I have knee pain when I run."How we do one thing is how we do all things."

I am not sure who made this statement first, otherwise we would share attributes to it, but it is a good quote. If you saw the back of my truck, you would know what my closet looks like at home. Organization is not a top shelf priority of mine. I can neve remember where i put anything.

IF this is how someone does a double support jump on the up and down loading phases, what do you think is likely to happen in single leg hops ? how about forward hops with movement? Forget about it. Oh wait, that is what running is, forward hops.

Simple principle today, sometimes the best place to start with someone's suspected problematic loading strategies, is to peel it back to the simplest root strategies of the more complex faulty strategy.
All to often we just "run", but we have no idea how to load and unload effectively. If some one cannot double support jump with controllable skill, how then will they single leg hop in place with controlled skill, let alone hop forward progressively with controlled skill, and then do so alternating leg to leg, (running) with controlled skill ?

Sometimes the solution is not an orthotic, or a more stable shoe, or some magical elixer corrective homework seen on a guru's youtube feed.
Sometimes, we just need to start from the beginning. Sometimes it is that simple, start from the start, and build up from there. Sometimes there is no magic, it is just simple progressive loading, which to some will seem too crude and wasteful, and to others who truly "get it", magical.

Sometimes, "how we do one thing, is how we do all things".

Shawn Allen, the other gait guy

Tibial Torsion and Genu Valgum

Join us in this brief video about tibial torsion and genu valgum in a 6-year-old

Mooney JF 3rd Lower extremity rotational and angular issues in children. Pediatr Clin North Am. 2014 Dec;61(6):1175-83. doi: 10.1016/j.pcl.2014.08.006. Epub 2014 Sep 18.

Killam PE. Orthopedic assessment of young children: developmental variations. Nurse Pract. 1989 Jul;14(7):27-30, 32-4, 36.

Kling TF Jr, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983 Jun;(176):136-47.

Forefoot varus and patellofemoral cartilage damage.

So you just give everyone a FOOT TRIPOD and ANKLE ROCKER exercise and think the world will all be sunshine and rainbows huh ? Beware all you movement wizards, there is far more to it !

"Knowing enough to think you're doing it right, but not enough to know you're doing it wrong." - Neil deGrasse Tyson

So your client has knee pain huh ? Look far and wide, this is a global game amigos.
"Of the 51% of limbs with forefoot varus, 91.3% had medial and 78.3% had lateral PFJ cartilage damage. . . . . this study suggest a relationship between forefoot varus and medial PFJ cartilage damage in older adults"- Lufler et al. (study link below)

*If you do not know your client has a rigid forefoot varus, and they have hip or low back pain and cannot keep their glutes activated and participating in movements, how long are you going to fail your client ? The forefoot varus may need addressed because of the excessive, abrupt degree of internal spin on the limb.

If you are truly going to treat people, people who move (yes, that means everyone !), you have to know feet and gait, BOTH. Your knowledge must go far past rudimentary knowledge of:
- high / low arch
- flat feet
- prontation and supination
- orthotics and footbeds

You will have to know your foot types, you will have to understand shoe anatomy, foot anatomy, flexible semi-flexible and rigid foot types, compensated and uncompensated foot types, and of course know how each of these responds under various loading responses. Forefoot varus will load differently in cutting sports than in sagittal locomotion such as walking and running (both of which are different even in themselves despite both being sagittal). A foot that looks like it has a flat collapsed arch has far more to it than that, and thus remedy and intervention MUST go far beyond rudimentary interventions like a "stability shoe" or orthotic. Are you practicing, coaching, training and being part of your client's solution, or are you part of the problem ? If you want to get better at this stuff, we cover it all in our several hour (very difficult for some) National Shoe Fit program (the link is on our website if you wish to become a foot/gait/shoe jediwww.thegaitguys.com). Do not be mistaken, this is far more than "shoe Fit". To know how to properly shoe fit someone, you have to know the foot types and how they compensate, load, and respond. Without this knowledge, you are just another bump in the "road of problems" without ample solutions.

