Podcast 131: Managing your injuries and body mechanics

Key Tag Words: thegaitguys, gait, gait analysis, hallux rigidus, hallux limitus, calf strength, calf endurance


Links to find the podcast:

http://traffic.libsyn.com/thegaitguys/pod_131f.mp3

http://thegaitguys.libsyn.com/podcast-131

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

http://directory.libsyn.com/episode/index/id/5958375

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Researchers turn skin cells into motor neurons without using stem cells
https://futurism.com/researchers-turn-skin-cells-into-motor-neurons-without-using-stem-cells/

Immune cells release “red flag” to activate muscle stem cells in response to damage
http://scopeblog.stanford.edu/2017/09/25/immune-cells-release-red-flag-to-activate-muscle-stem-cells-in-response-to-damage/

Does structural leg-length discrepancy affect postural control? Preliminary study.
Eliks M, et al. BMC Musculoskelet Disord. 2017.

Evidence for Joint Moment Asymmetry in Healthy Populations during Gait. Rebecca L. Lambach  et al. Gait Posture. 2014 Sep; 40(4): 526–531.

J Phys Ther Sci. 2017 Jun; 29(6): 1001–1005.
Published online 2017 Jun 7. doi:  10.1589/jpts.29.1001
PMCID: PMC5468184

Does the weakening of intrinsic foot muscles cause the decrease of medial longitudinal arch height?
Kazunori Okamura, RPT, MS,1,* Shusaku Kanai, RPT, PhD,2 Sadaaki Oki, MD, PhD,2 Satoshi Tanaka, RPT, PhD,2 Naohisa Hirata, RPT, MS,3 Yoshiaki Sakamura, RPT, MS,4 Norikatsu Idemoto, RPT,1 Hiroki Wada, RPT,1 and Akira Otsuka, RPT, PhD5

A Tale of 2 Footies

Time for a pedograph, folks. What do we have here?

To review :

Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.

First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.

Let’s start at the rear foot: The heel teardrop is elongated on both sides, slightly more on the right; this means incraesed calcaneal eversion (or rearfoot pronation) bilaterally, R > L. The right heel shows increased pressure (more ink = more pressure).

Next up, the mid foot. Similar shapes, more pressure and printing on the left. Did you notice the “tail” of the 5th metatarsal printing, giving it a wider print? This person is staying on the outside of their foot longer than normal, right (more ink) more than left.

How about the fore foot? Lots going on there.

Lets start on the left

Notice the mild increased printing of the 5th and 4th metatarsal heads. Force should be traveling from lateral to medial here, as the foot goes into supination. A relatively normal amount of pressure on the head of the 1st metatarsal.

Now look at the toes. Notice that space between the 2nd and 3rd? This gal had an old fracture and has an increased space between them.

Now how about the right?

Increased pressure on most of the heads with a concentration on the 1st metatarsal. Hmmm…what would cause that? this is typical of someone who has a 1st ray (cunieform and metatarsal) that is hypomobile, such as with someone with a forefoot valgus (as this person does) or a dropped 1st metatarsal head (which is usually rigid, as is NOT the case here).

Did you see that rpinting at the medial aspect of the proximal phalanyx of the hallux (ie. big toe)? This gal externally rotates the lower extremity to push off the big toe to propel herself forward. This is because the 1st metatarsal head hits the ground BEFORE the 5th (as we would normally expect to see, like in the left foot), and because the weight is now on the outside of the foot, she need to push off SOMETHING.

Getting better at this? We hope so. Keep reading the blog and look at some of our past pedograph posts here.

The Gait Guys. Teaching you about the importance of gait, each and every day!

What’s up, Doc?

Nothing like a little brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let’s start at the rear foot:

  • limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.
  • note the increased pressure at the  medial calcaneal facets on each side with the increased printing
  • very little fat pad displacement overall

Now let’s look at the mid foot:

  • decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

  • increased printing under the met heads bilaterally; L >> R
  • increased printing of 1st met head L >> R
  • increased printing at medial proximal phalynx of hallux  L >> R
  • increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

  • short leg on L
  • more rigid foot on L
  • increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot?

Here is what is going on:

  • there is no appreciable leg length deformity, functional or anatomical
  • The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

  • Can you feel how when your foot is supinated
  • can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction
  • Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?
  • now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What’s the fix?

  • create a more supple foot with manipulation, massage, muscle work
  • increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)
  • have them walk with their toes slightly elevated
  • we are sure you can think of more ways as well!

The Gait Guys. Increasing your gait literacy with each and every post. I

The pedograph as a window to the gait cycle

 

Have you ever studied footprints on the beach or looked at the print left by a wet foot when you get out of the water? These are some of the most primitive types of pedographs.

The pedograph, 1st described by Harris and Beath in 1947 is a rubber mat surface with multiple protruding, small grid lines on one side, which, when covered with ink, imprints an underlying sheet of paper when weight (usually a foot) passes over it. Relative plantar pressures are indicated by the size and density of the inked area, creating a “footprint” reflecting passages of force through the foot at that instance in time.  They have fallen into and out of usage over the years, often discarded for more expensive technology such as pedobarographs, individual pressure sensors, and pressure sensitive mats, which have computer interfaces and can provide many useful measurements and calculations to assist the clinician with rendering a diagnosis. These systems, though more precise in some ways (provided a controlled, reproducible testing procedure) are often thousands of dollars, require a computer and the necessary skills, and have a substantial learning curve.  

