Spring is here and Dr Ivo Waerlop of The Gait Guys talks about some common problems seen due to manufacturers defects in cleats and how they can affect athletes. From uppers put on the outsole incorrectly and contributing to and potentiating rearfoot varus and valgus to poor cleat placement affecting the 1st mtp mechanics; they all contribute to athlete performance.
We talk about leg length discrepancies all the time here on the blog and sometimes, how small discrepancies cause changes in peoples biomechanics. The gold standard for measuring a leg length difference is full length lower extremity X ray, but this presents a problem due to the ionizing radiation, accessibility as well as impracticality of X rays every person with a suspected difference.
We have talked about different compensations as to how to get around a leg length discrepancies. Last week we actually did a tell a seminar on this entire subject. Your patient or client needs to “create clearance” for the longer leg side. This can be accomplished in many ways.
The 5 most common strategies (keep in mind there are many more) are:
lean the torso to the short leg side (essentially hip adduction of the longer side)
hike the torso on the long leg side
circumduct the longer lower extremity
increase plantar flexion of the calf of the short leg side
increase hip and knee flexion on the longer leg side
And that is exactly what this study found. They looked at kinematics in people with anatomical leg length discrepancies and found that hip adduction as well as increased hip and knee flexion were 2 variables that were consistent in folks with anatomical differences and suggest these variables are a useful screening tool.
Paying attention to how people move and looking for asymmetries. In our opinion, that’s the name of the game : )
Dr Ivo Waerlop, on of The Gait Guys
Zeitoune G, Nadal J, Batista LA, Metsavaht L, Moraes AP, Leporace G.Prediction of mild anatomical leg length discrepancy based on gait kinematics and linear regression model. Gait Posture. 2019 Jan;67:117-121. doi: 10.1016/j.gaitpost.2018.09.027. Epub 2018 Sep 29.
#LLD #leglengthdifference #leglengthinequality #visualgaitanalysis #thegaitguys #gaitanalysis
We have talked many times here on TGG about pronation, supination, overpronation, asymmetrical pronation, and more.
When most people think of pronation, they think of midfoot pronation, or pronation about the subtalar or transverse tarsal joints. Pronation can actually occur about any articulation or bone, but with respect to the foot, we like to think of rearfoot (ie. talo-calcaneal), midfoot (talo-navicular) and forefoot (transverse tarsal). The question is why does this matter?
Pronation, with respect to the foot, is defined as a combination of eversion, abduction and dorsiflexion (see picture attached) which results in flattening of the planter vault encompassing the medial and lateral longitudinal arches. In a normal gait cycle, this begins at initial contact (heel strike) and terminates at midstance, lasting no more than 25% of the gait cycle.
In a perfect biomechanical world, shortly following initial contact with the ground, the calcaneus should evert 4-8 degrees, largely because the body of the calcaneus is lateral to the longitudinal axis of the tibia. This results in plantar flexion, adduction and eversion of the talus on the calcaneus, as it slides anteriorly. At this point, there should be dorsiflexion of the transverse tarsal (calcaneo-cuboid and talo-navicular joints). Due to the tight fit of the ankle mortise and its unique shape, the tibial rotates internally (medially). This translates up the kinetic chain and causes internal rotation of the femur, which causes subsequent nutation of the pelvis and extension of the lumbar spine. This should occur in the lower kinetic chain through the 1st half of stance phase. The sequence should reverse after the midpoint of midstance, causing supination and creating a rigid lever for forward propulsion.
Pronation, along with knee and hip flexion, allow for shock absorption during throughout the 1st half of stance phase. Pronation allows for the calcaneo-cuboid and talo-navicular joint axes to be parallel making the foot into a mobile adaptor so it can contour to irregular surfaces, like our hunter gatherer forefathers used to walk on before we paved the planet. Problems arise when the foot either under pronates (7 degrees valgus results in internal tibial rotation), resulting in poor shock absorption or over pronates (> 8 degrees or remains in pronation for greater than 50% of stance phase).
