June 27, 2013

Cheating Around Ankle Rocker (Dorsiflexion) in Gait: A cause for plantar foot pain.

June 27, 2013/ The Gait Guys

don’t miss this case video

June 26, 2013 June 26, 2013/ The Gait Guys

The Power of Observation: Part 2

Let’s take a closer look at yesterdays post and the findings. If you are just picking up here, the post will be more meaningful if you go back and read it.

The following are some explanations for what you were seeing:

torso lean to left during stance phase on L?

if he has a L short leg, he will need to clear right leg on swing phase. We have spoken of strategies around a short leg in another post. This gentleman employs 2 of the 5 strategies; torso lean is one of them

increased progression angle of both feet?

Remember he has femoral retroversion. You may have read about retrotorsion here. He has limited internal rotation o both thighs and must create the requisite 4-6 degrees necessary to walk. He does this by spinning his foot out (rotating externally).

decreased arm swing on L?

This is most likely cortical, as he seems to have decreased proprioception on both legs during 1 leg standing. Proprioception feeds to the cerebellum, which in turn fires axial extensors through connections with the vestibular system. Diminished input can lead to flexor dominance (and extensors not firing). Note the longer stride forward on the right leg compared to the left with less hip extension (yes, we know, a side view would be helpful here).

circumduction of right leg?

This is the 2nd strategy for getting around that L short leg.

clenched fist on L?(esp when standing on either leg)

see the decreased arm swing section. This is a subtle sign of flexor dominance, which appears to be greater on the right.

body lean to R during L leg standing?

This is again to compensate for the L short leg. He has very mild weakness of the left hip abductors as well, more when moving or using them in a synergistic fashion (ie functional weakness) than to manual testing.

Well, what do you think? Now you can see how important the subtle is and that gait analysis may complex than many think.

We are and we remain, the Geeky Guru’s of Gait: The Gait Guys

June 25, 2013 June 25, 2013/ The Gait Guys

OK, quiz time. The Powers of Observation.

Perhaps you have been following us for a while, perhaps you are just finding us for the 1st time. Here is some back ground on this footage. Let’s test you observation skills.

Watch this gait clip a few times and come back here to read on.

This triathlete presented with low chronic low back pain of about 1 years duration. The pain gets worse as the day goes on; it is best in the early am. Running and biking do not alter its intensity or character and swimming makes it worse. Rest and analgesics provide only temporary relief.

Physical exam findings include limited internal rotation of both hips (zero); a left anatomical short leg (tibial and femoral, 5mm total); diminished proprioception with 1 leg standing (<30 seconds). MRI reveals fatty infiltration of the lumbar spinal paraspinals and fibrotic changes within the musculature; degenerative changes in the L4 and L5 lumbar facet joints, degeneration of the L5-S1, L3-L4 and L2-L3 lumbar discs.

Now watch his gait again and come back here for more.

Did you see the following?

torso lean to left during stance phase on L?

increased progression angle of both feet?

decreased arm swing on L?

circumduction of right leg?

clenched fist on L?(esp when standing on either leg)

body lean to R during L leg standing?

How did you do? If you didn’t see all those things, then you are missing pieces of the puzzle. Remember, often what you see is not what is wrong, but the compensation

The powers of observation of the subtle make the difference between good results and great ones.

Try some of these tips.

break down the gait into smaller parts by watching one body part at a time: right leg, left leg, right arm, left arm, etc

watch for shifts in body weight in the coronal plane (laterally) and saggital plane (forward/backward) as weight transfers from one leg to another

watch for torso rotation (watch his shoulders. Did you notice he brings his torso more forward on the left than right when walking toward us?)

