Case Quiz: Part 2: The Questions

Here was our reply:

She has a cross over gait pattern Right > Left; assumedly due to the amount of tibial varum on the Left; is it that prominent unilaterally? The lateral shift is compromising the LCL (lateral collateral ligament on the Left, combined with poor gluteus medius control. She appears to have an uncompensated forefoot varus bilaterally as well. I would question if she has an LLD (let length discrepancy) on the Right, with more pelvic glide/drift occurring to that side during stance phase of gait. Her arm swing is also greater on the right. With the reconstruction, she has a greater stride length on the Right, as she tries to unload the Left side. Does she look any better in the orthotics ?

Our suspicions are:

  • LLD (leg length discrepancy), short on the right
  • moderate Forefoot varus, uncompensated
  • LCL (lateral collateral ligament) laxity
  • weak Gluteus medius complex bilaterally
  • crossover gait


What could be done?

  • continued acupuncture for muscle facilitation
  • “waddle walks” with theraband around legs (to challenge the gluteus medius), keeping them in some degree of abduction
  • Single leg standing exercises on foot tripod
  • foot intrinsic strengthening (lift, spread, reach exercise; EHB; FDB, EDL)
  • Sole lift if indicated to help with limb length challenge


prolotherapy may help but you need to know WHY the leg translates laterally; otherwise you are just band aiding it

Hope that helps. Let us know how it goes and if she has an LLD (short leg, anatomically).


Ivo and Shawn: asking the tough questions….

Case Quiz: Part 1

Here is a case submitted by a friend of ours, Dr Lance Robbins in Florida. You can see the problem (and a description below). Rather than just give you the answers, we want you to come up with what questions to ask. Tune in later for what we think.

Ivo and Shawn


Dr Robbins notes on the client in the video:

Intermittent left knee pain with a painless limp while walking
Medical History is positive for an ACL reconstruction on the Left many years ago where they used part of the patellar tendon
Currently wears orthotics made by Xtreme Footwerks
Exam:
Gait showed a lateral knee deviation 
Static exam findings showed a marked tibial varus on the left,  bilateral external tibial torsion, along with Bilateral abducto-hallux valgus and mild bilateral forefoot varus.
There is a decrease in the right side ankle rocker, mid and forefoot motion is WNL (within normal limits). 
She presents with unilateral right sided genu recurvatum. During the exam she explained that before her ACL reconstruction she had bilateral genu recurvatum and during the surgery they corrected the left side.
Static palpation reveals a tight hypertonicity in the posterior knee structure on the left. There is also a moderate a,out of swelling along the upper lateral side of the left knee around the insertion of vastus lateralis and the client indicates that this has been there for along time since the surgery. When she tried to reduce the swelling with a TENs unit her knee pain got worse.
Dynamic evaluation showed normal hip ROM (Range of Motion) and ankle ROM except for the decrease in ankle rocker noted above. The right knee ROM is WNL. The left knee has a very slight reduction in flexion compared to the other side but still falls within normal limits. There is a moderate amount of instability in the left knee during the Varus stress test indicating some LCL (lateral collateral ligament) laxity. 
There is a decrease in the Left popliteus, biceps femoris, and glute medius  muscle function.
After one session of CMT (chiropractic manipulative therapy) (L5, Left Sacroiliac joint), acupuncture to facilitate muscle function and kinesiotape to support ligament laxity she had an immediate reduction in the swelling around her knee without any occurrence of pain. This lasted for 4-5 days with a return of some swelling after. 
The ligament laxity was not majorly effected by the treatment. 
Prolotherapy is one alternative we are considering
My hunch is that this has developed as a post-surgical adaptation due to the change in structural orientation of the knee (unilateral correction of genu recurvatum).
Even with prolothery to tighten up ligament structure how do we proceed forward in order to prevent reoccurrence or early onset degenerative processes?
A case of the non-resolving ankle sprain.  Things to think about when the ankle and foot just do not fully come around after a sprain.
Gait Guys,
A while back I had a severe ankle sprain while trail running.  As I stepped on a rock my toes pointed d…

A case of the non-resolving ankle sprain.  Things to think about when the ankle and foot just do not fully come around after a sprain.

