Sorry for the late post, folks…We both had pretty crazy days at our clinics…

Yup, you saw it here 1st. We couldn’t believe it either. Look what we found in the Harvard archives.

Sport féminin : saut sur échasses. Korean women on stilts jumping hurdles in a chase, for fun. Advert for Liebig’s Extract of Meat Company. 1904. Via Harvard U.

What does meat extract have to do with women on stilts, jumping hurdles? We could use some help on this one. Anyone have any suggestions?

The Gait Guys. Not on stilts, but teetering while jumping hurdles sometimes….

A case of severe mechanical gait challenges.

This is a unique case. This is a complicated case, there is so much going on. If your eye is getting good at this gait analysis stuff you will know that just from the first pass this gait is very troubled.

This young middle distance runner who came to see us with complaints of chronic anterior and posterior shin splints. This is unusual because usually only one of the lower limb compartments are strained, either the anterior (tibialis anterior mostly) or the posterior compartment (tibialis posterior mostly). Admittedly this is not a fast runner but they love to run none the less, so you do what you can to help.

Please watch this video again and note the following:

1. crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs)
2. slightly wider based gait compared to knee postioning but neutral compared to hip spacing
3. client starts heavily on the outer edge of the feet and moves medially
4. client over strides (step length is increased) which is particularly evident when they are walking towards the camera
5. early bunion formation and troubles engaging the big toe during stance phase
6. the knees / patella also appear medially positioned in an environment of a neutral foot progression angle
7. if you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height.

Wow ! So much going on ! This is a gait from hell in some respects. So, what is driving so much of the terrible gait mechanics ? The answer is a congenital loss of ankle rocker (dorsiflexion) bilaterally. This client can barely squat because the ankles just do not dorsiflex. There was clear osseous lock at barely 90 degrees.

Lets break each one down.

1. Crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs). * This is occuring due to some genu valgum of the knees (slightly “knock-knee”). When the knees are valgum they are at risk for brushing together during gait. The client has no choice but to circumduct the limbs to avoid this behavior. Unfortunately they cannot abduct the thighs far enough during many of the gait cycles and so a “Scissored” appearance occurs where the thighs brush and cross over in appearance.
2. Slightly wider based gait compared to knee positioning but neutral compared to hip spacing. * This is closely related to our answer in #1. Valgus knees will widen the foot spacing side to side because the feet are not under the knee joints. Then couple this with the necessity to circumduct to avoid knees from contacting and the foot posturing is that of an even wider based gait. This can also occur from many hip problems. However as in this case with a congenital loss of ankle rocker, the client uses more foot pronation to progress the tibia over the talus (allowing the tibia to get past 90degrees) and allow them to move forward. This added pronation does magnify and likely progress the knee valgum but there are few other options for this client. This is often a destructive vicious cycle with few good outcomes decades down the road.
3. Client starts heavily on the outer edge of the feet and moves medially. *This may be to avoid the immediate rear foot pronation that is seen here.
4. Client over strides (step length is increased) which is particularly evident when they are walking towards the camera. * This may be a conscious attempt to lengthen the shortened stride that occurs because of the limited ankle dorsiflexion ranges. It appears at many moments however to be a result of the extra effort to circumduct the legs sufficiently. A longer stride does play into #3 above, a larger stride usually leads to a heavier lateral heel strike but it also means that the rearfoot pronation will be more aggressive, this is a negative resultant outcome.
5. Early bunion formation and troubles engaging the big toe during stance phase. *We are not surprised here. Whenever pronation is excessive the first metatarsal (medial foot tripod) is unstable and this changes the mechanics of the hallux muscles to pull towards the 5th metatarsal anchor generating the bunion. Look at the origin and insertion of the adductor hallucis muscle particularly the transverse head, if the 1st MET is anchored the 5th MET is pulled to the 1st and the transverse arch is formed. However, if the 1st MET is unstable and the 5th is the only anchor, the adductor hallucis will pull the toe laterally and form a bunion and hallux valgus and compromise the transverse arch. (particularly look at the left big toe at the :09 to :11 second mark, the big toe and first MET are clearly not anchored to the ground).
6. The knees / patella also appear medially positioned in an environment of a neutral foot progression angle. * Answers for #1-#5 clearly will medial patellar deviation and drive patellar tracking problems.
7. If you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height, but remember, that does not mean that pronation is not occurring. * This is a result of the loss of ankle rocker mechanics. If they start pronation early at the rear foot it will drive more pronation. When pronation is driven excessively the arch can drop, and with more arch height drop the tibial will pitch forward past the magical 90 degree mark and allow forward motion to occur.

