The Bird Dog rehab exercise is neurologically incorrect. Know what you are asking your client to do, and why..

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.

Arm swing, cross over, head over foot?

Here is a Birdseye view of someone in full stride gait. The left leg and the right arm are into flexion and external rotation.
The right leg and left arm are into extension and internal rotation.
We discussed this in depth on our lecture on wednesday night.
These counter movements drive,and are driven by, the anti-phasic properties of normal gait.
Now, lets posture some thoughts with the head-over-foot mentality (which we do not subscribe to(listen to podcasts 135-136)). . . . You can see the clear relationships here of coupled motions of the limbs. Now imagine that you forced a cross over arm swing, pumping arm Swing across your body. This is shoulder/arm adduction. So what do you think is likely going to happen in the lower limb? Yes step width narrowing, i.e. crossover gate/Leg adduction. By forcing the arms to cross the midline you are strongly encouraging the legs to do the same thing. As we have discussed many times previously, the arms can shape the movement of the lower limbs even though the lower limbs run the primary patterns of which the arms are driven from. So if you want a crossover gait , which we have for years documented research showing biomechanical challenges, and something we see many injuries driven from, go ahead and coach and train your arm swing across the body.

When runner do you want to be? 2 photos

Who do you want to be ? The guy loading his head over his foot
(narrow step width), or the gal loading the head and COM inside the foot (less narrow step width) ?

It is not hard to suspect who is gonna be faster and more powerful from these photos. This however does not mean on is more durable, more or less injured, more or less efficient but logical debates and thought experiments can be made here.

The lady is stacking the knee over the foot, the hip over the knee and stabilizing the hip and pelvis sufficiently and durably to keep the pelvis level for the next powerful loading step, and the other is flexion collapsing into the stance phase knee, insufficiently loading the hip and thus dropping the opposite side pelvis. He is not stacking the joints, there is a pending cross over (look at the swing leg knee approaching midline with barely any knee spacing, thus guaranteeing a cross over step or at the very least a very narrow step width.)
Sure, some one is going to say one is a distance runner and the other is a sprinter. Yes, and our point is that the sprinter is not head-over-foot, the one with all the highly suspect flaws is head over foot ! Wider step width means more glutes. Go ahead, walk around right now with a very narrow step width and see how little efficient glute contraction you get, then walk with a notably wider step width, and you will see wider means more glutes. Keep your COM moving forward, not oscillating back and forth sideways over each stance foot, that is a power leak.

The distance runner appears to be demonstrating less optimal in technique, appears is the key word here. Say what you want, but a decent argument might be made as to one of these runners being weak and very likely at greater risk for injury, the other is suspect to be strong and durable, and likely at less risk for injury.
If you ask us, but what do we know . . . . it is all a thought experiment, but based on some pretty decent ideas.
So, again, was ask . . . . which one do you want to be ?

The hip flexors do not cause initial hip flexion.

The hip flexors are not responsible for pulling/flexing the swing leg forward in gait or running. The psoas is a mere swing phase perpetuator, not an initiator.
For about 2 decades we have been saying in our lectures, posts and podcasts that it is the reduction of the obliquity of the pelvis during gait from various other tissues and biomechanical events that causes leg swing, meaning the trail leg is brought forward in swing largely by the abdominal muscle linkage to the pelvis (and other loaded tissues) that is responsible for forward swing of the leg. It is not the hip flexor group that does this hip flexion action. Thus it could be considered foolish to train the hip flexors to be the primary swing drivers. Here is another supporting piece of research.

"These experiments also showed that the trailing leg is brought forward during the swing phase without activity in the flexor muscles about the hip joint. This was verified by the absence of EMG activity in the iliacus muscle measured by intramuscular wire electrodes. Instead the strong ligaments restricting hip joint extension are stretched during the first half of the swing phase thereby storing elastic energy, which is released during the last half of the stance phase and accelerating the leg into the swing phase. This is considered an important energy conserving feature of human walking. "

Dan Med J. 2014 Apr;61(4):B4823.
Contributions to the understanding of gait control.
Simonsen EB1.

https://www.ncbi.nlm.nih.gov/pubmed/24814597?fbclid=IwAR3yZQLb2Z0X1LZSVp2hOFLCt3wefsPt4iWEGveswn7-aGaou5OdDqmj4lA

The Mighty Multifidus

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:

"Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity."

see also our post here: https://tmblr.co/ZrRYjx14tXWrD

Dr Ivo Waerlop, one of The Gait Guys

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print] The immediate effect of dry needling on multifidus muscles' function in healthy individuals. Dar G1,2, Hicks GE3.

