Ankle Sprains...A nice review here

A nice FREE FULL TEXT literature review about the biomechanics, diagnosis, grading and treatment (conservative and non conservative) of acute ankle sprains. There is an interesting section at the end for prevention. Consider this a staple for your library to refer to when needed.

 "This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. "

Fong DT, Chan Y-Y, Mok K-M, Yung PS, Chan K-M. Understanding acute ankle ligamentous sprain injury in sports. Sports Medicine, Arthroscopy, Rehabilitation, Therapy, and Technology : SMARTT. 2009;1:14. doi:10.1186/1758-2555-1-14.

link to full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724472/

 

Podcast: "Run to the Top" with Guests Ivo and Shawn, The Gait Guys


Show link:  https://runnersconnect.net/running-interviews/gait-guys/

We recently shared the mic for an hour with Tina Muir over at RunnersConnect.net.
It was a great open conversation and I think our gang here and elsewhere will really find some hearty information here. Some of the topics you have heard before if you have been with us at The Gait Guys Podcast previously, however, we take some unanticipated paths that lead us to some deeper conversations and some insights you may have not heard from us before.  The ability to facilitate this in a first time discussion with two strangers is the gift of a great interviewer, and Tina shined brightly in teasing these things from us.  We hope you will put your favorite ear cans on and go for a run or walk and give this lively discussion an hour of your time, we do not think you will be disappointed.  Tina laid out a beautiful show, and has gorgeous show notes and time stamp break downs for your OCD folks !  Bravo.  

Again, here is the link to her site, and the show.

Show link:  https://runnersconnect.net/running-interviews/gait-guys/

Offer her hard work some support and like her on all social media and give her other guest podcast shows a try. 

-Shawn and Ivo (and Tina, this time around !)

Screen Shot 2016-11-23 at 5.56.54 AM.png

medial to lateral stability....in older folks...

  • "older adults prioritized medial to lateral control over forward progression during adaptive walking challenges."

Did you know this? It makes sense, if you have been reading along with us and think about decomposition of movement when we get injured or as we age. 

Bottom line?

Older folks would rather move side to side and seem more concerned with lateral movement (i.e. coronal plane stability, possibly to avoid falling?) and will shorten their step length to adjust for moving forward, if needed.

"Simultaneous control of lower limb stepping movements and trunk motion is important for skilled walking; adapting gait to environmental constraints requires frequent alternations in stepping and trunk motion. These alterations provide a window into the locomotor strategies adopted by the walker. The authors examined gait strategies in young and healthy older adults when manipulating step width. Anteroposterior (AP) and mediolateral (ML) smoothness (quantified by harmonic ratios) and stepping consistency (quantified by gait variability) were analyzed during narrow and wide walking while controlling cadence to preferred pace. Results indicated older adults preserved ML smoothness at the expense of AP smoothness, shortened their steps, and exhibited reduced stepping consistency. The authors conclude that older adults prioritized ML control over forward progression during adaptive walking challenges."

J Mot Behav. 2016 Nov 21:1-6. [Epub ahead of print]
Age-Related Differences in Locomotor Strategies During Adaptive Walking.
Lowry KA, Sebastian K, Perera S, Van Swearingen J, Smiley-Oyen AL.

Who’s driving the compensation, anyway?

We often look at folks gait and see a pelvic drift or lean to the weak side and think “I should help them strengthen their gluteus medius”, which is often needed, but we need to think of what is driving that compensation.

Take a look at this gent that presented to the office with low back pain and watch his gait. 

Some things we hope you see are:

  • lean to the right during right stance phase
  • increased arm swing on the left
  • increased progression angle of the foot on the left
  • increased arm abduction on the left, adduction on the right
  • increased finger flexion on the left
  • slight head tilt to the left
  • tibial varum
  • crossover gait

Perhaps you are thinking, in the same order as above:

  • weak glute medius on left or QL on right or compensating for LLD on L
  • using L arm to try and help propel himself forward
  • increased balance requirements on the left so the “kickstand” foot
  • moving center of gravity the left
  • increased flexor tone to try and compensate for a weakness
  • moving center of gravity to the left, the brain needs to help keep the eyes parallel to the horizon
  • tibial varum and perhaps a more supinated foot posture, or increased forefoot pronation requirements
  • crossover

..or maybe you are thinking of something else?

The truth of the matter is that what is driving the largest part of his compensation is in fact a disc herniation, but not for what you may be thinking. The herniation is on the LEFT SIDE and at L3-L4. Take a look at the MRI Image. Yes, there is also a small herniation that L5-S1 but it DOES NOT occlude the foarmen nor hit the individual nerve roots and is on the LEFT (which you are hopefully thinking would cause left sided weakness)

Hmmm...

So what is driving his compensation is actually a LEFT SIDED quad/adductor weakness (the femoral and obturator nerves are from L2-4). Go back and watch the video again. Can you see it?

Someone needs to be driving the bus. Don’t be too quick to jump on it until you know who is driving it and where it is going. 

Podcast #115: Brain logging injuries and patterns

We go deep on how injuries get logged deep in the CNS, what to do and how to get around it all.  Join us today !