We are (and have been) here to help you be a better observer and a better clinician, coach, athlete, sales person, etc. If you haven’t already, join us here for some insightful posts each week; for our weekly (almost) PODcast on iTunes; follow us on Twitteror on Facebook: The Gait Guys

June 24, 2013

Podcast 34: Chimp feet, Marathon Monks & Statin drugs

June 24, 2013/ The Gait Guys

podcast link:

http://thegaitguys.libsyn.com/podcast-34-chimp-feet-marathon-monks-statin-drugs

iTunes link:

http://thegaitguys.libsyn.com/podcast-33-heart-beats-toe-walking-crawling

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com type in Dr. Waerlop or Dr. Allen Biomechanics

Today’s show notes:

1.Did Rock Climbing Help Us Start Walking Upright? By Shaunacy Ferro A new theory suggests humans became bipedal so that we could scramble up rugged terrain.
http://www.popsci.com/science/article/2013-05/did-rock-climbing-help-us-start-walking-upright?src=SOC&dom=tw

2. http://en.wikipedia.org/wiki/Kaih%C5%8Dgy%C5%8D

The Running Marathon monks of Mt. Hiei

The Kaihōgyō is a set of the ascetic physical endurance trainings for which the Japanese “marathon monks” of Mt. Hiei are known. These Japanese monks are from the Shugendō and the Tendai school of Buddhism, a denomination brought to Japan by the monk Saichō in 806 from China.

3. http://www.runnersworld.com/general-interest/do-you-have-chimpanzee-feet

Do you have Chimpanzee feet ?

About 8% of people tested by Boston University researchers had midfoot flexibility of the sort that apes use to climb trees, according to a study published in the American Journal of Physical Anthropolgy.

4. Statins Linked With Risk of Musculoskeletal Injury

Michael O'Riordan

http://www.medscape.com/viewarticle/805369?src=wnl_edit_medn_wir&spon=34

http://archinte.jamanetwork.com/article.aspx?articleid=1691918

Can Statins Cut the Benefits of Exercise?

By GRETCHEN REYNOLDS

http://well.blogs.nytimes.com/2013/05/22/can-statins-curb-the-benefits-of-exercise/

http://www.ncbi.nlm.nih.gov/pubmed/23583255

5. Shoes: The Primal Professional.com

http://theprimalprofessional.com/products/pre-order-the-primal-professional

http://well.bradrourke.com/2013/05/my-new-primal-dress-shoes/

6. Hallux valgus and lesser toe deformities are highly heritable in adult men and women: The Framingham foot study

Marian T. Hannan
http://onlinelibrary.wiley.com/doi/10.1002/acr.22040/abstract;jsessionid=99975015C3EE5678E6351273C2CD42A0.d02t04

7. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers

Kulmala, Juha-Pekka; Avela, Janne; Pasanen, Kati; Parkkari, Jari

http://journals.lww.com/acsm-msse/Abstract/publishahead/Forefoot_strikers_exhibit_lower_running_induced.98324.aspx

8. Why Where You Land On Your Foot Isn’t That Important

http://www.kinetic-revolution.com/why-where-you-land-on-your-foot-isnt-that-important/

June 20, 2013

If you do not undestand limb torsions, you are quite possibly screwing up your runners.

June 20, 2013/ The Gait Guys

You must understand all 3 of these (see below) to understand funky gaits that you see, and to clean up your physical exams with clients. If you are making gait or running form recommendations on this stuff without understanding Torsions you are quite possibly making very bad form recommendations and could be putting forces and torque into foot, ankle, knee or hip that are detrimental. Trust us. We know what we are talking about.

In light of our teleseminar on Chirocredit.com last night we will re-run the 5 Part series on limb Torsions and Versions.

