Introduction & Shoes and Sitting
Systemic biomechanical issues
Evaluation of lower body dysfunction and corrections
Soft tissue optimization and corrections
Summing it up
Soft tissue optimization and corrections
Table of Contents
Feet and Ankles
The Lower Leg
The Upper Leg
The Hips, SI Joint, and Low Back
Certain Injury Conditions
Soft tissue optimization and corrections
In this part, I am going to discuss how to correctly find and optimize our soft tissue structures. This will improve our ability to stand correctly and move correctly. For those developing or who currently have injury conditions, this will provide a basis of how to correctly evaluate what you need to work on to help start you on the road to recovery.
I do think that seeing a professional is always a good idea, especially if you had an acute injury. However, like I have said prior I cannot vouch for the quality of the professionals you see.
For those with injury conditions it is important to avoid aggravating exercises. With athletes the rehabilitative protocol should be the extent of your workout for those body parts especially if it is in bad condition. But that does not mean you can neglect other training that can be done – work on upper body, core strength, mobility, flexibility, or other sports specific drills. For those who are not injured but know they will be if they do not implement corrective exercises, add them to your warm up or cool down.
For non-athletes, I strongly suggest you start working out as well because of the benefits of exercise on health. However, you should not aggravate your condition. Working out improves blood flow and blood markers which will help you improve your conditions faster.
Nutrition is extremely important in recovery so do not eat crap. Quality foods are superior. If you are not on Paleo I would strongly suggest that you implement it.
We will start from the feet and work our way up.
Feet and ankles / To the top
- Barefoot or minimalist shoes
First, it is important to go barefoot or minimalist shoes as much as possible. This will help ensure proper alignment of the talus and tibia as well as encouraging and rebuilding the ankle stabilizers and proprioceptors on the bottom of the foot.
Since shoes are a necessity for most of us as not having footwear is often times inappropriate. The type of shoes we want to aim for are with little to no padding as to allow a better feel of the ground.
Remember the shoes for children abstract I mentioned on the first page? Well, they do have recommendations about the types of shoes that should be worn. In light of the evidence we have investigated let us take a look:
- Quadrangular, to conform to the normal foot configuration, with abundant space for the toes.
- Flexible to allow free foot movement [especially at the ankle].
- Flat without elevation of the heel.
- Porous. Uppers should be made of leather or unsealed fabric to avoid skin maceration or fungal infections.
- Moderately tractive. Sole friction should be equivalent to that of the bare foot. Sole that are slippery (leather) or that create excessive friction (some rubber soles) should be avoided.
- Light weight to reduce energy expenditure.
- Extended above the ankle in the toddler to prevent shoe from slipping off during running.
- Acceptable in appearance because children are very sensitive about that.
- Reasonably priced. Medically satisfactory footwear need not be expensive.
I would clearly agree with all of the points except for the last two which need not be followed for proper foot health. Basically, what the study is describing is minimalist shoes. Vibram fivefingers are like that. There are also other minimalist shoes that are made for running such as Puma’s H-street/K-street brand that adhere to most of the points above. These are the types of shoes you should be looking for.
If the feet are already deformed to the stress with conditions such as bunions, collapsed arches, or talipes valgus, then the alternative is orthotics if your condition is bad enough. These may provide relief. However, if these conditions are just starting to manifest, it is important to start correcting them right away.
- Balance work
Advanced form of balance work – Photo from lauravallas
It is important to progress to single leg balance work and eventually on unstable surfaces or with the eyes closed. Concentrate on firing the muscles in the bottom of the foot and the ankles to stabilize instead of waving your arms around to balance or moving the hips up and down. In fact, you should place your arms behind your back so you do not cheat. Aim to get 60s multiple times before trying to advance to harder progressions.
- Plantar muscle strengthening
Photo from revolutionhealth
For those who have collapsed arches that are hopefully not permanent, it is important to do foot flexor exercises to help stimulate the plantar aspect muscles to get stronger and take their role back to reform the arch. Putting a towel on the floor and scrunching it up with your toes, or picking up odd objects with your toes and putting them into a jar is a good way to do this. The same is true with plantar fasciitis.
My favorite thing to get the plantar muscles engaged is sand. If you have ever been to the beach and walked around for a while you may have noticed that all of the muscles in the feet get worked extensively and get sore. This is because sand is an unstable surface and is constantly changing. This will help get your plantar muscles firing again and hopefully get the arch back up to snuff. Start with low amounts of time (too much initially will make you very sore). Progressively work up to more as you get stronger.
- Soft tissue work
Roll your plantar fascia or use a golf ball to dig into it. Frozen water in a coke bottle may be very helpful for those with painful injury conditions on the bottom of the foot such as plantar fasciitis. If this is painful, you have something you need to work on.
Massage to the bottom of the foot, though awkward, is also a good tool to increase the mind-muscle proprioceptive connection. The way to do this is that you want the muscles in shortest range possible so they are not tight. Thus, you want to have your foot curled up itself, BUT not have the muscles contracted. Put the foot into plantar flexion and use one hand to curl your toes towards the plantar aspect of your foot and hold them. Use the other hand to massage. Focus on the sensations from the massage, and contract the plantar aspect muscles to stimulate activation.
- Foot drills
These foot drills (.doc) are also good for proprioceptive awareness and help the body distinguish good movement patterns.
If you are an athlete you should be doing these. No exceptions.
Notes
1. For those with the actual injury conditions such as plantar fasciitis or flat feet it is important to rest, ice and massage as well as do most if not all of the protocol above IF it does not aggravate your condition. You need to be proactive about your injuries.
2. As you may have figured out I do not like orthotics or “arch support.” At all. I believe they are, for the most part, a quick fix for problems that most people’s bodies have the capacity to handle given proper postural and biomechanical correction. Most of us were not born with congenital foot issues, and most of us do not have self-collapsing arches before adolescence.
Of course, if you absolutely have to exercise such as military PT or you are competing in race season, they are fine. Similarly, those who may already have joint deformations may need orthotics to keep their conditions from worsening. However, I do recommend that you begin and start corrective exercises and tissue work to help start fixing the problem so you do not need them later.
3. One thing I have noticed in the physical therapy clinic I currently work at is that often those people with darker skin are more prone to pronation in the foot and collapsed arches. This is due to Vitamin D deficiency. If levels of Vitamin D in the blood are low, proper bone growth and mineral density is decreased. Thus, this leads to bones that are softer and more likely to deform to the stresses we put on them. Couple this with the valgus stress of shoes and sitting, and you have an increased likelihood to develop flat feet, plantar fasciitis, and talipes valgus for those with darker skin.
Since 80-90% of all people are Vitamin D deficient or severely deficient it would be a good idea to increase intake by getting out in the sun more, drinking more milk, or eating more fish. If, however, you cannot do these, then it is a good idea to supplement. In the link above there are some links to the cheapest (and highly rated) Vitamin D that I have found online at the bottom of the article.
4. Finally, like many of the conditions described just because you have patellofemoral syndrome does not mean you should be skipping these corrective protocols. In fact, it is important that you see if these exercise help your condition because in all likelihood they may as the lower body is a system and not compartmentalized. Keep this in mind as we continue.
The lower leg / To the top
- The calves
The calves are an obvious hot spot. As mentioned before Carson Boddicker’s Alleviating Ailing Ankles has videos of different stretches to do. Similarly, Kelly Starrett’s Your calves are tight bro is a good article to read on how to stretch them out. Find out what exercises work the best for you to improve your ankle mobility.
As we have discussed before, the plantar fascia is continuous with the fascia of the rest of the posterior chain. People with plantar fasciitis especially usually have extremely tight calves. Loosing up the calves for people with foot problems often brings instant and continuous relief to such problems.
- Soft tissue work
It helps to get your calves with a foam roller or tennis ball. Golf balls are my preferred method of choice if you can tolerate it. It will hit all of the deep muscles under the gastrocnemius.
