Ankle inversion sprain ? or off-loading photo ?

How we do one thing, is how we do all things.

I was sitting having my morning coffee earlier than normal this morning, which left me time to ponder some things.
Look at this picture, is this not a magnification of the "cross over gait" x100 ? Thus, is that planted foot not inverted ? Yes, it has to be, to a degree, a high degree. There is a reason why soccer players have a great affinity for ankle sprains.
When we have a narrow based gait, we are most likely going to strike more laterally on the foot, more supinated, if you will. If you widen step width, less inversion, less lateral forces (typically) and less supination (typically) compared to a narrow based gait.
If we descend stairs with our feet in a more narrow based gait, we are not only going to be inverted more, but striking at the ball of the foot, thus, more on the lateral foot tripod. This is the typical inversion sprain injury position.
When we jump, we should be trying to land with our feet more abducted, certainly not narrow based, because if we are too narrow we are at more risk for the same lateral forefoot landing and thus ankle inversion event. Just like descending stairs.

We see plenty of ankle inversion events. Why?
Because most people do not have enough hip abduction or peroneal skill, strength, endurance and they are unaware of their weak gait patterns or their ankle spatial awareness. Many have lazy narrow based gaits and insufficient proprioceptive awareness. And, they carry these things over into running, walking, jump landing (ie. volleyball, basketball, etc), and descending stairs, just to name a few.

How we do one thing, is how we do all things (mostly).

Rickie Lovell As he struck the ball it would been everted. The momentum of the follow through will have off loaded the everted foot as the energy moves in a similar line to that of the ball. It is extremely rare for a footballer to get a sprain from this, I certainly didn't see over several years working in professional football.
On a side note, find some footage of David Beckham taking free kicks - the mechanics are astounding!

The Gait Guys possibly everted, but no guarantee.It still looks pretty inverted to me.But we see your point, and is a real good one, real good. Super good. We will check our the bender-man thanks for chiming in with such great insight !

The Gait Guys yes, the momentum of the leg kicking across the body would externally spin the stance leg. The picture is likely showing the offloading phase, not the loadin

Rickie Lovell The benefits of being a Brit that used to play!

The Beef on the EDL.....

We have long been promoting appropriate function of the long extensors of the toes  here, in our practices, our lectures, on Youtube, in our book......You get the idea. Lets take a closer look at this often weakened and overlooked muscle.

We remember that the EDL lies mostly in the superior and somewhat lateral part of the anterior compartment of the lower leg, comprising approximately the upper 2/3 from under the lateral tibial plateau and fibula, and from the interosseus membrane. It lies under the tibialis anterior, and the extensor hallucis longus lies below it. Its tendons pass inferiorly and travel under the extensor retinaculum and attaches to the base of the distal phalanges of toes 2-4. These muscles act from initial contact to loading response to help eccentrically lower the foot to the ground and ensure smooth heel rocker and most likely attenuate the speed of initial pronation as the talus glides anteriorly on the calcaneal facets and again from terminal stance through initial swing to provide compression of the metatarsal phalangeal and interphalangeal joints, to offset the long flexors (which are often overactive) and create clearance for the toes during swing.  

What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right (pair J howard r). what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has a forefoot supinatus, or possibly a forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod, possibly insufficient extensor hallucis brevis, peroneus longus, flexor digitorum brevis, or all of the above). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the supinatus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

• Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises.
• Make sure the articulations are mobile with joint mobilization, manipulation and massage.
• How about dry needling and acupuncture to improve function?
• Make sure the knee and hip are functioning appropriately.
• Put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe).
• As a last resort, if they cannot make an adequate tripod because of lack of motivation, anatomical constraints or both, use a foot leveling orthotic.

Threshold foot drop. Video case.

Threshold foot drop.
Do you see it in this gait? No. There is a clue though, the EHL on the right (extensor hallucis longus) does not seem to be all that hearty and robust during gait, the toe is not as extended/dorsiflexes as on the left foot. A Clue ? Yes.
This client had true blatant foot drop, but it was caught relatively immediately, and the source resolved and recovery ensued. There is still some residual weakness, as you see at the end of the video, but making steady gains. Previously, gait showed obvious foot drop, foot slap, abrupt knee flexion (the "catch" response as we call it as the client's knee suddenly flexed forward as foot slap occurs). But, as you can see , the gait is pretty much normal now except for a little EHL strength lag. But, at the end of the video, when they heel walk, one can see the weakness, they cannot keep the ball of the foot off the ground during attempted heel walk. We like to call this "threshold weakness", it is just hovering below the surface, when taxed, it can be seen, but doesn't show up in gait. But, it does show up in longer endurance based walking events. This may be when your client's symptoms show up, as fatigue expresses limitations in the system. It just goes to show you, if you are not testing and looking for these things, you just might not find the source of your clients knee pain, foot pain, hip or low back pain. Heel and toe walking takes 10 seconds, do not forget to check them off. It just might be the "big reveal" for you, and them ! #footdrop #gait

