Hip Biomechanics: Frontal Plane Part 3

This diagram (Figure 3)  also shows a balanced HAM x D1 = D2 x BW equation.  The BW is larger than the HAM but this is offset in the rules of the teeter-totter.  Shifting the pivot point towards the larger mass is offset by the smaller D2 and larger D1 moment arms.  This is a typical compensatory mechanism used by obese patients to ambulate effectively.  It does render significant frontal plane movement of the pelvis instead of the more desirable silent frontal plane pelvis.  In this compensation, even large body weights can be somewhat offset by the degree of contralateral hip hiking to reduce the D2 moment arm and increase the D1 moment arm however this compensation has its limits.  When the limits of alteration of moment arm length are reached the body’s only compensation at that point is to increase the HAM forces which increases joint compression and thus cartilage wear since the cyclical loading and unloading of the cartilage is much less.  This is also the same mechanism used by patients with a osteoarthritic painful hip joint.  We are not referring to increasing BW, rather we are suggesting that to reduce pain the patient will want less joint compression and thus a reduced HAM.  To do this we want to increase the D1 moment arm. The only way other than surgery to achieve this increase in D1 is to take the existing body weight and shift it closer to the pivot point. Ideally you would want to lean so far over the affected painful hip as to get your body weight (BW) immediately over the pivot point. This is what is done with a walking cane in the opposite hand of the stance leg, to help lift the swing phase leg and pelvis and to push the body mass over the hip WITHOUT using more HAM (glute medius contraction generated compression, which would generate pain). This would effectively reduce D2 to nil and significantly increase D1 thus allowing HAM to be minimal; thus reducing painful joint compression.  (In teeter-totter verbiage, put the small child on the long part of the teeter-totter arm and you can move large forces with little effort at the pivot point.) 

Get Certified!

Our 2nd Nationally Certified Individual! Congratulations to Marianne Fitzgerald, LMT.   Marianne is the coordinator of “ all things shoes and sox” @ Summit Chiropractic  Rehabilitation, PC in Dillon, Colorado ( Dr Ivo’s office).

“The course was super informative and well structured.  It was great to be able to watch the videos online at my own pace and on my schedule.  I learn by repetition so I was able to watch each one a couple of times. .  The exam was challenging but no trick questions.  I wish I had taken better notes because I know that all the information on the test was in the video.  Now when I’m working with someone to try on shoes and hopefully buy them, I feel more confident and actually sound like I know what I’m talking about.”

The Gait Guys: spreading gait, foot and shoe competency, one pair at a time…

A Tale of Two Footies

Time for a pedograph, folks. What do we have here? Look at the last analysis here.

To review :

Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.

First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.

Let’s start at the rear foot: The heel teardrop is elongated on both sides, slightly more on the right; this means incraesed calcaneal eversion (or rearfoot pronation) bilaterally, R > L. The right heel shows increased pressure (more ink = more pressure).

Next up, the mid foot. Similar shapes, more pressure and printing on the left. Did you notice the “tail” of the 5th metatarsal printing, giving it a wider print? This person is staying on the outside of their foot longer than normal, right (more ink) more than left.

How about the fore foot? Lots going on there.

Lets start on the left

Notice the mild increased printing of the 5th and 4th metatarsal heads. Force should be traveling from lateral to medial here, as the foot goes into supination. A relatively normal amount of pressure on the head of the 1st metatarsal.

Now look at the toes. Notice that space between the 2nd and 3rd? This gal had an old fracture and has an increased space between them.

Now how about the right?

Increased pressure on most of the heads with a concentration on the 1st metatarsal. Hmmm…what would cause that? this is typical of someone who has a 1st ray (cunieform and metatarsal) that is hypomobile, such as with someone with a forefoot valgus (as this person does) or a dropped 1st metatarsal head (which is usually rigid, as is NOT the case here).

Did you see that rpinting at the medial aspect of the proximal phalanyx of the hallux (ie. big toe)? This gal externally rotates the lower extremity to push off the big toe to propel herself forward. This is because the 1st metatarsal head hits the ground BEFORE the 5th (as we would normally expect to see, like in the left foot), and because the weight is now on the outside of the foot, she need to push off SOMETHING.

Getting better at this? We hope so. Keep reading the blog and look at some of our past pedograph posts here.

The Gait Guys. Teaching you about the importance of gait, each and every day!

Podcast #12 : Ice Spikes and Exercise

here is the PODCAST link and show notes. You can also find us on iTunes:

http://thegaitguys.libsyn.com/webpage

and here on iTunes (click)

______________________________

Payloadz link for our DVD’s and efile downloads: http://store.payloadz.com/results/results.asp?m=80204

1- Email from our New Newspaper “the Gait guys daily”:  
“What do to when you cannot run.” - Triathlon.Competitor.com
link: http://triathlon.competitor.com/2012/10/training/what-to-do-when-you-cant-run_63237

Research suggests that nearly half of all runners experience an injury every year. That’s a whole lot runners sentenced to time off
- so many runners want to still run……Alter G treadmill, pool running
-there are a number of workout alternatives that allow you time to heal without sending you back to square one of your training regimen.
- maintain general fitness, while also providing an important psychological boost
- rowing, nordic ski, swimming, skating (slide boards)
- lateral plane sports for glutes and ankle stability
- reduce injury

2- Winter running on ice……another article on our newspaper:

http://www.outsideonline.com/outdoor-gear/gear-guy/The-Best-Running-Solution-for-Icy-Roads-DIY-Sheet-Metal-Screws.html

sheet metal screws
yaktrax
Kohtoola Microspikes,
32 North Stabilicers Sport,
http://icespike.net/  “ICESPIKE™ is like sheet metal screws on STEROIDS
 

3- DISCLAIMER:
We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors !

4-  Updates and Sponsor talk:
A-  more lectures available  on www.onlineCE.com   Go there and look up our lectures

 
B- In January we will be taking on sponsors for our podcast.  We have had some interest already but we wanted to work out the quality control issues first. Early in means savings. 
Contact us if you would like to be a sponsor……If we believe your product has value to this listener community we will give you a professional and personalized company or product plug and advertisment.  From our lips to our listeners ears ! 
We will basically expose your product to our international fan base.
 The sponsors will help make our mission possible, defray costs and time to put out this podcast and blog. These things take is away from our practices a little.  Each week we will have 2 center-Stage sponsors . Your sponsorship can run as long as you want.

5- EMAIL FROM A Blog follower: 
Hi Gait Guys,

First of all I really enjoy reading your posts and watching the Youtube clips. They have really helped me in my work.

I have a small question for you if you don’t mind me asking. I’ve noticed on a number of running gait assessments that when viewing from the back the whole foot moves medially whilst the forefoot rotates outwards in some individuals. The knee also moves out to and looks like the hip is externally rotating.

I presume this is not normal (i may be wrong) as the leg needs to recover in a straight line.

My question is why does this happen and if it’s not normal how do you correct it?

I’ve attached a small video for viewing.

I look forward to hearing from you.

Kind regards, DAVID

6- Blog READER EMAIL:

 Hi,
I am a 57 year old runner turned triathlete with a long history of soft tissue running injuries.  I read your blog with avid interest for this reason.  .  It sometimes seems that most of the information is weighted more heavily toward the diagnostician rather than the athlete.  That is, more analysis than corrective measures.  I keep reading of problems and saying "by gosh I’ve got that too” and then I am disappointed that the last chapter (what to do about it) is missing and I am left in suspense.   Ideally I would fly to where ever you are and spend some time getting analyzed and diagnosed and then begin treatment.  In the mean time, I was wondering if your could put together a set of maintenance exercises that every runner should do on a regular basis to keep us aligned and running well.  It seems that then, if I found a particular set of exercises difficult, then I would need to focus on those either for stretching and/or strengthening.  The hips, ankles, core, and feet seem to be the source of a lot of problems.

If you are ever in Washington state, let me know!- Sharon

7- Our dvd’s and efile downloads
Are all on payloadz. Link is in the show notes.
Link: http://store.payloadz.com/results/results.asp?m=80204
 
8 - Email from a Blog Reader

9- From a blog reader:
jdawg70 asked us a questions on our tumblr blog page
I think I have external tibial torsion on the right with a dropped arch on that foot and front of hip and groin pain on the left leg. I have had standing x-rays of my pelvis from the chiropractor showing a difference in hip heights of 9mm from left to right, that is, the left being that much higher. I do have lots of pain and digestive problems. I was hoping you could help or advise me. I highly value your opinions

10- From one of our Blog readers who contacted us through the blog:
 My name is Maury. Two years ago I noticed my left foot turning out all the time -walking, standing, exercising, etc. I also had hip pain. Eventually we discovered a labral tear and a torn ligamentum teres in the left hip. I had the repair done arthroscopically February 1st, 2012. It is now August and I am still experiencing the hip/foot turned out. My rotation/mobility/flexibility is fairly equal on both sides. My strength is good. I am at a loss. What can I do about this? Thank you.

11- From another blog reader:
from Sherryb1 on the blog

I think there is a correlation between adducted toes–especially adducted and flexed ip joint toes and abdominal strength/weakness. When balance is difficult, you can usually spot the adducted and flexed IP toes. When you watch someone walking with a little balance inefficiency, often you will find adducted and flexed IP toes. Do you see it as the chicken or the egg? Belly/toes, or toes/belly. And have you seen this and, might you have seen anything in the literature to substantiate it? Thank you

Hip Biomechanics Part 2

Figure 1 shows the condensed version of the parameters (forces and moment arms) affecting movement and stability of the femur-acetabulum complex in the frontal plane during the closed kinetic chain.  (A moment arm such as D1 and D2 is defined as the length of a line that extends from the axis of rotation to a point of right angle intersection with a respective force, in this case HAM or BW.)

In Figure 1 above we see several parameters.  HAM represents the Hip Abductor Muscles, D1 represents the internal moment arm, D2 represents the external moment arm and BW represents the Body Weight of the individual.  These factors all come into play when considering the frontal plane equilibrium of the hip joint.  The equation representing the interaction of all of these parameters is HAM x D1 = D2 x BW.  Both sides of this equation must be equal and balanced in order for the pelvis to remain stable and without movement when in the closed chain stance phase of gait. In this diagram, if the left side of the equation is greater than the right the net effect will be a counterclockwise hip moment and the patient will move their torso over the hip creating a hiking or lifting of the contralateral hip.  This net movement will create abduction at the hip joint.  If the right side of the equation is greater than the left the net effect will be a clockwise hip moment and the patient will move their torso away from the hip creating a dropping of the contralateral hip.  This net movement will create adduction at the hip joint seen here and thus the classic Trendelenberg gait.  We need to keep in mind that this is not a perfect model presented here since we are ignoring acceleration of the body in the forward sagittal plane and rotational planes.  Investigating the equation further should bring the reader to further realization that if the body weight (BW) were to increase, mathematically the D2 external moment arm could decrease to keep the equation balanced.  However, since the length of this D2 moment arm is rather fixed (unless the pelvis were to go through a counterclockwise  rotation which would draw the body weight center closer to the hip joint center effectually abducting the stance hip, thus reducing the D2 moment arm) this is not a more likely scenario. Rather, the response would be to attempt to increase the left side of the mathematical equation thus increasing the HAM forces to attempt to keep the pelvis level and the equation from changing.  In other words, when body weight increases we must increase the gain or contraction in the HAM group during each step to keep the pelvis level and balanced.  Unfortunately the HAM strength has its limits of maximal contraction, sometimes far below any major increases in body weight.  One must keep in mind that with increased HAM contraction there is a corresponding increase in joint compression across the hip articular surfaces which at reasonable levels is well embraced but at unreasonable levels can damage articular cartilage.  One should thus conclude that maintaining a reasonable body weight for one’s bone structure keeps the right and left sides of the mathematical equation at tolerable levels, both for movement, stability and cartilage longevity.  Fortunately the equation has a built in safety mechanism for these counterclockwise hip moments, one that is beneficial.  In such scenarios, as the body is brought over the hip thus decreasing the D2 moment arm, the D1-internal moment arm increases in length and since the equation must be balanced the HAM force can decrease.  Thus, the magnitude of the HAM force is inversely proportional to the length of the D1-internal moment arm.  The whole equation can better be visualized and conceptualized by a teeter totter diagram with a sliding pivot point.

