Just when you thought it was safe to watch a Neuromechanics Weekly episode, Dr Ivo throws a curveball. Check out the interesting clinical asides about myelopathy (pressure on the spinal cord causing ataxic gait) and the importance of which modality to check 1st, when doing an exam.
Keep these things in mind the next time you are evaluating someone’s gait.
Robotic Exoskeleton: New device helps people with spinal cord injury walk upright
… Now, a robotic exoskeleton has allowed her to take her first independent steps in years. In March, Fejerdy, 36, began participating in a clinical trial of the device — called the ReWalk — in Philadelphia, where she and her husband moved three years ago. The device allows her to move independently in reality and in her dreams.
Population Insights on Hallux Valgus: “When the big toe heads West”.
(thanks to Emily Delzell and LER for their ongoing great work.)
Handicapping Hallux Valgus: Predictive variables include race, age By Emily Delzell
here are some of the study findings right from the article…….
- “In nonobese individuals, African Americans were almost two times more likely than whites to have hallux valgus. But in obese participants, prevalence was just as high in whites as in African Americans. This difference seen in the non-obese suggests a real racial difference,” said Golightly, the study’s lead author.
- Past high heel use increased HV risk by 22%. Investigators defined past use as participants’ self-reported primary shoe type during 10-year periods beginning when individuals were aged 20 years.“We found what we expected, that past—but not current—high heel use was predictive of hallux valgus. Women reported wearing high heels the most when they were aged 20 to 29, and high heel use diminished each decade until people reached 60, when wear really plummeted. It makes sense that people with hallux valgus and foot pain are uncomfortable in heels and are less likely to be current wearers,” Hannan said.
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The study showed that HV heritability overall was 39% for women and 38% for men (mean age 66 years, age range 39-99 years), but was significantly increased in the subset of participants younger than 60 years (HV heritability, 89%).
“We know that genes for obesity are also highly heritable and it could be that the gene for hallux valgus is linked to obesity genes,” Hannan said.
Our new friend, Dr. Mark Cucuzzella. An inspiring story.→
/OK, now you have read the article in the NYTimes. Here was Dr Cucuzella’s blog post following the article.
Mark Cucuzzella MD
Shepherdstown, WV
November 5th, 2011
9:58 pm
NYT Readers,
I’ve been flattered by the emails from around the globe of runners sharing their stories of recovery and discovery. Here is my story.
“A man’s errors are his portals of discovery” – James Joyce
Twice in the past two years, my running shoe store, Two Rivers Treads, which is in the small town of Shepherdstown, West Virginia, was honored to host and gain wisdom from best-selling author and force of nature Christopher McDougall. Locals came to hear from Chris aka “Mr. Born to Run.”
Chris and I both share a similar pathway in the discovery of better fitness and health through natural running. He is now a world-famous author, and in addition to owning a minimalist shoe store, I am a family physician in a town of 3,000. We both are in our mid 40s, and have trashed our feet and legs along the way, the result of a lifelong addiction to running.
Chris’s bestseller “Born to Run” follows several narrative threads, but it is also his own personal story of “why does my foot hurt?” He discussed the regular trips to the doctors, shoe stores, and orthotic makers. With each escalation in care there was more pain, that is, until he found a different route in the remote Copper Canyon of Mexico where the Tarahumara Indians run in flat-sole tire-tread sandals happily into their 80’s. He also met barefoot runners during his research for the book. He eventually arrived at the conclusion that most conventional running shoes are the cause of running injuries.
I began running barefoot on the beach as a pre-teen and easily covered distances of 10 or more miles. My personal path of pain began in high school and then into a college and post-collegiate running career. I had successes that were often tempered by injury, setbacks, surgery. I had acquired a closet full of arch supports, orthotics, various shoe types. This was always in search of the holy grail of pain- free running.
I pushed through the pain in pursuit of the Olympic Marathon Trials 2:22 standard and came within two minutes on two occasions. When I hit 34 years of age, my first toe joints were fused with arthritis, and I was forced to have surgical procedures to reduce the pain. The prognosis looked bleak for a future in running.
