External Tibial Torsion

[riley876]

I'm pretty sure I haz it.

http://thegaitguys.tumblr.com/post/23671468080/external-tibial-torsion-a-video-showing-the
http://thegaitguys.tumblr.com/post/24130213595/external-tibial-torsion-as-expressed-during-gait

This *exactly* matches my pattern of movements.

I've been trying to fix my posture (i.e. match what I see in ice dance videos), and I just can't do it.   My knee simply will not go over my toe unless I push the hip right out.   Coach Roller Dance and Coach Locum Roller Dance have both pulled me up on popping my hip out,  when doing pretty much anything involving a knee push (e.g. the pop of a 3 turn).   But I can see why I've been doing it now.   Because it's only way for me to get my knees over my toes.   Of course it's messed up, because the hip is then way off....

I've been playing with custom orthotics today.  If I build up the entire inside edge of the orthotic (by 10mm or so, so far) it tilts my foot out, which helps to improve the situation a fair bit, but it's not nearly a full solution.

The short story is that I'm really not built for skating. Not that I'm going to let a minor thing like that stop me.  Only positive is that I've always found spread-eagles trivial.

Anyone else built this way?  Solutions?  Remedies?  Workaraounds?   Funky moves only we oddballs can do?

[Doubletoe]

Wow!

[rd350]

If you know a good physio that focuses on manual therapy, maybe get an evaluation.  It might be treatable.

[riley876]

I'm planning on seeing how far I can push my wedge orthotics.   I know it's possible to get surgery to section and reset the bones, but screw that for a joke.    Other that than, since it's a structural issue, I think I'm stuck with it.    But I think a serious inside edge wedge (i.e 15-20mm of tilt) will go along way to getting things, if not in the ballpark, then at least in the carpark.

I now understand why my ITBs have been so stressed ever since I started doing three turns.   I've been subconsciously using the ITB to pull the knee back over the toe during the cusp.   At least I know roughly what's going on now, and I can come up with strategies with that in mind.   Rather than simply continually berating myself for being uncoordinated (OK that's a given, but also unhelpful).

I read somewhere that young ballet dancers can generate a tibial twist by habitually trying to force a turnout when the hip just isn't playing the game.   Maybe if I'm zealous about forcing turn ins (i.e. doing toe to toe plies), then I can coerce a few degrees of twist back in the other way.    Not sure adult bones will shift one iota though.   And it's not going to be nearly enough anyway.

In the end, between what improvements I can get with the wedges, and simply just accepting my hip is going to have to stay poking out a bit now and then,  life (and skating) goes on. 

[riley876]

Ditched work early to go make my orthotics from hell.    Experimented with a few things, eventually settled on using cork flooring tiles.   Everything else I could come up with was going to be too heavy for the 16mm of wedge I seem to need.   Laminated 3 6mm layers, and shaped them with a 40 grit belt sander.   Didn't take too long.    Did have to revise my lacing scheme, but amazingly enough I can stuff my feet in with them.

Just wearing them around the house they feel pretty nice.  Not stressing the ankle at all.   And I can feel the VMO being more engaged.   Can definitely stand up on a front wheel a ton easier

And cork feels *great* underfoot.  Just the merest hint of give.  Hope it's OK when it gets a bit sweaty.

Acid test tomorrow...

[Doubletoe]

Let us know  how it goes!

[riley876]

Inconclusive.   Feels somewhat better I think, but certainly no silver bullet.   But at least now I can feel the core of the problem manifesting (essentially a combo of the knee collapsing inward, and the hip collapsing outwards).

I had Coach have a look at me off skates, and she agreed, it's pretty major and it structural.   She didn't have much to suggest other than some generic glute/VMO/anti-pronation exercises,  which I'm not entirely sure what she thought might achieve.

I did have a revolutionary thought that maybe if I can't bring my knee over the front of my skate, perhaps I can bring the front of the skate more under my knee instead.  i.e. move/remount the frame/blade a few degrees toed-in, which did perhaps help a bit more too,  at the cost of having to work the ankle a bit to hold it from flopping onto the outside edge when up on the front of the skate.  Not the end of the world, maybe a useful compromise, I haven't decided for sure yet.

I'm being affected emotionally by this revelation.  On one hand it feels like dreams are dying, on the other hand not a damned thing has actually changed.   I have to remind myself that knowing is more useful than not knowing.    Just going to have to get smart and work on/out workable compromises in my form.

At the very least, my ITB's aren't on fire anymore, which is itself a major step up.