So, how can they run with all this going on ? Well, the answer is quite simple. They avoid most of these issues as best they can. How you ask ? Forefoot strike; they run avoiding heel strike and midfoot strike. By staying on the forefoot all of these rear and midfoot mechanical limitations as well as ankle rocker loss can be avoided by remaining on the forefoot. This makes distance running difficult but anything below the two mile mark is tolerable and the 100-800 distances are probably best suited for their feet. Incidentally they enjoy the 400 the best, no wonder. Also, moving at increased speed will necessitate a forward lean, and a forward lean makes the tibia progression over the talus easier taking out some of the ankle rocker limitations.

This is a foot type, with complications, that is really beyond much of what anyone can do conservatively. We would even argue that surgery is not an option, just a change in activity choice. This is simply a client that should not run beyond distances where they can stay on the forefoot. The foot, ankle and lower limb mechanics just suffer far to much from having to compensate (as discussed in #1-7) to enable pain and problem free running with anything other than forefoot loading. This means that walking is going to be difficult and problematic, as you can see from this video above.

Our only solution in this case ? ……… utilizing a rocker based footwear. Easy Spirit Get UP and Go (link) was our recommendation and it worked very well for this client for walking. Here is a link to this shoe and pictures of the huge forefoot rocker that helps (somewhat) to dampen the mid-forefoot rocker issues but there is not much that can be done for the rear foot rocker issues as discussed. If you use an orthotic to block the rearfoot valgus motion and rearfoot pronation you will pass more challenges to the midfoot-arch and forefoot. Sadly.

This was a very tough case. Getting every aspect of the case in your head during an evaluation is sometimes a challenge. Sometimes you need to see them a 2nd or 3rd time to digest it all. But be patient with yourself, it takes time to get decent at this stuff. This is a perfect case for “getting a feeling and flow” of the persons gait, at their speed. A case evaluation like this on a treadmill or via video analysis can make things tougher because the treadmill can change the dynamics (did you read our Treadmill article in last months Triathlete magazine ? It was linked on the blog 2 weeks ago) and make the client move at its speed and not their speed inhibiting and promoting different mechanics. There are times for a treadmill and times to avoid them. This is an art, in time you will know when to use and when not to use.

Happy Monday Gait Gang………. welcome to The Gaits of Hell !

Shawn and Ivo ……….two gnarly lookin dudes with pitchforks and a toothy grin.

see the previous  blog post for the Lower Body Drivers and our dialogue. 

Just scroll down to the next blog post.

Rolling patterns and their use in body assessment.

First a brief review from yesterday where we talked about the stabilizing function of the diaphragm possibly being an etiological factor in spinal disorders.  Yesterday we included a link to an abstract by the great Dr. P. Kolar.  It considered the correlation between the dynamics of the diaphragm in posture and chronic spinal disorders.  In review of that paper what they found seemed to indicate that poor diaphragm positioning, posturing and control correlated well in their sampling of chronic low back pain clients. The study found smaller diaphragm movements and a higher diaphragm positioning/posturing.  The study found maximum changes in the rib (costal) intervals and middle areas of the diaphragm which asks one to consider the absolute critical importance of thoracic mobility. Extension, lateral flexion and rotation are frequently reduced in chronic back pain clients but we find it rampant in many clients and athletes.  We also find and encourage you to look for, assess, and normalize your clients abdominal oblique, transverse abdominus and rectus abdominus control.  Failure to properly and adequately anchor the lower rib cage to the pelvis via the abdominal wall (the whole wall, circumferentially around the entire torso to the spine) will result in asymmetrical breathing patterns.  And abnormal breathing patterns lead to abnormal spine motion and mobility.

Yesterday we spoke about the need to assess, and if necessary treat, anything that impairs the diaphragm, breathing patterns, thoracic spine mobility and rib cage movement and flexibility.  Rolling patterns as seen above, and here is the Rolling Pattern for Upper Body Drivers (link), are helpful in determining some loss of coordination of the upper or lower body drivers, impaired thoracic spine mobility as well as loss of symmetrical abdominal skill and strength.  Remember, impairment of a primitive movement pattern like rolling is important to be aware of.  The last thing you want to do is drive your training or treatments therapies and rehab efforts into an asymmetrical pattern. These rolling patterns are first developed as a child to learn to turn over. It is a precursor to pressing up the torso like in a push up, which is of course a precursor to crawling, then cruising and then walking.

