Trampoline gyms are fun but risky places. It is fun leaping like spiderman from one trampoline to the next.
But, Foot placement from such a height onto a pliable sloped surface (ie. if you do not hit the next trapoline smack dab in the center) is just a bad place to load a foot. Hence the foot that i saw today in the office, 4 weeks post talus and forefoot dislocation, complete, as you can see here. Oy, no trampolines for my peeps. Nope. Never.
When the ankle lies to you.
Yesterday I saw something I see quite often. It was a client with dorsal foot pain, nothing shocking. But, this client had plentiful ankle dorsiflexion on the table during examination but when they walked, there was barely any use of ankle dorsiflexion-ankle rocker. Heel rise was premature.
It once again proves that just because you have it, doesn't mean it is available to be used. There was adequate hip extension and glute strength so it wasn't coming from there, though that is a frequent source. The examination was detailed, but to keep it brief here today, this client, had decent strength about the ankle from what could be determined, but they failed the hop test, control was terrible, and they could tell. Once again, if you cannot control the joint under load, the body will often not give you the full range, merely out of self preservation mode to protect the joint. This client was attempting to get more ankle rocker motion via arch collapse and over pronation to get the tibia to progress forward enough for normal gait. The collapse was causing a dorsal impingement on the foot. Lots more to come on these ideas in future posts.
None the less, it is a good lesson to all those people out there that think that everyone just needs more ankle rocker strength and range of motion. The truth is, not everyone does, and forcing it in some will cause them pain or problems or compensations . . . . and that is your fault if it is the case.
-Dr. Allen
The buck doesn't stop here..
image from: http://www.aofas.org/footcaremd/treatments/pages/triple-arthrodesis.aspx
One of the most pervasive problems following a ankle arthrodesis, particularly a triple arthrodesis which involves fusing the subtalar (talocalcaneal), calcaneocuboid , and talonavicular joints results in a loss of ankle rocker. The "buck" needs to be passed somewhere and this usually will mean proximally in the lower kinetic chain.
Seeing adjacent joints with osteoarthritic changes following hypomobility have another joint is nothing new; you probably see it all the time in practice. Remember that it is not always have to be a "fusion". Simple longstanding pathomechanics or longstanding hypomobility will often cause the same problems.
A nice, full text referenced review 1 of her favorite journals. Some nice side discussions as well. Enjoy : )
"Altered biomechanics after ankle arthrodesis often increase stress on the adjacent joints in the foot, which can cause or exacerbate osteoarthritic degeneration in those joints. Clinicians and researchers are working to better understand this process and how to minimize patients’ risk."
http://lermagazine.com/…/adjacent-joint-arthritis-after-ank…
#anklemobility #anklerocker #triplearthrodesis #hypomobility
A nice study looking at how sequential muscle activation patterns can change with dry needling. Think about the applications for gait?
"Removing LTrPs changes the order of muscle recruitment to a more sequential, stable pattern that is not significantly different to that displayed by the control group prior to fatiguing exercise. This suggests that removing LTrPs may allow subjects to better cope with the effects of fatigue, as evidenced by the reduced variability in activation times and the reduced co-activation of the muscles investigated. "
FREE FULL TEXT here: https://isbweb.org/images/conf/2003/longAbstracts/LUCAS_198-208_SB_LONGE.pdf
Regardless of the mechanism, dry needling and ischemic compression both seem to reduce myofascial pain. How about some more studies looking at muscle function and activation patterns?
"This study compared these treatment techniques to one another using the Neck Disability Index (NDI), a numeric rating scale (NRS), pressure pain threshold and muscle characteristics. 42 female patients with myofascial neck pain were randomly assigned to a treatment group and the 4 most painful MTrPs were treated using DN or MPT. No difference was found between the two techniques on the short and long term. Both techniques showed an improvement in NDI on the short and long term. "
Dry needling or manual pressure in myofascial pain? - Anatomy & Physiotherapy
The aim of this study was to compare dry needling to manual pressure in patients with myofascial pain.
ANATOMY-PHYSIOTHERAPY.COM|BY <A HREF="/AUTHORLIST/3:JOANNA1988" TITLE="VIEW ALL ARTICLES FROM JOANNA TUYNMAN">JOANNA TUYNMAN</A>
There is a paradoxical idea that the fitter someone is, the more likely they will experience respiratory limitations. This referenced article today suggests that every endurance athlete "has their own limit in endurance training", and that once exceeded it will produce all the possible respiratory disorders discussed in the article.
This article suggests there is a debate in the scientific community as to whether the lung can be defined “overbuilt” or “underbuilt” for facing strenuous exercise. In the ideal scenario, your athlete will have a respiratory system perfectly tailored to meet their body’s metabolic demands under normal conditions. However, it is when challenged by demand, whether that be intensity of exertion, environmental challenges or underlying physical pathology where limitations can impact the athletes demand and performance, thus, a pathological response can occur in a seemingly healthy athlete.