If you are going to do soft tissue work you want to have the muscle in a full contracted but relaxed position like described in the foot section. So have something hold your toe in plantar flexion, and bend your knee so that the gastrocnemius is shortened. For example, sit in front of the wall with the ankle up on the opposite knee, and use the wall to hold the foot in plantar flexion. Then use both hands to dig into your calves.
It is also a good use of time increasing plantar flexion through pointing the toes as well as loosen up the anterior tibialis as well. Especially if you are a now former heel-toe runner.
Doing massage right before stretching is a good idea. Similarly, heat allows the muscles to loosen up and stretch farther than they would otherwise. Keep these two things in mind if you are having trouble loosening up the calves or any other muscle.
- Popliteus and plantaris muscles
Photos from kneeguru and blogspot
The popliteus and plantaris muscles get very tight in most people. To hit these use the same setup as above and target the area right below the back of the knee on the lateral side (so near the bottom of the leg that is up on the knee). Most people will have trigger points here even with no injuries.
The upper leg / To the top
Photo from hippie.nu
- Tight, strong quadriceps
Stretch them out and do tons of soft tissue work on them. Initially, foam rolling will probably hurt a lot, but as you get better progress to tennis balls and beyond. Additionally, do hip flexor stretches daily including before and after exercise. Find out which work the best for you.
For self massage target all of the muscles of the quad especially the rectus femoris as it will be very tight because it is a hip flexor. To put this muscle into shortest range of motion possible for massage, sit in a chair and prop up your leg so that it is straight and resting on a higher surface. From there you can dig into your quads with your fist. If you need more pressure and have the flexibility, lean over your leg and use your elbow.
- Tight, strong TFL and IT Band
Pretty much the same as the quads. Start with foam rolling, the work your way into tennis ball or golf ball. Additionally, do IT band stretches.
For massage you can target anywhere along the band that is tender as well as the TFL itself. For TFL massage sit in a chair with no sides and rotate the leg you want to work out to the side as far as possible while keeping your pelvis neutral. From there locate your iliac crest which is at the top of your pelvis at the midline of your body if you are looking at your body from the side. Follow it to the front until you encounter a sharp point. This is your anterior superior iliac spine (ASIS – also used for measuring Q-angle). The TFL is right below the space between the ASIS top of the iliac crest that we started at. Most people will be very tender here so dig in and loosen it up.
For the IT band use the same side hand of the leg that is abducted and grind your knuckles into the side of your leg. You can use the opposite hand to brace the leg to get more force. Most of you will find that the whole thing will be sore and tender.
- Tight hamstrings and adductors
These are two separate muscle groups, but I am grouping them together because there are several stretches that hit the both effectively. Firstly, I recommend proprioceptive neuromuscular facilitation (PNF) as the method of choice (for the quads and TFL as well if possible). Here is one way that hamstring and adductor stretches can be implemented. Gymnastics has a great set of straddle and ‘pancake’ or split exercises to help stretch out the hamstrings and groin as well. You can find some of them here.
Massage is going to be harder for both the adductors and hamstrings because it is difficult to hit the back and inner leg without lengthening the muscles. Ideally, you could have someone else do it, but that cannot always be the case. For the hamstrings, lie on your back and prop your leg up on a chair bent at the knee. From there loop your hands on either side of the affected leg and use your fingers to locate any sore or tender areas. You may also consider using a foam roller, tennis ball or golf ball is this is ineffective.
For the adductors you may hit them from the same position as the hamstrings. Alternatively, you can sit in the chair and use the same side arm to brace the leg. From there use the opposite arm to dig your knuckles into your affected leg. You can use your weight to drive the knuckles or your elbow into the tissue as you are massaging just like the quads.
If you are extremely quad dominant, you must focus on bringing up the hamstrings strength to bring back proper balance to the knee. This will most likely help with the knee disorders such as patellofemoral syndrome, IT band syndrome, and chondromalacia patellae. Bret Contreras recently wrote a couple articles on t-nation that were good. One of them is this on hamstring strengthening.
Notes
Unfortunately, we cannot really do anything about ligament or meniscus issues. But if we ensure that the body is working correctly as a unit with correct movement patterns and muscle activation, then we do not need to worry too much about the connective tissue. Unless you are someone who works to the point of overuse injuries in which case you need to cut back and let your body heal.
Those with patellofemoral syndrome, IT band syndrome, and chondromalacia patellae will often have extremely tender quads, IT band and TFL. It is imperative to work out all of the kinks in the system, and stretch these muscles out to allow proper functioning of the knee. Similarly, tight adductors that need to be stretched will often contribute as will weak and tight hamstrings. Stretch out the adductors and hamstrings, and bring up the strength of the hamstrings.
For quad dominant athletes, you will also have extremely tight hamstrings and adductors. Loosen these up for optimal athletic ability. If you do not you should know that you are more susceptible to strains, and improper technique due to being too tight which may lead to more injuries.
The hips, SI joint, and low back / To the top
Photo from eorthopod
- The glutes
As I have indicated, the glutes play a major role in the dysfunction of the hip as their inactivation allows many bad things to happen to the lower extremities. This is because of their role in hip extension, abduction, and external rotation of the hip. The fact that they are inactivated leads towards lots of other muscle compensation which turns out bad for both the common person and the athlete.
Our first step is to get them activated again. Fortunately, Bret Contreras’ other article on the glutes is good for this. Do not skip phase I as easy as it may seem. This is needed to properly ensure and bring up activation in the glutes, especially if you have a desk job. Both parts of phase I must be followed because the first helps to activate your gluteus maximus and the second helps to activate the gluteus medius. Activating both of these are important for lower body health as we discussed earlier.
From there follow phase II, III and IV to bring up hypertrophy, strength, and power. This is important especially if you are an athlete as it will make you more explosive. If you are not an athlete, this will be important for you anyway to correcting your own posture and biomechanical dysfunctions we mentioned earlier.
Alternatively, Kelly Baggett’s No glutes = no results is also very good at illuminating this problem. His article includes some postural evaluations as well as a basic program which may help. You should read both.
Here is a good exercise from Nick Tumminello called the super bird dog which will show you if you are making progress with glute activation. Ideally, it should be easy.
If you have a desk job it is a good idea to get up every 20-30 minutes and do some glute exercises or at least squeeze your glutes so that you can increase activation and develop a good mind-muscle connection. If you have the possibility to stand a lot, that may be an option as well. Basically, our goal here is to minimize the problems associated with constantly sitting all of the time. By doing activation work and/or strengthening for the glutes very often we build a much stronger neural connection to them which will improve their activation in compound movements such as walking, stairs, running, squatting, and weightlifting activities.
If you can bring a foam roller or other device to help stretch out the hip flexors all the better. Here is a good video on utilizing a foam roller for the hips that can be used to help loosen up the area.
Finally, traumatic ankle injuries, (2) & (3), such as sprains have detrimental effects on the hip extensors like the glutes which lead to quad dominant compensation. Obviously, this is not good for athletic performance or normal life. So it is important if you have sprained a lower extremity to systemically rehabilitate yourself rather than just focusing at the ankle.
- Tight intrinsic butt muscles
Hitting and loosing these up is actually very easy and feels very good (no puns intended). This is the stretch I prefer as opposed to the piriformis stretch lying on the back with the leg crossed over and pulling. This one encourages a better lumbar position and is a bit more friendly on the knee by keeping it from torquing.
The other way you can loosen them up is with the internal hip rotation stretch such as this or the one I referenced earlier.
Another soft tissue technique to loosen up the muscles is to use a tennis ball and basically sit on it. This can be done sitting down onto it if you need more pressure, but the muscle will be shorter when you lie down and move your glutes around on it. Try both and see which one works better for you.
- SI joint and lumbar stability
Photo from singhealth
Obviously, with these joints you want decreased mobility and more stability as we discussed before. So it is imperative to increase core strength.
I am going to only discuss basics here, but I do prefer that development of the full body lifts are critical for developing a strong core. If you are specifically injured and an athlete, the core lifts such as squats, deadlifts, etc. may be contraindicated with some specific lower body dysfunctions. If any exercise is emphasizing improper biomechanical movement or pain, it is best to avoid it for now.