- Dr. Shawn Allen, one of the gait guys

The Association of Forefoot Varus Deformity with Patellofemoral Cartilage Damage in Older Adult Cadavers. Lufler, Stefanik, Niu, Sawyer, Hoagland, Gross http://onlinelibrary.wiley.com/doi/10.1002/ar.23524/full

images courtesy of aaronswansonpt.com and studyblue.com

Loss of medial tripod→

It is Rewind Friday.
Today, we are reaching back to a brief 2009 lecture I did for the local NSCA chapter on the patterns of kinetic chain compensation that match with loss of medial and lateral foot tripod. (video starts at 49 seconds, for some reason)
https://www.youtube.com/watch?v=yeCBGZkNaeM

Eating up a cardinal plane.

Simple post, simple principle today.  We found this case on the web, somewhere. Wish we could remember so we could give credit. 

Looks like simple right leg length discrepancy but the point we wanted to make is that any time you deviate into a plane, you eat up length. In this case, the right knee is severely valgus and that has at least in part contributed to a shorter limb and unleveling of the pelvis. And, it is not uncommon that rotation axis are changed when frontal or sagittal planes are compromised. It is easy to see this on the x-rays, if the foot posturing isn’t at least noted, look at the spacing between the tibia and fibula .  .  .  . rotational planes have changed as well. Is it from the femur or tibia? That is the topic of another day. 

In the larger photo you will notice that even with the right foot lifted there is still a pelvis unleveling. How can that be, unless it was further unleveled that what we are seeing ?  Well, just because you lift to fix doesn’t mean the lift will not enable further collapsing into the weakness and deformity.  We have described this principle on the topic of EVA shoe foam deformation.  When the foot presses the foam into the deformation, it leaves more room for possibly further and faster deformation loads (perhaps more so than had a new shoe been prescribed). So in some cases, more lift can allow more deformation.  How far, well as in this photo, at least until the right knee slams into the left knee and stops further deformation.

So, seeing a plane deficit clues you into possible unleveling of the pelvis and abnormal joint loading responses. It should clue you into looking for another cardinal plane compromise as well. But make no mistake, just adding a lift doesn’t mean the deformation is remedied and not enabling further deformation. It is possible that you can make your client worse if you do not teach them how to find the appropriate motor patterns with the lift so they can learn to protect the parts. Often teaching these types of clients how to control their deformities (when and if possible) is where the gold lies, not in just leveling out the foundation. 

One more “beating of the dead  horse”, lift the whole foot, heel and forefoot with a sole lift when you are “lifting and leveling”. Lifting only the heel puts them into ankle plantar flexion and can often facilitated earlier and faster forefoot loading and even earlier knee flexion.  Save the heel lift as a possible consideration when there are posterior compartment contractures or inflammation.  Certainly we could have gone into functional and structural leg length discrepancies, but we have blogged excessively on that topic in the past. Go ahead and search our blog if you want more on those topics.

Take home point, “just because you lift, doesn’t mean you are truly lifting, you may enable the opposite”.

Shawn Allen, one of the gait guys

Rearfoot to Hip Pathomechanical considerations.

In normal gait, the rearfoot strikes in slight inversion and then quickly moves through eversion in the frontal plane to help with the midfoot through forefoot pronation phases of gait. Some sources would refer this rearfoot eversion as the rearfoot pronatory phase, after all. pronation can occur at the rear, mid or forefoot. As with all pronation in all areas, when it occurs too fast, too soon or too much, it can be a problem and rearfoot eversion is no different.  If uncontrolled via muscles such as through tibialis posterior eccentric capabilities (Skill, endurance, strength) or from a structural presentation of Rearfoot Valgus pain can arise. 

From a scenario like in the video above, where a more rearfoot varus presentation is observed,  where the lateral to medial pronation progression is excessive and extreme in terms of speed, duration and magnitude this can also create too much lateral to medial foot, ankle and knee movement.  This will often accompany unchecked movements of internal spin through the hip. So one should see that these pronation and spin issues can occur and be controlled from the bottom or from the top, and hopefully adequately from both in a normal scenario.  It is when there is a biomechanical limitation or insufficiency somewhere in the chain that problems can arise. And remember, pain does not have to occur where the failure occurs, in fact it usually does not. So when you have knee pain from an apparent valgus posturing knee, make sure you look above and below that knee.  Also, keep in mind that as discussed last week in the blog post on ischiofemoral impingment syndrome (link), these spin scenarios can be quite frequently found with ipsilateral frontal plane lateral deviations (bumping of the hip-pelvis outside the vertical stacking of the foot-knee-hip stacking line). This stacking failure can also be the source of many of the issues discussed above, so be sure you are looking locally and globally. And remember, what you see is not the problem, it is their compensation around their deeper problem quite often.