Shawn and Ivo,  The Gait (and biomechanics) Guys

Fundamental Hip Biomechanics: Part 1

Hip Biomechanics

The following excerpted text is copywrited from the textbook; “Form and Function: The Scientific Basis of Movement and Movement Impairment” (Dr. S. Allen, Dr. E. Osar)


Frontal Plane Functional Biomechanics

The hip is a very complex joint.  It is a ball and socket joint with great stability and potentially great mobility.  One of the most critical and essential planes of motion and stability is the frontal plane of hip joint motion.  This plane (coronal/frontal) of motion and stability is largely determined by the hip abductor muscle (HAM) group through an axis of oriented in the anterior-posterior direction through the head of the femur.  The most obvious and simple function of the hip abductor muscles is to produce a movement or moment of abduction of the femur in the acetabulum in the frontal/coronal plane (as in a side lying leg lift).  As mentioned, this is a simple way to determine open kinetic chain range and open chain strength in this range but it is neither true nor transferable in theory or practicality when the foot is on the group.  When the foot engages the ground the typically usable functional range is much less and the muscular function is now to move the pelvis on the stable and somewhat static femoral head in the frontal plane.  Explained in another way, in this closed chain, the insertion of many muscles remains static and the force generated through the muscle will pull at the origin and generate movement at the joint in this manner.  In a nutshell, the hip abductor muscles (HAM) will produce either leg motion to the side (abduction) or it will produce a lateral bending or lateral flexing of the pelvis-torso into the same range of motion (abduction). 

The most critical and commonly considered hip abductor muscles (HAM) are the gluteus medius, gluteus minimus and tensor fascia lata-iliotibial band complex.  These muscles have the most favorable line of pull and all have a femur and pelvis attachment.  We will call these muscles collectively the HAM group.  In the stance phase of gait the body’s center of gravity (COG) is medial to the hip joint axis of motion.  Thus, in this single leg support phase of gait the tendency will be for the body mass above the hip to rotate or drop towards the swing leg side.  This gravitational movement should be offset by the concentric, isometric and eccentric muscular activation of the HAM group through the anterior-posterior oriented axis through the head of the femur.  Any functional strength deficits (concentric, isometric or eccentric) of the HAM group and/or neighboring synergistic stabilizers will result in an altered joint stability challenge because not only do the HAM and surrounding muscles product movement but they also generated joint compression and thus stability.  The possible undesirable outcome may be an altered movement patterning characterized by inappropriate muscle or muscle group activation in either timing, force, speed or coordination with typically coupled muscles.  These challenges to the joint and its normally expected movement patterns will result in the body’s search for more stable positions in the frontal, sagittal or oblique planes.  These newly established, yet less efficient, positions and patterns of movement are initially welcomed compensations but in time as the new accommodations become rooted in pattern the synergists and other recruitments become overburdened and further demand compensations from other neighboring muscles eventually resulting in pain, joint derangement and dysfunction.  These compensations in recruitment and movement eventually will lead to non-contractile soft tissue changes such as hip capsule pattern changes in tension and length. These non-contractile soft tissue changes can not only dictate or perpetuate the newly established aberrant joint movements but help engrain the abnormal movement patterns and their new neurologic patterns.  

The Almighty Foot Tripod

You have heard us talk time and time again about the importance of the foot tripod. To review, it consists of the center of the calcaneus, the base of the 1^st metatarsal and the base of the 5^th metatarsal.  To see some of our other posts on the foot tripod, including other exercises, click here

Join Dr Ivo in this brief and informative video demonstrating an exercise that most people with an inadequate foot tripod will benefit from.

Remember Skill, Endurance and Strength. There are many nuances to this simple exercise, don’t take it lightly!

The Gait Guys: Hammering it out, daily, to give you the goods!

Get Certified!

“In my experience, the Foot Wear Certification Series, is what is most needed by anyone in the position of helping an individual receive a more satisfying shoe fit experience.  Whether that is a simpler issue of finding the best athletic shoe to enhance their individual health goals, or to assess ones foot anatomy and the problem areas that can be hindering an individuals comfort and ability to function, the videos are informative and deeply educational.  The combined experience and knowledge of Drs. Ivo and Shawn Allen is so extensive, that it is the tool I would recommend for those of us in the industry.”

Our 1st IFGEC (International Foot & Gait Education Council) Certified Sales Associate. Congratulations to Julie Meyers; the nations 1st to be certified. Julie works for Dr Waerlop at Summit Chiropractic & Rehabilitation, PC in Dillon, Colorado. She is especially fond of Lemming shoes!

When asked about the exam, she said “Wow, it was really hard!”

Want to get certified? Stay tuned as the program is ramping up!

The Gait Guys. Making gait and foot competency viral!

Hey Guys

Check out these groovy shoes! We wonder if they are carnivorous!

Have a great weekend

Ivo and Shawn

Gait, Running and Sound. Are you listening to your body ?

