If you know, recognize that you know,
If you don’t know, then realize that you don’t know:
That is knowledge.
Confucius
True knowledge is when one knows the limitations of one’s knowledge.
Neuromechanics on Saturday?
We have long been talking about the importance of the cerebellum in gait and motor activity (see here).
Here is a study (Non-Invasive Brain Stimulation Shown to Impact Walking Patterns) that looks at a new technique for using electrical stimulation of the brain’s cerebellum (trans cranial direct current stimulation to be exact) to change gait on a split belt treadmill (a double treadmill where each leg moves a slightly different speed). The study found that during the electrical stimulation the anode (negative charge) seems to speed up the learning process (our theory: more electrons, possibly creating a temporary electrical gradient which depolarizes (excites) the cells to a greater degree). And the cathode seemed to slow things down (our theory, it hyperpolarizes the cell and makes it less excitable).
Take home message? There are new neurologic studies and experiments that may be proving helpful in retraining gait function. Stimulating the brain’s cerebellum seems to speed up learning or slow it down, depending on your client’s needs. We are sure we will be seeing more of this kind of stuff at technology advances.
Maybe Larry Niven wasn’t that far off. (We loved the story “The Long Arm of Gil Hamilton”). This could be a great, non invasive tool for rehab (or maybe improving performance!)
The Gait Guys…taking you deeper down the rabbit hole…
Arm swing in gait and running. Why it is crucial, and why it must be symmetrical.
It becomes clear that once you get the amazing feats seen in this video out of your head, and begin to watch just the variable use of the arms that you will begin to appreciate the amazing need for arm swing and function in movement.
We have written many articles on arm swing and its vital importance in gait and running. Have you missed all these articles ? If so, go to our blog main page, type in “arm swing” in the search box and you will have a solid morning of readings at your fingertips. We are still not done writing about this most commonly forgotten and overlooked aspect of gait and running analysis, and we probably never will be done. Why is no one else focusing on it ? We think it is because they do not see or understand its critical importance.
Without the presence and use of the arms in motion things like acceleration, deceleration, directional change, balance and many other critical components of body motion are not possible.
What is perhaps equally important for you to realize, as put forth in:
Huang et al in the Eur Spine Journal, 2011 Mar 20(3) “Gait Adaptations in low back pain patients with lumbar disc herniation: trunk coordination and arm swing.”
is that as spine pain presents, the shoulder and pelvic girdle anti-phase begins to move into a more in-phase favor. Meaning that the differential between the upper torso twist and pelvic twist is reduced. As spine pain presents, the free flowing pendulum motions of the upper and lower limbs becomes reduced to dampen the torsional “wringing” on the spine. When this anti-phase is reduced then arm swing should be reduced. The central neural processing mechanisms do this to reduce spinal twisting, because with reduced twist means reduced spinal motor unit compression and thus hopefully less pain. (Yes, for you uber biomechanics geeks out there, reduced spine compression means increased shear forces which are favorite topics of many of our prior University instructors, like Dr. Stuart McGill). The consequence to this reduced spinal rotation is reduced limb swing. And according to
Collins et al Proc Biol Sci, 2009, Oct 22 “Dynamic arm swinging in human walking.”
“normal arm swinging requires minimal shoulder torque, while volitionally holding the arms still requires 12 % more metabolic energy. Among measures of gait mechanics, vertical ground reactive moments are most affected by arm swinging and increased by 63% without arm swing.”
So, it is all about efficiency and protection. Efficiency comes with fluid unrestricted movements and energy conservation but protection has the cost of wasting energy and reduced mobility through a limb(s) and spine.
In past articles we have carried these thoughts into historical functional needs of man such as carrying spears and of modern day man in carrying briefcases. Today we show a great high functioning video of another parkour practitioner. Parkour is a physical discipline and non-competitive sport which focuses on efficient movement around obstacles. Watch closely the use of the arms. The need for arm use in jumping, in balance, in acceleration etc. It becomes clear that once you get the amazing feats seen in this video out of your head, and begin to watch just the use of the arms that you will begin to appreciate the amazing need for arm swing and function in movement.
