings me happiness, if it didn't, I would have stopped trying to fix things years ago, quit, and become a couch potato, but that is something that I have not enjoyed doing this past year.

Note my race nutrition for the Ironman distance triathlon: a baggie attatched to the handlebars filled with jelly beans!