Show sponsors:
newbalancechicago.com
altrarunning.com

www.thegaitguys.com
That is our website, and it 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.

* Podcast Links: 

http://traffic.libsyn.com/thegaitguys/pod_115f.mp3


http://thegaitguys.libsyn.com/podcast-115-brain-logging-injuries-and-patterns

_______________________________________
Show Notes:

Imagining workouts can improve strength
http://globalnews.ca/news/2885514/imagining-a-workout-may-be-almost-as-good-as-the-real-thing/

Your injuries are not forgotten
http://www.medicalnewstoday.com/articles/312665.php

Sending a V16, with tears of joy. More neurology of movement: Climbing impossible stuff.

This badass just did a V16 here in this video, translation, the Mount Everest of bouldering. He deserved to cry.

Spin this picture 180 and he is crawling, finding points of “fixation”. What is neat about climbing is that you can have one, two, three or four points of fixation, unlike walking (one or two points) and crawling (two, three or four points of fixation). The difference in climbing is that gravity is a bear, wearing you down, little by little. A deep similarity in climbing to any variety of crawling is that both involve pulling and pushing, compressing and extending over fixation points. Other common principles are those of fixation, stability, mobility and neurologic crawling patterns in order to progress.
Some research has determined that in quadrupeds the lower limbs displayed reduced orientation yet increased ranges of kinematic coordination in alternative patterns such as diagonal and lateral coordination.  

This was clearly different to the typical kinematics that are employed in upright bipedal locomotion. Furthermore, in skilled mountain climbers, these lateral and diagonal patterns are clearly more developed than in study controls largely due to repeated challenges and subsequent adaptive changes to these lateral and diagonal patterns.  What this seems to suggest is that there is a different demand and tax on the CPG’s (central pattern generators) and cord mediated neuromechanics moving from bipedal to quadrupedal locomotion. There seemed to be both advantages and disadvantages to both locomotion styles. Moving towards a more upright bipedal style of locomotion shows an increase in the lower spine (sacral motor pool) activity because of the increased and different demands on the musculature however at the potential cost to losing some of the skills and advantages of the lateral and diagonal quadrupedal skills. Naturally, different CPG reorganization is necessary moving towards bipedalism because of these different weight bearing demands on the lower limbs but also due to the change from weight bearing upper limbs to more mobile upper limbs free to not only optimize the speed of bipedalism but also to enable the function of carrying objects during locomotion. 

This brief excerpt was taken from one of the many articles I have written on the complex biomechanics and neurology of climbing and movement. Search for it all on our blog, thegatiguys.com

-Dr. Shawn Allen, the other gait guy
 

Chris Sharma free climbs a giant Redwood Tree

Chris is a legend, one of the best. He climbs routes and routes without ropes that others do not even consider possible. This time, he takes on a giant Redwood tree.


"In climbing there is suspicion of a shift in the central pattern generators because of the extraordinary demand by pseudo-quadrupedal gait climbing due to the demand on the upper limbs and their motorneuron pools to mobilize the organism up the mountain.  We know these quadrupedal circuits exist. In 2005 Shapiro and Raichien wrote “the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.”
I have written several articles on the complex neurology and biomechanics of climbing.  You can search for them on our blog.  - Dr. Allen
 

Pathologic Ankle Rocker: Part 2. “Passing the Buck Proximally”

This was an unexpected follow up blog post from yesterday’s piece we did on the rigid flat foot. We were purging some files from an old computer and came across these 2 videos. We are not even sure where they came from. They were AVI files from probably 2 decades gone by;  they reminded us how long we have been at this gait game and how many great patients have taught us along the way.
Yesterday we learned that if the ankle rocker (dorsiflexion) was impaired that we could ask for the motion to be passed into the midfoot via hyperpronation in order to get the tibia to progress past vertical to enable the body to pass by the rigid ankle mortise rocker.  (Remember from our previous teachings that there are 3 rockers in the foot. First there is heel rocker, then ankle rocker, then forefoot rocker. Each is essential for normal gait. You must understand the 3 rockers to understand gait and to recognize gait pathologies when they present.)
So, yesterday we saw a strategy of pronating excessively through the midfoot to artificially trick us into thinking we have more ankle rocker then we actually truly did. So this was a “pass the buck” into the foot. Today however we are going to show you a very atypical compensatory choice. Today this client shows that with a rigid and/or strong enough arch that the arch doesn’t always need to be the part that gives in to enable more rocker. Today this client chose a vertical strategy.
You are going to have to study these videos closely several times, this is a critical learning and teaching point today. The problem is the left ankle in the video.

