Abductory twist in your gait ?  Last night on our  www.onlinece.com  teleseminar we discussed some clinical applications and critical thinking of gait parameters and pathology. We discussed the dynamic gait pedograph below. Possible evidence of Abductory Twist gait pathology (video link https://youtu.be/F3DHRoHrYOs ). In this case, client had loss of internal hip rotation, but they sure love external rotation pivot at the ground interface, as the pedo shows here (more details were provided on the teleseminar last night).  *Fix the problem, retrain normal gait skills, add endurance and strength to the new gait pattern and you have a solution. Add an orthotic to treat what you see on the pedograph and you have a bandaid (and potentially/probably a problem down the road). You can’t fix a motor pattern compensation by forcing a compensatory fix. Get to the root of the problem, in this case hip and pelvic biomechanics ! It is all about mobility and stability ! 

Abductory twist in your gait ?

Last night on our www.onlinece.com teleseminar we discussed some clinical applications and critical thinking of gait parameters and pathology. We discussed the dynamic gait pedograph below. Possible evidence of Abductory Twist gait pathology (video linkhttps://youtu.be/F3DHRoHrYOs). In this case, client had loss of internal hip rotation, but they sure love external rotation pivot at the ground interface, as the pedo shows here (more details were provided on the teleseminar last night).
*Fix the problem, retrain normal gait skills, add endurance and strength to the new gait pattern and you have a solution. Add an orthotic to treat what you see on the pedograph and you have a bandaid (and potentially/probably a problem down the road). You can’t fix a motor pattern compensation by forcing a compensatory fix. Get to the root of the problem, in this case hip and pelvic biomechanics ! It is all about mobility and stability ! 

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Test your Mental Clinical Thinking Skills with this pedograph case. 

A few months ago, we discussed this case in great detail. There is likely little chance you will see our thinking progression with these final conclusions without sitting down with a warm cup of coffee and going over these 2 prior blog posts on this case (part 1 and part 2).  Besides, it will be a good review for you and it is great mental gymnastics.  This kind of analysis gets easier each time you do it but we have to through out our standard warning. This is the kind of stuff one needs to be able to go through on the fly in one’s practice, it is something to aspire to.

First of all, caveats:

  • Our discussions on this case were all theoretical.  What we went through was an exercise in static assessment and clinical thinking
  • One cannot, and must not, make clinical decisions from a static assessment. 
  • As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. 
  • Gait analysis or pedograph-type assessment are helpful tools, but not the final answer.

Our static exam proposal on this case came up with the following theories (please stand up and mimic as we discuss, trust us, it will help you). *Remember: the foot on YOUR LEFT is the RIGHT foot for the purposes of this discussion. And remember, this is all theoretical, this is an exercise in biomechanical and clinical thinking, nothing more.

  • Suspect Counter-clockwise pelvis distortion pattern (causes relative internal rotation on LEFT and external rotation on RIGHT), this will drive Left knee hyperextension and Right knee flexion (hence foot plantar pressures as we discussed in previous 2 blog posts linked above). This of course cannot be seen, but we are extrapolating from our clinical experiences.
  • poor pronation and internal limb spin control on the left (hence longer foot and toe hammering). Obviously, we would see a dramatic shift of the pressures to the medial foot if this were truly the case.  Perhaps this is because of the greater lateral left pelvis drift forcing the glute and foot pronatory controls to have to work harder and longer, and maybe even quicker, to control the internal spin and pronation. Over time, they fatigue and fail rendering a flatter, more pronated and longer heel:toe ball length ratio. This would also give credence to the left toe hammering/gripping response.
  • static increased left limb weight bearing (left hip drift)
  • abrupt right foot loading pattern (more mid-forefoot strike), perhaps as reflected by the static forefoot loading. Again, supposition.
  • with all of the above, it is suspect that this client will appear to have a subtle limp, coming off the left quickly or prematurely as they speed through uncontrolled pronation and resulting in an abrupt right limb loading response that mostly skips through heel strike and results in a more aggressive mid-forefoot loading response.  This, sort of, creates a catching of the loading response by the quadriceps more than the gluteals. This can cause medial knee drift (valgus loading) if the medial knee stabilizers are not up to task, this also creates a sudden patellofemoral compresson event and unappreciated sudden tension on the extensor mechanism (the quad-patella-patellar tendon complex).  Can you say generic anterior knee pain ?

