D1 Runner - Post Navicular Stress Fracture: Week in Review 39

Summary

In this solo podcast, Dr. Beau discusses a case study of a collegiate runner he has been treating since middle school. The conversation delves into the runner's injury history, particularly a navicular stress fracture, and the impact of carbon-plated shoes on their biomechanics. Dr. Beau explores the runner's phenotype, rehabilitation strategies, and the importance of maintaining mobility during growth spurts. The episode concludes with insights on performance goals and the significance of individualized care in sports medicine.

Dr. Beau (00:01.006)

Okay, it's time for solo cast the day after Christmas. So the office is a little bit quiet. So I feel like come in here and break down a case about a D1 collegiate runner, somebody that I've seen since honestly middle school. So I have a long track record with, you know, just kind of taking care of the little likes and pains, a few major injuries, a major injury here about a year ago, which I wasn't the lead on just because now they're in college. So then they're under the supervision of their athletic trainer and the team doc there, played a role in that. And then this person also got to see some,

decently well-known people within my field, the conservative musculoskeletal realm, looking around at the same issues. So you also got some interesting insights and input there. So to go back in time, let's just phenotype this runner. This is a male runner, he's in his sophomore year of college right now, or junior year, sorry, junior year college.

lost about a year of competition to a navicular stress fracture, which we'll get to that. But if we back up and we just go after the phenotype of this runner, this is your, know, if I use Keith Barr's kind of description of a stiff person versus a stretchy person. So we're just looking at tissue composition, maybe from a collagen standpoint. But that stiff person or stiffer person is gonna score lower on baiting criteria. From a running standpoint, they're going to be, have more proclivity to, you know, kind of bounce off of tissues.

maybe not getting to end ranges so they lack some of the, you know, maybe motor output from, you know, accessing a full range of motion, but they have a stiffer tissue profile, which sometimes can be advantageous for a faster runner. Now this is kind of a mid distance guy, you know, cross country 1500, two mile. You're going to hit a cap where, you know, this always blew my mind when I was doing research for my course, Rethinking, Running Rehab. I wanted to know from a literature standpoint, what,

what's that composition, what's that phenotype of elite, like marathon distance runners. I would have assumed it was like this person I'm talking about, the more stiff, the more, you know, kind of running into stiffness to allow them to bounce, you know, down the cross-country course of the track. It was actually the exact opposite. So these people aren't hyper mobile, but they're, you know, own a full range of motion, basically would in our world pass a top tier selective functional movement assessment. And then you kind of have to surmise, right? This wasn't in the data.

Dr. Beau (02:25.378)

but you kind of take the stab that, they probably have fantastic motor control, just like any good athlete would, because again, an elite marathoner is basically sprinting the entire marathon. So their motor control is through the roof. We always talk about this with elite athletes. have great inputs and really good outputs. Their sensory motor input-output game is just top-notch. Same thing with an elite marathoner, distance runner. And yeah, there are going to be, you know,

different veins off that, but if we look at a bell curve, they fall further to the right on the mobile side. And then in my opinion, we see a lot of these amateur runners that are decent, they fall more into that stiff profile. So maybe that's why we see some of these injuries show up, but we can also have that more mobile runner. And if we look at foot types, if we're zooming in on this runner in particular, they have that more pescavis, rigid midfoot.

And that can lead to more injuries. Now the data would say that that type of foot is going to dictate that they would have more injuries up the chain. So because they can maybe dampen forces at the foot using that soft tissue matrix, using the arch of the foot, that they're going to end up with more things about the knee, or I'd say knee and up. So knee, hip, things like that. That is not the case for this runner. And if we look at the flip side of that from the data, there's people that, again, this is not a, we're just talking the static position or posture of the foot, so more of a

pes planus or a collapsed medial longitudinal arch, they'll deal with more lower extremity injuries, metatarsal stress fractures, medial cibial stress syndrome, fibular stress fractures, things like that. This exact opposite, this runner in particular has dealt with everything more or less up until this last kind of thing that I've been seeing them for below the knee in terms of, so in particular lateral foot issues, pronial tendon issues, because they live in this kind of supinated, extremely springy,

rigid midfoot, which they've just kind of capitalized on, which I'll talk about why I think that's happened also. Some stress reactions, never a full blown stress fracture until this navicular stress fracture, which we'll get to that as well. But why I think this foot type didn't follow the literature, nobody follows it to a T of the expected outcomes. But I think why this happened was this runner is extremely motivated.