The pedograph in contrast is simplistic, inexpensive, and reliable and only requires that the user have an intact visual pathway and cerebral cortex and knowledge of the events occurring in the gait cycle. With some practice and a good knowledge base, the subtle nuances detected by the sensitive pedograph (nuances that can be undetected with high end computer driven plantar pressure devices) can offer information critical to a precise diagnosis and give solid clues to gait flaws and compensations.  With minimal training using a pedograph, reproducible “prints” can be produced for analysis, in light of your findings clinically. They also make wonderful educational tools for your patients and clients!

An essential part of a comprehensive patient evaluation should include examination of the entire kinetic chain both in a static and dynamic fashion. Often what you see statically is either directly translated to or compensated for in the dynamic evaluation. (It is important to note that many of the available foot scan units available from orthotic companies scan a patient in a static standing position and give little information on how the feet and lower limb dynamically engage the ground during movement.) The pedograph is a useful visual tool representing a 2 dimensional image of tridimensional motion, and you are seeing the end product and compensation (or lack thereof) of the individuals mechanics at that point in time. Because of the specificity of what you are seeing refers to a particular point in time, technique and reproducibility are of paramount importance. Prints should be performed several times to insure what you are looking at is what you are looking at, and not movement artifact, because of the way the patient stepped on to or off of the mat.

With a pedograph, seeing is believing. When you have objective data about how an individual moves through space and how their joints and motor system help them to accomplish that, you have a better appreciation for the type or form of therapy which may be most appropriate. In the hands of a skilled clinician, seeing abnormal plantar pressures tells you where the biomechanical fault lies, and thus where manipulation may be appropriate, which muscles need strengthening and where neuromotor coordination is lacking and gait rehabilitation is needed.  

excerpted from the 1st edition of our Book “Pedographs and Gait Analysis: Clinical Pearls and Case Studies” Trafford Publishing

Supination, anyone?

Pronation gets all the press; but what about its counterpart, supination? There could not be one without the other. If anything, supination is at least as, if not more important to create propulsion.

Pronation is dorsiflexion, eversion and abduction of the foot. It provides shock absorption. Supination is plantar flexion, inversion and adduction. It helps the foot become a rigid lever so we can GO (Like in Theo Selig’s “Go Dig Go” ).

external leg rotation supination.gif

Locking of the lateral column of the foot (4th and 5th metatarsal, cuboid and calcaneus) is a necessary prerequisite for normal force transmission through the foot and ultimately placing weight on the head of the 1st metatarsal for proper (high gear) toe off . Locking of the lateral column minimizes muscular strain as the musculature (soleus, peroneus longus and brevis, EHL, EDL, FDL and FHL) is usually not strong enough to perform the job on its own.

external rotary moment.gif

This process is initiated by the opposite leg going into swing phase, which initiates dorsiflexion, inversion and abduction of the talus

The peroneus longus tendon aids this process by wrapping around the cuboid (the brevis attaches to the base of the 1st metatarsal) on its way to insert onto the base of the 1st metatarsal. When the peoneus longus contracts, it dorsiflexes and everts the cuboid, which, along with the soleus (which plantar flexes and inverts the subtalar joint) allows dorsiflexion of 4th and 5th metatarsals and “locks” the lateral column. Without this mechanism, there is no locking. Without locking, there is no supination. Without supination, there is little rigidity and inefficient propulsion.

The calcaneo cuboid locking mechanism. Another cool thing you learned about gait today from The Gait Guys.

The Power of the 1st Ray?

PSM_V24_D673_Deforming_pressure_of_high_heels_on_the_foot_bone_structure.jpg

Does the 1st ray complex have super powers? Perhaps Marvel should consider a new superhero “Ray”? We are not sure but here is a story that gets us one step closer to the answer. 

While teaching a course this past weekend and doing a teaching case, we examined one of the participants who had high arches, a rigid rearfoot varus, internal tibial torsion, R > L, and foot pain R>L and a dorsal exostosis (growth of extra bone from stress at the base of her 1st metatarsal) where it articulated with the  1st cunieform on the right. No surprisingly, she also had a partially compensated forefoot supinatus on the right. She had increased wear on the lateral aspect of her shoes and a walking strategy which involved hiking the right side of the pelvis during stance phase on the left, and a pelvic shift to the right during stance phase on the right, as well as an inability to get the head of either 1st ray complex to the ground, R > L. It was also determined she had, not surprisingly, locking of the 1st metatarsal cunieform joint on the right and a loss of anterior and posterior shear at the superior tib fib articulation on the right, as well as hypomobility of the right sacoiliac joint. There was weakness of the abdominal external obliques bilaterally and posterior fibers of the left gluteus medius, along with the long toe extensors on the left and short toe flexors, a pattern that we often see clinically.

