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.