Piggy in the Middle

Do you remember that game where two people throw a ball to each other over the head of another player who is standing in between them? The ‘piggy in the middle’ has to run around like mad trying to intercept the pass, whilst the others play all sorts of tricks like ducking  or switching directions at the last moment. Yep, well, the piggy in the middle is a great metaphor for the knee.

When the ankle joint receives weight it is normally in contact with the ground. This restricts the movement possibilities within the ankle, providing a relatively stable base on which to stand (‘relatively’ being the operative word here). The hip joint is structurally stable being both deep inside the pelvis and reinforced by layers of strong tendons. In relative terms, the knee is in a much more precarious situation. In the downward spiral (my term, not a technical one), the knee has to accommodate the torsion created by deviations / restrictions above (in the hip) or below (in the foot) or both.

However, the knee is not designed to rotate! It’s a hinge joint. It is designed to allow us to flex in the lower limb. This decelerates the fall of the body, reducing the impact of the ground’s force when our weight is met by a hard surface. It should only move forwards (flex) or lengthen (extend – as opposed to hyper extend (that’s another story)). Restrictions around the ankle and hip force the knee into inward (knock knee) or outward (bow legs) rotation (- bow legs is not really a result of the Spiral Line collapsing, I’ll cover that on another post). Continuous torsion over time ultimately leads to injury. It’s the piggy in the middle, and all it can do is scream in pain.

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It is very rare that a knee injury is directly the result of poor functioning in the knee itself! (Dislocation and hyper extension are obviously an exception.) And yet the tendency is just to treat the knee with medications, massage and exercises that directly relate to the knee alone, instead of addressing the underlying cause of the torsion which may be in the ankle, the hip or both. No, I’m not saying you shouldn’t strengthen the VMO and release the ITB (if you have dodgy knees you’ll have come across these terms already). Unfortunately, we often only know about the pattern when the knee starts to create some noise, by which time damage within the knee itself has already taken root. So we then have a situation where we do need to treat the knee to relieve the pain. But the knee pain is a symptom of a wider pattern.

So how do we identify restrictions that may be putting a torsion strain on the knee before we get to that point of injury, and what can we do to reduce them? Here are some suggestions:

  1. When you next walk up a flight of stairs, look at how your knees move over your toes. Do your knees roll inwards or outwards? Both of these are a sign of some compensation. Try sending your knee directly forwards over your toes. It may feel strange, or effortful at first, but by gradually encouraging better alignment you start to unlock the poor pattern.
  2. Listen out for noise. It’s obvious enough, but constant cracking, popping and crunching in the knee is not a good sign. If it is on one side but not on the other (unilateral) then this could be a sign of whole body torsion (again, my term not a technical one), which is particularly common for people with a scoliosis or some other asymmetry (like a leg length discrepancy). Working to reduce the impact of this structural asymmetry on the soft tissue will help to reduce the constant pulling on the knee. You need to do a well rounded class that includes release and stabilisation for the pelvis and spine. Attacking the leg alone with a foam roller may just exacerbate the situation.
  3. Decompress the knee. If you are hearing clicking sounds in the knee and starting to experience pain you need to focus on decompressing the knee joint. The typical thing to do is to strengthen the VMO (the lowest fibres of the inner most quadriceps muscle) which helps to lift the knee cap, whilst releasing the ITB (the tough tissue on the outer side of the leg). You should also look to lengthen the hamstrings. (My next post will look at functional use of the hamstrings.) But you cannot ignore the lower leg. The muscles in the lower leg also tend to tighten up, especially the ones around the outer side (the peroneals), these are particularly hard to stretch, and are often by-passed in people with dropped arches. The Feldenkrais variations of calve stretching described in the video on my previous post will massively help to relieve this tension. Try to avoid really tough stretching. Work on creating glide between the layers of muscle instead.
  4. Strengthen the muscles around the hip. This will be covered on my next post.

Warning: Listen to your body. The aim is to move without pain and no blog can really tell you how to assess and correct your movement. Speak to a professional and get them to give you some feedback on your knee tracking. Just remember, the cause is not normally in the knee.

🙂

My next post will look at the hip – foot sling.

Bunions

Not the loveliest of thoughts, but if you’re reading this then chances are you may well have one or possibly even two.

A bunion (hallux valgus) is a condition where the big toe points inwards towards the other toes. It is a deviation at the metatarsophalangeal (MTP) joint of the big toe. It makes the inner edge of the first tarsal bone jut out to the side which rubs on shoes and can become inflamed and painful.

