Tricks of the trade: Backward walking

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

A single event can generate asynchronous sensory cues due to variable encoding, transmission, and processing delays. Robert Peterka talks about this, along with posture compensation and system apportionment when it comes to balance and coordination of the visual, vestibular and proprioceptive systems. We have talked about that here on the blog in the past.

We are often looking for ways to “highlight” pathology and make it more visible in the clinical exam. Having your patient/client walk backwards is one of those tools.

Walking and remaining upright in the gravitational plane requires 3 integrated systems to work in concert with one another: the visual, vestibular and proprioceptive systems. Backwards walking requires a more coordinated effort AND IF there is a “hiccup” or extra demand on the system (the proprioceptive in this case), neurological processing can take a little longer, efforts can be delayed and the end result is a greater compensation is needed; this often makes pathology more evident.

Try having your client walk backwards when you are doing your exam and see what we mean. We think you will be surprised with the results : )

Dr Ivo Waerlop, one of The Gait Guys

Peterka RJStatler KDWrisley DMHorak FB. Postural compensation for unilateral vestibular loss. Front Neurol. 2011 Sep 6;2:57. doi: 10.3389/fneur.2011.00057. eCollection 2011.

temporal Shayman CSSeo JHOh YLewis RFPeterka RJHullar TE.Relationship between vestibular sensitivity and multisensory temporal integration. J Neurophysiol. 2018 Oct 1;120(4):1572-1577. doi: 10.1152/jn.00379.2018. Epub 2018 Jul 18.

Hawkins KABalasubramanian CKVistamehr AConroy CRose DKClark DJFox EJ. Assessment of backward walking unmasks mobility impairments in post-stroke community ambulators. Top Stroke Rehabil. 2019 May 12:1-7. doi: 10.1080/10749357.2019.1609182. [Epub ahead of print]

#backwardwalking #clinicalexam #thegaitguys #gaitpathology #clinicaltricksofthetrade

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The case of the dropped (plantarflexed) metatarsal head. Or, “How metatarsalgia can happen”.

This gentleman came in with fore foot pain (3rd metatarsal head specifically), worse in the AM upon awakening, with first weight bearing that would improve somewhat during the day, but would again get worse at the end of the day and with increased activity. The began insidiously a few months ago (like so many problems do) and is getting progressively worse.

Rest and ice offer mild respite, as does ibuprofen. You can see his foot above. please note the “dropped” 3rd metatarsal head (or as we prefer to more accurately say, “plantarflexed 3rd metatarsal head”) and puffiness and prominence in that area on the plantar surface of the foot. 

To fully appreciate what is going on, we need to look at the anatomy of the short flexors of the foot. 

The flexor digitorum brevis (FDB) is innervated by the medial plantar nerve and arises from the medial aspect of the calcaneal tuberosity, the plantar aponeurosis (ie: plantar fascia) and the areas bewteen the plantar muscles. It travels distally, splitting at the metatarsal phalangeal articulation (this allows the long flexors to travel forward and insert on the distal phalanges); the ends come together to divide yet another time (see detail in picture above, yes, we are aware it is the hand, but the tendon structure in the foot is remarkably similar)) and each of the 2 portions of that tendon insert onto the middle of the middle phalanyx (1) 

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsal phalangeal joint, and proximal interphalangeal joint (although this second action is difficult to isolate. try it and you will see what we mean). In addition, it moves the axis of rotation of the metatasal phalangeal joint dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly (much like the function of the extensor hallucis brevis above in the drawing from Dr Michauds book, yes, we are aware this is a picture of the 1st MTP).

Can you see the subtle extension of the metatarsal phalangeal joint and flexion of the proximal interphalangeal joint in the picture?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a tole in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, especially if there is a concomitant loss of ankle rocker, the metatarsal heads are driven into the ground (plantarflexion), causing irritation and pain. Metatarsalgia is born….

So what is the fix? Getting the FDB back on line for one. 