We then proceeded to treat her tib posterior, peroneus longus and flexor digitorum on the right, all of which have an effect on descending the 1st ray, along with the long extensors on the right, which would effectively raise the distal aspect of the 1st ray, but we thought may provide better eccentric control of the foot from initial contact to loading response, and again from the end of terminal stance and through swing phase.  We then mobilized the 1st met cunieform articulation only. Ideally, we should have reassessed after we made EACH change, but due to time constraints, AFTER we had done ALL these things. 

Rexamination had better 1st ray motion, restoration of tib fib motion and restoration of R sided SI mechanics. Her 1st ray descended much better, tib fib motion was normalized, L sided hip hiking strategy and R sided pelvic shift were greatly improved. For the 1st time in 10 years, the participant had no foot pain. Coincidence? Perhaps. Placebo? Maybe. You decide. 

Sometimes, doing a little of the right thing can be a good thing. Sometimes we overdo. I have to admit, because I am a chiropractor, I would have started with manipulation 1st of all 3 articulations with a recheck immediately post treatment AND THEN treated the other dysfunctions. For those of you who are manual therapists, I am sure you see miraculous things happen when we cavitate joints and change their instantaneous axes of rotation. I can thank Dr Ted Carrick and my good friend and colleague, Dr Paul Chille, for teaching me that. The students, in this case, were driving the bus and I went along with it.  I was surprised (though I shouldn’t have been) to see the pathomechanics resolve WITHOUT manipulation, but it got me thinking I should consider treating the muscular dysfunctions 1st, and then recheck and manipulate later. It makes sense that the receptor density of the lower extremity musculature has a much larger population of muscle mechanoreceptors, especially in the foot, since it has a greater cortical representation than the joint mechanoreceptors.

My students never cease to teach me something new...

A few minutes with Shawn, Episode 1

Pruning, Baking, & Corrective Exercise.

Just a few thoughts, rants, pearls, analogies and stories, once or twice a month . . . mostly leading towards a clinical point of view and things I find myself thinking about.

Where to download:

http://traffic.libsyn.com/thegaitguys/Minutes_with_Shawn_1.mp3

http://thegaitguys.libsyn.com/a-few-minutes-with-shawn-1

http://directory.libsyn.com/episode/index/id/5910367

9cover-iStock-492571407-300x232.jpg

increased cushioning = increased impact forces (GRF)

increased impact forces = increased injuries?

possibly not...

 

footwear can impact injury and biomechanics but may not be the primary factor

a nice recap of the state of what we currently know about shoes, design and cushioning.

http://lermagazine.com/cover_story/running-shoes-and-injury-risk-rethinking-the-importance-of-cushioning-and-pronation

Muscle activation and gait: EMG studies that differentiate!

Got Muscle activation? Looking for some EMG data on what fires when in walking vs running gait? The conclusion and point of the study are good, but the EMG data and diagrams are awesome for those of you seeking a greater understanding of what goes on when

"The major difference between walking and running was that one temporal component, occurring during stance, was shifted to an earlier phase in the step cycle during running. These muscle activation differences between gaits did not simply depend on locomotion speed as shown by recordings during each gait over the same range of speeds (5–9 km/h). The results are consistent with an organization of locomotion motor programs having two parts, one that organizes muscle activation during swing and another during stance and the transition to swing. The timing shift between walking and running reflects therefore the difference in the relative duration of the stance phase in the two gaits."

A great read and FREE FULL TEXT

http://jn.physiology.org/content/95/6/3426

Zombie gait?

Zombies are a peculiar lot. Not wanting to limit our analysis to the living, we have begun to examine the undead.

In this entertaining and educational clip, we note that a common characteristic seems to be partial paralysis of an lower and/or upper extremity, along with the peculiar behavior of keeping their upper extremities in a flexed posture, similar to a stroke. They also seem to have an exaggerated gag reflex and difficulty with phonation (talking).  We believe this is a neurological phenomenon, based on the fact that the only way to truly kill a zombie is to kill their brain.

Have a great Halloween!

 

Needling Myofascial Meridians?

15079418828_c1a437b173_b.jpg

Beyond the Trigger Point...

Many clinicians needle. We are taught to dry needle trigger points and to needle the segmental innervation of the muscle involved. But should we do more? I think so, and here is one paper on incorporating needling myofascial meridians along with trigger points that supports that notion (1).

Since most of us treat patients that are ambulatory, we should be thinking of how a patient moves, especially through the gait cycle. Think of the kinetic chain in what I like to call “reverse engineering”, that is, from the ground up, rather from the torso down, in a closed chain fashion. This will profoundly effect the way you look at muscle function, for example: thinking of the vastus lateralis as a medial rotator of the thigh (yes, you read that right; think about it and try and get your head wrapped around it), or of the peroneus longus as an abductor of the lower leg and external rotator (assisting supination) during the latter half of the gait cycle. Reverse engineering gives you a whole new outlook on locomotion and human movement.

Tom Myers was insightful enough to write a great text talking about myofascial meridians or “lines of tissue stress ” describing the fascial connections of muscles utilized in a chain during movement (2). This built upon the original work of Valdimir Janda and his concepts of “loops and slings” (3), as well as the work of Paoletti (4) and Vleeming (5). 

