The Knee and Macerating Menisci

Take a good look at the above 2 slides.

Notice that, during pronation, there is a medial rotation of the lower leg and thigh. We remember that, during pronation, the talus plantar flexes, adducts, and everts. This anterior translation and medial rotation of the talus causes the tibia and subsequently the femur to follow. This, if everything is working right, results in medial rotation of the knee.

From the slides, it should also be evident that the medial condyle of the femur and a medial tibial plateau are larger than the lateral. This allows for an increased amount of internal and external rotation of the knee. We remember that the meniscus, like a washer, is between the tibia and femur. We if you think about this kinematically, it would make sense that the tibia, during pronation (which occurs from initial contact to mid stance) would have to rotate faster than the femur otherwise the meniscus would be caught "in between". If there is a mismatch in timing, the meniscus is "caught in the middle", which causes undue stress and can cause fraying, degeneration, etc.

Likewise, during supination (from mid stance to pre swing) the femur must externally rotate faster then the tibia, otherwise we see this same "mismatch". This is a scenario we commonly see in folks who over pronate at the mid foot and remain in pronation for too omg a period of time. 

We think of pronation as being initiated from the movement described above by the talus, and it is attenuated by the popliteus muscle as well as some of the deep flexors of the foot, which fire mostly during stance phase. You will notice that the popliteus  is eccentrically contracting at this point.

Supination, initiated by swing phase of the opposite leg and momentum, is assisted by concentric contraction of the popliteus muscle, internal rotation of the pelvis on the stance phase leg, contraction of the vastus medialis, deep flexors of the foot and peroneii.

Taking moment to "wrap your head around" this concept. Now you can see how complicated it can be when we started to throw in femoral and tibial torsions as well as possibly some orthotic therapy. For example, in an individual with internal tibial torsion, if you do not valgus post the forefoot of the orthotic, the knee is placed at outside the sagittal plane in external rotation further by the orthotic and this thwarts the function of his mechanism, leaving the meniscus holding the bag. 

Know your anatomy and know what is supposed to be firing when, your patients and clients knees depend on it!

 

OTS. It is taking down the best athletes, one by one.


Made famous in the beginning, first it was Alberto Salazar.  Now, just in the last decade it has been Anna Frost, Anton Krupicka, Geoff Roes, Kyle Skaggs, even Mike Wolfe. One by one they have fallen, to OTS.  More frighteningly, how many more have fallen to OTS that we never hear about? How many hundreds or thousands walking amongst us have OTS ? If you are a distance or heavy volume training athlete, do not brush off or take lightly what I have complied here today.


OTS, "Overtraining syndrome" is its name, but perhaps a better one would be "Insufficient Recovery Syndrome".  To use the broadest of terms, this is a self-generated, self-perpetuating dis-ease of one's own homeostasis. To be clear, there is a continuum here of multi-system failure, softer less severe forms of OTS. These less damaged states are referred to as Overreaching syndrome (OR). There are two forms of Overreaching syndrome, Functional OR and Nonfunctional OR. Nonfunctional OR shows decreases in performance for weeks to months while OTS being more severe and requiring months to years for recovery despite rest.
Over the past 10 years the best of the best are falling, one by one, victim to "too much".  They have just pushed themselves too much, too far, too long. It is the latest biggest thing in running these days, how far can you run ? Marathons are no longer enough for some, they have to see if 50 miles or 100 miles, or more, are enough and that means running 100-160 miles a week. And what is even more scary, some of these runners are in high school and college, they are still growing kids.

The physiology of these people is failing, truly. Some might suggest they in some respects showing signs of a slow death.  “OTS is one of the scariest things I’ve ever seen in my 30 plus years of working with athletes,” says David Nieman, former vice president of the American College of Sports Medicine. “To watch someone go from that degree of proficiency to a shell of their former self is unbelievably painful and frustrating.” - Meaghen Brown Jun 12, 2015.  Outside online. 

The first reference in which OTS was suggested was by a researcher and athlete named Robert Tait McKenzie.  In his 1909 book, Exercise in Education and Medicine, he mentioned a “slow poisoning of the nervous system which could last weeks or even months.” Then in 1985 South African physiologist professor Timothy Noakes discussed what appears to be the same condition in "The Lore of Running". Runners examined by Noakes had so over exerted themselves that both mind and body were failing.

OTS is truly a deeper problem. This is an immune, inflammatory, neurologic and psychological problem as best as anyone can tell.  In essence it seems the body is slowly dying. The body's parasympathetic nervous system, the system that counteracts the ramping up of the sympathetic nervous system, fails to properly respond to bring the systems back into balance. This means that many of the physiologic responses to activity fail to properly return to baseline. This means that blood pressure, heart rate, breathing, digestion, adrenal and hormonal rhythms amongst many other things go awry. Even other important things begin to decline, things like normal restful sleep, sometimes even insomnia, libido decline, metabolism dysfunction, appetite problems and even heart rate recovery and recurrent colds and viral infections.  We are talking about multi-system failure in these people, and this is serious business. The problem is, these athletes do not listen to the signals until it is too late and they are in full blown multi-system decline or failure. 