This client has chosen to goVERTICAL when they hit the ankle rocker limitation. Once they achieve their terminal range at the ankle mortise joint (the tibio-talar joint ) their brain realized that moving forward at the ankle was impossible. Since the midfoot did not collapse and give in, as in yesterday’s case, they had no choice but to “pass the buck” proximally into the kinetic chain. In this case we see that the knee was the next vertical joint. Now, they have 2 choices, either hyperextend the knee to enable a forward lurch of the body mass past the ankle rocker axis or “go vertical”. In this case you can see the early heel rise (we refer to is as premature heel rise). Frequently a premature heel rise can force knee flexion but in this case the rise just kept going vertical and forcing them into the use of the gastrocsoleus group and thus forcing a lift of the entire body. If you look hard you can see a greater development of the calf muscles on this side from doing this for years. (Oh, wait, memory data dump here…..we are recalling this case, it was the result of an old motorcycle accident. A student sent us this video back in the 1990’s when we were teaching at the university.)
What is interesting here is that if you think hard, and this will be a new thought process for many readers, that when he goes into heel rise he buys himself more ankle range again. You see, he first met the end range limitation of ankle rocker which appears to be about 90 degrees and then he hits the bony block. If he goes vertical into the calf he is moving back into plantarflexion. This means that even though he is on the forefoot now, he has bought himself more ankle dorsiflexion range again. Now he has the option of holding the posture on the forefoot as rigid and then re-utilizing the new-found extra degrees of ankle dorsiflexion to progress forward OR, he can just move into FOREFOOT ROCKER (the 3rd of the rockers we meantioned earlier).  This client is likely doing a bit of both, perhaps a little more of the forefoot rocker strategy.
You can also kind of see that this slightly shortens the time in the stance phase on this left side and causes an early dumping onto the right limb (which causes a frontal plane pelvis distortion compensation). This gives the appearance of a slight limp.
So, this was a nice follow up from yesterday’s principle of “passing the buck”. You can either ask for the motion from the next distal joint in the kinetic chain, oryou can back up the kinetic chain and dump it into the proximal joint from the pathologic one (the knee in this case). Which one would you want, if you had to choose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns. 

Here is a tougher question for you. Would you want this phenomenon on one side and be unilaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*Please do not try to help this client by putting a heel wedge in their shoe. You are just going to rush heel rocker into that bony block sooner and faster and speed up his pathologic stance phase. You will see his vertical strategy come even faster and thus pass the buck into the opposite right hip even stronger. It is a fleeting good initial thought because you are merely trying to help his poor calf muscles get to that heel rise easier, until you think about it for a minute.

When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

Part 2: The Turning: The thoracic spine in connecting the kinetic chain

Yesterday I provided a blog post on this photo here. Today I want to pose a rabbit hole for you to ponder, in the hopes that  you see how  much deeper this process is at looking at gait and locomotion  . . . . . thoracic rotation.
Below you will find yesterdays post, if you read it yesterday you can scroll down to the *** down below and read what I ask you to ponder today (but its always nice to review :)

From yesterday's blog post:


"It should be simple and clear in the photo that I am turning my neck and thoracic spine strongly to the left.  The left rotation has forced me to find stability over the lateral left foot while driving the rotation with the right foot.  Left foot had to supinate, right had to pronate. No rocket science here.

Earlier in the week I posted a brief discussion on the neck and proprioception and the upper and lower limb. I caught some questions on challenging the strength of the neurological linkages to the lower limb, so I promised a simple picture to solidify my point.
Where is what i wrote earlier this week.
"From the study: "Limb proprioception is an awareness by the central nervous system (CNS) of the location of a limb in three-dimensional space and is essential for movement and postural control. The CNS uses the position of the head and neck when interpreting the position of the upper limb, and altered input from neck muscles may affect the sensory inputs to the CNS and consequently may impair the awareness of upper limb joint position."

We say it is not just the upper limb however, the neck and head posture is used in interpreting the position of the lower limb as well. And similarly altered head/neck muscle input can impair awareness of the lower limb posture as well. Think about it, we are trying to stay upright in the gravitational plane while keeping the eyes and vestibular centers on the horizon. Gait is nothing more than a single leg balancing act repeated over and over. Faulty info on where our center of pressure is from a visual or vestibular aspect will alter where we put our foot in space. Just look at how many neurologic diseases end up with a wider based gait, because our proprioceptive centers no longer trust our base of support. It is all connected."

Exp Brain Res. 2015 May;233(5):1663-75. doi: 10.1007/s00221-015-4240-x. Epub 2015 Mar 13.Neck muscle fatigue alters upper limb proprioception. Zabihhosseinian M1, Holmes MW, Murphy B.

As in this study, and putting it together with my photo and discussion at the start here today, limb proprioception is an awareness by the CNS of the location of the limb and is essential for proper movement and postural control. If I had rotated to the left and had my CNS not known where the foot was in space and in relation to the rest of my body, I may have fallen over to the left. Instead, my CNS sensed the weight shift to the left from the neck and torso rotation, and moved my foot weight bearing into supination (affording a slightly greater lateral weight bearing on the foot) to accommodate the shift in my center of pressure and mass laterally.  So, the CNS used the position of the head and neck, and the weight shift, in interpreting the appropriate positioning of the lower limbs. Sometimes moving the foot into supination to accommodate the lateral load is not enough, and we need to actually step laterally to maintain upright.  Altered input from my neck muscles might affect the sensory inputs to the CNS and consequently may impair the awareness of my limb joint positioning in space. This happens often in vestibular challenged clients and in client of aging decline where the system is losing proprioception. If we do not know where a body part is in space, we don't know how to use it or how to load it (think about chronic ankle sprains).