Gait Guys,

A while back I had a severe ankle sprain while trail running.  As I stepped on a rock my toes pointed downward, my ankle was rolled in and I felt a pop. This was follow by a lot of swelling and bruising both on the inside and outside of my ankle.  Being experienced with ankle sprains, I jumped on the initial treatment immediately. The reduction in swelling and bruising lead me to believe that I was in for a 4-5 week recovery, then I would be back at what I love doing. I was proven wrong:  

1.       Initial treatment consisted of immobilization, icing, and a very high dose of Ibuprofen (3 days only). After a couple weeks of this I began stretching, massage and trying to get into some modified activities as the pain allowed me to. I was able to  do some hiking but running was too painful.

2.       After 6 weeks, I was still having pain in the posterior tibial tendon area as well as the deltoid ligament area. I tried running but, I was met with severe pain beginning in the middle of the gait cycle through  the push off. I saw a PA at this time and was told to give it more rest. For the next few weeks I wore a soft brace and spent most of my time in a chair.

3.       By week 9, there was no improvement. I could walk fine but, I had the same pain when I tried to run. I visited the PA again and was put in a walking cast and had an MRI. The MRI should a low grade deltoid and ATFL sprain as well as a bruised bone. I spent 2 weeks in the walking cast then returned to the soft cast for another week. During this time I did nothing besides give it rest.

4.       At week 11, I did not see a noticeable improvement. I still had a sharp pain in my posterior tibial tendon area and deltoid area during the middle of my gait (when trying to run). At this time, I had another visit with the PA. After looking at my MRI more closely, he saw fluid buildup behind my talus. He thinks that I had an impact injury to my Os Trigonum. He also noticed that I had very limited dorsiflexion.  He has advised me to stretch and give it a few more weeks. If it’s not going in a positive direction he recommended a cortisone shot.

As it stands today at week 12, in a dorsiflexion position, I have a sharp pain in what feels like my Achilles tendon and posterior tibial tendon area (the MRI shows these are intact). I also have a lot of tenderness in the deltoid area. Walking, I am almost pain free but as soon as I begin to run, the pain starts in the areas described above. This is the first injury I have ever had where I haven’t seen a steady improvement when recovering (maybe I am just getting old). The pain I am having now when trying to running is the same as it was at week 4. This really concerns me.

I guess my question is, where do I go from here? Do I keep doing what I am doing? Should I seek a second opinion?  Any help or guidance you could provide would be greatly appreciated.

On a side note, your blog has helped me to get though the last 12 run-less weeks without losing my mind or falling into a deep depression.  You guys do some great stuff.  Keep up the good work!

Best Regards,

MR

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Dear MR:

Somehow we missed this email. Sorry about that.

Whenever things are not resolving with reasonable intervention one must think of two things: either the injury was severe or the diagnosis is incorrect.

Without seeing you we are unable to determine either. But here are our thoughts.

The Os Trigonum syndrome is a good thought. It seems to be in the correct area of your complaint. These “Os” bones can be embedded in tendon or soft tissue and they can be fixed to the posterior talus by either bone or a cartilagenous bridge. It is possible for this to be your problem if the inversion event was severe enough although it is not that common in this described mechanism.

One must also be suspect of osseous compression of the medial talus against the medial calcaneus, which will bring thoughts of a posterior subtalar facet fracture. We pulled up an article we read a few years ago on this issue (click here), the article is entitled, “Pseudo os trigonum sign: missed posteromedial talar facet fracture”. Obviously this needs to be considered in your case since there are similar components in area and symptom of your complaints. Posteromedial talar facet fracture (PMTFF) is a rare injury, sparsely reported in the literature and it must be chased as a diagnosis of suspicion when all other clinical presentations have not panned out. Damage to the sustentaculum tali must also be assessed, as this too can be fractured.  Osteochondral defects are also always on the list in violent inversion events; they are classically seen anteromedially and posteriolaterally at the ankle mortise joint.