There is a reason that in our practices we treat contralateral upper and lower limbs so much. Because if you are paying attention, these in combination with the unilateral loss of spinal rotation are the things that need attention.
Yup, we are The Gait Guys….. we have been paying attention to this stuff long before the functional movement assessment programs became popular. If you just know gait, one of the single most primitive patterns other than crawling and breathing and the like, you will understand why you see altered squats, hip hinges, shoulder ROM screens etc. You have to have a deep rooted fundamental knowledge of the gait central processing and gait parameters. If you do not, every other screen that you put your athlete or patient through might have limited or false leading meaning.
Shawn and Ivo … combining 40 years of orthopedics, neurology, biomechanics and gait studies to get to the bottom of things.
External Tibial Torsion as expressed during gait.
So, last week we watched this young lad doing some static ankle and knee bends, essentially some mini squats. Here was what we found (LINK). It is IMPERATIVE that you watch this LINK first before watching today’s video above.
Now that you have watched that link here is what you should be seeing today.
You should see that the left foot is extremely turned out. We talked about why in the linked post from last week. It is because of the degree of external tibial torsion. When it is present the knee rides inside the foot progression line (the knee bends into the forward / sagittal plane when the ankle bends into its more lateral /coronal / frontal plane (they all mean the same thing) ie. when the foot points outwards.
Remember, the knee has only one choice of motion, to hinge forward and backward. When the knee is asked to hinge in any other direction once the foot is locked to the ground there is torque placed upon the knee joint and thus shear forces. Menisci do not like shear forces, nor does articular joint cartilage.
So, once again we see the rule of “you cannot beat the brain” playing out. The brain took the joint with the least amount of tolerance, the knee, and gave it the easy job. The foot was asked to entertain another plane of motion as evidenced here in this video with significant increased foot progression angle.
When the foot progression angle is increased but the knee still must follow the forward body progression (instead of following the foot direction) the motion through the foot will be directly through the medial longitudinal foot arch. And as seen here, over time this arch will fail and collapse.
Essentially this lad is hinging the ankle sagittally / forward through the subtalar and midtarsal joints, instead of through the ankle mortise joint where ankle hinging normally should occur.
This is a recipe for disaster. As you can see here. You MUST also know and see here that there is an obvious limp down onto that left limb. It appears the left limb is shorter. And with this degree of external tibial torsion and the excessive degree of foot pronation, the limb will be shorter. You need to know that internal limb spin and pronation both functionally shorten the limb length. This fella amongst other functional things is going to need a full length sole lift. We will start with 3mm rubber infused cork to do so. And let him accomodate to that to start.
We will attempt to correct as much foot tripod (anti-pronation) control as possible to help reduce leg shortness as well as to help reduce long term damage to the foot from this excessive pronation. We will also strengthen the left gluteus medius (it was very weak) to help him engage the frontal/lateral/coronal plane better. This may bring that foot in a little. But remember, the foot cannot come in so far that it drives the knee medially. Remember who is ruling the roost here !…… the knee. It only has one free range, the hip and foot have 3 !
Shawn and Ivo
Foot Landing Mechanics: Part 2 of 2 (Gait and Running)
/Foot orthoses and landing mechanics
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In Part 1 of this two part series (Part 1, link here) we wrote about the need to not omit observations of gluteal function when it came to the utilization of foot orthotics to control the knee. We felt that a tunnel vision perspective on just the foot was only telling half the story. Admittedly, we made the comment that research articles can look at isolated issues if it pleases them, but that it was our mission not to let tunnel visioned biases enter into things. Tunnel vision leads to assumptions that some problems have simple solutions. Our clients get evaluated through the entire kinetic chain when looking at foot and knee issues. Heck, even arm swing and opposite leg swing impact the function of the stance phase knee.
Here is again is the original article by Katie Bell over at LER (Lower Extremity Review) that brought up the initial PART 1 dialogue back in January and that is spurring Part 2 here today. It was good information but left some gaps in theory and application in our opinion.