And a lot like Chris’s own trip to Copper Canyon, my journey of discovery began afar: while watching Kenyan runners go barefoot. I applied this natural way of running to my own jogging. I learned how to run softly. Seven months after surgery and with a new efficient and painless running stride, I ran a 2:28 for third place in the 2001 Marine Corps Marathon, only four minutes shy of my best time ever for the distance.
A decade has passed and the learning I gained about natural running only became deeper and broader. You might say that I was being “home-schooled” on all aspects of movement and how the foot interacts with the ground. For example, the Tarahumara Indians run in a style reflective of how we all ran as children; they land lightly on their mid-foot (not the heel), have a slight forward lean, and are completely relaxed and happy. Also, the best shoe was less shoe.
My self-enlightenment about footwear and running was not as immediate as Chris, who experienced it by cultural immersion. Chris and I both agree that it is not about the shoes (or lack thereof), but more about understanding how your body stands and moves, improving strength and function, and then figure out what shoe (if any) to wear. Ten years after the foot surgery and being told not to run, I feel that I’m finally putting all the pieces of the puzzle together. I finished the Boston marathon in 2011 in 2:37:00, practically smiling the whole way. Several months later, I won the Air Force Marathon outright; and back running the day after the race. I love light and flat shoes for road races, trails, casual, and at work to get me secretly close to barefoot at my day job as a physician.
We all have to follow our own path of what works or doesn’t work. Our bodies and past running histories are different. View the resources Natural Running Center, you will have a practical way to make injury-free running a permanent fixture in your own life.
I especially want to thank colleagues for sharing knowledge: Danny Dreyer, Jay Dicharry, Lee Saxby, Danny Abshire, Dr. Ray McClanahan, Dr. Daniel Lieberman, Ian Adamson, Dr. Phil Maffetone, Blaise Dubois, Pete Larson, Dr. Irene Davis, Lorraine Moller, and Nobby Hashizume. And especially Bill Katovsky and Nicholas Pang for helping me create the Natural Running Center.
–Mark Cucuzzella, M.D. mark@freedomsrun.org
http://naturalrunningcenter.com/
https://www.tworiverstreads.com/
For our movie on Barefoot Running Style - enjoy
http://youtu.be/kpnhKcvbsMM
Here is a decent video on how to do the “100 up” and age old running practice technique developed as discussed in a three-page essay from 1908 titled “W. G. George’s Own Account From the 100-Up Exercise.” According to legend, this single drill turned a 16-year-old with almost no running experience into the foremost racer of his day.
In George’s words: “By its constant practice and regular use alone, I have myself established many records on the running path and won more amateur track-championships than any other individual.” And it was safe, George said: the 100-Up is “incapable of harm when practiced discreetly.”
comments from a follower of the gait guys.
/From a reader …..
“From what I’ve gathered from your posts/videos, I have some major issues with my foot function… ie weak Tib Anterior and Extensors. You have one video up where you demonstrate that a competent foot should be able to keep a solid arch and lower your big toe without losing arch integrity. I come no where close to this. In fact, I think it’s pretty amazing at what the foot is supposed to do which is demonstrated by you. When looking at what Dr. Allen’s foot does and looks like compared to most everyone else’s his seems much more muscular and solid unlike the case studies you put up. I almost liken most peoples feet to looking like a skeleton with very little muscle mass and function.”
Dr. Allen’s response…….
It has taken me quite a bit of time to get my foot to function this well. I am lucky in that i know what it is supposed to do and what exercises to implement to get it there. We have some exercises that we do which we are compiling and will eventually put in DVD format. We are completing our 3 part shoe fit and foot function DVD for the December Austin Texas IRRA program launch and the completed package should be available end of January 2012. Yes, finally they will be done ! There is another reason my foot functions as well as it does……. and we will be sharing some thoughts on this in several weeks once we can compile the information. Hint, awareness and encouraging skill is a big key. It all starts with Skill……. then build Endurance, and then Strength. S. E. S. as we say.
The Once and Future way to run. NewYorkTimes→
/excerpt from the article……….
“Martyn Shorten, the former director of the Nike Sports Research Lab who now conducts tests on shoes up for review in Runner’s World, followed him (Cucuzzella) to the microphone. “A physician talking about biomechanics — I guess I should talk about how to perform an appendectomy,” Shorten said. He then challenged Cucuzzella’s belief that cushioned shoes do more harm than good.
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As Steve Jobs might say to this………. "yes, there are bozos amongst us”
We know Dr. Mark Cucuzzella. We talk with him often over long conference calls. Dr Ivo was on the discussion panel with him at the Newton Running Retail Conference this year. We are becoming pretty good friends. We feel quite comfortable in saying that Mark has every right to talk about biomechanics, he has earned our respect.
The mind is like a parachute…It works best when open….
Shawn & Ivo, we are…….The Gait Guys (and hoping that we are someday challenged by guys like Shorten…we like bozos : ) ).
Today, something a little different. I worked for the world famous Joffrey Ballet Dance company on an off for a few years treating the dancers before shows and productions. These folks always had the most amazing strength (try this one ! bet you cannot do it……in fact, don’t try it…..you will probably dislocate your MTP (metatarsophalangeal joint; the big knuckle joint) of the big toe.)
These folks also had many problems with their hips, knees and spine mechanics from the demands of turn out, jumping, overuse and the demands of things like en pointe. This is an example of what is referred to as “en pointe” which means “on the tip”. There is “demi pointe” which means on the ball of the foot which is much safer and we will do another video on that another time to explain some critical components to it right, there is more to it than just getting up on the ball of your foot.
En Pointe is a terrible challenge in our opinion. So if you are thinking of putting your darling children in ballet…… just beware of the facts and do some logical thinking on your own.
En pointe or classical point ballet it typically done in point shoes or slippers which have a reinforced toe box that allows a more squared off stable surface to stand in pointe position. It does not however allow a reduction in the axial loading that you see in this video and it certainly does not help with proper angulation of the big toe, if anything the slipper will gently corral the toes together rendering abductor hallucis muscle function nearly obsolete. The box will also not stop the valgus loading that typically occurs at the joint as you see occurring here in her right foot if your joint line has a more aggressive angulation (genetics). You can already see the deforming force that is creating a valgus toe position here. Despite what the studies say, this is one we would watch carefully. Now, there are studies out there that do not support hallux valgus and bunion formation in dancers (see ** at end of this post). However, we are just asking you to use common sense. If you see a bunion forming, if the toe is getting chronically swollen, if the toe is drifting off line then one must use common sense and assume that the load is exceeding joint integrity. Prolonged and excessive loading of any joint cartilage is likely to create a risky environment to crack, fissure, wear down or damage the cartilage or the bony surface underneath (subchondral bone). So, if you think that loading your entire body mass axially on the small joint surface of the big toe is a great idea, that is fine, just do not bring your kids to our office and expect to get a happy face sticker at the check out counter. We are going to read you the risks that are born from logical thinking. This is not meant in any way to take away from the amazing feat that this is for dancers, but it just is not a smart thing to do if you want a healthy first joint (MPJ - metatarsophalangeal joint) and foot for that matter. After all, if you screw up this joint, toe off will be impaired and thus the windlass effect at the joint will be impaired thus leading to a multitude of other dysfunctional foot issues.
Now, back to the “en pointe” position. Did you try it yet ? Heed our warning ! Just trust us, this is bloody hard. Since serious foot deformities can result from starting pointe too early, pre-professional students do not usually begin dancing en pointe until after the age of 10 or so , remember, the adolescent foot has not completed its bone ossification and the bone growth plates have not closed. Thus, damage and deformity are to be expected if done at too young an age. If you asked our opinion on this, we would say to wait until at least the mid-teenage years……. but by that point in the dance world a prodigy would miss her or his opportunity. Thus, we see the problems from going “en pointe” too early in many. In the dance world, there are other qualifications for dancers before En Pointe is begun, things like holding turnout, combining center combinations, secure and stable releve etc.
Achieving en pointe is a process. There is a progression to get to it. Every teacher has their own methods but it is not a “just get up on your toes” kind of thing.
Shawn & Ivo……. Dreaming of Sugar Plum fairies…….. (ok, maybe not) but knowing your biomechanics of the foot and gait are an integral part of dance as well.
* and after watching this video, if your next thought was……“ I wonder what the incidence of posterior ankle impingement injures occur in dancers” or if you said under your breath……. “hey, extreme plantarflexion at the ankle loads the Lisfranc joint pathomechanically ….. I wonder if that joint is ever an issue in dancers……. ?" then you will clearly be on the route to becoming one of……… The Gait Guys
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** Hallux Valgus in Dancers. A Myth ?
Abstract: Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.
Today on Neuromechanics Weekly, we explain how the autonomic nervous system is linked to brain activity, particularly the cerebellum, which we all know is intimately linked to gait, walking and running. Now you will understand why you get dizzy when you have pain or why your heart beats faster or harder (they are different sides of the brain). Join Dr Waerlop in this fascinating lecture.
The Gait Guys…Providing explanations and making the complex easier to understand
Splay
Watch this video a few times through. Did you catch the subtle abduction moment of the Hallux (big toe) on impact? Did you see the collapse of the transverse metatarsal arch? No? Watch it until you do.
What gives? We thought toes were supposed to be stable when they hit the ground (and in fact they are). Read on…
Think of the adductor hallucis. It has 2 heads. The oblique head arises from the proximal shafts of metatarsals 2-4 and inserts on the MEDIAL aspect of the proximal phalynx of the hallux (along with medial fibers of the flexor hallucis brevis); the transverse head arises from the metatarsophalangeal ligaments of digits 3-5, and the transverse metatarsal ligament and inserts blending with the oblique head on the proximal phalynx of the hallux.
The action of the adductor hallucis mirrors that of the abductor hallucis (which inserts on the LATERAL side of the proximal phalynx. Together, they act to keep the hallux straight and provide a compressive force which stabilizes the big toe WHEN IT IS ON THE GROUND.
The problem here, is that the base of the Hallux is NOT anchored to the ground. This person has a faulty tripod (most likely an uncompensated forefoot varus) and cannot anchor the big toe, there fore the adductor cannot do it’s job. Is is weak (from lack of use) and we see the result: an abducting big toe AND collapse of the transverse metatarsal arch (which the transverse head of the adductor, under normal conditions maintains).
Looks like this guy needs some exercises to descend the head of the 1st metatarsal and make an adequate tripod. Flexing the distal phalynx of the hallux while extending the metatarsophalangeal joint would be a good start. (see Dr Allen demonstrate this here: http://www.youtube.com/user/TheGaitGuys?feature=grec_index#p/u/11/TyRE9dReVTE )
The Gait Guys…promoting foot literacy here and everywhere.
Its a great day to be a neuro geek
So if the receptors on the bottom of the foot aren’t involved aren’t involved in 2 joint muscles staying coordinated (like the hamstring and rectus femoris in this study), how do we determine the appropriate muscle length and ratios? How about our built in muscle length receptors? Lets hear it for muscle spindles! Hooray for Ia and type II afferents!
Sifting through the science so you don’t have to. We are The Gait Guys…
Exp Brain Res. 1998 Jun;120(4):479-86.
Coordination of two-joint rectus femoris and hamstrings during the swing phase of human walking and running.
Prilutsky BI, Gregor RJ, Ryan MM.
Source
Department of Health and Performance Sciences, Center for Human Movement Studies, The Georgia Institute of Technology, Atlanta 30332-0110, USA.
Abstract
It has been hypothesized previously that because a strong correlation was found between the difference in electromyographic activity (EMG) of rectus femoris (RF) and hamstrings (HA; EMG(RF)-EMG(HA)) and the difference in the resultant moments at the knee and hip (Mk-Mh) during exertion of external forces on the ground by the leg, input from skin receptors of the foot may play an important role in the control of the distribution of the resultant moments between the knee and hip by modulating activation of the two-joint RF and HA. In the present study, we examined the coordination of RF and HA during the swing phase of walking and running at different speeds, where activity of foot mechanoreceptors is not modulated by an external force. Four subjects walked at speeds of 1.8 m/s and 2.7 m/s and ran at speeds of 2.7 m/s and 3.6 m/s on a motor-driven treadmill. Surface EMG of RF, semimembranosus (SM), and long head of biceps femoris (BF) and coordinates of the four leg joints were recorded. An inverse dynamics analysis was used to calculate the resultant moments at the ankle, knee, and hip during the swing phase. EMG signals were rectified and low-pass filtered to obtain linear envelopes and then shifted in time to account for electromechanical delay between EMG and joint moments. During walking and running at all studied speeds, mean EMG envelope values of RF were statistically (P<0.05) higher in the first half of the swing (or at hip flexion/knee extension combinations of joint moments) than in the second half (or at hip extension/knee flexion combinations of joint moments). Mean EMG values of BF and SM were higher (P<0.05) in the second half of the swing than in the first half. EMG and joint moment peaks were substantially higher (P<0.05) in the swing phase of walking at 2.7 m/s than during the swing phase of running at the same speed. Correlation coefficients calculated between the differences (EMG(RF)-EMG(HA)) and (Mk-Mh), taken every 1% of the swing phase, were higher than 0.90 for all speeds of walking and running. Since the close relationship between EMG and joint moments was obtained in the absence of an external force applied to the foot, it was suggested that the observed coordination of RF and HA can be regulated without a stance-specific modulation of cutaneous afferent input from the foot. The functional role of the observed coordination of RF and HA was suggested to reduce muscle fatigue.
Those are some pretty big shoes!
This gentleman actually looks like he has acromegaly. Watch his movements and note his facial features throughout the video.
Acromegaly is a condition where excess growth hormone is produced after puberty and the bones steadily increase in girth. Abraham Lincoln was thought to be a acromegalic.
Everything gait. we are…The Gait Guys
What are correct toes and do they work?
correct toes:https://nwfootankle.com/correct-toes
We are quite familiar with them. Do they work? That is the question!
They are pretty bulky but that could be a good thing, for some though they are just too bulky we have found.
Some people are running in them……We think our friend Dr. Mark Cucuzzella does (naturalrunningcenter.com) .
We use them with clients to walk around the house barefoot and get used to engaging toes with a flat press (not gripping…like those silly, flexor dominant promoting towel scrunch exercises !)
So they MIGHT help someone retrain some muscles if used in this fashion but just wearing them does not produce magical results without some awareness use.
Keep in mind……forcing something doesn’t make it so……… spreading the toes with an object such as these doesn’t make them automatically go where they are supposed to.
Most people need to relearn toe separation (actually abduction)…we do alot of that in our offices….and then learn to bring the whole toe flat to the ground with a good, firm toe press……..no grip/scrunch/hyperflexion. The last thing we would ever want to do is overfacilitate the long toe flexors (flexor digitorum longus) because when we do, we inhibit other foot intrinsic muscles (ie. lumbricals).
The Gait Guys…promoting foot and gait literacy and helping you wade through the uncertainty.
Liquid Mountaineering.
Yup, we thought we had seen it all…And they appear to be serious about this. It takes all kinds to make the world go around, but who are we to judge. It is our guess that that lake was pretty shallow for those first 10 steps or so. You be the judge. Even Wallace Spearman Jr. could not reproduce this feat on Mythbusters (until they made an underwater floating bridge !).
Have a good Friday!
Ivo and Shawn
Oxygen cost of running barefoot vs. running Shod.
/This study concluded that at 70% of vVO (2)max pace, barefoot running is more economical than running shod, both overground and on a treadmill. So, if you have a competent enough foot to run barefoot or in minimalistic footwear, and it is important to note that some people are not purely from an anatomical perspective, you can improve your economy of running and use your energy sources efficiently. But if you are one of those unfortunate ones that has excessive pronation or other functional foot challenges, you will have to settle for the less economical shod running. That does not mean you will not have as good a workout, it just means that you will be protecting your foot doing so. Sure, you might not be the fastest one on the track, but you will be able to show up every day having not compromised your feet.
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Int J Sports Med. 2011 Jun;32(6):401-6. Epub 2011 Apr 6.
Oxygen cost of running barefoot vs. running Shod.
Hanson NJ, Berg K, Deka P, Meendering JR, Ryan C.
Source
Health, Physical Education and Recreation, University of Nebraska at Omaha, United States. njhanson@gmail.com
Abstract
The purpose of this study was to investigate the oxygen cost of running barefoot vs. running shod on the treadmill as well as overground. 10 healthy recreational runners, 5 male and 5 female, whose mean age was 23.8±3.39 volunteered to participate in the study. Subjects participated in 4 experimental conditions: 1) barefoot on treadmill, 2) shod on treadmill, 3) barefoot overground, and 4) shod overground. For each condition, subjects ran for 6 min at 70% vVO (2)max pace while VO (2), heart rate (HR), and rating of perceived exertion (RPE) were assessed. A 2 × 2 (shoe condition x surface) repeated measures ANOVA revealed that running with shoes showed significantly higher VO (2) values on both the treadmill and the overground track (p<0.05). HR and RPE were significantly higher in the shod condition as well (p<0.02 and p<0.01, respectively). For the overground and treadmill conditions, recorded VO (2) while running shod was 5.7% and 2.0% higher than running barefoot. It was concluded that at 70% of vVO (2)max pace, barefoot running is more economical than running shod, both overground and on a treadmill.
In this Neuromechanics weekly, Dr Waerlop Introduces the cerebellum and talks about its importance clinically, since it contains more than ½ of the neurons in the brain! It’s anatomy and inputs from the periphery are discussed. The take home message is the cerebellum is the key to understanding and directing movement, since it receives feedback from most ascending and descending pathways.
The Gait to Happiness (or, What do you mean I walk & run wrong !? )→
/Walking and running are a skill, and for the silent majority they are subconscious skills.
Somehow, for some reason, we just assumed and expected that nature would lead us to a proper gait as we moved from the crib, to crawling, to walking and eventually to running. But, with 36+ years combined experience, my partner in crime, Dr. Waerlop and I are certain of one thing, that nature left most of us with the parts to ambulate properly but with no rule book or users manual on how to use the parts correctly or most efficiently. We basically assumed that the neurological developmental windows or landmarks that we achieve from each developmental stage as an infant and young child would be learned on time, correctly, and with proper assimilation with the prior developmental landmarks.
Unfortunately, this is quite often not the case. We see evidence of these gait related neurological developmental delays or premature landmark achievements every day. Even our experienced patients who have been re-learning under our corrective eye for some time find they cannot go to a mall or airport or local cross country meet and not be amazed by the number of truly tortured gaits that are moving amongst us.
Our experienced patients admit they do not know what is wrong with what they have seen, but they most definitely know that what they have seen is not normal or optimal. They express wonder as to why no one addressed their own gait aberrancies sooner. We like to tell them that “no one gave us the Users Manual at a young age.” Truth be told, even if a “users manual” for the body was present, it would have to be pre-assembled and specific for their body type and specific body parts (ie. bowed legs), and then there would be the issue of being able to understand the complexity of such a manual at the necessary young age of required reading, not to mention the adolescent perspective of “Why do i have to pay attention to this manual? I already have enough reading homework, I am moving about just fine, I have no pain, I do not walk in circles and I run fast. Sure I might run funny, but look at everyone else, they do it too !”.
You see the dilemma here. The key word missing from that whole diatribe is the magical word, “Yet”. They are not yet in pain, not yet the slowest person on the field. Their gait patterns are not yet aberrant enough or have not been present long enough to create inflammation at a joint or generate sufficient dysfunction within enough muscles to present conscious problems. But, they are there, brewing beneath the conscious awareness; waiting, lurking.
The problems are there, waiting for that wrong step off the porch when you turn your ankle “for no reason”, when the knee suddenly buckles “for no apparent reason” when you are carrying the grocery bags up the stairs or when your knee suddenly begins aching at mile 5 “for no apparent reason” when on yesterday’s 15 mile run it was just fine. Like in the stealth of night, our body finally reaches that magical pinnacle moment, “I have had enough, I cannot compensate any longer”. It is as if the body is trying to say, “Look buddy, we have been dealing with this problem for months at a subconscious level, trying to figure this out. We have been cheating around your sad pathetic gait patterns long enough. Heck we even tried turning out that right foot. Nothing is helping anymore. We have had a meeting of ‘The Parts’, and we have decided we cannot go on like this any longer. It is time to let you know. We had to hit The Pain Button and bring this to your conscious attention once and for all.”
