Change the foot, change the knee (and vice versa). A video case of External Tibial Torsion.

Here is a perfect example of external tibial torsion. Are you treating and training people and messing with their orthotics, squat knee-foot posturing or making gait/running/jumping changes or recommendations? If you are doing all of this and you do not know about tibial torsions, then shame on you, go apologize to these people right now. You could be causing them mechanical grief. Go buy them ice cream (even if they are “paleo”), that fixes most unintentional human mistakes. 

This is a classic presentation of external tibial torsion. This is an anatomic problem, you cannot fix this intrinsically, but you can help extrinsically. You teach these people about this issue and why the foot and the knee cannot cooperate. You teach them why their feet are spun out (increased foot progression angle) while their knee tracks straight forward sagittally. You teach them why they might heel strike far laterally and why their pronation phase might be abrupt. As in this video, you teach them why they might fashionably choose to narrow the foot progression angle (foot turned in) while at the same time having to bear weight on the lateral foot (in supination to externally spin the tibia) to keep the knee tracking sagittally. You teach them why this will be impossible to do in pumps (inversion sprain ouch) and why over time this will anger many joints and tendons. You teach them that without this accommodation they will track the knee inside the sagittal plane (as seen in the video).  You teach them why they might be at greater risk of having foot prontation issue pathologies, why they might have limited internal hip rotation, why orthotics likely do not do much for them (yes, there are exceptions), why certain shoes are a challenge for them while others are magical and why over time their once beautiful arch has begun to “fall” and be less prominent as they attenuate the plantar tissues.  

As you get good with this gait and biomechanics stuff, you should readily see and understand all of the issues discussed here today in a mere flash of instant brilliance so you know what to offer your client, in understanding and remedy options. As you have seen in this video, when left to their own devices, they naturally allow the knee to find the sagittal plane in a nice forward hinge. In this posture the foot is excessively progressed outward. Again, this is because of the tibial long bone torsion. This is their anatomy, this is not functional in this case. You cannot fix this, you help them manage this, first with their awareness, then with your brilliance.  You may implement exercises and gait strategies to help them become aware of mechanical issues and how to protect the foot-ankle, the knee and the hip. You teach them why they might have a tendency towards anterior pelvis posturing or sway back type postures. You teach them why, in some cases, they choose knee hyperextension as a comfortable yet lazy stance postural habit. You teach them why some shoes are “happy” shoes for them, and why others are pure evil.

A foundational principle we teach here at The Gait Guys is that the knee is a simple hinge between two multiaxial joints on either side of the knee, the hip and the foot-ankle complex. The knee really can only flex and extend, and when the mechanics above and below are challenged the knee has little depth to its abilities to tolerate much of anything except simple sagittal hinging. You can see that the foot posturing and tibial torsion rule the roost here in this video. You should learn in time that managing this case above and below the knee is where the pot of gold is found. You will learn in time that taping the knee is often futile, yet a worthy experiment both for you and the client in the discovery process, but that a life time of taping is not logical. External tibial torsion, although affording the knee that sagittal hinge plane, can narrow its range of safe sagittal mechanics and it is up to you to  help them learn and discover that razor’s edge safely and effectively when the torsion is large.  You should also discuss with them that as they plastically tissue adapt over the years (ie. pronate more and lose more arch integrity), this razor’s edge may widen or narrow for the knee mechanics as well as the hip and foot-ankle complex.  

For your reading pleasure, a classic example of how to interrogate a safe sagittal knee progression was discussed in this blog video piece we wrote recently, linked here.

Look and you shall find, but only if you know what you are looking for.

* Please now know that you should never off the cuff tell someone to turn inwards their outwardly spun foot. But if you do, have ice cream on hand, just in case.

Need more to spin your head ? Think about whether their IT band complex is going to be functioning normally.  Oy, where is that ice cream !

Shawn Allen, one of the gait guys

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.

Cold war shoe lace tying

during the Cold War, CIA agents used a method of communication based on how their shoelaces were tied.

http://www.tydknow.com/did-you-know-that-during-the-cold-war-cia-agents-used-a-method-of-communication-based-on-how/

Salsa Dancing for Age related Functional Deficits.