Dr. Beau (04:47.598)

a driven type A, gonna do it on their own, and from a very early age started stacking on a bunch of volume.

there is no better window to gain mitochondrial density and build aerobic capacity from a physiologic adaptability standpoint than kind of in that 13 year old to 25 year old range. You're just never gonna be able to lay down mitochondria, new mitochondria, but also uptick mitochondrial density and also the secular size.

Like all these things are just kind of up ramped at this time. And that's why we see so many people. I was bringing up Lance Armstrong was a, and again, there's a genetic prowess there of his ability to shuttle lactate and things like that. But you see people at a young age get this aerobic base. Courtney DeWalter was a cross country skier. Lance Armstrong got on a triathlon. All these people had these huge, usually lower impact, massive aerobic base building periods of their life at a fairly early age that then capitalized on these elites.

on a genetic component for a bigger engine or VO2 max than a lot of us mere mortals will be running around with. So that being said, I think during that formative time of aerobic base building, this person went gung ho and already had the phenotype of the stiffer tissue profile. And we know when children or teens hit these adolescent growth spurts, which that peak height velocity kind of shift

It's kind of a curve where we have this initial bump, it comes back down, peak height velocity goes way up, goes down, then we have one more peak usually later. But that's gonna be about 12 to 15 years old, depending on sex. And we got all these things going on nowadays that shifts that earlier and earlier. But during that time, we see what happens to most children. They lose ranges of motion because bone growth outpaces muscle and for sure tendin-muscular tendinous junctions. And as they do that, they lose range of motion. So we're always telling.

Dr. Beau (06:50.924)

know, parents and student athletes. I wrote about this in my book. A lot of good information comes out of the Canadian Center for Sport on this of, you know, tracking gross spur to making sure that kids, athletes in particular, maintain mobility through this peak height velocity phase because if you lose it, it's hard to get back. So we want to maintain it. So going back to this runner, I think they stacked on a ton of miles, didn't do a lot of like mobility maintenance. This is just as we were kind of getting acquainted.

I I barked at them about it, you know, as we went, but you know, as you start to lose this stuff, it gets hard to get back. And then they built stiffness on stiffness. So their body had to capitalize on what they're already good at to maintain the amount of volume they're doing. But also like this is a, you know, a high motor output, good athlete as well as their, you know, ability to push into the ground or create kind of this, you know, a good power output in the ground is capitalized due to the stiffness. So they're using a stiff chassis more or less to like drive

you know, torque into the ground. So we have that component to it. So I follow this athlete through high school. They have a great high school career, help the team, you know, become state champions, gets recruited, goes to the University of Kentucky, is there. And this is right around the height. You know, the end of his high school career was the boom or the initiation of carbon plating in shoes in particular, you know, was supposed to be or it was aimed at race footwear.

And we didn't know, we didn't know. And all of a sudden, literally two or three weeks, which I've talked about this on social media before, two or three weeks before I saw this athlete in my office, which I didn't know this was happening, or maybe we heard from his mom initially, that there was a study that came out showing, and it was a small study, same amount, I wanna say it was 15 athletes, but it was all elite, collegiate runners that were basically being

stricken with, I don't know if that's term, navicular stress fractures. And they were correlating that there are mechanical changes that happen with carbon plated footwear that changes a wear load is first initiated the footwear displaced through the foot and ankle. And then there's debate on, the impact forces may be going up overall with the carbon footwear, which that's a whole nother conversation.

Dr. Beau (09:14.828)

Either way, there's been a very good, and again, we're not saying causation, there's been a very strong correlation of wearing carbon-plated shoes, and we're not saying just erase. This is where the trend started to come of people training in these things. So this was like, you know, being worn every day or multiple days a week, changing mechanics, and any time you introduce a new mechanical load, the tissue has to adapt. And in this case, we basically have, you know, the navicular, and I'll probably throw up an image at this point.

If we look at the navicular bone.

It's more or less, you know, I'm kind of pulling up.