The gap in our opinion is in failing to mention that perhaps this landing mechanics problem is present because of intrinsic foot weakness and kinetic chain cooperation of the entire limb and pelvis-core. One must remember that if the foot can be corrected or merely strengthened in a more functionally neutral manner that it should be a first line intervention. Merely inserting an orthotic, custom or off the shelf pre-fab does nothing to correct intrinsic and extrinsic weaknesses. They are an external device to correct alignment issues. Just because you put an orthotic in a shoe does not mean that the foot must function properly afterwards. A flat weak foot might just sit flat and weak upon the orthotic and nothing more. Sure it will be on a new platform and with different alignment, but there are no guarantees it will function better. The foot might just figure out a new way to compensate in another manner. Even worse, the foot and lower limb might be completely foreign in strategy, skill, endurance and strength in this new position and thus at even greater increased risk for injury than the one you tried to correct with the device in the first place. Just because you toss an intervention at something that should make a difference or create a result, does not mean it will occur. Just because you put a beer in someone’s mug does not guarantee they will drink it. That is the intention, but the outcome is not guaranteed, they might drink it but they also might not. Heck, they could even spill it (ie. compensation … undesirable outcome !). Just because the platform is different, new and possibly more optimal does not guarantee they will have the Skill, Endurance or Strength (S.E.S. - the mantra of The Gait Guys) to function any differently than before. This is why, when we choose to reach for an orthotic, that we educate the client on what it is doing, and how to treat it like any other piece of therapy. Meaning that it is to help reach an end goal, and when possible it is weaned away or minimalized to the new levels of S.E.S.
Now, back to the topic at hand.
This article talks about the hip adduction in females and mentions that it is not present in males but fails to even talk about possible reasoning behind this gender specific finding. Why wasn’t changed Q-angle in females talked about here ? Perhaps that was a discussion in the studies and merely not mentioned here.
The article also fails to talk about failed landing mechanics at forefoot load. When we load returning to the ground from a jump, we first load the forefoot. If the peronei and lateral calf are not strong enough to hold the rearfoot and forefoot in eversion at landing, making sure that the forefoot bipod is squared up at initial contact, the foot will be at a huge risk of inverting and spraining ligamentous tissues (esp. lateral restraints) as the load transitions from forefoot to rearfoot upon landing.
Think about all of this the next time your foot is in the air and quickly approaching the ground. If you are into a forefoot landing technique in your running, how is your forefoot landing platform ? is it flat ? Are you hitting laterally and risking injury or faulty mechanics ? Is your foot landing too medially and challenging the foot tripod prematurely ? Are you falling into the orthotic if you are using one ? Or are you merely using it as a crutch to improve your landing mechanics ? And……. do you even truly need an orthotic at all ? Or did your $ 500+ merely make for a nice mortgage payment on someone’s new boat ?
Orthotics …. they have value at times. Do you know when and how to implement them and when to hold off ? It is a tough game, you have to know the rules.
Shawn and Ivo
What’s your foot type: Part 5
And finally, the last foot type. Normal.
The normal foot is quite quiescent. It rarely complains unless you abuse it. Run too many miles with too few rest days, or put a shoe on it that is inappropriate such as a stability or motion control shoe and this foot will have something to say to you. But for the most part, this foot being neutral, it has appropriate shock absorption through normal pronation and it has nice rigidity at toe off from normal supination. This foot enjoys all of the perks of full joint motion ranges and nice skill, endurance and strength. It adequately controls the normal amounts of internal and external limb spin, and affords the ability to stabilize the pelvis in a strong neutral position all the while plowing through dozens of miles a week with pristine neuromuscular movement patterns. Like a run on a perfect early morning with the warmth of the sun on your face and wind at your back, several miles on the neutral foot is a beautiful thing to behold.
Knowing your foot type is a true key to understanding your strengths and weaknesses, as well as mechanical pathologies and propensity to certain injures. Understanding how your body has to strategize over your foot type will lead to a better understanding of how your injuries mount and more importantly, how to resolve or cope with them better. Finding someone who can help you discern your foot and bring the mechanical picture into clarity is of utmost importance.
The Gait Guys have designed a 3 part course fteaching you to fit your shoes to the appropriate foot type. Certification begins this spring through the IFGEC.
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.
