Wednesday, April 27, 2011

Why do our kids walk funny?

I had a great patient who I treated recently.  She's an 8 year old girl whose parents brought her in wondering why her shoes were wearing out oddly and why she walked "funny."  The examination was very revealing, and relevant to ALL parents with young children.  She only complained of some discomfort occasionally in the ankles and does admit to getting tired easily when running around.  Her feet pronate, or collapse inward, slightly and she has tight calves that are obvious when she walks.  The treatment that most everyone would prescribe would be either orthotics (corrective shoe inserts), stretching or do nothing and let it resolve as she grows out of it.

My treatment was based off exam findings not typically done by Podiatrists.  In performing gait analysis, it was evident that both hips were somewhat weak and incapable of supporting the body properly in a single leg stance.  Her left shoulder was held high and her right foot was more pronated than the left.  Her arm swing was out in front of her torso and asymmetric.  Static testing (standing, not walking) reveals her to be unable to touch her toes which is almost unheard of in an 8 year old, though when a yoga block was placed between her knees, her flexibility was improved.  Squat testing showed a complete inability to keep her feet on the ground during a squat unless the heel heights were elevated several inches.  So, are her hips and ankles really tight?  If they were really tight, then she wouldn't be able to assume a squat posture in any position, vertical or horizontal (standing or laying down).  When I had her lay on the ground, I was able to put her body into a perfect squat posture with ease.  This indicated that her joints aren't tight, which would be unusual in a young person.  Her problem was with gravity!  When she tried to move her body, certain muscles were firing that weren't supposed to be, and the timing or sequence of which muscle is supposed to fire and when, was off.  Thus, the muscles that should be relaxed to allow joint mobility were engaged, thereby preventing joint mobility.

Why does this happen and how do we fix it?

Two of the worst things we can do to our children, we do without thought.  We put shoes on their feet and we send them to school where they will be sitting in chairs for hours each day.  If shoes and chairs were part of a human beings "master plan," don't you think we would be born into them?  Humans are hunter-gatherers and are supposed to stand, walk and run.  Especially the growing body!  Shoes do two dangerous things: they do not allow the foot to use all of the smaller muscles that allow fine tuning within the foot, and more importantly, they interfere with the connection between the brain and the earth.  As we start school, our bodies are going through rapid growth and change.  When we sit, our pelvis tends to become fixed forward slightly and it relatively shortens our hip flexors (psoas muscle).  This is the muscle that is supposed to lift the leg and it originates off the lower spine, attaching the the femur (thigh bone).  If we lose our ability to use our core (sitting creates poor posture which leads to loss of core awareness), then we can no longer stabilize our spine, and our hip flexor has nothing to leverage against when trying to contract and lift the leg.  The muscle then becomes shortened and further adaptations will occur.  The brain will begin using other muscles that flex the hip and lift the leg.  Unfortunately, these muscles are also knee extenders and we end up lifting our leg and extending the knee at the same time.  This forces us to lift the toes, stride out in front with walking which ultimately encourages heel striking.  This brings us full circle with shoes as they enable the heel strike by cushioning the heel.  For those who believe what you have been told about heel to toe walking, you should think again.  It's not efficient, nor is it desired in proper mechanics.

Now back to our case.  With further questioning, she happens to be the tallest kid in her class.  Her feet have been growing fast and she has very long legs as well.  Therefore, in addition to the poor timing of her muscles, her body is continuing to change and force the brain to make constant adjustments.  This, of course, is in addition to the dysfunction in her body that is created by sitting and wearing shoes. 

The Treatment  

Our patient will be sent to a physical therapist who will work on neuromuscular re-education to help with the sequencing of muscle contraction.  Stretching will be useless as her muscles and joints aren't actually tight, they are just not working at the right time.  Also, she will be casted for orthotics, which will serve to stabilize her heels (not arches), which have been turning out and forcing her feet to function in an unstable manner.  By providing stability to the feet, we will provide the consistency that her body needs in order to re-learn how to walk over those feet.  Orthotics alone would miss the real cause of her "walking funny" and her leg fatigue.  Though orthotics, stretching and "tincture of time" may resolve some of the symptoms, her body's dysfunctional patterns would ultimately lead to degenerative changes in the hips as they haven't been moving, the feet because of the force through them are greater than it should be, and the back, which will be forced to adapt for the hips that are not moving.  If she does her work and continues to practice good movement habits as her body continues to change, there should be no long term consequences, or at the very least, they should be greatly reduced.  My fingers are crossed...

