Sunday, January 25, 2015

In Sickness and in Health: The lateral stabilization chain

The Glut Med – IT Band – Knee – Posterior Tib – Lateral foot chain

I’ve had left IT band issues for years.  They’re never major enough to be debilitating or really limit my running, but they’re always there, always tight, and always a little painful on the outside of my knee.  I’ve dealt with them in various ways – stretches for the TFL and piriformis, foam rolling the quad and hamstrings and the IT band itself, heat, ice, and, rarely, rest.  Everything I tried worked from a palliative point of view, but the ache in my leg now is evidence enough that none of it was curative.

Olivia is an orthopedic physical therapist, which makes me a bit ashamed to admit to chronic injuries.  You’d think that 24/7 access to an orthopedic specialist would render me immune to injury or at least keep me on the fast track to fixing my core problems, but it doesn’t often work that way.  Also, my problem is sadly worse than just the IT band.  The left knee, pulled by the tight IT, aches.  The left foot has chronic pain on the fifth metatarsal.  And the posterior tib that stabilizes that ankle has failed and become strained repeated.  Unfortunately I have a bit of a thick skull, so having one person identify my problem, the glut med, and proffer a solution isn’t enough.  Apparently, I need several.

Luckily I think I’ve finally gotten the message.  It started with a column on IRunFar from Joe Uhan.[1]  Joe talked about IT band pain and lateral foot soreness and “running narrow”.  I read that column just about the same time that I noticed the pain in the outside of my left foot.  I tried a few of the drills, but soon let it drop.  Then an Endurance Planet podcast from Tawnee and Lucho ID’d an article by Robert Camacho bashing foam rolling.[2], [3]  No foam rolling, really?  Sacrilege!  Fine, I’ll bite.  The article mentions that a weak glut med can fail to stabilize the knee, causing the TFL to kick in instead (tight TFL?  Check).  The TFL inserts on the IT band, so as it tires the body can start to stabilize the knee by tightening the IT band (tight IT band?  Check).   This is a poor solution, however, because the IT band can’t tighten and loosen dynamically.  It just stays tight (knee soreness? Check).

I started googling glut med and running and soon came to the Gait Guys’ You Tube channel, specifically the three part series on “The Problematic Cross-over Gait” (yes, cross-over is synonymous with Joe’s “running narrow” problem).[4]  There was a lot of discussion of the glut med controlling the stance leg while the lateral abdominal controls the striding leg, the point being to keep the hips level and the spine neutral while running.  I tried to understand, but it was hard to see.  Luckily, the sidebar showed a link to another one of their videos, this one on correct single leg squat form.[5]  The visual is perfect.  With good form, the shoulder, hip, knee, and ankle of the stance leg are in exact vertical alignment, and the hips are level.  To achieve this, the stance leg glut med has to contract powerfully and dynamically through the course of the squat motion to prevent the stance hip from sticking out to the side, and the lifted side lateral abdominals must contract to prevent the lifted hip from dropping.  It finally made sense.  Running narrow or crossing over isn’t an issue of the foot drifting to the middle, it’s a problem of the hip shifting to the outside long after foot strike.  The key to fixing my IT band issues, and probably the knee, foot, and posterior tib issues, is to keep vertical alignment of the foot, knee, hip, and shoulder. 

Sweet!  Except, how the hell do you do that?

Back to my wife, who patiently explained, probably for the fourth or fifth time, exactly what it takes to strengthen the glut med.  So here’re some of the exercises for glut med strengthening:

1) Clams.  Lie on my side with the shoulder, hip, and ankle in alignment and the knees forward (via hip and knee flexion).  Keep the hips stacked vertically with no rolling in the torso.  Lift the top knee while keeping the feet together on the ground, if effect spreading the knees by contracting the glute med.  Two sets of fifteen, morning and evening, and at lunch if it won’t create too much of a scene at work.

2) Side leg lifts (vertical at the beginning, lying down as strength improves).  Stand on one foot with the foot, knee, hip, and shoulder in vertical alignment.  Orient the lifted leg so that the foot points forward and the hip is slightly extended, such that the lifted foot toes are next to the stance foot’s heel.  Lift the foot to the side and slightly behind without rotating the leg or trunk.  Make sure the hips stay level throughout.  Same sets as the clams.

3) Single leg squats.  Watch the linked video for form.5  Essentially, the shoulder, hip, knee, and foot stay vertically aligned in the sagittal plane and the hips stay level.  Don’t let the stance hip shift out to the side, and don’t let the lifted hip drop.  Lower the butt down and back and the knee forward over the second toe, making sure that the stance knee doesn’t protrude forward beyond the toe or shift either inward or outward, then return to the fully upright position.  Focus on keeping the lifted side hip level with the stance hip – refuse to let it drop.  Same sets as the first two exercises.

As of now I’ve been on this program for exactly half of one day, so I can’t really comment on the results, but I have a good feeling about it.  Of course, if you have a glut med issue you’ll want to get a diagnosis and program from your own specialist, but in the mean time this might be a place to start.