Almost everyone can walk and run, but few can walk or run correctly and efficiently. Lack of efficiency or essential skill are what lead to pain, compromise of the body parts (joints, muscles, neurology) and complex compensation patterns. The difficulty however is that most of those walking among us, do not know that they are walking or running incorrectly until the “parts” start complaining. And by then, the body has been compensating around the problems for some time. Sometimes months, sometimes years. It is not until enough inflammation or tissue compromise has occurred that pain presents itself, and by then, most of us are far into a well engrained motor compensation pattern. Before we know it, someone is asking us why we are limping unbeknown to us. Before we know it, someone is asking us how long we have been turning out that right foot ?
As we like to say, “the brain will find a way”. What we mean by that is this; the brain has a task and goal at hand, whether that is to climb a tree, walk to the store, cut the lawn or run a marathon. The brain will inventory all the parts and players of the body and get busy with the task in the most efficient manner with the parts available. And if some parts are a bit rusty and degenerated, short or weak etc the body will begin to detour from the “standard protocol” use of the parts and initiate a compensation pattern that uses the parts differently, tap into others to assist, or move the anatomy into another plane to find an alternate strategy to avoid pain or achieve better force, power or efficiency (ie. turning out the foot to better engage the gluteus medius to avoid pain at a degenerative hip or knee). This is a subtle unconscious process that occurs under the veil of conscious awareness, the brain knows that pain is a deterrent to efficiency because pain is inhibitory to muscles and thus renders joints functionally unstable. So, like we said, “the body will find a way”, or better put “the brain will find a way”.
So, what is one to do with this information ?
Well, it is a difficult sales job to convince someone to take their body in for an evaluation of their gait and running, especially if there are no problems apparent or they don’t have any outward signs or symptoms that are obvious to them. But, we do this regularly for our cholesterol levels, we do it twice a year with our automobiles and we do it with our home furnace every so often. Why would it be so strange to do it with how we move ?
We don’t know why someone would not do it. We would rather have something evaluated and drawn to our attention while we can still make a difference rather than wait until the muscles are so tight or weak from compensating that it takes months of physical therapy to fix, or a joint replacement to amend, or God forbid daily pain medications to cope. Regardless, it still remains a rare occasion when a person will come into see us and ask us to just “look under the hood” and kick the tires and make sure things are working right and that they are walking and running properly. Sadly, the case is usually one of, “My knee has been killing me on my long runs for 5 weeks now, but nothing happened, I promise !”. It would be nice if they followed that sentence with, “However, I did sprain my ankle 3 months ago, I have had a hernia repair on that side two years prior, and my parents proudly told me that I barely crawled rather, I walked quite early on in life. Maybe we should talk about these things or at the very least look at my ankle rocker and hip extension ranges of motion because they feel a little off on the right, left internal hip rotation feels limited and I think I am into premature heel rise on the right.”
Heck, lets be honest, I would probably swallow my brain, a split second before I face plant on the floor in an all out neurosuppressive faint.
There is a saying that crops up from time to time in our lectures, one that has some great truth, “You cannot beat the brain.”
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Sometimes wonderful things come to us when we have a day off from patients, when we get to enjoy a warm cup of joe while staring out the window at a beautiful sunrise on a spectacular Fall morning. I think I will go for a run now, it is still early so no one will be out to see my right foot turn out as i subconsciously compensate down my leaf covered road. - Dr. Allen
You evidently can’t have your cake and eat it too…
Here is more research to show that running in shoes give you a mechanical advantage in force generation, but at the cost of increased stress on the knees.
“The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.”
No surprise really. You could swing a broomstick with little effort and a baseball bat with more effort, but which will hit the ball farther? Which may tax your shoulder more?
