"Stiff person syndrome": A clinical mystery ?

Stiff person syndrome (SPS), first noted in 1956, is a rare neurologic entity of unclear etiology. It is characterized by progressive rigidity and stiffness mainly affecting the axial trunk muscles thought it can affect the limb(s), one or more.  It looks much like a sensory-motor neuropathic gait, and similar to a CIDP (chronic inflammatory demyelinating polyneuropathy) client we have seen. Chronic pain, impaired mobility, and lumbar hyperlordosis are common symptoms. Spasms can be severe and leave the patient very sensitive to touch and sound, which can sometimes trigger spasms. Some studies have noted that patients generally tend to have anti-glutamic acid decarboxylase (GAD) antibodies, anti-amphiphysin, anti-gephyrin, and anti-gamma-aminobutyric acid A receptor-associated protein (GABARAP) antibodies leaving one to assume this is a variation of an autoimmune disorder expressing neurologically. This is complicated by lack of adequate or specific lab tests to pin point the diagnosis though some CSF and EMG tests are helpful. Generally this is a progressive disorder eventually leaving many clients with movement disabilities.  Enough patients tend towards cancer over time that there may be a paraneoplastic underpinning.
This is a bizarre one, what do you think ?  Have you seen it ?

Pract Neurol. 2011 Oct;11(5):272-82. doi: 10.1136/practneurol-2011-000071. Stiff person syndrome. Hadavi S1, Noyce AJ, Leslie RD, Giovannoni G.

Brain Nerve. 2010 Apr;62(4):377-85. [Stiff-person syndrome and other myelopathies constitute paraneoplastic neurological syndromes]. [Article in Japanese] Ishii A1.

Podcast 60: Speeding up at the finish line & Efferent Copy

A. Link to our server:

Direct Download: 

http://traffic.libsyn.com/thegaitguys/pod_60final.mp3

Permalink: 

http://thegaitguys.libsyn.com/podcast-60-speeding-up-at-the-finish-line-efferent-copy

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:

1.  Move Your Body, Grow Your Brain

http://www.edutopia.org/blog/move-body-grow-brain-donna-wilson

2. http://www.runnersworld.com/health/the-importance-of-breaks-in-sedentary-time

3. Why are elite athletes able to speed up when they see the finish line?

http://www.theglobeandmail.com/life/health-and-fitness/fitness/why-are-elite-athletes-able-to-speed-up-when-they-see-the-finish-line/article16747880/

4. How Your Thoughts Affect Your Running Efficiency 

http://www.runnersworld.com/sports-psychology/how-your-thoughts-affect-your-running-efficiency

5. How Alcohol Affects Muscle-Building

http://www.runnersworld.com/nutrition-for-runners/how-alcohol-affects-muscle-building

6. Blog reader: Hey again, I personally compete in this uphill/ downhill running race in 2 months. The slops are really steep(incline/ decline).I’m just looking for some useful tips on running biomechanics, cadence etc. Any hints on what things I should be doing and of course avoid doings that will lead to injury? An international podcast fun!

7. Blog reader:

How does subtalar supination/pronation affect plane deviations farther up the chain, specifically at the pelvis? I was going over some notes and found something saying that increased pronation leads to increased frontal plane motion at the pelvis during gait, and increased sup leads to increased transverse plane motion. However, in this video I was watching, the clinician states that increased sup will lead to increased frontal plane motion. Is this not a contradiction? Can both be true? Thanks

“Sagging Pants”: A different kind Self-Inflicted of Gait Pathology.

We have been absolutely dying to do a blog post on “sagging” pants for years but we just couldn’t find video that sufficiently provided the visuals we required to go into depth on the pathology it drives into one’s gait. Both of us at The Gait Guys knew we would never live it down if we actually did this walk ourselves (plus we realized we didn’t have the required jeans) so we waited for the perfect video(s).  Well folks, today is your lucky day because we found what we are looking for (there is a second video link down below but please read on before you look at it so you can understand what you are seeing).