This paper talks about how foot and ankle pathologies have effects on other articulations in the foot. They looked at stance phase of gait in 14 people without pathology at 3 different walking speeds. they found:
coupling relationships between rear foot inversion and hallux plantar flexion and rear foot eversion with hallux dorsiflexion.... When the rear foot everts (as it does as discussed above) during pronation from initial contact to mid stance , the hallux should be extending AND when the rear foot everts, as it should from mid stance to terminal stance/pre swing, the hallux should be plantar flexing to get the 1st ray down to the ground
medial (internal) rotation of there leg was accompanied by mid foot collapse (read pronation) and lateral (external) rotation with mid foot elevation (read supination).... Because of the shape of the talar dome and shape of the talo calcaneal facet joints, the talus plantar flexes, everts and adducts from initial contact to mid stance, and dorsiflexes, inverts and adducts from mid stance to terminal stance/ pre swing
walking speed significantly influenced these coupling relationships....meaning that the faster we go, the faster these things must happen and the greater degree that the surrounding musculature and associated cortical control mechanisms must act
So, when these relationships are compromised, problems (or more often, compensations) ensue. Think about these relationships and the kinetics and kinematics the next time you are studying someones gait.
Dr Ivo Waerlop, one of The Gait Guys
Dubbeldam R1, Nester C, Nene AV, Hermens HJ, Buurke JH. Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Kinematic coupling relationships exist between non-adjacent segments of the foot and ankle of healthy subjects.Gait Posture. 2013 Feb;37(2):159-64. doi: 10.1016/j.gaitpost.2012.06.033. Epub 2012 Aug 27
cool video on our blog to go with this post:
#gaitanalysis #thegaitguys #pronation #couplingrelationshipsandgait #pronation
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
In short, when it comes to stress fractures, IT band syndrome and patellofemoral pain, the literature says yes…
"In conclusion, decreasing stride length has been proposed as a method to treat and prevent running-related musculoskeletal injuries. While not directly examining the effect of stride length, research examining the effect of barefoot running and minimalist shoes indirectly evaluates stride length, as barefoot/minimalist runners tend to adopt a reduced stride length. Evidence suggests that decreasing stride length results in biomechanical changes, including reduced GRFs and joint moments, that can contribute to reduced injury risk. Clinical studies indicate that reducing stride length may help decrease the likelihood of stress fractures, iliotibial band syndrome, and patellofemoral pain."
a good read: https://lermagazine.com/article/implications-of-reduced-stride-length-in-running. ALSO the photo credit
#gait, #thegaitguys, #gaitanalysis, #running, #stridelength
Dr Ivo, one of The Gait Guys
While out cross country skiing after a few inches of fresh fallen snow it dawned on me, especially when going uphill on my cross-country skis, lifting your toes up definitely pushes the head of the first metatarsal down and helps you to gain more purchase with the scales on the bottom of the skis. It also helps to press the center portion of the camber of the ski downward so that you can get better traction. Thinking about this further, lifting your toes up also helps you to engage your glutes to a greater degree.
Try this: stand comfortably with your knees slightly flexed. Lift up your toes leaving the balls of your feet on the ground. Do you feel the first metatarsal head going down and making better contact with the ground? Can you feel your foot tripod between the head of the first metatarsal, head of the fifth metatarsal and the calcaneus? Now let your toes go down. Squeeze your glute max muscles. You should still be able to fart so don’t squeeze the sphincter. You can palpate these muscles to see if you’re actually getting to them. You can do this by placing your hands on top of your hips with your fingers calling around forward like when your mom used to put her hands on her hips and yell at you. Now relax with your toes up again leaving the balls of your feet on the ground. Now engage your glutes. See how much easier it is?
Now stand with your feet flat on the ground and put your hands on your abs, specifically your external obliques. Now raise your right leg. Do you feel your external oblique engage? Now, lift your toes up leaving the balls of your feet on the ground. Now lift your leg. Do you feel how much more your abs engage?
Little tricks of the trade. That’s why you listen here and why your patients/clients come to see you. Now go out and do it!
Dr. Ivo, one of The Gait Guys
#gaitanalysis, #crosscountryskiing, #skiing, hallux, #engage, #abs
Take a good look at the pedographs above. Can you figure out which side has the hallux limitus from the pictures?
You would think that with hallux limitus there would be increased printing over the distal phalanx of great toe and possibly over the distal metatarsal as seen in the print of the right foot. This would make sense as if you have limited motion here and the pressure will be more forward. However, often times Hallux limitus is painful and the patient develops a compensation to NOT load the joint, as we see on the print of the left foot. We see the lack of printing under the first metatarsal head and increased printing laterally in the foot from avoidance of that joint. Also notice a slight increased printing in the right heel teardrop (hash marks are more filled in) and slight widening of it anteriorly. He has a right sided leg length discrepancy and we would normally expect an increased amount of pronation on the longer leg side, however because of the weight shift to the left we are seeing increased pronation on the right. Now, with this valgus moment of the right foot do you understand why the printing is so heavy under the first metatarsal and distal phalanx. Note also the increased printing at the distal phalanx of toes number two, three and five on the right hand side in an attempt to stabilize as his center of gravity shifts to the right.