Just some thoughts. Please go back to the prior 2 blog posts to delve deeper into the conclusions we have brought about here, we have other good reasoning to suspect the above as the scenario. But remember, what you see is not the problem, we see people’s compensations, their strategies. This was just an exercise in “what ifs”, nothing more. But you will see it in your clinic, just substantiate it with an exam, not what you necessarily see in your clients gait or static assessment. Static assessments are for fools, don’t be a fooled fool.  What  you see is not the problem.

Remember this critical fact.  After an injury or a long standing problem, the job of muscles and motor patterns is to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries often leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is often a culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. Is the compensation top down, bottom up, or both ?

Don;t be a fooled fool. Get the facts.

Shawn and Ivo, the gait guys

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Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there. 

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left.  The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function  (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot  or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ?  Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. 

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow.  We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation.  See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1  
 * note: This is a  static  assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?” 
 * note the right and left sides by the R and L circled in pink. 
  ORANGE lines : The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot.  Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level.  If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg.  In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg.  Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ?  Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation.  Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here. 
  Remember this critical fact.   After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength  (S.E.S -our favorite mnemonic),  stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. 
 Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ?  What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption.  See you tomorrow friends ! 
  Shawn and ivo, the gait guys

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot.  Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level.  If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg.  In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg.  Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ?  Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation.  Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ?  What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption.  See you tomorrow friends !

Shawn and ivo, the gait guys

Using a Pedograph to get Dynamic Answers to Foot Dysfunction: 
 Pedograph topic: One quick topic here. Note the hot spot (ink concentration) at the big toe and note that the ink is proximal on the toe pad. We would like to see the pressure point at the center of the pad. This spot means this person walked across the Harris Ink mat with increased FHB (flexor hallucis brevis) use and not enough FHL (flexor hallucis longus);  too much short flexor, not enough long flexor. There is loss of synergy between the two. This will likely mean there is something going on in the extensors as well, something abnormal. 
 Need a review? Look at Monday’s video again on the EHB (extensor hallucis brevis) where we discuss all of the toes muscles. 
 Clinically this patient had a hallux limitus/rigidus (could not dorsiflex great toe) which complicated the mechanics at the joint and forward into the great toe, sadly also at the foot’s medial tripod as well. You cannot get an accurate read from a static (standing only) pressure mapping. Don’t rely on them for dynamic info ! 
 Too much FHB with not enough FHL means EHB (as well as long extensors of the lesser toes) is going to be impaired. Impair the EHB and you ask the EHL  to work differently as well.  Here’s a hint, look at all the printing under the lesser digits distally, there is too much flexor activity here as indicated by intense inking from toe clenching / hammering.  They are likely doing this to add more stability since the great toe cannot from what we discussed above. There are problems that come from these issues as well but we want to stay focused on the big toe today. 
  Now, go back and review Mondays blog video post  (here is the link) .  
  Treatment:  
 In a case where there is some loss of the 1st MPJ range of motion (metatarsaphalangeal joint) (depending on the source, 45 degrees is typically needed) there will be impairment of the long and short toe flexor/extensor pairing and synergy.  In this case above there is highly suspected increased short flexor (FHB) activity (hence the ink at the proximal big toe) and this means that the long flexor is usually submissive.  And, when the long flexor (FHL) is submissive the long extensor is dominant. When the long extensor is dominant the short extensor is submissive. Can you now see the beautiful symphony and harmony we need here. This is why we loosely say that the FHB and the EHL are paired and the FHL and EHB are paired.  It is not exactly the case but hopefully you catch our drift.  
 So, in this case, with a hallux limitus/rigidus when the 45 degrees of dorsiflexion is lost these pairing can be challenges and the synergy is lost.  The symphony of these muscles is “off tune”.  This can further provoke the 1st MPJ and it can also be the slow brewing initiation of the problem. It can be a vicious cycle when it gets going. And, when the 1st MPJ is limited the dorsiflexion that is supposed to occur at the joint can be shunted proximally into the midfoot or ankle and cause pain/pathology there.  It can also impair the normal pronation-supination cycles. The big toe when it goes sour makes the whole orchestra angry and play off tune.   Doing your best to normalize and maximize muscle harmony and function many times will dampen the pathology and pain and get the person going again.  Of course the problem is still lurking under the surface.  Test the muscles, try to isolate them but remember that your muscle tests need to be as specific as you can. Nothing is isolated in the body, but do your best.   Of course there are many other scenarios but this is the one we chose to teach today from this pedographing of the big toe. We will explore other options and challenges another time. 
  Shawn and Ivo.    Gait geeks promoting gait literacy and competency everywhere we can get an open ear.