In neurology, we have the conjoint concepts of temporal and spacial summation that can lead to some action on the part of the nervous system. They describe 2 ways that receptors or neurons can reach threshold and fire an action potential (6) .

Temporal summation is when a receptor or neuron is stimulated repetetively over time, with each potential bulding upon the previous, making the stimulus effectively larger and larger. If you were in a movie theater and the person seated behind you kept hitting the back of your seat repetitively (temporal summation), it would only be a matter of time before you turned around and said some thing to them(ie, you reached threshold).

Spacial summation is when a receptor or neuron is stimulated at multiple locations over time, with the potentials building and bringing the receptor or neuron closer to threshold.  Taking the same scenario as before, if many people began hitting your chair from multiple directions (spacial summation), it would be only a matter of time before you said something (ie: reached threshold).

These two things can work together as well, usually eliciting a result much faster, since the receptor or neuron is being hit multiple times from multiple directions and it can usually reach threshold faster.

Since one of our goals in needling is not only to reduce or eliminate the trigger point, but also to reduce pain and increase function, wouldn’t it make sense to take advantage of as much neurology as possible? How about more real estate (spacial summation) in a reasonable time frame from point to point (temporal summation)?

Needling appears to cause pain modulation, as well as many of its other effects,  through both peripheral and central mechanisms (7,8). Having our therapy stimulate more of these mechanisms should theoretically make our therapy more effective and improve outcomes. So, more needles may be a good thing, no? 

Getting back to the paper (1), they needled tender points (satellite trigger points?) along the lower portions of the “superficial back line” or “SBL”, along with points on the foot for plantar fascitis. The SBL contains plantar fascia, Achilles tendon, gastrocnemius,hamstrings, sacrotuberous ligament, and erector spinae. It continues to the suboccipital muscles and ends at the suboccipital muscles, galea aponeurotica of the skull and ultimately the frontalis muscle (2). They could have incorporated more, and perhaps had even better results, as the upper cervial spine contains one of the highest densities of mechanoreceptors in the body (9, 10), and afferent information from the upper 4 cervical neuromeres feed directly into the flocculonodular lobe of the cerebellum (11, 12).

So, how about incorporating myofascial meridians into your needling toolbox? The next time you see someone with a problem area, think about the kinetic chain that gets you there, starting from the ground up, and incorporate THAT into your treatment protocol. 

 

references:

1. Akhbari B, Salavati M, Ezzati K,  Mohammadi Rad S: The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis Journal of Chiropractic Medicine (2014) 13, 4348

2. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists. 2nd ed. Philadelphia: Churchill Livingstone; 2009.

3. Janda V, Vavrova M, Hervenova A, et al. Sensory motor stimulation. In: Liebenson C. ed Rehabilitation of the spine: a practitioners manual. 2nd edn. Lippincott Williams & Wilkins, 2006.

4. Paoletti S. The fasciae: anatomy, dysfunction & treatment. Eastland Press; 2006.

5. Vleeming A, Snijders C, Stoeckart R, Mens J. The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming A, et al, editor. Movement, stability and low back pain. Churchill Livingstone; 1997. p. 5371

6. Levin & Luders (2000). Comprehensive Clinical Neurophysiology. New York: W.B. Saunders Company.

7. Dommerholt j Dry needling — peripheral and central considerations Journal of Manual and Manipulative Therapy 2011 VOL. 19 NO. 4 223-237

8.  Li-Wei Chou,  Mu-Jung Kao, Jaung-Geng Lin  ProbableMechanisms of Needling Therapies for Myofascial Pain Control Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 705327, 11 pages doi:10.1155/2012/705327

9. Kulkarni V1, Chandy MJ, Babu KS  Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India. 2001 Dec;49(4):355-9

10. Bogduk N Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001 Aug;5(4):382-6.

11.   Luan H1, Gdowski MJ, Newlands SD, Gdowski GT  Convergence of vestibular and neck proprioceptive sensory signals in the cerebellar interpositus. J Neurosci. 2013 Jan 16;33(3):1198-210a. doi: 10.1523/JNEUROSCI.3460-12.2013.

12.  Seaman D Winterstein  Dysafferentation:   A Novel Term to Describe the Neuropathophysiological Effects of  Joint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation  J Manipulative Physiol Ther 1998 (May);   21 (4):   267-280

Podcast #130: Change your running form ?? Plus, concepts around ankle & knee Injuries.

More on asymmetries from a neurologic perspective, The neurophysiologic process that actually occurs during an injury. Plus, Should you change your clients running form? It is a big debate, and we think many of the experts get this wrong. 

Key Tagwords:

ankle sprains, knee pain, patellar tracking, isometric loading, gait, gait analysis, neurology, thegaitguys, analgesia, tendonopathy, movement disorders, running form


Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

http://traffic.libsyn.com/thegaitguys/pod_130f.mp3

http://thegaitguys.libsyn.com/podcast-130-concepts-around-ankle-knee-injuries

http://directory.libsyn.com/episode/index/id/5887731
 


Our Websites:
www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net


Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:


Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Alan J.Pearce, Jill Cook
http://bjsm.bmj.com/content/early/2015/05/15/bjsports-2014-094386

The constant switching between steady state cortical neuron discharge and and non-steady state discharge. 
Takakusaki , Neurophysiology of Gait: From the Spinal Cord to the Frontal Lobe. Movement Disorders, Vol. 28, No. 11, 2013

So you say your client needs more ankle rocker? Faking out ankle dorsiflexion and ankle rocker.

