An entertaining song that sums up how we feel about feet.
Geez, we ARE geeks!
Have a great Weekend
Ivo and Shawn
The Importance of the foot function and posturing at terminal swing in a great and talented runner. Part 2 of the Toe Extensor Dialogue.
* This is a follow up from yesterday’s video blog post. Lets review once again and then dive in, layering some deeper principles onto yesterday’s dialogue.
Stand up. Both feet on the floor. Close your eyes and raise your toes up off the floor, just the toes, and then let them fall. Pay great attention to what happens to your arch height as you raise and lower the toes. Yes, do this now. Then come sit down again and read some more. Go !
Ok, now you are back.
Do you think that toe extension ability (range, skill, endurance AND STRENGTH) will play a significant part in achieving adequate successful arch height and thus treating plantar foot pain syndromes (plantar fascitis to name the most obvious and simple nemesis)? You better believe it, we showed it in yesterday’s blog post ! * For a great little video sample of a young boy with flat feet using our queue’s to restore tripod positioning and arch height along with a more normal foot progression angle, see yesterday’s blog post or click here.
So, if toe extension is critical for arch height, both in preparation for foot strike/contact and in arch height and control should you ever try to consciously limit this natural phenomenon ?
In the video above the author and runner (Jordan McGowan) at 1:07 discusses his concern that the left foot is coming across in too much toe extension (ie. ankle dorsiflexion as well) in preparation for contact phase and that his right foot is coming across less extended/dorsiflexed, something we sometimes call shallow dorsiflexion. He indicates that he likes the appearance of the right foot pre-contact approach but he feels that he wants to relax the toe up/dorsiflexion exaggeration on the left. We do not necessarily agree based on the principles discussed above and yesterday because arch height preparation will be reduced (again, see yesterday’s blog post and video). However, Jordan is not wrong either. Read on !
Now, although Jordan himself does not discuss any deeper concerns we could imagine that some less skilled runners in this scenario might worry that if the toe extension is too excessive that it will pre-position the foot for a heel strike phenomenon. This does seem very reasonable thinking, but it is not necessarily so. Heel strike is a conscious choice. If this is your concern, it can easily be overcome; you will just have to do one of two things to avoid heel strike (ie. get to mid foot strike, which Jordan does very well on both sides, even the left, despite its increased toe extension/ankle dorsiflexion).
To overcome the concerns of heel striking with high toe extension pre-contact:
1. One will have to lean forward more to offset the possible early heel strike. Leaning forward more (as is done in natural/chi running form) will make it harder to heel strike because the foot will land even further under the body. Whenever the foot reaches out in front, the opportunity for heel strike increases. Make no mistake however, there is a difference between heel strike and heel contact. A skilled walker or runner can heel contact and quickly transition to midfoot load and get the same effect as a more pure midfoot strike. The difference is whether you LOAD the heel contact or quickly transition to the midfoot. Any skilled runner can do this and feel this. When done skillfully, a mere kissing of the heel, a mere light brushing with the ground, before the midfoot loading occurs is completely fine just do not load the heel otherwise a deceleration event is going to occur and that is a definite “no no”. This is a problem with amateur gait analysts and runners, and proves once again that what you see is not always what you get. We demo this illusion all the time with our runners and without a skilled eye they cannot see the difference, but they can feel the difference when asked to focus on the skill difference. To reiterate, for MOST runners there should be little if any rearfoot loading response, it is a mere zone of transition. This topic is absolutely no comment here on Jordan, he has superb midfoot contact.
2. Back to overcoming heel loading……. one will also have to better eccentrically control the descent of the forefoot to the ground. This is a normal biomechanical event. Yes, you can reduce this need if you bring the foot through shallowly as Jordan explained regarding his right foot, but at the possible consequences of entering the pronation phase with a partially unprepared arch and subtalar joint configuration (if the subtalar joint is starting its loading at the mid or anterior facet joint pronatory unlocking of the midfoot will occur too soon). A runner with a highly competent and strong foot can get away with cheating this mechanical event, and it is quite (very) possible that Jordan has such a foot with all his running experience. On the other hand, a more amateur runner could be loading a bullet into the pronation gun. Now, back to the eccentric loading of the anterior compartment muscles. Too slow an ankle dorsiflexion posture release and the heel will strike first, too fast and the forefoot could slap on the ground. One will thus need to get the proverbial porridge just right (not too hot, not too cold…..rather just right). Most skilled runners will be able to get this skill down within just one workout and then master it over the next 12 weeks (the time we find necessary to engrain a new motor pattern in the cerebellum and parabrachial nucleus, the primary pattern generators). And with more skill and foot strength a more risky shallow posturing can be taken with success. And, this may very well be the case with Jordan. He may be there and be correct in his evaluation. We just wanted to share both sides.
Understanding the end-phase swing foot and toe function is important. Understanding what your foot is doing is paramount. We wanted to share both sides of the coin because we would hate for amateur runners to see this and try to reduce their proper and necessary toe extension/ankle dorsiflexion and mimic a shallow late swing phase foot posture. This is where running moves from science to an art. Guys like Jordan can play with this stuff safely, but not everyone else can or should. For many, better preparation of the foot for the contact phase in a solid tripod will reduce excessive and possibly deformative pronatory forces. Presenting the foot to the ground with a less than optimal arch, via a conscious reduction in toe extension, will increase risk for the deformative pronatory forces to have a better chance of creating tissue pathology (ie. plantar fascitis etc).
Here is one of the reasons we recommend even our elite runners from time to time to exaggerate the toe extension-ankle dorsiflexion range off and on during runs. If you never use the FULL range Tib Anterior and extensor digitorum longus muscles (as in the shallow end swing foot posturing), you will begin to lose their strength at the end ranges. We often lose end range strength first. And in time that can trickle down those weaknesses into the ranges where more of the strength is truly needed. This is the “gosh, my pain just started out of the blue phenomenon !” Truth is, it did not, you just finally found yourself without that necessary extra little bit necessary to adequately protect a joint for the load at hand. And perhaps this is the take home point here. We all need to be sure that we still have what is necessary for optimal joint complex protection from time to time. It is why many athletes come to see us a few weeks before big events, for assessment to be sure that they are not trickling down into that risk zone as they peak their training and then taper.
In another post, we will discuss Jordan’s frontal view issues. He wisely has detected his foot pronation issues and we couldn’t agree more about his mention of the gluteal control and an important factor. So we will once again review our Cross over gait pathologic movement pattern which is somewhat evident here and part of the foot posturing, but we will also discuss the abductory twist phenomenon of his left foot, which is truly what is going on at the foot level (don’t get us wrong, the glute is part of the deal, but it is not the entire deal).