A few months ago we tried something new.  We tested your gait auditory skills while listening to a video of a runner on a treadmill. We queued you to listen to the foot falls listening for the one foot to slap or impact harder than the other at foot strike. Most of you got it right, we  got plenty of positive feedback on that piece. Here is that piece (link).

This is something we do during the initial evaluation for each and every patient that comes to see us, no matter what their issue. We ask them to walk. We ask them do they notice anything. The answer is almost always, “no”.  This is because they are accustomed to their walking habit.  The first queue we notice much of the time is that there is either a bilateral heavy heel strike (because heel strike is normal in walking) or it is  heavier on one side. We ask them to hear and feel that heavier strike once we point it out to them. Not only can they feel it, they can hear it. It is something they have rarely been aware of until that moment.  We then do the same for forefoot loading. If the anterior compartment is a little weaker on one side or if they departed abruptly off the opposite leg for some reason (decreased hip extension, tight calf, loss of ankle rocker etc), a heavier forefoot loading response will be felt and heard as well (opposite side of the mentioned issues).  These are great initial gait queues that anyone can use to gain diagnostic information.  It also draws the client into greater body awareness of their habitual patterns of movement. We then draw out the numbers and forces for them so they understand what several thousand cycles of this event can cause into their body and their clinical problems they are presenting with.  This is typically a new skill they will develop and always be aware of and be able to report to you as they progress through their care with you.  Sound and feeling are key biofeedback tools.

Just remember, they are feeling and hearing what they are doing, not what is wrong ! It is your job to take this information and figure out the “Why” it is happening, and the “how” to fix it.  This is the hard part.

Hey Folks

You know we are big Altra Fans. Check out their new commercial!

We are sure your keen eyes have picked up on the midfoot pronation at :17 and forefoot pronation at :28. This brings to mind a question we often get asked: How much pronation is too much pronation?

Some pronation is necessary, as it is one of the 4 shock normal absorbing mechanisms

1. midfoot pronation
2. ankle dorsiflexion
3. knee flexion
4. hip flexion)

We do not believe there is a perfect answer, but rather the ideal is: How much pronation can your (neuro and bio) mechanics control? Too much in one individual may be not enough in another. It has to do with foot structure, muscle competency, neuromuscular control, and a host of other things.

Remember the mantra: Skill, endurance, strength… in that order! Work to control the pronation you have and expand on that range.

The Bald Headed, Good Looking, Bringing you the facts Gait Guys.

all material copyright 2012 The Homunculus Group/The Gait Guys (except the commercial of course, which is property of Altra). If you want to use our stuff, ask nicely : )

Got Hip Pain ? Attention Runners and Athletes with Hip Pain.

Compensatory joint motions are quite often a source of a person’s pain. Shirley Sahrmann named her hip syndromes for the direction of the movement most consistently associated with pain. In a recent CME presentation we did for www.onlineCE.com we discussed the accessory movements found with the hip.

Lets look at the known normal biomechanical facts:

During hip flexion the accessory motion is posterior glide of the femoral head.

Hip extension: accessory motion is anterior glide of the femoral head.

Hip medial (internal) rotation: accessory motion is posterior glide of the femoral head.

Hip lateral (external) rotation: accessory motion is anterior glide of the femoral head.

Hip abduction: accessory motion is inferior glide of the femoral head.

Hip adduction: accessory motion is superior glide.

Impairment, either from joint/bony deformation (ie. torsions) or from functional muscular asymmetry, can lead to impairment of the accessory motions (compensation) that are necessary for clean joint function.  This can lead to pain. 

For you clinicians out there, knowing your hip torsions and versions will impact the amount/degree of these accessory motions. This is why we harp on knowing your fixed anatomic variants.  (You can find discussions on these in our prior blog posts and on previous recorded www.onlineCE.com teleseminar presentations.) For example, reduced medial rotation at the hip (usually met with increased external rotation) is often seen in people with retrotorsion of the femur. Said another way, when your client has impaired medial or lateral hip rotation you must go beyond looking at the muscles at some point and consider whether they have a form of ante or retro torsion.

Hip extension is a critical part of normal human ambulation, whether you are walking or running.  Normally the hip, when moving into extension during the final propulsive phase of ambulation, allows for the femoral head of the hip to glide anterior in the socket (acetabulum). This reduces labral RIM pinch (RIM Syndromes) and allows for greater safe extension range. If hip extension range is impaired then this accessory motion of anterior glide can be impaired and lead to compensation and pain.

Think about this:

What if the quadriceps are tight ?

What If the Glutes are weak ?

What if rotational muscles are short ?

What if ankle rocker (dorsiflexion) is impaired ?

What if there is neuro-inhibition from joint pain (ie. osteoarthritis or joint mal-centration etc) ?

What if there is imbalance and weaknesses about the hip ?

What if there are other faulty movement patterns ?

What if there is one of the femoral torsions present ?

Much of this is “chicken or the egg”, who came first ?  These “what ifs” are what make practicing medicine difficult and a real challenge. Some of these issues can be found during functional movement assessments, but some of them will be missed if that is all you are doing. These issues may be what separates the good clinician, therapist, coach or trainer from the “not so good”. Knowing if a person has an impaired rolling pattern (see here http://youtu.be/dqnR0EcW2YY) is great to know, but knowing if the lower limb driver is off because the hip cannot internally rotate is even greater. Merely giving the person the homework of practicing and repeating the rolls on the impaired driver side without assessing all of the parts (for example some of the issues above) may cause you to miss the boat, or to engrain a new faulty motor pattern. 

Knowledge is prince, application of knowledge is king.

Next week we will begin a blog post a week on the biomechanics of the hip. We hope you will join us.