If you have not read the blog post from last week on ischiofemoral impingement syndrome you might not know where the components of the cross over gait come in to play here nor how a rearfoot problem can present with a hip impingement scenario, so I can recommend that article one more time.

One last thing, just in case you think this stuff is easy to work through, remember that these rearfoot varus and valgus problems, and pronation rates. and limb spin rates are all highly variable when someone has varying degrees of femoral torsion, tibial torsion or talar torsion. Each case is different, and each will be unique in their presentation and in the uniqueness of the treatment recipe. I just thought I would throw that in to make your head spin a little in case it wasn’t already.

For example, a case where the rearfoot is a semi rigid varus, with tibial varum, and frontal plane lateral pelvic drift with components of cross over gait (ie. the video case above) will require a different treatment plan and strategy than the same rearfoot varus in a presentation of femoral torsion challenges and genu valgum. Same body parts, different orientations, different mechanics, different treatment recipe.  

So, you can fiddle with a dozen pair of shoes to find one that helps minimize your pains, you can go for massages and hope for the best, you can go and get activated over and over, you can try yet another new orthotic, you can go to a running clinic and try some form changes, throw in some yoga or pilates, compression wear, voodoo bands and gosh who knows what else. Sometimes they are the answer or stumble across it … or you can find someone who understands the pieces of the puzzle and how to piece a reasonable recipe together to bake the cake just right. We do not always get there, but we try.  

Want more ? Try our National Shoe Fit certification program for a starter or try our online teleseminars at www.onlinece.com (we did a one hour course on the RearFoot just the other night, and it was recorded over at onlineCE.com).

Dr. Shawn Allen,  of the gait guys

Reference:

Man Ther.  2014 Oct;19(5):379-85. doi: 10.1016/j.math.2013.10.003. Epub 2013 Oct 29.Clinical measures of hip and foot-ankle mechanics as predictors of rearfoot motion and posture.  Souza TR et al.

Health professionals are frequently interested in predicting rearfoot pronation during weight-bearing activities. Previous inconsistent results regarding the ability of clinical measures to predict rearfoot kinematics may have been influenced by the neglect of possible combined effects of alignment and mobility at the foot-ankle complex and by the disregard of possible influences of hip mobility on foot kinematics. The present study tested whether using a measure that combines frontal-plane bone alignment and mobility at the foot-ankle complex and a measure of hip internal rotation mobility predicts rearfoot kinematics, in walking and upright stance. Twenty-three healthy subjects underwent assessment of forefoot-shank angle (which combines varus bone alignments at the foot-ankle complex with inversion mobility at the midfoot joints), with a goniometer, and hip internal rotation mobility, with an inclinometer. Frontal-plane kinematics of the rearfoot was assessed with a three-dimensional system, during treadmill walking and upright stance. Multivariate linear regressions tested the predictive strength of these measures to inform about rearfoot kinematics. The measures significantly predicted (p ≤ 0.041) mean eversion-inversion position, during walking (r(2) = 0.40) and standing (r(2) = 0.31), and eversion peak in walking (r(2) = 0.27). Greater values of varus alignment at the foot-ankle complex combined with inversion mobility at the midfoot joints and greater hip internal rotation mobility are related to greater weight-bearing rearfoot eversion. Each measure (forefoot-shank angle and hip internal rotation mobility) alone and their combination partially predicted rearfoot kinematics. These measures may help detecting foot-ankle and hip mechanical variables possibly involved in an observed rearfoot motion or posture.

Holy Hand Grenades! What kind of shoe do I put these feet in?

Take a look at these feet. (* click on each of the photos to see the full photo, they get cropped in the viewer) Pretty bad, eh? How about a motion control shoe to help things along? NOT! OK. but WHY NOT? Let’s take a look and talk about it.

To orient you:

• top photo: full internal rotation of the Left leg
• 2nd photo: full internal rotation of the Right leg
• 3rd photo: full external rotation of the Left leg
• last photo: full external rotation of the Right leg

Yes, this gal has internal tibial torsion (yikes! what’s that? click here for a review).

Yes, it is worse on the Left side

Yes, she has a moderate genu valgus, bilaterally.

If someone has internal tibial torsion, the foot points inward when the knee is in the saggital plane (it is like a hinge). The brain will not allow us to walk this way, as we would trip, so we rotate the feet out. This moves the knee out of the saggital plane (ie. now it points outward).

