“If you screw-up toe-off, the rest of the movement is compensation.”
—The Gait Guys

Just when you thought the running gods had grown tired of tormenting us with new and ever more exasperating running injuries, I’m saddened to report they’re still at it and as sadistic as ever. This latest one— functional hallux limitus (FHL)—which, like all the other injuries, has a flashy Latin name, translates to “this really sucks” . . . well, not to that exactly, but if you’ve got it, it certainly does. That you’ve likely never heard of FHL isn’t a surprise; few have. That’s because FHL—a pint-sized affliction with big consequences for runners— keeps a low profile, literally and figuratively.

For something so ruinous, FHL doesn’t make its entrance with the drama of a sprained ankle or torn hamstring. Instead it infiltrates our body with a Ninja’s stealth, then conceals itself in the most inconspicuous of places: the big toe joint. From there, FHL sows the seeds of dysfunction throughout the body by creating the illusion that the joint operates perfectly, even as its mobility is seriously compromised. FHL’s deception leaves its victims oblivious and clinicians flummoxed, making it one of the most insidious, least-known, and shockingly underdiagnosed conditions in running.

Before venturing further into this dark place, it’s important to know what we’re dealing with, so I’ve parsed FHL’s three components:

functional—using something (in this case, our body, and more specifically the big toe and foot) to do something weight-bearing (running)

hallux—the medical/scientific/Latin name for the big toe

limitus—limited; in this case, referring to the big toe joint’s limited bendability

Translation complete, we now understand that FHL is a condition occurring only when the foot is used for its designed purpose: locomotion (and as a consequence of locomotion, bearing weight). It’s as a result of weight bearing that the big toe’s bendability becomes limited to 30 degrees, usually less. Capiche?

toe1

FHL’s Deception Revealed: The Left Image Shows the Hallux Bending Nicely with the Foot Unloaded; The Right Image Shows a Thumb Applying Load Under the First Metatarsal Head and the Hallux’s Range of Motion Disappearing Almost Completely

You should also know that there are two other, much worse conditions that are part of the hallux trilogy which I won’t talk about because they’re just too damned depressing, but I’ll give them a brief mention anyway. They are structural hallux limitus, where the mobility of the hallux is disrupted during both weight-bearing and non-weight-bearing activities, and the ultra-nasty hallux rigidus, where an unbendable big toe is accompanied by significant degeneration of the big toe joint. These baddies can substantially disrupt, even end, your running.

In a nutshell, what happens to those hapless souls who cross paths with FHL is that the big toe joint, known to those in the trade as the metatarsophalangeal joint (in short MTP joint or sometimes MPJ), loses its bendability when the foot is weight bearing. The more dynamic the type of locomotion we’re engaged in—for us it’s running, which is very dynamic—the more important a mobile MTP joint is. As mentioned, it must bend, or dorsiflex, a bare minimum of 30 degrees, but ideally between 65 and 75 degrees, as we run to ensure a proper and powerful toe-off. I define a proper toe-off as a high heel with the sole of the foot close to, or at, vertical, and the heel neither abducting or adducting (tipping in or tipping out). Check out these guys . . .

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Finland’s Pekka Vasala and Kenya’s Kip Keino Display Awesome Form – With Perfect Toe-Off – In the 1972 Olympic 1500 Metre Final. Whether We’re Olympians or Casual Runners, Hallux Range of Motion Plays a Huge Role in Our Ability to Run Fast and Pain Free

Most runners with FHL are aware of blocked movement and pain in their MTP joint, so they use a simple and somewhat effective strategy to deal with it: they lessen the bending of the joint by moving around the restriction. And voilà, the pain is gone . . . or reduced. Brilliant, no? At first it is, but in the long run it’s terrible. Why’s that? Because as clever as runners think they are, they’re oblivious to the mayhem compensations like this can create.

Assuming that all our bodily systems are in perfect working order (that’s a really big assumption, but I won’t address the many variables now), here’s a very simple way of looking at how the body gets things done: think of your body as a home computer, consisting of two essential components, the operating system (OS) and the hardware (the physical parts of the computer). Your nervous system is the OS; your body (in this case, your musculoskeletal system) is the hardware. When given orders from the nervous system, the musculoskeletal system (the bones, skeletal muscles, fascia, ligaments and tendons) has one goal: task completion. It doesn’t think about movement economy or efficiency, or about the implications of lifting heavy things with bad form. The orders sent by the nervous system to the musculoskeletal system are starkly unambiguous: it doesn’t have to be pretty, just get the job done.

And movement for many isn’t pretty: if we’re dealing with injuries, pain, advanced age, poor body awareness, excess weight, or an array of pathologies/diseases (take your pick), the way we’ll move might be downright ugly. It’s against this backdrop that the musculoskeletal system “gets the job done” by moving in a way that’s not only unhealthy, but which perpetuates continued poor movement by grooving an aberrant pattern in the nervous system. And once that pattern has been established, it’s damned hard to correct.

Compensation—automatically shifting movement/load away from the “natural” or “best” path for a particular movement to an alternate route—begins a process of musculoskeletal overload, eventually leading to syndromes and inefficiencies, imbalances and pain. Is it really that bad? Yes, it usually is. Compounding the problem is that we’re usually not even aware we’re compensating; the body simply defaults to a path that’s free of restriction or pain. Even if we know we’re compensating, we’re probably okay with it simply because it allows us to run, or move, unencumbered, or at least with less pain.

One consequence of FHL, gluteal amnesia, shows how a particular structure (in this case, the gluteus maximus muscles) far from the source of the problem (the MTP joint) can be adversely affected. Gluteal amnesia occurs when an immobile MTP joint prevents full hip extension in late mid-stance, otherwise known as the hip extension phase of gait. Because the gluteus maximus is the primary extender of the hip, it won’t contract properly when hip extension is compromised, and as a result becomes partially deactivated and weaker. It then is less effective at doing its job, which is to extend, abduct and externally rotate the hip/leg when we run.