As i said earlier this week, think about it, we are trying to stay upright in the gravitational plane while keeping the eyes and vestibular centers on the horizon. Gait is nothing more than a single leg balancing act repeated over and over. Faulty info on where our center of pressure is from a visual or vestibular aspect will alter where we put our foot in space. Just look at how many neurologic diseases end up with a wider based gait, because our proprioceptive centers no longer trust our base of support. It is all connected.

Think about how amazing this system is when it works right, we can run on a track leaning into the curve, we can ride a bike and lean into turns, we can run forward and yet turn to look behind us, all without falling over -- thanks to our CNS and joint proprioception.

*** Today, to build on the above principles, adding the concept of thoracic rotation and even more, scapular stability, breathing, rib cage and thoracic spine mobility and stability, specifically thoracic rotation is critical.  What if any of these movements are lost in this client's turning attempt ?  Let's keep it simple, what if thoracic rotation is lost, specifically what if the client has lost left thoracic rotation? What happens then to the left foot in this scenario ? Can they achieve enough left foot supination to achieve enough left lateral weight shift to make up for the loss of left thoracic rotation ? Can they achieve enough of these movements without exceeding the tipping point at the ankle creating an inversion sprain?  For the task to be completed, the motion is going to occur somewhere, the question is, will the place it occurs be a safe place ?

Lets complicate things further, and ask about hip rotation, what if the left hip has impaired internal rotation, after all it is part of the left turning pattern.  At the terminal end range of thoracic rotation in this case, any further rotation needs will come from hip internal rotation typically (once the pelvis stops spinning leftward with the spine rotation).  What if that hip rotation end range is impaired or limited ?  Something has to give, the turning goal is defined, the question remains does the client have the working parts to get the turning done without overloading any single area causing pathology ?  Furthermore, the right foot must be able to perform the requisite pronation and external hip rotation for similar reasons during the turning. Sharp directional change cutting sports like soccer, basketball and football all require this kind of motion, namely the discussed cervical rotation, thoracic rotation, hip rotation and ability to stabilize safely on a supinated foot at times.  For example, try running downfield at a full clip and suddenly look and turn back over your left shoulder to catch a football pass, these are the component parts I just outlined above. If any of them are limited or missing we can see injury, whether its a torn ACL, hip impingement, sprained ankle, neck or shoulder strain etc.  Everything i have outlined in the last 3 blog posts has to be clean and with safe sensory-motor patterning.  The problem is, we teach people to run and catch, but we often do not look at these component parts as I have discussed looking for limitations, potential places were these glitches harbor.  These are the component things and frameworks of thinking and problem solving that I do in my office.  I hope you do think the same way as well, we can be friends then :)

The next time your client comes in with an ankle inversion sprain, or hip pain, or shoulder or thoracic pain just as examples, try asking them about what they were doing at the time of the event.  Work backwards from there and see if they had the component parts or if one was missing that could be the culprit.

 I had a client just this past week during the NYC marathon invert his ankle when he looked back to snap  a selfie with the crowd behind him.  What i discussed today was the likely mechanism -- his thoracic rotation to that side sucked when I examined him and he had loss of internal hip rotation on that side.  The motion had to go somewhere , sadly it was one degree of ankle supination too much this time.  Many injuries do not occur in a vacuum, there is a reason if you know how to think it through and examine the parts -- go beyond your movement screenings though, it is just a piece of the pie. Oh, one more thing, if this was your client and all you did was begin managing his ankle sprain and nothing else, well, you are just a technician, and you are better than that.  Your job is to find the problems within the system, not the compensations which often only show up in movement screens,  you must examine your client. You must see if they are neurologically intact, determine if there are weaknesses, compensations, shortness, tightness, endurance issues, skill issues, joint range limitations, aberrant movement patterns amongst other things.  You must find these things, then you must figure out why they are there, then you must begin to remedy them. 

Dr. Shawn Allen, the other gait guy

Turning: Connecting the kinetic chain

Look at the photo, which way am I turning my head ? How hard am I turning ? Perhaps I am turning hard through my neck and thoracic spine to look over my shoulder.  The point is, you can see it in my feet and if you know your biomechanics you should easily know which way I am turned.

 It should be simple and clear that I am turning my neck and thoracic spine strongly to the left.  The left rotation has forced me to find stability over the lateral left foot while driving the rotation with the right foot.  Left foot had to supinate, right had to pronate. No rocket science here.
Earlier in the week I posted a brief discussion on the neck and proprioception and the upper and lower limb. I caught some questions on challenging the strength of the neurological linkages to the lower limb, so I promised a simple picture to solidify my point.
Where is what i wrote earlier this week.
"From the study: "Limb proprioception is an awareness by the central nervous system (CNS) of the location of a limb in three-dimensional space and is essential for movement and postural control. The CNS uses the position of the head and neck when interpreting the position of the upper limb, and altered input from neck muscles may affect the sensory inputs to the CNS and consequently may impair the awareness of upper limb joint position."