What happens when we place a motion control shoe (with a generous arch and midfoot and rearfoot control) under the foot? It lifts the arch (ie it creates supination and it PREVENTS pronation). This creates EXTERNAL rotation of the leg and thigh, moving the knee EVEN FURTHER outside the saggital plane. No bueno for walking forward and bad news for the menisci.

Another point worth mentioning is the genu valgus. What happens when you pick up the arch? It forces the knee laterally, correct? It does this by externally rotating the leg. This places more pressure/compression on the medial aspect of the knee joint (particularly the medial condyle of the femur). Not a good idea if there is any degeneration present, as it will increase pain. And this is no way to let younger clients start out their life either.

So, what type of shoe would be best?

• a shoe with little to no torsional rigidity (the shoe needs to have some “give”)
• a shoe with no motion control features
• a shoe with less of a ramp delta (ie; less drop, because more drop = more supination of the foot (supination is plantarflexion, inversion and adduction)
• a shoe that matches her sox, so as not to interfere with the harmonic radiation of the colors (OK, maybe not so much…)

Sometimes giving the foot what it appears to need can wreak  havoc elsewhere. One needs to understand the whole system and understand what interventions will do to each part. Sometimes one has to compromise to a partial remedy in one area so as not to create a problem elsewhere. (Kind of like your eye-glass doctor. Rarely do they give you the full prescription you need, because the full prescription might be too much for the brain all at once.  Better to see decent and not fall over, than to see perfectly while face down in the dirt.) 

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

We are the Gait Guys, and yes, we like her sox : )

Limitations: The powers of observation will help you.

Physical examination, FMS, DNS, gait analysis … . . these are all very important tools for the coach, trainer, therapist, clinician.  They will all offer information and lead the “therapy giver” in a direction for intervention.  But when something doesn’t match up with the basic standard protocols, you have to go outside the standard box.  We have all been there and today is just a little reminder not to get caught up in the “proceedures” and merely running through protocol without an engaged brain putting the pieces together.  

Here we see 2 classic examples of deviations from the mean, the client on the left has drifted further outside the frontal plane because of tibial varum and a little genu varus.  The client on the right has imploded deep into the frontal plane via rigid pes planus foot collapse and genu valgum.  These will both affect your physical screenings for these clients. And keep in mind, and this is probably the most important point of today’s blog post, either client may have good or bad strategies around their anatomy.  In other words, some clients will have great compensations to limit further functional pathology, and some will have poor compensation strategies, and thus, both will have different physical exam findings, different screenings and different neuromotor patterns embedded deep into their CPGs (central pattern generators).   Put yet another way, all of the scenarios discussed may/will have varying screening assessment outcomes but for different reasons.  If you know the cause of these faults and the impaired neuro-recruitment patterns that are likely, your assessments will make more sense, and so will your exercise/therapy/rehab prescriptions.  If you do not understand the fundamental differences (ie long bone torsions or various femoral-neck shaft angles, foot types such as an uncompensated forefoot valgus etc) , one could prescribe therapies that will not address the underlying problems, rather they might address the compensations and strategies found with these client’s challenges.

It can get sloppy messy.  Wear a bib.

Dig for the roots, don’t mow the grass…… Shawn and Ivo, The Gait Guys

Podcast 36: Heel lift lies, the Exercise Drug & Malcolm Gladwell's 10,000 hours.

http://thegaitguys.libsyn.com/podcast-36-heel-lift-lies-and-the-exercise-drug

iTunes link:

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

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 piece:

Description

1. Health Scanner Scanadu Scout: the future of medical info gathering ?

http://techcrunch.com/2013/07/12/health-scanner-scanadu-scout-breaks-indiegogos-crowdfunding-record/

2. The Exercise Drug:

www.gizmag.com/scripps-drug-sr9009-exercise-mimic/28651

3. FB reader sent us a message:

- am posting this to see if I can get a little bit of help from the best professionals in the area (you). 

