The next time they have gait asymmetry, try changing out the insole...

or putting a textured one in there...or maybe putting a some sand or dirt in their shoe...

 image credit: https://torange.biz

image credit: https://torange.biz

Textured insoles change (we like to think for the better) proprioceptive input and can improve balance and gait performance, both statically and dynamically. We have seen this in folks with parkinsons (1) as well as stroke (2), though it can be used in the elderly (3), in diabetes and neuropathy (4), as well as healthy individuals (5,6). Changes from postural stability, to changes in anterior/posterior sway, to medial/lateral sway, to step length and height, the research is there.

These results support the hypothesis that enhanced somatosensory feedback to the sensory system, both through the spinocerebellar and dorsal column pathways, as well as the vestibular system, results in an improved motor output (and most likely coordination) of gait.

  1. Qiu F, Cole MH, Davids KW, et al. Effects of textured insoles on balance in people with Parkinson's disease. PLoS One. 2013;8(12):e83309. Published 2013 Dec 12. doi:10.1371/journal.pone.00833

  2. Ma CC1, Rao N2, Muthukrishnan S3, Aruin AS4. A textured insole improves gait symmetry in individuals with stroke. Disabil Rehabil. 2017 Aug 7:1-5. doi: 10.1080/09638288.2017.1362477. [Epub ahead of print]

  3. Annino G1,2,3, Palazzo F2, Alwardat MS4, Manzi V5, Lebone P2, Tancredi V1,2,3, Sinibaldi Salimei P2,6,7, Caronti A2, Panzarino M2,3, Padua E2,3. Effects of long-term stimulation of textured insoles on postural control in health elderly. J Sports Med Phys Fitness. 2018 Apr;58(4):377-384. doi: 10.23736/S0022-4707.16.06705-0. Epub 2016 Sep 15.

  4. Paton J, Glasser S, Collings R, Marsden J. Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy. J Foot Ankle Res. 2016;9:40. Published 2016 Oct 5. doi:10.1186/s13047-016-0172-3

  5. Steinberg N1, Tirosh O, Adams R, Karin J, Waddington G. Influence of Textured Insoles on Dynamic Postural Balance of Young Dancers. Med Probl Perform Art. 2017 Jun;32(2):63-70. doi: 10.21091/mppa.2017.2012.

  6. Collings R1, Paton J2, Chockalingam N3, Gorst T2, Marsden J2. Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking. Foot (Edinb). 2015 Sep;25(3):159-63. doi: 10.1016/j.foot.2015.05.003. Epub 2015 May 11.

Toe extension matters.

The season to pathologize our feet is upon us. Toe extension matters.

I blew out my flip flop,
Stepped on a pop top;
Cut my heel, had to cruise on back home.
But there's booze in the blender,
And soon it will render
That frozen concoction that helps me hang on. - Jimmy Buffett

I continue to see more and more people with inadequate toe extension. It is complicated. I see those who do not even have the awareness of toe extension, loss of strength of toe extension, loss of endurance of toe extension, loss of global range of toe extension (dorsiflexion at the MTP joint), more failure of long toe extensor (EHL) strength and more prominence of increased short toe extensor strength (EDB) and more frightening, a lack of disassociation of toe extension (MTP dorsiflexion) and ankle dorsiflexion. Many clients when asked to life their toes, will drive into ankle mortise dorsiflexion; ask them to just purely toe dorsiflex and the mental games begin, a wrinkled brow, intense concentration. If you cannot extended the toes sitting, how are you going to find them in swing phase of gait when balance, and other things, are more important?
Stand and lift your toes. The arch should go up, you have engaged the Windlass Mechanism, that winds up the plantar fascia and raised the arch. If you do not have competent, unconsciously competent, toe extension, your arch is not all that it can, and should, be. If you cannot raise your toes, thus raise the arch, thus plantarflex the first metatarsal, then in gait, when the foot is on the ground, you cannot properly position the sesamoids, properly get safe terminal ranges of hallux dorsiflexion at toe off, properly position the foot for loading and unloading, adequately achieve ankle dorsiflexion, adequately offer the hip a chance for ample hip extension, offer the glutes optimal chance to work in all phases to help control spin of the limb during loading and unloading, and the list goes on and on. I am sure I left much out there, this was written in a few minutes and unedited, just a short rant for the weekend. But if you have not championed toe extension, both in an unloaded and loaded foot (on the ground), achieved control of both long and short extensor muscles to the toes (and paired them well with the long and short toe flexors), disassociated toe extension from ankle dorsiflexion, and then figured out how to properly, timely, engage all these processes into your gait unconsciously, you are working on less of an optimal system than you should be. So, if your feet hurt, hips hurt, or a plethora of other problems that you are trying to fix with orthotics or other toys, maybe start with, "can you lift your toes?". It is a piece of the puzzle, trust me.
Or, you can just stay in your flip flops and perpetuate your toe flexion and wait for bad things to take root After all, tis the season soon !
Yes, toe extension in flip flops (we must flex our toes to keep them on) is as rare as a good multi-tasking man.

