Active Community: Message List - hip tendonitis/marathon training

Re: hip tendonitis/marathon training--update

guest — Wed, 20 Apr 2011 22:44:30 GMT

I wanted to update you guys on my hip tendonitis. After scaling back on running, treating with ice, stretching and compex machine, my pain is totally gone! I am able to run 13 miles with no pain at all!! Unfortunately, my marathon is in 1 1/2 weeks. My plan is to run half though. Then, at least I show up and do something! And if I feel good after 13, I'll see how far I can go. BTW, I did go to my md to get an x-ray, which ruled out a stress fracture. (She told me to stop running.) My gut feeling is that the stretching and ice are key for the tendonitis, at least the kind I have. I also have some ideas about how I got injured in the first place, so next time I know what to do differently.

Re: hip tendonitis/marathon training

guest — Thu, 31 Mar 2011 18:44:50 GMT

Also my hip does not get tight when I cross my legs, although it has not been bothering me as much as usual in general.

Re: hip tendonitis/marathon training

guest — Thu, 31 Mar 2011 18:23:38 GMT

My 2nd met head is closer to my toes than the 1st. The 2nd starts almost where my 1st ends. My 1st and 5th seem aligned but my 2,3, and 4 are all higher. I don't feel like my foot turns out like a duck but when my knee turns in my whole leg from my hip to my foot is inwardly rotated but I am not absolutely positive. I don't know if that changes anything.

Re: hip tendonitis/marathon training

guest — Thu, 31 Mar 2011 16:26:18 GMT

Good questions all, so we'll keep plugging away. Met head #1, behind the big toe, is the most important impact-bearing part of your foot for competitive running. It's the biggest for a reason. The easiest way to see where you stand, so to speak, is to hold your bare foot up to a mirror and look to see where the main ball of the foot is versus the next four. If the 2nd one is ahead of the 1st, you are almost guaranteed to have problems.Look at the top of the foot to confirm when you scrunch the toes downward. You can see how the heads line up. They should be straight across from MH1 through MH5, with no deviations. even a quarter inch setback for MH1 requires compensation. I've seen it happen with less than that.

During a forefoot strike, or during pushoff after both midfoot and heel strike to forefoot transition, weight should shift to the largest metatarsal head during the pronation phase. Otherwise, the 2nd takes most of the heat and it is not designed sturdilyenough for this. Especially as you tire, the brain will shift weight more and more the the largest head by turning the foot outward and by flattening the arch, to bring MH1 into contact with the ground sooner.

This action also requires Tib Posterior to stretch out of its normal position to allow the arch to flatten, and over a period of time it may lose tone and require more duckfoot action to maitain stability.

While we're on that subject, these muscular systems do not act in isolation but in concert as systems, and as Damien alluded to earlier, it can be pretty complicated to guess over the internet, but we know how these systems are supposed to work. Glute medius as a hip stabilizer is of course important, but the hip rotators deep to the glutes are the main actors turning your leg outward. They get stuck a lot in spasm to the point they will not release at all, especially if they have been overused during overpronation, so you can see how things move full circle.

I'm very vocal about correcting the proprioceptive feedback from the fot first, because without that step, so to speak, the problem is made fresh daily. If you can trick the brain into thinking MH1 is long enough, the learned action of overpronation will reverse in time, sometimes starting immediately, and the perpetual dysfunction of the supinating muscles, hip stabilizers, and hip rotators will follow. That's why I contend retraining alone is not enough, until the potential cause is removed.

To summarize, there are probably a lot of muscles in the powertrain that are exhausted from overuse, not because you run too much, but because of overcompensation for a structural issue. Once these muscles become tired we tend to focus on them as the problem when we need to look a little deeper into the fundamental reasons for their fatigue. Once we solve that part, we will still be left with rehabbing the beat-up muscles and gradually losing our compensations. In this case, it is not a chicken-or-egg question, just how far we look into the dysfunction for a cause. If it's MH1, that would be the most common explanation. Next, we look for Tib Post dysfunction.

A couple quick checks: When you sit in a chair and cross one knee over the other and your hip feels tight, and tighter as you lean forward over the knee, it shows the hip rotator is cranked up really tight, most likely from rotating outward too much and too often during excess pronation. Working down, we check the Tib P between the lower leg bones, about halfway up the calf way deep to the lower Gastroc. If the muscle has given up from too much arch flattening or for any other reason, you will still have issues of footplant stability with or without a short MH1. Then, if we look down and find a short MH1, everything else up the leg starts to come into focus.

