Two out of Three ain't Bad...But sometimes it is

image credit: https://commons.wikimedia.org/wiki/File:Meatloaf_(1).jpg

“What do you mean my plantar fasciitis is due to my hip?”

I recently saw a 60 YO male patient with right-sided plantar fasciitis of approximately 1-1/2 months duration. It began insidiously with pain located at the medial calcaneal facet on the right hand side. He had localized tenderness in this area with some spread distally towards the metatarsal heads. He has ankle dorsiflexion was relatively symmetrical with mild impairment on the right compared to left but only approximately 2 degrees. He had hip extension is 0 degrees on the affected side and 10 degrees on the affected side. Sacroiliac pathomechanics were present as well with the loss of flexion and extension. He had a slight leg length discrepancy, short on the symptomatic side.

So what is going on?

Moving forward in the sagittal plane requires a few things:

Adequate hip extension

Adequate ankle dorsiflexion

Adequate hallux dorsiflexion with an intact Windlass mechanism

He has a diminished step length going from right to left. Because of the lack of hip extension, the motion needs to occur somewhere. His ankle dorsiflexion is almost sufficient but less sufficient on the right (symptomatic) side than it is on the left. He has adequate hallux dorsiflexion but lacks adequate hip extension. Like the song goes, begin "Two of of three ain’t bad". However in this case, it is bad. He has an intact windlass mechanism. In fact, a little too intact. This is causing a tug at the medial calcaneal facet, creating an insertional tendinitis that we know as "plantar fasciitis".

So we did we do?

• Manipulated the right sacroiliac joint

• Gave him lift she/spread/reach exercises

• Gave him shuffle walk exercises

• Worked on hip flexor lengthening

• Treated the plantar fascial insertion locally with acupuncture and laser therapy

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis,#thegaitguys, #anklerocker#halluxdorsiflexion, #plantarfascitis

Making Kim Jong-un a better sprinter. Kim Jong-un has no shoulder extension. Video proof.

Kim Jong-un has no shoulder extension. Video proof.

Perfect gait example here today, Video of Kim Jong-un's gait.
This is what aberrant arm swing looks like during someone's gait when they do not swing the arms from the glenohumeral joint, specifically not acquiring shoulder extension (posterior arm swing) . Here Jong-un is seen merely performing arm swing from flexion and extension of THE ELBOW. This is not uncommon in the obese and those without ample hip extension. Remember, the motor patterns for the arms take massive queues from the lower limb motor patterns. Without hip extension you will typically not see shoulder extension (or thoracic rotation). Do not coach arm swing, fix leg swing and stance first. -dr. allen

Making Kim Jong-un a better sprinter.

". . . .these same issues are playing out in your runners. Many do not have enough thoracic mobility or scapular stability and that is why you see their sucky arm swing (on one or both sides) that you so desperately hate and are trying to coach out of them. Or, their arm swing suck starts from somewhere deeper, down below in the core, pelvis or lower limbs. Go for the fix, and you will get the arm swing you want. Be part of your client's solution, not part of building a suckier arm swing compensation, heck, they already have one, so don't layer your desirable arm swing on top of their ever present problem."

We are pounding arm swing yet again this week. If you missed it, go back to Wednesdays post here on FB (and on our thegaitguys blog) to get caught up on those concepts, but make sure you read my post from yesterday as well.

Look at Kim Jung-un's arm swing again. As we mentioned Wednesday, there is only elbow swing, there is really very minimal if any shoulder extension swinging. But how could there be? After all, there is ZERO thoracic rotation to base this off of. Look at the video, it does not lie, his shoulders are silent, there is no thoracic rotation.
Yesterday I discussed the principles of the normal antiphasic gait, that being the pelvis and torso should rotate in equal and opposite directions (antiphasic). That requisite torso rotation helps to drive the posterior shoulder extension swing and thus the anterior shoulder flexion swing on the opposite side. Without torso/trunk rotation, the shoulders are going to be silent, and thus, arm swing must come from the elbows. This is really crappy gait mechanics.
Now, if you are going to coach him to be a sprinter (ok, lets settle for a better walker), are you going to force the arm swing you want ? or are you going to help him restore his antiphasic gait, and help him earn separation in opposite rotation between the torso/trunk and the pelvis ? If you want him to be Usain Bolt fast, help him regain antiphasic . . . give him hip and pelvis drills to help him get more hip extension (but give him the requisite core work first so he doesn't flare up his back pain) and help him get better pelvis obliquity, of which much has to come from better abdominal engagement. And then give him some thoracic/truck rotation drills to earn more of that. Then help him combine these parts. But, don't just teach him how to pump his arms as one does in sprint drills.
My point in this over exaggerated case is this, these same issues are playing out in your runners. Many do not have enough thoracic mobility or scapular stability and that is why you see their sucky arm swing (on one or both sides) that you so desperately hate and are trying to coach out of them. Or, their arm swing suck starts from somewhere deeper, down below in the core, pelvis or lower limbs. Go for the fix, and you will get the arm swing you want. Be part of your client's solution, not part of building a suckier arm swing compensation, heck, they already have one, so don't layer your desirable arm swing on top of their ever present problem. -Dr. Allen