And now you know!
Dr Ivo, one of The Gait Guys
#halluxlimitis, #gaitanalysis, #pedograph, #leglengthdiscrepancy, #LLD
1. Running with the extensors. Convergence and divergence of neurons.
2. Fighting your gait neurology. The lies about the Bird dog rehab exercise.
3. ACL and ACL rehab. Surgery or no sugery. Wise? Risks ? How social media discussions might just be getting it wrong.
4. Cross over gait and lateral heel strike and ensuing problems at great toe off. A failure to medial foot tripod high gear toe off ?
5. Are the hip flexors actually hip flexors in gait ? what are your high knee drills doing? Anything good?
Key words: acl, analysis, cross, extensor, flexors, gait, heel, hip, instability, knee, over, plri, pools, problems, running, strike, surgery
Links to find the podcast:
iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
Libsyn URL: http://directory.libsyn.com/episode/index/id/6978817
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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.
Cavus foot? Loss of the transverse arch? Prominence of extensor tendons?
The question is: Why?
It’s about reciprocal inhibition. The concept, though observed in the 19th century, was not fully understood and accepted until it earned a Nobel prize for its creditor, Sir Charles Sherrington, in 1932. Simply put, when a muscle contracts, its antagonist is neurologically inhibited, So when your bicep contracts, your tricep is inhibited. This holds true whether you actively contract the muscle or if the muscle is irritated (causing contraction).
So how does this apply to this foot?
We see prominence of the extensor tendons (particularly the extensor digitorum brevis EDB; the longus would have caused extension at the distal interphalangeal joint). The belly of the muscle is visible, telling us that it is active. It is neurologically linked to the flexor digitorum brevis (FDB). This muscle, in turn, has slips which attach it to the abductor hallucis brevis (AHB) medially and the abductor digiti minimi (ADM) laterally. These muscles together form 2 triangles (to be discussed in another post) on the bottom of the foot, which lend to the stability of the foot and the arches, especially the transverse.
When the EDB fires, it inhibits the FDB, (which, in addition to flexing the MTP’s, assists in maintaining the arch). The EDB has an effect which drops the distal heads of the metatarsals as well (Hmm, think about all the people with met head pain) Now, look at the course of the tendons of the EDB. In a cavus foot, there is also a mild abductory moment, which flattens the arch. Conversely, the FDB in a cavus foot would serve to actually increase the arch, and would have a ,mild adductory moment. Net result? A flattened transverse arch.
Now look at the Flexor digitorum longus, overactive in tbis foot (as evidenced by the flexion of the distal interphalangeal joints, mild adduction of the toes (due to the change of direction of pull in a cavus foot) and lowering of the met heads due to hyperextesnion at the MTP joints ). This mm is reciprocally linked with the extensor digitorum longus. The prominence of the extensor tendons is do to increased activity of the EDB (go ahead, extend all your fingers and look at the tendons in your hand. Now flex the DIP and IP joints and extend the MTP; see how they become more prominent?).
Reciprocal inhibition. It’s not just for dinner anymore…
We are and remain; The Gait Guys
Have a young patient with severe calcaneal valgus? Here are some of our thoughts...
Time for a pedograph, folks. What do we have here?
To review :
Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.
First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.
Let’s start at the rear foot: The heel teardrop is elongated on both sides, slightly more on the right; this means incraesed calcaneal eversion (or rearfoot pronation) bilaterally, R > L. The right heel shows increased pressure (more ink = more pressure).
Next up, the mid foot. Similar shapes, more pressure and printing on the left. Did you notice the “tail” of the 5th metatarsal printing, giving it a wider print? This person is staying on the outside of their foot longer than normal, right (more ink) more than left.
How about the fore foot? Lots going on there.
Lets start on the left
Notice the mild increased printing of the 5th and 4th metatarsal heads. Force should be traveling from lateral to medial here, as the foot goes into supination. A relatively normal amount of pressure on the head of the 1st metatarsal.