Here is likely an incomplete list of things that might be slowing showing up, softly, one by one as multi-system failure ramps up:

- anemia
- chronic dehydration
- increased resting heart rate
- breathing changes
- digestive troubles , bowel troubles (ie. runners diarrhea)
- endocrine problems: adrenal and hormonal shifts
- insomnia and sleeplessness
- blood pressure changes
- libido changes
- metabolism and appetite changes
- recurrent colds and viral infections
- generalized fatigue
- muscle soreness
- recurrent headaches
- inability to relax, listlessness
- swelling of lymph glands
- arrhythmias
- depression (neurotransmitter dysfunction)


There is a way out of OTS. But, one has to wrap their head around the fact that one's goals and mental drive have pushed them to this point. This is one's own fault and they will have to take some hard advice and make some tough decisions, decisions they do not want to make, but ultimately will have no choice but to make. That means changing those goals and habits, otherwise this could get real serious real fast. And wrapping one's head around the toughest part will be the most painful part for most, many months of rest, sometimes a year or more, to fully recover if one hasn't done too much irreparable damage to begin with.  Of course, the immediate course of action is to see a doctor. Hopefully, a doctor who is familiar with elite athletes and one that can rule out any other more serious immediate health concerns and disease processes that can mimic OTS and OR syndromes.

As with solving most problems, one has to first start to realize one is heading towards a problem, and accept responsibility. In this case, over training and under recovering.  One must look at their habits, and the subsequent outcomes, and see if there are signs of impending problems and if so be willing to make behavioral changes. This is a hard thing for endurance athletes, because it is asking them to look at enjoyable, admittedly addictive, endeavors. Endeavors that have always improved many facets of their life, yet ones that have a double edged-sword nature to them which can very quickly chop down all the hard work that has been put in. Ultimately, the answer is balance, balance in all aspects of one's life. But, who is truly good with balance ? Very few of us I am afraid.

Dr. Shawn Allen, one of the gait guys
 

References:

Running on Empty By: Meaghen Brown Jun 12, 2015.  Outside online. 
https://www.outsideonline.com/1986361/running-empty

Sports Health. 2012 Mar; 4(2): 128–138.Overtraining Syndrome. A Practical Guide
Jeffrey B. Kreher, MD†* and Jennifer B. Schwartz, MD‡
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435910/

Med Sci Sports Exerc. 2013 Jan;45(1):186-205. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine.
Meeusen R, Duclos M, Foster C, Fry A, Gleeson M, Nieman D, Raglin J, Rietjens G, Steinacker J, Urhausen A; European College of Sport Science; American College of Sports Medicine.

Open Access J Sports Med. 2016; 7: 115–122. Published online 2016 Sep 8.  Diagnosis and prevention of overtraining syndrome: an opinion on education strategies. Jeffrey B Kreher

Overtraining, Exercise, and Adrenal Insufficiency
KA Brooks, JG Carter
J Nov Physiother. Author manuscript; available in PMC 2013 May 9.
Published in final edited form as: J Nov Physiother. 2013 Feb 16; 3(125): 11717

Related citations:
https://scholar.google.com/scholar?ion=1&espv=2&bav=on.2,or.r_cp.&biw=1179&bih=705&dpr=1.5&um=1&ie=UTF-8&lr&cites=3025342060917260626
 

Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles.

 

Attached is an older video from a few years back , it is very similar in execution to the heel-rise ball squeeze exercise which is the precursor to this more functional engagement as shown in this video today.  


The important premise is that you have to have command of the entire posterior compartment if you are to get safe, effective, efficient and adequate ankle plantarflexion. As we have discussed many times, if you do not have the requisite skills as shown in this video you are in trouble and ankle sprains and other functional pathologies are not unlikely to visit you.  Additionally, without requisite posterior compartment endurance and an ability to engage what I like to refer to as "top end" strength in the heel rise is an asymmetrial loading issue and can lead to compensatory adaptations up the kinetic chain. Make no mistake, the load will go somewhere, and thus the work will be done somewhere. In this video you should be able to clearly see and understand that one must be able to achieve top end posturing and have command of lateral and medial forefoot loading responses and challenges if clean forward function and power is to be achieved, and injuries from extremes of motion medially and laterally are to be avoided. Furthermore, as eluded to here and in several of our podcasts (and in the study included below), an inability to achieve top end posturing will lead to changes in forefoot loading, may spill over into endurance challenges prematurely in the posterior mechanism, and create changes in the timing of the gait cycle (things like premature or delayed heel rise, premature or delayed forefoot loading, recruitment of other components of the posterior chain just to name a few). This parsing and sharing of loads and responsibilities is laid out in the Kulmala study referenced today. The study could be extrapolated to say, I believe, that particularly in sprinting, a failure to achieve top end heel rise through effective posterior mechanism contraction, will change the load sharing between the posterior compartment and the quadriceps. After all, if the calf is weak, the ankle is not in as much plantarflexion, this could mean more knee flexion and thus raise demands on the quadriceps, logically changing knee mechanics.  This is exactly why we spend so much time at every patient visit looking for full range of motion at the joints and then determine the skill, endurance and strength of the associated muscles in supporting that range. Then, of course, comparing this function to the opposite limb.  Symmetry is not everything, but it is definitely a major factor in safe efficient and injury free locomotion.

* Please give great thought to the part in the video where I discuss the drop phase in jumping. All too often we at looking for the propulsive mechanics and forget that a failure there will also be represented during the adaptive phase. Ankle sprains rarely occur from propulsive pushing off, they occur from a failure to properly reacquaint the foot to the ground on the following step.
-Dr. Shawn Allen, one of the gait guys.