From the start our mission has never been to strike at the moral fiber of someones good intent. Rather, our mission has always been to dispel the myths and state the facts. This was a great assessment by Jordan, we just wanted to point out a few possible misconceptions and explain some of the differences between a skilled runner and what they are working on and what an amateur runner should be aware of mainly so that the masses of runners who will see this great video will get the honest facts and not start to, or too early, consciously change normal behaviors and start to generate compensations.
We spoke to Jordan about this blog post before we ran it and he was a champion about it. It opened some productive dialogue on both ends, that’s the way it should always work. Jordan was all for stating the truth and facts from all angles.
We are Jordan and Newton fans. We thank Jordan for his input, his feedback and for sharing his nearly flawless running form in his Newton’s. This is a form everyone should take note of and try to strive for.
The Gait Guys
Shawn and Ivo
The foot tripod: the importance of the toe extensors in raising the arch.
* this is a two part series……. we have a great follow up video tomorrow that requires this video and blog post first. So, wrap your head around these simple principles today and then we will apply them to a great runner and their video, tomorrow.
Stand up. Both feet on the floor. Close your eyes and raise your toes up off the floor, just the toes, and then let them fall. Pay great attention to what happens to your arch height as you raise and lower the toes. Yes, do this now. Then come sit down again and watch this video and read some more . Go !
What you should have noted, unless your foot is so flat and weak is that when you raise your toes off the floor (when standing or non-weight bearing actually) is that your arch should raise up. This lifting of the arch will improve your foot tripod ability (anchoring of the heads of the 1st and 5th metatarsal heads, with the heel at the 3rd point of the tripod) and it will shorten the longitudinal arch length. So, do you think that toe extension ability (range, skill, endurance AND STRENGTH) will play a significant part in treating plantar foot pain syndromes (plantar fascitis to name the most obvious and simple nemesis)? You better believe it ! Go ahead, prove us wrong.
In this video the young fella starts out with flat pes planus feet, increased foot progression angles (30 degree splay outwards) and excessive internal limb spin which is helping to drive the flat feet.
For you clinical nerds, yes he could have external tibial torsion however, what you cannot see is that when we bring his feet back to neutral forward posturing and correct his arches his patella aligned forward and a squat test showed a pristine forward sagittal tracking. Had it been a case of external tibial torsion, the knees would have been angled inwards and tracked medially, eventually knocking together. Again, this was not the case.
This was just a young boy with feet that had never learned the S.E.S (Skill, Endurance, Strength) of normal foot posture and intrinsic and extrinsic foot neuromuscular use. Yes, we are once again harping on S.E.S. It is critical that you get that SES concept down, in prior posts we have discussed the neurological logic to this progression via looking at nerve diameter/conductance. It is factual, not something we made up.
It took all of 1 week for this young man to gain this quick skill correction. On the first visit we spent 20 minutes teaching him awareness of arch changes with toe extension use (the Windlass mechanism is engaged with Toe Extension) and awareness of the forefoot bipod contact points. We then followed that up with foot progression improvements to get his feel aligned better. Soften the knee hyperextension that is frequent with pes planus and we were off to the races. Stage two for “Shuffle walks” was set, all he needed was this initial skill set, and you can see that in one week he had it nailed down to under a 1 second !!!! Rock Star !!!
He was now at our office to get the homework for the Endurance and Strength components. In this case, an orthotic had been attempted previously by other doctors but he still was not getting the skill set to find the corrected foot posturing on his own. Orthotics pre-position and offer a platform of correction to work off of, but you still have to earn the skill (unless you want to depend on orthotics for your whole life !).
We like the term Orthotic Therapy, meaning (when appropriate) use the device to help the process along when the client cannot find the pattern sufficiently. It is clear in this case, this boy does not need the orthotic help he just needs the endurance and strength now that we have taught him the skill. Sure, in basketball camp when he is focused on the ball the feet could use the help of an orthotic, but with the goal to earn his way from them in time. Some people with severe prontation control issues will always need the help. But our goal is to lessen the need and perhaps relegate the need to sports only. On the other hand, some people have such mild over-pronation issues, that this homework is sufficient to allow the orthotics to be tossed in the garbage. Each case is different.
What is amusing is that in one week this boy practiced so hard and so much (as you can see) that he made me laugh at the end because it was clear he was already laying down the new skill pattern subconsicously, as noted by the fact that he was having troubles collapsing in the new tripod-neutral position.
Fixing flat feet. It is possible, not always , but often. You just have to know what your client has and what to do with it. Anyone can prescribe orthotics, be different, go the extra mile for your athletes and clients.
Start with working toe extensors and increase their awareness of what happens with the arch when the toes go up and down. Teach them the tripod and then to integrate the two. People will travel far and wide to find you if you master this stuff. We are honored that people fly in to see us from around the country. And when they see how simple a logical process can be, they wonder why they had to. But they are still happy they did.
Shawn and Ivo……. sometimes described as the fruit out on the far far branches (yes, maybe the ugly gnarly fruit) but we are still hanging tight to the branch none the less.
Feel the Pain: Part 4: Pain Modulation
In previous posts, we reviewed the tissue producing the pain, the character of the pain, and how pain impulses travel from the periphery up to the brain. We should have called this post: Stop the Pain, since we will be talking about how what you do helps modulate the pain.
We recall that pain results from adequate activation of the nociceptive afferent system, the pain carrying sensory pathways. Most modulation occurs due to inhibition that attenuates activation. Think of it like a dimmer switch for a light.
- your hand is the stimulus (or your foot if you are really talented, like Dr Allen)
- the dimmer is the receptor (in the case of pain it is a bare nerve ending)
- the wiring are the pathways from the periphery to the brain (path from the dimmer switch to fuse box)
- and the fuse box represents the brain
- the light going on represents pain
- and the dimmer represents pain modulation (lots of pain or less pain)
Are you with me so far? Are you smelling what we are stepping in?
How can we stop from turning the light on ? We can never touch the switch. This represents good biomechanics; if we have good biomechanics, we are less likely to cause tissue damage and less likely to elicit pain because the receptor (the dimmer switch) was not stimulated, hence no turning on of the light.
What else? … There is a possibility that we can turn the light on only a little. This is means we activate the receptor (the dimmer) only a little. This is what happens in the spinal cord. All primary afferents (sensory nerves from mechanoreceptors, muscle spindles and golgi tendon organs) activate an inhibitory interneuron in the spinal cord (see diagrams above) which presynaptically inhibits the the 2nd neuron in the pain pathway (the pain neuron comes into the cord, synapses in the dorsal horn with a 2nd neuron which travels up the cord to the reticular formation and parietal lobe of the brain, to let us experience pain).
Think about it. Good mechanics, massage, manipulation, and exercise all involve stimulating primary afferents (sensory nerves). They all inhibit the 2nd order neuron in the pain pathway. They all affect the “adequate” part of the equation, making it more or less adequate, thus different degrees of pain are possible.
