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Last Monday I had a cortisone shot. It was supposed to be a diagnostic tool and I guess it was.
The shot was great. I didn't feel a thing just a small needle  pinch. Nothing hurt or got sore afterward either. That night I ran 1 mile on the treadmill. The next morning, I woke up and ran another mile. Everything was OK, so I ran 3 miles that night. I was still fine so I looked forward to the next day. I ran 8 miles. Everything around the hip felt loose (no muscle problems) and at the same time the hip joint felt firm and tight. I had no problems on the run or after the run. The next morning I could lift my leg up without the stiffness that I usually would have. I liked the feeling. I ran 8 miles again the next day with the same result. This was unusual. Nothing was making my hip sore. I didn't want to overdue it so I took a day off and Saturday ran again. My left foot was rotated a bit to the outside and my stride wasn't the best, but I decided to "test" things. About a mile into the run, I felt "something" in the muscle of my right back side-lower ribs. It was like a muscle "let go". I have had this a couple times in the past and I end up having muscle spasms or a back pinching for a week or two after. I kept running, but I wasn't as loose as before. I felt things deteriorating and my left glutes were having a problem. After 30 minutes of running, I had to stop. The back hip "glute medius" or "piriformis" had tightened right up and was in something like a spasm. It was cold and I was in shorts. I had to walk for an hour to get home. It hurt to lift my left leg and swing it forward as well as put it on the ground each step of the way. This felt like a  muscular pain, but I also noticed a tightness or rubbing in the hip joint. If it wasn't so cold, I would have just sat on the ground because it hurt to walk. That was the last I have run. My lower right ribs still have a stiff spasmy spot and my glutes have been sore since the run. The cortisone was great while it lasted, unfortunately it didn't last long.

Today, I saw the physiastrist again. He looked at everything again and thinks it is not so much tibial torsion, but femoral anteversion. He thinks it is the hips that make the leg do what it does. Labels! He said that it looks like the cortisone wore off. I think it is still a bit of being out of balance. I have felt like a truck has hit me since Saturday's run. I think that my body was running smoother and then  muscles reacted to a new pattern to protect itself-even though nothing hurt. I have had the upper back go off like that before, and it was usually after I had some body work done to relieve tightness in the hips.

The physiatrist wants me to get a gait analysis done to see exactly what my body is doing with the tibial torsion and femoral anteversion. I am not sure if insurance will cover this. He thinks my body has done a remarkable job compensating through the years to keep me running and doesn't want to alter that much. He is also sending me to a physical therapist to work on stretching my left internal hip rotators and adductors, and to strengthen my left hips external rotators and abductors. He made an extra label on my referral slip: "high level runner". Well, I have never been called that before, but I like it. At least he is not treating me like a joke. I do feel that way when I see the other people who are in all sort of pain and distress in his office.  I can't really complain about my problems, but I like the challenge of figuring this all out.

What is femoral anteversion? 

Femoral anteversion is an inward twisting of the thigh bone, also known as the femur (the bone that is located between the hip and the knee). The physiatrist thinks that this is causing an impingement in my hip due to the rotation and that is the source of my pain. The twisting of the femur means my left glutes get weak and stretched and that is why it is sore. He showed me where he thinks the small labral tear is, but isn't sure if this is the real problem. Anyhow, he wants to treat things conservatively with therapy before he looks into more aggressive  things like surgery. The surgery to fix a femoral anteversion is usually only performed on children. He doesn't think it has is performed on athletes to keep them running. It seems to involve breaking the bone and having it grow back again. I don't think I want to be the first or next runner to have this type of surgery!

Anyhow right now I am back to being a low-level non-runner. The cortisone was great the few days it lasted. That was the longest string of days without pain of many in years! I was really enjoying the added hip mobility and the feeling of what a normal leg would feel like.

Here is a very cool web site  I found to learn about muscles. You click on a muscle and the animations show you the origin, insertion, and actions of the muscle. It is called Get Body Smart.

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).

A Trip to the Physiatrist

I had my first appointment with a physiatrist scheduled for the end of the month, but I got a call yesterday that there was an opening so today I had my first visit. When I arrived, I really wondered what I was doing there, It is a pain clinic and the people coming and going looked like they were in bad shape and I was just sauntering into the joint. Then I had to fill out all sorts of forms, a lot of them dealing with drugs and pain medicines. It was a longish appointment (over an hour with the doctor) to go over my history. He had already viewed my records. I liked the physiatrist, he was young and seemed  interested and puzzled. He listened and didn't jump to conclusions like he was a know-it-all and thought about each tidbit I presented him with. So things were off to a good start.

He moved my leg around and like the last orthopaedist didn't believe I had a labral tear because nothing was painful. That would be good news if I don't need surgury. From my x-rays he said my hip was in pretty good condition (just mild arthritis). He said this could be because of all my running, strangely enough my body has found it own way to move without damaging itself. He recognized the tibial torsion in my left shin and said I also had femoral antiversion (internal rotation) in my left hip. I was born that way and I guess you can't change either of those without breaking bones in surgury so that they grow back a different way (no thanks!). He said it is very rare for someone to continue running with these "defects". The average-normal-thinking person would have found something different to do with their time. But, he also doesn't think that running has to be a bad thing. I agree on one level, despite this new hip pain that I got in the summer, once I stopped running in September all my musclulo-skeletal imbalances actually feel worse throughout the day and night. Running usually removes a lot of this tension and pain for me.

He thinks the internal rotation of my hip has led to an impingement, not an FAI impingement that begets a labral tear, but a ligament or muscular impingment. The adductors are too tight to compensate and the abductors are too weak because the are not working. He is going to work with me to see what we can do.
First off, he wants x-rays of my knees to see if there is something going on in my left knee. I have avoided knee pains for much of my life, but when my leg and hip is out of balance and rotating wrong, I do get a tightness in my knee.

He also wants to try a cortizone shot in the hip. I guess I am supposed to not want it to work. If it clears things up for a while then it could mean a labral tear. But I wasn't clear on all that he said this would be about. That will be Monday morning.

He also said it would be very interesting to get a gait analysis done. I don't know if my insurance would cover some of this. What I did appreciate is that he went to a school with another doctor who specializes in running gaits  and he is going to call her and ask her about what to look for and to look into with my stride.

I am glad I got in there earlier to get the ball rolling. I am not sure what treatment or therapy I might get as I have already done most things that we talked about, but hopefully the doctor can stick with me and things a bit more to at least get me up and going again.



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.