https://youtu.be/7BRuCYcXKJs

Muscle activation and gait: EMG studies that differentiate!

image credit: Cappellini G, Ivanenko YP, Poppele RE, Lacquaniti F. Motor patterns in human walking and running. J Neurophysiol. 2006 Jun;95(6):3426-37. Epub 2006 Mar 22.

Got Muscle activation? Looking for some EMG data on what fires when in walking vs running gait? The conclusion and point of the study are good, but the EMG data and diagrams are awesome for those of you seeking a greater understanding of what goes on when

“The major difference between walking and running was that one temporal component, occurring during stance, was shifted to an earlier phase in the step cycle during running. These muscle activation differences between gaits did not simply depend on locomotion speed as shown by recordings during each gait over the same range of speeds (5–9 km/h). The results are consistent with an organization of locomotion motor programs having two parts, one that organizes muscle activation during swing and another during stance and the transition to swing. The timing shift between walking and running reflects therefore the difference in the relative duration of the stance phase in the two gaits.”

A great read and FREE FULL TEXT

Dr Ivo, one of The Gait Guys

Cappellini G, Ivanenko YP, Poppele RE, Lacquaniti F. Motor patterns in human walking and running. J Neurophysiol. 2006 Jun;95(6):3426-37. Epub 2006 Mar 22. link to free full text: http://jn.physiology.org/content/95/6/3426

#gait, #gaitanalysis, #thegaitguys, #gaitabnormality, #EMGgait, #muscleactivation, #musclerecruitmentpattern

Hearing IS related to balance

"Hearing had a clearly beneficial effect of auditory inputs on vestibulospinal coordination, especially for distance of displacement and angle of rotation." 

Given that these 2 systems, hearing as well as balance, are contained within the same location; “the organ of corti”, this is not surprising. The cochlea is the organ for hearing and the semicircular canals, utricle of saccule componenents of the vestibular apparatus. They share a common internal "fluid" called endolymph in the membranous labrynth of the inner ear that can flow freely from the vestibular apparatus to the cochlea. You will remember that the vestibular apparatus controls the vestibula spinal pathway which keeps us upright in the gravitational plain, along with vision and the joint mechanoreceptors. Involvement of 1 system will usually affect the other.

Dr Ivo, one of The Gait Guys

Seiwerth I, Jonen J, Rahne T, Schwesig R, Lauenroth A, Hullar TE, Plontke SK. Influence of hearing on vestibulospinal control in healthy subjects. HNO. 2018 Jul;66(Suppl 2):49-55. doi: 10.1007/s00106-018-0520-7.

#hearing, #balance, #gait, #thegaitguys, #gaitanalysis, #gaitcompensations, #vestibular

What does a pedograph of a person with hallux limitus look like?

Take a good look at the pedographs above. Can you figure out which side has the hallux limitus from the pictures? 

You would think that with hallux limitus there would be increased printing over the distal phalanx of great toe and possibly over the distal metatarsal as seen in the print of the right foot. This would make sense as if you have limited motion here and the pressure will be more forward. However, often times Hallux limitus is painful and the patient develops a compensation to NOT load the joint, as we see on the print of the left foot. We see the lack of printing under the first metatarsal head and increased printing laterally in the foot from avoidance of that joint. Also notice a slight increased printing in the right heel teardrop (hash marks are more filled in) and slight widening of it anteriorly. He has a right sided leg length discrepancy and we would normally expect an increased amount of pronation on the longer leg side, however because of the weight shift to the left we are seeing increased pronation on the right. Now, with this valgus moment of the right foot do you understand why the printing is so heavy under the first metatarsal and distal phalanx. Note also the increased printing at the distal phalanx of toes number two, three and five on the right hand side in an attempt to stabilize as his center of gravity shifts to the right.