#gait, #gaitanalysis, #multifidus, #lowbackpain, #proprioception,#thegaitguys

A foot bump. What might this be, and mean?

A foot bump.
We see this kind of thing all the time. This is a fixed pes planus (flat foot). When we dorsiflex the big toe, the arch does not go up as you see in the photo. That is passive dorsiflexion, if the arch does not go up passively, there is no way you are actively going to achieve this. And, using an orthotic to "attempt" to raise this arch is not only pointless, but it is futile and it will likely cause them pain. This arch does not rise, no matter how hard you put up into it. The bump, that is the navicular bone, and its associated arthritic build up at the adjacent joints, and likely soft tissue accomodation/hypertrophy. You can't needle, ultrasound, tape, adjust or rub this bump away, so stop wasting your and your patient's time selling them that wasteful thinking. It ain't gonna happen.
This is what happens when someone earns a collapsed longitidinal arch, the 1st metatarsal no longer plantarflexes (arch up) and it becomes fixed in dorsiflexion, thus affecting the mechanics at the proximal aspect of the 1st ray complex (navicular-cuneiform-met intervals).
Why? This happened because this client has significantly compromised ankle mortise dorsiflexion, and they chose to find it at the next joint complex distally, as mentioned above. So, they are finding pseudo-ankle rocker at arch collapse? Yes, we discuss this often, more pronation will advance the tibia forward. It is not desirable, but moving forward has to occur, and some people have no choice but to find it from excessive internal rotation and pronation of the limb. And this is what happens when it happens over years. Now the deformity is painful itself in the shoe, it is a new set of problems for this client.
Can this problem occur in reverse ? Yes, a loss of hallux dorsiflexion can afford the same end result.
We have a rule, at the very VERY least, check the joint above and below the area of problem/symptom. Often you will find another piece of the puzzle causing your client's pain.

Tibial Torsion and Motion control shoes... Be Careful!

In this short video, Dr Ivo Waerlop of The Gait Guys discusses the pitfalls of using motion control shoes in folks with internal tibial torsion.

#thegaitguys, #gaitanalysis, #tibialtorsion, #motioncontrolshoes, #kneepain

Right arch pain, can you see a possible reason in this video?

Do you see a possible reason for right foot pain? There is something not kosher to be seen. It doesnt mean it is valid, or the cause, or that it is primary or secondary, but it should be something that cues up a clinical exam focus to rule in/rule out.
Answer below (don;'t read further, test yourself)
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the right hallux does not fully extend. And we know that hallux dorisflexion at the 1st MTP joint engages the windlass, and helps to plantarflex the 1st MET and raise the arch and prepare the foot for loading and for forefoot transition. If the hallux doesn't extend sufficiently (like in a hallux rigidus, painful turf toe etc) then we can have some loading issues. Just something to think about. In this case, it was the cause and answer. But might not always be such.

What do torsions and versions look like on exam?

Here, we talk about some of the basics from the clinical exam on femoral and tibial torsions

Dr Ivo Waerlop, one of The Gait Guys

#thegaitguys, #gait, #torsion, #tibial, #femoral

When your calf is weak, things can dorsiflex too much sometimes.

When your calf is weak, things can dorsiflex too much sometimes. Maybe this is why you have Achilles tendinopathy. Maybe.

When we run, we either heel strike, midfoot strike, or forefoot strike. The literature is pretty clear on this now, that any one of them is not better than the other and there are many variables that need to be taken into consideration (even though many folks, who stopped reading the studies long after the barefoot craze began, will proclaim at the grave of their mother that rearfoot strike and anything but zero drop shoes are the root of all evil).

