Crooked feet are not random

Although misaligned toes and bunions are fairly common, there are numerous misconceptions about such deformities. Many people fail to realize that their crooked, calloused feet and their ankle and foot issues like achilles tendonitis and plantar fasciitis go -ahem- hand in hand.

My patients often look down at their feet and blame their stuctural condition on one of their parents. But bunions and drifting and overlapping toes are not random occurances like a cyst or a plantar wart. They are the body's typical response to mechanical forces. What's inherited is not the bunion itself, but a faulty foot or lower leg structure and gait pattern that make a person prone to developing a bunion.

This may seem like trivial information. But it's important when deciding the best way to treat such problems. Seeing callousing and bunions primarily as cosmetic issues that need to be addressed at the spa or surgically will produce a far different outcome than seeing them as biomechanical problems in need of biomechanical correction away from the actual bunion.

For example, treatment for someone with a mild to moderate bunion and/or hallux valgus (first toe migration) may include:
  1. Placing a splint or spacer between the first and second toes.  
  2. Appropriate width footwear that doesn't perpetuate the pain and sensitivity by putting pressure on the area.
  3. Custom or semi custom orthotics that correct for structural misalignment in the midfoot or rearfoot and allow for more normal forces as the patient rolls off the ball of the big toe.
  4. Stretching and select strengthening of the foot, and more likely, the ankle and the hip, which promotes more normal motion elsewhere and unloading of the areas taking a beating.
  5. Gait training aimed at forming a "new groove" of walking that places more normal forces at the hip, knee, and foot and again, minimizing the biomechanical forces which cause the deformity. 
Pain relievers help relieve pain and surgical correction is absolutely needed at times. But can you see how a toe splint and anti-inflammatory drugs are a short sighted fix for something that may be due to biomechanical forces all the way up at the hip? Orthotics and surgery are even of limited benefit if you walk like Donal Duck.

Donald seriously needs some hip internal rotation mobilization.


Mothers heritage

Mom was about 53 when a young horse smashed her into the barn wall, blunt metal stirrup splitting her lower leg wide open.

"Can you drive to the ER, help me get in the car?"

They call them foals because it's almost the same as fool. Mom always had one of those fools at the house following around her trained competitive quarter horse. She got into dealing to support her own riding habit, churned out domesticated animals worthy of aspiring barrel racers without the knowledge or desire to train them.

Well that and because she loved it.

That's why she's...over 53, still trying to teach foals that it's acceptable to have a human on their back. Not to wig out. Not to smash the human into the barn.

Is it any wonder why I suffer an injury or few while pushing it, horsing around in middle age? This didn't come from my father. He was a pro athlete though. I suspect something about getting paid to be athletic squelches your desire to compete and push physically. Even so, it must be the Minick genes, in my case, the mothers heritage of having balls.

Let's see, where do I begin? Great-Legendary Uncle Bill Minick, the guy who had is eye gouged out while bull riding? Crazy Uncle Tom. Aunt "Tiz" Diane, who skid through a glass wall? Cousin Roger, recent parachuting and ski injury? There's more, and then cousin Tim. He was a paid pro athlete, so he doesn't overdo fitness. But he's not above the Minick gene. His mom is signing up for bungee jumping. I hear Tim's wife regularly complain about Advil overkill and constant wound seepage going on all over their couch and bed sheets.

That's why I will never tell mom, while driving her to the ER, to BINGO, or elsewhere, in as many years that follow, that 50, 60, 70 year-olds shouldn't be riding, competing, breakin fools. I will never suggest that some major part of her sit down and die before it's time.

I understand.

And with that I'll view each of my unique hand crafted orthopedic injuries as a loving keepsake from mom.

Thanks mom!

injury: truth is...

I often talk about taking something away from each training session. Just one thing learned, usually regarding form or recovery. I quit keeping a training journal long ago, but I certainly make plenty of mental notes.