And now you know!

Dr Ivo, one of The Gait Guys

#halluxlimitis, #gaitanalysis, #pedograph, #leglengthdiscrepancy, #LLD

Step width and peak knee forces.

Forget older adults, this is for everyone. If you have a step width that affords knee over foot, hip over knee, and you load those stacked joints, there will be less peak adduction and abduction loads at the knees . . . . and less risk for frontal plane drift of the hip-pelvis, improved control of limb rotation during loading, and reduced risks for over pronation at the foot-ankle complex. These are anti-cross over gait principles.
And, this is obviously not just a stair descent or ascent issue, these are normal fundamental gait (walk and run) principles that just make good common sense !

Knee. 2014 Aug;21(4):821-6. doi: 10.1016/j.knee.2014.03.006. Epub 2014 Apr 3.

Effects of increased step width on frontal plane knee biomechanics in healthy older adults during stair descent.

Paquette MR1, Zhang S2, Milner CE3, Fairbrother JT2, Reinbolt JA4.

Could your low back pain be related to your big toe?

Ok, he has low back pain. But i can also see that high gear (1st toe off) is impaired from loss of terminal dorisflexion at that 1st MTP joint.

Ok , so this means heel rise will be premature and when it does happen the toe off will be towards the lesser toes, low gear toe off.
This means the knee will be carried laterally as opposed to the more desirable sagittal tracking/hinging.
And, if heel rise is premature, this means the knee will likely flex and hinge sagittally just a little, when it should actually be extending and coupling with the gastroc and glute to produce propulsion.
And, when the knee flexes, I know the hip flexes, when we should again be moving into hip extension for propulsion.
And when the knee and hip flex, the vertical length of the leg is shorter functionally, which means a subtle lateral pelvis dip and compensatory thoracolumbar lateral bend to the other side to compensate. This leads to imbalance in the lumbar spine musculature and more work in some areas, and less in others.

So, doc, are you telling me my low back pain is from my big toe? It could be Sir. Lets get into it and find out.
Game ?
Game . . . .

One has to be able to quickly juggle normal known gait biomechanics with pathologic biomechanics. You don't have all day with your patient. Play these games in your head, often.
Example: So, if the knee doesn't terminally extend, what could this mean to the rest of the system ?

Stop treating the area of pain, is might not be the problem.

Shawn Allen, one of the gait guys.

#gait, #thegaitguys, #gaitproblems, #gaitcompensations, #halluxlimitus, #turftoe, #hipextension, #prematureheelrise

Podcast 143: Future of movement, Running Cadence. Plus: gait rehab, eye control, plantar fascia talk

Topics:


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Show notes:

The future of human movement control ?
https://www.zerohedge.com/news/2019-01-01/zuckerberg-funds-wireless-mind-control-using-game-changing-brain-implants

Really interesting study: in-race cadence data from world 100K champs. Fatigue matters less than expected;
https://www.outsideonline.com/2377976/stop-overthinking-your-running-cadence?utm_medium=social&utm_source=twitter&utm_campaign=onsiteshare

A new study shows a majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of two years: ow.ly/GXtC30n49nc pic.twitter.com/dyr4f6pEOU

Gait Rehab
https://academic.oup.com/ptj/article/88/12/1460/2742171
" Rehabilitation of gait in PSP should also include oculomotor training because the ability to control eye movements is directly related to the control of gait and safe ambulation. Vision plays a critical role in the control of locomotion because it provides input for anticipatory reactions of the body in response to constraints of the environment. Anticipatory saccades occur normally in situations that involve changing the direction of walking17 or avoiding obstacles.18 When downward saccades are not frequently generated during obstacle avoidance tasks, there is an increase in the risk for falling. Di Fabio et al19 reported that elderly people at a high risk for falling generated fewer saccades than their low-risk counterparts during activities involving stepping over obstacles. In addition, foot clearance trajectories were asymmetric in the high-risk group, with the lag foot trajectory being significantly lower than the lead foot trajectory. Similar behavior has been observed in patients with PSP during stair-climbing activities. Di Fabio et al20 recently reported that patients with severe oculomotor limitations had a lower lag foot trajectory than those with mild oculomotor limitations. "

