"Action Expresses Priorities"- Gandhi

“Action expresses priorities.” -Mahatma Gandhi

So much truth to this statement.  It pertains to gait analysis perfectly.  

For years now you have heard us say, “What you see is NOT what is wrong with someones gait, rather you see their COMPENSATION STRATEGY around what IS wrong." 

The body is always strategizing to negotiate around pain, instability (functional or anatomic) or immobility.  What you see in gait are those strategies. You may not see their immobility for example, you see how they move when increasing mobility in one or multiple areas to cope with immobility in another. 

*Translation= The gait action strategy you see expresses the body’s compensation priority to make gait possible around the underlying problems that are preventing the clean, optimal and primary gait motor pattern from surfacing.

Thanks to Gray Cook for unearthing this Gandhi quote on his twitter.

A Study Supporting much of what we have been saying.

“ Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index.”

This study brings about a few points worth mentioning:

• folks in the Indian population have flatter feet
• the amount of great toe extension is important, especially as it relates to foot pain
• foot prints can tell you a lot about a foot
• foot exercise and footwear modifications achieved the best outcomes

Lets look at some of these points.

folks in the Indian population have flatter feet

foot morphology is not only developmental, but has a genetic component, that can differ in different populations

the amount of great toe extension is important, especially as it relates to foot pain

just how much great toe extension (or dorsiflexion as foot geeks like to say) is necessary? The great toe must extend 40 degrees to walk normally and most folks can dorsiflex 65 degrees. If this is impaired (something called “hallux limitus”) it can:

• shorten your stride length
• make you have difficulty with high gear push off
• will probably give you pain at the metatarsal phalangeal junction

foot prints can tell you a lot about a foot

Gee, we have been saying this for a few years now and have been advocating the use of a pedograph as well. In fact, we wrote the ONLY book about it’s interpretation, available by clicking here.

foot exercise and footwear modifications achieved the best outcomes

We have almost a thousand posts on this blog, and nearly 100 youtube videos, many of which talk about foot exercises, their indications and how to do them

The Gait Guys. Increasing your “Foot IQ” each and every day. If you are new to us, thanks for reading and feel free to “dig in” and search this blog, as well as our youtube channel. Have a question? Want to take your learning to the next level? Consider taking the International Shoe Fit Certification Program and put yourself at the front of the line when it comes to shoe fit. email us at thegaitguys@gmail.com for more info. 

 

J Orthop Surg (Hong Kong). 2013 Apr;21(1):32-6.

Flatfoot in Indian population.

Pandey S, Pal CP, Kumar D, Singh P.

Source

Department of Orthopaedics, Moti Lal Nehru Medical College, Allahabad, India.

Abstract

PURPOSE. To compare outcomes of different conservative treatments for flatfoot using the foot print index and valgus index. METHODS. 150 symptomatic flatfoot patients and 50 controls (without any flatfoot or lower limb deformity) aged older than 8 years were evaluated. The diagnosis was based on pain during walking a distance, the great toe extension test, the valgus index, the foot print index (FPI), as well as eversion/ inversion and dorsiflexion at the ankle. The patients were unequally randomised into 4 treatment groups: (1) foot exercises (n=60), (2) use of the Thomas crooked and elongated heel with or without arch support (n=45), (3) use of the Rose Schwartz insoles (n=18), and (4) foot exercises combined with both footwear modifications (n=27). RESULTS. Of the 150 symptomatic flatfoot patients, 96 had severe flatfoot (FPI, >75) and 54 had incipient flatfoot (FPI, 45-74). The great toe extension test was positive in all 50 controls and 144 patients, and negative in 6 patients (p=0.1734, one-tailed test), which yielded a sensitivity of 96% and a positive predictive value of 74%. Symptoms correlated with the FPI (Chi squared=9.7, p=0.0213). Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index. CONCLUSION. The great toe extension test was the best screening tool. The FPI was a good tool for diagnosing and grading of flatfoot and evaluating treatment progress. Combining foot exercises and foot wear modifications achieved the best outcome.