In this study the authors noted:
"During walking, the relative effort of the ankle extensors was almost two times greater compared with the knee extensors. Changing walking to running decreased the difference in the relative effort between the extensor muscle groups, but still, the ankle extensors operated at a 25% greater level than the knee extensors. At top speed sprinting, the ankle extensors reached their maximum operating level, whereas the knee extensors still worked well below their limits, showing a 25% lower relative effort compared with the ankle extensors."

And concluded that:
"Regardless of the mode of locomotion, humans operate at a much greater relative effort at the ankle than knee extensor muscles. As a consequence, the great demand on ankle extensors may be a key biomechanical factor limiting our locomotor ability and influencing the way we locomote and adapt to accommodate compromised neuromuscular system function."

Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189. Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles. Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.
https://www.ncbi.nlm.nih.gov/pubmed/27327033

Mouthguard's and improved performance?

This paper looks at the concept or preloading motor neuronal pools. We have written about this before on the blog. 

The Temporomandibular joint (TMJ) is blessed with many mechanoreceptors and receives innervation from Cranial Nerve V (trigeminal nerve) and the upper cervical spine. There is physiological overlap through the trigeminocervical nucleus (in the upper midbrain or mesencephalon, the principal sensory nucleus) which receives the same innervation from the trigeminal nerve distribution and the upper 4 cervical neuromeres(nerve levels) (so double input into same pathway). Nicoli Bogduk published abody of research on this, along with Susan Lord and Leslie Barnsley.

The upper 4 cervical nerve root levels also directly input into the flocculonodular lobe of the cerebellum (which coordinates alot of motor activity, especially of axial extensor muscles). This preloads the motor neuronal pool (just like contracting your muscle slightly, or clenching to get a better response from a reflex exam). By optimizing input (through a bite guard), you optimize mechanoreception, which optimizes cerebellar activity, which in turn pre loads the motor neuronal pool.  You would get SIMILAR ( and better tasting!) results with having them clench or bite down on gum, though not as good due to possible imperfect mechanics.

We have not seen all of the research but we are sure it is legit. It’s like an orthotic for the mouth. Keep in mind changing bite mechanics closer to symmetrical occlusion will be helpful ( ie. Orthodontics, invisalign etc).

There you have it. Next time you want to get some extra performance, or are trying to accomplish an especially difficult exercise, try clenching hard to preload those neuronal pools.

Ivo and Shawn…Preloading your neuronal pools to make learning this stuff easier for you….one pathway at a time.

 

http://lermagazine.com/cover_story/mouthguard-mysteries-can-wearing-one-really-improve-athletic-performance

Is Turning off the Quads a good thing?

foamrolling.jpg

Especially in light of the Vastis lateralis acting as an internal rotator in closed chain? 

"Foam rolling of the quadriceps muscle is associated with decreased biceps femoris activation, an effect that may be related to pain perception, according to research from the Memorial University of Newfoundland in St. John’s, Canada.

In 18 recreationally active individuals (eight women), the investigators used surface electromyography to assess vastus lateralis, vastus medialis, and biceps femoris activation during a single-leg landing from a hurdle jump under four foam-rolling conditions: application to the hamstrings only, the quadriceps only, both, and neither.

Biceps femoris activation was significantly lower for the conditions in which foam rolling was applied to the quadriceps. However, the reverse was not true: Foam rolling of the hamstrings had no significant effect on activation of either of the quadriceps muscles.

The authors hypothesized that the perceived pain associated with quadriceps foam rolling, which was significantly greater than that associated with hamstrings foam rolling, may trigger the alteration in antagonist muscle function."

Cavanaugh MT, Aboodarda SJ, Hodgson D, Behm DG. Foam rolling of quadriceps decreases biceps femoris activation. J Strength Cond Res 2016 Sep 6. [Epub ahead of print]

Achilles Tendinitis

You should read this study if you haven't already

We all treat different forms of achilles tendinitis and tendonosis. This landmark study uses loaded eccentrics and showed better tendon organization and decreased tendon thickness at follow up. 

Tendons do seem to respond better to tension and loaded eccentrics certainly seems to do the job. 

"Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon."

Ohberg L, Lorentzon R, Alfredson H, Maffulli N. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004;38(1):8-11. doi:10.1136/bjsm.2001.000284.

link to abstract: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724744/

Forefoot varus and patellofemoral cartilage damage.

So you just give everyone a FOOT TRIPOD and ANKLE ROCKER exercise and think the world will all be sunshine and rainbows huh ? Beware all you movement wizards, there is far more to it !

"Knowing enough to think you're doing it right, but not enough to know you're doing it wrong." - Neil deGrasse Tyson

So your client has knee pain huh ? Look far and wide, this is a global game amigos.
"Of the 51% of limbs with forefoot varus, 91.3% had medial and 78.3% had lateral PFJ cartilage damage. . . . . this study suggest a relationship between forefoot varus and medial PFJ cartilage damage in older adults"- Lufler et al. (study link below)

*If you do not know your client has a rigid forefoot varus, and they have hip or low back pain and cannot keep their glutes activated and participating in movements, how long are you going to fail your client ? The forefoot varus may need addressed because of the excessive, abrupt degree of internal spin on the limb.

