External tibial torsion and lower back pain

How can external tibial torsion and lower back pain possibly be related? Let’s take a quick look at the anatomy and see how.

knees neutral, note external rotation of the right foot and decreased progression angle

knees neutral, note external rotation of the right foot and decreased progression angle

Remember the external tibial torsion is present if we drop a plumbline from the tibial tuberosity and it passes between the first and second metatarsals or more medially. This increases the progression angle of the foot. This occurs due to “over rotation" of the lower extremity during development, often exceeding the 1.5 degrees per year of external rotation per year up to age 15 or occurring for a longer period of time, up to skeletal maturity. It can be uni or bilateral.

note when the foot is neutral, the knee points inward

note when the foot is neutral, the knee points inward

Often, due to the increased progression angle, people will try to "straighten their feet" (ie, decrees their progression angle) to move forward in the sagittal plane. This places the knees to the inside of the sagittal plane which causes medial knee fall and sometimes increased mid and forefoot pronation. This results in increased medial spin of the thigh bilaterally which increases the lumbar lordosis. Combine this with a sway back or anterior pelvic tilt and you have increased pressure on the lumbar facet joints. The facets are designed to carry approximately 20% of the load put in these circumstances are often called upon to carry the much more. This often results in facet imbrication and lower back pain. You can strengthen the abdomen all you like but if you do not change the attitude of the foot, a will often develop lower back pain, especially when the abs fatigue. Now think about if the deformity is unilateral; this will often cause asymmetrical rotation of the pelvis in a clockwise or counter clockwise direction.

So, what can you do you?

Since external tibial torsion is a "hard deformity", we can influence how the bone grows before skeletal maturity but after that will not change significantly with stretching or exercise.

  • You can teach them to walk with an increase in progression angle (ie “duck footed”). This will often keep the knee in the sagittal plane and can be surprisingly well tolerated

  • You can use a foot leveling orthotic or arch support to bolster the arch and change the mechanics of the foot, causing external rotation of the tibia which will often result in a decrease in progression angle in compensation while still keeping the knee in the sagittal plane

  • You could place a full length varus wedge in the shoe which, by inverting the foot, externally rotates the tibia which the person will often compensates for by decreasing there progression angle to keep the knee and the sagittal plane



Dr Ivo Waerlop, one of The Gait Guys



#tibialtorsion #lowbackpain #LBP #progressionangle





We’ve told you once and we will tell you again…

Folks with femoral retro torsion often experience lower back pain with twisting movements

This left handed hydrology engineer Presented to the office with an acute onset of lower back pain following “swinging a softball bat”. He comments that he always “hit it out of the park“ and hit “five home runs“ in the last game prior to his backs demise.

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

He presented antalgic with a pelvic shift to the left side, flexion of the lumbar spine with 0° extension and a complete loss of the lumbar lordosis. He could not extend his lumbar spine past 0° and was able to flex approximately 70. Lateral bending was approximately 20° on each side. Neurological exam negative. Physical exam revealed bilateral femoral retro torsion as seen above. Note above the loss of internal rotation at the hips of both legs, thus he has very limited internal rotation of the hips. Femoral retroversion means that the angle of the neck of the femur (also known as the femoral neck angle) is less than 8°, severely limiting internal rotation of the hip and often leading to CAM lesions.

Stand like you’re in a batters box and swing like you’re left handed. What do you notice? As you come through your swing your left hip externally rotates and your right hip must internally rotate. He has no internal rotation of the right hip and on a good day, the lumbar spine has about 5° of rotation with half of that occurring at the lumbosacral junction. Guess what? The facet joints are going to become compressed!

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

Now combine that with bilateral 4 foot adductus (see photos above). His foot is already in supination so it is a poor shock observer.

Go back to your “batters box“. Come through your swing left handed. What do you notice? The left foot goes into a greater amount of pronation in the right foot goes into a greater amount of supination. Do you think this is going to help the amount of internal rotation available to the hip?