Shawn and Ivo

Here are some of our prior blog posts to add and deepen this dialogue:

• http://thegaitguys.tumblr.com/post/7493909435/the-hip-part-1-hip-labral-tears-the-rim-syndromes
• http://thegaitguys.tumblr.com/post/7533986761/ars-acetabular-rim-syndromes-hip-pain-some
• http://thegaitguys.tumblr.com/post/7573791535/the-hip-part-3-more-on-hip-rim-syndromes-and-labral

Podcast #11: Walking and Ozzy

http://thegaitguys.libsyn.com/podcast-11-walking-and-ozzy

Topics and Show Notes:

- Flips Flops, Walking Biomechanics, Minimalism Shoe Formula

Payloadz link for our DVD’s and efile downloads: http://store.payloadz.com/results/results.asp?m=80204

1- NEUROSCIENCE PIECE: Walking Statistics

2- Email from a Facebook Follower:
Hey guys, I was wondering if you had any links to articles about the effects of open back shoes on gait?  All I can seem to find are articles about flip flops, which I know have the similar effect, however some of my collegues don’t agree with that, so I was hoping to help inform them on the effects of the open back shoes/sandals on gait function.
 Thanks for your time,Tyler

http://www.ncbi.nlm.nih.gov/pubmed/22185067
http://www.webmd.com/healthy-beauty/features/worst-shoes-for-your-feet?page=3

3- DISCLAIMER:
We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors !

4-  Updates and Sponsor talk:

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

B- In January we will be taking on sponsors for our podcast.  We have had some interest already but we wanted to work out the quality control issues first. Early in means savings.

Contact us if you would like to be a sponsor……If we believe your product has value to this listener community we will give you a professional and personalized company or product plug and advertisment.  From our lips to our listeners ears ! 
We will basically expose your product to our international fan base.
The sponsors will help make our mission possible, defray costs and time to put out this podcast and blog. These things take is away from our practices a little.  Each week we will have 2 center-Stage sponsors . Your sponsorship can run as long as you want.

5-  Mail from an International Follower of our Blog:

Hi Dr’s,
Im here again. Just a quick question about functional LLD’s again. As you said before, most people who have a LLD are functional, but what causes such an apparent problem? What muscles are affected? Also, what exercises do you do to start to fix a functional LLD?

Thanks again for your reply and the attachment. It would be great if you could put it on a future podcast, I am keeping up with them. I’m a little sad as the first thing I check on facebook each day is what you guys have put on. The seminar over here is still a possibility, I was thinking about coming out to you guys first if that’s a possibility to learn direct? Have you thought about trying to do the fitness conventions? Experts like paul chek, Charles Poliquin, Gary Gray amongst others have been very successful and made a lot of money doing this. Gary Gray has done a huge dvd educational series and offers an internship out of his house, which he does once per year and is always full. I personally know 12 people from this country that have done it. Regarding your comment on facebook, I find the case studies more educational than anything else you put on there as it directly relates to my clients, but I have to keep watching them to fully appreciate what your saying. I can imagine most trainers just want quick fixes and new exercises they can give their clients as they are easy to understand. What are your sales of case studies on the onlice CEC compared to your performance downloads?  I can imagine not as many?   Kind Regards,   Luke

6- EMAIL FROM A Blog follower: 
Dear GaitGuys, on the video “Doing Squats, Lunges as well as Walking and Running using the Big Toe Ineffectively.”, I would like your opinion on the participation of the intrinsic (lumbricals) muscles, in stabilizing the proximal phalanx when we activate the FHL. I would consider it important, would be pleased to hear your opinion on it. Thanks, keep up the good work! Regards,  - Claudio

7- Blog READER EMAIL:
 field100 asked you:
Hi I wondered whether you could point me to the best exercises to increase strength and arch in the foot - I am flat footed. Also would you recommend the use of vivobarefoot shoes or the like to increase overall strength in the foot and ankle. thanks

 8- Blog post we liked recently
Minimalism: Is there a formula?
On one of our many forays into cyberspace, we ran across this easy to understand formula, from one of our friends Blaise Dubois. After we contacted him, he allowed us to reprint it here, for your enjoyment. Thank You Blaise!

Today, we propose a new formula so that you can rate your running shoes on a scale from 1 to 100 (100 being “extremely minimalist” -bare feet- and 1 “extremely maximalist”). The range of variation of your final rating will be more or less 5 points regardless of the comfort criteria, which is subjective. The only thing you need to do is to choose a language, then select the tab of your country at the bottom of the formula page, rate your shoes on the 6 criteria set out and there you go! Please note that we have used average values for criteria to which you don’t have the information. The multiple formats of the formula for every country are represented in accordance with their measuring system, currency and the average selling price of a running shoe for each of these countries.

As for health professionals and scientists, you will see that weighting factors have been applied to all criteria as a function of their importance, which is their effect on the body (biomechanics, tissue adaptation, etc.)
You can now rate your running shoes based upon The Running Clinic’s “TRC Rating” methodology!

12 - Email from a Blog Reader

hoblingoblin asked you:
I have a very strange gait problem that has caused me a great deal of problems in my everyday life. I get a painful, loud snap somewhere in my tarsal tunnel (Post tib, FDL, or something) as I try to control my foot descent from heel strike to midstance and also sometimes as I try to plantar flex at toe off. My ankle also feels kinda loose. I’ve seen multiple ankle specialists who don’t really have answers for me. Any thoughts?        

Category
Educational

What do you think of when you watch Zsa Zsa Gabor walk , or a woman like “Madeline” describes in this post?

Hip swing.

Yup, like it or leave it. It is here to stay. And evidently. It makes women more attractive to men (or more likely to attract a mate, click here to read our post on that).

So the question is, Why?

Besides the aesthetically pleasing aspect of this, it is most likely biomechanics. Women (generally) have

a. wider hips,

b. more femoral anteversion (or ante torsion) and

c. an increased Q angle.

This means more:

a. lateral displacement of the pelvis,

b. more internal and less external hip rotation available and

c. more lateral displacement again, with increased demand on the gluteus medius, due to the anatomical attachments.

