Threshold foot drop. Video case.

Threshold foot drop.
Do you see it in this gait? No. There is a clue though, the EHL on the right (extensor hallucis longus) does not seem to be all that hearty and robust during gait, the toe is not as extended/dorsiflexes as on the left foot. A Clue ? Yes.
This client had true blatant foot drop, but it was caught relatively immediately, and the source resolved and recovery ensued. There is still some residual weakness, as you see at the end of the video, but making steady gains. Previously, gait showed obvious foot drop, foot slap, abrupt knee flexion (the "catch" response as we call it as the client's knee suddenly flexed forward as foot slap occurs). But, as you can see , the gait is pretty much normal now except for a little EHL strength lag. But, at the end of the video, when they heel walk, one can see the weakness, they cannot keep the ball of the foot off the ground during attempted heel walk. We like to call this "threshold weakness", it is just hovering below the surface, when taxed, it can be seen, but doesn't show up in gait. But, it does show up in longer endurance based walking events. This may be when your client's symptoms show up, as fatigue expresses limitations in the system. It just goes to show you, if you are not testing and looking for these things, you just might not find the source of your clients knee pain, foot pain, hip or low back pain. Heel and toe walking takes 10 seconds, do not forget to check them off. It just might be the "big reveal" for you, and them ! #footdrop #gait

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Gait Video case: Foot drop, a closer look.

I hope my final thoughts in today's important gait video will be profound to you as a clinician. It is the soft subtle presentations that are the tough ones, but the same messages are there, if you spend the time to assess for them.
* Remember, what you see in your client's gait is not their problem (as is obvious in today's video), instead you see how they are moving around their deficits. This is a key point we hammer home all the time. If you are making recommendations for your clients on how to move differently through corrective exercises that you THINK they need, merely because you see something in their movement that you do not like, you are very likely going to be fooled. You are not doing your client great service if that is your methodology. For example, telling this guy to engage his left tibialis anterior and lift his toes is the obvious visual correction, but the fact of the matter is, he cannot. So, what you see is how he has figured out how to move through the world, his compensation.
And for those who wish to argue, yes, hard neurologic deficits like you see here are not fixable. In this case, yes, you need to help them gain more skill endurance and strength in a better armored pattern for protective durability. But in many people, those without hardwired neuro or orthopedic deficits, you should be looking to fix their deficits, not merely fix aberrant movements that you just do not think LOOK good.

Threshold Foot Drop

Threshold foot drop.  
Do you see it in this gait? No. There is a clue though, the EHL on the right (extensor hallucis longus) does not seem to be all that hearty and robust during gait, the toe is not as extended/dorsiflexes as on the left foot. A Clue ? Yes. 
This client had true blatant foot drop, but it was caught relatively immediately, and the source resolved and recovery ensued. There is still some residual weakness, as you see at the end of the video,  but making steady gains. Previously, gait showed obvious foot drop, foot slap, abrupt knee flexion (the "catch" response as we call it as the client's knee suddenly flexed forward as foot slap occurs). But, as you can see , the gait is pretty much normal now except for a little EHL strength lag. But, at the end of the video, when they heel walk, one can see the weakness, they cannot keep the ball of the foot off the ground during attempted heel walk. We like to call this "threshold weakness", it is just hovering below the surface, when taxed, it can be seen, but doesn't show up in gait. But, it does show up in longer endurance based walking events. This may be when your client's symptoms show up, as fatigue expresses limitations in the system. It just goes to show you, if you are not testing and looking for these things, you just might not find the source of your clients knee pain, foot pain, hip or low back pain. Heel and toe walking takes 10 seconds, do not forget to check them off.  It just might be the "big reveal" for you, and them !

-Shawn and Ivo, the gait guys

The weeping calf and the deconstructed arm swing.

Last week we showed you this video and blog post of a compressive left lower leg neuropathy and what it looks like when both heel and toe walking are attempted when both are compromised. It was nothing exciting but to see both in a clinical presentation is not all that common.

In today’s videos (the one above and this one here), the videos were all shot on the same day incidentally, we wanted you to see this gentleman’s gait in it’s normal gait pattern attempt.  Because less of the extremes of range and strength are required, it is far more difficult to detect the issues than in last week’s video clip (here).

