We live in pretty amazing times. This device will change some people’s lives. As long as you have sufficient limb function this is a nice alternative to a wheelchair.
We found this while searching for another image and thought it fitting for a Friday:
“May you walk barefoot in joy and empathy, or shod with the shoes of your choice (or your charity), and may your path be the one that takes you where you need to go”
Have a great Friday
Ivo and Shawn
source: http://kathleenkirkpoetry.blogspot.com/2011_03_01_archive.html
Are you "running" yourself into hormonal trouble ?→
/Do those 40+ mile weeks do only good things to your body or could they be hurting you ? Is all this exercise catabolic ? Have you ever heard of hypothyroidism ? How about screwing up the hypothalamus-pituitary-adrenal axis ? If you are a chronic exerciser you might want to read on.
Define catabolic: The metabolic breakdown of complex molecules into simpler ones, often resulting in a release of energy.
“I tried to rescue my Jessica from the clutches of the cardio contingent, but to no avail until a month ago when she called to tell me that a blood test had confirmed her doctor’s suspicion: she had hypothyroidism — her body no longer made enough thyroid hormone. Her metabolism slowed to a snail’s pace and the fat was accumulating. Now she had a culprit to blame, it wasn’t the cardio causing her problems, it was her body rebelling. When Jessica asked my advice, I told her to do two things: schedule a second test for two weeks later and until then, stop all the goddamn running.”-From the article, Women Running into Trouble. By John Keifer, on Elitefts.com
There are plenty of studies showing that chronic cardiovascular workouts may help to shut down the thyroid gland and its production of T3 thyroid, the body’s metabolic regulator. If you need those references, the 2 articles in this blog post, one by Keifer and one by Kresser, have plenty to just get you started.
Wait a minute Gait Guys, months ago you wrote about gluten in my food affecting the thyroid and now possibly longer cardio exercise as well ? Yup, there are suggestions that it can be the case in many people. But that doesn’t mean you need to freak out. You just need to be aware and be smart.
First, lets review the gluten thing one more time for our new readers. (if you want to read our gluten ataxia article from moons ago, here it is). Several studies show a strong link between AITD (autoimmune thyroid disease (both Hashimoto’s and Graves’)) and gluten intolerance. The link is so well-established that researchers suggest all people with AITD be screened for gluten intolerance, and vice versa. And some experts will even tell you to not trust the intolerance screens, rather just stay away from gluten all together.
AITD is a case of mistaken identity says Dr. Kresser in his article. He mentions that
“the molecular structure of gliadin, the protein portion of gluten, closely resembles that of the thyroid gland. When gliadin breaches the protective barrier of the intestinal gut, and enters the bloodstream, the immune system tags it for destruction. These antibodies to gliadin also cause the body to attack thyroid tissue. This means if you have AITD and you eat foods containing gluten, your immune system will attack your thyroid”
Ok. Back to exercise now.
OK Gait Guys you have my attention now. So, you are telling me that regularly repeated sustained exercise can also possibly affect me as well ? The answer is yes. There is some reasonable and growing research on this topic, so just educate yourself and make your choices and watch for signs.
Here is how it works. T3 is the body’s metabolic regulator and it can crank up to generate heat and fuel production through catabolic processes generating energy. It can also down-regulate (hypothyroidism) to slow the body’s metabolism and lower body core temperatures. This slow down can cause weight gain and lethargy even if the person is active and exercising (Do you ever go to the gym and see those folks who are always on the treadmill or ellipticals, never seeming to lose weight ? Sure they could be eating 3 square meals at Crispy Creme but it could also be their thyroid). When T3 is in balance the body can regulate temperature and energy production without problems. Thus it can be extrapolated that long standing steady exercise (floating around that 65-75% VO2max) will generate long periods of increased body core temperatures and energy expenditure raising the watchful eye of the thyroid. If it could talk, the thyroid would be saying, “Hey, what’s going on out there guys ? Why are we cranking up the heat and blowing all these fuel sources, EVERYDAY !? ” And since the thyroid is always on this alert, it is watching for signs it needs to REACT to preserve the organism and its energy stores. So when it see these long periods of increased temperature and energy expenditure it naturally senses that it must intervene to preserve them. Thus, it drops T3 output, temperature drops as well as metabolism. The brain and hormonal regulatory feedback systems decide then that the problem is solved, the organism can survive to live another day. Unfortunately for the athlete this is not a productive thing when training for a marathon, so they override the signs and symptoms and get back at it tomorrow. Now, in this state, other fuel sources become vulnerable including muscle and bone mass. Plus cortisol ramps up and we all know how destructive long term heightened levels of cortisol can be. Not only are they catabolic in sustained high levels, they alter the adrenal hormonal loops with the brain, sacrificing hormones like DHEA and pregenalone to mention only a few (ie.Pregnenalone Steal Syndrome) and their associated feedback loops.
