Premature heel rise: Part 2

VIDEO: an atypical case of Premature heel rise. A follow up video for yesterdays discussion on the topic.

You should easily see premature heel rise here in this video. We will discuss this case at length with other video projections on our Patreon site next week, if you wish to dive further.

But here you should see, lets focus on the right limb, premature heel rise (again, stick with just watching the right foot/leg). This is, in-part, because this person does not achieve adequate hip extension, you should clearly be able to see that. Loss of terminal hip extension means premature heel rise, no exceptions. Train your eye to see this, you do not need expensive video software to see this.

So, Why inadequate hip extension? Well, just look at the amount of right knee flexion going into terminal stance, it is still heavily flexed and this forces them to prematurely heel rise, avoiding terminal hip extension, and prematurely load the forefoot. Without a knee that extends sufficiently, the hip cannot extend sufficiently, and thus premature heel rise is inevitable. And, trying to solve this issue down at the foot/ankle level is foolish in this case. Stretching this calf day after day until aliens come visit earth will still not be enough stretch time to fix this premature heel rise (ie. get that heel to stay down longer). There is a good reason why this is happening in this person, and it is a neurologic one, one we will discuss on the Patreon site for our Patrons. And, the reason does not matter for the concept I am teaching here today.

For today, you need to be able to see premature heel rise, and know all of the issues behind it, including causes, so that you can direct your phyiscial examination to solve your client's puzzle.
I have included yesterday's post below so you can review and bring this further together.
This is the kind of stuff we will do at Dr. Allen's Friday night Gait Lab, over some beverages. A unique, clinically curious and hungry 25 people need only apply. If you want to get to the next level of your human movement game, this is a way to get there.

Yesterday's post: We know that early/premature heel rise (PHR) leads to premature loading of the forefoot.
We know that premature heel rise (PHR) speeds us through many of the timely mechanical events that need and should occur for to get to safe and effective toe off during walking and running gaits.
This is why there are so many variables that need to be assessed and checked before instituting care to address the premature heel rise, because many times the problem is not even near the heel.
Consider, examine, assess (this is not an exhaustive list either) of causes of PHR
-short calf complex
-short quad (limits hip extension)
- short hip flexors
-anterior pelvis tilt as one's deviated norm posture
- prolonged or excessive rearfoot inversion
-lack of appropriate pronation (sustained supination)
-hallux limitus, rigidus
- weak anterior compartment lower leg
-lack of hip extension/weak glutes
-knee flexion contracture
- neurologic (toe walking gait from youth)
-painful achilles tendon mechanism
- loss of ankle rocker (which has its own long list)
. . . . to name a few

This is why you need to examine your clients, even after a gait analysis. Because, as we like to say, what you see is not your clients gait problem, it is their work around to other mechanical deficits.
After all, telling someone they just need to lengthen/stretch their calf to keep that heel down longer is utterly foolish.

*want to learn more about this stuff, you can join the upcoming Dr. Allen, Friday night Gait Lab series that he will be having in his office one Friday a month, in his Chicagoland office. Stay tuned for that notice. I will take only 25 people per session. We will dive into videos, cases, concepts, white-board rabbit holes, and enjoy some beverages and learn together. Stay tuned. The first 25 to pay and sign up are in !

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #heelrise, #PHR, #prematureheelrise, #achilles, #achillestendinitis, #anklerocker, #heelrocker, #forefootpain, #halluxlimitus, #halluxrigidus, #heelpain

When the boot is the cause of your client's problems/pain.

Our Patreon site is LIVE.
Patreon Sampler video,
Here's the kind of exclusive stuff you'll get as a Patreon sponsor, even at the 1$ and 5$ tier levels. Stuff right from our clinics, right when we see them, as fresh as content can get.
Of course, the 10$, 20$ and 50$ tier contributors will get this stuff too, but also "juicier" stuff , so if you don't wanna miss a step, come on over to our Patreon page and join even the lowest tiers, become part of a more intensive advanced focus group with ivo and I weekly ! (And in the process you'll be helping us keep new, advanced stuff coming your way).

You need toe extension, more than you might think.

Screen Shot 2018-07-20 at 9.24.08 AM.png

There is a major difference in these 2 photos.One foot is ready for foot loading, the other has one foot over the starting line, and is going to possibly have the risks related to inappropriate loading.