Supine posterior pelvis tilts, planks with the pelvis posterior tilted, bird dogs, upright bird dogs, supermans, etc. are all basic core exercises to get you started.
Notes
By now you should have a greater understanding of lower body anatomy and potential solutions for your dysfunctions. Usually tender or tight areas will tend to mean that something is out of balance or you have let your tissue quality become poor. Your health and performance will only improve by fixing these troubled areas.
It is in your best interests with any of the injury conditions I mentioned (and even possibly some I did not mention) to evaluate your body and find all of the different trigger points or tender areas and eliminate them. Foot conditions such as bunions and flat feet can be affected by inactivated glutes especially gluteus medius, while lower back pain can be caused by problems down in the foot. This is in addition to the rehabilitative protocol specific to your condition that I mentioned.
Use the list that you wrote down in the last section and go through the specific soft tissue work I have listed and start working out the kinks.
As I have been harping on the Neanderthal Series great. Here is their take on rehabilitative protocol and reintroduction of lifting exercises. This is whole body so you may have to pick out the core/lower body work out from the upper body. I would suggest this as a read through if you want a non-focused program you can follow; however, you should definitely still target specific tight tissues with above soft tissue work as well.
Here’s a shorter version focused solely on the hips from Mike Robertson.
Certain injury conditions / To the top
Now that we have discussed most of the specific work I am going to talk specifically about some of the injury conditions. It is an extremely good idea to hit up all the different muscles and other exercises I mentioned to see if you are tight, tender, or need strengthening in those areas. Rather than me specifically telling you what to do you will be able to figure it out for yourself.
That said, I will go over some of the main points of each of the injury conditions that I have mentioned as some guidelines. This is by no means complete. If you wish to have professional advice and a plan optimized towards your health, see a physical therapist.
As we discussed, there are multiple things you should be checking with any of the injury conditions. These include the (1) inward tracking knees during normal standing posture, movement, or exercise, (2) reactivation and strengthening of the gluteus maximum and medius, (3) increase calves mobility especially if your dorsiflexion ROM is bad (bent leg stretching for soleus, straight leg for gastrocnemius), and (4) loosening up the adductors. These should be done in all of the injury cases I am describing below.
Pain management can be taken care of with resting, ice, and massage pulling the blood towards the heart especially if there is swelling/edema.
Flat feet / pes planus / collapsing or collapsed arches – focus needs to be stimulating and strengthening the plantar aspect muscles and improving balance. It really depends on how long the arch has collapsed if it can fully reform before the bones have totally deformed to the collapsed orientation. Improving glute function and calf mobility is a must.
If the condition has lasted for long periods of time, orthotics may be indicated especially with varying degrees of pain as well as preventing the arch from further collapsing. Again, ideally we want to not have to use orthotics, but sometimes they are necessary.
Hallux valgus – Treatment may vary depending on the orientation of the joints. Generally, restoring proper biomechanics and weight distribution will help the most, as will the same foot exercises described the flat feet section. Improving glute function and calf mobility is a must as is correcting weight distribution patterns. Improper footwear can also be a cause so be wary of that.
Plantar fasciitis – Same as flat feet, especially if you have flat feet and this condition.
Achilles tendonitis – First, read this on tendonitis. Second, fix your running form and/or avoid high impact scenarios to let it heal. If you have a valgus condition in particular this will exacerbate it so be sure to focus on correcting this improper movement pattern.
Sprained ankles – Depends on the severity of the sprain. Surgery may be needed or not. First, focus needs to be on reducing the swelling, and restoring range of motion with painful stretching. Secondly, strengthening and balance must be improved. Also, as noted by the studies focus on proper gluteal strengthening as well.
Be sure not to compensate a lot on the opposite leg. This will cause muscular imbalances that are very difficult to get rid of.
Shin splints – Focus on fixing proper movement patterns especially running. The improper heel-toe running is one of things that exacerbates this condition the most.
In general, rest, direct ice massage to the bone, and massage will help. Strengthening the anterior tibialis and loosening up the calves will help significantly.
Patellar tendonitis – Same as the achilles. First, read this on tendonitis. Second, fix your running form and/or avoid high impact scenarios to let it heal. It is very important to stretch the quads, TFL and IT bands thoroughly, and improve glute and hamstring strength as well as ankle mobility.
patellofemoral syndrome / chondromalacia patellae – Focus needs to be on the entire upper leg-hip complex by restoration of correct tissue function and movement patterns. For those of you who missed the boat that is the calves, quads, hamstrings, TFL, IT band, glutes (both), and butt muscles.
IT band syndrome – Focus needs to be on the entire upper leg-hip complex by restoration of correct tissue function and movement patterns. For those of you who missed the boat that is the calves, quads, hamstrings, TFL, IT band, glutes (both), and butt muscles.
Ligament or meniscal damage – See an orthopedic doctor.
If you are past a surgery such as ACL repair, this study may interest you. Focus on restoring proper movement patterns, and regaining proper strength ratios in the leg. Gluteal strengthening will help out a lot to reduce the amount of force at the knees.
Joint deformities – Depending on severity orthotics or other things may be indicated. Even so, proper movement patterns should alleviate problems, but it is going to be a long uphill battle. Hopefully, you did not wait this long for this to happen before you started looking for help.
Conclusion
Extensive use of manual soft tissue work is the key to rehabilitating injuries. Just like I listed the importance of massage in On Tendonitis, I fully expect if you are trying to recover from a lower body injury or are close to one that you do an extensive analysis of your soft tissue quality and movement patterns as I described above. This information should set you on the road to recovery and help you maintain optimal athletic ability or get back to your daily life pain free. In conjunction, for those who do not exercise, it will significant improve your quality of health.
This concludes this section. In the next, I will give a summary and the key points you should be taking away from this article. Also, I will provide a large list of links that may provide additional help to those of you suffering with injuries or other information on the topics I have discussed.
thanks for this excellent article steven.
question. if with hel striking, the foot is in dorsiflexion, doesn’t this mean that the calves are in a stretched, not contracted position, most of the time?
Ah, I mentioned this.
“This study showed that “a significant increase in leg stiffness from the barefoot to the “cushioned” shoe condition was noted during hopping. When running shod, runners landed more dorsiflexed (foot tilted upward) but had less ankle motion than when running barefoot. [...] The primary kinematic difference was identified as running speed increased: runners landed in more knee flexion. At the ankle, barefoot runners increased ankle motion to a significantly greater extent than did shod runners as speed increased.” When running barefoot, the forefoot receives the ground* with less than 90 degrees of dorsiflexion. Thus, the comment above regarding dorsiflexion with shoes running is deceptive. Obviously, decreased range of motion is the big thing as I talked about above.”
Basically, in barefoot or minimalist shoes, the ankle receives the ground plantar flexioned then the calves are allowed to eccentrically work as the ankle bends and loads them. This means the ROM expressed is actually a large range of motion. You can try this moving in the grass sometime barefoot.
With a heel first strike, the foot is coming down and the foot is not being plantar flexed at all as the weight is shifted forward to the foot. If you do relax and let the foot strike down this is one of the key eccentrics on the anterior tibialis that leads to shin splints. So as I said the “flexed” foot in heel-toe running is very deceptive because there is actually a lot less net ROM and less overall dorsiflexion of the foot compared to barefoot/minimalist.
thanks for clarifying. I will have too read more closelyl next time! great work, all the articles i have read so far are top notch!
Steven – Had a question for you on the shoes/sitting essay you wrote. Excellent by the way. Like many I read “Born to Run” and was sold on barefoot running. Bought myself a pair of vibrams. Started running again. Loved it… no knee or hip pain like the previously times I had taken up running. Bought myself another pair of vibrams and started upping my distance. Ran one day when my calves were sore and compensated for the calf tightness by running more flat-footed. Ran only 3 miles but the next day both my feet had classic signs of plantar fasciitis, with pain mostly in the arches and the balls. I’m now on day 4 and still have some pain. Interestingly the only time I hurt is really when I’m shod and sitting. Walking, and even a test light jog yesterday seemed to illicit no pain. My question is, “do I need to treat these and not run until the pain is completely gone?” I would plan to run very short and let pain, if any, be my guide. Any thoughts you could share?