Shawn Allen, one of the gait guys.


" "Stand and lift your toes. The arch should go up, you have engaged the Windlass Mechanism, which winds up the plantar fascia and raises the arch. If you do not have competent, unconsciously competent for that matter, toe extension, your arch is not all that it can, and should, be. If you cannot raise your toes, thus raise the arch, thus plantarflex the first metatarsal, then in gait, when the foot is on the ground, you cannot properly position the sesamoids, properly get safe terminal ranges of hallux dorsiflexion at toe off, properly position the foot for loading and unloading, adequately achieve ankle dorsiflexion, adequately offer the hip a chance for ample hip extension, offer the glutes optimal chance to work in all phases to help control spin of the limb during loading and unloading, and the list goes on and on."

More asymmetrical thoughts

Again, in this study, like the last we discussed here, we are looking at experienced (and in this case, young) runners; sprinters specifically. Again, they ran relatively short distances (20 meters). More than 1/2 the runners had “large” asymmetries, and they all had asymmetries of some type. Some athletes had injuries and some did not.

There wasn’t a difference in sprint performance over this short distance. This is not surprising in light of the previous paper we discussed; asymmetries seem to worsen over time (Hanley 2018). The level of compensation present (since these are experienced runners) may also be better; the folks that were uninjured having compensation patterns that were more in line with their anatomy, than the injured ones.

  • The asymmetries did not change. Thinking about anatomy, especially with hard deformities like torsions or versions, why would they? You can’t change the stripes on a tiger.

  • Injured and non injured athletes did not differ in asymmetry before or after the study. Again, why would they? We are talking about gait changes (or perhaps compensations). What is significant for one individual (tibial torsion, femoral retroversion, leg length discrepacy) may not be as significant as it for another, depending on the compensation present.

The study concludes “... kinematic asymmetries in the stride cycle were not associated with neither maximal sprint running performance nor the prevalence of injury among high-level athletic sprinters.” Note that they are talking about prevalence of injury, not incidence of injury.

We still think that asymmetry matters...

Haugen T, Danielsen J, McGhie D, Sandbakk Ø, Ettema G. Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters. Scand J Med Sci Sports. 2018 Mar;28(3):1001-1008. doi: 10.1111/sms.12953. Epub 2017 Aug 15.

Thought experiment on symmetry: Does symmetry always matter?

the short answer is probably not. the long answer is maybe...

This study looked at gait variability asymmetry in small cohort of experienced distance runnners. They measured different variables at 1500, 3000, 5000, 7500 and 9500 m of a 10000 meter run (about 6.2 miles) on a treadmill. Generally speaking, variability was low and athletes were symmetrical for 5 of seven variables measured and assymetry, when present, was in flight time and impact forces Most aththletes were asymetrical for at least one variable as well.

Their conclusion basically said that being asymmetrical in a few variables is not abnormal and not indicative of asymmetrical gait and since many practitioners analyze symmetry (and variability) caution should be exercised when determining the need for intervention.