Remember, that which travels up the spinal cord to the brain is the sum total of ALL MODALITIES acting on the 2nd order pain neuron. MORE ACTIVATION = LESS PAIN.
Wow, is there more? You bet! What if the wiring goes to a junction box to join other wires? This is what happens in both the spinal cord and thalamus; MORE MODULATION (Incidentally, ALL AFFERENT STIMULI EXCEPT SMELL pass through the thalamus). You mean vision and hearing can affect the perception of pain? Yes, remember it is an emotional response. Is it better to go to the dentist with the nice relaxing music, private rooms, soft colors and clean smells or is it better to have your dental work done in a prison camp? There are visual, auditory and emotional components to pain.
The brain itself can modulate the perception of pain (think of people who are wounded in battle and never feel the pain) both at the level of the brain, AND by sending stimuli back down the cord to modulate it at the thalamus and spinal cord. Remember endorphins, your bodies own little heroin factory?
Wow, LOTS of things we do can modulate pain!
It makes shaking your hand after you whack it with a hammer (or your head after making it through this blog post) kind of make sense: that being, activating more peripheral receptors to modulate the pain. It is also what elicits a possible different emotional response when comparing being kicked high between the legs by your best friend while standing in a fresh spring meadow with birds chirping gleefully or by your worst enemy in a dark rainy alley during a thunderstorm (don’t believe us ? Give us a call, we are pleased to give free personal demonstrations). The environment, the mental settings, the smell, the sounds, your emotional standpoint, your overall pro-inflammatory health …… they all play into your pain and how it is interpreted, modulated and responded.
The Gait Guys. Modulating the learning process to make it easier for all to understand.
Ivo and Shawn…….. part-time, semi-pro punters. Give us a call on your way to divorce court or your next custody suit ….. our loving kicks will help modulate your true pain.
A Case for “Reverse Engineering”
You have often heard us say: “think of muscle function from a closed kinetic chain perspective”. In other words, the muscle(in the case of gait) working from the foot (or ground) up. Here is a study exemplifying this with the tibialis anterior and peroneus longus.
We remember the tibialis anterior is usually the most prominent muscle on the anterior leg (see 1st 2 pictures above). It has two origins, the lateral tibial condyle and the upper lateral surface of the tibia; it inserts on the medial surface of the 1st (medial) cuneiform and proximal part of base of the first metatarsal of the foot. It is a dorsiflexor and inverter of the foot in open chain (ie before and at heel strike/initial contact), and a dorsi flexor and inverter of the foot (or it brings the tibia medially and everts the foot relative to the tibia) from loading response to midstance. It also helps to maintain the medial longitudinal arch up to this point, and assist in decelerating pronation (along with its antagonist to dorsiflexion, the tibialis posterior). It takes a break at midstance and then contracts again at terminal stance (to counter act its antagonist, the peroneus longus). When running, it remains active through midstance to help pull the leg forward over the foot.
The authors have this to say: “Tibialis anterior restrained rearfoot plantarflexion from heel contact to 10% stance, and eversion between 10% stance and footflat.”
No surprises here.
Now the peroneus longus: “Activity in peroneus longus was consistent with its role in causing eversion after heel contact, then as a stabiliser of the forefoot after heel rise. ”
The peroneus (or fibularis) longus arises from the head and upper two-thirds of the lateral surface of the fibula, from the deep surface of the fascia, and from the intermuscular septa between it and the muscles on the front and back of the leg; occasionally also by a few fibers from the lateral condyle of the tibia. You can see from it attachments that it can influence the entire upper lateral leg.
It’s tendon runs down the fibular shaft, wraps around the lateral malleolus, travels obliquely under the foot, crossing the lateral cubiod (which it everts after midstance to help with supination) crosses the sole of the foot obliquely, and inserts into the lateral side of the base of the first metatarsal and lateral aspect of the 1st cunieform.
It acts from just prior to heel strike to limit excessive rearfoot inversion, through midstance to decelerate subtalar pronation and assists in stabilization of the midfoot articulations, and into terminal stance and pre swing to lock the lateral column of the foot for toe off and plantar flex the 1st ray (creating a good foot tripod), allowing dorsal posterior shift of the 1st metatarsal-phalangeal joint axis (necessary for dorsiflexion of the hallux (big toe)).
The peroneus brevis arises from the lower two-thirds of the lateral surface of the shaft of the fibua and from the intermuscular septa separating it from the adjacent muscles on the front and back of the leg. Again. lots of influence here.
It travels behind the lateral malleolus (and in front of the peroneus longus) and inserts into the tuberosity at the base of the fifth metatarsal.
It acts in a similar timeframe as the longus, copressing the tarsals to provide midfoot stabilization, and a significant eversion moment of the foot (helping to push you on to the base of the 1st metatarsal).
You can see how the peroneii could work together also to produce a small plantar flexion moment of the ankle and lateral movement of the lower leg. Because of their route around the lateral malleolus, they also can internally rotate the tibia (from a closed chain perspective; remember the tibia SHOULD be extenally rotation at this this point) so it can act to dampen or attenuate supination. This is also supported by the study:
“Activity in peroneus brevis suggested a role in restraining lateral rotation of the leg over the foot, late in stance.”
We are definitely the Uber Gait Nerds of the internet. We are bending your mind around the foot (rather than the foot around your mind).
Ivo and Shawn
Abstract
This study examined stance phase foot kinematics, kinetics and electromyographic (EMG) activity of extrinsic muscles of 18 healthy males. Three-dimensional kinematic and kinetic data were obtained via video analysis of surface markers and a force plate. Ankle joint moments are described about orthogonal axes in a segmental coordinate system. Kinematic data comprise rearfoot and forefoot motion, described about axes of a joint coordinate system, and medial longitudinal arch height. Surface EMG was obtained for tibialis anterior, soleus, gastocnemius medialis and lateralis, peroneus longus and peroneus brevis and extensor digitorum longus. It was concluded that the demands on the controlling muscles are greatest prior to foot flat and after heel rise. Tibialis anterior restrained rearfoot plantarflexion from heel contact to 10% stance, and eversion between 10% stance and footflat. Activity in peroneus longus was consistent with its role in causing eversion after heel contact, then as a stabiliser of the forefoot after heel rise. Activity in peroneus brevis suggested a role in restraining lateral rotation of the leg over the foot, late in stance.
Foot Ankle Int. 2001 Jan;22(1):31-41.
Extrinsic muscle activity, foot motion and ankle joint moments during the stance phase of walking.
School of Physiotherapy, Faculty of Health Sciences, Lidcombe, NSW, Australia. a.hunt@cchs.usyd.edu.au
Erratum in
- Foot Ankle Int 2001 Jul;22(7):543.