Running when the body is sore, or excessively in general is a good way to develop overuse injuries like plantar fasciitis.
I suggest to new people that they start off with < 200m per session, and increment by at most 100m per session. Reason being that your body is learning new movement patterns, and you honestly wouldn't go off and do hundreds of repetitions of new exercises… so why would you do the same with running?
Assuming someone is taking about 2m per stride with two feet that's 50 repetitions per leg per 200m. While it doesn't seem like a lot, it really is for learning new movements. At most I would do 400m if you really wanted to push the envelope. The main problem is that you don't "feel" the problem until it's too late when you're bombarded with massive soreness in the arches and calves the next day since running is so low intensity — but the muscles from previous running have not properly adapted to the stresses.
3 miles on sore calves is definitely excessive, and since the calves wouldn't be able to absorb the impact properly your arches started to do that. When the intrinsic foot muscles get tired, the connective tissue starts bearing the brunt of the stress — namely your plantar fascia.
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I would back off for a bit even if there's no pain running or jogging. Walking at most.
1. Ice if it helps,
2. massage to the plantar aspect of the foot & calves — loosen stuff up,
3. anti-inflams (ibuprofin, etc.) are fine,
4. maintain your mobility in calves and arches by going to edge of ROM but don't push it too much. You just want to keep them active so that nothing tightens up on you.
Obviously, rest and work your way back in slowly. You don't want to develop overuse injuries or reaggravate your conditions.
You're on the right track though… just a little too much so far.
I’m interested in reading the full text shoes in Pediatrics. I’ve got a ten month old son and he is just beginning to walk. I’m avid that he should run around barefoot because that’s how it’s supposed to be, but I can’t seem to convince my wife. She’s, unfortunately, fallen in to that category where she puts shoes on our son because they are cute; not out of necessity or to serve any functional purpose. For my interest and my sons benefit please email the text. I’d greatly appreciate it.
Fantastic article BTW despite it’s length it was a really good read.
Shoot me an e-mail at “steve” at this website name.
Thanks for the compliments.
Wow! Great work, really!
Thanks so much for sharing this!
– A flat feeted, hallux valgused, genu varumed, glutes inactivated, hamstring tightened french guy
Steven,
Wow, what an amazingly comprehensive and useful article. I think it’s incredible that you devoted so much time and effort to writing all that, and putting in all the links, for our benefit.
Thank you!
I realize that you can’t answer detailed questions from every reader, but… I guess it can’t hurt to ask, so what the hell!
I got the maintainence staff at my office to jerry-rig a stand-up desk for me a few weeks ago. It’s great. No back pain at the end of the day, and my hip flexors seems to be less tight. It’s all good, except… my feet hurt from standing still in regular shoes for hours at a time.
My office is a pretty high-level department in the government. Dress shoes are basically required. No one has a problem with the standing desk, but if people saw me wearing just socks in my office, it would be regarded as inappropriate.
Any suggestions?
(Btw, stats are: 42, 6′, 200 lbs, 1RM squat = 375)
Well, the question is (1) how adapted are you to barefoot standing/movement, and (2) do you move around a lot during the day?
If you could just buy some flat soled dress shoes with ample foot room you can stand/move around in your office. Basically, you want to simulate barefoot condition with your shoes as much as possible. You could have your other dress shoes around for when you have to go out of the office for other stuff.
That’s just a guess at what your conditions are though so…
Feet are going to hurt if you’re not used to be being on them a lot though regardless of if you are bare foot or not if you haven’t done it for a long time, and if your weight is up there which it is. Heck, I’m under 140 lbs and my feet still hurt from standing up hours at a time. Hopefully, this will go away as you adapt better though.
Thanks!
Hey,
Great work in this article. I’m very impressed. I couldn’t agree more especially on the topic of shoes and the natural foot. I’m excited for you to finish your degree and working with you! We need more PTs of your caliber.
I have tight adductors and deep butt muscle tightness. To increase the ROM of these muscles, should I just practice middle splits and the stretch in the included picture everyday? Or are there other stretches that will help with this?
Also, I’ve had flat feet for as long as I can remember. I want to try and correct my posture and build up the strength to have an arch in my feet. All I need to do is simply strengthen the plantar aspect muscles correct? And this can be done by doing the mentioned exercise and http://hubpages.com/hub/Foot-Gymnastics-Exercises-and-Games-for-People-with-Flat-Feet/Us or anything similar?
The stretches provided are the ones I would do. That does not mean there are other stretches that may work as well. If you know of some better ones or want different ones feel free to use them.
Your second scenario is a little more difficult. It depends a lot if you can reform the muscles based on how long it’s been that way. There’s no harm in trying though. And, improving the plantar aspect muscle strength + rolling the plantar fascia and stretching out the calves and hamstrings should help get you there. (The fascia/connective tissue if it’s tight may not allow reformation of the arch thus why you need to do that in conjuction with the strengthening).
Hi Steven… fabulous article, that I just found today (1/6/10). I started barefoot running last year (during the warmer months) after correlating exactly what you said about the feet and legs. I miss it during the cold months; I’m in Maryland also, feeling the winter now. Perhaps not coincidentally, I have been also experiencing the tight hips and weak glutes – I diagnosed myself last week. Have started myself on rehab and improvements. Can’t wait to delve more deeply into the article! Have also passed your article along to not only friends but some colleagues. I also found an article on you in American Parkour (and saw the pics from Primal Fitness, which I recognize
.
Hey Steven,
I followed a link from the CF discussion board to this article. Good stuff. I have passed the link on to several parents from my daughter’s soccer team.
My daughter (age 12) suffers from Sever’s disease in her left heel. The recommended treatment is conservative – ice, stretching and padded shoes. She wears Superfeet inserts in her cleats. Much of her pain is caused by her calf muscle pulling on the growth plate in her heel, but I was wondering if a gradual introduction to barefoot walking/running might help her by strengthening the muscles in her feet and lower legs. What do you think?
Thanks!
Yep, stretching out the calves and hammies will go a long way to help. Similarly, strengthening the muscles of the plantar foot and balance work.
Barefoot may help in time once it calms down like Osgood Schlatter’s does. If it’s active I bet she won’t want to do anything regardless because of the pain.
Steve – do you know any places that sell Puma H-Street or Salohs online (haven’t had any luck finding places that stock them in Australia)? Also, what are your thoughts on Nike Frees as a running shoe?
I know they have some on amazon at the very least (H streets you’re basically outta luck unless you can find some rarely offered ones around… they do have K streets though which are very similar):
PUMA Men’s K-Street II Sneaker
Puma Men’s Saloh Ripstop
As far as Nike frees go too much heel padding for my taste. But if you like them sure.
I would tend to stay away from anything padded if possible. You want as little between your feet and the ground as possible both in the forefoot and the heel.
Make sure you have enough room for the toes as well.
Hi Steven!
You commented on one of my posts on the CF forum about a lower back injury, and I followed you here to this site and am learning a ton. I am living in Japan, and being able to read extensively about back injuries and narrow it down to an SI joint injury was super valuable when dealing with my doctor (in another language, medical terms are difficult.) Thank you.
Now I read this article and am reading Starting Strength, and I’m starting to think about getting some minimalist shoes. You make a convincing argument. I definitely have tight hammies/hips/all of the above. This, combined with some torn ligaments last year and my SI joint injury have me rethinking all of my mechanics, techniques, and outlooks on exercise.
On that note, since I have to build from scratch after injury anyways, would you recommend getting minimalist shoes and starting now? For Crossfit/everyday use, would it be better to get a pair of five fingers or one of the shoes geared towards running? Also, do you think even with a slightly sore lower back that working on walking barefoot etc. would be okay/safe/good to start right aways?
As always, your advice and input is much appreciated.
Of course. Minimalist shoes are good, but if you’re having problems I would definitely not run in them yet.
A couple weeks/months to get yourself acclimated, and do all of the necessarily prehab/rehab work (section 4) that you need to do to do before you start jogging/running in them.