When folks present with lower back pain due to twisting injuries, make sure to check for femoral torsions. They’re often present with internal tibial torsion, which is also present in this individual.

Remember a while ago we said “things occur in threes”. That goes for congenital abnormalities as well: in this patient: femoral retro torsion, internal tibial torsion and forefoot adductus.

What do we do? Treat locally to reduce inflammation and take steps to try to improve internal rotation of the hips bilaterally as well as having him externally rotate his right foot when he is in the batteries box to allow him to "create" more internal rotation of the right hip.

Dr Ivo Waerlop, one of The Gait Guys

#internalrotation #hipproblem #femoraltorsion #femoralversion #retroversion #retrotorsion #thegaitguys

Subtle clues to an LLD?

Leg length discrepancies, whether their functional anatomical, have biomechanical consequences north of the foot. This low back pain patient exhibited 2 signs. Can you tell what they are?

can you see the difference ?

can you see the difference ?

how about now?

how about now?

compare right to left

compare right to left

compare right to left

compare right to left

can you see the difference in the Q angles?

can you see the difference in the Q angles?

Look at the first picture and noticed how the left knee is hyper extended compared to the right. Sometimes we see flexion of this extremity. This is to "functionally shorten" that extremity.

Now look at the Q angles. Can you see how the left QL angle is greater than the right? This usually results from a long-term leg length discrepancy where the body is attempting to compensate by increasing the valgus angle of that knee, effectively shortening the extremity.

Dr Ivo Waerlop, one of The Gait Guys

#subtle #clues #LLD #leglengthdiscrepancy #leglengthinequality #thegaitguys #gaitabnormality

Low Back Pain? Check for Femoral Retrotorsion on the Same Side

note the right sided leg length discrepancy

note the right sided leg length discrepancy

right tibia is anatomically shorter

right tibia is anatomically shorter

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

very little internal rotation available at the right hip

very little internal rotation available at the right hip

This right handed concrete worker presented to our office with right-sided lower back pain. He was lifting a bag of concrete moving from left to right which she estimates weighing between 60 and 80 pounds. He did this repetitively throughout the day and subsequently developed right sided lower back pain. The pain is in the suprailiac region and is described as dull, achey. Is exacerbated by right rotation and right lateral bending.

His exam found him to have a right sided anatomical leg length discrepancy, tibial left (see above) and femoral retro torsion on the right with no internal rotation of the hip past 0 degrees (see picture of full internal rotation of the right hip and cmpare it with the left); left side had approximately 10 degrees internal rotation. He also has bilateral internal tibial torsion, R > L. Palpation findings revealed tightness in the lumbar multifidus and quadratus lumborum with a loss of lateral bending to the right at L2 through L4 and a loss of flexion about the right sacroiliac joint. Lower extremity reflexes were 2+ with bilateral symmetry; sensation to vibration was intact at the distal phalanges; motor strength was strong and graded as 5/5.

Think about the implications of his right-sided leg length discrepancy first. This places his foot and a relative supinated posture compared to the left. Remember that supination is plantar flexion, inversion and adduction.

His femoral retro torsion on the right limits his internal rotation at the hip. When his foot planted with a diminished progression angle secondary to the internal tibial torsion, and he has to rotate from left to right, very little, if any motion, can occur at the right hip and therefore must occur in the lumbar spine. Remember the lumbar spine has very limited range of motion begin with with most of that occurring at the L5-S1 junction, depending upon its anatomy. Now superimpose a long lever load and rotary force. Back pain!

We instructed him on proper lifting technique and also talked about keeping the shoulders and hips in the same plane when lifting or load. If he does need to lift a load and spin unilateral on his right lower extremity, we asked him to externally rotate the right lower extremity. He was treated with manipulation and neuromuscular acupuncture.

If you have somebody with unilateral lower back pain, think about the implications if they have any femoral torsion or version present

Dr. Ivo Waerlop, one of The Gait Guys.