  • How about the toe waving exercise? 
  • How about the lift spread reach exercise? 
  • How about retraining ankle rocker and improving hip extension?
  • How about an orthotic with a metatarsal pad in the short term? 
  • How about some inflammation reducing modalities, like ice and pulsed ultrasound. Maybe some herbal or enzymatic anti inflammatories?

The Gait Guys. Increasing your gait and foot literacy with each and every post. 

1. http://en.wikipedia.org/wiki/Flexor_digitorum_brevis_muscle

2. Tosovic D1, Ghebremedhin E, Glen C, Gorelick M, Mark Brown J.The architecture and contraction time of intrinsic foot muscles.J Electromyogr Kinesiol. 2012 Dec;22(6):930-8. doi: 10.1016/j.jelekin.2012.05.002. Epub 2012 Jun 27.

3.Okai LA1, Kohn AF. Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.Motor Control. 2014 Jul 15. [Epub ahead of print]

4. Zelik KE1, La Scaleia V, Ivanenko YP, Lacquaniti F.Coordination of intrinsic and extrinsic foot muscles during walking.Eur J Appl Physiol. 2014 Nov 25. [Epub ahead of print]

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How good is your tripod? Looks can be deceiving

You have heard us here on the blog talking about the foot tripod. For those of you who may not remember; click here and here for a refresher.
In the right foot (far left image) pedograph, you notice increased ink under the three points of the tripod (pass your mouse or click on the image to enlarge): The center of the calcaneus, the head of the 1st metatarsal and the head of the 5th metatarsal. Looks pretty good, correct ? The left one (center image) shows more weight on the lateral aspect of the foot.

Note now the picture of the feet that go with this tripod (far right). Pretty scary, huh ? Their left foot actually looks like a better tripod, especially the medial tripod.  So, what does that tell you? It tells you that from the pedograph print (remember the person is walking across the pedograph), they are able to compensate better on the right than on the left.  Remember what we always say, what you see is not what is wrong or what is actually truthfully going on.
So, what do you do?
consider exercises to increase the foot tripod (tripod standing, the Extensor hallucis brevis exercise,  lift spread reach ) and try and make the weight distribution equal from side to side.

The Gait Guys. Making sure you are firing on all your cylinders (or walking on all 3 points of the tripod). 

Want to know more? Consider taking the 3 part National Shoe Fit Program. Email us at thegaitguys@gmail.com for more details. 

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Hmmm. We are fully internally rotating this gentleman’s lower leg (and thus hip) on each side. What can you tell us?

Look at the upper picture. Does the knee go past midline? NO! So we have limnited internal rotation of the hip. What are the possible causes?

  • femoral retro torsion
  • tight posterior capsule of hip
  • OA of hip
  • tight gluteal group (max or posterior fibers of medius)
  • labral derangement

Now line up the tibial tuberosity and the foot. What do you see? The foot is externally rotated with respect to the leg. What are the possible causes?

  • external tibial torsion
  • subtalar valgus
  • fracture/derangement causing this position

Now look at the bottom picture. Awesome forearm and nice choice of watch. Good thing we didn’t wear Mickey Mouse!

Look at upper leg. Hmm. Same story as the right side.

Look at the lower leg and line up the tibial tuberosity and the foot. What do you see? The foot is internally rotated with respect to the leg. What are the possible causes?

  • internal tibial torsion
  • subtalar varum
  • fracture/derangement causing this position

So this individual will have very different lower leg mechanics on the right side compared to the left (external torsion right, internal left). We refere to this as “windswept” biomechanics, as it looks like the wind came in from the right and “swept” the feet together to the left.

What will this look like? Most likely increased pronation on the right and supination on the left. What may we see?

  • calcaneal (rearfoot) valgus on right
  • calcaneal (rearfoot) varum on the left
  • bilateral knee fall to midline
  • knee fall to midline on right occurring smoother than on left
     (the patient has an uncompensated forefoot varus bilaterally; he is already partially pronated on the right, so it may appear to be less abrupt)
  • toeing off in supination more pronounced on the left (due to the internal torsion and forefoot varus)

The Gait Guys. Increasing your foot and gait IQ with each and every post.

