More on Rockered footwear and Hallux Limitus

Rockered footwear is for more than Hallux Limitus..

To go along with yesterdays post on Hallux Limitus... In case you missed it, click here

In other words, footwear with more "drop" in the front lessens the need for forefoot rocker (otherwise known as 1st metatarsophalangeal joint extension, or "the ability to bend your big toe backward)

“Most people have to wear MBTs a little at a time until they gain strength and stamina, so we recommend wearing them an hour a day for the first few days and to increase gradually until they feel strong enough to wear them for a full day,”

...sounds an awful lot like our mantra "skill, endurance, strength"...

A great read here. Keep this one around for reference...

http://lermagazine.com/article/rocker-bottom-footwear-effects-on-balance-gait

#rockeredshoe #rocker #footwear

The Q angle and Kids: The Basics

Screen Shot 2017-05-01 at 3.37.08 PM.png

Genu valgum in kids: What you need to know

We have all seen this. The kid with the awful “knock knees”.  It is a Latin word “which means “bent” or “knock kneed”. It appears to have 1st been used in 1884.

This condition, where the Q angle angle exceeds 15 degrees, usually presents maximally at age 3 and should resolve by age 9. It is usually physiologic in development due to obliquity of the femur, when the medial condyle is lower than the lateral. Normal development and weight bearing lead to an overgrowth of the medial condyle of the femur. This, combined with varying development of the medial and lateral epiphysies of the tibial plateau leads to the valgus development. Gradually, with increased weight bearing, the lateral femoral condyle (and thus the tibial epiphysis) bear more weight and this appears to slow, and eventually reverse the valgum.

Normal knee angulation usually progresses from 10-15 degrees varus at birth to a maximal valgus angle of 10-15 degreesat 3-3.5 years (see picture).  The valgus usually decreases to an adult angle of 5-7 degrees.  Remember that in women, the Q angle should be less than 22 degrees with the knee in extension and in men, less than 18 degrees. It is measured by measuring the angle between the line drawn from the ASIS to the center of the patella and one from the center of the patella through the tibial tuberosty, while the leg is extended.

Further evaluation of a child is probably indicated if:

  • The angle is greater than 2 standard deviations for their age (see chart) 
  • If their height is > 25th percentile 
  • If it is increasing in severity 
  • If it is developing asymmetrically

Management is by serial measurement of the intermalleolar distance (the distance between ankles when the child’s knee are placed together) to document gradual spontaneous resolution (hopefully). If physiologic genu valgum persists beyond 7-8 years of age, an orthopaedic referral would be indicated but certainly intervention with attempts at corrective exercises and gait therapy should be employed. Persistence in the adult can cause a myriad of gait, foot, patello femoral and hip disorders, and that is the topic on another post.

Promotion of good foot biomechanics through the use of minimally supportive shoes, encouraging walking on sand (time to take that trip to the beach!), walking on uneven surfaces (like rocks, dirt and gravel), gentle massage (to promote muscle facilitation for those muscles which test weak (origin/insertion work) and circulation), gait therapeutic exercises and acupuncture when indicated, can all be helpful.

To drop or not to drop...That is the question...

Like to run in Zero Drop shoes? Good... we do too... but look at this:

"Barefoot running induced higher loading rates during overground running than the highest drop condition, while it was the opposite during treadmill running. Ankle plantar flexion and knee flexion angles at touchdown were higher during treadmill than overground running for all conditions, except for barefoot which did not show any difference between the tasks."

So, if you want to reduce vertical loading rates, run barefoot on a treadmill.

Does this mean if we want to decrease vertical loading rates when running overground (NOT on a treadmill) we should run in shoes with a large drop?

It seems, according to this study, that kinematics are the same with barefoot but not with shoes.

Which is best for you? You decide...

 

http://link.springer.com/article/10.1007%2Fs00421-014-3072-x

Medial tibial stress syndrome (MTSS) and the long flexor of the big toe.