[amy1984]

I'd second the idea for physio.  I can see what you mean about it being structural, but they will be able to give you exercises to make things optimal for you, strengthen muscles that might help, etc.  Also, many of them work with orthotics and could help you with that if you think orthotics would help.  If you look around you might be able to find a physio who works almost exclusively with orthotics, and if you're even more lucky, specializes in athletics.  We have one around where I live and he's helped quite a few skaters.

[riley876]

Another day, another 6mm of arch support.   It's now 22mm high through the arch and 16mm down the rest of the inside edge. 

It certainly improves the knee mechanics.   To achieve parallel knee bending, without any orthotics, my feet need to form a 70-75 degree vee.   With the orthotics from hell,  it's about 30 degrees.   Which is not miles off average I believe (though I suspect talented skates have much less than average,  judging from youtube research).    Anyone here care to eyeball theirs?

Anyway, yes, it's definitely an improvement.  For reference I went back to the old little 6mm orthotic, and OMG horrible.  Knees miles away from toes, and horrible flat foot feeling.   So even if it feels like nothing it IS a big help after all.   

Still have to engage the ITBs more than I'd like to keep the knees from collapsing inwards in knee bends,  but it's way less than what it was for sure.

Three turns are still meh, but feeling generally less contorted, less out of control and less effortful to pop the turn.

So, tentatively, the dream, such that it is, is back on. 

As for physios.  I'm putting out the feelers for someone with experience in these matters.  Xmess/Summer holiday madness probably means not until late January anyway.

[riley876]

At the risk of turning this thread into a monologue:

Another day, but no more orthotic changes today.   Had a really good inline session today just playing with edges and crossrolls and other things knee bend related (what isn't?).   I've clicked that I don't actually need to get my knees over my toes, but only need to be over the contact point with the floor.   i.e.  a decent amount of outside boot lean can move the contact point inwards by 10mm easily,  which along with the geometry improvements from the orthotics and tweaking the frame placement,  puts the wheels nicely under knees and under my hip.   BINGO.   No more ITB pain AT ALL.   And feels like I can put power through my knees finally.   Crossrolls feel SO nice, and it startled me slightly how easy it was to build up speed.   

Luckily on inlines the edges themselves don't matter at all (i.e. edges and curves are largely independent things),  so I can sit on an outside edge semi-permanently (i.e. even on inside "edge" curves).   Which is a bit of an inline slalom thing anyway.    Probably not a viable strategy on ice, and certainly not on quad skates, but oh well,  those bits of my skating may just have to be shelved.

F3 turns still suck, but they do feel different, so that's probably just me being useless.

Also hello to a little bit of new hip muscle pain (good pain) and a smidge of quadricep tendon protest (benign),  shows me I've changed something fundamentally.    Knees feeling a bit wobbly too shows me I'm at the alignment point finally, and that I need to orthoticize-from-hell some sneakers and start putting together an "off ice" workout to strengthen those.

[riley876]

(Sorry for the above self-quote, I have no idea how I did that.  Mods, please delete it).

I've worked out I needed loads more heel lift too.   So added 12mm of that (as much as I dare).    And indeed, another noticeable improvement.   After nearly face planting on the first couple of glide strokes      Utterly decimated my prototypal back threes.   And can't do my outside spread eagle anymore.   But they'll be back.

Intensive inner quad muscle work started today too.   So weak.   Never had any decent way of loading up these muscles before.

[Doubletoe]

Sounds like you are doing some great problem-solving here!

[riley876]

Actually measured my tibial torsion with a protractor, and got bang on 75deg,  which is about 37deg per foot,  which puts me at least 3 standard deviations off normal (i.e. only 1 in 3000 have it worse).     And a definite candidate for surgery, though I'm absolutely not going to be doing that.     But no wonder I've been having so many problems.

Further playing with shoes and pistol squats i.e. "shoot the duck"/sit spins (definitely assisted at this point).   I've found if I wear a 2.5inch heel (so so SO not me, fashion-wise, BTW), together with a 15mm inside edge wedge,  I can get the full range of motion without any patellofemoral pain whatsoever.   Which I now realise is caused by twisting of the knee during the up/down motion.

There is no way I can get this amount of lift out of my skates with just orthotics/inserts.    So I'm now looking at adding a 20mm chunk of plastic to increase the "rear stanchion" height (to use an ice skate equivalent metaphor)    Desperate times, desperate measures.   But to be totally free of knee/ITB/PF pain AND be able to use a decent knee bend,  it could well be worth it.   Just hope my ankles are up to it, laterally.

