Loss of coordination in leg - Official runner's dystonia / focal dystonia discussion thread

I'll try to keep my answers short:

1) Before this issue I was a high mileage runner (100+ mpw in summer/winter). I did a lot of long tempo work, some track workouts, and not very much strength training.

2) Unlike some people in this thread, I initially felt it even at easy pace. It got much worse as I tried to go faster. I could cheat my way through it for a while if I did intervals instead of a sustained effort, but when it got worse even that was messed up.

3) I'm a 'slouch' when I sit, and as a student, I did my fair share of sitting. I don't really buy into the pelvic rotation/skeletal alignment stuff, though. It's never really brought a productive result for me in any injury.

4) I had weak glutes when I developed the problem, though prodigious strengthening did little/nothing to remedy my symptoms. I had super-strong glutes by the end of the summer, but still couldn't run more than a few miles. Without an EMG machine it's not really possible to definitively say whether someone has "misfiring" glute muscles.

5) Early on, the first symptom I got was a numbness/tightness in my right calf/behind the knee, on the medial side. Very close to where the popliteal muscle is. This tightness gradually spread up my hamstring and that's when I started to feel like my stride was "off." My right leg would adduct abnormally during the swing phase, so much so that my calf would hit my opposite knee as it swung by. My foot would splay out at footstrike, with my entire leg externally rotating. As I moved over my planted foot, I'd pronate excessively (because of the external rotation and foot splay) and my torso would move across my right leg, and it would feel like I was using my abs and hip flexors to "pull" my leg through (even through I was supposed to be "pushing" at that point in my stride). If I continued to run for a while, the tightness/weakness/loss of coordination feeling would spread from my hamstring to my quads and eventually to my shins as well. Generally, though, it was confined to my upper medial calf and lower medial hamstring.

6) I think running on varied surfaces lessens the symptoms because it is stressing the hip in a different way. A hard, consistent surface like a treadmill or road stresses the hip the same way every single footstrike. A trail is a little bit different every time. A PT I worked with also suggested it could be because the body is forced to be "extra stable" on uneven surfaces and engage the stabilizing muscles at a higher level, counteracting whatever the inherent cause of the instability/loss of coordination is.

You've got some interesting ideas, One of You, and for a long time I thought it was a sciatic nerve issue. But there are several problems with it:

*Several people (including myself) have had lumbar spine MRIs come back completely clean, and most people don't report back pain

*The classic tests for sciatic nerve problems (straight leg lifts and the like) that doctors perform are always negative

*Many people report having weakness and coordination problems in their quads and shins, but the sciatic nerve does not innervate either of these muscle groups. In fact, I'm pretty sure that nerve that does innervate the quads doesn't even originate at the same vertebrae as the sciatic nerve. It's possible these quad/shin effects are secondary RESULTS of a sciatic nerve problem, but the aforementioned reasons are why I looked elsewhere for the root of the problem.

There is some very interesting circumstantial evidence in the scientific literature that has pointed me towards the labrum as the root of this problem. Like I said, when I have some free time (perhaps after my own surgery), I'll start working on a longer piece about all of that. I'm not 100% convinced, but the MR-A (and CT for impingement) is the ONLY objective medical test people in this thread have had that has come back positive. Nerve conduction tests, X-rays, spine MRIs, hip MRIs, etc., all come back completely normal.

Finally, I don't think it's an impact issue either, since many of the problems show up in the swing phase of the stride (abnormally high hip adduction and external rotation, foot splaying out in front of body). If it was solely an impact problem, you'd expect to see only problems during the drive phase of the stride (pushoff). While there ARE major problems in the drive phase, there are also problems in the swing phase. Again, these could be secondary results from an impact issue, but my opinion is that they are not.

frustrated runner wrote:

You've got some interesting ideas, One of You, and for a long time I thought it was a sciatic nerve issue. But there are several problems with it:

*Several people (including myself) have had lumbar spine MRIs come back completely clean, and most people don't report back pain

*The classic tests for sciatic nerve problems (straight leg lifts and the like) that doctors perform are always negative

*Many people report having weakness and coordination problems in their quads and shins, but the sciatic nerve does not innervate either of these muscle groups. In fact, I'm pretty sure that nerve that does innervate the quads doesn't even originate at the same vertebrae as the sciatic nerve. It's possible these quad/shin effects are secondary RESULTS of a sciatic nerve problem, but the aforementioned reasons are why I looked elsewhere for the root of the problem.