We say it is not just the upper limb however, the neck and head posture is used in interpreting the position of the lower limb as well. And similarly altered head/neck muscle input can impair awareness of the lower limb posture as well. Think about it, we are trying to stay upright in the gravitational plane while keeping the eyes and vestibular centers on the horizon. Gait is nothing more than a single leg balancing act repeated over and over. Faulty info on where our center of pressure is from a visual or vestibular aspect will alter where we put our foot in space. Just look at how many neurologic diseases end up with a wider based gait, because our proprioceptive centers no longer trust our base of support. It is all connected."

Exp Brain Res. 2015 May;233(5):1663-75. doi: 10.1007/s00221-015-4240-x. Epub 2015 Mar 13.

Neck muscle fatigue alters upper limb proprioception.

Zabihhosseinian M1, Holmes MW, Murphy B.
 

As in this study, and putting it together with my photo and discussion at the start here today, limb proprioception is an awareness by the CNS of the location of the limb and is essential for proper movement and postural control. If I had rotated to the left and had my CNS not known where the foot was in space and in relation to the rest of my body, I may have fallen over to the left. Instead, my CNS sensed the weight shift to the left from the neck and torso rotation, and moved my foot weight bearing into supination (affording a slightly greater lateral weight bearing on the foot) to accommodate the shift in my center of pressure and mass laterally.  So, the CNS used the position of the head and neck, and the weight shift, in interpreting the appropriate positioning of the lower limbs. Sometimes moving the foot into supination to accommodate the lateral load is not enough, and we need to actually step laterally to maintain upright.  Altered input from my neck muscles might affect the sensory inputs to the CNS and consequently may impair the awareness of my limb joint positioning in space. This happens often in vestibular challenged clients and in client of aging decline where the system is losing proprioception. If we do not know where a body part is in space, we don't know how to use it or how to load it (think about chronic ankle sprains).

As i said earlier this week, think about it, we are trying to stay upright in the gravitational plane while keeping the eyes and vestibular centers on the horizon. Gait is nothing more than a single leg balancing act repeated over and over. Faulty info on where our center of pressure is from a visual or vestibular aspect will alter where we put our foot in space. Just look at how many neurologic diseases end up with a wider based gait, because our proprioceptive centers no longer trust our base of support. It is all connected.

Think about how amazing this system is when it works right, we can run on a track leaning into the curve, we can ride a bike and lean into turns, we can run forward and yet turn to look behind us, all without falling over -- thanks to our CNS and joint proprioception.

Dr. Shawn Allen, the other gait guy

Can you spot the problem?

Take a look at the pictures before proceeding, knowing that this gal presented with L sided outside knee pain and see if you can tell what may be wrong. She does wear orthotics. 

Take a good look at the lateral flare on each of these shoes. Yes, it is a Brooks Pure series with a 4mm drop. Yes the shoe has a medial (sl larger) and lateral flare, posteriorly and anteriorly.

Do you see the discoloration and increased wear on the lateral heel counter on the left compared to the left? There is also increased wear of the lugs on the outside of this left shoe. The forefoot is also worn into slight varus, but this difficult to see. The shoe, especially in combination with her orthotic, is keeping her in varus (ie inverted) for too long, taking her knee outside the saggital plane and contributing to her knee pain. 

ROTATE YOUR SHOES!

When the wrong shoe, meets the right foot

Is it any wonder that this gentleman has pain on the dorsum of this his feet?

1st of all, how about his internal tibial torsion? It is bilateral, L > R. This places the majority of his weight on the outside of his feet, keeping him somewhat supinated most of the time.

2nd: he has an anatomical leg length discrepancy on the right which is tibial (see pictures 2 and 3). This will place EVEN MORE weight on the outside of the right foot, as it will often remain in supination in an attempt to "lengthen" itself.

3rd, take a look at his shoes. Is this particular model supposed to be rear foot posted in varus? Talk about adding insult to injury! This will place this guys feet into EVEN MORE supination and EVEN MORE on the outside of his feet. maybe the right shoe is worn into more supination because of his right sided LLD?

And if that wasn't enough, this particular shoe has increased torsional rigidity through the midfoot, slowing or arresting any hope of shock absorption that he may have. 

Yikes! We sure wish more folks knew more about feet and shoes! Maybe they should think about taking the National Shoe Fit Program? Email us for more info.

Compensation patterns and the baloney sandwich: What kinda crap are you feeding your clients ?

For as long as we can remember we have been saying that what you see in someone's gait is not their problem, it is their strategy to cope with loading, movement and locomotion, taking into account the clients neuromusculoskeletal parts and the primitive reflexive patterns we learned, or didn't learn. We see in someones movement the parts that are available to actually participate in the task, the strategies that are often more pain free, and the ones that help the client feel stable. That does not mean, BY ANY MEANS WHATSOEVER, that the deployed pattern is more efficient, economical or stronger. It means the client and their nervous system chose the deployed movement strategy for a reason that is meaningful to their system.  Sometimes that means they feel less pain, sometimes more stable, sometimes stronger -- it all depends on the task and demand. A weightlifter might shift their squat load to one leg more because it feels stronger, a runner might feel more endurance in a pattern, a gymnast or ballerina might feel more balance and stability in a certain pattern, an elderly person might be searching for stability and less pain.  It all depends.  These things may not be via conscious choice, they are often not.

