Glutes or feet – what really causes your running injuries and muscle pains

Glutes or feet – what really causes your running injuries and muscle pains

When I speak to runners who have recently been treated for injury one of the most common pieces of the information they share with me is that ‘the physio told me I had weak glutes’*. This often goes with a comment that ‘I have tight hips’ and a prescription to do an exercise like this one (demonstrated by CrossFit physiotherapy guru Kelly Starrett about 2:40 minutes in).

* ‘Weak glutes’ is vague misnomer because those muscles are often not weak at all – they merely contract at the wrong time or stay inactive due to poor movement patterns. More on this below.

Can we have more feet please?

There’s nothing wrong with this approach per se but our job as a coaches would be much easier if there was more focus on the feet and less on the glutes because it is the feet that are the true root cause and not the glutes. How do we know this? Well, before delving into the history behind it – let us see if we can figure it out through common-sense without peer-reviewed studies. Imagine this example:

A runner comes to see me and I decide that his problems are ‘weak glutes’ and ‘tight hips’. I spend six weeks with him making his

If your coach looks like this you may wake up without big toes
If your coach looks like this you may wake up without big toes

glutes strong as iron and giving him the mobility of Jean Claude Van Damme. Then I have the athlete stay over. While he is asleep I chop off his big toes. The next day I ask him to go out and run. Do you think his ‘strong glutes’ and ‘amazing hip range of motion’ is going to matter one jolt? No – you guessed it – our runner is pretty much finished as a runner.

While this example may seem absurd it is not – because although most of us are not so unlucky as to completely lose our big toe to some psychopath movement coach trying to make a point – most of us do in fact lose most of the big toe for the purposes of our general movement. This discovery was made by the eminent medical doctor and podiatrist – Dr Dudley Joy Morton – and later linked to a whole host of sports injuries by another famous GP – Dr Janet Travell, the personal physician to John F Kennedy, but let’s start with Dr Dudley. The following section is basically a summary from Why You Really Hurt: It All Starts In The Foot by Dr Burton Schuler who brought the combined insights of Dr Morton and Dr Travell back to a modern audience (Morton’s and Travell’s original works now sell at very high prices).

Dr Dudley Morton

One of Morton's most influential books. While his teachings where fresh , his conclusions were widely remembered. Today they are widely forgotten
One of Morton’s most influential books. While his teachings where fresh , his conclusions were widely remembered. Today they are widely forgotten

Many runners will know Dr Morton from the conditions he discovered: ‘Morton’s foot’ and ‘Morton’s toe’ (but not ‘Morton’s neuroma’ – that was another doctor called Thomas Morton – these Morton’s sure love their feet!).

The great insight of Dr Morton (which most running coaches today will only learn about on the VivoBarefoot coaching course where it is part of the standard curriculum for certification) was that the majority of activity-related pains and injuries can be traced back to a malfunction of the foot.

Dr Morton identified two basic issues with the foot fundamental to most of the problems he observed in his practice:

  • A 1st metatarsal shorter than the 2nd metatarsal
  • A hypermobile first metatarsal joint

For those who are not podiatrists: the metatarsals are like the ‘fingers of the foot’ – the part of each foot bone that runs roughly from the middle of your arch to the toe joint. The 1st metatarsal is the big toe joint.

 

Hereditary or fixable

In a few unlucky people the 1st metatarsal joint is shorter than the 2nd for hereditary reasons but for the majority that is not the case as current research has suggested less than 10% of the population carries this trait (yet we see it in 9 out of 10 clients, if not more). That it is not widespread makes sense from an evolutionary perspective – with the wide-ranging negative implications of Morton’s foot it is simply inconceivable that we should have thrived as a species for hundreds of thousands of years without access to toe inserts and therapists.

Rather the 1st metatarsal joint is compressed side-ways and backwards by wearing shoes that are too tight fitting (narrow toe-boxes being the prime culprit). This process begins around the age of 4 at a stage where our feet are extremely malleable when we get our first pair of narrow shoes.* It is likely that even for those who have a slightly shortened 1st metatarsal this would never have become a problem in societies where feet where not further altered by restrictive footwear (i.e. adding insult to injury).

