Hitting ReStart: When in doubt always go back to the feet!

After nearly one month of not feeling right and barely running and just feeling like I was wasting time on Stand By mode, I have hopefully found a Restart point again as well as a new perspective of how long it may take to recover my stride. Last week's mileage was minimal again. After running 3 miles on Sunday, I did the same thing on Monday. I ran 2 miles on the trails, did a lunge matrix and other mobility and stretching moves and then went to run the mile back to my car. The glutes started tightening up again, so I walked it in. I knew deep down what was wrong, but I am trying to do one thing at a time to see what works and doesn't work and at this time the trigger point injections from the previous week did not do much. When things started going south a few weeks back as I was upping the mileage, the glutes were the obvious thing giving me pain, but I also noticed my left foot was pointing  out to the side more and not landing correctly on the ground. In the past couple of weeks I tried everything to fix it: rest, different stretches, mobility exercises, massaging or pressing on tight spots on my lower leg, but nothing would fix the rotation around the ankle joint  or the stressing of the muscles, joints, and fascia going up the left side of my body pulling and pinching.

I then got an another appointment with podiatrist Dr. Howard Dannanberg to have him do adjustments on my lower leg and foot. The last time he did this back in December it helped bring that foot rotation under control. Friday, I went in and had the simple adjustments to my stuck fibula and then to the cuboid bone. It was over quickly, but Dr. Dannanberg knows his stuff and works magic on those bones. I get pretty much instant relief and then it takes a couple of days for the muscle tissues to readjust and finish calming down.

According to Dr. Dannanberg the bones just get stuck and or get out of position. There doesn't seem to be a real stressor that "makes" that happen and not much I can do, except come back when it happens again. He does say that in time it will take more and more time between adjustments until I won't need it done again. It does seem to be the best magic bullet I have to get things back into the best alignment that I can.  I guess next time I notice the glute pain coming on along with the joint and muscle pain, I need to look down and see where my foot is pointing as well as notice that my foot cannot roll on the ground properly, then I need to make a phone call as soon as possible to get those bones manipulated back into position.

I lost a lot of my enthusiasm for getting back into shape as quickly as possible with this setback and realized that I may not be ready for 40-50 mile weeks just yet or trying to get into some sort of racing shape by the summer. I think this is going to take longer than I thought, so I don't want to blow it by being too ambitious. Dr. Dannanberg told me the same thing. I need to tone it down. My bones may be fine, but it takes a long time for the soft tissues to catch up. He thinks I should stick to 20-30 miles per week with runs between 3-5 miles for another six months. This is hard as I think an 8 mile run is a happy run, but I see the sense in being patient even when I don't want to be patient. I need to start cranking the kettlebells more again and take out my TRX and must work on overall strength and fitness instead of jumping into the marathoner mindset.Maybe I can throw a little speed in there too.

I ran 3 miles after my appointment and then finally decided what training shoes to get so that I can do my best running in the next few months. The four shoes I have used running since the operation in July are unusual shoes: the Skechers GoRun, the Altra Instinct, the Hoka One One Bondi B, and a 5 year old pair of extremely worn out Asics HyperSpeeds. Most people might consider my shoe choice quite interesting, but I won't spill the beans just yet. It took a lot of thought and experience of using the different shoes with and without orthotics over the past two months. I got the new shoes on Saturday and ran 4 miles in them on Sunday and am pretty much pleased with my choice!

Total miles for the week: 9 miles

Dr. Dannanberg also told me to try this topical creme on my muscles and joints pre and post run or when my muscles are tight. It is called Motion Medicine and it looks like he is introducing it here in the USA after discovering it Canada. Dr. Dannanberg is a very smart guy who knows his stuff so I am giving it a shot. Strangely enough, when my foot is tweaked to the outside, I get really tight all up my leg and lower back. The night before seeing Dr. Dannanberg, I spent an hour or two not sleeping and using a stick and foam roller on my quads which had somehow tightened up despite not exercising for a few days. I think it is a chain reaction effect from one thing being tight and passing it on upstream as that leg goes out of balance. I haven't used anything on my muscles like this for years (could have used it the night before), so I will be interested in seeing how it works for me. It has a camphor oil smell-so yes, you will get noticed if you use it out in public, and it goes on cool and then is supposed to feel warm. It doesn't overheat if you run with it on. I tried that with a Capsaicin based creme once right before a run many years ago and boy did things heat up to an intolerable level! Never used that stuff again!

Here Dr. Dannanberg explains how he was introduced to Motion Medicine and how it works.