Depending on where you are five fingers may be OK. If there’s a lot of uneven terrain or gravel or whatever else have you then it may be a better idea to get specific minimalist running shoes.
For flat feet: “For those of you who have flat feet/collapsing arches or plantar fasciitis, you know you tend to put more weight on the medial edge of the foot.”
Isn’t that the opposite of what I should be doing. Since my weight is already always medial which causes my arch to collapse. Shouldn’t more time be spent with my weight on the outer foot -5th MTP- (pinky bone)?
Yep. I said:
“you know you tend to put more weight on the medial edge of the foot.”
Which means that you know it happens, which means you want to distribute more weight to the lateral edge of the foot.
Thanks for catching that though I can definitely rewrite that to make it more clearer.
Steven,
I thought I had strong, healthy feet (I do hill sprints on grass with Vibrams once a week; lift in Puma’s), but maybe not!
I have a stand-up desk at work and kick off my shoes whenever I can. I brought in a golf ball today to roll under my feet. I was _shocked_ at how “lumpy” my plantar fascia felt, and how many very sensitive trigger points I have. Even mild pressure is painful on some spots. Is this normal!
Thanks for all your effort on this great blog, btw.
Yes, it’s normal if you’ve never done it before. Even in unsymptomatic laypeople and athletes.
Our bodies can tolerate a lot before they start to break down. When things start to become painful that means your body is letting you know that things are in very bad shape. Things can be in pretty bad shape without pain at all as exemplified by our poor posture with the shoulders and neck, in non-painful valgus conditions like flat feet and bunions, and other such orthopedic maladies.
Good stuff, thank you.
Steven, I am plagued with knee pain, my knee pain is in most areas of the knew except the outsides. Middle, top, front, bottoms all give me negative feed back when exercising. After reading this article I noticed my feet are always splayed outward at about 30-40 degrees angle when standing relaxed. They also turn outward when I am walking, but the Vibrams are helping a bit.
I was thinking I should just get a reverse hyper and go to town on my glutes every day while simultaneously stretching everything out. But what do you think would be best? The knee pain is definitely the biggest thing that slows my training progress down and I would like to eradicate it once and for all.
Do everything on page 4. Take notes see what helps and what hurts for a week. Whatever hurts drop for a bit and come back to it later. If it helps, then great keep doing that.
You should be able to figure out what helps and what doesn’t… but if you still can’t then post your notes here and we’ll discuss.
OK so I was doing some cleans the other day and the pain got pretty unbearable. I tried to do a pistol and I collapse from pain. I went to see a PT and he said I have chondromalacia. He told me I have the tightest hammys he had ever seen and I need to stretch them as well as strengthen my glutes. So pretty much the same thing you said.
I told him I have been working on my hammys for about an hour a day after reading this and I have not gotten so much as a millimeter out of them so far. He referred me to this thingamajig from hamstretch.com so I ordered 2.
Will update on knee pain but I don’t think the hammys will budge..been doing PNF a lot too.
Sometimes less is more.
What is your current routine for all of the days of the week?
Well it was CrossFit every day and maybe take Sunday off, but now…. Gonna work more on stamina for pull ups/pushups….press strength & glute strength. And of course hamstring flexibility (still have my doubts that they will actually loosen up).
I’m thinking of doing the strength exercises followed by some type of upper body metcon (this is going to be pretty limited variety w/o being able to bend my knees).
I will probably rotate chest&shoulder strength / pull up strength and core strength / glute strength on a three day cycle and follow each with a metcon of some sort. Foot drills, light glute work with hamstring and hip adductor stretching every day.
If you can put heat on your hammies before you stretch them. Also stretch everything in your posterior chain — plantar fascia, calves, hammies, glutes and low back.
Make sure you get enough magnesium too.
I really meant what are you doing for stretching? How long are the holds? How many sets? What type of PNF are you doing? What frequency?
I refuse to believe that if you are doing it correctly that you are making no progress.
“I really meant what are you doing for stretching? How long are the holds? How many sets? What type of PNF are you doing? What frequency?”
Daily Stretching
-Warm-up with rolling every part of my legs with “The Stick”
-Dynamic stretching with kick the hand drills…I can’t quit get up to chest height yet.
Calves – Put foot against a pole (as seen in Kstar’s your calves are tight BRO) with knee straight and get a deep stretch for 5 seconds then I flex the calve by pressing the ball of my foot into the pole (heel is on ground) for 5 seconds. As soon as I release the flex I immediately go into a deeper stretch for 10 seconds and after that I flex for 10 seconds…….I do this in 5 second increments until I get to 30 seconds. Once I complete this with each leg I do it again with the knee bent. Once I complete it with knee bent on each leg I do it a final time with leg straight once again.
Hamstrings – Feet together I bend down and give it everything I’ve got to try and touch my toes. I do 3 sets 30 seconds each. Then I get against a wall and sit with my feet together and push down on my knees to stretch the adductors for 5 seconds, then I resist for 5 seconds and so on up to 30 seconds. One set.
Then I kick my leg up on the desk (not an easy task) and stretch forward on it 5 five seconds, then I drive my heel into the desk with knees straight for five seconds and so on up to 30 seconds. I do 3 sets on each leg. The main thing that hurts when I do all these stretches is the tendons behind my knee more so than the muscles themselves. If I have some time I lay on the ground in supine position, one leg up with a rope tied around my foot and I pull it back as much as I can and do similar PNF just laying on the ground. I also ordered the devices from hamstretch.com to help with this.
That’s pretty much it. At the end of it all I can put my finger tips under my toes just barely, but when I wake up the next day I can’t even touch my toes.
The PNF is too short.
Leave the contraction phase at 5s, but let yourself stretch for 10-15 seconds.
You do not always have to do PNF either. I would alternate days where you just relax in your stretch and let your body normalize. 30-60s for the regular ones.
Too much PNF as you’ve found especially with short holds/contraction phases are counter productive.
OK thanks, I will try this and the heat and get back to you in a couple weeks with results.
Steven,
After searching through youtube for Hallux Valgus corrections, all I find are surgeries. Please tell me there’s something else I can do about it. So far I’ve been stretching them passively. If I try actively, all I get are my 2nd to 5th MTPs rising. The toe doesn’t move!
It’s possible you can get orthotics to fix some stuff. But if it’s really bad and immobile (at the joint itself)… then you’re likely going to have to get surgery for it. IF the muscles are atrophied then maybe not.
There’s stuff like toe spreaders that may help. If the arched is collapsed then you have to fix that first though.
Hi Steven,
I just have a quick question about shoes. What about running on concrete or any other hard surfaces? Would a minimalist shoe, like the above mentioned Puma be suitable to run on concrete? Wouldn’t it be too hard on the joints?
Great site BTW! Lots of excellent info!
Thanks in advance!
If your muscles are working properly they should absorb the force.
The only reason your joints would be taking the force is if you are running heel-toe.
Like the studies have shown (that I linked) there are more forces involved with running poorly than running with minimalist shoes.
I’ve been searching for dress shoes I can wear to work and I finally found some that are working well for me. I just take the inserts out so you can see the green on the bottom inside of the shoe and they feel pretty good. I need to dress professionally but work at a job where I am on my feet 8 hours a day and walking multiple miles, so I’m glad I finally found something. Just thought I’d share in case anyone else was looking because I haven’t really found anything else that would work.
http://www1.macys.com/catalog/product/index.ognc?ID=448092&PseudoCat=se-xx-xx-xx.esn_results
I hope its ok to post this link, if not feel free to take it down
Nice find. Hopefully that will be helpful to others.
Brendan, thanks for that link!
Hi Steven,
First off, awesome article! Really comprehensive, the most comprehensive approach to this issue in a systems-based approach that I’ve seen!
I will take issue with one thing you’ve mentioned in this section, however. From my experience, squatting should be done first without load, and effort should be made to enable the individual to squat “naturally” (like this guy – http://tinyurl.com/2fxfuyh). That’s how most of the world “sits,” and how most humans, I would imagine, sat for most of our existence.