Unfortunately, treatment often tends to be quite superficial. It’s true that it can be caused partly by wearing poor footwear, and that the tendency can be hereditary. But more often it is the result of how you are moving. So fixing the aesthetics without addressing the underlying problem will only lead to recurring issues.

In my last post I spoke about the Spiral Line: one of the fascial continuities defined by Thomas Myers.The spiral line allows us to move forwards with greater efficiency, by using the torque created by the cross lateral co-ordination of arms, trunk and legs during walking and running.

Relying on this torque without the underlying support of the inner line of the body (the core), causes a downward spiral, where people are literally twisting around their joints. The bunion is a symptom of this twisting.

(Small interlude here: I have come across at least one client for whom the bunion resulted from an adjustment in her gait pattern due to inflamed sesamoid bones in the big toe joint. So if correcting the alignment of the toe, by using your fingers to pull the toe back into alignment, and trying to roll over the big toe joint, causes pain, it may be that the rotation around this toe is an adjustment and that there is an underlying problem that needs to be addressed. Even so, the management described below would not hurt.)

There are two things that need to be addressed to correct the deviation of the big toe joint:

  1. Tone the muscles within the spiral line to bring more stability into the joints of the lower limb. (Please see my Spiral Line – Practical post to learn more about how to bring tone to the Spiral Line.)
  2. Address the movement restrictions in the other lines which may be causing you to take the spiral pathway in the first place.

I just want to pick up on this second point because it’s often left out. What I see quite a lot with people who have some degree of bunion is that their sagittal plane movement (forward and backwards) around the ankle and toes is restricted. They find it hard to do a standing knee bend (a plie) without letting the heels come off the floor, or they have a restriction around the metatarsal joints during push off. Whereas collapsing into the spiral line is a problem of tone, using it to by-pass forward/ backward movement is a problem of mobility.

So do we just need to stretch? Yes A simple calve stretch will help to increase mobility in the angle joint. My favourite is Katy Bowman’s rainbow calve stretch and the soleus stretch here. However, I’m tending to move away from stretches in general because they can sometimes be quite counterproductive and just lead to more stiffness. My favourite mobilisations around the ankle joint are the Feldenkrais variations of footwork. I try to include some of these in my classes from time to time but here’s a little sequence for you to try out:

(Apologies for my very basic filming skills and for the shadows under my eyes. I’m really not made for the camera!)

 

If you notice, I basically haven’t said much about targeting the big toe itself. That’s partly because there’s so much stuff out there about specific toe exercises. I just don’t think the toes are really the cause. My feeling is that it is often stiffness around the ankle joint and collapsing into the arches that changes the push off during walking so that instead of articulating forwards through the big toe and second toe metatarsals people are twisting around the big toe which brings about the bunion. The exercises described above and in previous posts may help to bring some tone and release into the foot and ankle joint which will help to unlock this pattern. But bringing your awareness to how you’re moving will also help.

 

 

 

The Downward Spiral – Practical Tasks

In my last post I talked about the Spiral Line and the danger of collapsing down into it. Here are some very practical things you can do to get out of your downward spiral.

  1. Stand on one Leg. That’s it. you’ll find that it’s impossible to balance unless you bring your weight into the outside of your feet and get the outside of your hip to fire up.
  2. Send your knees over your toes and engage your buttocks when walking up and down stairs. Don’t let your knees roll inwards or outwards. Yes it is that simple.
  3. Do clams, ok but this one comes with a massive warning sign: you need to ensure you are doing them properly so speak to your Pilates teacher if you’re not sure.
  4. Do some Lazy Angels, also known as ‘around the worlds’ where you lie on your side and circle an arm around. This really helps to bring some movement into the shoulder blade area which is often quite sticky in downward spiral clients.
  5. Releasing the ITB and the calve muscles with a foam roller.
  6. Do some basic core stability, keep it really simple. If you’re lying on a foam roller and keep falling off you’re just going to be gripping to stay on it. Don’t be ambitious about it! The important thing is to do something that will require you to engage your inner line, do some knee floats or arms on a roller. Something to get your centre to wake up.

And finally: stop blaming your grandmother! Yes genetics do play a part, but we all know these days that nature is only half the story. The other half is in your hands. 🙂

The Downward Spiral

I’ve been thinking about it for ages and today I will finally begin tackling a problem that I have seen with increasing frequency: deviations in the big toe (bunions) and knees (knock knees), both of which I think are a result of a collapse in the spiral line.