Breathing, how to do it right, how you are doing it wrong. It is all over the internet these days and there are so many "experts" teaching it now. Some are also teaching it and diaphragm "activation" as the answer to every ailment you have, including why you received a "B minus" grade on your 6th grade spelling test.
Make no mistake, how to breath properly is important. But, like much of the work Ivo and I do, and much of the preaching we do here on The Gait Guys is about getting to the root of the problem. Converting someone to diaphragmatic breathing from a thoracic cage breathing pattern (use whatever nomenclature you wish, we are trying to keep it simple here) is important, but not as important as finding out why someone is doing it. So are you looking deep enough? Are you asking the right questions before you just assume they forgot how to abdominally breathe ? All to often we have our clients and athletes come in with their newest epiphany from their latest alternative "guru". Lately is it is, "my yoga/pilates/trainer/coach/bodyworker/massage therapist etc showed me how to belly breathe and use my diaphragm properly ! All is going to be ok now ! Everything will now be right in the world !" However, all to often they fail to realize that all of the things this article delves into, not including the obvious things such as posture, thoracic spine mobility and stability, prehension patterns, workout habits, soft tissue tension/shortness/tightness, muscle weakness, motor pattern aberrancies, etc these are all just a piece of the potential "causes" of the breathing choice and problems. Fixing the problem helps to allow the natural breathing pattern to occur, with some helpful correction and re-education of course.
There is a paradoxical idea that the fitter someone is, the more likely they will experience respiratory limitations. One's respiratory abilities as an athlete must be built up, just like any other component of their training. The lungs must be trained to satisfy the metabolic demands of the system, however, often their are parameters existing that are outside of the athletes training efforts. Ask any athlete who jumps into altitude training and this becomes painfully apparent. Endurance athletes do die, thankfully not very often, but they do die and it is not always directly from sudden cardiac failure. There is often a reason the endurance athlete dies shortly after the event, not during, when the physical exertion was actually occurring. Think about it. Exercise-induced respiratory disorders do exist in athletes and they are often the limiting factor in excelling physically. Ask any runner who has done a cold weather run, they will often be able to describe the thermal stress of cold air inhalation and dehydration. This is airway cooling followed by rewarming cycle. The coldness triggers a parasympatheic driven brochoconstiction and a vasoconstriction of the brochial venules. Subsequent rewarming follows and the opposite happens, followed by mucosal edema.
This article proposes: "the question is precisely to understand if there is a limit in terms of intensity and/or in terms of duration in years to endurance training, before respiratory disorders can appear, and if we can apply any preventive strategies. To be an endurance champion, this inevitably means accepting all the labors of strong training but also enduring all possible health problems caused by the same."
There are many factors to consider, asthma, exercise induced asthma, temperature intolerance to cold or warm weather, a sensitive bronchial tree, long time smoker, prior smoker, medications, bronchospasms, reduced ventilation abilities, pulmonary edema, allergies . . . the list goes on an on, read the article.
One must consider all of those cardio-respiratory limiting pathologies, but, do not forget posture, faulty breathing technique, tight scalenes and pectorals, weak abdominals, poor thoracic rotation and extension, faulty arm swing, protracted shoulders and the list goes on. And, even more so, think of all the things we do when we started getting "winded" as an athlete, we move into more chest wall breathing, tap into the accessory respiratory muscles and all the pathologic patterns that go with it. We begin to struggle, first subtly, then more profoundly until we must stop. Now, do that several times a week and see what happens to your breathing habits. Respiration in the sedentary and in the athlete is a real issue, but it is multifactorial and complex. It is more than, "Mr. Jones, please lie down. I am now going to teach you to abdominal breath and use your diaphragm correctly (because I just went to a seminar) and all of the stars will align and your next born child will become the next Michael Jordan." Don't be that guy/gal.
Breath deep my friends.
Have a read of the referenced article , it should open up your world as to how complex this machine truly is.
-Dr. Shawn Allen, the other gait guy
Reference:
Respiratory disorders in endurance athletes – how much do they really have to endure?
Maurizio Bussotti, Silvia Di Marco, and Giovanni Marchese
Open Access J Sports Med. 2014; 5: 47–63.
Published online 2014 Apr 2. doi: 10.2147/OAJSM.S57828
Have you heard of Asymmetrical Tonic Neck Reflexes? 1st described by Magnus and de Kleyn in 1912, when the head is rotated to one side, there is ipsilateral extension of the upper and lower extremity on that side, and flexion of the contralateral (the side AWAY from where you are rotating) upper and lower extremity. Take a few minutes to see the subtleness of the reflex in the picture above. Now think about how this occurs in your clients/patients. The reflex is everywhere!
This reflex often persists into adulthood and is modulated by both eye movement and muscular activity. When there is neurological compromise, the reflex can be more prevalent, and it appears to arise from the joint mechanoreceptors in the neck and its connection to the reticular formation of the brainstem.