Friday, April 22, 2011

Belly Breathing

Is there one thing to do, one exercise possibly, that a person can do to help with pain in the foot?  The surprising answer is yes.  Even more surprising; it doesn't involve the foot!

As a physician who treats people who want to walk, run and play without foot pain, I'm given the task of trying to find out why that person is having trouble.  Though the reasons why people hurt vary, there is almost a universal link that all of these patients (people who are having foot trouble) share; difficulty with posture.

Posture is what children neurodevelopmentally "learn" and what ultimately allows them to sit upright for extended periods of time, stand, walk and eventually run.  And the first step involved in the development of posture occurs mere seconds after birth, when we begin to breathe.  A recent blog post written by Mark Sisson on his Mark's Daily Apple site highlights exactly what I've been trying to explain to patients for years.  Breathing is the most fundamental of movements we make as humans.  All newborn and young children breathe the same way, using their diaphragm’s (belly breathing), which is the proper way to breathe.  It is the child's first act in preparing the body's core to become engaged.  In fact, the diaphragm makes up the ceiling of our core!  Thus, when we stop using our diaphragm to breathe, we lose the ability to properly engage our core, and by extension, lose the ability to properly maintain and sustain good posture.

So how does this relate to foot pain?  I'll keep the answer as simple as possible.  If you have good posture, then the body will not have to work very hard to stand and move.  It will be inherently stable.  It is the reason that children and exceptionally good runners move gracefully and effortlessly; they are maintaining their posture with movement.  It allows all the muscles and body parts to work together as they should in the act of movement.  If we start with poor posture, then our muscles have a different job to do: help hold us upright.  Therefore, when we try and move (stand, walk or run), our muscles now have to do additional work.  Movement is no longer effortless and it becomes work.  Because our bodies move over our feet with every step we take, we tend to place more stress through our feet with every step, predisposing us to developing pain.

As I alluded to at the onset, there is one thing we can do, that can be practiced at any time of day, in any place, and can have a major impact on improving posture and reducing foot pain.  That one thing is breathing.  We did it the right way when we started in this world, and we did it that way for a reason.  For more information on this topic and practical information on how to regain our breathing form, please click here.

Thursday, April 21, 2011

"You can’t always get what you want…"

This will be the final installment of this portion of the blog chronicling my training for a hopeful sub 3 hour Boston Marathon.  Though that goal was not achieved, the race ended well, and I’m walking today; always a good sign.

It’s hard to be disappointed in a 3:06:28 marathon, which is only a minute slower than my previous best time of 3:05:24 at Boston in 2007.  If I was disappointed in anything, it was that I broke from the initial plan of going out at a modest pace in the 6:40’s to 6:50’s and avoiding any hard efforts.  As it turned out, my perceived exertion was less than the actual effort and the 1st 5k split was in 19:54.  Way too fast considering it should have been around 21 minutes.  That is a huge difference early on in a marathon.  Factor in a hot sun and swirling wind, and the conditions weren’t as optimal as they seemed for the elite runners (with a lot of runners on the course, you don’t benefit from the tail wind as much, though there was quite a bit of headwind as well). 