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Building a Better Bridge

Using bridge exercises? Want to make it more effective? Here's one simple way: bend the weight bearing knee to 135 degrees rather than the traditional 90. It preferentially activates the g max and med more (relatively, compared to the hamstring ; the actual values for the max and med remained similar) and the hamstring significantly less (24% vs 75%)

CONCLUSION:

"Modifying the traditional single-leg bridge by flexing the active knee to 135 ° instead of 90 ° minimizes hamstring activity while maintaining high levels of gluteal activation, effectively building a bridge better suited for preferential gluteal activation.

Lehecka BJ, Edwards M, Haverkamp R, et al. BUILDING A BETTER GLUTEAL BRIDGE: ELECTROMYOGRAPHIC ANALYSIS OF HIP MUSCLE ACTIVITY DURING MODIFIED SINGLE-LEG BRIDGES. International Journal of Sports Physical Therapy. 2017;12(4):543-549.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5534144/

Arm swing during gait. An energetic cost of locomotion?

"Arm swing during gait has an important role in decreasing energetic cost of locomotion. Several pathologies
may lead to various abnormalities in arm movements during
walking. It may therefore be expected that pathological gait is
energetically more demanding, not only because of the pathology, but also because of affected arm movements."- Meyns et all.

The Gait Guys ponder:
Can forcing what we think is a "better" arm swing pattern in turn be considered generating locomotor pathology? After all, we very well may be forcing a change to that which we see, a visual which we do not like, which was already a fundamental compensation around another locomotor deficit. ???

The how and why of arm swing during human walking
Pieter Meyns a,1, Sjoerd M. Bruijn a,b,1, Jacques Duysens a,c
Gait & Posture 38 (2013) 555–562

You won't read this. So send it to a colleague who will.

Beating a point to near-death. Consider this our Thursday Rant.

Yes, we won't let this go, and, you should not either.

We highlight the word ADAPTIVE below, because it is the key to all of this.

"The observed postural responses could be viewed as an ADAPTIVE process to cope with an unilateral alteration in the hip neuromuscular function induced by the fatiguing exercise for controlling bipedal stance. The increase in CoP displacements observed under the non-fatigued leg in the fatigue condition could reflect enhanced exploratory "testing of the ground" movements with sensors of the non-fatigued leg's feet, providing supplementary somatosensory inputs to the central nervous system to preserve/facilitate postural control in condition of altered neuromuscular function of the dominant leg's hip abductors induced by the fatiguing exercise."-*Vuillerme N1, Sporbert C, Pinsault N.

When one prescribes or chooses a corrective exercise for a client, one based sheerly on what is visualized as an "apparently" faulty movement pattern or aberrant screen, one is making many assumptions. Assumptions that are likely not entirely correct (we are being kind, most assumptions made based on partial fragmented information are incorrect to a high degree).

Here is comes again, . . . . what you SEE and TEST in your client's movement is not what is wrong with them most of the time. What you see is how your client is ADAPTING to the variables they can engage, avoiding the ones that are painful or perceived as unstable, or finding ways around immobility and as the article as quote above suggests. This was a basic tenet of Karel Lewit's and Janda's work to not focusing on the area of pain, rather to seek out the root cause, we are just saying it in a different manner.

Continuing, we also adapt around fatigue which can take place even in everyday tasks and how we move around our world, yes, even in our gait. Yes, you are seeing a client's best attempts, ones that are likely deeply rooted and now their new norm, their baseline to base all other patterns off of. Their attempts can be based off of immobility, instability (true or functional), lack of skill, proprioceptive deficits, fatigue (lack of baseline endurance), lack of strength or power. For some clients, forget challenging screens that really test them, heck, we find some athletes do not even have the requisite baseline endurance or strength in a few primary fundamental patterns of which they have built more robust patterns atop of. We all to often read about "robustness" of a skill and pattern and interpret it as a good thing. Robustness can also be build atop of a bad pattern of movement, atop of poor stability patterns.

Thus, asking a client to change that ADAPTIVE norm, based off of what you visualize, based on the working parts available to them, without rooting out the cause, is asking them to compensate around their new norm base of compensation. When done this way, we are merely giving our client armor to their dysfunction, faulty robustness if you will. We are in fact moving further from the remedy. To correctly play this multi-layered game of helping people, one has to examine the client, not just put them through screens and assessments that show us (and them) what they can and cannot do.