Dr. Beau (09:57.314)

You know, can have accessory naviculars, I guess would be the most common plight around here, which is kind of like, it's basically a little shelf on the bone called your sustentacular tali. In my opinion that accessory naviculars becoming a wolf's law on demand that we're seeing more of a bony overgrowth on that sustentacular tali because you're probably using a passive stability

process or strategy around the mid-foot. So then we see that the posterior tibialis tendon crosses or goes under that, you little hook and then you basically create more bone to lean on it. But in this scenario, we see this rash of navicular stress fractures and you know, the navicular is this kind of floating bone. It's basically supported by other bones around it. it, know, navicular means boat in the foot or sorry, in

Latin and this floating bone is a rarity to have a stress fracture and because it's not having impact forces basically dictated upon it because it's basically conforming to the rest of foot. Now you can get stress reactions anywhere. We've seen people that get multiple, you know, like cuneiform, know, cuneo navicular stress reactions, degenerative change within that joint structure. But this basically floating bone

rarely get the stress reaction, in particular in elite runners. So then we see this kind of change. Well, we hear from this runner that, or I think his mom is the one that told us that the surgical intervention for the stress reaction, which it becomes surgical because you can have basically an island of bone or what's called an osteochondritis dissecans kind of lesion occur where that island of bone within this floating bone just kind of becomes dead. It's hard to heal. It's also, you know, it can be a tough diagnosis because of where it's at, MRIs.

are the best we have for stress fractures. But by time we catch them, I don't know, it's just a hard diagnosis, I'm being honest. So bone plugs, basically a bone plug of your own bone that's usually being harvested from elsewhere in the body, the pelvis or something like that, is being used to drive in to fill the gap of this bone island or the stress reaction, stress fractured area. So this runner had this surgical intervention over a year ago.

Dr. Beau (12:24.35)

Gets told the timeline. I think the initial timeline I am not for sure was 12 weeks to you know Maybe it was eight weeks to start loading which would be typical bone healing timelines again I have another chart in our exterior rethink or any rehab of the actual full scale healing times for a healthy individual We're always you know thinking six to eight weeks somebody's out of a cast or a boot the bone injury That's not full healing. It's around 24 to 30 weeks is full bone healing to get the full

know, cortical structure, trabecular structure in place. And if we think of a bone like this, you know, and now we have to think if we're changing and, without getting too lost in the details, because a lot of this is theorized and there's different plates and different shoes and different super foams. And so I'm not going to speak for all the shoes, but the overall theory, if we had to be very simplistic about this was that with a carbon fiber plate, basically that plate winds up right. And it just allows us to,

collect more potential energy, which we can then drive into the ground in terms of kinetic energy without, it's a passive energy source for us, which is largely what your foot and the windlass mechanism of adequate range of motion, right? We were talking about this range of motion equation where if we lack range of motion, we may lack motor output because you're going to be sparing of the tissues. If I can't control the range of motion, I lack motor output because I just kind of get trapped in these end ranges. You know, like maybe somebody that's a little

more of the hypermobile side. But you know, this Goldilocks zone of good range of motion with good motor output is the key. Well, if I can, know, the windless mechanism is basically, you know, winding up the big toe across the plantar fascia through the Achilles tending, displacing, you know, or allowing all that to wind up. And yeah, with some drive from the soleus as the biggest driver of endurance output, we get a bunch of elastic recoil or integer return to the ground. Well, you throw a carbon plate in there, wind that plate up.

you get more, but what they found out was it was displacing force earlier into the front of the foot. And then basically, instead of force being driven up into the tibia, which is what we typically see. the lower portion, lower medial portion of the tibia or lower distal third of the tibia is the highest impact point on a human when they're running or just bounding or anything like that. That's why you'll see a force sensor put there when we're doing like gait analysis and force studies.

Dr. Beau (14:50.722)

So now we see it's displaced into the foot. you know, as the foot hits the ground and we see a lot of, you know, faster runners or more of a forefoot to midfoot or full foot runner, we see that the force is being driven through the foot instead of up the chain. And it was going into this, you know, kind of floating navicular boat like bone, you know, no bueno, even though you get more energy return and, know, probably an adaptation period where if they, you people weren't training in these all the time, which they weren't being coached to do, all these things are at play anyways.