In clients with one of several possible issues related to poor control of the arch during weight bearing loading, it is not all too uncommon for us to bring to their attention that not only do they NOT utilize toe extension appropriately, and at the right time, they just simply have poor strength and endurance of the toe extensors (we will not be bringing up the complicated orchestration of the long and short toe extensors today, lets just keep it loosely as looking at them as a whole for today).

We know we say it an awful lot, that clients need more toe extension endurance and strength. But more often than not, they need more awareness of how little they are actually using their toe extensors during foot loading. This is why we despise flip flops and foot wear without a back strap on them, the flexors have to dominate to keep the footwear on the foot.  And, if you are into your toe flexors, you are definitely not into your toe extensors.

Screen Shot 2018-07-20 at 9.23.54 AM.png

You can easily see in this photo that there is a major difference in the integrity and preparation of the foot arch prior to foot loading in these 2 sample photos. One the toes are up in extension, the other the toes are lazy and neutral.  The toe up photo demonstrates well that when the toes are extended, the Windlass mechanism draws the forefoot and rearfoot together and raises the arch. Go ahead, lift your toes, it will happen on you as well (unless your arch is so collapsed that the first metatarsal actually dorsiflexes during toe extension, in this case, you are a whole different management tier). From this arch raised position, the first metatarsal is adequately plantarflexed, this means the joint complexes proximal and distal to the metatarsals are all in the right position to load and cope with loads. In the toe neutral picture, these components are not prepared, the arch is already getting ready to weight bear load from a half-baked position. One cannot expect the foot complex to load well when it is starting from a position of "half way there". One should start the loading of the foot from the starting line, not 3 steps over the line and not 3 steps before the starting line.  There is no athletic or mechanical endeavor that does well when we start the challenge too soon or too late, timing is everything.

How you choose to prep your foot for contact loading, and yes, there is some conscious choice  here, one is lazy the other is optimal, can determine to a large degree if you or your client is about to fall into the long list of problems related to poorly controlled pronation (too much, too soon, too often, too fast). Any of those bracketed problems lead to improper loading and strains during time under tension.

We will almost always start our clients on our progressing protocol of arch awareness and we will loosely say arch restoration, and attempts at better optimizing the anatomy they have, with toe up awareness.  Many clients will have poor awareness of this component issue, on top of poor endurance and frank weakness. The arch is to a great degree build from a lifting mechanical windlass effect, from the extensors and foot dorslflexors, not from the foot flexors. This is one of our primary beefs with the short foot exercise of Janda, there needs to be a toe extensor component in that exercise (search our blog for why the short foot exercise is dead). The short foot exercise is not actually dead, all exercises have some value when placed and performed properly, but the short foot exercise is based off of the toes being down and utilizing the plantar intrinsics to push the arch up and shorten the foot, this is a retrograde motion and it is not how we load the foot, but, it does have value if you understand this and place it into your clients repertoire appropriately.  This is also why we have some conceptual problems in stuffing an orthotic under someones arch to "lift it up", ie. slow its fall/pronation.  There are times for this, but why not rebuild the proper pathways, patterns and mechanics ?

Teach your clients about toe extension awareness. TEach them that they need to relearn the skill that when the toes drop down to the ground that the arch does NOT have to follow them down, that the client can relearn, "toe up, arch up . . . . . then toes down, but keep the arch up".  IT is a mantra in our office, "don't let your arch play follow the leader".  Reteach the proper neurologic disassociation between the toes and arch.

Perhaps the first place you should be starting your clients with foot and ankle issues, is regaining awareness of proper toe extension from the moment of toe off, maintaining it through swing, and then keeping it until the forefoot has purchase on the ground again, and not any time sooner than that ! If their toes are coming down prior to foot contact, it is quite likely their arch is following the leader.

So, if your client comes in with any of the following, to name just a few:  tibialis posterior tendonitis, plantar fascitis, heel pain, forefoot pain, painful bunions, arch pain, hallux limitus, turf toe, . . . . and the list goes on. Perhaps this will help you get your client to the starting line.

Shawn & Ivo, thegaitguys.com

 

Podcast 129: The Random Topic Podcast.