Lateral Foot Pain

Well then, why does this young man have pain on the outside of this foot, near his little toe, when walking for long periods of time, along with cramping of the feet. He recently undertook a “bussing tables” job at a local restaurant and is (suddenly) on his feet for 8-10 hours daily for 7-8 days at a stretch?

Take a good look at the top few photos. What do you see?

You should see:

• windswept biomechanics of the legs (i.e. internal tibial torsion on the left and relative external tibial torsion on the right). missed out on torsions? click here. 

Internal tibial torsion often places extra force on the lateral aspect of the foot. You (often) rotate the extremity internally to maintain the knee in the saggital plane.  

• he has inverted feet bilaterally with (most likely) and forefoot varus (the forefoot is inverted with respect to the rear foot). This is easier to see with exam, as it looks like he may have a forefoot valgus in the picture

for what we hope are obvious reasons, when a person has an uncompensated (cannot form an adequate foot tripod) forefoot varus, this will place extra force on the outside of the foot. 

• he has a left short leg (functional or anatomical)

folks will often (but not always) pronate through the mid foot more on the longer leg side (in an attempt to shorten the leg) and supinate (remember: plantar flexion, inversion and adduction) on the shorter leg side in an attempt to lengthen the limb. 

Now can you see why he has lateral foot pain?

What about the cramping?

Hmmmm. going from almost zero to 8-10 ours daily of standing on hard floors. think the intrinsic muscles of the foot might be called to task? And this is exactly what is happening. Those muscles, which have little endurance capacity, are going through glycolytic pathways to function, this the cramping.

So what do we do?

• for starters, we valgus posted the insoles of his shoes L >>R to try and push him off the lateral aspect of his foot and toward the head of the 1st metatarsal (see pics)
• we gave him a temporary 3mm lift in the L side (a full sole lift). A heel lift only puts the foot in plantarflexion, lift the whole foot.
• we gave him the tripod standing, lift toes, spread toes and reach “shuffle walk” exercises (you can search the blog under “exercise” or “tripod” to see these posts again: 3 sets, 10 reps, 3X daily
• we advised him to stay out of motion control shoes (which would push his L knee too far laterally and outside the saggital plane
• we manipulated his feet to insure his mechanics were biomechanically appropriate
• we did manual stimulation of the tibialis anterior, extensor digitorum longus, interossei, extensor hallucis brevis and tibialis posterior followed by multiangle isometric resistance 

We will see how he does and may need to consider a custom crafted orthotic with intrinsic valgus posting if he does not respond well to therapy. we may need to consider dry needling and/or acupuncture as a supportive modality as well.

We hope you followed our reasoning in this case. If not, maybe search through our blog and youtube channel and catch up on some of this cool stuff!

The Gait Guys: Making you smarter each and every post

Podcast 35: Future-tech of shoe fit, Case studies & technology.

Podcast 35: Future-tech of shoe fit, Case studies & technology.

podcast link:

http://thegaitguys.libsyn.com/podcast-35-future-of-shoe-fit-case-studies-technology

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

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:

Neuroscience piece:

 

1- Wearable computers will be inside us

Read more at http://venturebeat.com/2013/07/09/wearable-computers-will-be-inside-us/#QvypWtr2mA3gJkEi.99 

2- First ever head transplants are possible and not far off.

http://qz.com/99413/first-ever-human-head-transplant-is-now-possible-says-neuroscientist/________

3- 3D printed casts for shoe fit. The new future ?

4- FB reader sent us a message:

-Hi Gait Guys,

I have anterior pelvic tilt and overpronation of the right foot.

at gait, LEFT foot does toe off properly and straight.
However, RIGHT foot moves towards my center at toe off. It just sort of caves in & moves in as well.