If you are truly going to treat people, people who move (yes, that means everyone !), you have to know feet and gait, BOTH. Your knowledge must go far past rudimentary knowledge of:
- high / low arch
- flat feet
- prontation and supination
- orthotics and footbeds

You will have to know your foot types, you will have to understand shoe anatomy, foot anatomy, flexible semi-flexible and rigid foot types, compensated and uncompensated foot types, and of course know how each of these responds under various loading responses. Forefoot varus will load differently in cutting sports than in sagittal locomotion such as walking and running (both of which are different even in themselves despite both being sagittal). A foot that looks like it has a flat collapsed arch has far more to it than that, and thus remedy and intervention MUST go far beyond rudimentary interventions like a "stability shoe" or orthotic. Are you practicing, coaching, training and being part of your client's solution, or are you part of the problem ? If you want to get better at this stuff, we cover it all in our several hour (very difficult for some) National Shoe Fit program (the link is on our website if you wish to become a foot/gait/shoe jediwww.thegaitguys.com). Do not be mistaken, this is far more than "shoe Fit". To know how to properly shoe fit someone, you have to know the foot types and how they compensate, load, and respond. Without this knowledge, you are just another bump in the "road of problems" without ample solutions.

- Dr. Shawn Allen, one of the gait guys

The Association of Forefoot Varus Deformity with Patellofemoral Cartilage Damage in Older Adult Cadavers. Lufler, Stefanik, Niu, Sawyer, Hoagland, Gross http://onlinelibrary.wiley.com/doi/10.1002/ar.23524/full

images courtesy of aaronswansonpt.com and studyblue.com

Ankle Function: Be a chef, be a scientist, not a juice bar junkie.

Today, another "no rocket science here" post, however these are things to keep in mind.
Ankle stability is critical, whether is it walking or sport related running. We must have ample S.E.S. (skill, endurance and strength as we like to say here at TGG, and in that order might we remind you !).  
And on that point, one is building strength on a skill without being able to do that skill repeatedly with durability (Endurance) then you are probably skipping a critical step in the rehab process. Yes, exceptions do occur, but rarely.  If you cannot do something well repeatedly and maintain the clean skill pattern, they why are we adding more strength to it first ?  Do something well, often, repetatedly, with durability, then add more strength and up the skill level.
The ankles are no different. There are multiple planes of movement down there, every direction is possible. We approach things from a cylinder perspective, every quadrant of that cylinder must be stable,  have skill, endurance and strength.  There are tremendous forces going down through that area, they had better be clean, controlled and the limb better be durable ("The absolute forces in the two joints (knee and ankle) were similar, equivalent to eight to nine times body weight in both cases."-Alex Hutchinson, excerpt from Medicine & Science in Sports & Exercise by researchers at the University of Jyvaskyla in Finland, link below.
Power had better not precede, S.E.S,.  From the article:  "And the progressive loss of ankle power as we age may be one of the key reasons we slow down".

As Hutchinson extracted from the Finnish study, "But the knees were capable of much greater maximum forces – nearly 14 body weights, on average – when the subjects jumped up and down as high as they could. In contrast, the ankles had a maximum force of less than 10 body weights, meaning that they’re already working at nearly their maximum strength even during a gentle jog. This suggests that the ankles are much more likely to hold you back if they’re weak, according to Juha-Pekka Kulmala, the study’s lead author. “The muscles working closest to their upper functional limits are the ‘weakest link,’” he says."

The Hutchinson article goes into other thoughts and perspectives, read it. The link is below.

Just know that this is just not about just doing heel raises, the science is more than than. If it were that simple the schooling for all that we all do would be a 3 hour internet youtube video course.  The pieces have to play well together and if you train strength into faulty patterns, you get strong faulty patterns which can increase injury risks.  There is a time for peroneal work, time for tibialis posterior work, time for single leg balance work, time for heel raises, for double hoping, single hopping, multidirectional hopping, skipping, walking, running or sprinting. The process isn't like your morning smoothie, meaning just throw it all in and blend, there is a science and sequence.  And, that science and sequence is variable and specific to each and every client. The process cannot be "cook booked ", you will do many people injustice if you just go for the smoothie routine.  Be a chef, be a scientist, not a juice bar junkie.

- Dr. Allen, one of the gait guys


1. Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189.

Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles.

Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.


2. "Pay attention to your ankles — they can slow you down with age." Alex Hutchinson. Special to The Globe and Mail

http://www.theglobeandmail.com/life/health-and-fitness/how-weak-ankles-slow-us-down-with-age/article33458151/

Fatigue and muscle activation.

"Increased muscle activation with decreased movement in a fatigued state may represent an effort to increase trunk stiffness to protect lumbo-pelvic-hip structures from overload"

No rocket science here . . . but good to remember that fatigue sets us all up for injury if one does not observe and listen to the signs of fatigue . . . . especially when athletic and loading demand is increasing rather than tapering at the same time as the fatigue is building. As we fatigue, compensation recruitment is supposed to generate more stiffness to protect the motor units. But, can this be at a cost ?

This study looked at whether fatigue may affect muscle recruitment, active muscle stiffness and trunk kinematics, compromising trunk stability. The purpose of this study was to compare trunk muscle activation patterns, and trunk and lower extremity kinematics during walking gait before and after exercise.

The study used surface EMG to look at the rectus abdominis, external oblique, erector spinae, gluteus medius, vastus lateralis, and vastus medialis in a group of otherwise healthy individuals.

Essentially the study concluded that:
"There was less trunk and hip rotation from initial contact to midstance after exercise. Neuromuscular fatigue significantly influenced the activation patterns of superficial musculature and kinematics of the lumbo-pelvic-hip complex during walking. 
."