Now look at the toes. Notice that space between the 2nd and 3rd? This gal had an old fracture and has an increased space between them.
Now how about the right?
Increased pressure on most of the heads with a concentration on the 1st metatarsal. Hmmm…what would cause that? this is typical of someone who has a 1st ray (cunieform and metatarsal) that is hypomobile, such as with someone with a forefoot valgus (as this person does) or a dropped 1st metatarsal head (which is usually rigid, as is NOT the case here).
Did you see that rpinting at the medial aspect of the proximal phalanyx of the hallux (ie. big toe)? This gal externally rotates the lower extremity to push off the big toe to propel herself forward. This is because the 1st metatarsal head hits the ground BEFORE the 5th (as we would normally expect to see, like in the left foot), and because the weight is now on the outside of the foot, she need to push off SOMETHING.
Getting better at this? We hope so. Keep reading the blog and look at some of our past pedograph posts here.
The Gait Guys. Teaching you about the importance of gait, each and every day!
Have you ever studied footprints on the beach or looked at the print left by a wet foot when you get out of the water? These are some of the most primitive types of pedographs.
The pedograph, 1st described by Harris and Beath in 1947 is a rubber mat surface with multiple protruding, small grid lines on one side, which, when covered with ink, imprints an underlying sheet of paper when weight (usually a foot) passes over it. Relative plantar pressures are indicated by the size and density of the inked area, creating a “footprint” reflecting passages of force through the foot at that instance in time. They have fallen into and out of usage over the years, often discarded for more expensive technology such as pedobarographs, individual pressure sensors, and pressure sensitive mats, which have computer interfaces and can provide many useful measurements and calculations to assist the clinician with rendering a diagnosis. These systems, though more precise in some ways (provided a controlled, reproducible testing procedure) are often thousands of dollars, require a computer and the necessary skills, and have a substantial learning curve.
The pedograph in contrast is simplistic, inexpensive, and reliable and only requires that the user have an intact visual pathway and cerebral cortex and knowledge of the events occurring in the gait cycle. With some practice and a good knowledge base, the subtle nuances detected by the sensitive pedograph (nuances that can be undetected with high end computer driven plantar pressure devices) can offer information critical to a precise diagnosis and give solid clues to gait flaws and compensations. With minimal training using a pedograph, reproducible “prints” can be produced for analysis, in light of your findings clinically. They also make wonderful educational tools for your patients and clients!
An essential part of a comprehensive patient evaluation should include examination of the entire kinetic chain both in a static and dynamic fashion. Often what you see statically is either directly translated to or compensated for in the dynamic evaluation. (It is important to note that many of the available foot scan units available from orthotic companies scan a patient in a static standing position and give little information on how the feet and lower limb dynamically engage the ground during movement.) The pedograph is a useful visual tool representing a 2 dimensional image of tridimensional motion, and you are seeing the end product and compensation (or lack thereof) of the individuals mechanics at that point in time. Because of the specificity of what you are seeing refers to a particular point in time, technique and reproducibility are of paramount importance. Prints should be performed several times to insure what you are looking at is what you are looking at, and not movement artifact, because of the way the patient stepped on to or off of the mat.
With a pedograph, seeing is believing. When you have objective data about how an individual moves through space and how their joints and motor system help them to accomplish that, you have a better appreciation for the type or form of therapy which may be most appropriate. In the hands of a skilled clinician, seeing abnormal plantar pressures tells you where the biomechanical fault lies, and thus where manipulation may be appropriate, which muscles need strengthening and where neuromotor coordination is lacking and gait rehabilitation is needed.
excerpted from the 1st edition of our Book “Pedographs and Gait Analysis: Clinical Pearls and Case Studies” Trafford Publishing
Got Muscle activation? Looking for some EMG data on what fires when in walking vs running gait? The conclusion and point of the study are good, but the EMG data and diagrams are awesome for those of you seeking a greater understanding of what goes on when
"The major difference between walking and running was that one temporal component, occurring during stance, was shifted to an earlier phase in the step cycle during running. These muscle activation differences between gaits did not simply depend on locomotion speed as shown by recordings during each gait over the same range of speeds (5–9 km/h). The results are consistent with an organization of locomotion motor programs having two parts, one that organizes muscle activation during swing and another during stance and the transition to swing. The timing shift between walking and running reflects therefore the difference in the relative duration of the stance phase in the two gaits."