Today we start this blog post with a classic video example of what “sagging pants” gait looks like. This poor fella is either having some real difficulties or he is taking it to the next level (and if so, good on him !) You know what we are referring to, the culturally proclaimed cool style of wearing your pants down around your upper thighs with your junk barely kept in the trunk.  But there is more to this gait than you might think and there is a reason why we have wanted to so badly present this gait to you. The reason is because, well, it is darn right entertaining to watch, but more so because it creates a very unique variant of the classic Abductor gait.  in order to keep one’s pants up, and from falling down to one’s ankles, one must abduct the thighs and legs to push out into the waist of the pants to keep the pressure constant and keep the pants up.  But wait, there is soooo much more than just that.  This gait throws off:

• the normal stance and swing phases
• impairs the normal gait rhythm
• clearly impairs arm swing (and this video above is interesting because it so very nicely shows in the video that the more the legs abduct the more the arms abduct on the contralateral side. More proof to all you runners out there who are trying to coach a new arm swing, you must realize that a huge part of arm swing is predicated on what is happening in the contralateral lower limb.  Perhaps a unique addition to the “crossed extensor response” for all you neuro geeks out there !).  So before you try to change a runner’s arm swing you better assess the lower limbs, they likely have reasons as to why they are doing what they are doing. Once again, proof that what you see is not the problem and what you see is not necessarily what needs corrected.
• causes and abduction of the feet and legs (perhaps this should be mandatory therapy to reduce all runner “cross over gaits” ?  Can we bill insurance for that ?). This is one reason why we love “monster walks” with an ankle theraband loop as ONE way to train less cross over neuropatterning. This is not to be confused with the more medically classic “abduction gait” pathologic gait pattern.
• lessens the normal pelvic obliquity of the pelvis (ie. when the right leg is behind and in full hip extension just prior to push off phase of gait, the pelvis is obliqued posteriorly).  Remember that the initiation of the swing phase is initially brought on by the reduction of the obliquity by abdominal contraction to pull the pelvis forward (during opposite leg stance/support phase) and then the psoas (ipsilaterally/swing side) becomes a swing phase perpetuator. The psoas is not a swing phase initiator, it is a perpetuator.
• impairs hip extension, and thus will cause gluteal atrophy in time (oh gosh, combined pathology now!)
• impairs terminal swing phase of gait
• recruits pathologic gait patterns
• impairs one’s ability to run from the cops, your girlfriend’s father who might have a shotgun, a guard dog, a nasty bout of diarrhea and finding a toilet, or if you are late to catch the morning bus)

This may be the silliest, self-chosen, and self-consciously acquired, pathologic gait pattern ever.  But it is none the less really entertaining to watch as the main video shows. 

Now, here (link) is a better video showing the pathologic problems we itemized above.  Look closely in this video you will see that in order for this gait style to “Work” (if that is what you call it) the pants have to be riding up higher in the front around the front of the thighs.  And to do this one has to tip into a slight posterior pelvic tilt most likely driven by the glutes and create a slight constant flexion of the knees (which also further impairs hip extension and gluteal recruitment). This will cause overactivity of the glutes and eventual shortening of them. We wonder how many of these fellas have developed piriformis syndrome radiculopathy ? 

http://youtu.be/KcvDr-bys2A

http://youtu.be/OvPpewa86yI

For the love of all things sane and wise…….. please pull up your pants if you are doing this…….we can’t fix everyone’s gait on the face of the earth but we certainly do not need folks intentionally screwing up their gait just to show off your hot underwear ? Wouldn’t it be more proper just to ask someone if they want to see your hot new Calvin Klein’s ?.  On a positive note, showing off your undies in this Sagging Pants manner will improve hygiene, if you know what we mean.

Shawn and Ivo, Sagging our pants regularly, but only in the privacy of our own homes, and we suggest you keep it there as well.

More Foot Rocker pathology Clues.

Is ankle rocker normal and adequate or is it limited ?  Is it limited in early midstance or late midstance ? How about at Toe off?  Is it even possible to distinguish this ? Well, we are splitting hairs now but we do think that it is possible. It is important to understand the pathologies on either end of the foot that can impact premature ankle rocker. 

Look at the photo above. You can see the clinical hint in the toe wear that this runner may have a premature heel rise. However, this is not solid evidence that every time you see this you must assume pathologic ankle rocker. The question is obviously, what is the cause.

Considerations:

1- weak anterior compartment, which is quite often paired with the evil neuroprotective tight calf-achilles posterior complex to offer the necessary sagittal protection at the ankle mortise.  This will cause premature heel rise from a posterior foot aspect.

2- rigid acquired blocked ankle rocker from something like “Footballer’s ankle”. This will also cause premature heel rise from a relatively posterior foot aspect.