However, if you are a forefoot striker, the calf complex must be durable, strong and have enough endurance that when the foot strike occurs, that over time the complex does not allow the heel drop to become excessive or uncontrolled to the point that the achilles tendon proper exceeds its capacity to tolerate the drop, the stretch load capacity. It is more complex than this, because when the heel drops too much, too far, too fast and the arch is not durable enough, the metatarsals may dorsiflex too much and compromise the arch and stiffness of the midfoot, this can also have its complications. A weak calf can impact the rest of the foot. Remember, when the forefoot is engaged on the ground, and the heel drops in an uncontrolled fashion, we are increasing ankle dorsiflexion too, and this may not be welcomed during a stance phase of running where we are hoping for sufficient foot stiffness to load across it and propulse off of it.

This study showed that "analysis revealed that male recruits with lower plantar flexor strength and increased dorsiflexion excursion were at a greater risk of Achilles tendon overuse injury".

Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study.

Mahieu NN, et al. Am J Sports Med. 2006.

Pigeon holed into a particular running form. Some thoughts.

We should not pigeon hole everyone into one of the major (often discussed) "running forms". Every person's running form has some unique parameters that work for them (and perhaps some components that do not work for them and lead to injury), and asking their body to do something else that you "deem" better for them because it looks right/better can at times lead to new issues or complications in resolving their complaints. Work with their system, their anatomy. Help them correct mechanical flaws related to their problems/complaints/injuries. Do not try to get everyone into one of the classically pristine and magazine cover running forms. As Allan on our FB page said, "gait correction requires work". And may we say this . . . . that prescribing corrective exercises does not mean they will spill over into their gait with positive changes. There must be teachable time that is hands on to help them blend over the corrective work into new gait patterns. This is a skill that takes a long time to learn and figure out, and each client is different and each client requires different cues and different exercises to tap into the desirable cues for them. This is why internet/youtube corrective exercise prescribed homework (ie. do this exercise to correct your iliotibial band syndrome) often does not work and sometimes creates new problems down the road. Why? . . . because there are holes missing when there is not a hands on exam to ensure the corrective work is the right work, and, just as importantly, it takes time and skill to show, demo, and translate how and why the homework will take over into a new gait pattern. Translation, corrective exercises do not guarantee a new gait pattern or new running form. There are so many bad examples we could use, "just going to the mechanic does not guarantee they will fix your car", "changing your tires does not necessarily make you a safer driver", "watching some youtube videos on learning to drive does not mean you actually know how to sit in a car and drive".

Adaptations and compensations.

. . . the entire system has to adapt to that deficiency. That means compensation. Now, does adding strength to that asymmetry (compensation) have a consequence. Most likely. Will it lead to injury? That is the question.

We are going to keep pounding sand on this one because we believe this is important.
All too often people are working out and strengthening their systems, and that is good. But, if they are strengthening a system that is asymmetric or strengthening a faulty pattern (clearly, as in too much arch collapse) they are likely overburdening the hierarchical system and a component of the chain of that system.
Now, many are going to argue, and we know who those folks are, they are going to argue that if the movement is not painful, if the posturing of the load is not painful, then it is not a problem. Sure, and that is easy to say, but there is no proof they are right either. And, we are not saying we are stonewalled right either, but we are trying to be logical with what we know and what some of the research says (yes, that fits our bias). But our eyes are open and we hear the arguments from the other side, but those arguments come from a crystal ball in our opinion. Truthfully, no one has that crystal ball and can see into the future to see if one side of this argument has any more "legs" to it.
However, we know that . . .

"Human movement is initiated, controlled and executed in a hierarchical system including the nervous system, muscle and tendon. If a component in the loop loses its integrity, the entire system has to adapt to that deficiency. Achilles tendon, when degenerated, exhibits lower stiffness. This local mechanical deficit may be compensated for by an alteration of motor commands from the CNS. These modulations in motor commands from the CNS may lead to altered activation of the agonist, synergist and antagonist muscles."- Chang and Kulig

So, when we see a pattern of loading that is aberrant, and especially when it is most likely playing into a client's painful presentation, it is an easier sell on the thought-arguments above. We know that the entire system has to adapt to deficiencies. It is how we are synergistically built. We have redundancies build into us that protect us. Compensation is part of the redundancy. So, does adding strength to that asymmetry (compensation) have a consequence? Most likely it does, in our opinion. Why allow an area to undergo more loading than we know it should, (ie. valgus knee loading) even if it is non-painful to a client ? Will it lead to eventual injury or pain? That is the question. But we have picked our side of the story, for now, until proven otherwise, and we work from that side of the line. For now.