[Doubletoe]

I have seen ice dancers who have a stacked heel on one or both boots.  Would you consider getting boots with custom heels like that?

[riley876]

Yes, that's effectively what I've done/doing.

Do you know their reason for doing it?   Out of curiosity, how much stacking did they have approximately?   

At this point, I'm going to just keep modifying the setup I already have,  at least until the geometry/shape gets too screwy.   If I end up needing anything *really* radical,  then I'm keen to build my own boots from scratch.   A hell of a lot of work, but I'm sure it'd be a neat learning experience. 

[Doubletoe]

I think some of them stack their heels to make them look taller next to their partners.  But I know one ice dance coach who only has one of her heels stacked.  It's because that leg is actually shorter than the other.

[riley876]

First big long session on new setup (2.5hrs).   Ankle somewhat fatigued from all the new height (heel is now 5" off the floor in total) , but not stressed.    Summary so far:  it's definitely helping, but far from perfect.

The problem is that, all my modifications are related to freeing the ankle such that I can point the foot (relatively) inwards.   Which is all good, until a deep knee bend is called for,  which infers a deep ankle bend,  i.e. all my new flexion goes away, and therefore the foot rotates back outwards to it's natural location and I'm back to square one, the knee collapsing inwards, and hip sticking out,  and associated ITB/PF pain.   *Sigh*.

Oh well, best I can do at this point, I don't think I can cope with any higher heel,  so just getting on with it like this.   Who needs knee bend anyway? 

[riley876]

A programme of strengthening hamstrings and VMOs seems to have mostly relieved the PF/ITB stresses.  So I'm skating essentially pain free now.   Which is itself a minor miracle.   It also means I can support a somewhat deeper knee bend that before, which is helping too.

I still have the issue that knee bends end up being a composite movement, i.e. deeper causes twist, which has to be compensated with a slight opposite upper body movement, but that seems workable in practice.   

Have had a bit of a breakthrough with edges though.   I've spent years trying to copy you human's hips and shoulders positions.   Which was (in hindsight) a major mistake.   What I've worked out I need to do instead, is to hold as neutral as possible posture. 

Which means facing my hips/torso/shoulders 30deg (i.e. my amount of tibial twist) away from the curve's tangent.   This is neutral for me,  i.e. it causes no turning forces on the skate.     In FO and BO this means facing out of the circle by this amount, and FI and BI facing into the circle by this amount.   Accurately holding that relative angle is the challenge at the moment.     All really obvious in hindsight (and that none of my ex-coaches would have picked up in a million years).

BTW if you're lucky(ha!) enough to have internal tibial torsion, I imagine exactly the opposite would be called for.

Previously I was trying to copy what you <sneer>humans</sneer> do.  That was a big mistake, because I was having to compensate the turning forces that results from that by using other mechanisms.    I may as well have been trying to learn to fly by watching birds. 

[Doubletoe]

Glad to hear you are skating pain free now!  Even those of us without external tibial tortion benefit from hamstring exercises, as figure skating is a sport that disproportionately strengthens the outer quads and results in an uneven pull on the kneecap.  Building hamstring strength (and stretching my quads) pretty much eliminated my knee pain.  For some, inner quad strengthening is necessary as well.

[riley876]

Another post from the same folks, this time about a woman with internal tibial torsion, and knee pain whilst skiing.

http://thegaitguys.tumblr.com/post/140210845944/medial-knee-pain-in-a-skier-considering-an

The (probably too modest) wedge they added is indeed the opposite to what I've made for myself.

[riley876]

Knee pain still gone.  Miracle!    I've gone down to an 18mm wedge now.   I was finding the large angle of the 22mm wedge was causing nerve compression in the front of the foot.  The 18mm calmed that down, and it's still OK on the knees.   Some stresses on the ankle, but they're survivable at this stage.

I've become a bit of a student of podiatry.  I've worked out I have another abnormality.

Its called Rearfoot Valgus.  It's rare apparently (ha! I'm a 3 sigma freak in yet *another* way?  whatever, throw it on the pile).   This pic is not me, but it looks like this:



I would hazard a guess it's developmentally related to the tibial torsion.   But it makes more sense to me now why big inside-edge wedges help me SO much. 

The other one that I'm looking at is the inclination angle of the ankle.  I haven't compared my foot to anyone elses,  but I think the "hinge pin" of my ankle joint isn't level.   In a normal person, flexing the ankle joint just results in the toes going up and down.   In me they go side to side significantly too.   

Which means the angle between the direction of my foot vs the direction of my knee changes significantly depending on how deeply my knees/ankles are bent.    Which as you might imagine tends to throw me off balance, unless I compensate with some upper body movement.