We see alot of serious athletes with this kind of stuff and sometimes we have to order hormone panels for these problems to see just how messed up the loops are and to determine where to start. Sometimes we just look at them and ask why they think more training trumps rest and recovery.
As a brilliant doctor in these fields said to me the other day while discussing Keifer’s article, “When the HPA axis is activated, the CRH response from the hypothalamus to pituitary begins the upregulation of the adrenal axis and directly inhibits TSH. And the glucocorticoid response will also inhibit TSH. If the body is under siege and goes into a catabolic state it should naturally have an inbuilt protective mechanism to slow the rate of breakdown! ” Thank goodness our body has this mechanism !
What did he say ? In a nutshell, what he said is that the hormonal systems are all connected via feedforward and feedback loops to make sure the body is balanced and healthy. When the body is working out too much and expending too much energy, heat and breakdown for long periods of time turn on these protective feedback loops in an attempt to protect the body. The thyroid and adrenals are often at the mercy of the process, as well as your healthy hormone levels, muscle and bone mass (read more on this in Kresser’s short article) as well as energy.
Staying healthy, it is a fine line. Don’t forget that rest and recovery are critical for your performance, but more importantly for your health. A recovery day should be just that, recovery ! Not an easy 50 mile bike ride ! That is not deemed as recovery to the hormonal regulatory mechanisms of the body. This stuff bodes us to share the statement……. “more is not always better”. Don’t forget that your body needs to be fed rest and recovery just as much as good food and sleep. And, do not mistake this article to say that exercise is bad either, we all know the truth there.
There are some really great articles out there that talk about the similar physiologic effects of brief high intensity workouts when compared to sustained steady state exercise. And, they might help save your body in the process if you are one of the vulnerable ones (and there are alot of vulnerable ones !).
Want to read John Keifer’s orginal article on this, go back up to the link provided at the top of the page. We tried to summarize a very difficult topic (even for some physicians) so don’t feel bad.
Shawn and Ivo
Ya, we are a little more than just Gait Guys. We try to take care of our athletes on every level. This may not have been gait related today, but it sure was running related.
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Retail Focus Thursday: The Heel Counter/ Heel box
Let’s differentiate between the heel counter and a lateral flare of the out sole.
The heel counter refers to the back part of the upper of a shoe that actually holds the heel in place (see left above).
The lateral flare is part of the outsole, where it is enlarged laterally, to create stability to a shoe. (see right above). It does this at the expense of speeding up pronation (we usually strike on the outside of the heel, creating a greater sidtance to travel in the same amount of time; again, another post for another time). Good idea for one problem, but often creates another.
The heel counter is necessary, because as the foot pronates from its initial contact with the ground through midstance, the calcaneus moves laterally (or as shoe pro’s say “it everts”). If the calcaneus does not encounter something to abut up against (like the heel counter), to stop rearfoot pronation at the appropriate time, it will continue to evert and the medial arch will collapse.
“So what” you say? Excessive rearfoot motion, like this can not only cause prolonged midfoot pronation (remember it pronates to absorb shock to midstance, then supinates to create a rigid lever to push off of. Click here if you need a pronation review), but is a common cause of heel blisters. How many times do you remove a clients shoe (hopefully you are removing their shoes and looking at their feet before selling them some shoes) and you notice a “bump” (and sometimes a blister) on the back of the heel (see above) and the outer portion of the heel box is worn on the inside of the shoe? Hmm, sounds like too much room in the heel box.