 

Gait Posture. 2016 Nov 9;52:15-21. doi: 10.1016/j.gaitpost.2016.11.016. [Epub ahead of print]

Muscle activation patterns of the lumbo-pelvic-hip complex during walking gait before and after exercise.

Chang M1, Slater LV2, Corbett RO1, Hart JM1, Hertel J1.

https://www.ncbi.nlm.nih.gov/pubmed/27846435

Movement, can it make us better Humans ?

Human movement, grace and beauty.

This will be the last blog post you read from us …  for 2016. Happy New year wishes to you all !

This is a rehash of some old stuff, and some new, it seems to bring together many good points and thoughts of our work this past year. We hope you agree. If this seems familiar for those who have been with us for the last 7 years, it is our typical year end post, but it is worth your time

We have an amazing video for you today, a testament to how amazing the human frame is and how amazing movement can be.  But first … . it has been an amazing year for both of us here at The Gait Guys. Through this year, we have bridged further chasms. Our podcasts went into high gear and our number continue to grow globally, we were blessed to know our voices spanned the miles into 85 countries. The National Shoe Fit Certification Program continues to bring us deep gratitude emails from all professions. We blogged weekly , added some new videos and have made plans for more. We also made many new friends while learning much on our own end in our relentless research and readings. We appreciate every one of you who has followed us, and we thank you for your friendship.

As we find ourselves here at the end of another year, it is normal to look back and see our path to growth but to look forward to plan for ways to further develop our growth.  Many of you who read our blog are runners, but many of you are in one way or another involved with a sport or activity that incorporates running and gait. Hey, we all walk !  Even in the video above the dancers are seen running and walking. What we mean is that many of you are coaches or trainers or movement experts who develop those who run or move in one way or another in various sports, but many of you are also in the medical field helping those to run and move to get out of pain or improve performance.  And still yet we have discovered that some of you are in the fields of bodywork such as yoga, pilates, dance, martial arts and movement therapies.  It is perhaps these fields that we at The Gait Guys are least experienced at (but are learning) and like many others we find ourselves drawn to that which we are unaware and wish to know more in the hope that it will expand and improve that which we do regularly.  For many of you that is also likely the case.  For example, since a number of you are runners we would bet to say that you have taken up yoga, pilates, lifting or cross training to improve your running and to reduce or manage injuries or limitations in your body. But why stop there ? So, here today, we will try to slowly bring you full circle into other fields of advanced movement. As you can see in this modern dance video above the grace, skill, endurance, strength, flexibility and awareness are amazing and beautiful.  Wouldn’t you like to see them in a sporting event ? Wouldn’t you like to see them run ? Aren’t you at least curious ? Their movements are so effortless. Are yours in your chosen sport ? How would they be at soccer for example ? How would they be at gymnastics ? Martial arts ? Do you know that some of the greatest martial artists were first dancers ? Did you know that Bruce Lee was the Cha Cha Dance Champion of Hong Kong ? He is only one of many. Dance, martial arts, gymnastics …  all some of the most complex body movements that exist. And none of them are simple, some taking decades to master, if that, but most of which none of us can do. In 2017 we will continue to expand your horizons of these advanced movement practices as our horizons expand. We plan to return to dance again to advance our thinking of foot and body movements, incorporating many aspects into our treatment and exercise regimens, and now that we have almost 4 years of jiu jitsu under our belts it is time to consider adding the sport of Parkour and climbing as we have hinted. Why not add this knowledge to your repertoire ?  Many of our athletes do not even know that much of their exercise homework is from basic dance principles, until we tell them at the end of a session.  There is a reason why some of the best athletes in the NBA, NFL and other sports have turned to almost secret study of dance and martial arts because there is huge value in it.  Look at any gymnast, martial artist or dancer. Look at their body, their posture, their grace.  It is as if their bodies know something that ours do not.  And so, in 2017 The Gait Guys will dive even deeper into these professions to learn principles and bring them back to you. After all, everything we do is about movement. Movement is after all what keeps the brain alive and learning. 

Below are excerpts from a great article from Kimerer Lamothe, PhD. She wrote a wonderful article in Psychology Today a few years ago  on her experience with McDougall’s book “Born to Run” and how she translated it into something more.  At some point, take the time to read her whole article.  But do not cut yourself short now, you only have a little more reading below, take the next 2 minutes, it might change something in your life.

We leave you now with our 2017 gratitude for this great growing brethren and community that is unfolding here at The Gait Guys. We have great plans for 2017 so stay with us, grow with us, and continue to learn and improve your own body and those that you work with.  Again, read Kimerer’s most excellent excerpts below, for now, and watch the amazing body demonstrations in the video above. It will be worth it.

Shawn and Ivo, the gait guys

_____________________

Can Running Make us Better Humans ?….. excerpts from the artcle by Kimerer LaMothe.

http://www.psychologytoday.com/blog/what-body-knows/201109/can-running-make-us-better-humans

“The Tarahumara are not only Running People, they are also Dancing People. Like other people who practice endurance running, such as the Kalahari Kung, dancing occupies a central place in Tarahumara culture. Or at least, it has. The Tarahumara dance to pray, to celebrate life passages, to mark seasonal and religious events. They dance outside where Father God and Mother Moon can see, in patterns consisting of steps and shuffles, taps and hops, performed in a line or a circle with others. And they dance the night before a long running race, while the native corn beer, or tesguino flows.