Remember, there are three areas this needs to be considered in:

1. torsion of the talus

2. tibial torsion

3. femoral torsion

here is the link to our old post on this topic, part 1a

http://thegaitguys.tumblr.com/post/30799942620/torsions-this-gentleman-has-2-excellent-examples

Shawn and Ivo

June 18, 2013 June 18, 2013/ The Gait Guys

The “Top-End” Peroneal Walk Foot Skill: Another Restoration Foot Trick by The Gait Guys

Have stability problems in your ankles ? Lots of people do !
Here is a brief video of a simple, but difficult, functional exercise to strengthen the peroneal muscles in full plantar flexion (we will give more detailed tricks and techniques away on the Foot-Ankle DVD exercise series, once we get some time to get to it !). The key here is to not let the heel drop during single fore-foot loading and to keep the ankle pressing inwards as if to try and touch the ankles together medially …..if you feel the heel drop on the single foot loaded side (or you can feel the calf is weaker or if you feel strain to keep the inward press of the ankle) then it might be more than the peronei, it could be the combined peroneal-gastrocsoleus complex. The key to the assessment and home work is to make sure that the heel always stays in “top-end” heel rise plantarflexion. But you have to strongly consider the peronei just as seriously. Studies show that even single event sprains let alone chronic ankle sprains create serious incompetence of the peronei. Most people do not notice this because they never assess the ability to hold the foot in full heel rise (plantarflexion) while creating a valgus load (created by the peronei mostly, a less amount from the lateral calf) at the ankle. This is why repetitive sprains occur. The true key to recovery is to be able to walk on the foot in this heel-up “top-end” position while in ankle eversion (ankles squeezed together) as you see in this video. This is something we do with all of our basketball and jumping sports athletes and it is critical in our dancers of all kinds. And if they cannot do the walking skill or if they feel weakness then we keep it static and put a densely rolled towel or a small air filled ball between the ankles and have them do slow calf raises and descents while squeezing the towel-ball with all their ability. This will create a nice burn in the peroneal muscles after just a few repetitions. The user will also quickly become acutely aware of their old tendency to roll to the outside of the foot and ankle because of this lack of awareness and strength of those laterally placed ankle evertors - the peronei. It is critical to note that If you return to the ground from a jump and cannot FIRST load the forefoot squarely and then, and only then, control the rate of ankle inversion and neutral heel drop (ankle dorsiflexion) then you should not be shocked at chronic repetitive ankle sprains. Remember, the metatarsals and toes are shorter as we move away from the big toe, so there is already a huge risk and tendency to roll to the outside of the foot through ankle inversion. Hence why ankle sprains are so common. We call this “top end” peroneal strength but for it to be effectively implemented one must have sufficient top end calf strength as well, you cannot have sound loading mechanics without both.
It is not as easy as it appears in this video. We encourage you to give this a try and we bet that 1 out of every 2 people who try it will notice “top end” weakness felt either in the peronei and/or in the calf via inability to keep the heel in “top-end”. Oh, and do not think that you can simply correct this by more calf work, not if the peronei are involved, which they usually are.
One more trick by The Gait Guys………bet you cannot wait for the foot dvd huh !? Ya, it has only been on our list for 3 years now !
We talk more about this kind of stuff on our National Shoe Fit Certification program.
Email us if you are interested thegaitguys@gmail.com

June 17, 2013 June 17, 2013/ The Gait Guys

A Window into the Glutes: Anatomy lesson for the day.

A rather literal statement for a rather literal picture. Taken from the Human Body Exhibit at the Denver Museum of Science, this picture offers us a glimpse into, or in this case through, one of our favorite muscle groups. This group that we see here, is probably our second favorite group. They are often called the “deep six” and are the deep hip external rotators. If you count, you will notice there are only five….one remains unseen the obturator internus. More on that later.

See the linear white lines on the right of the window? That’ s the two portions of the sciatic nerve. Notice how it runs under the muscle at the top and over the others? The muscle it runs under is the famous piriformis. When this muscle gets tight, it can impinge the sciatic nerve, causing pain down the leg (known as sciatica). This represents one of many causes of pain radiating down the leg.

The next muscle south is the gemelli superior, then the obturator externus, gemelli inferior, and quadratus femoris. The sixth of the deep six is the obturator internus, which runs from the inside of the pelvis on the obtrobturator foramen (those huge “eyes” you see in an x ray when looking at a pelvis from the front) to a similar place on the femur.