Let’s say you want to improve hip extension on the right:
actively looking with the eyes to the right and rotating the head to the right facilitates the right tricep, quadricep and glute max and facilitates the left bicep, hamstring and iliopsoas
We remember while walking, that the left arm is tied to the right lower extremity neurologically. If you were to rotate your head to the right, you will facilitate extension of the right hip, extension of the right upper extremity (and flexion of the left arm/shoulder and left lower extremity). So, simply put, be like Robocop or the Terminator and rotate your head to the right while your right leg is extending.
Note that the upper extremity is opposite of what we would want to get out of the reflex to take full advantage so you can:
Why not try all 3 and see what works best for you and your patient/client?
The Gait Guys. Giving you info you can use in a practical manner, each and every post. Be a gait geek. Spread the word.
http://www.worldneurologyonline.com/article/arthur-simons-tonic-neck-reflexes-hemiplegic-persons/#sthash.6QS3Eat3.dpuf
Bruijn SM1, Massaad F, Maclellan MJ, Van Gestel L, Ivanenko YP, Duysens J. Are effects of the symmetric and asymmetric tonic neck reflexes still visible in healthy adults?Neurosci Lett. 2013 Nov 27;556:89-92. doi: 10.1016/j.neulet.2013.10.028. Epub 2013 Oct
Le Pellec A1, Maton B. Influence of tonic neck reflexes on the upper limb stretch reflex in man. J Electromyogr Kinesiol. 1996 Jun;6(2):73-82.
Michael D. Ellis, Justin Drogos, Carolina Carmona, Thierry Keller, Julius P. A. Dewal Neck rotation modulates flexion synergy torques, indicating an ipsilateral reticulospinal source for impairment in stroke Journal of NeurophysiologyDec 2012,108(11)3096-3104;DOI: 10.1152/jn.01030.2011
Key tag words:
ankle rocker, hip extension, z-angle, parkinson's disease, ankle dorsiflexion, movement patterns, marathons, brain function
Website link: www.thegaitguys.com
Podcast links:
http://traffic.libsyn.com/thegaitguys/118ff.mp3
http://thegaitguys.libsyn.com/podcast-118-the-z-angle-ankle-hip-function
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That is our website, and it is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Show Notes:
Movement disorders in the news:
Parkinson's linked to gut bacteria
http://www.cnbc.com/2016/12/01/parkinsons-linked-to-gut-bacteria.html
Young runners have stronger brain connections
http://www.futurity.org/running-functional-connectivity-1317802-2/
Increasing muscle strength can improve brain function: study
http://www.psypost.org/2016/10/increasing-muscle-strength-can-improve-brain-function-study-45575
A sub-two-hour marathon, once seen as ‘impossible,’ could happen much sooner than experts thought
https://www.washingtonpost.com/news/early-lead/wp/2016/12/13/a-sub-two-hour-marathon-long-seen-as-impossible-could-happen-much-sooner-than-experts-thought/?utm_term=.c7d161d6c2c5
Ankle rocker, z -angle, etc
When driving more ankle dorsiflexion could get you into trouble
More is not alway better, too much of a good thing at some point stops being good.
Foot slap / Foot drop........there is a difference
What could be its sources ?
Open dialogue
Stick on sweat monitor
http://www.popsci.com/stick-on-sweat-monitor-would-warn-you-when-youre-getting-dehydrated
As the viewer should note in the video, the right knee is undergoing a sudden abrupt varus (lateral) shift during the gait loading response. The tib-femoral joint is a sagittal hinge, not a frontal-lateral plane hinge, so this is clearly pathomechanical movement. This knee will likely undergo premature knee cartilage and meniscal degeneration.
However, there are other thoughts and considerations here. The big question is, likely, how did this happen and what is wrong ? The cause of this issue is likely more simple than complicated however there may also be multiple factors coming together in a perfect storm. However, make no mistake, in order to understand a varus thrust gait, one has to understand the why and how of the gait presentation. Additionally, one must have a clinical knowledge of the restraining systems of the knee, both active and passive, and have a high degree of clinical suspicion and working knowledge of how to assess for these types of problems.
Things to consider:
- old ACL/PCL and posterolateral corner damage (read this post here, link)
When the posterolateral corner complex of the knee is torn up from a blow to the knee or a torsional loading failure, the 3 components of the posterolateral corner (the lateral collateral ligament (LCL), the popliteal tendon, and the popliteo-fibular ligament complex). This complex attaches just in front of the origin of the lateral gastrocnemius tendon off the lateral femoral epicondyle. This complex can be blown out from either a PCL or ACL injury mechanism, these big player ligaments are rarely torn in isolation.
- is there a Pivot Shift phenomenon, likely. A positive Pivot Shift test will be present. One must know how to perform this test to confirm its presence, it can be a tricky test if one does not know the load vectors to apply and what the shift feels like and where it occurs during the test. This can be a very subtle positive test, again, first hand experience is everything.
