Barefoot Versus Running Shoes: Which Is (Surprisingly) More Efficient?→

Many folks extol the virtues of barefoot or minimal running shoes and or styles. We have contended that you often need to “earn the right” to be able to do this through our mantra “skill, endurance, strength”.

Here is an interesting take by Alex Hutchinson from Runner World and his review of Franz, Wierzbinski and Kram’s study published in Medicine and Science in Sports and Exercise, explaining why, metabolically speaking, shod running may be more efficient

The Gait Guys: sifting and surfing so you don’t have to…

For the 1st time ever, the Gait Guys are offering a “celebrity gait instructional series”…

OK, maybe not; but forensically speaking, you will recognize this gait immediately

Have a great Friday

Shawn and Ivo

Plantar Fascitis?  

 

You’ve got plantar fascitis? We’ll try steroid injections. If that does not work, no problem, we’ll just cut it out…. 

 

Ah, yes…..Nothing like cutting one of the main stabilizing influences for the foot (via the windlass mechanism) to accomplish your goals. We sure are glad they used dead feet in this study!                 

And now, here is more evidence that those ligaments play a significant role (along, of course, with competent musculature) in stability of the foot.    

          The conclusion: “The data suggest that operations involving fasciotomy affect arch stability and should not be performed in patients with evidence of concomitant pes planus deformity, because of the likelihood of further deformation.”    

 

                                                                                                                                   The Gait Guys: Just the facts, so you can make more educated decisions..                                                              

                                                                                                                                  Foot Ankle Int. 1997 Jan;18(1):8-15.

Mechanical behavior of the foot and ankle after plantar fascia release in the unstable foot.

Kitaoka HB, Luo ZP, An KN.

Department of Orthopedics, Mayo Clinic, Rochester, Minnesota, USA.

Abstract

The change in position of the bones of the foot was studied in three dimensions after plantar fascia release in intact and destabilized feet. Fifteen fresh-frozen human foot specimens were used. Physiologic loads of 445 newtons were applied axially to simulate standing at ease, and the three-dimensional position of tarsal bones was determined with a magnetic tracking device. The positions were presented in the form of screw axis displacements, quantitating rotation, and axis of rotation orientation. After fasciotomy in the six intact feet, significant differences in rotation were observed at the talotibial and calcaneotalar levels. After fasciotomy in the four unstable feet with three supporting elements sectioned, significant differences in position were observed at the talotibial joint and a significant decrease in arch height was observed. After fasciotomy in the five unstable feet with five supporting elements sectioned, significant differences in rotation were observed at the talotibial joint (mean, 5.5 +/- 1.6 degrees; P = 0.001), calcaneotalar joint (mean, 6.1 +/- 2.1 degrees; P = 0.003), and metatarsotalar level (mean, 9.3 +/- 4.1 degrees; P = 0.007). The average decrease in arch height was 7.4 +/- 4.1 mm (P = 0.015). Displacement of all joints tested occurred after fasciotomy, with rotation about all three axes. These changes in displacement were more pronounced in unstable or destabilized feet. The data suggest that operations involving fasciotomy affect arch stability and should not be performed in patients with evidence of concomitant pes planus deformity, because of the likelihood of further deformation.

http://www.ncbi.nlm.nih.gov/pubmed/9013108

Recognize this one? Gait evaulation of a skunk. Pepe Le Pew. We did this post a year ago. Has it been a year already ? This one is worth looking at again.

The Foot Slap Gait Style:  

This is a funny little video that shows a few important points.

Our purpose here is to help train your eyes to the important things.  There are multiple clues in every gait compensation.  There is head movement (which we will discuss in this case), there is arm swing (is it equal and symmetrical), torso rotation, hip lateral sway in the frontal plane, violations of sagittal knee progression, and then the always difficult multiplanar foot and ankle motions as well as so many other parameters we consider.  So, when one component goes wrong, with enough experience and skill, one can make predictions as to what is wrong.  And, the more flaws (correlative compensations) that are noted, the higher the predictive value of the assumption.  After decades of doing gait analysis, as with anything, a skill is developed and an art in doing it begins to take shape, as we will see here (without stop frame, without foot mapping devices etc).  One begins to form a mental algorithm to the process.  We always start with, “is the head silent in the vertical, frontal and sagital plane?”.  When a person’s gait is off, the head is almost never silent in space.  And arm swing also begins an assymetrical pendulum effect.  This could be called an energy conservation mode (as talked about in the article on the blog entitled, Dynamic Arm Swing in Human Walking, (http://www.ncbi.nlm.nih.gov/pubmed/19640879) where it was determined that normal arm swinging required minimal shoulder torque, while volitionally holding the arms still required 12% more metabolic energy. Among measures of gait mechanics, vertical ground reaction moment was most affected by arm swinging and increased by 63% without it.

  So, as  you do this more and more you will develop the skills of observation to improve the art form of assessing one’s gait.  But remember this KEY POINT *** what you see is mere information gathering, it is not always and frequently ever, the problem that you see.  You are seeing their compensation pattern around some neurologic, orthopedic or biomechanical problems…..things that are making a silent pristine gait impossible.  You MUST then, take this information and correlate it to your clinical findings in terms of neuro-orthopedic-biomechanical limitations during your exam.  Things like, joint range limitations, muscle weakness, instabilities and the like….things that you cannot accurately detect just watching or video taping a person’s gait. So, you are trying to take what you see, and what you find, and develop a logical algorithm as to where their problem lies and one that tells a solitary lesion logical mechanical story as to the gait pattern you are seeing.

OK, soap box aside………

lets build on that skill set we are trying to develop, the powers of observation and what they COULD mean.

THE SKUNK FU GAIT:

The first thing we see is, the Sagittal head bob.…..each step there is a propulsive head anterior oscillation and then dropping downwards at the end. This can mean there is an apropulsive problem in midstance such as loss of ankle rocker but that is not so in this case, the ankle rocker is great.  The head drop in this case coincides with successive heel strikes each time.  This in essence means that they are dropping from a height each time.  How can this be ? The little fella is on flat ground ! (more on this in a minute).  This could mean a lack of core maintenance in the late midstance phase of gait (heel rise-toe off) and subsequent movement onto the next heel strike.  This can come from overstriding, as in this case, but it can also come from an aggressive forward lean in a person’s gait style (like walking into a strong head wind).  In this case, we have a more reasonable ASSUMPTION, it comes back to the “falling from a height issue”. In this case, lack of adequate anterior compartment lower limb strength (tibialis anterior and the long and short toe extensors, EDL, EDB, EHL, EHB) allows PEPE to move from heel strike to foot flat in an uncontrolled and abrupt fashion.  When this occurs, pronation (even the normal amount of pronation) occurs fast.  And we know that when a person moves from supination to pronation there is a drop in height of the arch and thus a drop in the body (try this to prove the point, …..stand up straight, look in a mirror and begin raising up your toes and then dropping them.  If you do it right, each rise of the toes should raise the arch (The Windlass Effect), and each fall should drop the arch demonstrated in the mirror by a rise and fall of the head vertically.)  And so here you have the height differential in this case.  So, in a nutshell, PEPE is over-striding (as evidenced by his also aggressive arm swing), and falling hard from  heel strike abruptly into foot flat, a double whammy !  There is basically zero eccentric phase activity of the lower anterior compartment musculature and so the foot accelerated to the ground from its starting peak height at heel strike.  The poor fella probably has a raging anterior shin splint condition because of this but you would be hard to tell from the smile on the little stinkers face.  …………but remember, prove your facts on the table……who knows, maybe he has posterior column spinal cord disease, but an examination will have to be done to confirm your findings and suspicions.  In this case, we highly recommend an upwind exam table and plenty of air fresheners. 

we remain,…  The Gait Guys

Gait, Running, Dance, Martial Arts and the Mirror neurons of the brain. Today The Gait Guys put it all together.  (Why you need to get familiar with mirror neurons).