While McDougall notes the irony of “partying” the night before a race, he doesn’t ask the question: might the dancing actually serve the running? Might it be that the Tarahumara dance in order to run—to ensure the success of their run—for themselves and for the community?

At the very least, the fact that the Tarahumara dance when and how they do is evidence that they live in a world where bodily movement matters. They believe that how they move their bodies matters to who they are and to how life happens. They have survived as a people by adapting their traditional method of endurance hunting (running animals to exhaustion) to the challenges of fleeing Spanish invaders, accessing inaccessible wilderness, and staying in touch with one another while scattered throughout its canyons. As McDougall notes, they have kept alive an ancient genetic human heritage: to love running is to love life, for running enables life.

Yet McDougall is also clear: even the Tarahumara are not born knowing how to run. Like all humans, they must learn. Even though human bodies are designed to flourish when subject to the stresses of long distance loping, we still need to learn how to coordinate our limbs to allow that growth to happen. We must learn to run with head up, carriage straight, and toes reaching for the ground. We must land softly and roll inwardly, before snapping our heels behind us. We must learn to glide—easy, light, smooth—uphill and down, breathing through it all. How do we learn?

How do we learn to run? We learn by paying attention to other people, and taking note of the movements they are making. We learn by cultivating a sensory awareness of our own movements, noting the pain and pleasure they produce, and finding ways to adjust. We learn by creating and becoming patterns of movement that release our energy boldly and efficiently across space. We learn, in a word, by dancing.

While dancing, people open up their sensory selves and play with movement possibilities. The rhythm marks a time and space of exploration. Moving with another heightens the energy available for it. Learning and repeating sequences of steps exercises a human’s most fundamental creativity, operating at a sensory level, that enables us to learn to make any movement in any realm of endeavor with precision and grace. Even the movements of love. Dancing, people affirm for themselves and with each other that movement matters.

In this sense, dancing before the night of a running race makes perfect sense. Moving in time with one another, stepping and stretching in proximity to one another, the Tarahumara would affirm what is true for them: they learn from one another how to run.  They learn to run for one another. They run with one another. And when they race, they give each other the chance to learn how to be the best that they each can be, for the good of all.

It may be that the dancing is what gives the running its meaning, and makes it matter.

Yet the link with dance suggests another response as well. In order for running to emerge in human practice as something we are born to do, we need a culture that values movement—that is, we need a general appreciation that and how the bodily movements we make matter. It is an appreciation that our modern western culture lacks. 

Those of us raised in the modern west grow up in human-built worlds. We wake up in static boxes, packed with still, stale air, largely impervious to wind and rain and light. We pride ourselves at being able to sit while others move food, fuel, clothing, and other goods for us. We train ourselves not to move, not to notice movement, and not to want to move. We are so good at recreating the movement patterns we perceive that we grow as stationary as the walls around us (or take drugs to help us).

Yet we are desperate for movement, and seek to calm our agitated senses by turning on the TV, checking email, or twisting the radio dial to get movement in a frame, on demand. It isn’t enough. Without the sensory stimulation provided by the experiences of moving with other people in the infinite motility of the natural world, we lose touch with the movement of our own bodily selves. We forget that we are born to dance and run and run and dance.

The movements that we make make us. We feel the results. Riddled with injury and illness, paralyzed by fears, and dizzy with exhaustion, our bodily selves call us to remember that where, how, and with whom we move matters. We need to remember that how we move our bodies matters to the thoughts we think, the feelings we feel, the futures we can imagine, and the relationships we can create with ourselves, one another, and the earth.

Without this consciousness, we won’t be able to appreciate what the Tarahumara know: that the dancing and the running go hand in hand as mutually enabling expressions of a worldview in which movement matters.”

Thanks for a great article Kimerer. (entire article here)http://www.psychologytoday.com/blog/what-body-knows/201109/can-running-make-us-better-humans

*oh, and want a little more of these performers in the video, check this out……. it will move you.

http://youtu.be/CvQBUccxBr4

Wishing a Happy New Year to you all, from our hearts……. Shawn and Ivo

The Gait Guys

"Stiff person syndrome": A clinical mystery ?


Stiff person syndrome (SPS), first noted in 1956, is a rare neurologic entity of unclear etiology. It is characterized by progressive rigidity and stiffness mainly affecting the axial trunk muscles thought it can affect the limb(s), one or more.  It looks much like a sensory-motor neuropathic gait, and similar to a CIDP (chronic inflammatory demyelinating polyneuropathy) client we have seen. Chronic pain, impaired mobility, and lumbar hyperlordosis are common symptoms. Spasms can be severe and leave the patient very sensitive to touch and sound, which can sometimes trigger spasms. Some studies have noted that patients generally tend to have anti-glutamic acid decarboxylase (GAD) antibodies, anti-amphiphysin, anti-gephyrin, and anti-gamma-aminobutyric acid A receptor-associated protein (GABARAP) antibodies leaving one to assume this is a variation of an autoimmune disorder expressing neurologically. This is complicated by lack of adequate or specific lab tests to pin point the diagnosis though some CSF and EMG tests are helpful. Generally this is a progressive disorder eventually leaving many clients with movement disabilities.  Enough patients tend towards cancer over time that there may be a paraneoplastic underpinning.
This is a bizarre one, what do you think ?  Have you seen it ?

Pract Neurol. 2011 Oct;11(5):272-82. doi: 10.1136/practneurol-2011-000071. Stiff person syndrome. Hadavi S1, Noyce AJ, Leslie RD, Giovannoni G.


