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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Vuillerme N1, Sporbert C, Pinsault N.

Season 1: Podcast 8 of the Gait Guys Experience Now available!

You know you want it! Here it is:

You can check it out on Libsyn, by clicking here:

This link will get you a nicely laid out “show notes” and pod player.
http://thegaitguys.libsyn.com/the-gait-guys-experience-podcast-8-s1e8

This one will get you to the show player of ALL of our podcasts.
http://directory.libsyn.com/shows/view/id/thegaitguys

Here are the show liner notes:

1-   neuroscience story

 http://www.scientificamerican.com/article.cfm?id=how-do-whales-and-dolphin
What do dolphins and sleep walking have in common?
Do ultra marathoners sleep while they run ?
Join us for the podcast neuroscience introduction.

2- More lectures available  on www.onlineCE.com 13 hours of courses there !  Go there and look up our lectures

3- OFF TOPIC Discussion:
Hi gents ! What is with the wide tripod abducted legs in obese folks >?
So many of them supinate and have a wide tripod…….
thanks alot
Julio C, in Sao Palo Brazil !

4- Off Topic:   Sole lifts or heel lifts ? Which should you use and why ? And When ?
 
5- EMAIL Question:
Hi! 
I saw your blog and one of your youtube videos and thought I would mail in a gait question! I appreciate any input or information you have about this. I was wondering about people that walk with their foot in the abducted position - why is this and what are the implications for such a gait? I know some people with flat feet have that tendency but I don’t have that and walk at baseline with my foot abducted. I took note of this since I’ve developed some hip pain recently and noticed that when I make a conscious effort to walk with my feet straight it actually feels abnormal (more comfortable and natural with the feet abducted). Why is this? Any input into this puzzle would be appreciated. 
Thanks much!  -Sheeva

6- EMAIL CASE:
Guys, love you, love your show
you guys need to do a stand up routine at a club……..maybe host Saturday Night Live !  Maybe pair  you up with Justin Timberlake !
Anyhow…….enough ego stroking…….
What is your take on the biomechanical implications of a short quadriceps muscle in gait ?

7- Pedographs or software ???? what is our take ?

8- EMAIL CASE
Hi Fellas
Can you talk a bit more about the proprisensory system in gait ?
You talked about it several blog posts but i would love to hear you expand upon it. 
thanks
Jordan

9- EMAIL:
 Is it true that walking in flip flops is bad for you?  I’ve heard a lot of “experts” say it will cause your arches to fall.  Thanks! - Norma

Left foot pain in a 30 year runner.

Hi,

I could use some help. I’ve been running/cycling for 30 years. Three years ago, I had surgery on my left knee that realigned my patella (lateral release.) Until recently, I lived in custom orthotics and motion control shoes. I’ve been reading chi-running and natural running and bought a pair of shoes for which I’m transitioning a little a day. My left foot is the problem: it severly overpronates and I have a neuroma. I’ve been walking barefoot and in five-fingers for a while and my feet a definitely getting much better. The natural running style feels much better on my ankles,knees and hips, which used to hurt a lot. Also, cycling hurts only when I get off my bike, my knee is killing me for a while.

My left forefront seems to move too much even with this new style of walking/running. I’m wondering if I have forefront varus that could be helped with a wedge. My real problem is that I currently live in Las Cruces, NM, where there is no running store and no experts on this stuff. Most podiatrists do the same, generic thing for all patients. Is there a little wedge I could try without having it inserted into a custom orthotic? Is there a place to go to analyze my gait/running that would be worth my time and expense to visit? Any advice would be gratefully received.

Thanks for your time,

AT

Thanks for the note AT.

We are glad that the natural style running is helping. remember to go slowly and follow the rules of Skill, Endurance, Strength as you progress into less supportive shoes.