There is an awful lot of armchair doctoring going on out there, thankfully it all comes from a good place in the heart's of many good folk. We have so many people come in to see us who have problems and a list of corrective exercises that have been prescribed to them, exercises that clearly have been based off of correcting what is seen in their screens and movements. We discuss their workout patterns, their activities, and hear about how they are attempting to build up their bodies for the apparent good. But all to often, with a client in front of us in pain, we hear the clues that the problem is being exercised around. Meaning, building robustness on top of a dysfunctional base somewhere in their system. Many of these people have been given these exercises as part of their corrective work and strengthening programs at their place (gym, box, trainer, coach etc). Many times there was no in depth hands on examination coupled with screens and gait to root out the cause of why they are moving the aberrant way that they are. We all must commit ourselves to a complete process for our clients. Screens and tests and exercises are not enough. Please read yesterdays post if you have not already, we make our point once again in a video case.

To close this post, we fully acknowledge regularly that we are on the same bus to the same temple of higher wisdom as everyone else that reads these kinds of posts. We write to share, but we write to learn, to dive deeper into our thoughts, to challenge our biases and rooted assumptions through thought experiments, challenging thoughts and old ways that get us into troubled automated patterns of approaching all things. Again, we write to learn. And, part of that learning is accepting our limitations and hearing from others who are wiser in other areas than us, so, please comment and add insight below if you wish. Debates are good, for us all.  Pull up a chair, grab a pint, join us around the hearth for some gab.

Shawn Allen, . . .  the other gait guy.    www.doctorallen.co    &    www.shawnallen.net

"One of the few ways I can almost be certain I'll understand something is by sitting down and writing about it. Because by forcing yourself to write about it and putting it down in words, you can't avoid having to come to grips with it. You might be wrong, but you have to think about it very intensely to write about it. So I use writing as a learning tool. " - Hunter S. Thompson

*Postural adaptation to unilateral hip muscle fatigue during human bipedal standing.

Gait Posture. 2009 Jul;30(1):122-5. doi: 10.1016/j.gaitpost.2009.03.004. Epub 2009 Apr 28.

Vuillerme N1, Sporbert C, Pinsault N.

Is this a gluteus medius foot targeting problem in swing phase or is this a loss of internal hip rotation? Or . . . .

Is this a gluteus medius foot targeting problem in swing phase or is this a loss of internal hip rotation? Or . . . .

You have to examine your client to know what to treat, a gait analysis or a series of screens is not enough. The saying "an exercise is a test and a test is an exercise" has some sharp edges around it. A screen doesn't tell you what exercise a client necessarily needs or should be prescribed.
This stuff really does matter.
What you see is not the problem , it is their compensatory strategy in coping with a problem. When someone has a pebble in their shoe and they walk on the outside edge of their shoe to avoid the pebble the solution is not to tell them to stop walking on the outside of the shoe, the solution is the de-pebble the shoe. Corrective exercises can be a similar path to this pebble analogy. One must look deeper and beyond what we see in our clients, we merely see how they have adapted, not the problem. A Trendelenburg leaning gait is not met with a solution to prescribe a corrective exercise to correct the lean, the solution is to see why the client is reducing the compressive loading across the hip. Stop giving corrective exercises if you are not examining your client. Yes, that means you need to have hands on diagnostic skills. Sorry.

Loading the wrong pattern drives a compensation, and maybe another problem or a compensation to the compensation deeper.

Loading the pattern that is corrective, the one that solves the deficit leading to the gait you see should be your target. Corrective exercises are supposed to be corrective to the problem, not to the gait aberation you see. Without the exam to solidify proper path, corrective exercises often are directed at the things we see, not the aberation that drove what we see. Be part of your clients solution.
If you aren't examining your client, you don't know for certain what you are actually doing.

This is me, Dr. Allen, i am walking in a matter to prove my point.
Do i have a loss of right internal hip rotation (thus the externally rotated limb?). Do i have a swing leg gluteus medius weakness that is allowing me to adduct the limb rendering a mere foot targeting problem? Do i have weak peronei ? A weak glute max ? A right frontal plane drift that i am avoiding by turning my leg out so i can use my quads to help the deficient glutes better block the frontal plane drift ? I could go on an on as to possible causes.
Or do i merely have a pebble in my shoe?
Mic drop.

To give a corrective exercise you have to know what is wrong. That means you have to have the knowledge and the hands on skills to diagnose the "why". So you can prescribe the correct "how".