3- there are multiple reasons for late midstance ankle rocker pathology. The client could completely avoid the normal pronation/supination phase of gait because of pain anywhere in the foot. For example, they could have plantar fascial pain, sesamoiditis, a weak first ray complex from hallux vaglus, they could have a painful bunion, they could be avoiding the collapse of a forefoot varus. There are many reasons but any of them can impair the timely pronation-supination phase in attempting to gain a rigid lever foot to toe off the big toe-medial column in “high gear” fashion. And when this happens the preparatory late midstance phase of gait can be delayed or rushed causing them to move into premature heel rise for any one of several reasons.  Rolling off to the outside and off of the lesser toes creates premature heel rise.  

4- And now for one anterior aspect cause of premature heel rise. This is obviously past the midstance phase but it can also cause premature heel rise. Turf toe, Hallux rigidus/limitus or even the dreaded fake out, the often mysterious Functional Hallux limitus (FnHL) can cause the heel to come up just a little early if the client cannot get to the full big toe dorsiflexion range.  

We could go on and on and include other issues such as altered Hip Extension Patterning, loss of hip extension range of motion, weak glutes, or even loss of terminal knee extension (from things like an incompleted ACL rehab, Osteoarthritis etc) but these are things for another time. Lets stay in the foot today.

All of these causes, with their premature heel rise component, will rush the foot to the forefoot and likely create Metatarsal head plantar loading and could cause forces appropriate enough to create stress responses to the bone. This abrupt forefoot loading thrust will often cause a reactive hammer toe effect.  Quite often just looking at the resting nature of a clients toes while they are lying down will show the underlying increase in neuro-protective hammering pattern (increased long toe flexor and short toe extensor activity paired with shortness of the opposing pairs which we review here in this short video link).  The astute observer will also note the EVA foam compressing of the shoe’s foot bed, and will also note the distal displacement of the MET head fat pad rendering the MET head pressures even greater osseously. 

Premature ankle rocker and heel rise can occur for many reasons. It can occur from problems with the shoe, posterior foot, anterior foot, toe off, ankle mortise, knee, hip or even arm swing pathomechanics.  

When premature heel rise and impaired ankle rocker rushes us to the front of the foot we drive the front half of the shoe into the ground as the foot plantarflexion is imparted into the shoe.  The timing of the normal biomechanical events is off and the pressures are altered.  instead of rolling over the forefoot and front half of the shoe after our body has moved past the foot these forces are occurring more so as our body mass is still over the foot. And the shoe can show us clues as to the torture it has sustained, just like in this photo case.

You must know the normal biomechanical gait events if you are going to put together the clues of each runner’s clinical mystery.  If you do not know normal how will you know abnormal when you see it ? If all you know is what you know, how will you know when you see something you don’t know ?

Shawn and Ivo, The Gait Guys … .  stomping out the world’s pathologic gait mechanics one person at a time. 

Pathologic Ankle Rocker: Part 2. “Passing the Buck Proximally”

This was an unexpected follow up blog post from yesterday’s piece we did on the rigid flat foot. We were purging some files from an old computer and came across these 2 videos. We are not even sure where they came from. They were AVI files from probably 2 decades gone by;  they reminded us how long we have been at this gait game and how many great patients have taught us along the way.
Yesterday we learned that if the ankle rocker (dorsiflexion) was impaired that we could ask for the motion to be passed into the midfoot via hyperpronation in order to get the tibia to progress past vertical to enable the body to pass by the rigid ankle mortise rocker.  (Remember from our previous teachings that there are 3 rockers in the foot. First there is heel rocker, then ankle rocker, then forefoot rocker. Each is essential for normal gait. You must understand the 3 rockers to understand gait and to recognize gait pathologies when they present.)
So, yesterday we saw a strategy of pronating excessively through the midfoot to artificially trick us into thinking we have more ankle rocker then we actually truly did. So this was a “pass the buck” into the foot. Today however we are going to show you a very atypical compensatory choice. Today this client shows that with a rigid and/or strong enough arch that the arch doesn’t always need to be the part that gives in to enable more rocker. Today this client chose a vertical strategy.
You are going to have to study these videos closely several times, this is a critical learning and teaching point today. The problem is the left ankle in the video.