When was the last time you actually truly “listened” to music and “used it” while you worked out or ran?  Many of us do it, but many of us are not using the music to its optimal advantage. This is something we will talk about at the end as we summarize today’s very important article.

Beautiful human movement is something to behold.  Being able to watch and appreciate beautiful movement does several things within the brain.

According the the Scientific American Article (LINK) by Columbia University neurologist John Krakauer:

“some reward-related areas in the brain are connected with motor areas …  and mounting evidence suggests that we are sensitive and attuned to the movements of others’ bodies, because similar brain regions are activated when certain movements are both made and observed. For example, the motor regions of professional dancers’ brains show more activation when they watch other dancers compared with people who don’t dance.”

Many things stimulate our brains’ reward centers, among them, both the participation in and the observance of coordinated movements thanks to our mirror neurons. Today we show an example of the world famous Slavik Kryklyvyy once again. The combination of the physical capabilities and the artistic rendering of the fluid and complex movements stir something in your brain.  Thanks to the mirror neuron cells in the brain’s cortex, which link the sensory experience from when a person is performing a movement or when watching someone else do it generates a subsequent motor experience in the brain.  Watching someone execute a complex athletic task for example, your brain’s movement areas subconscously activate and mentally plan and predict how the athlete would move based on what you would do. We do this when watching sports all the time. How many times have you watched an athlete and either verbally or mentally said to yourself “Oh man ! That was a dumb move ! I would never have done that ! I would have done ______ !"  Krakauer mentioned, ” the motor regions of professional dancers’ brains show more activation when they watch other dancers compared with people who don’t dance.“  This will be the same for all athletes. This is the same neurologic phenomenon that also allows you to truly appreciate a movement when it is done with amazing skill and precision.  Think of Cirque du Soleil and you will instantly know what we mean.

Watching Slavik move in the video above is complex motor tasking at its best. Dancers are amazing athletes, they are not just dancers. They are much like martial artists. Take Capoeira for example. It is a Brazilian martial art that combines elements of dance and music. It was created in Brazil mainly by descendants of African slaves with Brazilian native influences. It is a complex and feared martial art known by quick and complex moves, using mainly power, speed, and leverage for leg sweeps. It is a beautiful art, and a deadly art.

So, why does music make it that much better ? It is the same reason why weddings are less touching without music.  It is why music is used in church. It is why dance is paired with music.  Music stimulates the pleasure and reward areas of the brain, such as the orbitofrontal cortex, the ventral striatum and the cerebellum where timing, coordination and movement planning is performed. The combination of music with the motor task amplifies the reward zone in the brain. It is the task of trying to add timing and rhythm to movement that makes these activities that much harder, but that much more rewarding to the brain.  Runners who run with music, those who truly hear the timing and rhythm of the music and then use it in their workouts get a little something extra out of it. But sadly so many people "just listen” to the music instead of incorporating it into the movement.  A smart runner will vary the music and combine it with a run to vary tempo, cadence, speed etc.  That way the brain will be on fire and dish out rewards at a  new level. Dancers have no choice but to force the issue. We will sometimes use a metronome snapping of our fingers or clapping in the rhythm of a clients gait to help them hear the rhythm of their gait, particularly when it is arrhythmic due to pain or faulty biomechanics. We will do this so that it cues a heightened awareness in them. Seeing, feeling and hearing are all additive when sensory-motor relearning is concerned.

Gait and running are complex movements which we take for granted.  They are so automatized that we really do not realize how complex and amazing they are until something goes wrong or until someone brings the subtle flaws to our attention.  Maybe it is a stroke that compromises it, or maybe a neurologic disease like Parkinsons, or maybe it is as simple as a sprained ankle, a torn knee mensicus, a strained hamstring or a degenerative hip.  But any compromise to this complex sensory-motor task of ambulation immediately brings about a recognition that something is wrong to the skilled and aware observer. As in life, we do not appreciate something until something goes wrong with it.  Getting good at recognizing beautiful clean fluid gait and running is our job, and it is now your job. Now that you know better you cannot ignore gait in your clients, your artists, your athletes. Now that you know better, you must hold yourself to a higher level of expertise. Knowing what beautiful looks like will help you better understand what loss of beauty looks like.  It is what will make you better at understanding gait and human movement and locomotion and better at your chosen craft. It is what will heighten your appreciation of the amazing beauty of the human form and motion, whatever form it might take.

Shawn and Ivo,  the gait guys

The Collective Goal of Natural Running. The Gait Guys Opinion.

Is this minimalist shoe trend a fad or is it truly a trend? What is the truth. (What are you not being told ?)

It appears that over the last few years this question is finding its own answer, for the most part.

We believe this minimalist direction has become entrenched enough now seeing the increased work and attention from most companies. We suspect that this is a firm trend which will not be going anywhere soon, although modifications will be likely. The research papers are convincing that there are benefits. However, we feel the industry is not spending enough time discussing the risks and concerns. And we are finding out that there are two issues here on that topic.

1. That discussing the demerits of a product is not likely good marketing.

2. One must know the underlying problems around the product, and more importantly the foot that is going into the product to understand a product’s drawbacks and risks.

None the less, there are issues not being talked about.

The fact of the matter is that some foot types do not, and never will, have any business being in such minimalistic shoes (ie. a rigid flat foot pes planovalgus or a rigid forefoot varus foot type are just a few examples). We remain concerned about the vague existing dialogue that these types of shoes will make everyone’s feet stronger. For some, they will, but many times strength education must be directed (There is a right way to do a squat, and a wrong way. There is a right strategy for toe off, and a wrong one.). With the wrong strategies employed, one can easily strengthen the incorrect motor patterns. Merely putting on a minimalistic shoe does not mean that the correct patterns and strategies for foot strengthening are being instituted. The shoes do not come with a magic potion guarantee. For those with challenged foot types (FF varus, Rothbart Foot, cavovarus foot, excessive tibial varum and/or tibial torsion etc) these folks will likely trend towards local foot problems or injuries further up the kinetic chain (hip, knee, low back etc). Understandably, these are heavy medical terms and conditions but they are very much out there in the running public and with little attention to the “buyer beware” warning when attempting to add a minimalist shoe to their mix. We know these issues exist, we see them daily in our clinic. As we see it, the problem could be that those providing the education often do not have enough clinical background to know what these issues are let alone recognize them or prescribe the right shoe for the combined presentation . So how can they then draw these issues to the surface in educating the public ? As we say in our lectures, “You first have to know what a platypus is in order to identify it. Otherwise it is just a hedge hog with flippers and a duck bill.” This is the elephant in the room that everyone is missing, everyone except us. We get the folks who are running in these minimalist devices and we get to see those who should never have been in them in the first place.

The good thing is that many companies are setting up educational programs to help folks drop down into “minimalism 2.0”. But still, to date, two problems exists in that arena.

1. no one is talking about the elephants in the room, those being those foot types that are too risky to be in the shoes and even more specifically, how to strengthen the foot. But who would admit to those risks, that would be stupid advertising.

2. those teaching the courses and those individuals that rep for the companies and act as an intermediary between the shoe company and the store either do not have the fundamental knowledge to educate the shoe stores about the merits and demerits of the products or they find there is too much of a knowledge gap between the parties so things are left unspoken. You have to be able to see the elephant in the room to address it.