I have read some of the information on your site and I think I have quite a problem on my right foot. It happens that the medial part of the foot tripod does not touches the floor at all and I have lack of support in that zone. So it seems like my forefoot is varus. I have also noticed that when I am standing it looks like my rear foot is valgus. So, I can’t really compensate this problem because if the forefoot is varus and I try to put it neutral, the rear foot gets even more valgus, and if it I try to put the rear foot neutral, the forefoot gets even more varus and my big toe does not touch any part of the floor. Can you please help me? I do not know what to do and I am a little bit desperate because nobody I went to could help me. You are probably my last hope. I know I can correct this and I have the will and dedication to pull it off. I bet there are some exercises I can do but I do not really know which at all. 
Thanks in advance. -Jorge

4. Another TUMBLR reader asks question about

Guys what are the possible muscular causes of genu varum during initial swing?

5. Another off tumblr:  Anything  you can talk about on this topic ?

How does running in low-to-no light conditions effect your gait/running/injuries/etc?

6. Topic: step  width

Changing step width alters lower extremity biomechanics during running

http://www.gaitposture.com/article/S0966-6362(13)00291-9/abstract

7.  heel lift vs. sole lift

why and when would you use only a heel lift…..unilaterally ?

8. National Shoe Fit program: 

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

9. Questions from a field doc:

Hey guys,

 I have heard you guys say many times that many people who choose to venture into minimalistic footwear have not “earned their right" to do such without increasing their risk for problems.  I was wondering if you could explain what parameters you use to determine if and when they are ready.  

Thanks,

Ryan 

10. Shoes: does pronation matter

http://www.runnersworld.com/running-shoes/does-pronation-matter

11. Shoes #2:

http://www.theglobeandmail.com/life/health-and-fitness/fitness/runners-its-time-to-rethink-your-shoes/article13321948/

12. Malcolm Gladwell debate, 10,000 hours

http://www.theatlanticwire.com/entertainment/2013/08/malcolm-gladwell-defends-disputed-10000-hours-rule/68624/– 

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.

A visual demonstration of 3 different foot strike patterns. Lets test some of what you have learned here at The Gait Guys over the last few months.

On the readers left, blue shirt Bib 232:
 The left leg appears to have all joints stacked at this viewer angle (knee is vertically over the foot, hip is over the knee). What we love here is that the foot profile (look at the black sole of the shoe) is parallel to the ground, it is hard to believe that it won’t strike as such. The medial and lateral aspects of the foot should strike flush and simultaneously. This is a neutral foot and is very likely without valgus or varus forefoot typing.  The tibia looks pristine and straight without any torsion, at least from this limited perspective. He also looks to be striding nicely, it seems to appear (albeit this is reaching from this head on view) that the foot will strike below the body mass, this may be because he subtly appears to be leaning forward, again hard to see on this view.

Middle runner, white shirt:  We see some problems here.  First of all, it appears (and again, this is reaching from a front on view) that this runner is striding out with the foot beyond the body mass and will likely heel strike, he also seems to be in more backward lean that the Blue Bib Man but again hard to tell on a frontal view. We also see that the foot is pitched in inversion (note the outward tip of his foot compared to the man in Blue) quite aggressively which will facilitate a strong excessive lateral heel and/or forefoot strike pattern.  You can also see that drawing a line through the length of the long bones (tibia and femur) that they are in alignment, they are even in alignment with the 90 degree perpendicular to the forefoot inverted angulation.  This clearly represents our classic “cross over gait” which was first brought to you and the internet by yours truly a few years ago (here on Youtube link).  It is easy to see that the projected foot landing will be on a virtual line and thus appear to run on a line or even cross the feet over the line indicating that this client is not stacking the foot, knee and hips vertically and thus challenging the gluteus medius and hip stability into the frontal plane (video link here). This client will be wasting energy and efficiency in the frontal plane (side to side movement) and challenging the core, risking knee tracking issues and excessive foot pronation forces beyond the safe and normal.  

Running on the readers right, green shirt #8:  There appears to be a strong stance phase leg collapse, the hip is lateral to the foot and the knee is perhaps on its way to medial from a vertical line from the foot. This can be, and often is, from the issues of cross over described in the middle runner above but it can also be simply found in someone who is striking with the foot/knee/hip joints stacked but does not have sufficient gluteus medius strength to keep the pelvis level on the horizon (thus drift laterally). When this happens the downward collapse of the opposite side pelvis is often, but not always, see as a valgus collapse at the knee since the femur is allowed to drift medially from insufficient strength, skill or endurance pairing of the gluteus medius/maximus pairing and the medial quadriceps. This client is  likely a cross over victim as well and this would give good reason to the aforementioned.  Again, this is all theoretical from a static picture but knowing these patterns like we do, we know these typical patterns of breakdown. This is also suspect because of the foot more positioned under the midline of the body instead of under the knee and hip vertically stacked and the obvious proximity of the knees to one another.  These clients often kick or brush the foot or shoe against the stance phase lower leg as they swing the foot through. 