I managed to really reduce that(i think) from massages and strengthening glutes etc but I would just like to know what causes that so I know what to target.

Once again, congratulations on your work. Not only has it not been done before over the whole internet it is excellent.

-a tormented athlete with postural difficulties

5- Another FB reader asks question about heel spurs, plantar fascitis, ankle biomechanics

6- Questions from a field doc:

Hey guys,

I have a couple questions for you that you could possibly use or you could simply answer them via email. 

1)  Ivo, in one of your videos on muscle function you talk about muscle inhibition.  I always thought the CNS simply chooses not to recruit all of the motor units in a muscle or chain of muscles to protect from injury, compensate, etc.  You mentioned in your video the CNS somehow recognizes the spindles in these motor units are already “turned on” so they will not activate.  I’m not sure I have this correct but I was hoping you could elaborate on this confusing but interesting neurological phenomenon.

7- Patient case yesterday:

Runner comes in and says “i keep landing on the outside of my left foot when i run, it is there a little when i walk, but more prominent when i run. Everywhere i read the armchair experts are saying to just let foot strike happen naturally.  Do i leave this alone ? Oh, and my left hip is always tight.”

How to properly regain ankle rocker: A Prince of an Exercise

If you have been with us here at The Gait Guys you will know by now that we like to take Fridays and make them a blog post recycle.  This week we have a beauty and it parlays beautifully into our blog posts from the last 2 days on ankle rocker. We did this video about 3 years ago. We can tell because Dr. Allen hasn’t yet shaved his dome and he looks much younger.  Plus he stopped wearing sweater vests !  Ouch !

Today we show a staple in our in-office and home exercise programs. The Shuffle Walk and the Moon Walk.  We have altered these exercises in the last year or so, thus we really need to get that Foot Exercise DVD done that we have been promising for 2 years+.  

Anyhow, STOP passively stretching your calf muscles !!!!!!

Do the Shuffle walk instead.  We have a rule in our offices. If you are going to participate in a running sport, you must do 2 minutes of Shuffle Walks EVERY SINGLE DAY.  

The size of the anterior compartment muscles is much smaller than the bulbous large posterior compartment so the tug of war is always in the favor of the calf to become too dominant.  Drive some SES (Skill, Endurance and Strength) into the anterior compartment and you will see a stronger arch, control pronation better and very likely see shin splints disappear once and for all. 

Watch the video today and learn why some of our teams can be seen Shuffling around the outdoor track. It is pretty amazing to drive by a school and see an entire team shuffling and know that they are doing it because of The Gait Guys. It is comforting that we do not have to see many shin splint cases in our offices anymore because the teams are being proactive. Shin splints are SOOOOO boring and easy to fix.  

Enjoy gang, From the archives……..

Shawn and Ivo

Pathologic Ankle Rocker: Part 2. “Passing the Buck Proximally”

This was an unexpected follow up blog post from yesterday’s piece we did on the rigid flat foot. We were purging some files from an old computer and came across these 2 videos. We are not even sure where they came from. They were AVI files from probably 2 decades gone by;  they reminded us how long we have been at this gait game and how many great patients have taught us along the way.
Yesterday we learned that if the ankle rocker (dorsiflexion) was impaired that we could ask for the motion to be passed into the midfoot via hyperpronation in order to get the tibia to progress past vertical to enable the body to pass by the rigid ankle mortise rocker.  (Remember from our previous teachings that there are 3 rockers in the foot. First there is heel rocker, then ankle rocker, then forefoot rocker. Each is essential for normal gait. You must understand the 3 rockers to understand gait and to recognize gait pathologies when they present.)
So, yesterday we saw a strategy of pronating excessively through the midfoot to artificially trick us into thinking we have more ankle rocker then we actually truly did. So this was a “pass the buck” into the foot. Today however we are going to show you a very atypical compensatory choice. Today this client shows that with a rigid and/or strong enough arch that the arch doesn’t always need to be the part that gives in to enable more rocker. Today this client chose a vertical strategy.
You are going to have to study these videos closely several times, this is a critical learning and teaching point today. The problem is the left ankle in the video.