This client has chosen to go  VERTICAL when they hit the ankle rocker limitation. Once they achieve their terminal range at the ankle mortise joint (the tibio-talar joint ) their brain realized that moving forward at the ankle was impossible. Since the midfoot did not collapse and give in, as in yesterday’s case, they had no choice but to “pass the buck” proximally into the kinetic chain. In this case we see that the knee was the next vertical joint. Now, they have 2 choices, either hyperextend the knee to enable a forward lurch of the body mass past the ankle rocker axis or “go vertical”. In this case you can see the early heel rise (we refer to is as premature heel rise). Frequently a premature heel rise can force knee flexion but in this case the rise just kept going vertical and forcing them into the use of the gastrocsoleus group and thus forcing a lift of the entire body. If you look hard you can see a greater development of the calf muscles on this side from doing this for years. (Oh, wait, memory data dump here…..we are recalling this case, it was the result of an old motorcycle accident. A student sent us this video back in the 1990’s when we were teaching at the university.)
What is interesting here is that if you think hard, and this will be a new thought process for many readers, that when he goes into heel rise he buys himself more ankle range again. You see, he first met the end range limitation of ankle rocker which appears to be about 90 degrees and then he hits the bony block. If he goes vertical into the calf he is moving back into plantarflexion. This means that even though he is on the forefoot now, he has bought himself more ankle dorsiflexion range again. Now he has the option of holding the posture on the forefoot as rigid and then re-utilizing the new-found extra degrees of ankle dorsiflexion to progress forward OR, he can just move into FOREFOOT ROCKER (the 3rd of the rockers we meantioned earlier).  This client is likely doing a bit of both, perhaps a little more of the forefoot rocker strategy.
You can also kind of see that this slightly shortens the time in the stance phase on this left side and causes an early dumping onto the right limb (which causes a frontal plane pelvis distortion compensation). This gives the appearance of a slight limp.
So, this was a nice follow up from yesterday’s principle of “passing the buck”. You can either ask for the motion from the next distal joint in the kinetic chain, or  you can back up the kinetic chain and dump it into the proximal joint from the pathologic one (the knee in this case). Which one would you want, if you had to choose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns.

Here is a tougher question for you. Would you want this phenomenon on one side and be unilaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*Please do not try to help this client by putting a heel wedge in their shoe. You are just going to rush heel rocker into that bony block sooner and faster and speed up his pathologic stance phase. You will see his vertical strategy come even faster and thus pass the buck into the opposite right hip even stronger. It is a fleeting good initial thought because you are merely trying to help his poor calf muscles get to that heel rise easier, until you think about it for a minute.

When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.

What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
- a rigid high arched cavus foot
- perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
- a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
- weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
- contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
- presence of a rigid forefoot valgus
- avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop

Podcast 34: Chimp feet, Marathon Monks & Statin drugs

podcast link:

http://thegaitguys.libsyn.com/podcast-34-chimp-feet-marathon-monks-statin-drugs

iTunes link:

http://thegaitguys.libsyn.com/podcast-33-heart-beats-toe-walking-crawling

Gait Guys online /download store:

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

other web based Gait Guys lectures:

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

Today’s show notes:

 1.Did Rock Climbing Help Us Start Walking Upright?   By Shaunacy Ferro A new theory suggests humans became bipedal so that we could scramble up rugged terrain.
http://www.popsci.com/science/article/2013-05/did-rock-climbing-help-us-start-walking-upright?src=SOC&dom=tw


2. http://en.wikipedia.org/wiki/Kaih%C5%8Dgy%C5%8D

The Running Marathon monks of Mt. Hiei

The Kaihōgyō is a set of the ascetic physical endurance trainings for which the Japanese “marathon monks” of Mt. Hiei are known. These Japanese monks are from the Shugendō and the Tendai school of Buddhism, a denomination brought to Japan by the monk Saichō in 806 from China.

3. http://www.runnersworld.com/general-interest/do-you-have-chimpanzee-feet

Do you have Chimpanzee feet ?

About 8% of people tested by Boston University researchers had midfoot flexibility of the sort that apes use to climb trees, according to a study published in the American Journal of Physical Anthropolgy.

4. Statins Linked With Risk of Musculoskeletal Injury

Michael O'Riordan

http://www.medscape.com/viewarticle/805369?src=wnl_edit_medn_wir&spon=34

http://archinte.jamanetwork.com/article.aspx?articleid=1691918

Can Statins Cut the Benefits of Exercise?