It is at the heart of these issues that we feel we can make a difference. A few companies are finally listening to us on these topics. We are getting more calls, emails and inquiries as to how we can help them bring these issues to light and improve upon their products. Sadly, most companies are not doing the same and we feel they will be left behind. Companies are sharing exciting yet difficult challenges and many are struggling to catch up. Some of them are really on board and doing their homework and are coming to the table with really impressive dialogue. We are excited to work closely with these types of companies so that all runners can reap the safe and effective benefits of better products and more knowledgeable intermediaries. These companies, some big, some small, get a big thumbs up from us because the knowledge behind the product is spot on but more so because the product is excellent and does what it says it is supposed to do and goes beyond what the other products seem to be doing at this point. But there is always someone around the corner pushing the guys at the front.

Our one ‘stick in the mud’ issue is that still no one is talking about the elephants. And we believe its mostly because no one can see them. There is a main danger in doing too much barefoot running too soon. We made this clear initially on Vibram’s website when we wrote the part on how to progress out of your running shoe and down into Vibrams. For us it is, and has always been, about “keeping them honest” and putting out the facts. But don’t expect us not to make mistakes, nor to not own up to them. But do expect us to try to “right the wrongs”. From time to time we try to make the calls on the products that have questionable statements and applaud those that stick their neck out to do the right thing. We do not know everything, but we seem to know much more than many when it comes to the biomechanics of what is going in a product and in knowing when there is a giant tusked animal in the room.

If you put 10 different feet in a product, you will get 10 different biomechanical presentations from the shoe, and that is the difficult truth. So, logically, much of what is being missed is the education of that issues and of what is going on in the shoe, and that is our world. It is usually the problems that exist with the thing you are putting into all of these products, a person. A person who likely does not have the classic middle of the road, ‘Average Foot’ these shoes may have been designed and researched around.

To us, the most important thing is to raise the knowledge and awareness to the public, shoe companies, shoe stores and everyone else in between.

At this point, if this minimalist shoe trend is to survive we believe there must be enough companies that extol the virtues of honesty and education to the end user, the shoe company-shoe rep intermediaries, running form clinic presenters and educators. And, that means talking also about the elephants in the room. Our new, soon to launch, Shoe Fit Educational Program will help everyone get on the same page, and the same elephant.

Shawn Allen and Ivo Waerlop……… The Gait Guys

What’s your foot type? : Part 3 of a 5 part series

Forefoot varus.

Here the forefoot is inverted (twisted inward about its long axis) with respect to the rear foot and the big toe side of one of the front legs of the tripod is able to touch the ground without compromising normal mechanics and collapsing medially to bring the foot to the ground.  In doing so, this foot like the rearfoot valgus foot, has to rotate internally more dramatically, forcing pronation (dorsiflexion, eversion and adduction) to occur more violently and for a longer period of time.  This action drags the knee medially and leads to the same hip and pelvic stability and external rotation challenges we discussed in the rearfoot valgus, as well as patellofemoral tracking syndromes.

A little lost? We were too. That’s why we have this blog and have come up with a the only of it’s kind “Shoe Fit Program” . Launching soon with the new website. The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail.

WE ARE The Gait Guys: foot and gait literacy for everyone! 

The Gait Guys are Ridiculously Esoteric (apparently)

Any attention to your work is good attention. This one made us truly smile (it means we are doing our job) …. we will take being ridiculously esoteric as a compliment ! If paying attention to details wasn’t important no one would never do it. Take any professional (athlete or otherwise) and ask them not to pay attention to the small details of their craft and see how far they get !

http://www.sherdog.net/forums/f13/gait-guys-1892419/

“Here’s a fine series of videos designed to make you paranoid about walking. Some of the videos on their (The Gait Guys) channel veer into ridiculously esoteric territory of interest only to brain surgeons, but there are also several comprehensible explanations of the workings of the hip, the foot and some great practical assessments…

History Lesson Saturday:  The Shoe Fitting Fluroscope

The following was copied from the following YouTube Channel, LINK here.   Please visit their, “The Historic Workplace & Environmental Health and Safety Films” YouTube page at that link.  This is good historical information. Rather than put it into our own words and risk degrading its thoroughness we quote it here.  It is good to look back at history. Some folks say this because we are told that those who do not know the history of things are destined to repeat them.  However, we have heard it put “History will repeat itself. Knowing history will make us aware of when it is about to repeat itself."  Enjoy this piece of history.

"The shoe fitting fluoroscope was a common fixture in shoe stores during the 1930s, 1940s and 1950s. The first fluoroscopic device for x-raying feet may have been created during World War I to eliminating the need for patients to remove their boots, to speed up the processing of the large number of injured military personnel who were seeking help. After the war the device was modified the device for shoe-fitting and showed it for the first time at a shoe retailers convention in Boston in 1920. The X-ray Shoe Fitter Corporation of Milwaukee Wisconsin and the Pedoscope Company of St. Albans in the U.K, were the two largest manufacturers of shoe fitting fluoroscopes. In the early 1950s, estimates placed the number of operating units in the United States, the United Kingdom and Canada at 10,000, 3,000 and 1,000 respectively. After WWII, the manufacturers of shoe fitting fluoroscopes became concerned that their products would have to meet a myriad of standards that varied from location to location, and they asked the American Conference of Governmental Industrial Hygienists (ACGIH) to recommend a uniform set of standards. The ACGIH did so and issued their guidance in 1950, an event that allowed the manufacturers to advertise that they met the ACGIH standards. By the early 1950s, a number of professional organizations had issued warnings about the continued use of shoe-fitting fluoroscopes, A few years later, Massachusetts passed regulations requiring that the machines be operated by a licensed physician. In 1957 the State of Pennsylvania became the first jurisdiction to ban the use of shoe fitting fluoroscopes. Attempts to impose regulatory restrictions on the use of shoe fitting fluoroscopes seem to have been limited to the United States . These machines continued to be used in Canada and the UK to a limited extent, at least until 1970. Many shoe salespersons put their hands into the x-ray beam to squeeze the shoe during the fitting. As a result, one saleswoman who had operated a shoe fitting fluoroscope 10 to 20 times each day over a ten year period developed dermatitis of the hands. One of the more serious injuries linked to the operation of these machines involved a shoe model who received such a serious radiation burn that her leg had to be amputated. For more on the history and use of these devices, go to: http://www.orau.org/ptp/collection/shoefittingfluor/shoe.htm . This clip is from the 1920s silent film, General Personal Hygiene, available on the Internet Archives.”

Does your Yoga Tree Suck ? Yoga tree for runners.

Look at the 2 photos above. Click on the lady in the blue shorts so you can see her full photo and then toggle back and forth between the 2 photos. Both show a lady doing the Yoga Tree pose.  There are alot of ways to do this post.  Which one is right ? Which one is best ? Is one wrong ? How can a runner, and all of us for that matter, take advantage of the Tree pose ?

This blog post is all about PROPERLY improving strength and PROPER motor programs of the stance phase leg so that the opposite pendulum swing leg works through the simplest freely swinging swing phase.  A correct swing phase will result from good stance phase biomechanics on the stance side.  So what you do on well on one side will render safe mechanics on that side and show good results on the opposite side or it if what you do it poor mechanics, it risks both sides for functional pathology and injury.