There are several mechanisms in place to stabilize the medial foot tripod. Some, we would hope many in fact, would argue that the process starts up in the glutes in controlling the rate of internal rotation of the limb during the weight bearing response. The glute has to help slow down that spin, hopefully to the point that when the knee reaches its sagittal tracking plane, the spin stops. And, if the knee stops its inward course, the tibia will stop spinning and thus excessive pronation loads into the foot tripod.
Jumping past a bunch of other variables here, for the sake of a shorter article, many typically feel that the tibialis posterior and peroneal sling is additionally important and cannot be ignored.  Then there is a concept we pound hard here on TGG, that one must have adequate control of the rate, speed, degree of pronation.  Again, that comes in part from the sling we just mentioned and of course the skill, endurance and strength of the anterior compartment components, mostly the toe extensors and tibialis anterior.  Their eccentric control slows the forefoot loading and thus controls the rate and degree of foot tripod splay/collapse. If too weak /too fatigued will render too much splay and too much pronation for too long.  All this, and of course other components (too many to get into here today) when insufficient will create a differential in rotation and bending/flexing loads into the tibia, classically presenting at the distal third of the tibia where Medial Tibial Stress Syndrome (MTSS) classically takes root.
We have discussed many times, here on the blog and on our 100+ podcasts about having a competent foot tripod for a given loading response. Specifically addressing the medial tripod, because this is classically where the foot tripod fails, this anchoring of the medial foot tripod around the 1st metatarsophalangeal joint can only occur if there is a harmonious activation of the long and short flexors and extensors of the hallux, and predicated on a proper plantarflexion of the 1st metatarsal to procure proper orientation and purchase of the metatarsal head on the surface/ground not to mention a competent foot tripod.

This study, investigated and determined some curious findings of linking a history of MTSS with increased isometric FHL (flexor hallucis longus) strength.  Namely, they felt that when there was a history of MTSS, it resulted in increased FHL isometric strength.
Why might this be pre-predictive in our mind ? Well, hammering the big toe into aggressive flexion will act to help synergistically stabilize the medial foot tripod, and thus assist in pronation control even though it is not a primary optimal strategy.  This scenario, thought clearly not an optimal strategy, rather a compensation, often sets up global toe gripping strategies, and as we have discussed long ago, a strong link to subungal hematomas (black toenail, bleeding under the toe nails. (link:https://thegaitguys.tumblr.com/post/6355488304/the-black-plague-ok-kinda-sort-ofsubungal). However, to be fair, as mentioned at the end of this article, the authors of the study in question felt that the increased FHL  might be from an attempt to make up for weakened FDL to the lesser toes.  If you are looking for it, someone who has an incompetent medial foot tripod, will often hammer the big toe down while sometime completely disabling the 1st metatarsal purchase on the ground. I have termed these clients as "knuckle poppers" because they cannot find the medial tripod, and their attempts are from over-recruitment of the long hallux flexor (FHL).  The problem here in lies that one cannot properly toe off the big toe, which should be in extension, when they were still just in a FHL life or death strategy. This can set up a functional hallux limitus.  Often, someone with such a functionally troubled medial tripod strategy, will toe off more laterally, choosing not to drive through the medial tripod and hallux, merely because they cannot do so well.


"In this study, the MVIC torque of the 1st MTPJ plantar flexion was significantly higher in runners with a history of MTSS than without it." 

"Our results suggest that runners with a history of MTSS adopt a strategy of reducing the load to the medial tibia because of their history of MTSS."

This may be the case in some, but i am not sure we entirely agree this is the case. We are trying to postulate that the failed tripod is more likely.  Meaning, more uncontrolled medial loading of the foot and thus increased load to the medial tibia. This leans towards this articles comment that, 

"A previous study reported that excessive pronation during motion is a risk factor of developing MTSS [9, 11]. The results also suggest that the FDL and TP muscles that act to support the arch of the foot tend to be stressed in runners who potentially have a risk for developing MTSS. On the other hand, although the FHL, which is an agonist of 1st MTPJ plantar flexion, has a function similar to those of the FDL and TP as the inversion muscle of the ankle, FHL is not likely to be related to development of MTSS because the FHL does not connect to tibial fascia [22]. "

We would suggest that, it does not have to connect to the tibial fascia to be a relevant issue. It is about the loads directly and indirectly across the tibia, not the actual connections. 

However, we do not argue with their statement,  

"Thus, this characteristic increase in MVIC torque of the 1st MTPJ in runners with a history of MTSS could be considered to be a result of increased activity of the FHL to avoid pain caused by contraction stress of the FDL, which could be a possible cause of MTSS." But, what we are suggesting is that perhaps the increased FHL is not to avoid the pain, but an attempt to help stabilize the medial foot tripod. 