This client has chosen to go  VERTICAL when they hit the ankle rocker limitation. Once they achieve their terminal range at the ankle mortise joint (the tibio-talar joint ) their brain realized that moving forward at the ankle was impossible. Since the midfoot did not collapse and give in, as in yesterday’s case, they had no choice but to “pass the buck” proximally into the kinetic chain. In this case we see that the knee was the next vertical joint. Now, they have 2 choices, either hyperextend the knee to enable a forward lurch of the body mass past the ankle rocker axis or “go vertical”. In this case you can see the early heel rise (we refer to is as premature heel rise). Frequently a premature heel rise can force knee flexion but in this case the rise just kept going vertical and forcing them into the use of the gastrocsoleus group and thus forcing a lift of the entire body. If you look hard you can see a greater development of the calf muscles on this side from doing this for years. (Oh, wait, memory data dump here…..we are recalling this case, it was the result of an old motorcycle accident. A student sent us this video back in the 1990’s when we were teaching at the university.)
What is interesting here is that if you think hard, and this will be a new thought process for many readers, that when he goes into heel rise he buys himself more ankle range again. You see, he first met the end range limitation of ankle rocker which appears to be about 90 degrees and then he hits the bony block. If he goes vertical into the calf he is moving back into plantarflexion. This means that even though he is on the forefoot now, he has bought himself more ankle dorsiflexion range again. Now he has the option of holding the posture on the forefoot as rigid and then re-utilizing the new-found extra degrees of ankle dorsiflexion to progress forward OR, he can just move into FOREFOOT ROCKER (the 3rd of the rockers we meantioned earlier).  This client is likely doing a bit of both, perhaps a little more of the forefoot rocker strategy.
You can also kind of see that this slightly shortens the time in the stance phase on this left side and causes an early dumping onto the right limb (which causes a frontal plane pelvis distortion compensation). This gives the appearance of a slight limp.
So, this was a nice follow up from yesterday’s principle of “passing the buck”. You can either ask for the motion from the next distal joint in the kinetic chain, or  you can back up the kinetic chain and dump it into the proximal joint from the pathologic one (the knee in this case). Which one would you want, if you had to choose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns.

Here is a tougher question for you. Would you want this phenomenon on one side and be unilaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*Please do not try to help this client by putting a heel wedge in their shoe. You are just going to rush heel rocker into that bony block sooner and faster and speed up his pathologic stance phase. You will see his vertical strategy come even faster and thus pass the buck into the opposite right hip even stronger. It is a fleeting good initial thought because you are merely trying to help his poor calf muscles get to that heel rise easier, until you think about it for a minute.

When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

The Rigid Flat Foot: Do you know what you are actually dealing with ?

In these 5 photos of a client with a flat arch we see some great opportunity to discuss some of the clinical issues and clinical thinking that needs to occur.  As usual we write our blog posts on the fly with a principle at hand that we want to drive home, or in this case “into the ground”.  There are many more clinical issues with this type of foot and its problems, so today’s list and dialogue is not meant to be exhaustive.  But, if you take one thing away from this case, it should be that not all flat feet can take a stability shoe or an orthotic. So, if you are in the mind set that “when it is flat, jack it up (the arch)” and “when it is high (the arch), cushion it” hopefully you will open your eyes a bit to the reality that it just is not that simple.  IF you want to learn more about these issues we have purposefully put together the National Shoe Fit program for stores and doctors/therapists so they can learn more about the anatomy of the feet and shoes and how to pair them up to create the best recipe for a person.  

Now, onto this case.

In this case you should notice a few things. 

