Welcome to Friday Follies Folks.

A funny Fila commercial on tap for you here. Hope you have a great weekend

Ivo and Shawn

Classic Crossover Gait Case.

Here is a client with a uncompensated forefoot varus (ie: the forefoot is inverted with respect to the rearfoot) and a cross over gait, secondary to incompetence of the medial tripod of the foot (he cannot descend the head of his 1st metatarsal to form the medial tripod due to the uncompensated forefoot varus) and weak right lower abdominal external obliques which we discovered on examination (perhaps you can detect a subtle  sag of the right side during stance phase on that side).

Note how he circumducts the lower extremities around each other. This takes the cross over to another level and it can occur when a client is pronating through the medial tripod such as in this forefoot varus case (we know this from the examination, it cannot be detected for sure from the video with the foot in the shoe, that would be an assumption).

How do you fix this?

• tripod standing exercises
• core stabilization exercises with attention to the right lower oblique (see our core series available for download on Payloadz here and here
• foot manual therapy to improve motion of the 1st ray
• see our crossover gait series on youtube here: part 1, part 2, and part 3
• form running classes such as Chi Running

The Gait Guys. Bringing you the meat, without the fat.

all material copyright 2012 The Gait Guys/ The Homunculus Group: all rights reserved

READY

The Gait Guys Case of the week: What do you see?

This individual presents with Right achilles tendonitis, bilateral foot pain and a history of plantar fascitis. What do you think?

Take a look at his foot type, particularly the forefoot to rearfoot orientation. Hmmm….Asymmetrical. Notice the dropped 1^st metatarsal on the left that is not present on the right. He has a forefoot valgus on the left with a quasi flexible 1^st ray (1^st ray = medial cuneiform, 1^st metatarsal and associated phalanges) which is dropped and an uncompensated forefoot valgus on the right, with an inflexible 1^st ray.

He has bilateral external tibial torsion (which you cannot see in these pictures) right greater than left (OK, you can see that), as well as a Left anatomically short leg (tibial) of approximately 7mm.

Now look at the pedographs. BIG difference from left to right. Good tripod on right with clear markings over the calcaneus, the head of 5^th metetarsal and the head of 1^st metatarsals.  But I thought you said he had an UNCOMPENSATED forefoot valgus ?  Look at the shape of the forefoot print. It is very different from right to left. Remember, with a forefoot valgus, the medial side of the foot hits the ground before the lateral side most of the time,

How about the left? Look at all that metatarsal pressure. Looks like a loss of ankle rocker. Think that might be causing some of that left sided foot pain? Notice the print under the 1^st metatarsal is even greater; and look at all that printing of the 5^th metatarsal head. Remember, this is the shorter leg side, so this foot will have a tendency to supinate more, thus he increased pressures laterally.

Achilles tendonitis?  Stand on one leg on your foot tripod and rock between the head of your 1^st metatrsal and head of the 5^th.  Where do you feel the strain? The gastroc/soleus and peroneals. Now put all your weight on the lead of the 1^st metatarsal. What do you notice? The foot is everted. What everts the foot? The peroneals. So, if the foot is everted (like in the forefoot valgus), what muscle is left to shoulder the load? Remember also, that the gatroc/soleus group contracts from mid to late stance phase to invert the heel and assist with supination of the foot.

The Gait Guys. Your guiding light to gait literacy and competency.

Want to know more about pedographs? Get a copy of our book here.

All material copyright 2012 The Gait Guys/The Homunculus Group.

The Gait Guys Podcast #6 : S1E6

The Gait Guys Podcast #6 : S1E6

This one will get you to the show player of all of our podcasts.
http://directory.libsyn.com/shows/view/id/thegaitguys

And this link will get you a nicely laid out “show notes”.
http://thegaitguys.libsyn.com/webpage/2012/08

Show Notes: The Gait Guys Podcast, Season 1, Episode 6

1-  Cannabinoids and the Runners High
 http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=151936266&m=152175552

http://www.npr.org/blogs/health/2012/05/07/151936266/wired-to-run-runners-high-may-have-been-evolutionary-advantage

Endurance athletes sometimes say they’re “addicted” to exercise. In fact, scientists have shown that rhythmic, continuous exercise — aerobic exercise — can in fact produce narcoticlike chemicals in the body.

2-  more lectures available  on www.onlineCE.com   Go there and look up our lectures. New www.PAYLOADZ.COM lectures.
 
3- A lot of people cycle either as a less stress option to running or in conjunction with it (tri-athletes). No biomechanics-minded gait gurus are analyzing cycling posture, gait and cadence and putting it out there for us all to learn from. What can you teach us gait gurus?
Sincerely,
Ben, A lifelong student

4-   Cuboid Syndrome
Hi Gait Guys,I’m doing research on cuboid syndrome and wanted to know your thoughts on addressing the strength of the arch and how it might influence recovery.  Also, what impact would retraining/changing  the reflexive action of the of the peroneus longus may have on reducing the reoccurrence  of cuboid syndrome.  Any thoughts or feedback would be very helpful.
Thank you,Chase in Mooresville, NC

5- Part 2 on the LISA foot case , the suspect neuroma, seroma, tarsal tunnel case. We discussed her initial case in podcast 5
 DVDs , website, email,

6- Shoe talk / product talk

7-  EMAIL CASE
 Hi - I have been watching your videos for 2 years and find them very informative.  Here’s my problem:
I have had foot/ankle pain for more than 3 years.  The pain is traveling up/down my kinetic chain on the left side.  I’ve been diagnosed with:

        PTTD
        Achilles Tendinopathy
        Ankle instability
        Possible Tarsal Tunnel Syndrome
        Equinus
        Gluteal Medial Tendinopathy

I’ve seen 11 foot/ankle specialists (the BEST in Philadelphia).  I’ve seen orthopedic doctors for my glute problem.   I’ve seen 2 physiatrists to determine if this is a problem with my back.  I’ve had 4 surgical procedures on my ankle.  Had a tenotomy on my glute med tendon.  Gone thru 5 rounds of physical therapy for my foot/ankle.  4 months of therapy for my glute med tendinopathy.  I have 5 pairs of custom orthotics; 1 UCBL; 1 Arizona AFO.  Countless OTC devices.

hope you will join us for  Lorraine’s case.

