Oh Pippa ! For God’s sake (or at least the Queen’s) start using your gluteus medius for crying out loud ! That opposite hip drop isn’t winning Dr. Allen over. !
(internal tibial torsion, knees approximating (due to the lack of left g. medius use, high ramp angle shoe……..mon dieu !……. great dress, bad shoe though ! )
Gluteus medius avoidance and blood pudding, apparently it’s what’s for brunch these days !
The Gait Guys
Gluteal Asymmetry: it means something !
Two photos above, toggle the red bar on the right. What do you see ?
Here is a case of a young football star we saw last night. He came in with a fresh right mid-belly quadriceps strain. This is a simple case if you know what the visuals are telling you. Just be sure you test your visuals (which are ASSUMPTIONS !), in other words, prove or disprove your hunches. What you SEE is not always what is present as the problem.
You can see clearly that in a prone position this chap has significant right gluteal underdevelopment compared to his left. This is a “quick peak” method of screening that i do on every patient when they turn over prone on the table as he is positioned.
There are many nuiances to this case, but here is what i was thinking the moment he told me about the injury…. “Doc, we were doing short 40 sprints, and my right quad just seized up?”.
I thought, hummmm….. i wonder if he was anchoring his thigh into his glutes and abdominals. Lets test his glutes first. If the glute is weak then i can assume he is quadriceps dominant and not anchoring the limb into the pelvis and core correctly. If he is gluteal inhibited, that means he will have underdeveloped glute if it has been there long enough. And if so, the glute cannot power hip extension so that range will be deficient. Sagittal extension will occur the next level above (lumbar spine) and inhibit the lower abdominals on the right. The hamstrings can also be called in to drive hip extension (welcome to the world of chronic hamstring issues in athletes). And if hip extension is limited, then internal rotation is likely somewhat limited. And if internal hip rotation and hip extension are limited then ankle dorsiflexion (“ankle rocker”) will be impaired and limited during midstance thus creating early heel rise during push off thus forcing the calf muscles to create more body mass lift than forward propulsion.
I put him on the table……saw the atrophied right gluteal……and proceeded to confirm all of the above. Treatment is based on figuring out who started this whole mess and reversing the functional pathologies in the pattern that makes sense to that patient’s neurologic system. It can be different for each person. You cannot “cook book” good manual medicine.
Prove or disprove your differential diagnoses or hunches……. make sure your direction is the right one. We all know what ASSUMING lead us to ……. it makes a donkey out of all of us.
We are….. The Gait Guys……. just a couple of donkeys.
Factors that adversely effect the natural history of the pronated foot.→
/“Risk Factors that may adversely modify the natural history of the pediatric pronated foot." Clin Podiatr Med Surg. 2000 Jul;17(3):397-417. Napolitano C, Walsh S, Mahoney L, McCrea J.Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois, USA.
This article is a nice follow up to the video post from yesterday. The article talks about the flexible and rigid flat foot. In yesterday’s video example we are dealing with a flexible flat foot deformity. When he was non-weightbearing (which wasn’t seen in the video) he formed an arch. As you can see in the video upon weightbearing the arch disappears but you can see that with the correct patterning employed, he can find an arch. This is what we term a flexible flat foot deformity. These types of feet have potential if there is sufficient muscular ability and if hyperlaxity in the ligamentous system can be overcome by neuromuscular support. If not, an orthotic may need to be utilized and be assistive. The rigid flat foot, is one that does not form a competent arch, ever. These feet are what they are, flat. But, keep in mind…… some genetics do render a competent flatter foot. Some of the strongest feet we have seen are on very low arched people / runners. So, flatter does not always mean weak, be careful. What you see is not necessarily what you get, even a rusted out Ford Pinto might have a Ferrari engine in it……. you just don’t know by looking, you have to test the competency of the foot (another example, look at Arnold Palmer’s golf swing, it isn’t the prettiest swing by any means…… but you probably wouldn’t bet a penny against him even these days, if you get our drift.)
As the abstract says. "Normally developing infants have a flexible flatfoot and gradually develop a normal arch during the first decade of life." The key word is NORMALLY. You must consider risk factors that may affect the foot in its overall development. The risk factors include ligamentous laxity, obesity, rotational deformities, tibial influence, pathological tibia varum, equinus, presence of an os tibiale externum, and tarsal coalitions.
Again, this is a nice follow up to our video from yesterday and brings home some additional good points to cogitate over. We knew we had a flexible flat foot with potential. Knowing what you are starting with it vital for your success in treating the problem, and vital in determining long term success.
We are, The Gait Guys ………. and even a bit geeky in neurodevelopmental physiology. (Yes, we have no life.)
Shawn and Ivo
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Abstract of the Journal Article……. the link to the article is at the top of the blog post if you wish to obtain the article for further study.
