Rock your clinical exam!
What sensation is probably the most important to test and why?
What’s wrong with this picture?
The model is obviously well sculpted and hopefully will paid for the toll that this exercise will be taking on her nervous system overtime. Take a close look at the picture above on the left. Look carefully and what do you notice? Do you see it?
This exercise is neurologically incongruent. Her right arm is flexed at the same time as her right hip. When does this ever happen in gait?
Do you remember crossed extensor responses or tonic neck reflexes? If not, see here and here. When we walk the right arm and left leg or flexed while the left arm and right leg are extended. During a tonic neck response, and that is rotated to one side the upper and lower extremity (upper greater than lower) should extend on that side with flexion on the contralateral side.
During a tonic neck reflex, the head is rotated to one side the upper and lower extremity (upper greater than lower) should extend on that side with flexion on the contralateral side. In the picture above her torso is rotated to the left while looking straight ahead which is effectively right neck rotation and her extremities are flexed on that side.
In the picture above her torso is rotated to the left while looking straight ahead which is effectively right neck rotation and her extremities are flexed on that side.
Who thinks of these things? Certainly not folks that are paying attention to appropriate neurology and physiology! Oh yeah, and the ad was for massage cream. Jeez…
There are few places we will accept a cross over gait as safe and normal, this is one of them.
Anyone want to place a bet this person does not have a rigid pes planus ? We are happy to take your money if you bet against this one. (hint: a rigid pes planus, is RIGID, it will not form an arch like this, even from upward pressure, in most people who have it).
A rigid pes planus can result from a long standing (years) insufficient tibialis posterior or complete tear of one (again, moon’s ago) resulting in an inability to invert the heel and raise the arch. We saw one this week.
The Vasti
Do you treat runners? Do you treat folks with knee pain? Patellar tracking issues? Do you treat the quadriceps? Do you realize that the vastus lateralis, in closed chain, is actually an INTERNAL rotator of the thigh (not a typo), and many folks have a loss of internal rotation of the hip? Do you give them “IT band stretches” to perform?
In this short video, Dr Ivo demonstrates some needling techniques for the quads and offers some (entertaining) clinical commentary on the IT band. A definite view for those of you who have needling in their clinical tool box.
The Elusive Iliocapsularis
As with many things, one thing often leads to another. I had a patient with anterior hip pain and what i believed was iliopsoas dysfunction, but I wanted to know EXACTLY which muscles attached to the hip capsule, to make sure I wasn’t missing anything.
I turned up some great info, including a nice .pdf lecture, which I am including the link to along with a second paper that began my journey.
I had thought the iliopsoas attached to the hip capsule, but it turns out it doesn’t, but the iliocapsularis does along with a host of others, including one of my favs, the gluteus minimus, which was believed to be part of the psoas, but actually is a completely separate muscle. Did I mention that these are FREE, FULL TEXT articles?
Anyway, I began reading, with great interest, about the iliocapsularis and I found yet another great review paper on it, along with mechanical hip pain. This last paper has some real clinical pearls and I recommend reading it the next opportunity you have a bit of time.
I began thinking about when the iliopsoas fires in the gait cycle (terminal stance to mid swing). So, it is firing eccentrically at pre swing (perhaps limiting or attenuating hip extension?), then concentrically through early and mid swing, when it becomes electrically silent. During running gait, the activation pattern is similar. This muscle is also implicated in femoroacetabular impingement (FAI), or more correctly anterior inferior iliac spine subspine impingement (AIIS Impingement) or iliopsoas impingement (IPI). They all can cause anterior hip pain and they should all be considered in your differential.
The iliocapsularis muscle has its proximal attachment at the anterior-inferior iliac spine and the anterior hip capsule and does not attach to the labrum . Its distal insertion is just distal to the lesser trochanter. It can sometimes inset into the iliofemoral ligament and/or the trochanteric line of the femur. It is innervated by a branch of the femoral nerve (L2-4). It is believed to act to raise the capsule of the hip and be an accessory stabilizer of the hip.
OK, there you have it. the iliocapsularis. Another muscle you didn’t know you could access. It pays to know your anatomy!
https://www.mcjconsulting.com/meetings/2012/asm/ePosters/files/ISHA_Poster_202.pdf
Dr. Allen’s Quiz question of the week. See if you can get this one.