I want to add a few ideas to this pile. You have all done a great job at depicting a rather complicated and confusing motor control issue.

You are right that the quadriceps are not innervated by the sciatic nerve. They are fed by the femoral nerve which originates from the 2nd, 3rd, and 4th lumbar nerve roots. One common thing I notice in MOST posts on here is lack of nerve pain, but a key theme of muscular dysfunction and focus on "labral tears."

I read the symptom of "my foot splays out" or "slaps the ground" quite often. This could be a hip alignment issue with many people, but there is also an alignment issue that may be going on intraarticularly. If you were to draw an imaginary line from the center of the femoral head, through the head and into the shaft of the femur, you could use this to measure the angle of inclination of the bone itself which directly affects not only how it sits in the acetabelum, but also the amount of ROM the joint is permitted. NORMAL angles typically measure about 125-135 deg. You can have an increased angle (+135) also known as Coxa Valgus, or a decreased angle (-125) which is known as Coxa Vara. People with Coxa vara tend to experience symptoms of having a short leg and can even begin to present with a limp. You don't have to be born this way. The deformity usually happens gradually (it's usually congenital and develops after puberty).

A second alignment issue within the hip joint itself is the angle of torsion. This can be measured with a transverse line through the condyles of the femur and lining it up with an axis through the neck of the femur. This should come out to around 18-25 degrees in a healthy hip. However, if stresses on the bone have changed this angle the person can experience femoral anteversion (the neck of the femur leans forward compared to the entire bone itself). Other people develop retroversion (the neck of the femur is positioned posteriorly). People with anteversion tend to toe-in on the affected leg while retroversion tends to cause the femur to externally rotate in the socket producing a toeing-out affect. Even if these measurements are only off by a few degrees it can GREATLY impact the functionality of the pelvis as a whole, especially in regards to competitive running which is by definition a plyometric activity and requires a very complex shock system from the pelvic girdle.

One reason I wanted to point out these two bone deformities is because of the breakdown in the kinetic chain of the leg that everyone describes. There is not a smooth impact and transfer of force during the landing phase of the gait which to me is a big indicator that many people on this thread may not be able to land with both femurs correctly positioned in the socket to allow for a smooth landing.

This could also be due to a bony impingement. For example if you had an anterior impingement (either on the femoral head itself or the rim of the acetabelum) it would gradually begin to limit the amount of hip flexion allowed at the joint (usually the impingements are congenital and develop slowly). Overtime, as you continue with training, your hip flexion will become less and to compensate for the restriction of movement in the sagital plane of motion, your hip will stray to the side (a type of forced external rotation) and the amount of internal rotation will also become limited. This is how many people end up putting greater stress on muslces like the glute medius and TFL because they start to over-rely on them.

Hi All,

I just got cleared for surgery on my torn labrum. I am looking through my options for doctors, and in the meantime I was wondering if it would be possible to make a list of people who have gone through with the surgery, who was their doctor, and how like is post surgery.

Thanks

Everyone strengthen the popiliteus on the affeted leg behind the knee, and also the glute medius on the affected side. The problem will be resolved as soon as you can effectively walk forward with that leg first with the knee going out directly over the midfoot.

hdndnndndndndn wrote:

Everyone strengthen the popiliteus on the affeted leg behind the knee, and also the glute medius on the affected side. The problem will be resolved as soon as you can effectively walk forward with that leg first with the knee going out directly over the midfoot.