This runner deals with this, has a surgery, gets cleared to run, gets back into running, short order, we're talking a month or two into run training, I think 20, 30 mile weeks, they start getting a literal bump on that distal portion of the medial tibia that we're talking about, like a little bony reaction. It's sore, it's not stopping him running, but now there's a little hypervigilance, we talked about this last time he was in the office, a little hypervigilance that's occurred because now,

They've had all these little injuries in the past, but now they had a big injury that kind of, you know, been a little insidious, hard to pin down. Then when it pinned it down, it was a surgical intervention, knocked them out of running. They get back in running, they're like, dude, my medial shin's hurting. So they are going back to school. I kind of, you know, just concur on that. You know, it looks like a little bit of stress reaction, the medial tibia, you're probably offloading or changing, which we know happens with any injury and surgery is just a planned injury that's, you know, made to heal eventually.

and they get back into running and it takes a little bit of rehab and kind of, you know, bouts of time on time off to kind of get over this medial shin stuff. And then they kind of, you know, they start having, you know, maybe some mid foot pain, which really worries them because that's where initial injury was. And then some lateral foot pain and kind of basically my take on it is where you're going through it was, you know, you're to have to accommodate with, you know, a foot that A doesn't move quite the same. You've probably lost a little bit of mobility just from the injury and the surgery that you had.

But also you're trying to stack much miles on again on a compensation and you know, this is part of the game of like You know, how far can we go before the scales get to too far in one way? So this person, you know competed they Had a cross-country season all these things occurred this year. Well, then I see him in the office For the first time, you know two three weeks ago and now the complaint is, know I'm having some like almost like distal anterior tib around the front side of their ankle like

Dr. Beau (17:16.942)

tightness, soreness, but the main complaint is they're having like inside of the hip and back of the hip kind of discomfort that usually is only there with easy runs and almost non-existent or non-existent at all with a harder workout, faster tempo run also dissipates fairly quick. This person had the opportunity to see early with this injury, a really good practitioner in Chicago that was well known in the gate world. They also on this go round were coming back from a training camp.

in Big Bear, California, and this person got to see Courtney Conley, who's just like, you know, the OG of foot stuff at this point in the world. And again, I haven't talked to Courtney about this specifically, but I'm assuming we're saying the same thing. But if you feel what's going on in this person's hip, I mean, they have a ton of tension and more or less adductor magnus and a giant Hawking trigger point and the deep posterior rotators of the hips. When we're looking at, you know, quadriceps,

and the gameli group. And anytime I see trigger points in that deep rotator cuff of the hip, it just is like a lockdown of security or you're having to do more work to stabilize your hip. Well, if we think about bipedal stabilization on one leg at a time, there's kind of just this, know, a gross heuristic, but it makes sense. So if I'm stepping onto my right foot,

more or less the lateral posterior portion of my hip, the lateral rotators, the muscles we're talking about, glute med, men, you know, max a little bit, along with the adductor group and then the opposite side QL are kind of what are stabilizing single leg stance. Obviously there's a lot more stuff built in there, but we think of these like these deep kind of lines or groups of muscles. So when we see things can change around the foot, we can, you know, almost map predictable.

compensatory patterns around the hip or up the chain. Well, so now we take somebody that has always more or less lacked calcaneal eversion, right? And the ability to eaver your calcaneus means that you're gonna be able to max out force displacement, in particular torque, through the first race. So if we kind of hit on the outside of the heel, which they're great at, right? They live in inversion or a supinated position. In particular now,

Dr. Beau (19:34.958)

and then cross over control pronation into that kind of Myers line orientation, displaced force view, lat calc annual eversion, you kind of come off it lacking a little bit of that end range so you can have more drive out of the calf, more drive out of the hip, whatever, everybody's got their thing. So this person came in and the one thing that they did tell me that Dr. Conley told them was that when they did a gait analysis, they kind of had this weird little, basically they were whipping back out into like heavy.

supination on this right side more so than the left. One of the weirder things to me with lower extremity injuries is inversion ankle sprains and the secondary compensation to it. What you'll see with an inversion ankle sprain, so everybody's rolled their ankle, you roll it to the outside, yeah, you can roll it to the inside. Way more common, roll it to the outside. You would think people would want to live where they're kind of walking on the inside of their foot and towards their big toe to get away from the rolling of their ankle again. It's the exact opposite.