Shawn Allen, one of the gait guys

Pronation as a shock absorber?

We sometimes (or often) think of pronation as a BAD thing. It's actually a pretty good thing... Along with ankle dorsiflexion, knee flexion, hip flexion and drop of the contralateral pelvis

Check out our quick video on all the shock absorbing mechanisms

Gait is all-encompassing.

Last week we did a presentation on some very classic, yet challenging, gait video case presentations. This slide was a big piece of our presentation.
We discussed that there are volitional and non-volitional movements that accompany the adequate and appropriate postural system control.
If you want to hurt your brain, read this paper.
But in a nutshell what this paper says is that we have a constant switching between steady state cortical neuron discharge and and non-steady state discharge. For example, when we are on a flat road, no obstacles ahead of us, nothing but boring open road, the system sort of runs on an automated program, making limb movements calculated off of a normal unchallenged baseline. But, if there are roots, rocks, curbs, bikes to dodge, puddles to hurdle etc, the volitional and postural systems must change their operation, and alter limb movements based off of those postural systems as we pay attention, and negotiate the obstacles. There is this delicate symphony occurring between automated posture, calculated posture, rhythmic limb movements. In other words, there are volitional, reactionary and anticipatory plans and adjustments occurring in the background at all times.
But, make no mistake, bad, faulty, inefficient motor patterns can become automated if injuries are left, if they are left partially rehabed, if we teach our clients faulty patterns by overloading them and forcing adaptive patterns to inappropriate load or fatigue. These modifications occur deep in the CNS, much in the premotor cortices, and take into account body schema (their correct or distorted perception of where they are, or their limbs are, in space). Build strength or endurance on an altered schema, one that might be present from an old injury, and one will build strength and endurance where one does not want them to go. Properly training clients, offering corrective exercise and the like is far deeper that just asking your client to load and get stronger, unless you wish to assume that their limitations and compensations are unimportant. This takes us right back to the asymmetry debate, which we know so many love to dive into. Asymmetry is the norm of course, just don't be the person creating more of it for your client.

"Adaptive gait control requires constant recalibration of walking pattern to navigate different terrains and environments. For example, motor cortical neurons do not exhibit altered discharge during steady-state locomotion, but altered discharge occurs when the experimental animal has to overcome obstacles. Loops from the motor cortical areas to the basal ganglia and the cerebellum may contribute to this purpose (ie, contribute to accurate and adaptive movement control that requires volition, cognition, attention, and prediction). In contrast, cortical processing seems unnecessary during the automatic execution of locomotion. Rather, high-level processing may occur in the systems between the basal ganglia, cerebellum, and brainstem in the absence of conscious awareness. - TAKAKUSAKI , Neurophysiology of Gait: From the Spinal Cord to the Frontal Lobe

Movement Disorders, Vol. 28, No. 11, 2013

Runners . . . can you hop ?

Photo credit: Lenore Edman

You might think you are a great hopper, but that is because you are never on the same leg hopping forward sequentially. Running is hopping off one good leg, potentially onto another that is just a little less optimal, then back onto a better leg, never fully appreciating a potential asymmetry. 

If you are not assessing your client's hop ability you might be missing some very valuable information. The trouble will be, determining what the deficit is. Telling them they merely have to hop more on the perceived-deficit side is not solving the problem. More does not equal better (unless one is referring to ice cream).

Today, we are in the podcast studio and we will briefly be talking again about the importance of assessing your client's hop ability. Do they have the skill, endurance and strength to hop well, and hop symmetrically?  After all, running is a hopping skill, it is a long jump hop forward in the sagittal plane, followed by an airborne float phase, and an abrupt landing onto the next limb, it is a long jump hop one after the other. If you cannot hop competently, you are at risk.

Skill: Do you have the skill to hop symmetrically ? When you do 15 fast hops forward do the legs feel the same side to side in terms of coordination? or is your foot all over the place "exploring for stability"? Does your knee swim inward, does your hip drift a little into the frontal plane, do you drop the swing leg pelvis ?

Endurance: Can you do it 15 -20 times or more, how about 50? After all, you are about to do a 5mile run (or more !). If you fatigue in any of the components on one leg, your hops are not the same. Get ready for compensation adaptations. So, when you feel something going "funky" wrong in a long run, what do you do? Do you stop, walk and recover or do you keep going ? Many of us are good at ignoring the "blinking check engine light". There is nothing wrong will walking for a bit and giving some fatigued tissue a little time to recover before you start into your run again. We believe many injuries could be avoided if we could get past our "mental moron" issues as runners.