What exercises did you use to strengthen the popliteus muscle? Also, I don't know about others, but my gluteus medius and minimus muscles are much larger and tighter on my affected side.

Re: strengthen gluteal/popliteus muscles: been there, done that. I had the strongest glutes in the world (or felt like it at least =P ) in August, but still couldn't run. I had also strengthened my popliteus muscle, to no effect.

If you do want to try strengthening the popliteus, sit on a table with an exercise band wrapped around your forefoot and anchored to the table's leg or something similar. Use the muscle behind your calf to rotate your foot inward, in the transverse plane. Your tibia should rotate slightly too.

Every so often, people pop into this thread and say "Oh, you all just need to strengthen/stretch X and your problems are over!" but as has been painfully illustrated in the last 47 pages, that isn't the case for those of us left. IIRC one or two posters have found relief with glute strength, and one with hamstring strength/stretching, but that's it. At some point I'll go through the whole thread again and tally up who's actually recovered from this and how. I've strengthened and stretched practically every muscle in my body at some point in the last year and a half to no avail, and I think a lot of people in this thread feel the same way!

Interesting stuff on femoral -versions (ante/retro) Neliah. That's one aspect of all this I haven't looked into.

I know this isn't what you want to hear, frustrated runner, but I may have solved my version of this problem.

I ran my first three mile tempo run today without experiencing any loss of coordination whatsoever. I ran negative splits and finished in disbelief. I was waiting for the symptoms to come on and they never did. Now, it was only three miles and I have yet to experiment with anything longer, but for the past three years, my leg spazzes out between 1.5 & 2 miles like clockwork.

Two weeks ago I did a similar tempo run on the same route at the same effort and experienced the loss of control that has plagued me on any sustained effort on hard, flat surfaces for the last three years.

So, in just two weeks I went from no control to complete control. Here's my routine:

1) Stretch glutes and hip flexors. Any classic stretch will do.

2) Align hips through slow, controlled bridge lifts, pulling straight upward utilizing BOTH glute muscles in a balanced manner. Keep your hips level throughout the entire motion. 10 reps

3) Practice tightening lower abs. Lie in a sit up position with a neutral, relaxed pelvis and focus on tightening ONLY the lower abs. It is a very subtle control and it takes practice. Work on firing them quickly as well as sustaining the contraction. 10 reps

4) Find a wall. Lie down on your side with you butt facing the wall, approximately 6-12" away from it. Make sure your hips are aligned in a neutral position with your torso and lower body. Extend your top (target) leg back 10-20 degrees so that your heel almost touches the wall. Raise and lower your lege in a slow, controlled lift to work the gluteus medius. Make sure that your hips stay neutral and don't open up. DO NOT use your lower back to perform this motion. Use only your gluteus medius. Also, practice contracting your lower abs during this motion. 10 reps on each side.

5) I do the final balancing exercise in this routine:

http://www.youtube.com/watch?v=aVS0JWAkV1U

I do 10 reps on each side. I also practice tightening my lower abs during the motion.

Now, to try to explain what all this accomplishes. I'm not as well read as some in physiology, but for me, these exercises have helped my stabilize my pelvis by making a connection between my lower abs and my gluteus medius. I can't explain it, but after just a day of doing these exercises, I noticed that i was more aware of my glutes and abs during my stride. I could physically feel my glutes firing and I was conscious of my lower abs contracting and relaxing through the stride motion.

During my tempo today, I ran across the flat stretches, hills, and downhills. None of which brought on the symptoms. I was driving off my forefoot and my knees came right over the top of my big toes.

I hope this routine will be useful for some of you. I'll report back with any developments in my own progress.

Best of luck to you all.

I coached a boy a few years ago that was a very good little runner his 6th grade year and then became very slow and clumsy by the fall of his 7th grade year. After a day or 2 of practice I called his mother as I was very worried about both his running and his mental state. As you all know he was frustrated about his decreased athletic ability.