So the architecture and the design of the human foot dictates what? That the stiff rigid position of the foot is the supinated or inverted position. Cause you're kind of stacking in particular stacking the cuneiforms and that navicular bone into a conformation that allows for a rigid foot both from bony architecture but also winding up the passive tissues around the lateral portion of the foot. When an ankle sprain occurs, you'll see people live in that position cause people come in with restriction in.

pronation or eversion through, you know, calcaneo-novicular joint, cuneiform-novicular, all these kind of different restrictions, but then soft tissue, you know, people are sore up through the pronius or the muscles going up the outside or fibularis group, whatever, I'm old school. This person, that's what they're complaining of is pain and kind of the anterior tib pronius group. They've always had this rigid foot, which is a little more rigid and eversion, you know, kind of midfoot pronation than the left.

And now they're having like lateral and inside of the hip stuff that's worse on easy runs. You'd be like, okay, well, let's break this down. And these are all just trying to create a narrative that makes sense. So we can make sure we're working towards an appropriate goal instead of just kind of being like, we're going after your stiff foot and it should work out. Like I like to write a narrative that doesn't just go too crazy into the weeds of like, you know, a plus B plus C plus D plus, you know, it's like a plus B equals C. Does that make sense? Cool. Go with it. If it doesn't change or re address.

Dr. Beau (22:00.15)

In this scenario, if I had a navicular stress fracture, a mid-foot injury, and maybe I lacked motor control, which literally we lay this person down the table over a out from injury, just testing static positions, right? What you would do with a low lying orthopedic exam, when we wind them up into a inverted position, they can't resist inversion, not with, because they have pain, just not there, they can't resist eversion. So when we see that, you'd be like, well, you know, muscle testing sucks, applied kinesiology sucks, whatever.

Just a protective mechanism of the body is to decrease motor output to basically spare tissues or pain itself will decrease motor output. So you just take it like that, you have decreased motor output. Yeah, you could change it by having them think a positive thought, think about unicorns rubbing their earlobe. I always tell people if they come back in, second visit, third visit and it's not like that anymore, that's what matters. Because we don't want just lingering decreased motor output just like if, I'm not saying we do this, if you did it.

a single leg glute bridge test and said, your glutes weak. If they couldn't do it, whatever that means to you, cool. But if they can't do it, that's still not normal, okay? That's all we're saying. As we said, there's also joint and tissue restrictions around here, but then we see the hip really bothers them. Their go-to, they're showing me, not me asking them, is a single leg pogo jump on that right side. And when they do it, they basically turn Dellenberg. So they lean to the right, jumping on the right leg. And again, if you imagine biomechanically what's going on.

The outside of the hip is in a massive concentric load and it's like the outside or the lateral rotators and posterior hip musculature are creating a sandwich of driving, you know, the femoral head into the acetabulum and then leaning on the adductors and their biggest complaint is this like inner hip burn tightness work pain in particular with squats and easy running. So back to why easy running might be bugging it.

When they get into these higher speeds, they're saying it's non-existent. What's this person? Tight, springy phenotype. What are they gonna do less of? Have to control the motion from pronation or supination or pronation. They get to bounce off mid ranges. Their ground contact time is nil. This is a fast runner. They also have much bigger arcs of motion through hip extension. So now he can use the front of his hip to drive, Or allow his leg to drive behind him and pull it back into him.

Dr. Beau (24:25.902)

So this is where, again, if we took a small tangent on decreasing impact as the end all be all, I know it's harnessing impact into the ground for upward and forward propulsion. So we kind of demonized upward propulsion in runners for a long time and then realizing the average of elite runners in upward travel is around 15 centimeters. That's a huge amount of motion. Well, then we're basically jumping from limb to limb or leg to leg when we're running. We don't want to decrease that. We don't want to flatten runners out, which was a coaching cue for a long time.