Eye movements:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932064/
" The content of the eye movement program was as follows: First, a picture card was shown to the patient, and then mixed with 20 other cards and spread face up on the desk. The patient was instructed to find that one card. This task was repeated approximately 20 times. Second, the therapist moved a baton slowly while drawing curves and the patient was instructed to keep his or her gaze fixed on the tip of the baton. In this task, the distance between the baton and the patient was maintained at approximately 1 m and the task was performed for approximately five minutes. Third, the patient was instructed to shake his or her head laterally as quickly as possible and a letter card with letters written upside down was presented to the patient to read. This task was repeated approximately 10 times. Fourth, the therapist moved a baton slowly from a point approximately 5 cm away from the patient to a point approximately 50 cm away and the patient was instructed to keep his or her eyes on the baton. This task was performed for approximately five minutes. The experimental group underwent eye movement training while the control group underwent gait training for 20 minutes per session, five times per week for six months in total."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259492/

Plantar fascia loads higher when forefoot striking . . . .
https://www.sciencedirect.com/science/article/pii/S0021929018308959
Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis
Tony Lin-WeiChen et al

High pronation was associated with 20-fold higher odds of injury than neutral foot posture
Association between the Foot Posture Index and running related injuries: A case-control study
AitorPérez-Morcillo et al
https://www.sciencedirect.com/science/article/pii/S0268003318304303

movement, gait, thegaitguys, running, cadence, step length, stride length, eye movements, rehab, gait analysis, gait problems, pronation, plantar fascia,

Leg exercise is critical to brain and nervous system health

Leg exercise is critical to brain and nervous system health

"New research shows that using the legs, particularly in weight-bearing exercise, sends signals to the brain that are vital for the production of healthy neural cells."

This research supports what we already know, but in a new spin, that sensory input is just as important as motor output. This study gives new clues into why people with motorneuron diseases (spinalmuscular atrophy etc) decline so quickly as their movement impairment deepens.

This research might suggest that those who do not continue to weight bear load, such as bedridden or chronically ill patients and even the aging population, are at risk for faster decline. "Not only (do they) lose muscle mass, but their body chemistry is altered at the cellular level and even their nervous system is adversely impacted," says Dr. Raffaella Adami from the Università degli Studi di Milano, Italy.

"Limiting physical activity decreased the number of neural stem cells by 70 percent compared to a control group of mice, which were allowed to roam. Furthermore, both neurons and oligodendrocytes -- specialized cells that support and insulate nerve cells -- didn't fully mature when exercise was severely reduced."

"Reducing exercise also seems to impact two genes, one of which, CDK5Rap1, is very important for the health of mitochondria -- the cellular powerhouse that releases energy the body can then use. This represents another feedback loop."

Bottom line here folks, you have to move, you have to load, especially if you have a neurologic disorder and especially if you are declining in age. At the very least, throw some lunges or body weight squats into your day. Walk the stairs, don't ride the elevator. Move. Lift. Strain.

https://www.sciencedaily.com/releases/2018/05/180523080214.htm

Heel lift or sole lift ?

*DO NOT USE A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts to correct a length length discrepancy, and thus causing plantarflexion at the ankle by raising just the heel. What about raising the forefoot, too ?! Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, unload a barking unresponsive achilles tendonitis, or for some strange reason you wish to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
Besides, many people's problems arise from insufficient ankle rocker/dorsiflexion as it is , so why are you sentencing them to the depths of hell by predisposing them to pre-plantarflexed strategies ? You should love your clients ! Using a heel lift requires smarts, deep smarts, and intimate understanding of the pitfalls of pre-positioning the heel higher than the forefoot and what it may do to your clients mechanics over time. Did decades of high heel ramp, high heel-toe drop shoes or a century of high heeled women's shoes not teach us anything? (ok, we are going overboard here to make our point :)
When do we almost exclusively use a heel lift? Very temporarily in unresponsive achilles tendonopathies, and even that can be argued. But, sometimes you have to use unicorns and black magic.
Use your noggin, daily.

shawn and ivo, the gait guys

#gait, #gaitproblems, #gaitanalysis, #thegaitguys, #heellifts, #solelifts, #anklerocker, #ankleplantarflexion, #ankledorsiflexion, #heeltoedrop, #heelrise, #shortachilles

a happy cerebellum = better learning

We are not sure how many of these (little) guys you treat, but this article is germane.

