“Due to the shape of the condyles and the menisci, and the location of ligaments of and muscles acting on the knee, the joint rotation axis is located medially in the knee joint. This also in part explains why the lateral condyle and meniscus are more mobile. Maximum extension of the knee is caused by these factors and the “screw home” mechanism of the cruciate ligaments. The popliteal muscle is connected with the lateral meniscus and the caput fibulae: it locks the knee joint in and unlocks the knee joint out of its maximum extension. Moreover, it plays an important role for proprioception in the knee joint and is known to cause posterolateral knee pain.
”

from: http://www.anatomy-physiotherapy.com/…/94-test-your-knowled…

Forefoot valgus: A fixed structural defect in which the plantar aspect of the forefoot is everted on the frontal plane relative to the plantar aspect of the rearfoot; the calcaneum is vertical, the mid tarsal joints are locked and fully pronated

Want to know more? Join us Wednesday evening: 5 PST, 6 MST, 7 CST, 8 EST for Biomechanics 309: Focus on the forefoot on onlinece.com.

McGraw-Hill Concise Dictionary of Modern Medicine. © 2002 by The McGraw-Hill Companies, Inc.

Fore foot types: Differences between forefoot varus and forefoot supinatus.

Certainly this can be a contraversial topic. Perhaps this will help clear up some questions.

Supination of the forefoot that develops with adult acquired flatfoot is defined as forefoot supinatus. This deformity 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. A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation (1).

A Forefoot Varus induces STJ pronation whereas a Forefoot Supinatus is created because of STJ pronation (2).

As the foot experiences increased subtalar joint (STJ) pronation moments during weightbearing activities (as in forefoot supinatus) , the medial metatarsal rays will be subjected to increased dorsiflexion moments and the lateral metatarsal rays will be subjected to decreased dorsiflexion moments. Over time, this increase in STJ pronation moments will tend to cause a lengthening of the plantar ligaments and medial fibers of the central component of the plantar aponeurosis and a shortening of the dorsal ligaments in the medial longitudinal arch. As a result, the influence of increased STJ pronation moments occurring over time during weightbearing activities will tend to cause the following (3):

1. An increase in inverted forefoot deformity.
2. A decrease in everted forefoot deformity.
3. A change in everted forefoot deformity to either a perpendicular forefoot to rearfoot relationship or to an inverted forefoot deformity.

More on the forefoot tomorrow evening on onlinece.com: Biomechanics 309. Join us!

1. Clin Podiatr Med Surg. 2014 Jul;31(3):405-13. doi: 10.1016/j.cpm.2014.03.009. Forefoot supinatus. Evans EL1, Catanzariti AR2.

2. https://kenva.wordpress.com/…/…/forefoot-varus-or-supinatus/

3. http://www.podiatry-arena.com/podiatry-forum/showthread.php…

Here is another nice review. Consider Sever’s with all your younger heel pain patients

We posted on this a few weeks ago. see here:http://thegaitguys.tumblr.com/…/clinical-tidbit-heel-pain-i…

Does gait (re)training alter peoples biomechanics? You bet it does! Should we be retraining peoples gait? We like to think, yes. What do you think?

“Overall, this systematic review shows that many biomechanical parameters can be altered by running modification training programmes. These interventions result in short term small to large effects on kinetic, kinematic and spatiotemporal outcomes during running. In general, runners tend to employ a distal strategy of gait modification unless given specific cues. The most effective strategy for reducing high-risk factors for running-related injury-such as impact loading-was through real-time feedback of kinetics and/or kinematics.’

Br J Sports Med. 2015 Jun 23. pii: bjsports-2014-094393. doi: 10.1136/bjsports-2014-094393. [Epub ahead of print]
Gait modifications to change lower extremity gait biomechanics in runners: a systematic review.
Napier C1, Cochrane CK1, Taunton JE2, Hunt MA1.

How much “dip” in the coronal plane is in your single leg squat?

“In conclusion, the Single-Leg Squat is a reliable tool to identify patients that would need to improve their hip and trunk muscle weakness and dysfunction (by strengthening and neuromuscular coordination retraining). ”

Crossley et al., Am J Sports Med 39 (2011) 866 - 873.