8- Discussion on who controls individual cell control/coordination (and email from Jesse in Luxembourg). We dicuss several things including the effects of neuropepties.

Gait analysis case study: A runner with achilles pain.

Please watch this clip a few times and pay special attention to the lateral views. This client had persistent Left Achilles pain which has improved with care and foot exercise, but is developing Left soleus pain.

Lets try something new. Lets test your gait auditory skills. Run the video and listen. Listen to the foot falls. Can you hear one foot slap harder than the other on strike ? Can you hear the right forefoot slap harder than the left ?  It is there, it is subtle, keep re-running the video until you are convinced. The left foot just lands softer. Take your gait assessment to the next level, listen to your clients gait. Use all your senses. This finding should ask you to assess the anterior compartment of the right lower limb (tibialis anterior and toe extensors).  And if they are not weak then you should begin to ask yourself why they may be loading the right foot abruptly. Perhaps it is because they are departing off of the left prematurely, in this case possibly because of a short leg that has a shorter stride length. 

From clinical examination he has a 10mm anatomically short left leg (not worn in these videos), bilateral uncompensated forefoot varus deformities, bilateral internal tibial torsion and tibial varum ( 10 degrees Left, less on Right).

Exam reveals:

• weakness of the fourth and fifth lumbricals (small intrinsic foot muscles to the 4th and 5th toes) left greater than right. This will afford some lateral foot weakness during stance phase.
• weakness of all long toe extensors bilaterally (their weakness will allow dominance of toe flexors)
• weakness of the extensor hallucis brevis bilaterally
• weak left iliacus (a hip flexor muscle)
• slight pelvic shift to the left when testing the right abdominal external obliques
• weakness bilaterally of the quadratus femoris (a deep hip stabilizing muscle)
• weakness superior and inferior gemelli left, superior right (again, more deep hip stabilzer muscles)

So, what gives?

Did you pick up the nice ankle rocker present?  There is good ankle dorsiflexion. What is missing? Look carefully at the hip (in the lateral/ side video views). There is not much hip extension going on there. So, the question is how does he get the ankle rocker he is achieving ? Look at the knees. He is getting it through knee flexion! It would be more effective and economical to achieve this kind of ankle dorsiflexion from a nice hip extension and utilize the glutes for all they can provide.

Remember, he has an uncompensated forefoot varus. This means he has trouble making the medial part of his foot tripod get to the ground. This means that the foot tripod will be challenged when the foot is grounded and when combined with the clinical foot weaknesses we noted on examination this is a foregone conclusion.  With all that knee flexion which muscle will be called upon to control the foot? The soleus  (which DOES NOT cross the knee).

The answer to helping this chap ? Achieve more hip extension! How? Gluteal activation through some means (acupuncuture, dry needling, MAT, K tape, rehab and motor skill patterns etc), conscious dorsiflexion of the toes, conscious activation of the glutes and anything else you might find useful from your skill set. Gain more from the hips and  you will gain more control from that area and ask for the soleus to do just its small job.

Subtle? Maybe. Now that you know what you are looking at it is pretty easy isn’t it ? It’s like the “invisible gorilla in the room” we talked about in our previous Podcast.  Unless someone brings it to your attention your focus will be on what you are accustomed to looking for and what you have seen before. Sometimes we just need someone to direct our vision.  There is a difference between seeing something and recognizing something. In order to recognize something you have to go beyond seeing it, the brain must be engaged to process the vision.

The Gait Guys. Let us be your Peter Frampton and “Show you the Way” : )

Big Toe Exercise: Regaining Control of the Extensor Hallucis Brevis.

Exercise Anyone?

Here Dr Ivo briefly talks about the 1st part of the famous “Extensor Hallucis Brevis” or “EHB” exercise (Part 1) with a patient. More of this to follow after we launch the shoe program (yes, we know, it has been a long time coming. We would have had it out earlier had our site not been hacked). We plan on a foot muscle testing and Exercise DVD this winter.

Special thanks to our patient or letting us use the footage, and his wife to film the clip!

Ivo and Shawn

Welcome to Friday folks! Here is a funny commercial that lets us know why some people run : )

See you next week

Ivo and Shawn

Proprioceptive effects of aging: It’s all in the details

Here is a brief video of a gentleman that presented to us with neck discomfort and limited range of motion. Step through it several times before proceeding.

Hopefully, you noted the following:

Increased arm swing on the right (or, decreased on Left)

Pelvic shift to the left on Left stance phase

Decreased step length on the left

Hip hike on Left during Right stance phase

The patient does not have a leg length deficiency.

We remember that there are 3 systems that keep us upright in the gravitational plane:

1. vision

2. vestibular system

3. proprioceptive system

We also remember that as one of these systems become impaired, the others will usually increase their function to help maintain homeostasis. All these systems are known to decline in function with aging. So we have 3 systems breaking down simultaneously.

Did you also note the head forward posture, to move the center of gravity forward? How about the subtle head tilt to the right and “bobble” right and left? Motions which have to do with the head are functions of the vestibular system. He is attempting to increase the input to these areas (by exaggerating movements) to increase input.

How about the glasses? Presbyopia (hardening of the lens) makes it more difficult to focus. Movement (detected largely by rods in the eyes have a much higher density than cones, which are for visual acuity). By moving the head, he provides more input to the visual (and thus nervous system)

Amplified extremity movements provide greater input to the proprioceptive system (muscle spindles and golgi tendon organs (GTO’s), as well as joint mechanoreceptors).

Think of the cortical implications (and effects on the cerebellum, the queen of motor activity and important component for learning).  You are witnessing the cognitive effects of aging playing out on the ability to ambulate and its effect on gait.

 So what do we do?

Improve quality of joint motion, whether that is mobilization or manual methods to improve motion where motion is lost. Perhaps acupuncture to help establish homeostasis and improve muscular function. There are many options.