By GRETCHEN REYNOLDS

http://well.blogs.nytimes.com/2013/05/22/can-statins-curb-the-benefits-of-exercise/

http://www.ncbi.nlm.nih.gov/pubmed/23583255

5. Shoes: The Primal Professional.com

http://theprimalprofessional.com/products/pre-order-the-primal-professional

http://well.bradrourke.com/2013/05/my-new-primal-dress-shoes/

6. Hallux valgus and lesser toe deformities are highly heritable in adult men and women: The Framingham foot study

Marian T. Hannan
http://onlinelibrary.wiley.com/doi/10.1002/acr.22040/abstract;jsessionid=99975015C3EE5678E6351273C2CD42A0.d02t04

7. Forefoot strikers exhibit lower running-induced knee loading than rearfoot strikers

Kulmala, Juha-Pekka; Avela, Janne; Pasanen, Kati; Parkkari, Jari

http://journals.lww.com/acsm-msse/Abstract/publishahead/Forefoot_strikers_exhibit_lower_running_induced.98324.aspx

8. Why Where You Land On Your Foot Isn’t That Important

http://www.kinetic-revolution.com/why-where-you-land-on-your-foot-isnt-that-important/

Stop Doing Kegels: Real Pelvic Floor Advice For Women (and Men)

This web article just came out today and we felt it was important to share. 

Nicole Crawford did a nice job with the article (LINK) and you need to read it.  The pelvic floor is a complicated place. There needs to be balanced muscular contraction and there has to be neutral pelvis and lumbar spine.  We have to agree with her comment:

A Kegel attempts to strengthen the pelvic floor, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF (pelvic floor) gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to pelvic floor disorder (PFD). Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the pelvic floor is beginning to weaken. An easier way to say this is: Weak glutes + too many Kegels = PFD.

 There are too many people who have a shallow lumbar spine lordotic curve. These folks often hold the pelvis as neutrally as they can by keeping a constant squeeze of the glutes to “push” the pelvis “tipped up or levelled up” in the front when in fact the lower abdominals should “hold” them up in the front, to a notable degree.  It is easier for many to push the pelvis up with the glutes particularly when so many individuals are lacking in the abdominal compartment. 

We have so many of our patients learn the “potty squat” where the buttock is pushed backwards in a proper squatting technique.  We do this to reteach gluteal work, hamstring length in an environment of proper abdominal bracing. IT takes time to get the technique down, but it is worth it.  And, Crawford’s article gives it even more validity with its effect on the sacral posturing and impairing pelvic floor tension.

There is much good information in this article by Crawford.  It is worth everyone’s read. If you have been here with us on The Gait Guys for awhile you will know that we hold the mighty glutes on a high pedestal.  They are absolute key in gait and many folks do not use them properly.  After a few rough weeks practicing going gradually deeper as tissue length and strength is earned many of our patients have an epiphany of how little they were using their glutes, and how poorly they squat and how weak they were in the lower limbs.  Even our elderly patients in their 70s and 80s benefit from early shallow potty squat progressions.  We just put a chair behind them in case they fall back. It is never shocking to see what a few weeks of propper “potty-ing” will do to a person.  Do them alot, and do them often.

Good potty-ing to ya’ll.

Shawn and Ivo………Kings of our own Potty Thrones

Here is Crawford’s article link once again.

http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-women-and-men

So, what kind of shoes do I put this guy in?

The answer is, well…it depends.

This gentleman has a large Q angle (need to know more about Q angles? click here). The second photo is taken from above looking down at his knee.

If he has medial (inside) knee pain (possibly from shear forces), you would want to unload the medial knee, so a more flexible shoe that would allow more pronation of the foot and INCREASE the amount of valgus would open the medial joint space and probably be more appropriate.

If he had lateral (outside) knee pain (possibly from compressive forces), then a shoe with more support (like a motion control shoe) would help to unload the lateral knee and create more space may be appropriate. And that just covers the local knee issue. What if he has a pes planus and needs more than a “more stable” shoe ? And, what if that pes planus is rigid and won’t accept a more rigid arch supporting device ? What are you gonna do then ?

The caveat?

There are no hard and fast rules AND there is no substitute for examining the person and asking LOTS of questions BEFORE putting them in a shoe. You must approach each case on a case-by-case basis with all factors brought into the fold to make the best clinical decision.  Simply watching them walk, as you have heard it over and over again here on The Gait Guys, will lead you into wrong assumptions much of the time. Sometimes the obvious fix is not possible or won’t be tolerated by the person’s foot, knee, hip or body.  So, sometimes you have to settle with something in-between. 

Need to, or dying to, know more? Take our 3 part National Shoe Fit Program and be a shoe guru!