Something else that is often missed in ankle inversion sprains is avulsion or rupture of the extensor digitorum brevis on the lateral foot. As the rearfoot inverts and forefoot plantarflexes the EDB is tensioned to the point of tearing. Although you seem to have no symptoms in this area it can never be overlooked. These are easy to discern from the lateral ligamentous structure damage because the areas are clearly separate from eachother.  Look for tenderness down into the top of the metatarsals into the forefoot. Also test for weakness and pain of toe extension.

So, lots to consider here in this case. When things to not resolve you have to start looking for less common problems and damage.  We would love to hear how you are doing MR. Drop us a line.

Shawn and Ivo……. also geeks of orthopedics.  We paid the piper long ago.

Forefoot balance and forefoot variants. Are you a forefoot strike runner ? You had better read this.
So, what about the attached video ?
What do you see as this gentleman loads onto the forefoot.  Watch the left hallux (big toe) and watch the long flexor strategy for the lesser toes.  It is plain to see that this subject has flawed forefoot stability. The big toe does not even engage during forefoot loading ! The metatarsal head it taking it all, and that can mean risk to the metatarsal shaft, ligaments, sesamoids and soft tissues.  Can you imagine this person running ? Without proper toe function, one of which is to help add stability and to offset metatarsal loading pressures, this person is at risk for pathologic loading responses in the forefoot.  We see flawed patterns like this all the time in our runners, of all ages.  Think this kind of educational information needs to be part of the form running classes and natural running courses being offered around the country ? We think so.  Education does not mean you cannot do something, it merely helps the end user to be more aware of their limitations and risks. Education can lead to the adjustment of a behavior. But you often have to bring the behavior to a persons recognition. 
The next time you decide to lace up your shoes, before you do it slip off your socks and do a double and a single leg forefoot heel risk like this fella in the video.  What is your strategy? Do you clench the toes or do you PRESS them like you should with a balanced strategy with the long and short toe flexors and long and short extensors ?  Do you load the big toe nicely?  Do you have hammer toes ?  How is your forefoot bipod stability ? Are you wobbling all over the place ? Remember, running is a single leg strategy. You are merely alternating one legged balancing when you run. You never have both feet on the ground.  So, what is that single leg stability like?  You may say that a  static assessment like we have suggested is not reality.  But we say that is incorrect. Sure it is different. But one main difference is that the forward speed of running allows momentum to blur the pathologies you might see in a quieter slower assessment.  The forward momentum will surely blur frontal plane stabilities but we assure you, they are still there.  One of our favorite lines is “speed kills”.  But in this case speed will hide the tiny instabilities and flaws that exist. Just because you cannot see them or feel them when you run doesn’t mean they are not there. Kinda like the “Boogey Man”. 
Work on your forefoot loading response every day. Get to the point that you can get to a single leg stance with good posture and stability with reduced sway. Then see if you can get to a clean quiet forefoot load on that leg as you lean forward into a wall. 
The smallest of things can make the biggest difference. Especially if you are doing sometihng (like walking or running) thousands of times a day.
Don’t be a casualty. Do the work you need to do.
Here is some research to support or views.
Everyone is on the barefoot and minimalist running kick these days. Much of the time, justifiably so. But, if you have been reading our work here on our blog you will know that there are many issues that these same folks are just not talking about.  We have tried to share our concerns about the forefoot load when there is a forefoot varus or forefoot valgus and the implications of faulty mechanics and injury resulting from asymmetrical forefeet.  Not everyone can forefoot strike without heightened injury risk.  This is why many times we suggest a midfoot strike since it dampens some of these risk factors when present.  Manufacturers who promote a forefoot landing loading event need to be talking about these risks. 
Today we share a research article giving a little more rooting to some of these concerns but from a slightly different angle.  In this article,
 
