Discover the Missing Key to BETTER Hip Motion And Core Strength. Hip stretching, glute exercises, and core strengthening are all important for healthy hips. Yet, these typically only keep the problem at bay instead of really fixing the problem. If you stop your routine, will all your tightens come back? So what's missing? In this article I tell a story about the importance of looking at your feet, particularly your big toe, and how that has a significantly greater impact than your foam roller or glute bridges.

Discover The Missing Key to BETTER Hip Motion

Dr. Ellen McNally
If I Only Knew Then What I Know Now!
I was walking through the airport recently and couldn't help but notice all the sneakers and shoes binding everyone's toes together, and their turned out feet. I deal with this every day in practice when trying to help someone have better hip mobility and core strength.
 
Understanding what this means for preventing back pain and injuries, even the need for joint replacements, is a new perspective. It's mind blowing to me that we didn't realize this sooner, especially with the impact it has over all the traditional hip focused rehab people are doing. 
Feeling Strong + Tearing My Labrum
I started exercising more seriously and running when I was in college. I did my first half ironman triathlon (and several sprint and Olympic triathlons before prior) while in my last year of chiropractic school. Shortly after my second half ironman, while I was feeling my strongest, I tore the labrum in my right hip while running. I had no indications that anything was wrong, it was a total shock.
It was a beautiful sunny and not too hot day, perfect for running. I had done a full body lifting routine in the gym that morning and I felt so good that I decided to go for an easy run. At this point I was practicing Chiropractic and already had a lot of training in functional movement, I told myself I'll enjoy the run and as soon as I feel fatigued I'll walk the rest of the way. That's what I would have told my patients. 
 
After 6 miles I was feeling strong but thought it was best to walk the mile back home for a proper cool down. It was my right leg that initiated the transition to walking, when my heel hit the ground I felt a sudden severe sharp pan in the front of my right hip that made me double over. Then my hip flexors went into spasm. In one instance I went from feeling stronger than I ever had to having to seriously limp back home, in a lot of pain.
 
How could that happen?
 
Hind sight is always 20/20 and it's clear to me now how the layers of dysfunction built up over the years and changed everything for me that moment. 
My Sneakers + My Chiropractor
When I started running Asics were my go to sneakers. I knew my heel was more narrow than my forefoot, and that I need some support in my arch. They just felt right on my foot.
 
I actually dealt with chronic SI and IT Band pain basically from the time I started running, prior to chiropractic school. I would need to be adjusted almost weekly by my chiropractor at the time in order to keep running. This was acceptable to him and I definitely didn't know better then, but it was annoying to have to constantly be going to get adjusted to be able to run without pain. 
 
My brother had also started running and we signed up for a local 5K for some family comradery (ah hem, competition) but the day before the race I developed sharp pain on the big toe joint of my right foot. Bending there even while walking was painful, so I had to pull out of the race. You're welcome Kevin!
 
It resolved with rest after a few days and never happened again. I think it stuck in my memory because I never had other foot pain and it was so brief. Even then I was puzzled why it happened. Now I know it was just another layer of dysfunction forming before my hip injury.
 
Fast forward to chiropractic school where I continued running and signed up for my first sprint triathlon. I was able to continue getting chiropractic adjustments on campus for my chronic SI and IT Band pain because the 10th trimester students work in the student clinic (the chiropractic version of residency). One fateful day I was assigned a student doctor who had taken some outside training in myofascial treatment called ART (Active Release Technique). This was a major moment of course correction for my career, and recovery.
 
I quickly gave him the low down of my issue and what was typically done, he chose to include myofascial release of my Psoas muscles which made a HUGE difference in decreasing the amount of adjusting I needed in order to run without pain. Why wasn't every chiropractor doing this?
Glute Amnesia
Needless to say I saved all my absences and money, shared travel and hotel costs with several others students, and started getting certified in Active Release Technique before I graduated from chiropractic school.
I even contributed on the ART treatment team at Ironman Lake Placid before I graduated, a great way to gain experience as a soon to be Doctor of Chiropractic. This is where I began developing the skill of understanding the body functioning through a kinetic chain. I was focused on hip flexors and triathlons as I made my way through chiropractic school. Now I was working in the school clinic myself, in Long Island, NY.
At night and on the weekends I worked as a personal trainer in a Boston Sports Club. That's were I was introduced to the concepts of Gray Cook and Functional Movement Systems. I continued my 'outside the box' education with their certifications, just when the term glute amnesia was getting popular. I was definitely riding that wave!
 

