Achilles Tendonitis
The motion needs to occur somewhere…Make sure you look at the whole picture
Since the knee was bent, perhaps we should be looking at the soleus? And the talo crural articulation?
“A more limited ankle Dorsi Flexion Range Of Motion as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendonitis among military recruits taking part in intensive physical training.”
J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.
Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study.
Rabin A1, Kozol Z1, Finestone AS2.
GOT GLUTE MEDS?
Want to strengthen that gluteus medius we were talking about Monday? Have you considered walking lunges with dumbbells? These seem to activate the side contralateral to a better extent than split squats.
We wonder if you get the same effect with a medicine ball. Anyone out there have some data or experience with that?
Stastny P1, Lehnert M, Zaatar Zaki AM, Svoboda Z, Xaverova Z. DOES THE DUMBBELL CARRYING POSITION CHANGE THE MUSCLE ACTIVITY DURING SPLIT SQUATS AND WALKING LUNGES? J Strength Cond Res. 2015 May 8. [Epub ahead of print]
Foot orthoses and patellofemoral pain: frontal plane effects during running | Lower Extremity Review Magazine→
/We all see people with patellofemoral pain. Some of those cases may have responded to orthotic therapy. Some studies show that the effects on frontal plane kinematics are minimal (1 degree); this doesn’t mean it didn’t work, or this amount is not clinically significant. So why do they help? Perhaps it is a “timing” issue and the knee abduction moment.
“Our results are consistent with a 2003 study by Mundermann et al that compared the effects of custom orthoses (with posting, molding, or a combination of both) to flat inserts. For each orthotic condition, these authors reported a significant delay in the timing of the peak knee abduction moment. This finding may be related to the aforementioned clinical effects, as delaying the peak knee abduction moment would effectively decrease the rate of loading at the knee joint. The rate of loading has been previously implicated as a possible contributing factor in running-related overuse injuries, as runners with a history of injury have demonstrated a higher rate of loading of the vertical ground reaction force than runners with no history of running-related injury.”
This is an interesting take. If you have a few moments, give it a read:
Lumbar link? Ankle, spinal pathologies coexist in cadavers | Lower Extremity Review Magazine→
/It makes sense…but which came 1st?
Just make sure you ask your foot patients about their back, and your back patients about their feet
The Gait Guys
Forefoot Varus or Forefoot Supinatus?
Forefoot varus is a fixed, frontal plane deformity where the forefoot is inverted with respect to the rearfoot. Forefoot varus is normal in early childhood, but should not persist past 6 years of age (i.e. when developmental valgus rotation of forefoot on rearfoot is complete, and plantar aspects of fore- and rearfoot become parallel to, and on same plane as, one another (1)
Forefoot supinatus is the supination of the forefoot that develops with adult acquired flatfoot deformity. This is an acquired soft tissue adaptation in which the forefoot is inverted on the rearfoot. Forefoot supinatus is a reducible deformity. Forefoot supinatus can mimic, and often be mistaken for, a forefoot varus. (2)
A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous where a forefoot supinatus is acquired and develops because of subtalar joint pronation.
“Interestingly, only internal rotation of the hip was increased in subjects with FV – no differences were present in hip adduction and knee abduction between subjects with and without FV. The authors nevertheless conclude that FV causes significant changes in mechanics of proximal segments in the lower extremity and speculate that during high-speed weight-bearing tasks such as running, the effects of FV on proximal segments in the kinetic chain might be more pronounced.”
We wonder if the folks in this study had a true forefoot varus, or actually a forefoot supinatus (3).
The Gait Guys
1. Illustrated Dictionary of Podiatry and Foot Science by Jean Mooney © 2009 Elsevier Limited.
2. Evans EL1, Catanzariti AR2. Forefoot supinatus.
Clin Podiatr Med Surg. 2014 Jul;31(3):405-13. doi: 10.1016/j.cpm.2014.03.009.
3. Scattone Silva R1, Maciel CD2, Serrão FV3. The effects of forefoot varus on hip and knee kinematics during single-leg squat. Man Ther. 2015 Feb;20(1):79-83. doi: 10.1016/j.math.2014.07.001. Epub 2014 Jul 12.
Foam rolling, a literature review - Anatomy & Physiotherapy→
/What does the literature say about foam rolling?
The folks here bring up a good point: “ Despite these findings, without clearly defined parameters and more importantly, mechanisms of action, to what extent should we incorporate SMR and foam rolling into our programming?”
#92: Your Brain on running. Ankle tightness, Femur rotation and more.