A Scientific Look at High Heels
http://well.blogs.nytimes.com/2012/01/25/scientists-look-at-the-dangers-of-high-heels/
PROCEED WITH CAUTION! INFO DENSE POST AHEAD!
Can you think of a better way to start the week than with a discussion of high heels? We all like high heels… Well, at least guys do (and we know quite a few women who do as well…some of you may be reading this post). NO, WE DO NOT LIKE TO WEAR THEM, but we can admire the way they make the calves look so great and the increased lumbar lordosis and accentuation of the greatest gait muscles ever created!
Were they based off “chopines” from the 15th century; an elevated shoe (7-30 inches high!) which kept the peoples feet literally “out of the muck” (they didn’t have modern plumbing back then) or are they older? Or was the heel invented out of necessity to keep horse riders literally “in the saddle” ? Chinese and Turkish history says maybe they were to keep women (particularly concubines) from escaping. For the intents of discussion, we will stick with this last premise, as it fits nicely with the findings of this article (based on the study published here)
Remember the neuromechanics posts on muscle spindles or golgi tendon organs (GTO’s) ? If not, click the links and check them out; suffice it to say that the take home message is: Spindles respond to length and GTO’s respond to tension.
We also remember that GTO;’s modulate the muscles function that they come from. In other words, they literally “turn off” the muscle they come from (it is a disynaptic, post synaptic pathway for you neuro geeks out there). In light of that, lets look at some quotes form the article:
“the scientists found that heel wearers moved with shorter, more forceful strides than the control group, their feet perpetually in a flexed, toes-pointed position. This movement pattern continued even when the women kicked off their heels and walked barefoot. ”
No surprises here. Go up on your toes and take a few strides (more difficult for guys, since the biggest heel we may have is about 12mm in our running shoes). Which muscles are engaging? See how difficult it is to take a full stride? Try to engage your glutes. Not so easy, eh? Now put your foot flat on the floor, extend your toes and NOW engage your glutes. Easier? Presyanptic loading of the motor neuron pool pays big dividends!
They go on to say: “As a result, the fibers in their calf muscles had shortened and they put much greater mechanical strain on their calf muscles than the control group did.”
Hmmm… shortened muscles put under greater tension. Sounds like a job for the golgi’s, and what do they do? Inhibit the muscle from contracting. No wonder is was harder.
“In the control group, the women who rarely wore heels, walking primarily involved stretching and stressing their tendons, especially the Achilles tendon. But in the heel wearers, the walking mostly engaged their muscles.”
Wow, here is evidence They changed their motor programming! Did you ever think that high heels could change the way our brain works? Maybe it’s a secret plot to take over the world….or maybe not…
The Gait Guys…Lovers of high heels as long as you don’t walk in them….
Athlete with Plantar Fascitis
/Gentlemen,
I have enjoyed your blog tremendously. My inner mechanics geek motivated me to read all the blog posts, and go through the Youtube videos as well. Fascinating stuff.
My reason for writing, however is more desperate.
I have an athlete with a problem, and hope you might provide some guidance. She is experiencing what has been diagnosed as plantar fasciitis, with her pain on the medial side of her calcaneus - roughly 2 inches forward of her achilles, and about a half inch up. MRI was negative for a calcaneal fracture. She’s taken several months off, and had the site injected, but any return to running brings her pain back. It’s her mechanics that might catch your interest; she has what a doctor once referred to as ‘an Equinus Deformity", essentially running completely on her forefoot. She had heel contact when walking, but is completely on the balls of her feet when racing or training. Her injury history to this point has been minimal, with only a minor adductor issue for a day or two in her background. She has been told her options are injection (tried, helps for only a short time) or surgery. Humbly, is there anything we can do to help her overcome this? I am convinced there is an underlying mechanical issue, but her somewhat nontraditional running style leaves me with few ideas. Any suggestions would be worth their weight in gold.
Sincerely,
Girls XC/track coach
Dear Track CoachThank you for the Kudos and we are glad you have an “inner mechanics” geek as well .We are sorry to hear about your athletes recalcitrant problem. It was astute observation on your part regarding her gait. Given the history you have provided, what has already been done, and the description of what you see, please understand that our opinion is limited, without the opportunity to examine her (which we would be glad to do; we have offices in the Chicago, IL suburbs and West of Denver, CO). Video would be helpful in the future as well, as we are not sure she has a true talipes equino varus foot or it is merely describing the attitude of the foot while running.It sounds like she may have a rigid foot and a forefoot varus deformity. This would parlay with the “equinis” description.A forefoot varus is when the forefoot to rearfoot relationship is such that the forefoot is inverted with respect to the rearfoot. This causes increased torque on the plantar fascia, as the forefoot lands on the outside of the foot and the medial side of the foot immediately descends: this must be controlled some how: either through flexion (downward motion) of the 1st metatarsal and cunieform (ie 1st Ray complex) provided adequate range of motion is available; the other scenario is that there IS NOT adequate range of motion of the 1st ray available and the knee collapses medially to bring the 1st ray down to the ground. A third possibility (most likely) is that it is a combination of the two.The fix lies in the etiology: follow the mantra: skill, endurance, strength. Insuring the foot has adequate range of motion and is able to control it (skill), the appropriate endurance of the muscles to carry out the job (endurance) and the foot intrinsics have the cross sectional area needed to do the job (strength).1. Does the athlete have a adequate foot tripod and are they able to keep all 3 legs of the tripod on the ground with the knee comfortably over the 2nd metatarsal? see a video here2. does the athlete have enough muscular control of the lower extremity to ensure proper mechanics (foot intrinsics, knee motion, hip motion) ?3. Is their running gait appropriate for their anatomy and any physical limitations? we have numerous posts covering many different gait scenarios on the blog, as well as on our youtube channel.Again, without an exam, pictures or video, the exact diagnosis and fix is difficult. Thanks for the opportunity to respond.The Gait Guys
News about Our blog.
/Are you following us on our FACEBOOK page ?
every day we try to add extra stuff that will broaden the info, for example, today we added some extra info onto Facebook regarding muscular infarts such as what House has.
If you are not a daily follower of our Facebook page you are missing out on a little extra info.
Just sayin ……
here is the link……. go ahead…….. click the LIKE button…… WE DARE YA !
House MD. : Is he using his cane on the correct side ?
This is a great video clip (when you click on the youtube link it might not work. Try clicking here ……go ahead and click that link to watch and then come back. Note to listeners…. there is controversy over the lyrics, there always has been and always will be …..but they are listed below at the end of the post.)
When can you ever go wrong with AC/DC ? Combine that with Hugh Laurie from HOUSE MD and you have a great mix.