Strength: can you protect the joints and planes from compromise, drift, rotation etc ?

Hopping comprises: proprio, forefoot take off and loading, ankle rocker, a competent tibialis posterior, peroneal group, and achilles-calf complex, knee flexion dampening ability, hip flexion and others . . .

you must be able to stabilize the frontal plane

you must be able to dampen rotational loads

you must be able to keep the knee sagittal

you must control the rate of pronation

you must be able to cyclically convert the foot from flexible to rigid and back again, almost immediately

Just some things to think about before your long run this weekend. We will follow up this post with a long form discussion on an upcoming podcast. We hope you will tune in.

"It is concluded that the fatiguing exercise protocol combined with single-leg hop testing was a reliable method for investigating functional performance under fatigued test conditions. Further, subjects utilized an adapted hop strategy, which employed less hip and knee flexion and generated powers for the knee and ankle joints during take-off, and less hip joint moments during landing under fatigued conditions. The large negative power values observed at the knee joint during the landing phase of the single-leg hop, during which the quadriceps muscle activates eccentrically, indicate that not only hop distance but also the ability to perform successful landings should be investigated when assessing dynamic knee function.

Single-leg hop testing following fatiguing exercise: reliability and biomechanical analysis. Scand J Med Sci Sports. 2006 Apr;16(2):111-20 Augustsson J1, Thomeé R, Lindén C, Folkesson M, Tranberg R, Karlsson J.    https://www.ncbi.nlm.nih.gov/pubmed/16533349

Building a better Bridge: Part 2

Along the same vein as our last post, consider abducting the leg 30 degrees, which increases gluteus maximus activity, lessens anterior pelvic tilt and lessens erector spinae activity. Of course, pelvic tilt should have clued you in to a weak core in the 1st place : )

PURPOSE: To investigate how the erector spinae (ES) and gluteus maximus (GM) muscle activity and the anterior pelvic tilt angle change with different hip abduction angles during a bridging exercise.

METHODS: Twenty healthy participants (10 males and 10 females, aged 21.6 ± 1.6) voluntarily participated in this study. Surface electromyography (EMG) signals were recorded from the ES and GM during bridging at three hip abduction angles: 0°, 15°, and 30°. Simultaneously, the anterior pelvic tilt angle was measured using Image J software.

RESULTS: The EMG amplitude of the GM muscle and the GM/ES EMG ratio were greatest at 30° hip abduction, followed by 15° and then 0° hip abduction during the bridging exercise. In contrast, the ES EMG amplitude at 30° hip abduction was significantly lesser than that at 0° and 15° abduction. Additionally, the anterior pelvic tilt angle was significantly lower at 30° hip abduction than at 0° or 15°.

CONCLUSIONS: Bridging with 30° hip abduction can be recommended as an effective method to selectively facilitate GM muscle activity, minimize compensatory ES muscle activity, and decrease the anterior pelvic tilt angle.

Kang SY1, Choung SD2, Jeon HS3. Modifying the hip abduction angle during bridging exercise can facilitate gluteus maximus activity. Man Ther. 2016 Apr;22:211-5. doi: 10.1016/j.math.2015.12.010. Epub 2016 Jan 2.

Pod 135: Part 1: Head over Foot? Where should we put our COM (center of mass)?

Key words: cross over gait, head over foot, HOF, gait, gait analysis, COM, COP, center of mass, center of pressure, step width, sprinting, symmetry, running injuries

This podcast (135) and its soon to launch follow up podcast (136), as the intro explains, comes at the tail end of a series of thought debates between Shawn and Ivo with some folks who have a different view point.  While the debate is unsettled because there is not sufficient research to support one side, we feel the research leans towards our side of things.  However, as the debates went on, it became clear to us that both parties were approaching the debate from a different metric to gauge each party's beliefs.  We outline this in the introduction and then more forward into our dialogue.  We hope you find this a productive thought experiment.
 

Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_135final.mp3

Permalink URL: http://thegaitguys.libsyn.com/pod-135-part-1-head-over-foot-where-should-we-put-our-com-center-of-mass

Libsyn URL: http://directory.libsyn.com/episode/index/id/6309104

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com doctorallen.co shawnallen.net

Our website 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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Acupuncture and Endurance?