Email us at thegaitguys@gmail.com for details.

Injures induced by running the same direction on an indoor/outdoor track.

We have been seeing, addressing and treating this problem for years, far too many years. There are few things that frustrate us more than coaches and athletes who refuse to alternate their track workouts into the clockwise direction to help avoid the repetitious detrimental training effects of continued and repeated counterclockwise track training. 

Here is a study from 2000 that tends to validate a causal link to our point. The study confirms a statistically significant asymmetrical strength development in the hindfoot invertor and evertor muscle groups. 

Imbalances are a frequent and well known cause of injury.  Consciously driving this asymmetry is the equivalent to purposefully encouraging injury if you as us.  Why anyone would not heed recommendations to balance out workout effects is beyond us.  We encourage road work so that there are no repetitive track banks to negotiate and thus knowingly drive asymmetry.  When weather makes outdoor work an impossibility then days should ideally alternate the flow on the track to counter the direction of the previous day.  And as track event days get closer then the inevitable will occur that you want to simulate race day direction but at least deeply engrained (skill, endurance and strength) training effects in the counterclockwise direction will not terribly risk injury as much as if there had been no training changes and accommodations.

The smaller the track radius the more detrimental the training effects. Frequency and duration of the training further magnifies training effects. A banked track will mute some of the effects but not all of them. 
So why not just reverse the direction of your track training ?  And don’t tell is it is logistically too difficult to coordinate, that is a lame excuse. You are training yourself or your athletes to be better runners, so you should want to reduce risks and optimize training effects. Period.

Shawn and Ivo……… The Gait Guys

Clin J Sport Med. 2000 Oct;10(4):245-50.

Asymmetrical strength changes and injuries in athletes training on a small radius curve indoor track.

Beukeboom C, Birmingham TB, Forwell L, Ohrling D.

Abstract

OBJECTIVES:

1) To evaluate strength changes in the hindfoot invertor and evertor muscle groups of athletes training and competing primarily in the counterclockwise direction on an indoor, unbanked track, and 2) to observe injuries occurring in these same runners over the course of an indoor season.

DESIGN:

Prospective observational study.

SETTING:

Fowler-Kennedy Sport Medicine Clinic, The University of Western Ontario, London, Ontario.

PARTICIPANTS:

A convenience sample of 25 intercollegiate, long sprinters (200-600 m) and middle distance runners (800-3,000 m) competing and training with the 1995-1996 University of Western Ontario Track and Field team.

MAIN OUTCOME MEASURES:

A standardized protocol using the Cybex 6000 isokinetic dynamometer was used to measure peak torques of the hindfoot invertor and evertor muscle groups of both limbs using concentric and eccentric contractions performed at angular velocities of 60, 120, and 300 degrees/sec. Changes in peak torques between the preseason and postseason values were calculated and compared using a repeated measures analysis of variance test. Injury reports were collected by student athletic trainers and in the Sport Medicine and Physiotherapy clinic.

RESULTS:

Primary analysis indicated that the left (inside limb) invertors increased in strength significantly more than the right (outside limb) invertors (p = 0.01), while the right evertors increased in strength significantly more than the left evertors (p = 0.04). A high incidence of lower extremity injury (68%) occurred in this sample of runners, corresponding to an injury rate of 0.75 injuries per 100 person-hours of sport exposure. Although sample size was limited, secondary analysis indicated that strength changes were not significantly different for injured (n = 17) and uninjured (n = 8) runners (p > 0.05).

CONCLUSIONS:

The observed small, but statistically significant, asymmetrical changes in strength of the hindfoot invertor and evertor muscle groups can best be described as a training effect. Altered biomechanics proposed to occur in the stance foot while running on the curve of the track are discussed in relation to the observed strength imbalance. A causal link between strength changes and lower extremity injuries cannot be inferred from this study, but suggestions for further research are made.

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. 

Do you bank your head into the turns when you run corners ? You had better !

From time to time we get asked, why have you guys focused so intently on gait ?  Our answer is always the same. It is the most frequently engaged motor pattern that the body does other than breathing. Without the ability to walk our health declines on many levels.  And, because gait impacts every aspect of the human organism when it comes to locomotion.  All too often gait is thought of as what the feet are doing. We see this as evidenced by how many shoe stores still just do a foot treadmill video analysis, but thankfully, many stores have gotten the message from somewhere that the rest of the body is vital to the assessment as well. However,  how many of you are capturing the  head on your gait analysis ?  The head is where the software exists. Balance, visual, many proprioceptive centers, auditory and the processing of these and more are all located north of all of the other body parts.  