At the time, it was so clear why patients needed orthotics. Like every good chiropractic school we were introduced to a 'chiropractic specific' brand that we should offer our patients once we graduated (feel my sarcasm) because they were the best.

I felt so confident in a message that now feels outdated to me. The arch of the foot collapses, the ankle over pronates, the knee collapses to the inside, your hips drops down AND because you sit so much you have glute amnesia and overuse your hip flexors.

Luckily with all good science, we've learned a lot more since then. It was a good start to what we understand now, unfortunately the detail corrections don't seem to have caught on the same way.

Fast forward to 2009, post labrum tear. It took me two months to walk normally again, I guess a full week of riding in a mini van non stop across the country as a support crew for a team on RAAM didn't help my hip recovery. Another 2 years to get out of almost daily pain sitting and walking, forget about trying to run.
 
I worked with many professionals trying to rehab my hip because surgery was not an option for me at the time. I would have had to be out of work for months, and that was not realistic. Finally a friend and amazing Rolfer worked deep through my iliacus (the ilio part of the Iliopsoas and so often ignored) and my quadriceps. Finally I was able to get better hip strength through my functional rehab exercises. Working through assisting my activation pattern (the neurology to how you perform exercises) and building to unassisted then resisted. Now I could do everything I wanted, as long as I didn't run.
 
Basically I could do whatever I wanted with only minimal glimpses of pain when I knew I tested it too much. Accepting that I wouldn't run again got easier over time, plus you know how painful it is to start again.
Orthotics
In the midst of my labrum recovery I met a professional shoe fitter we'll call, The Shoe Man. AT this point I had never measured patients feet to make sure they were actually wearing the right size shoes. Frankly I hadn't even thought about what a Brannock device was. I just squished peoples dysfunctional feet into a mold and had their orthotics casted for them which only braced them in their dysfunction. Of course it decreased strain, but we know now it also only perpetuates the layering of dysfunction. More on this in another post, but understand that at this point in time I was hard sold on the fact that orthotics were necessary for anyone with reoccurring lower extremity or lower back pain. 
 
The shoe man grew up working in the shoe industry and his entire career was fitting shoes through the 1960s, 70s, and 80s when there were lots of changes. He has a unique perspective on the shoe industry because he witnessed the transitions in manufacturing and how shoes were sold. He often laments how quickly it become common for someone to need a podiatrist and orthotics after the 1980s.
 

In 2014 I had a part time private practice in Providence, RI and maintained a part time contract with Acushnet Company to treat employees onsite, you may know them better as the owners of Titleist and FootJoy golf brands. Within a week of each other a patient from each location, who had no connection, go to see The Shoe Man without telling me until afterwards.

At their next visit I remember commenting first about the significant shift in their hip tightness, I was surprised at the sudden change. That's when they told me about the The Shoe Man. He changed their shoe fit, took out their orthotics and the effect on their hip tightness was shocking. He created results that I wasn't able to, with all my advanced training and understanding of movement. I had to know more and this started a more than 5 year journey that is worthy of a separate post.

So let's just say through unexpected circumstances I realized that orthotics were not doing all we thought. Once I started actually measuring patients feet I realized that roughly 70% of the people coming to my office were wearing the wrong size shoes. This change in perspective helped a tremendous amount of people I was already working with and future patients. So many of the people that were coming into my office (and therefore any chiropractic or rehab office) had been wearing shoes that were too short in length and too wide for their mid foot and heel.
 
Most people did not have foot pain and not one person thought their shoe were uncomfortable. Even men wearing 2 sizes too short. But within 2 months of changing their shoe fit they couldn't get their feet into the old shoes any more or they felt just how crammed they made their feet. 
 
Most of these patients needed a narrow shoe for the right volume around their mid foot and heel, not a standard medium width or even wide width. The industry has long been self serving so it's only natural that they shorten the shoe to prevent your heal from slipping out because medium and wide were the only available options at most stores. And people started buying shoes for fashion only, not fit. I'm not exaggerating when I say this is modern day foot binding. It's the basis of developing plantar fasciitis, Achille's tendonitis, IT Band syndrome, knee pain, piriformis syndrome, SI pain, excessive hip flexor tightness and more.
I too went from a 7.5 medium to an 8 narrow Asics. This still wasn't right but it was better than what I was doing so I was sold. I rode the wave for years, helping people in a way I wasn't able to before, by partially unbinding their feet. At least now their arches had the available length and there was the right fit along the sides of the mid foot and heel. 
 