We were treating patient that with low back pain that had decreased lumbar endurance the other day (you should be able to hold a "superman" post with your arms at your sides for 150 seconds. He has been continuing to improve and is now virtually pain free.

many folks don't realize a nice side effect of acupuncture is increased increased endurance, among other things. How about trying this on other muscles as well? We ran across this article you may find interesting

"Acupuncture therapy is able to eliminate free radicals, resist lipid peroxidation, prevent dysfunction of the motor hypothalamus-pituitary-gonadal axis, reduce the creatine kinase content, and lower lactic acid concentration, so as to play an important role in the elimination of sports fatigue and improvement of athletic ability of the body. "

link to free full text:

https://link.springer.com/article/10.1007/s11726-009-0123-7

A fresh calf tear. Video case

As fresh as fresh gets, trauma hours ago. Running in soft sand, felt a pop left medial calf.
So, is it:
1. a full medial head tear ?
2. Partial low grade tear that has just bled into the area that normally would have shown the medial calf definition? ie Bleeding blurring the definition ?
3. Muscular pain inhibition because the calf raise is painful ?
The latter two of the 3 ?
All the above?
Saving grace, there is a palpable medial calf contraction, it is just not authoritative like the other leg, painful to engage.
So, MRI ? If not even considering surgery regardless, does it change our treatment ? Let it heal and deal with the aftermath ?
Wait and see ? If in a few days-week the swelling and pain inhibition reduce and the strength comes back, regardless of definition restoration, is that a bullet dodged ?
What would you do ?

* injury is on the left, i am pointing to the normal defniition on the right. Note the absense on the left.

The gluteus medius is playing target practice.

We think about the gluteus medius often, mostly, during stance phases of locomotion. But, do not forget about the absolutely necessary function of the gluteus medius on the swing limb. Foot placement of that swing leg is in part dictated by how well the pendulum leg receives gluteus medius control to abduct the leg. When it fails to abduct adequately, a more adducted/medial foot placement occurs. An agreeable balance between the abductors and adductors affords a more pure forward sagittal pendulum of the hinging leg. When imbalanced, from insufficient gmedius and the rest of the abductory team, the foot and leg can target a more medial pendulum swing and thus a more medial foot target placement. Thus, the gluteus medius is important in both the stance and swing phases of gait. We discussed this in the webinar last night. Failure to develop the skill, endurance and strength of the gluteus medius and related complex of muscles will often result in frontal plane pelvis drift on the stance limb, and adduction targeting of the foot. What is this called ? We call it the Cross Over gait and we have written oodles of articles about this gait phenomenon, more than anyone else we believe. It is real, it has economical advantages and similar liabilities. Want to learn more, type it into the SEARCH box on our website-blog. Many people this is a normal gait, how we should all run. We think like most things in this world, there is a benefit and a drawback to things, and it is how you use it, as long as you read the instructions. Sadly, we were never given our users manual when we were born. That is, in part, what we are trying to do here at . . . . www.thegaitguys.com

Where the knee hinges matters.

It is easy to see the big things, but, we sometimes forget that the small things matter.
Sometimes it take an obvious glaring asymmetry to make us appreciate that the small asymmetries can make the same or similar impact over a long period of time. Rivers can carve out canyons over time.

Here we see the gross difference that polio can make in leg size and in leg length. We must remember that changing a leg length also changes the symmetrical relationship of where the 2 knees hinge. A foot that pronates more than the other leg can lower the knee hinge point just a little because the talus drops further from its vertical height. We know very well that it for certain alters the hinge direction, posturing it more medially, but we cannot forget that a cranky knee on a side where the foot is flatter or pronates more excessively than the other is not to be ignored.
In this photo, we have dotted the knee at the same point on the patella. It is clear the knees will not hinge at the same time, thus stride and step lengths will change, and step width will be impacted. The pelvis will also spin more to one side on a pelvis that is lower on one side. This will impact lumbar spine sagittal happiness and stability/mobility. Hip and pelvis drift are real things in this case, and need your attention. *Just like a client that has a painful foot, a more pronated foot, more tibial torsion on one side etc. these things matter, and they often matter years down the road when many thousands of miles have been clocked into the subtle asymmetry. Sometimes these little things matter in our athletes too, who put the pedal to the floor asking the body for more.

Come hear our lecture tonight on www.onlineCE.com. You have to sign up early to get in. We won't disappoint. See you then. 7pm central time.

Conservative Mangement of Parkinsons

Most, if not all of us have either patients, family or friends that have been touched by PD. Here is a video talking about some of the conservative approaches from the literature. We don't talk about gait specifically, but because it is a movement disorder, we felt it appropriate to share.

Do you really need your 5th "pinky" toe ?

This little piggy went to market  . . . . .  as the nursery rhyme goes.

rewind blog post for your enjoyment

Do I Really Need My Pinky Toe?

Just the other day we saw this article in Popular Science written by Sally Zhang.  Sally obviously does not read our blog, but she got a lot of stuff right.