A semi-serious injury will earn you opinions and questions and sage advice, mostly from folks who don't train. I hear each of them, nod my head, cannot disagree in their context. Truth is, there's a flip side that many will not appreciate.

"What are you bench pressing all that weight for anyway?"

315 pounds for a relatively easy set of 5 is just where I arrived, resistance training two days per week for years, keeping my head and body clear and strong, because I could. One of the main things that I learned from this injury is that if you want to train seriously hard two days per week, you should allow more than 1 day of recovery from the previous session.

There was nothing reckless or irresponsible involved with this. Truth is, bench press is one of the more lame and benign activities that I do for kicks. And isn't that usually how it happens - when you least expect it?

"All that exercise stuff is good for is getting hurt."

People get injured engaging in all varieties of good and not-so-good exercise. Part of my job is helping them not to. Truth is, we have mounds of evidence that regular exercise, especially resistance training, helps prevent injuries in sports and every day life, especially as we age.

When someone needs a triple bypass or trips while carrying groceries and fractures their wrist, our first reaction is to lend them a hand, comfort them, pray for them.  It's just not acceptable to give them a sedentary lifestyle version of the Nelson Muntz laugh that I seem to be getting from pushing myself.

But you don't want to hear about evidence based prediction of fall risk or protocols that minimize the risk of ACL injury.

Maybe you can appreciate that this whole issue is a lifestyle decision. At 35 I play flag football and basketball with young men in their prime, and regularly take major hits while biking and horsing around with nary a pulled anything. That didn't happen by way of strolling through the park.

You may not think it's cool to 180 a mountain bike, ride backwards, and pull out of it to ride forward. But I do. It took some lumps to learn that in my 30s. My kids think it's cool to be home. And with the cast of characters that regularly shows up around here, it IS cool. I was never a very cool or confident guy, and years of weight training seems to have helped me (some!) with that.  

"Y'know you're not 20 any more." 

Thanks for the reminder. Given the interaction with young adults at work and church and a few friends who train with me, it's almost every single day that I both lament and celebrate not being twenty. Truth is, I'm not 50 either. It would be a shame and unnatural to be as careful and wise and lame as a 50 year old. Good thing I also know some pretty bad dudes in their fifties.

Though, Lord willing, 50 is coming. Thank God that 20 and 35 and 50 don't happen all at once. I have some pretty strong preferences on the road I'll be taking.


MRI not very helpful

MRI shows that there is tearing of the pectoral muscle, but the tendon insertion into the humerus cannot be located. Apparently this is a relatively uncommon injury and an akward anatomical location to visualize under MRI.

Whether the tear is at the muscle-tendon interface versus the tendon-bone interface is important. When the muscle tears away from the tendon, there's nothing to be done surgically. When things scar down things tend to recover to an adequate level. But when the tendon tears away from the bone, surgically reattaching the tendon to the bone will allow for the best long term recovery.

Decisions decisions, surgery or no surgery?

Surgery is a freakin chore. The time and expense of surgery, plus two to four weeks of immobilization to allow for healing and then a very slow process of regaining range of motion and strength.  Caring for children and work is out of the question during that period of immobilization, much less fun.

I really don't care if my chest looks a little uneven or I lose the big bench press. I should function just fine, even with 75% of my "normal" strength level. Right?

On the other hand, if the tendon is tore off the bone and I fail to have that surgically repaired, I'll end up with much less strength. The doctor says that there's really no way to tell without going in surgically, and it's up to me.



Torn Pec

I'm always eager to report various feats of fitness, grit, and awesomeness accomplished by a half dozen or so people training in my basement and around the yard. Well, not today. Today I bring a story of the dis-awesome and plain ugly.

After a few progressively heavier warm up sets the blogger lays on his back under 315 pounds. In many times recently passed, he's benched pressed this plus plenty more. So it's no big deal. But he's taking it seriously. He must, or it's not worth doing.