[riley876]

(Still posting here, for future reference, in case some weary fellow tibially twisted traveller stumbles across this some day)

A nice clip showing the compensation of "tipping to the outside edge".  i.e. like the massive wedge orthotics I'm now using provide.

https://wikigait.wordpress.com/2016/01/05/change-the-foot-change-the-knee-and-vice-versa/

Great write up on the subject too.

And in case you were wondering how us freaks walk:

https://wikigait.wordpress.com/2014/07/30/foot-progression-angle-exaggeration-external/

Interesting to me is that I'm seeing the same rearfoot valgus as I have.  Which makes me wonder if the whole thing usually comes as a package.

And another link:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2443695/  ... biomodelling indicating a rather deleterious effect on muscle capability.   (Tell me something I didn't already know).   Guess those quad axels aren't coming anytime soon

All that said, I'm less pessimistic about skating with tibial torsions than I was 6 months ago.    Pretty much all posture has to be modified to suit though.   The basic idea is that when "getting low in the knee" when on one foot,  the posture has to be modified to suit.   

Normal* people fold up (like a fan) at the hips, knees and ankles.  Everything stays more or less over the skating line during this fold up and unfolding that represents a push.   i.e. in particular knees stay roughly over the skating line.  nose over knees over toes and all that jazz.   

With the likes of myself the knees always point 35ish degrees away from the skating line.  Which means when I bend my knees (i.e. fold up at the hip, knees and ankles)  my knees are no longer on the skating line.  Which means the hip needs to be pushed out in the other direction to maintain the CoG over the skating line.    This carries the complication that managing the rotational momentum of hip/lower torso becomes trickier (i.e. the stuck out hip tends to store more rotational momentum than you'd ideally like.  though I suspect with sufficient training this could lead to some really interesting and unique moves).   

I've found it's better to face the torso 35ish degrees (my amount of tibial twist) away from the direction of travel on average.     It leads to freer knees and easier knee bends.   This gives essentially zero hip internal/external rotation, which means the glutes and quads work more effectively.

Trying to be normal is a killer.  Skating like a normal person just won't work.  e.g. trying not to stick out the hip will just make it impossible to get a deep enough knee bend, or will torque the knee joint (ouch).   Ditto trying to face forward and be symmetrical during one foot power pulls etc.    Trying to force normality leads to nothing but awkwardness.   Gotta be a student of physics and your own anatomy and relegate conformity to the scrap heap where it belongs.

* Pronounced with an appropriate sneer.

[riley876]

Have been getting quite pessimistic about this whole thing again lately (still cycling through some anger, bargaining & depression on this one TBH).

Found this interesting though:



(One of the roller dancers from the just completed NZ roller champs, sorry don't know her name).   

One can notice:
- the skating knee and foot pointing in radically different directions, i.e. twisted tibia.
- knee in (a bit), hip out (lot), torso in (a bit).  Typical zig-zag line of balance compensations.
- pelvis (and torso) rotated back at approx same angle as tibial twist.   (though it's true she has just done a mohawk here)
- no significant hip internal/external rotation (i.e. knee in front of pelvis/torso)
- composite lean

Most of which I had already figured out in principle, but I'm very happy that I finally a) have someone I can theoretically copy b) have confirmation that it IS possible to skate with grace and flow despite having some non-trivial degree of this oddity.

Full vid of her skating: (the following skater had the same issue too).

https://www.facebook.com/SkateNationNZ/videos/832640050171343/  (starts at 00:24)

[riley876]

Fantastic picture of Goldie Hawn.  Ballet teacher, amongst her many other talents.



Lookie lookie at her feet vs her knees, especially her right.  She's got twisted tibias about as bad as I have.  Clearly I'm in the wrong art.   I wonder if it's induced though,  i.e. forced the foot turnout too much when she was very young and malleable.

[riley876]

(Leaving this here again for any other similarly torsioned lunatics that might come after me...)

Silvia Nemesio:  showing off her tibial torsion, gobs thereof.



Again note the feet and femur pointing in radically different directions.   She's the first high level skater I've seen with large amounts of external tibial torsion.  I had thought this was a major handicap, and therefore never to be seen in high level skaters, but apparently not.

Her whole LP from the worlds last year:

http://firs.rollersports.tv/video/?videoId=e-5048  (skip forward to 39:10)

I would love to know if she's also got lots of forefoot/rearfoot varus, and what orthotics she uses, if any.   Silvia, if you ever read this, please let me know!