Two interesting side notes/thoughts from this article are,

"Collectively, muscle strength characteristics in runners with a history of MTSS could be considered to be a result of increasing activity of the FHL to reduce the load on FDL and avoid pain caused by contraction stress of the FDL."

 "A previous study reported that the FHL tendon branches to the 2nd and 3rd toe in most cases [24]. Therefore, it could be considered that the absence of a significant difference in the MVIC torques of the 2nd–5th MTPJ between runners with and without a history of MTSS could be due to the effects of the branching of FHL tendon to the 2nd and 3rd toe."

This investigators did admit some possible limitations in this study, one of which was "we investigated the relationships between MTSS and muscle strength as a static assessment. Therefore, it is unclear whether the results directly reflect muscle endurance or activity during running. " 

- the gait guys

Reference:

Ankle and toe muscle strength characteristics in runners with a history of medial tibial stress syndrome

Junya Saeki
Masatoshi Nakamura,
Sayaka Nakao,
Kosuke Fujita,
Ko Yanase,
Katsuyuki Morishita and
Noriaki Ichihashi

https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-017-0197-2

Tibial Torsion and Genu Valgum

Join us in this brief video about tibial torsion and genu valgum in a 6-year-old

Mooney JF 3rd Lower extremity rotational and angular issues in children. Pediatr Clin North Am. 2014 Dec;61(6):1175-83. doi: 10.1016/j.pcl.2014.08.006. Epub 2014 Sep 18.

Killam PE. Orthopedic assessment of young children: developmental variations. Nurse Pract. 1989 Jul;14(7):27-30, 32-4, 36.

Kling TF Jr, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983 Jun;(176):136-47.

Podcast 123: The Rear foot: Understanding your RearFoot type

Key tag words:
foot types, rearfoot, forefoot, pronation, supination, shoe fit, forefoot varus, forefoot supinatus, rearfoot inversion, ankle rocker, injuries, rehab, corrective exercises

Rearfoot varus and Rearfoot valgus. Knowing the anatomy of your rear foot and its anatomic and functional posturing can lead to many problems in anyone. If you do not know the rearfoot type and posturing, you will not understand the rest of the foot mechanics. Without this knowledge, you will not know the reason for midfoot or forefoot problems, not understand what shoe you are in, or even why the shoe, footbed, orthotic you have chosen is either not fixing your problems, or causing them.  Join us on a journey down the rearfoot rabbit hole over the next hour.  Plus a few funny stories to lighten the biomechanics-heavy dialogue.
 

Show links:
http://traffic.libsyn.com/thegaitguys/pod_123final_cut.mp3

http://thegaitguys.libsyn.com/podcast-123-the-rear-foot-understanding-your-rearfoot-type

Show sponsors:
www.newbalancechicago.com

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

https://www.ncbi.nlm.nih.gov/pubmed/27134364

https://www.ncbi.nlm.nih.gov/pubmed/25364132

RearFoot positions:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3588658/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990938/

Powers CM, Maffucci R, Hampton S. Rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther. 1995 Oct;22(4):155-60.

Power V, Clifford AM. The Effects of Rearfoot Position on Lower Limb Kinematics during Bilateral Squatting in Asymptomatic Individuals with a Pronated Foot Type. J Hum Kinet. 2012 Mar;31:5-15. doi: 10.2478/v10078-012-0001-0. Epub 2012 Apr 3.

Shultz SP, Song J, Kraszewski AP, Hafer JF, Rao S, Backus , Mootanah R, Hillstrom HJ. An Investigation of Structure, Flexibility and Function Variables that Discriminate Asymptomatic Foot Types. J Appl Biomech. 2016 Dec 19:1-25. [Epub ahead of print]

 

You better keep that Hallux Dorsiflexion

Geee....Looks like forefoot rocker really IS IMPORTANT, eh?

...and what have we been saying about being able to dorsiflex your big toe? Watch how well you or your client can descend the 1st ray (remember that if the head of the 1st does not go down and anchor, its axis of rotation moves dorsally and posterior, limiting dorsiflexion of the joint)

This article should make you look at the "toe break" in a shoe...