Gait Posture. 2011 Jul;34(3):347-51. Epub 2011 Jun 22. Gait, balance and plantar pressures in older people with toe deformities. Mickle KJ, Munro BJ, Lord SR, Menz HB, Steele JR.  Biomechanics Research Laboratory, University of Wollongong, NSW 2522, Australia. kmickle@uow.edu.au
Mickle et al discuss toe deformities such as hallux valgus and very likely hammer toes and their effects on balance and stability. In their abstract they focus more on older folks with hallux valgus and lesser toe deformities who displayed different gait, balance and plantar pressure characteristics compared to individuals without toe deformities.
Spatiotemporal gait parameters were measured as well as postural sway. Their results indicated that, although there were no effects of toe deformities on spatiotemporal gait characteristics or postural sway, older people with hallux valgus and lesser toe deformities were found to display altered forefoot plantar pressure patterns. These findings suggest that toe deformities alter weight distribution under the foot when walking, but that the relationship between toe deformities and falls may be mediated by factors other than changes in spatiotemporal gait parameters or impaired postural sway.
Make of this research what you will, but in our opinion you just cannot ignore the fact that faulty forefoot function will impact stability and performance.  It may even be a predictor for injury, in this case falls from instability, but in our opinion other musculoskeletal injuries in the lower limbs.  It is clear that altered biomechanics result in compensations and we all know that compensations are alternative strategies from the norm.  And if you add enough miles to alternative strategies, injuries are not likely to be far behind.
Here is another article:
Foot Ankle Int. 2005 Jun;26(6):483-9. Gait instability in older people with hallux valgus. Menz HB, Lord SR. Musculoskeletal Research Centre, L Trobe University, Bundoora, Victoria.
In their study they determined that “subjects with moderate to severe hallux valgus were found to exhibit significantly reduced velocity and step length on both walking surfaces and less rhythmic acceleration patterns in the vertical plane when walking on the irregular surface compared to subjects with no or mild hallux valgus.”
They thus concluded that “hallux valgus has a significant detrimental impact on gait patterns that may contribute to instability and risk of falling in older people, particularly when walking on irregular terrain.”
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The smallest of things can make the biggest difference. Especially if you are doing something (like walking or running) thousands of times a day.
Don’t be a casualty. Do the work you need to do.
Shawn and Ivo
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Saturday quickie:

Hmmm…. Rearfoot Valgus 
(Make sure to hover mouse over each image to examine more closely)

When the rearfoot is everted with respect to the fore foot. (wondering what this means? maybe you need to view our upcoming video course on foot types!)

Cardinal signs and pathomechanics
  • Everted (heel is collapsed inward as in the pics above)
  • midfoot/arch collapse: insufficient foot tripod
  • due to midfoot collapse, the foot is in excessive pronation and is poor lever for toe off and propulsion
  • Excessive internal rotation of the limb during gait cycle
 
 Should you give up on fixing this? NO!
Should you put them in orthotics? Maybe
Should you sterilize them so they can’t reproduce? Definitely not!
Is there help for this? Of course! 
 
What would you do?  Think about that this weekend and tune in next week for some  treatment ideas. 
 
See you on the blog next week
 
Have a great Saturday.
 
Ivo and Shawn

OK, something different this Friday.

We admit computer models can only approximate human gait, and here is a perfect example. Watch the video a time or 2 and come back and read on….

Really….Did you watch it? Maybe you really should…

What do we see?

  • A prime example of heel rocker but what is missing? How about midfoot pronation, a requisite for normal gait and one of the 4 shock absorbing mechanisms (pronation, ankle dorsiflexion, knee flexion and hip flexion)
  • dip of the opposite hip with initial contact and loading response. looks like the computer model had built in gluteus medius weakness!
  • what about that lack of anterior and posterior rock of the ilia?
  • they do show g max activation (posterior view) during propulsion…nice!
  • where are the abs initiating hip flexion?
  • how about that forward head posture?
  • we think there should be exaggerated torso rotation (contralateral to the side of strike) with no arms

So what does this prove?