So, watching this video, why is he using his cane incorrectly? We all know that House’s has a problem with the right hip and leg. “The Rules” state that with a hip problem the cane should always be used on the opposite side to change the D2 lever arm (Click here for a great lesson on this) with a nice follow up here (click). After watching these 2 Gait Guys videos you will clearly understand (perhaps to a better level than most of your therapists and doctors who gave you the cane) why it is used on the opposite side.
So, why in the world is the brilliant Dr. House using it on the same side ? We have received this question more than once. And the answer is quite simple. His problem is extracapsular. In the pilot episode of House MD it was explained that he suffered a vascular infarct to the quadriceps muscle. Like bone infarcts, muscular infarcts can be painful. If he contracts the quadriceps when loading the leg there will be pain. Just like if the infarct were osseous, the loading of the cortical bone and stress on the trabecular infrastructure in that case, axial loading of the limb (muscular or osseous) will drive pain. So, to lessen the issue he uses the cane on the same side to literally share his body mass load over the length of the cane. He is essentially attempting to use the cane as his weight bearing limb. The cane use on the opposite side is best used when you are attempting to unload the muscular compressive forces across the hip (acetabulofemoral) joint. Contraction of the gluteus medius generates the greatest joint compressive loading of all of the hip muscles because of its orientation during gait. Thus, utilizing the cane on the opposite side acts as a hydraulic lift necessitating a shift in body mass closer to the joint and reducing the compressive demands on the gluteus medius muscle.
* Rule breaker: sure, you can still use the cane on the same side to reduce the gluteus medius forces, it is just a bit more awkward. But it can be done. Think about and elderly folk who had a weaker opposite arm, they would feel more comfortable using House’s strategy. The rules are not hard pressed.
So, House is using the cane correctly for his condition.
Rules are meant to be broken. Look at our leaders (all parties) in Washington, they do it everyday ! And when you are as smart as House you know when to break the rules.
Thanks for the reminder AC/DC ……lyrics
“Living easy, living free
Season ticket on a one-way ride
Hey Momma, look at me
I’m on my way to the promised land.
Asking nothing, leave me be
Taking everything in my stride
Dont need reason, dont need rhyme
Aint nothing I’d rather do”
Shawn and Ivo……….. or maybe it is Beavis & Butthead ?
(uh, that’s cool dude ! huhhh huhhhhh …… Those Gait Guys Rule…… !!!! )
The Truth about treadmills. Our Triathlete magazine article finds its way to the TRi website.→
/Regarding our treadmill article in Triathlete magazine.
Most things in this world have a place, a function, an advantage and a disadvantage. It is the wise and informed that can extract what they need from a device to serve its purpose. Knives are useful but you can also cut yourself with them if you do not know what you are doing…..that doesnt mean you empty your knife drawer at the side of the road on garbage day ! Keep on running. - The Gait Guys
chase the article through the linked above
Anterior knee pain in a young marathon hopeful, someday !
Here we see three (3) pictures of a very young boy, 4 years old. His mother brought him into our office for evaluation. His knees were painful immediately below the patellae bilaterally.
As you can see here the little fella has a few issues, some of which he will likely grow out of and some of which he may not. So this is a good case to follow. First time parents are always more vigilant and that is why we like them, but just fractionally more ! In the view from behind you need to see a few things:
- valgus knees
- wider than normal base of stance between the feet
- slightly valgus ankles
- and on the side frontal view……. obvious hyperextension of the knees and increased ankle plantarflexion posturing (we chose that word carefully) that obviously goes hand in hand with this retro-postured knees.
After a few more questions it was clear that the pain had been around for quite some time and was at a specific pencil eraser sized area above the anterior joint line, slightly medially to center and without question not at the joint line proper but directly on the medial femoral condyle. So, do you know what he has ? You should always suspect this in knees that hyperextend this far or in athlete that have sustained or repetitive hyperextension stressing:
- gymnastics
- kicking sports (martial arts, soccer, swimming etc)
- postural syndrome folks (like this little fella) who have low core tone, anterior pelvic tilt both of which drive knee hyperextension.
- any one who has a loss of ankle rocker dorsiflexion range and who then chooses the knee hyperextension option to regain ankle range in an attempt to normalize progressive gait. Frequently flatter feet/hyperpronators will drive more tibial internal spin resulting in hyperextension as well.
This little fella has the last 2 factors, BIG TIME !
So, clearly understanding these biomechanical factors and coupling a palpatory tenderness at the correct spot on the medial femoral condyle indicates that he has (the youngest we have ever seen)…….drum roll…….
Anterior meniscofemoral impingement syndrome. Never heard of it ? Probably not. Why, because it was glazed over in school, and maybe not at all for many doctors to be honest. Go ahead, look it up under Pubmed and see how many referenced papers you find on it. We see it enough to know that it is frequently diagnosed as a patellar tracking problem but those clients do not have the same risk and anatomy factors. We have had our doctor referrals call us back saying they have never even heard of it. Most have not to be honest. Bottom line, if you know your anatomy and your biomechanics you can figure out most things. If you are slim and skinny on either one you might be missing a few things. We do sometimes as well.
Summary: When the knee hyperextends either too much, too long, or for too many repetitions either statically or in dynamic walking, running or in activity the leading upper edge of the medial meniscus (see anatomy diagram above) can impinge repeatedly and forcefully into the soft medial femoral articular cartilage (see the colored purple area in the diagram) and over time create a softening of the cartilage (condromalacia as it is known). Do it long enough or enough times and you create an inflammatory reaction with a cartilagenous defect.
This poor little guy was hating walking. Interestingly, what do you think happened when we had him crouch walk (knees flexed)……yup…..no pain. He looked up at me in wonderment immediately and of course saw us smiling knowing very well he would be pain free.
Solution in a 4 year old. Slightly flex the knees and place a long strip of tape down the back side of the upper and lower leg. If he extends the knee he forces the tape taught and is instantly reminded (pseudo biofeedback if you will) that he is approaching the danger zone. As this case and many other find, after a few days the skin gets pretty irritated but that is time to take the tape off and let him go back to his old tricks……. trust us, it is only for a few hours until he will figure it out……meaning….. hyperextension is evil ! Teaching this little guy our now famous “Shuffle walks” (to drive ankle dorsiflexion strength in the tibialis anterior and toe extensors in a posture of knee flexion) was on the menu and we turned it into a fun game for him to play with mom and dad.
Anterior Meniscofemoral Impingement Syndrome. Say it 3 times fast with a mouthful of organic chunky peanut butter. We dare ya ! (Sounds like a whimpy frat house hazing technique if you as me.)
Hope you never see it in a little one. if you do, smile and reach for some tape and put on some 70’s music and shuffle to some oldies.
Shawn and Ivo……. yup, orthopedics is also in our soup of letters after our names. But it ain’t the letters that matter, it is what you do with them. Anyone up for Scrabble ?
* Oh, look, we found one journal article ……from 1996 ! Sad.