"They found that increasing bending stiffness assisted with propulsion during running, reducing the metabolic cost of running by about 1%. However, at a certain level, the increased elasticity began to interfere with the natural flexion of the first MTP joint, reducing the contribution of ankle joint torque to push-off and counteracting the metabolic benefits. Within the study population, the threshold of bending stiffness for optimal energetics varied significantly from one runner to the next, suggesting running shoe design may need to be tuned to an individual runner’s needs." 

http://lermagazine.com/news/in-the-moment-sports-medicine/stiffer-shoes-improve-running-energetics-as-long-as-first-mtp-flexion-is-preserved

Metatarsus Adductus: The Basics

Metatarsus Adductus: The Basics

A few points to remember:

  • Metatarsus adductus deformity is a forefoot which is adducted in the transverse plane with the apex of the deformity at LisFranc’s (tarso-metatarsal) joint. The fifth metatarsal base will be prominent and the lateral border of the foot which is convex in shape . The medial foot border is concave with a deep vertical skin crease located at the first metatarso cuneiform joint level. The hallux (great toe) may be widely separated from the second digit and the lesser digits will usually be adducted at their bases (se below). ln some cases the abductor hallucis tendon may be palpably taut just proximal to its insertion into the inferomedial aspect of the proximal phalanx (1)
  • To measure the deviation of the metatarsals, the midline of the foot correspondingto bisecting the heel is used as a reference. This is the line that divides the heel pad into equal parts and, when extended, runs through the second toe or the second web space. In mild deformities, the midline of the foot runs through the third toe. In moderate adductus deformities, it falls between the third and fourth toes. In severe deformities the line is lateral to the third web space.(2)
  • If detected early, stretching is a common and effective treatment for mild and some moderate cases. The heel is steadied with one hand while the forefoot is abducted in relation to the hind foot. This is done for 5 reps, 5-7 times per day. (2)
  • 85% will resolve spontaneously, is caused by intrauterine position, is flexible & resolves spontaneously in more than 90 % of children. (3)
  • Though often used interchangeably, the term "metatarsus adductus" is usually reserved for milder cases, where the forefoot is adducted on the hindfoot at the tarso-metatarsal articulation. Metatarsus varus is often reserved for conditions where the matatrsals are actually curved AND the forefoot is adducted on the hindfoot. (4) The term "Metatarsus primus varus" is reserved for feet which have the same neutral or valgus hindfoot and varus forefoot but, in addition, increased divergence of the first and second metatarsals. (5)
  • It is interesting to note that along with forefoot adductus, hip dysplasia and internal tibial torsion are common (6) and this patient has the latter
  • Gait abnormalities seen with this deformity include a decreased progression angle, in toed gait, excessive supination of the feet with low gear push off from the lesser metatarsals. 

 

1.  Bleck E: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatric Orthop 3:2-9,1983.

2. Bohne W. Metatarsus adductus. Bulletin of the New York Academy of Medicine. 1987;63(9):835-838.  link to FREE full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1629274/

3. http://www.wheelessonline.com/ortho/metatarsus_adductus

4. Peabody, C.W. and Muro, F.: Congenital metatarsus varus. J. Bone Joint Surg. 15:171-89, 1933.

5. Truslow, W.: Metatarsus primus varus or hallux valgus? J. Bone Joint Surg.23:98-108, 1925.

6. Jacobs J: Metatarsus varus and hip dysplasia. C/inO rth o p 16:203-212, 1960


additional references:

Kane R. Metatarsus varus. Bulletin of the New York Academy of Medicine. 1987;63(9):828-834. link to FREE full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1629282/

Wynne-Davies R, Littlejohn A, Gormley J. Aetiology and interrelationship of some common skeletal deformities. (Talipes equinovarus and calcaneovalgus, metatarsus varus, congenital dislocation of the hip, and infantile idiopathic scoliosis). Journal of Medical Genetics. 1982;19(5):321-328. link to FREE full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1048914/

 

Take the minute to tie your shoes properly.

Plantar thermal stress response (TSR) leads to skin shear forces.

"Fifteen eligible subjects were enrolled. The left foot was used as a reference and fitted to a self-adjusted and habitual lace-tightening method by each subject. The right foot was used as a test closure and fitted into three lace closure conditions: loose, tight, and preset optimal closure (reel clutch, BOA technology). Thermal images were taken after 5 minutes of acclimatization (pre-trial) and immediately after 200 walking steps in each shoe closure condition (post-trial)."