1- the rigidity of the flat foot as portrayed in the photo where we are pushing up with our thumb on what once was the peak of the arch (yes, there are 5 photos in this case, click on one to enlarge or scroll) . We are attempting to push up, but the midfoot is completely rigid. This is a classic Rigid Flat Foot Deformity, A Rigid Pes Planus if you will. 

2- There is a prominence at the navicular bone, both top (dorsal) and bottom (plantar) aspects of the foot (see photo of my hand with finger and thumb indicating these areas). The plantar prominence is the actual naviular bone (mostly) that has become weight bearing (termed “weight bearing  navicular” and crudely by some as a dropped navicular, a term we dislike). And the dorsal prominence is a dorsal crown of osteophytes. This means a dorsal ridge of bone has formed at the navicular-1st cuneiform bone/joint interval because of the constant and repetitive compression of the two against each other dorsally as midfoot arch collapse occurred repeatedly and then became a fixed permanent entity.

3- The hyper dorsiflexion range at the 1st MTP joint (the big toe). This range is excessive at actually was able to exceed 90 degrees (see photo) !  Even at rest the hallux (big toe) is extended suggesting the volume of dorsiflexion it gets all the time.  By the way, there was little to no hallux 1st MPJ joint plantarflexion (downward bend), not in a foot this flat. In fact most of that is from the contracture of the short extensors of the toes as noted by the photo showing the hammer toe formation (hammer toe = contractured short extensor myotendon, and to the long flexors as well). Hammer toes are almost always seen in a flat foot presentation, to a degree.

Now, lets put some things together (but a reminder, this is a single principle today, there are many more issues here).

Today’s Principle: Passing the Buck

Normally we need to have just slightly greater than 90 degrees of ankle mortise dorsiflexion to progress the body over the ankle.  Put in other words, we need to be able to get the tibia slightly past vertical (perpendicular to the ground, hence 90+ degrees). Depending on the reference, anywhere from 15-25 degrees past that 90 degree vertical, thus 105 to 120 degrees) is the goal.

If an ankle cannot get that range, the range must be achieved either proximal or distal to that joint, ie. Passing the Buck beyond the ankle mortise joint.  Proximally, one can hyperextend the knee to enable the body mass to pass sagittally over the ankle but a better strategy (arguably) is to compensate distally via collapsing the arch and pronate more than normally through the midfoot putting undue stress and strain into the plantar fascia and over time eventually collapsing the arch and creating the dorsal and plantar bony prominences we mentioned in #2. By dropping the arch, the subtalar joint exceeds its ranges and the talus and navicular collapse medially and plantarwards. 

When the arch drops to the planus stage the tibia is passively thrust forward achieving the necessary forward tibial progression to get body over and past the ankle to enable forward progression. 

Remember, this pes planus will dorsiflex the long metatarsal bone (meaning make it parallel to the ground). This will screw up the 1st Metatarsal-phalangeal joint function and  impair the Windlass Mechanism of Hicks at the big toe (translation, it will impair the sesamoids, possibly leading to sesamoiditis, and change the normal toe function and its tendons.  This is seen both in the pes planus foot and in hallux rigidus turf toe presentations where the big toe loses its  normal ranges as compared to this case here).

So, the normal range can as for the buck to be passed proximally into the kinetic chain or distally. Which one would you want, if you had to chose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns. 

Here is a tougher question for you. Would you want this phenomenon on one side and be uniliaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*So, a flat RIGID foot.  If you jam an agressive orthotic (or possibly even a motion control shoe) under this foot it could very likely be painful to those rigid bony prominences and it will remove the client’s “passing the buck” compensation. Now the forces may have to revert to the proximal strategy at the knee.  So, when do YOU go with the orthotic or motion control shoe ? When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

Lets test your visual skills again.

This is a 7 year old with gait abnormalities that has hypertrophied calves and difficulty with attention span (what 7 year old doesn’t) and being “slightly behind in learning”. This young lad was brought in by his mom because other therapists had felt they had reached an end point of care and was offered little from the allopathic physicians they visited.