With the fast early pace, I tempered it slowly through the halfway point, still maintaining sub 7’s, but trying not to work too hard.  I wanted to reach the half at around 1:29, and with a half marathon time of 1:28:44, seemed right on target.  Again, the early speed took its toll.  With the early hard effort, and the sun, I should have taken in more fluids than normal, and was starting to feel the effects of a fluid deficit.  The calorie intake (Powerbar Powergel every 5 miles and a salt tab at mile 12) seemed adequate, though my usual 4 ounces (2 mouthfuls of Gatorade at each stop) was insufficient on this day.  By the time I realized I was at a deficit by mile 13 or 14, it was tough to take in more fluids without getting nauseous.  So I took in what I could at every aid station, even adding water to the mix, took an extra gel at miles 17 and 22, and tried to hold on.  I tried to keep the reality of not being able to break 3 hours out of my mind, but every hard effort I started to make to get back on pace (before and after each of the hills: Rt 16 going over 128, turning on Rt 30 after Newton-Wellesley Hospital, and of course Heartbreak Hill just past mile 20), my body said no.   With that realization in place by mile 22, after the left onto Beacon Street at Cleveland Circle, it was a matter of trying to hold an even pace, continue to enjoy the crowd and soak it all in.  If interested in seeing the Garmin data file for my race, click here.

There really is nothing like the Boston Marathon.  For me, it brings back childhood memories of seeing Alberto Salazar win in 1981 and 1982 while watching with a friend and his Dad at Heartbreak Hill.  There I was, running the last few miles of my 6th Boston Marathon, floating along a river of runners, getting caught up in the current.  I could have been 11 years old again, or 40.  It didn't matter.   
We set goals to achieve them.  I’m disappointed that I didn’t reach mine Monday, but glad I put in my best effort.  There are no guarantees in life, and to me, it ain’t worth living if you don’t have goals to shoot for.  We won’t always reach them, but it doesn’t mean we shouldn’t try.  And there is no better reminder of that than the 1000’s of charity runners out there, and 100’s of thousand’s of fans lining the streets from Hopkinton to Boston cheering them/us on.  I drove with my neighbor Paula to the start of the race.  She’s less than 4 months from finishing her chemotherapy!!  What’s more, she finished in 4:50.  Talk about inspirational.

It’s been fun to put my thoughts on training down in the last few months and I truly hope you’ve enjoyed reading my blog.  I’m going to try and keep it entertaining and informative with a broader appeal to the non-runners of the world too.  Talk to you soon!

Friday, April 15, 2011

Thoughts on Minimalist Running

Last night I attended a great conference put on by Saucony, “Step into Minimalism!”, listened to some fabulous speakers, and as always, tried to learn a few things.  One of the questions asked of the panel of experts, Michael Sandler (barefoot runner and author), Jack Daniels, PhD (Olympian, exercise physiologist, coach extraordinaire) and Marybeth Crane, DPM (podiatrist, runner) was if they thought minimalist running was a fad or a trend.  Ironically, I answered this same question just last week in an interview.  The consensus is that this is certainly a trend, which is the opinion I share as well.  The ground swell is too large right now and the buying trends of the running public are guiding the way.  However, the ultimate question is if this trend is a good thing?  My answer is without a doubt, YES!

Why so emphatic?  It gets people at least thinking again about our basic design, the human form and human motion.  Dr. Daniels said it so eloquently last evening (paraphrased here): “Parents spend the early years of their child’s life asking them to run around, play, be happy and take their shoes off.  Once they get to school, we then tell them to put their shoes on, sit down, shut up and listen!”  That thinking goes hand in hand with my guiding principle in that children have all the answers, and adults end up messing them up.  Life is about using our bodies and our minds in the ways they were intended, before being changed and altered by shoes, chairs, sitting and especially the stressful poison of adult worries that seep into our heads. 

As a foot doctor, and from what I see in the medical profession, we have learned to deal with injury and pain in a way that treats the symptoms and not the root cause of how the injury or pain developed.  I am not making the leap that minimalist shoes will correct the root cause of foot pain or bodily injury.  I am however, making the leap that people are now interested in finding out why they hurt more than just finding out how not to hurt.  That is a major step forward.  Our society has lived under the mantra of “take two and call me in the morning” for far too long.  We’ve become lazy and unconcerned about the “why we hurt”; as long as we think someone can fix it.  More and more people are trying to get back to the basics of our human instincts, and running has been one of the best way for most people.  It goes beyond that though; we are not just content with running.  We, as humans, have a pressing need to experience running as it was intended to be: free and connected with the past.  And in the past we wore no shoes.  That is why I believe the minimalist movement is a good one, and here to stay.