Don’t dismiss it until you have tried it. For 3 years we did it here at The Gait Guys (and salsa was one of our favorites), so we know what it is all about … . the foot work, the amount of core stability needed, hip stability, lower abdominal skills, balance, proprio, vestibular accommodation etc. Dancing is no joke, and no you are not too cool to do it. Here in America we are the exception, not the rule. In most countries, after dinner, they push the tables to the sides and people dance the night away. In many countries, men dance. Looking to impress guys? Take some lessons. Looking to get your elderly clients active, set them up with your local dance studio and improve their health. 

- random thoughts from Dr. Allen

Their study’s conclusions: “Salsa proved to be a safe and feasible exercise programme for older adults accompanied with a high adherence rate. Age-related deficits in measures of static and particularly dynamic postural control can be mitigated by salsa dancing in older adults. High physical activity and fitness/mobility levels of our participants could be responsible for the nonsignificant findings in gait variability and leg extensor power.” - Granacher et al.
http://www.ncbi.nlm.nih.gov/pubmed/22236951

https://www.youtube.com/watch?v=m62CUqzdJRM

Difference between adult and infant gait compensation.

We highly doubt the infants compensated to the point of “recovering symmetrical gait”. It just isn’t possible seeing as there was frank asymmetry in leg length. However, it is quite possible they accomodated quicker with a more reasonable compensation, that MAY have appeared to have less limp. We did not do the study, but over a beer we might guess that the investigators might agree that our verbiage is closer to accurate. None the less, cool stuff to cogitate. We are very appreciative of this study, there is something to take from this study.

“The stability of a system affects how it will handle a perturbation: The system may compensate for the perturbation or not. This study examined how 14-month-old infants-notoriously unstable walkers-and adults cope with a perturbation to walking. We attached a platform to one of participants’ shoes, forcing them to walk with one elongated leg. At first, the platform shoe caused both age groups to slow down and limp, and caused infants to misstep and fall. But after a few trials, infants altered their gait to compensate for the platform shoe whereas adults did not; infants recovered symmetrical gait whereas adults continued to limp. Apparently, adult walking was stable enough to cope with the perturbation, but infants risked falling if they did not compensate. Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”- From the Cole et all study (reference below)

- thoughts by Shawn Allen

references:

Infant Behav Dev. 2014 Aug;37(3):305-14. doi: 10.1016/j.infbeh.2014.04.006. Epub 2014 May 20.Coping with asymmetry: how infants and adults walk with one elongated leg.Cole WG¹, Gill SV², Vereijken B³, Adolph KE⁴.

http://www.ncbi.nlm.nih.gov/pubmed/24857934

Hmmmm…

The question is: “is the earlier activation a good thing”?

What do you say?

“A study of patients with chronic ankle instability (CAI) suggests the onset of knee and ankle muscle activity occurs significantly earlier when shoes and orthoses are worn than when the patients are barefoot.”

http://lermagazine.com/issues/october/shoes-orthoses-improve-muscle-activation-onset-in-unstable-ankles

Eating up a cardinal plane.

Simple post, simple principle today.  We found this case on the web, somewhere. Wish we could remember so we could give credit. 

Looks like simple right leg length discrepancy but the point we wanted to make is that any time you deviate into a plane, you eat up length. In this case, the right knee is severely valgus and that has at least in part contributed to a shorter limb and unleveling of the pelvis. And, it is not uncommon that rotation axis are changed when frontal or sagittal planes are compromised. It is easy to see this on the x-rays, if the foot posturing isn’t at least noted, look at the spacing between the tibia and fibula .  .  .  . rotational planes have changed as well. Is it from the femur or tibia? That is the topic of another day. 

In the larger photo you will notice that even with the right foot lifted there is still a pelvis unleveling. How can that be, unless it was further unleveled that what we are seeing ?  Well, just because you lift to fix doesn’t mean the lift will not enable further collapsing into the weakness and deformity.  We have described this principle on the topic of EVA shoe foam deformation.  When the foot presses the foam into the deformation, it leaves more room for possibly further and faster deformation loads (perhaps more so than had a new shoe been prescribed). So in some cases, more lift can allow more deformation.  How far, well as in this photo, at least until the right knee slams into the left knee and stops further deformation.