This is a great attempt at simulating human gait, but gait being so complex and ….well….human, it is difficult to approximate with a computer modeling program.

We are the geeks of gait…The Gait Guys…Ivo and Shawn

We could have easily made this a blog post about shoe sizes or how to use the Brannock device. And maybe we will in time. But this picture, if you are really thinking, can give you more insight into the entire biomechanical flaw of a client. If you …

We could have easily made this a blog post about shoe sizes or how to use the Brannock device. And maybe we will in time. But this picture, if you are really thinking, can give you more insight into the entire biomechanical flaw of a client. If you read our post today we bet you will forever look and compare the size of both feet of your clients … forever !

This is a picture of one of our patients. This person had a congenital “club foot” at birth also know as congenital talipes equinovarus (CTEV). It is a congenital deformity involving one or both feet. In this case it affected on the right foot (the smaller one). Multiple surgeries were performed at an infant to correct, and the correction is beautiful as these things go. TEV is classified into 2 groups: Postural TEV or Structural TEV.

That all aside, we have a smaller shorter right foot.

Where are we going with this ?

Foot size is often measured with the Brannock device in shoe stores, you know, the weird looking thing with the slider that measures foot length and width. In this case, the right heel:ball ratio, the length from the heel to the first metatarsal head, is shorter. The heel:toe length is also shorter, nothing like stating the obvious ! IF they are shorter then the plantar fascia is shorter, the bones are shorter, the muscles are smaller etc.

So, taking yesterday’s blog post in tow here (LINK to that posting), the maximal height of the arch on the right when the foot is fully supinated is less than that of the left side when also fully supinated (ie. during the second half of the stance phase of gait). Even with maximal strength of the toe extensors which we spoke of yesterday will not sufficiently raise the arch on the right to the degree of the left.

  1. Thus, this client is very likely to have a structural short leg. Certainly you must confirm it but you will likely see it in their gait if you look close enough.
  2. Also, you must remember that the shorter foot will also spend fractionally less time on the ground and will reach toe off quicker than the left. This may also play into a subtle limp.
  3. This client may have a mal-fitting shoe, the right foot will swim a little in a shoe that fits correctly on the left. You may be easily able to remedy all issues with a cork full length sole insert lifting both the heel and forefoot. This can negate the shoe size differential, change the toe off timing and remedy much of the short leg issue. * IMPORTANT: keep in mind, if you know your shoe anatomy (and you will if you get on board with our very soon to release “Shoe Fit Course”) you will know that the right foot at the metatarsal-phalangeal joint bending line will not be flexing where the shoe flexes on that right foot. The Right foot will be trying to bend proximal to the siping line where the shoe is supposed to naturally bend. This will place more stress into that foot. This brings up the rule for shoe fit: never size a persons shoe by pinching the toebox to see if there is ample room, the shoe should be fit to meet the great toe bend point to the flex point of the shoe.
  4. Strength of muscles is directly proportional to the cross sectional area of the muscle. With smaller muscles, this right limb is very likely to be underpowered when compared to the left.
  5. All of these issues can cause a failure of symmetrical hip rotation and pelvic distortion patterning.
  6. Altered arm swing (most likely on the contralateral side) is very likely to accommodate to the smaller weaker right lower limb. Do not be surprised to hear about low back pain or tightness or neck/shoulder issues.
  7. A shorter right leg, due to the issues we have discussed above, will place more impact load into the right hip ( from stepping down into the shorter leg) and more compressive load into the left hip (due to more demand on the left gluteus medius to attempt to lift the shorter leg during the right leg swing phase). This will also challenge the pelvic symmetry and can cause some minor frontal plane lumbar spine architecture changes (structural or functional scoliosis…… if you want to drop such a heavy term on it).

Gait plays deeply into everything. Never underestimate any asymmetry in the body. Some part as to take up the slack or take the hit.

Shawn and Ivo…….. far from symmetrical lads.

Gait Parameter: Ankle Rocker during the Squat as a predictor for Shin Splints.