Postural advice and exercises

Core work

Proprioceptive exercises (like head repositioning accuracy, heel to toe and heel to shin)

Gait retraining

 You get the idea. Providing some of that increased input for him and helping the system to better process the information will be the key to improving his function and helping to counteract and maybe slow the effects of aging on the locomotor system.

We are the Gait Guys. Two geeks, giving you the info so we can all make a difference, every day

Special thanks to RM, who allowed us to use this video for this discussion.

Copyright 2012 , The Gait Guys/Homunculus Group

Materials and content cannot be used, copied or distributed without proper author credit /reference or without prior written consent.

Doing Squats, Lunges as well as Walking and Running using the Big Toe Ineffectively.

This is an important video.
Here in the initial frames you should see that this fella is using his big toe muscles incorrectly.  There is a long flexor and short flexor of the big toe, just like there is a long and short extensor muscle.
You should clearly see that the big toe sort of curls upwards in the early frames before he is coached to correct in the later frames. In these early frames his medial tripod stabilizing strategy is to use the short toe flexor (FHB - flexor halucis brevis) and more long toe extensor (EHL- extensor hallucis longus). This is what is giving the upward curl presentation. The problem with this strategy is that it is ineffective and uneconomical. It does not help to engage the medial tripod of the foot (ie. keep the big toe knuckle, the metatarsal head, down and purchased well on the ground) nor does it effectively assist the arch posturing of the foot.

You can see at the 17 second mark, with our coaching, he begins to learn and teach himself about the differing uses of the long and short hallux flexors. You can see him over correct from too much short flexor (FHB) into too much long flexor (FHL) where he claws the toe into the ground. You can then see in subsequent frames that he begins to play with the relationship to find a balance between the two. Then, you see that he loses the purchase of the medial tripod at 21 seconds where you see our hand enter the picture and queue the metatarsal head/knuckle down. When done correctly a double arch will form, one in the longitudinal arch of the foot and a second one just under the big toe. This big toe arch should be subtle but visible. If the client collapses this “toe arch” as we call it, they are driving the toe down with abundant short flexor (FHB). This can be easily seen on a pedograph mapping or foot scan represented by too much ink or pressure mapping at the proximal toe and little to no pressure distally through the pad of the big toe. These folks will struggle with adequate anchoring and purchase of the medial tripod (the 1st metatarsal head) and will challenge the longitudinal arch of the foot and thus the tibialis posterior as well as other structures. They can pronate too much and challenge the ankle mortise dorsiflexion range.  Rear foot eversion can become abundant as well. 

Balance of the long and short flexors of the big toe in concert with the long and short extensors. Too much short flexor usually couples with too much long toe extensor (hence the upward curl of the toe as we saw in the early video frames). Too much long flexor couples with too much short extensor, forming a claw-hammer toe presentation. There is a science to this. Balance must be achieved.  Just running barefoot or in minimalism does not guarantee a stronger foot or better form. It may in fact get you a more strength in a bad pattern (as you saw in the first few seconds of the video) which leads to injury  and it may get you stronger into many bad running and walking forms, both at the foot and higher up into your body.

There is more to this game than shoes and random exercises. This is a specific science, if you care to look beyond the basics that allow alot of injuries.  This is how detailed our game is with our athletes and patients, because it is the way the game should be played.

The devil is in the details
Shawn and Ivo………Uber gait geeks.

The Cross Over Running Technique (again):  A New Quick Case Study

Walk on a piece of string or along a seam in the concrete or walk on the lane dividing lines on your local high school or college track.  What happens ?  If you walk on a single line you will find yourself more unstable as compared to walking with a foot fall directly under your hips and knees the way it is supposed to occur.  The limbs are a pendulum and economy and biomechanical efficiency as well as injury reduction will occur when the parts operate in the most effective manner.

We have all of our cross over runners, as you see her doing in the first half of this video before she corrects to anti-cross over (ie. natural),  first walk on a line. In our case we use the metal drainage grate outside our office that you see in the video for just that purpose, they walk the grate. Then they run the grate.  We ask them to feel how unstable they are in the frontal plane walking the grate.  Then we have them walk with their feet only touching the outer edges of the grate, now not crossing over.  They can feel the difference, the increased stability.  They all say it is easier to walk with the thighs, knees and feet all barely scuffing past one another but after they feel the other most will comment that they can see and feel how lazy their gait and running gait have become. They can feel the better posture, more gluteals and more power that an anti-cross over gait affords them. Then they run the grate again. Then they run the edges of the grate.  You see this skill builder in the video above.

In this video clip, after 60 seconds of coaching, this top NCAA distance track athlete (often injured) was able to make the change immediately. You can see after just a few strides the immediate and dramatic change in her gait.  We then had her drift back and forth between lazy cross over and the corrected anti-cross over gait.  We do this so that on her long runs, when she notices the inside shoes scuff past one another, when they notice the feet begin to run on a line, when the thighs begin brushing past each other that she can immediately make the correction. It will happen often during the beginning stages of developing the new neurologic skill pattern. Motor pattern learning takes up to 12 weeks before the neuroplasticity becomes more worthy of the dominant pattern of choice.

We have all of our athletes head over to the oval track and run not in the lanes, but on the line. To be precise, they run with their feet on either side of the line, making sure they have that visual feedback for the correction. They run over the line. We drove past a local high school the other day and saw the entire girls cross country team on the track running not in the lanes, but over the lines.  We smiled big, and long. We know the coach, he follows our stuff, and he will prevent so many injuries this year in his runners.  They have a 15 minute pre-run warm up and skill building for their runners.  They will be competitive at the State level once again because they will show up with everyone healthy and free of injury, we can only hope.  They will have a better chance than others who keep doing what they did last year, and the year before that, and the year before that.

If you are doing what you did last year in your training, expect last years results.
Have you watched the cross over series we put together on youtube ? The 3 part video series ?  It is worth your time to watch it.