In the 2 photos we see two different levels of the two pelvi. One waist line is horizontal and the other is on an angle.  Do you know which one is more correct ? Draw a vertical line in your mind from the foot up through the body on both ladies.  Can you see that the lady in the black leggings has far more body mass lateral to the line ? Look at the dramatic angle of attack of the leg into the ground (draw a mental line from the hip joint to the foot on both, the line is much more vertical in the lady with the blue shorts.) The lady on the left in the blue shorts shows good gluteus medius use. The stance phase leg is more vertical, the pelvis is elevated on the swing leg (the bent knee side in this case) and with that same vertical line reference there is little more than the lateral hip outside/lateral to the line. Shorts-lady shows opposite pelvis elevation acquired by good stance leg gluteus medius and abdominal core use.  This stance limb is in the concentric-isometric gluteus medius phase.  The lady on the right has a lower pelvis and a laterally shifted pelvis.  The body mass is over the hip joint (for you detailed fact “sticklers”, yes she could be moving the non-stance phase pelvis down through the hip frontal plane via an eccentric exercise if she is doing a dynamic tree pose).  None the less, this lady’s static posture requires very little gluteus medius use because she has most of her body mass over her hip joint axis.  The gluteus medius under needle EMG would show very little activity. This is an easier Tree pose and this client is not getting all she can out of the pose.  It would ask more of her gluteus medius and core as well as more lower limb and foot strength, skill and balance to do what the lady on the left is doing.  Try it yourself. Are you getting as much as you should out of your tree ? IS your balance really as good as you think it is if you are doing the pose right ?  The lady on the left will have to work harder but will get far more out of the pose.

The lady on the left in the blue shorts also has her hands above her body, extending actively reaching for the ceiling. This will lift the rib cage from the pelvis and make it more difficult for the abominals to stabilize the core. This is a level-up challenge. Plus the arms when not out to the sides cannot act as balance stabilizers.  The lady in the shorts is getting far more out of her pose and is working for that smile. 

As a runner this is a GREAT exercise. We have our patients do this one for homework to teach, learn and master the use of the gluteus medius and core musculature.  Afterall, you need these muscles to be optimal during each stance phase when you are running.  Each landing is nothing more than a rushed single leg stance, and you can do it right and stay injury free or you can do it wrong and risk some down time.

* key point= make sure you keep your pelvis in the frontal plane, many folks will let the pelvis spin (the non-stance leg) can drift backwards. Thus you are spinning your pelvis on the stance leg. Most unknowing people will let it spin until they find the point where they have good strength and balance.  What is the point in doing that !!! ????  Do the pose where it is challenging, not where it is easy ! 

* Now for your test: Based on what we have talked about here today, watch this very short video of 2 gentlemen doing the pose and see if you can see which of the 2 needs more gluteus medius work, or at least which of the 2 needs to work on abducting the hip better ?  One of the 2 is more stable in the frontal plane, and does not drift laterally.  Ready ? Go ! VIDEO LINK

Cross train to stay injury free.

Cross train smarter, not harder or longer.  Get the most out of what you do. 

Shawn and Ivo.  Just 2 trees in a very large forest.  And using the optimal view of the forest that we have had for so very long (40+ years of clinical practice) to help other trees to grow up straight and strong.

Retail Focus…Really…

The Vamp: What you need to know… (3 pics here today)

Vamp may refer to anything from a Norwegian folk band, a repeating musical figure in a song, a femme fatale, a vampire, a movie, action figure or comic character. It can also be part of a shoe. 

For our intents and purposes, though these are all interesting topics, we are going to limit our discussion to shoes…

Every shoe has an upper part that helps hold the shoe onto the foot. The “vamp” refers to the upper at can cover anywhere on the top part of the foot between where the toes and the legs connect to the foot.

In styles that don’t offer a lot of coverage on top of the foot, the part that covers the tops of the toes might also be referred to as the vamp. Closed footwear, such as boots, trainers and most men’s shoes, will have a more complex upper. This part is often decorated or is made in a certain style to look attractive.

The vamp has a medial and lateral part. The medial vamp (located on the inside or big toe side of the shoe) often gives support to the medial longitudinal arch of the foot (since most shoes offer little if any arch support in and of themselves). Likewise, the lateral vamp can (but often does not) offer support to the lateral longitudinal arch.

Most folks like shoes with a larger, snug medial vamp, because it “feels” better and that’s what they are used to. Then again, most people wear shoes that are too tight for their feet anyway. More on this in a post on the Brannock’s Device.

The Vamp. An athletic supporter for your feet : )

Ivo and Shawn. Definitely Foot geeks, but not shoe vamps.

MBT Revisited:

Perhaps you have read our previous thoughts on the MBT shoe. If not, click here, or listen to an old podcast here.

This is a video from their website which has a few redeeming qualities and teaching value.

1st of all, we notice that the shoe is rockered in the saggital (:02-:05 and :49-:54) AND coronal (:55-:59) planes. Rockers in the saggital plane are a Godsend for folks with hallux limitus and functional hallux limitus (limited ablility to dorsiflex the great toe, aka Turf Toe). Rockers in the coronal plane (the side to side motion plane) promote medial/lateral instability. This can be therapeutic, but ONLY if you have earned the right (through skill, endurance, strength) to be able to handle that instability. Challenges to the coronal plane, sometimes referred to as the lateral plane, are helpful in rehabilitating things like ankle sprains. Rockers, in general, have a higher metabolic cost and require greater proprioception and skill to handle, thus the “increased muscle activation” (1:12-1:23).

A saggital rocker can decrease stress on the knees and hips (1:27-1:30) because it limits the amount of ankle dorsiflexion needed and the “rolling” motion assists in knee and hip flexion. This increased motion comes at a cost of increased hamstring activation (1:15-1:17) and a smaller increase in gluteal activation (1:18-1:20). Do we really want to promote the hamstring dominance when the gluteus medius-maximus team is supposed to help carry us through the gait cycle? Remember, the Gluteus Maximus is only supposed to contract up to the moment before midstance, with a burst at toe off.

It would be interesting to see what effect (positive or negative), or if any, they have on foot intrinsic activity. With a rigid last (you cannot bend these shoes because of the rigid built-in rocker) the foot may be pretty silent since the shoe merely passively rocks you forward into each step.

On a positive note, they do promote a more upright posture (:18-:27) compared to a traditional heeled shoe which purchases the user forward as noted in the video.  The shoes also have a decreased amplitude of vertical oscillation (:19-:22).

We again caution that need to “earn” you way into this shoe, and though it can be a  rehab tool, we do not feel it is a great shoe for day to day activities or running in.  One of our greatest concerns, other than what the shoe can be doing to the normal function of the foot muscles and joints, is the extremely soft crash-entry zone at the rear 1/3rd of the shoe (depicted here in red in the video).  The EVA  foam is so soft that a heel strike cannot be achieved. Heel strike is part of  normal gait. However, as we have coined, there is a difference between heel strike/impact and heel contact.  We recommend the thought of the heel “kissing” the ground and smoothly transitioning to midfoot strike, no matter what shoe is used in walking.  Certainly running is a different matter, we prefer midfoot strike, where the foot type is accomodating so such a strike.  Not everyone has a foot type that will respond to a forefoot strike (ie. forefoot varus) without eventual pathology or injury.  If heel strike were to occur in the MBT the risk of knee hyperextension would be on the table and retrograde knee motion is never good and never helpful when progression forward is desired.

Almost every shoe has a perk and a drawback. You just need to understand the engineering of the shoe  and understand the foot and body that is going into the shoe, to decide how it might help you.  We do use this shoe for some foot types, mostly as a therapeutic device to help someone heal or improve skills to achieve performance success.  But as a day to day shoe, this is not a shoe we ever recommend. This shoe alters normal biomechanical events, a compensated gait if you will. 

The Gait Guys: just the facts, so you can make more educated decisions.

Upright bipedal walking and the stoned chimpanzee.

How different is our human gait to the chimpanzee gait ? Months ago we did a blog post on the Sasquatch aka Bigfoot. You can find our blog post here (click). Bipedal walking is evident in the earliest hominins [Zollikofer CPE, Ponce de Leon MS, Lieberman DE, Guy F, Pilbeam D, et al. (2005) Nature 434:755–759], but still today the true reason as to why our unique two-legged gait evolved remains unknown for certain. Scientists 7 years ago found fossil evidence in Ethiopia that showed human ancestors walked on two legs as early as 5.2 million years ago. The fossils were of the earliest hominid known, and dated from close to the time when human ancestors are believed to have split off from the chimpanzees on the first steps of their evolutionary trip to modern Homo sapiens.