/Plus a little on Oliver Sacks and homeostasis.
Show sponsors:
www.newbalancechicago.com
A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_92final2.mp3
Direct Download:
http://thegaitguys.libsyn.com/92-your-brain-on-running-ankle-tightness-femur-rotation-and-more
Other Gait Guys stuff
B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”
Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:
Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E
Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895
https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11
Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx
Show notes:
A General Feeling of Disorder: Oliver Sacks
http://www.nybooks.com/articles/archives/2015/apr/23/general-feeling-disorder/
How Running Keeps Your Brain Humming
http://www.runnersworld.com/sports-psychology/how-running-keeps-your-brain-humming?adbid=10152565232831987&adbpl=fb&adbpr=9815486986&cid=socBeg_20150123_39089627
Hey Gait Guys,
I’ve been reading your blog and listening to your pod-casts (now on 71 but have listened to some new ones too so maybe 10 more to go). I’ve become so much more aware of the body’s biomechanics. Maybe this has been discussed by you guys before but I haven’t come across it yet. I was in Walmart and saw the Dr. Scholl’s foot map system and arch supports. I don’t know if you’ve seen the machine or have tested it out but they are everywhere. I found it interesting that for EVERY foot type they are recommending a ‘specialized’ heel lift. It involves statically standing on the machine on one leg. Interestingly there are handles which one can hold to help support the body on this single leg stance. After listening to so many podcasts and applying my new found knowledge, it immediately raises red flags in my brain. Thought you might be interested.
http://www.drscholls.com/productsandbrands/CustomFitOrthotics.aspx#tablink_2
Overtightening of the ankle syndesmosis: is it really possible?
Tornetta P 3rd1, Spoo JE, Reynolds FA, Lee C.
http://www.ncbi.nlm.nih.gov/pubmed/11315776
J Bone Joint Surg Am. 2001 Apr;83-A(4):489-92.
Femur rotation
http://journals.lww.com/acsm-msse/Abstract/publishahead/Femur_Rotation_Increases_Patella_Cartilage_Stress.97824.aspx
Reader:
Hi there Dr Ivo and Dr Allen
I thought this article may interest you.
http://leonchaitow.com/2015/01/21/rediscovering-better-posture-a-foot-related-personal-saga/
http://www.mortonsfoot.com/pickingrightpci.html
This last paragraph/quote in particular caught my eye.
I was wondering what your opinion of this would be and wether you agree with it entirely?
Wenger et al (1989) suggest that, since flexible flat foot is generally a benign condition, it rarely requires treatment.
wreck method, squats ?
https://www.weckmethod.com/articles/improve-squatting-form-using-the-neutral-squat-technique
High performance high heels ?
/oy. At $925 a pair, maybe she is the smart one (but we don’t think so). There is always an opportunist it seems.
“If I was to continue to [wear heels] in the same level as I did in my 20s, I would literally end up with super deformed, damaged feet,” said Singh, 36.
Traditionally, the structure of a high heel relies on a single metal shank running along the sole of the shoe providing a very stiff — and uncomfortable — platform that puts 75 percent of the pressure on the ball of the foot.
Singh and her team are trying to adjust the distribution of load so that the ball of the foot carries 50 percent of the weight and the heel carries the other 50 percent such that the impact — and with it, the pain — is lessened.
http://nypost.com/2015/05/03/these-high-performance-heels-wont-kill-your-feet/
One of our favorite (and biggest brained) people in the world !
In his own words: “Gait is the most important biomarker for neurological integrity and is considered a quantifiable variable that might serve as a window of disease or functional neurological progression or attenuation.”
Prof. Carrick has had almost 4 decades of clinical experience in this gait knowledge area. His knowledge application base in this functional approach to human stance, balance and gait is world renown. He will share his clinical experience so that the learner will be able to gain a fluency in this exciting evidence based clinical area of expertise.
Check out this teaser 15" talk on his Amsterdam course coming up in June.
http://lp.carrickinstitute.org/advanced-human-gait/
Increase glute medius activity with weighted unilateral carries.
/Looking for a way to increase functional-gait related gluteus medius activity, skill, endurance and strength ? Do not forget to implement the unilateral weighted “carries”.
The forward walking lunge and split squats are similar exercises that have differences in the eccentric phase, and both can be performed in the ipsilateral or contralateral carrying conditions. Contralateral walking lunges highly activate the gluteus medius. You can vary these challenges with unilateral overhead carry (the waiter’s carry) to help engage the shoulder, core and incorporate breathing skills.
http://journals.lww.com/…/DOES_THE_DUMBBELL_CARRYING_POSITI…
Running yourself into thyroid troubles ?