My next issue is with the “optimal desk arrangement.” I’d rather see people sit at a very-low desk (having to sit cross-legged or squat) or a standing desk. As Dr. Michael Leahy said a bunch of years ago in his “Law of Repetitive Motion” – the body conforms to the position its in the majority of the time. Fixing a desk-space doesn’t change the flexion of the hips…and remember that people sit like that in their cars and at home, too. Get them sitting on the floor more (like most of the world’s population still does)…I think that’s a better recommendation.
Finally, have you seen the book “Assessment and Treatment of Muscle Imbalance: The Janda Approach.” The reflex neuromotor aspect of gait that is disrupted by covering the surface of the foot has a huge impact on general body patterning as well…..
Thanks for the great post!
Josh
Good addition…check out Deric Stockton’s foam roll sequence for opening the hips: http://www.youtube.com/watch?v=yXty_MpgQt4&feature=digest
he also has an article about his method in the most recent issue of PLUSA:
http://www.powerliftingusa.com/current_issue.php
Josh,
Hey yeah good stuff. I’ve actually been meaning to add a lot of other information to this and you brought up some I was going to add and some I didn’t even think about as well.
Definitely agree about the “third world squat” and the rest of it.
I’ll add in a lot of that shortly. Unfortunately, I have not read that book you mentioned; it sounds good though. I am quite short on money right now so I’m try to spare the expense of purchasing any extra things.
Hey Steven –
Love your stuff. I too have an undergrad degree in Biochem and am applying to PT school in the fall. Your approach makes a ton of sense to me.
Anyway, I poked around but couldn’t find too much on your take to piriformis syndrome. I have a couple of clients with diagnosed piriformis syndrome and I am wondering if there is self-treatment they can do in between trips to a PT? Piriformis stretching and SMR with a lacrosse/TriggerPoint type ball is given. I have had them do some hip capsule mobilization I picked up from Starrett’s mobility seminar. Anything else I’m missing?
Thanks again…I am always happy to send people to your site because of the quality of info and your responses to them.
Brandon
Piriformis syndrome is a bit tricky from what I’ve seen.
Sometime it’s actually the piriformis pinching down on the sciatic nerve, but sometimes the complications occur much higher up in the chain in the lumbar spine or SI joint. Length length discrepancy or rotated pelvis may be a good thing to check for as well (in regards to SI joint and such).
Check to see if they have tight hip flexors, rectus abdominus, quadratus lumborum, or paraspinals & erectors. Mobilize these muscles too and you might get some better results.
Also, I would also check how well they internally and externally rotate their hips. If one side is tight and affected that can tell you something as well.
Also, get the glutes firing correctly with bridging, etc. so the hip doesn’t have to have the piriformis lock up on you. The only reason the deep muscles such as piriformis get tight is if there is a problem stability-wise with the whole lumbo-pelvic area. It’s like the rotator cuff muscles and scapular muscles locking down the shoulder after something traumatic or instability from weak posterior scapular muscles.
Let me know if this helps any of your clients. Always looking for feedback on to what tends to help and what doesn’t because it’s sometimes a bit different from person to person especially with hip/pelvic dysfunction.
Steven –
Yes, with one the hip flexors are crazy tight; same side as the piriformis issue. Noticed it when I was doing a hip assessment and observed the tight side lower than the other.
Running is at least a correlative factor if not a causative one. Both clients have been 30+ lbs. overweight and running is the mythical treatment that each thinks has contributed greatly to their weightloss. Working on POSE with each but they are only about 50% POSE in a given run.
Regarding lumbar/other SI issues, yes they are tight and mobilization is a priority. Right now one can’t move well enough to stretch on his own.
I would assume the ramp-up to full activity needs to be a slow process after they are cleared for exercise?
Thanks,
Brandon
If you can get them to change shoes towards more flat soled ones that goes a long way to help correcting proper running technique. There’s absoultely no way you can heel-toe run with no padding.
To be honest though a lot of mobilization work with the foam roller and things such as third world squat mobility work ARE workouts in themselves especially for people that are overweight. It may be beneficial to use that as part of not just warm up but in skill work and possibly workouts if you can find a good way of integrating it.
Ramp up to activity is definitely recommended especially if they have orthopedic issues like you mentioned.
Do you think it’s enough to just squat (like the man in the image Josh showed) 8 hours a day without any tension in the hip flexors to make them tight? Or do you think there has to be tension in order to get tight muscles?
I read Esther Gokhale’s book and she wrote that women in burkina faso sit on the ground with the back against a wall for a long time every day. I suppose there is no tension in the psoas in this position. They don’t develop and back problems. That would suggest that the psoas won’t get short if there is no tension, even if it’s short for long periods of time. What do you think?
Most people who sit a lot have pretty tight psoas because of the extended periods in hip flexion. Tension is not required for this to happen.
For example, what happens when your muscles are in a cast? This is just like sitting down 8+ hours a day. Your muscles are immobilized and they start to tighten up. When you get the cast off, everything is extremely tight and you generally have to stretch repeatedly to get back range of motion and proper movement. The same is true with this.
Tight psoas themselves aren’t enough to cause back pain. There’s many females with insane amounts of anterior pelvic tilt with no pain. It’s when there’s multiple issues and they compound you get back pain.
Steven,
I’ve been working on my third-world squat, and find that when I’m in position there is a lot of stress on the muscles along my shins. Also, it feels as though my weight wants to sit out the outside edge of my feet. (No real stress in the quads, hamstrings or glutes.) Does this point to any particular tightness?
Thanks, and thanks for the interesting article.
Well, it’s likely a lot of your groin muscles are tight and inhibited proper stance. I would strongly suggest stretching everything in your hip area (hamstrings, adductors, abductions, etc.) as well as widening your stance a bit. Also, try to loosen up your flexors and extensors in your legs too. That should help.
Okay, I’ll continue to work on stretching the hips. (I think groins and some hip flexors are still pretty tight, since I often feel a burning/pinching sensation in the crease of my hips when squatting below parallel.) I hope all of this will help my knees, too, which have become pretty grumpy as I’ve switched to crossfit WODs during the last six months.
By the way, widening my stance to beyond shoulder width results in similar burning in the shin muscles (especially near the knee) and weight shifting to the *inside* of my foot. But all of this may clear up as my flexibility improves.
Hi Steven, as a follow up, my third-world squat has improved (in terms of depth and time I can hold it) quite a bit. But recently I’ve noticed that when I stand up from the squat there is pain on the medial aspect of my knee, and it remains for a while. I notice the same problem occasionally after deadlifts and (of course) squats. Any thoughts?
I don’t know if this is signficant or not, but I did recently notice that the “bump” at the top of my tibia sits somewhat laterally to the kneecap on the affected leg, but not on the other.
Pain on the medial-inferior aspect of the patella, or underneat in the patellofemoral groove, or where?
Remember, I addressed the rotated tibia problem as internal rotation of the femur (valgus knees). Make sure these get aligned properly when doing squats and other movements. If you have to massage tightened muscle tissues, and work on your hip and ankle mobility then so be it. Biceps femoris may also be tight.
Well, when I wrote my comment it was on the inside of the knee, not near the kneecap at all, probably centered on the groove where the femur and tibia slide over each other. The pain was a dull, burning ache that would last for several minutes. But yesterday I did a 5×5 squat workout, and during the last set I felt a sharp burning in the same knee. *This* pain is on the medial side of the kneecap itself; if I could “lift” the medial side of my kneecap, it feels like I could point to the most painful spot, just underneath. It doesn’t hurt when I’m walking around, but if I close the angle between my femur and tibia to less than about 45 degrees it lights up.
Perhaps different things, perhaps related, I don’t know. This knee has been troubling me since June. It all started with pain above and a laterally to the knee, somewhere around where the IT band attached into the knee… That’s when I started to foam roll, tennis ball roll, stretch everything in the leg and hips, third-world squat, etc. I suppose that has helped, but the knee continues to bother me.
Tom,
The first one sounds like mensicus then… if that persists I would get that checked out by an orthopedic doc ASAP.
