Loading protocols for achilles tendinopathy.

We all know now that the smartest way out of a chronic tendinopathy is painfree, progressive loading. We, as many others have found, that isometrics serve the initial process well because there is no movement through a painful arc, the isometrics can help reduce the neurologic pain loop, and we can more easily find positions where there is no pain in the tendon. This allows us to load the affected tendon, without adding insult to the tendon portion that is injured. It them prepares us for the weeks to months of eccentric and concentric loading that is often necessary to restore function. Keep in mind that some of the literature indicates that some tendons never fully heal, but we replace things with a better functioning of the remaining competent tendon.

This study found that there was an improvement in pain and function as early as 2 weeks. You might find this interesting because on imaging tendon structure does not change within 2 weeks and muscular hypertrophy is not seen for at least 4 weeks following inception of a loading protocol (Murphy). Thus, we all need to continue our education and understanding of central pain mechanisms. Meaning, that these initial early changes, are in part, and maybe a huge part, are neurologic.

Sports Med. 2018 May 15. doi: 10.1007/s40279-018-0932-2. [Epub ahead of print]
Rate of Improvement of Pain and Function in Mid-Portion Achilles Tendinopathy with Loading Protocols: A Systematic Review and Longitudinal Meta-Analysis.
Murphy M1,2,3, Travers M4,5, Gibson W4, Chivers P6,7, Debenham J4, Docking S8, Rio E8,9.

When the Windlass is lost.

When the Windlass is lost.
Here, this case again (hallux amputation), when the Windlass is lost or at the very least, impaired, what holds up the arch?
Without the winding of the plantar fascia through hallux dorsiflexion (toe extension) and without the FHL (flexor hallucis longus) we lose major engineering advantages to lift/support the arch and control pronation variables.
So what is left ?
Tibialis posterior, tibialis anterior, peroneus longus, mostly, are what is left. So when these guys are suffering (ie, tendinopathy etc) it could be due to the other previously mentioned engineering marvels being impaired.

It is a team effort to keep the foot healthy and functioning without expressible pathology.

*note the heavy flexion attempts of the 2nd toe, the next soldier in line, no surprise there.
Now you should realize why you see this 2nd toe over-flexion attempts when even an existing, yet incompetent, hallux is present.

This slide is part of a new presentation, one we will be doing a WEBEX on that you can all join in on, and it will be a new presentation for our onlineCE Wednesday night seminars.

Now, go read this dudes blog, inspirational journey through big toe cancer. Thanks for sharing your story Kevin, and your case photos. (PS: presentation is almost done, so i will be in touch soon so we can go over it and collaborate).
https://www.theagecoach.com/

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #gaitcompensations, #halluxamputation, #windlassmechanism, #halluxdorsiflexion, #pronation, #FHB, #FHL, #hammertoes, #theagecoach

Podcast 145: Tendons, Heel Drop and their impacts on the posterior chain,

Heel lifts, Sole lifts and their impact on the EMG of the posterior chain.

Keywords: gait, gait analysis, gait problems, running, ankle, tendinopathy, heel lifts, sole lifts, EMG, paraspinal activity, gluteal inhibition, posterior chain, anterior pelvic tilt, tight quads, diagnostic ultrasound

Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".

Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
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.

Where to find us, the podcast Links:

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

Google Play:
https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_149raw_-_31619.mp3

Permalink URL: http://thegaitguys.libsyn.com/podcast-tendons-heel-drop-and-their-impacts-on-the-posterior-chain

Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/9027890

Show notes:

Current trends in tendinopathy management
Tanusha B.Cardosoa, TaniaPizzarib, RitaKinsellab, DanielleHopec, Jill L.Cook
https://www.sciencedirect.com/science/article/pii/S1521694219300233

https://www.jospt.org/doi/full/10.2519/jospt.2015.5880


Insightful paper on how tendon adapts to loading and unloading. Discusses a lack of evidence supporting eccentric training as the treatment of choice for injury and notes that tendon response to loading is not normalized until ~6-12 months after injury
https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP275450
The impact of loading, unloading, ageing and injury on the human tendon
S. Peter Magnusson, Michael Kjaer

Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review
Chantel L.Rabusinac, Hylton B.MenzacJodie A.McClellandbcJade M.TanacGlen A.WhittakeracAngela M.EvansaShannon E.Munteanuac
https://www.sciencedirect.com/science/article/pii/S0966636218310075?dgcid=coauthor

The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip extensor complex during trunk forward flexion and return task
AnnaMikaa, Brian C.ClarkbcŁukaszOleksy
https://www.sciencedirect.com/science/article/abs/pii/S1356689X13000428


The effect of heel lifts on trunk muscle activation during gait: A study of young healthy females
Christian J.Bartonac, Julia A.CoyleaPaulTinley
https://www.sciencedirect.com/science/article/pii/S1050641108000424

A Systematic Review and Meta-Analysis of Crossover Studies Comparing Physiological, Perceptual and Performance Measures Between Treadmill and Overground Running
https://link.springer.com/article/10.1007/s40279-019-01087-9

Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus - ScienceDirect
https://www.sciencedirect.com/science/article/pii/S1466853X18305017

1st MTP Pain? The Biomechanics of the Big Toe...

Remember the rockers? We have done a series on this in the past. Remember there are three: heel, ankle and forefoot. We are going to concentrate on the forefoot today.

As a reminder, forefoot rocker occurs at the 1st metatarsal phalangeal joint (big toe knuckle) as the tibia progresses over the forefoot during forward movement. You NEED 50 degrees to do this competently; you SHOULD have 65 degrees. When you don’t, you have a condition called hallux limitus. This could be from a number of reasons, from overpronation in the mid foot, to a bunion, to faulty firing patterns of the muscles which help to descend the 1st ray (the extensor hallucinations brevis, the peroneus longs and the short flexors off the toes). Pretty much, ANYTHING that causes a dorsal and posterior shift of the 1st MTP axis will cause limited forefoot rocker.

So, the question is, “Do you know where 1st 1st MTP pain may be coming from? How familiar are you with the mechanics of that joint?”

Take a few minutes to review it in this video with Dr Ivo Waerlop of The Gait Guys.

#gait, #gaitanalysis, #1stmtp, #forefootrocker, #thegaitguys,

NO hip internal rotation? Forget the glutes, have you looked at the femur?

Screen Shot 2019-02-14 at 3.13.23 PM.png

Some developmental versions involve the femur. 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 FNA angle, therefore, 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. See the person with external tibial torsion in the above picture?

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:

  •  FNA 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.

Dr Ivo Waerlop, one of The Gait Guys

#gait, gait analysis, #thegaitguys, #femoraltorsion, #antetorsion, #retrotorsion

Crawling patterns and the Bird Dog look alike, but they are clearly not. Do you understand this ?

Screen Shot 2019-02-24 at 9.48.00 AM.png

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.

Screen Shot 2019-02-24 at 9.44.31 AM.png

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.

Screen Shot 2019-02-24 at 9.44.19 AM.png

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.

An often overlooked culprit...In hip and hamstring insertional pain


The "Deep 6". In order from proximal to distal; the piriformis, obturator internus, gemelli superior, obturator externus, gemelli inferior and quadratus femoris. They are primarily external rotators but have a small footprint and act primarily as stabilizers. Here is what we think and what we have to say about them...



Dr Ivo Waerlop, one of The Gait Guys



#deepsix, #gait, #thegaitguys, #hipexternalrotators, #hipstabilizers, #running



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

Screen Shot 2019-02-24 at 9.44.19 AM.png

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.

Screen Shot 2019-02-24 at 9.44.31 AM.png

* 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?

Screen Shot 2018-11-16 at 5.16.36 PM.png

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

Screen Shot 2019-02-24 at 9.29.56 AM.png
Screen Shot 2019-02-24 at 9.29.44 AM.png

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?

Screen Shot 2019-02-23 at 7.27.35 AM.png

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.

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.

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.

Screen Shot 2018-10-25 at 10.54.01 AM.png

. . . 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