Tuesday, September 6, 2011

is your butt broken? look no further!

When my entire body fell apart back in March, it took a while to for lots of physical therapists to untangle what was going on.  My sacrum had been living out of alignment for months, and the pain was coming from someone putting it back in.  My body kept trying to force it back out, so all the bones grinding together were making me pretty unhappy.  
However, all that pain was just a symptom of what was actually going on, and now that I'm on the other side and have mostly figured it out, I thought it might be interesting or helpful to talk about the process of rehabilitation.  
Here's what I thought I knew prior to the massage that brought my world tumbling down: I had been living with a very tight hip flexor and a very tight piriformis for months.  When I ran, almost nothing bothered me, but when I stopped, everything clamped down and it hurt to sit for long periods of time.  Fast running - like 400m repeat pace - made my hip flexor burn and lock up.  Very occasionally, I would get some weird sensation - like little nerve zaps - down the back of my leg.  
Here's what was actually going on.  Like billions of other athletes that sit all day, my psoas had become a little bit shortened.  Your psoas is in a big group called "hip flexors."  It's one of the largest muscles in your body, and it's responsible for lots of important things, like hip and thigh flexion, but also lumbar posture.  It lives about 2 inches east of your belly button, and runs from the bottom of your rib cage into your crotch.  When you are seated, it's in a shortened position.  After spending hours every day seated, your psoas starts to think that this shortened position is normal, so when you stand and try and use it normally, BANG, too late sucker, it's already tight.  A tight psoas does lots of bad things, but the two things it did to me were bringing my lower back forward into what's called an anterior tilt and stopped my glutes from firing (if they ever were).  Your psoas and your glutes work in opposition to each other, so if one is screwy, the other is going to go batshit crazy. 
How does this translate to running?  Well, because of my anterior tilt, I was already bringing my lower back forward, which sends my butt back.  When you run, your hips should be under you so your glutes can provide power - my hips were far behind me, so my glutes weren't being used, so instead I was using my quads to provide all the power.  Using only your quads means your hip flexors are getting over-used, and mine were so tight that they were reaching around (heh) and pulling on my piriformis.  As I got more tired, the tightness of my psoas would bend me over forwards (heh heh) which would involve my glutes even less and so on into the spiral of bad.  Eventually my psoas was so tight that it was pulling on all of my other hip muscles, including my external rotators, and that's what pulled my sacrum out of alignment.  You can see my overwhelming anterior tilt and my knees clanking together because my glutes aren't firing here: 
So how to fix it?  Well, first we spent a lot of time just trying to calm everything down.  Lots of ice, anti-inflammatories, and very gentle exercise that didn't cause pain - for the most part, this was swimming with a pull buoy while everything got real chill.  I think it took about 3-4 weeks for everything to truly calm down.  In that time, I added cycling but with the caution that I could not use my right leg to provide power at all, because the muscles that should be providing power weren't strong enough to do so correctly, so until they were, it was no power spinning.  You may recall my grumpiness about the month of easy riding.  
The first round of exercises I was given were the following:
- Hold the bridge position for 10 seconds, 20 times, up to 3 times a day.  Make sure glutes are firm and hamstrings are loose.  Pull your belly button towards your spine but not excessively, just firm.
- Laying on your stomach, keep your legs straight and contract the glutes to lift the feet off the floor for 5 seconds, 15 times, up to 3 times a day.  Make sure quads and hamstrings are loose.
- Laying on your stomach, bend your knee and point your heel at the ceiling.  Use the glutes to lift the knee off the ground for 5 seconds, 15 times on each side, up to 3 times a day.