So, seeing a plane deficit clues you into possible unleveling of the pelvis and abnormal joint loading responses. It should clue you into looking for another cardinal plane compromise as well. But make no mistake, just adding a lift doesn’t mean the deformation is remedied and not enabling further deformation. It is possible that you can make your client worse if you do not teach them how to find the appropriate motor patterns with the lift so they can learn to protect the parts. Often teaching these types of clients how to control their deformities (when and if possible) is where the gold lies, not in just leveling out the foundation. 

One more “beating of the dead  horse”, lift the whole foot, heel and forefoot with a sole lift when you are “lifting and leveling”. Lifting only the heel puts them into ankle plantar flexion and can often facilitated earlier and faster forefoot loading and even earlier knee flexion.  Save the heel lift as a possible consideration when there are posterior compartment contractures or inflammation.  Certainly we could have gone into functional and structural leg length discrepancies, but we have blogged excessively on that topic in the past. Go ahead and search our blog if you want more on those topics.

Take home point, “just because you lift, doesn’t mean you are truly lifting, you may enable the opposite”.

Shawn Allen, one of the gait guys

What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another

“The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.

The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”

From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.

Welcome to Monday and News You Can Use. Got Arm swing? This exercise, borrowed from Shirley Saurmann can be a great adjunct to your rehab program, dispensed with some muscle physiology : )

Do it on your self
Try it on a client
Teach someone else

Happy Holidays from The Gait Guys

Twas the night before Christmas, and all through the land, and the Gait Guys were there to give St Nick a hand. 

This poor fellows knees had been in pain as of late. He had taken up running to help lose some weight. 

To his clinician he went, who prescibed an orthotic for pronation, without a look or thought, or a very methodic examination.

So across the country, Dillon, Chicago and the nation, He went to see the Gait Guys for a comprehensive evaluation.

They watched him run on the treadmill and analyzed his stride and they saw he had a heavy foot strike on one side

And his knees fell outside of center, left side more than the right and an adductory twist, from a heel cord wound too tight.

They looked at each other and at the same time said they thought that they knew what the problem was with the man who wore red.

Then they placed him on the table, with the highest efficiency, they found that he had a left sided leg length deficiency.

When his knees were straight, his feet pointed to the middle; internal tibial torsion they thought, and that solves the riddle.

An orthotic for internal torsion, without a valgus post is sure to macerate the meniscus, and turn it to toast. 

That orthotic they took, from his shoe in a jiffy and knees were more midline, now wasn’t that spiffy

and a sole lift for his shoe, to correct the difference, even though it was small, it had a significance…

And exercises they gave, to be done three times each day to anchor the medial tripod, and push off through the 1st ray. 

“Thanks Gents”, he said, as he took off running with a smile, His knees were much better, even after running a mile. 

Shawn and Ivo looked at each other feeling fulfilled, Having helped this poor fellow, and they hope they instilled

In each and every reader and follower and student the desire to look closer and do what is prudent

Happy Holidays we wish to all our sisters and brothers, We hope we have inspired you to continue to learn and teach one another. 

Have a great one : )

We always like to try and reproduce the problem. We like to say “If we can reproduce the pain, we can probably fix the cause”, which seems to hold true in many cases. This article makes us think about seeing the patient at a point in their training that they feel the discomfort or are having the problem (after 30 minutes, after 20 miles, etc). There may be some value to scheduling their exam later, rather than sooner. A nice fatigue article from one of our favs “LER”.

http://lermagazine.com/article/running-in-an-exerted-state-mechanical-effects

Hyperthermic Conditioning for Hypertrophy, Endurance, and Neurogenesis→

An interesting take on “heat” conditioning by one of our new favs, Dr Rhonda Patrick. Some pretty cool stuff here. We have a talk on hyperthermic training on an upcoming PODcast. Check her out

More on the Minimalist Debate

“Nearly a third (29%) of those who had tried minimalist running shoes reported they had experienced an injury or pain while using the shoes. The most common body part involved was the foot. Most (61%) of those reports involved a new injury or pain, 22% involved recurrences of old problems, and 18% were a combination of both old and new musculoskeletal problems.