  Just like yesterday, we come full circle !  From breathing and the diaphragm to rolling and gait…… it is all connected.  Any faulty strategy or pattern driven into the body, even breathing, can impair gait.  And remember, because with gait we have to attach anti-phasic arm swinging with leg swinging. Anything that disturbs this anti-phasic patterning, such as low back pain or loss of thoracic mobility, will drive contralateral arm-leg swing to phasic patterning.

These are nice, simple assessments.  Hope you enjoyed another window into what we do every day when dealing with athletes, patients and runners.  It is all a part of restoring the symmetrical function to a body.

Shawn and Ivo ……. Rock and Rollers.

The Roll of Breathing and Diaphragm Control in Gait, Running and Human Locomotion

In this video you will see many great things. This video of Rickson Gracie is a testament to free fluid movement and body control.  Great athletes do not just practice one thing.  There is some great demonstrations of breathing and diaphragm control at the 3 minute mark, and we will try to parlay this nicely into today’s brief discussion on the Diaphragm.

Abnormal stabilizing function of the diaphragm may be one etiological factor in spinal disorders.  Today we have included a link to an abstract by the great and brilliant Dr. P. Kolar who we have studied under.  It considers the correlation between the dynamics of the diaphragm in posture and chronic spinal disorders.  What they found seemed to indicate that poor diaphragm positioning, posturing and control correlated well in their sampling of chronic low back pain clients. The study found smaller diaphragm movements and a higher diaphragm positioning/posturing.  The study found maximum changes in the rib (costal) intervals and middle areas of the diaphragm which asks one to consider the absolute critical importance of thoracic mobility. Extension, lateral flexion and rotation are frequently reduced in chronic back pain clients but we find it rampant in many clients and athletes.  We also find and encourage you to look for, assess, and normalize your clients abdominal oblique, transverse abdominus and rectus abdominus control.  Failure to properly and adequately anchor the lower rib cage to the pelvis via the abdominal wall (the whole wall, circumferentially around the entire torso to the spine) will result in asymmetrical breathing patterns.  And abnormal breathing patterns lead to abnormal spine motion and mobility. We frequently have to treat and instruct proper breathing patterns to help normalize lateral and posterior rib cage expansion and decent in athletes and clients, particularly those with low back issues but that is not an exclusive group to this problem. Tomorrow we will show you some simple but great videos showing rolling patterns and we will want you to think back to today’s blog post here on how loss of thoracic mobility in extension, rotation and lateral bend as well as loss of symmetrical abdominal skill and strength can impair a primitive movement pattern like rolling. This is a pattern that is first developed as a child to learn to turn over. It is a precursor to pressing up the torso like in a push up, which is of course a precursor to crawling, then cruising and then walking.

See, we were finally able to come full circle !  From breathing and the diaphragm to gait…… it is all connected.  Any faulty strategy or pattern driven into the body, even breathing, can impair gait.  Because with gait we have to attach anti-phasic arm swinging with leg swinging. Anything that disturbs this anti-phasic patterning, such as low back pain, will drive contralateral arm-leg swing to phasic patterning. Don’t think this is important to athletes and humans ? Well, you must have missed our 2 part blog series on Arm Swing.  We provide those links here. Part 1 link and Part 2 link. 

If you are an athlete, coach, or in the medical movement assessment or gait analysis field……heck, if you study the human body at all and you are not looking at or into arm swing you are not doing what we are doing. And you are missing the bigger boat. So many “gait specialists” and “gait analysis” programs are not even capturing the arm swing let alone looking at it and discovering its critical importance. Did you miss our dialogue on frozen shoulder and impaired contralateral hip dysfunction ?  If you look for it, which many in the therapy world are not, you will see why we treat that opposite lower limb.  Maybe the rest of the folks around the world will catch on in time.  We are slowly getting there, we now have readership in 23 countries, and growing.  If only we had more time, the apocalypse of December 21, 2012 is coming on fast !

The article also found maximal changes in the middle diaphragm areas which suggests looking at the psoas, quadratus lumborum and crus because of their fascial blending into the diaphragm from below.  Thus, investigation of many muscles from below must also be a part of your assessment or training.  But we will save this discussion for another blog post.