A few observations you should make.

when someone chews your butt off, or chews you a new one, this picture gives it a whole new meaning

the sciatic nerve runs under the piriformis

The top (superior) five muscles have a tendonous insertion to the femur that you can see as a whitish area on the left

the last (or most inferior muscle) has a muscular insertion to the femur (which is a reddish area on the left)

the positioning of these muscles allows them to be external rotators of the femur when the foot is in the air

when the foot is planted, they become external rotators of the pelvis or can act to slow internal rotation of the femur during stance phase

as you proceed caudally, the muscles become stronger adductors of the thigh

We will see this post as a reference for some future posts on this most fascinating muscle groups. Until then, study up!

The Gait Guys. Uber Foot Geeks. Join us in our mission to educate the world on the importance of understanding human motion and its impact on translating us forward in the gravitational plane.

June 14, 2013

Lombard's Paradox: A unique look at the cooperation of the quadriceps and hamstrings

June 14, 2013/ The Gait Guys

Lombard’s Paradox

In searching our personal archives for neat stuff we came across an oldie but a goodie. We posted this one on the blog for the first time in July 2011 so it was time to revisit it here on the blogs “Rerun Fridays”. This is one to certainly make your head spin. We do not even know where this came from and how much was our original material and how much was someone else’s. If you can find the reference we would love to give it credit. We do now that we added some stuff to this but we don’t even know what parts were ours ! Regardless, there is a brain twister here worth juggling in your heads. Lets start with this thought……..

When you are sitting the rectus femoris (a quad muscle) is “theoretically” shortened because the hip is in flexion. It crosses the bent knee in the front at it blends with the patellar tendon, thus it is “theoretically” lengthened at the knee. When we stand up, the hip extends and the knee extends, making the R. Femoris “theoretically” lengthen at the hip and shorten at the knee. This, it bodes the question…….did the R. Femoris even change length at all ? And the hamstrings kind of go through the same phenomenon. It is part of the uniqueness of “two joint” muscles. Now, onto Lombard’s paradox with more in depth thought on this topic.

Warren Plimpton Lombard (1855-1939) sought to explain why the quadriceps and hamstring muscles contracted simultaneously during the sit-to-stand motion. He noted that the rectus femoris and the hamstrings are antagonistic, and this coactivation is known as Lombard’s paradox.

The paradox is classically explained by noting the relative moment arms of the hamstrings and rectus femoris at either the hip or the knee, and their effects on the magnitude of the moments produced by either muscle group at each of the two joints.

By virtue of the fact that muscles cannot develop different amounts of force in their different parts, the paradox develops. The hamstrings cannot selectively extend the hip without imparting an equal force at the knee. Thus, the only way for hip extension and knee extension to occur simultaneously in the act of standing (or eccentrically in the act of sitting) is for the net moment to be an extensor moment at both the hip and knee joints. Lombard suggested three necessary conditions for such paradoxical co-contraction:

the lever arm of the muscle must be greater at its extensor end
a two-joint muscle must exist with opposite function
the muscle must have sufficient leverage so as to use the passive tendon properties of the other muscle

In 1989, Felix Zajac & co-workers pointed out that the role of muscles, particularly two-joint muscles, was much more complex than has traditionally been assumed. For example, in certain situations, the gastrocnemius could act as a knee extensor. It is clear now that the direction in which a joint is accelerated depends on the dynamic state of all body segments, making it difficult to predict the effect of an individual muscle contraction without extensive and accurate biomechanical models (Zajac et al, 2003).

In fact, back to the gastrocnemius another 2+ joint muscle (crosses knee, mortise and subtalar joints), we all typically think of it as a “push off” muscle. It causes the heel to rise and accelerates push off in gait and running. But, when the foot is fixed on the ground the insertion is more stable and thus the contraction, because the origin is above the posterior joint line, can pull the femoral condyles into a posterior shear vector. It thus, like the hamstrings, needs to be adequately trained in a ACL or post-operative ACL, deficient knee to help reduce the anterior shear of normal joint loading. It is vital to note, that when ankle rocker is less than 90 degrees (less than 90 degrees of ankle dorsiflexion is available), knee hyperextension is a viable strategy to progress forward in the sagittal plane. But in this scenarios, the posterior shear capabilites of the gastrocnemius are brought to the front of the line as a frequent strategy. And not a good one for the menisci we should mention.