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OK Folks

Take a look at these pics for a moment, then come back and read.

Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : )  ) They were wondering if the child needed orthotics. What do we see?

top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).

top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).

Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.

Bottom left: I am fully internally rotating the left lower leg. It appears normal  with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.

Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.                               

In summary:

  • External tibial torsion, R > L
  • flattened longitudinal arches
  • Right femoral retrotorsion
  • Left femoral version, NORMAL

Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.                                                                                                           

How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.

The Gait Guys. Twisted in a good way. Versioned but not torsioned.

all material copyright 2013 The Gait Guys/The Homunculus Group. all rights reserved. please don’t use our stuff without asking : )

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Case of the Week: Rib Pain while Running: Part 2

Welcome back. Glad you picked choice d (or maybe you had a pint anyway)

Assessment: This patient has a significant difference in the length of her legs; her left leg being short, right leg being longer. The right ilia is rotated posteriorly (thus the tissue fold) in an attempt to shorten the extremity and the left ilia is rotated anteriorly, in an attempt to lengthen the leg. This is putting the abdominal external obliques in a  lengthened and shortened position, respectively. The right is short weak and the left is long (stretch).  The obliques attach to the lower ribs 5-12 (for external) and ribs 10-12 (for the internals).

The psoas muscle takes its origin form the lumbar vertebral bodies and inserts on the lesser trochanter of the femur. Due to the poterior rotation of the right ilia, it has been lengthened over time (thus the difference in hip extension) and is stretch weak on the right.

So why only on the right and during running?

due to the anatomical leg length difference, the right oblique has shortened over time. Running (forced inspiration and expiration) causes us to use some of our accessory muscles of respiration (obliques, intercostals, serratus posterior superior and inferior, sternocleidomastoid, scalenes. Remember that for quiet respiration, only the diaphragm is used for inspiration; passive tension in muscles for expiration).

Also, the stride length will be increased on the longer leg side (ie when the L leg is in swing and R in stance); this put additional stretch on the R iliopsoas and R abdominal obliques.

iliopsoasthe

Treatment Plan: We placed a 3 mm lift in her left shoe. We treated with manipulative therapy of the lumbar spine.  She was given the nontripod, side bridge, cross/crawl quadruped and hip flexor stretch with side bending exercises to perform on a daily basis.  She felt better post treatment.

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Case of the Week: Rib Pain while Running: Part 1

This 39 year old woman presents with with rib pain, pointing to right ribs. First time it “went out” 1 ½ year ago, second time a year ago and recently two weeks ago. It is usually related to running with pain the day of and day after it is acute; it hurts to lie on her back or roll onto that side or breathe deep. She seems to do best when she is semiflexed on her knees.  Stretching can take the edge off.  When she has an acute episode, it usually lasts about a day.

She is very physically active and works out almost everyday. She runs triathlons and Ironman’s (or Ironwoman’s in this case), and generally is in good shape.

Above is what you see physically (hover mouse over each picture) and here are her exam findings:

She is 5’ and weighs approx. 105 pounds. BP 100/72 left, pulse ox 94, pulse 52. Lungs auscultate clearly, normal heart sounds, abdomen non tender and normal to percussion and auscultation.

Viewed from posterior in a standing position, she had increased tibial varum bi-lat., right greater than left, right hip had posterior rotation, less space between iliac crest and rib margin right hand side. No tenderness noted over the obliques or lower ribs left hand side. She had a loss of lateral bending to the left L2 through L4 negative theta-z stress.

She has a L  left short leg (tibial) 5 mm, bi-lat. external tibial torsion left greater than right. There is weakness of the abdominal internal and external obliques bi-lat. as well as iliopsoas, R > L. There was point tenderness at the R lesser trochanter; active and passive hip extensoin was 10 degrees right, 15 degrees left.

Question: What is your assessment and what are you going to do?

a. do not know, go have a beer

b. do not know, go have 2 beers

c. do not know, do not drink beer, have a double latte after reading Fridays post and try not to spill it

d. reply to this post,  think about it and check back later to see what The Gait Guys have to say