Here is a brief video we shot in our clinic. One of the primary assessments we do with all clients is a basic squat. No a “potty squat” were the tibia remains vertical and the hips press backwards, just a basic squat where the knees come forward.  We do this with toes down and toes up.

We shot this video so that we could have some visual to talk about a few things.

1.  Why toes up ?  You have read it here before on our blog.  Raising the toes is done by use of the log and short toe extensor muscles (Extensor digitorum longus and brevis, EDL, EDB and of the hallux extensors EHL, EHB).  When we activate the extensors the toes dorsiflex around the metatarsals and the toes elevate. This activates the windlass mechanism.  This mechanism tightens the plantar fascia thus shortening the distance between the metatarsal heads and the heel. Thus, the arch is  driven up.  This is why we harp on gaining toe extensor strength in flat footed and hyperpronators.  Go ahead, stand up, raise your toes and feel the arch lift. It is a solid biomechanical phenomenon. 

So, why do the squat with the toes up ?

Because when the foot is weaker than it should be a squat can allow the arch to drop too much during the down-squat.  If the arch drops the foot could pronate more than necessary. This can drive subtalar joint motion which can fake out the true squat determination and the true determination of available ankle rocker.  The client will be able to get deeper into the squat but for assessment purposes this will be a fake out.  We want to know  true available functional range at the ankle mortise joint (tibial talar joint). With the toes up, the arch is maximized and cannot drop unless the toes drop. As you will see in this video, you can thus see the true ankle rocker in this client is barely sufficient however it is likely enough (100-110 degrees) for normal gait in the sagittal plane. 

What if when they do this there is little if any rocker, less than this guy?

Then to get more (100-110, ie. 10-20 degrees past vertical) they will have to compensate.  We talk about the strategies in this old video of ours (LINK HERE).  One of the best ways to compensate is to pronate through the arch more than normal.  This will drop the arch height and carry the tibia forward enough to allow for forward motion. Sadly, this increased pronation can do alot of things.  One is to carry the knee medially and this can create patellar tracking issues or IT band tightness, to name just a few. 

So, what is our point today ?

  1. You need to make sure your assessments are telling you what you need them to tell you.
  2. Sufficient toe extensor strength and range is critical in the gait cycle to ensure sufficient ankle rocker occurs at the tibial-talar joint and not somewhere else you do not want it ( a compensation).  Any strength you put into a client who has insufficient true ankle rocker is strength into a compensation pattern.  Can you say heightened eventual injury risk ?
  3. Ability to find the foot tripod is a skill. It needs to be developed in a simple skill like we show here and then  the sensation can be carried forward into gait and running.
  4. A forefoot varus or forefoot valgus (please read our foot type blog posts over the past 3 weeks) can impair the foot tripod and thus the true ankle rocker.
  5. Make sure the knees hinges straight forward in this ankle rocker-squat test. If it is not a forward bend you must consider foot pronation excess, tibial torsion, hip version or torison, or simply the weak foot issues we are talking about here today.
  6. This is a form of homework for our clients, just want you see above in the video. We add layers to this as the gain strength. But that is a topic for another day.

This is a huge predictor and problem in chronic shin splints ? You bet ya it is ! It may be the main missed deficit we see in shin splints (both anterior and posterior shin splints).  There is lots more to this topic, but we will stop here for today. 

Shawn and Ivo…….. you have to know what you are seeing. And as Johnny Nash once said in his song

I can see clearly now, the rain is gone,
I can see all obstacles in my way
Gone are the dark clouds that had me blind
It’s gonna be a bright (bright), bright (bright)
Sun-Shiny day now that i understand ankle rockers better.“

:-)

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Retail Focus: Last (No, not the last retail focus, but a retail focus on lasts)

Lasts: What you need to know

Strictly speaking, a last is the mold or template for creating the shoe. It defines the shape of a shoe. We remember that men’s and women’s feet are shaped differently. Men (usually) have rectangular feet (the forefoot and heels are wider, or have less difference in width); Ladies (usually) have triangular feet (the forefoot is much wider than the heel). This is why it is important to know if the shoes you are fitting are a men’s or women’s specific last. Many thimes, the shoes come off the production line and the boy shoes are blue and the girls pink: both made from the same last.