The latter sounds maybe some patellofemoral symptoms. If you have tight quads the patella can ride up and aggravate the femoral notch there. That’s a bit different than the PF I describe in the article, but the fix is essentially the same. Stretch out your quads and hip flexors, especially rectis femoris, take your fish oil, etc.
It seems like you may have enough problems that you might want to get that evaled by a doc or PT though. If you have any other issues with your feet or your back/hips it might be a good idea to have them evaluate your whole lower body.
This is familiar territory for me, but thanks for a well written article. Since this is from a year ago, are there any updates you’d care to add?
Thanks,
Steven
I need to add updates to about 80% of our articles.
As it is this one could be rewritten a bit clearer with more pictures to make it more accessible to the layperson but it’s pretty good stand alone.
I’m pretty much trying to focus on book work at this point.
Hi Steven, I just read this article and perused most of the associated links. I found this after coming across some of your posts on the CF injury forum. Very good information. Thanks for your research on this.
I have been struggling with a hamstring injury for over a year that worked itself into some hip problems. After a couple of MRIs, an SI joint injection (that did not help) and 4 months of PT, the hip/SI is doing a lot better but the hamstring problem persists and does not seem to have improved at all, although the PT said the weakened area of the hamstring was showing improvement in strength. I can’t run because of the pain and even t-mill walking is painful. Have been working on strengthening my glutes and abductors, which the PT found were weakened. I believe you are in Maryland. I wonder if you can recommend a good sports med doc and/or PT office in the area (I’m in Howard County) who would understand the needs of an athlete like myself. The PT I was working with was very dedicated and competent, but she is not athletic and discouraged things like deadlifts and box jumps. By the end of 4 months of PT, she seemed unsure as to what to try next. Wondering if there is someone who can help me get over this injury so I can get back to running. I have continued to cycle regularly and CF several times a week. But I’m a triathlete, so not running is killing me. Any suggestions? Thanks!
I’m sorry I don’t know anyone in your neck of the woods as I know no one in Howard County. And to be honest, I’m not sure of the better sports related people around even Maryland either. A bunch of the PTs at the clinics I worked as a tech for were good, but they weren’t geared towards more of the stuff I write about and will likely practice in (when the highest DBs you get to work with are 10 lbs that’s not much and no barbells).
It may be a good idea to call say Howard Community College sports department and ask them who they use as their orthopedic specialist and physical therapists. Any of the colleges in your area may work as well. I think that’s the best way to handle something like this.
Did your PT ever figure out why your hamstring was having issues in the first place and why it’s not responding to rehab as well as it should? It seems like some more systemic things are at work, maybe down in the feet or up in the lumbar spine region.
Thanks for replying to me. The intial injury occured during a race in Oct 2009 and I did not have it treated immediately (1st big mistake) and continued to try to train on it (2nd big mistake). It definitely started in the middle hamstring during the last few miles of a very hilly bike course and I continued the race despite cramping in the hamstring during the run. Anyway, the hip/SI/lumbar area started to get involved a few months later. The 1st MRI was to check for disc involvement in the lumbar region. It looked fine so we did 8 PT visits working mainly on the hamstring. After a couple of months of slight improvement in pain, the PT thought the pain might be referred from the SI joint, so I went back in for a 2nd MRI of the pelvis that showed a couple of non displaced tears in my hip labrum and some arthropathy of the SI joint. So we tried an SI joint injection, which only made me hurt worse for a week. After that, it was more therapy, this time focused on strengthening my abductors and glutes. She did not understand why the hamstring was not responding to the rehab as well as it should. I have maxed out my PT visits for now unless a doctor thinks I need more. I have not felt like going back for more visits when it seems I have not made any progress with the numerous visits and $$$$ I’ve spent. I’ve been doing Kelly Starrett’s mwod and am finding many tight spots. My hips are feeling much better than before but the hamstring still hurts sometimes when I am doing nothing. Running really seems to bother it. I would be willing to see docs in Baltimore city, PG or Montgomery counties if they are good. I already drive to see my rheumatologist in Montgomery Co, so its more important to me that the doc/PT be competent and understand where I am coming from (not going to be satisfied with a light workout but I’m willing to do whatever it takes to get back to normal) than be local. Thanks for the suggestion to call HCC’s sports department. When do you graduate? Going to set up clinic here when you are done? Seems there is a shortage of PTs with your perspective. Thanks.
Hah, I graduate in about 2.25 years. Unlikely clinic when I get out though.. have no capital and no clue what the market is like. I will probably be somewhere in the area though.
It might not be a bad idea to treat the hamstring like a strain and see how it responds with massage, heat, controlled weighted eccentrics, and light mobility work to see if that works in the meantime while you’re looking for something especially if it’s a more sore kind of hurting pain.
Thanks. One question, what would be controlled weighted eccentrics? And in the meantime, other than not running, are there other things I should be avoiding if I’m treating it like a hamstring strain?
So you can do assisted hamstring curls, and then slowly control the weight as it comes down (if you use an ankle weight) or slowly control it as it goes out if you use a machine. Something along those lines. Can be standing or prone with an ankle weight, generally seated with a machine.
If stretching hurts it then obviously don’t do that, but if mobility works helps to keep it loose and mobile then you do want to do that. For a strain, stretching tends to act on it negatively.
Same thing with ice or heat. Whatever helps use it. Generally, if it’s a contractile/hamstring strain issue heat will tend to work better.
It’s probably NOT a strain, but sometimes trigger pointed muscles or tight/irritable muscles respond well to strain rehab protocol so that’s why I’m suggesting that.
Thanks for the info on the eccentric exercises. What do you think about donkey kicks? Weighted donkey kicks? It seems like it gets bothered when it is in extension (not sure if that is the right word). But I noticed last week when I was practicing handstands it felt a bit aggravated from the kick up. I am now nursing a shoulder injury, so I won’t be doing handstands for awhile (or pullups, or push presses . . . )
Donkey kicks are fine for hams/glutes/posterior chain.
If they help then use them for sure.
I have work orthotics since I was a teenager, but still have problems with plantar faciitis, heel pain, etc. when I am active. I am 39, trying to be active, and would like to get my feeet arched and strong enough to no longer need orthotics. How can I achieve this? What sort of medical professional can I work with to help guide my process? The Podiatrist just wants me to pay for orthos for the rest of my life…
I do not even know where to start with this type of stuff online.
I have listed many good exercises that may be beneficial, but that can only go so far sometimes.
For an individualized case it is best if you found a physical therapist or chiropractor who believes in barefoot training and is willing to work with you to try to solve your issues.
On Q-angle – can’t you just spread your legs? I know there’s plenty of cultural pressure for women to keep their legs together, but I don’t see any biological reason for it.
Q-angle is not a product of culture and women holding their legs together.
Bringing the legs together or apart does not change the relationship of the angle at the knee in measurements — e.g. knee structure does not change whether your legs are together or apart.
Q-angle is greater in women because both ASIS are set farther apart from each other because women have structurally wider hips and the measurement is thusly reflected in the structure at the knees.
Therefore, Q-angle reflects a purely anatomical difference between the sexes which unfortunately predisposes women to greater knee injuries because of greater potential for twisting torques at the knee joint. This is why proper strength and conditioning and technique is important for women in sports. ACL injuries rates between men and women in sports reflect why this is an important area to look at.
Hey, went back to check this post out, when I saw it linked to from the article on feet specifically. I’m still working through it, but noticed that you had implicated sitting as shortening the hip flexors. I was curious whether you’d seen this http://toddhargrove.wordpress.com/2011/05/29/does-excessive-sitting-shorten-the-hip-flexors/ and whether it had any effect on your assessment.
I actually read that when I came out.
I think it’s honestly multifactorial, and sitting is one factor.
No one doubts that high heels do damage to the body (chronic shortening of calves, etc.), but sitting likely does similar things even in dynamic vs. static positions.
When you look at the populations you see that women, on average, tend to have increased anterior pelvic tilt compared to males. However, on average, I do not expect to see a difference between women and men in regards to time spent sitting.