Their conclusions:
"The results from this study suggest that shoelace closure technique can have a profound effect on TSR. It therefore stands to reason that optimal lace closure may have an impact in reducing risk of plantar ulcers in people with Diabetic peripheral neuropathy (DPN). Interestingly, results revealed that even a self-adjusted lace closure may not be necessarily optimal and a preset closure setting like reel clutch might ultimately be recommended to minimize risk."


Lace Up for Healthy Feet: The Impact of Shoe Closure on Plantar Stress Response

Hadi Rahemi, PhD, David G. Armstrong, DPM, MD, PhD, Ana Enriquez, BSc, Joshua Owl,BSc, Talal K. Talal, DPM, Bijan Najafi, PhD, MSc
First Published April 18, 2017


http://journals.sagepub.com/doi/abs/10.1177/1932296817703669?platform=hootsuite&journalCode=dsta

Wool socks ?

Blisters, wet feet, smell, skin maceration, who needs that. 
Here at The Gait Guys, we swear by wool socks. We wear them everyday, every season, and even in our running and hiking or athletic shoes. Cotton and synthetics are not in our life, and this is a personal choice. Ivo likes the Darn Tough brand, so do I, but I also love the REI thinner black dress socks for every day wear. I could wear a single pair all week if i wanted, and admittedly often do, without any smell. Yes, you read that right, no odor.  That is the genius of wool. But, there are other benefits as well.
Wool is also king for moving moisture, the fatty acids in the wool fibers eat up the bacteria and microbes that can possibly cause infection. 

Darn Tough ran a test where they soaked their socks in a bacteria that hikers might encounter on the trail; within an hour, 50 to 80 percent of the bacteria ws gone. 

Wool is also great in all temperatures. They insulate when its cold and assist in evaporation when warm. Plus, these things are durable, it is why we love them, and hence the name, Darn Tough Socks. The will get you through a 1000 mile hike, as long as you have shoes on over them :)

https://www.outsideonline.com/2173601/do-i-really-need-25-merino-hiking-socks

https://darntough.com/

 

The "Bad Guys" are watching your gait, too.

It is cold coffee and stale donut Thursday here on The Gait Guys, poorly palatable stuff, but stuff we need to eat anyways.  This is gait related. Read on.

"The cues used by prisoners were: gait, body posture (body movements not related to gait), age, gender, attractiveness, build, clothing, attention, fitness, environment (e.g., lack of lighting), and whether target was alone."

Yes, "Bad Guys" are looking at your gait.
___________

"Bad guys" are relentless and patient, opportunistic and flexible — and they pay attention, to us. And so, what does this mean to us ? And to our gait, how we move about our communities ?

It is in the MSM everyday, so we might as well pay attention to it. It is happening all around us, all the time. Opportunists. You should up your awareness game when you are out an about. We are not talking about becoming paranoid, but we should all be more aware. And, this article proves it.  

Are you a soft target ? "Bad Guys" like easy soft targets. So, read this and don't be a softie.  

"In a classic study conducted by a prison psychologist where dozens of convicted felons were interviewed, the psychologist played videos or presented several snapshots of random crowds of people in shopping malls, subway stations, and busy city streets and asked each of the inmates to point out for him the softest target in the pictures–that is the individual that they would most likely attack if given the opportunity. All responses were recorded. The study concluded that nearly every inmate selected the same people in each segment for similar reasons—these reasons form the baseline definition of Soft Target Indicators."
"Examples that help describe a Soft Target Indicator come from snippets of those recorded study responses, and include “looks sheepish,” “eyes were looking down,” ”obviously lost,” “an easy mark,” “looks out of place,” “not paying attention,” “distracted,”  and the most common—“unaware of their surroundings.”

These are all gait related. We have talked about dual tasking and many other gait and locomotion distractors that can make us vulnerable to falling and stepping off of cliffs and into ponds at the local mall. But now we should all be aware that there are other people watching our gait for reasons other than capturing the next viral video for YouTube. They are opportunists. 

The top vulnerable cues for these opportunists were: 

- Walk/gait – walking with confidence versus walking like a soft target. 