Never mind - that in the previous month he went on-and-on about the overrated, uninspired exercise that he cared for very little. Neither did he pay heed to the fairly severe muscle soreness lingering in his shoulders and arms from heavy pressing just two days prior. It was Tuesday, lifting day, and he's here, so he may as well give a damn and go hard. It was time to battle or be crushed, yeah, just like he wrote about a few weeks ago.

The core tensed, scapula rigid, lats flared, he un-racks the weight. The first rep feels light, throws it up. The second rep accelerates as well. Descending into the third rep of 5, he feels and hears the sound of a T-shirt being torn apart at a seam. In a fraction of a second the weight crashes down as his right pectoral muscle peels off the insertion into his upper arm bone (humerus).

"Torn pec" he blurts, writhing under the load as his friend regroups, heaves the load off his sternum and back to the stand. 

He stands up.

"It doesn't hurt that bad."

"I am NOT having surgery."

"I feel dizzy."

He sits down. Then stands up, shirt off, poking at his protruding right...it turned from a chest to a boob.

He works until lunch the next day, calls his friend who specializes in shoulders at the Orthopedic Institute of Pennsylvania.

"Come in tomorrow at 9. If the MRI shows a full tear you'll need to have surgery."

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You'll hurt your back (not) doing deadlifts

I did.

It was about two years ago, trying to pull up 405 pounds after four years of not doing a single dead lift. Failing to lock out one clean repetition, I dropped lowered the barbell and immediately assumed the hands on knees shameful hurt back posture. Proceeding directly to the medicine cabinet, I heard a mocking chant of "You'll hurt your back," much like the "You'll shoot your eye out" taunting in the old Christmas Story movie.

These days I pull far more weight for a total of at least 20 reps every Tuesday, and my back is definitely less achy now than it was 2 or 4 years ago. I credit that, in part, to dead lifts.

So what gives? Personally, I planned and now try to allow sporadic form checks, better recovery, and respect for the body's inability to make constant, linear gains. There is most definitely an art to progression once you approach a double body weight dead lift.

But the main point of this is to emphasize the value of the less extreme dead lift variations. I mean, dead lifts don't have to look like this...Or this:


Instead, try one of about 10 more sane variations, preferable WITHOUT the singlet:

Dead lifts accomplish what no machine or training device or supplement can: teaching the brain to dial in the correct movement pattern for functional lifting. Picking things up is a part of life, unless you can find a way to hamstring curl your suitcase through the airport or leg press your new TV up to the bed room.

The spine is highly resilient when it comes to compressive loading. Almost every movement we make results in some degree of compression, not just loading the spine vertically (as in the squat exercise or carrying jugs of water on our head).

The bad guy is shear force, the tendency of vertebrae to slide forward or backward or rotate on one another. Approximately one zillion muscles in the back, abdominals, and hips are responsible for stabilizing the spine against shear forces. If those muscles are out of sync or plain weak, the passive structures of the spine take a beating.

That's how dead lifts save, yes SAVE, the vertebrae, discs, and ligaments of the spine! More than just stretching and typical training machines, dead lifts demand controlled mobility, hinging the ankles, knees, and hips, while the trunk muscles brace hard to maintain the back in a neutral position. 

Of course the problem is that some of us see how awesome and miserable and rewarding dead lifts truly are. We experience how they make you look and feel and perform like most people simply cannot look and feel and perform. And so we're ever so eager to up the ante on the risk:reward ratio. We're always asking for more reps, more weight, more awesomeness, iron addicted junkie.

If you're one of those, dead lifts will probably hurt your back. How else are you going to know how much you can pull? Even if you're really smart and careful about progression, you'll be wondering why you didn't add 10 more pounds because you really hammered that final work set. 

On the other hand, sitting at a desk, golfing, driving, falling off things, and ninja kicks in the back will also probably hurt your back.

But again, you don't have to dead lift small vehicles to (literally) get off the treadmill of training mediocrity. If you're working out training anyway, why not include something that's effective, requires little space and gear, and translates to more than just burnt calories?

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