What causes too much room in a heel box? Narrow heels (or calcaneii , as we like to say) or literally, too much room. The “too much room” scenario often happens when you put a woman’s heel (usually narrow) in a men’s shoe (often wide)
A little lost? Have no fear; the complete shoe fit program (with IFGEC certification if desired) is coming in the next few months. Watch here, on Facebook or Twitter for the announcement.
The Gait Guys…Shoe afficianado’s. Bringing you the facts so you can make better decisions….
heel counter image from: www.hughston.com
The Boston Marathon Black & Bloody Toe nail epidemic. (want the truth, read on)
Just in time for all those black bloody toenails at the Boston Marathon. We are going to try to repost this blog post (last June 2011) every year around the Boston Marathon. We need to kill the myth of “ I lost my toe nails because my shoes were too short”. How stupid is that theory !
Our next statement is always “well, if you bought shoes that short you deserve it. But we doubt that is the case." Here is likely why you got a black toenail or lost your nail in the marathon. ”
The Gait Guys have it figured out for you. This just makes more sense gang. It makes sense because it is the answer. Click the link below.
http://thegaitguys.tumblr.com/post/6355488304/the-black-plague-ok-kinda-sort-of-subungal
Neuromechanics Weekly
Bad posture is ubiquitous:Our Flexor Driven Society
We know you visit here often and read the blog. You do it because of your desire to learn and possibly because of curiosity and wondering what exactly it is that we are saying, or not believing that we actually said it…and can back it up! Do you remember that we said most joint and muscle receptor activity goes to the cerebellum? Do you remember that the cerebellum is NECESSARY for learning? Not just motor learning but ALL learning…
Curious? Read on…
If you think the economy is our problem, maybe you need to look a little closer. These pictures are from a few days ago while at the playground with my kids (yes, the gait cam again…yes, we are watching YOU).
Many human ailments can be linked to imbalance. The Chinese recognized this a few thousand years ago with the concepts of Yin and Yang (pronounced Yin and Yawn; I can still hear Dr Springfield saying “Anyone who says Yang (rhymes with Tang) fails the course). Equal opposing forces are meant to remain in balance to create homeostasis.
This picture is a perfect example of flexor/extensor imbalance (stooped posture creating slow stretch of the extensors of the spine/back and gluteal muscles), which, over time (30 mins or more) increases muscle length.
We are a flexor driven society. Think about all of the voluntary, fine manipulative movements you can make consciously (buttoning a shirt, typing, pushing off with gait). These are all corticospinal (long neurologic tracts from brain to spine) driven phenomenon (ie under conscious control) which are ultimately driving the flexors (go ahead, try and button your shirt with the backs of your fingers (ie. extensors); if you can do it, please send us the video, so we can post it).
Now think about the activities, like standing upright, that are dependent on our extensors, which are largely under the purview of the vestibulospinal system (driven from the cerebellum and vestibular nucleii in the brainstem). Try and contract your L2-L3 lumbar multifidus on the right: you can’t, because it is not under conscious control.
Let’s extrapolate further…We tend to use that which we can control, thus we use our calves and deep flexors of the posterior compartment of the leg. These cause knee flexion and plantar flexion of the foot (and dorsiflexion of the 1st MTP, provided there is adequate range of motion available), which reduce ankle rocker. They will reciprocally inhibit the anterior compartment muscles (like TA and EDL, EHL). Your center of gravity shifts and now you need to engage the quads to right it, rather than the more efficient gluteals. Now the pelvis tips forward due to action of the rectus femoris, shortening the glutes and putting them at a mechanical disadvantage (in addition to functionally weakening the lower abdominal compartment, making athletes more susceptable to hernias), so now we use the hamstrings (but these are reciprocally inhibited by the quads), so we default to the lumbar erectors and so on up the chain.
Flexor dominance leading to extensor inhibition. Not to mention that the cortico spinal pathway (flexors) inhibits the vestibulo spinal and retculospinal pathways (which both drive the extensors) in the brain stem. So, there is a local, segmental effect and cortical loop. When we continue to utilize certain pathways in the brain, they become ingrained (collateralization and facilitation) and that’s how bad motor patterns begin.