IMG_6907.JPG

I was reminded again yesterday, after yet another foot pain client came in to see me, that many do not understand the absolute and deeper ramifications of putting an orthotic into a shoe (and onto a foot) and what effects of doing so can have on changing a necessary adaptation.

This client had medial heel pain, not plantar heel pain, not the posterior calcaneal area, the medial edge (see photo). The edge where the inside/medial edge of the calcaneus/heel meets the ground. This client could reproduce the pain on palpation and could reproduce it if they stood up, and everted the heel just a tiny bit.

This client had a healthy appearing foot and arch. But, as often is the case, appearances are deceiving. 

Here was the major problem:

- client had loss of terminal ankle dorsiflexion from prior fracture immobilization

 

- top end calf weakness * (see later)

- client had clear fatiguability of the anterior shin compartment muscles, and mild toe extensor weakness

- the client had high arched supportive orthotics

So, what is happening here, and often happens with the above limitations, the client does not have the muscular ability to maintain the arch sufficiently from the big players, as noted. In other words, the ankle has lost mobility and the foot has lost stability, a common pattern. To make up for a loss of ankle dorsiflexion we often collapse the arch a sufficient amount to pitch the talus medially and forward to help the tibia progress forward the requisite amount needed for forward locomotion across the foot-ankle complex. This is a normal compensation, and in time there may be a pathologic cost. This medial approach of the talus and arch collapse, requires calcaneal eversion. This eversion means more medial calcaneal loading into the shoe, orthotic or ground, including medial soft tissue (mostly fat pad) loading between the ground and the everting calcaneus.  

This is a normal compensatory strategy to move forward over a restricted ankle dorsiflexion range. However, the doctor this client saw previously (for plantar fascitis), felt that this motion was a problem they needed to block with an orthotic. One that resisted the heel eversion and more than normal arch collapse/pronation cycle. This remedy resolved the plantar fascial pain. But, the medial heel pain began shortly thereafter. 

So, here we have a client that is compensating, and finding a way (though there are biomechanical costs to this way), to get past a limitation, loss of ankle rocker in this case. But, the doctor put an orthotic in the shoe that stopped this "way".  Now the client has to evert the heel even harder, because of the presence of the orthotic preventing it) and it is causing a "bite" or friction plus compression of the medial soft tissues. 

So, this client now still cannot compensate well, in the manner they have attempted to do so, because of the orthotic. So, where are the loads going to go now ? Yes, some are being rammed into the medial aspect of the orthotic, but some are likely going to so elsewhere. Remember, the client is trying to progress their mass over and past the limited ankle rocker, and more pronation was their strategy. But, the orthotic is preventing that.  So, the loads are very likely going to move up the chain (because the orthotic is muting loads down into the foot). 

______

Me:     "Oh, wait, "Mr. Jones", didn't you say you were just recently beginning to have some posterior knee pain ?  Let me tell you why you are hyperextending your knee a little more than normal and taxing out your gastrocneumius.* One way you can progress forward, if you cannot do it through ankle rocker, is to extend your knee a little by contracting your quadriceps a small amount at midstance.  Lets discuss why the orthotic is not helping you, not solving your problem, and creating some new issues for you. Then lets get down to fixing the root problem."

Some things to think about.  Orthotics are not bad, but the user has to know when they are a device to help a client progress through a problem, and when they are inappropriate. Not all increased pronation is bad, particularly when it helps a client get through a problem. But, fix the root problem, and then help them regain proper amounts of pronation.

Oh, and one more thing, all you "drive more ankle rocker and dorsiflexion" people out there. Are you driving more ankle dorsiflexion, or are you merely pressing the talus into more medial posturing, plantarflexion and adduction? These are the talar motions in pronation. And when you pronate, you get more ankle rocker, faked out ankle rocker. So, are you truly helping your client get more ankle rocker and dorsiflexion ? Is this increased pronation what they are doing during their squats, to "apparently" get enough ankle rocker/dorsiflexion?  Be careful all those new found ankle rocker mobility drills are not just making your client pronate more than normal. We know it happens, we see all the time. Loss of ankle mobility and loss of foot stability are often a paired phenomenon, they are trying to talk to you and tell you to treat the root cause.

-Dr. Allen, one of the gait guys

The Latissimus in Gait

Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, rostrally to the lower 3 or 4 ribs and inferior angle of the scapula, to travel superiorly and laterally to the attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements.

It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically during walking gait (1,2) until speed increases or you are running (2-4).  The latissimus dorsi is THE functional link between the upper and lower extremity, particularly though its connections with the thoracolumbar fascia (5,6). Latissimus activity, through gait and arm swing seems to profoundly influence and be influenced by gluteal activity, through the posterior oblique sling system (3,4), consisting of the latissimus dorsi, thoracolumbar fascia and contralateral gluteus maximus (7). The posterior oblique sling system provides trunk stability and power delivery to the upper extremity from the contralateral lower extremity and promotes mutual gait patterns between the upper and lower extremities (8), while creating joint contraction in running, turning and walking (9,10). Recent studies conversely show that arm swing can, in turn, effect lower extremity movement as well (3,4). 