So what do we think this means?

most likely:

  • these folks were symmetrical with low variability. In other words, when asymmetry was present, it was small

  • some asymmetry, in some parameters, is probably normal...but,it is usually small if it doesn’t matter. Keep in mind these were expreienced, uninjured folks. th results could have been different with a bigger cohort and less experienced runners and thus...

  • The study does not talk about inexperienced runners. Symmetry and/or asymmetry may not be normal for inexperienced runners

  • Results may have been vastly different if the run had been longer. The study did show that variability increased the further along on the run the athlete was.

  • The study was performed on a treadmill, which may not exemplify or highlight asymmetry, as it creates artificial constraints which we have discussed in by us here, here, and here:

  • We think asymmetry matters, particularly when it comes to hard deformities like torsions and versions, which change the biomechanics of that individual extremity and can be a diagnostic tool for future problems

  • perhaps asymmetry is significant in his population of runners on a subclinical basis

Hanley B, Tucker CB. Gait variability and symmetry remain consistent during high-intensity 10,000 m treadmill running. J Biomech. 2018 Oct 5;79:129-134. doi: 10.1016/j.jbiomech.2018.08.008. Epub 2018 Aug 16.

Subtle clues to flexor dominance

IMG_5515.jpg

Take a close look at these photographs. Compare the prominence of the extensor tendon‘s left to right. What do you see? Do you notice the deeper furrowing of the extensor tendons on the left? Do you see the subtle increased extension of the metatarsophalangeal and requisite increased flexion of the inter-phalangeal articulations, left versus right? What about the height of the arches?

Keep a keen eye out for subtle signs. They can make a real difference in your clinical diagnosis and results…

Shoe causing knee pain? You decide… 

IMG_5522.jpg
IMG_5526.jpg
IMG_5525.jpg

This gentleman presented with left-sided knee pain at the medial collateral ligament. His left foot was planted when he rotated to the left. Take a close look at the shoes in the picture. If you look closely, you will notice the right shoe is tilted on its axis due to a rear foot to forefoot deformity (forefoot supinatus)and the left shoe upper was assembled canted on its axis, Most likely in manufacturing defect. Can you see the subtle valgus in the left shoe rearfoot?

Think of the implications of a shoe with this orientation. Putting the rearfoot in valgus “prepronates“ the foot, causing medial rotation of the tibia and femur and increase valgus stress on the knee, stressing the medial collateral ligament and stabilizing complex. This will most likely manifest itself as anterior rotation of the ilium on the left-hand side with relative posterior rotation on the right and a clockwise Pelvic distortion pattern. With the foot planted on the left side and it being pre-pronated, can you see how the rotation to the left leaves a greater amount of external rotation that must occur to just get the foot to neutral, never mind supination for stability and pushoff?
What about the popliteus having to work on time to assist and extra rotation and the appropriate femoral/tibial rotation ratios to spare the medial meniscus?

These are the kind of things to keep us awake at night…

On the road to a cruciate reconstruction?

Screen Shot 2018-10-12 at 8.24.50 AM.png

While at a recent soccer game, I noticed this gal standing on the side lines. Talk about knee problems waiting to happen ! Note the hyperextended posture of the knees with increase in lumbar lordosis and anterior carriage of the entire pelvis with an increase in the thoracic kyphosis and head forward carriage to match! You can imagine the anterior pelvic tilt as well as stretch weakness of the abdominal obliques creating "core instability". At least she is not wearing heels, although a negative inclination [negative ramp delta] shoe would probably help.

Think of the strain on her poor posterior cruciate ligaments with all of that anterior femoral translation! We remember that the popliteus acts as an "accessory PCL" at initial contact in the gait cycle. It fires at heel strike and again from loading response until toe off

Think about the forces on these knees while descending hills or stairs. The momentum will carry the femur forward (or anteriorly). There needs to be something to reststrain this; enter the PCL. Because of the laxity (and instability), the poplitues will need to fire to take up the slack. We wrote about that here and here.

Note, this is a mere thought experiment, don’t get bent outta shape, these things might not occur, or they might. Time will tell.

Podcast #140: Running, hallux amputation, building deeper gait concepts.