Performance on the single-leg squat task indicates hip abductor muscle function. - Anatomy &…

Clinical assessment of performance on the single-leg squat task is a reliable tool that may be used to identify people with hip muscle dysfunction.ANATOMY-PHYSIOTHERAPY.COM

How many times have you seen us post and talk about the shoulder complex and lower extremity relation? Here is another

“Kids grow up thinking that throwing a baseball hard is all about strength in the arm and shoulder, but new evidence suggests that muscle strength and range of motion in the hip affect shoulder function during throwing in youth baseball players.”

Lower-body focus could help youth baseball player arms | Lower Extremity Review Magazine

How do your gluteus maximus and gluteus medius exercises stack up?

Looks like side planks (DL=dominant leg) and single leg squats scored big, as did front planks and good old “glute squeezes”

Check out this free full text articlehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201064/

Yes, we know it was surface emg; yes we know they are not necessarily testing functional movements. The EMG does not lie and offers objective data. Note that the one graph is labelled wrong and is the G max, not medius.

Kristen Boren, DPT,1 Cara Conrey, DPT,1 Jennifer Le Coguic, DPT,1 Lindsey Paprocki, DPT,1 Michael Voight, PT, DHSc, SCS, OCS, ATC, CSCS,1 and T. Kevin Robinson, PT, DSc, OCS1 ELECTROMYOGRAPHIC ANALYSIS OF GLUTEUS MEDIUS AND GLUTEUS MAXIMUS DURING REHABILITATION EXERCISES Int J Sports Phys Ther. 2011 Sep; 6(3): 206–223.

Who’d a thought? Can someone make an “app” for that?

Interesting study that we just found out about in the June 15th LER journal titled “Patients with ankle instability respond to auditory feedback by changing gait”

In this study they put a sensor under the head of the 5th metatarsal in 10 folks with chronic ankle instability that would emit a sound in respose to excessive lateral ankle pressure. They were told to “walk quietly” and not let the beeper beep. After a short time, the people in the study were able to walk with decreased pressures in the lateral forefoot, in addition to the midfoot and central forefoot. EMG showed increase in peroneal and medial gastroc activity.

Interesting implications and also some questions.

This study shows that auditory feedback can alter behavior and gait. Is this a good thing? We suppose this depends on what you are trying to accomplish and does it ultimately benefit the patient?

this sensor could be made into an “app” that has some cool rehabilitation implications. Imagine a moveable sensor or multiple sensors that could track patterns over time and plot them for you? The auditory could be used to discourage some bevaiors/characteristics of gait and the “tracking” feature could provide progress information. Or maybe is it hooked up to some of your favorite music and it stops playing when you are not weighting appropriately. Wondering if your patient is loading the head of the 1st metatarsal? This could provide some feedback.

Check it out:

Donovan l, Hart JM, Saliba S et al. Effects of an auditory feedback device on plantar pressure in participants with chronic ankle instability. Med Sci Sports Exerc 2015; 46(5 suppl); S104

Folks with patellofemoarl pain move differently. But they don’t necessarily engage their trunk differntly. We think we all knew this, but here is a study that looks at it. 

“Compared with the control group, the PFP group demonstrated increased ipsilateral trunk lean, hip adduction and knee abduction (p = 0.02-0.04) during single-leg squat accompanied with decreased trunk isometric strength (p = < 0.001-0.009). There was no between-group difference in trunk muscle activation. Only in the control group, ipsilateral trunk lean was significantly correlated with hip adduction (r = -0.66) and knee abduction (r = 0.49); also, the side bridge test correlated with knee abduction (r = -0.51). Differences in trunk, hip and knee biomechanics were found in people with PFP. No relationship among trunk, hip and knee biomechanics was found in the PFP group, suggesting that people with PFP show different movement patterns compared to the control group.”

Man Ther. 2015 Feb;20(1):189-93. doi: 10.1016/j.math.2014.08.013. Epub 2014 Sep 9.Trunk biomechanics and its association with hip and knee kinematics in patients with and without patellofemoral pain.Nakagawa TH¹, Maciel CD², Serrão FV³.

