Podcast 148: A deep dive case study. Plus, Central and Peripheral fatigue explained

tag/key words: gait, gaitproblems, gaitanalysis, forefootrunning, forefootstrike, heelstrike, pronation, central fatigue, peripheral fatigue, fatigue, hip rotation, gait biomechanics, running

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What kind of shoe do you put this foot in?

Look carefully at these dogs. Notice anything peculiar? Look at the forefoot to rearfoot relationship. What do you see?

Normally, we should be able to draw a line from the center of the heel and it should pass between the 2nd and 3rd metatarsal heads. If the line passes through or outside the 3rd metatarsal heads, you have a condition called metatarsus adductus. It occurs from fetal positioning in utero. In children (18 mos to 4 years) it can often be corrected by wearing the shoes on the opposite feet (yes, you read that correctly)

We usually try and distinguish whether the adductus is occurring at the tarsal/ metatrsal articulation or the transverse tarsal joint.

 

OK, so now what?

 

Think of the unique biomechanics that happen here. Adduction (along with plantar flexion and inversion) are components of supination. So, the adduction component makes for  a more rigid foot (notice the arch structure in the pedograph). We are not saying this foot does not pronate, only that it pronates less.

Total amount of pronation will be determined by several factors,

  • including body weight

  • available rear foot motion
  • available forefoot motion

  • knee angulation (ie genu valgus or varus)
  • available internal rotation of the hips (how much ante or retroversion/torsion is present)

  • strength of abdominals, particularly the external obliques
  • tibial torsion

 

This individual had

·       markedly increased valgus angle (14 degrees)

·       moderate external tibial torsion

·       femoral antetorsion

 

this, along with their body weight, explains the rear foot pronation seen on the pedograph.

 

So, what type of shoe? You should pick a shoe that:

·       does not exaggerate the deformity (ie. a shoe that does not have an excessively curved last)

·       a shoe that does not work (too much) against the deformity (ie. an extremely straight lasted shoe)

·       In this case, a shoe with some motion control features (to assist in controlling some of the increased rear foot motion. This may be something as simple as a dual density midsole

·       a shoe that, upon gait analysis, works to provide the best biomechanics for the circumstances.

 

As you can see, when it comes to shoe fit and prescription, there are no had and fast rules. You need to examine the individual and have all the facts.

 

If you are a little lost, or want to know more, you should take our National Shoe Fit Program. Maybe you even should consider getting Level 1 certified by taking the International Foot and Gait Education Council exam. Need more details? Email us at: thegaitguys@gmail.com

The Power of Observation: Part 2

Let’s take a closer look at yesterdays post and the findings. If you are just picking up here, the post will be more meaningful if you go back and read it. 


The following are some explanations for what you were seeing:

torso lean to left during stance phase on L?

if he has a L short leg, he will need to clear right leg on swing phase. We have spoken of strategies around a short leg in another post. This gentleman employs 2 of the 5 strategies; torso lean is one of them

increased progression angle of both feet?

Remember he has femoral retroversion. You may have read about retrotorsion here. He has limited internal rotation o both thighs and must create the requisite 4-6 degrees necessary to walk. He does this by spinning his foot out (rotating externally).

decreased arm swing on L?

This is most likely cortical, as he seems to have decreased proprioception on both legs during 1 leg standing. Proprioception feeds to the cerebellum, which in turn fires axial extensors through connections with the vestibular system. Diminished input can lead to flexor dominance (and extensors not firing). Note the longer stride forward on the right leg compared to the left with less hip extension (yes, we know, a side view would be helpful here).

circumduction of right leg?

This is the 2nd strategy for getting around that L short leg.

clenched fist on L?(esp when standing on either leg)

see the decreased arm swing section. This is a subtle sign of flexor dominance, which appears to be greater on the right.

body lean to R during L leg standing?

This is again to compensate for the L short leg. He has very mild weakness of the left hip abductors as well, more when moving or using them in a synergistic fashion (ie functional weakness) than to manual testing.

Well, what do you think? Now you can see how important the subtle is and that gait analysis may complex than many think.

We are and we remain, the Geeky Guru’s of Gait: The Gait Guys

OK, quiz time. The Powers of Observation.

Perhaps you have been following us for a while, perhaps you are just finding us for the 1st time. Here is some back ground on this footage. Let’s test you observation skills.

Watch this gait clip a few times and come back here to read on.

This triathlete presented with low chronic low back pain of about 1 years duration. The   pain gets worse as the day goes on; it is best in the early am. Running and biking do not alter its intensity or character and swimming makes it worse. Rest and analgesics provide only temporary relief.

Physical exam findings include limited internal rotation of both hips (zero); a left anatomical short leg (tibial and femoral, 5mm total); diminished proprioception with 1 leg standing (<30 seconds). MRI reveals fatty infiltration of the lumbar spinal paraspinals and fibrotic changes within the musculature; degenerative changes in the L4 and L5 lumbar facet joints, degeneration of the L5-S1, L3-L4 and L2-L3 lumbar discs.