Topics:

hallux amputation, achilles tendon, achilles tendinopathy, rehab achilles, bursae, marathons, vapourfly, shoes, shoe fit, gait, gait problems, gait correction, gait retraining, running, foot strike, heel strike, midfoot strike, rearfoot strike, heel strike, loading responses, gait rehab, muscle strength, isotonics

Links to find the podcast:

Look for us on iTunes, Google Play, Podbean, PlayerFM and more.

Just Google "the gait guys podcast".

Our Websites:
www.thegaitguys.com

doctorallen.co

summitchiroandrehab.com

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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:

iTunes page:

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

Google Play:

https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_140real_-_10618_9.18_AM.mp3


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Libsyn Directory URL:http://directory.libsyn.com/episode/index/id/7135745


Topics and links:


The tendinopathic Achilles tendon does not remain iso-volumetric upon repeated loading: insights from 3D ultrasound. Nuri L, et al. J Exp Biol. 2017.

https://www.ncbi.nlm.nih.gov/m/pubmed/28620014/

Good tip to decrease loading and help decrease injury risk in runners: See study by Chan et al.:
http://journals.sagepub.com/doi/abs/10.1177/0363546517736277?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&

Vapourfly shoe
https://www.nytimes.com/interactive/2018/07/18/upshot/nike-vaporfly-shoe-strava.html

Men’s marathon:
https://twitter.com/chrisbramah/status/1019481750039343104/photo/1


fun facts:

Foot strike patterns of the World Championships Marathon:
Women’s race:
73% rearfoot, 24% midfoot, 3% forefoot
Men’s race:
67% rearfoot, 30% midfoot, 3% forefoot
pic.twitter.com/iWRzjImQBZ
https://www.iaaf.org/about-iaaf/documents/research#biomechanical-research-projects

Foot structure and stiffness is critical
https://www.nature.com/articles/srep29870

Tendons can change
Progressive calf strength training led to increased achilles stiffness @ 4 weeks & increased tendon cross sectional area @ 8 weeks
https://link.springer.com/article/10.1007/s00421-018-3904-1

Bursae can thicken painlessly as a normal adaption to activity... just like skin calluses!
https://www.ncbi.nlm.nih.gov/pubmed/24907190

Between 63-72% of participants were wearing incorrectly sized footwear. review of the literature here from @LTPodiatry team:
https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-018-0284-z

How Neuroscientists Explain the Mind-Clearing Magic of Running -- from the Science of Us
https://www.huffingtonpost.com/science-of-us/how-neuroscientists-expla_b_9787466.html

And why does this guy have hip pain?

 line up the center of the heel counters with the outsoles, and what do you see?

line up the center of the heel counters with the outsoles, and what do you see?

 can you see how the heel counter is centered on the outsole, like it is supposed to be

can you see how the heel counter is centered on the outsole, like it is supposed to be

 notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

Take a guy with lower back and left sided sub patellar pain that also has a left anatomically short leg (tibial) and bilateral internal tibial torsion and put him in these baby’s to play pickleball and you have a prescription for disaster.

Folks with an LLD generally (soft rule here) have a tendency to supinate more on the short leg side (in an attempt to make the limb longer) and pronate more on the longer leg side (to make the limb shorter). Supination causes external rotation of the lower limb (remember, we are trying to make the foot into a rigid lever in a “normal” gait cycle). this external rotation with rotate the knee externally (laterally). Folks with internal tibial torsion usually rotate their limb externally to give them a better progression angle (of the foot) so they don’t trip and fall from having their feet pointing inward. This ALSO moves the knee into external rotation (laterally), often moving it OUTSIDE the saggital plane. In this case, the knee, because of the difference in leg length AND internal tibial torsion AND the varus cant of the shoe, has his knee WAY OUTSIDE the saggital plane, causing faulty patellar tracking and LBP.

Moral of the story? When people present with a problem ALWAYS TAKE TIME TO LOOK AT THEIR SHOES!