Here are the links:
Part 1: http://youtu.be/LG-xLi2m5Rc
Part 2: http://youtu.be/WptxNrj2gCo
Part 3: http://youtu.be/oJ6ewQ8YUAA

Shawn and Ivo……… still pounding the floor on eradicating the modern day plague in running…… The Cross Over Gait.  You don’t want to catch this illness !

Slow Your Gait & Shorten Your Stride and Your Brain May Slow

Slow Your Gait & Shorten Your Stride and Your Brain May Slow

Well, you have heard it here before, the receptors drive the brain, and here is another study that backs this up. Remember that receptors, which include not only joint mechanoreceptors, but also muscle mechanoreceptors (muscle spindles and golgi tendon organs) and tactile receptors in the skin (Merkels discs, paccinian corpuscles, etc) feed into the brain cortex (via the dorsal column system) and the cerebellum (via the spino cerebellar system). This afferent (sensory information) input is important for proper coordination as well as cognition and learning.

Remember, your brain is always remodeling. Here, the old adage “if you don’t use it, you will lose it” applies. More input = more synapses = more neuronal growth. So less motion = less input=synaptic atrophy = fewer connections and thus slower brain function.

Increased speed and length of stride stretches receptors more; decreased speed and shorter stride lengths decrease receptor activation. So, take big steps quickly, or you may turn into a zombie ! There is a reason why they walk slowly !

In July 2012 at the Alzheimer’s Association International Conference in Vancouver, British Columbia Mayo Clinic researchers presented research indicating that walking problems such as a slow gait and short stride are associated with an increased risk of cognitive decline. Computer assessed gait parameters (stride length, cadence and velocity) in study participants at two or more visits roughly 15 months apart. They revealed that participants with lower cadence, velocity and length of stride experienced significantly larger declines in global cognition, memory and executive function.

references:

http://www.aansneurosurgeon.org/2012/08/02/slow-gait-short-stride-linked-to-increased-risk-of-cognitive-decline/

http://www.newswise.com/articles/view/591437/?sc=dwhn

Welcome to Friday Follies

Here is a funny sketchers commercial to ease you into the weekend. Have a good one!

Ivo and Shawn

Gait Problem ? But where is the problem ? A case of failed single leg stance in a runner during the “3 Second Gait Challenge”.

Remember, what you see is not the problem most of the time.
You have heard it from us over and over again. What you are seeing in someone’s gait or running, the thing that does not look right, is their strategy to cope with the body parts that are dysfunctional. You are quite often not seeing what is wrong.
For example, here during our “3 Second Gait Challenge” this gentleman shows a solid left stance phase of gait. At times it is so solid and calm that it looks like we still-framed the video. The right side is another matter. During right stance there is excessive “checking” of the frontal plane (side to side) at the ankle. You also clearly see him using the right arm as a ballast moving it out to the right during right stance phase to help offset and dampen the frontal plane challenges.
Now going back to our initial thesis (“Remember, what you see is not the problem most of the time.”) surely you will agree that what you are seeing that right arm doing is probably not the problem here. Correct ? 
Now, this is a patient of ours, so we know what is wrong with him.  But from an outsider looking in, the problem in this case is more likely in the right lower limb, but you cannot see what is wrong with it. So remember, what you see is frequently not the problem, rather it is a compensation strategy. This gentleman’s problem is coming from his right lower abdominal functional impairment (specificially the lower transverse abdominus and internal abdominal oblique functional weaknesses, we know because we  clinically muscle assessed him for strength, skill, and motor patterns in our office.) These muscles were clearly neurologically inhibited and weak and the motor pattern he has laid down is many years in the making, driving a deeply seated compensation pattern.  Basically, he cannot stabilize his torso on the pelvis-hip during single leg stance. This lets the pelvis drift to the right. In this case it was not gluteus medius weakness allowing for the drift, which is more common. The torso is weak on the right side making it difficult to stabilize right lateral torso movement so he cheats by moving his torso to the left (which you can see) but does so ineffectively and thus needs to use the right arm to “check” the poor strategy.  His Rolling patterns were clearly disfuctional however even after correcting them he still had the gait neurologic pattern as his default,  hence gait retraining is necessary in this and all cases. We do many other functional assessments, methods we have developed and they all clearly directed and confirmed the diagnosis.  Just remember, if you fix a person’s movement patterns but then do not fix the repetitive gait pattern they have been using then their gait is cycling the problems right back into the person and you are wasting your, and their, time. 

Additionally, It would be easy to say that this gentleman has a proprioceptive deficit and that he needs to do some balance work on a Bosu ball or  tilt board.  But that is “so last year” thinking. If someone is having troubles standing and balancing on a stable concrete floor why in the world would you make his stance surface training even more unstable ?  This again is just not wise thinking. You don’t first learn to drive on the freeway, you start in a parking lot or back street where you can learn skills at a slow speed first. Conquer stability on a stable surface, then progress them to a more unstable surface.

Today we showed you a small diamond in our assessments. The “3 second gait challenge”.  This one is a keeper for us.  As we always say “Speed kills”. And in gait speed also is a disguise, it blends and blurs the deficits and challenges.  Slow your clients done to 3-4 seconds and watch what jumps out at you !  (did you read our blog post on Speed and Gait deficits ? Here is the link.) Speed is the devil when it comes to gait. At a normal walking pace and running pace these deficits were not perceptible, because speed in the sagittal plane (moving forward) reduced the lateral challenges. Speed blurs, speed blends and speed kills.

We continue to ask “Of all the functional movement courses being offered out there now, why do they not get into functional gait screening?"  We think we have the answer.  It is likely because this stuff is difficult, it is because it takes a deep knowledge base of whole body biomechanics/functional anatomy (from arm swing to big toe function) and it is because what you see in someone’s gait is very often not the problem.  A deep and broad understanding of human gait is not something you can pick up in a single weekend seminar nor can it be something done simply by a "check off” sheet.  This is complicated stuff, our 700+ blog posts with 230 in the draft folder plus 90 YouTube videos proves that there is great depth to gait and proves how complex it can be. But, if you have been with us for awhile and continue to work at this stuff you are likely getting better and better at this gait stuff. Do not give up. This is a worthwhile journey.