Reference point is the Girl in the middle, big sister. Choose all that apply. Note: there is something deeper than the obvious going on here, it doesn’t make sense. Can you see it ?
a. she (big sister) is out of phase with her little sister
b. she is in phase with her little sister
c. she is out of phase with her little brother
d. she is in phase with her little brother
e. A and C
f. B and C
g. B and D
h. A and D
i. AC~DC rules
Yes, Answer “i” is always right.
otherwise the answer is … . scroll down
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F. she is in phase with her sister to her left and out of phase with her brother (at least if you are referencing her leg swing). With her little sister, left feet are both forward in swing at the same time.
However, there is something deeper and requires some true critical thinking. IF you got the answer correct, congratulations. IF you did not, type in “in phase gait” or “arm swing” into the blog search engine and you will be able to read more about “in phase” and “out of phase” gaits.
Now, look at the picture again. If she is “in phase” with her little sister to the left big sister should technically have her left arm in anterior/forward swing to meet little sister’s right arm swing. But, big sister’s left foot is forward, which technically means her left arm swing should be posterior to match her normal Anti-phasic gait. But this does not pair with little sister. Can you see that this is a conflict in synchrony ?
In phase and phasic are not the same thing, nor are out of phase and anti-phasic. Search our blog for these differences.
Obviously you should glean by now that “In and out of phase” gait refers to the leg swing. Whereas, phasic and anti phasic gait refers to the synchrony of the upper and lower limbs in an individual. The lower limb spinal cord motor neuron pools are more dominant than the upper arm pools (except in climbing, which is why I spent so much time last week talking about climbing and crawling here on the blog). Thus the lower legs often run the protocols and thus why arm swing changes should not be primarily or initially coached or amended in an athlete, they are very adaptive and accommodating. The legs need to run the show, we need our arms free to be able to carry things while walking or running (water bottle, babies, spears, rifle, brief case etc) without disrupting the normal leg swing gait mechanics.
Big sister is “out of phase” with her brother when it comes to the legs, but their arm swings are matching in phase so that there is no conflict. When people walk “out of phase” their arm swings will always match. Thus, it would seem that this is the more harmonious way to walk with a partner.
So how are they all walking together ? Certainly not in harmony.
Obviously the little sister is not in sync with big sister. She is much shorter, and thus her step length is going to be different and that is the likely answer. She will have to pick up cadence to keep up and that will mean much of the time she will not synchronize with her big sister. As I mentioned in a prior post on these topics, often the larger or more dominant person’s arm swing will dictate the arm swing pattern of the other partner, and this will in turn, dictate how the lower limbs synchronize to the dominant partner. It would make sense that perfect harmony would bring about “out of phase” leg swing, but it does not always occur. Why? There are many reasons I discussed here today, things like differing arm and leg lengths and step lengths come to mind.
* There is one more option, none of them are in anti-phasic gait. Maybe they all have back pain :) Back pain patients tend to shift towards phasic gait to reduce spinal torsion and shear. If they all are anti-phasic then arm and leg swing matter very little in terms of full limb swing propulsive gait. This is quite possible as well, perhaps this is just a still photo representing a very slow strolling gait and thus little need for anti phasic gaits from all 3 of them.
Neat points if you are a true gait nerd. Did you catch it ? A picture is worth a thousand words.
Hope this little quiz helped you to put some pieces together.
One more thing, here is a clinical pearl. By walking hand in hand with someone, you can help a person learn arm swing and leg swing and how to create a clean cadence, the normal anti-phasic gait, and learn how to dual task as well as add audible, visual and tactile queues to one’s gait. It is a great tool for helping neurologic gait pathologies, post stroke gait training and helping someone who has joint replacements or back pain regain normal anti-phasic gait traits where gait has become phasic and apropulsive.
Dr. Shawn Allen
Manipulation and Mechanoreceptors
Do YOU do joint manipulations or mobilizations? Could you explain how they are working and accomplishing what you think (or say) they are accomplishing?
All of this information applies to ANY articulation, not just the spine. This is essential information that all folks performing manipulations or mobilizations should know.
What ARE the different types of mechanoreceptors and how do they work? How does that relate to manipulation and its effects? How can mechanoreceptors inhibit pain and influence muscle tone? Dr Ivo answers these questions and more in this video, excerpted from a recent seminar.
Gait and Climbing (and DNS): Part 2. Introducing 14 year old Ashima Shiraishi.
14 year old “sends” V15 , a 30 move roof climb in Hiei, Japan, called “Horizon”.
“the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.” - 2005 Shapiro and Raichien
I am flipping the script a little today for DNS’ers (Dynamic Neuromuscular Stabilization). Watch the video if you wish, but the point I will be drawing your attention to is the 2:15 mark when she goes inverted on the roof of this apparently “more simple” V9 route. Note, this is not a video of her historic ~30 move V15 route. Stay tuned for that, it is not available yet.
Look closely. In the video, a then 9 year old Ashima is climbing upside down, a roof climb, defying gravity’s push. Spin this picture 180 and she is crawling, finding points of “fixation” or “punctum fixum”. What is neat about climbing is that you can have one, two, three or four points of fixation, unlike walking (one or two points) and crawling (two, three or four points of fixation). The difference in climbing is that gravity is a bear, wearing you down, little by little. A deep similarity in climbing to any variety of crawling is that both involve pulling and pushing, compressing and extending over fixation points. Other common principles are those of fixation, stability, mobility and neurologic crawling patterns in order to progress.
Ashima just recently, in early 2016, was the first female to complete a V14d (it is said it may even be upgraded to a V15a, maybe even a V16). Not many pros of any gender can say they can complete a V15 so this is a real big deal for a 14 year old. Stay tuned for that video.
DNS, Kolar and Climbing
I took my first DNS course with Prof. Kolar 10 years ago. It was an interesting eye opener and I had just enough clinical experience (9 years at that point) to grasp just enough to take it back to my practice and integrate it. Since that time, it has been fun to see it grow and see young practitioners excited to get their first face palm epiphanies. I have been returning to it often, blending it into my rehab work much of the time. There are few hip, shoulder, spine, breathing or global stabilization exercises I prescribe that do not have a DNS component to them, with my own flare and alterations and amendments as necessary. If you have taken a DNS course you will know why I am bring the topic into climbing. If you have not taking a course, you will be a little lost on the conceptual spill over.
As you can see in the video above, start really paying attention at the 2:15 mark in the video when she goes inverted on the roof. Cross crawl patterns, concepts of fixation, compression, expansion, crossing over, and tremendous feats of shoulder and hip stability on spinal stiffness and rotation. Now add breathing, oy ! Now add doing all of this by mere finger tip and toe tip fixation ! When you consider all of this, it becomes almost incomprehensible what she and other climbers are doing when they go inverted like this. Amazing stuff, finger pulling/compression and foot pushing to compressively attach the body to the wall and progress forward.
Lucid Dreaming, A climb in the Buttermilks
Last year I wrote a piece on Lucid Dreaming, the name of a rock (another V15 climb) in the Buttermilks of Bishop, California. Here is that blog post. Lucid Dreaming is no ordinary rock. To summit this rock is
basically only three moves off of three holds, from your fingertips, starting from a sitting position. The
remainder of the climb is sliced bread. If you can do the three, you can get
to the top. The problem is, only a handful of people in the world can accomplish the feat. In the piece I outlined many principles of crawling, quadruped and climbing from a neuro-biomechanical perspective. Here is a excerpt from what i wrote in Gait and Climbing, Part 1:
In climbing there is suspicion of a shift in the central pattern generators because of the extraordinary demand by pseudo-quadrupedal gait climbing due to the demand on the upper limbs and their motorneuron pools to mobilize the organism up the mountain. We know these quadrupedal circuits exist. In 2005 Shapiro and Raichien wrote “the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.”
Some research has determined that in quadrupeds the lower limbs displayed reduced orientation yet increased ranges of kinematic coordination in alternative patterns such as diagonal and lateral coordination. This was clearly different to the typical kinematics that are employed in upright bipedal locomotion. Furthermore, in skilled mountain climbers, these lateral and diagonal patterns are clearly more developed than in study controls largely due to repeated challenges and subsequent adaptive changes to these lateral and diagonal patterns. What this seems to suggest is that there is a different demand and tax on the CPG’s and cord mediated neuromechanics moving from bipedal to quadrupedal locomotion. There seemed to be both advantages and disadvantages to both locomotion styles. Moving towards a more upright bipedal style of locomotion shows an increase in the lower spine (sacral motor pool) activity because of the increased and different demands on the musculature however at the potential cost to losing some of the skills and advantages of the lateral and diagonal quadrupedal skills. Naturally, different CPG reorganization is necessary moving towards bipedalism because of these different weight bearing demands on the lower limbs but also due to the change from weight bearing upper limbs to more mobile upper limbs free to not only optimize the speed of bipedalism but also to enable the function of carrying objects during locomotion.
The take home seems to suggest the development of proper early crawling and progressive quadruped locomotor patterns. Both will tax different motor pools within the spine and thus different central pattern generators (CPG). A orchestration of both seems to possibly offer the highest rewards and thus not only should crawling be a part of rehab and training but so should forward, lateral and diagonal pattern quadrupedal movements, on varying inclines for optimal benefits.
Dancing, Jiu Jitsu and Climbing. Bringing things together.
So, what am I doing with all this information? As some of you may know, I have been expanding my locomotion experiences over the years. First there was three years of ballroom and latin dance, some of the hardest stuff I have ever done, combining complex combined body movements to timing and music at different speeds, each time changing to different rhythms or genres of music. Some of my deepest insights into foot work and hip, pelvis and core stability and spinal mobility originated from my dance experiences, particularly Rumba, Cha Cha, Jive, Waltz and Foxtrot. On a side note, some of my greatest epiphanies about the true function of the peroneal-calf muscle complex came during a private session on a difficult Waltz step concept. It was such an epiphany I sat down and wrote scratch notes on the enlightenment for 20 minutes right there in the ballroom. Next I moved into the very complex martial art of Brazilian Jiu Jitsu, and after three years it is clear it is an art that you could do for a lifetime and never get to the end of the complex algorithms of defense and offense. This art will stay in my wheelhouse to the end if I am able to keep it there.
Rock climbing, this one is the next on the list. After years of sharing my hands on peoples physical problems I know I already have above average grip and finger strength, so this could either prove to be a blessing or a “career ender” in terms of finally finishing off my hands for good. But it is on the list, and it won’t leave my head, so for me that is the tipping point. Climbing is next. I need to understand and experience this, so I can understand human locomotion better.
I will have the video of Ashima “sending” V15+ when they put it up, stay tuned. I have a feeling it is going to be a jaw dropper, I hear the whole send is inverted which boggles my mind. We will dissect her roof crawling and I will try to have some new research for you.
If you want to come down my rabbit hole, come read some of my other related articles:
Part 1: Gait and Climbing. Lucid Dreaming
and my 3 part series on Uner Tan Syndrome. The people who walk on all fours.
Dr. Shawn Allen, one of the gait guys
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References:
Shapiro L. J., Raichien D. A. (2005). Lateral sequence walking in infant papio cynocephalus: implications for the evolution of diagonal sequence walking in primates. Am. J. Phys. Anthropol.126, 205–213 10.1002/ajpa.20049
Scand J Med Sci Sports. 2011 Oct;21(5):688-99. Idiosyncratic control of the center of mass in expert climbers. Zampagni ML , Brigadoi S, Schena F, Tosi P, Ivanenko YP
J Neurophysiol. 2012 Jan;107(1):114-25. Features of hand-foot crawling behavior in human adults. Maclellan MJ, Ivanenko YP, Cappellini G, Sylos Labini F, Lacquaniti F.
SoftScience “The Terrain Ultra Lyte” shoe update:
Introducing “The Terrain Ultra Lyte”. Fresh off the UPS truck today
and just unboxed ! Uber excited. Wearing them right now. Dang, zero drop
with good cush. I could run in these babies ! And I will just to try,
even thought that is likely not their intended purpose. Gorgeous roomy
toe box. True to fit. These feel like a favorite pair of worn in
favorite leather gloves … they are soft cotton canvass right out of
the box. I don’t think i even need to wait a few days, they
should have a label that says “pre-worn in”. I may have just found yet
another new favorite weekend casual shoes, I will save my Altra
Everyday’s for work. I can see where the thinking came when the partners
brought their wisdom over from Crocs (only the best parts were brought,
the materials, from what i can see).
Removable, washable Trileon™ insole, non-marking, slip-resistant outsole
Ultra lightweight, a pair in size 10 weighs just 1.6 lbs. (that is per pair !)
*Welcome to Soft Science. one of our Podcast sponsors. Because we believe in them.
Update one day later:
Some have been asking about this shoe. I
think they have done something unique here. This shoe is about 6 oz,
yes, that is seriously uber light. That means there is no room for
stabilizing rigidity factors in this shoe. It appears to be a well
thought out “outsole” and a soft cotton canvas upper. That is it. If you
need control, this shoe may not be for you. The outsole however offers a
nice wide foot print with some flare of the sole out from the foot
(look at their website, look at the shoe from behind), and that in
itself offers stabilizing over something compared to like a glove type
shoe.
Now, on to the insole:
I know what the website says, a
“minimal heal to toe elevation”. I emailed the guru over as Soft
Science. I have been told they are zero drop and after wearing i believe
they are, and if not, maybe a millimeter ? I have sensitive feet, I
wear zero drop all day long at work because I can. Not everyone can and
this is important to note.
I do not have any info outsole thickness
of this particular shoe, the foot does recede somewhat into the outsole
that you see, so there is not a tremendous amount of stack height as
portrayed in photos, some of that is the outsole lipping up to grab onto
the shoe’s upper.
TRileon Insole:There is a VERY mild arch
contour, not as much as in crocs (as one person asked) but it is present
and mild. If you have a flatter arch, you will feel it, but, Trileon is
uber cush so it is not offending at all. If you have a normal arch
posture, you may not even notice it, it is that subtle.
Insole:
there feels like a 1-2 degree or 1-2 mm varus forefoot post, i have
pretty sensitive feet and can tell these things readily, i may choose to
grind this down on the insole, it wouldn’t take much to do this. If you
take out the insole and put it on a hard floor and stand on it, you
will notice the subtle forefoot varus posting of the foam. And if you
put the insole in your hands and pinch finger tips together at the 1st
metatarsal head and 5th met. head you will notice the thickness
difference. * It is not much, but it is there. Some people can really
benefit from it since many feet are have a slight FF varus. Some may not
notice it at all. I did notice it because my forefoot is not varus’d at
all. I noted it less so when the insole was in the shoe so it may be
off setting a slight depression in the outsole shell. I am not sure, so
do not quote me on this. For most folks, this is “princess and the pea”
subtle jibber jab talk and is not worthy of noting. But we are shoe
geeks and some of you want to know about peas.
To be clear, I like
this shoe so far, very much actually. It will be on my feet all week and
all weekend……..many weekends. Soft, uber light, no break in, zero
drop, good looks, minimal, wide platform, ….. things i like and things
that are important to me. The question is, “is it for you ?” That is up
to you. Nice work Soft Science.
-Dr. Allen
Great, FREE FULL TEXT article on the hip.
an EXCELLENT review with some great rehab tips at the conclusion like this
“Once isolated contraction of the deep external rotator muscles
is successfully achieved, progression can be made to the
rehabilitation of secondary stabilisers and prime movers of the
hip, particularly the gluteus maximus, initially using nonweight
bearing exercises and progressing to weight bearing
exercises once motor control and strength allows. Pre-activation
of the deep external rotators may make these exercises
more effective. Deficits in flexibility and proprioception
should also be addressed at this stage. Once adequate hip muscle
strength and endurance is achieved, functional and sports
specific exercises can then be implemented. ”
Can local muscles augment stability in the hip?: A narrative literature review T.H. Retchford, K.M. Crossley, A. Grimaldi , J.L. Kemp, S.M. Cowan J Musculoskelet Neuronal Interact 2013; 13(1):1-12
http://www.ismni.org/jmni/pdf/51/01RETCHFORD.pdf
image from: https://www.researchgate.net/…/258427127_fig12_Fig-11-Anato…
A test question from Dr. Allen, see how you do with this photo critical thinking.
When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface.
Here is the game … to keep the pelvis level on the horizon, one would have to:
a. shorten the water side leg
b. lengthen the water side leg
c. pronate the water side leg
d. supinate the water side leg
e. lengthen the beach side leg
f. shorten the beach side leg
g. pronate the beach side leg
h. supinate the beach side leg
i. externally rotate the water side leg
j. internally rotate the water side leg
k. externally rotate the beach side leg
l. internally rotate the beach side leg
m. flex the water side hip
n. extend the water side hip
o. flex the beach side hip
p. extend the beach side hip
******Ok, Stop scrolling right now !!!!!
List all the letters that apply first.
You should have many letters. *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.
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don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.
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Answer: B, D, F , G, I ,L , N, O
* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.
ok, we were messing with ya on the Beatles thing. Sorry.
Dr. Shawn Allen
The Pitfalls of Motion Control Features.
Welcome to Monday, folks. Today Dr Ivo discusses why not all shoes are created equal and why you need to understand and educate your peeps about shoes!
Internal tibial torsion is when the foot is rotated internally with respect to the tibia. When the foot is straight (like when you are walking, because the brain will not let you walk too internally rotated because you will trip and fall), the knee will rotated OUTSIDE the saggital plane (knee points out). Putting a medially posted shoe on that foot rotates the foot EVEN FURTHER laterally. Since the knee is a hinge joint, this can spell disaster for the meniscus.
need to know more? email us or send us a message about our National Shoe Fit Program.
Yes, Virginia. Dizziness and Vertigo are costly
I had a Parkinson’s pt that came in this morning and had fatigue (more than usual) related to a recent onset of dizziness. He was trying to figure out why and It got me to thinking about the metabolic costs of disequilibrium.
A quick pub med search found me having to try multiple search terms and all I was able to turn up was a few papers on the topic. I found that surprising, considering the prevalence of fatigue complaints with dizziness and vertigo.
It makes sense to think of as proprioception is impaired (or altered), it would have a greater energy cost to get normal tasks done. I was able to turn up a few full text papers (below), and yes, the short answer is it does cost more to have impairment.
Gait Posture. 2015 Feb;41(2):646-51. doi: 10.1016/j.gaitpost.2015.01.015. Epub 2015 Jan 24.Metabolic cost of lateral stabilization during walking in people with incomplete spinal cord injury.Matsubara JH1, Wu M2, Gordon KE3.
Arch Phys Med Rehabil. 2013 Nov;94(11):2255-61. doi: 10.1016/j.apmr.2013.04.022. Epub 2013 May 20.Effect of balance support on the energy cost of walking after stroke.Ijmker T1, Houdijk H, Lamoth CJ, Jarbandhan AV, Rijntjes D, Beek PJ, van der Woude LH.
Dragging your tongue ? When the tongue of your shoe keeps getting pulled to the side. Do you know what it means ? It means plenty, if you are sharp.
By: Dr. Shawn Allen
This one pisses off most people it happens to. Why does it typically happen only on one side, on one shoe ? Look at the photo case above. Look closely to the left foot, the tongue of the shoe is pulled laterally compared to the right, or shall I say, dragged.
This is a fairly common phenomenon, and there is a reason for it, several actually. So, no, you do not need to staple the tongue to the shoe upper, or tighten your shoe laces, or stitch the tongue to the medial shoe upper. You need to stop externally spinning your foot in your darn shoe. What ?!
Yes, you very well may be avoiding normal internal rotation progression of the pelvis over the fixated limb. Loss of internal hip rotation is often a common finding clinically. As one passes the swing leg forward, the forward progressing pelvis eventually meets this loss of internal rotation over the fixated leg and femoral head. The swing leg none the less progresses further forward to get to its’ heel strike and the stance phase leg has to externally spin over the ground (I like to give the analogy of putting out a cigarette butt on the ground or squishing a bug (PETA don’t come after me)). This is called an Abductory or Adductory twist (good video demo here) depending on whether your reference point is the forefoot or rear foot. Regardless, the heel is spinning inward, the forefoot is relatively spinning outward. This spin of the foot inside the shoe (this happens minutely just before the shoe spins on the ground) and pulls the tongue laterally with it.
This problem can also come from, and often does, a premature heel rise from things like a:
- loss of ankle rocker
- short calf
- lack of hip extension
- hallux rigidus / limitus or even a painful big toe
- etc
There are even several other causes I will not list here today, I could have you waste your whole day on the list and the mental gymnastics of things to consider. Basically, anything that impairs the stance phase mechanics creating a premature heel rise or failure of completing internal hip rotation can cause an Abd/Adductor twist of the foot/heel and drag the tongue laterally. Sure, there are others, but the purpose of my blog post here today was to explain a neat little biomechanical phenomenon that has huge clinical insight if you know what it means. You cannot fix this problem if you do not do a physical exam, understand clean and faulty gait biomechanics, and maybe can even find small objects in a dark room. What I mean is it takes some educated exploration and a curiosity to want to fix things.
There are clues often right in front of you, all you have to do is pay attention and sometimes ask a simple question.
“Mr. Jones, when you stick out your tongue, does it drag laterally ?”
Ok, maybe not that exact question. But, when I see a loss of internal rotation or terminal hip extension in a runner, and when I have time to explain things deeply with a openly receiving client, I might start the conversation with that fun question and then explain what I really meant was the tongue of the shoe on that affected side.
You can’t swallow bandaids to fix things, as much as you wish it was that easy. Sure, you can avoid all of this fun by buying a shoe that has the tongue of the shoe sewn to the medial upper of the shoe, but then you wouldn’t have to fix anything. Where would you “get your fun on” then ? Be brave, go all in, fix the problem dammit.
These are the things that keep me up at night. Welcome to my nightmares.
Dr. Shawn Allen, one of the gait guys
Photo courtesy of this weartested.org link: http://weartested.org/wp-content/uploads/2015/03/altra-superior-2-top-socks.jpg
Why is that muscle so tight?
We often think of neurological reasons (increased facilitation of the agonist, decreased reciprocal inhibition of the antagonist, increase gamma drive, etc), but how about the series elastic element (ie the connective tissue)? Or perhaps the sarcomere (individual contractile unit of the muscle)? How can we fix that? It is easier than you thought!
An oldie but a goodie. A great FREE FULL TEXT paper on sarcomere loss and how to prevent it. Yep, would you have guessed static stretching? Yes, this study was on mice and it seems plausible that it would be applicable to humans as well.
“When muscle is immobilised in a shortened position there is both a reduction in muscle fibre length due to a loss of serial sarcomeres and a remodelling of the intramuscular connective tissue, leading to increased muscle stiffness. Such changes are likely to produce many of the muscle contractures seen by clinicians, who find that such muscles cannot be passively extended to the full length, which normal joint motion should allow, without the production of muscle pain or injury.…These experiments show that in addition to preventing the remodelling of the intramuscular connective tissue component daily periods of stretch of ½ h or more also prevent the loss ofserial sarcomeres which occurs in mouse soleus muscles immobilised in the shortened position.”
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1004076/pdf/annrheumd00439-0044.pdf
link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1004076/pdf/annrheumd00439-0044.pdf
A great, quick read from one of our fav’s: Dr Tom Michaud.
Here is my favorite excerpt. I had not thought of imaging the ankle quite this way
“Physical examination reveals pinpoint sensitivity over the anteromedial capsule. When the ankle is slightly plantarflexed, the osteophytes on the talus and tibia can be readily palpated. Surprisingly, lateral X-rays only identify approximately 40 percent of the talotibial spurs, because the natural torsion of the distal tibia obstructs direct visualization of the anteromedial tibia. To improve radiographic accuracy, van Dijk, et al., recommend oblique radiographs be taken with a 45-degree craniocaudal angle, with the lower extremity externally rotated 30 degrees. The authors demonstrated that oblique radiographs identify 73 percent of the spurs located on the talus and 85 percent of the spurs located on the distal tibia.”
Where your gait might break down.
/Gait appears most robust to weakness of hip and knee extensors, which can tolerate weakness well and without a substantial increase in muscle stress. In contrast, gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors. - van der Krogt
In the past few weeks I have shared my thoughts on some articles regarding low back paraspinal musculature fatigue and the subsequent effects on motorneuron pools, specifically excitability of the soleus and quadriceps. These shared thoughts are from recent papers in the literature (search the blog over the last week). These effects are suggested to indicate a postural response to preserve lower limb function. In other words, as paraspinal fatigue set in, lower extremity muscle compensation ramped up to sustain postural locomotion demands. Obviously, one should think this a step further and translate it all into questions of assessment of ankle dorsiflexion (ankle rocker) and control of progressing knee and hip flexion when pertaining to these muscles. The issues of stability and mobility should heighten. The one big problem in these studies, and you have even likely had these thoughts during your clinical examinations, is that one cannot truly fatigue one muscle group alone especially during activity, nor can one assess a single muscle group during manual testing. Luckily we have EMG testing capabilities in this day and age and we can more easily look into the function and reaction of a muscle and its’ direct response reactions.