We have a very bouncy runner by nature here. And when they get to bounce, AKA run fast, he does pretty good. When he takes bounce out of it, because you slow things down, you reduce the ability to wind up this tissue or this passive tissue is quite so stiff, he has to use a little more motor output, which creates in my head, more workload around his hip because he's having to basically live or he lives, he doesn't have to. The compensatory mechanism that he's lived with is it's like, I'm just gonna live in this rigid,

supinated foot that seems like a safety mechanism that he has to learn to unlock. Now, I will put this video in the podcast video for you to watch as I'm doing it, but I'm just gonna kinda talk through it. So we had him in the PT bay here the other day, and this is our second visit since I've seen him, and we kinda knew like, hey, from an audit standpoint, what do wanna see change? Your foot's gotta move a little bit different. It's always been stiff, but I'd like to see a little more, know, navicular eversion.

mid-foot open up. So we started working on that and we're using basically the trigger points in his hip and adductor as audits. Those are compensatory mechanisms. They're secondary, they're not primary. Don't treat secondary things, use them as know, dashboard lights to dictate if we're on the right track or not. So we do a lot of work using his foot.

to kind of work his hip into submission, using some DNS stuff, lateral lunges, cueing, really cueing the foot position and the stabilizing features of his foot. And we can improve it. He goes out and runs and he's like, yeah, it's kind of the same. Comes back in and we throw him into this drill and I'm gonna put the video up. And you're gonna see two different sides. So his right side is the injured side. And I just wanna say on here, we had permission to show these to everybody.

Dr. Beau (26:44.48)

It is a night and day difference. And you can even see I zoom in on his right hip at one point. He literally does what we said. He leans on his hip, which is this extremely common compensation pattern across a lot of athletes. So if we look at MLB pitchers, you'll see a lot of a cam deformities, which could be, you know, early pitching. And again, creating a bony deformation or bony response. Maybe we call it, shouldn't call it deformation, just adaptation to the demand.

but they'll start leaning on the inside portion of their hip. Any type of rotary athlete, we see it in runners all the time, that they make this like sandwich where they'll just use passive stability. Like just imagine that we're using the head of the femur as deep into the acetabulum as we could, not necessarily maximizing surface area, which would be called like functional joint centration, not maximizing surface area of the acetabulum, but we're just kind of driving into one portion and making make.

Basically a concentric muscular contraction sandwich and what's his complaint? Pain in the back of his hip pain is adductor In their palpable trigger points there and we can change it actively and then he goes out and runs and it comes back So we put him in this drill So you'd be like why is he lean on his hip and then in my opinion, it's he lacks Basically tibio-tailor rotation which plays in the navicular eversion but not from a passive stable standpoint

This is the shutdown mechanism that he's used to kind of keep himself safe post injury. Because in my opinion, if you can unlock tibiotalor rotation, which AKA is how you kind of drive torque into the ground. If we look back at Sergey Grekovichky's, know, kind of spinal engine theory, that if I can't create that torque through that, you know, that domed joint of the tailor, you know, the tailor joint there.

If that's a good way to kind of keep yourself safe, but not maximize power output in the ground, decrease speed, displace force elsewhere that has to work. And now that's what we're seeing in my opinion. So you can see the drastic difference of left versus right. But then you'd say, okay, well, why aren't we working to the ankle? We are, we just, have to load his hip. So his ankle has to dictate what his hip does. So what we had to do was we didn't send him home with this drill. This drill kind of puts him into a stranglehold. It's like putting somebody in a half Nelson and saying, use your arms, not going to happen.

Dr. Beau (29:07.47)

What we did is we kind of did some, use some wedging to play around with basically like a supination, uh, curtsy or a curtsy lunge. Um, we really queued up his footwork, right? His foot stability kind of creating a tripod active, um, you know, toes, but really through the ball of the foot, right? So through that first ray through things like a lateral lunge split squat, front foot elevated split squats. We kind of get deep into the hip to work on, you know, those posterior hip musculature and the lateral rotators.

really like the lateral lunge, especially slide plated because his adductors just want to walk down. So now we get to essentially load his adductor while we get to work on foot mechanics. And these, as I explained to him numerous times, these are active mobility drills for basically his, his tailor joint, like his ankle in particular for rotation, which he totally got. And we even threw a little drill, which I can put a video in here of like we call them, God, if I could.

You remember ankle pendulum. Sorry. I named stuff weird and blanked ankle pendulums. We just have a sandbag on the knee. saying, keep your foot planted. Gently let your knee, if it was a flashlight, like kind of pan to the right and left, which is forcing rotation yet. You know, femurotibial joint for sure, but it really at the tibia Taylor joint. And he just can't do it. But he goes, you know, when I keep my foot planted, he doesn't get any of that pinch in his adductor, you know, groin area on that right side.