We are The Gait Guys. Shawn and Ivo.

Providing a stable surface for your knowledge base!

Retail/Coach/Trainer Focus: When a stability shoe does not stop gait or running pronation.

This video is unlisted. You will need this link to view it if it does not show up in the player above this blog post:    http://youtu.be/Lt6RbEtALUY

This is a higher end stability shoe. We know what shoe it is and you can see the significant amount of dual density mid sole foam in the shoe, represented by the darker grey foam in the medial mid sole.  The point here is not to pick on the shoe or the brand. The point here is to:

1. not prescribe a shoe entirely on the appearance of the foot architecture

2. not to prescribe a shoe merely because a person is a pronator

3. not to assume that a stability shoe will prevent pronation

4. not to assume that technique does not play a part in shoe prescription

5. not to assume that all pronation occurs at the mid foot (which is the traditional thinking by the majority of the population, including shoe store sales people)

There you go, plenty of negatives. But there are positives here. Knowing the answers and responses to the above 5 detractors will make you a better athlete, better coach, better shoe sales person, a safer runner, a more educated doctor or therapist and a  wiser person when it comes to human locomotion. 

A shoe prescription does not always make things better. You have heard it here and we will say it again. What you see is not necessarily what you get.  This case is a classic example of how everything done for the right reasons when so very wrong for this young runner.

What do you see ?

Pronation can occur at:

1. the rear foot (we refer to this as excessive rear foot eversion or calcaneal eversion driven sometimes by rearfoot valgus). This can be structural (congenital) in the bone (calcaneus or talus) or functional from weaknesses in one or several rear foot eversion controlling muscles.
2. the mid foot as is traditionally assumed (this is often referred to as “arch collapse” ).
3. the fore foot. (possibly many causes, such as a Rothbart Foot variant, short first metatarsal, a bunion , forefoot varus, hallux valgus, weakness of the hallux controlling muscles etc)

So, in this case you might assume that the stability shoe that is designed to prevent rear and midfoot pronation is:

1. not doing its job sufficiently OR
2. the pronation is occuring at the forefoot OR
3. there is a myriad of of issues (yes, this is the answer)

However, the keen eye can clearly see that this is a case of heavy forefoot pronation but there are also mechanical flaws in technique (driven by weaknesses, hence just working on her running form will not solve her issues, it will merely force her to adopt a new set of strategies around those weaknesses !). The problems must be resolved before a new technique is forced.  This is perhaps the number one mistake runners make that drives new injuries.  They tend to blame the injury on new shoes, old shoes, increased miles, the fartlek they did the other day, the weather, their mom, there spouse, their kids…….runners come up with some great theories. Heck, all of our athletes do ! It keeps things amusing for us and we get to joke around with our athletes and throw out funny responses like, “I disagree, it was more likely the coming precession of the equinox that caused this injury !”. 

Although his individual does not have a fore foot varus deformity (because we have examined  her) it needs to be ruled out because it is  big driver of what you see in many folks.  In FF varus the forefoot is inverted with respect to the rear foot. This can be rigid (cannot descend the 1st ray and medial side of the tripod) or plastic (has the range of motion, but it hasn’t been developed).

We, as clinicians, like to assume that MOST FEET have a range of motion that folks are not using, which may be due to muscle weakness, ligamentous tightness, pathomechanics, joint fixation, etc. Our 1st job is to examine test the feet and make sure they are competent. Then and only then, after a trial of therapy and exercise, would you consider any type of more permanent “shoe prescription”.

If the individual has a rigid deformity, then you MAY consider a shoe that “brings the ground up” to the foot. Often time we find, with diligent effort on your and the individuals part, that a shoe with motion control features is not needed.

Sometimes the individual is not willing to do their homework and put in the work necessary to make things happen. This would also be a case where an orthotic or shoe can assist in giving the person mechanics that they do not have.

We have not seen many (or any) shoes that correct specifically for a fore foot varus (ie a shoe with fore foot motion control ONLY). The Altra Provision/Provisioness has a full length varus post which may help, but may over correct the mid foot as well. Be careful of what you prescribe.

Yes, we have been studying, blogging, videoing and talking about this stuff for a long time. Yes, much of it is often subtle and takes a trained eye to see. It is also the stuff that goes the “extra mile” and separates good results from great ones.

We are The Gait Guys. Watch for some seminars on some of our analysis and treatment techniques this fall and winter, and some pretty cool video, soon to be released.

Midfoot strike 5 year old running barefoot in grass.

So, heel strike you say ?  Have  a closer look.  This is a near perfect midfoot strike. What you cannot see is his torso progression. As long as the torso has enough forward lean heel strike cannot occur. Heel contact can occur, but not heel strike or impact.

We have talked about this on many occasions here on The Gait Guys Blog. No one else is talking about this fine line difference between heel strike and heel contact.  Everyone still seems hell bent on talking about forefoot strike. Forefoot strike in distance running is not normal, midfoot strike like you see here in this young child is natural and normal. This 5 year old was likely just asked to run barefoot, he was not likely coached. This is because midfoot strike is natural and normal.  As we said, as long as the torso is directly above or in front of the foot contact position there is no way that heel STRIKE can occur, rather heel CONTACT can only occur (unless you have hamstrings like cirque du soleil acrobats and do not mind going into a posterior tilted pelvis at contact). 

We tell our runners to:

• lift the chest and lean
• raise the toes and dorsiflex the ankle  (engage the anterior lower leg compartment) so that the arch is maximally prepared
• a heel KISS of the ground is fine, just no impact
• you do not need to forefoot strike to run naturally
• * and, here is one more reason why we like a midfoot strike over a forefoot strike…. because a midfoot strike means that the body continues forward whereas a forefoot strike that then allows into a heel kiss/touchdown means that there is a posterior progression and eccentric lengthening of the posterior chain (hamstrings and calf muscles). This posterior directed motions is not exactly wise when forward progression is the goal of running !