Still not knowing your MH1 status, I'll explain the pad fix. If MH1 is short, it leaves the ground as the heel lifts upward, MH2 still in contact with the ground. Pronation brings MH1 back down to earth to help out MH2-5 with weight bearing. Duckfoot begins, and continues as long as MH1 would leave the ground first without it. A quarter-sized pad, or roughly the size and shape of the ball of your foot, stuck to the bottom of the insole under the depression made into it by the ball of your foot, keeps MH1 in contact with the ground longer, making the compensation unnecessary, at least in the early phases of the gait cycle. Your size, weight, extent of MH difference, footstrike style, shoe structure, running surface, and perhaps other factors wil determine the ideal height of the pad, but I've settled on a chunk of tough gel that I cut out of an insole with a pair of scissors, and glued in place with shoe-goo. I tape them first to experiment for ideal placement before gluing. Every case will be different- different thicknesses, sizes, and fore-aft placement. Just make sure you start small and work your way up over time if the compensation continues.

So, if your MH1 is short, you are not lazy or sloppy in your running. There is an explanation for it that makes sense, and an easy solution. If the muscles alone are dysfunctional, some deep manual pressure as described above should bring them back from the dead so you can retrain them. In a small minority of cases, there may be other structural issues with the foot, femur, hip, or spine to look at. We'll cross that bridge when we get to it, but one less common variation is worth mentioning. MH1 can not only be short, but short and hypermobile, or normal length and hypermobile. Either case causes instabiity and compensation, with more difficult decisions to make about treatment and correction. I suppose this is enough info for now.

Re: hip tendonitis/marathon training

guest — Thu, 31 Mar 2011 13:26:30 GMT

Thank you I will try the tennis ball. As far as orthotics, how do I know my 1st metatarsal is shorter? Does it matter if I have more of a rearfoot pronation? So I would need an orthotic that builds up the area under my met heads or more the medial arch just under my 1st met head? I have also recently tried running on the treadmill with the thought of running like a duck on my injured side. It does not cause any pain and appears to me that my knee is tracking forward instead of inward. I have only ran like this for less than a mile as I do not want to develop bad habits but was wondering if this would also be a type of retraining. This is very interesting and you seem very knowledge able on the subject matter. Another question, Why does this injury come and go? Why can I run for a few months pain free and than I aggravate it and than get better and a few months later re-aggravate it again.

Re: hip tendonitis/marathon training

guest — Wed, 30 Mar 2011 23:00:32 GMT

The reluctance of your glutes to function properly should not be perceived as a sign of weakness. As a personal trainer you have certainly done your share of exercise, and while you may be overpowering some muscles with others, a muscle war may leave you muscle-bound. They have probably been overworked, if anything. The question to ask is why the excess motion? The answer is in your pronation, which requires excess movement all the way into the hips and beyond. Restraining a pronated foot with a shoe or orthotic does not solve the original problem, but applies a temporary band-aid instead.

Meanwhile, what to do with a tight glute that does not want to be stretched? Well, you could potentially tighten it more with further exercise, risk injuring it with stretching, or release it so it can go back to doing its job. My vote is to release it. While I do this for others, including athletes for a living, you no more have to be a professional to do it right, than you have to be a professional runner to run.

Remember that all tone for your muscles is set by your brain, based on the feedback it gets from the muscles it manages. The feedback can be proprioceptive, as in where it is in space, or pain, in which case the brain can choose to deactivate it so it is lax, or splint it ((tighten) to prevent movement. Yours is apparently splinted in response to excess movement, and the wear-and-tear that it causes. All you have to do is change the feedback to change the tone. There's nothing you can do about the accumulated damage in a new york minute - that will have to heal - but you can do plenty to restore normal tone so the glute does not suck your hip into your pelvis. Just don't expect to put the hammer down right away, or you will be back at square one. There will be time to model your repair with gradual increases in exercise intensity, but later.

Without the toning contractions from the brain, your muscles are dead meat - literally, with about the same jelly-like consistency. They do not get loose or tight on their own. That's why most remedial stretching and strengthening is a game of solitaire. Many professional athletes of greater means than ours get regular therapeutic attention to their muscles to take care of the tone without the wear and tear. Guys like myself work on their own and save a lot of money. You can work the glutes yourself with a tennis ball. The idea is to briefly restrict circulation with static pressure, and release to allow the blood vessels to dilate as they rush to re-supply. It's a simple adaptation that speeds healing, by increasing the immune system activity through which all healing occurs. A few sets a day of multiple reps of this pressure, and you are on the mend if you don't overdo it. Just like exercise, any therapy can irritate if done to excess.