Given the importance of the latissimus, it would stand to reason we would want it to function at its best. Dry needling is one modality we seem to be able to use to change its function,not only reducing central sensitization, but reducing local and referred pain, improves range of motion and muscle activation patterns (11-13). There are other modalities, including supportive exercises, that can be used to both activate and rehabilitate the lat as well (14-17)

Here is one method we like to use to needle the latissimus dorsi. Consider adding this to your clinical toolbag. 

 

references: 

1. Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558

2. G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006

3. Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.

4. Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.

5. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.

6. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy,  function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.

7. Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D Exercise treatment for sacroiliac pain. Orthopedics. 2001 Jan; 24(1):29-32.

8. Page P, Frank C, Lardner R: Assessment and treatment of muscle imbalance. Champaign: Human Kinetics Pub, 2010, pp 30–37. 

9. Bergmark A Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989; 230():1-54.

10. Collins SH, Adamczyk PG, Ferris DP, Kuo AD A simple method for calibrating force plates and force treadmills using an instrumented pole. Gait Posture. 2009 Jan; 29(1):59-64.

11. Dar GHicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.

12. Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.

13. Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.

14. Youdas JW, Coleman KC, Holstad EE, Long SD, Veldkamp NL, Hollman JH. Magnitudes of muscle activation of spine stabilizers in healthy adults during prone on elbow planking exercises with and without a fitness ball. Physiother Theory Pract. 2017 Sep 18:1-11. doi: 10.1080/09593985.2017.1377792. [Epub ahead of print]

15. Crane P, Ladden J, Monica D. Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction: A case report. Physiother Theory Pract. 2017 Aug 30:1-5. doi: 10.1080/09593985.2017.1368755. [Epub ahead of print]

16. Massé-Alarie H, Beaulieu LD, Preuss R, Schneider C. Influence of paravertebral muscles training on brain plasticity and postural control in chronic low backpain. Scand J Pain. 2016 Jul;12:74-83. doi: 10.1016/j.sjpain.2016.03.005. Epub 2016 May 11.

17. Snarr RL, Hallmark AV, Casey JC, Esco MR. Electromyographical Comparison of a Traditional, Suspension Device, and Towel Pull-Up. J Hum Kinet. 2017 Aug 1;58:5-13. doi: 10.1515/hukin-2017-0068. eCollection 2017 Sep.

Inverted ? Cross over gait? How we do all things ?

How we do one thing, is how we do all things.

Screen Shot 2017-10-19 at 12.45.46 PM.png

I was sitting having my morning coffee earlier than normal this morning, which left me time to ponder some things.
Look at this picture, is this not a magnification of the "cross over gait" x100 ? Thus, is that planted foot not inverted ? Yes, it has to be, to a degree, a high degree. There is a reason why soccer players have a great affinity for ankle sprains.
When we have a narrow based gait, we are most likely going to strike more laterally on the foot, more supinated, if you will. If you widen step width, less inversion, less lateral forces (typically) and less supination (typically) compared to a narrow based gait. 
If we descend stairs with our feet in a more narrow based gait, we are not only going to be inverted more, but striking at the ball of the foot, thus, more on the lateral foot tripod. This is the typical inversion sprain injury position. 
When we jump, we should be trying to land with our feet more abducted, certainly not narrow based, because if we are too narrow we are at more risk for the same lateral forefoot landing and thus ankle inversion event. Just like descending stairs.

We see plenty of ankle inversion events. Why? 
Because most people do not have enough hip abduction or peroneal skill, strength, endurance and they are unaware of their weak gait patterns or their ankle spatial awareness. Many have lazy narrow based gaits and insufficient proprioceptive awareness. And, they carry these things over into running, walking, jump landing (ie. volleyball, basketball, etc), and descending stairs, just to name a few.

How we do one thing, is how we do all things (mostly).

-Dr. Allen

Addendum:

Rickie Lovell : As he struck the ball it would been everted. The momentum of the follow through will have off loaded the everted foot as the energy moves in a similar line to that of the ball. It is extremely rare for a footballer to get a sprain from this, I certainly didn't see over several years working in professional football. 
On a side note, find some footage of David Beckham taking free kicks - the mechanics are astounding!

The Gait Guys: possibly everted, but no guarantee.It still looks pretty inverted to me.But we see your point, and is a real good one, real good. Super good. We will check our the bender-man thanks for chiming in with such great insight !

The Gait Guys:  yes, the momentum of the leg kicking across the body would externally spin the stance leg. The picture is likely showing the offloading phase, not the loading. Bueno !

Should you rotate your shoes?

Rotate your shoes more often? Maybe not, if you are concerned about plantar pressures. But do increased plantar pressures actually cause injuries? That is the million dollar question, isn't it?