Arthroscopy. 1996 Dec;12(6):675-9.
Meniscal impingement syndrome.
Source
Plano Orthopedic and Sports Medicine Center, Texas, USA.
Abstract
The meniscal impingement syndrome consists of three elements: impaction on the anterior medial femoral condyle by the leading edge of the medial meniscus, articular cartilage damage of at least Outerbridge grade 3, and knee hyperextension of at least 5 degrees. This report reviews this condition in a series of seven knees with an average follow-up of 39 months. The time from the onset of symptoms until surgery averaged 45 months. Treatment consisted of a thorough arthroscopic knee evaluation and debridement of the articular cartilage fragmentation and any impinging synovitis. Postoperative rehabilitation includes extension block bracing, hamstring strengthening, and closed-chain exercise. With this regimen, there was improvement in the Tegner scores and a reduction in postoperative knee hyperextension. Identification of this uncommon condition requires a complete evaluation of the medial femoral condyle in patients with knee hyperextension.
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Neuromechanics Weekly: Third Installment
FEEL THE PAIN: PART 3
The Pain Pathway
Pain is the emotional response to adequate activation of the nociceptive afferent system.
What?
Pain is an emotional response. We feel (or experience) it in the cingulate gyrus (the gyrus right above the corpus callosum, that thing they cut in “One Flew Over the Cukoo’s Nest, see the 1st picture above). Your pain is different than your patients/clients pain. Like John Travolta said in Swordfish "It’s all about perception…”
Pain is subjective. Men usually have lower tolerance for physical pain than women (We think this has to do with their wiring, as it is all connected for them, and we males have our little boxes we keep everything in (see here if you don’t understand).
We know what “adequate activation” is. Enough stimulus to elicit a response. Like when someone keeps pestering you and finally you let them have it!
The “nociceptive afferent system” is the pain pathway. You remember: the C fibers (or pain fibers) in the periphery get activated (adequately, of course), the impulse travels up the peripheral nerve to the dorsal horn of the spinal cord, synapses in lamina 2-5 (the key here is that it synapses; proprioceptive and other sensory stimuli DO NOT synapse, but travel higher up the chain. The synapse allows modulation of the signal, the subject for the next in this series’s post). The next neuron in the pathway (remember, we are still in the cord, right after the 1st synapse) crosses (or decussates) the cord and travels up the ever famous lateral spinothalamic pathway (see middle picture above). We would think this pathway (from the name) goes an synapses at the thalamus next (THE central relay for ALL sensory stimuli EXCEPT SMELL); in reality only about 27% of the fibers synapse here, and then go to the parietal lobe. to tell you WHERE the pain is.
What about the other 73%? They go to the reticular formation ( a loosely organized group of nuclei in the brainstem) to cause the autonomic concomitants of pain (increased heart rate, increased breathing, nausea, urge to urinate, etc).
So, the next time someone has pain in their knee or foot, or _______, not only will you be able to tell what tissue is causing the pain, but now can trace the pathway north to the brain. Why is this important? Because of the modulation that YOU can influence with your therapy. More on that in the next neuromechanics.
The Gait Guys. Eliciting a response in your cingulate gyrus. Hopefully, you are storing this in your inferior temporal gyrus (memory area) for future use.
When the knee hinges sideways. A clinical video case.
This is not a difficult case today, not by any means. Most people will can see what is not normal here. But there are some simple principles we wanted to highlight and remind you of that this case shows nicely.
This is a fairly typical advanced degenerative arthritic right knee and the gait that accompanies it.
Here you can see that when the gentleman steps onto the right limb the knee has a small lateral hinge moment, you can see the knee joint buckle sideways. This is not normal, the knee is supposed to hinge only forward and backwards (flexion and extension) in the sagittal plane. Here it is hinging in the frontal plane. You can easily see that after many years of abnormal stresses that the tibia has deformed into a varus bowed position. This is a great example for you engineer-type out there about long term deformation of solids.
* Deformation of Solids:
- Stress: is a measure of the force required to cause a particular deformation.
- Strain: is a measure of the degree of deformation.
- Elastic Modulus: the ratio of stress to strain:
Elastic modulus = Stress divided by Strain or
EM= Stress / Strain
The lateral forces and hinging over time forced the tibial to varus bow which is a reactionary measure. In simplest of terms, as the bone cells (osteoclasts and osteoblasts) continued to cyclically turn over they laid down new osseous structure along lines of stress which happen to be in the frontal plane, hence the frontal plane bow. At the joint line it was simple to feel and advanced gapping and shifting of the joint in medial-lateral-medial stressing. One can only imagine the maceration of the cartilagenous menisci in such a knee from the abnormal shear forces. Oy !
In this gait, this joint is quite clearly painful as evidenced by the pronounced limp. As right limb weight bearing is initiated carefully and slowly to reduce pain and gain stable purchase of the limb with balance the lateral shift is seen to occur. This lateral shift challenges all of the frontal plane stabilizers so it should be no surprise to anyone that he has significiant gluteus medius, peroneal and abdominal weaknesses in guarding that right frontal plane (to name just a few).
It is most difficult to see on this video because of the loss of 3D specs and because we do not have a frontal view of this gait, but what you typically see in the gait of these clients is a normal left to right step length and an abbreviated right to left. As the brain loads that right limb there is pain and instability sensed by joint and pain receptors. This sparks an early and abrupt departure off of the right limb and hence an abbreviated and shortened right to left step length. This will impart a quick load onto the left leg with an abrupt loading into the left quadriceps. It is not uncommon at all for these clients to develop anterior knee pain syndromes (such as patellofemoral tracking syndromes) or foot problems because of repeated abrupt mid-forefoot loading which drives significant of calf-posterior compartment loading (this will also drive long toe flexor strategies). Also, an abrupt right to left weight bearing shift will generate excessive left lateral (frontal plane) forces thus it is not uncommon to show or develop left hip issues or to see more sustained supination of the left foot. The Peronei can be challenged too to fend off this over-supination that can frequently occur.
* clinical pearl: In our clinics when we see a one sided increase in toe clench and long flexor tone, even when the client lies down, we will once again review gait and look and test for clinical instabilities of stance phase mechanics on the OPPOSITE side of the long toe flexor evidence (in this case there was increased left long toe flexor evidence and early hammer toe formation). This is a huge key, we have just sold a few acres of the farm giving away this pearl. This is one of our goto tricks to find deeper embedded clinical problems. It is not always the case, because the long flexor problem can be local or same sided but you have to at least consider the thought we have proposed.
This is the exact same gait pattern as in a sprained ankle, in fact, same pattern when any part of a limb is painful. As you leave the healthy left foot the brain already knows that right foot impact is going to be painful so a pre-calculation is make to soften the loading and to reduce the loading time, hence the premature limp off the right and onto the left.