#lowbackpain #LBP #femoralretrotorsion #femoral #torsion #gait #gaitanalysis #thegaituys

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

Asymmetry seems to matter with pathology.

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

When you have low back pain, your gait is apt to be asymmetrical

...And that is just what this study showed. It looked at 82 right leg dominant folks with slightly less than 1/2 of them havong low back pain. The folks with lower back pain spent more time on their non dominant leg at the beginning of a gait cycle and on their dominant leg at the end of it. Not surprising that they wanted to find a more stable base or center their COP over the weight bearing foot, especially in light to the fact that the back has such poor cortical representation.

Sung PS, Danial P. A Kinematic Symmetry Index of Gait Patterns Between Older Adults With and Without Low Back Pain. Spine (Phila Pa 1976). 2017 Dec 1;42(23):E1350-E1356. doi: 10.1097/BRS.0000000000002161.

And why does this guy have hip pain?

line up the center of the heel counters with the outsoles, and what do you see?

line up the center of the heel counters with the outsoles, and what do you see?

can you see how the heel counter is centered on the outsole, like it is supposed to be

can you see how the heel counter is centered on the outsole, like it is supposed to be

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

Take a guy with lower back and left sided sub patellar pain that also has a left anatomically short leg (tibial) and bilateral internal tibial torsion and put him in these baby’s to play pickleball and you have a prescription for disaster.

Folks with an LLD generally (soft rule here) have a tendency to supinate more on the short leg side (in an attempt to make the limb longer) and pronate more on the longer leg side (to make the limb shorter). Supination causes external rotation of the lower limb (remember, we are trying to make the foot into a rigid lever in a “normal” gait cycle). this external rotation with rotate the knee externally (laterally). Folks with internal tibial torsion usually rotate their limb externally to give them a better progression angle (of the foot) so they don’t trip and fall from having their feet pointing inward. This ALSO moves the knee into external rotation (laterally), often moving it OUTSIDE the saggital plane. In this case, the knee, because of the difference in leg length AND internal tibial torsion AND the varus cant of the shoe, has his knee WAY OUTSIDE the saggital plane, causing faulty patellar tracking and LBP.

Moral of the story? When people present with a problem ALWAYS TAKE TIME TO LOOK AT THEIR SHOES!

More Flip Flop Madness. Can a flip flop reduce impact forces?

Flip Flop Madness. Can a flip flop reduce loading/impact force? Maybe...

We agree that the increased ankle dorsiflexion moment is to try and keep the flip flop on.  This particular flip flop, the Fit Flop, has different gait parameters (see figure 2 in the article) compared to normal flip flops and barefoot. We hypothesize this is most likely due to the semi rockered design along with the heel cup. Rockered shoes reduce the amount of hallux dorsiflexion needed for forefoot rocker and reduce plantar pressures in the forefoot (1) What surprised us most were the decreased impact forces.

"The current study identified increased ankle dorsiflexor activity in flip-flop style footwear compared to barefoot, coupled with increased dorsiflexion in swing, assumed to be a mechanism to hold the shoe on the foot. The FitFlop limited foot motion in the frontal plane and significantly reduced loading at impact, compared to flip-flop and barefoot. However, it is not clear whether the reductions in these parameters are enough to reduce any potential injury or overuse injuries associated with flip-flop footwear and further, longitudinal, research would be needed to clarify this relationship." (2)

More on the subject with a free, full text below.

 

 

 

1. Sobhani S, van den Heuvel E, Bredeweg S, Kluitenberg B, Postema K, Hijmans JM, Dekker R. Effect of rocker shoes on plantar pressure pattern in healthy female runners. Gait Posture. 2014 Mar;39(3):920-5. doi: 10.1016/j.gaitpost.2013.12.003. Epub 2013 Dec 9.

2.  Price C, Andrejevas V, Findlow AH, Graham-Smith P, Jones R. Does flip-flop style footwear modify ankle biomechanics and foot loading patterns? Journal of Foot and Ankle Research. 2014;7:40. doi:10.1186/s13047-014-0040-y.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182831/

A bit about the QL...