The forefoot motion you are sensing may indeed be a forefoot varus; we would need to see and examine your foot to know for sure. If it is a rigid deformity, it may never totally be gone, though you may be able to increase the range of motion of your foot sufficiently to compensate elsewhere.

Getting a thorough evaluation is paramount. We are not aware of any gait labs in Las Cruces, but Jaqueline Perry’s Pathokinesiology lab is in Rancho Los Amigos (click here for more info). Dr Waerlop is located about 70 miles west of Denver and Dr Allen is in the Chicago suburbs. Only after an evaluation, could exercise suggestions or an orthotic or other device recommendation could be made.

Thanks for your inquiry

Ivo and Shawn

Ataxic gait?

We hope you have begun the new year in a NON ATAXIC manner. Lets look at the origin of the word:

Ataxia: Greek, from a or without + tassein to put in order or “without order”. Ataxia is truly gait without order, and we will see why momentarily. The term was coined in 1670. Every September 25th is International Ataxia Awareness Day. Mark THAT ONE on your calendars!

Ataxia an inability to coordinate voluntary muscular movements that is symptomatic of some nervous system disorders and injuries and not due to muscle weakness.

It is a lack of afferent information either GETTING TO the CNS, BEING PROCESSED BY the CNS, or OUTPUT FROM the CNS. We can still hear Dr Carrick saying “where is the longitudinal level of the lesion? Is it at the receptor, the effector, the peripheral nerve, the spinal cord, the brain stem, the thalamus, the cerebellum or cerebrum?” This mantra, still rings true many years later, as it gives us the afferent pathway to the brain and higher centers of the CNS.

Ataxic gait, not to be considered synonymous with Fredreich’s Ataxia (the genetic disorder described in the 1860’s, related to spinal cord and cerebellar degeneration), can be due to any number of causes which affect processing of afferent information. One too many Tequila’s (100% agave of course), barbituates, joint pathomechanics, diseases affecting receptors (like syphilis or leprosy), diabetes and other forms of peripheral neuropathy, spinal cord injury or disease are only a few of the causes. Virtually anything that can affect the afferent processing or efferent arc of the processing of proprioceptive information.

The large amplitude corrective movements are clues to the CNS that something is awry and are a necessary component of the compensation. Here , you truly are seeing the result of the compensation.

The video offers a simplified explanation and nice clinical example of an ataxic gait. If you don’t believe it, try some field research (or perhaps you already have) with the ethanol of your choice and see for yourself. Of course, some of THAT ataxia comes from changes in specific gravity of the endolymph in your inner year, but that is the subject of another post.

Ivo and Shawn. The Gait Guys…New and Improved for 2012

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Power of Splay: New and improved

This time with some anatomy pix.

Think about triangles. Hey Pythaogoras did! They are powerful distributors of force. Here we will talk about 3 of them.

There are 4 layers of muscles in the foot. The 1st triangle occurs in the 1st layer. Think of the abductor hallucis and the abductor digiti minimi. Proximally they both attach to the calcaneus and distally to the 1st and 5th proximal phalanges. Now think about the transverse metatarsal ligament that runs between the disal metatarsal heads. Wow, a triangle! this one is superficial.

Now think about the adductor hallicus. It has a transverse and oblique head. think about that transverse metatarsal ligament again. Wow, another triangle!

What about the flexor hallicus brevis and flexor digiti minimi? The former originates from the cuboid, lateral cunieform andd portion of the tib posterior tendon; the latter from the proximal 5th metatarsal. They both go forward and insert into the respective proximal phalynx (with the sesamoids intervening in the case of the FHB). and what connects these? The deep transverse metatarsal ligament of course! And this triangle surrounds the adductor triangle, with both occurring the 3rd layer of the 4 layers of foot muscles.

Triangles… and you thought geometry was boring!

Remaining triangular when we need to (because of our pointy heads)…Ivo and Shawn

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Keep Digging

We are often asked “What is wrong with this gait?” or “Why do I have pain?”. Sometimes, we are able to provide an explanation which seems too simple, but is often correct. It often corrects the immediate problem, only to have another crop up a few weeks later.