Big Toe Woes: One way to learn to load the head of the 1st metatarsal

On Thursday morning, while sprinting up a hill on the latter part of a run, I had the fortuosity of catching my big toe on what I beleive was an exposed root and fell sudddenly. Instinctively I rolled to protect my back (as you often do if you have had any history of back injuries). After a few expletives and a bruised ego, I took inventory of my body: back was fine, an abrasion and contusion on my left elbow and a really sore big toe. I got up and decided to run home as I was less than a mile from there.

I immediately noticed that my gait would need to be altered if I was going to make it home. I had injured the distal interphalangeal joint and distal phalanyx from the best I could tell; loading them in any way brought excruciating pain, so I was forced into one of my mantra’s: “Keep your toes up”*. I did this for the rest of my run and noticed, probably more than ever, how much this simple technique shifts the weight to the head of the 1st metatarsal and sesamoids. It also made me make my gait more “circular” (rather than pendular, another thing we teach in gait retraining).

I made it home and promptly iced. After getting to the office, an X ray confirmed my suspicion of a fracture in the proximal portion of the distal phalanyx. A day later and from my distal to my 1st metatarsal phalangeal joint is sausage like and a beautiful violet color. I am grateful I did not seem to injure the MTP…Oh well, I will either have to run carefully or switch to mountain biking for the next few weeks. Some ipriflavone (to assist in calcium absorption), cucumin and essentail oils (for inflammation) and I was good to go. Yes it throbs a bit, but it is a reminder that I need to push off through the head of the 1st : )

Try “toes up”with your peeps and let us know how it goes.

TGG

* “Toes up” technique involves conciously firing the anterior compartment muscles, particularly the extensor digitorum longus. It fires more into the extensor pool and assists in firing ALL your extensors through spacial and temporal summation and also heps to shut down flexor tone through reciprocal inhibition. It will also help you to rocker through your stance phase and get more into your hip extensors.

The eccentric aspect of the shuffle walk

Hey guys, I’m an Osteopath from Australia and am a keen follower of your work. I just had a quick question about your tib ant training via the shuffle gait. I am comfortable with the theory behind it, my only issue is that clinically, tib ants role as an eccentric controller of pronation is significant. Therefore, shouldn’t we develop an exercise which trains it in an eccentric fashion? perhaps there is some controlled pronation in the shuffle gait that I have missed, but i’m interested to hear your thoughts as they are thoughts I respect! Thanks very much for all your work, it’s great to see practitioners using evidence based practice in a creative and practical way. Cheers, D

________

our response:

Hi D. Good question and it is a major point.. If you think about the exercise, you are slowly putting the ball of the foot back on the ground AND maintaining the arch as best as possible. In essence, the arch will drop a bit as your weight is born on the foot, so it will pronate, but you are trying to hold it up, so in a manner of speaking you are controlling the arch descent, so you are eccentrically focusing on the activity. If we were to reshoot the video, this would be part of teh dialogue, because we do have our clients focus on this.  Remember, we are giving this exercise to many folks who have pronation control issues (yes, and ankle rocker issues) so we are kinda hitting the aspect you are questioning.  How this helps a bit.  As they get better, they take bigger steps in the shuffle walk, so that means more acceleration of the prontation, so they will have to try to maintain the arch under greater loads…….hence, more eccentric focus.  That is the way we see it anyways.  

Compression socks. Worth your time ?

“if putting strawberry bubble gum in your right ear on Tuesday mornings helps to alleviate your left hip pain, who am I to say to "don’t do it”.
Preamble: When patients ask me if XYZ might help their problem/pain I sometimes have been heard to jokingly tell my patients that the placebo effect has been shown as high as 40% in some studies. i say that different things work for different people, so if there is no harm in trying something “fringe” and as of yet unproven, I tell them to feel free to try it. I often jokingly end the conversation with this statement “if putting strawberry bubble gum in your right ear on Tuesday mornings helps to alleviate your left hip pain, who am I to say to "don’t do it”.
My mom wears compression stockings for minor swelling in her lower legs. These socks are rated at a graduated 20-30mmHg. Most athletic compression socks are rated far lower, but we have seen some that are rated that high.
Originally developed for the treatment of deep vein thrombosis (DVT), some compression socks are now marketed as a tool to improve venous return, thus believed to improve both performance and recovery in athletes. Some feel that the socks during training are directed to help the skeletal muscle pump, increase deep venous velocity, and/or decrease blood pooling in the calf veins. Some even claim they will alleviate delayed-onset muscle soreness (DOMS).