We have done many previous blog posts on the visual and auditory centers and how they impact gait.  You can goto our blog and type these into our SEARCH box and read more about these topics however today we wanted to share with you an article that is a few years older to show that there are many predictive gait parameters that are pre-calculated and have a huge determining effect and outcome on one’s gait. 

Anticipatory head movements during turns, whether running on a banked track, taking tight turns on your local road, trail running on the side of slopes or even when biking and trail riding, all occur in order to gather advance visual information about the trajectory and potential obstacles.  Below is an abstract that pretty much speaks for itself and you should read it. In the study they investigate the relationship between head and trunk movements during ambulation.  They discuss how the head makes its calculated turn prior to the trunk turning, setting up the body for a proper negotiation of the banking of the turn thus gathering “visual information about the trajectory and potential obstacles”. 

If you are truly a gait geek, you should get a little warm and fuzzy about this. And if you do not, well, you might still be a gait geek if you think a bit further about this and understand that cervical spine stability and mobility can negatively or positively affect the outcome.  It just goes to prove once again, if you are going to address someones gait, you better have a clinical examination as part of their gait assessment if you want to truly find out where their impairment exists, and hides. If you depend solely on video, you are most likely giving advice on missing information, this we pretty much promise you. For example, we recall a younger lady from a few years ago, a patient of ours, who was left with unilateral deafness from a vaccine complication (MMR vaccine). She would always have her better ear turned more forward to gain an auditory edge to her hearing loss on the opposite side (we all do the same thing when we are talking to someone in a loud place). What we noticed, and what she was unaware of, what that this impaired her arm swing bilaterally making the one side swing more and the other less (which was a huge clue into her shoulder problem that she was seeing us for).  This in turn, because they are neurologically connected by reflexive locomotion patterns, impaired swing and stance phases of her gait on both sides.  It just goes to prove our point earlier, and to further make the point that, you cannot impact symmetry in one place and not expect that the body will not compensate for that asymmetry elsewhere. It is all connected … . you know the song.

If you are a gait geek, you can see the entire picture of the human organism clearer than many others.  

Enjoy the whole abstract below for the great details by Sreenivasa et al.

* Shawn and Ivo …….. not your average wild and crazy guys……unless there is a gait topic to talk about.

Exp Brain Res. 2008 Nov;191(3):313-20. doi: 10.1007/s00221-008-1525-3. Epub 2008 Aug 8.

Walking along curved paths of different angles: the relationship between head and trunk turning.

Sreenivasa MN, Frissen I, Souman JL, Ernst MO.

Source

Max Planck Institute for Biological Cybernetics, Spemannstrasse 41, 72076 Tübingen, Germany.

Abstract

Walking along a curved path requires coordinated motor actions of the entire body. Here, we investigate the relationship between head and trunk movements during walking. Previous studies have found that the head systematically turns into turns before the trunk does. This has been found to occur at a constant distance rather than at a constant time before a turn. We tested whether this anticipatory head behavior is spatially invariant for turns of different angles. Head and trunk positions and orientations were measured while participants walked around obstacles in 45 degrees, 90 degrees, 135 degrees or 180 degrees turns. The radius of the turns was either imposed or left free. We found that the head started to turn into the direction of the turn at a constant distance before the obstacle (approximately 1.1 m) for turn angles up to 135 degrees . During turns, the head was consistently oriented more into the direction of the turn than the trunk. This difference increased for larger turning angles and reached its maximum later in the turn for larger turns. Walking speeds decreased monotonically for increasing turn angles. Imposing fixed turn radii only affected the point at which the trunk started to turn into a turn. Our results support the view that anticipatory head movements during turns occur in order to gather advance visual information about the trajectory and potential obstacles.

Podcast 33: Heart Beats, Toe walking & Crawling

podcast link:

http://thegaitguys.libsyn.com/podcast-31-walking-straight-matalgia-queen

iTunes link:

http://thegaitguys.libsyn.com/podcast-33-heart-beats-toe-walking-crawling

Gait Guys online /download store:

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

other web based Gait Guys lectures:

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

Today’s show notes:

Neuroscience Pieces:

1.Superhuman sight and hearing.

http://mashable.com/2013/05/06/mask-superhuman/
http://vimeo.com/58771063#

2. Kickstart device

http://www.gizmag.com/kickstart-kinetic-walk-assist/24255/

Kickstart from Cadence Biomedical is designed to help improve the gait of people who have difficulty walking and help them regain their mobility and independence. But unlike its robotic cousins that are powered by weighty rechargeable batteries, the Kickstart is able to ditch the batteries altogether because it has no motors to power. Instead, it is purely mechanical and provides assistance by storing and releasing kinetic energy generated by a person when walking.