Look at the picture above again. Flexed lumbar and thoracic spines, flexed arms, flexed wrists, flexed hips, flexed knees. Not too much extensor activity going on, eh? Thus, More inhibition of the extensors.
We know you visit here often and read the blog, because of your desire to learn. Do you remember that most joint and muscle receptor activity goes to the cerebellum? Do you remember that the cerebellum is NECESSARY for learning? Not just motor learning but ALL learning…
So, sit up straight. Eat your vegetables and work your extensors. Your intelligence depends on it!
Ivo and Shawn. The Gait Guys. Telling you what you need to hear, but don’t necessarily want to hear. Yes, we are watching and yes, our glutes are engaged.
What you think, and what you think about matters…
More fodder for motor planning and other cortical activities. This article talks about what the movie “What the Bleep Do We Know” is all about; what you think can effect the outcome, but this article is focused on you and your actions, rather than the world around us.
This goes for gait retraining, rehab and a host of other things you may be trying to accomplish (even beyond the world of gait, if you can believe such a world exists!)
What you do matters bascially. And when you do it right, there is neurologic reinforcement of those motor behaviours. And when you do it wrong, meaning you cheat or compensate, there is neurologic reinforcement of those motor behaviours as well.
We often hear it is better to do something right the first time than to have to do it truly properly a second time. There is far more to it than correcting your ways. Now you have to rewrite another motor pattern, while the old one remains stored waiting for you to cheat or take a short cut the next time.
If something is worth doing, do it right the first time. This goes for gait and running form retraining. This is why running form is such a big business these days, so many have been running incorrectly, emulating improper motor patterns.
When Nike said “Just do it”…….we think they meant, “Just do it right.”
The Gait Guys
Front Hum Neurosci. 2011; 5 : 54.
Published online 2011 May 27. doi: 10.3389/fnhum.2011.00054
Abstract
Emulations, defined as ongoing internal representations of potential actions and the futures those actions are expected to produce, play a critical role in directing human bodily activities. Studies of gross motor behavior, perception, allocation of attention, response to errors, interoception, and homeostatic activities, and higher cognitive reasoning suggest that the proper execution of all these functions relies on emulations. Further evidence supports the notion that reinforcement learning in humans is aimed at updating emulations, and that action selection occurs via the advancement of preferred emulations toward realization of their action and environmental prediction. Emulations are hypothesized to exist as distributed active networks of neurons in cortical and sub-cortical structures. This manuscript ties together previously unrelated theories of the role of prediction in different aspects of human information processing to create an integrated framework for cognition.
You have seen the artwork of British Photographer Eadward Muybridge in some of our videos and online education programs (with credit). Here is a Google Doodle based on “The Horse in Motion” you may enjoy. Click on the picture to follow the link.
The Gait Guys
Have a great day!
Curse of the Bunion
Hi Dr. Allen,
My husband was able to stop using his orthotics by utilizing the exercises he learned from The Gait Guys on YouTube so I thought I would send you an email to ask your opinion about my daughter’s foot issues. She is 14 years old and a serious dancer (eight hours of class per week plus up to eight hours of rehearsal). She has developed a bunion which is starting to cause her significant pain in the joint of her big toe. We took her to an Orthopedist who gave her a Cortizone shot in her joint and suggested she will need surgery. Considering she is only 14 and surgery would take her out of dance for at least 3-4 months, we do not view it as a viable option. Is it possible to fix a bunion without surgery and is that something you have had success doing? I know she is not currently a patient of yours but I would be interested to hear your opinion on the issue.
Thanks, PG
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Dear PG
Wow, that is great news for your husband ! Although we do not recommend taking our information as medical advice it is always nice to hear that by simply using our stuff to self educate oneself that people are fixing what therapy was unable to achieve.
I used to treat many in the dance company at the Chicago Joffrey Ballet along side a few other brilliant doctors (who are Gait Guys followers as well !) and we always cringed when a nasty bunion would walk and and cry for help.