Alex Hutchinson (link below) does another nice job reviewing compression socks. His conclusion is the same as ours; 

“So the overall picture is quite mixed. The fact that pre-existing beliefs have a big effect on how well compression socks work definitely seems to suggest that some of the benefits are "all in your head.” But it’s worth remembering that the same is probably true of any kind of intervention, including “real” ones.“

Below is a study that suggests no measurable benefits. But as always, you can find any study to support what you want to believe. So perhaps it comes down to, how suggestive is your brain, and what seems to work for you ?

So, compression socks or strawberry bubble gum ? Choices choices choices. 

Eur J Appl Physiol. 2014 Mar;114(3):587-95. doi: 10.1007/s00421-013-2789-2. Epub 2013 Dec 13.
Compression stockings do not improve muscular performance during a half-ironman triathlon race.
Del Coso J.

http://www.runnersworld.com/sweat-science/do-you-believe-in-compression-socks

Deep brain stimulation and movement.

We talk much about movement patterns and movement problems here and on our blog. In recent years there has been much research on stimulating the subthalamic nucleus with deep brain stimulation (STN-DBS) to alter freezing of gait (FOG) in patients with advanced Parkinson’s disease. We will likely see more and more research, and likely therapeutic options in time, on deep brain stimulation (DBS). The future looks bright. If you want to get into the deeper stuff, search Pubmed for DBS.
From the article:
“There are more than 100 nervous system disorders that afflict millions of people across the globe. Many of the disorders affect a person’s movement and alter their motor controls. This includes balance, gait, speed of movement, tremors, jerks and abnormal postures. Deep brain stimulation or DBS has successfully treated these symptoms and allowed many sufferers to reclaim their lives.”
Read more here …

http://brainmysteries.com/deep-brain-stimulation-movement-disorders-tuning-brain/

Corticospinal axon regeneration.

In the world of gait challenges from spinal cord injury, this is potentially huge.
“In the July 1st issue of The Journal of Neuroscience, HKUST researchers report that the deletion of the PTEN gene would enhance compensatory sprouting of uninjured CST axons.”

“It not only promoted the sprouting of uninjured CST axons, but also enabled the regeneration of injured axons past the lesion in a mouse model of spinal cord injury, even when treatment was delayed up to 1 year after the original injury. The results considerably extend the window of opportunity for regenerating CST axons severed in spinal cord injuries.”

http://www.deepstuff.org/researchers-discover-way-to-regenerate-corticospinal-tract-axons/

It is not your gait, it is where you take it

Often, it is not your gait, it is where you take it and make use of it.

“Specifically, the study finds that people who walked for 90 minutes in a natural area, as opposed to participants who walked in a high-traffic urban setting, showed decreased activity in a region of the brain associated with a key factor in depression.”
In the next few decades it is projected that 70% of the world’s population will exist in urban settings. Urbanization and disconnection from nature have grown dramatically, as have mental disorders such as depression.
“In fact, city dwellers have a 20 percent higher risk of anxiety disorders and a 40 percent higher risk of mood disorders as compared to people in rural areas. People born and raised in cities are twice as likely to develop schizophrenia.”

http://www.futurity.org/nature-depression-951762/

XBox and gait analysis

The revised Xbox One Kinect, also known as the Microsoft Kinect V2 for Windows, includes enhanced hardware which may improve its utility as a gait assessment tool.
“In conclusion, while the Kinect V2 body tracking may not accurately obtain lower body kinematic data, it shows great potential as a tool for measuring spatiotemporal aspects of gait.”

J Biomech. 2015 May 28. pii: S0021-9290(15)00298-5. doi: 10.1016/j.jbiomech.2015.05.021. [Epub ahead of print]
Gait assessment using the Microsoft Xbox One Kinect: Concurrent validity and inter-day reliability of spatiotemporal and kinematic variables.
Mentiplay BF

The gluteus medius and low back pain.