Another problem associated with FHL is a low gear push-off. When the bendability of the MTP joint is comprised during gait, the foot will move around the block and the heel, in turn, will abduct (tip to the outside). Because of this, the plantar fascia can’t tension or load energy (an essential step for loading strain energy by tensioning the plantar fascia is known as the windlass mechanism), and the propulsive force that must happen with toe-off is lost, hence the term “low-gear push-off.”

The million-dollar question is, of course, how does a person get FHL? Without question, certain foot types are at risk for FHL, the over-pronated foot in particular, but the current thinking on its cause(s) is not definitive. As is often the case, conditions or pathologies like FHL manifest when an inherited predisposition meets the right circumstances, commonly known as the interaction of nature and nurture. The website of the Mayo Clinic (mayoclinic.org) notes that “wearing tight, narrow shoes might cause bunions or make them worse” and, in the next sentence, that “bunions also can develop as a result of an inherited structural defect.” Others assert that FHL is entirely self-inflicted, created by the habitual use of toe-constricting footwear.

For those hoping to avoid the horrors of MTP joint dysfunction, here are some recommendations:

1. All footwear (this means anything you put on your feet) must have a wide toe box—no exceptions.

2. Go barefoot whenever possible.

3. Use toe spacers.

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Toe Spacers Can Help Reverse the Inward Migration of the Big Toe (Hallux Valgus)

4. Do lots of yoga, with postures that focus on mobilizing the ankles and big toe joints.

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A Great Posture for Mobilizing Our Feet, the Big Toe in Particular

As a yoga teacher, movement coach, and runner, I see the consequences of limited or rigid halluces (“ha loo sees”: more than one hallux) every day: bunions, bouncy strides when walking or running, an inward migration or abduction, of the big toe toward the second toe, and unexplained pain in the knee, hip or low back.

FHL is frequently overlooked by health care professionals as a cause of dysfunction and pain elsewhere in the body. Those who should catch FHL are medical doctors with training in orthopedics or sports medicine, as well as doctors of chiropractic and podiatry, and physical therapists, all of whom possess an excellent understanding of the musculoskeletal system and the consequences of limited mobility in the MTP joint.

An important final point (and repeating what I mentioned earlier): the test for FHL is dynamic, meaning the foot must be in a fully weight-bearing, closed kinetic chain position when the MTP joint is assessed. Remember, the name for this condition is functional hallux limitus; it appears only when the foot is functioning, not when you’re kickin’ back and the foot’s propped up on an ottoman. Clinicians, if they consider the big toe at all, miss FHL because their assessment is passive, not dynamic. If the leg is supported and your friend bends your big toe back 80 degrees without pain or restriction, that’s great, but it only means you don’t have either of the two more severe manifestations of the hallux trilogy. You can, however, still have FHL.

I’d be interested in hearing from readers about your experiences with FHL, structural hallux limitus, or hallux rigidus and how it affects your running. Send your story to info@yogamadeforrunners.com

Thanks.

It was Saturday afternoon, Thanksgiving weekend, when an e-mail landed with a joyless clunk, rousing me from my post-run stupor. A friend wrote that he had just attended a presentation at the Victoria Marathon expo entitled “Running Sport Science: 35 Years of Progress – The New and the Tried and True.” In his message, my friend reported that the seminar’s guest speaker responded to a question from the audience with “Why would any runner want to do yoga?” The speaker explained his position by citing the need for “stiffness” in a runner’s muscles and claiming that yoga made the muscles “loosey-goosey.” Yes, he actually said “loosey-goosey.” This is progress?

Sigh. Just when I thought we’d seen the last of these nitwits, another yoga basher rises from the muck, this one conjuring the insightful “loosey-goosey” to describe the hellish reckoning that awaits runners who do yoga. As a bonus, the condescending snark of “why would any runner want to do yoga?” saves us rubes from getting conned into buying a worthless yoga membership by some smooth talkin’ hustler. We should all be grateful.

If you follow this type of thing, and it seems that in my role as a teacher of yoga to runners I have to, then you know it’s fashionable in certain circles to trash yoga. Some strength and conditioning experts, running coaches, and other athletic types believe that yoga for runners/athletes (I will toggle between the two throughout this piece) is stupid, for want of a better word, mainly because it ruins “athleticism”, a word whose meaning has evolved well beyond the quaint “displaying the attributes of an athlete” found in musty dictionaries.


Athleticism!

Nowadays, “athleticism” is that quality of being a superbly trained, finely-tuned athletic machine, possessing the exquisite neuromuscular skills needed to nail a triple axel or curve a penalty shot past a human wall into the last six inches of net. Athleticism is also the capacity to generate the explosive biomechanical force needed for rocket-sled starts from blocks or the blue line, as well as the enormous oppositional forces for hit-the-brakes decelerations and full stops and turn-on-a-dime changes in direction.

Yoga, some contend, is decidedly un- or even anti-athletic, because the stretching part “deadens the muscle” and reduces “peak strength and power” (the words of a different expert), thereby impairing the body’s ability to perform these astoundingly complex neuromuscular actions.

Adding to the shaming of yoga, those who have swallowed the Crossfit Kool-Aid know that Crossfit’s fundamentalist faction, the group that hews to the strictest interpretation of its doctrine, ranks yoga one notch below pedophilia in their hierarchy of reprehensible activities (a list that also includes long, slow running). So before I go on, a bit of advice: if you join Crossfit, best not to mention your love of downward dog and leisurely two-hour runs or you’ll be frog marched onto the next bus to Camp Dumbbell, their “re-education” centre. There, with your eyes clamped open like Malcolm McDowell in A Clockwork Orange, you’ll be forced to watch box-jumping videos until you’re a weeping puddle of flesh.

malcolm_mcdowell_being_made_to_look_in_Clockwork_OrangeNooo! Not another box jumping video!