"yet" is a powerful looming word.
When adding strength takes someones pain away, it doesn't mean you fixed them. It likely means you helped them adapt and protect and better negotiate the loads. However, it also does not mean that your instruction did not build a layer of initial protective strength that will not have a cost further down the road because it wasn't the right medicine for the problem.
When your cars alignment is off, and it is pulling the car to the right towards the ditch, pulling harder to the left on the steering wheel keeps the alignment aberrancy, and the ditch at bay. But nothing was fixed. You adapted and compensated. The problem is still sitting there. And you will get used to the adapted and compensated pattern of steering wheel pull in time. Until the next thing occurs. Maybe the tire will start to chirp in time, the treads silently wear unevenly, and maybe it will be your left shoulder that chirps at you, and not the car.

The squeaky wheel may get the grease, but the misaligned tire is ignored.

Shawn and Ivo, the gait guys

J Physiol. 2015 Aug 1; 593(Pt 15): 3373–3387.
Published online 2015 Jun 30. doi: 10.1113/JP270220
The neuromechanical adaptations to Achilles tendinosis
Yu-Jen Chang and Kornelia Kulig

#gait, #thegaitguys, #gaitcompensations, #gaitproblems, #compensations, #running, #walking, #genuvalgus, #pronation, #CNS, #synergist

The knee follows the arch/ankle.

*in the video, watch the left knee
Hopefully this video and post will make you think deeper about patellofemoral tracking, runners knee, meniscal issues and anterior knee pain syndromes as a whole.

This is subtle, but in this case, this is relevant to the LEFT knee complaints of this client.
When the foot complex is a little weak, the arch can collapse more than it should, rendering too much pronation, this means the talus will adduct, plantarflex and medially rotate more than it should. Since the tibia sits on top of this talus it must follow. This will allow more internal tibia spin (medial rotation) and this will drag the knee medially (it appears in the video to be a valgus load but it is more internal/medial rotation than valgus).
So, what the foot-ankle complex does, the knee follows. Conversely, when the knee moves medially or valgus because of a hip weakness (poor external rotation control) the foot will move medially.
So, are you going to "fix" this with an orthotic ? A stability shoe? Or are you going to actually help the client gain better control ?
You can see that our "raise the toes, to raise the arch" helps the client find the more appropriate arch posture with the help of more anterior compartment engagement and windlass effect at the 1st MPT-hallux joint. This is where our reteaching of the component parts via "motor chunking" via the Shuffle Walk (see our youtube channel) can help them control the rate and amount of arch "collapse" and thus control the rate of medial knee spin.
i say it on our podcast all the time, the knee is a simple sagittal hinge joint between 2 multiaxial joints. It is often a follower, not a leader.
Or you can bandaid this client with an expensive orthotic and never fix their problem. This keeps them coming back over and over for symptom management. It is a good business model (insert sarcasm), but helping this client learn and remedy their deficiency is a better one. Happy people talk to their friends, even strangers.

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #ovepronation, #archcollapse, #valgusknee, #tibialspin, #internalhiprotation, #thegaitguys, #kneepain, #runnersknee, #patellapain, #anteriorkneepain

"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."

We say this so often in our offices.
"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."
Translation: compromised mechanics leading to tissue overloading.
But we all have to strongly consider that injury is a result of the loading you have not trained gradually into, failure to adapt and accommodate, excessive mileage without adequate tissue recovery,

From the article:
"So Napier and co-author Richard Willy from the University of Montana reviewed the highest-quality research featuring randomized controlled trials and systematic reviews.
"What we see is that there's really no high-level evidence that any running shoe design can prevent injuries," Napier said."

Now, to be honest, in our (the gait guys) opinion, there are times we do recommend a change in the foot wear for a client, and it is often because it appears to be working against someone mechanics and is a contributory factor in their injury or complaint. And sometimes that shoe recommendation is a temporary one, and sometimes a permanent one. We can use a shoe to help us get to a better/faster end point. After all, when we sprain an ankle sometime a brace or crutches are helpful and protective, of temporary value. A wisely chosen shoe can act the same if we are dealing with an acute achilles tendinopathy or a painful bunion for example. And in those cases we might recommend a shoe that can give us an assist. Sometime, when appropriate perhaps it is a shoe with a stronger medial post, perhaps one with a higher or lower heel drop/delta, or more or less stack height, or perhaps a mid/forefoot rocker built into the shoe. The truth is, people come in with functional or "fixed" pathology and sometimes pairing up a shoe to help us around some conflicting biomechanics can be temporarily, and sometimes permanently, helpful. But, the shoe is never the only answer, a wise clinician has many things they can utilize, all the way up the kinetic chain sometimes.
The more you know, the better you can assist someone.