The last determines whether a shoe is  a high, medium or low volume shoe… Pretty important, if they have a high instep or flat foot. Companies like Altra have as many as 6 different, sex specific lasts. This results in a wide range of fit (and thus a bigger market share).

Take off your clients shoes and look at their feet. Note their shape and curve. Lasts need to match that “curve” so they can be relatively straight or curved (this refers to the shape of the “sole” of the shoe: see above). Turn a shoe over and look at the sole. Mentally bisect the heel with a line going to the front of the shoe. If the line bisects the front of the shoe, it is a straight lasted shoe (this corresponds to the axis of the 2nd metatarsal, or slightly lateral to it). If more of the shoe falls medial to this (more of the sole on the big toe side) it has a curved last.

Curved last shoes can vary in the degree of curvature. Curved last shoes are designed to help control pronation, as they provide medial support and slow its rate by causing a relative supination of the foot after heel strike (it weights the lateral border of the shoe for a longer period of time, theoretically allowing less pronation). Curved last shoes can put more motion into a foot, especially one with limited rearfoot motion (it still must pronate, but due to the lack of rearfoot motion, the forefoot must compensate and now must do so in a shorter period of time).

“Last” also refers to the material (or way that the material) overlays the midsole of the shoe. This “last” (look inside the shoe on top of the shank) is the surface that the insole of the shoe lays on, where the sole and upper are attached).    Shoes can be board lasted, slip lasted or combination lasted.

A board lasted shoe is very stiff and has a piece of cardboard or fiber overlying the shank and sole (sometimes the shank is incorporated into the midsole or last).  It is very effective for motion control (pronation) but can be uncomfortable for somebody who does not have this problem. 

A slip lasted shoe is made like a slipper and is sewn up the middle.  It allows great amounts of flexibility, which is better for people with more rigid feet. 

A combination lasted shoe has a board lasted heel and slip lasted front portion, giving you the best of both worlds (theoretically).

A general rule of thumb is: You really can’t go wrong with a straight last. It will work for most feet, especially if you are using an orthotic. This is especially important with people with forefoot abductus, moderate to severe pronators and rigid feet (rear or forefoot). A forefoot abductus and severe pronator’s feet will move laterally in the shoe, often causing crushing, rubbing, cramping and blistering of the little toe against the side of the shoe. A rigid foot, because the foot needs to be able to pronate at the mid and forefoot, will have a similar problem. You can use a curved last with people with mobile or hypermobile feet, provided their pronation is not too severe (clinical judgment, trial and error).

We hope this clarifies some of the issues surrounding lasts, their shape, and usage. This will probably not be the last word on lasts, but hopefully will suffice some of the burning curiosities surrounding the subject.

We want to succeed as retailers. Consider taking our course and getting IFGEC certified, for your benefit as well as your clients.

Ivo and Shawn: The Gait Guys

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What’s your foot type: Part 4

Forefoot valgus.

In this foot type, the fore foot is everted with respect to the rear foot and the little toe side of the tripod cannot gain purchase on the ground. This foot is a poor lever. The problem here is that in normal ambulation we progress our body mass lateral to medial, which engages normal biomechanics.  In this foot, the body moves from medial to lateral, so we are unable to toe off  from the bog toe side of the tripod. Lack of optimal toe off means poor propulsion strategies from the calf and gluteals. Consequently, patellar tracking is challenged, the limb is in a more relative external rotation, and the peroneal muscles are typically overburdened in an attempt to stabilize the lateral ankle area.

Missing something? Check out the last 3 weeks posts on foot types. Our shoe fit program is launching soon. You too can become certified and become “all that you can be” in shoe fitting.

Ivo and Shawn: Bald…Middle aged…Geeky…Good Looking….promoting foot and gait literacy here on a daily basis

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…

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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

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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!