Continue reading

Please, have a seat. Comfortable?  Good. Would you like some water? No? Okay, let’s begin. I’d like you to close your eyes; now breathe deeply and allow your mind to drift off to some place warm and happy.    Walmart?  Um . . . sure, why not.  I’m going to say two words, when I say those words I want you to stay calm and relaxed.  Ready?  Plantar Fasciitis.  Wait, don’t get up, where are you going? Come back!

Hmm, you seem a bit sensitive. Maybe you’ve had a bad experience with the PF thing. On the other hand, it’s possible you have no clue what I’m talking about, and if that’s the case then consider yourself lucky. After all, why trouble your mind with negative stuff: ignorance is bliss, baby. That is until you’re mid-way through a build-up for your next half marathon, logging big miles, and your first steps out of bed the morning after a hard run that was maybe a little too hard feel like you’re stepping on broken glass. Then six months on, you’re still dealing with the same &%$# problem, you’re “cross-training” (oh yeah, who doesn’t love pool running???), your racing plans are a smoldering ruin, and you realize that given the option you’d have gladly stepped on broken glass so this nightmare would have ended about the same time they removed the stitches from your foot.

I’m here to offer what help I can, but be forewarned, this article will not present the cure for PF simply because it’s not a condition that favors its victims with specific causes and certain cures. I’ll merely explain what is currently known about its origins, and then offer some therapies that might give succor to the afflicted. So don’t expect a miracle; there’ll be no tossing of crutches, canes or night splints into a bonfire, no spontaneous healings. Sorry. As a yoga teacher I’m biased, naturally, toward “stretching” tissue, because I believe, and the evidence suggests, that poor flexibility has a causative role in PF. But it’s just that, a contributing factor, and not the smoking gun that sufferers are desperately seeking. Anecdotally, reports from my students suffering from PF tell me that stretching has been effective in alleviating symptoms, and some have reported their pain disappears completely.  Hallelujah!  Send your donations to my PayPal account, all major credit cards accepted. 

What is the Plantar Fascia?

It’s a sheet of connective tissue (fascia) that runs along the sole of each foot (the plantar), from the heel to the toes. Like all fascia, the plantar fascia is made of extremely tough and resilient tissue. It is this durability that allows it to absorb and withstand the huge mechanical forces that act on it when we walk, run, or jump. But it’s that same toughness that can make it very challenging to fix when injured.  

One impediment to fast healing is that the fascia, unlike muscle, has limited blood flow. The vital nutrients in blood play a critical role in the health and healing of tissue, and if there isn’t much of it, the process of repair and regeneration won’t happen as quickly.

Yet another problem is that the plantar fascia is in an awkward location. If you’re interested in moving from place to place during the course of your day and you’re not using any type of mechanical conveyance, then you need your feet. So when you stand, walk, or run, the plantar fascia is being stressed, and unless you’re off our feet it won’t get a break. But even resting the plantar fascia can be a problem because it can tighten up, especially during sleep, resulting in those painful first steps every morning.

What is Plantar Fasciitis?

Plantar fasciitis is a degenerative condition of the plantar fascia that causes pain on the bottom of the foot. The plantar fascia usually begins to hurt due to overuse or trauma, and it shows up commonly in runners because they tend to overuse things. The typical locations for PF pain are the heel, just in front of the heel, or the arch. So if you have chronic pain in those places, you probably have PF. But it could be something else, like a heel spur or flat feet.

The pain from PF can range from very debilitating and life altering, to low-grade, annoying and something that its sufferers can live with. It’s common for runners or other athletes with PF to continue with their sport, albeit in a modified fashion.  But as we’ll see, this approach is self-defeating.

Plantar fasciitis has a murky provenance. A good description comes from Lemont et al. (2003): “Plantar fasciitis is widely described . . . as having a multi-factorial and widely disputed etiology.” Translation: many potential causes with little agreement on an actual cause. In an influential 1965 study, “Painful Heel”, Lapidus and Guidotti wrote that “the name ‘Painful Heel’ is used deliberately in preference to any other more precise . . . diagnosis, since the cause . . . remains unknown.” Fast-forward to 2003, Lemont and company commented on the previous quotation from the “Painful Heel” study, writing “Now, 40 years later, this statement can still be considered accurate.” So in the space of nearly four decades, little progress has been made on discovering a cause of PF. The one exception is that now it’s now considered a degenerative condition, not an inflammatory one.  But this just describes the nature of the condition rather than identifying a cause.

What Causes The Pain: Inflammation Or Degeneration? 

Over the last few decades, there’s been a significant shift in the medical-scientific community’s thinking about the nature of overuse injuries in connective tissue (in particular tendons and fascia). According to Khan et al (2000), “Advances in the understanding of tendon pathology indicate that the conditions that have been traditionally labeled as Achilles tendonitis, patellar tendonitis . . . are in fact tendinosis.” Three years later Lemont, writing about plantar fasciitis, presented findings that strongly suggest that PF “is a degenerative fasciosis without inflammation.”

Hmm, tendonitis or tendinosis; fasciosis or fasciitis: what’s the difference other than four letters tacked on to the end?  As it turns out, a great deal. In essence, this discovery has shown that the pain in your plantar fascia is not due to inflammation (signified by the suffix “itis”, Latin for inflammation, stuck to the end of tendon, fascia, etc.), but instead results from degeneration of the tissue (signified by “osis”, short for “necrosis”, or tissue death). In other words the tissue that makes up your plantar fascia is not inflamed, it’s degenerating, or worse, dying.

Our continued misunderstanding of PF results from the persistence of its description as fasciitis, rather than fasciosis. The medical community, either through habit or misunderstanding, continues to refer to it as an inflammatory condition. This is important, because at a minimum the absence of inflammation and the presence of necrosis in tendon and fascia overuse injuries change the treatment protocol for the injury. In the not-too-distant past the thinking was that if you were a runner and you hurt your plantar fascia, then the pain was from inflammation. The treatment for this was familiar to many runners: rest, ice, anti-inflammatory medication, and visits to the physiotherapist, who, among other things, would do stuff to the injured area with strange machines. During my days as a hard-core runner, I ingested fistfuls of anti-inflammatories and spent countless hours icing for a variety of running-related overuse injuries.