What's also mean? I don't know because I do not have a feedback visit yet off of this last one, but we also saw a change, drastic changes in the trigger point, like abolishment of the trigger point is post your hips. So that kind of deep rotator cuff of the hip adductor was better tone was decreased. But if we, two of the passive things, we put them into hip internal rotation from a 90 degree, position supine, you get a little bit of like pull there, but we could decrease all of the active pain components in things like a squat.

lateral lunge, split squat with cuing his foot, right? So when he uses his foot different, I'm not saying better, but different than what he's learned and to compensate with, he has no pain whatsoever. And he would kind of be like, which from a motor learning standpoint or concept, that's what I wanted him to adhere to. So it's kind of a negative feedback loop. So sometimes I might wanna say,

Dr. Beau (31:28.492)

Hey, what do you feel here? He's like, I feel my big toe or the ball in my foot or whatever he feels. That's his feel for whatever we deem a correct rep. But I'm gonna be honest you. I think sometimes for him right now, it's better to say, when do you not feel your adductor? Well, that was the highlight for him when he's like, ooh. And then he's like, when I do this with my foot, that's why I feel my adductor. You know, ding, ding, ding, here we go. Now.

You know, he's got big goals. He's basically high, you know, going into he's an indoor right now wants to have an indoor season, which is also the indoor track is stressing, you know, that right side into, if you think we, you know, I think there should be way more alternating directions, especially in training with track athletes in particular indoor, cause it's such a tight, small track. but now you got to think of the bank of the track, the material and indoor track is made out of. it's a little bit spring year.

And then we put the right foot, which in this scenario, it's right side up the track. What's it have to do way more of? Well, it's going to land. we remember we said we use some wedging. So when we wedge him to the outside, he's like, God, I have no pain. But what's he have to do? He still has to drive back through his first ray. And if that's what he lacks, which in my opinion, it is, it's just, think, giving him a good challenge. And he even said that without me queuing that up first visit, he goes, I think indoor has kind of, you know, made this a little bit worse or staying out a little.

It's just a different challenge, right? So again, your adaptation threshold is kind of what, not kind of what, it usually is what determines injury or not. So we'll see, but he has big goals and definitely big goals for outdoor. And then this is, you know, like I told him, the cool thing is this is kind of no different than what we've ever worked on. You just went back to your, your strong suit or your play from a compensation or safety standpoint. And it showed up for the first time ever with hip stuff. Like I said, him like,

you don't have a hip injury. You don't have a tendonopathy. You're not having, you know, sports hernia or this, know, pubic gramus, you know, or ischial or ischium kind of irritation yet. So, you know, just kind of stay the path, keep working on your foot. And then this could not only, you know, decrease pain, but have some performance outputs. We kind of drive into the ground a little bit harder and more efficiently, which we know so much now about how much more running economy is affecting outputs of even these, you know, mid distance athletes than, you know, maybe a greater

Dr. Beau (33:46.786)

maybe not greater equal component of real capacity and VO2 max. So it's kind of cool, but I know that was a lot of nerd talk about lower extremity injuries and running. but it's just a very interesting case, especially being, being a solo podcast to kind of just go over with somebody I've seen for almost the entirety of my career right now, which is going on 10 years and following them through their career. yeah, it'll be interesting and I will for sure do a follow up. I will put some videos in

or you guys will have seen some videos throughout this. But if you have questions, you can always reach out to me because I know some people are more interested in this others. My big thing is if you're a patient or runner listening to this and you have a question on this stuff, it probably behooves you to just do a consult and that's not me just trying to sell you on a consult, but trying to answer a high level question for a personal medical question or personal performance.

question being answered via email, it's just like that's very hard to do and you're not going to get the value out of it. So my suggestion would be to do a console or go see somebody, you know, like me or that's just kind of trained and can look at, you know, running and mechanics and gate and tied all into good functional approach. I hope if you're a, you know, a student, a doc in the profession that you learn something, if you're a patient or an athlete, same goes for you. And I hope everybody had a good Christmas and we'll see you in 2025.