For some additional perspective on injuries, one of my favorite long-running threads on Letsrun.com is the "loss of coordination in leg" thread started in 2006. I started chiming in back in 2007 before I even started this blog. It is where I first met other runners with similar problems as mine and we shared all sorts of ideas and information. I first heard of labral tears on this thread. Last week there was a sobering thread by a poster named "tumor". I am TDF on the thread. Tumor talked about the symptoms he had the led to a scary problem:

A couple of years ago I started to develop some scuffing in my left foot. I also found myself tripping while I ran in the trails. I would also find that my big toe would tingle or occasionally go numb. I also had three stress fractures occur in my left shin two years ago. The doctor took an MRI of my lower back two years ago and they felt it was a pinched nerve at L5. 
Fast forward to this past summer I found myself scuffing and an increasing pronounced foot drop. I asked to have another MRI and all looked good. The doctor agreed to take another MRI further up my spine and they found an egg sized tumor in the upper thoracic spinal canal. I went in for surgery to have my tumor removed and thank god it was not cancerous. I was left paralyzed from the waist down and rehab has been going well and there is hope I may be able to walk and possibly run again. My recommendation to anyone with loss of coordination is to make sure you advocate for yourself. The neurosurgeon told me that if I had not pushed for the another MRI of the upper spine I might of had only another month and it would of left me completely paralyzed from the waist down.

Sunday morning, an article on the local newspapers website caught my attention. I realized that I knew who Tumor was. He is a local runner, teacher, and coach and the article tells more about what happened to him. I am very glad Art found the tumor in time and wish him the best on his recovery. You can't complain about your own injuries when someone you know is dealing with so much more.

 I think about how valuable the internet is for runners and other people to share and learn from each other. I know I would be completely retired from running if I didn't' do the diligence to find out what was wrong with my leg and hip.  We also get to meet people with similar problems and offer help and advice to each other in many ways like on message boards. A runner named Sue has written back and forth at times with me before and within hours after my appointment on Friday, I got another email that was just spot on! She is working through problems with the ankle joint like I am and has a similar stride. She mentioned getting foot mobilizations and that she was doing Somatic exercises too! I liked the line she sent, "When in doubt always go back to the feet!" That was perfect after realizing the same thing hours before. She also sent some Somatic foot movements that were simple and just what I needed for exploration, so thanks, Sue! We'll get this thing licked sooner or later!

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.

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!

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.
XOZTCATPREZ

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.

XOZTCATPREZ

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).

Higher Mileage

Good mileage this week for a total of 73 miles:
Sun 8
Mon-8
Tues 8 + 5k race
Wed 8
Thurs 13
Fri 9
Sat 16

I am slowly adjusting to the new insoles, but here is the peculiar thing; when I went to Dr. Dananberg to get the insoles for Functional Hallux Limitis, he said in passing that I had a shorter left leg. I told him that I have always had a shorter right leg (measured by many doctors from junior high and on) and then just let the comment pass as he is the noted podiatrist. Two days ago though, I noticed that he had glued a post on the bottom of the left insoles of about 1/4 inch. I didn't know he did that, but the funny thing is, I feel more stable and balanced with the insoles and the lift. He never measured my legs, he just used his observations, but who I am to argue if it works. Maybe it has to do with a more "functional" difference under walking and running conditions. I am still running slower than I would like, but it is nice to start getting the mileage up and the more I ran this week the better I felt.

Here is an intersting improvement on the hip flexor (psoas) stretch by Mike Boyle author of Advances in Functional Training: Training Techniques for Coaches, Personal Trainers and Athletes. You will find this stretch in the book, along with the advice to treat the soft tissue (I am getting ART), to stretch (like with this stretch), and to strengthen (he suggests doing seated psoas contractions with hands behind the back to maintain the lumbar curve and seating high enough that your feet don't touch the floor. Then begin with three ten-second holds and work up to ten X ten second holds).

"The Gait Guys" Offer an In Depth Report

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.

Functional Hallux Limitis

Functional Hallux Limitis. That is the name. Hopefully I have the fix. I have been trying to get my hip, back and stride fixed for too many years. I now have a name for what has been causing my imbalance, form, functioning, and pain problems. I have to give kudus to Dr. Baroody for identifying the problem. Well, actually I believe it was identified 20 years ago, but I did not understand the issue and could not afford the treatment. Twenty year after seeing Dr. Dananberg the first time, I went back again yesterday. He also identified the Functional Hallix Limitis and fit me in a pair of the Vasyli-Dananberg insoles specifically engineered for FHL. The product is named after Dr. Dananberg as he is known worldwide for his work with FHL.

Named among the most influential Podiatrists in America by Podiatry Management Magazine, and is a founding member of the new Vasyli Think Tank™.