We hope you can see that after a year of blog posts (over 500) that you can begin to see the method of our obvious madness.  That being that everything is important for human gait. Remember, we will blend this blog post into the roll assessments you will see on tomorrows post.  So ya’ll come back now……. ya hear ? 

In closing, it is blog posts like this one that we always hope will go viral on the internet. Especially because it has links to two previous articles we wrote on arm swing which we feel are so very important and commonly overlooked.  And we have more arm swing stuff to share, we just need more time.  Consider linking this article to your website, sending it to friends in the fields we discussed. This information is important. It is why we take the time every day to write and share our 40+ years of clinical experience for free. Because the world needs to know this stuff so more people can be helped all over the world.  Consider sharing this with someone or linking it to your Facebook page or website or slap it up on someones forum to create dialogue. Thanks.

The leg bone is connected to the thigh bone…. as the song goes…….

Shawn and Ivo

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here is Kolar’s abstract……

J Orthop Sports Phys Ther. 2011 Dec 21. [Epub ahead of print]

Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain.

Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A.

Abstract

OBJECTIVES:To examine the function of the diaphragm during postural limb activities in patients with chronic low back pain and healthy controls.

BACKGROUND: Abnormal stabilizing function of the diaphragm may be one etiological factor in spinal disorders, but a study designed specifically to test the dynamics of the diaphragm in chronic spinal disorders is lacking.

METHODS: Eighteen patients with chronic low back pain due to chronic overloading, ascertained via clinical assessment and MRI examination, and 29 healthy subjects were examined. Both groups presented with normal pulmonary function test results. A dynamic MRI system and specialized spirometric readings with subjects in the supine position were used. Measurements during tidal breathing (TB), isometric flexion of the upper or lower extremities against external resistance together with TB (LETB and UETB) were performed. Standard pulmonary function tests (PFT) including respiratory muscles drive (PImax and PEmax) were also assessed.

RESULTS: Using multivariate analysis of covariance, smaller diaphragm excursions (DEs) and higher diaphragm position were found in the patient group (p’s<.05) during the UETB and LETB conditions. Maximum changes were found in costal and middle points of the diaphragm. In one-way analysis of covariance, a steeper slope in the middle-posterior diaphragm in the patient group was found both in the UETB and LETB conditions (p´s<0.05).

CONCLUSION: Patients with chronic low back pain appear to have both abnormal position and a steeper slope of the diaphragm, which may contribute to the etiology of the disorder. J Orthop Sports Phys Ther, Epub 21 December 2011. doi:10.2519/jospt.2012.3830.

It is Friday Follies.  You may remember this video (link) we ran months ago called Liquid Mountaineering.

Well, we found the Myth Busters video discussing the myth/facts of Running on Water.

Enjoy !

Exercise Training Increases Mitochondrial Biogenesis in the Brain. A Journal of Applied Physiology topic.

We have included an indirectly related video link today. It will add some spice to a bland topic. This is a video of World Champions Slavik Kryklyvyy and Karina Smirnoff (last years Dancing with the Stars Champion). The video shows complex body motions that they make look simple, particularly at the 2:52 minute mark (right when you think the video is over) where we see the best in the word effortlessly solo demonstrate arguably some of the most difficult body movements, “Cuban/latin motion” of the Cha Cha. Even though the rest of the world embraces dance more than America, it isn’t for everyone. But, when some of America’s best athletes try this stuff and flounder repeatedly in front of America TV audiences despite weeks of practice one must trust the complexity of the motion from foot work to body control. We will see how Green Bay Packers NFL wide receiver Donald Driver will do when he trades in his football cleats for dancing shoes in a few weeks on Dancing with the Stars. There is a reason why top level pro athletes have challenged themselves behind closed doors with this stuff, because it makes them a better athlete. Our point? Master complex motions and simple ones become effortless. Here is a little piece of trivia for you…… name one of the best Latin dancers of all time ? Martial Artist Bruce Lee. Yup, Cha Cha Champion of Hong Kong. Looks like balance, flexibility, coordination, strength and speed of limb movement served him well in both ! We are not trying to pull the wool over your eyes gang, If you watch the first 10 seconds of the video again you can easily see how Slavik’s lightening fast, coordinated fluid moves are very much similar to open martial art moves. You cannot even see his footwork from the inside edges it is so fast. There is a reason we study these complex motions, because everything is simple after this stuff !