In this study they found that by increasing a foot toe-in pattern and a wider step width that this gait modification seemed to be successful in reducing knee joint loading in all three planes during stair ascent, regardless of knee alignment.  This pattern appeared to be a pain reduction choice, whether conscious or unconscious, likely both over time. Sometimes it is about pain, sometimes it is not.

This once again goes to prove that making recommendations off of what we see in a gait analysis is often useless and fraught with a load of lies and baloney if there is no further correlative information, we see it all the time in reports from gait lab reports we are shown.  It also means that making gait or running change recommendations off of the gait analysis alone, without a clear understanding of normal gait or absence of the findings off of a physical exam, completes the utter nonsense of the baloney sandwich. One might say there is little value, or nutrition, in this silly process when it is all you serve your client.   

Dr. Shawn Allen, the other gait guy

Effects of Toe-In and Wider Step Width in Stair Ascent with Different Knee Alignments.

Bennett, Hunter J.; Zhang, Songning; Shen, Guangping; Weinhandl, Joshua T.; Paquette, Max R.; Reinbolt, Jeffrey; Coe, Dawn P.

http://journals.lww.com/acsm-msse/Abstract/publishahead/Effects_of_Toe_In_and_Wider_Step_Width_in_Stair.97366.aspx

Hallux valgus can affect the entire kinetic chain(s)


Here at The Gait Guys we have been mentioning hallux valgus in many different clincial and biomechanical scenarios over the years.  Inability to stabilize this all critical joint is a severe handicap for the recipient. Not only is there a lateral drift of the hallux (big toe) which has its own challenges, but clients have a rotational stability challenge that makes anchoring the distal 1st metatarsal extremely difficult.  Often clients have few other options other than to begin strategies into lesser toe hammering and even flexion hammering of the hallux itself which does little than to further create the rotational vectors about the metatarsal head.  This is one of the most difficult problems to address let alone a remote changes of correction.  Surgery, when absolutely the last resort, has its own set of challenges to say the least.  
Impairing of the hallux-metatarsal interval makes toe off inefficient and can often lead to instability and pain that begins to impair the medial foot tripod, splay of the forefoot-rearfoot relationship, challenges the tibialis posterior and contributes to hip extension motor pattern impairment and thus gluteal function. These are all realms we have beaten into our readers heads over and over for years. 
The background of this study was "The aim of our study was to compare spatiotemporal parameters and lower limb and pelvis kinematics during the walking in patients with hallux valgus before and after surgery and in relation to a control group."
Here were their summary highlights from the study, things we have been saying for years and and could not agree with more:

Hallux valgus deformity is not only a problem of the foot's structure and function.
•Hallux valgus affects the entire lower limb and the pelvis motion during walking.
•Hallux valgus surgery itself solves only problems related with skeletal alignment.
•Hallux valgus surgery does not solve dynamic related problems that occur during walking.
•Hallux valgus surgery solves only consequences and not causes.



Hallux valgus surgery affects kinematic parameters during gait

Jitka Klugarova
http://www.clinbiomech.com/article/S0268-0033(16)30154-1/abstract?platform=hootsuite

A little more on the tibialis posterior (or any tendon for that matter)....

We tend to think of the etiology of tendinopathies as being overuse or biomecanically stressful situations, which are often true, but have you thought about vascularization? My partner Dr Allen wrote a great post on vascularization in a yo yo professional here. It has to make you think...

I wrote about posterior tibial tendinopathies in a post a few days ago. A recent paper shows that vascularization can be a major player in posterior tibial tendinopathies (1). Tendon blood flow tends to decrease with age and compression, which often results from increased mechanical load. This decreased vascularization, at least theoretically, can contribuute to the probability of tissue damage as tissue compliance and flexibilty will be compromised (LER). Oxygen consumption of ligaments and tendons is 7.5% lower than skeletal muscle, which may contribute to longer healing times (2,3).

So, how can we increase vascularization?
 

  • Aerobic conditioning increases mitochondrial content, myoglobin content and capillary number, among other things, due to increased demand (4).
  • Manipulation, mobilization and massage, locally as well as segmentally, can increase blood flow, at least temporarily (5,6). The L4-S1 segments of the posterior tibial nerve are the segmental levels for the tibialis posterior .
  • How about some moist heat to cause local peripheral vasodilation?
  • I wrote a commentary on how needling can effect local vasodilation here (7), based on this article (8).
  • Tissue engineering with various techniques is an upcoming and promising field (9)
  • the early research on laser therapy (photobiomodulation) has shown some positive outcomes (10)

Finally, there is some great information about medications and current research from The Angiogenesis Foundation (11)

Adding a modality like needling or acupuncture, combined with exercise and some moist heat and perhaps some laser may help to improve your outcomes. There appears only upside potential and the methods are easy to apply and implement.

