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.

What is a Physiatrist???

Today I completed only my 3rd run of the month. I wasn't too happy with a doctor today, so I went for a run. The past two weekends, I dusted off my running shoes and went for one 8 mile run to just see if things are improving in my left hip. I haven't run much since the beginning of September (and have gained about 10 pounds-yikes!) and was hoping for a sign that things were getting better. Both runs started off great. My legs and hip felt fine, without the stiffness that I had in the left hip all summer. I was thinking I might be healed.

But about 1/2 mile into each run, the muscle or bone right on the inside crease of where my leg meets my pelvis would start hurting. The inner thigh muscle then would start tightening up. As I ran, the tightness would spread around the inside and then at about 4 miles my glutes would start tightening up like they did all summer. As I ran things would get tighter and tighter all around my hip. Saturday, I had no choice but to stop just 1/4 mile from my house, not because I was tired, but because it started shutting down on me. The next day, after both runs, I would have to fight all sorts of sore and stiff muscles (not running sore-but out of place sore).

After failing to complete two MRIs, I was to see an orthopedist this morning. I was looking forward to see what the next step would be. So much of my malfunctioning hip sounds like a labral tear (what they wanted to check out on an MRI), but I wasn't ruling out a stress fracture, or some other problem. I was expecting to be sent to Boston for an MRI (where they can put you out!) or maybe get a cortisone shot to see if that would help things.

The new doctor did a few tests of moving my joint around, measured leg lengths and then said that she didn't think I have a labral tear at all. She said she looked at the x-ray (which the previous doctor said showed nothing) and said that I have a little bit of arthritis. I always assumed "arthritis" is the "name" given to something that you are not sure of and that you don't want to treat. I guess that was the easy answer. She said I was good enough to run again. "Hello", I have been trying that and something is still wrong. If I could run every day, I most certainly would.

This was a ridiculous appointment, coupled with the fact that I was her first appointment of the day and it still started over 1/2 hour late. She said she would like to refer me to a Physiatrist. She wrote down 4 local names (which I can't even read it is so poorly written). I asked her if they worked with athletes and she said she wasn't sure, but she said I could research it myself if I wanted to find someone different. I don't know anything about physiatrists. It seems that a physiatist is a medical doctor who focuses in on rehabilitation (rather than surgery). They are like a physical therapist but with more training. They treat the whole body and not the symptoms with a lot of different approaches. It sounds good to me, but where do you find one that specializes in sports injuries and if it worked so good, why do I never hear runners talk about them? I see that they also work with accident victims, amputees, the elderly (almost there), and people with other needs so I am not sure that every one has the training, knowlege, insight, or desire to work with a runner that refuses to stop running. I am sure great ones are out there, but is that person nearby and how do I find him or her? I will be working on it, however. Hopefully, I can find someone real good!

So even though it was a lousy appointment and I think I was just gracefully "shown the door" I can only hope that I find the right physiatrist and find a way to figure out what is wrong with my hip and how to fix it!

I could have bought a nice television or an iPad or something really cool, but I got these instead so I better show them off!

On another note, I picked up my permanent orthotics last night (three weeks after getting them molded for my feet). Not only are they expensive (I think that is the most I have spent on any one item in a long time) but they seem really fragile. That could be good or it could be bad. They are the lightest orthotics I have ever had. I had a pair in the 80s and another in the 90s and they were like boats. The base is reduced in size compared to what I have had in the past and they are incredibly light. They feel like they are made out of chalk and that they could break or dissolve in a few days of use. It has a seemingly flimsy covering with the cutouts for my 1st MPT joint (to treat Functional Hallux Limitis). They are extremely light in my shoes and have a different feel than the generic FHL insoles that I have been using since the summer. I think the cutout for my joint is deeper and my feet roll differently in them.

One thing that I hope is that they may help my hip. I have wondered is if the "off the shelf" insoles might be helping my FLM, but at the same time hurting my hip. An angle or balancing point may shift my foot, leg, and eventually hip into a position that stresses my hip. While many things got better for me in my foot through the use of the insoles all summer, my hip seemed to get worse and worse.

As I ran in them today, I liked the feel of them in my shoes and apppreciated the lightness of them. I noticed my foot working a bit differently and I noticed that as I ran the tightness went from the inside of my hip to the front outside of my hip joint and that was new, as if I was using the joint in a different way. I have decided that I will try to run more, but for smaller distances (I ran 4 miles today) to keep my glutes from acting up and tightening. Maybe things will improve.

I will be on the starting line of the Bay State Marthon on Sunday. I would like to see how far I can go before  the tightness sets in. Maybe I'll only get a few miles in. Maybe I will get a 1/2 marathon in. Who knows, maybe the orthotics will work and I can jog the whole 26.2 mile thing. I don't give it much of a chance, but if the hip doesn't hurt, it would be interesting to do a marathon after barely running the past month and a half! At least, I can cheer on my teammates out on the course once I do stop.

On a final note, I have used many different types of foam rollers, but I think I have found that best foam roller ever made. I have been using this for two weeks and it is quite a monster and can hit muscles in ways that a traditional foam roller cannot and it feels better than it looks as it can really isolate tight spots and trigger points.

I also got this book today. I am going to need something for my abs after all the weight I have gained after shifting from my favorite pastime (running) to my second favorite (eating ice cream). Actually, I have an opportunity to talk with the author, Jonathan Ross, on the phone next week and I want to be ready. He is one of the countries top trainers and I look forward to asking him about the use of the TRX as well as what insights he might have to fix my imbalances. Here is his website for his book "Abs Revealed".

                    

"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.