We never questioned this approach, or should I say that most people never questioned it. That is of course until someone realized that the accepted thinking on the matter was flawed. Again, Khan et al write that “an increasing body of evidence supports the notion that these overuse tendon conditions do not involve inflammation” and “tendonitis is a rather rare condition.” What researchers have discovered is that inflammatory cells were not present in the injured tissue of tendon or fascia; what they found instead was collagen breakdown, a key indicator for necrosis. You don’t treat tissue degeneration the same way you treat inflammation. Nowadays the accepted treatment for tendinosis or fasciosis includes plenty of icing (so glad that all the time I spent icing my Achilles tendon wasn’t wasted) and the “encouragement of collagen-synthesis,” in other words building the strength of the tissue by developing collagen.

Will this shift in our understanding of connective tissue reduce the recovery time for those with PF? Well, yes and no. First, time won’t be wasted with treatment methods that have little or no effect. On the other hand, the recovery from “osis” is generally much longer than from “itis”, something those of you with PF already know.

When a girl in a bikini promises “to cure your plan-TAR fasciitis in just a few days” as she kicks and punches a heavy bag, my advice is to be a bit skeptical.

Looking For A Cure

The PF I’m currently dealing with was the result of trauma, not overuse. While taking out the trash in my slippers last summer I stepped on a sharp rock directly under my heel. For two months I barely noticed it, and was able to walk and run free of pain. Then in December it suddenly got worse, and it’s been a problem ever since. Why did it happen this way?  I have no idea and my doctors offer only vague explanations. Like most runners with PF I continued to run, thinking that because my case was the result of trauma and not overuse then somehow it would be different. Ah . . . no.  I’ve just completed three weeks of no running and minimal walking and my foot is feeling pretty good. I’ve been maintaining my fitness and strength with indoor cycling and I’ll start back soon with a walk/run program.

After talking with other runners who have PF, most, at least initially, don’t rest. Considering the rather obsessive nature of most runners, this shouldn’t be a surprise. Two recent conversations with students of mine provide examples. Both are avid runners who injured their plantar fasciae and continued to run despite (tolerable) pain. So they kept at it, but not in a way that was enjoyable or that would allow them to train productively. Stopping completely to rest the injury was something they weren’t prepared to do, but it was a necessary step toward resolving the issue. In fact, the refusal-to-accept-reality mindset of most runners with PF is probably the reason that it has a reputation for being persistent, and one of the main reasons it takes so long for it to heal: runners just don’t want to stop running!

Some advice: when PF is diagnosed, stop running. Trust me, it will keep hurting unless you stop, and the longer you continue to run, the longer it will take to heal. The sad fact is that tendonosis takes substantially longer to heal than tendonitis.

In his excellent, in-depth review of the literature on PF, Paul Ingraham provides a synopsis of the most viable treatments.

 

1) Arch support (with inserts or supportive shoes)

2) Calf stretches

3) Plantar fascia stretches

4) Night splints (devices that hold the plantar fascia in a constant stretch, or traction, as you sleep)

5) Icing*

6) Rest

7) Massage

* Icing, popular as an anti-inflammatory, is also effective in treating tendonosis. I now ice my plantar fasciosis frequently and it definitely helps.

 

Note that of Ingraham’s seven recommendations, three involve stretching tissue, either the plantar fascia itself or the calf (really all the muscles on the back of the lower leg). Also, #3 and #4 are essentially the same: while #4 uses a device to hold the foot dorsi-flexed for a prolonged time, usually overnight, #3 would be short duration yoga-type stretching.

In my yoga classes and workshops, I teach specific postures that create a deep stretch on the front and back of the lower leg, and the top and bottom of the foot. While in Virasana (see photo), students plantar-flex (point toes and feet) and dorsi-flex (curl toes under) their feet. The structures most affected by this routine are the calf, soleus, Achilles tendon, and posterior tibialis on the back of the lower leg; the anterior tibialis on the front of the lower leg; the plantar fascia on the bottom of the foot; and the peroneals on the lateral side of the lower leg.

To those of you suffering from PF, I can only say good luck and don’t give up hope. Investigate your options, do the work, and be optimistic. The vast majority of those afflicted are completely cured or a have a substantial reduction in their symptoms.  If you are proactive, diligent, and patient, you’ll be part of that majority.

When examining the architecture of the foot we see that it is, in fact, a tripod. The three “feet” that make up the tripod are the heel bone (calcaneus), the head of the first metatarsal (the big toe mound), and the head of the fifth metatarsal (the little toe mound). Connecting each of the three feet are three myofascial slings, or arches. These are the medial longitudinal arch that runs along the medial side of the foot; the lateral longitudinal arch that runs along the lateral side of the foot; and the transverse arch that spans the foot from the head of the first metatarsal to the head of the fifth metatarsal. When the three feet of the tripod bear weight equally, then the foot is in a stable position. If one of the feet is not bearing load our nervous system will sense instability and turn off or inhibit some of the muscles responsible for whichever action we’re trying to produce.

Plantar sensory feedback, primarily from the proprioceptors, plays a central role in safe and effective locomotion and in stabilizing the stationary body. When we are upright and supported by our feet the nervous system measures the fluctuation of pressure from receptors on the sole of the foot. From that proprioceptive feedback, we unconsciously put our body in the right place, balanced over that foot. When the body responds properly to feedback from the feet, the positive response feedback turns on, and in turn it switches on the anti-gravity muscles of the leg.