Thursday, April 7, 2011

Head Games

Tapers mess with your head!!  In the last few weeks before the big race, the body physically starts to feel better, yet emotionally you can start to fall apart.  This is especially true if you are not fully aware of the process, whether you’re a first time marathon runner or ironman, or have years of experience.  The training volume is decreasing which allows the body to get ready for the race.  With the shorter, and less frequent runs, you may find that, at times you feel fast and ready to go.  At other times, you may feel like you're wearing a lead apron.  Sometimes, there are runs during the taper where both of these happen within a few minutes of each other!  As a rule, if you feel fast, beware of not pushing too hard or too long; recovery is goal number one.  If you feel slow and sluggish, don't panic, and realize it is all part of the taper.

The physical part of training for a marathon is now essentially over.  With the extra time we have in these last days leading up to the race, our (race) focus should be more on the race itself, rather than the training that it took to get to this point.  We should already have our nutrition plan in place, and should be prepared for any race condition, whether it's 40 degrees and windy or 90 degrees and humid.  We should have an idea of how our pacing is going to be, think about the clothing, make sure our shoes are going to hold up and even plan how we will get to the start of the race (not always an easy task with the Boston Marathon).

We should also be watching what we put in our mouths.  With less training, comes less calorie burn.  If the intake remains high, the weight will go up.  For me, this is a time to be serious about cutting those last few pounds and optimizing body composition (weight, body fat %, hydration) and getting to the desired race weight.  It’s not a time to load up on carbohydrates or skimp on the protein.  In fact, the opposite is true, if anything.  However, radical changes in the diet should be avoided. 

My goals are set, I’ve prepared to the extent I can prepare, and race day will be here very soon.  I won’t worry about anything out of my control, such as the weather conditions.  It’s time to get excited about the attempt to achieve a goal that was set many years ago.  It’s another chance to check one more thing off "the list":  Sub 3 hour Boston.

Sunday, April 3, 2011

Staying fresh during the taper

"Trust thy taper" is a phrase I've repeated many a time in the weeks leading up to a significant race.  We have to balance the recovery process our bodies need from the rigors of training, with keeping the body fresh and ready to perform on race day.  The more experience a runner, cyclist or triathlete has, the quicker the body tends to recover.  Thus, the taper can focus more on honing in on a specific goal rather than simply recovering.  If you think of a training program being like a pyramid: Base training at the bottom and the race at the top, the taper is that final narrowing near the top, where the apex is the race itself.  With 2 weeks to go before the key race, all efforts should be shorter and less intense.  The long run shortens and the heart rate moves back toward the same levels we were striving for during the base building phase of training, save for a few brief pick ups at marathon pace.  The tempo/speed work becomes much shorter, with a greater focus placed on full recovery between any interval.  My last blog, Speed work in Disguise, substituted hill repeats for a Yasso 800 type work out.  Yesterday came the "long" run that will be the longest run between the Dress Rehearsal of last week, and Showtime; the marathon.  Not too long where you may damage your legs or risk injury, but enough "time on feet," so that the next time you pass this point during the race, it's not such a shock to the system.  It's an important run when it comes to being able to maximize your chances at a personal best, but an important run to skip, or cut significantly shorter, if the risk of injury or the need for the body to fully recover is great.  This is when a lot of new marathoners end up injured as they don't "trust thy taper."  They panic, thinking they have to do more, and end up running too long, and at marathon pace, and scratch their head when they just don't seem to have the "legs" on race day.

Stats from my Taper period long run: 2 hours, 14.2 miles, 8:17 average moving pace, 139 average Heart rate, 1000 feet of elevation gain/loss, NO injuries!

Friday, April 1, 2011

“Speed Work in Disguise”

On the eve of an April Fools’ snowstorm, a speed workout needed to get done.  Unfortunately, Mother Nature decided to continue her wicked ways and make life most difficult for all of us here in the Northeast.

Two weeks out is the time for working on speed, turn over of the legs, and yet running at night in the driving snow made keeping the eyes open a difficult task.  Given the circumstance, all we could do is adapt, and disguise our speed work in the hills of Holden.  This article from highlights the premise for those who are interested. Click here for last nights Garmin run data: