Does stretching make a difference? Does it enhance or inhibit performance?

Today’s discussion is not fiction or merely our opinion, you should know by now that The Gait Guys are not about presenting misinformation, we are about presenting the facts. Today’s dialogue is based on hard, solid, peer-reviewed research and neurophysiology principles. If you feel you disagree with us, please present your research papers so we can begin a productive dialogue amongst us.

Join Dr Ivo in this weeks neuromechanics to explore these questions and more. Also check out past episodes of neuromechanics weekly on our Youtube channel: “The Gait Guys”

Have a great day!

A few minutes in our Brains.

We were over at a book store on the weekend and picked up a book called Incognito written by neuroscientist David Eagleman.

The gist of the book was that the majority of brain activity is largely subconscious. That the brain is continuously processing information and working algorithms to questions and problems that we have inquired about either consciously or subconsciously. A conscious example might be pondering which new computer to buy, factoring in price, model, manufacturer, specs, hard drive size, peripherals desired, etc. Over a period of minutes, hours or days you bounce around the issues until you rationalize a best decision for your needs and wallet. On the other end, a subconscious example might be learning a new motor skill in your gait pattern. For example perhaps, a pathologic pattern is the one being learned. In one case the brain may be subconsciously learning to reduce gluteus medius muscle in an attempt reduce hip joint compression forces and thus hip pain due to a degenerative joint cartilage surface (see Dr. Allen’s recent video, Applied Hip Gait Biomechanics, Sept 15). In this scenario the brain was working out the algorithm to solve for the pain. The brain is continuously subconsciously processing to solve these problems, it is always working in the background, in sleep or in a wakeful state. We have all had these epiphany moments where the solution to a problem comes to you seemingly out of the blue. However, it is not the case. The brain had been at it for some time.

Eagleman describes the conscious brain as a CEO who is handed a final product that has been worked on by hundreds of employees for weeks, those employees being the subconscious brain parts. The CEO is the last to know, they only get to see the end success of hundreds of hours of work by the employees, and they often take full credit because they are the CEO afterall. It is a long process to achieve solutions to complicated problems. Afterall, do you really think Steve Jobs made the iPad all by himself ? Some might.

Where are we going with this ?

Unconscious incompetence: you do not know the right foot has turned out during gait.

Conscious Incompetence : someone has brought it to your attention.

Conscious Competence: you find a reasonable motor pattern to turn the foot in, but you must stay conscious of this pattern for the correction to be maintained.

Unconscious Competence: eventually unknowingly achieving the foot alignment correction. Give the brain the correct information … then give it time and the correct supportive exercise and let the brain figure it out. It will bring that foot inline eventually as long as there are not other impeding factors. The key is making sure that the pattern you teach your client , or that you institute yourself, is not a compensation. That’s the hard part ! You have to know what is right before you know what is wrong. Pick the wrong pattern and you find yourself down a fork in the road that is full of potholes and problems. Don’t guess. See someone who KNOWS. We had a guy fly in to see us yesterday and this was exactly the case. Therapy has been prescribed in-part off of a video gait analysis and incorrect physical evaluation. You can’t guess at this stuff. You gotta study!

Coming directly from our temporal lobes, we are…The Gait Guys

The Gait Guys. Two weeks ago you talked about a dog’s gait, now cockroaches ? Yup, watching nature at work fosters much insight into gait principles.

Biomimetics, also known as Bionics, is another name for engineering systems that copy principles found in nature.

If you are real gait geeks you have probably seen some of the cool robots inspired after  the insect world. Many of these robots are called hexapods (six legged robots), just like insects. With 6 legs alternating limbs on opposite sides of their exoskeleton (see diagram above) it can provide an inherently stable tripod mechanism that is effective and efficient in when it comes to locomotion. Insects are great models because they have an extremely stable and efficient model of locomotion through something called a tripod gait. We have a video link demonstrating this a little further down.  At any time, cockroaches for example have 3 limbs in contact with a surface.   This tripod structure makes them very stable and mobile.

The stability of the hexapod comes from its ability to establish this gait pattern in which at least three legs are on the ground at any time. Just like the 3 legs of a tripod, when they are firmly planted, the platform is very stable.  You will notice from our year of blogging that we continue to talk about the foot tripod, consisting of stability points at the head of the 1st and 5th metatarsals and the heel. These 3 points of stability of the foot are necessary to make up the longitudinal and transverse arches of the foot. Without the ability to anchor these 3 points effectively on the ground the foot becomes unstable and compromised. Hence why we see bunions, hallux valgus, metatarsalgia, abnormal plantar callus patterns as well as various presentations of foot pain in feet that have lost the tripod ability. The key however is then to place, and maintain, the body mass within the confines or borders of the triangle made by joining these 3 tripod points (see the colored area in the diagram above). In humans, if your body mass deviates towards the outside of the tripod, in other words approaching or violating an imaginary line drawn from your 5th metatarsal to the heel (ie. approaching supination), you tip the foot laterally and begin to compromise the anchoring of the medial foot tripod (under the 1st metatarsal) and risk formation of bunions and hallux valgus among other functional pathologies of excessive or constant supination. On the other hand, If your body mass approaches or exceeds the arbitrary medial border of the triangle delineated by a line drawn from the head of the metatarsal to the heel  you are considered a possible hyperpronator and all of the functional pathologies that accompany it (ie. plantar fasciitis etc).  Bottom line … a tripod is stable, just stay withing the colored lines. Note in this cool video (click here) how clear the 3 pronged tripod engages and how the body mass of the robot stays within the borders of the tripod limbs. In other words, keep your ankle and more specifically the force vector, over your foot tripod (the colored lines),  and most pathology issues will be absent. The closer you get to tipping the tripod, the closer  you are getting to developing biomechanical pathology in the lower limb.  Put another way, by increasing weaknesses in the foot intrinsic and extrinsic muscles and possibly the other stabilizers of the lower limb and pelvis, the closer your body mass will fall towards the edges/limits of the tripod triangle borders. And the closer you are to the risk of gait pathology and pain.

( In the diagram above, for you hexapod insect loving gait fans, the most basic hexapod walking pattern is called the alternating tripod gait. Taken from this site, in this gait, the six legs are treated in two groups of three. Either group of three is a tripod formed by the front and rear legs of one side, and the middle leg of the opposite side. The three component legs of each tripod are moved as a unit. As one tripod is lifted, the other tripod pushes forward. In this gait it can be helpful to think of each tripod as a foot and compare it to your own bipedal walking where as one foot is lifted the other foot pushes forward.)

And you still thought we were just your average Gait Guys, didn’t you ?! If it walks, trots, gallops, canters, jumps, runs, jogs or whatever….. we are on top of it.  Yes, even if that means cockroaches ! We are here to stay gang, in 2012 we will begin to execute our plan for intergalactic dominance, gait related only of course.

Nerd Shawn & Geek Ivo

A Coach with Anterior knee pain:  About as common a problem as finding dirt on a child.

We get emails like this all the time. Here is one from a coach with a problem.

Hi Gait Guys,

I was just found your blog visiting one of the running sites I like coachjayjohnson.com. I’m a high school xc/track coach and a former runner myself. I say former because I dug a nice hole in my cartilage in the lateral trochlear groove about 4 years ago from running. This actually happened 3 months after I stopped wearing the custom orthotics i had been wearing for about 8 years. What a mistake that was, but the biggest mistake might have been getting them in the first place.

Anyways, 3 months ago I had a procedure done to regrow the cartilage. this was done at the stone clinic in San Francisco. The doctor said I should wait a year before I attempt to run again. I’m fine with that but sometime next year once my knee is feeling good enough I’d like to come see you guys before I start running again so that you can help analyze everything and get me out there running again with good form and in the correct shoes etc. Where are you guys located? Also, are you going to come out with some new DVDs?

Thanks,
(name removed)

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What The Gait Guys have to say …

Dear Coach:

(Links in our discussion have been embedded for you and other readers and we have included a picture above so everyone else will know where your problem was.)

Anterior knee pain in runners is about as common a problem as finding dirt on a child. You have described the all to common, osteochondral defect. IT is a defect of bone and cartilage quite often from blunt or repetitive trauma.

Knee joint anterior malalignment is multivariably associated with patellofemoral osteoarthritis (study). Alignment issues at the knee can be driven by variations of the optimal anatomy (versions and torsions, see a post on this from ~3 weeks ago) but in our opinion they are often driven from other factors most notably improper biomechanics driven by muscle weaknesses-tighness. However, other factors can come into play to complicate the scenario, such as poorly selected footwear for a foot type. Alignment at the knee is subservient to the mechanics at the hip and foot. Both the hip and foot are multiaxial  joints, whereas the knee in its healthy state and most basic description, a sagittal hinge joint (sure, miniscule rotation). When the hip or foot are prostituted and some of the availability of their normal motion is lost or changed (as is possibly the case of an orthotic as you eluded to, however in the hands of a skilled practictioner the orthotic can help positively restore compromised function, if they understand and assess whole limb kinetic function) the knee joint can often find itself in the middle of altered biomechanical force streams. This all to often can lead to anterior knee pain, compromised function of the patellofemoral joint.  This, as in your suspected case, can lead to abnormal cartilage wear at the interface of the two bones.

In one article it was proposed that physical activity may modify the association between joint incongruity and cartilage loss, and can be further affected by subject characteristics such as gender. It must be part of the thought process that rather than it being the activity, is more likely to suspect altered biomechanics during said activity as being the culprit.  Understanding these complex interactions will help optimize strategies to maintain patellofemoral joint health. However, this study found that for every one-degree increase in the proximal trochlear groove angle at baseline, there was an associated 1.12 mm  increase in the annual rate of patella cartilage volume loss. This brings a person’s given anatomy, perhaps suboptimal anatomy, into play and thus adds one’s risk factors. There was a trend for this effect to occur for males, as well as people participating in vigorous physical activity. Males who exercised vigorously were more adversely affected.

In conclusion, this study showed that in vivo engineered cartilage was remodeled when implanted; however, its extent to maturity varied with cultivation period. The results showed that the more matured the engineered cartilage was, the better repaired the osteochondral defect was, highlighting the importance of the in vitro cultivation period.

There are many surgical interventions out there for anterior knee pain, such as tuberosity transfers, retinacular releases, injections, and God forbid patellectomies among others (yes, we have clients who decades ago had this done, imagine that! Thankfully this radical move is no longer done !). Most people simply need a well versed biomechanist who understands the whole kinetic chain, understands the force streams, can assess for the limitations and reduce them to restore the previous normal mechanics.  Sadly, sometimes interventions are not optimal or precise and folks end up like you coach. And then surgery is your only option.  Thanks for sharing your story and reaching out to us. Sharing your anonymous story may help others avoid your painful journey. We would be happy to see you, we are getting more and more letters like yours both here in the home land and internationally. Hopefully, our mission will help reduce these problems, if at least just a little. (PS: yes, our 3 part Shoe Fit / Biomechanics & Functional Anatomy DVD and online program should launch in February. Information about the launch will be right about the time phase 2 of the website will lauch www.thegaitguys.com).

Best to you.

Shawn and Ivo, The Gait Guys

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 1^st 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 degrees  at 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 devaitions for their age (see chart) 
• If their height is > 25^th 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.

Ivo and Shawn…  The Gait Guys…Promoting foot and gait literacy for everyone.

We are not generally fans of Nike, but they do have some cool commercials. Here is one of our favs of cyborg parkour.

Have a great Friday

Ivo & Shawn

Gait ischemia? Blood flow affecting performance.→

Research evidence that gait is altered in ischemia (inadequate blood supply) environments.

Know someone with diabetes, peripheral artery disease or spinal stenosis (especially the vascular variety) ?

This study’s findings indicate increased “noise” and irregularity of gait variability patterns post-ischemia. In young healthy individuals who do not have neuromuscular impairments, significant gait alterations are present during walking after a period of interruption of blood flow. This could be from something as simple as muscular compression, or something more serious.     

We just wanted to wet  your appetite for some stuff like this coming your way, from us, The Gait Guys.  If this does not make you think about compressive socks and stockings, you need a second cup of coffee this morning !

Shawn and Ivo

                                                                                                                                                                                             

Gait variability patterns are altered in healthy young individuals during the acute reperfusion phase of ischemia-reperfusion.

J Surg Res. 2010 Nov;164(1):6-12. Epub 2010 May 18. Myers SA, Stergiou N, Pipinos II, Johanning JM.

Source

Nebraska Biomechanics Core Facility, University of Nebraska at Omaha, Omaha, Nebraska 68198-3280, USA.

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Gait: Does Minimizing center of mass vertical movement change your metabolic cost ?→

Research article: Minimizing center of mass vertical movement increases metabolic cost in walking.

Ortega JD, Farley CT. Locomotion Laboratory, Dept. of Integrative Physiology, University of Colorado, Boulder, CO 80309-0354, USA. ortegajd@colorado.edu

J Appl Physiol. 2005 Dec;99(6):2099-107. Epub 2005 Jul 28.

So what is this article’s bottom line ? The premise of the research article was to look at the relationship between vertical movement in gait and its metabolic cost by having human subjects walk normally and with minimal center of mass vertical movement (“flat-trajectory walking”). What the article found was that it costs more to move with a flat trajectory. In other words, dampening the normal vertical oscillations is not a good thing.  But we have some concerns.

Not that we have a major problem with this study, but we do have two concerns we think should have been brought up problem.

1- Were these folks in the study assessed for biomechanical compensations ? You have read our discussions on impaired ankle rocker. And one of the major flaws of impaired ankle rocker is the premature heel rise gait, where the person can adopt a rather boucey vertical gait, almost appearing to walk on the ball of their foot. These folks have a very vertical gait.

2- Since the study concluded that the less vertical trajectory gait was seen to be far less metabolically efficient it is a well founded question to ask more about the strategy they employed. In the study they merely added more joint flexion to dampen the vertical trajectory.  But, had they been coached to use the core to minimize vertical trajectory and utilize the energy moving forward while still obtaining some of the normal biomechanical components, some of which take advantage of limb extension, would the study have found the same thing ?  Once again we find a good study but one that bodes more questions than it answers, such as, did the researchers really know enough about gait biomechanics to give good cues?  Furthermore, how much vertical is too much ? How much dampening is too much ?

  We still appreciate the study and its findings, but you cannot trust everything you read, at least not without reading the fine print.  Here is the full abstract below. Read it yourself and if you are curious enough, get the full study for yourself.

Shawn and Ivo…….keeping you on the edge of the research.

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Journal Abstract

A human walker vaults up and over each stance limb like an inverted pendulum. This similarity suggests that the vertical motion of a walker’s center of mass reduces metabolic cost by providing a mechanism for pendulum-like mechanical energy exchange. Alternatively, some researchers have hypothesized that minimizing vertical movements of the center of mass during walking minimizes the metabolic cost, and this view remains prevalent in clinical gait analysis. We examined the relationship between vertical movement and metabolic cost by having human subjects walk normally and with minimal center of mass vertical movement (“flat-trajectory walking”). In flat-trajectory walking, subjects reduced center of mass vertical displacement by an average of 69% (P = 0.0001) but consumed approximately twice as much metabolic energy over a range of speeds (0.7-1.8 m/s) (P = 0.0001). In flat-trajectory walking, passive pendulum-like mechanical energy exchange provided only a small portion of the energy required to accelerate the center of mass because gravitational potential energy fluctuated minimally. Thus, despite the smaller vertical movements in flat-trajectory walking, the net external mechanical work needed to move the center of mass was similar in both types of walking (P = 0.73). Subjects walked with more flexed stance limbs in flat-trajectory walking (P < 0.001), and the resultant increase in stance limb force generation likely helped cause the doubling in metabolic cost compared with normal walking. Regardless of the cause, these findings clearly demonstrate that human walkers consume substantially more metabolic energy when they minimize vertical motion.

You have heard us talk about weakness (short weak and tight weak) muscles all the time on Youtube: The Gait Guys; now here is the neurology behind it. Think about this concept the next time you see a gait compensation and think of the muscles (agonists/antagonists) involved.

On and on goes the barefoot debate. 

There is no single right answer, so use your head.

article link, click here

We have been saying what this article talks about all along, even years before the Vibram 5’s hit the market, back when Vibram came to us to ask us for our thoughts on the early versions.  You will see our soapbox rant on this topic over and over again in our blog posts and it is the modus operandi behind our new 2012 Shoe Fit program that will likely launch February 1st in several forms for several professions to meet everyone’s needs.

That modus operandi being that not everyone has a foot type, anatomy or biomechanics to get into minimalist shoes, without a possible cost that is.

In this nicely written article by Cynthia Billhartz Gregorian “Barefoot running: Sales grow, but so does debate about benefits, safety” at the link above she lightly covers some of the aspects of the debate.  We have read just about every piece that has come out on the barefoot-minimalist trend. Sadly, some of the blogs are mere opinion and it is rare that the honest truth comes out.  That truth being our mention above that some folks just do not have the skill, endurance, strength or anatomy to delve into footwear that does not support or protect their physical limitations.  Lets be honest, at 5'9’’ I have to come to the realization that no matter how much i practice to be in the NBA I am not going to make it. I just do not have the physical anatomy to be an NBA star.  And some people, no matter how much they want to run barefoot or minimalist, just do not have the anatomy to allow it. Someone with a history of foot pain who has a rigid forefoot varus really is not going to do well in minimalist shoes. There are articles written out there that just tell people to bite the bullet and go 100% into their new minimalist shoes, into the natural way they were supposed to run from the very start and force the body to adapt, that the new form they adopt will take care of any problems. Well, in our experienced and educated opinion, that is just not smart. Someone who has a shortened posterior compartment (calf-achilles) after being in heel shoes for years is going to have several flaws biomechanically going to minimalist shoes right off the bat. One example, just one for now, is that the person is going to have premature heel rise and thus premature forefoot loading response around a compromised ankle rocker mechanism. And there are many others of course.

Here is the bottom line as we see it. No shoe company is going to run a commercial or add on their product with the warnings on the cover or in the fine print. We are not talking about cigarettes here.  Admitting that some people should not be in their product would be admitting that the product has limitations and risks.  What kind of advertising add would that be ? Besides, admitting to limitations or mentioning warnings is a mere step away from liability cases.  We are pretty sure of this, after all, look what happened to the Shape Up Shoe in the courts.

Here is what we say to the naysayers, look at the research and use logic.  If you are new to the game, leave the extremist blog sites for those that are looking for radical opinions. Because we do not have any openings in our clinics for the next several weeks if you throw caution to the wind.

Good running to you all in 2012, use your head, for the sake of your feet.

Shawn and Ivo

Ataxic gait?

We hope you have begun the new year in a NON ATAXIC manner. Lets look at the origin of the word:

Ataxia: Greek, from a or without + tassein to put in order or “without order”. Ataxia is truly gait without order, and we will see why momentarily. The term was coined in 1670. Every September 25th is International Ataxia Awareness Day. Mark THAT ONE on your calendars!

Ataxia an inability to coordinate voluntary muscular movements that is symptomatic of some nervous system disorders and injuries and not due to muscle weakness.

It is a lack of afferent information either GETTING TO the CNS, BEING PROCESSED BY the CNS, or OUTPUT FROM the CNS. We can still hear Dr Carrick saying “where is the longitudinal level of the lesion? Is it at the receptor, the effector, the peripheral nerve, the spinal cord, the brain stem, the thalamus, the cerebellum or cerebrum?” This mantra, still rings true many years later, as it gives us the afferent pathway to the brain and higher centers of the CNS.

Ataxic gait, not to be considered synonymous with Fredreich’s Ataxia (the genetic disorder described in the 1860’s, related to spinal cord and cerebellar degeneration), can be due to any number of causes which affect processing of afferent information. One too many Tequila’s (100% agave of course), barbituates, joint pathomechanics, diseases affecting receptors (like syphilis or leprosy), diabetes and other forms of peripheral neuropathy, spinal cord injury or disease are only a few of the causes. Virtually anything that can affect the afferent processing or efferent arc of the processing of proprioceptive information.

The large amplitude corrective movements are clues to the CNS that something is awry and are a necessary component of the compensation. Here , you truly are seeing the result of the compensation.

The video offers a simplified explanation and nice clinical example of an ataxic gait. If you don’t believe it, try some field research (or perhaps you already have) with the ethanol of your choice and see for yourself. Of course, some of THAT ataxia comes from changes in specific gravity of the endolymph in your inner year, but that is the subject of another post.

Ivo and Shawn. The Gait Guys…New and Improved for 2012

Proof that the contralateral limbs are programmed. Wait, are you guys showing dog gait video today ? yup, and for good reason.

This is how good our eyes are trained at gait stuff.  How good are yours ? Can you pick out what we saw immediately when watching this clip ? It is something really cool, perhaps proof that contralateral limbs, upper and lower,  are programmed and automatic. Even in dogs apparently. Did you see it ?  You may have to have to watch the video several times.

The dog initially is striking with the left forelimb while pairing that with right hindlimb just after (remember, this is running gait, not walking) . Kind of like how in human gait the left arm swing is in sync with the right leg swing (both in either flexion or extension, at the same time). We believe the central pattern generator for gait occurs in an area of the spinal cord at the junction of the the thoracic and lumbar spines (just like in the large sauropod dinosaurs!) click here for more info

But what is really cool is that there is a sudden change at 0:23sec.  The dog changes midstride to strike first with the right forelimb and immediately alters the hind limb to strike first with the left. Can you see it ? Look again. Isn’t the nervous system amazing!

Just as in humans the pattern change seems to be immediate and subconscious.  The rhythm and sync is predictable. It appears that even in animals the arm swing topics of weeks ago on in-phase and anti-phase of the shoulder and pelvic girdles hold true.

Did you see it immediately ? It may take you time to train your eyes like ours, but if you watch enough videos perhaps you too will have gait observation superpowers. 

Limb swing, even in animals, offer information to learn from and extrapolate to humans. Bipeds, quadrupeds….we don’t discriminate.

Shawn and Ivo……..gait experts……. on many levels.

Not another Cross over runner ! Yup, and some new pearls on the topic.

Watch this video (and we will post her second video shot from the side in a separate blog post) so you can see some of the components we will talk about today.