On the subject of manual muscle work…

 image credit: https://commons.wikimedia.org/wiki/File:Muscle_spindle_model.jpg

image credit: https://commons.wikimedia.org/wiki/File:Muscle_spindle_model.jpg

Here is an older article that may seem verbose, but has interesting implications for practitioners who do manual muscle work with their clients. We would invite you to work your way through the entire article, a little at a time, to fully grasp it’s implications.

Plowing through the neurophysiology, here is a synopsis for you:

Tactile and muscle afferent (or sensory) information travels into the dorsal (or posterior) part of the spinal cord called the “dorsal horn”. This “dorsal horn” is divided into 4 layers; 2 superficial and 2 deep. The superficial layers get their info from the A delta and C fibers (cold, warm, light touch and pain) and the deeper layers get their info from the A alpha and A beta fibers (ie: joint, skin and muscle mechanoreceptors).

So what you may say

The superficial layers are involved with pain and tissue damage modulation, both at the spinal cord level and from descending inhibition from the brain. The deeper layers are involved with apprising the central nervous system about information relating directly to movement (of the skin, joints and muscles).

Information in this deeper layer is much more specific that that entering the more superficial layers. This happens because of 3 reasons:

  1. there are more one to one connections of neurons (30% as opposed to 10%) with the information distributed to many pathways in the CNS, instead of just a dedicated few in the more superficial layers

  2. the connections in the deeper layers are largely unidirectional and 69% are inhibitory connections (ie they modulate output, rather than input)

  3. the connections in the deeper layers use both GABA and Glycine as neurotransmitters (Glycine is a more specific neurotransmitter).

Ok, this is getting long and complex, tell me something useful...

This supports that much of what we do when we do manual therapy on a patient or client is we stimulate inhibitory neurons or interneurons which can either (directly or indirectly)

  • inhibit a muscle

  • excite a muscle because we inhibited the inhibitory neuron or interneuron acting on it (you see, 2 negatives can be positive)

So, much of what we do is inhibit muscle function, even though the muscle may be testing stronger. Are we inhibiting the antagonist and thus strengthening the agonist? Are we removing the inhibition of the agonist by inhibiting the inhibitory action on it? Whichever it may be, keep in mind we are probably modulating inhibition, rather than creating excitation.


Semantics? Maybe…But we constantly talk about being specific for a fix, not just cover up the compensation. Is it easier to keep filling up the tire (facilitating) or patching the hole (inhibiting). It’s your call


Yan Lu Synaptic Wiring in the Deep Dorsal Horn. Focus on Local Circuit Connections Between Hamster Laminae III and IV Dorsal Horn Neurons J Neurophys Volume 99 Issue 3

March 2008 Pages 1051-1052 link: http://jn.physiology.org/content/99/3/1051

Music to my ears. Movement to my steps...

 https://en.wikipedia.org/wiki/Music

https://en.wikipedia.org/wiki/Music

"The applicable contribution of these novel findings is that music tempo could serve as an unprompted means to impact running cadence. As increases in step rate may prove beneficial in the prevention and treatment of common running-related injuries, this finding could be especially relevant for treatment purposes, such as exercise prescription and gait retraining."

Van Dyck E, Moens B, Buhmann J, Demey M, Coorevits E, Dalla Bella S, Leman M. Spontaneous Entrainment of Running Cadence to Music Tempo. Sports Med Open. 2015;1(1):15. Epub 2015 Jul 14.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526248/

image credit: http://pressplay.pbworks.com/w/page/82954552/Loebner%20Keith%20HW%203

Podcast 139: STEM &PRP therapies for athletes

Topics:
We are all over the board today folks, topics like PRP but more so we go down some paths that are more fundamentally clinical and neurologic with a sprinkling of orthopedics to round things out. Sometimes these are our best shows.