Now, onto today’s article discussing complex movements and exercise and their effect on brain function.

Exercise and complex movements put a demand on both the body and the brain. There are numerous articles confirming the positive benefits of continue physical activity through our life, even into our senior years. In fact, many peer reviewed articles confirm that for the elderly one of the best activities with low risk and high benefit is dancing. For the aged, dancing improves and positively challenges joint motion, balance and vestibular issues, cardiovascular health and muscle activity (strength and endurance) to name a few. It is well documented that with demands on the muscular system more mitochondrial production occurs in the muscles.

However, in 2011 in the Journal of Applied Physiology the authors sought to prove or disprove changes in mitochondria in the brain from exercise and activity demands.

In their mouse study (yes, there are human gene correlations with mice studies) where a treadmill to fatigue (8 weeks of treadmill running for 1 hr/d, 6 d/wk at 25m/min and a 5% incline) demand was executed followed up with specimen sacrifice. Twenty-four hours after the last training bout a subgroup of mice were sacrificed and brain (brainstem, cerebellum, cortex, frontal lobe, hippocampus, hypothalamus, and midbrain), and muscle (soleus) tissues were isolated for analysis of mRNA expression of several markers including mitochondrial DNA (mtDNA).

All specimens showed improved Run-to-fatigue (RTF) but the study findings also suggested “that exercise training increases brain mitochondrial biogenesis which may have important implications, not only with regard to fatigue, but also with respect to various central nervous system diseases and age-related dementia that are often characterized by mitochondrial dysfunction.” - Steiner et al.

In the recent issue of Scientific American (link) Feb 29, 2012 the author Stephani Sutherland summarized their article by quoting one of the study’s authors,

“The finding(s) could help scientists understand how exercise staves off age- and disease-related declines in brain function, because neurons naturally lose mito­chondria as we age, Davis explains. Although past research has shown that exercise encourages the growth of new neurons in certain regions, the widespread expansion of the energy supply could underlie the benefits of exercise to more general brain functions such as mood regulation and dementia pre­vention. “The evidence is accumulating rapidly that exercise keeps the brain younger,” Davis says.

* Remember……. the cells in your body, whether in your lungs, your heart or your quadriceps, do not know if you are on a treadmill, in the water, on the dance floor or on the bike. All they know of is the neuro-endocrine/physiological demands that are placed on it by any given activity. This is the premise and value of cross training the body, to expand its challenges and experiences and to reduce repetitive strain type injuries. It is the act of being active that makes the cellular changes, not the activity of choice.

Shawn and Ivo……… keeping up with the research (and keeping it interesting), so you do not have to. We are…… The Gait Guys

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J Appl Physiol. 2011 Aug 4. [Epub ahead of print]

Exercise Training Increases Mitochondrial Biogenesis in the Brain.

Steiner JL, Murphy EA, McClellan JL, Carmichael MD, Davis JM.

Source : University of South Carolina.

Abstract (abstract link)

Increased muscle mitochondria are largely responsible for the increased resistance to fatigue and health benefits ascribed to exercise training. However, very little attention has been given to the likely benefits of increased brain mitochondria in this regard. We examined the effects of exercise training on markers of both brain and muscle mitochondrial biogenesis in relation to endurance capacity assessed by a treadmill run to fatigue (RTF) in mice. Male ICR mice were assigned to exercise (EX) or sedentary (SED) conditions (n=16-19/gr). EX mice performed 8 weeks of treadmill running for 1 hr/d, 6 d/wk at 25m/min and a 5% incline. Twenty-four hours after the last training bout a subgroup of mice (n=9-11/gr) were sacrificed and brain (brainstem, cerebellum, cortex, frontal lobe, hippocampus, hypothalamus, and midbrain), and muscle (soleus) tissues were isolated for analysis of mRNA expression of peroxisome proliferator-activated receptor gamma coactivator-1-alpha (PGC-1α), Silent Information Regulator T1 (SIRT1), citrate synthase (CS), and mitochondrial DNA (mtDNA) using RT-PCR. A different sub-group of EX and SED mice (n=7-8/gr), performed a treadmill RTF test. Exercise training increased PGC-1α, SIRT1 and CS mRNA and mtDNA, in most brain regions in addition to the soleus (P<0.05). Mean treadmill RTF increased from 74.0±9.6 min to 126.5±16.1 min following training (P<0.05). These findings suggest that exercise training increases brain mitochondrial biogenesis which may have important implications, not only with regard to fatigue, but also with respect to various central nervous system diseases and age-related dementia that are often characterized by mitochondrial dysfunction.