Yup, there usually is a reason and it is often biomechanical, not aesthetics.

The Gait Guys. Ivo and Shawn. Gait Geeks to the core!

Gait Differences between men and women

J Womens Health Gend Based Med. 2002 Jun;11(5):453-8. Gender differences in pelvic motions and center of mass displacement during walking: stereotypes quantified. Smith LK, Lelas JL, Kerrigan DC. Source

Center for Rehabilitation Science, Spaulding Rehabilitation Hospital, Boston, Massachusetts, USA.

Abstract OBJECTIVES:

A general perception that women and men walk differently has yet to be supported by quantitative walking (gait) studies, which have found more similarities than differences. Never previously examined, however, are pelvic and center of mass (COM) motions. We hypothesize the presence of gender differences in both pelvic obliquity (motion of the pelvis in the coronal plane) and vertical COM displacement. Quantifiable differences may have clinical as well as biomechanical importance.

METHODS:

We tested 120 subjects separated into four groups by age and gender. Pelvic motions and COM displacements were recorded using a 3-D motion analysis system and averaged over three walking trials at comfortable walking speed. Data were plotted, and temporal values, pelvic angle ranges, and COM displacements normalized for leg length were quantitatively compared among groups.

RESULTS:

Comparing all women to all men, women exhibited significantly more pelvic obliquity range (mean ISD): 9.4 +/- 3.5 degrees for women and 7.4 +/- 3.4 degrees for men (p = 0.0024), and less vertical COM displacement: 3.7 +/- 0.8% of leg length for women and 3.3 +/- 0.9% for men (p = 0.0056).

CONCLUSIONS:

Stereotypically based gender differences were documented with greater pelvic obliquity and less vertical COM displacement in women compared with men. It is unclear if these differences are the intrinsic result of gender vs. social or cultural effects. It is possible that women use greater pelvic motion in the coronal plane to reduce their vertical COM displacement and, thus, conserve energy during walking. An increase in pelvic obliquity motion may be advantageous from an energy standpoint, but it is also associated with increased lumbosacral motion, which may be maladaptive with respect to the etiology and progression of low back pain.

Policing Gait on the Web

There is some decent information here but we do have some issues with this video. We were asked on our Facebook PAGE to talk about our thoughts on this piece.  We are not trying to criticize anyone, merely helping to keep the information accurate on the web:

1. They are promoting external rotation of the limb into the ground. They refer to this as “screwing” (as they put it) the foot into the ground. The issues here are that the foot supinates when you do this and when you do this too far you weight bear on the lateral foot and disengage the medial foot tripod. They do refer to limits on this but we need to heighten the awareness here. Someone with a forefoot valgus will go to far most likely, and someone with a forefoot varus will disengage the medial tripod quickly.  Most people will also disengage the FHB (flexor hallucis brevis) quickly during this “screwing” technique.  Furthermore, people can also become too dependent on their glutes to hold the “screwed” or supinated position and this is not a safe and reasonable way to support the limb and pelvic posturing. We see this as a very detrimental strategy when sustained PPT (Posterior Pelvic Tilt) is maintained during gait and stance.  There needs to be help from the lower abdominals and adductors as well.   Their “20%” torque is a nice mention and may help many to keep this moderate but this is really dependent on foot type and tibial torsion issues which are not discussed here. As always, not everything fixes everyone, and some things go against an admirable intention.  No digs against these nice fellas, we are just stating what we feel are critical facts not discussed. We watched part 2 and 3 in the hopes of hearing about these issues above, but they were not discussed. We wanted to comment on the videos but they have disabled the comments on youtube.

2. This posturing promotes knee hyperextension which is never good. Go ahead, try it yourself.  You cannot employ a whole lot of this external screwing during gait without changing the knee biomechanics into the hyperextension direction.  It is another reason we mention a caveat here.  If you try it, just pay close attention to what you are doing. You may try to get around the hyperextenion by dropping the pelvis anterior, disengaging your abdominals and changing hip and low back function. 

3. Merely doing what they propose here does not necessarily ramp up the intrinsic muscles of the feet (4:00 mark).  They can remain silent in this maneuver.  Keeping the toes pressed might be more productive to this end.

We watched part 2 and 3 of their Rebuilding the Foot youtube videos and frankly they just scare us a little (go ahead have a look yourself) so we will not comment on anything there. Although we strongly do not advise many of their recommendations in either part 2 or 3 for our clients you may find some stuff you like here … . . heck, who are we to say what you will be willing to try !

To each his own. We give these guys mad props for putting themselves on the net and trying to share their info.  It takes guts to put your stuff on the web, we hope they will enable the comments section so productive dialogues can ensue there in the future.

Shawn and Ivo

Is Your Foot Tripod Stable Enough to Walk or Run without Injury or Problem ?

The all to common case of the Wobbling Tripod.

Note the music we have chosen today. We tried to match the rate of the dancing tibialis anterior tendon to the tempo of the song, just for fun of course. Well, actually, for neurological reasons as well, as with a steady tempo or beat, your nervous system can learn better. Why do you think we teach kids songs to learn (or you can’t get the theme from the “Jetsons” out of your head).

This is a great video. This client has an obvious problem stabilizing the foot tripod during single leg stance as seen here.  There is also evidence of long term tripod problems by the degree of redness and size (although difficult to see on this plane of view) of the medial metatarsophalangeal (MTP) joint (the MPJ or big knuckle joint) just proximal to the big toe.  This is the area of the METatarsal head, the medial aspect of the foot tripod.

As this client moves slowly from stance into a mild single leg squat knee bend the challenges to the foot’s stability, the tripod, become obvious.  Stability is under duress. There is much frontal plane “Checking” or shifting and the tibial and body mass is rocking back and forth on a microscopic level as evidenced by the dancing tibialis tendon at the ankle level.  The medial foot tripod is loading and unloading multiple times a second. 