Brain Nerve. 2010 Apr;62(4):377-85. [Stiff-person syndrome and other myelopathies constitute paraneoplastic neurological syndromes]. [Article in Japanese] Ishii A1.

Abnormal Forefoot loading creates fatigue ?

How is your medial-lateral foot and ankle stability ? In many injured folks it is an issue and needs to be investigated. Remember, skill, endurance, strength IN THAT ORDER ! Today, Fatigue is the topic du jour !
If you are in a heeled shoe of any degree (greater heels suggests greater risk) , and this likely pertains to increased heel dropped running shoes we would propose, fatigue of the frontal plane is risky business. 
“EMG measurements from habitual high-heeled shoe wearers demonstrated an imbalance of gastrocnemius lateralis versus gastrocnemius medialis activity in fatigue conditions, which correlated with abnormal lateral shifts in the foot-ground or shoe-ground COP of these women.”
Some of this is from the natural foot architecture, a blog post on this very topic is in order we think !
“The results demonstrated accelerated fatigue of the peroneus longus muscle in marching conditions … . EMG analysis further revealed substantial fatigue of the pre-tibial and triceps surae muscles during intensive marching”
Don’t forget to assess fatigue gait brethren ! Motor patterns, skill, strength are all great, but what about fatigue ?! Test for it and you will find it ! 
And, think about this if you are a forefoot strike runner, for obvious reasons, the heels is similarly in a raised posture.

Dr. Shawn Allen

Gait Posture. 2002 Feb;15(1):56-63.
Analysis of muscular fatigue and foot stability during high-heeled gait.
Gefen A

Med Biol Eng Comput. 2002 May;40(3):302-10.
Biomechanical analysis of fatigue-related foot injury mechanisms in athletes and recruits during intensive marching.
Gefen A1.

Podcast 117: The glutes in rotation

Key tag words:

running, glutes, climbing, hip rotation, movement patterns, hominids, bone density, gait

Links:

http://traffic.libsyn.com/thegaitguys/pod_117ffinal.mp3

http://thegaitguys.libsyn.com/episode-117

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.

 

Show Notes:

3D printed talus replacement surgery helps patients regain up to 75% normal ankle function
http://www.3ders.org/articles/20160504-3d-printed-talus-replacement-surgery-helps-patients-regain-up-to-normal-ankle-function.html

http://pubs.rsna.org/doi/full/10.1148/rg.2015140156

Stopping Exercise Decreases Brain Blood Flow
http://neurosciencenews.com/exercise-brain-blood-flow-4927/?utm_medium=email&utm_source=flipboard

Babies Who Walk Earlier May Have Stronger Bones in Their Teens
http://news.health.com/2016/06/02/babys-early-walking-may-mean-stronger-bones-as-teen/

NEW EVIDENCE SUGGESTS OUR HOMINID COUSIN LUCY LOVED CLIMBING TREES
http://www.popsci.com/new-evidence-that-our-hominid-cousin-lucy-loved-climbing-trees

Glutes as internal hip rotators
https://www.thegaitguys.com/thedailyblog/2016/12/7/the-glutes-are-in-fact-great-internal-hip-rotators-too-open-your-mind

Retraining movement patterns, mind or muscles or vision ?
http://www.theglobeandmail.com/life/health-and-fitness/fitness/study-suggests-visual-feedback-doesnt-speed-up-learning-of-new-movements-health/article33142789/

Crawling and EMG

With all the talk last week on the blog about the glutes and their functions, especially INTERNAL ROTATION along with crawling, we thought this FREE FULL TEXT article was germane

The following conclusions are drawn from the current study:
1. The highest gait velocity in confined space is achieved with stoopwalking, followed by four-point and two-point crawling. 2. Wearing kneepads did not influence thigh muscle EMG or knee
kinematics during stoopwalking or crawling; however, wearing kneepads in two-point crawling decreased cadence and increased stride length.
3. Compared to upright walking, EMG activity of the thigh muscles during stance in stoopwalking is more prolonged.
4. A variety of interlimb coordination patterns were observed in four-point crawling, including trot-like, pace-like, and no-limb pairing contact patterns.
5. Two-point crawling was unique among the techniques in that the hamstrings exhibited greater activity than the vasti muscles.

 

 

 

https://www.cdc.gov/niosh/mining/UserFiles/works/pdfs/lirsk.pdf

Podcast 116: Running Cadence & Tricks


Key tag words:
running, cadence, form, running form, running tricks, gait, gait analysis, the gait guys, CRISPR, brain implants, spinal regeneration, coordination

Direct download URL:
http://traffic.libsyn.com/thegaitguys/pod_116_final_2.mp3

Permalink URL:
http://thegaitguys.libsyn.com/episode-116

Libsyn directory URL:  http://directory.libsyn.com/episode/index/id/4901265

Key tag words:
running, cadence, form, running form, running tricks, gait, gait analysis, the gait guys, CRISPR, brain implants, spinal regeneration, coordination
 
Show sponsors:
 
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.
 
Show Notes:

Human patient treated with CRISPR gene editing for the first time.
http://www.popsci.com/crispr-tested-in-human-patient-for-first-time

For the First Time, a Wireless Brain Implant Has Enabled Paralysed Primates to Walk Again
http://www.sciencealert.com/for-the-first-time-a-wireless-brain-implant-has-enabled-paralysed-primates-to-walk-again

Scientists May Have Found Protein That Could Help Unlock Spinal Regeneration in Humans
http://futurism.com/scientists-may-have-found-protein-that-could-help-unlock-spinal-regeneration-in-humans/

Cadence:
"Coordination variability decreased with an increase in cadence across all couples and phases of gait. These results suggest examination of coordination and its variability could give insight into the risk of intervention-induced injury."