And that was it.  For about 2 weeks, that was all I was allowed to do.   My PT at the time also told me to lay on the ground on my stomach and prop myself up on my elbows and read or do computer work for a little while each day.  This was helping to undo the anterior tilt problem.  Once everything had stopped being irritated, it was time to start trying to actually teach my body how to fire the glutes.  We added reverse lunges done with my weight on my heels.  We add a resistance band around my knees for the bridges to start involving my gluteus medius, a tiny little bastard that gives a lot of people problems.  We also added single leg bridges, marching bridges, planks, side planks, and very slow hip hikes on a stair.  The hip hikes were done very slowly so I could put my hand on my gluteus medius and feel it firing.  All of this work helped me to get through Kinetic, but I also plateaued here and ended up moving to a new PT after a few weeks of no progress.  What you see here is anterior tilt less pronounced even when incredibly tired, feet landing just slightly in front of my hips:
My new PT agreed that my glutes not firing were the source of the problem, and he started me out with a few easy exercises.  Doing squats on a chair until my butt cheeks just brushed the chair, spreading my knees as wide as I could without angling my feet.  This didn't tire my glutes but I learned to activate them on the press back up to standing.  I did a set of 20 of these, up to 3 times a day.  He also had me do these on one leg.  When I started out, I could only do 4-5 reps before my form broke down, and it took me about a month to build up to 10 reps on each side, but with these, I could actually feel my glutes burning.
The next step after I had mastered these was to add very targeted, heavy strength training.  The first thing he taught me was how to do a proper deadlift.  He had me start out at 60lbs and do one set of 5 reps at each weight, adding 10lbs at a time until my form broke down, with at least 2 minutes of rest between sets.  When I started out with these, I was able to do 5 reps up to about 80lbs.  Over the course of about 6 weeks, I worked up to 5 reps of 110lbs.  I did these as a stand-alone workout, and only once a week.  On my other "legs" day of the week, I would do a set of these with very low weight (20lbs) just to continue teaching my neuromuscular patterns what good form was.  I also added:
- Single leg deadlifts at 10lbs, 3 sets of 10 reps.  This is a pretty good video of what it should look like, although I do it slower than he does to really make sure I can feel my glute working.  Keeping your knee bent at about a 15º angle and not bending/straightening it at all during the exercise is key.  
- Single leg squats on a box.  This is a pretty good video of what it should look like, although I started and continue to do it without weights.  The key here is to really sit back with your butt, and not let your knee collapse either inwards towards your body or move forward past your toe.  
- Lateral lunges.  Step out to the side with one foot and really sit back with your butt.


I also continued with regular squats, adding very light weight (20lbs) and doing a set of 20 reps on my legs day.  On my non-legs days, I would pick 1-2 of the exercises and do them with no weight.  After some progression with this, maybe 2-3 weeks, we added kettlebell work.  All the movements I had been doing up to this point were slow, concentrated movements.  Adding the kettlebell work was adding a plyometrics aspect to my strengthening, which is how I slowly started to bridge the gap between using my glutes to lift and using my glutes to run.  With the kettlebells, I would do the basic swing and the single arm swing, 2 sets of 15 reps, once or twice a week.  My PT also taught me how to do squats and Romanian deadlifts with very heavy weight, but while these are both fantastic exercises, I found that the deadlifts worked better for glute activation for me.  
Working with a PT through all of this was great, but I learned about a month ago that I shouldn't be doing ALL of these exercises so many times a week.  His strategy was more to equip me with the knowledge of how to strengthen these muscles, and then let me pick and choose which ones worked best for me.  Throughout the entire summer, I was seeing him once a week.  ART worked well on my external rotators and glutes, but didn't really do the trick for my hip flexors, so he Graston'd them instead, and about 2 weeks of that did the trick.  The Graston technique is essentially using a giant steel toothbrush to loosen up the tight muscle and send inflammation off and running.  This is what is looks like when your IT band gets Graston'd:
The last piece of the puzzle was added by both my PT and my running coach: drills.  Throughout this whole process, I spent every moment that I was running focusing on keeping my hips under me.  As I got stronger, my gait changed (I hesitate to use the word "improved," although that's what happened) and my feet started landing more underneath my hips.  Here's partway through that process.  My hip is still collapsing forward but my glutes are starting to pull them back:
And a few months later, running with my hips squarely under my shoulders:
This changed me from a very serious heel-striking over-strider to a solid mid-foot striker with almost (but not quite) perfect cadence.  It also helped immensely that the Tuesday CAR workout was a hill workout during this process, as running hills with proper form is FANTASTIC for teaching your glutes how to activate during the run (thanks, George!).  So all of this helped send me in the right direction, and now I just have little tweaks to work on.  I do a series of drills barefoot:
- Swinging the leg back and forth, making sure that the ball of the foot is touching the grass in the same place every time.
- Adding a "bring the knee forward fast" piece to the drill.
- Adding a "pawback" to the drill - springing against the ground with the ball of the foot as the leg moves back.
- 20 second strides, focusing on the foot leaving the ground.


I've also been taught proper form for the "high knee" drill, the "butt kick" drill, the "B skip" drill, and several cadence drills.  Throughout all of these drills, I can feel my body desperately wanted to become a forefoot striker, but as soon as I put my shoes back on, midfoot is what I am.  However, they are still valuable in that I am learning proper forward lean - from the ankles, not the waist - and upper body carriage.  (Gratitutious puppy ass shots).