The problem is that many runners have lost connection with their feet. Most runners have either non-responsive, floppy feet, or they have functionally rigid feet, which is the complete opposite of the listening foot. This is a foot that hangs on like grim death by grabbing the floor, trying to maintain some semblance of equilibrium or balance so the body doesn’t topple. Suddenly, all of the athlete’s control and tension is from the knee down. This is a common sight in yoga classes: when stability is tested, as with a balancing posture for example, the student’s toes curl under and grip the floor, the foot shrinks, and the muscles of the lower leg twitch and quiver in an attempt to stabilize the body. So if the practitioner lacks balance, stability, or control, peripheral tension is created and the listening foot is doing anything but listening. Now it’s not able to relay high quality proprioceptive information, which is essential to the body’s ability to orientate itself in space and maintain equilibrium.

What we want is for the information from our feet to flow freely and orient our body with perfect alignment, balance, and control. So if the emotional, neuromuscular, and cognitive connection with our feet is dysfunctional, this will be reflected in the quality of the sensory information flowing through the body, with predictable consequences. Yoga is a method of integration that requires the practitioner to bring awareness to all regions of the body, without regard to how challenging that process may be.

Whenever I think of ankles, I think of Misery.  It was 1990, and the movie based on Stephen King’s novel Misery had just been released. It starred James Caan as an acclaimed novelist and Kathy Bates as a nurse who cares for him after he is seriously injured in a car crash near her isolated, snowbound house.

As the bedridden Caan recuperates in her house, he (along with the audience) begins to realize that Bates is kind of . . . um . . . off.  Well, not just kind of off, very off. Despite the fact that Bates’s nurse character is a huge fan of Caan’s writer character, she takes issue with the plot line in his new novel, and, well, at that point things pretty much go south for Caan. Sensing that something is amiss with Bates, he uses her absence from the house to leave his sick bed and roam the house in a wheelchair, plotting an escape. Oops, bad move. Bates returns, cottons on to his unauthorized wandering, and decides a preventative measure is warranted to ensure this behavior is not repeated. So she does what any demented caregiver would do: with Caan now tied to the bed, she grabs a sledgehammer and breaks his ankles. Yes, both ankles . . . with a sledgehammer. Need I emphasize that these are not light taps she administers, but a full wind-up?  I think you get the picture.

There’s little doubt that in the annals of movie sadism Bates’s “hobbling” of Caan ranks near the top of any list of non-gratuitous, ghastly acts. As to the audience’s reaction, 23 years has done little to diminish the freshness of my memory of that moment. The collective gasp, muffled screams, and “oh my Gods” still ring clearly today.

But as macabre a story as Misery was, I like to think of Nurse Bates less as a destroying angel and more as a symbol of what awaits runners if they lose the range of motion (ROM) in their ankles. The demon image of Bates looming over us haunts our sleep like a perpetual nightmare. There she stands, smiling grotesquely, sledgehammer slung over her shoulder, preparing to dispense her own brand of therapy as you lie tied to your bed, mouth open but unable to scream.

When we consider the ankle joint, we see that an important requirement for its proper functioning is a high degree of mobility in the sagittal (forward and back) plane. This mobility is demonstrated by the ability to dorsi-flex (bring the top of the foot, or dorsum, closer to the shin bone, or tibia) and plantar-flex (point the foot and toes) the foot. With the bare foot flat on the floor and the heel grounded, we should be able to move the knee forward over the toes, reducing the 90-degree angle between the tibia and foot by at least 20 degrees. But runners with poor ankle mobility can barely dorsi-flex their foot/ankle, almost as if the shinbone and top of the foot are frozen into a right angle.

Unless it’s the ankle itself that’s been injured, it’s usually starved for attention. Unlike the knee, with its diva-like needs and neuroses, and the depressive foot, with its fallen arches and calloused skin, the ankle tends to linger in obscurity, unloved and easily overlooked as we rush our attention back and forth between the knee and the foot.  Part of the problem is that most runners are clueless as to the true source of their pain and dysfunction. This is because pain can be a terrible liar, and has a way of manifesting where the real problem isn’t. The compensatory tricks the body employs to move around the ankle’s limited mobility are devilishly effective, but the results of that compensation are pernicious.

This is because the body plays a kind of zero-sum game, and at some point the ankle will reclaim its lost range of motion from elsewhere in the body. When we walk or run with tight ankles the body searches for the lost mobility by initiating a series of compensatory actions, and this is where the problems really begin. What’s so perplexing is that runners won’t necessarily feel this limited mobility. Instead, they’ll experience the effects of the compensations: collapsed arches, bunions or hyper-pronation in the feet, anterior knee pain, various problems in the hips, or low back pain.  

There are several ways mobility in the ankle joint can be compromised. The first is as a result of injury. If the ankle has been sprained or broken, scar tissue or impingements can impair its ability to move freely, reducing range of motion.

Ankle mobility can also be reduced if the tissue in the back of the lower leg is tight. The structures that can become very short and tight, thereby reducing mobility, include the Achilles tendon, gastrocnemius (calf), soleus, and posterior tibialis.

Finally, choice of footwear can affect the ankle’s ROM. Our favorite sport (or sports) may require footwear that allows the ankle little or no movement. Downhill ski boots, hockey skates, and high-top basketball sneakers are examples of footwear that can limit ankle mobility. Also, habitually wearing shoes with high or stacked heels will shorten the tissue in the back of the lower leg, limiting dorsi-flexion.

That I stress the importance of ankle mobility in my runner’s yoga classes and workshops shouldn’t be a surprise. In class, people with tight ankles are easy to spot. As they sit in any posture that requires substantial plantar flexion of the foot (Virasana, for example: see photo), they’re the ones who have difficulty keeping their ankles and feet straight. One of the body’s tricks is that it will try to move around areas of stiffness, so if the ankles are tight they will crescent outwards to avoid the restriction and find room to move. When I see “bowed” ankles, I reposition them to be sure they’re straight. This way they’re moving into the stiffness and not around it.