Bunions are developmental for the most part. They are found paired with Hallux Valgus. This journal article has a real nice verbiage that we like:
“The first ray is an inherently unstable axial array that relies on a fine balance between its static (capsule, ligaments, and plantar fascia) and dynamic stabilizers (peroneus longus and small muscles of the foot) to maintain its alignment. In some feet, there is a genetic predisposition for a nonlinear osseous alignment or a laxity of the static stabilizers that disrupts this muscle balance. Many inherent or acquired biomechanical abnormalities are identified in feet with hallux valgus. However, these associations are incomplete and nonlinear. In any patient, a number of factors have to come together to cause the hallux valgus.”
In working with dancers we found plenty that did not have bunions or hallux valgus. So it is not always the dancing that is the culprit. But it can be a factor if the osseous alignment is suboptimal (the joint line architecture at the metatarsophalangeal joint at the big toe is angled to allow for lateral hallux drift or the intermetatarsal angle is predisposed (wider than optimal)).
The main problem however in dancers is multifactorial:
- the “turn out” predisposes the foot to more pronation which can easily destabilize the medial foot tripod anchoring of the 1st metatarsal to the ground. This will change the pull of the adductor hallucis causing the hallux to drift laterally and the 1st metatarsal to drift medially widening the gap between the 1st and 2nd metatarsals (ie. the intermetatarsal angle).
- dancers also axially load the hallux. This is called “en pointe”. Please read our prior blog post on “en pointe” (click here). As you can see in the video above, the angle at the big toe (the 1st metatarsophalangeal joint) immediately begins to drift into hallux valgus. Continuing to do this will render this poor gal a nasty bunion in time we highly suspect. These are the challenges that dancers put into the foot. Once the hallux drifts laterally the first metatarsal loses more anchoring capacity at the medial foot tripod and the viscous cycle continues.
- Remember, a bunion is a soft tissue adventitious mal-development. It is often erroneously confused as a bony proliferation at the medial joint, the knuckle area. This is not the case. Hallux valgus drives the metatarsal head medially and exposes the head of the bone medially giving the appearance of a bump (the “bunion”). In fact, the bunion is an inflamed or adventitious bursal sac combined with the prominence of the MET head and angry inflammed skin, ligaments, joint capsule etc
To “fix the bunion” is a loaded issue. Once these begin to develop they frequently progress in degree and pain. They are very hard to correct conservatively but you have to give it a chance, surgery has to be the last road. Unfortunately if this is going to happen it must be determined if dance is a provoking factor, which is very likely. Being in En Pointe will make this a quick trip into a nasty bunion we fear. Use caution and logic on this one PG. Your daughter has to live with these feet for many decades at the very least, and there is nothing like walking on painful incompetent feet for the rest of your life. Further correction possibilities may come from determining if she can adequately form a good foot tripod and achieve competent strength in the muscles that stabilize the joint (FHL, FHB, EHL, EHB, ABD H., ADD H., tib posterior and anterior …… to name most of them). A strong competent foot with excellent medial tripod anchoring ability will rarely develop into a bunion or hallux valgus. But you have to catch the incompetencies early and correct them before things get out of hand.
Good luck to you and your daughter PG. Find someone good at these things. Find your local “Gait Guy or Gait Gal” and you will be in good hands (or should we say “good feet”).
The government needs to start a “Just say no to bunions” grassroots program. Although on second thought, maybe that is not a good idea. It would only get caught up in congress and the senate for years.
Warm regards,
Shawn and Ivo
Friday Follies:
Going through our archived pictures, we ran across this shot of Dr Ivo with Frank Shorter (Center) at last years Newton Conference that The Gait Guys were invited to speak at.
Knowing that Dr Ivo plays the bass, and is a former rock star, we are always searching for posts which may include a musical reference (even if peripheral). We closely compared some pictures of Alice Cooper (Left and Right) with Frank Shorter.
Hmmm…. Could Frank be Alice? The similarities are uncanny….This is an Uber compliment if you ask us !
Arnold Palmer, Gait & The difference between Muscle Tightness vs Muscle Shortness.
/Arnold Palmer did not exactly have the prettiest golf swing but we doubt too many are going to argue that in the height of his uber successful professional career he should mess with it.