Here is their abstract:
"Flatfoot is one of the most common conditions seen in pediatric podiatry practice. There is no universally accepted definition for flatfoot. Flatfoot is a term used to describe a recognizable clinical deformity created by malalignment at several adjacent joints. Clinically, a flatfoot is one that has a low or absent longitudinal arch. Determining flexibility (physiologic) or rigidity (pathologic) is the first step in management. A flexible flat foot will have an arch that is present in open kinetic chain (off weight-bearing) and lost in closed kinetic chain (weight-bearing). A rigid flatfoot has loss of the longitudinal arch height in open and closed kinetic chain. According to Mosca, "The anatomic characteristics of a flatfoot are excessive eversion of the subtalar complex during weight-bearing with plantarflexion of the talus, plantarflexion of the calcaneus in relation to the tibia, a dorsiflexed and abducted navicular and a supinated forefoot.” Normally developing infants have a flexible flatfoot and gradually develop a normal arch during the first decade of life. When evaluating an infant for a pronated condition, the examiner must also consider other risk factors that may affect the foot in its overall development. These contributing factors will play a role in the development of a treatment plan. The risk factors include ligamentous laxity, obesity, rotational deformities, tibial influence, pathological tibia varum, equinus, presence of an os tibiale externum, and tarsal coalitions. The authors realize other less significant factors exist but are not as detrimental to the foot as the primary ones discussed in depth. The primary risk factors that affect the pronated foot have been outlined. The clinician should always examine for these conditions when presented with a child exhibiting pronatory changes. A thorough explanation to the parents as to the consequential effects of these risk factors and their effects on the pediatric pronated foot is paramount to providing an acceptable comprehensive treatment program. Children often are noncompliant with such treatments as stretching and orthotic maintenance. The support of the parents is crucial to maintaining an effective treatment program continued at home.“
Online Barefoot Lecture: by The Gait Guys→
/Wednesday August 24, 8 pm Eastern time zone.
Come join Dr. Allen and Dr. Waerlop for a 1 hour powerpoint and video case presentation discussing the merits, issues and biomechanics of barefoot running. This is a CEU course, 19 $
Stage 1 of Correcting a flat foot, video demonstration.
Here is a case of a young man that was brought into us by his parents. Their concern was that their son was displaying what they thought was foot weakness.
At the beginning of the video you can see that his foot progression angle is significant. Certainly greater than the 10-15 degree “so called” normal range. His arches are also somewhat collapsed. His knees were also displaying some hyperextension which is quite common with flat foot posturing.
This was his third visit into our office. He was given the corrective neuromuscular strategy that you see here and some specific exercises to help him get to this stage of correction. The first stage of any correction is developing the awareness of what you are doing wrong (ie. become consciously aware of your incompetence). That was session one. Session two focused on developing this corrective pattern, helping him find the skills to develop some conscious competence with a more normal foot stability skill pattern (endurance and strength still need to be added).
Here you will see that, when queued, he immediately moves into a narrower base of stance (this will always happen when they can form a competent foot tripod, as you can see here). In other words, the worse the foot collapse, the wider the feet will be positioned. In his case, he now positions his feet under his hips and knees.
You will also see the early success (after just 2 visits !) of a critical neuromuscular pattern. He is showing some competence in holding the arch up and letting the toes move into flexion onto the ground. Most flat footed children cannot separate “maintaining arch up, and moving into toes down”, rather they are into the pattern of “when the toes drop to the floor, the arch drops as well”. This is a critical pattern (ability to hold arch up) to recognize and develop. The child must develop the ability to independently flex and extend the toes on a static arch, while holding tripod, before gait retraining can ensue. This is mainly because the speed of gait and difficulty of single leg stance while displaying the correct pattern is just too much of a skill mastery issue. Often these pupils do not have enough hip frontal plane stability nor pelvic stability as well.
Also, note that he uses the skill of toe extension to help with arch height determination. This goes right back to our blog posts last week on the Windlass Mechanism. He is using the power of the windlass effect (toe extension) to take up the slack in the plantar fascial around the great toe metatarsal joint and thus pull the rear foot towards the forefoot (ie. raising the arch via this mechanism ! ). Without a competent windlass a competent arch cannot be obtained (thus the ridiculousness of plantar fascial release surgery !). Additionally, understanding the windlass and the effects of this simple video should give you insight into our success in quickly treating plantar fascitis.
(addendum: also note at the end of the video that i ask him to collapse into his old pattern, this was after 30 minutes of corrective motor pattern exercises. I laugh because in a solid posture that he shows at the end of the video, plus 30 minutes of new patterning, he found it difficult to find his old collapsed pattern. This is a frequent occurance ! It gives you and the patient confidence that headway is being made.)
You must develop isometric, eccentric and concentric strength of the plantar intrinsic muscles that stabilize, raise, and control the lowering of the arch (as well as the arch controlling extrinsic muscles such as tibialis anterior and posterior among others) if you are going to make a difference in someones foot mechanics. Just putting someone into a pair of ANY minimalist shoe (let alone barefoot) doesn’t guarantee strengthening of the foot or a remedy for a pair of feet like in this video. The process is a little more complicated than slipping on a pair of low ramp angle “shoes” and wearing them all day long…….in these types of cases all it does is raise their risk of injury or further foot incompetence down the road.