MIke Dennison 

Weird looking dude in Supported Virasana (Hero) pose, with feet and ankles plantar-flexed

Outside of yoga class, another tight ankle “tell” is a bouncy stride. As we run, the main direction of movement should be forward, with slight up and down motion. But the runner with ankle mobility issues avoids the restriction by lifting their heel of the ground prematurely at the end of the stance phase. This action sends them “up” instead of forward, wasting substantial energy and shifting the mobility emphasis from the ankle to the forefoot. The calves and other posterior structures of the lower leg are now being used to push them through the gait cycle. Runners with this type of gait pattern are referred to as “quad dominant”, because rather than using the powerful gluteus maximus (buttock) muscles, they extend through the quads and calves. 

If there’s any lesson to be learned from Misery, it’s to keep your ankles mobile and avoid the problems that poor ROM creates. For added incentive, rent the movie. Think of it as Nurse Bates making a house call.

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If you laughed yourself sick when you read this, then you’ll get sick again if you miss my intensives in Halifax and Vancouver.  Check the schedule and sign up soon!

This cautionary tale, dear reader, is shocking but true. I ask only that you gather your loved ones and hold them close as you read my anguished words. And after, as you dab at wet eyes, you will nod with agreement that it would be impossible for all but the most depraved mind to fabricate such a frightful event. This sad case involves one dearer to me than any other, a person of such character and standing that . . . ah, what is the use of this charade, for I am the hapless victim. For me to claim that this episode was an impulsive escapade springing from youthful folly would be nothing but a bald lie. Because, as you well know, I am firmly ensconced in mid-life, even though I regularly feign an adolescent energy by singing along with Lady Gaga and driving like Justin Bieber.

But enough of this; on to my story . . .

One glorious summer day a few years back, I was headed to Vancouver’s North Shore to run the trails and slopes around Grouse Mountain, Mecca for local trail runners. I avoided the mob of Lulufied awesomeness on the Grouse Grind and instead headed east along the Baden-Powell trail, eventually running up the rather cruel “Cut” ski slope to the top of the mountain. But once there, I saw that hordes of tourists and “Grinders” had created a long wait for the gondola ride to the bottom of the mountain. I decided to run down.

So down and down I went, retracing my path up. Arriving back at the parking lot my legs were tired and sore, but nothing I hadn’t experienced before. The next morning, however, I awoke to something quite peculiar: as I rolled out of bed and took to my feet, my legs, painful and tender, nearly buckled as they tried to support me. Alarmed by this feebleness I returned to my bed, where a thousand bleak scenarios ricocheted around my mind. I was gripped by the kind of dread one feels when they realize their body is under attack by those ghastly, multi-word afflictions that, seemingly overnight, ambush the hale and hearty. In my mind’s eye a dark future beckoned, and all that was visible down life’s narrow and ever-shortening corridor was a wasteland of respirators, 24-hour care, and specialists who shake their heads grimly as they speak in whispers to everyone but you.

But after several minutes my rational mind elbowed its way back and the hysteria abated. It was then that I recalled the previous day’s misadventure and realized, blessedly, that my present condition was not going to be one of those things. What this was, in comparison, was really quite prosaic: it was my introduction, rather my re-introduction, to the world of eccentric muscle contractions and delayed onset muscle soreness, a painful world that all athletes, runners in particular, inhabit. I’ve been a visitor to this place many times in the past, as no doubt have you, but it’s always jarring to return and have our bodies remind us, in their own way, that none of us are exempt from the sometimes harsh rules of physiology and bio-mechanics.

We certainly don’t need to run down a mountain, throw a javelin, or fast-pitch a softball to discover eccentric contractions. They occur routinely in everyone, athlete or not. But because of the demands that athletes place on their bodies, eccentric contractions can be more frequent and intense, and their after-effects far more debilitating. So what are eccentric muscle contractions and what can be done, if anything, to lessen their after-effects?

Acting on orders from the nervous system, the body uses three types of skeletal muscle contraction to achieve its goals: isometric, concentric, eccentric. The concentric contraction, where the muscle shortens or contracts, is how we typically think our muscles work all the time, but this is not the case. Have a look . . .

Isometric: muscle does not change length as it fires
Concentric: muscle shortens as it fires
Eccentric: muscle lengthens as it fires

To wrap your minds around this it might be helpful to think of muscles functioning much like the gas pedal and brakes on a car. The concentric contraction (muscle shortens) is like stepping on the gas pedal; it creates force to move or accelerate the musculoskeletal system. The eccentric contraction (muscle lengthens) does the opposite: it acts as a brake to slow and stabilize the body and store elastic energy. Remember, the essence of an eccentric contraction is that the muscle lengthens as it fires. And, as Shakespeare wrote, there’s the rub . . . or in our case, the pain.

The problem is that the biomechanical process at the heart of an eccentric contraction is quite violent. Enormous negative, or oppositional, forces are applied to the working muscles to slow (or brake) them, causing them to pull apart with every stride. There is substantial evidence that eccentric contractions cause damage to the muscle, which is why they increase the risk of muscle and tendon injuries and inflammation, and cause pain for the athlete who hasn’t specifically prepared for them.

The “day after” pain we feel is called delayed onset muscle soreness, or DOMS. The symptoms of DOMS can range from muscle tenderness to intense, debilitating pain that peaks 24 to 48 hours after the exercise and usually subsides within 96 hours. DOMS is common after a race or when runners initiate new, unfamiliar types of training, or even when re-introducing specific training that our muscles have “forgotten.” This could include faster interval or speed training, long runs, and yes, even downhill running. All can be painful if done for the first time or for the first time in a while.

To add insult to injury, the pain from DOMS is also accompanied by an acute loss of strength that can continue for several days after the exercise, even outlasting the soreness from DOMS. This loss of strength is substantially greater than that found in other types of muscle contractions and takes longer to recuperate from.