“If you’re born without a pinky toe or have an accident and it’s removed, you can completely do everything you wanted to do,” Dr. Anne Holly Johnson, instructor in orthopaedic surgery at Harvard Medical School, says.

Above you will see a photo of one of the gait guy’s feet.  It is quite clear from the photo that competent use of the pinky toe is not necessary for adequate, and possibly exceptionally skilled, foot function.  Here, check out this video of our foot in these 2 videos (here and here) for some advanced foot function (sans pinky toe). As you can see in the photo above, this 5th toe has likely never felt the ground, this is a fixed deformity.  Flexor and extensor function of the toe are intact, but it does not reach the ground and so assistance in gaining adequate purchase of the 5th metatarsal on the ground is absent. 

This brings us to a deeper question, what about the 5th metatarsal then? Is it necessary ?  Our answer even without deeper research is a solid “yes”. The foot tripod is severely compromised without the 5th metatarsal. The lateral stability of the foot is impaired without the 5th MET.  The natural locking of the calcaneocuboid joint mechanism will be impaired, the peroneal muscles that provide such critical lateral ankle and foot stability will have fascial planes and tendon attachments disengaged, the natural walking gait lateral to medial foot progression would be impaired, propulsion would be impaired and the list goes on and on. And, not even on the local foot/ankle level. Because, if you take out the function and stability of the lateral foot the hip is very likely to suffer lateral (frontal plane) stability deficits. Meaning, the gluteus medius and abdominal obliques will have more difficulty guarding frontal plane drift when in stance phase rendering all of the “cross over gait” risks (link) highly probable.  

So, not much exciting stuff here today. The presence of a functioning pinky toe does not appear to be critical but don’t take away its big brother neighbor, the 5th Metatarsal or trouble is just around the corner. Don’t believe us? Just ask anyone with a non-union fracture (Jones fracture) of the 5th metatarsal.

The answer goes back to the evolutionary history of humans, explains Dr. Anish Kadakia, assistant professor in orthopaedic surgery at Northwestern University. "Primates use their feet to grab, claw, to climb trees, but humans, we don’t need that function anymore,“ Kadakia says. "Clearly we’re not jumping up and down trees and using our feet to grab. We have toes embryologically, evolutionary for that particular reason because we descended from apes, but we don’t need them as people.”

The gait guys, working with 4 toes on each foot, one step ahead of evolution it seems.

Shawn and Ivo,

The gait guys

reference:

http://www.popsci.com/science/article/2013-05/fyi-do-i-really-need-my-pinky-toe?dom=tw&src=SOC

https://thegaitguys.tumblr.com/post/96538178584/do-i-really-need-my-pinky-toe-just-the-other
 

How the CNS adapts. Exploratory testing of the ground.

What is happening at the 150 meter mark in a 200m sprint when that glute starts to fatigue ? What is happening at the 12th mile in a half marathon when stabilzation around that knee starts to falter?
In this article below, the authors discuss postural adaptations to unilateral hip muscle fatigue. This study merely looks at the effects during standing, so imagine what happens during locomotion when things start to fatigue.

Anyone who has sprained an ankle or banged up a knee knows what it is like to have an automated limping gait. The CNS is trying to reduce and shorten the loading response (and time) on the affected limb. This scenario goes on for awhile, days, maybe weeks, until it becomes somewhat more automated.
We just saw a client in the office just yesterday who had a subtle limp from a foot fracture 6 months ago. I mentioned it in passing, "isn't it amazing that your CNS can still be generating that limping adaptive gait even after 6 months, even now that the pain is no longer present?" His response, "What ? I am still limping? No I'm not ! Am I? Really?" I showed him the video, he was shocked. Things get automated, the CNS adapts, and it often doesn't know when to let go of an adaptive pattern even when it is no longer warrented. It is amazing to think that the brain often cannot logically process the incoming data and revert back to the sensory-motor program that was engaged pre-injury. Amazingly, perhaps the brain still knows better, perhaps it knows that things might seem fine, but lurking beneath the surface the sensory receptors are still sending soft warning signs that things still are not kosher.
We say something like this often to our clients, "The CNS makes momentary adaptive choices, but it has no way of foreseeing the consequences of an adaptive measure which is necessary in the moment. It makes these choices based on perceived stability, necessary mobility, economy, and pain avoidance, most of the time. But, it has no way of seeing into the future to see whether its choices have ramifications, it just chooses what makes the most sense in that moment." This is one of the reasons why we get so cranky about people who offer training and corrective exercise queues to people without deep thought, examination, and consideration. There can be ramifications down the road, that, in the present, are unseen and unknown. For example, just because you are running faster because you altered or augmented a client's arm swing, doesn't mean that newly trained pattern, that might even have the positive performance outcomes, won't have consequences that need to be walked back in the future. This is one of the premises of our recent arguments with the HOF (Head over Foot) crowd, who explicitly convey they only care about the clock and a client's speed, not about their well being down the road. There is no free lunch, the piper always gets paid, but just because we are not there to see the payment, it doesn't mean the day of reckoning isn't coming. We have been playing this human mechanic game now collectively for about 50 years, we know the payback is real, we see it often, eventually the tab for that free lunch shows up.