Howard is renowned for his work in the development of the concepts associated with Functional Hallux Limitus. His published articles on Sagittal Plane Biomechanics, his patented Kinetic wedge and work on gait-related back pain is recognized world wide.

Here is a great article which explains FHL, the compenstations the body "invents" in order to "work", and how the insole restores proper function. Dr. Dananberg did not really discuss FHL with me in detail, but fortunately I had done my homework so I knew what he was talking about and referring to as he checked out my feet.



The good news is that he feels that this is treatable with his insoles and I can decide later if I need a more specialized pair of orthotics built up for me. He wasn't worried about the pain over my right big toe. I have had this for about four months now after every run and I was worried that my toe may be going to a more rigid diagnosis that usually leads to surgery. I was very much  thinking he might end up telling me my running days were over. He was not concerend with this at all which puts me at ease. He also said the inverted heel is probably a result of the FHL and things should improve. I am thrilled and hope the insoles really work. They do feel good (they were heat-molded to my feet) and the cutouts and shape very much give my feet balance when standing and certainly let my feet "roll" forward as I run. They are not miracle workers as I used them in the Lowell 5K race last night and was about 20 seconds slower than the week before, but if they allow me to run without the imbalances (over time) then I can get my mileage back up and my race times down. Most important I want to get my running stride back so that I can enjoy just running again instead of trying to constantly figure out what is wrong and how to fix it.

With FHL, the first metatarsal joint does not function correctly. The 1st MTP joint is the joint leading to the big toe. When you stride forward all of your body weight is supposed to hinge forward over this joint and it is suppposed to support your foot and body and raise your heel through the gait cycle (or this is how I understand it). Unfortunately if you have FHL the 1st MTP joint cannot do its job and the body attempts all sorts of compensations to try to correct itself. I have noticed this problem through the years and explained what I thought was happening in my foot to many experts, but I guess no one was informed enough on this condition until Dr. Baroody identified it. I have tried many remedies on my own because they "seemed" to make sense such as cutting out an insole under the 5th (little toe) joint to try to balance the bottom of my foot or running with wedges under the 1st metatarsal and big toe to try to give them support so my foot wouldn't  cave in.  My intution was correct, but maybe not the remedies! With the new insoles an area is cut out underneath the 1st MTP joint which allows it to descend so that the 1st metatarsal head can plantarflex which allows the 1st MTP joint to dorsiflex.

I think what this means is that with the insole my feet can now support my stride. With FHL your 1st MTP joint cannot work properly and so your toe cannot get involved with the stride either. My main compensation on the left foot was that the 1st MPT joint would collapse on contact with the ground giving me no support. The foot would then severely pronate over the toe and evert my foot out to the side throwing off my stride and giving me the constant hip and back problems. On the right foot the pronation wasn't as pronounced, but the joint and toe still weren't doing their job as the toe would stiffen up when bearing weight and again giving me no push off. Dr. Baroody also explained that this is why I have a mutlitude of stiff muscles. That is bad, but it was somewhat good as my body was doing whatever it could to achieve a running stride and protect itself and make itself work in my own unique way. Besides the ART treatments for my muslces, I am hoping that the insoles will take the stress off many of my overworked muscles and allow them to release and function properly.

Dr. Dananberg's article describes walking with FHL as akin to walking with swim fins on your feet. Since the body can't properly go forward with the fins on, it is like stepping upwards with no propulsion forward or a mechanical stride. He suggests four compensations that the body will do to achieve a gait. One, a midfoot collapse with delayed heel lift (the PT did say that my left stride was slower than my right- this is the side with most of my symptoms). Number two is an absence of heel lift during single support phase that can lead to balance problems. Three is inversion compensation (I not sure if this is similar to the inverted heel that Dr. Bardooy suggested). The fourth symptom is abducted compensation. As Dr. Dananberg descibes, when the forward motion over the toe joint is blocked then the foot will find the least path of resistance in order to move forward, So the foot pronates and twists and the effects of that go up the alignment of the skeleton. I certainly hope that the insoles do what they are supposed to do and my body starts fixing itself. My feet feel "strong" under the metatarals for a change once I put them in my shoes and my left hip also felt stronger and in a better position. Let's hope that those are good signs.

Dr. Dananberg also did some manipulations of my feet and ankles to restore lost motion and free restrictions. In these videos he is seen doing similar manipulations and other manipulations. These are to be done by an expert, I am only showing them because they are interesting.

An Opportunity Missed?