4 hours per day, 5 days per week. It takes time to recannalize (or re create) new (or rejuvenate old) neurological pathways.

"After only two weeks, the children in the experimental group demonstrated a significant increase in locomotor and object control skills and in gross quotient (a composite measure of both skills categories). Participants’ locomotor improvements plateaued between weeks four and eight, and object control skills improved during the first two weeks but demonstrated nonsignificant changes between weeks two and four, four and six, and six and eight. A significant gain in locomotor skills also occurred between weeks four and eight."

...and don't forget about the "neurological windows" we are always talking about. Aggressive, early intervention is indicated

"Early childhood is a sensitive time in development, and motor researchers have an opportunity to improve motor skills very early—even as young as 2 years, said Ketcheson. Early intervention may give children with ASD the ability to play and interact in age-appropriate ways with their peers entering kindergarten. Early intense motor skills instruction within a CPRT framework can be a valuable addition to practitioners’ intervention strategies aimed at improving social success for children with ASD, she said."

Get them up, get them moving!

Testing the Spinocerebellar Pathways

Though we know about the importance of the neck and gait function, like where we discussed here and here, we cannot leave out the integrity of the spincerebellar pathways. Can you test them and discern their functions? This quick video demonstrates how. Some great clinical pearls in this short segment.

Dr Ivo, one of the Gait Guys

#spinocerebellar, #pathways, #clinicaltesting, #gait, #gaitanalysis

Loaded Carry, Addendum idea

Recently, Jan 13th, 2018, we posted 2 photos of the Farmer's carry, in that specific case how to use it to drive more load into the hip stabilizers as opposed to the lateral abdominals. Here is how we progress someone from wide step walking corrections, we add the step up. The next progression is to be sure they do not lose the hip hike as they try to return the foot to the ground, which you do not see here. Note the kettlebell in the LEFT hand. They will have to do that (return the RIGHTfoot to the ground) through a knee bent knee mini-squat-lunge, to keep the gmedius on. Or, they can just do a controlled eccentric, but that is even more attention. Most people just let the RIGHT glutes go entirely to get the LEFT swing leg back to the ground, no bueno ! This is not normal gait, but it is what most people do because they do not have command of the glutes in the 3 phasese: early, mid and late stance. In fact, most people fail through all 3 phases, but certainly the Early and Late phases are the toughest, with the Late phase being the most challenging. The glutes should remain active through the next foot contact phase.

Details matter in a Loaded Carry.

Last night I lectured on the Cross over gait. I discussed at one point using one sided carries, a heavy farmer's carry, to stimulate more activity on the stance leg , particularly focusing on driving more hip stability. But, it matters how you do it.

The photos i have attached are both technically a farmers carry unilaterally. One I am working my gluteus medius and hip stabilizers more, and the other i am using my lateral abdominal chain more (more of a compensated Trendeleberg type gait, and we know that hip pain patients lean in a Trendeleberg gait to reduce the activity of the glute medius to reduce compression across the joint (2/3 reduction)). If you are trying to help your client reduce their cross over gait with more hip stability building, one of them is going to hit the mark far better than the other.
So, if your clients are walking a line in their Farmer's carry, think about what you/they are actually doing (likely less hip stability stimulation).
The exercise should fit your goal. Have them walk feet on either side of a wider balance beam to get more stance phase glute activity (try it yourself, the wider your step width the more hip loading you get), or, have them walk a line and lean more into the frontal plane to get more abdominal. It is not a perfect science, but you do get a different feel from how you do it.

But, it matters how you do it.

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Understanding a strange leg swing problem.
This is an olympic hopeful in the marathon from Australia who came to see us to help with some chronic injuries that she hasn't been able to get help with. We discuss the issue here in the video.

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LLD's and Achilles Tendinopathy

Sometimes, it doesn't matter whether it is long or short.