- Gender – females appear as softer targets than males. 

- Body type – In good physical shape versus heavy set or slow - - - - Apparent Fitness level – 

- Attention to surroundings versus Not paying attention; Appears to be cautious versus appears to be clueless.

So, our advice, especially if you are in a new environment or travelling?  Plan ahead, so you can pay attention. Keep your head up and look around, walk with confidence and be observant. If your head is down in your phone and you are dual tasking, this articles suggests that the "Bad Guys" are looking for you. 


http://www.recoilweb.com/adversarial-attraction-predators-optic-90271.html

Podcast 122: Achilles problems, glutes, & feet.

Key tag words:
neuroscience, elon musk, achilles, tendonitis, tendonopathy, eccentric loading, tendon loading, gluteus maximus, gmax, glutes, abductor hallucis, foot pain, hip biomechanics, navicular drop, BEAR, ACL tear, ACL reconstruction, plantar fascitis
 

Show links:

http://traffic.libsyn.com/thegaitguys/pod_122f.mp3

http://thegaitguys.libsyn.com/podcast-122-achilles-problems-glutes-the-feet
Show sponsors:
 www.newbalancechicago.com


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

Stanford Develops Computer That Literally Plugs Into People's Brains

https://www.entrepreneur.com/article/289645


Elon Musk says humans must become cyborgs to stay relevant. 

https://www.theguardian.com/technology/2017/feb/15/elon-musk-cyborgs-robots-artificial-intelligence-is-he-right

1. achilles tendonopathy:

http://www.jospt.org/doi/abs/10.2519/jospt.2016.6462?platform=hootsuite&code=jospt-site

2. achilles tendinitis and tendonosis.

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/

3. Is Achilles tendon blood flow related to foot pronation?
 E. Wezenbeek,T. M. Willems,N. Mahieu,I. Van Caekenberghe,E. Witvrouw,D. De Clercq

http://onlinelibrary.wiley.com/doi/10.1111/sms.12834/full

4.  The effects of gluteus maximus and abductor hallucis strengthening exercises for four weeks on navicular drop and lower extremity muscle activity during gait with flatfoot

Young-Mi Goo, MS, PT,1 Tae-Ho Kim, PhD, PT,1,* and Jin-Yong Lim, MS, PT1  J Phys Ther Sci. 2016 Mar; 28(3): 911–915.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842464/

5. BEAR
https://www.youtube.com/watch?v=k3g-CagCrZM

Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) procedure uses stitches and a bridging scaffold (a sponge injected with the patient’s blood) to stimulate healing of the torn ACL eliminating the need tendon graft.

References:
Murray, M., Flutie, B., Kalish, L., Ecklund, K., Fleming, B., Proffen, B. and Micheli, L. (2016). The Bridge-Enhanced Anterior Cruciate Ligament Repair (BEAR) Procedure: An Early Feasibility Cohort Study. Orthopaedic Journal of Sports Medicine, 4(11).

L. Proffen, B., S. Perrone, G., Roberts, G. and M. Murray, M. (2015). Bridge-Enhanced ACL Repair: A Review of the Science and the Pathway Through FDA Investigational Device Approval. Annals of Biomedical Engineering, 43(3), pp.805-818.

Distracted Kids Walk Slower

kid-walking-on-road-2592x3408_47863.jpg

Do Gait rehab on Kids?

Distracted kids walk slower and spend more time in double leg stance.

We know it can effect adults, usually resulting a mild decomposition of gait, by decreasing step length in many and slowing of gait in older folks (becoming more primitive).

Watch where you do your gait rehab in the younger set; keep them focused and engaged for better outcomes.

"Significant main effects of walking experience groupand visual distraction condition were found. Visual environmental distraction significantly affected gait performance in children regardless of walking experience. Velocity decreased from 110.04 to 97.73 cm/sec (p = 0.003) while double limb stance % of gait cycle increased from 18.29% to 20.39% (p = 0.025)."

Phys Occup Ther Pediatr. 2017 Apr 10:1-10. doi: 10.1080/01942638.2017.1297987. [Epub ahead of print]
The Effect of Visual Environmental Distraction on Gait Performance in Children.
Bizama F, Medley A, Trudelle-Jackson E, Csiza L.