Quite often in the Cross over gait the runner has great difficulty getting into the glutes (max and medius) effectively.

In this video today from Runblogger, we see yet another runner who is lacking skill and strength in the appropriate muscles and patterns to run efficiently.

1. In this video it is clear that she has the classic Cross-Over stride flaw. This video is nice because there is a line present to support our cause, the feet at basically falling on a line instead of below the hips. We see the typical far lateral foot strike in this runner that is classic for Crossing over.  This more lateral strike, even though it is a nice midfoot strike (see the side video shot in the other video of her we post), causes pronation to occur quicker and longer than normal and can create an abductory twist when the heel departs from the ground. However, we do not see the abductory twist like we saw in the Lauren Fleshman videos.  Why not ? because this runner has the foot progression angle at zero, perhaps negative 5 degrees (what we are saying is that she is toe’d-in). This is appears to be from her having mild internal tibial torsion. And a negative foot progression angle will help hold the arch through pronation and in this case is protecting from the abductory twist of the foot at heel rise. There is most likely a forefoot varus here as well (note the inversion at strike). Most likely it is functional; she appears to have inadequate motion in the rear and midfoot, so the pronation must occur somewhere and we see it here in the forefoot.

 Pretty cool to see how a subtle change in one’s anatomy can play out differently.  Go back and watch the Fleshman video blog of weeks ago and watch for the abductory twist of the feet.

2. In this runner, what we really wanted to discuss however is the poor motor control of the gluteus medius and maximus (maximus will be in #3). We can clearly see in this video that during all phases of stance, the pelvis is dipping on the contralateral side. This downward drop is creating a greater gluteus medius lever arm and thus greater demand on the gluteus medius, and in this case a failed attempt (if the opposite hip were hiked, the lever arm would be reduced and put lesser demand on the gluteus medius, less fatigue factor). New to this concept ? Click here.Think now about the reciprocal pairing with the adductors and you could understand why her adductors are probably shortened as well; the adductor magnus especially, as it has a secondary motion of external rotation, and it is probably being substituted here to help decelerate the internal spin of the lower extremity

As the longer lever pairs with the body weight factor, there is a vertical descent of the body and this must be made up by eccentric control of the gluteus maximus (the option of optimal choice) or it is dumped into the quadriceps and they are expected to cope with the body mass descent by slowing knee flexion.  She appears to be opting for the later, not a good choice.

3. Now switch over to the frontal plane (side) shot of this runner in the other blog post. Can you clearly see that the quadriceps are being asked to control the decent? Look at the vertical oscillations of her body. Look at the amount of knee flexion occuring at impact.  It is clear that the gluteus maximus is not dampening this drop and this can be seen by the amount of hip flexion noted here. We always think of the glutes as extensors but in gait they are huge dampeners of the rate and degree of hip flexion.

This is very inefficient running.  She could be much more effective and faster if she works on these issues.  If she can just pair improved gluteus medius to control the frontal plane pelvis drop, and improve the maximus to control the sagittal drop there would be more energy to move forward and less wasted into overcoming the ground reaction forces (which she is maximizing) as dictated by Newton’s Laws.

are we the only ones seeing this stuff ?  hopefully you are starting to get real good at this stuff. 

The Gait Guys, saving one runners life (and hips and knees) one day at a time.

Shawn and Ivo

Part 2: Not another cross over gait runner.

read part one to get the pearls on this runner’s issues.

Here is some classic Shawn and Ivo, talking about rearfoot varus in one of our older “Manual Medicine Advisor” Podcasts. Sit back and enjoy!

The Gait Guys on Movement, Physiologic Overflow & Muscle Function.

Movement is largely isotonic, meaning that muscles maintain a steady state of contraction (“same tone”) throughout a physiological range of motion; in other words, our body mass does not change as we move through space. Exercise is specific as to the type of contraction (isometric, isotonic, isokinetic) and speed on contraction. Different rehabilitative exercises we prescribe can have different results based on the points or angles of application. This video discusses some of these points. See us also on You Tube: The Gait Guys

Watch for a Podcast of classic Shawn and Ivo at noon!

SCARY gait of the week.

OK, so we do not even have one complete gait cycle to look at, but what an excellent clinical example.

Here is an example of someone who has not earned the right to forefoot strike. Go ahead, step through the video a few frames at a time.