This too had it's limitations and I'm always looking for a better resolution. I wasn't making orthotics anymore and the more I learned about shoe making, shoe fit, and foot function I realized stretching and strengthening was the next important piece of the puzzle. to be strengthening the foot directly. But the standard rehab exercises didn't really work, people were told plantar fasciitis can take 6 weeks to resolve if it goes away at all. Now I can get people walking without pain in a few minutes. So there was a whole lot I didn't know yet.
Joint Training + Wide Toe Boxes
I'm always in search of better solutions. It's the strength of my ADHD that I need to understand something I'm interested in to the utmost detail, and I can't accept when things just don't work for some people when there is no explanation why. I love to learn and patients who have worked with me over many years know that first hand it's a terrible business model really. While I think getting adjusted periodically is healthy, I don't think it's good that someone needs to be adjusted weekly or monthly in order to stay out of pain. Sure there is some circumstances that is necessary, but for the majority of people they haven't been given all the resources. Supporting someone to true joint health and longevity means giving them resources and so they don't need to be adjusted. There will be another post that covers this topic soon!
 
We shouldn't need external support to simply keep our bodies functioning on a base level. Back pain, plantar fasciitis, knee and hip replacements are an ever growing issue and high cost despite the advancement in orthotics and surgeries. I believe your body is capable of amazing things, as long as your training supports continued progressive improvement. 
 
Did I mention that hind sight is 20/20?
 

Looking back, the timing of my introduction to Functional Range Conditioning was on target while becoming fully aware of research by those like Irene Davis, MD who coined the term The foot core system: A new paradigm for understanding intrinsic foot muscle function.

 
 
Foot Structure + Function Complexity
 

26 bones | 33 articulations | 23 muscle act on the foot, 11 intrinsic and 12 extrinsic | 4 layers of arch muscle, comprised of 10 muscles | 6 degrees of freedom

The truth is you shouldn't need orthotics or that your sit too much (well that does have issues but not so much the glute amnesia story). For most people, not those with actual structural deformities they are born with or significant arthritis that's developed, orthotics only serve a purpose of removing strain because the foot is weak. Strengthening the foot is the only way to re-establishing the dynamic function, heal injury and prevent injury. Except for the short foot exercise recommended by Czech physiologist and postural expert Vladimir Janda, MD, I knew we needed better exercises for the foot and ankle. 
 
Weakness of several specific muscles in the foot, ankle, and lower leg are the cause of the majority of overuse soft tissue injuries and joint arthritis in the lower extremity and lower back. This is only exaggerated and worsened with increasing amounts of joint hypermobility or ligament laxity, more on that in a future post. 
 
The two important muscles of the big toe, one that pulls it away from the other toes (adductor hallucis) and one that presses the big toe into the ground (flexor hallucis brevis) and the most overlooked.
 
These specific weaknesses with weakness of the fibularis longus (commonly injured in typical ankle sprains, it runs along the outside of the lower leg but actually attaches under the big toe at the arch) results in the kinetic chain breakdown. You simply can not have proper dynamic function in the arch of the foot when these muscles are weak.
 
I've realized the tapered toe box shape to the vast majority of shoes today is a big cause or exaggerator of this problem! Here are a couple interesting articles on the history of shoe design. 
 
You've seen this pattern breakdown and just didn't realize it. It's most obvious in females due to a higher likelihood of joint hypermobility. It's also more obvious when someone is running because of the exaggeration from increased load bearing. 
 
The pattern breakdown | basically a lack of dynamic stabilization through the foot causes the foot turn outward and the ankle to roll in too much. Then the lower leg turns outward (think of your shin relative to your knee) to counter balance. Now the thigh pulls to the mid midline and makes it very difficult to properly engage the gluteal muscle to stabilize the pelvis and extend the hip. So the hip flexors are left to pick up all the load. They get tight and they get weak. 
 
No one wants to be doing another's job. You're always stretching your hip flexors and training those glutes, but how much progress have your really made?  
Assess Your Foot
Two years ago I began my training with Functional Range Conditioning® and Kinstretch®, it answered so many questions about what I had previously learned. It validated so many things I understood working with various people and completely supported my next evolution in helping people develop healthy joints and become less reliant on the medical system.
 