Shawn Allen, one of the gait guys

#Nigg, #barefoot, #shoes, #stackheight, #heeldrop, #achillestendinitis, #bunion, #pronation, #supination, #running, #gait, #thegaitguys, #gaitanalysis, #gaitproblems, #gaitcompensation

Can the design of a running shoe help prevent injury? A B.C. researcher says he has the answer

Kelly Crowe · CBC News · Posted: Dec 15, 2018 9:00 AM ET

https://www.cbc.ca/news/health/running-shoe-injury-prevention-second-opinion-1.4947408?fbclid=IwAR3XaGPdgfQ68wj2N0tHqIamDdpYuxTIIL2LeudUd-doYN8YqQrIZI9-s9E

The Alex Honnold climb you haven’t heard about.

On janurary 15, 2014 Alex Honnold, Free-Soloed El Sendero Luminoso (The Shining Path) in El Potrero Chico, Mexico in a little over 3 hours. The climb rises 2500 feet to the summit of El Toro. At the time, it was considered to possibly be the most difficult rope-less climb in history, . . . until El Capitan.

An Alternate View of Crawling and Quadrupedal Motor Patterns: A Correlation to Free Solo Mountain Climbers ?

snippet from our redux blog post (link below):
"The interlimb coordination in climbing and crawling biomechanics shares similar features to other quadrupeds, both primate and non-primate, because of similarities in our central pattern generators (CPG’s). New research has however determined that the spaciotemportal patterns of spinal cord activity that helps to mediate and coordinate arm and leg function both centrally, and on a cord mediated level, significantly differ between the quadruped and bipedal gaits."

Blog link:

https://www.thegaitguys.com/thedailyblog/2019/2/10/an-alternate-view-of-crawling-and-quadrupedal-motor-patterns-a-correlation-to-free-solo-mountain-climbers-?fbclid=IwAR314kcjj6_KCnIczXksa6_5qUDQfy30NEPseH_RBmgVYEzNRSHcm8hq-IQ

What do the hip flexors have to do with the knee extensors ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment."

This is just a small example of how I approach a client through small assessment window.
As best as I am able, knowing the absolute limitations of a supine examinations translation to vertical loading, I will approach a client's ability to stabilize in all 3 planes of movement. Today, i will micro-dissect a thought process.

The straight leg resistance test (SLR):
just a few incomplete thoughts on a SAGITTAL perspective (so as to avoid writing a book).
I will do it looking at **pelvis posture (anterior, posterior, oblique), lumbar spine posture (incr/decr lordosis), if they can keep their knee locked in a position, does the pelvis rotate, do they want to deviate into internal or external rotation at the hip, do they plantar or dorsiflex their ankle or toes. Lots to see here in how a client will recruit, and this is just a small snapshot of things they might do. Yes, head position, arm position were left out , again, to avoid a longer post today.
I will add consistent (as best as possible) resistance in the SLR test , with full locked knee, at hip 30, 45 and then full straight leg SLR (at the client's hamstring tension limit), then again at 45 degree knee lock with partial hip flexion, 90 degree hip and knee. I am changing loading vectors frequently to see if their is a directional loading failure. I am looking for their ability to provide ample resistance, and how they might cheat (see above).
But here is how my mind works through the test on the most basic level, which will give me insight on the above cheats** the client may employ.
* In the MOST SIMPLEST thought of the assessment, can they EFFECTIVELY stabilize the pelvis to the lumbar spine, can they stabilize the femur into the pelvis, can they stabilize the tibia onto the femur? It is how they choose to engage the system that matters, and that might be partly why their "Screen" shows up shoddy and may be a window into their pain.
The question is, if they fail, where are they failing and what tissues are overburdened or over protecting ? Where is the load, and where NOT is the load, going ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment. This is how you need to be thinking when you perform many of the mostly useless orthopedic tests in the textbooks.