 

from this paper:

  • Footwear characteristics have been implicated as a cause of foot pain (1)
  • Ill fitting footwear has been associated with foot pain.(2)
  • Individually fitted sport shoes were found to be effective in reducing the incidence of foot fatigue.(3)
  • There is an association between using inappropriate footwear and injuries.(4) 
  • An association between injuries and the age of sport shoes has been reported. (5)
  • The recommendations are that running shoes need to be changed every 500 - 700 kilometres as they lose their shock-absorbing capabilities.(6)
  • Elevated plantar pressures cause increased foot pain in people with cavus feet.(7)

"Walking plantar pressures in running shoes need to be investigated. There are no pedobarographic studies in the literature that compare new with old running shoes. We hypothesized that old running shoes transmitted higher plantar pressures as compared to new running shoes. If so, are old running shoes detrimental to our feet? The purpose of this study was to see whether the mean peak pressures & pressure-time integrals exerted at the plantar surface of feet were higher when using old running shoes as compared to new running shoes.

Plantar pressure measurements in general were higher in new running shoes. This could be due to the lack of flexibility in new running shoes. The risk of injury to the foot and ankle would appear to be higher if running shoes are changed frequently. We recommend breaking into new running shoes slowly using them for mild physical activity.

 Rethnam U, Makwana N. Are old running shoes detrimental to your feet? A pedobarographic study. BMC Research Notes. 2011;4:307. doi:10.1186/1756-0500-4-307. link to FREE FULL TEXThttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228510/

references:

  1. Grier TL, Knapik JJ, Swedler D. et al. Footwear in the United States Army Band: Injury incidence and risk factors associated with foot pain. Foot (Edinb) 2011;21(2):60–5. [PubMed]
  2. Burns SL, Leese GP, McMurdo ME. Older people and ill fitting shoes. Postgrad Med J.2002;78(920):344–6. doi: 10.1136/pmj.78.920.344. [PMC free article] [PubMed] [Cross Ref]
  3. Torkki M, Malmivaara A, Reivonen N. et al. Individually fitted sports shoes for overuse injuries among newspaper carriers. Scand J Work Environ Health. 2002;28(3):176–83. [PubMed]
  4. Taunton JE, Ryan MB, Clement DB. et al. A prospective study of running injuries: the Vancouver Sun Run "In Training" clinics. Br J Sports Med. 2003;37:239–44. doi: 10.1136/bjsm.37.3.239.[PMC free article] [PubMed] [Cross Ref]
  5. van Mechelen W. Running injuries: A review of the epidemiological literature. Sports Med.1992;14(5):320–35. doi: 10.2165/00007256-199214050-00004. [PubMed] [Cross Ref]
  6. Fredericson M. Common injuries in runners: diagnosis, rehabilitation, prevention. Sports Med.1996;21(1):49–72. doi: 10.2165/00007256-199621010-00005. [PubMed] [Cross Ref]
  7. Wegener C, Burns J, Penkala S. Effect of neutral-cushioned running shoes on plantar pressure loading and comfort in athletes with cavus feet: a crossover randomized controlled trial. Am J Sports Med. 2008;36(11):2139–46. doi: 10.1177/0363546508318191. [PubMed] [Cross Ref]

Threshold Foot Drop

Threshold foot drop.  
Do you see it in this gait? No. There is a clue though, the EHL on the right (extensor hallucis longus) does not seem to be all that hearty and robust during gait, the toe is not as extended/dorsiflexes as on the left foot. A Clue ? Yes. 
This client had true blatant foot drop, but it was caught relatively immediately, and the source resolved and recovery ensued. There is still some residual weakness, as you see at the end of the video,  but making steady gains. Previously, gait showed obvious foot drop, foot slap, abrupt knee flexion (the "catch" response as we call it as the client's knee suddenly flexed forward as foot slap occurs). But, as you can see , the gait is pretty much normal now except for a little EHL strength lag. But, at the end of the video, when they heel walk, one can see the weakness, they cannot keep the ball of the foot off the ground during attempted heel walk. We like to call this "threshold weakness", it is just hovering below the surface, when taxed, it can be seen, but doesn't show up in gait. But, it does show up in longer endurance based walking events. This may be when your client's symptoms show up, as fatigue expresses limitations in the system. It just goes to show you, if you are not testing and looking for these things, you just might not find the source of your clients knee pain, foot pain, hip or low back pain. Heel and toe walking takes 10 seconds, do not forget to check them off.  It just might be the "big reveal" for you, and them !

-Shawn and Ivo, the gait guys

Arm Swing and dynamic stability of the system.

Screen Shot 2017-10-16 at 1.33.03 PM.png

We have discussed the arm swing issue so many times over the years that we have lost count. By many sources, arm swing is a product of lower limb action and a product of the effective, or ineffective, relationship between the shoulder "girdle" (maybe thoracic rotation component) and the pelvic girdle (lumbopelvic rhythm) during gait.  This is the concept of phasic and anti-phasic limb swing. If you want to dive into that, and you should if you are unfamiliar with the concept, you can look it up on our blog using the search box.  We are not to forget that the arms, and thus arm swing, is a major factor in maintaining balance. We have used the term "ballast" many times to describe the effects of arm swing, rotation, abduction, circumduction etc on assisting balance maintenance of the body during various locomotion strategies. These are largely subconscious actions, hence why we agree with the research suggesting that arm swing is secondary, compensatory, and takes its queues off of the activity of the lower limb motor actions. In essence, arm swing variants are necessary compensations to assist in maintaining things like balance, center of pressure, equilibrium and the like. 