A great read and FREE FULL TEXT
Zombies are a peculiar lot. Not wanting to limit our analysis to the living, we have begun to examine the undead.
In this entertaining and educational clip, we note that a common characteristic seems to be partial paralysis of an lower and/or upper extremity, along with the peculiar behavior of keeping their upper extremities in a flexed posture, similar to a stroke. They also seem to have an exaggerated gag reflex and difficulty with phonation (talking). We believe this is a neurological phenomenon, based on the fact that the only way to truly kill a zombie is to kill their brain.
Have a great Halloween!
Here we discuss a runner with forefoot virus and some of the pitfalls
Look at the position of his knee with respect to his foot. Both are pointing outward into external rotation. They are in the same plane so a torsion is unlikely, but he is probably trying to gain some stability as his center of gravity moves across his body.
Now look at his pelvis and see how it is tilted (or dropped) down on the left. We would definitely want to check his right gluteus medius and his left quadratus lumborum.
And what about that arm swing? Is he creating more space on the left (ie abducting his left arm) from his body lean to the right? More than likely, this is to make up for his hip muscle problem. we say this because his head tilt is to the left. Remember that your body will always try to make your visual fields parallel with the ground, so as his body goes to the right, his head will go to the left. There must be a great deal of body rotation going on, as his entire jersey has moved to his right!
So you want to do a Gait Analysis: Part 3
Again, a quick review of the walking gait cycle components:
There are two phases of gait: stance and swing.
Stance consists of:
- Initial contact
- Loading response
- Terminal stance
Swing consists of:
- initial (early) swing
- mid swing
- terminal (late) swing
today, lets explore Midstance
we remember that midstance is the mid point of the stance phase of the gait cycle. It is when the maximal amount of midfoot pronation should be occurring
Lets look at what is happening here at the major anatomical areas:
- Pronation begins: The talus should have slid anteriorly on the calcaneus and it then plantar flexed, everted and adducted to its greatest degree. The subtalar joint should have its axes parallel with the calcaneocuboid joint, essentially “unlocking” the midfoot. This allows the midfoot to assist in absorbing shock, along with knee flexion, hip flexion and a dip of the contralateral pelvis.
- the calcaneus everts to a max of approximately 5-8°
- the center of gravity of the foot is lowest at this point, and the ankle mortise its deepest.
- The lower leg should be internally rotated (as it follows the talus) 4-6°
- The thigh should follow the lower leg and should also be internally rotated 4-6°; sometimes to a greater extent due to the shape and size of the medial condyle of the femur (which is larger than the lateral)
- these actions are (still) attenuated by eccentric action of both the long flexors and extensors of the ankle, as well as the foot intrinsics
- The ankle should be neutral, as it should be at the mid point of ankle rocker
- Flexion to 20°. This is attenuated largely by the quadriceps, contracting eccentrically. The popliteus has often concentrically contracting to assist in internal rotation of the thigh up until midstance. It is quiescent at midstance and will begin to contract eccentrically as soon as the knee passes midstance.
- The hip is at full flexion at loading response, decreasing as it approached midtsnce and now begins to extend. This is facilitated by a brief contraction of the gluteus maximus (which started at initial contact)
Can you see what is happening? Try and visualize this in your mind. Can you understand why you need to know what is going on at each phase to be able to identify problems? If you don’t know what normal looks like, you will have a tougher time figuring out what is abnormal.
Ivo and Shawn. Gait and foot geeks extraordinaire. Helping you to build a better foundation to put all this stuff you are learning on.
Join us tonite 8PM EST (7PM CST, 6PM MST) for a case study in gait analysis on chirocredit.com or onlinece.com. Tonite’s case involves a common neurological lesion that effects gait. In addition to a history and gait analysis, remediation of this commonly seen problem is discussed.
Hope t see you there
Ivo and Shawn
Being a gait geek offers you a unique perspective in many situations.
Perhaps you have been with us for some time now and would like to check your gait acumen. If you are new, or these terms are foreign to you; search here on our blog through hundreds of posts to become more comfortable with some of the vocabulary.
Watch this video a few times (we slowed it down for you) and write down what you see.
Did you see all of these in this brief video?
- bilateral loss of hip extension
- bilateral loss of ankle rocker
- less ankle rocker on right
- bilateral increased progression angle
- dip in right pelvis at right heel strike
- arm swing increased on R
The Gait Guys. Increasing your gait competency each and every day.
special thanks to NL for allowing us to use this video footage.