Links to find the podcast:

iTunes page:

http://traffic.libsyn.com/thegaitguys/pod_139finalfull_-_92218_7.16_AM.mp3

Google Play:

https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_139finalfull_-_92218_7.16_AM.mp3

Permalink URL:
http://thegaitguys.libsyn.com/podcast-139-stem-prp-therapies-for-athletes

Libsyn URL: http://directory.libsyn.com/episode/index/id/7077174


Our Websites:
www.thegaitguys.com

doctorallen.co

summitchiroandrehab.com

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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Is there a need for "Gait Retraining'?...We think so

 photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

There seems to be some controversy with regards to gait retraining. Some folks seem to believe that it should be “left to itself” and they are fully compensated already (1). Perhaps this is true…or not. We have not seen any studies that compare gait retraining vs non gait retraining as a whole, but there seems to be plenty for specific conditions (2). We all see folks AFTER THE FACT and seek to correct the problems and reverse, halt or slow the progression of further pathology. That seems to be what many of us do.

This recent study (3) looks ate altered loads and muscle recruitment patterns in patients with osteoarthritis. they conclude:

“This study documents alterations in hip kinematics and kinetics resulting in decreased hip loading in patients with hip OA. The results suggested that patients altered their gait to increase medio-lateral stability, thereby decreasing demand on the hip abductors. These findings support discharge of abductor muscles that may bear clinical relevance of tailored rehabilitation targeting hip abductor muscles strengthening and gait retraining.”

There is substantial evidence that hip pathomechanics lead to osteoarthritis (4, 5). Wouldn’t it make sense to assist in altering motor patterns and correct those biomechanical faults before it becomes a problem? Lets change our focus (if we haven’t already) and concentrate on skill, endurance and strength, in that order for the betterment of ourselves, our patients and humanity.

  1. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: “preferred movement path” and “comfort filter” Br J Sports Med. 2015 Jul; doi: 10.1136/bjsports-2015-095054. bjsports - 2015-095054. 

  2. Davis IS, Futrell E. Gait Retraining: Altering the Fingerprint of Gait. Physical medicine and rehabilitation clinics of North America. 2016;27(1):339-355. doi:10.1016/j.pmr.2015.09.002. FREE FULL TEXT

  3. Meyer CAG, Wesseling M, Corten K, Nieuwenhuys A, Monari D5, Simon JP, Jonkers I, Desloovere K. Hip movement pathomechanics of patients with hip osteoarthritis aim at reducing hip joint loading on the osteoarthritic side. Gait Posture. 2018 Jan;59:11-17. doi: 10.1016/j.gaitpost.2017.09.020. Epub 2017 Sep 22.

  4. Christian Egloff, Thomas Hügle, Victor Valderrabano: Biomechanics and pathomechanisms of osteoarthritis Swiss Med Wkly. 2012;142:w13583 FREE FULL TEXT

  5. https://www.the-rheumatologist.org/article/get-out-of-your-oa-box/?singlepage=1&theme=print-friendly

People who are injured move differently

Like we have said before, often times when folks are injured they often lose cortical function (afferent input) from a particular area, and their gait becomes more primitive, often taking a broader base, slower movement, increased amplitude of movement and sometimes requiring assistance or something to help them balance, like our post here

"Findings suggest that movement variability in those with a musculo-skeletal injury differs from uninjured individuals. Interestingly, there was an overall trend toward greater movement variability being associated with the injured groups, although it should be noted that this trend was not consistent across all subcategories (eg, injury type). "

Baida SR, Gore SJ, Franklyn-Miller AD, Moran KA. Does the amount of lower extremity movement variability differ between injured and uninjured populations? A systematic review. Scand J Med Sci Sports. 2018 Apr;28(4):1320-1338. doi: 10.1111/sms.13036. Epub 2018 Feb 14. (

Zonas vs K Tape

 image source: https://commons.wikimedia.org/wiki/File:Kinesio_Taping_for_Soleus_and_Achilles_tendon.jpg

image source: https://commons.wikimedia.org/wiki/File:Kinesio_Taping_for_Soleus_and_Achilles_tendon.jpg

In this case, flexibility and an elastic component (K Tape), which adds proprioception, rather than rigid (Zonas), which takes it away, seems to work better. 

"Compared to Athletic Tape, Kinesio Tape (KT)  provides a flexible pulling force that facilitates foot eversion during early stance, while not restricting normal inversion in late stance during walking. KT may be a useful clinical tool in correcting aberrant motion while not limiting natural movement in sports."