I still am spending about 100% of my time trying to run very carefully and doing a series of mental checks.  Are my hips under me?  Do I feel like a string is pulling my hips forward?  Are my feet landing under me and not in front of me?  Am I keeping my shoulders back and down?  Is my chin up?  Are my eyes focused in front of me and not on the ground?  Is my cadence up in the 90s?  Are my feet landing side-by-side and not tight-rope running?  I essentially rotate through these thoughts the entire time I am running.  My body is learning, but it's not natural yet.  I'm also starting to learn the post-run signs of not enough glute work.  My IT bands being tight and hurting is the #1 sign of glutes not firing enough.  I can also tell if my quads are extra tired or if my hip flexors are a bit tight.  However, more and more often I am finishing tough running workouts with two sore butt cheeks, and THAT, boys and girls, is the goal of this whole project.
I also am trying to not spend all day sitting, but instead will stand some, lay on the floor on my stomach some, and kneel some.  The goal here is to simply keep changing up the way I am when not in motion so nothing gets tight or short.  Please feel free to ask me questions about any of this.  Not using your glutes is VERY common for runners, especially when you are just starting out, but you might not have to go through this giant mess like I did if you are smarter about your strength training and concentrate on your run.  


So, enough about my ass already.  How was everyone's long weekend?  I spent the weekend mostly unplugged, and it was kind of fabulous.  

84 comments:

  1. There is not enough ass in this post.

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  2. With all of those ass shots, you probably could have just left out the words. The gratuitous puppy ass shots are my favorite.

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  3. That was a lot of Katie-ass pictures; and a LOT of information about things I had never heard before. So informative (and picturesque)!

    I was actually shopping online last night (Craigs list) for a table / shelf to put in the kitchen that would also happen to be the perfect height to resume my 'standing desk' approach. We had a counter/breakfast bar-thing in the CO apartment, but not here. Now I have even more reason to believe this is a necessary purchase - no sitting all day! There's no way I could remember all those questions + exercises to fix me if my body reacted the same way.

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  4. So I basically didn't read the post the first time around and looked at the pictures instead. Highlight, obviously.

    Seriously, though, this story makes my head spin. If I could do my work lying on my stomach for half the day I probably would but I don't think my coworkers would really get it.

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  5. You ever try one of those kneeling chairs? Might work for you. Might not.

    Speaking of broken butts, my lovely wife described mine as looking "like a rhino's" last night. It's because it's gone from porky but pert to extremely muscly (thanks to lunges and squats to sort a knee issue out) with a bit of droop. Tragic.

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  6. Thanks for all the info - great pointers to keep in mind for all of us. And a wealth of info to people who are having issues.
    I love the ass shots. None of the Poet, though? Hmph.

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  7. I have no idea if my butt works when I am running. I probably should figure that out before I end up in trouble.

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  8. First off--wow have you worked hard to straighten things out! I am impressed with your dedication; I'm sure you would say it was all well worth it.

    Second off--I think I want your PT's name for when I get back. I KNOW I have lots of little issues going on that can lead to bigger issues down the road. One in particular--the dead glutes.

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  9. Thank you for this! I'm going to print it out. I've had the PIA symptoms for some time now. I KNOW something's up and need to do more glute stuff. How are you not bankrupt after all that PT??

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  10. Great post -- I loved reading it, and found it very helpful, as I am working through many of the same glute issues. I keep running and thinking "fire left, fire right, fire left, fire right..."

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  11. Daaaang, woman! I never realized how much work it took for you to run normal. I am so glad everything is going well now. WOW. Great pictures, by the way! It was really neat to read the explanations behind everything. Very informative post!

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  12. What a long journey. This blog is a great technical resource for anyone else with these issues. Glad you are better!

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  13. I love your bootie...especially now that it is healthy. Its crazy how our body compensates and leads to further damage.

    I especially appreciate the G and M ass shots!!!

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  14. It's pretty amazing that you got that all figured out. Your determination always impresses me, Katie. You're so dedicated!

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  15. BOOTY. Your ability to rebound from injury and pain is awesome.
    I've been sidelined for most of August with serious foot pain and am just now coming back to running. I considered dropping my 9/25 marathon but then thought, "Katie would suck it up and do it." So I'm going to do it.

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  16. I k ow that this has been a very long, tiring and frustrating process for you but I am SO glad you atevseeing real progress and getting healthier! Yaaay for a healthy ass!
    A lot of the exercises you mentioned are the ones my chiro gave me while I was be treated for weak glueteus medius. And am still doing today tom stay strong!
    Doing the happy dance for you! (tom the tune of Three 6 Mafia's "Shake My")

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  17. Nice article. I have to be careful about my glutes, too. My biggest problem, I think, is not stretching enough (hamstrings, IT band, glutes, etc...). But it's very interesting the number of different strengthening exercises you were doing to try to get things back under control.

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  18. I had the same problem! I had no idea to fire my glutes.

    If you're bored, here's a link to my blog entry with a very embarrassing video of how not professional I looked when I was running:

    http://www.therunninggreengirl.com/2010/06/green-girl-tries-active-release.html

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  19. Poor dogs. Did you get their permission before posting ass shots???

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  20. Thanx for all the ass-tastic info Katie.