It is also important in these cases of significant unilateral bow/varum of the tibia to investigate whether a true leg length discrepancy has developed. It can be a part of the visual limping/lurching gait but it is part of the deformation of the tibia. In this case we ended up using a 3mm sole lift (don’t use a heel lift, why would you just raise the heel ?) to level out his pelvis to decrease the frequent low back pain and tightness that goes with such a gait and also to reduce the step-down drop onto that degenerative knee. In this case, the lift reduced the degree and rate of lateral hinge and thus reduced much of his pain and back discomfort. By bringing the ground up to his foot he thus did not have to step down onto the right limb which accelerates the lateral shift.
* Try it yourself, find a curb on your street and walk along the top surface of the curb with the left foot, stepping down onto the right foot to street level. Do this for a year and you would quickly appreciate what this gentleman was experiencing daily……to a degree of course. The lift on the right would be warmly welcomed !
We were actually able to keep the client very comfortable for almost a year which got him to a time frame that worked for his work and vacation time frame to have the surgery. This is often what a client needs, time. Just time to plan, to prepare mentally for a TKA (Total Knee Arthroplasty (replacement)).
The laterally hinging knee. It is so much more than just a degenerative joint. There is much to be appreciated and learned from pathologic gait patterns.
We are…… Shawn and Ivo…… The Gait Guys ……. center focused but considered by many to be a little off plumb.
A video case of a gait impairment. Chronic dorsal foot pain.
This client came to see us recently. They had a current (2 year) history of dorsal foot achey/burning pain and anterior ankle pain, right greater than left. They had been just about everywhere for these complaints and were pretty much resolved that it was not fixable. They also had a chronic history of anterior shin splints.
This is a pretty simple case. It is missed alot of the time. The reason it is missed is because nothing much shows up on examination. However, we used some tricks to bring out their symptoms. There are also some subtle hints on the gait video above but when you cannot pair what you see with what you find on a clinical exam the issues can get lost in the mix, as they did in this case. This is thus a case based much on clinical experience. We have seen this before. A great clinician (who’s name we have forgotten) used to have a quote that went something like this:
It is only after you have seen the beast once before that it will serve you well to be able to recognize it the next time. Having never seen the beast previously will leave you with a terrible bloody battle on how to slay it the first go-round.“
ln this video above you should basically see 2 things:
1. the easy one to see: the right foot immediately after toe off does not come forward sagitally rather it spins out into abduction in the swing phase to prepare for the next heel strike.
2. the harder one to see: both feet pronate immediately in the rear and mid foot excessively.
This patient has some limitations in normal ankle rocker. More simply put, they cannot get enough adequate tibial progression forward into dorsiflexion over the talar dome. The squat test was really the only positive movement assessment that was confirmatory. As they squatted the ankle met early dorsiflexion restriction and thus the foot had no choice but to pronate early and heavily thus collapsing medially and drawing the knees in medially. Normally the arch should remain unaffected and the tibia should merely pivot cleanly and effortlessly over the talus allowing the knees to come purely forward. Not in this case.
So, we have a client that has impaired sagittal mechanics. They cannot move through ankle rocker effectively and thus they cannot pronate in a timely manner. As the right foot leaves the ground at toe off they need to have sufficient ankle dorsiflexion to carry the foot cleanly forward to prepare for heel strike (this looks pretty good on the left in the video) but the right side is met with ankle range loss. If they did not circumduct the right foot like you see here they would drag their toes on the ground and likely trip. So, foot abduction is the strategy to avoid this issue. However, when you circumduct the foot you begin to lose the strength and endurance of the toe extensors and tibialis anterior.
There is it, we just gave it away. Your question all along should have been, "but what about the dorsal foot and anterior ankle pain and chronic shin splint history?”.
After our gait assessment and history we had a strong hunch. We did our clinical exam which was unremarkable, mostly. But we saw some things that might correlate with our hunches. So, we put the client on our Total Gym at 45 degree incline to do some partially weight bearing squats. Simple stuff. But, we put the feet in a challenged position. We had them hold a neutral foot position on the platform (zero degree progression ankle), the foot was not allowed to spin. We told them they had to keep the toes up at all times and directed them to not let the arch drop or heel spin (these are all compensations to get around impaired ankle rocker in gait, and we see them in her gait video). It seemed simple to them so they began to squat repeatedly, slowly with good form. At about 2 minutes into the movement challenge there began some burning and achey pain reproduction at the dorsal foot from the toes to the anterior ankle. Then it started up their shins. The knees began to hurt. Their toes began to lose their earlier extension/lift. They then started to avoid the depth of the initial first squats so we made them aware and insisted they challenge the initial ranges. After about another 30 seconds the anterior ankle pain began. Our exam was pretty much done. We went back into the room, their pain had stopped. On the exam table it was clear that they now had more toe extension and ankle dorsiflexion range but had no strength in this new range. You see, they initially tested strong in these ranges, but they were strong only in the limited range available to them. On our exam we felt that the ranges were a bit meager, but for some people that is just their anatomy. But we had to be sure, so we gently drove some of those old lost ranges and our examination was concluded.
So, it turns out that this patient had enough weakness in the tibialis anterior and long toe extensors (EDL) sufficient enough to lose ankle rocker ranges over time. When you lose ankle rocker range you meet resistance early. This means you will begin pronation in the foot earlier than normal and begin one or several compensations:
- arch collapse
- heel abduction twist
- increased foot splay (progression angle)
- external limb rotation (paired usu. with #3)
- foot circumduction
- medial knee collapse
- just to name a few…… knee hyperextension etc
Chronic fatiguing and weakness of the toe extensors and tibialis anterior are frequent findings in many people. Sometimes they are subtle and you have to tease them out.
Now, remember the initial pain quality ? Achey burning pain. Now, lets review last weeks pain posts.
Remember the Krebs cycle? How about glycolysis? What was one of the end products of glycolysis? Lactic acid. Your ability to recycle it and make it into oxaloacetic acid and stuff it back into the Krebs cycle determines your aerobic capacity. When lactic acid builds up, we get muscular inefficiency due to the drop in pH (initially this helps, but too much of a good thing creates a problem), The result? Burning pain. Burning pain is the burn of glycolysis, or muscular overuse.
Aching/ throbbing pain is that deep, boring pain, like a toothache in a bone. It is the pain of the mesoderm, or what is often called sclerotogenous pain. Aching/Throbbing pain is the pain of connective tissue dysfunction (remember that connective tissue is bone, cartilage and collagenous structures like ligaments and tendons). Throbbing pain can sometimes be vascular in origin, as the connective tissue elements of the vessels (the tunica adventitia to be exact) is stretched (which contains a perineural plexus; think about the pain of a migraine headache).