The whole is greater than the sum of its parts…

This week in Neuromechanics Weekly, we will explore proprioception and total hip replacements.

You would think proprioception (ie body position awareness) would be impaired in a total hip replacement (THR). Not according to this study (see below) BUT Balance, the dynamic interaction of proprioception and the ability to maintain ourselves upright in the gravitational plane AND GAIT were…

We remember there are 3 systems that keep us upright: vision, the vestibular system and the proprioceptive system (ie joint and muscle mechanoreceptors). A THR would effect mostly the latter, especially in this case, whee they REMOVED the hip capsule (capsulectomy). This, of course, would remove any of the joint mechanoreceptors, but probably not the muscle mechanoreceptors (ie spindles and golgi tendon organs).

Look at the conclusion “Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential.”

So, they required a GREATER amount of sensory input and the response was DELAYED. This leads us to believe that is must be the integration of the systems that is the key.

The whole is greater than the sum of the parts… 

All this information is integrated in the cerebellum. Think about the 4 types of joint mechanoreceptors: Type 1 on the outside of the joint (tonic or respond to small movements); Type 2 on the inside of the joint phasic, or respond to large amplitude movements); Type 3, basically a golgi tendon organ type receptor, and Type 4, pain receptors. All this is taken away and they can still tell you where the limb is in space.

What does that mean? ..It means there are MORE receptors, somewhere, providing this info to the brain. They also required “extra input”. Hmmm…something needed to tell the brain that the action (in this case balance and gait) were happening. What was providing it? Muscle spindles and golgi tendon organs (see last weeks high heels post for more info); the former responds to length change and the latter to tension change.

The whole is greater than the sum of the parts.

Rehab it. Work on motor control strategies. Skill, endurance, strength; in that order. Ivo and Shawn. The Gait Guys. Exploring the literature to bring you the best of the best and help you to help others….better.

Balance and gait in total hip replacement: a pilot study. Nallegowda M, Singh U, Bhan S, Wadhwa S, Handa G, Dwivedi SN.

2003 Sep;82(9):669-77. AM J Phys Med Rehabil

Abstract OBJECTIVE:

Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects.

DESIGN:

A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group.

RESULTS:

Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living.

CONCLUSIONS:

Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.

http://www.ncbi.nlm.nih.gov/pubmed/12960908

hip replacement image from: http://www.wpclipart.com

champagne lady from: icr.org

When the toe extensors become short or tight.

Here is a really great video.

One of us was treating physicians for the Chicago Joffrey Ballet for a time in the early 2000’s. Feet like these were nothing new. For the most part there was amazing flexibility, amazing strength and occasionally some nasty bunions but not as often as one might think. What was clear however was that the majority of the population of feet seen were freakishly strong, amazingly flexible and with skill levels that most of us only dream of.

In this video we can see two things which we just highlighted. Full uninhibited ranges of motion and apparent strength. In order to have full ranges we usually see wonderful strength. When we see a loss of range of motion, frequently but not always, we see weakness of the muscles necessary to drive that range. In other words, if we had the strength we would have the ability to engage the full range because of that strength.

You have heard it here before, that when there is weakness in a muscle around a joint (since all muscles cross a joint) we will see a neuro-protective loss of range due to a neuro-protective tightening (we are using the word TIGHTENING very carefully, note we did not use the word SHORTNESS) of some related muscles in a response to attempt to stabilize the joint. It is not a perfect remedy, but what other strategy do we have ? Sadly, it is usually the strategy of the owner of the broken part to try to stretch that tightened (again, note we did not use the word shortened) muscular interval which then presents the joint again with the afferent detection that the joint is unstable and unprotected. So, more tightness develops and the vicious cycle continues. It is our hope that those that find they need to stretch daily will someday have a light bulb moment and see that they are doing nothing to remedy the vicious cycle. That searching for the weakness that drives the neuro-protective tightness (as opposed to true “Shortness”, which is truly physiologic loss of the length-tension relationship) is where the answer lies to remedy the joint imbalance.