Why?

To paraphrase from the words of SHREK; peoples compensations are like onions; they have layers. Uncovering and remedying one problem often leads us to the next weakest link in the chain.

We still have fond memories of Dr Ted Carrick grilling us in the post graduate neurology program “What is the longitudinal level of the lesion? Most pathologies occur at one locus; if you diagnose more than one, it is usually due to metastasis, multiple vascular occlusions, or clinical incompetence. Is the lesion at the receptor, the effector, the peripheral nerve, the spinal cord, the brainstem, the thalamus, the cerebellum or cerebrum”.

The information to glean here is that often we need to establish and limit our focus to ONE area where the problem could be. This necessitates us thinking through the problem and coming up with ONE problem which could cause all the problems you are seeing. This applies to gait and motion assessment as well.

Think of the patient with r sided knee pain caused by patellar tracking issues. Is the retro patellar inflammation the cause? Not usually (unless there has been direct trauma), it is often the symptom (or compensation). Maybe the cause is a forefoot varus deformity because they cannot descend the 1st ray adequately. Maybe this is due to insufficient extensor hallicus brevis function, or is it the peroneus longus? Maybe it is due to a congenital deformity of the foot. Maybe it is due to a functional (or anatomical)leg length discrepancy. Or maybe it is a problem with the left shoulder…you get the idea.

Keep looking and digging until you have found the 1 THING that can explain what is going on. Maybe it’s the individual; maybe it’s their footwear. maybe something else. If you can’t explain it by a single problem or fault, maybe it is time to run some blood work, send them for a vascular flow analysis, or more often than not; expand our knowledge base.

We are the Gait Guys. Two guys digging deeper and looking for the cause.

Gait Guys/IRRA Running Event Recap  
 Well, it was a fast a furious 2 days for us. We arrived Tuesday evening and put the finishing touches on the presentation for Wednesday morning. We were up and lecturing, 8AM Texas time and were very well received with many interesting questions. This was one one smart group of retailers! 
 We then had a photo session and whisked off to the Austin School of Film (Thank You Anna, KIrk and Brian!) to finish filming the rest of the Shoe Fit Certification Program (Excerpts to be posted soon!). A few hours later we were back at the event and met up with Dr Mark Cucuzella (a good friend and colleague of ours; you have seen his videos here on the blog) and David Jonson from Sole Running. We were then off to a mixer and out to dinner with Dick Beardsley (yes, THE Dick Beardsley from the 1982 Boston Marathon with Salazar), his wife, Curt Munson and Daren DeCavitte from Playmakers, and Dr Mark. Thursday morning was filled with meetings, including a Magazine interview with Max Lockwood of the Georgetown Running Company. Then we were off to the airport by 2PM and away we went. We have full days at the clinic today and are looking forward to some much needed rest (and a lot of film editing!) this weekend! 
 Thanks again for all your support. 
 Ivo and Shawn

Gait Guys/IRRA Running Event Recap

Well, it was a fast a furious 2 days for us. We arrived Tuesday evening and put the finishing touches on the presentation for Wednesday morning. We were up and lecturing, 8AM Texas time and were very well received with many interesting questions. This was one one smart group of retailers!

We then had a photo session and whisked off to the Austin School of Film (Thank You Anna, KIrk and Brian!) to finish filming the rest of the Shoe Fit Certification Program (Excerpts to be posted soon!). A few hours later we were back at the event and met up with Dr Mark Cucuzella (a good friend and colleague of ours; you have seen his videos here on the blog) and David Jonson from Sole Running. We were then off to a mixer and out to dinner with Dick Beardsley (yes, THE Dick Beardsley from the 1982 Boston Marathon with Salazar), his wife, Curt Munson and Daren DeCavitte from Playmakers, and Dr Mark. Thursday morning was filled with meetings, including a Magazine interview with Max Lockwood of the Georgetown Running Company. Then we were off to the airport by 2PM and away we went. We have full days at the clinic today and are looking forward to some much needed rest (and a lot of film editing!) this weekend!