J Neuroeng Rehabil. 2014 Apr 28;11:74. doi: 10.1186/1743-0003-11-74.
Effect of explicit visual feedback distortion on human gait.
Kim SJ, Mugisha D.

Curr Gerontol Geriatr Res. 2011;2011:651718. doi: 10.1155/2011/651718. Epub 2011 Jun 16.
Effects of a Visual Distracter Task on the Gait of Elderly versus Young Persons.
Bock O, Beurskens R.

You can only take so many whacks to the head before it starts to show...

In addition to vision and the vestibular system, proprioceptive information is gathered by primarily 2 sources: The peripheral joint mechanoreceptors left (type 1, type 2, type 3, and type 4 ), as well as the muscle mechanoreceptors: Muscle spindles and golgi tendon organs. This information is transmitted to the cortex via the dorsal column and spinocerebellar pathways. The information is then integrated in the parietal lobe (for information in the dorsal columns) and cerebellum. The information is then relayed to the motor cortex, basal ganglia, and vestibular system. The interplay of these 3 systems, vision, the vestibular system, and the joint/muscle mechanoreceptors is what allows us to keep our bodies up right and functioning in the gravitational field. When integration is compromised, at either a peripheral or cortical level, proprioception suffers.

" Measures of cumulative subconcussive head impacts during a men’s lacrosse season are associated with decreases in balance scores from pre- to postseason, according to findings from Sacred Heart University in Fairfield, CT, that could have implications for lower extremity injury risk. The findings suggest that, even in the absence of a concussion, repetitive subconcussive impacts can negatively affect an athlete’s balance, which in turn can increase the risk of lower extremity injury"

http://lermagazine.com/news/in-the-moment-sports-medicine/subconcussive-subtleties-lacrosse-study-links-balance-impacts

Miyashita TL, Diakogeorgiou E, Marrie K. Correlation of head impacts to change in balance error scoring system scores in Division I Men’s lacrosse players. Sports Health 2017 Jan 1. [Epub ahead of print]

Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther 2006;36(12):911-919.

Podcast 121: Carrying things, Overtraining Syndrome, Ankle Rocker and more.

Key tag words:  OTS, overtraining, carries, carrying babies, ankle rocker, foot types, forefoot supinatus, forefoot varus, ankle sprains, nervous system, mitochondria, motor patterns, fatigue

Show links:  http://traffic.libsyn.com/thegaitguys/pod_121final.mp3

http://thegaitguys.libsyn.com/podcast-121-carrying-things-overtraining-syndrome-ankle-rocker-and-more

Show sponsors:  newbalancechicago.com

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Show Notes:

Neuroscience:
1. Why women carry babies on their left side
- perhaps a transition talk into arm swing symmetry, and built in asymmetries in peoples gait

http://www.dailytelegraph.com.au/lifestyle/parenting/why-most-women-carry-babies-on-their-left-side/news-story/f5489a944a37487ce7e6b6ccd10a79e1?utm_content=SocialFlow&utm_campaign=EditorialSF&utm_source=DailyTelegraph&utm_medium=Facebook

2. OTS: Overtraining syndrome
this post got many hits
- CNS sympathetic-parasympathetic talk again, homeostasis
https://www.thegaitguys.com/thedailyblog/2017/1/14/ots-it-is-taking-down-the-best-athletes-one-by-one

3. Chris Beardsley   Strength and Conditioning Research
From posts: December 24, 2016 , Nov 24, 2016

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

https://www.thegaitguys.com/thedailyblog/2017/1/4/ankle-function-be-a-chef-be-a-scientist-not-a-juice-bar-junkie

5. Foot types and knee arthritis:
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

http://www.itsafootcaptain.com/is-forefoot-varus-related-to-patellofemoral-osteoarthritis/

6. Fatigue and motor patterns:
https://www.ncbi.nlm.nih.gov/pubmed/27846435

7. Forefoot loading:
https://www.thegaitguys.com/thedailyblog/2016/12/27/abnormal-forefoot-loading-creates-fatigue-

Where do you do YOUR gait retraining?

It may seem like we are stating the obvious, but visual contrast seems to matter more than visual acuity. When we look at light contrast in lower frequencies (red ranges), we start to see some decomposition of gait with regards to step length, but not necessarily cadence or speed in this study of over 4,000 folks over 50 (hey, that’s us!). What are your patients wearing on their feet? What color is your floor? How about the walls?