I met him and his mother at the track to run a few laps to talk to him and observe his running. His feet were slapping very badly and one foot kept tripping him. He actually fell twice. It only took 1 lap for his mom and I to know that something was far more wrong than we had thought.

A few weeks later an MRI confirmed that there was a small lesion pressing on the inside of his spine in the area between his shoulder blades. Sorry not very technical as I don't have any MD knowledge. It was surgically removed and by his 8th grade year he was a good little runner again.

It was very lucky that the damage was reversable.

Actually that's fantastic news! I hope you continue to have success running problem-free. Had you done other ab/glute strength in the past? If you continue to be healthy, we'll chalk one up in the "cured by glute/ab strength and stretching" category.

I'm a 22 year old competitive long distance runner who has had coordination problems when running at high speeds for extended periods of time (e.g. tempos. 3k+ track races) on hard, monotonous surfaces such as pavement or tracks. I have no pain, only inaudible clicking/catching on the outside of my right hip which can be felt when I press my hand to it while walking or running.

I have had this problem for the last 1.5 years and have tried hip, glute, hamstring, and core strengthening to no avail.

I recently had an MRI arthrogram which revealed a nondisplaced tear of the anterior labrum and a mild gluteus minimus myotendinous juntion strain with minimal gluteus minimus insertional tendinopathy. I have not talked with the doctor yet, only seen the results, so I have not made any plans going forward.

As others have noted, the labral tear seems to be the only firm diagnosis many of us posters share. EMGs etc have all come back negative. My question is, how common are labral tears in runners? If we took a survey of the general competitive running community, would the prevalence of tears among our "poor coordination" community be higher than the prevalence among the general running community? Could it be a coincidence that we all have torn labrums? Correlation does not mean causation.

If it is not a coincidence, labral tears seem to be the root of our problem.

I think my next step is likely a cortisone shot to see if it temporarily improves my coordination problems. I am not sure if I want to have surgery considering I have no pain and the injury only affects me in very specific running instances.

bump

Get the cortisone + local anesthetic injection and see if that makes a difference. It might be hard to tell when you are only having coordination problems though. I did not decide to go ahead with surgery (scheduled in 3 weeks) until I started to have true hip pain during daily activities (which was probably brought on by intentionally running aggressively on my bad leg). Keep in mind I had the loss of coordination at all speeds, even easy running, unlike many people in this thread.

As for the prevalence of labral tears: I have yet to see a study of healthy runners. Studies of cadavers (which are 70-90 years old) have found that the majority of regular folks have labral tears at old age. MR-A studies of hockey players have found something like 40% of healthy players have labral tears too. But keep in mind that hockey aggressively stresses the hips in ways that running usually doesn't. So it's hard to tell. My doctor told me that labral tears are not uncommon even among healthy runners. But that being said, good luck finding any other test that comes back positive! A lot of other people in this thread have had MRIs, EMGs/nerve conduction studies on their lower body with nothing returning a positive result. The only other possible option that would actually show up on a diagnostic test is a vascular issue.

In my mind, there are 4 possible causes: a nerve issue, labral tear, a vascular issue, or a muscular weakness/imbalance/firing issue.

True nerve problems (like sciatica or a pinched nerve) should show up on nerve conduction tests and EMGs, and the problem (bulged disc, cyst, whatever) should show up on an MRI.

A labral tear will show up on an MR-A, but as mentioned above may be present in healthy runners. Interestingly, I think herniated discs are also fairly common even in healthy people with no back pain.

A vascular issue ("crimped" artery for example) should show up on an ankle/brachial ratio test post-exercise, contrast MRI, or an angiogram.

A muscle imbalance, weakness, or firing issue won't show up on any tests or imaging. Perhaps an extremely advanced biomechanics lab could do some sort of treadmill EMG study to test muscle firing patterns and compare them against a healthy control, but this is very much theoretical.