Today I have an article by van der Krogt that we read long ago, but that which one of our readers brought back into our wheelhouse. This is pretty amazing stuff.
“This study examines the extent to which lower limb muscles can be weakened before normal walking is affected. We developed muscle-driven simulations of normal walking and then progressively weakened all major muscle groups, one at the time and simultaneously, to evaluate how much weakness could be tolerated before execution of normal gait became impossible. We further examined the compensations that arose as a result of weakening muscles. Our simulations revealed that normal walking is remarkably robust to weakness of some muscles but sensitive to weakness of others. Gait appears most robust to weakness of hip and knee extensors, which can tolerate weakness well and without a substantial increase in muscle stress. In contrast, gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors. Weakness of individual muscles results in increased activation of the weak muscle, and in compensatory activation of other muscles. These compensations are generally inefficient, and generate unbalanced joint moments that require compensatory activation in yet other muscles. As a result, total muscle activation increases with weakness as does the cost of walking.“-van der Krogt
So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles. You may want to consider which muscles are, according to this article, most robust and sensitive to weakness. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. Today’s article seemed to confirm that this muscle group is sensitive to weakness. In today’s discussion, not only is the impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) possibly related to low back pain, in this case, paraspinal fatigue but it may be a muscle group robust to weakness which is a darn good thing when the paraspinals go to nap.
Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If this is all too much for you, in teasing out this quagmire of a system, just throw corrective exercises at your client and hope for the best. What is the worst that can happen if you get it wrong ? Stronger compensations on already present compensations … . . why not, it is good for return business (insert sarcasm emoticon). But, lets be honest, if it was easy everyone would be doing it the right way. But the truth is that it is a long journey, and we are on the same bus of discovery with you all.
Dr. Shawn Allen, one of the gait guys.
Reference:
Gait Posture. 2012 May;36(1):113-9. doi: 10.1016/j.gaitpost.2012.01.017. Epub 2012 Mar 3.How robust is human gait to muscle weakness?van der Krogt MM1, Delp SL, Schwartz MH.
Low back pain and quadriceps compensation. A study.
/“Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.“- Hart et al.
Recently I discussed a paper (link below) about how soleus motoneuron pool excitability increased following lumbar paraspinal fatigue and how it may indicate a postural response to preserve lower extremity function.
Today I bring you an article of a similar sort. This paper discusses the plausibility that a relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation and the subsequent changes in hip and knee function when running fatigue ensued.
"Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.”- Hart et al.
Whether this or any study was perfectly performed or has validity does not matter in my discussion here today. What does matter pertaining to my dialogue here today is understanding and respecting the value of the clinical examination (and not depending on a gait analysis to determine your corrective exercise prescription and treatment). When an area fatigues and cannot stabilize itself adequately, compensation must occur to adapt. Protective postural control strategies must be attempted and deployed to stay safely upright during locomotion. The system must adapt or pain or injury may ensue, sometimes this may take months or years and the cause is not clear until clinical examination is performed. Your exam must include mobility and stability assessments, motor pattern evaluation, and certainly skill, coordination, ENDURANCE and strength assessments if you are to get a clear picture of what is driving your clients compensation and pain.
So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles and bash them and other similar ones into your brain. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. In today’s discussion, impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) may also be related to low back pain, in this case, paraspinal fatigue.
Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If only it were as simple as, “you need to work on abdominal breathing”, or “you need to strengthen your core”. If only it were that simple.
Dr. Shawn Allen, one of the gait guys
References:
J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.
Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain. Bunn EA1, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.
J Electromyogr Kinesiol. 2009 Dec;19(6):e458-64. doi: 10.1016/j.jelekin.2008.09.003. Epub 2008 Dec 16. Jogging gait kinetics following fatiguing lumbar paraspinal exercise.
Hart JM1, Kerrigan DC, Fritz JM, Saliba EN, Gansneder B, Ingersoll CD