First notice the abductory twist of the Left foot as it leaves the ground (toe off). You will also notice that the left foot also leaves the ground with a low gear toe off instead of a strong push off the big toe/medial foot. Now watch the external rotation and abduction of that extremity (:05) so it can plan for the next footstrike and try and clear the Right leg.  Why is this ?  Well, we do not have a complete gait cycle but if you were to draw a line down the middle of the treadmill you would see that this is a great example of some of the things that occur during the CROSSOVER GAIT.  Yup, we are back pounding this flawed gait technique. It is common to strike the ground on the far lateral foot and then pronate quickly through the midfoot. It is also common to increase the foot progression angle. 

One might suspected forefoot varus as seen from :03-0:05, with the sudden forefoot pronation of the Right foot. It does look mostly controlled however, the steep Right forefoot varus positioning the the air before contact could bode more for the mechanics that go with the CROSSOVER gait.  (CrossOver gait you say ? Haven’t seen our 3 Part Cross Over gait video series on YouTube ?  click here for Part 1)

DO NOT TRY THIS AT HOME!!!  Ditch the prison socks, read our treadmill article coming out soon in Triathlete magazine so you know the true problems of treadmills, and learn to run with good technique.

Have a marvy day, you footgeek, you

Ivo and Shawn

A young lady with knee recurvatum. Even at the airport you are not safe from The Gait Guys !

Standing waiting for my parents luggage I had to do a double take when i saw this excessive genu recurvatum of the knees. Of course it was much worse in person because of the added dimension that a photo cannot give.  This poor gal probably doesn’t even know she needs us. 

What do we see here and what assumptions can we extrapolate (assumptions from mere standing of course)  ?:

We are going to keep it to things from pelvis down or we will be here all day.

1. Anterior pelvis tilt. She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  Combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis.
2. The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extennsion.
3. The knees are likely locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis.
4. She will be in relative ankle plantarflexion instead of balancing the tibia neutrally over the talus.  Relative constant plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. This gal will likely have problems controlling pronation we suspect because of such assumed imbalances.

These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. I was going to walk behind to take a pic so we could make some assumptions about the frontal plane, but people all around were already getting suspicious of me snap photos of so many of them. 

Remember, these are just assumptions from a single static photo. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us.

Oh, and we must not forget to once again thank Mr. UGG boot for helping add another dimension of challenge to this lovely lady ! Although this assumption would be better made off of a frontal plane photo.

Beware of geeks in the airport and shopping malls snapping photos and video. It is likely us, The Gait Guys.

Shawn and Ivo

At this time of year, we are thankful for people like you and appreciate the trust you put in us.

 

In the words of Helen Keller:

The best and most beautiful things in the world cannot be seen or even touched. They must be felt with the heart.

Wishing you Happiness, Health and Prosperity (and excellent gait mechanics).

 

Ivo and Shawn

A case of plantar foot pain during gait.

This client came to see us after a surgical proceedure to remove a dead (osteonecrosis) medial sesamoid under the 1st metatarsal head and a later surgery to fix a progressing hammer toe of the 2nd digit. What we really want you to see is the huge divot/depression under the 2-3 metatarsal heads. Also note the accumulation and relocation of the normal MET head fat pad now located distal to the MET heads.  It is as if the fat pad is trying to hitch a ride on the toes now ! This is a case of Metatarsalgia secondary to fat pad displacement (displaced from the divot area to the flexor crease) secondary to surgical sequelae. 

What is additionally cool in this case is the fact that this client has an almost complete webbing of the 2-3 toes so many of the normal independent muscular functions are no longer independent. After the surgeries this person presents with tremendous loss of flexor and extensor function of the 2-3 toes.  Lumbrical testing was most obviously impaired, completely absent in fact, in these 2-3 toes. On the ground the patient was also unable to achieve any flexion-press of the toes into the ground, he was able to flexion/hammer curl which will obviously put them at risk for hammer toes in the future.  But what is important here is that without the ability to PRESS the toes into the ground particularly while in stance phase the lumbricals will not help to hold the fat pad in its normal location under the MET heads. Nor will they be able to to perform their other major functions, namely: thinking from a distal to proximal orientation (a closed chain mode of thinking), they actually plantarflex the metatarsal on the fixed phalynx, assist in dorsiflexion of the ankle, and help to keep the toes from clawing from over recruitment of the flexor digitorum longus.

This client’s MET head pain is obviously caused by lack of cushioning of the head since the fat pad is displaced. There are plenty of other biomechanical abberancies now, the Windlass mechanism will never be the same becuase it is without one of the sesamoids, the hallux short flexor (FHB) is impaired on the medial head without the sesamoid so hallux flexion will become a problem.  Do we really want to see such compromise of the medial tripod ? Heck no, we need sesamoid implants ! There is a novel idea ! When a sesamoid is taken out we need to replace it ! Think about it !