/A few years ago we wrote about this:
“Are you running yourself into hormonal problems?”
here is the link: http://thegaitguys.tumblr.com/…/are-you-running-yourself-in…
Well, there has been some new research and one of our fav authors has brought things to present day research. Here is what Alex Hutchinson has to say and share with us all over as Sweat Science.
http://www.runnersworld.com/health/endurance-training-and-thyroid-function
Weighted Carries for glute training
/Looking for a way to increase functional-gait related gluteus medius activity, skill, endurance and strength ? Do not forget to implement the unilateral weighted “carries”.
The forward walking lunge and split squats are similar exercises that have differences in the eccentric phase, and both can be performed in the ipsilateral or contralateral carrying conditions. Contralateral walking lunges highly activate the gluteus medius. You can vary these challenges with unilateral overhead carry (the waiter’s carry) to help engage the shoulder, core and incorporate breathing skills.
Mental training
/“research findings that mental skills are underutilized by injured athletes in the 3 countries examined. More effort should be focused on educating and training athletes, coaches, and sports medicine professionals on the effectiveness of mental training in the injury rehabilitation context.”
Shoes and Pronation and Injuries
/Our brief (very) thoughts on the topic in Triathlete.com. We do not do much of this stuff anymore, our thoughts get so “cooked down” that they often lose context. But thankfully the main principle was conveyed pretty well here, albeit not in entirety.
We were asked about this topic many moons ago. We did not know this was published in January, until a patient brought it to our attention this week.
http://triathlon.competitor.com/2015/01/training/pronation-blame-injuries_111767
Fascia Science
/So you talk about fascia and adhesion and scar tissue with your clients, do you?
Glad someone finally said it. Kudos.
Hope this will foster good debate. Careful you do not get stuck on your loyalty to a method or guru.
Beware of research data
/Be aware of what you read.
We have had many people over the years criticize some of the articles we put up….“hey, the N on this study is 6 ! That isn’t a reliable study” etc.
As we have said many times, you can pick apart many studies. Few are comprehensive, many just look at a small piece, and as our link today eludes to, some are frauds and listed from “pay-for-play” publications. Some however are just so flawed that publication should never have occurred.
However, just because you have a problem with an article does necessarily mean to throw the baby out with the bath water. Good or bad, most valid articles have something good or bad to learn from. Sometimes they spark ideas in our minds, sometime they encourage thought, change or avoidance. This is the value of a valid journal article to us, the bigger picture, not because the study only looked at one aspect of a theory or hypothesis.
Here is an article that is raising Cane in the nutrition world and it sort of highlights some problems.
“Bohannon, a science journalist who also has a Ph.D., lays out how he carried out an elaborate hoax to expose just how easily bad nutrition science gets disseminated in the mainstream media. "You have to know how to read a scientific paper — and actually bother to do it,” he writes. For starters, as Bohannon explains in great detail, the study design itself was flawed — it had too few subjects, and the research measured too many factors, making it likelier that some random factor would appear to have statistical significance.
The cross over gait and achilles pathologies.
/From our post earlier today:
Part 2:
Considered another way, from the top down this time, if at the moment of heel contact the gmedius is delayed (as suggested in the study below from achilles pain), the pelvis is likely to drift laterally and this could cause a reactive inversion strategy of the rearfoot, and maybe even forefoot as well, as an instinctive measure to try and draw support beneath the laterally drifting body mass center of gravity. (This in essence sets up the “cross over gait” deployment strategy we have talked about here for years now).This too could cause a change in load to the achilles mechanism, resulting in tendonopathy thus putting one into a vicious cycle of achilles causing glute and then glute perpetuating altered strike and thus abnormal achilles loads . This is also a major cause of ankle inversion sprains, so be extra aware of this pattern. We see this all the time in practice, we hope you do as well. IF you haven’t already, If you wish to dive deeper, goto our blogwww.thegaitguys.tumblr.com and type in Cross Over Gait and it will get you going.
* Remember this, if you are spending time moving sideways, you are taking from time moving forwards, in the allotted amount of time given for the stance phase of gait. Yet, you will still move forwards, so one way around this is a premature heel rise (ie. speed up certain mechanical events) via premature plantarflexion mechanism loading (calf-achilles complex). Remember to also look for all the other reasons for premature heel rise (ie. loss of ankle rocker etc).
Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.