So many times I come across clients who tell me they’ve had surgery on both big toes to correct bunions, and yet the bunions recur. I come across many runners with chronic recurring knee pain, normally treated with massage and insoles in their shoes. Over time the wear and tear builds up until they cannot run at all. Make no mistake about it: walking around against gravity does put load on our joints. Good alignment means that the loads get channelled through efficient pathways. Poor alignment leads to stresses and therefor injury. But fixing the issue by repositioning bones will achieve nothing unless the underlying movement pattern that is causing the deviation is addressed. Form follows function, you are how you move.

The other thing you need to do is stop thinking about the body as a number of separate parts stuck to each other. Your little toe is connected via fascial pathways all the way up to your neck and face. No it’s not Woo Woo. It’s fact.When we talk about holistic movement practices this is what we mean. It’s an approach to the body that sees it as a whole, interconnected structure. Key to this approach, is an emphasis on connective tissue, the stuff that literally connects every cell within the body. In 2001 Thomas Myers identified specific lines of pull across the fascial web, pathways around the body that he called ‘myofascial trains’. One of these is the Spiral Line.

Rather than take you through the anatomical details of this pathway, it might be easier to just look at this very short video of the spiral line, narrated by Thomas Myers. The line runs along specific muscles that are fascially connected so as to create one continual line along which tension is transferred and distributed. They’ve drawn the line on just one side, but obviously this is also present on the other side of the body too. The lines cross the body and create a stirrup around the foot.

I think this is such a key fascial line because it moves across a number of planes. The front and back lines are mainly involved in forwards and backwards movement, the lateral line stabilises the sides of the body. They are the ‘simpler’ lines in this sense. But the spiral line works with or against rotation making it a more complex one. Forward, backward and side ways movement never really is simply forwards, backwards or sideways. When we walk we don’t just move forwards. We’re actually moving in spirals. The problem occurs when there simply isn’t enough support from the other lines, in particular from the inner line of the body (the core) and lateral line (the gluts) which means that rather than using the spiral line to make our movement more efficient, many of us are hanging into our spirals.

When you do not lift out of the spiral line from the feet upwards, you place the rotational force on the vulnerable joints of the knees, ankles and toes. The knees knocking inwards and big toes pointing outwards are adjustments to the force of body weight being channelled downwards and inwards when we attempt to move forwards. I’ve come to think of this as the downward spiral and its effects can be pretty debilitating.

Spiral line issues do not only affect the legs. When clients complain of knee pain there is often a degree of ‘fuzzing’ (a build up of fascial tissue) under the opposite shoulder blade to the affected knee. This is because the inefficiency of the lower limb puts strain on the line higher up the body. You don’t run or walk with your legs only, your arm swing and rotation in the spine is all part of the movement too. This is why a long distance runner can get shoulder pain when they tire.

So how does one pull out of the downward spiral?

First of all, stop thinking about the parts in isolation. You need to look at your overall movement. Clients often get a bit confused when I start teaching a standard class and don’t simply focus on the ‘bad’ bit. The truth is that the painful area is rarely the  source of the pattern. It is more likely to simply be the area that has compensated the most. So yes we do need to work to relieve the stress on the area. However the re-training focus needs to be on what’s happening above and below the point of torsion. Also note that sometimes relieving one part of the structure involves just leaving it alone! The thoraco-lumbar fascia (in the lower back) is one area in particular that should not be stretched around.

Secondly, we need to work the muscles. Sounds obvious enough, but it’s surprisingly difficult especially for hyper-mobile clients. Connective tissue itself (which includes tendons and ligaments), cannot be contracted. We cannot really change the elasticity or rigidity of connective tissues. But we can control the tone of muscles which lie within the fascial lines. As James Earls says in ‘Born to Walk’: “the muscles are essentially the fine tuners of the system, adding or subtracting  tension when needed, via the fascial tissues of the body.”

And finally, if you are moving in a way that causes the deviation, then that ‘way’ is also going to feel the most natural. Most of us stand and move more or less unconsciously so changing a pattern requires increasing your body awareness so that you notice when you are falling into a bad habit in the first place. Increasing awareness takes time and requires some kind of external feedback system too, ie: we need someone else to tell us how we are moving. Going to an exercise class where a teacher is able to look at how you are moving and give you regular feedback and corrections is essential.

I’ve learnt from working with various clients that there is no quick fix, in my next post/s I’ll focus on a few key areas and offer some suggestions of things you can do alone to stop the downward spiral in its tracks 🙂