Hafer JF, Freedman Silvernail J, Hillstrom HJ, Boyer KA. Changes in coordination and its variability with an increase in running cadence. J Sports Sci. 2016 Aug;34(15):1388-95. doi: 10.1080/02640414.2015.1112021. Epub 2015 Nov 20.

http://www.thegaitguys.com/thedailyblog/2016/10/16/music-to-my-earsand-steps-to-my-cadence

http://www.thegaitguys.com/thedailyblog/2016/10/16/step-rate-to-change-foot-strike

http://www.thegaitguys.com/thedailyblog/2016/10/16/cadence
-cadence and running. Increasing it as little as 5% seems to decrease vertical loading rates in the achilles tendon.

The glutes are in fact great internal hip rotators, too. Open your mind.

I recently got a message from a colleague questioning as to how in the world, that when the hip is in flexion, the glutes and piriformis become internal rotators.  This is again another example of lack of functional anatomy knowledge.  It took me awhile to find a picture to help explain this, but I finally found one reasonable to do so. Many readers who are stuck on this concept are just too stuck on the anatomy as presented in the image to the right, neutral stance-like.  This article today will be all about internal and external moment arms, here, this lecture will help a little, it is on glute medius internal moment arms in stance phase however, so there is little carry over but it will at least get you understanding moment arms more clearly. 

We tend to just think of the glute max as a hip stabilizer and extensor, for the most part. It also decelerates flexion in terminal swing.  The glute medius is mostly thought of as a lateral hip stabilizer and abductor, either of the femur (open chain) or of the pelvis in stance position (closed chain), meaning zero degrees or neutral plus or minus the trivial degrees of engaged hip flexion and extension used in normal gait.

No one I know consciously trains the glutes as an internal rotator, but there are many actions where we need this function, such as in crawling and many high functioning activities such as martial arts grappling and kicking for example. Gymnasts should also know that the glutes are powerful internal hip rotators.  If you are doing quadruped crawling work you also need to know this as your client approaches 90 degrees of hip flexion. No one ever seems to check this critical gluteal function, at least I see it missed all the time from my referring doctors and therapists for unresolving hip pain cases. Patients with hip pain, anterior, lateral or posterior, with lack of internal hip rotation need the glutes checked just as much as the other known internal hip rotators we all seem to know (though some still do not understand how powerful the vastus lateralis is as an internal rotator, but again, those are folks who just have not spend the time in a mental 3D space looking at functional anatomy. I live mentally in that 3D space all day long when working with patients, you should too.) Let me be more clear, the anterior bundle, the iliac bundle of the glute max, is an internal rotator in flexion, the sacral and coccyxgeal divisions are not, they are external hip rotators in flexion. The gluteus medius and minimus are internal hip rotators closing in on 90 degrees hip flexion.  Hence, you must be able to tease out these divisions in your muscle testing, one cannot just test the glutes as external rotators or extensors, you are doing a really sloppy job if that is all you are doing. Nor should someone just train the glutes as hip stabilizers, external hip rotators and extensors (which is probably 90% of the trainers and coaches out there I might assume?). IF one knows the origin and insertions (see the blue and green arrows) and moves those points towards each other in a fashion of concentric contraction (purple arrows) one should be able to easily see that this will orient the femur to spin into internal rotation in the acetabulum (follow the arc of the black arrows). The same goes for eccentric contractions, it is the same game.  If you are doing DNS and crawling work, you should know this stuff cold gang. When you close chain the hip in sitting, or are moving from tall kneeling into flexed kneeling chops, performing high knees in sprint training,  or especially in crawling and climbing type actions, you must understand the mechanisms of internal rotation creation and stabilization -- if the glutes are not present and trained and useful in flexion, you are missing a chunk of something big. Amongst many other things, your client must be capable, stable, strong and skilled in moving from supine to quadruped all in one turning-over motion to teach how to stabilize the hip in the quadruped action and then progress into crawling.  This is a reflexive action learned in the early motor developmental phase of locomotion.  So take your client back through this motor pattern if they have some of the hip problems with internal rotation, it is a small piece of the gluteal puzzle.

I am sure this will show up in someone's seminar at some point, hopefully it is in many already, it has always been in my lectures when going down the rabbit hole of all things glutes. And to be fair, I haven't been to seminars in years as I get too frustrated, so this concept may be everywhere for all I know (lets hope).  But that is something I have to get over, I am sure I still have much to learn.  

To give credit where credit is due, which we always insist upon here at The Gait Guys, this was refreshed in my mind by Greg Lehman in a Facebook post forwarded to me by the inquiring doctor.   Link here  and from the article that spurred him to discuss it, an old article I read long ago just after completing my residency, the article is by Delp et al.  It is worth your time.  Thanks Greg for bringing this back into the dialogue, it is critical base knowledge everyone should already know. 

Variation of rotation moment arms with hip flexion.  Scott L. Delp,*, William E. Hess, David S. Hungerford, Lynne C. Jones  J. of Biomechanics 32, (1999)

-Dr. Shawn Allen, the other Gait Guy

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/