 Achilles tendinopathy .. there are many factors that can contribute. Have you considered leg length inequality? Generally speaking, People have a tendency to overpronate on the longer leg side and under prone only shorter leg side with strain on the medial and lateral aspects of the Achilles tendon respectively. It would make sense that this could be a contributing factor.

 "The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. "

Age and pathology can play a role with younger, healthy tender and having greater compliance.

Proprioception is impaired on the affected side of folks with Achilles tendinopathy. This is a "chicken and the egg" scenario. Did impaired proprioception cause the tendinopathy or is the tendinopathy causing the impaired proprioception? Probably, a little bit of both.

Dr Ivo, one of The Gait Guys

Leppilahti J, Korpelainen R, Karpakka J, Kvist M, Orava S. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Foot Ankle Int. 1998 Oct;19(10):683-7.

Scholes M, Stadler S, Connell D, Barton C, Clarke RA, Bryant AL, Malliaras P. Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side. J Sci Med Sport. 2018 May;21(5):479-482. doi: 10.1016/j.jsams.2017.09.594. Epub 2017 Oct 6.

Intziegianni K, Cassel M, Rauf S, White S, Rector M, Kaplick H, Wahmkow G, Kratzenstein S, Mayer F. Influence of Age and Pathology on Achilles Tendon Properties During a Single-leg Jump. Int J Sports Med. 2016 Nov;37(12):973-978. Epub 2016 Aug 8.

#achilles,#tendon, #achillestendon, #tendinopathy, #proprioception

Got a kid that "toes in"?

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett, M.D illustration for International Association for Dance Medicine and Science 2011

image courtesy: T Michaud

Got a kid that "toes in" during gait? Are you seeing this?

• smaller foot progression angle

• greater knee adduction

• more internally rotated and flexed hips

• greater anterior pelvic tilt

Wondering what could be causing it?

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is.

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The angle of the femur neck to its shaft diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

There are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. 

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

• the angle of the femur neck to shaft values that exist one to two standard deviations outside the range are considered “torsions”

• Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

• Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

• Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

• Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

• Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

Great paper here

link to full text: http://onlinelibrary.wiley.com/doi/10.1002/jor.22746/abstract;jsessionid=AC848D963DCA526402D71260BDFC91F6.f04t04

Dr Ivo, one of the Gait Guys

#gait,#gaitanalysis,#femoralneckangle, #femoraltorsion, #antetorsion, #retrotorsion, #toein

Changing step width alters lower extremity biomechanics during running.

The Cross over gait. We have been talking about this for years, our theories have been supported by the available research and years of patient care.
Here is another study that goes with our ideas, which gives it deeper clinical relevance.

Changing step width alters lower extremity biomechanics during running. Brindle RA1, Milner CE, Zhang S, Fitzhugh EC. Gait Posture. 2014

"Step width is a spatiotemporal parameter that may influence lower extremity biomechanics at the hip and knee joint. Peak hip adduction and rearfoot eversion angles decreased as step width increased from narrow to wide."
Step width influences lower extremity biomechanics in healthy runners. "When step width increased from narrow to wide, peak values of frontal plane variables decreased.

The Fredericson paper (Hip Abductor weakness in distance runners with iliotibial band syndrome) is also supportive. That paper found that increasing step width reduced the strain on the iliotibial band during running. Greater ITB strain and strain rate were found in the narrower step width condition.

We have said it, and will say it again, because someone will post here, "maybe, but all the pros when you watch then and see photos of them, they all have a very narrow step width, basically qualifying for what you guys call a Cross Over gait. So how can you make such bold statements?"
Our response would be, "every attempt at squeezing out more economy in ones gait, walking that fine line of riskier gait mechanics, is a game of playing ECONOMY vs. LIABILITY. And if you have built enough durability and conditioning into your system that you can nudge right up to that fence of RISK, you can play with those liabilities and squeeze out the economy of your gait (like the pros) with that narrower step width. Just be aware and careful, that when you are losing control, as the runs lengthen, that the LIABILITIES are increasing and thus so is the RISK for injury. Just remember, you are likely not a pro, and have not spend the time building a safe zone of durability on your system to endure narrow step width for 26 miles.