Links to find the podcast:

iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

http://traffic.libsyn.com/thegaitguys/pod_129final.mp3

http://thegaitguys.libsyn.com/podcast-129

Key Tagwords:

usain bolt, gait, gait asymmetry, isometrics, isotonics, RF ablation, COOLIEF, OA, deafferentation, knee arthritis, ibuprofin, kidney damage, NSAIDS, heel drop, achilles, tendonitis, heel pain, 

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net


Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Healing Tech in Neuroscience:

New device can heal with a single touch
https://www.usatoday.com/story/news/nation-now/2017/08/07/miracle-device-can-heal-single-touch-and-even-repair-brain-injuries/537326001/

Cool radiofrequency ablation
http://www.nbcnews.com/health/health-news/cool-new-knee-procedure-eases-arthritis-pain-without-surgery-n771221

Updates on Ibuprofin in runners
http://womensrunning.competitor.com/2017/07/news/ibuprofen-risks-endurance-runners_78580#EyIoMyAdkPW9UBpP.97

PeerJ. 2017 Jul 19;5:e3592. doi: 10.7717/peerj.3592. eCollection 2017.
Sonographic evaluation of the immediate effects of eccentric heel drop exercise on Achilles tendon and gastrocnemius muscle stiffness using shear wave elastography.
Leung WKC1, Chu KL1, Lai C1.

Front Physiol. 2017 Feb 28;8:91. doi: 10.3389/fphys.2017.00091. eCollection 2017.
Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise.
Maganaris CN1, Chatzistergos P2, Reeves ND3, Narici MV4.

Oman Med J. 2010 Jul; 25(3): 155–1661.
An Overview of Clinical Pharmacology of Ibuprofen
Rabia Bushra* and Nousheen Aslam
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191627/

Pharm Biol. 2014 Feb;52(2):182-6. doi: 10.3109/13880209.2013.821665. Epub 2013 Sep 30.
Zizyphus jujuba protects against ibuprofen-induced nephrotoxicity in rats. Awad DS1, Ali RM, Mhaidat NM, Shotar AM.
https://www.ncbi.nlm.nih.gov/pubmed/24074058

Gait asymmetry ?
https://www.ncbi.nlm.nih.gov/pubmed/28759127
Scand J Med Sci Sports. 2017 Jul 31. doi: 10.1111/sms.12953. [Epub ahead of print]
Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters.
Haugen T1, Danielsen J2, McGhie D2, Sandbakk Ø1,2, Ettema G2.

Podcast 112: Strengthening the foot's arch


Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 

Show links:
http://traffic.libsyn.com/thegaitguys/pod_112f.mp3
http://traffic.libsyn.com/thegaitguys/pod_112f.mp3
* and on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 

Show notes:

Job security, become so good and so unique that Ai cant replace your skills as a doctor
http://www.techinsider.io/age-of-ems-machines-will-take-over-all-jobs-2016-8

How prosthetics are working now, and will in the future
and why you should be scared
http://thenextweb.com/insider/2016/08/04/researches-think-we-may-have-to-protect-our-brains-from-hackers-in-a-few-years/

Open talk about how coordination is the first strength changes someone notes. It comes before true strength is achieved. It is neurologic, and its can feel decievingly safe, but it is a lie.

Foot Strengthening ?
https://drjohnrusin.com/advanced-strength-training-for-feet/

http://www.jospt.org/doi/abs/10.2519/jospt.2016.6482?platform=hootsuite&

Impaired Foot Plantar Flexor Muscle Performance in Individuals With Plantar Heel Pain and Association With Foot Orthosis Use

Tags:
foot arch, foot intrinsics, short foot, yoga toes, gastrocnemius, soleus, heel pain, hammer toes, correct toes, foot exercises, thegaitguys, squatting, gait, gait analysis, gait assessment,  orthotics, prosthetics
 

Forefoot strike running: Do you have enough calf muscle endurance to do it without a cost ?

Below you will find an article on footwear and running. Rice et al concluded that 

“ When running in a standard shoe, peak resultant and component instantaneous loadrates were similar between footstrike patterns. However, loadrates were lower when running in minimal shoes with a FFS (forefoot strike), compared with running in standard shoes with either foot strike. Therefore, it appears that footwear alters the loadrates during running, even with similar foot strike patterns.

They concluded that footwear alters the load rates during running. No brain surgery here. But that is not the point I want to discuss today. Foot strike matters. Shoes matter. And pairing the foot type and your strike patterns of mental choice, or out of natural choice, is critical. For example, you are not likely (hopefully) to choose a HOKA shoe if you are a forefoot striker. The problem is, novice runners are not likely to have a clue about this, especially if they are fashonistas about their reasoning behind shoe purchases. Most serious runners do not care about the look/color of the shoe. This is serious business to them and they know it is just a 2-3 months in the shoe, depending on their mileage. But, pairing the foot type, foot strike pattern and shoe anatomy is a bit of a science and an art. I will just mention our National Shoe Fit Certification program here if you want to get deeper into that science and art. (Beware, this is not a course for the feint of heart.)