It's system focused on training the joint capsule first, re-establishing and training lost joint motion (without pain) and strengthening the system from the inside out. Used as a cross training system with your regular training, you work to gain as full motion to all the joints as they are designed and develop neurological control of that motion.

It's been a game changer for my patients, especially those with ligament laxity and joint hypermobility because the traditional exercise and rehab models do not work for them with out significant assistances for proper pattern activation. In this training model the full available motion is almost an asset and the tissue is isometrically trained at end ranges, using the weaknesses as an advantage to strengthening. 

So if you have tight hip flexors and any of the other related issues, take a look at your feet. 

1. Assess your imprint on the inserts of your sneakers | Is the pad of the big toe pushed or squeezed to the toward the small toes relative to the ball of the foot? are the toe pad impressions cut off at all? Are they squished on top of each other?
What you want to see is similar to my imprint in these Lems sneakers. There is a pretty even color to the imprint throughout, there is clear definition of all the toe pads and the pad of my big toe is in good alignment with the ball of the foot. 
2. Measure your HV Angle | Put your foot on top of a white piece of paper and take a picture over head. Use the photo edit to put a line through the middle of the big toe metatarsal bone (it should run through the mid point of the ball of the foot (1st MTP joint), blue line. Now put a second line through the middle of the big toe so it connects to the other line at the middle of the ball of the foot. Use the ruler feature to see the angle of each line and determine the difference between the two. That is your HV Angle. A normal HVA is <15┬░. Greater than that and you have significant weakness in the muscles I mentioned above.
The toe box of your shoes is likely tapered relative to proper alignment of your big toe. So your shoes are actually forcing this and preventing you, over your lifetime, from being able to engage those muscles of the big toe.
 
That is also the basis of why bunions forms, more on that in a future post.
3. Stand on your inserts | Take your inserts out of your sneakers and place them on the floor. Stand on top of them, ideally you would do this with ZenToes toe spacers on first so your foot is held in alignment as if all the muscles were strong.
 
Do your toes extend over the sides?
If any of these are true for you then you need to transition to wide toe box sneakers and shoes so that your forefoot has the appropriate space for it's actual shape. If you don't then the foot exercises will help, but it's like drinking from a firehose to really get control because your shoes are forcing the weakness.
 
I recommend these as good transitional shoes. They have a good balance of support and cushioning while you begin to develop better strength in your feet so you can tolerate more barefoot styles shoes with wide toe boxes.
 
Narrow width | Altra Running Rivera
Medium width | Altra Running Provision and Paradigm
 
I'm Running Again
I came to appreciate that so much begins with proper function of the big toe and associated coupled movements through the ankle and knee, but I was in for a real surprise!
 
I needed a better resource for my patients so I developed the
Foot | Ankle | Knee Playbook. It's a 6-week video guided daily progressive training for improving specific joint function in the foot, especially the big toe, ankle, and rotation of the lower leg at the knee.

I knew this was something that everyone could benefit from, I knew it was a solution my patients had been been asking for, a step by step guided recipe. What I didn't appreciate was that by developing the program I was going to be able to run again. Half way through the program development, on a random day walking my dog I needed to run with her a short distance. Until this point I would have definitely felt a twinge at least in the front of my right hip. I felt nothing then and haven't felt anything since. 
 

While I'm not planning on doing any triathlons any time soon, the fact that I can now run with my kids and dog in the neighborhood without any hip pain during or after, from focused training of my big toe, foot, ankle, and knee shocked me. I had long accepted that I was not going to be able to run again because of my hip labral tear, based on all the previous knowledge I had.

This is extremely exciting, I realize that we beginning to redefine what we expect from rehab and injury prevention with these new systems. What movement would you like to gain better control over?

Strengthen Your Foot
Here are a few resources for you to begin developing better strength in your big toe and arches. 
 
Beginner Arch Strengthening:
Toe + Arch Strengthening with band and tennis ball assists:
If you want more advanced help correcting your foot, ankle, and knee function then check out the Foot | Ankle | Knee Playbook!
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Author: Dr. Ellen McNally
Dr. Ellen McNally is a chiropractor, functional movement specialist and preventative health strategist. She practices in Providence, RI as well as helping others virtually. She is the creator of Wellnes|Savvy, online and app based programming for optimized joint health and longevity outcomes. 
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