This little fella is doing it right. Largely because he has not been in shoes long enough to corrupt the natural tissues and mechanisms (both the body parts and the natural neuromotor patterns).

* Addendum: after a really productive FAcebook dialogue with some readers we felt we needed to be more clear on some of our unspoken assumptions here.  If the heel hits first, it will be a STRIKE and not a KISS and the load will be high. The only way the heel can kiss the ground like we mention above is if the heel is absolutely contacting at the same time as the forefoot, one could say that there is a more dominant load on the mid-forefoot but the heel can still strike at this same time.  Striking clearly on the forefoot and then touching down the heel is satisfactory but there is still a retrograde movement which we believe is not as economical yet certainly better than heel impact/strike.  To get the perfect midfoot strike with barely a subtle heel CONTACT (not impact or strike) requires greater skill and more mastery as a runner.  And if you are wearing a shoe that is not minimalist or zero drop developing this skill will be a challenge and you will be misleading yourself.    This ammendment added 1 hour post blog post launch.

Shawn and Ivo…….. the Devil is in the Details. 

The Gait Guys Podcast #5 : S1E5

The Gait Guys Podcast #5: S1E5

This one will get you to the show player of all of our podcasts.
http://directory.libsyn.com/shows/view/id/thegaitguys

And this link will get you a nicely laid out “show notes”.
http://thegaitguys.libsyn.com/the-gait-guys-podcast-4-s1e4

Topics to be discussed in Podcast #5:

1-  more lectures available  on www.onlineCE.com   Go there and look up our lectures

2. EMAIL INQUIRY:

Hi guys,
I was wondering if you do distance/online consultations at all? I’m a
former athlete trying to get back into sprint training for decathlon
and am having great trouble with shin splints. I’ve been going to
various therapists in my area for months now, have spent loads of
money and am not really seeing any improvement. I’m at a bit of a loss
for what to do right now! I can easily provide good quality video of
me walking/running etc for assessment. Please let me know if you can
help and what the cost would be, it would be very much appreciated!
Thanks for your time.
Best regards,
Chae
Join us today for an in depth dialogue on this topic.

3. EMAIL CASE:

Hey Gait Guys,
I have just recently began watching your videos and must say it is changing the way I look at mobility and functionality. I have been vigorously exercising for 5 years now but seem to be stumbling over physical limitations that are obviously my way of compensating for asymmetries and weaknesses. In the last two years has been horrible bouts with over tight hams and weak glute issues. Re training is a slow process.
 From watching your videos, I already identify with being a toe curler. The awareness alone does not help and gets worst when running. I tried to switch to minimalist shoes for running but my left heel got so tight I had to shelve that plan. I am back in stability shoes for running. I use minimalist shoes for everything else. I have horrible time balancing and it seems to emanate from weak ankles stabilizers however, I do not have weak ankles (don’t roll them etc.) but the fatigue seems to emanate from the ankles. I have also noticed that my feet have straitened pretty good from a pronounced pigeon toe that I have had since I could walk (I’m 47 now). So the feet are straighter but when approaching a mirror at the gym, I notice that I have noticeable internal rotation on my legs and my gait looks awkward. My thinking is that this is a part of the puzzle that I need to solve to get more functional and hopefully out of stability shoes and learn to have an arch again instead of flat feet.
Regards, Charles
Join us today for an in depth dialogue on this topic.

 
4. REVIEW of our favorite BLOG POST OF THE WEEK:

forefoot strike……olympic trials video review.
4 of these runners seem to have a significant varus in either their fore foot or rear foot. However this is difficult to truly tell from such small single snapshot pictures.  And just because it appears to be a varus landing does not mean that it is true on examination, a foot that has reduced peroneal activity can appear to have a  varus strike, but that does not truly then comment on a true forefoot varus. Also, remember from our previous posts, if a runners is employing a notable degree of cross over gait technique the approach of the foot to the ground and at the ground can appear to be forefoot varus. * These are critical points, because what you see is not necessarily what you truly have.  There are possibly many variables playing out.

Join us today for an in depth dialogue on this topic.

5. STORY OF THE DAY:   

  A dialogue on muscle testing.  Be sure what you are testing is accurate and true.  Testing someone where they preposition themselves will always show strength.
 
6. SHOE TALK:

Darn Wool Socks

7. EMAIL CASE:

Hello Gait Guys!

I LOVE your educational videos. I have such a passion for foot bio-mechanics, and am eager to sort out my own issues without the use of supports.

I am a big believer in “barefoot is best”. I exercise my feet in this manner regularly.

My question is regarding Morton’s toe, or Rothbarts’ foot. I have this on both feet, with it more pronounced on the right. I’ve got some compensations going on and would like to know if you can offer some exercise recommendations to help sort out my feet.

I consistently work on spreading the toes, and feel the need to stretch the left foot by twisting my leg to the left and stretch the right foot by twisting that leg to the left as well. When lying down, the left leg turns out, and the right leg turns in.

Am I doing enough? How long do you think it will be before my toes straighten out and I no longer get sore on the balls of my feet? 

I have had orthotics in the past which did not help, even after several adjustments. In fact, they made things worse because of course they weaken the foot.

Keep on doing what you're doing!
-Tracy - Toronto

Some Biomechanical Facts on Oscar Pistorius: 400 m London Olympic Games

Following Saturday’s 400m men’s preliminary heats Jere Longman’s wrote an article in the NYTimes entitled “Pistorius Advances to Semifinals”. In it were some interesting facts. Here is the link to the article. 

Ever since Pistorius’s shut out from the Beijing Olympics scientific and legal debate has continued about whether his prosthetic legs gave him an unfair advantage over sprinters using their natural legs. However, as we all knew, this time around would different in London 2012. Competing on carbon-fiber prosthetics called Cheetahs, Pistorius was going to get his chance and in the process further the debate on what is considered able and disabled.