Andrews J G (1982) On the relationship between resultant joint torques and muscular activity Med Sci Sports Exerc 14: 361-367.

Andrews J G (1985) A general method for determining the functional role of a muscle J Biomech Eng 107: 348-353.

Bobbert MF, van Soest AJ (2000) Two-joint muscles offer the solution - but what was the problem? Motor Control 4: 48-52 & 97-116.

Gregor, R.J., Cavanagh, P.R., & LaFortune, M. (1985). Knee flexor moments during propulsion in cycling—a creative solution to Lombard’s Paradox. Journal of Biomechanics, 18, 307-16 .

Ingen-Schenau GJv (1989) From rotation to translation: constraints on multi-joint movement and the unique action of bi-articular muscles. Hum. Mov. Sci. 8:301-37.

Lombard, W.P., & Abbott, F.M. (1907). The mechanical effects produced by the contraction of individual muscles of the thigh of the frog. American Journal of Physiology, 20, 1-60.

Mansour J M & Pereira J M (1987) Quantitative functional anatomy of the lower limb with application to human gait J Biomech 20: 51-58.

Park S, Krebs DE, Mann RW (1999) Hip muscle co-contraction: evidence from concurrent in vivo pressure measurement and force estimation. Gait & Posture 10: 211-222.

Rasch, P.J., & Burke, R.K. (1978). Kinesiology and applied anatomy. (6th ed.). Philadelphia: Lea & Febiger.

Visser JJ, Hoogkamer JE, Bobbert MF & Huijing PA (1990) Length and Moment Arm of Human Leg Muscles as a Function of Knee and Hip Angles. Eur. J Appl Physiol 61: 453-460.

Zajac FE & Gordon MF (1989) Determining muscle’s force and action in multi-articular movement Exerc Sport Sci Revs 17: 187-230.

Zajac FE, Neptune RR, Kautz SA (2003) Biomechanics and muscle coordination of human walking - Part II: Lessons from
dynamical simulations and clinical implications, Gait & Posure 17 (1): 1-17.

June 14, 2013

Stop Doing Kegels: Real Pelvic Floor Advice For Women (and Men)

June 14, 2013/ The Gait Guys

This web article just came out today and we felt it was important to share.

Nicole Crawford did a nice job with the article (LINK) and you need to read it. The pelvic floor is a complicated place. There needs to be balanced muscular contraction and there has to be neutral pelvis and lumbar spine. We have to agree with her comment:

A Kegel attempts to strengthen the pelvic floor, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF (pelvic floor) gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to pelvic floor disorder (PFD). Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the pelvic floor is beginning to weaken. An easier way to say this is: Weak glutes + too many Kegels = PFD.

There are too many people who have a shallow lumbar spine lordotic curve. These folks often hold the pelvis as neutrally as they can by keeping a constant squeeze of the glutes to “push” the pelvis “tipped up or levelled up” in the front when in fact the lower abdominals should “hold” them up in the front, to a notable degree. It is easier for many to push the pelvis up with the glutes particularly when so many individuals are lacking in the abdominal compartment.

We have so many of our patients learn the “potty squat” where the buttock is pushed backwards in a proper squatting technique. We do this to reteach gluteal work, hamstring length in an environment of proper abdominal bracing. IT takes time to get the technique down, but it is worth it. And, Crawford’s article gives it even more validity with its effect on the sacral posturing and impairing pelvic floor tension.