A side note: For those who hope to run the Boston Marathon someday, prepare well. Boston’s insidious nature reveals itself in the first 4 miles, during which the course loses about 310 feet of elevation; by 16 miles, the course loses another 120 feet, for a total to that point of 430 feet. “So what’s wrong with that?” you may ask. Well, maybe nothing, or possibly a great deal. Because of the strength-sapping nature of eccentric contractions, runners whose legs are not “calloused” for downhill running can feel substantially weakened by the time they reach the Newton hills, beginning at about 16 miles, and the notorious Heartbreak Hill at roughly 20 miles. Their legs, feeling wobbly due to the substantial downhill running in the first half of the course, not to mention the exhaustion of running that far, can often feel exceedingly fatigued in the race’s later stages, much more than on a flatter course.

But fear not, a solution is at hand. Researchers have shown that “muscle damage need not be an obligatory response following high-force eccentric contractions” (LaStayo et al). In other words, if we prepare the body for eccentric work, we can do a great deal to substantially diminish or eliminate their nasty side effects. Even better, “inoculation” to eccentric contractions occurs rapidly.

The irony is that the original cause of the damage and pain is what we use to inoculate against further pain and suffering. This is no different than getting a flu shot, where a watered-down version of the virus itself is used to build an immunity to the specific strain of flu. We introduce the “new,” more specific eccentric work, whether it’s faster interval training, downhill running, or long runs, and build immunity by applying the eccentric stimulus progressively and repeatedly. The protective adaptation occurs quickly, with the effects being felt within 24 to 48 hours of the initial exposure to the damaging eccentric bout (Lindstedt et al).

What’s important to remember is that it doesn’t matter how long you’ve been running or how much experience you have, if you’re new to a specific type of training, or you haven’t done that type of training in a while, progress slowly. If you’re training for a hilly trail race, don’t run down the side of a mountain the first time out.

Armed with this information, we can train with a better understanding of why running hurts, and what we need to do to reduce the effect eccentric contractions have on our body.


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The foot is the best piece of running equipment there is.
– Percy Cerutty

Ah, our lowly feet: shunned like lepers by some, abused by others, forgotten by the rest. If they’re not being squeezed into suffocating containers for hours each day, then they’re bound, writhing and naked, onto rigid slabs, the heels lifted provocatively, the toes crushed mercilessly, their contorted suffering visible to all. Our feet are the playthings of the fashion gods, and subjecting them to stylish tortures seems to be a price many pay all too willingly. If what we’re doing to our feet wasn’t so pernicious, it might be funny; can we blame them for being the source of so much discontent?

But what we wear on our feet is only part of the problem. For many of us, the feet are so removed from our everyday awareness they seem to exist only in the imagination, perhaps occupying a dusty corner of our consciousness as some barely-remembered, far-off land we once visited. Yet despite their physical and emotional remoteness, the feet are vital to both yoga and running, and we rely on them to guide and support us as they connect us energetically and mechanically to the ground. Our emotional and physical stability is dependent in large part on our ability to create connection through our legs, particularly through the feet.

That our culture acknowledges the significant role of the feet in creating a life of purpose is evident by the many commonly used foot-based metaphors: standing on our own two feet (independence); having both feet on the ground (stability, rootedness); knowing where you stand (confidence, decisiveness); getting off on the right foot (making a strong start, moving in the right direction); putting one foot in front of the other (moving forward with deliberation); putting your foot down (establishing boundaries). The list goes on, but these symbolic references all imply the necessity of using the feet to create a strong foundation for a meaningful and grounded life.

Even as our language shows the value, if mostly only symbolic, we place on our feet, history is full of examples that illustrate how ambivalent our relationship with the feet really is. They are the basis of the near mythological status attained by Ethiopian runner Abebe Bikila, who ran barefoot through the streets of Rome to win the 1960 Olympic marathon. Devout yogis prostrate before “the lotus feet of the guru,” believing those feet to be the repository of divine energy and a “terminal of magical and spiritual power and grace.” But for many centuries in Japan, women cultivated tightly bound, mutilated “lotus feet” in a belief that small feet were beautiful, even erotic. Some of us decorate and proudly display our feet; others see them as fonts of unsightly afflictions and a source of embarrassment, if not shame. In the Hindu social structure feet are symbolically “dirty”, and the servile or “Shudra” class is typically assigned to the lowest limb of the Cosmic Man to denote their low status. But just as the feet are vital to a fully functioning human being, so the Shudra class is important to the wellbeing of society. And so it goes . . . contradiction follows contradiction.

Given this bi-polar relationship, it shouldn’t be a surprise that runners obsess over nothing as much as their footwear. They believe that the right pair of shoes will save them from injury, protect them from the elements, elevate their status, shave minutes from their race times, and cushion them as they traverse rough terrain. But in yet another foot-related contradiction, a fringe group known as minimalists preaches that society’s accepted idea of footwear is absurd, that overbuilt and over-cushioned shoes are the source of misery and suffering for runners. Minimalists believe first and foremost in the architectural wonder and beauty of the foot, and in the foot’s ability, when used correctly, to absorb the punishment of running as it goes about its job of support and locomotion.

The foot/ankle complex is a focus of attention in this course because, as yoga teacher Tias Little tells us, “the foot is the foundation to the temple of the body.” But the feet are more than a foundation, they are the starting point of the body’s kinetic chain and the only point where the body interacts with the ground. Feedback from plantar sensors on the sole of the foot plays a central role in safe and effective locomotion, in stabilizing our pelvis, and in maintaining balance. The ankle is the first significant joint in the body, and as such it forms a crucial starting point for the “joint-by-joint approach”, a way of looking at the alternating mobility and stability needs of our body.  As we will see, dysfunction in the foot or ankle initiates a biomechanical wave that flows through the body, usually with negative consequences. And because kinetic forces in the body are magnified significantly when we run, the opportunity for dysfunction is magnified as well.