Our point here today is just to briefly discuss a few of the biomechanical characteristics of the chimpanzee gait and to correlate them to problems we see in human gait. Our point however is not to bring up issues of evolution, creation or anything of the sort that might offend anyone’s beliefs (however at the end of this piece we do have some creative “outside the box” fun thinking and offer some challenging possibilities in correlating them to theories of how man’s brain might have grown so suddenly and possibly where the advancement of complex motor patterns evolved).

This time we look at the chimpanzee. How does the chimpanzee differ from the gorilla in quadrupedal ambulation ? Both walk with a knuckle-type weight bearing but chimpanzees ambulate quadruped with bend wrists, their carpal bones have ridges and grooves like humans that allow for end range lockout while gorillas quadruped via straight arm and neutral wrist knuckle weight bearing.

But what about humans and these hairy precursors ? Are there similarities ? Differences ? Well, the main question we wanted to ask since apes were not far enough evolutionarily to walk effectively upright is, “are there similarities to pathologic gait problems that lead to injury and these hairy ancestors ?”. We believe the answer is yes.

1. posteriorly tilted pelvis
2. small weakended glutes
3. quadriceps dominant
4. lack of knee extension
5. lack of hip extension and gluteal development

There are many interesting thoughts here. Including the question that the documentary video above poses in part 2 found on youtube. Can two species with 99% of the same DNA have similar problems? Should they? The numbers are in favor of this theory. It also bodes the question that recurs in the video series on Oliver the chimp, if he is even closer to human DNA than his siblings then is this why he walked upright like us humans ?

article link: http://www.pnas.org/content/104/30/12265.full

In this article link above, the authors support the possible hypothesis that energetics played an important role in the evolution of bipedalism. Unfortunately there still remains an evidence gap archaeologically to fully support this hypothesis that locomotor economy provided the initial evolutionary advantage for hominin bipedalism. The study above indicated that

“the biomechanical analysis of adult chimpanzee costs, coupled with previous analyses of early hominin pelvic and hindlimb morphology, suggest that improved locomotor economy may have accrued very early within the hominin lineage. Future fossil discoveries from the earliest hominins will resolve whether this energetic advantage was in fact the key factor in the evolution of hominin bipedalism.”

Similar to this study, some sources discuss that moving to an upright gait is what caused our brains to suddenly expand in size and thus begin to cerebrally dominate all other creatures on earth. This does however remain a hotly debated topic. Our recent interests on these topics have brought us far and wide. Topics on brain expansion have included the strategizing of carrying infants, food and weapons for distances to hunt for food to being able to run distances more efficiently to hunt. Language (complex communication verbally and with symbols), art (cave wall paintings), religion, spiritual belief development and developing the manual dexterity and complex thinking to build and use tools for specific tasks are just some of the other reasons as to what spurred the massive growth of the human brain roughly 50,000 years ago (Google search “brain expansion 50,000 years ago”).

But, if you really want to challenge your beliefs on the topic of brain size expansion and the development of complex neurologic patterning read some of the fascinating work by Graham Hancock or Terrance McKenna on ayahuasca (yes, The Gait Guys are about to talk about mind expanding hallucinogenic drugs). From Wikipedia,

Ayahuasca (ayawaska pronounced [ajaˈwaska] in the Quechua language) is any of various psychoactive infusions or decoctions prepared from the Banisteriopsis spp. vine, usually mixed with the leaves of dimethyltryptamine (DMT)-containing species of shrubs from the genus Psychotria. The brew, first described academically in the early 1950s by Harvard ethnobotanist Richard Evans Schultes, who found it employed for divinatory and healing purposes by the native peoples of Amazonian Colombia, is known by a number of different names (see below). It has been reported that some effects can be had from consuming the caapi vine alone, but that DMT-containing plants (such as Psychotria) remain inactive when drunk as a brew without a source of monoamine oxidase inhibitor (MAOI) such as B. caapi. “

You may find it interesting that some new age theories by gentlemen such as mentioned above propose that it was the use of these hallucinogenics containing DMT as well as Psilocybin (aka magic mushrooms) as possible mechanisms for the massive growth of the human brain and subsequent abilities to tackle more complex motor tasks, especially those that incorporated ambulation.

Think that we, and these men, are a bit crazy ? That is ok, probably many folks already think that. But heck, even in some sources that discuss what was present in the Garden of Eden show possible evidence of this wild theorizing because according to several sources the "potential forbidden fruits of the Garden of Eden include the apple, pomegranate,the fig, the carob, the etrog or citron, the pear, and, more recently, the datura (a hallucinogenic) ( were all present). And, "A fresco in the 13th-century Plaincourault Abbey in France depicts Adam and Eve in the Garden of Eden, flanking a Tree of Knowledge that has the appearance of a gigantic Amanita muscaria, a poisonous and psychoactive mushroom”, was also possibly present. Now, do not put words in our mouths, we are not saying by any stretch of the imagination that Adam and Eve were stoners. McKenna and Hancock and many others merely theorize (with logical inquiry) that at some point in history, they believe around 50,000 years ago, that mind expanding drugs may have helped force the brain to develop by experiencing cerebral alternative phenomena that the real world was not able to offer. And it is postulated that this brain expansion is what has allowed higher function and higher cognition. And if you think we are crazy to even bring this up as a possibility you might consider doing your own investigations looking into the minds of some brilliant and educated people in science today. You will find that some of them will not dismiss this seemingly radical topic as the reason for the massive and sudden expansion in brain size. Yes, like some of these researchers we are pushing the limits here, but who are we to say that we know the truth any better ? None the less, this blog is not the place to discuss mind expanding hallucinogenics, although we are happy to offer it as just one of the theories of wiser men and women to wet your curiosity to wilder ideas ! Heck, something made our brains suddenly expand some 50,000 years ago. We had millions of years for it to happen, so why was it right around 50,000 years ago ? Because that was the first documented evidence of mind altering natural (yes, organic) herbals? Professor Davis Lewis Williams apparently thinks so. It certainly would have been easier to reach down and grab some leaves and vines or mushrooms wouldn’t it ? Take today’s post with a grin, a pinch of salt, and a pinch of curiosity !

And to further tease your mind to open up, do you wanna guess who else might have done a little substance experimenting ? Search the web for “Einstein and drugs”. One source claims that Einstien’s blood was tested after his death with the autopsy apparently showing traces of LSD as well as Dimethyl-triptimene (DMT). Still wondering how he got so smart ? Hmmm. Now, if you do your homework you will find that DMT is a natural chemical in the body as well as in many plant types, it is a chemical possibly involved with the pineal gland. Many theorize that the dream state we experience every night is from the natural low levels of DMT in our brain, it is possibly why our dreams are so wild and wonderful. But DMT is found in many foods as well, we just break it down with MAO (mono amine oxidase). This is why the psychadelic trips with DMT require a MAO inhibitor to the drug can do its thing. Anyhow, enough drug and brain education for today………

Einstein and many others…….. smart, big brained, world changing folks, many dabbling in mind expanding substances. Heck, how else does one come up with String Theory, Dark Matter, Black holes, Space-Time continuum etc ? Maybe you have to be thinking outside the box and possibly tapping into another dimension to come up with such broad thoughts. Who knows ? Kinda makes you wonder what you might have missed out on in college doesn’t it … if in fact you missed out on it.