Here this client has generous ranges of motion and highly suspected appropriate strength. The two often go hand in hand unless the client has the phenomenon commonly referred to as “double jointed” which is truly just a collagen abundance in the passive restraints (lets leave this as a merely generalized term for now, it is a topic of another blog post).

What we wanted to talk about here today was the plethora of tightness AND shortness we see daily in the extensors of the toes. How many of your clients have the flexion (toe curl, at all joints) range of the toes that this client has ? Not many correct ? But most have near full extension ranges of the toes correct ? This can only come down to one theory that must be proved or disproved. That being that the toe extensors are either tight because the flexors and plantar intrinsics are weak OR that the toe extensors are short because they have been in this environment of flexor-plantar weakness for so long that the tightness eventually morphed into a more permanent reduced length-tension relationship.

Go ahead, see if you can flex your toes or those of your spouse or clients as far at this dancer can. See if you have full range at the metatarsophalangeal joints like this dancer does. Very likely you will notice a nasty painful tension and stretch across the top (dorsum) of your foot. This is reduced length of the long and/or short toe extensors and likely fascial connective tissue as well. Heck, what else runs across the top of your feet ? Nothing else really. So, what is one to assume ?

Digit extensor tightness is rampant in our society. We have been in shoes and orthotics and stable shoes for so long that our flexors and foot intrinsic muscles have become pathologically weak. As the opposing pull of the flexors and extensors across the end of the foot at the metatarsalphalangeal joints becomes so imbalanced our foot has no other choice but to express this imbalance.

Is this why we see bunions, hammer toes, even gentle flexion of our toes even at rest ?

Yup, the mass population of feet we see are slowly going into a coma. The pattern we see most commonly is even a bit more complex however, it is not quite as simple as tight-short extensors and weak flexors and intrinsics. Looking at the functional neuro-pathology of the hammer toe proves the complexity of our compensations. Here is the most typical pattern (and hence the hammer toes that are taking over the earth):

• weak long toe extensors
• strong short toe extensors
• weak short toe flexors
• strong long toe flexors

This combination ends up in a functional/flexible hammer toe, and if left alone to fester, a rigid hammer toe in time.

From this combination you should now as the question, “So, when I attempt to put my foot and toes in the flexion positioning of this dancer in the video above what is the tightness i feel across the top of my foot ?”

Answer: functional tightness (and possibly shortness if it has been there long enough, which is likely for most folks) of BOTH the long and short digit extensors (EDB, EDL). Think about it, in the hammer toe position both are short, but for different reasons. The EDB because of the resting extension position at the metatarsal phalangeal joint and the EDL becuase it is wrapped around two distal chronically flexed interphalangeal joints in the presence of an ALREADY extended metatarsophalangeal joint ( which takes up EDL length).

This phenomenon occurs rampantly in the upper limb as well across the elbow, carpals and finger joints. It is a big component of TOS and carpal tunnel and of the multitude of functional problems that the elbow such as medial and lateral epicondylitis.

Why do you care ? After all we are The Gait Guys. Well, because most of us swing our arms during gait and what is pathologic in the upper limb can affect the lower limbs and gait. It is all connected after all, according to the song ……

Chronic disruption of the length-tension relationships of the toe extensors.

It is a bigger problem than you think.

Shawn and Ivo. Discussing the distal sister disease of polio……… affecting just the toes of course. Ever hear of Tolio ? (pronounced……Toe-Lee-oh). Just kidding.

Forefoot Valgus: What you need to know

Hi Shawn and Ivo,

With Forefoot valgus problems do you find it useful to mobilise the calcaneus? Also any other forms of manual therapy worth addressing before doing the arch strengthening exercises as decribed on youtube?

Also whens your professional presentation on shoes available and also any other ones beside the ones available on wannabefast. I bought all the ones available on wannabefast.

Thanks for your time,
D

Dear D

Appropriate physiological ROM’s are ALWAYS important prior to ANY rehabilitative procedure. So, if you are referring to any of the articulations with the calcaneus (talo-calcaneal (any or all of the 3) and calcaneio-cuboid), yes. The calcanueus needs to evert 4-6 degrees beginning at initial contact through midstance and pathomechanics here would limit subtalar pronation and reduce the shock absorbtion that these joints provide. This could result in a functional forefoot varus. Likewise, if there were no inversion, you would not be able to supinate and the foot would remain in an “unlocked”” position, being a poor lever arm.

It would be prudent to assure all ROM’s are within physiological ranges (or subluxation free) before proceeding with exercises.