Morton's foot
An illustration showing Morton’s foot – note how the first metatarsal (B) has moved behind the 2nd metatarsal (A). The image also shows common calluses that give away this issue

* Thankfully this can be avoided, my niece and nephew have perfect feet and to keep them that way I purchase them a pair of wide-fitting and flat shoes. This will keep them off the therapists table if they otherwise do nothing stupid as they take up sport later in life!

In our coaching experience we have seen many runners able to fully reverse Morton’s toe within 2-3 years showing that it is very likely you do not have to be stuck with ‘a bad foot’.

The Big Toe and pronation

If you remember back to my example of the psychopath coach who chopped his athlete’s big toes off. When you think about this you can instinctively imagine how difficult it is to walk, nevermind run, without a big toe. So putting two and two together it’s easy to see that is problematic if the big toe is displaced backwards and sideways. But just how big a deal is it?

To understand this we need to look at the three basic actions of the foot when it hits the ground during walking or running:

  • The foot lands on the ground as a ‘bag of bones’ (to borrow a term from Dr Schuler) and begins to pronate (rolling inwards) to mould itself and adapt to the surface it landed on
  • The moment the foot has ‘moulded itself’ to the ground the inward roll (pronation) must stop so the foot becomes rigid enough to provide a stable platform for take-off
  • It is the big toe that provides the anchor and serves as the block to stop the pronation moment

When the big toe is not in the right place at the right time and with the right strength to do this job then the pronation becomes abnormal (what is called over-pronation in running shops). The permanent fix is therefore not an anti-pronation shoe (besides, research suggest this doesn’t work anyway as many recent studies have shown – Gretchen Reynolds provides an overview of some here) – but a properly functioning big toe. The solution is in ‘your equipment’ not ‘bought equipment’.*

While some parts of Morton's toe may be hereditary a shoe that displaces the big toe like this will cause excess pronation even in a healthy foot
While some parts of Morton’s toe may be hereditary a shoe that displaces the big toe like this will cause excess pronation even in a healthy foot

The compensations that arise from ‘the big toe slacking on the job’ are manifold: first of all it means the foot is unstable at exactly the moment it’s meant to be stable. Let’s turn out attention to the ‘control room’ – our brain – for a moment. This ‘control room’ is monitoring everything you do – so imagine if it sees that at the moment where you require stability (or you’ll topple over and hurt yourself) there is instability. What does a good control room do? Well it activates as many emergency systems as possible to try and create stability. An example could be the posterior tibialis muscle – the key stabilising muscle of the lower leg –  or a large number of other muscles involved in creating stability. Suddenly all of these systems have to go in and pick up the slack of the missing big toe. (Dr Janet Travell listed six muscles as primarily suffering trigger points from Morton’s toe – gluteus medius, gluteus minimus, vastus medialis, peroneus longus, posterior tibialis and flexor digitorum longus. If this is where your issue is then Morton’s toe is a very likely primary cause). 

* This is one of our founding principles and you will see this as a red thread throughout our reading: artificial supports should be avoided when natural supports can be created

Trigger point referred pain
Referred pain of the posterior tibialis trigger point ‘ (from TriggerPoints.net)

This situation is like having an organisation where everyone has a critical job assigned that they have just enough hours to do. Now one person in the organisation is doing a critical job that everything else relies on. One day he goes missing – imagine the panic of everyone else trying to rush into his position and keep things going. These other workers will be stressed, burned-out and flat-out incompetent at doing the job of the missing worker. This is what happens when the ‘big toe’ takes a day off. For most of us: the big toe is always taking a day off. And that’s why we hurt.