Twenty years ago, soon after I moved up to Nashua, someone recommended to me that I visit a podiatrist named Howard Dananberg. He was noted to be a top notch podiatrist and I was having terrible back problems from my 5 years in triathlons. I went for an initial visit, but it was going to cost over $1000 dollars further and I could not afford the price. I went to a local podiatrist instead who refurbished the old pair of orthotics I had used off and on with no success for about 5 years. They still didn't do much for me after that.

I recall Dr. Dananberg telling me something was wrong with my forefoot, but I can't recall what it was. He taped up my feet in a special way and I ran great for a couple of runs until the tape fell off. Still, I could not imagine how the front of my feet and the way they lined up could possibly affect my left lower back (and no way to research online either). I have since seen Dr. Dananberg's name repeatedly over the years in all sorts of studies and references. He is a very well-known podiatrist. I have often wondered what would have happened if I could have afforded those orthotics and recieved his care those 20 years ago.

I tried orthotics again a little over 10 years ago. That did not go well either. While they were comfortable, they seemed to make my "supposed" leg-length difference worse. Even a local chiropracter was speechless when he tried to x-ray me with and without the orthotics. When I put a heel lift in my right shoe under the orthotic, the x-rays showed the right leg getting shorter. He could not figure it out. Two months into wearing the orthotics, I ran the Cape Cod Marathon. My legs felt balanced only when I added a heel lift to the right shoe, and by then I had over 1/2 inch of extra lift under the right orthotic, and my back couldn't handle the stress. I was holding my right lower back rigid and tight the first 16 miles of the race. Then I grabbed a drink of water and relaxed, immediately my back went into severe spasms and I was out of the race and running for many days. That was the end of wearing those orthotics!

I have tried the minimalism thing for the past few years, but there is still something wrong with my feet, hips, and back. When I first went to Dr. Baroody (the ART doctor)last week, he said that both my feet have "functional hallux limitis" and my left foot has an inverted heel. I have been trying to research both of these issues. I can't find much on the inverted heel, but there is a lot on functional hallux limitis. The other day I googled Dr. Dananberg's name to see if he still practiced in the area and found out that...

"Howard Dananberg, is renowned worldwide for development of
the concepts of Functional Hallux Limitus and the relationship of
gait style to Chronic Lower Back Pain."

I found a very recent video where Dr. Dananberg describes this condition in an easy to understand way.



I also noticed that there is an insole which is named after him that is supposed to manage the condition (see video). I decided to call his office to see if they sell the insole "off the rack". I explained that I had been in 20 years earlier and the price I was quoted (that I could not afford). I was told that at that time Dr. Dannanberg probably wanted a specific and costly gait analysis done and that he doesn't need to do that anymore. When I asked about current pricing, it was like $120 for an initial visit (comparable to 20 years ago)and that the insoles would be about $150 unless I needed some posting done. Different orthotics would be about $480. That is not much more than the orthotics I had 10+ years ago from a no longer remembered podiatrist. Well, I missed the opportunity 20 years ago and I am not going to do that again when I have one of the most well-regarded and innovatice doctors in the field just miles down the road. I have an appointment set for next Tuesday.

I am still getting ART treatment. Dr. Baroody viewed my videos and saw "lots" of things. Well that wasn't hard to do. He has worked on my tight hip flexors and has now started working on my tight glutes and hamstrings. The funny thing is, I keep reading how ART treatment is supposed to hurt. Just like with the last ART doctor I went to, I barely feel anything but the pressure of fingers. There is no pain and I was watching Dr. Baroody as he kept looking at me in surprise. He was sure I would feel something on some of those muscles, but there was no pain at all. Oh well, that is fine with me!

I did cut out a section of under the first metatarsal on a pair of Dr. Scholls generic plastic insolesas Dr. Baroody suggested. I ran in them Friday for 8 miles as soon as I cut them out (probably not good- I know) and they changed my stride some and fatigued the hip in a different place, but I did not like the high arch on the insoles. I ran 8 miles the next two days, and they made me run slow and I felt real awkward. I stopped wearing them as my whole left side was now messed up and it felt like something was pinching. I ran the Mine Falls race Monday night without them and my left hip was stuck. I ran 20:24. After an ART visit Tuesday morning things felt better. I ran with the insoles in my light Puma K Street shoes in the Lowell race. That felt a bit better and I ran 19:33 for an easier course. My hip wasn't stuck, but muscles were not balanced properly.

Here are some of Dr. Dananberg's artices that relate to Functional Hallix Limitis from the Vasyli Think Tank™ and the insole company.

Here is a Carson Boddicker article on "Mobilizing the Big Toe" and a video.



Here is a Gary Moller video on mobilizing the big toe. He is the older brother of Lorraine Moller, one of the great female marathoners (Olympic medal, BAA Marathon win, ect.)