 

 

Yen SC, Folmar E, Friend KA, Wang YC, Chui KK. Effects of kinesiotaping and athletic taping on ankle kinematics during walking in individuals with chronic ankle instability: A pilot study. Gait Posture. 2018 Aug 28;66:118-123. doi: 10.1016/j.gaitpost.2018.08.034. [Epub ahead of print]

 

 

What specific movement pattern(s) does a person with chronic ankle instability have?

 image source: https://en.wikipedia.org/wiki/Ligament

image source: https://en.wikipedia.org/wiki/Ligament

...it is unique and depends on their compensation

 

"The researchers concluded that multiple distinct movement patterns were found in a high percentage of CAI subjects and each person likely incorporates unique positions and loads that contribute to the chronic nature of instability. Additionally, the data revealed distal joint stiffness was lower in those with CAI than controls generally, while proximal joint stiffness was greater than controls. These data support the theory that the hop plays a vital role in controlling lower extremity movement in CAI subjects."

 

Hopkins JT, Son SJ, Kim J, et al. Joint Stiffness Alterations, Grouped by Movement Strategy, in Chronic Ankle Instability.

http://lermagazine.com/special-section/conference-coverage/identifying-cai-through-specific-movement-patterns

 

Muscle Spindles and Proprioception

 image source: https://en.wikipedia.org/wiki/File:Fusimotor_action.jpg

image source: https://en.wikipedia.org/wiki/File:Fusimotor_action.jpg

And what have we been saying for the last 6 years? 

Connected to the nervous system by large diameter afferent (sensory) fibers, they are classically thought of as appraising the nervous system of vital information like length and rate of change of length of muscle fibers, so we can be coordinated. They act like volume controls for muscle sensitivity. Turn them up and the muscle becomes more sensitive to ANY input, especially stretch (so they become touchy…maybe like you get if you are hungry and tired and someone asks you to do something); turn them down and they become less or unresponsive.

Their excitability is governed by the sum total (excitatory and inhibitory) of all neurons (like interneuron’s) acting on them (their cell bodies reside in the anterior horn of the spinal cord).

Along with with Golgi tendon organs and joint mechanoreceptors, they also act as proprioceptive sentinels, telling us where our body parts are in space. We have been teaching this for years. Here is a paper that exemplifies that, identifying several proteins responsible for neurotransduction including the Piezo2 channel as a candidate for the principal mechanotransduction channel. Many neuromuscular diseases are accompanied by impaired  muscle spindle function, causing a decline of motor performance and coordination. This is yet another key finding in the kinesthetic system and its workings. 

Remember to include proprioceptive exercises and drills (on flat planar surfaces, like we talked about here) in your muscle rehab programs

 

 

 

 

Kröger S Proprioception 2.0: novel functions for muscle spindles. Curr Opin Neurol. 2018 Oct;31(5):592-598. 

Woo SH, Lukacs V, de Nooij JC, Zaytseva D, Criddle CR, Francisco A, Jessell TM, Wilkinson KA, Patapoutian A. Piezo2 is the principal mechanotransduction channel for proprioception.Nat Neurosci. 2015 Dec; 18(12):1756-62. Epub 2015 Nov 9.

Fusimotor control of proprioceptive feedback during locomotion and balancing: can simple lessons be learned for artificial control of gait?

Hulliger M. Fusimotor control of proprioceptive feedback during locomotion and balancing: can simple lessons be learned for artificial control of gait? Prog Brain Res. 1993; 97:173-80.

All that creaks may not be pathological...

 image source: https://commons.wikimedia.org/wiki/File:Runners-knee_SAG.jpg

image source: https://commons.wikimedia.org/wiki/File:Runners-knee_SAG.jpg

Gal with creaky knees? Patellar crepitus? Does all that noise mean something?

Well, it means that knee function is suboptimal and more than likely, there is abnormal patellar tracking. But is that clinically significant? The answer is ....maybe.