Do your gait retraining in a well lit area with lots of contrast between the floor and your patients shoes, as well as the surroundings.

 

Duggan E, Donoghue O, Kenny RA, Cronin H, Loughman J, Finucane C. Time to Refocus Assessment of Vision in Older Adults? Contrast Sensitivity but Not Visual Acuity Is Associated With Gait in Older Adults. J Gerontol A Biol Sci Med Sci. 2017 Feb 28. doi: 10.1093/gerona/glx021. [Epub ahead of print]

 

More on that post operative foot

This is part 2 of a series following a case. If you missed part 1, please go back here and read what we found.

The patient returns 1 week later and reports being approximately 25% improved. She has been performing her "toes up" exercises while walking all the time. She is having some difficulty still with balance. She has been performing her toe waving exercises a few times daily.

X-rays performed 2/17 reveal screw fixation of the navicular. I cannot find evidence of a previous cuboid fracture. The ankle mortise is clear.

She still has 4/5 weakness of the long and short toe extensors; long greater than short. She has tenderness to palpation along the anterior aspect of the deltoid ligament on the left hand side which is made worse with eversion of the ankle. There is a loss of long axis extension at the talocrural and talonavicular articulations. Less tenderness is noted in the inter metatarsal intervals and the interossei musculature.

There is significant improvement over last time. Lack of fixation of the navicular to other articulations will allow us to perform manipulation/mobilization of the foot.

We treated with diagnostic manipulation and mobilization of the foot. I reviewed exercises to date and added the shuffle walk exercise. Since acupunture and needling can influence blodd flow (1-4) We utilized acupuncture points stomach 36, spleen 6, gallbladder 41, liver 3, points in the inter metatarsal intervals, bladder 67 and liver 1.Neelding has been shown to improve muscke activation (4-7) so I did origin/insertion stimulation of the long extensors with 3 sets of 10 repetition cocontraction along with origin/insertion stimulation of the short extensors with 3 sets, 10 repetitions cocontraction was performed. She will follow back in approximately 2 weeks because of travel.

So far, so good. We will keep you posted : )

 

1. Sandberg, M., Larsson, B., Lindberg, L.-G. and Gerdle, B. (2005), Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia. European Journal of Pain, 9: 497. doi:10.1016/j.ejpain.2004.11.002

2.  Cagnie, Barbara et al. The Influence of Dry Needling of the Trapezius Muscle on Muscle Blood Flow and Oxygenation Journal of Manipulative & Physiological Therapeutics , Volume 35 , Issue 9 , 685 - 691

3. Tsuchiya, Masahiko; Sato, Eisuke F.; Inoue, Masayasu; Asada, Akira† Acupuncture Enhances Generation of Nitric Oxide and Increases Local Circulation  Anesthesia & Analgesia: February 2007 - Volume 104 - Issue 2 - pp 301-307

4. Jan Dommerholt Dry needling — peripheral and central considerations Journal Of Manual & Manipulative Therapy Vol. 19 , Iss. 4,2011

5. Zanin, Marília Silva et al. Electromyographic and Strength Analyses of Activation Patterns of the Wrist Flexor Muscles after Acupuncture Journal of Acupuncture and Meridian Studies , Volume 7 , Issue 5 , 231 - 237

6. https://youtu.be/02-M0i6AKAk

7. Fragoso APS, Ferreira AS. Immediate effects of acupuncture on biceps brachii muscle function in healthy and post-stroke subjects. Chinese Medicine. 2012;7:7. doi:10.1186/1749-8546-7-7.

 

Varus anyone?

Varus anyone?

Does patello femoral pain have anything to do with rearfoot varus? Perhaps, according to this study:

" A small but significant increase in rearfoot varus was found in the patellofemoral pain group compared with the control group (8.9 vs. 6.8 degrees; p = .0002). These results suggest that increased rearfoot varus may be a contributing factor in patellofemoral pain and should be assessed when evaluating the events at the subtalar joint and the lower extremity. In addition, it has been demonstrated that consistent rearfoot measurements can be obtained by an individual clinician."


Powers CM, Maffucci R, Hampton S. Rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther. 1995 Oct;22(4):155-60.