The “Stoned Ape Theory” tangent. It is a very radical extreme theory for brain size expansion 50,000 years ago. But radical theories are cool, they make you stretch your thinking and comfort zone. And they just might be true , who knows ? If we can for a moment put aside preconceived biases, old education and embedded religious beliefs and open our mind and thinking we just might see things that expand our wisdom. That’s the hard work. It doesn’t mean we have to accept them. Challenging radical ideas can do that if you can open your curiosity. Regardless, paleo brain or neo brain , we ambulated with both. Brain expansion changed gait, because it changed what we do while we ambulate. And then we changed it all further by adding shoes and paving the surfaces of our world.

Shawn and Ivo…… more than just gait geeks but certainly not Stoned Apes. Maybe just two guys here to further expand the brains of 21st century man with theories on gait and biomechanics.

What’s your Foot Type? : Part 2

Welcome to Monday! Here is the next in the series…

Rearfoot valgus.

Remember the foot tripod? It consists of the the 3 points: the base of the 1st metatarsal (under the sesamoids), the base of the 5th metatarsal, and the calcaneus. In this foot type the rear leg of the tripod is compromised as the rear foot collapses medially (the heel or calcaneus,  everts or moves laterally) causing subsequent collapse of the arch and midfoot.

This foot type causes an excessive internal rotation strain on the lower kinetic chain, often with collapse of the knees inward (genu valgum or “knock knees”). Due to the midfoot collapse, the deep calf muscles are typically overused and strained leading to medial ankle region tendonopathies, as they attempt to slow the rate of pronation and arch collapse.

This foot type has a difficult time going from pronation to supination to prepare for a rigid foot push off in the propulsive phase. Because the lower limb is internally rotated so much, the external rotators are over burdened leading to fatigue and weakness of the glutes and shortening of the TFL, leading to the chronic IT Band syndromes. Low back pain is common because of forward tip of the pelvis.

2 down, 3 to go!

Confused between the ear?

Have no fear. Shed no tear.

Our shoe fit program is almost here!     (Everyone has a little Dr. Seuss in them)

The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail.

The Gait Guys: promoting foot and gait competency everywhere!

Gait, Arm Swing and Reorganizing the Brain→

When we injure a body part there is a price to pay. The brain takes note of pain and usually uses its backup plan of neurologic inhibition or alteration of a motor pattern to protect that injured area and allow it to heal by moderating or altering the forces and demands upon said tissues.

This is a mechanism we need to have in place. But if we do not heed its warnings to dial things back and rest, recover and heal the brain will make alternative changes.

In this neurologically based article linked above in the title, the authors discuss several important things.

“Getting a cast or splint causes the brain to rapidly shift its resources to make righties function better as lefties, researchers found.
Right-handed individuals whose dominant arm had to be immobilized after an injury showed a drop in (brain) cortical thickness in the area that controls primary motor and sensory areas for the hand, Nicolas Langer, MSc, of the University of Zurich in Switzerland, and colleagues reported.
Over the same two-week period, white and gray matter increased in the areas that controlled the uninjured left hand, suggesting "skill transfer from the right to the left hand,” the group reported in the Jan. 17 issue of Neurology.
The findings highlight the plasticity of the brain in rapidly adapting to changing demands, but also hold implications for clinical practice, they noted.“

This article highlights the rapid changes in motor programs that occur. It does not take long for the body to begin to develop not only functional adaptations but neurologic changes at the brain level within days and certainly less than 2 weeks.

We tell our patients, if pain does not go away fairly quickly, that we need to get on top of the injury quickly. That is not to say you need to reach for the phone every time you  have pain but you need to heighten your awareness of the injury’s status and  you need to make sure you are not driving session after session of training into a festering injury. If you do not let something heal and recover, the brain will find a way around it.  And it will imprint that new motor pattern into hard wiring if you do not heed the warning signs.  This new wiring is a compensation pattern. And the longer it is there the more the neurologic pattern becomes embedded by layerings of myelin coating.  Which means that in the future, if you fatigue or injury another local tissue, this old compensation pattern is waiting in the shadows looking for an opening to rear its ugly head for old times sake. 

Shawn and Ivo …  Two plastic fellas, just like everyone else. 

Email from a reader: Chronic IT Band and Plantar Fasciitis

I have been reviewing your Youtube videos and blog posts over the last few weeks, I am a triathlete suffering from plantar fasciitis and ITB issues, and I’m not really close to a major center where I can get treatment so I’m self educating. I’m very interested in the videos you have about function of the foot, and how the toes relate to the arch, fascinating! You mention exercises for the feet, to help the muscles function and learn to work separately. I was wondering if you have any of these exercises posted online, I am not able to hold the arch position or use my toes separately, I think these movements would go a long way to helping me figure why I’m having issues with the PF. Great job on all the info, I love being able to access info like you guys have online, makes me want to learn more… thanks!!

 

 

Becky H

AB, Canada

_______________________

Dear Becky:

Sorry to hear about your chronic issues.  Make sure you evaluate your glutes. The pelvis must remain relatively quiet and not tip forward or backward (anterior or posterior tilt) during all forms of ambulation. When it tips more forward the glutes become challenged and can become inhibited. When inhibited internal rotation of the hip minimizes or is lost and the ITBand tightens to attempt to drive that internal rotation. It is a good internal rotator as is the anterior g. medius and coccygeal division of the glute maximus (hence the glute connection).  This will put stain on the patellofemoral joint and may cause tracking issues or lateral knee regional pain (or ELPS….. excessive lateral patellar pressure syndrome).  Additionally, when the foot tries to pronate more to drive more internal limb rotation (because it is obviously not happening at the hip in this scenario) the plantar fascia can become strained because of the pronation lengthening of the longitudinal arch of the foot.

Regarding the foot exercises……. they are coming….. we just need time. We would pay for more time, but we cannot seem to find it on amazon or ebay.  If anyone is selling, we will line up to buy !

thanks for your email question.

Keep the emails coming. Those of you who have emailed us recently or in the past, we  have received them and they are being answered in length in the podcasts we are about to launch. They are coming, you will love them.  It just comes down to editing time.  There is that “time” word again !

A runner with an inverted heel and functional hallux limitus

Here is a long Q and A Dr. Ivo had with a client who emailed us quite awhile back. It is very informative and it has links to the readers gait videos.  We hope you find this informative.

Q:    I am a long time distance runner (33 years of marathoning so far ) that has had back and hip problems since the 1980’s. I have tried all sorts of therapies, but I have a funky stride on my left side. I started going to an ART doctor this week. He said I have an inverted heel on the left side and functional hallux limitus on both sides, however on the left side (with the inverted heel) the foot pronates down to get the first metatarsal to touch the ground. So my left heel supinates and the forefoot pronates and does this strange movement that creates havoc with my leg and hip (at least that is my understanding).

By checking out your videos, is rearfoot varus the same as inverted heel? or is there something else you can point me to. I am getting ART treatment for the heel, mobilizations on the foot, and the doctor suggested cutting out part of a Dr. Schools ¾ foot insole underneath the first metatarsal to see if this makes the toe and metatarsal work.

You can see short videos of my funky left foot stride here: http://recoveryourstride.blogspot.com/2010/06/inverted-heel.html
Any thoughts or advice would be much appreciated.
Jim

______________________

Hi Jim

Thanks for the post and video. I apologize for the late response. It was very helpful as we use it to analyze most athletes. I am not sure if you can email the original file; it would make an excellent teaching tool.

To answer your question, an inverted heel is usually synonymous with rear foot varus deformity. The latter technically means that you are unable to evert your heel to zero degrees. Eversion is a necessary component of rearfoot pronation and if it cannot occur there, it will occur in the midfoot or forefoot. I would need to see a picture of your foot to tell you where yours is probably occurring; my guess is the forefoot. It appears you may also have a difference in the length of your legs as well, either functional or anatomical.