For our fellow clinicians out there who are following us and trying to learn more about this kind of stuff……. wouldn’t your clinical world be nice if just prescribing a minimalist shoe would strengthen the foot in the correct pattern !? We argue that, as in this kids foot, they would strengthen his foot in his poor postured patterns. So, we guess these companies are not lying when they say their shoes “strengthen” your feet, they just leave out the word “correctly”.
So, we do not argue with the point that going minimalist will strengthen your foot…… the question is “do you want to strengthen the correct pattern or a compensated one?”.
here at The Gait Guys…….we know which pattern we want to strengthen.
We remain strong advocates that not all feet belong in minimalist shoes…… at least not initially, and some, never. It would be nice if just slipping on a shoe could fix all of your foot problems, but it just isn’t that easy. This is the topic no one is talking about, except The Gait Guys ……… because it doesn’t sell shoes.
There is much more to it than this video shows……. but we have to start somewhere. Educating you with the issues we feel passionate about is the first step sometimes.
We remain…….obviously passionate………..
Shawn and Ivo….. The Gait Guys
2011 Newton Natural Running Symposium, Experts Panel→
/We were honored to be asked to participate on the experts panel this year. Enjoy the video.
The London Looter’s Getaway Stride: Gait analysis by The Gait Guys
We did this one yesterday in collaboration with our good friends at Zero-drop.com on their awesome blog. Check out their stuff.
The images coming out of England of young hoodie-wearing hoodlums rioting, stealing, smashing store windows, torching cars, and causing all-out mayhem in London and elsewhere is unsettling for several reasons. What exactly are these lawless yobs protesting? Are these race-induced riots? Public outcry over political and social injustice? Or are these roaming gangs of hooligans more interested in something else–like getting their hands on free stuff such as 46-inch flat-screen high-definition televisions and Nike sneakers.
In the photo here, it appears as though a young lad has just swiped a bottle of something lip smacking from a Manchester food store. It seems that he dressed for the occasion –Adidas track suit and running shoes– to facilitate a quick, speed getaway. He’s much too young to be hitting the bottle. Plus, one can easily assume that he didn’t expect to make the front page of the U.K. Daily Mail where this photo first appeared. (He’s probably sitting right now in juvie detention.) In any case, Zero Drop asked the Gait Guys to look at his running stride. Here’s their expert analysis:
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This chap looks a bit young to be drinking, and we doubt he is a courier. Let’s see if he will make a clean getaway, shall we?
Beginning from the bottom, we see his left foot is turned in and his knee appears straight, He does appear to be banking a left turn, but we would expect him to probably have his toe out a bit for stability since he is really banking heavily into the frontal plane (he must have a great right gluteus medius because he is holding a fairly decent pelvic line into the bank), so our guess is he has a bit of internal tibial torsion (i.e., his foot points in when his knee is straight ahead. This is usually a condition from birth). Folks with internal tibial torsion tend to have their feet in supination more, so they are excellent levers, but it usually means they lack some shock absorption (so maybe we find a forefoot valgus in that shoe, who knows). Because his knee is not in line with his line of forward progression, there will be a conflict there, which could potentially hurt his knee, besides cutting down on his mechanical efficiency (the knee is like a door hinge, and works best when moving in one direction).
His lean to the left nicely complements his probable forefoot varus (or inversion of the forefoot), so at least he has that working for him. There is a little hip sag on the left, indicating a weak gluteus medius on the right; which further cuts down his mechanical efficiency; it is moving to the right as he is cutting to the left. Holding that bottle sure cuts down on his arm swing, and he looks a bit tense, as his left shoulder is higher than the right. Like he is trying to hide something. Finally, his head posture looks forward. This facilitates his flexors and inhibits his extensors, taking away from power to drive him forward. We could go on and on, and we have. Guess we told you how to build a clock and you only wanted to know what time it is. In short, whether he gets caught depends on the biomechanics of his pursuer.
We hope he doesn’t have internet access to our blog, we would hate for him to recognize his problems and improve upon them. We would be contributing to improved “get-aways” in the future. That wouldn’t be good, unless someone was chasing him with a .22 , then we might feel ok with it.
Hooch for the youngers, it’s not just for the back alley’s anymore !
- the gait guys
A different kind of Marathon: So you think you are tough ? This guy was tough. A marathon a day for over 120 days…..on one leg, with cancer. Today, a Tribute to Terry Fox.
Half of The Gait Guys grew up in Canada. We were barely a teenager when Terry began his plight. His mission, 26 miles a day, every day, until he had crossed the expanse of Canada. He made it an amazing 120+ days in a row, 3339 miles, before his cancer returned. The whole country stood cheering watching him do something no mortal man would attempt, let along with one leg, and cancer. Today we pay a tribute to this rockstar……. his candle went out long before it should have. So, still think you are a tough runner ? This kind of stuff amazes us. RIP Terry. You did more in 22 years of life than most of us will do in a lifetime. We have neither not forgotten you nor what you stood for, and we never will. Shawn & Ivo