Now watch his gait again and come back here for more.

Did you see the following?

  • torso lean to left during stance phase on L?
  • increased progression angle of both feet?
  • decreased arm swing on L?
  • circumduction of right leg?
  • clenched fist on L?(esp when standing on either leg)
  • body lean to R during L leg standing?


How did you do? If you didn’t see all those things, then you are missing pieces of the puzzle. Remember, often what you see is not what is wrong, but the compensation

The powers of observation of the subtle make the difference between good results and great ones.

Try some of these tips.

  • break down the gait into smaller parts by watching one body part at a time: right leg, left leg, right arm, left arm, etc
  • watch for shifts in body weight in the coronal plane (laterally) and saggital plane (forward/backward) as weight transfers from one leg to another
  • watch for torso rotation (watch his shoulders. Did you notice he brings his torso more forward on the left than right when walking toward us?)


We are (and have been) here to help you be a better observer and a better clinician, coach, athlete, sales person, etc. If you haven’t already, join us here for some insightful posts each week; for our weekly (almost) PODcast on iTunes; follow us on Twitteror on Facebook: The Gait Guys

MORE compensations for short legs…

We remember from 2 weeks ago, the week before, AND last week, there at least SIX common compensations for a short leg.

We spoke about circumducting the long leg last time. Once again, here is the list

  •  pronation of the longer side, supination of the shorter
  • leaning to he shorter leg side
  • circumduction of the longer leg around the shorter
  •  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive ankle plantar flexion on short side
  •  excessive knee bend on the long leg side

Lets look at “hip hiking” of the longer extremity today. Hiking the hip allows one to create enough room (hopefully) to get that long leg through without dragging on the ground. Again,  it makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the longer leg.

This gal in the video has cerebral palsy (CP), affecting the left side. She has a short R leg and hikes the L pelvis pelvis up to get it to clear (she has L g med weakness due to the CP)

Watch the above video a few times to see what we are talking about. You can really see it when she is walking toward you.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Hip Hiking. Not quite the “Walk in the Woods” Bill Bryson was talking about, but yet another compensation for a short leg.

Ivo and Shawn. …bald, good looking, geeky…… The Gait Guys

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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

Case Quiz: Part 2: The Questions

Here was our reply:

She has a cross over gait pattern Right > Left; assumedly due to the amount of tibial varum on the Left; is it that prominent unilaterally? The lateral shift is compromising the LCL (lateral collateral ligament on the Left, combined with poor gluteus medius control. She appears to have an uncompensated forefoot varus bilaterally as well. I would question if she has an LLD (let length discrepancy) on the Right, with more pelvic glide/drift occurring to that side during stance phase of gait. Her arm swing is also greater on the right. With the reconstruction, she has a greater stride length on the Right, as she tries to unload the Left side. Does she look any better in the orthotics ?

Our suspicions are:

  • LLD (leg length discrepancy), short on the right
  • moderate Forefoot varus, uncompensated
  • LCL (lateral collateral ligament) laxity
  • weak Gluteus medius complex bilaterally
  • crossover gait


What could be done?

  • continued acupuncture for muscle facilitation
  • “waddle walks” with theraband around legs (to challenge the gluteus medius), keeping them in some degree of abduction
  • Single leg standing exercises on foot tripod
  • foot intrinsic strengthening (lift, spread, reach exercise; EHB; FDB, EDL)
  • Sole lift if indicated to help with limb length challenge


prolotherapy may help but you need to know WHY the leg translates laterally; otherwise you are just band aiding it

Hope that helps. Let us know how it goes and if she has an LLD (short leg, anatomically).


Ivo and Shawn: asking the tough questions….

Case Quiz: Part 1

Here is a case submitted by a friend of ours, Dr Lance Robbins in Florida. You can see the problem (and a description below). Rather than just give you the answers, we want you to come up with what questions to ask. Tune in later for what we think.

Ivo and Shawn


Dr Robbins notes on the client in the video:

