Detective Work

I had planned on chickening out on the Thanksgiving morning Great Gobbler 5k in Nashua, but woke up and decided to endure it as I haven't raced a full race since last years Great Gobbler ( I did do a leg in the Mill Cities Relay last December and did the first loop of a snowshoe race -2.5 miles last January).  It didn't go well, but it went as expected. I set an all-time personal worst over the 5k distance. I was huffing and puffing, but my stride was way off and was very discouraging to realize how far out of shape I now am. The only good thing was that I looked at all the results printed from previous editions of the race on the side of the shed and realized I have raced in all editions of this race.  It is now my only annual racing streak left. Listing the results show a huge decline in recent years in my times. I hope it goes on the upswing starting next year as I don't like running like a turkey!

Great Gobbler race results:
2003 19:59 16th originally called a Nashua High School Alumni race.
2004 19:38 15th
2005 19:19  7th  (Awesome snowstorm during the race!)
2006 18:16  13th
2007 18:09  18th
2008  20:10 28th
2009 20:46 31st
2010 22:00 77th  (off the fumes of summer training)
2011 24:45 170th (Ouch- even got passed by a guy dresses as a turkey!)

Last week I only ran twice: this race and 8 miles on Saturday. My body isn't working right, so I don't feel like running.

I know something is off with my body and I am still working on figuring it out. The last few days have been helpful. I had an MRI for my lower back about 10 days ago. Yesterday, I went for the result. I was expecting to hear something about my disks and nerve problems. I was stunned when I was told my back looks really good. I have had left lower back problems since the mid 1980s so this was a weird result. It is good news to have a good back, but what next?

The following is more to clarify my current thinking and keeping it for future reference, so don't bother to read if you have even gotten this far. I tell my students that they should enjoy solving math problems as it is like detective work and they are going to be solving problems all their lives. I feel like I have spent half a life trying to solve the problem of my back and hip. So it is back to asking questions and looking for answers.

I was absolutely floored that my back looked fine and I realised that I forgot to ask more probing questions about the MRI results. They did sign me up for another appointment with another doctor for the week before Christmas. This is another physiatrist at The Spine Center in Newton-Wellesley. This doctor will be looking more a musculoskeletal problems. I was told they made look to do things like trigger-point injections if they find a problem. I would guess they they might find a problem in the piriformis area.

I had a couple of valuable internet interactions over the weekend that were very pertinent and thought provoking. The limiting factor in my running now is my left foot/ankle "tibial torsion" or rotation outwards. The Gait Guys commented on this in 2010 for me- although their response was on their previous website and is now gone. My foot seems to be stuck and angling out more, the left side of my knee is also "stuck" and has a twisty feel to it, and because of this my femur doesn't feel right in my hip (where I was operated on), and my lower back gets tight. I have been stuck in this position for over a month now and nothing I do gets me out of it.  The Gait Guys had a post last week on an external rotation in the foot. I couldn't answer on their blog, but I did have a Facebook conversation with them on this post. It was an interesting post as the externally rotated foot was seen as a "brain issue" where the brain maps out what is the best position in space for a body part to work in it's perceived "best position".

It is quite possible and reasonable to assume that a motor pattern is a natural mechanism for joint and multi-joint protection. Consciously trying to alter a motor pattern is likely to drive an improper pattern or one that is deemed unstable by the brain.


Scenario: client has right foot spun externally into the frontal plane by 15 degrees more than the opposite side.

In this scenario, this could be the reason why merely attempting to turn inwards a right foot that has drifted its way in time outwards does not hold even though it is clearly a deviation from symmetry. It is likely the fact that the brain, in such a scenario, has calculated that there is not sufficient stability in a more neutral symmetrical foot progression angle and thus has found the necessary stability in a more turned out position. As we have always said, subconsciously turning the foot outwards helps to cheat into the frontal plane, likely because that plane is less stable with a neutral foot and with the foot “kickstand” turned out, stability is achieved. Thus, engaging the foot better in that plane gives the brain and body the perceived and actual stability that it feels it needs to more naturally provide joint or multi-joint stability. (read more)

So I wanted to know "what to do about this"... and I was told firstly that,

"The labral tear does not surprise us and the "wanting to turn the foot out more" is most likely a compensation to avoid internal rotation of the hip and impinging on a labrum that isn't there. The fix depends on the etiology: does it start at the foot or is it from above down?"

Ahh, the question I have been asking for years! Their suggestion for me was to visit Tom Michaud who is a chiropractor in Newton and who has worked on many runners including those of international stature. It seems Tom Michaud just published a new and well-received book this year called Human Locomotion.

In the course of a year, more than 1.9 million runners will fracture at least one bone and approximately 50% will suffer some form of overuse injury that prevents them from running. Despite the widespread prevalence of gait-related injuries, the majority of health care practitioners continue to rely on outdated and ineffective treatment protocols emphasizing passive interventions, such as anti-inflammatory medications and rest.

If you start here and forward ahead to pages 8-9, that is a picture that pretty much looks like how my left leg works. The book is $100 and is written for doctors, so it is not something I would buy, but the parts online sure look interesting as it addresses abnormal gaits and even has a section on labral tears. Do I think this guy could look at the whole picture of what my body is doing? I sure do. So I called to set up an appointment. His office is just down the road from the Newton-Wellesley Hospital where I had my hip surgery and where I am going now to their Spine Center. I got a call into his office yesterday. He doesn't take my insurance, which stinks, but still I wanted an appointment. Seems he is a busy guy. I got the first available appointment. It is for April 19, 2012. Well. that is a bit of a wait!