This is key,
a SLR screen will not show you any of this, it will just show you their range of motion, nothing more, not how they did it, what parts worked harder than other parts, and which parts are weak, injured or inhibited, for example. It is not what a client does, it is how they go about it that has the most value to you in helping them.

Today's article below is what spurred my rant today. It gives light that most already know, that everything is connected. And perhaps we can translate it into deeper thoughts for our clients, namely, what part is not doing its job, and where are they not connecting the parts, and where are they putting the loads ?

From the Ema study:
"Our findings indicate that hip flexion training results in substantial neuromuscular adaptations during knee extensions similar to those induced by knee extension training."-Ema et al.

We need a stable and strong core-spine-pelvis connection to display powerful knee extension, and, we need a stable and strong femur-pelvis connection as well. So, where is your client doing more or less of the work, and is it related to their hip, low back or knee pain? Or are they tossing it into the ankle perhaps? This is the beauty of the game we all play every day, if we are actually paying attention.

Now, remember my discussion last week about "adding strength to dysfunction" ? Where is your client going to put the load?, the answer, where they can/able. And that doesn't exactly mean where they should be putting it. Mindless prescription of corrective exercises is a real problem in my opinion.

Shawn Allen, the other gait guy.

#gait, #gaitproblems, #gaitanalysis, #correctiveexercises, #running, #hipflexors, #kneeextension, #SLR, #corestrength, #thegaitguys

Scand J Med Sci Sports. 2018 Mar;28(3):947-960. doi: 10.1111/sms.13008. Epub 2017 Nov 22.
Neuromuscular adaptations induced by adjacent joint training.
Ema R1,2, Saito I3, Akagi R1,3.

Imposter syndrome and careful what you say, and read.

Why most published research findings are false.
Ioannidis JP1.
PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30.

"Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research."

Artwork:
from what we can tell, a rework of @rundavidrun artwork, reworked by @MatthewJDalby. Thank you gentlemen.

People received an incomplete picture from a small slice of a clinical exam pie yesterday and made some bold , yet reasonable judgements admittedly. We admit they are germane points and arguments, though easily biased on this small slice video, and unfair in the bigger picture. I will always back Ivo, he is one of the smartest clinicians i know, and if you have listened to our podcast it should be clear to anyone that he can run circles around most with his deep well of knowledge. Dr. Ivo showed a video that discussed some of the things he likes to consider on an exam, not his entire exam, to discuss some things he likes to think about and incorporate into his exam sometimes, things that have become reliable patterns that work for him in practice. Many of us have gone through these exam methods at one time if we have been in the fields long enough, and many of us know that "i do not feel a darn thing that they say i am supposed to" BUT, when put into a full complete exam, for Ivo, these things meshed with other exam inputs honed over a 25+ year history in the field mean something to him. And bottom line, results speak. That is all that matters because a lot of research is often full of holes. I too have some old tricks in my bag that are admittedly somewhat unsupported, but in a bigger picture when all the exam intake variables are brought together, decades of experience allow us to use deeper clinical experience to bring forth some ideas on the client's pain and problems. If we were all to abandon all of our older tricks that have proven valuable, who suffers ? And for what? a few studies that question validity? Everyone's educational past is full of holes and ignorance that has been disproven (yes, even your high school physics knowledge has been rewritten, but it does not mean that the broader insights that have grown from said knowledge is wrong. For example, even today's Low back pain research is becoming more and more untenable in some studies as to the true source of the pain, this has been a huge topic of discussion on some forums by very intelligent people. We are all reading small pieces of new research that tell us "this thing" or that thing is of low reliabilty and we question ideas of old. Some new research is now suggesting that ACL tears do not need surgery, so do we just stop doing ACL repairs? No, that is foolish, but just because the new doesn't support the old doesn't mean the old is useless and without clinical value. Here is what matters, can you help the person in front of you ? That is what matters. How you assess and go about it is not what matters to your patient. Ivo is top shelf, period. There are few people that have the depth and breadth of his knowledge in neurology and if you knew his depth of physiology was even deeper you'd be fully blown away. Listen to one of our podcasts if you do not believe me, he can run circles around me, for what little that might be worth. Productive comments can be made to create a debate without being snide. You only show you are a turd and your true colors (brown) when you cannot be professional. We work hard here, if you can't be professional, go somewhere else, please.