There are plenty of things to talk about in this video but lets just point out one of them here today.  Remember, the lesion is in the left lower leg.

Absent right arm swing. 

We have been harping about arm swing for a long time.  Go to the search box here on our blog and type in “arm swing” and you will find an abundance of articles on the biomechanics and neurology of arm swing and how it is tied to leg swing.  In this case we have foot drop and impaired calf raise (video link) on the left. Their function is impaired/depressed. We are seeing this matching in the absence of right upper limb swing.  Remember, most of the time the upper limb takes the queue from the opposite lower limb. This is why coaching arm swing changes is not a sound idea most of the time, look for functional opportunities for changes in the opposite lower limb if deficits are present there.  

Part of what you are seeing is the increased activity in the left arm swing.  Why ? Because the client is abruptly lurching off of the left leg because of the stability and strength deficits in that limb. The brain knows that bearing weight on the left limb has challenges.  This causes an abrupt pitch (early departure) forward onto the right leg and this will be met with increased left arm swing (go limb around your home or office, you will see that it is a coupled phenomenon).  So, is it increased left arm swing you are seeing because of this issue we just mentioned or are you seeing decreased right arm swing because of the matching neuro-suppression of left leg ? 

This is where your clinical examination must come into play. Shame on anyone that is making the changes without clinical information. One must see that there rare two (at least) possible scenarios for the differential in arm swing. And one must also see that the arms in this case are not the issue, that it is the left lower limb deficits that are driving the issue.  Guaranteed.

Arm swing……..more to it than you might think.

Shawn and Ivo, The gait guys

A Serious Gait Problem: Pancompartmental Compromise of the Lower Leg.

“Pan” is a prefix (combining form) meaning all, entire, everything, everywhere 

This was a case we discussed during a more recent podcast, perhaps pod 63 or 64? This doctor had fallen asleep with the left leg dangling over the side of his bed. The issue was that the leg not only dangled over the mattress, but also over a wooded side bed frame, so there was a firm upward compression into the posterior/popliteal compartment. He awoke the next day with complete loss of function of the foot and ankle.  This video is 8 weeks after the compressive event and there has been a significant improvement in function, but there are still some deficits here.  Can you see them ?  We will show you come other video clips in a future blog post discussing some other components of his gait but lets get you familiar with the case today.

What you should see here:

1- Left heel shows a staggered drop. He cannot hold heel rise because of compromise to the posterior compartment strength (gastrocsoleus complex). This was a drastic improvement from his complete inability to heel rise at all at on his initial visit. You can easily see the fatiguability of the calf after just a few steps. 

2- There is a pathetic attempt at heel walking; gross function testing of the anterior compartment. What appears to be an attempt at just right heel walking is actually an attempt to do it on both sides, there is just still so much weakness in the left anterior compartment that you cannot even see his attempts to dorsiflex the foot/ankle or toes. But, what we do not show here is that he has non-weight bearing dorsiflexion now, which was completely absent for the first 6 weeks.  

Neuronal regeneration is possible. It takes time.  Depending on your referenced source the numbers vary. But in his case, in 8 weeks there is progressive improvements and he can say for certain that in the last 2 weeks they are exponential.  The time to restoration of neuronal function is said to be directly proportional to the measurable length of nerve damage.  

What is interesting in this case, is that there is anterior and posterior compartment neurologic compromise. This was a case of vascular and mechanical compression to the neurovascular bundle at the popliteal/knee level. 

Wallerian degeneration is a process that results when a nerve is severely damaged. The axon of the nerve which is separated from the neuron cell body degenerates distal to the injury. The part of the axon distal to the injury begins its degeneration within 24-36 hours of the lesioning event and is followed by myelin sheath degradation. Somewhere around 4 days from the time of the injury, the distal end of the portion of the nerve fiber proximal to the lesion begins sprouting in an attempt to regrow and fill the gap along the length of axonal damage. Sources vary, but many seem to indicate a 1mm per day reinnervation. 

More on this case next time, but the stage has been set.

Shawn and Ivo

Podcast 50: Lactate Thresholds, Fartleks ? & more.