Watch his gait cycle several times and see if you note the following:

• exaggerated upper body movement
• increased progression angle (r foot particularly)
• toe walking gait
• wide base of gait with running

Physical exam findings reveal

·       cavus foot

·       ankle dorsiflexion at 0 degrees

·       intact lower extremity reflexes, sensation and motor strength

·       general weaker upper body strength (particularly shoulders)

Rather than play “name the pathology”, lets concentrate on what we would do for this young man.

·       Increase ankle dorsiflexion and ankle rocker

·       Increase hip extension and gluteal recruitment

·       Increase proproioception

·       Increase coordination

·       Increase upper body strength

The Gait Guys. Helping you to see things more clearly and find solutions to complex gait challenges.

Special thanks to JM for allowing us to present this teaching case.

What kind of shoe do you put this foot in?

Look carefully at these dogs. Notice anything peculiar? Look at the forefoot to rearfoot relationship. What do you see?

Normally, we should be able to draw a line from the center of the heel and it should pass between the 2nd and 3rd metatarsal heads. If the line passes through or outside the 3rd metatarsal heads, you have a condition called metatarsus adductus. It occurs from fetal positioning in utero. In children (18 mos to 4 years) it can often be corrected by wearing the shoes on the opposite feet (yes, you read that correctly)

We usually try and distinguish whether the adductus is occurring at the tarsal/ metatrsal articulation or the transverse tarsal joint.

OK, so now what?

Think of the unique biomechanics that happen here. Adduction (along with plantar flexion and inversion) are components of supination. So, the adduction component makes for  a more rigid foot (notice the arch structure in the pedograph). We are not saying this foot does not pronate, only that it pronates less.

Total amount of pronation will be determined by several factors,

• including body weight

• available rear foot motion

• available forefoot motion

• knee angulation (ie genu valgus or varus)

• available internal rotation of the hips (how much ante or retroversion/torsion is present)

• strength of abdominals, particularly the external obliques

• tibial torsion

This individual had

·       markedly increased valgus angle (14 degrees)

·       moderate external tibial torsion

·       femoral antetorsion

this, along with their body weight, explains the rear foot pronation seen on the pedograph.

So, what type of shoe? You should pick a shoe that:

·       does not exaggerate the deformity (ie. a shoe that does not have an excessively curved last)

·       a shoe that does not work (too much) against the deformity (ie. an extremely straight lasted shoe)

·       In this case, a shoe with some motion control features (to assist in controlling some of the increased rear foot motion. This may be something as simple as a dual density midsole

·       a shoe that, upon gait analysis, works to provide the best biomechanics for the circumstances.

As you can see, when it comes to shoe fit and prescription, there are no had and fast rules. You need to examine the individual and have all the facts.

If you are a little lost, or want to know more, you should take our National Shoe Fit Program. Maybe you even should consider getting Level 1 certified by taking the International Foot and Gait Education Council exam. Need more details? Email us at: thegaitguys@gmail.com

The Problematic Cross-over Gait Motor Pattern: Part 1

It seems that many of our newer viewers have come on in the last year, sometime after we did the 3 part series on The Cross Over Gait.  So, we are putting this one up for all those noobs when it comes to The Cross-Over. Remember, it is a 3 part series, just type in “cross over” into our Youtube channel search.  Happy 4th everyone !

Here Dr. Shawn Allen of The Gait Guys works with elite athlete Jack Driggs to reduce a power leak in his running form. The Cross-over gait is a product of gluteus medius and abdominal weakness and leaves the runner with much frontal plane hip movement, very little separation of the knees and a “cross over” of the feet, rendering a near “tight rope” running appearance where the feet seem to land on a straight line path. In Part 2, Dr. Allen will discuss a more detailed specific method to fix this. You will see this problem in well over 50% of runners. This problem leads to injury at the hip, knee and foot levels quite frequently. To date we have not met anyone who had a good grasp on this clinical issue or a remedy quite like ours. Help us make this video go viral so we can help more runners with this problem. Forward it to your coaches, your friends, everyone.
Thanks for watching our video, thanks for your time.
-Dr. Shawn Allen, The Gait Guys
see you daily on the blog ! thegaitguys.tumblr.com

What is Visual Parallax and how does it affect gait analysis? : Is your video gait analysis really telling you what you think it is telling you ?