To my knowledge, after many tests, 3 or 4 posters including myself have found labral tears; one found a herniated disc, and none found any nerve issues. I think one poster had a contrast MRI to examine arteries and came up clean but IIRC nobody else has has been checked for a vascular issue. I've posted earlier on why I don't think vascular issues make sense anyways.

I know my previous post was a bit lengthy, but I want to stress again to the people who are having "coordination" problems without a clear pain pathway that there is a very good chance it's not just as simple as a "labral" tear.

The labral tear may or may not be symptomatic. It is true that many "healthy" people develop tears and are not affected by them.

What there is not a lot of research on or discussion about is the positioning of the femoral head within the joint. The way that your leg lines up and strikes the ground is dictated by the arthrokinematics in the joint.

There are 2 different types of movements occurring at a joint. Osteokinematics (flexion/extension, abduction/adduction, internal/external rotation, etc.). These are movements you can voluntarily control and see happening outside of the joint. The second type is Arthrokinematic movement. This is the gliding, spinning, and rolling that occurs within a joint as the two bones articulate with one another. In the hip joint ALL of these motions need to occur in order for you to have biomechanically sound osteokinematic movement. If something compromises this (such as a bony impingement) it's going to change your osteokinematic movement. There also a very large chance it's going to affect the way your femoral head is situated within the acetabulum.

Even if a doctor finds a position problem during surgery for a labral repair it's not commonly discussed with the patient because it's a complex topic and not easily understood. You would only know the issue was addressed if you asked for a copy of your surgical notes and thoroughly read through them. It's also not something that is easily detected on x-ray/MRI because it's difficult to measure unless you have a clear look at the joint in a 3D manner (such as during open surgery). Even a degree or two could make all the mechanical difference in the world for some people. It's also a problem that can reek havoc on your running form but won't be acutely painful. It's changing your movement but it's not an acute injury in itself.

From everything I've read, it's impossible to actually change how the femur sits in the hip socket, short of fracturing it and repositioning it. You say that a "bump" (FAI) on your femur can change it, but then we're right back at labral tears caused by hip FAI. Where are you getting this info on femur positioning?

afsdsdafsadf wrote:

From everything I've read, it's impossible to actually change how the femur sits in the hip socket, short of fracturing it and repositioning it. You say that a "bump" (FAI) on your femur can change it, but then we're right back at labral tears caused by hip FAI. Where are you getting this info on femur positioning?

Either medical search engines with published articles or directly from my text books. Also I've discussed the same thing with 2 different surgeons (both very devoted to research).

I am simplifying the explanation a bit so your question is warranted. Some individuals are born with an acute form or anteversion or retroversion and it's fairly apparent from the outside due to other abnormalities that occur below the hip joints (i.e. tibial torsion, genu valgum or "knock knees", etc). When I'm referring to the runners on this forum, I'm not referring to this rather acute form of positioning.

There is a less black and white issue which is still congenital, but there is a significant link between patients with FAI and the positioning of their femur within the joint. It tends to change very gradually overtime. Hence why many people have a good number of years of healthy running, hit a stage where they have on/off problems (i.e. piriformis syndrome, ITBS, PFPS, etc.), and eventually they begin to loose stability and coordination in the joint altogether. Again, usually this onset is slow.

The more complicated issue I skipped over is there's a chicken/egg argument. For example, there is a significant correlation between femoral anteversion and also a condition where the femoral neck literally becomes impinged against the acetabulum -- this is known as "protrusio acetabuli".

It's symptoms are not very clear. Usually it begins with a loss of ROM within the hip joint (affecting coordination). It's mostly diagnosed with x-ray or possibly a CT scan although many times it's not clearly diagnosed until arthroscopy is performed. Protrusio acetabuli is a form of impingement in itself -- don't just think of impingement as a "bump". It's a term used to indicate that there is not a proper end-feel within the joint and it limits or even blocks one of the 3 degrees of freedom (sagittal, transverse, and frontal). In summary, impingement is an abnormality that can occur on the femoral head OR the acetabulum.