More than two thirds (69%) of those who had tried minimally shod running said they were still using minimalist running shoes at the time of the survey, but nearly half of those who had stopped said they did so because of an injury or pain. The most common sites of pain or injury that caused survey participants to discontinue minimally shod running were the foot (56%) and the leg (44%).

While some runners who tried minimalist running shoes suffered some pain and discomfort, a greater percentage (54%) said they had pain that improved after making the switch. The anatomical area most often associated with improvement was the knee. The results were published in the August issue of PM&R.”

Welcome to Monday and News You Can Use!

Any of your patients of clients taking anti inflammatories? Especially after a rehab session or dry needling/acupuncture? They may be thwarting the healing process. Excerpted from a recent lecture, Dr Ivo talks about how they can down regulate the healing process.

Walking changes our mental state, and our mental state changes our walking.

60 second audio pod.  Our mental state changes our gait, and our gait changes our mental state.
We highly suspect that this is not the “bouncy” gait we typically refer to, the loss of ankle rocker gait.
http://www.scientificamerican.com/podcast/episode/bouncy-gait-improves-mood/

Calf strength screen?  Um, maybe not. Specifics matter.
Thanks to barbellphysio.com for putting this up. We would like to take this deeper, because it is very important.
This screen in our strong opinion is mostly for testing sub optimal endurance, sure there is some strength assessment going on but if you are trying to determine strength, is it single rep strength ? Very likely what he truly meant is how does the calf strength hold up at a 20 rep endurance challenge.  This is more accurate and we are fussing about specifics here, but specifics matter.
*However, the potentially BIG HOLE here in the assessment, is that “perceived” top end calf/heel raise ROM is not necessarily top end FULL ROM. If one side is truly weak, and you cannot get to top end strength (say the heel is 10% lower than the other side) someone has to be there to assess and notice that top end strength failure (a top end ROM that could reduce as endurance challenge continues, but someone has to be there to observe. Going on just “feel” alone is a bad recipe there). One like is not going to feel that top end range loss even if it is large, you will perceive the effort which could feel the same as the good side but actually be a loss.  And is 20 reps enough? Sure, it is a start but is your test really telling you what you think it is telling you ? This is being shown as a gross screen in our opinion but it has holes even as a screen.  Top end strength, something we talk about here often, is critical to performance. Top end loss means  terminal plantarflexion ROM is insufficient, and this can lead to a whole host of injuries and biomechanical flaws including achilles tendonopathy to mention just one. Remember, the gastroc does  not play alone here (and gastrocs crosses the knee joint posteriorly, some of the other posterior compartment muscles do not). There is soleus, peronei, tib posterior, long flexors etc. So are you doing your test with bent knee or locked ? It makes a difference if you are trying to tease things out.  Are you ramming your toes into flexion to get more out of them to make up for a loss elsewhere ? Is the forefoot or rearfoot inverting or everting  on the up or down phase ? These things matter. Specifics matter.  For example, you can see in this video that the hip is a little lateral to the foot placement. This will mean that the heel rise will result in a lateral forefoot weight bearing load. Do you want to see if the peronei are doing their job during the heel rise ? Well then you should go into a hip hike to posture the hip over the foot so that you can get the weight bearing transition to occur terminally over to the big toe, the peronei and lateral gastroc help drive that last little shift and if they are weak and you are not driving that last piece of the movement the test may not show you the whole picture you are thinking it is. Clue, if you cannot feel the lateral compartment contract to finalize that medial foot weight bearing load shift, you may be weak there. You better assess then.

Can you do 20 reps at 80% of the full plantarflexion ROM or can you do 20 reps at 100% full plantarflexion ROM ? There is a performance difference, and to the client unobserved, the 80% on one side may feel and perform like the 100% on the other side. But make no mistake, there is a world of difference.  Someone has to  watch that you are comparing apple to apples, and not apples to figs, oranges, turnips or squash.
-Dr.Shawn Allen, the gait guys

https://www.youtube.com/watch?time_continue=55&v=QdWiXHsI8Q8

Ever wonder why Vladimir Putin Walks Like That?

the quotes below are from the NBC article referenced below.
“Neurology professor Bastiaan Bloem of the Radboud University Medical Center in the Netherlands and colleagues had noticed that Putin often walks with his right arm held rigid, while his left arms swings freely.”