- one must find this before surgery occurs for the ACL or PCL. Failure to find and address this damaged complex will likely result in rotational stability problems once return to play occurs. IT will not likely be noted in the initial post-operative months as the aggressive loading response will not be performed early on. Failure to address this problem will likely put ACL-PCL reconstruction success at a high risk.
Other critical factors to consider in the Varus Thrust Gait:
- is there medial knee osteoarthritis ?
- what is the foot type and what are the mechanics ? ie. Forefoot varus, Forefoot supinatus, rearfoot variances
- does the patient have excessive pronation challenges that create massive internal spin into the tibia ?
- is the hip frontal and rotation plane stable? Can the patient adequately control rotation at the hip level ?
- is there a Cross Over gait phenomenon with narrow based step width ? (search our blog and youtube for "gait guys crossover gait"). A narrow step width will create an "unstacked" limb and promote more rotational risk into the limb, often playing out at the least tolerable joint to rotation . . . the knee.
- Does the client have Tibial Varum ? Genu Varum, Genu Valgum ? These can promote and complicate the Varus Thrust gait.
- Does the client have Tibial torsion or Femoral Torsion variants ? These can promote and complicate the Varus Thrust gait.
- is there weakness of the lateral gastrocnemius or biceps femoris (to name just two the directly cross over this posterolateral interval and can offer joint compression/stability ? What about weaknesses in the medial leg ? Not that these are anywhere sufficient to offset a PLRI (posterolateral rotatory instability), but, they are secondary helpers/restraints.
One should clearly see now that the Varus Thrust gait is potentially complicated and multifactorial. One MUST understand:
1. many components of normal gait and normal anatomy from foot to pelvis, at least.
2. be able to assess for aberrant mechanics and pathologies within all joints of the lower limb
3. be able to assess for post operative rotational stability and laxity (*even a healed, yet partially attenuated, Posterolateral corner complex that was not noted or addressed in the ACL-PCL reconstruction can come back to haunt even the best reconstruction. Those little rotational instabiliites will build over the years and render attenuation of the other secondary posterior restraints in the knee. Like a Lisfranc injury, sometimes things take a few years to brew and blossom before the "career ender" instability shows up. Trust us, we have seen it enough times.
Rule: if one does not know it exists, one will miss it. If one does not know how to assess it, one will miss it. If one does not know normal anatomy, torsional variants, foot types and gait types, one is likely to be lost and left fumbling. Our clients deserve more.
Dr. Shawn Allen
Varus Thrust and Knee Frontal Plane Dynamic Motion in Persons with Knee Osteoarthritis. Osteoarthritis Cartilage. 2013 Nov; 21(11): 1668–1673. Published online 2013 Aug 12.
Alison H. Chang, PT, DPT, MS, Joan S. Chmiel, PhD, Kirsten C. Moisio, PT, PhD, Orit Almagor, MS, Yunhui Zhang, MS, September Cahue, MPH, and Leena Sharma, MD
Compliance is often the issue ...especially in younger folks
Just say no to the exercise video. You need:
a nice review article in LER, full text here
additionally, this was covered in a great PODcast by David Pope here: http://physioedge.com.au/physio-edge-039-patellofemoral-pain-adolescents-dr-michael-rathleff/
Neuro Hack of the Week.
Did you see our Facebook post on Monday of this week about children with autism spectrum disorder, physical exercise and rehabilitation, and improved learning scores? If so, this short piece while have much more meaning. If not, if you take time to go back and read it now, this will have more meaning.
Try this at home
Sit down in a comfortable place and take a book off of the shelf which has a moderate amount of complexity to it. Open the book to any page and start a recorder (on your phone or with a dictaphone/tape recorder if your are old school). Begin reading and record your voice for approximately 1 minute.
Now standup on 1 leg in a place where you won't fall down. Open the book to a different page, start the recorder, and read for approximately 1 minute.
Go back and listen to both recordings. What did you hear? Pay attention to things like the flow of words left (called prosody), enunciation, pronunciation, and comprehension. How much do you remember for the first versus the second reading?
We have just witnessed the power of the cerebellum and it is implications in learning. If learning has a proprioceptive component, you will generally have a better understanding, better comprehension, and better pronunciation. This is why few years ago when they did that study and schools and replaced kids desks with bicycles fitted with a desk attached to it, their test scores soared. (see here https://www.fastcoexist.com/3036607/this-school-has-bikes-instead-of-desks-and-it-turns-out-thats-a-better-way-to-learn)
When you need to learn something, stand up, walk around, balance on 1 leg, use a bosu ball, rocker board etc. Do the same with your patients. He will get much more of it, it will take last time, and your outcomes will improve.
Just a little neuro hack from The Gait Guys
Take a good look at the above 2 slides.
Notice that, during pronation, there is a medial rotation of the lower leg and thigh. We remember that, during pronation, the talus plantar flexes, adducts, and everts. This anterior translation and medial rotation of the talus causes the tibia and subsequently the femur to follow. This, if everything is working right, results in medial rotation of the knee.
From the slides, it should also be evident that the medial condyle of the femur and a medial tibial plateau are larger than the lateral. This allows for an increased amount of internal and external rotation of the knee. We remember that the meniscus, like a washer, is between the tibia and femur. We if you think about this kinematically, it would make sense that the tibia, during pronation (which occurs from initial contact to mid stance) would have to rotate faster than the femur otherwise the meniscus would be caught "in between". If there is a mismatch in timing, the meniscus is "caught in the middle", which causes undue stress and can cause fraying, degeneration, etc.
Likewise, during supination (from mid stance to pre swing) the femur must externally rotate faster then the tibia, otherwise we see this same "mismatch". This is a scenario we commonly see in folks who over pronate at the mid foot and remain in pronation for too omg a period of time.
We think of pronation as being initiated from the movement described above by the talus, and it is attenuated by the popliteus muscle as well as some of the deep flexors of the foot, which fire mostly during stance phase. You will notice that the popliteus is eccentrically contracting at this point.
Supination, initiated by swing phase of the opposite leg and momentum, is assisted by concentric contraction of the popliteus muscle, internal rotation of the pelvis on the stance phase leg, contraction of the vastus medialis, deep flexors of the foot and peroneii.
Taking moment to "wrap your head around" this concept. Now you can see how complicated it can be when we started to throw in femoral and tibial torsions as well as possibly some orthotic therapy. For example, in an individual with internal tibial torsion, if you do not valgus post the forefoot of the orthotic, the knee is placed at outside the sagittal plane in external rotation further by the orthotic and this thwarts the function of his mechanism, leaving the meniscus holding the bag.
Know your anatomy and know what is supposed to be firing when, your patients and clients knees depend on it!
Made famous in the beginning, first it was Alberto Salazar. Now, just in the last decade it has been Anna Frost, Anton Krupicka, Geoff Roes, Kyle Skaggs, even Mike Wolfe. One by one they have fallen, to OTS. More frighteningly, how many more have fallen to OTS that we never hear about? How many hundreds or thousands walking amongst us have OTS ? If you are a distance or heavy volume training athlete, do not brush off or take lightly what I have complied here today.
OTS, "Overtraining syndrome" is its name, but perhaps a better one would be "Insufficient Recovery Syndrome". To use the broadest of terms, this is a self-generated, self-perpetuating dis-ease of one's own homeostasis. To be clear, there is a continuum here of multi-system failure, softer less severe forms of OTS. These less damaged states are referred to as Overreaching syndrome (OR). There are two forms of Overreaching syndrome, Functional OR and Nonfunctional OR. Nonfunctional OR shows decreases in performance for weeks to months while OTS being more severe and requiring months to years for recovery despite rest.
Over the past 10 years the best of the best are falling, one by one, victim to "too much". They have just pushed themselves too much, too far, too long. It is the latest biggest thing in running these days, how far can you run ? Marathons are no longer enough for some, they have to see if 50 miles or 100 miles, or more, are enough and that means running 100-160 miles a week. And what is even more scary, some of these runners are in high school and college, they are still growing kids.
The physiology of these people is failing, truly. Some might suggest they in some respects showing signs of a slow death. “OTS is one of the scariest things I’ve ever seen in my 30 plus years of working with athletes,” says David Nieman, former vice president of the American College of Sports Medicine. “To watch someone go from that degree of proficiency to a shell of their former self is unbelievably painful and frustrating.” - Meaghen Brown Jun 12, 2015. Outside online.
The first reference in which OTS was suggested was by a researcher and athlete named Robert Tait McKenzie. In his 1909 book, Exercise in Education and Medicine, he mentioned a “slow poisoning of the nervous system which could last weeks or even months.” Then in 1985 South African physiologist professor Timothy Noakes discussed what appears to be the same condition in "The Lore of Running". Runners examined by Noakes had so over exerted themselves that both mind and body were failing.
OTS is truly a deeper problem. This is an immune, inflammatory, neurologic and psychological problem as best as anyone can tell. In essence it seems the body is slowly dying. The body's parasympathetic nervous system, the system that counteracts the ramping up of the sympathetic nervous system, fails to properly respond to bring the systems back into balance. This means that many of the physiologic responses to activity fail to properly return to baseline. This means that blood pressure, heart rate, breathing, digestion, adrenal and hormonal rhythms amongst many other things go awry. Even other important things begin to decline, things like normal restful sleep, sometimes even insomnia, libido decline, metabolism dysfunction, appetite problems and even heart rate recovery and recurrent colds and viral infections. We are talking about multi-system failure in these people, and this is serious business. The problem is, these athletes do not listen to the signals until it is too late and they are in full blown multi-system decline or failure.
Here is likely an incomplete list of things that might be slowing showing up, softly, one by one as multi-system failure ramps up:
- anemia
- chronic dehydration
- increased resting heart rate
- breathing changes
- digestive troubles , bowel troubles (ie. runners diarrhea)
- endocrine problems: adrenal and hormonal shifts
- insomnia and sleeplessness
- blood pressure changes
- libido changes
- metabolism and appetite changes
- recurrent colds and viral infections
- generalized fatigue
- muscle soreness
- recurrent headaches
- inability to relax, listlessness
- swelling of lymph glands
- arrhythmias
- depression (neurotransmitter dysfunction)
There is a way out of OTS. But, one has to wrap their head around the fact that one's goals and mental drive have pushed them to this point. This is one's own fault and they will have to take some hard advice and make some tough decisions, decisions they do not want to make, but ultimately will have no choice but to make. That means changing those goals and habits, otherwise this could get real serious real fast. And wrapping one's head around the toughest part will be the most painful part for most, many months of rest, sometimes a year or more, to fully recover if one hasn't done too much irreparable damage to begin with. Of course, the immediate course of action is to see a doctor. Hopefully, a doctor who is familiar with elite athletes and one that can rule out any other more serious immediate health concerns and disease processes that can mimic OTS and OR syndromes.
As with solving most problems, one has to first start to realize one is heading towards a problem, and accept responsibility. In this case, over training and under recovering. One must look at their habits, and the subsequent outcomes, and see if there are signs of impending problems and if so be willing to make behavioral changes. This is a hard thing for endurance athletes, because it is asking them to look at enjoyable, admittedly addictive, endeavors. Endeavors that have always improved many facets of their life, yet ones that have a double edged-sword nature to them which can very quickly chop down all the hard work that has been put in. Ultimately, the answer is balance, balance in all aspects of one's life. But, who is truly good with balance ? Very few of us I am afraid.
Dr. Shawn Allen, one of the gait guys
References:
Running on Empty By: Meaghen Brown Jun 12, 2015. Outside online.
https://www.outsideonline.com/1986361/running-empty
Sports Health. 2012 Mar; 4(2): 128–138.Overtraining Syndrome. A Practical Guide
Jeffrey B. Kreher, MD†* and Jennifer B. Schwartz, MD‡
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435910/
Med Sci Sports Exerc. 2013 Jan;45(1):186-205. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine.
Meeusen R, Duclos M, Foster C, Fry A, Gleeson M, Nieman D, Raglin J, Rietjens G, Steinacker J, Urhausen A; European College of Sport Science; American College of Sports Medicine.
Open Access J Sports Med. 2016; 7: 115–122. Published online 2016 Sep 8. Diagnosis and prevention of overtraining syndrome: an opinion on education strategies. Jeffrey B Kreher
Overtraining, Exercise, and Adrenal Insufficiency
KA Brooks, JG Carter
J Nov Physiother. Author manuscript; available in PMC 2013 May 9.
Published in final edited form as: J Nov Physiother. 2013 Feb 16; 3(125): 11717
Related citations:
https://scholar.google.com/scholar?ion=1&espv=2&bav=on.2,or.r_cp.&biw=1179&bih=705&dpr=1.5&um=1&ie=UTF-8&lr&cites=3025342060917260626
Attached is an older video from a few years back , it is very similar in execution to the heel-rise ball squeeze exercise which is the precursor to this more functional engagement as shown in this video today.
The important premise is that you have to have command of the entire posterior compartment if you are to get safe, effective, efficient and adequate ankle plantarflexion. As we have discussed many times, if you do not have the requisite skills as shown in this video you are in trouble and ankle sprains and other functional pathologies are not unlikely to visit you. Additionally, without requisite posterior compartment endurance and an ability to engage what I like to refer to as "top end" strength in the heel rise is an asymmetrial loading issue and can lead to compensatory adaptations up the kinetic chain. Make no mistake, the load will go somewhere, and thus the work will be done somewhere. In this video you should be able to clearly see and understand that one must be able to achieve top end posturing and have command of lateral and medial forefoot loading responses and challenges if clean forward function and power is to be achieved, and injuries from extremes of motion medially and laterally are to be avoided. Furthermore, as eluded to here and in several of our podcasts (and in the study included below), an inability to achieve top end posturing will lead to changes in forefoot loading, may spill over into endurance challenges prematurely in the posterior mechanism, and create changes in the timing of the gait cycle (things like premature or delayed heel rise, premature or delayed forefoot loading, recruitment of other components of the posterior chain just to name a few). This parsing and sharing of loads and responsibilities is laid out in the Kulmala study referenced today. The study could be extrapolated to say, I believe, that particularly in sprinting, a failure to achieve top end heel rise through effective posterior mechanism contraction, will change the load sharing between the posterior compartment and the quadriceps. After all, if the calf is weak, the ankle is not in as much plantarflexion, this could mean more knee flexion and thus raise demands on the quadriceps, logically changing knee mechanics. This is exactly why we spend so much time at every patient visit looking for full range of motion at the joints and then determine the skill, endurance and strength of the associated muscles in supporting that range. Then, of course, comparing this function to the opposite limb. Symmetry is not everything, but it is definitely a major factor in safe efficient and injury free locomotion.