However, I just wanted to approach a theoretical topic today, playing off of the “Forefoot strike” methodology mentioned in the article today.  I see this often in my practice, I know Ivo does as well. The issue can be one of insufficient endurance and top end strength (top end ankle plantar flexion) of the posterior mechanism, the gastrocsoleus-achilles complex. If your calf complex starts to fatigue and you are forefoot striker, the heel will begin to drop, and sometimes abruptly right after forefoot load. The posterior compartment is a great spring loading mechanism and can be used effectively in many runners, the question is, if you fatigue your’s beyond what is safe and effective are you going to pay a price ? This heel drop can put a sudden unexpected and possibly excessive load into the posterior compartment and achilles. This act will move you into more relative dorsiflexion, this will also likely start abrupt loading the calf-achilles eccentrically. IF you have not trained this compartment for eccentric loads, your achilles may begin to call you out angrily. Can you control the heel decent sufficiently to use the stored energy efficiently and effectively? Or will you be a casualty?  This drop if uncontrolled or excessive may also start to cause some heel counter slippage at the back of the shoe, friction is never a good thing between skin and shoe. This may cause some insertional tendonitis or achilles proper hypertrophy or adaptive thickening. This may cause some knee extension when the knee should not be extending. This may cause some pelvis drop, a lateral foot weight bear shift and supination tendencies, some patellofemoral compression, anterior meniscofemoral compression/impingement, altered arm swing etc.  You catch my drift. Simply put, an endurance challenged posterior compartment, one that may not express its problem until the latter miles, is something to be aware of. 

Imagine being a forefoot striker and 6 miles into a run your calf starts to fatigue. That forefoot strike now becomes a potential liability. We like, when possible, a mid foot strike. This avoids heel strike, avoids the problems above, and is still a highly effective running strike pattern. Think about this, if you are a forefoot striker and yet you still feel your heel touch down each step after the forefoot load, you may be experiencing some of the things I mentioned above on a low level. And, you momentarily moved backwards when you are trying to run forwards. Why not just make a subtle change towards mid foot strike, when that heel touches down after your forefoot strike, you are essentially there anyways. Think about it.

Shawn Allen, one of The Gait Guys

Footwear Matters: Influence of Footwear and Foot Strike on Loadrates During Running. Medicine & Science in Sports & Exercise:
Rice, Hannah M.; Jamison, Steve T.; Davis, Irene S.

http://journals.lww.com/acsm-msse/Abstract/publishahead/Footwear_Matters___Influence_of_Footwear_and_Foot.97456.aspx

A Pedograph mapping case.  Everyone wants to use the high tech stuff, we say you dont need it most of the time.  What do you see in this case ? 
 Answers: Increased heel pressure, Uncompensated forefoot varus (as evidenced by a lack of ink under the first metatarsals (you could even put a Rothbart foot-type on your DDx list), increased clawing of the 2nd-3rd digits on the right, and bilateral Morton’s second toes.  If you look carefully at the big toe ink presentation you can see a “pinch” callus on the left foot at the medial aspect of the hallux. This might also represent some increased pressure being exerted by the short big toe flexor (flexor hallucis brevis), the longus (FHL) would give a more distinct distal pressure and ink response at or near the tip of the toe. What you want to see is a nice ink spot that is well blended throughout the entire pad of the hallux.  There is also similar hint of more use of the short flexor on the right and less of the long flexor. Overall the toes are bunched together in a group, there is not much separation, we sometimes take this as a global representation of a weaker foot. 
 Q: What could this transfer to as a clinical presentation (what kinds of things might you be suspicious of as you conduct your examination ?: 
 Answer: 
 Obviously heel pain has to be on the list.  There is a fair amount of heel pressure going on here.  With a forefoot varus or, simply put, incompetence of the medial foot tripod stability structure the person is more likely to generate more medial rotation of legs.  This, if not met will good pelvic and core resistance, can lead to lumbopelvic functional instability and thus low back pain. Typically, Forefoot varus clients either pronate very heavily, sometimes late (as in this case) as evidenced by lack of heavy ink printing through the arch area, or they tend to compensate and try to walk on the outsides of their feet. Anyone who delays or rushes the 3 rockers of the foot (rear, mid or forefoot rockers) is going to see compensations to the compromised the ankle rocker movement.  This obviously has its complications as well.  There is no good compensation.  As we say, if something is not working right……..someone has to pay, eventually.

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

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

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

Answer:

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