Who is going to win this race ? One cannot tell. But if they were the same on all levels of endurance, training, VO2 max and equal on every parameter except what was mentioned above, well then our man in Blue, # 232 would be the most efficient and likely the least injured.

Photo from an Outside Magazine article. We Would reference it, and would be happy to do so, but we cannot find the net article anywhere now. Please send it our way if you happen across it !

Shawn and Ivo, The Gait Guys … .  followed in 51 countries and counting.

Quiz: Let’s see how your blog reading has been going. 

These 5 photos are of a 2.5 year old child brought into your office for evaluation by his father. They have been seen by another practitioner who has given him orthotics with full length varus posts to wear.

• What do you see?
• What is your assessment?
• What do you tell the parent?

In the standing views, what stands out?

1. a moderate rearfoot (calcaneal) valgus (ie. rear foot medial  heel collapse)
2. the flattened medial longitudinal arches of the foot ( ie. a little flat footed)
3. the genu valgus (ie. knees are a little “knock knee’d”)
4. he bears weight separately on each lower extremity as you can see from the pictures.  He never bears weight on both limb symmetrically, there is much weight bearing shifting meaning there is always a dominant limb bearing most of the weight.
5. the knees face inward in the standing position
6. the feet point outward (with the knees straight) in the supine position

did you see all of these?

What is your assessment?

1, 2)  pes planus and hyperpronation are the norm for children under 6 years of age

3) genu valgus is not abnormal in children, with many presenting maximally at age 3, and usually resolving by age 9 (see our post here)

4) he bears weight separately on each lower extremity (L>R from rear, R>L from front) so there probably is not a leg length discrepancy.  This is often a hip-core stability issue and as fatigue sets in weight bearing shift is automatized. 

5,6) This child has external tibial torsion. As seen in the supine photo, when the knees face forward, the feet have an increased progression angle (they turn out). We are born with some degree / or little to none, tibial torsion and the in-toeing of infants is due to the angle of the talar neck (30 degrees) and femoral anteversion (the angle of the neck of the femur and the distal end is 35 degrees).  The lower limbs rotate outward at a rate of approximately 1.5 degrees per year to reach a final angle of 22 degrees….. that is of course if the normal derotation that a child’s lower limbs go through occurs timely and completely.

What do you tell the parent?

1,2)  Although research shows that wearing arch supports (navicular wedge or “cookie”, not a full varus wedge as was the case here) can speed development of the the arches, they will in fact most often develop regardless of supportive footwear or support.  Many studies show that footwear impairs muscular development of the foot. One study showed that arch supports in children prevent derotation of the talar head and promote development of a Rothbart Foot Type. How about some flexible shoes (or no shoes) for the boy?  (need to review the Rothbart foot type ? click here for one of our very first blog posts on the topic)

3. We will measure the genu valgus and track it every 6 months to make sure it is regressing. If it persists or becomes worse, we may address it then. How about having your kid walk barefoot?

4. no worries, he is resting each side as the other fatigues. Endurance development takes time, just like marathon training. For gosh sake, the kid is 2.5 years old. Give him a break !

5,6) We will measure his progression angle and degree of torsion every 6 months (along with the genu valgus). This is normal up to reaching skeletal maturity.

Well, how did you do?

Corrective exercises are always nice, but when is too soon? Can their immature nervous system handle it ?  CAn they comprehend the exercise ? Sometimes turning them into a game and taking what you can get is good enough to help promote healthy limb derotation.  Walking with the toes up helps develop arch independence and helps to teach the brain about the foot tripod. But at 2.5 years old, good luck expecting more than that.  

The Gait Guys: two handsome bald guys (one by genetics, and one by aspiring choice) aging gracefully and promoting foot and gait literacy, one case at a time.

A case of severe mechanical gait challenges.

This is a unique case. This is a complicated case, there is so much going on. If your eye is getting good at this gait analysis stuff you will know that just from the first pass this gait is very troubled.