 Mystery injuries perhaps explainedGone fishing

One of the mechanisms through which we get a number of ‘strange injuries’ is because the ‘extra work’ done by other muscles to compensate for the ‘missing big toe’ creates a phenomenon called ‘trigger points’. ‘Trigger points’ were first discovered by Dr Janet Travell and covered in one of the great classics of modern medical lore – Travell and Simon’s Myofascial Pain and Dysfunction: v. 1 & v. 2: Two Volume Set: Second Edition/Volume 1 and First Edition/Volume 2: Trigger Point Manual.

Describing trigger points is too big an area for this post but what you need to know about them for now is this:

 

 

  • They are abnormally sore spots in your muscles that shorten the muscle and handicap its normal function and range of motion
  • They are spots that refer pain into adjacent joints – i.e. calf trigger points refer pain into the ankle and Achilles

For the curious – anyone can view trigger point charts online and have a play around with trying to check yourself for them. Using our example from above – think about trigger points as the chronic stress you would get if you had to go in everyday and do your job as well as someone else’s. An early grave and no retirement under southern skies would likely be your predicament.

So I hope you can begin to see the sequence of events unfolding: big toe goes missing -> other muscles pick up the work -> other muscles develop trigger points -> trigger points refer pain into joints -> chronic injury syndrome appears. Dr Morton linked this malfunction of the big toe with injuries ranging from plantar fasciitis, heel pain and fallen arches to back pain, night cramps, arthritis and fibromyalgia.

Glutes – we all love them!

Glutes
Let’s face it: it’s hard not to focus on glutes!

I once asked a physiotherapist who attended our workshops why there was so much focus within the profession on pain in the hips, glutes, lower back and other ‘central areas’. She answered me that the general assumption is that ‘proximal issues create distal pain’ – or in layman’s term ‘issues centrally create pain further away in the joints’ either through referring pain or by loss of stability. An example of this thinking is as follows: you jump from a step down onto one leg. Your glute does not fire to help stabilise you upon landing. This causes a wobble and the foot, ankle and knee all have to do extra work to try to stabilise. Long-term result: ankle and foot issues as a result of glute not firing. Sounds like the exact opposite theory to what I just described above doesn’t it? It is – but the two theories are not mutually exclusive. Instead – one leads to the other but to understand the right sequence, and focus our attention in the most important place first, we need to understand a few simple things about muscles.

Muscles are always referred to as ‘acting’, ‘firing’ or ‘contracting’. Gary Ward, the creator of Anatomy in Motion, points out in his book ‘What the foot’ that muscles do not really ‘act’ as much as they ‘react’ and that rather ‘joints act, muscles react’*. The difference is more than semantic: it requires an understanding of what governs movement on Planet Earth:

The prime mover of everything is gravity – the force that causes objects to attract each other. Without gravity we’d all be floating away into space – you could be firing your glutes all you want and nothing will happen. Motion thus developed as, in Leonardo da Vinci’s words ‘the destruction of balance’. The moment your centre of mass (most of your weight) moves outside your base of support (such as your foot when running) balance is destroyed and your muscles must react to arrest what would otherwise be a freefall.

* Gary Ward’s argument is a bit more complicated than that and I recommend reading his book for the full story. Essentially, eccentric movement has joints acting and muscles reacting whereas concentric movements (such as a biceps curl) is governed by the opposite logic – muscles act, joints react. His summary, however, is what is most important: that both muscles and joints are merely reacting to external stimuli – position of the centre of mass, pressure and gravity among other things. Because of that – in dynamic movement – positioning yourself correctly is the key – not trying to consciously ‘fire a muscle group’. This is getting things backwards!

A drunken night in Dublin

Consider this example from a drunken night out in Dublin: you are staggering along, minding your own business, as another person suddenly changes direction, slams into your shoulder and sends you flying towards the ground. Most likely, unless your intoxication has reached truly impressive levels, you are going to reach out with a leg or an arm to grab and object or try to arrest your fall. You had not time to control this action: your brain simply reacted by firing the muscles necessary to perform a ‘catch myself from falling pattern’. In this case, an outside force (the push of another person) put you off balance and conspired with the downward pull of gravity to accelerate your body downwards towards the hard wet ground. Your brain, serving its function as the control room, reacted the best way it could.