One of the gait guys used to date (eons ago) a gal who’s father used to be on the PGA tour. (Although it was not the case, Go ahead and accuse us of using her to get to him ! We have no shame. LOL). We got to golf with him once a week. Needless to say there were deep lessons each time they went out. Some days it was “today we will play with a 7 iron and a putter and nothing more”. But one lesson that really stuck out was …. “Don’t be afraid to bet against the golfer with a beautiful swing who can golf well most days…… be afraid to bet against the golfer with a butt-ugly swing that always hits the middle of the green in 2 strokes every single time.”
Now, this may be a confusing point. What this meant in the golf world was that if you do something enough times, no matter how bad it looks, you will get really consistent and accurate with it. You can bet on it. Now this does not mean there is not a better way, a smarter way, a more economical way. Ask any golfer who cannot hit a driver but can groove a 3 wood and they will tell you they will pick out the 3 wood every time in friendly competition over the risk of driving the ball off the Tee with the driver at the risk of entering the woods or deep rough. That does not mean that picking up the driver at the range and getting some lessons would have a better and wiser outcome in time.
Our point here today is that many times there is a better way, our bodies just cannot always find that better way on the working body parts available. Hitting the driver is just a different skill set and needs some different skills and work to harness its benefits. When we cannot find a “better way”, because of muscle inhibition from an injury or from challenged anatomy (ie. forefoot varus) or for some other reason, the body will attempt a reasonable strategy. It will be a strategy to protect the involved joints, to maximize ranges of motion and over all limb function, as best as possible. Sometimes this works for a short while, sometimes for months or years. But it is usually inevitable that the compensation will fail or the repetitive nature of the tasks will tax the tissues and end in pain or injury.
Sometimes we find a better way on our own, sometimes we need help to find a better way around problems. Heck, we all need crutches for a sprained ankle from time to time, but after the first few weeks we do not continue to use the crutches. Eventually function must be restored. Either the pristine biomechanically correct function, or a compensation pattern. One is optimal with little consequences, the other is suboptimal. The real trick is knowing if you have the optimal pattern or if you are adding strength and putting miles on the compensation pattern. Sometimes it is hard to tell.
We will choose conscious incompetence any day over unconscious incompetence. We would rather know we are doing something wrong so we can correct it, or at least be able to monitor it.
So, next time you are foam rolling your “tight” IT Band or stretching out your tight calf……. we hope you will ask the question, “am I bandaiding the problem or am I fixing the problem?” Remember, tightness and shortness are not the same beast. One is a neuro-protective phenomenon and the other is just plain vanilla shortness. One needs stretched and the other craves the strength around the joint to afford the protective tightness (the heightened tone) some resolve.
Athough we love Arnold Palmer, we bet had someone caught him early enough in his young career he would have opted for the optimal swing as opposed to what we all grew to know.
Now, go watch the Masters on TV !
Four !
Shawn and Ivo
Shoe Retail Thursday: Today we have a client in some shoes that appear to be a good match, until you look more closely. See if you can see it.
“ Just because the shoe fits, doesn’t mean you should wear it ! ”- The Gait Guys
First of all, we apologize for the crummy video. But we were scouring through some old stuff while working on our long awaited “Shoe Fit” program and this video just had to be shown. This is a short video, you might get some vertigo from the nasty camera work. Sorry about that.
Initially this client looks great from behind. The rear foot looks neutral, no valgus heel collapse into rearfoot pronation and no over burdening of the lateral crash zone (lateral/outside tipping of the shoe into supination). If anything could be said, they look like there could be a subtle rearfoot supination from the initial shot before they start to walk.
We are also not sure what shoe this is, we do however know it is a New Balance stability shoe from the video. This client had purchased these shoes 1-2 weeks prior in a trusted high end specialty running store. As the client walks away from us everything looks pretty good. We could point out some subtleties but those are not the point of our talk today. It is not until they come walking back that something is clearly wrong. Did you see it ? The LEFT foot is drastically supinating displaying a lateral weight bearing shift all the way through toe off.
Now, on the surface this is a simple case. (We just shot a concept video last night to take this blog post today to the next level. We will present it next week once we get it edited.) But the points we need you to understand today are :
- Just because someone has a flat foot standing in front of you does not mean they need a stability shoe. We see plenty of folks who are serious walkers, runners all the way up to professional athletes who have flatter, or flattened, medial longitudinal arches but still have very strong competent feet. There are ethnic groupings that have flat feet. So just because a foot looks flat does not mean one should reach for a stability shoe or an orthotic or additional foot bed insert. This client had flatter arches but had competent feet. They also had some issues of tibial torsion that negated some of the challenges of flatter feet. So, our point here is what you see is not always what you get, nor what you should fix either for that matter.