This young middle distance runner who came to see us with complaints of chronic anterior and posterior shin splints. This is unusual because usually only one of the lower limb compartments are strained, either the anterior (tibialis anterior mostly) or the posterior compartment (tibialis posterior mostly). Admittedly this is not a fast runner but they love to run none the less, so you do what you can to help.

Please watch this video again and note the following:

1. crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs)
2. slightly wider based gait compared to knee postioning but neutral compared to hip spacing
3. client starts heavily on the outer edge of the feet and moves medially
4. client over strides (step length is increased) which is particularly evident when they are walking towards the camera
5. early bunion formation and troubles engaging the big toe during stance phase
6. the knees / patella also appear medially positioned in an environment of a neutral foot progression angle
7. if you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height.

Wow ! So much going on ! This is a gait from hell in some respects. So, what is driving so much of the terrible gait mechanics ? The answer is a congenital loss of ankle rocker (dorsiflexion) bilaterally. This client can barely squat because the ankles just do not dorsiflex. There was clear osseous lock at barely 90 degrees.

Lets break each one down.

1. Crossing over of the knees at the midline (this indicates a scissored gait / circumductory motion of the limbs). * This is occuring due to some genu valgum of the knees (slightly “knock-knee”). When the knees are valgum they are at risk for brushing together during gait. The client has no choice but to circumduct the limbs to avoid this behavior. Unfortunately they cannot abduct the thighs far enough during many of the gait cycles and so a “Scissored” appearance occurs where the thighs brush and cross over in appearance.
2. Slightly wider based gait compared to knee positioning but neutral compared to hip spacing. * This is closely related to our answer in #1. Valgus knees will widen the foot spacing side to side because the feet are not under the knee joints. Then couple this with the necessity to circumduct to avoid knees from contacting and the foot posturing is that of an even wider based gait. This can also occur from many hip problems. However as in this case with a congenital loss of ankle rocker, the client uses more foot pronation to progress the tibia over the talus (allowing the tibia to get past 90degrees) and allow them to move forward. This added pronation does magnify and likely progress the knee valgum but there are few other options for this client. This is often a destructive vicious cycle with few good outcomes decades down the road.
3. Client starts heavily on the outer edge of the feet and moves medially. *This may be to avoid the immediate rear foot pronation that is seen here.
4. Client over strides (step length is increased) which is particularly evident when they are walking towards the camera. * This may be a conscious attempt to lengthen the shortened stride that occurs because of the limited ankle dorsiflexion ranges. It appears at many moments however to be a result of the extra effort to circumduct the legs sufficiently. A longer stride does play into #3 above, a larger stride usually leads to a heavier lateral heel strike but it also means that the rearfoot pronation will be more aggressive, this is a negative resultant outcome.
5. Early bunion formation and troubles engaging the big toe during stance phase. *We are not surprised here. Whenever pronation is excessive the first metatarsal (medial foot tripod) is unstable and this changes the mechanics of the hallux muscles to pull towards the 5th metatarsal anchor generating the bunion. Look at the origin and insertion of the adductor hallucis muscle particularly the transverse head, if the 1st MET is anchored the 5th MET is pulled to the 1st and the transverse arch is formed. However, if the 1st MET is unstable and the 5th is the only anchor, the adductor hallucis will pull the toe laterally and form a bunion and hallux valgus and compromise the transverse arch. (particularly look at the left big toe at the :09 to :11 second mark, the big toe and first MET are clearly not anchored to the ground).
6. The knees / patella also appear medially positioned in an environment of a neutral foot progression angle. * Answers for #1-#5 clearly will medial patellar deviation and drive patellar tracking problems.
7. If you look carefully you can see that they rear foot immediately moves into a valgus posturing (this is rearfoot pronation) and they are also pronating into the forefoot heavily. Interestingly they have decent arch height, but remember, that does not mean that pronation is not occurring. * This is a result of the loss of ankle rocker mechanics. If they start pronation early at the rear foot it will drive more pronation. When pronation is driven excessively the arch can drop, and with more arch height drop the tibial will pitch forward past the magical 90 degree mark and allow forward motion to occur.

So, how can they run with all this going on ? Well, the answer is quite simple. They avoid most of these issues as best they can. How you ask ? Forefoot strike; they run avoiding heel strike and midfoot strike. By staying on the forefoot all of these rear and midfoot mechanical limitations as well as ankle rocker loss can be avoided by remaining on the forefoot. This makes distance running difficult but anything below the two mile mark is tolerable and the 100-800 distances are probably best suited for their feet. Incidentally they enjoy the 400 the best, no wonder. Also, moving at increased speed will necessitate a forward lean, and a forward lean makes the tibia progression over the talus easier taking out some of the ankle rocker limitations.