This study (1) looked at over 300 women, about 1/2 with patellofemoral pain and half without looking at the following outcomes: 

  • the knee crepitis test
  • anterior knee pain scale
  • self reported knee pain in the last month
  • knee pain after 10 squats 
  • knee pain after climbing 10 stairs

They found that if you had patello femoral pain, you were 4 times more likely to have crepitus than not, but there was no correlation of crepitus with  Knee crepitus had no relationship with function, physical activity level , worst pain, pain climbing stairs or pain squatting. 

We would have loved to have seen any correlation in this group with knee valgus angles (i.e. "Q" angles 2 ) and how much tibial or femoral torsion was present (as these things change pressure and contact area 3), but that will hopefully be found in the literature elsewhere. 

 

1. , Pazzinatto MFPriore LBDFerreira ASBriani RVFerrari DBazett-Jones DAzevedo FM. Knee crepitus is prevalent in women with patellofemoral pain, but is not related with function, physical activity and pain. Phys Ther Sport. 2018 Sep;33:7-11. doi: 10.1016/j.ptsp.2018.06.002. Epub 2018 Jun 6.

2. Emami MJ1, Ghahramani MHAbdinejad FNamazi H. Q-angle: an invaluable parameter for evaluation of anterior knee pain. Arch Iran Med. 2007 Jan;10(1):24-6.

3. Thay Q. Lee, PhD, Garrett Morris, BS, Rick P. Csintalan, MDThe Influence of Tibial and Femoral Rotation on Patellofemoral Contact Area and Pressure Orthop Sports Phys Ther 2003;33:686-693.

Recalcitrant medial knee pain? Have you heard about the "Problematic Pes"...

 image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

Recalcitrant knee pain just below the medial tibial plateau? Worse with sprints, hills and after running a while? It may be the pes anserine insertion(s).

Made up of the tibial insertions, from anterior to posterior, of the sartorius, gracilis and semitendinosis which lie superficial to the distal tibial insertion of the superficial medial collateral ligament. This structure is named from the way it looks, like a goose's foot (anserine pes), rather than its anatomical location. The pes anserine bursa lies below it and between the MCL and hamstring tendons and can be subject to compressive forces if compromised in some way, by injury or pathomechanics

The muscles of the pes anserine arise from three different compartments in the thigh. The sartorius originates from the anterior compartment,  the gracilis from the medial compartment and the semitendinosus, the posterior compartment. Their varied origins, paths, and actions, as these muscles approach their insertion all add stability to the medial aspect of the knee.

During an ideal gait cycle, the sartorius fires from toe off through nearly terminal swing, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off  and gracilis tonically throughout stance phase with bursts from terminal swing through initial contact and again from pre swing to initial swing.

 image source: Tom Michaud, with permission

image source: Tom Michaud, with permission

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain with the innocent pes anserine bursa directly beneath. This is complemented by the compressive forces of this gracilis firing because of the increased coronal plane motion occurring at the pelvis.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing.

Look to this troublesome trio the next time you have recalcitrant medial knee pain.

 

 

Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 

https://www.anatomy-physiotherapy.com/knee/articles/systems/musculoskeletal/lower-extremity/knee/test-your-knowledge-the-pes-anserinus

 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011

Podcast 138 (for real). Are you fighting your own gait/running neurology?

Topics:
1. Running with the extensors. Convergence and divergence of neurons.
2. Fighting your gait neurology. The lies about the Bird dog rehab exercise.
3. ACL and ACL rehab. Surgery or no sugery. Wise? Risks ? How social media discussions might just be getting it wrong.
4. Cross over gait and lateral heel strike and ensuing problems at great toe off. A failure to medial foot tripod high gear toe off ?
5. Are the hip flexors actually hip flexors in gait ? what are your high knee drills doing? Anything good?

Key words: acl, analysis, cross, extensor, flexors, gait, heel, hip, instability, knee, over, plri, pools, problems, running, strike, surgery

Links to find the podcast:

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

Direct Download:http://traffic.libsyn.com/thegaitguys/pod_138_real_-_82818_2.12_PM.mp3

Permalink URL:http://thegaitguys.libsyn.com/podcast-138-for-real

Libsyn URL: http://directory.libsyn.com/episode/index/id/6978817

Our Websites:
www.thegaitguys.com

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