A. Link to our server:

http://thegaitguys.libsyn.com/pod-50

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

________________________________________

* Today’s show notes:

Neuroscience

1. Yes, this is dog: No More Woof aims to translate canine thoughts into human speech
http://www.engadget.com/2013/12/18/no-more-woof-indiegogo-concept-dog-headset/

2. Foot Drop solution ?

http://www.walkaide.com/en-US/Pages/default.aspx

3. Mini Implantable Microscopes to Watch Living Cells Inside the Body
http://www.popularmechanics.com/science/health/med-tech/mini-implantable-microscopes-to-watch-living-cells-inside-the-body-16286695?%3Fsrc=rss

4. Gait Talk:

How Your Running Form Changes During Long Runs and Easy Runs
http://www.formbeforefootwear.com/how-your-running-form-changes-during-long-runs-and-easy-runs/

4B . Lactate Threshold Talk

5. Footprints of the gait gods.

6. Fascial NeuroBiology: An explanation for possible manual therapy treatment effects «
http://www.thebodymechanic.ca/2012/10/28/fascial-neurobiology-an-explanation-for-possible-manual-therapy-treatment-effects/

7. National Shoe Fit Certification Program

The Clown Shoe That’s Changing Minimalist Running
http://www.outsideonline.com/outdoor-gear/footwear/Sole-Power-Nicolas-Mermoud-Minimalist-Running.html

8. Email:

Hi Guys -
I’m based in the UK. I’ve been running again for a year. I upped to 35 miles per week a month ago (from 25/30) and two weeks later I was injured with an inflamed piriformis muscle (it’s not syndrome). The pain is on my left side. I have a weaker gluteus medius on my left side. I did also put a chainsaw through my right inner thigh near the knee (it fell short of the bone and main artery in the leg) when i was 18 (i am now 40) - which may also have something to do with my question, but maybe not.
When I run, my right foot points outward during my right foot’s swing phase (but it lands straight). I can’t find an answer anywhere: is my outward pointing right foot perhaps the cause of the piriformis inflammation, and if so, how do i correct my foot movement during the swing phase? Help!!!
Weirdly, i have been obsessing about it for months but cannot correct it, and because of that I’ve noticed that a number of other people have from the same problem.

* Disclaimer

10 . How Does Foam Rolling Work? And Why “SMR” Should be Called “SMT” | Bret Contreras
http://bretcontreras.com/how-does-foam-rolling-work-and-why-smr-should-be-called-smt/

11. Behold The ‘Strength Axle’

http://www.thepostgame.com/blog/eye-performance/201312/strength-axle-craig-thompson-core-training-fitness-innovation

The Ankle-Foot Orthosis : Another option for foot drop.

Do you have a client who suffers from some foot drop ? Do they have a classical AFO but it drives them nuts ? Foot drop occurs when the anterior compartment of the lower leg (mostly tibialis anterior and/or long toe extensors) gets compromised neurologically leaving a persons gait compromised during the swing phase and early half of stance phase.  Early to mid stance phase of gait requires that the anterior compartment muscles slowly (eccentrically) lowers the foot to the ground in a controlled manner.  When this is compromised the foot quickly, and without strategy, slaps to the ground thus rushing the persons gait onto the forefoot.  This often occurs in an uncontrolled fashion and renders some balance and weight transfer complications. Then, during late stance phase, when the foot comes off of the ground merely by forward body progression, these clients leave the foot in the pointed plantarflexed position leaving the toes without proper clearance. This often leads to tripping and stumbling.

Always looking out for newer and better solutions, we came across this variation on the AFO (ankle-foot orthosis) strategy. It seems like it could have some advantages from a logistical side. Whereas the typical AFO comes under the foot and maintains the foot in a 90 degree ankle rocker (dorsiflexion) position this one has a bit of a dynamic effect. The bungee cord-like device should slowly lower the foot to the ground as well as help to spring the foot back into dorsiflexion for swing phase clearance so that the toes are not catching on the ground.  Seems so simple we have to wonder.  We might give this one a try on a few patients who have varying degrees of footdrop and report back.

Regardless, we wanted to share……. we love outside the box thinking. Especially when it is so simple !

bravo !

shawn and ivo…………. toss in a side of orthopedics and a main course of neurology, sprinkle a little biomechanics on that and you have a well rounded meal.  We are …… The Gait Guys