Is it any shock to you that this person has chronic foot problems which are exacerbated by running ?  Every time this foot hits the ground the foot is trying to find stability. The medial tripod fails and the big knuckle joint (the 1st MPJ or big toe joint) is enlarging from inflammation, uncontrolled loading through the joint, and early cartilage wear and decay, not to mention the knee falling medially to the foot line as well.  Hallux limitus (turf toe) is subclinical at this time, but it is on the menu for a later date. A dorsal crown of osteophytes (the turf toe ridge on the top of the foot) is developing steadily, soon to block out the range necessary for adequate toe off in this client.  And that means a limitation in  hip extension sometime down the road (and premature heel rise……. did you read Wednesday’s blog post on that topic ?).

*addendum:

Take the time to develop the skill. We ask our clients to work on standing with the toes up to find a clean tripod and do some shallow squats working on holding the tripod quietly. Be sure your glutes are in charge, spin of the limb is in part controlled at the core-hip level so that can a primary location to hunt as well. Eventually work into toes pressed flat but be sure the tripod is still valid, esp the medial tripod. Don’t be what Dr. Allen refers to as a “knuckle popper”. No toe curling/hammering either. Keep that glute on. Move the swing leg forward during a lunge, and then behind you during a squat (mimicking early and late midstance phases of gait/running). This will help your brain realize when it needs this stability and it will also act to press you off balance and will make the foot check and challenge. Do this until you feel the foot fatigue on the bottom. Then Stop. Repeat later. If the medial tripod collapses, the knee will drop inwards and excess pronation is inevitable. We modified this with our prescription of the “100 ups”…..combine the two !

Shawn and Ivo … .  comfortably numb.

Once you have been to the Dark Side of the Moon  (and hopefully you didn’t have any Brain Damage) you will know it well and know what to expect when you return again.  Meaning, when you have seen these issues over and over again, hopefully in your daily work if not regularly here at The Gait Guys, you will quickly know what things to assess and look for in your athletes.  And you might just turn into a Pink Floyd fan at the same time, or at least crave some Figgy Pudding (but you have to eat yer’ meat! How can you have any pudding if you don’t eat  yer’ meat?).

READY

A little beach forensics, anyone?

As far as we know, there is only one shoe that makes a print like this one. You guessed it, a Newton (great going guys! You are all the way out here on the east coast!). We are pretty sure it is an MV2, because it has 5 actuator lugs. (Danny, Ian, Jordan, please feel free to chime in!)

Look at the top left and right images; left is running, right appears to be walking or a midfoot strike). What do you see? One foot imprint (the left) is accentuated and they are a forefoot striker. We are pretty sure this is how Newton encourages folks to run and if you have ever been in the shoe, you know it is pretty rockered and pushes you on to your toes.

Now look at the images that compare left to right. Notice how the outside of the forefoot makes a deeper impression on the left? Looks like that lateral column is sinking in the sand more. What type of forefoot type may cause this? You guessed it, a forefoot varus!. The forefoot is striking (and coming off the ground) in more supination on the left than the right.

Anything else? what about that right foot in the top right image? More printing on the medial aspect. Hmmm, maybe some increased forefoot pronation or possibly some forefoot valgus.

You could argue that due to the slop on the beach, we may be seeing this…and that would be a good argument, except that these are on the flats and repeat for many cycles.

Yup, we probably should be looking at all stuff north of the feet on the beach, but hey, we ARE geeks and “feet” are our thing.

The Gait Guys. Yes, we are always watching!…Even at the beach!

copyright 2012 The Gait Guys/The Homunculus Group. Al rights reserved. If you want to use our stuff, just ask nicely : )

Abnormal wear pattern on a Newton Shoe

Understanding what went wrong in this runner to cause unilateral Right shoe “toe off” wear pattern is important.  It happens alot.  Many times it doesn’t get this far but there is evidence on a shoe, more on one side, none the less.  It is quite often “What is wrong with the part/person that goes into a shoe”, than “the shoe itself”. It wasn’t the Newton Shoe in this case (it is almost never a shoe material issue), it was the limb attached to it. The shoes are the window to the gait cycle!

This is one of our running clients.  They presented with some right hamstring soreness and pain after longer runs.  There were no foot complaints, the shoe wear pattern was just something that we felt was interesting to share as it made sense with their clinical presentation. 

Client clinically demonstrated:

1. inhibited right glute max
2. tight right quadriceps
3. weak right lower abdominals

Summary:

Subsequent to #1-3 above there was a loss of right hip extension, thus shortened right stride. When hip extension is limited the heel rise is premature and the calf engagement can be premature. When premature the calf is asked to lift the person during midstance instead of forward propulsion and its other activities during late midstance.

Premature heel rise, premature calf muscle engagement, premature foot plantarflexion all lead to greater pressure at the forefoot and thus through toe off……plus some hamstrings complaining as well !

Knowing your gait cycles, knowing which muscles should fire at a given time in the gait cycle, and knowing why they fire and what joints they stabilize is a valuable tool in diagnosis of a runners issues.  Of course, it would be very simple to say “hey, you are toeing off real hard on that right side”.  “BRILLIANT SHERLOCK ! ” would be our first response, there is nothing like stating the obvious.  But the how and why is where the brain actually needs to be engaged, and when it is, things can get very interesting and fun in figuring out what is going on in athletes and patients. Knowing how and why things happen allows you to fix the problem.  And in this case if you are attempting to fix this person at the level of the foot you are missing the true problem originating at the hip.  And when you know the origin of the problem in this case, you also get a new shoe wear pattern for the next shoes and best of all, you conquer a chronic  hamstring problem as well.

Shawn and Ivo………. Pipe smoking English sleuths…….. (OK, we are good at the board game CLUE and nothing more, who are we kidding !)