The Gait Guys: promoting foot and gait competency everywhere!
We have talked alot of gait this week, especially this past Wednesday night on our monthly teleseminar on Chirocredit.com. Suffice it to say, it has been a long week
Friday Follies could not be complete with at least one musical reference….
Get out there and Walk Like an Egyptian! (really)
Have a great Friday
Ivo and Shawn
The Secrets to Running Downhill Fast.→
/Last month we contributed to Jene Shaw’s article in Triathlete Magazine.
Please hit the link here for the entire great article by Jene Shaw. There is lots more here. LINK
http://triathlon.competitor.com/2012/05/training/the-secrets-to-running-downhill-fast_54031
Here were some of our Form tips used in Jene’s article for going fast downhill.
Lean forward from the hips, not the shoulders. Gravity naturally pulls you downhill. Avoid the urge to lean back and focus on keeping your body perpendicular to the ground. “As you increase speed, move your center of gravity forward with you; not enough and your feet are sliding out from under you, too much and you’re on your face,” Waerlop says.
Perfect Foot Position
Think of your foot as a tripod, with the three points being the heads of the big and little toes (at the ball line) and the heel. This tripod needs to be level for the foot to function optimally. If you are too much on your heel, your shins need to slow the descent of the foot, which can lead to shin splints. If you land too much on your forefoot, your calves have to work harder to lower your heel and will exaggerate any forefoot abnormality you have in your gait; this will place additional stress on your knees. —The Gait Guys, Drs. Ivo Waerlop and Shawn Allen
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Here are some other things to remember when running down hill:
Be a drop of water: The Zen of watching water run downhill can teach us much. Taking the path of least resistance often is the least stressful for our bodies. Though terrain features like rocks, grass and dirt mounds can be useful to control speed, they also cause deceleration of our bodies, which means you need to reaccelerate them (remember Newtons 1st law?). This costs energy and wear and tear on our chassis. If you need to regulate speed on your descent, use the terrain options as described or angle your approach to one side or another zigzagging the descent. Taking the descent on an angle enables you to get 2 legs of your foot tripod on the ground almost immediately for added stability and it shifts your center of gravity to a more vertical or stable position, it also puts your body mass closer to the hill. A slip when descending on an angle is a better controlled slip. As you gain skill, you can point your feet more progressively down hill.
Do your homework: In the simplest explanation, muscles contract two ways: concentrically and eccentrically. Concentric contractions explain how the muscle shortens as it contracts, like picking up something. Eccentric contractions explain how the muscle lengthens as it contracts, like putting something you picked up back down. Eccentric contractions are much more costly from an energy and wear and tear perspective, as it takes more energy to break bonds between muscle fibers than make them. Running down hill requires lots of eccentric contraction of muscle, especially the quadriceps and muscles on the front of the shins, as there is a shift from glute drive to quadriceps loading. Running hills requires more (or extra) training particularly the eccentric phase for hill descents because of the increased demand.
The faster you go, the more perpendicular to the ground your body needs to be: Because of gravity, you are pulled down a hill. Our instinct may tell us to lean away (or backward) as we descend and pick up speed, but that could spell out disaster and perhaps your last run for quite some time. As you increase speed, you need to have your center of gravity move forward with you; not enough and your feet are sliding out from under you, too much and you are on your face. Again, if speed control is getting challenging, like in backwoods steep descents, zigzag your descent. Managing speed but covering more terrain safely is better than being the first down the hill while the last to get out of the first aid tent.
Look down the hill, not at your feet: Your brain works best pre-planning the next thing it should do, and works better when multitasking. Looking down at you feet actually facilitates your flexor muscles (the muscles which make you bend forward). This does two things: it makes you tend to fall forward and it turns off your extensor muscles (glutes, hams, back muscles) which are (or should be) the muscles in charge to keep you upright.
Engage your core: Think of your core as your engine and your legs as your transmission. An engine needs to drive the transmission. Your core muscles (abs, glutes) provide a stable platform for the other limb muscles to work upon. Not having the core engaged makes you more susceptible to injury, just like if your engine mount were broken.