Thanks again for all your support.

Ivo and Shawn

In this Neuromechanics weekly, Dr Waerlop Introduces the cerebellum and talks about its importance clinically, since it contains more than ½ of the neurons in the brain! It’s anatomy and inputs from the periphery are discussed. The take home message is the cerebellum is the key to understanding and directing movement, since it receives feedback from most ascending and descending pathways.

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You evidently can’t have your cake and eat it too…

Here is more research to show that running in shoes give you a mechanical advantage in force generation,  but at the cost of increased stress on the knees.

“The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.”

No surprise really. You could swing a broomstick with little effort and a baseball bat with more effort, but which will hit the ball farther? Which may tax your shoulder more?

Whenever we take a foot, that SHOULD supinate, effectively decrease its mobility (making it stiffer)  and MAKE IT supinate, we will have more power. Remember P = W/t? P is power, W is work and t is time.  W is also F X s, where F is force and s is displacement; so we have P= Force X displacement/time. We are increasing displacement here: with force and time remaining unchanged, we have more power.

But…all things wear out in time with use; including your joint cartilage. Hmmm, maybe we reduce the force and allow the joints (like the ankle) to displace (we see increased displacement in unshod running) and we run into our 100’s.

The choice is yours.

The Gait Guys: 2 docs, making a difference, one step at a time.


J Biomech. 2010 Aug 10;43(11):2120-5. Epub 2010 May 11. Footwear affects the gearing at the ankle and knee joints during running. Braunstein B, Arampatzis A, Eysel P, Brüggemann GP. Source

Institute of Biomechanics and Orthopaedics, German Sport University Cologne, Germany. braunstein@dshs-koeln.de

Abstract

The objective of the study was to investigate the adjustment of running mechanics by wearing five different types of running shoes on tartan compared to barefoot running on grass focusing on the gearing at the ankle and knee joints. The gear ratio, defined as the ratio of the moment arm of the ground reaction force (GRF) to the moment arm of the counteracting muscle tendon unit, is considered to be an indicator of joint loading and mechanical efficiency. Lower extremity kinematics and kinetics of 14 healthy volunteers were quantified three dimensionally and compared between running in shoes on tartan and barefoot on grass. Results showed no differences for the gear ratios and resultant joint moments for the ankle and knee joints across the five different shoes, but showed that wearing running shoes affects the gearing at the ankle and knee joints due to changes in the moment arm of the GRF. During barefoot running the ankle joint showed a higher gear ratio in early stance and a lower ratio in the late stance, while the gear ratio at the knee joint was lower during midstance compared to shod running. Because the moment arms of the counteracting muscle tendon units did not change, the determinants of the gear ratios were the moment arms of the GRF’s. The results imply higher mechanical stress in shod running for the knee joint structures during midstance but also indicate an improved mechanical advantage in force generation for the ankle extensors during the push-off phase.

http://www.ncbi.nlm.nih.gov/pubmed/20462583

“Shoe Insanity” – Highlights from the 2011 Paris and New York Fashion Shows


Our good friend, Bill Katovsky of http://zero-drop.com, did an awesome expose of wild and crazy shoes! If you are unflamiliar with Bill, or his work, please visit his site!

Thanks for the entertainment, Bill!

Ivo and Shawn

The information you have been waiting for. How do you facilitate a muscle? How do you defacilitate a muscle? Do you already know how? Do you know the mechanism?

Fear not… In this weeks Neuromechanics, Dr Waerlop simplifies the function of Golgi Tendon Organs. Clinical correlations are made throughout the presentation with his usual sense of humor. Neuro and foot geeks around the world are rejoicing…

Wow, we really are geeks!