* Please give great thought to the part in the video where I discuss the drop phase in jumping. All too often we at looking for the propulsive mechanics and forget that a failure there will also be represented during the adaptive phase. Ankle sprains rarely occur from propulsive pushing off, they occur from a failure to properly reacquaint the foot to the ground on the following step.
-Dr. Shawn Allen, one of the gait guys.
In this study the authors noted:
"During walking, the relative effort of the ankle extensors was almost two times greater compared with the knee extensors. Changing walking to running decreased the difference in the relative effort between the extensor muscle groups, but still, the ankle extensors operated at a 25% greater level than the knee extensors. At top speed sprinting, the ankle extensors reached their maximum operating level, whereas the knee extensors still worked well below their limits, showing a 25% lower relative effort compared with the ankle extensors."
And concluded that:
"Regardless of the mode of locomotion, humans operate at a much greater relative effort at the ankle than knee extensor muscles. As a consequence, the great demand on ankle extensors may be a key biomechanical factor limiting our locomotor ability and influencing the way we locomote and adapt to accommodate compromised neuromuscular system function."
Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189. Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles. Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.
https://www.ncbi.nlm.nih.gov/pubmed/27327033
Dr Ivo discusses a pediatric case and some treatment modalities
This paper looks at the concept or preloading motor neuronal pools. We have written about this before on the blog.
The Temporomandibular joint (TMJ) is blessed with many mechanoreceptors and receives innervation from Cranial Nerve V (trigeminal nerve) and the upper cervical spine. There is physiological overlap through the trigeminocervical nucleus (in the upper midbrain or mesencephalon, the principal sensory nucleus) which receives the same innervation from the trigeminal nerve distribution and the upper 4 cervical neuromeres(nerve levels) (so double input into same pathway). Nicoli Bogduk published abody of research on this, along with Susan Lord and Leslie Barnsley.
The upper 4 cervical nerve root levels also directly input into the flocculonodular lobe of the cerebellum (which coordinates alot of motor activity, especially of axial extensor muscles). This preloads the motor neuronal pool (just like contracting your muscle slightly, or clenching to get a better response from a reflex exam). By optimizing input (through a bite guard), you optimize mechanoreception, which optimizes cerebellar activity, which in turn pre loads the motor neuronal pool. You would get SIMILAR ( and better tasting!) results with having them clench or bite down on gum, though not as good due to possible imperfect mechanics.
We have not seen all of the research but we are sure it is legit. It’s like an orthotic for the mouth. Keep in mind changing bite mechanics closer to symmetrical occlusion will be helpful ( ie. Orthodontics, invisalign etc).
There you have it. Next time you want to get some extra performance, or are trying to accomplish an especially difficult exercise, try clenching hard to preload those neuronal pools.
Ivo and Shawn…Preloading your neuronal pools to make learning this stuff easier for you….one pathway at a time.
http://lermagazine.com/cover_story/mouthguard-mysteries-can-wearing-one-really-improve-athletic-performance
Especially in light of the Vastis lateralis acting as an internal rotator in closed chain?
"Foam rolling of the quadriceps muscle is associated with decreased biceps femoris activation, an effect that may be related to pain perception, according to research from the Memorial University of Newfoundland in St. John’s, Canada.
In 18 recreationally active individuals (eight women), the investigators used surface electromyography to assess vastus lateralis, vastus medialis, and biceps femoris activation during a single-leg landing from a hurdle jump under four foam-rolling conditions: application to the hamstrings only, the quadriceps only, both, and neither.
Biceps femoris activation was significantly lower for the conditions in which foam rolling was applied to the quadriceps. However, the reverse was not true: Foam rolling of the hamstrings had no significant effect on activation of either of the quadriceps muscles.
The authors hypothesized that the perceived pain associated with quadriceps foam rolling, which was significantly greater than that associated with hamstrings foam rolling, may trigger the alteration in antagonist muscle function."
Cavanaugh MT, Aboodarda SJ, Hodgson D, Behm DG. Foam rolling of quadriceps decreases biceps femoris activation. J Strength Cond Res 2016 Sep 6. [Epub ahead of print]
You should read this study if you haven't already
We all treat different forms of achilles tendinitis and tendonosis. This landmark study uses loaded eccentrics and showed better tendon organization and decreased tendon thickness at follow up.
Tendons do seem to respond better to tension and loaded eccentrics certainly seems to do the job.
"Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon."
Ohberg L, Lorentzon R, Alfredson H, Maffulli N. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004;38(1):8-11. doi:10.1136/bjsm.2001.000284.
link to abstract: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724744/
So you just give everyone a FOOT TRIPOD and ANKLE ROCKER exercise and think the world will all be sunshine and rainbows huh ? Beware all you movement wizards, there is far more to it !
So your client has knee pain huh ? Look far and wide, this is a global game amigos.