When you move certain muscles are better at doing certain jobs. Your brain will recruit the ideal muscles, if it can. But sometimes something gets in the way. If the glutes ‘go missing’ (like our workshy big toe) then the brain has to recruit something else – perhaps the lower back muscles. This again is like hiring a less qualified candidate to do the job you want to get done.

But what causes muscles to ‘go missing’? The simple answer is: incorrect positioning or compensations. Incorrect positioning happens when the body is not ideally aligned or when it stays for too long in static positions such as sitting in a chair. Imagine trying to walk a tightrope with your chin forced down to your chest. Ideally you would want to have your head straight over the column of your spine. By forcing the head into this position, you have to compensate for the misalignment of having the roughly 5 kilos of your head hanging out in front of you. Similarly sitting in a chair requires no work from the glutes – they can just ‘fall asleep’. Since most of us sit for extended periods this is a common scenario and one reason that we accompany the foot work with lots of extension work in both our workshops and personal consulting. It’s rare to find a modern runner who doesn’t benefit from this type of movement.

sitting
Too much sitting not only deprives many muscles of electrical stimulus but turns your default ‘shape’ into one that is very much not optimal for athletic movement

Bad software emerges

Over time such a misalignment can lead to a new motor pattern emerging – quite simply: because the glutes are not being used for work, they decide to ‘go home’. After all – what’s the point about being ready to do work that never comes? So this is fundamentally a ‘movement problem’ – not a muscular problem. The muscle might have its issues to deal with (trigger points etc.) but the real problem is in the ‘control room’ (your brain) which cannot access the glutes when it needs to.

And here’s the kicker: a lot of the misalignments, trigger points, bad movement patterns other issues that caused the glutes to stop doing their job when needed, began because our feet are messed up to begin with. Improving the hips without improving the feet is like repairing the engine of your car but leaving the tires flat – i.e. a pretty short-term solution.

Conclusions

I hope by now you are convinced that whether someone tells you that you have weak glutes or not, the first thing you need to look at is whether your have good strong natural feet or whether you suffer from Morton’s foot (most of you will). That’s your priority. All conditioning and practice you do until you sort those feet out is essentially pointless because you are doing them on an unstable footing. It is like training without your big toes.

Once you have begun to sort your feet, a movement coach can assess your general movement patterns – elements such as your posture, the relaxation levels of muscles and the shapes you make as you move and whether all joints have normal range of motion. But this is done on the basis that you have begun the journey to rehabilitating your feet. Otherwise all these other elements will have to compensate for your unstable footing. This again is like building a beautiful palace – with every detail meticulously planned – but placing it on a foundation of soft sand.

To get started you can check out our recent article on one of the new techniques for fixing Morton’s foot – the ‘toe-ga’ drills invented by Lee Saxby and watch out for our upcoming piece on how to check whether you have Morton’s foot.

Don’t want to wait? Then purchase ‘Why you really hurt’ by Dr Schuler* or view a summary video on YouTube.


Dr Schuler’s book – while heavily recommended for general information – remains strongly wedded to the current medical model of attempting to use artificial inserts rather than trusting that the body can be conditioned back to its normal function through proper training methods. That is all that speaks against it.

Take-aways

  • Most running injuries can likely be traced back to a dysfunctional foot
  • If you’re told you have weak glutes, acknowledge it but ask your therapist to check whether you have Morton’s foot and ask them to assess whether its impacting your movement and refer you to a movement coach as appropriate
  • Check yourself for Morton’s foot and see a movement coach, contact us  for a solution or book in on our upcoming workshops where the full ‘toe fix’ is taught amongst many other skills so you can take care of ‘your own wheels’ rather than leaving it with ‘a mechanic’

Also published on Medium.

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René

Director and coach at Borg Coaching Services
Rene Borg is the head coach of Glendalough AC and a passionate runner competing over all distances and terrains.
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