A good runner will train the frontal and rotational planes regularly as they engage in their sagittal sport of running. So that as fatigue sets in and the step width begins to narrow, they have some durability of the lower limb to sustain the risky mechanics of the narrow step width. There is a limit for everyone, when the well goes dry.

Runners, athletes . . . Even in your drills, do it correctly ! Is this Bird Dog standing up? No, look more closely.

Runners, athletes . . . Even in your drills, do it correctly !
Is this Bird Dog standing up? No, look more closely.

Photo #1: pull that right swing leg outwards with your abductors/external rotators. Do not let the knee drift inwards, it will lead to that foot targeting the midline. Plus, because of the neurologic links, it will encourage the left arm to cross the mid line (see yesterdays FB blog post). The upper limb movement can shape lower limb movement. An aggressively narrow cross over gait is undesirable in many aspects, it might be more economical, but it has a wallet full of potential liabilities.
IF you train your machine in a lazy manner, it is not unlikely it will perform as such. Get that knee under the shoulder, not under your head.

Aside from that, this is a good drill. It is neurologically correct. Note that:
- the right arm is in extension and the left hip is in extension
- the left arm is in flexion and the left knee is in flexion.
This is neurologically correct cross crawling.

* VERY important point:
the Bird Dog exercise is not neurologically correct for the reason of training the proper crossed patterning from a neuro perspective. Note that in the 2nd photo, the bird dog, the same left arm is in flexion, but his left leg is in EXTENSION ! If you want to use the bird dog to teach core engagement, that is one thing, but do not think you are coordinating normal gait patterns or the proper crossed response. This is why we do not use the Bird Dog with our patients, it goes against training fundamental gait patterns.
When we crawl, we use the following pattern:
- the right arm is in extension and the left hip is in extension
- the left arm is in flexion and the left knee is in flexion.

This is neurologically correct cross crawling. Don't believe us ? Get on the floor and crawl like an infant, it is no where near the bird dog exercise, in crawling the coupled crossed extension and flexion responses are NOT conflicting. So, just because the Bird Dog "sort of looks like crawling" do not get it confused with crawling, because it is not. It is a mere balance exercise, some use it for the core stability, but it is one based on UN-fundamental neurologic patterning we use every day.......something called gait, and running, things we do in our sports. So understand what message you are sending to the CNS.
We are not saying the Bird Dog does not have value, not at all, but if you are not thinking about what it actually is doing, you might be driving patterns you do not want.

Crawling and Bird Dog, a subtle but important difference.Can you see it ?

Crawling and Bird Dog, a subtle but important difference.
Can you see it ?
When we crawl, as in the photo, we use the following pattern:
- the right shoulder is in extension (but it is fixed on the ground, it is the body that is moving forward/extending over this fixated point, it is approximating the flexing right hip as the knee moves up towards the hand)
- the left hip is in extension, pairing appropriately with the right shoulder extension.
- similarly, the left shoulder is in flexion (it is over head in this photo, just like in the other photo of the runner similarly doing the same patterning but standing up, meanwhile the right hip is in flexion.
* take the photo of the runner in the green shirt, and put him in a quadruped crawling pattern as you will see that it is the same pattern as the one of me in the crawling posture.
* This is not bird dog, as seen in the photo, do not confuse them.

The Bird Dog exercise is not neurologically correct for the reason of training the proper crossed patterning from a neuro perspective. Note that in the 2nd photo, the bird dog, the same left arm is in flexion, but his left leg is in EXTENSION ! If you want to use the bird dog to teach core engagement, that is one thing, but do not think you are coordinating normal gait patterns or the proper crossed response. This is why we do not use the Bird Dog with our patients, it goes against training fundamental gait patterns.

This first photo of me in the black shirt is normal, natural, neurologically correct, cross crawling. Don't believe us ? Get on the floor and crawl like an infant, it is no where near the bird dog exercise, in crawling the coupled crossed extension and flexion responses are NOT conflicting. So, just because the Bird Dog "sort of looks like crawling" do not get it confused with crawling, because it is not. It is a mere balance exercise, some use it for the core stability, but it is one based on UN-fundamental neurologic patterning we use every day.......something called gait, and running, things we do in our sports. So understand what message you are sending to the CNS.
We are not saying the Bird Dog does not have value, not at all, but if you are not thinking about what it actually is doing, you might be driving patterns you do not want.