This weekend I saw another interesting video on the piriformis. I guess since I don't have a back or nerve problem, according to my MRI, that this video is even more important, as I still have an extremely tight or knotted piriformis that can be aggravated by running. I left this comment on the site, because the doctor talks about a link between the piriformis and a foot turning out (hey,  my two problems):

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

 

Dr. Gangemi wrote this in reply:

Hi Jim, yes I’d say that is exactly what is happening to you. The left foot would be the tight piriformis (could be your psoas too), with the right side being inhibited (“weak”). The twist is really not what is causing the pain, but the piriformis being too tight is causing both the pain and the lateral rotation – that puts a significant amount of stress on your labrum, hence your surgery.

It is interesting learning about the connection between the piriformis and my left foot as well as the resultant labral tear, But I really don't' want to wait until April to see Dr. Michaud or even the end of the month to have an initial visit at The Spine Center. Will they address the piriformis? Is there where I could get a trigger point injection? Will it help my misaligned left side?

On the way back from the hospital, it suddenly occurred to me what to do short term. Today, I set up an appointment with Dr. Dannanburg, the podiatrist who gave me shoe inserts and later orthotics for my functional hallux limitis in my 1st MPT joints. When I first got the inserts in the summer of 2010, my foot felt great, within a week I was doing a 65 mile week, which I soon bumped up to 85 miles. My leg had a new alignment. However, while I continued to run, my left hip got worse and worse till I had a full blown labral tear in less than two months and I couldn't run at all. My feeling is that my foot and leg were tracking better and my left leg couldn't compensate and "hide from" the torn labrum (which it had been doing for years).

I was thinking about my orthotics post surgery, my leg turn-out and misalignment is getting worse. Then I remembered that it just wasn't orthotics or inserts that Dr. Dannenburg gave me. He adjusted bones in my foot and ankles as well as my fibula. So I think I might need him to adjust my bones again, as several bones in my ankle, foot, and where the fibula joins the knee feel stuck or trapped. He doesn't take my insurance either, but he is a podiatrist who is known throughout the world for his work, so I set up an appointment and will see what he says and does next week. Hopefully, he can get me up and running again with his manipulations.

So it is all about problem solving. I can't tell if there is an end in sight, but I will keep trying to figure out how to get my body out the door and running pain-free again. Never give up!

Awesome story about getting your legs back!

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

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

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

 

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

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

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

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

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

Monique van der Vorst



 

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

Dathan Ritzenhein on warming up before a run

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

New York Times Article: Hip Procedure Grows Popular Despite Doubt

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

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

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

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



Update:
This new book from the author of The Entrepreneurial Patient blog is a must read book for anyone with hip problems and is thinking about about arthroscopic hip surgery or has had arthroscopic hip surgery for a labral tear or FAI.

Happiness is an 8 mile run

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

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

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

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



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


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

Dr. Eric Goodman - TedxAmericanRiviera 2011

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

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

Keeping up with Ryan Hall

This is in a subway station in New York City. People are trying to keep up with Ryan Hall for 60 feet. This is his pace for a full marathon. Even Ryan had a hard time keeping up in street clothes. I think it is a neat way to make people aware of how fast the elites do run.

I am a runner

American distance runner, Adam Goucher wrote a blog post today saying he is retiring from competitive running. He has had a great run: Footlocker champion way back in 1993, NCAA cross country champion way in 1998, US 5000 Olympic trials champion in the year 2000, 6th place in the short course race at the IAFF Worlds Cross-Country Championships in 2006 among other championship races. Adam's NCAA cross-country championship race was highlighted in the book Running with the Buffaloes. He has also cowritten a recently released book Running the Edge: Discover the Secrets to Better Running and a Better Life. On the Run the Edge blogpost about his retirement, I liked the opening quote from his book:

“I am not somebody who just likes to run. I am a runner. This is the difference between a pastime and a passion. I like to play golf, but I am not a golfer. I like to cook, but I am not a chef. I don’t just like to run. I am a runner. It is a passion. It is part of who I am and is woven into the fabric of my personality, character, and psyche.” – Adam Goucher from “Running the Edge”

Yes, I am a runner, too and that quote sums it up for many of us who enjoy the sport for more than just the physical exercise!


That is what has made the last year without running real difficult: not being able to run and compte for the first time in almost 40 years. I can't wait to be fully up and running some day, but it is not going as easily as I would have hoped post-surgery. Improvements are hard to come by, as I feel the same as I did one month ago.

Last weeks total mileage = 20 miles:
Thursday: 8 miles
Saturday: 8 miles
Sunday:4 miles

Some days the running feels good and I feel like I am getting right back into it. Other days, I get a pinching pain in my inner thigh and along with it tight shin muscles and discomfort that goes under my knee, around my ankle, under my arch, and into my big toe. I am always thinking it is muscular, but today I learned from my PT that it is probably a pinched nerve of some type in my lower back that radiates all down the nerve. I guess I better call to get that MRI of my lower back that I have been putting off. The back doctor told me that if the MRI shows something then maybe I would get a cortizone shot. I had figured this may be a temporary thing like the diagnostic cortizone shot I had in my hip to confirm the labral tear earlier this year. I was now told that the cortizone shot could be a more long-term solution to a pinched nerve. Today, at PT I got some heavy ART treatment of hamstrings, adductors, hip, and lower back. I think my skin is still glowing with redness, although the PT doing the ART seemed even more sore because his thumb was pressing so hard it was hurting him. This should relieve some of the nerve issues, but if needed it looks like cortizone may help.