So, the main argument is whether or not the impingement came first or the positioning problem. With patients who develop FAI on a very gradual level, some medical professionals have discussed the issue of abnormal bone remodeling. For example, if you have a femoral head with impingement (CAM), the abnormal shape of that bone may cause small changes in the remodeling of the Ilium as well as damage to the labrum.

I don't want to get into annoying amounts of detail, but I can appreciate your question, it's a good one. The best answer I can give you is there have been very significant correlations found between FAI and femoral positioning problems. This isn't in ALL cases -- but a fair amount. I know from going through my surgical notes that my right leg (which had the worst coordination problems) had a higher degree of anteversion than the left leg. This caused my femur to actually rotate too far internally.

If I can find some of the articles I used for a paper 2 years ago I will try to post links on the forum for anyone who is interested. I just have to find the flash drive to check references I used.

1. How would you characterize your training level? Mileage? Workouts? Long Runs? Strength Work? Be specific in your description.

Pre "injury" I ran 100-115 mile weeks. Long run(or race) one interval session. Some weightlifting.

After I developed the "injury"= 100-140 mile weeks. Everything slower though. Still do intervals and an occasional long run.

2. How would you describe the effort level that brings on the symptoms of this condition? Does it come on with acceleration? Sustained effort?

Sustained effort definitely brings the loss of coordination on. I can do 20x400 at 65 seconds with no problem. But if I do a 3 mile tempo run it will get me at like 1.5 miles.

3. How would you describe your posture? Do you slouch? Do you spend significant time sitting in a chair (Letsrun viewing aside :) ) Has this condition affected any sort of physiological alignment that your are aware of?

I sit a lot as I'm in college. I probably slouch way too much. A chiropractor told me I have a minor bulged disc.

4. Do you have "inactive glutes"? Many elite distance runners, including Meb, have found that their glutes don't fire properly during the gait cycle. Do you have any experience with this condition?

I don't think so.

5. Lastly, please describe the onset of symptoms as you experience them, especially how your footstrike changes.

When "it" happens, my hamstring area seems to get tighter and tighter, and then my knee doesnt want to bend correctly, so I cant properly get a full stride and it makes me feel completely awkward.

Finally, if applicable, why do YOU think running on hills, soft surfaces, and in spikes lessens/eliminates the symptoms of this condition? Does running downhill worsen symptoms?

I think running uphill makes it worse for me. Spikes or non spikes its the same.

So is there any way to fix problems of femoral version? Or are we all screwed? I'd be interested in seeing those articles if you can find them.

The only issue I have with your explanation here is that, presumably, runners with this issue would have poor hip ROM. I don't know about other people in this thread, but my hip ROM wasn't really inhibited much or at all, especially early on.

I will look for you. I have a week of vacation starting Friday and am going home to visit family so I'll check through the work I have there.

To be a bit more clear, I am not trying to say that the positioning of the femoral head is the only thing creating ROM issues, but I think it's extremely under appreciated. My goal was to help make more sense of biomechanics for runners who are complaining of concerns such as coordination, loss of stability during the impact phase, problems with hills, and also faster paces.

I am a firm believer in always taking the conservative approach and attempting to fix any simple/obvious weaknesses (i.e. weak hip abductors, pelvic alignment, core, etc). But there comes a point when for some individuals, that's not going to fix the issue and they inevitably get worse. Essentially, I'm trying to bring about a few ideas that haven't been mentioned so if anyone on here has been struggling for a diagnosis or feels they need a 2nd opinion on imaging they have had they can use these ideas for reference.

I don't think you are "screwed." The key is to find the main reason the mechanics of the joint are being compromised and where the decrease in stability is coming from. There is a lot of discussion on here about external factors -- which is GOOD. Many times that is the case. But rarely does someone discuss intra-articular problems. I'll check back on here in a week or so and hopefully my parents haven't moved around too much of my papers.