- What should happen in a shoe does not always truly happen. This means you have missed some calculations or you simply do not have enough experiential wisdom to predict the oddities in certain situations or with the given anatomy of a given athlete. This comes in time, with experience.
- Sometimes supination is not really supination. This client has a flatter foot. Flatter feet do not supinate well. Ok, better put they run out of time to supinate the foot because they have spent too much time into the pronation phase. However, they also could have weakness in the supinatory mechanisms to drive it adequately. Remember, some clients will fall into their weaknesses and some will strategize to avoid the weaknesses if they have enough body awareness and strength to do so. They just do not seem to have the skills to find the more appropriate pattern to correct the underlying issues. But there is certainly something positive to be said to knowing you have a problem and that you are cheating around it rather than being oblivious.
This case was possibly, maybe even likely, one of several problems:
- wrong shoe for the foot type
- possibly a faulty shoe fabrication
- poor strategy to make for a rigid foot structure
This case also draws clinical inquiry into:
- whether there is weakness of the ankle and forefoot everting muscles namely the peronei and extensor digitorum longus and brevis. * This the topic of the video we are producing because these muscles have huge implications in the cross over gait (which we have senselessly beat you all with in previous blog posts) at the lower end of the limb.
Who are we ? The Gait Guys…… Shawn and Ivo. The dynamic duo of all things gait.
Neuromechanics Weekly: Gait and Running and the Crossed Extensor Responses
This week we discuss why upper and lower limbs are paired in gait, and the neuronal wiring that is involved.
Yup, this is pretty geeky stuff, but geez…isn’t it nice to know WHY something works? Think of the implications if YOU DON’T see the upper and lower limb pairing. Think of the implications during rehab. One limb SHOULD be doing the opposite of the other AND always look at the upper limbs and arm swing. Yes, the central nervous system is involved. It is more than just biomechanics, perhaps this is why this stuff comes easier to us because of our deeper neurology background. The whole is greater than the sum of the parts….
Ivo and Shawn
More on Micah and the future of ultra marathoning: click for AP article link
Quiz: Let’s see how your blog reading has been going.
These 5 photos are of a 2.5 year old child brought into your office for evaluation by his father. They have been seen by another practitioner who has given him orthotics with full length varus posts to wear.
- What do you see?
- What is your assessment?
- What do you tell the parent?
In the standing views, what stands out?
- a moderate rearfoot (calcaneal) valgus (ie. rear foot medial heel collapse)
- the flattened medial longitudinal arches of the foot ( ie. a little flat footed)
- the genu valgus (ie. knees are a little “knock knee’d”)
- he bears weight separately on each lower extremity as you can see from the pictures. He never bears weight on both limb symmetrically, there is much weight bearing shifting meaning there is always a dominant limb bearing most of the weight.
- the knees face inward in the standing position
- the feet point outward (with the knees straight) in the supine position
did you see all of these?
What is your assessment?
1, 2) pes planus and hyperpronation are the norm for children under 6 years of age
3) genu valgus is not abnormal in children, with many presenting maximally at age 3, and usually resolving by age 9 (see our post here)
4) he bears weight separately on each lower extremity (L>R from rear, R>L from front) so there probably is not a leg length discrepancy. This is often a hip-core stability issue and as fatigue sets in weight bearing shift is automatized.
5,6) This child has external tibial torsion. As seen in the supine photo, when the knees face forward, the feet have an increased progression angle (they turn out). We are born with some degree / or little to none, tibial torsion and the in-toeing of infants is due to the angle of the talar neck (30 degrees) and femoral anteversion (the angle of the neck of the femur and the distal end is 35 degrees). The lower limbs rotate outward at a rate of approximately 1.5 degrees per year to reach a final angle of 22 degrees….. that is of course if the normal derotation that a child’s lower limbs go through occurs timely and completely.
What do you tell the parent?