In this article below, the authors discuss postural adaptations to unilateral hip muscle fatigue. We are again looking for that Piper, he wants to get paid, so what is the consequence to the fatigue ? This study merely looks at standing, so imagine what happens during locomotion when things start to fatigue.

"The purpose of the present experiment was designed to address this issue by assessing the effect of unilateral muscle fatigue induced on the hip's abductors of the dominant leg on bipedal standing."

"Results of the experimental group showed that unilateral muscle fatigue induced on the hip's abductors of the dominant leg had different effects on the plantar CoP displacements (1) under the non-fatigued and fatigued legs, yielding larger displacements under the non-fatigued leg only, and (2) in the anteroposterior and mediolateral axes, yielding larger displacements along the mediolateral axis only. These observations could not be accounted for by any asymmetrical distribution of the body weight on both legs which were similar for both pre- and post-fatigue conditions. The observed postural responses could be viewed as an adaptive process to cope with an unilateral alteration in the hip neuromuscular function induced by the fatiguing exercise for controlling bipedal stance. The increase in CoP displacements observed under the non-fatigued leg in the fatigue condition could reflect enhanced exploratory "testing of the ground" movements with sensors of the non-fatigued leg's feet, providing supplementary somatosensory inputs to the central nervous system to preserve/facilitate postural control in condition of altered neuromuscular function of the dominant leg's hip abductors induced by the fatiguing exercise." - Vuillerme et at, 2009

We have discussed arm swing many dozens of times over the 9 years of blogging research on the web. You can search our blog for "arm swing" and go down the deep rabbit hole we have dug if you wish to learn how arm swing is not only necessary, but highly adaptive ballasts to help maintain balance and effective and adaptive locomotion. They can be used for improving or changing locomotion of all types. They can be looked at as prime movers or passive followers of the higher order leg swing. They can be coached right and wrong. The have a huge impact on COM (center of mass) and COP (center of pressure). And as a tangential comment of the article above, when the adaptive postural responses of the body are activated from a given fatigue in the body, COM and COP must change and adapt to keep us upright in the gravitational plane. These COM and COP changes are exploratory postural compensations, of which altered arm swing is often one adaptive and assistive measure. In this articles discussions, these compensations provide supplemental somatosensory inputs to the central nervous system to "preserve/facilitate postural control in conditions of altered neuromuscular function" when fatigue sets in somewhere. Bringing this all full circle, changing someone's arm swing, because you do not like how it looks (ie asymmetry, cadence, direction, etc), is foolish. The brain is doing it, because it likely has to do it to help adapt to a problem elsewhere that is altering the brain's perception of a safe COP and COM. Your job is to find out why and correct it, not to teach them a new way, which is very likely a new compensation to their already employed adaptive compensation.
-Shawn Allen, the other gait guy

Postural adaptation to unilateral hip muscle fatigue during human bipedal standing. Vuillerme N1, Sporbert C, Pinsault N. Gait Posture. 2009 Jul;30(1):122-5. doi: 10.1016/j.gaitpost.2009.03.004. Epub 2009 Apr 28.

Too much extensor tone: The banana toe.

Too much extensor tone.
We are often talking about the subtle balanced relationship of the long and short toe flexors and extensors. We often discuss that hammer toes are too much long flexor and short extensor tone (with too little in the short flexor and long extensor).
Here we see the opposite. We see too much long extensor tone (note the upward banana-shaped orientation of the big toe). When this foot is on the ground, the pad and distal 1/2 of the big toe does not even touch the ground, standing or in gait. IF you look closely at the blown up pic, you can sort of see (sorry, should have taken more pics) the increased callus development in the contact area of the short flexor attachment (FHB, flexor hallucis brevis).

This relationship is the opposite of the above with hammer toes. Too much long extensor, too much short flexor, and not enough long flexor and short extensor. These clients need more homework for long flexor and short extensor. This is one of the reasons why we developed the exercise below in the youtube link.