We see this one ALL the time. We are sure you do as well.
“Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP.”
It is often more on the side of pelvic frontal plane drift. The abdominals and spinal stabilizers also often test weak on this same side. We often see compromise of hip rotation stability as well because , since the hip is relatively adducting (because the pelvis is undergoing repeated frontal plane drift, hence no hip abduction) there is often a component of cross over gait phenomenon which can threaten rotation stability of the lower limb (type “cross over gait” into the search box of our tumblr blog for a landslide of work we have written on that phenomenon).

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

http://www.ncbi.nlm.nih.gov/pubmed/26006705

Abs on the UP, Glutes on the DOWN

I had the opportunity to go on my 1st mountain bike ride of the season last Sunday morning. Yes, I am aware it is JUNE, but the snow has finally melted (we had over 7 FEET at arapahoe Basin in May) and you need to understand that I am usually a runner). In the cool morning 44 degree air I was reminded of the importance of my gluteal muscles (rather than just my quads) while climbing a technical hill which was clearly pushing my aerobic capacity. We have the opportunity to perform many bike fits in the office and treat many cycling ailments. We also train and retraing pedal stroke and one of our mantras (in addition to skill, endurance and strength) is “Glutes on the downstroke; Abs on the upstroke”. Meaning use your glutes to extend the hip from 12 to 6 o’clock and use your abs to initiate the upstroke. Quadricep (on the downtstroke) and hamstring dominance (on the upstroke) is something we see often and this mantra often proves useful in the “retraining process”.

I have been a fan of Ed Burkes work (“Serious Cycling” and “Competitive Cycling”) for years and have read (and lectured about) these books many times. In my effort to find a basis in the literature for my mantra, I ran across a paper (1) that seemed to substantiate, at least in part, the mantra. It is a small study looked at elite athletes that explores changes that occur in muscle recruitment as the body fatigues after a sub maximal exercise session.

Their conclusion “The large increases in activity for gluteus maximus and biceps femoris, which are in accordance with the increase in force production during the propulsive phase, could be considered as instinctive coordination strategies that compensate for potential fatigue and loss of force of the knee extensors (i.e., vastus lateralis and vastus medialis) by a higher moment of the hip extensors.”

This makes sense, although may be contradicted by this study (2), which showed LESS gluteal activity at higher mechanical efficiency, with increased tricep surae activity. They conclude “These findings imply that cycling at 55%-60% V˙O(2max) will maximize the rider’s exposure to high efficient muscle coordination and kinematics.”  Although this study looks at mechanical efficiency and the 1st lloks at muscle activity.

Being seated on a bike and having your torso, as well as hips flexed is not the most mechanically efficient posture for driving the glutes, but clinical observation seems to dictate that the less quad and hamstring dominant people are on the down and up stroke respectively, then the more pain free they are. This does not always equte to being the fastest, but it does equate to fewer injuries showing up in the office.

1. Dorel S1, Drouet JM, Couturier A, Champoux Y, Hug F. Changes of pedaling technique and muscle coordination during an exhaustive exercise. Med Sci Sports Exerc. 2009 Jun;41(6):1277-86. doi: 10.1249/MSS.0b013e31819825f8.
2. Blake OM1, Champoux Y, Wakeling JM.  Muscle coordination patterns for efficient cycling. Med Sci Sports Exerc. 2012 May;44(5):926-38. doi: 10.1249/MSS.0b013e3182404d4b.

Abductory twist in your gait ?

Last night on our www.onlinece.com teleseminar we discussed some clinical applications and critical thinking of gait parameters and pathology. We discussed the dynamic gait pedograph below. Possible evidence of Abductory Twist gait pathology (video linkhttps://youtu.be/F3DHRoHrYOs). In this case, client had loss of internal hip rotation, but they sure love external rotation pivot at the ground interface, as the pedo shows here (more details were provided on the teleseminar last night).
*Fix the problem, retrain normal gait skills, add endurance and strength to the new gait pattern and you have a solution. Add an orthotic to treat what you see on the pedograph and you have a bandaid (and potentially/probably a problem down the road). You can’t fix a motor pattern compensation by forcing a compensatory fix. Get to the root of the problem, in this case hip and pelvic biomechanics ! It is all about mobility and stability !