3. Bionic ear
Scientists have created a 3D-printed cartilage ear with an antenna that extends hearing far beyond the normal human range.
In general, there are mechanical and thermal challenges with interfacing electronic materials with biological materials,“ said Michael McAlpine, an assistant professor of mechanical and aerospace engineering at Princeton and the lead researcher. "Previously, researchers have suggested some strategies to tailor the electronics so that this merger is less awkward. That typically happens between a 2D sheet of electronics and a surface of the tissue. However, our work suggests a new approach — to build and grow the biology up with the electronics synergistically and in a 3D interwoven format.”

http://www.cnet.com.au/printable-bionic-ear-sends-hearing-to-the-dogs-339344149.htm

http://www.runnersworld.com/health/how-many-heart-beats-do-we-get

4. Blog reader asks:
I recently came across “The solitary externally rotated foot”, as well as the Cross Over Gait, and Applied Gait Hip Mechanics videos. First of all, your material very insightful, so thank you! I am an amateur runner that exhibits external foot rotation and cross over running, which I suspect causes my hip pain (where the GMed joins the femur) over long distances. Curiously, this pain completely disappears when running up hill. Is this an anomaly, or does the slope correct my gait somehow?

5. FACEBOOK readers asks:
Dayle

• HI: Can you tell us what role the gluteus medius plays in foot pronation. What if they are weak or tight? And how about the QL, too? Would a foot supinator have weakened QLs (they don’t get to work much) and a foot overpronator have over-worked/loaded QLs (controlling spin)? And hey, if I toss in functional scoliosis in the lumbar region to this mix, well, what a tight mess I have, eh? Any insights on how to become unscrewed?

6. Karis

• Hi there, I’m sure you get 100,000 messages so thank you for your time for reading this! Today I had a revelation that I have external tibial torsion. After much googling about my knees turning in quite a lot when my feet are straight I finally found it! Then I found your blog on Tumblr and read all about it and watched the videos. I just wondered if you had any advice on running, I am keen to start running but I didn’t know whether to run with my feet sticking out as my natural position or anything else I should be doing? I also wondered if it can be corrected marginally by doing any strength exercises? Thank you for your help in advance! Karis

 

7. PUBMED
Overtraining:
Some of the signs of overtraining may include an unexplained decrease in performance, changes in mood state, excessive fatigue, the need for additional sleep, frequent infections, continued muscle soreness and loss of training/competitive drive.

We have included an article that puts it into simple light for the athlete:
http://www.running-physio.com/overtraining/

J Nov Physiother. 2013 Feb 16;3(125). pii: 11717.

8. Toe walking in children
In most cases no etiology of toe walking is found. The medical literature considers it abnormal if it persists after 3 years of age. Idiopathic Toe Walking (ITW) is considered a diagnosis of exclusion and is employed only when all other possibilities have been eliminated with a meticulous clinical examination and various investigations. If any etiology is found, the treatment should be first non operative
The differential diagnosis in children who walk on their toes includes mild spastic diplegia, congenital short achilles,  and idiopathic toe walking (ITW).  A reduced ankle range of motion is common……one just needs to find the source of the reduction…….meaning funcitonal,  ablative (structural). Reported treatments have included serial casting, Botulinum toxin type A or surgery to improve the ankle range of motion.  Is there an immediate impact of footwear, footwear with orthotics and whole body vibration on ITW to determine if any one intervention improves heel contact and spatial-temporal gait measures.

BMC Musculoskelet Disord. 2011 Mar 21;12:61. doi: 10.1186/1471-2474-12-61.

9. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness?

Engelbert R, 

_______

10. J Foot Ankle Res. 2010 Aug 16;3:16. doi: 10.1186/1757-1146-3-16.

Idiopathic toe walking and sensory processing dysfunction.

11. Crawling May Be Unnecessary for Normal Child Development?

http://www.scientificamerican.com/article.cfm?id=crawling-may-be-unnecessary