The Listening Foot

Conceived by physical therapist and movement specialist Joanne Elphinston, the “listening foot” concept asks us to look beyond our limited ideas of the foot’s purpose and capacities. As runners, we typically think of our feet in mechanical terms: do the feet pronate or supinate? But our pre-occupation with the foot’s mechanical workings can prevent us from seeing the bigger picture, that of the foot as sense organ with a significant sensory and motor representation in the brain (only the hands and face have more representation by the sensory and motor homunculus of the brain). Elphinston wants runners to understand and appreciate the subtle but powerful dynamics of the feet, and the importance of the information the feet draw from their connection to the ground. It’s only then that we begin to understand the vast capabilities of the feet, which far surpass the somewhat mundane mechanistic viewpoint held by most runners. Looked at this way, the foot transcends its role as support and locomotion and morphs into a highly sensitive piece of running equipment.

 

Ask runners about their hamstrings and you might hear sad stories about chronically tight and painful muscles. No matter how much stretching they do or how many hot yoga classes they attend, some never seem to get relief from the unrelenting tension that plagues their hamstrings and makes their running less than enjoyable. Does this sound familiar?

 

What’s important to understand is that many factors affect the tension of the hamstrings, and of these running may be the least influential. There are two likely culprits when it comes to the creation of tight and painful “hams”: the position of the pelvis and dormant or weak Gluteus Maximus (GM) muscles.

 

The Pelvis

 

First, a bit of anatomy: the hamstrings are three large, strong, bi-lateral muscles that begin or “originate” on each side and at the very bottom of the pelvis. From there they run down the back of the thighs, then via tendons cross over the back of the knee and attach high up to the bones of the lower leg. They play a crucial role in stabilizing our knees and, of course, in running, where one of their jobs is to assist with hip extension. (This just means they help bring the hip and leg behind us as we run.)

 

Because the hamstrings originate primarily on the pelvis (one half of one of the hamstrings, the biceps femoris, originates on the back of the femur), the position of the pelvis plays a key role in determining the amount of “pull” that is exerted on the hamstrings. From its ideal “neutral” orientation, the pelvis can be moved into many different positions, acted on by dozens of soft tissue attachments. If the pelvis is in “anterior rotation” (tipped forward) then the leverage will cause the hamstrings (attached to the bottom of the pelvis) to be pulled more taut. Presto, you’ve got tight hamstrings.

 

Is it really that simple? Well, yes and no. Now we have to figure out why the pelvis is tipped forward. The usual (but not only) reason is that the hip flexor muscles, especially those that originate on the anterior (front) of the pelvis, exert considerable influence on pelvic position. And because the hip flexors are usually very tight, they can create a strong forward pull. Voila, there’s your anterior tilt. So by stretching the hip flexors you’ll reduce the grip they have on the front of the pelvis, and this, everything else being equal, will help return the pelvis to a neutral position. Got it? Well . . . maybe.

 

Let’s figure out why the hip flexors are tight to begin with, and from there we can determine if we really need to stretch, or if some other remedy is called for. Your hip flexors may be tight simply because of the activities of daily living, in particular too much sitting. If this is the case then they will respond well to stretching. But what if your hip flexors are like your hamstrings, chronically tight and seemingly immune to the effects of a regular stretching program? Then there’s a possibility that your core or low back is unstable, and in their search for stability the back and core recruit, and overload, the hip flexors. As a result they become overworked and, predictably, very tight.

 


This nationally ranked U.S. marathoner displays a nasty anterior pelvic tilt

 

If you’ve been stretching the hip flexors doggedly without the slightest improvement, stop, and do side and forearm planks instead. Stretching will do you no good until the core/spine is stabilized. If you find that hip flexor stretches actually offer relief, then continue with them.

 

The Gluteus Maximus

 

A second possible cause of your hamstring woes is the Gluteus Maximus, or buttock, muscles. A wide assortment of muscles play important roles in running, but the GM is preeminent among them. Quite simply, the “glute max” is the mother of running muscles, and if it’s not working properly it is far more likely that some malfunction will occur.

 

More anatomy: the bilateral GM muscles sit prominently on the posterior (back) of the pelvis. The GM muscles are the main muscles or “prime movers” when it comes to hip extension in running. When I said earlier that one of the jobs of the hamstrings is to assist hip extension, what I meant specifically is that they’re assisting the GM.

 

The problems begin when the GM is either “dormant” or weak, and for many runners it is definitely in poor shape. If the GM is not functioning optimally, then the hamstrings (and the adductors as well: chronic groin strains anyone?) must take over the role vacated by the GM. This is a role the hamstrings were not designed for or intended to fulfill, and because of this added burden they become overworked and yes, you guessed it, very tight. This is precisely the same scenario we saw with the hip flexors, but now it’s the hamstrings that are being asked to pick up the slack for a deficit in strength or stability.

 

But why does the GM get weak or dormant to begin with? That’s a bit beyond the scope of this article, but briefly: the GM is a phasic muscle. This means, in part, that it can react to problems elsewhere by becoming weak and/or inhibited. Those problems can include reciprocal inhibition or injury to muscles or joints in the leg (the ankle in particular).

 

Poor GM development is something I see commonly in runners; more accurately I see flat bums and prominent hamstrings. If you’ll excuse my rude humor, this is ass backwards, a classic sign that the “hams” are doing too much of the work and the “glutes” too little or none at all. Effective remedies for lazy or weak glutes can include deep squats, supine bridges, lunges, and one-legged postures.

 

If you can restore the pelvis to its proper, “neutral” position and activate and strengthen your Gluteus Maximus muscles, then you’ll have taken huge steps toward restoring your body’s functional motor pattern and proper biomechanical alignment. You’ll feel relief in the hamstrings (and likely other areas as well), and your running will feel fun again.

 

Did this article excite you beyond belief? If yes, then consider attending my runner’s yoga certificate course happening in November over the Remembrance Day long-weekend. There’ll be three days (15 hours) worth of lectures full of fantastic information and runner’s yoga practice for attendees. No experience is necessary in either running or yoga.

 


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