Relax: Your mind is like a parachute; it works best when open. Stiffening up elicits protective reflexes that could be dangerous while running downhill. Imagine trying to drive your car with the airbag inflated. Let go and follow the flow.
External Tibial Torsion: A Video showing the effects on the knee, foot and hip.
Tibial torsion is measured as the angular difference between the tibial plateau and the distal malleoli. Here we have put 2 blue dots on the tibia, one at the middle of the tibial plateau and one at the half-way bisection of the malleoli (“ankle bones”). You can see that the dots clearly do not rest on the same vertical plane, they are nowhere close in this case ! This is tibial torsion. And since the lower dot is outside the upper dot, this is EXTERNAL TIBIAL TORSION. It is one of the factors which determine the progression angle of the foot (see our post here). It is easily seen here that, the foot will follow the lower dot because that is where the foot is attached to the ankle mortise joint. This is thus what is referred to as an “increased or excessive” Foot Progression Angle. Some will loosely, and humorously, refer to this as being “Duck Footed”. (But we have never seen a duck with external tibial torsion so who knows how this came about ! :-)
Normally, the angle is 0 degrees in an infant leaving the feet straight or slightly “in-toed”, and the tibia “unwinds” with growth, leaving the angle in adults at approximately 22 degrees. Angles in excess of 25 degrees are considered external tibial torsion; angles less than 15 degrees, internal tibial torsion.
In this case video it is critical to note a few things:
1- at the beginning we coached the client to straighten the feet forward so we could see the effects of the tibial torsion on the knees. In External Tibial Torsion, as in this case, the knees will always drift inwards (this is why these clients will always turn out the feet so that the knees and patella can track forward in the normal hinge progression that is necessary for gait. A case of external tibial torsion like this case will never see them walking with the feet straight forward (0 degree foot progression angle) because they will knock the knees together and the patella will track incorrectly and develop knee tracking pain.
2- you should be able to see that the client cannot dorsiflex the ankle sufficiently at the start because of the binding of the ankle into the torsioned distal tibia-fibula ankle mortise joint. The client gets “locked out” and cannot squat more than a few degrees. Be sure to notice this. These clients should not be pigeon-holed into how they do squats and lunges (“Straighten your feed lad!” should not be your recommendation, they just won’t be able to do much if they do. They will cheat !)
3. The second set of squats show them with the feet turned out excessively. They are able to get down further now, but the knees are now tracking too far outside and not forward. This was too much accommodation for the external tibial torsion.
4. The 3rd set are done (at 0:28 seconds into the video) with a more reasonable foot alignment. Reasonable for this client but far too much for someone who does NOT have external tibial torsion. You can see that the single planar hinge joint knee (the joint with the least tolerance) now moves nicely forward towards the camera. So, they will walk with the feet at this progression angle because this is where the external tibial torsion has left the knees to rest in the sagittal (forward) plane. Here the client will have minimal if any knee issues. However, one can only imagine what their ankles and feet and hips will think of all this !
To discern tibial torsions from femoral torsions, observe the orientation of the tibial tuberosity (the upper blue dot) with respect to the foot; in tibial torsion, there is a large difference. If this angle is withing the 15-25 degree range, then the torsion lies in the femur (femoral retro torsion and ante torsion…the subject of another post).
So, if you are training, coaching or rehabing a client are you aware of issues like these ? Are you attempting to drive skill, endurance and strength into your clients into a lower limb plane that is reasonable for their bony alignment? Maybe you were not even aware of these issues at all ? Lets hope not. You just cannot pigeon-hole all of your clients into a similar paradigm. It just isn’t that simple. Not if you do not want to injure someone. We get alot of these cases, sadly.
We discuss this in more detail in our Shoe Fit program that is soon to launch, but we also presented several 1 hour slide presentations on www.onlineCE.com in the recent months if you wanted to take those lectures.
Shawn and Ivo, two twisted fellas. Torsioned dudes. One is internally torsioned, the other external……… we cancel eachother out !
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 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,
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
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 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.
- 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.
- 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.
- 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.
- 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.
- All of these issues can cause a failure of symmetrical hip rotation and pelvic distortion patterning.
- 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.
- 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.