 

As we have said in previous posts,  though they can’t act independently we like to think to think of the QL as having two divisions. The lower division arises from the medial portion of the iliac crest and adjacent iliolumbar ligament and inserts onto the transverse processes of the lumbar vertebrae, in the coronal plane from lateral to medial and in the saggital plane from posterior to anterior. The upper division arises from the lumbar transverse processes of the upper 4 lumbar vertebrae and insert into the inferior border of the 12th rib, running in the coronal plane from medial to lateral and in the saggital plane from anterior to posterior; about half of the fascicles of this second division act on the twelfth rib and the rest act on the lumbar spine.

The QL is primarily a coronal plane stabilizer causing lateral bending to the ipsilateral side when the foot is planted as well as posterior rotation of the lumbar spine on the weight bearing side.   When acting unilaterally without the ipsilateral foot fixed on the ground, it can raise the ilia on the side of contraction. It is active during single limb support during stance phase of gait on the contralateral side (along with the external oblique) to elevate the ilium. This is coupled with the ipsilateral anterior fibers of the gluteus medius and minimus pulling the iliac crest toward the stable femur. Sahrmann states “the QL is optimally situated to provide control of lateral flexion to the opposite side via its eccentric contraction to provide control of the return from lateral flexion via its concentric contraction. The muscle is also positioned to play a role in the rotation that occurs between the pelvis and spine during walking”.

Acting bilaterally, it extends the lumbar spine, deepening the lordosis and acting to limit anterior shear of the vertebral bodies.

It is also able to stabilize the 12th rib during forced expiration, thus acting as an accessory muscle of respiration. This fixation is important when we need to superimpose pelvic movements upon it. Furthermore, it increased activation in response to increasing compression in static upright standing postures.

Here is a video of a low back screen we often use

How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Full internal rotation

Full internal rotation

full external rotation

full external rotation

full internal rotation

full internal rotation

full external rotation

full external rotation

neutral

neutral

neutral

neutral

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

  • Top: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
  • second picture: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
  • third picture: normal internal rotation of the left hip; internal tibial torsion
  • 4th picture: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
  • last 2 pictures: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle. If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist androtating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limitinghis follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

  • we treated the injured joint locally, with manipulation of the pathomechanical segments
  • we reduced inflammation and muscle spasm with acupuncture
  • we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
  • we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
  • we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

Those Multifidi   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 .    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.

Those Multifidi

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.

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.

tumblr_oa5t63IlXj1qhko2so1_1280.jpg
tumblr_oa5t63IlXj1qhko2so2_1280.jpg
tumblr_oa5t63IlXj1qhko2so3_1280.jpg
tumblr_oa5t63IlXj1qhko2so4_1280.jpg

A visual example of the consequences of a leg length discrepancy.

This patient has an anatomical (femoral) discrepancy between three and 5 mm. She has occasional lower back discomfort and also describes being very “aware” of her second and third metatarsals on the left foot during running.

You can clearly see the difference in where patterns on her flip-flops. Note how much more in varus wear on the left side compared to the right. This is most likely in compensation for an increased supination moment on that side. She is constantly trying to lengthen her left side by anteriorly rotated pelvis on that side and supinating her foot  and trying to “short” the right side by rotating the pelvis posteriorly and pronating the foot.

With the pelvic rotation present described above (which is what we found in the exam) you can see how she has intermittent low back pain. Combine this with the fact that she runs a daycare and is extremely right-handed and you can see part of the problem.

Leg length discrepancies become clinically important when they resulting in a compensation pattern that no longer works for the patient. Be on the lookout for differences and wear patterns from side to side.