 

1. Geideman WM, Johnson JE. Posterior tibial tendon dysfunction. J Orthop Sports Phys Ther 2000;30(2):68‐

2. Patla CE, Abbott JH. Tibialis posterior myofascial tightness as a source of heel pain: diagnosis and treatment. J Orthop Sports Phys Ther 2000;30(10):624‐

3. Vailas AC, Tipton CM, Laughlin HL, et al. Physical activity and hypophysectomy on the aerobic capacity of ligaments and tendons. J Appl Physiol 1978;44(4):542-546.

4. https://www.cdc.gov/nccdphp/.../chap3.pdf

5.Pickar JG Neurophysiological effects of spinal manipulation. Spine J. 2002 Sep-Oct;2(5):357-71.

6. http://emedicine.medscape.com/article/324694-overview

7. http://www.rehabchalktalk.com/dry-needling-and-vascular-changes

8. BMC Complement Altern Med. 2015; 15: 72. Published online 2015 Mar 20. doi:  10.1186/s12906-015-0587-6PMCID: PMC4426539 Intensive vasodilatation in the sciatic pain area after dry needling

SOUTH LOOP PODCAST #17: DR. SHAWN ALLEN OF THE GAIT GUYS

As promised. Here is Dr. Allen on the Chicago Southloop CrossFit podcast.
Thanks to Todd Nief for a fun interview hour. Always love talking to this smart fella.
Podcast link: http://southloopsc.com/articles/dr-shawn-allen-interview

taken from Todd's Southloop Strength and Conditioning Crossfit site:
Anyone who has ever been to a physical therapist has inevitably been told that they have “weak glutes” and been given Jane Fondas or some other form of band exercise.

Does every human being actually have weak glutes? Is the contractile potential of the muscle limited? Do glutes really not “fire correctly”? Can we actually come up with biomechanical explanations for all of the injuries and issues that we find in athletes?

Dr. Shawn Allen is one half of The Gait Guys along with Dr. Ivo Waerlop – a duo renowned for their information dense podcasts and blog posts in which they dissect the latest research articles in rehab, injuries, nervous system development, and strength training.

Dr. Allen practices not too far from my parents’ house in the suburbs of Chicago, so I made the trek out to see him for some chronic groin issues I’d had from playing soccer. And, it turns out I had some glute issues myself.

However, it’s not as simple as simply contracting the offending muscle group over and over and over again. The pattern in which dysfunction is present must be identified, and then a new pattern must be learned to replace the dysfunctional pattern – which is a higher order way of approaching injuries and movement issues.

Dr. Allen and I have had several interesting conversations about injury mechanisms, the nervous system’s control of movement, and best practices in rehab and training, so we decided to record one of them here.

http://southloopsc.com/articles/dr-shawn-allen-interview

Lets take another look at the tibialis posterior

As cinincians , we often needle and treat the tibialis posterior for posterior tibial tendon dysfunction, platar fasicits, patellofemoral joint pain, and a host of other conditions. Lets take a look at some of the anatomy and see why it is a big player in these conditions. 

The tibialis posterior takes its origin from the proximal posterior tibia, fibula and interosseous membrane. It is deep to the tricep surae and more superior than the flexors hallucis and didgitorum longus. The tendon descends medially, travels around the medial malleolus and divides into 3 portions: plantar, main and recurrent components. It inserts into all the tarsals and metatarsals 2-4.(1) Note that it DOES NOT insert into the 1st metatarsal. There must be a good reason for this, no?

The tibialis posterior acts to plantar flex and invert the foot as well as help eccentrically control eversion of the foot. It fires from initial conact to almost terminal swing. This assists in plantart flexion of the foot from initial contact to loading response, eccentric slowing of the foot during pronation from loading response to misdstance and concentric contraction to assist in and speed up supination from midstance to terminal stance.  When you look at the EMG studies for walking (2,3) , you will see that it starts ramping down activity just after midstance as the peroneus longus starts to ramp up more (firing from just after loading response to pre swing, with a bust of activity from midstance on). 

So, with all this talk, there has to be a reason, right? Think about this. In order to move forward in the gravitational plane and have high gear push off (ie, pushing off the base of the hallux), the 1st ray needs to descend to gain purchase on the ground (2,4, 5) . This is largely through the actions of the peroneus longus, extensor hallucis brevis and flexor digitorum brevis (6,7). The function of the peroneus longus should be obvious with its attachment to the base of the 1st metatarsal. The extensor hallucis brevis moves the axis of the 1st MTP downward when it contracts, as discussed here and here (8, 9). The flexor digitorum brevis moves the axis of metatarsalphalangeal joints 2-5 dorsally and posterior which effectively moves the axis of the head of the 1st metatarsal phalangeal joint ventral and anteriorly. This is requisite for you to have adequate hallux dorsiflexion of about 60 degrees to toe off normally. 

OK, so what about the tibialis posterior? 