Whenever we take a foot, that SHOULD supinate, effectively decrease its mobility (making it stiffer) and MAKE IT supinate, we will have more power. Remember P = W/t? P is power, W is work and t is time. W is also F X s, where F is force and s is displacement; so we have P= Force X displacement/time. We are increasing displacement here: with force and time remaining unchanged, we have more power.
But…all things wear out in time with use; including your joint cartilage. Hmmm, maybe we reduce the force and allow the joints (like the ankle) to displace (we see increased displacement in unshod running) and we run into our 100’s.
The choice is yours.
The Gait Guys: 2 docs, making a difference, one step at a time.
J Biomech. 2010 Aug 10;43(11):2120-5. Epub 2010 May 11. Footwear affects the gearing at the ankle and knee joints during running. Braunstein B, Arampatzis A, Eysel P, Brüggemann GP. Source
Institute of Biomechanics and Orthopaedics, German Sport University Cologne, Germany. braunstein@dshs-koeln.de
Abstract
The objective of the study was to investigate the adjustment of running mechanics by wearing five different types of running shoes on tartan compared to barefoot running on grass focusing on the gearing at the ankle and knee joints. The gear ratio, defined as the ratio of the moment arm of the ground reaction force (GRF) to the moment arm of the counteracting muscle tendon unit, is considered to be an indicator of joint loading and mechanical efficiency. Lower extremity kinematics and kinetics of 14 healthy volunteers were quantified three dimensionally and compared between running in shoes on tartan and barefoot on grass. Results showed no differences for the gear ratios and resultant joint moments for the ankle and knee joints across the five different shoes, but showed that wearing running shoes affects the gearing at the ankle and knee joints due to changes in the moment arm of the GRF. During barefoot running the ankle joint showed a higher gear ratio in early stance and a lower ratio in the late stance, while the gear ratio at the knee joint was lower during midstance compared to shod running. Because the moment arms of the counteracting muscle tendon units did not change, the determinants of the gear ratios were the moment arms of the GRF’s. The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.
Effects of children's shoes on their gait.
/“Shoes affect the gait of children. With shoes, children walk faster by taking longer steps with greater ankle and knee motion and increased tibialis anterior activity. Shoes reduce foot motion and increase the support phases of the gait cycle. During running, shoes reduce swing phase leg speed, attenuate some shock and encourage a rearfoot strike pattern. The long-term effect of these changes on growth and development are currently unknown. The impact of footwear on gait should be considered when assessing the paediatric patient and evaluating the effect of shoe or in-shoe interventions.” -Study
What The Gait Guys have to say…… First of all, we are in line with this studies findings.
To get started with some hard and simple research facts, current research has been conducted showing that plantar (bottom of the foot) sensory feedback plays a central role in safe and effective locomotion, that more shoe cushioning can lead to higher impact forces on the joints and higher risk of injury, that unshod (without shoes) lowers contact time , that there are higher braking and pushing impulses in shod versus unshod, that unshod presents a reduction of impact peak force that would reduce the high mechanical stress that occurs during repetitive events and that the unshod foot induces a neural-mechanical adaptation which could enhance the storage and restitution of elastic energy at ankle extensor level. These are only some of the research findings but they are some of the more significant ones. Bottom line, shoes can be a problem. Give a shoe that has the minimal amount of necessary support (if the foot needs come pronatory control) and the maximal amount of ability to allow the child to “feel” the ground. A shoe with a thick cushioned or stiff sole must be like, one might assume, what the foot senses in a diabetic peripheral neuropathy. Why would we want to numb our child’s attention to the surfaces they are on, Especially with the broad spectrum of neuroreceptors in the foot ?
Shawn & Ivo…… an orthopedic nerd, and a neurology nerd…… two peas in a nerd-pod. Trying to help you, help your kids. We are so much more than just The Gait Guys.
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J Foot Ankle Res. 2011 Jan 18;4:3.
Wegener C, Hunt AE, Vanwanseele B, Burns J, Smith RM.
Effect of children’s shoes on gait: a systematic review and meta-analysis.
Discipline of Exercise and Sports Science, Faculty of Health Sciences, The University of Sydney, Cumberland Campus, PO Box 170, Lidcombe, 1825, NSW, Australia. cweg6974@uni.sydney.edu.au.