This is a foot type, with complications, that is really beyond much of what anyone can do conservatively. We would even argue that surgery is not an option, just a change in activity choice. This is simply a client that should not run beyond distances where they can stay on the forefoot. The foot, ankle and lower limb mechanics just suffer far to much from having to compensate (as discussed in #1-7) to enable pain and problem free running with anything other than forefoot loading. This means that walking is going to be difficult and problematic, as you can see from this video above.

Our only solution in this case ? ……… utilizing a rocker based footwear. Easy Spirit Get UP and Go (link) was our recommendation and it worked very well for this client for walking. Here is a link to this shoe and pictures of the huge forefoot rocker that helps (somewhat) to dampen the mid-forefoot rocker issues but there is not much that can be done for the rear foot rocker issues as discussed. If you use an orthotic to block the rearfoot valgus motion and rearfoot pronation you will pass more challenges to the midfoot-arch and forefoot. Sadly.

This was a very tough case. Getting every aspect of the case in your head during an evaluation is sometimes a challenge. Sometimes you need to see them a 2nd or 3rd time to digest it all. But be patient with yourself, it takes time to get decent at this stuff. This is a perfect case for “getting a feeling and flow” of the persons gait, at their speed. A case evaluation like this on a treadmill or via video analysis can make things tougher because the treadmill can change the dynamics (did you read our Treadmill article in last months Triathlete magazine ? It was linked on the blog 2 weeks ago) and make the client move at its speed and not their speed inhibiting and promoting different mechanics. There are times for a treadmill and times to avoid them. This is an art, in time you will know when to use and when not to use.

Happy Monday Gait Gang………. welcome to The Gaits of Hell !

Shawn and Ivo ……….two gnarly lookin dudes with pitchforks and a toothy grin.

Genu valgum in kids: What you need to know

We have all seen this. The kid with the awful “knock knees”.  It is a Latin word “which means “bent” or “knock kneed”. It appears to have 1^st been used in 1884.

This condition, where the Q angle angle exceeds 15 degrees, usually presents maximally at age 3 and should resolve by age 9. It is usually physiologic in development due to obliquity of the femur, when the medial condyle is lower than the lateral. Normal development and weight bearing lead to an overgrowth of the medial condyle of the femur. This, combined with varying development of the medial and lateral epiphysies of the tibial plateau leads to the valgus development. Gradually, with increased weight bearing, the lateral femoral condyle (and thus the tibial epiphysis) bear more weight and this appears to slow, and eventually reverse the valgum.

Normal knee angulation usually progresses from 10-15 degrees varus at birth to a maximal valgus angle of 10-15 degrees  at 3-3.5 years (see picture).  The valgus usually decreases to an adult angle of 5-7 degrees.  Remember that in women, the Q angle should be less than 22 degrees with the knee in extension and in men, less than 18 degrees. It is measured by measuring the angle between the line drawn from the ASIS to the center of the patella and one from the center of the patella through the tibial tuberosty, while the leg is extended.

Further evaluation of a child is probably indicated if:

• The angle is greater than 2 standard devaitions for their age (see chart) 
• If their height is > 25^th percentile 
• If it is increasing in severity 
• If it is developing asymmetrically

Management is by serial measurement of the intermalleolar distance (the distance between ankles when the child’s knee are placed together) to document gradual spontaneous resolution (hopefully). If physiologic genu valgum persists beyond 7-8 years of age, an orthopaedic referral would be indicated but certainly intervention with attempts at corrective exercises and gait therapy should be employed. Persistence in the adult can cause a myriad of gait, foot, patello femoral and hip disorders, and that is the topic on another post.

Promotion of good foot biomechanics through the use of minimally supportive shoes, encouraging walking on sand (time to take that trip to the beach!), walking on uneven surfaces (like rocks, dirt and gravel), gentle massage (to promote muscle facilitation for those muscles which test weak (origin/insertion work) and circulation), gait therapeutic exercises and acupuncture when indicated, can all be helpful.

Ivo and Shawn…  The Gait Guys…Promoting foot and gait literacy for everyone.