Watch for our Show fit program, which is in the final editing stages. Stay tuned here or on our Facebook page for details.

The Gait Geeks

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The Perfect Forefoot Bipod

The ostrich is distinctive in its appearance, with a long neck and legs and the ability to run at maximum speeds of about 70 kilometres per hour (43 mph)^[3], the top land speed of any bird.

he bird has just two toes on each foot (most birds have four), with the nail on the larger, inner toe resembling a hoof. The outer toe has no nail.^[14] The reduced number of toes is an adaptation that appears to aid in running. Ostriches can run at over 70 kilometres per hour (43 mph) for up to 30 minutes. Although this bird cannot fly, it can run faster than the swiftest horse.their primary means of locomotion is running, so the feet have developed into feet fit for frequent, and very fast running especially to escape preditors. If it would keep on in a straight line no animal could overtake it; but it is sometimes so foolish as to run around in a circle, and then, after a long chase, it may perhaps be caught. A traveller speaking of the ostrich, says, “She sets off at a hard gallop; but she afterwards spreads her wings as if to catch the wind, and goes so rapidly that she seems not to touch the ground.” This explains what is meant by the verse, “When she lifteth up herself on high she scorneth the horse and his rider.”

It is a good thing that ostrich’s do not wear shoes. Over time their feet would have weakened and flattened and they would need orthotics.  Some animals are just smarter than humans.

:-)

In our ever popular; ask the Docs, here is another question from a reader

Transverse Arch

How would one go about “rebuilding” their transverse arch? The latter is pretty much convex. This also accomapnied by very tight long toe extensors (as evidenced by their tendons being very prominent at the top of my foot and my toes being curled at rest) and have suffered on and off from Morton’s neuroma. The ball of my shoes (right in the middle) is where the insoles of my shoes see the most wear. It’s not a huge concern of mine, but I would like to deal with this. I’ve suffered several ankle injuries (as a basketball player) and although I’ve tried orthotics in the past (for the neuroma), I’ve relied mostly on minimalist footwear (except when playing ball of course…). I know some rehab would be in order and would likely work. I’ve “reconditoned” my big toe abductors in the past and can even cross my second to over my big toe, so am just looking for some direction.

Thanks

E

 

Hi E

As you probably are aware, there are 3 arches in the foot: the medial longitudinal (the one most people refer to as the “arch”, the lateral longitudinal (on the outside of the foot) and transverse (across the met heads).

Your collapsed transverse arch seems like it may be compensated for by a rigid, probably high medial and lateral longitudinal arches. This creates rigidity through the midfoot (and often rear foot) and creates excessive motion to try and occur in the forefoot. Depending on how much motion is available, this may or may not occur.

You don’t seem to be able to get your 1st metatarsal head to the ground to form an adequate tripod, so you are trying, in succession, to get some of the other, more flexible ones there (thus the wear in the “ball” of the foot you noted). This results in increased pressure, metatarsal head pain, possibly a bunion and often neuromas.

From your description, you actually have very weak long toe extensors (and possibly some shortening) which is causing the prominence of the tendons, along with overactivity of the long flexors (and thus the clawing) in an attempt to create stability. I am willing to bet you have tight calves as well (especially medially, from overuse of the gastroc to control the foot) and limited hip extension with tight hip flexors.

The foot tripod exercises are a great place to start, as well as heel walking with the toes extended and walking with the toes up (emphasizing extension, which counteracts the flexors). Stay away from open back shoes and flip flops/sandals; continue to go barefoot and get some foot massages to loosen things up. Maybe use one of those golfballs to massage the bottom of the foot when you get off the course and get some golf shoes that aren’t quite so rigid.

Ivo and Shawn. Still middle aged. Still bald. Still good looking….

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 2^nd neuron in the pain pathway (the pain neuron comes into the cord, synapses in the dorsal horn with a 2^nd 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 2^nd 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 2^nd 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.

http://www.ncbi.nlm.nih.gov/pubmed/11206820

Foot Ankle Int. 2001 Jan;22(1):31-41.

Extrinsic muscle activity, foot motion and ankle joint moments during the stance phase of walking.

Hunt AE, Smith RM, Torode M.

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 Coach

Thank 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 here

2. 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

It has been a year, but this video is still as important as it ever was. Now that we have many of new viewers, perhaps they missed this one. It is always good to review. Enjoy !