There is much good information in this article by Crawford. It is worth everyone’s read. If you have been here with us on The Gait Guys for awhile you will know that we hold the mighty glutes on a high pedestal. They are absolute key in gait and many folks do not use them properly. After a few rough weeks practicing going gradually deeper as tissue length and strength is earned many of our patients have an epiphany of how little they were using their glutes, and how poorly they squat and how weak they were in the lower limbs. Even our elderly patients in their 70s and 80s benefit from early shallow potty squat progressions. We just put a chair behind them in case they fall back. It is never shocking to see what a few weeks of propper “potty-ing” will do to a person. Do them alot, and do them often.

Good potty-ing to ya’ll.

Shawn and Ivo………Kings of our own Potty Thrones

Here is Crawford’s article link once again.

http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-women-and-men

June 13, 2013

A tangled tail of two, 2-joint muscles: Lombard’s Paradox

June 13, 2013/ The Gait Guys

Two years ago we wrote this little piece on these 2 two joint muscles. Their companionship mentally came up during the sorting out of a strange client case so we felt it was good karma to share it again. This one may make your head spin.

We do not know where this write up came from and how much was our original material and how much was someone else’s. It was found on an old computer of long ago. If you can find the reference we would love to give it credit. We do know that we added some stuff to this but we don’t even know what parts were ours ! Regardless, there is a brain twister here worth juggling in your heads. Some of it we know is far reaching and even marginally incorrect, but we like mental aerobics to take it for what its worth. There is value in thinking about things this way. Lets start with this thought……..

When you are sitting the rectus femoris (a quad muscle) is “theoretically” shortened at the hip because the hip is in flexion. It also crosses the bent knee in the front at it blends with the patellar tendon, thus it is “theoretically” lengthened at the knee. When we stand up, the hip extends and the knee extends, making the R. Femoris “theoretically” lengthen at the hip and shorten at the knee. Thus, it bodes the question…….did the R. Femoris even change length at all ? Did a concentric event occur at one end and an eccentric contractile event occur at the other ? Is that even possible ? And, the hamstrings kind of go through the same phenomenon on the other side of the knee and hip so you possibly have a very complex dialogue across the front and the back of the knee and hip during movement. And for every angle of flexion or extension change around the knee or hip both the quads and the hamstrings have this sliding scale of change they have to play, it should be a perfect give and take phenomenon. And when orchestrated cleanly the joints do not see impairment. This is part of the uniqueness of “two joint” muscles. However, think about how a short quadriceps, a very common clinical finding, will impair this orchestra. Like an instrument out of tune the orchestration is in flux and alternative strategies ensue. How will the function at the knee be changed by this short quadriceps ? How will hip extension be impaired ? How will the hamstring alter its function ? What will the consequences be ? What alternative motor patterns will be deployed ? And if you are just doing your gait analysis without a clinical examination what will you see as their compensation ? Now that your head is buzzing, onto Lombard’s paradox with more in depth thought on this topic.

the lever arm of the muscle must be greater at its extensor end
a two-joint muscle must exist with opposite function
the muscle must have sufficient leverage so as to use the passive tendon properties of the other muscle

In fact, back to the gastrocnemius another 2+ joint muscle (crosses knee, mortise and subtalar joints), we all typically think of it as a “push off” muscle. It causes the heel to rise and accelerates push off in gait and running. But, when the foot is fixed on the ground the insertion is more stable and thus the contraction, because the origin is above the posterior joint line, can pull the femoral condyles into a posterior shear vector. It thus, like the hamstrings, needs to be adequately trained in a ACL or post-operative ACL, deficient knee to help reduce the anterior shear of normal joint loading. It is vital to note, that when ankle rocker is less than 90 degrees (less than 90 degrees of ankle dorsiflexion is available), knee hyperextension is a viable strategy to progress forward over the ankle in the sagittal plane. But in this scenario, the posterior shear capabilites of the gastrocnemius are brought to the front of the line as a frequent strategy. And not a good one for the menisci we should mention.

Just some random thoughts for you today. We used to play such mental games during my orthopedic residency. The “what would happen if” scenarios. They stimulate thought, dialogue and debate and get the brain thinking more globally. We hope you enjoyed the circus show today !

Shawn and Ivo…….. the gait guys