Might it be Parkinson’s disease, which can cause stiff movements?

in an old Russian KGB manual it was discovered:
“According to this manual, KGB operatives were instructed to keep their weapon in their right hand close to their chest and to move forward with one side, usually the left, presumably allowing subjects to draw the gun as quickly as possible when confronted with a foe.”
https://www.youtube.com/watch?v=K2yj2uMTqSs

http://www.nbcnews.com/health/health-news/why-does-vladimir-putin-walk-n480611

Gait Retraining: be careful.

Compensations and adaptive motor patterns that alter the normal joint mechanics can cause injury.

This study discusses whether a 10% increase in running cadence has a correlation to injury incidence. 

“With increased cadence, there was a decrease in peak knee flexion and a later occurrence of peak knee flexion and internal rotation and shank internal rotation. Segment coordination was altered with most changes occurring in mid-late stance. Coordination variability decreased with an increase in cadence across all couples and phases of gait. These results suggest examination of coordination and its variability could give insight into the risk of intervention-induced injury.”

The paper discusses the reorganization of movement patterns.  It is suggested that one follow our SES (Skill, Endurance, Strength) principles as adaptation ensues.  Gain safe skill on the new pattern and drive it suboptimally at high repetition (ie. gain endurance on the new skill set).  Then heighten the skill again, and then again drive more endurance on it.  Then add some strength, then more skill, then more endurance,  … . rinse and repeat).

Anything too much, too fast, for too long is a risk. The CNS needs time for adaptation. Any change, even if globally deemed good, can be a problem. 

The Gait Guys

http://www.tandfonline.com/doi/abs/10.1080/02640414.2015.1112021?journalCode=rjsp20

Changes in coordination and its variability with an increase in running cadence. 
Jocelyn F Hafer^a*, Julia Freedman Silvernail^b, Howard J Hillstrom^c & Katherine A Boyer^a Accepted: 20 Oct 2015Published online: 20 Nov 2015

Why can’t I squat.

Client presents to you:
On the exam table they have plenty of ankle dorsiflexion range of motion (ROM), full knee flexion ROM, full hip flexion ROM.
You then ask them to perform all 3 together in the form of a squat. The result is that they cannot even squat past parallel thighs. They have used a mere portion of the ranges which they showed plentiful on the exam table. Why ?

Possibilities: The exam showed passive movements, not active loading. Perhaps lack of Skill (unfamiliarity of the skill), lack of coordination (lack of knowing how to put the pieces together), lack of balance and body mass space awareness (ie. where do i put my parts so i do not fall over), lack of hip, knee, pelvis-core stability, etc.

“Just because you have it, doesn’t mean you own it. Nor does it necessarily mean you know how to use it or have the right to push the limits if you have never been there before.”

Gait stopping.

You are walking to the sink to wash dishes:
Your Brain: “ok, we are about 3 more steps from the sink, you had better slow down … . ok, 2 more steps … 1 more step, this is the last one … . ok, that is it, you have arrived at the sink, both feet I now command you to stop moving … . . now, initiate double stance support, 50% weight on both feet… . . begin standing mode.”

Can you imagine being unable to stop moving graciously? Imagine that every attempt to halt your walking or running was like smacking into a wall or stumbling to a halt ? Kind of like that amateur driver who uses no grace or finesse, every start is a stomp on the gas and every stop is a slamming on the brakes.
We take stopping for granted, as do we underestimate the complexity of initiating movement. It is one of those things, you do not know what you have until you lose it. Sometimes it is the simplest of things which we take for granted.
There is a brainstem pathway specifically dedicated to control locomotor arrest. Activating this pathway stops locomotion, while inhibiting the pathway enables locomotion.

enjoy this short blog post today: http://tmblr.co/ZrRYjx1ycc8Q4