What do you see? A pedograph analysis

You have heard us time and time again talking about pedographs. When our site finally relaunches, we will have a link for you to be able to purchase one if you like. They really are indispensable and are a window to the gait cycle. In a retail setting, they are an excellent sales tool. With practice, they are a valuable asset to your skill set. As you look at more and more of them, they become easier to interpret in light of what you are seeing when you evaluate the individual.

So what do we see here?

Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.

First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.

Let’s start at the rear foot: Left looks relatively normal; Right shows some artifact from either the sock, pants being stepped on, or perhaps a heel smudge. More pressure at the medial calcaneal facet on the right as well (more ink = more pressure). The shapes are relatively symmetrical, so equal amounts of rear foot pronation (or motion)

Next up, the mid foot. similar shapes, more pressure and printing on the right. Why? Increased weighting, maybe a leg length deficiency.

How about the fore foot? Lots going on here.

Let’s start with the right foot.

The forces should be coming across from right to left (lateral to medial). See the gap in printing between the lesser metatarsal heads and the big toe? Can you see how the printing under the great toe is further back than you would expect? This tells you the force is behind the head of the 1st metatarsal, not on it. This is a cardinal sign of a partially compensated forefoot varus (in other words, the individual can only partially get the head of the 1st metatarsal down to the ground). this printing is due to the soft tissue around the toe being pressed into the ground.

How about those toes? See the dark printing at the most medial aspect of the great toe? this is most likely caused by a callus. See how it spreads laterally? This is the area of the flexor hallucis brevis insertion, and ink here means it is firing. Now look at the increased printing of the 2nd and 4th toes. They are gripping (via flexor digitorum longus) to attempt to stabilize the foot.

How about the left foot? Different than the right. A similiar pattern for mets 2-4 that we saw on the right BUT look at the at 1st metatarsal! WOW, is it printing alot! This means that 1st met head is being driven into the ground pretty hard. It is probably accompanied by pain. This persons 1st metatarsal is making a medial tripod, but perhaps too much so. You usually see this type of printing in someone who has an uncompensated fore foot valgus (forefoot everted with respect to rear foot) or a plantar flexed 1st ray deformity (in other words, the 1st metatarsal is “stuck:” in a downward position).

How about the gripping of the 4 lesser toes? Trying to stabilize that foot, no doubt, as it will be trying to tip to the outside (rather than the inside, like we often see).

What about that big toe? This results from the foot being turned outward and the individual rolling off of the medial aspect of the great toe. It is too far medial and toward the edge of the big to for the flexor hallucis brevis tendon.

Lots of info. Were you able to see most of what we were talking about? Perfect practice makes perfect!

Want to know more? Get a pedograph! Want to find out more about interpretation? We literally wrote the book. Get your copy by clicking here.

The Gait Guys. Spread the feet, spread the word! Increasing the understanding of gait, one post at time.

all material copyright 2012 The Gait Guys/The Homunculus Group. If you want to use our stuff, please ask and give us credit.

Foot Talk

It’s all about communication. In this case, compartmental communication. There has not been alot on consensus about how many compartments the foot has, but it is known that all the compartments talk to one another. This study identified six compartments: dorsal, medial, lateral, superficial central, deep forefoot, and deep hindfoot. It goes on to say: Communication was evident between the deep hindfoot compartment and the superficial central and deep central forefoot compartments.

This should not be that surprising. In this case, the deep hindfoot intrinsic muscles would include the quadratus plantae (seen above attaching to the calcaneus), which augments the pull of the long the long flexor muscles and helps to keep the toes flat on the ground.

The superficial central compartment would include the short flexors (flexor digitorum brevis), another stance phase muscle that is also important in keeping the toes flat on the ground.

The deep central forefoot compartment would include the transverse head of the adductor hallucis. important in maintaining 1st ray stability and keeping the head of the 1st metatarsal on the ground and maintaining an adequate foot tripod.

Another point worth mentioning was this: In the hindfoot, the neurovascular bundles were located in separate tissue sheaths between the central hindfoot compartment and the medial compartment. In the forefoot, the medial and lateral bundles entered the deep central forefoot compartment.

This tells us that in the rearfoot, the important neurology is in the muscles which help to invert the rearfoot, and help create supination. In the central forefoot, information is fed from the lateral and medial aspects of the foot tripod to the transverse head of the adductor longus. this muscle, when biomechanics are appropriate and the head of the 1st metatarsal is anchored, assists in supination. It seems all roads leaad to assisting in supination and propelling us forward in the gravitational plane…

Communication. Not just for interpersonal relationships : )

The Gait Guys: communicating with you daily and keeping you current on all things feet.

Surg Radiol Anat. 2012 May 26. [Epub ahead of print] Compartments of the foot: topographic anatomy. Faymonville C, Andermahr J, Seidel U, Müller LP, Skouras E, Eysel P, Stein G. Source

Department of Orthopaedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50924, Cologne, Germany, christoph@faymonville.de.

Abstract

Recent publications have renewed the debate regarding the number of foot compartments. There is also no consensus regarding allocation of individual muscles and communication between compartments. The current study examines the anatomic topography of the foot compartments anew using 32 injections of epoxy-resin and subsequent sheet plastination in 12 cadaveric foot specimens. Six compartments were identified: dorsal, medial, lateral, superficial central, deep forefoot, and deep hindfoot compartments. Communication was evident between the deep hindfoot compartment and the superficial central and deep central forefoot compartments. In the hindfoot, the neurovascular bundles were located in separate tissue sheaths between the central hindfoot compartment and the medial compartment. In the forefoot, the medial and lateral bundles entered the deep central forefoot compartment. The deep central hindfoot compartment housed the quadratus plantae muscle, and after calcaneus fracture could develop an isolated compartment syndrome.