Prior to Beijing the I.A.A.F. said Pistorius’ carbon-fiber blades violated its ban against springs or wheels that gave an athlete a competitive edge over able bodied athletes. The prosthetic legs allowed him to run as fast as elite sprinters while consuming less energy, the governing body concluded. None the less, the debate has continued over the past few years since Beijing pertaining to where to draw the line between fair play and the right to compete. In 2009 in The Journal of Applied Physiology a study concluded that Pistorius could take his strides more rapidly and with more power than a sprinter on biological legs.

An acquantance of ours who we talk to from time to time, Professor Peter Weyand at SMU Locomotor Performance Laboratory in 2009 looked at Oscar Pistorius-type carbon fiber Cheetah blades a little more closely. In his study (referenced below), in the Journal of Applied Physiology, he conducted three tests of functional similarity between an amputee sprinter and competitive male runners with intact limbs: the metabolic cost of running, sprinting endurance, and running mechanics. What he found was:

• the mean gross metabolic cost of transport of the amputee sprint subject was only 3.8% lower than mean values for intact-limb elite distance runners and 6.7% lower than for subelite distance runners but 17% lower than for intact-limb 400-m specialists
• the speeds that the amputee sprinter maintained for six all-out, constant-speed trials to failure were within 2.2 (SD 0.6)% of those predicted for intact-limb sprinters.
• at sprinting speeds of 8.0, 9.0, and 10.0 m/s, the amputee subject had longer foot-ground contact times ,shorter aerial and swing times and lower stance-averaged vertical forces than intact-limb sprinters [top speeds = 10.8 vs. 10.8 (SD 0.6) m/s].

Weyand concluded that running on modern, lower-limb sprinting prostheses appears to be physiologically similar but mechanically different from running with intact limbs.

Longman’s article listed some of the other facts that have come up in recent years, facts that led to the eventual acceptance of Pistorius in London 2012’s Olympic events.  We have not captured these references specifically (yet, but we will) but in the mean time to keep this blog article timely, lets look at some of the other facts that Longman mentioned in his NYTimes article:

• While calf muscles generate about 250 percent energy return with each strike of the track, propelling a runner forward, Pistorius’s carbon-fiber blades generate only 80 percent return, Gailey said.
• Given that Pistorius has no feet or calves, he must generate his power with his hips, working harder than able-bodied athletes who use their ankles, calves and hips, Gailey said.
• And because the blades are narrow and Pistorius essentially runs on his tip toes, he pops straight up out of the blocks instead of driving forward in a low, aerodynamic position for the first 30 or 35 meters, making him more susceptible to wind resistance, Gailey said.
• Compared with runners with biological feet, Pistorius also must work harder against centrifugal force in the curves, and his arms and legs tend to begin flailing more in the homestretch, costing him valuable time, Gailey said. His stride is not longer than other runners, as many presume, Gailey said. “It’s not like he’s bouncing high with a giant spring,” Gailey said.
• The blades “basically allow him to roll over the foot and get a little bounce,” Gailey said, adding: “The human foot operates like a spring, and his feet operate like a spring. But the human foot produces more power than the blades do.”

There is an abundance of interesting information here. We will likely return to some of these topics and facts in the future, but in the meantime we say that everyone has their own demons and deficits. We all have injuries and limitations we have to cope with, in life and in sport. So where the line gets drawn will always be a blurred. This debate on this specific case with Pistorius could go on for years and never reach an agreeable conclusion as to a fair playing field. So, let the games begin and may the best man or woman win, with his or her demons and deficits in tow.  Good work Oscar. Thanks for the inspiration.

Shawn and Ivo, The Gait Guys

____________________________

We found 3 other journal articles on Pubmed on Oscar.

1. Enhancing disabilities: transhumanism under the veil of inclusion? Van Hilvoorde I, Landeweerd L.   Disabil Rehabil. 2010;32(26):2222-7.

2. Oscar Pistorius, enhancement and post-humans. Camporesi S. J Med Ethics. 2008 Sep;34(9):639.

3. By designing ‘blades’ for Oscar Pistorius are prosthetists creating an unfair advantage for Pistorius and an uneven playing field? Chockalingam N, Thomas NB, Smith A, Dunning D. Prosthet Orthot Int. 2011 Dec;35(4):482-3.

4. J Appl Physiol. 2009 Sep;107(3):903-11. Epub 2009 Jun 18.

   The fastest runner on artificial legs: different limbs, similar function?

   Weyand PG, Bundle MW, McGowan CP, Grabowski A, Brown MB, Kram R, Herr H. LINK   http://www.ncbi.nlm.nih.gov/pubmed?term=2009%20journal%20of%20applied%20physiology%20weyand

Welcome to Friday Follies, Folks.

A fun Adidas commercial on tap here.

Have a great weekend

Ivo and Shawn

The Essex Swagger: Are Gait (Walking and Running) Styles Cultural and/or Geographical ?

Do Australians move like Americans ?  Does a woman in Israel move like a woman in Ireland ? Do Swedish men move differently than a rural farmer in Tibet ?

Sure there are many variables that come to mind that can drive differing answers; things like foot wear (winter boots, rugged rural shoes/boots to fashionable Manhattan), terrain, tight or loose clothing an so on.  But the main question we are asking here is this: are there cultural and geographical differences in the way we walk devoid of issues related to climate, terrain, and fashion?  In other words, because of our deeply rooted genetic codes that may have been slightly tweaked over the centuries, are there subtle differences in the way these different cultures walk and run ?

Recently we came across an internet article on a gait study “College walking study to capture the Essex swagger” being done at the Chelmsford University . Scientists at Anglia Ruskin University, in Bishops Hall Lane, are calling on people to help them capture “the Essex swagger”, which could help provide better treatment for UK patients.  The gait analysis lab, at the university’s postgraduate medical institute, is a replica of the one at the Hospital for Special Surgery in New York, the leading hospital for orthopaedics in the United State so one might assume this is no meager investigation.

He believes establishing a local database will allow more accurate testing and analysis of patients, ranging from burns victims to those who have just undergone hip or knee surgery.

Dr Rajshree Mootanah, director of the university’s medical engineering research group mentioned that “When we are working with patients it is important to have a reference database of ‘normal’ gait to compare them to. The only database we have is of the New York population and we believe there may be slight, but still significant, differences to the way our local population walks due to the different racial make-up of the two groups.” 