This client had fatigue weakness. This is a physiologic energy production issue. Thus the BURNING pain in the toe extensor muscles. They also had the chronic achey pain of sclerotogenous referral from connective (mesoderm) tissue challenges.
See how this all comes together ?! Putting the pieces together is not hard once you know what the pieces are supposed to do and what their limitations are. Then you have to listen to them and hear what they are telling you.
This was a case that did not have to go on for 2+ years. This client did not need to suffer and become a shoe and orthotic obsessed fanatic (searching for answers on their own). Their body was screaming for someone to just listen and look at its communications.
We started them with our famous Shuffle Walks to drive toe extension, ankle rocker/tibialis anterior strength and then showed them how to use more of both during normal gait. As with most of the cases like this. We will let them go for 2-3 weeks to improve these SKILL and ENDURANCE components of the movement pattern. We bet this one will take 2-3 visits to resolve. As endurance builds and then as STRENGTH (the last component) builds they will own the changes and be pain free. And then return to then normal shoe shopping habits like the rest of the world.
We are The Gait Guys……..saving humanity from the scourge of gait related pain, one lovely person at a time.
Shawn and Ivo
Chronic ITB -ITBand tightness in a runner. What is the real issue and solution ?
We get dozens of emails daily, and we try to anonymously post a good case weekly.
Dear Drs. Waerlop and Allen:
I am hoping that you will be able to help me, by referring me to the right professionals.
I am a 45 year old woman who has been plagued by what doctors have told me is Iliotibial band friction syndrome for the past three years. When my injury first occurred, I was running approximately 4 miles three to four times per week. Most of the time, I ran in the woods, but I also ran in the street.
When it first occurred, I walked home and rested my legs for two weeks. After resting it, I learned that if I wore compression pants, I was able to run for 3 miles with no pain. So, I cut back on my running and endured that distance for a while. Eventually, it became so bad that I could not run two miles, so I decided to go to the doctors.
The first doctor I went to for the problem told me to stretch my Iliotibial band and strengthen it by doing the four way leg exercise. I did exactly as I was told, but to no avail. I went back to the doctor and he could not understand why I was not getting better. Since it became apparent to me that seeing him was fruitless, I did not go back a third time. He told me that the problem would resolve itself within time.
For the next year, I self-treated. I stretched, strengthened my hips and iced my knee. At times, I could run 3 to 4 miles in the woods wearing a brace. As soon as I felt any pain, I stopped running, and walked to my destination. I would rest my leg again for a few weeks, and start back to running gradually, i.e. .5 miles every other day. I took spin class two or three days per week to keep my cardio level up. Interestingly, biking has never bothered my knee.
Last summer, it became so bad that I could not run .2 of a mile. In September, I walked about 4 miles in Philadelphia in flip flops (I can hear you gasping now), and my knee began to hurt (you are probably saying no wonder!). That was the first time my knee hurt while walking. It was so sore for the next few days that the pain woke me up at night. Shortly thereafter, I was walking and my back started to hurt so I went to another doctor.
The second doctor I went to told me to do a single leg squat and said you have Iliotibial band friction syndrome. He prescribed physical therapy. I have been going to physical therapy since the beginning of October. I returned to running slowly and eventually I was able to run 20 minutes on the treadmill at a level between 7.4 and 7.6. I ran three days per week.
I have also endured the Graston Technique and ART twice a week since November. My physical therapist feels that it was successful in breaking up my scar tissue. I can foam roll my Iliotibial band with both legs in the air without any pain.
Yesterday, I tried running outside. I ran on the flattest road I could find, but was unable to make it a mile. I stopped running as soon as I felt the pain (similar to a throbbing pain) on the outside of my knee and walked home. I iced it and took Advil. I went to physical therapy today, and she cannot understand why I cannot run for one mile outside. She believes I need to see another doctor for another opinion.
Do you know of anyone in the Philadelphia area who would provide me the type of care that you provide to your patients? I found you on Facebook (I am Nellie Eplin) and find you fascinating.
I really want to get this fixed. I want to run for the rest of my life. It makes me a better person.
I appreciate all of the help that you are able to provide.
Best regards,
E.L.
_______________________________________________
Response from The Gait Guys:
Dear E.L. :
ITB problems usually, but not always, occur from Weak gluteal support or from factors that allow or promote too much internal spin of the limb. Sadly the typical response people get are the same as you heard, stretch the ITB out and foam roll. There is a reason this is frequently fruitless to resolve your issues. The ITB mechanism can shorten because there is weakness somewhere in the limb and internal spin and frontal plane stability is lost. The internal spin issues can come from flat feet, hyper pronating, tibial torsion issues and valgus knees to name a few let alone general eccentric and isometric weakness of the muscles controlling internal spin rate (glutes and medial quads for example) .
ITB problems usually, but not always, occur from Weak gluteal support or from factors that allow or promote too much internal spin of the limb. Sadly the typical response people get are the same as you heard, stretch the ITB out and foam roll. There is a reason this is frequently fruitless to resolve your issues. The ITB mechanism can shorten because there is weakness somewhere in the limb and internal spin and frontal plane stability is lost. The internal spin issues can come from flat feet, hyper pronating, tibial torsion issues and valgus knees to name a few let alone general eccentric and isometric weakness of the muscles controlling internal spin rate (glutes and medial quads for example) .
The TFL-ITB are internal rotators, provide stability through limb rotation and provide some lateral stability. When the gluteals get weak you lose some of the lateral plane stability (mostly gluteus medius) and you lose some of the ability of the gluteals (iliac div. of g. maximus and posterior g. medius) to control rotation (eccentrically control the rate of internal spin). A few weeks back we did a several part series on the functions of the gluteal, here is the link of the first one & the second one and their effect on the IT Band-TFL mechanism.
We would start with reading these 2 blog posts and then go back to the 3 part series on the Cross Over Gait which you can find here on our Youtube channel.
Without an examination we are guessing but perhaps the 2 blog posts and investigating these 3 videos we did will help you to look at Cross over gait issues which can be a big component of excessive internal spin. Within the videos you will see some exercise skills that might help you.
Good luck, We are in Chicago and Colorado. We do not know of anyone that does our kind of work in your town. Sorry
Good luck and keep in touch with us regarding your progress and discoveries, in the mean time investigating our ideas above rethinking the stretching - foam roller approach for the brief time might help you.
Shawn and Ivo, The Gait Guys …. helping solve one unresolved case at a time.
* (in all case discussions our disclaimer applies, available on our website).
113 Marathons in one year ! What ?→
/A Texas lawyer spent 2011 a little bit busier than most people: He ran 113 marathons. R. Laurence Macon spent much of the year and over 200,000 air miles running in 113 marathons. That bests the current record, and the Guinness World Records is currently reviewing Macon’s accomplishment. At 67, he is ….. click on the link to read the article ….