In this recent 2017 study, we have another suggesting arm swings function in assisting, even improving, dynamic stability. We are reminded of MdGill's suggestion, and the concepts of phasic and antiphasic torso-pelvis counter rotational movements, of how spinal loads can be affected by changes or differences in arm position.  Even arm position changes in sitting and standing can alter spinal loads, so during movement it is a virtual guarantee. 

This study looked at "how arm swing could influence the lumbar spine and hip joint forces and motions during walking." In this study, the researchers had each subject perform walking with different arm swing amplitudes and arm positions. Here is a comment from the researchers on what they found, it is pretty much what we have been writing about for several years based off of other research"

"The range of motion of the thorax with respect to the pelvis and of the pelvis with respect to the ground in the transversal plane were significantly associated with arm position and swing amplitude during gait. The hip external-internal rotation range of motion statistically varied only for non-dominant limb. Unlike hip joint reaction forces, predicted peak spinal loads at T12-L1 and L5-S1 showed significant differences at approximately the time of contralateral toe off and contralateral heel strike."

Thus, we find yet another study confirming what many will say is obvious, that being arm position and movements have notable effects on whole body kinetics and spinal loads. This study suggested that arm variations did not have an effect on spinal loads during walking. We find this curious; it is something we will be looking into, and pondering. We hope you do as well.

Effect of arm swinging on lumbar spine and hip joint forces. Lorenza Angelini et al. Journal of Biomechanics, Sept 2017
http://www.sciencedirect.com/science/article/pii/S0021929017304670

Vitamin D and Gait?

Vitamin-D.jpg

So, is it the effects on calcium and nerve function (neurotransmitter release), the effects on calcium and muscular contraction, the antioxidants properties, some other function? Supplementing Vitamin D and getting people more sun exposure are easy things to do...

"These findings reveal an important new relationship between parathyroid hormone and gait stability parameters and add to understanding of the role of 25-OHD in motor control of gait and dynamic balance in community-dwelling women across a wide age span."

Bird MLEl Haber NBatchelor FHill KWark JD. Vitamin D and parathyroid hormone are associated with gait instability and poor balance performance in mid-age to older aged women. Gait Posture. 2017 Sep 28;59:71-75. doi: 10.1016/j.gaitpost.2017.09.036. [Epub ahead of print]

 

https://www.ncbi.nlm.nih.gov/pubmed/29017107

Podcast 129: The Random Topic Podcast.

Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

http://traffic.libsyn.com/thegaitguys/pod_129final.mp3

http://thegaitguys.libsyn.com/podcast-129

Key Tagwords:

usain bolt, gait, gait asymmetry, isometrics, isotonics, RF ablation, COOLIEF, OA, deafferentation, knee arthritis, ibuprofin, kidney damage, NSAIDS, heel drop, achilles, tendonitis, heel pain, 

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net


Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Healing Tech in Neuroscience:

New device can heal with a single touch
https://www.usatoday.com/story/news/nation-now/2017/08/07/miracle-device-can-heal-single-touch-and-even-repair-brain-injuries/537326001/

Cool radiofrequency ablation
http://www.nbcnews.com/health/health-news/cool-new-knee-procedure-eases-arthritis-pain-without-surgery-n771221

Updates on Ibuprofin in runners
http://womensrunning.competitor.com/2017/07/news/ibuprofen-risks-endurance-runners_78580#EyIoMyAdkPW9UBpP.97

PeerJ. 2017 Jul 19;5:e3592. doi: 10.7717/peerj.3592. eCollection 2017.
Sonographic evaluation of the immediate effects of eccentric heel drop exercise on Achilles tendon and gastrocnemius muscle stiffness using shear wave elastography.
Leung WKC1, Chu KL1, Lai C1.

Front Physiol. 2017 Feb 28;8:91. doi: 10.3389/fphys.2017.00091. eCollection 2017.
Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise.
Maganaris CN1, Chatzistergos P2, Reeves ND3, Narici MV4.

Oman Med J. 2010 Jul; 25(3): 155–1661.
An Overview of Clinical Pharmacology of Ibuprofen
Rabia Bushra* and Nousheen Aslam
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191627/

Pharm Biol. 2014 Feb;52(2):182-6. doi: 10.3109/13880209.2013.821665. Epub 2013 Sep 30.
Zizyphus jujuba protects against ibuprofen-induced nephrotoxicity in rats. Awad DS1, Ali RM, Mhaidat NM, Shotar AM.
https://www.ncbi.nlm.nih.gov/pubmed/24074058

Gait asymmetry ?
https://www.ncbi.nlm.nih.gov/pubmed/28759127
Scand J Med Sci Sports. 2017 Jul 31. doi: 10.1111/sms.12953. [Epub ahead of print]
Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters.
Haugen T1, Danielsen J2, McGhie D2, Sandbakk Ø1,2, Ettema G2.