So the bigger question is in fact, are geographic and/or cultural differences present significant enough to warrant different baselines for gait studies ? This question had us looking deeper into the research.  Unfortunately there is not much in the literature on transcultural movement differences but what we did find was supportive of our hypothesis.  To keep this blog article within readable limits for now, we have included the two journal articles we wanted to mention to support the hypothesis.  In Ebersbach’s study (references below) the

“healthy subjects in Berlin showed faster gait velocity than their counterparts in Tyrol, Austria, and patients with Parkinson’s disease were slightly slower than their respective healthy peers in both environments”.

Surprisingly, his study found that patients with Parkinson’s disease from Berlin had significantly faster walking speeds than both patients and healthy control subjects from Tyrol. There was a high gait tempo in Parkinsonian patients from Berlin characterized by fast step-rates and short strides. Thus, it appeared that in Ebersbach’s study there were sociocultural differences in gait, even in disease processes such as Parkinson’s disease. This certainly opens ones eyes into the understanding of disease. After all, we thought that a disease was a disease, not matter what part of the world you are in. And this study shows that this may not be the case.

In Al-Obaidi’s study the gait of healthy young adult Kuwaiti subjects from both genders were compared those in Sweden. The study indicated several significant differences between the subjects in their manner of walking regarding walking at “free, slow and fast” rates.

Both of these studies suggest that people move differently from each other around the world, and surprisingly, even differently from within the disease group of “movement impairment syndromes”. People in Australia move different from those in England, Canada, Germany, Sudan etc.  it suggests that our gait is as unique as our language and as subtle as an accent within a common tongue.  The studies also  suggest that if the gait world is to expand further in terms of research that multi cross-cultural data bases must be built.

Shawn and Ivo, The Gait Guys.

Two geeks looking for the missing links in how humans move.

_______

Mov Disord. 2000 Nov;15(6):1145-7. Sociocultural differences in gait. Ebersbach G, Sojer M, Müller J, Heijmenberg M, Poewe W. Source

Fachkrankenhaus für Bewegungsstörungen/Parkinson, Beelitz-Heilstätten, Germany.

Abstract

Transcultural differences in routine motor behavior and movement disorders have rarely been assessed. In the present study gait was studied in 47 healthy inhabitants of Tyrol living in rural or semi-urban (Innsbruck, Austria) settings and 43 healthy subjects residing in Berlin, Germany. In addition, gait was assessed in 23 patients in early stages of idiopathic Parkinson’s disease (11 in Berlin, 12 in Innsbruck). Healthy subjects in Berlin showed faster gait velocity than their counterparts in Tyrol, and patients with Parkinson’s disease were slightly slower than their respective healthy peers in both environments. Surprisingly, patients with Parkinson’s disease from Berlin had significantly faster walking speeds than both patients and healthy control subjects from Tyrol. High gait tempo in parkinsonian patients from Berlin was characterized by fast step-rates and short strides. Differences in normal gait in different sociocultural settings are thus reflected in parkinsonian slowing of gait.

________

J Rehabil Res Dev. 2003 Jul-Aug;40(4):361-6. Basic gait parameters: a comparison of reference data for normal subjects 20 to 29 years of age from Kuwait and Scandinavia. Al-Obaidi S, Wall JC, Al-Yaqoub A, Al-Ghanim M. Source

Department of Physical Therapy, Faculty of Allied Health Sciences, Kuwait University, Kuwait.

Abstract

This study obtained measurements of the spatiotemporal gait parameters of healthy young adult Kuwaiti subjects from both genders and compared the data to those collected in a similar study performed in Sweden. Thirty healthy subjects volunteered to participate in the study (which included being asked to walk at their “free,” “slow,” and “fast” self-selected speeds). We collected the spatiotemporal gait data using an automated system. Descriptive statistics were calculated for each variable measured at each walking condition. The data were then compared to those from the Swedish study. The results indicate several significant differences between Kuwaiti and Swedish subjects in their manner of walking. These results suggest a need to include data from subjects with diverse cultural backgrounds when a database on normal gait is developed or a need to limit the results of the database to a specified ethnic population.

More on Leg Length Discrepancies

Hi Guys,

I hope you guys are well?

I have a question I hope you can help me with?

Last week I assessed an entire football team, and over 90% have some sort of Leg Length Discrepancy (LLD). I am working with the physiotherapist to improve their weaknesses, including using sole lifts.

My question is if it’s a tibial short leg, then a lift with align the knee and hip. But a lift in a leg with a short femur will align the pelvis but raise the knee higher than the other side. Would you still insert a sole raise, and if not, what would you do?

Kind Regards

Luke

____________

Hi Luke

Yes, you are correct in your assumption of the change in mechanics, and yes, most often, we prescribe a sole lift, if a lift is indicated. Keep in mind that if they are asymptomatic and test out well, a lift may not be indicated. Hope that helps. You can also search LLD on the blog; we have written extensively on it: http://thegaitguys.tumblr.com

Remember sole lifts will correct the LLD but it could shift the pelvis off further…….many LLDs are from pelvic asymmetry and core weakness, this encompasses hip rotation differences which is a typical response to the core and pelvis that is distorted. 
merely forcing a change at the Sole does not mean you are making the positive change at the top……however it may in some cases……you have to determine that with your evaluations.

Most folks legs are of symmetrical length……..the changes at the top (core / pelvis/ hip) is what throws the apparent length off.

i wish i had a good answer for your great insight……..but it is about
1- making the right changes……..so that all parts are in cooperation for the restoration change
2- that you are directing change and not a further body compensattion to the compensation you have forced…….(if it is in fact a forced compensation and not the correction you are hoping for)….. time and re-evals will determine this
3- after restoration and strengthenging you must quickly wean off the lifts from them
4- you are speaking of tibial and femoral short………those are structural short LLDs , make sure you know if you are dealing with functional or structural shortness

Hope that Helps

Ivo and Shawn