Carry a backpack?    Unless you are a great compensator, like some limb amputees seem to be (see yesterdays post), be prepared for some changes in your gait. During some of our “backpack” research for yesterdays post, we turned up this full text article:  “In conclusion, college students currently carry too much weight in their backpacks. The average weight carried by UVU students caused an  increase in trunk flexion  regardless of age, gender or year in school. The load carried in the backpacks also  slowed gait velocity, increased time spent in double support , and with the messenger bags caused a  change in the right foot angle  implying that the hip was rotated due to the contralateral bag placement. In an effort to avoid such potentially harmful conditions, college students should avoid using messenger bags, should always follow the manufacturer settings for proper bag positioning, and carry less weight in their backpacks.”   https://www.western.edu/sites/default/files/page/docs/jensen.et_.al_.spring.2014.pdf

Carry a backpack?

Unless you are a great compensator, like some limb amputees seem to be (see yesterdays post), be prepared for some changes in your gait. During some of our “backpack” research for yesterdays post, we turned up this full text article:

“In conclusion, college students currently carry too much weight in their backpacks. The average weight carried by UVU students caused an increase in trunk flexion regardless of age, gender or year in school. The load carried in the backpacks also slowed gait velocity, increased time spent in double support, and with the messenger bags caused a change in the right foot angle implying that the hip was rotated due to the contralateral bag placement. In an effort to avoid such potentially harmful conditions, college students should avoid using messenger bags, should always follow the manufacturer settings for proper bag positioning, and carry less weight in their backpacks.”

https://www.western.edu/sites/default/files/page/docs/jensen.et_.al_.spring.2014.pdf

Carry a pack?    Have a LLD or other gait altering condition like a lower limb amputation? Carrying a pack may not necessarily change your center of gravity.   Yes, we were surprised as well…  “There are many scenarios where it becomes necessary to carry a load, and a back pack is often the most realistic option to carry this load. The additional load is thought to lead to changes in kinematics of the persons movement. This hypothesis, however, is not supported by results of this study. Asymmetry in movement did not significantly alter centre of pressure (COP) parameters for an amputee carrying a loaded backpack.”       Abstract    Understanding how load carriage affects walking is important for people with a lower extremity amputation who may use different strategies to accommodate to the additional weight. Nine unilateral traumatic transtibial amputees (K4-level) walked over four surfaces (level-ground, uneven ground, incline, decline) with and without a 24.5 kg backpack. Center of pressure (COP) and total force were analyzed from F-Scan insole pressuresensor data. COP parameters were greater on the intact limb than on the prosthetic limb, which was likely a compensation for the loss of ankle control. Double support time (DST) was greater when walking with a backpack. Although longer DST is often considered a strategy to enhance stability and/or reduce loading forces, changes in DST were only moderately correlated with changes in peak force. High functioning transtibialamputees were able to accommodate to a standard backpack load and to maintain COP progression, even when walking over different surfac es.   Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.     Appl Ergon.  2016 Jan;52:169-76. doi: 10.1016/j.apergo.2015.07.014. Epub 2015 Jul 31.Center of pressure and total force analyses for amputees walking with a backpack load over four surfaces.  Sinitski EH ,  Herbert-Copley AG , et al

Carry a pack? 

Have a LLD or other gait altering condition like a lower limb amputation? Carrying a pack may not necessarily change your center of gravity. 

Yes, we were surprised as well…

“There are many scenarios where it becomes necessary to carry a load, and a back pack is often the most realistic option to carry this load. The additional load is thought to lead to changes in kinematics of the persons movement. This hypothesis, however, is not supported by results of this study. Asymmetry in movement did not significantly alter centre of pressure (COP) parameters for an amputee carrying a loaded backpack.”


Abstract

Understanding how load carriage affects walking is important for people with a lower extremity amputation who may use different strategies to accommodate to the additional weight. Nine unilateral traumatic transtibial amputees (K4-level) walked over four surfaces (level-ground, uneven ground, incline, decline) with and without a 24.5 kg backpack. Center of pressure (COP) and total force were analyzed from F-Scan insole pressuresensor data. COP parameters were greater on the intact limb than on the prosthetic limb, which was likely a compensation for the loss of ankle control. Double support time (DST) was greater when walking with a backpack. Although longer DST is often considered a strategy to enhance stability and/or reduce loading forces, changes in DST were only moderately correlated with changes in peak force. High functioning transtibialamputees were able to accommodate to a standard backpack load and to maintain COP progression, even when walking over different surfaces.

Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.

Appl Ergon. 2016 Jan;52:169-76. doi: 10.1016/j.apergo.2015.07.014. Epub 2015 Jul 31.Center of pressure and total force analyses for amputees walking with a backpack load over four surfaces. Sinitski EH, Herbert-Copley AG, et al

What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another  “The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.  The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”  From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.

What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another

“The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.

The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”

From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.

Zero Drop? Think before you drop. More to think about before you make the jump (or run, or walk or stand…)

Ramp Delta. Drop. Heel to toe differential. Stack height differential. You have likely heard all the words before. We are talking about the difference in height between the center of the heel and ball of the big toe on the foot. It is literally “how much heel” the shoe has. Some have upwards of 20mm, some none at all (zero drop). The average seems to be 10-15 mm for many shoes, but that tradition is evolving to less and less (Brooks for example now has the “Pure” Series with a 4 mm average and one shoe that can be either 4 or zero (The Drift)). New Balance has their miniumus, Altra has their army of shoes, Saucony has a variable selection. Everyone is on target with their collection of minimalist or minimalist-trending (or as we like to call them, “gateway”) shoes.

Since we are born “sans” shoes, zero seems “natural” or maybe the best, right? Maybe, maybe not. A lot depends on you and your anatomy however logic dictates that we were born with the rear and forefoot on the same plane so there has to be a natural logic to the zero drop trend. The problem remains, how long have you been forcing this non-natural state and how long (if at all) will you be able to return to the “less is more” trend?

If you have been in shoes with more drop your whole life, your musculoskeletal system and neurology has adapted to that. If we take away our favorite chair, pair of shoes, golf club or whatever, you may have something to say about it. Same for your feet. If you drop/lower your heel, there are biomechanical changes and possible consequences.

You may have read this weeks post, talking about having enough ankle range of motion available. Dropping the heel requires more dorsiflexion (or extension) of the ankle. If that range of motion is not available, then the motion needs to occur somewhere else.

So, where elsewhere in the body is the motion going to occur ? Dropping the ankle requires more knee extension. Do you have that range of motion available? Are your knees painful when you wear a zero drop shoe?

How about your hips? Dropping the heel requires more hip extension as well. This extension is often accompanied by internal rotation of the hip (ankle dorsiflexion, along with foot abduction and forefoot eversion are all components of pronation, which will cause medial rotation of the hip. Do you have this range of motion available, or do you have femoral retro torsion, and a zero drop shoe makes that worse?

What about the effect on the low back? Dropping the heel decreases the lumbar lordosis (the natural curve forward). Don’t believe us ? Just look at any woman in a 3 inch pump and you will see some lovely curves. This places additional stress on the posterior ligaments and joint capsules and compression and shear on the discs. Some spines won’t tolerate this, just like some won’t tolerate heels, which increases the lumbar lordosis and places more stress on the posterior joints.

What about the mid back? Dropping the heel decreases the thoracic curve. How much extension (backward movement) do you have in your mid back?

The same with the neck…and the list goes on….

As you can see, it is much more complex than just changing to a shoe with less drop. Because of the biomechanical changes and demands, it will probably cost you something, be it range of motion, comfort, function. We are not saying it isn’t worth it, or that you shouldn’t do it; we are saying go slow and listen to your body. What may be right for someone else may not be right for you … . either in the short or long term.

Earn your way. Don’t throw caution to the wind. We see people everyday that have suffered the above consequences due to listening to the wonderful marketing of the minimalist trend and from embracing some of the nonsense on the web.  We call these people, “patients”.  Don’t make yourself a patient, use your head when it comes to your feet.

The Gait Guys

Ivo and Shawn

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our material.