1,2) Although research shows that wearing arch supports (navicular wedge or “cookie”, not a full varus wedge as was the case here) can speed development of the the arches, they will in fact most often develop regardless of supportive footwear or support. Many studies show that footwear impairs muscular development of the foot. One study showed that arch supports in children prevent derotation of the talar head and promote development of a Rothbart Foot Type. How about some flexible shoes (or no shoes) for the boy? (need to review the Rothbart foot type ? click here for one of our very first blog posts on the topic)
3. We will measure the genu valgus and track it every 6 months to make sure it is regressing. If it persists or becomes worse, we may address it then. How about having your kid walk barefoot?
4. no worries, he is resting each side as the other fatigues. Endurance development takes time, just like marathon training. For gosh sake, the kid is 2.5 years old. Give him a break !
5,6) We will measure his progression angle and degree of torsion every 6 months (along with the genu valgus). This is normal up to reaching skeletal maturity.
Well, how did you do?
Corrective exercises are always nice, but when is too soon? Can their immature nervous system handle it ? CAn they comprehend the exercise ? Sometimes turning them into a game and taking what you can get is good enough to help promote healthy limb derotation. Walking with the toes up helps develop arch independence and helps to teach the brain about the foot tripod. But at 2.5 years old, good luck expecting more than that.
The Gait Guys: two handsome bald guys (one by genetics, and one by aspiring choice) aging gracefully and promoting foot and gait literacy, one case at a time.
Ultrarunning Running has lost one of it’s best, the 58 year old from Boulder Colorado, Micah True. Full story of what we know here: http://abcnews.go.com/US/micah-true-ultrarunners-body-found-mexicos-wilderness/story?id=16048218#.T3j03e3Da20
Often times, we find ourselves in a difficult place, often because we made a bad decision. Sometimes, we are in a difficult place because someone decides for us. We must remember that only you have the power to change. If you do not know things are supposed to be different, then they don’t have to be.
Confucius once said “It does not matter how slowly you go so long as you do not stop.”
On your quest, don’t stop
Have a great Sunday
Ivo and Shawn
Bunions
/Dear Gait Guys:
if treated when still a child can you change a bunion without surgery? I have a young kid, 12, with a bilateral forefoot varus and bilateral bunions, he has started to compensate even through his hip and core already which I have been working on but wondered if, by retraining the foot, tripod exercises, lumbricals, interossei, can we actually change his foot? And do you have any other ways that I might be able to attack this foot in order to change it?
Thanks
J
Dear J
As we sure you are aware, bunions form from unopposed activity of the adductor hallicus. Normally, with an appropriate tripod, it serves to assist in forming the transverse and longitudinal arches of the foot during the stance phase of gait. When the 1st ray (in basic terms, the medial aspect of the foot) isn’t anchored, it acts unopposed and adducts the hallux instead, forming an abductovalgus deformity over time. This causes a medial shift of weight in the foot and the metatarsals to abduct to compensate for this. In other words, the big toe and medial tripod are supposed to be well anchored so that the lateral foot is pulled towards it. This forms the forefoot’s transverse arch. But when the medial tripod is not anchored, the lateral foot serves as the anchor and thus the big to is pulled towards that lateral anchor by the adductor hallucis muscle.
It is imperative that you restore function (and the ability) to fully descend the 1st ray (your child must relearn how to anchor that metatarsal head aspect of the tripod). This is imperative for success. We have a youtube video of a young child demonstrating how they learned this. You can often accomplish this with manual methods, mobilization, appropriate footwear and most importantly exercises to descend the 1st ray , particularly toe extensor exercises (both the EHB and the EHL which descend the head of the 1st). Sometimes, if the 1st ray is rigid and won’t descend, you will need to use an orthotic or a cork addition to their footbed with a Mortons toe extension to bring the ground up to the base of the 1st metatarsal.
It sounds like you are strengthening the core, which provides stability from above down. Pay close attention to the external rotators, as they will often be lengthened due to excessive internal rotation of the extremity. But the key is restoring the skill, endurance and strength of those muscles that descend the head of the 1st metatarsal and that help reengage the medial tripod.
We hope this helps. PLease let us know
Ivo and Shawn