You have external tibial torsion. This means the angle your ankle makes with your lower leg (ie the angle formed by a line bisecting the medial and lateral malleolus and a straight one) is in excess of 25 degrees (it is usually 20-25 degrees). It is a congenital condition that appears largely unilateral in your case. Internal tibial torsion would be when the angle is less than 20 degrees and the foot points in.

The limb buds appear somewhere near the end of the 5th week of embryological development and continue to develop into the paddle shaped vestiges we have come to know as hands and feet over the ensuing weeks. At around 7 weeks, the axes of the upper and lower extremity buds are parallel. They then bend 90 degrees (forming elbows and knees) and stearicaly rotate opposite one another, so that the ventral (or flexor) surfaces of the arm and forearm face anteriorly in norma anatomica and the ventral (or flexor) surfaces of the lower extremities face posteriorly. So in other words, this is a genetically determined sequence of events, which can sometimes (but rarely) run awry, with no influence from muscle activity or inherent osseous torsions.

This condition means that when your knees point straight ahead, the foot points to the outside; if you point your foot straight, the knee points to the inside (both are demonstrated on your video). This creates a problem because if you straighten your foot, anatomical constraints do not allow your ankle to dorsiflex (ie extend) and this is another necessary component off pronation. If the pronation cannot occur here, shock absorption will need to occur elsewhere (ie your knees, hips and spine; see our post entitled “learning to walk properly”). This is ultimately what caused your hallux limitus.

The 1st ray cutout you are describing may help; however if you have a hallux limitus, you probably do not have enough range of motion available to get the head of the 1st metatarsal down to the ground to make an adequate tripod. ART, exercise, and mobilization may help but you must be diligent. If conservative measures fail, you may need an orthotic, custom built by someone who understands the problem and can help alter your mechanics accordingly. Orthotic therapy should help to make the problem less and less, and should be used in conjunction with exercises, to insure your prescription is becoming less and less and you are not becoming dependent on them.

Hope that helps.

Dr Ivo

_______________________

Thank you for the reply Dr. Ivo,
I assume you are referring to the Youtube videos of my running. I can send them to you. Which one (ones) do you want. I have to study your reply as there is a lot in there and a lot that makes sense as to what I have noticed.
You also wanted to look at pictures of my feet. I put some up a couple of years ago when I was trying to figure out what was going on with them and attempting various solutions of my own. Would these be adequate (look down the page) or were you thinking of something else: http://recoveryourstride.blogspot.com/2008/06/if-foundation-is-off.html

I have moved away from the cut out insole that I described earlier and had an insole specifically made for HFLput in my shoe yesterday by the Doctor who is well-known for his work with HFL. I guess Dr. Dananberg would be the best guy to see for this and fortunately his office is close by. http://recoveryourstride.blogspot.com/2010/06/functional-hallux-limitis.html

That is interesting and comforting that you infer that some can be weaned from the use of orthotics for FHL. Thanks again for your replay.
Jim

_________________________________

You are welcome Jim.

I looked at your pictures. You can see in the 2nd one down that you invert the foot and have space between the 1st and 2nd toes (from trying to reach medially with your big toe and create a medial leg of your foot tripod). I was not sure you would do well with the 1st ray cutout, as it appears your foot doesn’t have the flexibility. You can also see the toes hammering (ie curling of the toes) to try and maintain some stability of your foot.

The 3rd picture shows your tibial torsion quite nicely, with your knee turned in and the 4th with the knee straight and foot toeing out (increasing the progression angle).

I would love the front and rear view video of your running. with your permission, I would like you to send these and allow us to use your photos from the site to create a teaching case. We will give you and your site full recognition.

Dr Dananberg is top notch. I knew him when I practiced in Gloucester, MA. You are in good hands.

Dr Ivo

Neuromechanics Weekly:

Gait Noise

Think of “Gait Noise” as those things which alter the sum total of all neuronal activity acting at a specific locus. Gait noise is all of the aberrant signals that distort the correct and most functionally desirable signal necessary for a clean gait.  Think of noise as the static found between radio stations, that irritating white noise that blurs out the perfect radio station from coming in clearly.  Gait noise is thus anything that impairs a clear sensory and motor signal to and from the central nervous system required for clean uncompensated gait. These definitions will help you understand where we are going with this.

1. Communication: Anything that interferes with, slows down, or reduces the clarity or accuracy of a communication. Thus, superfluous data or words in a message are noise because they detract from its meaning.

2. Quality control: Variability that may be caused by changes in the ambient conditions, faulty machine performance, or uneven quality of the material or human factor inputs.

3. Telecommunications: Random disturbance introduced into a communication signal, caused by circuit components, electromagnetic interference, or weather conditions. Also called line noise.

Gait noise is therefore very undesirable. It could be interpreted as seeing a foot turned out more than normal, more than the other side. Seeing that compensation is a motor impairment and an undesirable motor pattern, but it also sends aberrant sensory information back into the nervous system. Bad information in, bad information out, and a viscous cycle ensues.  Gait noise can occur from a total knee replacement, from a scar, from a sprain, a broken bone, from the numbness of a diabetic neuropathy etc.  These all cause impairment of the sensory-motor-sensory loop.  Gait Noise theoretically could occur anywhere along the neuraxis (spinal cord and brain-brainstem) or even the peripheral nervous system, but it makes most sense to think of it happening where neurons congregate; most likely at synapses, especially at the spinal cord level. The wiring of the nervous system extends to all tissues, so the noise can occur anywhere for almost any reason.

In the words of Dr Ted Carrick, “Is the lesion at the receptor, the effector, the peripheral nerve, the spinal cord, the brainstem, the thalamus, the cerebellum or cerebrum?”  Where is the problem in otherwords ?  Lets explore how this relates to “Gait Noise”.

Today lets look at the receptor. Receptors are the information gatherers of the nervous system. Think of your 5 senses (vision, smell, taste, sound and touch). These are all subserved by receptors. Vision and touch seem to most affect gait and movement. This post will concentrate on touch.

Touch encompasses not only physical touch but also proprioception (see here for review of proprioception and receptors). These receptors: Pacinian corpuscles, Merkel discs, end bulbs of Krause, bare nerve endings, joint mechanoreceptors, muscle spindles and Golgi tendon organs are all included here. These sentinels provide the central nervous system (CNS) with mechanical environmental information, for comparison with that same information (there is much redundancy in the CNS) and other environmental information (balance, vision, hearing, etc), so that you can formulate (consciously or subconsciously) a response.

In short, there are multiple systems converging, in this case, on the peripheral receptor. Remember, receptors can be activated in may ways. A touch receptor could be activated not only by touch, but also by heat, cold, pressure, or even chemical (metabolic or toxic) means. Just like you may be a great tennis player, you could probably play racquet ball, handball, or football, even if you never played before. You may not excel, but you could get by. Receptors are no different; they may be BEST activated by touch, but other means could certainly do the job. This inadvertent activation creates receptor bias, as we like to call it “noise”, and that information is sent to the CNS for processing. If a touch receptor is activated, it is activated, and the CNS  sees it as an activation, whether it is intentional or not. These mixed signals are then processed along with everything else, creating “noise”.  And the noise might not be a desired signal. And these signals can be what initiates a gait change, a compensation, whether it be from information mis-processing or a strategy to cope.