There is so much more to this case, but we will stop here. It’s Christmas after all ! This poor lady was told to wish from Santa for a medial sesamoid implant under the tree and a sudden spontaneous activation of the lumbricals to retract the fat pad back under the MET head so as to reduce her pain.  Hey, wishing can’t hurt !

Merry Christmas and Happy Holidays to you all gang, whatever your faith we wish you well,

from Shawn and Ivo…… The Gait Guys

(PS: we included below more from the body of the article we wrote long ago called “The Lost Lumbricals”.  So for those of you who wish to geek out more on Christmas, read on …

______________

EXCERPTS FROM “THE LOST LUMBRICALS”

The lumbricals of the foot attach proximally to the sides of adjacent  tendons of the flexor digitorum longus (with the exception of the 1st, which only attaches to the medial side) and attach distally to the medial aspect of the head of the proximal phalynx and continue on to the extensor hoods in toes 2 through 5. Their typical function is described as flexion of the proximal phalynx and extension of the proximal and distal interphalangeal joints. They have the unique ability to compress the metatarsal-phalangeal and interphalangeal joints. These are “open chain” functions as described, unless you are in the habit of waving to people with your toes, they often are used quite differently in the gait cycle with the foot affixed to the ground.

The lumbricals are most active from midstance to preswing. That means they act predominantly in the closed chain. The lumbricals, along with the other intrinsic muscles of the foot, play a role in maintaining the medial longitudinal arch of the foot.  Along with the interossei, they play a role in stabilization of the forefoot during stance phase and rearfoot during preswing. One author has proposed that overpronation is due to a lack of neuromuscular control of the intrinsic foot muscles to stabilize the tarsal and metatarsal bones and therefore modulate the speed of pronation.

Thinking from a distal to proximal orientation (a closed chain mode of thinking), they actually plantarflex the metatarsal on the fixed phalynx, assist in dorsiflexion of the ankle, and help to keep the toes from clawing from over recruitment of the flexor digitorum longus.

Clawing toes during gait, which are considered abnormal, are defined as extension of the metatarsophalangeal articulation, and flexion of the proximal and distal interphalangeal joints result from a foot attempting to stabilize itself during the terminal stance and preswing phases of gait.  This is an attempt to help propel the body forward, often accompanied by overactivity of the flexor digitorum longus, tibialis posterior, flexor pollicus longus, and gastroc soleus groups. Overactivity of these groups causes reciprocal inhibition of the long toe extensors and ankle dorsiflexors (tibialis anterior for example), causing the toes to buckle further and a loss of ankle dorsiflexion; in short, diminished ankle rocker.

Now think about the changes in the gait cycle in the above scenario. There will be a resultant shortened step length, diminished ankle rocker, increased forefoot rocker and premature heel rise. This will necessitate an increased extension at the metatarsophalangeal joints, shifting the tendon of the lumbricals upward and behind the transverse metatarsal joint axis, causing even more extension now at this joint. Chronically over time, this causes displacement of the fat pads anteriorly from under the metatarsal heads and is one of the main reasons metatarsal head pain (metatarsalgia). In the past have you made the apparent simple diagnoses of metatarsalgia, shin splints, stress fractures or Morton’s neuroma without knowing a more plausible cause ?  Do you now feel you have better answers to these clinical phenomena ?

Now think about changes up the kinetic chain and the potential musculoskeletal implications of muscle inhibition, overfacilitation and joint dysfunction, often with neurological sequelae. With lumbrical dysfunction (weakness) and the resultant lack of ankle dorsiflexion, you have less hip extension.  So, you borrow some from the lumbar spine, with increased compressive forces there and an increase in the lordosis, which causes an increase in the thoracic kyphosis and cervical lordosis. We still need to get this leg up and forward to continue our progression ahead, so now we fire our hip flexors instead of the abdominal obliques. And because there needs to be cooperation of the abdominals and hamstrings to maintain pelvis neutrality, this further fuels inhibition of the gluteals thus further compounding the loss of hip extension. Now how about a little increased shoulder flexion on the contralateral side to assist getting that leg forward? Don’t forget that we have altered the thoracic kyphosis and thus changed scapulo humeral mechanics. Now neck/shoulder pain all from bad feet?  Maybe. These muscles developed and exist for a good reason, do your best not to dismiss them and their function the next time you see a tortured foot.

When patients have continued dysfunction, consider the base and where it all begins. Consider function in the context of where it occurs. Proper evaluation of the feet and gait can provide valuable clues as to the etiology or manifestation of continued problems. Important? You decide.