As you’ll read, women have increased Q-angle over males. Whether this ia causative factor for quadriceps dominance and related to chronic hip flexor shortening, gluteal weakness, hamstring lengthening, abdominal weakness, etc. is up for some debate. I think that sitting plays some role in all of this as it encourages a lot of the states of tissues above.
When you have a myriad of risk factors it is very hard to determine what may actually be the factor that sets it off. Maybe it’s a combination. Maybe it’s a single event. Do you see where I’m going with this?
I do agree that sitting is not a causative factor (but likely a significant risk factor or correlative factor — perhaps a causative in some) and will update that with my analysis once I have time.
Thanks for the comment.
Yeah, I see what you mean. And of course, it’s just a detail in the larger picture–there’s no arguing with the high morbidity rates, etc. associated with sitting, even if that’s just displacement–time spent sitting is not spent doing something, anything, just to keep the body moving.
And I’m 100% with you that ‘corrective shoe’ is an oxymoron. My dad has been wearing orthotics in his shoes for years, and is surprised he still has bursitis, tight calves, and a host of other things. It’s actually painful just to *look* at the man’s feet, and I’m convinced it has a lot to do with the fact that he only takes his shoes off to sleep, and sometimes not even then.
You can’t go around on crutches all day, and then wonder why your legs are stiff.
Hi. I get knee pain walking or running. I was accessed by a orthotic specialist, and prescribed insoles for my shoes, which apparently correct the way my feet land on the ground, which is the reason why I have apparently got knee pain. I am very tight in the muscles. I have two short questions. 1. If you say walking in bare feet is good, but my foot is naturally landing incorrectly on the ground, wouldn’t walking in bare feet be worse for me, than wearing shoes, with corrective orthotics fitted? Since I would still be landing incorrectly on the ground in bare feet. And, If I stretch a lot and become flexible, could the way my feet land on the ground change over time? Thank you
Jacob,
Because barefoot movement would be painful the way you’re currently automatically walking (and yes, worsen your situation), you are forced to fix the way you walk to make it less painful (and this usually consequently fixes the mechanics that are a major cause of the knee pain).
Proper stretching aimed at the correct musculature will be a generally beneficial thing to do since improved flexibility (along with knowledge of proper technique during both exercise and daily life activities) tends to be a MAJOR contributor to avoiding orthopedic issues throughout life.
Tangentially, the shoes you were prescribed will simply help fix the symptoms but not much of the root problem. This would be much like taping flashlights to the front of your car because your headlights are broken.
Jacob,
Pretty much what KC said.
Issues like these are often correctable by proper stretching and strengthening of certain muscles, and re-education and posture and gait. So yes, your mechanics can be changed over time to potentially remove orthotics completely.
Since you have pain now orthotics would be good to help control it, but that does not mean you shouldn’t be stretching/strengthening/working on proper mechanics. Unless you want to be in orthotics for the rest of your life.
I notice you have some core exercises up there and one of them are (planks with the pelvis posterior tilted), which teaches you to do the plank with a posterior pelvic tilt, but every other expert that I have read about so far, has told people to do the plank with a neutral pelvis, a slight lumbar curve. It was just interesting to see that your video says otherwise.
PPT planks focus more of the work onto the abdominals and less onto the hip flexors. Generally speaking, this is better for those who already have anteriorly rotated pelvises (tight hip flexors, weak abdominals) which is a hallmark of adaptations to sitting posture. This is consistent with what I have addressed in the article.
In a vacuum with no dysfunctions, then yes you would want to keep a neutral pelvis.
Steven,
I am an Olympic Weightlifter and I have been dealing with some pain when I squat. My low back (erectors) gets really tight in the hole as well as a sharp pain in the tendon where it attaches at the top and lateral part of the patella on my left leg only; my knee generally pops as well when I squat or catch it in the receiving position; I have tight hip flexors, hamstrings, and calves; Every now and then I get pain in my SI joint as well; and I sometimes get pain in the back of my knee (moreso the left)and top of my calve from doing posterior chain work (glute ham). I’m really struggling to find a proper corrective exercise strategy that caters to all of these ailments, which is keeping me from competeting as heavy as I ought to be. Keep in mind I am in college and I sit a fair amount during the day and that I use a lifting shoe with a .75 inch heel for training. I have good flexibility in the squat (ironically enough) and can go ATG while keeping my spine pretty vertical. If you can, I would greatly appreciate some ideas or pointing me in the right direction. Thanks!
P.S. My friend gave me a pair of vibrams, and when I wear them throughout the day, my lower extremities don’t seem to hurt as much compared to my regular tennis shoes.
The number stuff is what you probably need to do. Rest is just explanations.
1. I would definitely stick with the vibrams if they’re helping.
2. If you’re having trouble in the hole with weight it may be a good idea to back off the weight until you can work with it non-painfully.
Just from a general perspective the fact that calves and hammies are tight plus low back is getting tight deep in the hole tends to mean you’re not getting enough anterior rotation of the pelvis. To compensate your knees will come forwards more putting more quad emphasis at expense of glutes.
Glute ham — since the calves are also knee flexor, that means your hammies aren’t doing most of the work there. That probably also means they’re tight and weak which is generally a bad combination.
3. To emphasize more hammy/glute work I would go with some romanian deadlifts and cut the GHR for now. And work on a good hip hinge exercise such as good mornings or other variant.
4. Increase your mobility in calves/hammies. It also might be a good idea to look at your thoracic extension if low back is an issue. Use a foam roller for this. Also target your glutes to decrease quad emphasis with something like weighted hip thrusts although if you do have gluteal amnesia you should start with glute bridges and focus on activation and squeezing the muscles for 10s each rep for 20-30 reps and a couple sets.
There’s so many issues here it may be a good idea to get to a physical therapist to get them all sorted out regardless, but I think the above is a good place to start.
Thanks Steven, I really appreciate it. I think it’s great that this site available.
In response to keeping a posterior pelvic tilt in the plank exercise for people with an anterior pelvic tilt, do you think this would also translate to exercises such as bird dogs? Thanks, last post from me.
Since the main target of the bird dog is usually the back, glutes, etc. and not the abs I would generally say no. Keep a neutral spine (with slight lumbar arch) for these.
I’m having alot of trouble with my sacroilliac joint and I’m sure I came across a link from this website, which directed me to a website that showed some wall sacroilliac joint exercises. Any help would be greatly appreciated.
That would be in this article:
http://www.eatmoveimprove.com/2010/02/so-you-hurt-your-lower-back/
However, if you are having trouble with it I would very strongly suggest to see a physical therapist as you don’t know whether your SI joint is rotated, slipped, or whatever else. So the correction exercises need to be oriented for specific dysfunctions depending on which way the issue is. Thus, if you don’t know what you are doing it is best not to do anything yourself as you can potentially make it worse.
I have a interesting problem and I have no idea what’s going on. When I sit on the ground and straighten my leg, just before my leg is fully extended, I get a loud noise from what seems to be a bone in my leg that runs from the inside of my thigh on the abductor area just barely above the knee, up to my glutes/ lower back on the left hand side of one leg. I would decribe the noise as a bang or a pop. It almost feels as though a bone is going back into, or out of place. Then it will stop doing it, but several minutes later it happens again. It’s sometimes accompanied by lower back pain, on the left hand side just above where the top of the bone seems to move. This doesn’t happen when I try it from a standing position, or any other position that I have tried. Any thoughts on this would be greatly appreciated.
The pop is in the knee, or the hip, or what?
Regardless, this is serious enough that you should go to an orthopedic doc to have it evaluated.
Good luck. Let us know what the ortho says.
The pop happens in the groin bone just above the knee.
So the pelvis?
That’s something you would want to get checked out by a professional. If the pelvis is popping you, might be a good idea to see a physical therapist instead as there may be some things that need to be mobilized to make you work correctly + exercises to fix it.
I noticed now when I stop doing the butterfly stretch where you sit on the ground, back straight with soles of feet together and pushing down on your knees with hands or forearms, and pain and popping noise has gone. When I bring this stretch back into my program, the popping and pain gets worse
Get it checked out dude…