When your brain feels these beneficial changes taking place, it will adjust the tone for you, just as it is supposed to do. All we have to do is cooperate, simple as that. In a few days to a few weeks, depending on the extent of your injury, your muscles should be ready to retrain. If they are not yet healed, they will train themselves back into dysfunction. Don't let that happen, no matter how hard it is to contain the motivation that drives you to run.

So why do you pronate? Well, as you know, everybody does, but not to the extent that you might be doing. Pronation is an adaptation to absorb shock and optimize thrust, as you found on the hills. Glutes that pull the hip into position to do this, soon burn out, as you discovered the hard way. Would an orthotic prevent this excess movement? Some of them do, and some of them make things worse. A smart orthotic addresses the specific structure of your foot so it works most efficiently. Many off-the-shelf types, even some customs that are prescribed, only restrict movement, which basically fights your physiology. You can train yourself to run differently, but it's worth your time now to examine why you ran that way in the first place.

If your foot turns to the side to maximize thrust, and your knee bends inward to flatten the arch, it is a sign the bones of your foot are not aligned to get maximum thrust and bounce without this adaptation. Depending on the population studied, anywhere from 10-50% of people can have a foot structure that forces this kind of motion to occur. The power from your legs is transmitted downward through the flexible ankle tarsal structure to the long metatarsal bones that form the arch of your foot, focusing at the ends of the metatarsals a.k.a. balls of your feet. On many people, these are not lined up in a horizontal row, and the foot has to be turned to line them up as best as possible, for maximum thrust. Otherwise, the power focuses on the smaller metatarsal heads rather than the large one behind the big toe, causing pain and injury. To compensate, the big toe is turned forward via pronation to receive the impact first, with the smaller heads helping to finish the movement as they should. If the 1st metatarsal is short, the arch must be flattened to make it strike the ground sooner. This requires the knee movement you describe and positioning of the femur via external rotation to avoid twisting the knee. The glutes wind up in an unnatural position in the gait cycle and voila - excess motion, and in the case of hard-driven pronators - eventual surgery.

If this is the case in your foot (you can't tell by toe length, which is irrelevant), your orthotic needs to supply the perceived length your 1st metatarsal now lacks. Simply building up the portion under the ball of your foot - incrementally over time to allow adaptation - will change the way your brain uses the muscles, when it no longer has to account for foot structure. It has worked for me and countless others for many years.

In conclusion, we can try to force this and force that - attempting to overpower our physiology and risking injury - or we can cooperate with it. The choice is yours.

Re: hip tendonitis/marathon training

guest — Wed, 30 Mar 2011 20:31:53 GMT

I am actually an athletic trainer and have a few people around to help. Any tips on beginning to re-train through gait training?

Re: hip tendonitis/marathon training

guest — Wed, 30 Mar 2011 20:13:12 GMT

There are two steps to learning to NOT sit with legs crossed chronically stretching the gluteus medius, first recognize you are doing it and the second step is "don't sit with legs crossed". The first step is the much tougher step. We have difficulty recognizing habits that are frequent. Ask for help. Show significant others that you sit with your legs crossed, and ask if you see me sitting this way pinch or punch me. It is very difficult to describe how to do gait training to engage the glut medius. This part of Physical Therapy that requires a physical presence and can not be done in virtual space of the cloud. Find a good PT.

Damien Howell PT, DPT, OCS - www.damienhowellpt.com

Re: hip tendonitis/marathon training

guest — Wed, 30 Mar 2011 19:20:58 GMT

Damien, it does nother me more when I sit cross legged. I read the article and it does make sense. How do you retrain your gait to use the glut medius as the article suggested? Are you out of Howell, NJ?

Re: hip tendonitis/marathon training

guest — Wed, 30 Mar 2011 19:18:59 GMT

Thank you for your help. I do not have a leg length discrepency but have not checked my tibia or femur specifically. I was looking into getting orthotics.....would that solve the problem as far as collapsed arches? I know I pronate with both feet. I was doing hill sprints when it started bothering me. I try to correct my gait and think about keeping my knee from pointing in but that seems to bother my gluts more. This happened to me in the fall as well and after 2 frustrating months I was able to get it better. Now it is back again.