Remember that the tib posterior attaches to most of the proximal bottom of the foot with the exception of the 1st metatarsal base? In the area of the 1st ray, the tib posterior attaches to the navicular. When it contracts, it will pull the navicular posterior and inferior, effectively rasing the base of (and lowering the head of) the 1st metatrsal. If it attached to the 1st metatarsal, its base would be pulled posterior and inferior which would raise the head of the 1st ray, exactly what we are trying NOT TO DO

Armed with this clinical tidbit, can you see how posterior tibial tendon dysfunction can be involved with so many foot and therefore lower kinetic chain problems? If you can’t descend the 1st ray, the foot will need to toe off its lateral aspect, with less effectiveness of the calcaneocuboid locking mechanism (more on that here (10) and here (11)), so problems with propulsion off of an “unlocked” foot. Can you see how the forefoot may be somewhat more everted in this situation? Can you see how this would contribute to more calcaneal eversion and sustained midfoot pronation from midstance through the rest of the gait cycle?  What muscle is sitauted to help maintain the arch as well as decelerate pronation? Tibialis posterior. What muscle will be called into play to assist the gastroc/soleus to help propel you forward? Tibialis posterior. You get the picture.

The tibialis posterior. An important player in the gait game. A great muscle to needle thatpays clinical dividends in more ways than you can imagine. 


1. Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior Tibial Tendon Dysfunction: An Overlooked Cause of Foot Deformity. Journal of Family Medicine and Primary Care. 2015;4(1):26-29. doi:10.4103/2249-4863.152245.

 2. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Thomas Michaud Newton, MA 1993

3. ValmasseyR. Clinical Biomechanics of the lower extremities. Mosby, St Louis, Philadelphia. 101-107: 1996

4. Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore, Williams and Wilkins, 1981

5. Scranton PE, et al. Support phase kinematics of the foot.  In Bateman JE, Trott AW (eds). The Foot and Ankle. New York, Thieme-Stratton, 1980

6. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack 1992

7. The Pathokinesiology Service and the Physical Therapy Department. Observational Gait Analysis. Rancho Los Amigos National Rehabilitation Center Downey, CA 2001

8. https://tmblr.co/ZrRYjxFOn2hk

9. https://tmblr.co/ZrRYjxFSJ4Yz

10. https://tmblr.co/ZrRYjx1MjeIVN

11. https://tmblr.co/ZrRYjxToM8SI

Podcast 114: Pooping your pants

This podcast is big on the neurology of  motor control and movement, plus more on glutes and quads, runners diarrhea and lots of other good stuff.  Join us today !


Show sponsors:
newbalancechicago.com
altrarunning.com


www.thegaitguys.com
That is our website, and it 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.

* Podcast Links: 

http://traffic.libsyn.com/thegaitguys/pod_114f.mp3

http://thegaitguys.libsyn.com/poop
_______________________________________
Show Notes:
Motor control and the immune system.
http://www.thegaitguys.com/thedailyblog/2016/9/12/motor-control-and-the-immune-system

The Exercise Drug is on its way.
http://qz.com/783958/scientists-have-created-a-drug-that-replicates-the-health-benefits-of-exercise/

http://www.cell.com/cell-reports/pdf/S2211-1247(16)31051-8.pdf
 
Glutes and Achilles.
http://www.thegaitguys.com/thedailyblog/2016/9/28/david-and-goliath-the-calf-and-the-glute

https://www.ncbi.nlm.nih.gov/pubmed/24121244

More glutes and quads
 http://www.thegaitguys.com/thedailyblog/2016/10/5/who-rules-the-glutes-or-the-quads-well-it-is-complicated

Runners Diarrhea. What's up with that ?
Am Fam Physician. 1993 Sep 15;48(4):623-7.
Runner's diarrhea and other intestinal problems of athletes. Butcher JD1.

gut and zonulin full text link     https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589170/

2012 article here: http://www.karger.com/Article/Abstract/342169

Case: Forefoot pain from achilles repair.

Gentleman came in, several month history of left forefoot pain and plantar foot cramping after long walks and long bikes or sessions on the indoor bike trainer.  Typically clipped in.  Notable, left calf atrophy (see pic) from a 30 year old achilles repair.  Terminal Heel rise is impaired and weak and challenged calf endurance.  Left calf is also short, obviously.

Exam found notable over recruitment of the long toe flexors (also off that posterior compartment) -- afterall, someone in that posterior compartment has to be creating propulsion and heel rise (even that is a long shot of a strategy for the long toe flexors).  

Long toe flexor overactivity causes toe hammering, inhibition of the short toe flexors, distal migration of the metatarsal fat pad and inhibition of the lumbricals.  

Translation: overburden of the forefoot in loading, both from fat pad migration, lumbrical inhibition and premature heel rise (from short calf-achilles and atrophy, and altered heel rise strategy as noted above). 

The metatarsals are small bones -- they don't mind loading but it has to be clean appropriate loading to repetitively endure it without problem. Forefoot loading can be a challenge when the mechanics are off. The lumbricals are part of this scenario -- if they are weak or inhibited proper posturing of the forefoot during forefoot loading is compromised and the ability to stabilize the toe is flawed (this is a common problem in hammer toes (functional or anatomical)).

One has to get to the root of the problem on this one . . . . the old achilles trauma and weak calf. Its been 30  years.  Time to dig in on this one, start with the basics, and look at a long calendar for change.

Just some quick thoughts on this case that walked in today.  Forefoot pain -- it can be complicated. 

Oh, and guess what else was off ?  Yup, hip extension and gluteal-hip stability. Duh.

- Dr. Shawn Allen, the other gait guy