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  21. Dang girl. I feel like I am adequately familiar with all things ASS. Now I can power through my Wednesday ;)

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  22. Ok, now that I have had the chance to read this, I have no idea if I'm doing better or worse. I do know I've never had a sore butt after running.

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  23. great article and super well done for getting yourself back on track again.

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  24. This post is so helpful! I read it when you first posted it several months ago, but I didn't really understand it. But now that my iliopsoas, piriformis, gracilis and everything in that general region have gone to hell, now I get it! My hip flexor is making me miserable. I made the mistake of doing no other workouts but running, then sitting at a computer all day. I had to stop training for a marathon 4 weeks ago and it's still not better. I've been seeing a chiropractor & getting weekly massages, but it still hasn't calmed down. Guess it's time to see a real doc for PT?

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  25. I've had some similar issues in ye' ol' piriformis and hip lately. Your article was awesome to help me get my brain around what may be, or is going on. Thanks!

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  26. I love reading about runners that debug problems with their running/bodies. Great writeup!
    I found your blog by googling for 'running sore glutes' 8)

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  27. I had the same problem. I regularly ran 70-80 miles/week as a distance runner at a fairly competitive level. It turns out I had an insanely tight psoas/hip flexor that was stopping my glutes from working at all and causing pretty severe back pain and not only preventing me from running pain-free but also affecting my daily activities. I couldn't get in my car and drive anywhere pain-free. Finally I spent some time in PT stretching my psoas out holding it a full 3-5minutes daily, and now I'm not only able to run again, but I feel like I have my life back where I can go out places pain-free. I am back up to 40 miles/wk now since figuring this out and hoping to get back to higher volumes once I've finished the course of PT.

    I think there's an epidemic of tight psoas and inhibited glutes among endurance athletes who work 9-5 jobs in a chair and spend more time in a chair browsing the Internet. This sitting causes psoas to shorten a lot and as it says in this article the body thinks this is normal. Even if you make sure to get up a lot, the psoas can still get really tight over time. I had low back pain, hip pain, and adductor pain and very few doctors knew what was wrong. I had someone watch me run and they could see I was getting almost zero hip extension and that my hip flexors and psoas were so tight the range of motion was negative (i.e. if you lie down and bring one knee to your chest and let the other knee hang, it should be able to stay down and not come up...if it comes up even a smidge, you have some serious work to do on your psoas/hip flexors).

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  28. Again, for those of you still having problems with tight psoas, I suggest you really need to try stretching out the psoas for a full 3 minutes daily. Do this for a full 10-12 weeks and you will see LASTING results. You'll feel MUCH BETTER after just 2-3 weeks....Don't do what most PTs do with you and just hold it for 20secs - I tried this with the 1st PT I saw and this won't help much and you'll likely still have pain.

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  49. I got a lot of useful info from your post - thanks! I'm not a runner but I rarely feel my glutes fire, even though I walk hills. My quads are huge, my butt the same, sticking out and basically, reading your post made me recognise some issues I hadn't been able to pin down. Thanks again

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  50. Thanks for the article - 35 years of being a serious cyclist/gym rat -I've had few injuries - 2 bike wrecks, road rash, cracked ribs, hematoma on hip etc.

    A month ago, I became aware of a pain in the ass. I figured, I'd take it a little easier on the elliptical and knock off the squats. Then suddenly - I couldn't sleep, can't walk the block to the gym and am living on NSAIDs.

    Haven't been to the gym in 2 weeks. After stretching my Piriformis, hamstrings etc. No better. Going in for massage. I forgot about my psoas.

    Thanks for the great article. And wheel suckers are the reason I pretty much rode time trials exclusively until I quit cycling 3 years ago.

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  76. افضل شركات نقل اثاث بالمدينة المنورة تساعدك على نقل اثاثك بامان فلا داعى للقلق مع افضل شركات نقل اثاث بجدة

    عزيزى العميل انت من محبى التنقل باستمرار بالتالى انت بحاجة ماسة وضروية الى الاستعانة بالمختصين في نقل العفش خاصة افضل شركات نقل اثاث بالرياض لان الاستعانة باى من عمالة الشوارع الغير مدربة والتي لا تمتلك خبرة كافية في نقل العفش او الحفاظ علية وليس هذا فقط فقد يؤدى الاستعانة بعمالة الشوارع الى حدوث حالة فقدان وتكسير للاثاث بالتالى التاثير الضار عليك عزيزى العميل

    لا تقلق مطلقاً الان بشأن نقل اي منقولات خاصة بك طالما استعنت بشركة الاول لـ نقل الأثاث في الرياض وخارج الرياض فنحن ليس الوحيدون ولكننا متميزون عن اى مؤسسة أخرى داخل وخارج الدمام وشهرتنا كافضل شركة نقل اثاث بينبع
    ارخص شركات نقل العفش بجدة

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