We recently were asked by a student at a physical therapy school to help with a teaching case. They asked us to look at a gait video to assist in outlining some things in the case.  Here was our response.

“Hello Jane Doe

We are happy to look at the video for you so you and others can learn.

Just please know, as we say all the time here on the Gait Guys, that without an examination that what we are all seeing is not the problem rather the persons compensatory strategy around the dysfunctional parts.

Plus, video negates binocular parallax viewing so things that would stand out in in a exam where we are physically present will be masked quite a bit in/on video or on a computer screen. We try to minimize these visual losses by getting multiplanar gait video views (sagittal from front and back and coronal from left and right sides) but even these will not fill the visual gap from transferring data from 3D to 2D and then trying to interpret a 3D answer from the 2D.  But it is the best one can do with our technology today unless you use a body suit sensor system, and then you still have the limitations of "what you see is not the problem, its their compensation” so one still needs the physical exam to put the puzzle together.

Here…….. read this if you are wondering what we mean.

*This blog article (link below) which we wrote 18 month ago is the heart of what we wanted you to read today. Visual parallax and binocular vision both need to be understood so that you can better understand why what you see on your gait analysis video might not be what  you think you are seeing. Seeing is one thing, knowing what you are seeing is another, knowing the limitations and the “why” of what you are seeing is yet another.

http://thegaitguys.tumblr.com/post/16760849274/what-is-visual-parallax-and-how-does-it-affect

So, we can tell you what we see………but without an exam we cannot tell you with great accuracy why you are seeing what we see.

that make sense ?“

best
shawn and ivo

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.

What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
- a rigid high arched cavus foot
- perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
- a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
- weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
- contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
- presence of a rigid forefoot valgus
- avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop

So you think you are tough ? This guy was tough. A marathon a day for over 120 days…..on one leg, with cancer.
Today, a Tribute to Terry Fox. Every year we post a reminder of perhaps one of the toughest dudes who ever lived.
Today , this day, 1981 Terry Fox died.
Half of The Gait Guys grew up in Canada. We were barely a teenager when Terry began his plight. His mission, 26 miles a day, every day, until he had crossed the expanse of Canada. He made it an amazing 120+ days in a row, 3339 miles, before his cancer returned. The whole country stood cheering watching him do something no mortal man would attempt, let along with one leg, and cancer. Today we pay a tribute to this rockstar.

Rest in Peace Terry.

Cheating the Ankle Rocker: a review post of Anothony Bourdain.

Today seems like the perfect day to link you to this old blog post because it parlays beautifully with yesterdays video and blog article.

Once again, we present “The Chef: Anthony Bourdain, Cheating the ankle rocker”. We hope he won’t get upset we snipped this little clip from his old show No Reservations. He is a smart reasonable guy, we think that if he knew he was helping others that he would say “go for it”.

Here is a rewind of our blog post:

http://thegaitguys.tumblr.com/post/21713480315/the-chef-another-abnormal-gait-pattern-in

PS: we follow Bourdain on Twitter……one prolific guy and great TV shows too. Did you see his recent show (on CNN) on the Congo? We are huge fans of The Chef ! One guy we would someday definitely love to meet and share a beer with. Even if he has some impaired gait mechanics. But hey, who doesn’t !?

The Gait Guys

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

don’t miss this case video

http://youtu.be/J0z8lpK7X1E

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

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

Podcast 34: Chimp feet, Marathon Monks & Statin drugs

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/

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

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

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