Oh, and still want to question things, good, you should, we all should. So, here, question EVERYTHING then.
Then again, there are those that will question this too, as they should. And so, if we just left our selves to decide to only use things deemed valid per today's thin research standards (what is your predatory journal count up to these days?) , then we dismiss much of what we used in our past that we used to actually help people. Do i dare ask those slinging stones to remember this post when 20 years from now the then research might dismiss many of the things they presently deem "law" and solid research?

Bottom line, judge softly, with open eyes, a touch of wisdom and skepticism, and self honesty in the knowledge that much of what we do, and think we do, is also rubbish, but sometimes yet still seems to help people.
And for those who still think they know it all, look at today's art work.

Shawn Allen, humble partner of a wise man, wiser than most. Dr. Ivo

PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30.
Why most published research findings are false.
Ioannidis JP1.
"Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research."

Comment in

Modeling and research on research. [Clin Chem. 2014]
The clinical interpretation of research. [PLoS Med. 2005]
Minimizing mistakes and embracing uncertainty. [PLoS Med. 2005]
Truth, probability, and frameworks. [PLoS Med. 2005]
Power, reliability, and heterogeneous results. [PLoS Med. 2005]
Why most published research findings are false: problems in the analysis. [PLoS Med. 2007]
When research evidence is misleading. [Virtual Mentor. 2013]
The Value of P. [Am J Transplant. 2016]

https://www.ncbi.nlm.nih.gov/pubmed/16060722

another Patreon video cast study

Adding strength to dysfunction ?

Are you adding strength to dysfunction? Will you be apologizing?
We have been saying this for at least a decade now, glad Michael Boyle feels the same way (see his tweet below).
See ? we are not alone and crazy ! Other smart people are thinking the same things. This is just logic to us and seems Mike feels the same way. We do not fully understand the nay-sayers and push back on this topic.
And so, if you are not examining your client, rather just "movement screening" them and then making corrective exercise prescriptions based off of mere screen outcomes, you are likely, in our strong opinion, risking merely building strength on top of how they already are moving, which is quite possibly dysfunction.
Now, many will argue, a more durable pattern, even if it is dysfunctional, is less likely to be injured. And we can agree with that. But, if you are going to spend all that time, why not just fix the darn problem and then add durability on top of that sound loading pattern in the first place?

Are you going to leave that spare tire on the car just because it drives fine? There is a reason you don't tow a trailer with a spare tire on, and there is a reason you do not drive it at 100mph either. Get the original tire fixed darnit ! Do not settle with, "hey it works fine right now! Leave it alone!" (doh !)

Adding compensations to compensations can have ramifications down the road.
Do you want to be apologizing down the road? Scratching your head asking, "is this a result of what i recommended?"

hmmmmm
It should make you think more about what you are doing, everyday. It sure keeps us in line, everyday.
Makes you ask the hard question of why you are recommending something.
Sorry for the continuous 10 year rant on this. But it is nice to know we are not alone.

shawn allen, one of the gait guys.

#gait, #gaitcompensations, #gaitproblems, #dysfunction, #compensations, #strengthfirst

Knee pain and the the semitendinosis?

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

The semitendinosus hails from the posterior compartment.

During an ideal gait cycle, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off.

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain.

The semitendinosis is the most superficial of the hamstrings and originates between the biceps femoris, with which it shares a common tendinous attchment, which is anterior and slightly lateral and the semimembranosis which is just beneath it and slightly medial. It is fusiform and the muscle body ends about mid thigh, before becoming a long "piano string" and ultimately inserting most inferiorly of the trio, below the gracilis, on the pes anserine.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing. Look to this troublesome trio the next time you have recalcitrant medial knee pain.

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #gaitdysfunction, #thegaitguys, #pesanserine, #semitendinosis

Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SH. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013;26(3):249-54. 

Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 

Gray H:  Anatomy of the Human Body  Lea and Febiger, Phildelphia and New York 1918

https://www.anatomy-physiotherapy.com/knee/articles/systems/musculoskeletal/lower-extremity/knee/test-your-knowledge-the-pes-anserinus

 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011