Intermittent left knee pain with a painless limp while walking
Medical History is positive for an ACL reconstruction on the Left many years ago where they used part of the patellar tendon
Currently wears orthotics made by Xtreme Footwerks
Exam:
Gait showed a lateral knee deviation 
Static exam findings showed a marked tibial varus on the left,  bilateral external tibial torsion, along with Bilateral abducto-hallux valgus and mild bilateral forefoot varus.
There is a decrease in the right side ankle rocker, mid and forefoot motion is WNL (within normal limits). 
She presents with unilateral right sided genu recurvatum. During the exam she explained that before her ACL reconstruction she had bilateral genu recurvatum and during the surgery they corrected the left side.
Static palpation reveals a tight hypertonicity in the posterior knee structure on the left. There is also a moderate a,out of swelling along the upper lateral side of the left knee around the insertion of vastus lateralis and the client indicates that this has been there for along time since the surgery. When she tried to reduce the swelling with a TENs unit her knee pain got worse.
Dynamic evaluation showed normal hip ROM (Range of Motion) and ankle ROM except for the decrease in ankle rocker noted above. The right knee ROM is WNL. The left knee has a very slight reduction in flexion compared to the other side but still falls within normal limits. There is a moderate amount of instability in the left knee during the Varus stress test indicating some LCL (lateral collateral ligament) laxity. 
There is a decrease in the Left popliteus, biceps femoris, and glute medius  muscle function.
After one session of CMT (chiropractic manipulative therapy) (L5, Left Sacroiliac joint), acupuncture to facilitate muscle function and kinesiotape to support ligament laxity she had an immediate reduction in the swelling around her knee without any occurrence of pain. This lasted for 4-5 days with a return of some swelling after. 
The ligament laxity was not majorly effected by the treatment. 
Prolotherapy is one alternative we are considering
My hunch is that this has developed as a post-surgical adaptation due to the change in structural orientation of the knee (unilateral correction of genu recurvatum).
Even with prolothery to tighten up ligament structure how do we proceed forward in order to prevent reoccurrence or early onset degenerative processes?
A Pedograph mapping case.  Everyone wants to use the high tech stuff, we say you dont need it most of the time.  What do you see in this case ? 
 Answers: Increased heel pressure, Uncompensated forefoot varus (as evidenced by a lack of ink under the first metatarsals (you could even put a Rothbart foot-type on your DDx list), increased clawing of the 2nd-3rd digits on the right, and bilateral Morton&rsquo;s second toes.  If you look carefully at the big toe ink presentation you can see a &ldquo;pinch&rdquo; callus on the left foot at the medial aspect of the hallux. This might also represent some increased pressure being exerted by the short big toe flexor (flexor hallucis brevis), the longus (FHL) would give a more distinct distal pressure and ink response at or near the tip of the toe. What you want to see is a nice ink spot that is well blended throughout the entire pad of the hallux.  There is also similar hint of more use of the short flexor on the right and less of the long flexor. Overall the toes are bunched together in a group, there is not much separation, we sometimes take this as a global representation of a weaker foot. 
 Q: What could this transfer to as a clinical presentation (what kinds of things might you be suspicious of as you conduct your examination ?: 
 Answer: 
 Obviously heel pain has to be on the list.  There is a fair amount of heel pressure going on here.  With a forefoot varus or, simply put, incompetence of the medial foot tripod stability structure the person is more likely to generate more medial rotation of legs.  This, if not met will good pelvic and core resistance, can lead to lumbopelvic functional instability and thus low back pain. Typically, Forefoot varus clients either pronate very heavily, sometimes late (as in this case) as evidenced by lack of heavy ink printing through the arch area, or they tend to compensate and try to walk on the outsides of their feet. Anyone who delays or rushes the 3 rockers of the foot (rear, mid or forefoot rockers) is going to see compensations to the compromised the ankle rocker movement.  This obviously has its complications as well.  There is no good compensation.  As we say, if something is not working right&hellip;&hellip;..someone has to pay, eventually.

A Pedograph mapping case.  Everyone wants to use the high tech stuff, we say you dont need it most of the time.  What do you see in this case ?

Answers: Increased heel pressure, Uncompensated forefoot varus (as evidenced by a lack of ink under the first metatarsals (you could even put a Rothbart foot-type on your DDx list), increased clawing of the 2nd-3rd digits on the right, and bilateral Morton’s second toes.  If you look carefully at the big toe ink presentation you can see a “pinch” callus on the left foot at the medial aspect of the hallux. This might also represent some increased pressure being exerted by the short big toe flexor (flexor hallucis brevis), the longus (FHL) would give a more distinct distal pressure and ink response at or near the tip of the toe. What you want to see is a nice ink spot that is well blended throughout the entire pad of the hallux.  There is also similar hint of more use of the short flexor on the right and less of the long flexor. Overall the toes are bunched together in a group, there is not much separation, we sometimes take this as a global representation of a weaker foot.

Q: What could this transfer to as a clinical presentation (what kinds of things might you be suspicious of as you conduct your examination ?:

Answer:

Obviously heel pain has to be on the list.  There is a fair amount of heel pressure going on here.  With a forefoot varus or, simply put, incompetence of the medial foot tripod stability structure the person is more likely to generate more medial rotation of legs.  This, if not met will good pelvic and core resistance, can lead to lumbopelvic functional instability and thus low back pain. Typically, Forefoot varus clients either pronate very heavily, sometimes late (as in this case) as evidenced by lack of heavy ink printing through the arch area, or they tend to compensate and try to walk on the outsides of their feet. Anyone who delays or rushes the 3 rockers of the foot (rear, mid or forefoot rockers) is going to see compensations to the compromised the ankle rocker movement.  This obviously has its complications as well.  There is no good compensation.  As we say, if something is not working right……..someone has to pay, eventually.