______________
Part 1
The mighty Gluteus Medius, in all its glory!
Perhaps the delayed action of the gluteus medius allows an adductory moment of the pelvis, moving the center of gravity medially. This could conceivably place additional stress on the achilles tendon (via the lateral gastroc) to create more eversion of the foot from midstance onward.
“The results of the study demonstrate altered neuromuscular control of the GMED and GMED in runners with Achilles Tendonitis. During running, GMED typically activates before heel strike so as to stabilize the hip and the pelvis. In runners with Achilles Tendonitis, GMED is activated with a delay, which consequently might affect the kinematics of knee and ankle resulting in rear foot inversion. Similarly, GMAX is activated with a delay and for a shorter duration in runners with Achilles Tendonitis. GMAX is the primary hip extensor and via a kinetic chain, a decreased hip extension moment might be compensated by an increased ankle plantarflexion moment which could potentially increase the load on the Achilles tendon.”
Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. : Neuromotor control of gluteal muscles in runners with achilles tendinopathy.
Med Sci Sports Exerc. 2014 Mar;46(3):594-9.
Post stroke spatiotemporal gait asymmetries.
/This could be translated into your non-stroke patients gait. Making changes in their gait must be specific, accurate (what they need, not changes that you are seeing which you do not like), and consciously engrained through repetition. As with most things, awareness is the first step toward change. And making changes based on what you see is just asking them to create a new pattern on what was likely their compensation, not their problem. Never change what you see in someones gait without a complete physical examination first, what you see is how they are moving with their presenting problem(s).
“Asymmetry magnitudes need to exceed usual overground levels to reach conscious awareness. Therefore, it is proposed that the spatiotemporal asymmetry that is specific to each participant may need to be augmented beyond what he or she usually walks with in order to promote awareness of asymmetric gait patterns for long-term correction and learning.”
“Following stroke, spatiotemporal gait asymmetries persist into the chronic phases, despite the neuromuscular capacity to produce symmetric walking patterns. This persistence of gait asymmetry may be due to deficits in perception, as the newly established asymmetric gait pattern is perceived as normal.”
http://ptjournal.apta.org/…/2015/04/30/ptj.20140482.abstract
Walking meditation
/A different perspective on walking.
When we give our gait retraining homework to clients, we ask that it is mindful and that each step is focused on the changes we have recommended. We ask that they notice the local changes and eventually the global manifestations of these gait alterations. This is key to making changes, and as this piece eludes to……there is something deeper cerebrally going on that can change other deeper aspects of your life.
How to Walk is the fourth title in Parallax’s popular Mindfulness Essentials Series of how-to titles by Zen Master Thich Nhat Hanh, introducing beginners and reminding seasoned practitioners of the essentials of mindfulness practice. Slow, concentrated walking while focusing on in- and out-breaths allows for a unique opportunity to be in the present. - See more at:
http://www.parallax.org/how-to-walk-thich-nhat-hanh-mindfulness-essentials/
Isometrics for patellar tendonitis?
We are familiar with different modes of exercise: isometric, isotonic and isokinetic. Isometric exercises have a physiological overflow of 10 degrees on each side of the point of application (ie; to do the exercise at 20 degrees flexion, and you have strength gains from 10 to 30 degrees); isotonics and isokinetics, 15 degrees. Taking advantage of physiological overflow often allows us to bypass painful ranges of motion and still strengthen in that range of motion.
In this study, they looked at immediate and 45 minute later pain reduction (not function) comparing isometric (max voluntary quadricep contraction) and isotonic (single leg decline squat) exercises. They also looked at cortical inhibition (via the cortico spinal tract) as a result of the exercises.
Here is what they found: “A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms. Isometric contractions can be completed without pain for people with PT. The clinical implications are that isometric muscle contractions may be used to reduce pain in people with PT without a reduction in muscle strength.” These same results were not seen with the isotonic exercise.
Did the decrease in pain result in the decrease in cortical inhibition (muscle contraction is inhibited across an inflamed joint: Rice, McNair 2010; Iles, Stokes 1987)? Was it a play on post isometric inhibition (most likely not, since this usually only lasts seconds to minutes post contraction) ? Or is there another mechanism at play here? There has been one other paper we found here, that shows cortical inhibition of quadriceps post isometric exercise. Time will tell. In the meantime, start using those multiple angle isometrics!
The Gait Guys
Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J.Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy Br J Sports Med. 2015 May 15. pii: bjsports-2014-094386. doi: 10.1136/bjsports-2014-094386. [Epub ahead of print]