Using a Pedograph to get Dynamic Answers to Foot Dysfunction:

Pedograph topic: One quick topic here. Note the hot spot (ink concentration) at the big toe and note that the ink is proximal on the toe pad. We would like to see the pressure point at the center of the pad. This spot means this person walked across the Harris Ink mat with increased FHB (flexor hallucis brevis) use and not enough FHL (flexor hallucis longus);  too much short flexor, not enough long flexor. There is loss of synergy between the two. This will likely mean there is something going on in the extensors as well, something abnormal.

Need a review? Look at Monday’s video again on the EHB (extensor hallucis brevis) where we discuss all of the toes muscles.

Clinically this patient had a hallux limitus/rigidus (could not dorsiflex great toe) which complicated the mechanics at the joint and forward into the great toe, sadly also at the foot’s medial tripod as well. You cannot get an accurate read from a static (standing only) pressure mapping. Don’t rely on them for dynamic info !

Too much FHB with not enough FHL means EHB (as well as long extensors of the lesser toes) is going to be impaired. Impair the EHB and you ask the EHL  to work differently as well.  Here’s a hint, look at all the printing under the lesser digits distally, there is too much flexor activity here as indicated by intense inking from toe clenching / hammering.  They are likely doing this to add more stability since the great toe cannot from what we discussed above. There are problems that come from these issues as well but we want to stay focused on the big toe today.

Now, go back and review Mondays blog video post (here is the link).

Treatment:

In a case where there is some loss of the 1st MPJ range of motion (metatarsaphalangeal joint) (depending on the source, 45 degrees is typically needed) there will be impairment of the long and short toe flexor/extensor pairing and synergy.  In this case above there is highly suspected increased short flexor (FHB) activity (hence the ink at the proximal big toe) and this means that the long flexor is usually submissive.  And, when the long flexor (FHL) is submissive the long extensor is dominant. When the long extensor is dominant the short extensor is submissive. Can you now see the beautiful symphony and harmony we need here. This is why we loosely say that the FHB and the EHL are paired and the FHL and EHB are paired.  It is not exactly the case but hopefully you catch our drift. 

So, in this case, with a hallux limitus/rigidus when the 45 degrees of dorsiflexion is lost these pairing can be challenges and the synergy is lost.  The symphony of these muscles is “off tune”.  This can further provoke the 1st MPJ and it can also be the slow brewing initiation of the problem. It can be a vicious cycle when it gets going. And, when the 1st MPJ is limited the dorsiflexion that is supposed to occur at the joint can be shunted proximally into the midfoot or ankle and cause pain/pathology there.  It can also impair the normal pronation-supination cycles. The big toe when it goes sour makes the whole orchestra angry and play off tune.

Doing your best to normalize and maximize muscle harmony and function many times will dampen the pathology and pain and get the person going again.  Of course the problem is still lurking under the surface.  Test the muscles, try to isolate them but remember that your muscle tests need to be as specific as you can. Nothing is isolated in the body, but do your best.

Of course there are many other scenarios but this is the one we chose to teach today from this pedographing of the big toe. We will explore other options and challenges another time.

Shawn and Ivo.    Gait geeks promoting gait literacy and competency everywhere we can get an open ear.