Think of the application to your gait analysis, next time you are seeing something that you think you shouldn’t be seeing.  This is the problem with video gait analysis (as we take a moment to pound the wall on this topic ONE MORE TIME !).  What we see on a video analysis is not necessarily the problem, nor does what you see warrant a correction or a specific shoe. What we are seeing on video is their coping strategy after all of the CNS signals (noise and non-noise) have been processed, it is what they can do with what is available to them and with what makes most sense to the brain.  We have said before, as a classic example, that an over pronating foot might be a necessity to compensate for lack of internal hip rotation because the brain deems that functional pathology as more damaging at the hip than the hyperpronation at the foot.  Who are we to deem that the foot needs an orthotic or a stability shoe because of what we see?  Who are we to think that we can outsmart all the sensory-motor calculations of that persons brain without knowing all of the functional limitations of their body ? Perhaps if we take an hour to assess our client, and then see them for another visit or two, we can then correlate the gait video, our findings and our corrective work and then truly qualify a logical reasoning.  But this is a far more difficult game that this simple gait video or foot plantar pressure digital foot mapping nonsense.

Ivo and Shawn; the voices in your head, helping you sift out the noise.

The Chef: Another abnormal gait pattern in celebrity chef and The Travel Channel’s Anthony Bourdain.

It was just a few nights ago after a 13  hour day with patients that I got home and climbed into bed, looking forward to flipping through channels to find something to alter my brainwave state. I needed to find something that would allow me to dial down into a slumber.  Much to my happiness I found one of my favorite shows, “No Reservations” with my favorite chef.  I get a real kick out of Tony. This is one smart dude. He is pretty slick with the english language.  Did you ever get to read his New
York Times best seller “Kitchen Confidential”?  What a killer book. We recommend the audio book read by the author himself.  It turned the restaurant scene upside down.  Has anyone ever told you not to order fish Monday through Thursday ? It is all in the book.  Why else do I love Bourdain?  His command of the english language is exceptional, and creative.  For example, he once said, “what would it be like to be a meat-filled Pinata at a Pit Bull convention?”.  Things like that stick with you.

Anyhow, so there I am lying in bed dozing off, listening to Bourdain talk about Mozambique and there he is in all his slender glory walking down the street with his sidekick Samir.  “Red Alert, Red Alert ! "  The clinical brain snaps back on.  Dammit !  Knowing very well I had to rewind the cable box to see it again, but knowing I was slowly descending into deeper brainwaves, I quickly rewind and grab my iphone to record the gait you see above.  You see, when you are a gait nerd like us, nothing escapes you when it is this obviously wrong. It is a disease; trust us.  We cannot go anywhere anymore without noticing pathologic gait.  It appears we cannot even watch a cooking show. And since we live on a planet where everyone walks, it must be a penance for something we must have done in another life.

Onto Bourdain’s gait. 

Look at Tony’s circumducting feet compared to Samirs (on the right).  Samir clearly engages pelvis lift on the swing leg side which is typically brought on by engagement of the hip abductors (g. medius) on the stance leg side. This lift on the swing side allows the swing leg to have ample room to pendulum through without having to prostitute the knee or foot posturing.  The knee and foot simply sagittally hinge through, this is economical gait.

Bourdain on the other hand shows little if any swing side pelvis lift driven by stance leg hip gluteus medius engagement.  This creates a clearance problem for the pendulum swing leg.  So now the problem becomes how to get the leg to swing through without catching the toes and foot. You must create clearance. Clearance can be obtained by:

1. generating opposite  hip abduction forcing the swing leg hemi-pelvis to lift
2. increasing hip flexion which will initiate a steppage gait. This will be combined with increased knee flexion. This is productive and necessary if you are climbing stairs or trying to unload a painful turf toe near the end of stance phase push off.  When seen in normal walking gait it may represent neurologic pathology.  But folks with hip problems or weakness will use it to get around to avoid tripping.
3. circumduct the swing leg hip. The act of swinging the leg outward and around will eat up the leg length.
4. circumduct the foot.

Bourdain is doing #4. It is a pretty lazy gait strategy, you can see it is lazy. It probably requires very little energy to flip the foot outside the normal ankle dorsiflexion foot swing progression.  What must be the cost to activating the peronei and the lateral toe extensors to flip that foot around like that ? Sure you can see that the knees are for a moment carried outside the sagittal plane but who cares, right ? 

There are a couple of concerns. One is that failure on a single step to generate sufficient foot/ankle circumduction will result in a foot catch and a fall.  Another is the trouble in always getting that circumducting foot to land precisely in the near sagittal plane. When you move the foot on an arc you really only have a narrow target to land the foot within the 5-15degree landing zone. Circumduct too far and the foot is in-toed and more rigid due to it being supinated during midstance, circumduct too little and the foot is more out-toed and increased pronation risk increases.  This goes for running as well.

Go back and watch Samir’s walk. Clean and done right, the swing leg is a passive pendulum. Tony’s is obviously different. Who knows, maybe he has bad hips ? Maybe it was always a struggle to walk normally. He is 6'4” so we cannot blame it on excessive height unless he lives in a house that has 6 foot ceilings, because then his strategy would be our gait of choice. It would be the only one that would effectively work !  Maybe that is it. Maybe he lives in Smallville ?

We don’t think so.  The only for sure way to know would be to get him on our exam table and see what parts he is not using. We would put big money on weak gluteus medius, bilaterally.  It is the one we see most often in this abnormal gait pattern.

Shawn and Ivo, tortured gait observers in a world of ambulatory pathology.

Welcome to our hell.

What’s your Foot Type?: Part 1

Ready for Monday Morning? This is the 1st of a 5 part series to get your week going and help get you in a “Gait Guys” frame of mind

Rearfoot varus

What if many of your nagging and seemingly un resolvable injuries as an athlete were from an undiagnosed foot type? What if every shoe, insert and orthotic you implemented in an attempt to help manage these problems was not the solution, but rather a means of “band aiding” the problem because your anatomy was compromised from the start? 

Wouldn’t it be nice to have some answers to all the questions you have as to why your interventions were less than optimal? Wouldn’t life be better if you knew that your anatomy was slightly left of center and that this was the true cause?  Life as an athlete sure would be more tolerable and perhaps, just perhaps, a life with fewer nagging injuries.

The main issue is that the majority of humans have less than perfect feet. The “perfect” neutral foot is one in which the rearfoot and the forefoot lie on the same plane, meaning that the forefoot and the rearfoot lie square on the ground when ankle and subtalar joint mechanics are neutral.  This insures the tripod of the foot (the base of the big toe, the base of the little toe and the center of the heel) remain on equal footing, creating a balance of power between the muscles and articulations.

There are many reasons at to why we do not all have perfect feet with pristine mechanics to run and walk on.  Some are genetic, some congenital, and some developmental. Regardless, as the saying goes “You have what you have, so why not make the best of it?”

In a nutshell, there are 5 basic foot types; two involving challenges to the forefoot, and two challenging the rear foot. These can be rigid and non adapting, flexible and adapting, or somewhere in between. The fifth type is the ideal of what we all hope to have. This 5 part series will help you to understand each and the biomechanics associated with the anatomical variant.

Rearfoot varus.

The rear foot varus is a foot that has the heel inverted, almost appearing as though the ankle is about to roll, like a common ankle sprain. Here the rear of the tripod is compromised. Because of this lateral shift of weight through the contact phase of walking or running, the foot is over supinated  (plantar flexed, inverted and adducted) at toe off.  The owner of this foot type usually has excessive use of the peroneal muscle group to fight this supinated tendency and prevent ankle sprains.  The 4^th and 5th metatarsals typically take on more stress, and are often painful. Loading the lateral aspect of the limb shifts the center of gravity and challenges stability in the frontal plane, often leading to hip problems, such as trochanteric bursitits and IT band friction type syndromes and knee/patellar tracking issues.

Confused? Have no fear. Our shoe fit program is almost here! The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail. Watch here on Mondays for a different foot type each week!

The Gait Guys: promoting foot and gait competency everywhere!