"Of the 51% of limbs with forefoot varus, 91.3% had medial and 78.3% had lateral PFJ cartilage damage. . . . . this study suggest a relationship between forefoot varus and medial PFJ cartilage damage in older adults"- Lufler et al. (study link below)
*If you do not know your client has a rigid forefoot varus, and they have hip or low back pain and cannot keep their glutes activated and participating in movements, how long are you going to fail your client ? The forefoot varus may need addressed because of the excessive, abrupt degree of internal spin on the limb.
If you are truly going to treat people, people who move (yes, that means everyone !), you have to know feet and gait, BOTH. Your knowledge must go far past rudimentary knowledge of:
- high / low arch
- flat feet
- prontation and supination
- orthotics and footbeds
You will have to know your foot types, you will have to understand shoe anatomy, foot anatomy, flexible semi-flexible and rigid foot types, compensated and uncompensated foot types, and of course know how each of these responds under various loading responses. Forefoot varus will load differently in cutting sports than in sagittal locomotion such as walking and running (both of which are different even in themselves despite both being sagittal). A foot that looks like it has a flat collapsed arch has far more to it than that, and thus remedy and intervention MUST go far beyond rudimentary interventions like a "stability shoe" or orthotic. Are you practicing, coaching, training and being part of your client's solution, or are you part of the problem ? If you want to get better at this stuff, we cover it all in our several hour (very difficult for some) National Shoe Fit program (the link is on our website if you wish to become a foot/gait/shoe jediwww.thegaitguys.com). Do not be mistaken, this is far more than "shoe Fit". To know how to properly shoe fit someone, you have to know the foot types and how they compensate, load, and respond. Without this knowledge, you are just another bump in the "road of problems" without ample solutions.
- Dr. Shawn Allen, one of the gait guys
The Association of Forefoot Varus Deformity with Patellofemoral Cartilage Damage in Older Adult Cadavers. Lufler, Stefanik, Niu, Sawyer, Hoagland, Gross http://onlinelibrary.wiley.com/doi/10.1002/ar.23524/full
images courtesy of aaronswansonpt.com and studyblue.com
Today, another "no rocket science here" post, however these are things to keep in mind.
Ankle stability is critical, whether is it walking or sport related running. We must have ample S.E.S. (skill, endurance and strength as we like to say here at TGG, and in that order might we remind you !).
And on that point, one is building strength on a skill without being able to do that skill repeatedly with durability (Endurance) then you are probably skipping a critical step in the rehab process. Yes, exceptions do occur, but rarely. If you cannot do something well repeatedly and maintain the clean skill pattern, they why are we adding more strength to it first ? Do something well, often, repetatedly, with durability, then add more strength and up the skill level.
The ankles are no different. There are multiple planes of movement down there, every direction is possible. We approach things from a cylinder perspective, every quadrant of that cylinder must be stable, have skill, endurance and strength. There are tremendous forces going down through that area, they had better be clean, controlled and the limb better be durable ("The absolute forces in the two joints (knee and ankle) were similar, equivalent to eight to nine times body weight in both cases."-Alex Hutchinson, excerpt from Medicine & Science in Sports & Exercise by researchers at the University of Jyvaskyla in Finland, link below.
Power had better not precede, S.E.S,. From the article: "And the progressive loss of ankle power as we age may be one of the key reasons we slow down".
As Hutchinson extracted from the Finnish study, "But the knees were capable of much greater maximum forces – nearly 14 body weights, on average – when the subjects jumped up and down as high as they could. In contrast, the ankles had a maximum force of less than 10 body weights, meaning that they’re already working at nearly their maximum strength even during a gentle jog. This suggests that the ankles are much more likely to hold you back if they’re weak, according to Juha-Pekka Kulmala, the study’s lead author. “The muscles working closest to their upper functional limits are the ‘weakest link,’” he says."
The Hutchinson article goes into other thoughts and perspectives, read it. The link is below.
Just know that this is just not about just doing heel raises, the science is more than than. If it were that simple the schooling for all that we all do would be a 3 hour internet youtube video course. The pieces have to play well together and if you train strength into faulty patterns, you get strong faulty patterns which can increase injury risks. There is a time for peroneal work, time for tibialis posterior work, time for single leg balance work, time for heel raises, for double hoping, single hopping, multidirectional hopping, skipping, walking, running or sprinting. The process isn't like your morning smoothie, meaning just throw it all in and blend, there is a science and sequence. And, that science and sequence is variable and specific to each and every client. The process cannot be "cook booked ", you will do many people injustice if you just go for the smoothie routine. Be a chef, be a scientist, not a juice bar junkie.
- Dr. Allen, one of the gait guys
1. Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189.
Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles.
Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.
2. "Pay attention to your ankles — they can slow you down with age." Alex Hutchinson. Special to The Globe and Mail
http://www.theglobeandmail.com/life/health-and-fitness/how-weak-ankles-slow-us-down-with-age/article33458151/
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