Podcast 163: The hip and foot talk to each other. A research paper.

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Today's article link: https://pubmed.ncbi.nlm.nih.gov/32717719/

Gluteal tendinopathy and the Cross Over gait pattern.

Gluteal tendinopathy, often lateral hip pain at or around the region of the greater trochanter. (note: the pain referral of this problem can dispurse far and wide, from low back and even into groin or to the knee). It is not gluteal bursitis, the research barely supports that. You'd be better off using the term "greater trochanteric pain syndrome" (yes, its an ICD10 code).

The problem often involves the abductors, the gluteus medius and/or gluteus minimus tendons as weakness or poor co-contraction stabilization patterning creates a compressive adduction of the tendons and gr.trochanter. But, know this, mere strengthening is not the entire answer, and it is not supported as the cause or cure, it is just part of the solution. As with most problems, resolution is about load, how we load, load over time, tolerance to load, time under tension, loads we can manage, loads we are unprepared for. These are variables certainly pertinent to novice runners and athletes (though for some everyday folk even walking can be vulnerable) but also high level athletes who either mal-adapt, compensate, over protect or under-recover.
About 10 years ago I began my dive into something I was seeing often, something that did not seem to have a name from what I was able to determine, but one that was fraught with mechanical loading issues that was part of my athletes' symptom collage. I referred to it by what it appeared to be, a "cross over gait", and since then have written a few dozen pieces, at least, that go into the problem, pathomechanics, and correction for my athletes and patients. I have often referred this to as a "failure to stack the lower limb joints", but that is so remedial and non-descript. Almost a decade ago I did the 3 part video series (part 1 is below) and it brought a lot of light to gait problems in runners and a huge variable in unresponsive gluteal tendonopathies, amongst others. One can strengthen the glutes all they want, but if the pattern of pathologic loading is not amended, altered, improved, then the model will fail.
And here is another factor that is interesting brought forth at a recent conference,
"@Bill_Vicenzino Imaging over-estimates compared to clinical presentation - MRI positive for Gluteal Tendinopathy in 77% of cases but clinical presentation only positive in 52%"

Watch my 3 part series, starting with the video below. Get to understand the cross over gait variables and you will get better at remedying gluteal tendonopathy. It is more than just prescribing half a dozen glute exercises.

Shawn Allen, the other gait guy.

#gait, #thegaitguys, #gaitproblems, #gaitanalysis, #glutealtendinopathy, #hippain, #crossovergait, #hipadductors, #hipabduction, #greatertrochanter, #hipbursitis

Hip Abductor Strength In Individuals With Gluteal Tendinopathy: A Cross-sectional Study. Kim Allison et al.
https://bjsm.bmj.com/content/48/Suppl_2/A6.2

Failure to Adduct the hip in symptomatic runners with iliotibial band syndrome.

This is an interesting finding. They took symptomatic iliotibial band runners and looked at the hip adduction as they fatigued. When they found was not what one might initially expect, meaning more hip adduction because of the fatigue. Instead, they found was that when exerted, the female subjects independently modify their running gait to decrease hip adduction, potentially as a result of pain....... they compensated to protect. Not earth shattering, but support for the neuroprotective biomechanical mechanisms. This is how we all find a way to keep going, we find away around the problem. The problem here is that by the time they come to see us for care, we may be hearing of the next level of compensatory break down, and not the primary issue.

https://www.ncbi.nlm.nih.gov/pubmed/27718393

“When you run up a hill, most of the cross over gait disappears. Runners will tend toward beautifully stacked lower limb joints.”- Dr. Allen

Are people running up a hill more likely to tend towards a cross over gait style, in other words tend toward a more narrow gait step or a wider gait step ?

Watch people run up hill closely. Even if they are cross over (narrow foot fall) runners, when running up hills a few things will negate much of the narrow foot fall.

1- Running up hill requires more gluteals, more power is needed for all that extra required hip extension to power up the hill. More gluteal max use can, and will, spill over into the posterior fibers of the gluteus medius and this will tend to abduct the leg/hip and reduce some of the cross over tendency.

2- When one runs up a hill, there is a forward pitch of the upper torso, often with a some degree of forward pitch occurring at the hips. More importantly, because one is running up hill, they are stepping up and so more than normal hip flexion is necessary than in normal running. The forward pitch of the body and the greater degree of hip flexion is the culprit here. If the hip/leg is adducted in a cross over style, adding this to a more than normal flexing hip, it will create a scenario for anterior hip impingement and risk of femoral acetabular impingement (FAI) syndromes. Go ahead, test it for yourself. Lie on your back and flex your hip, drawing your knee straight up towards your shoulder.  Pretty good range correct ?  Now, flex the hip drawing your knee towards your navel, adducting it a little across your body. Feel the abrupt range of motion loss and possible pinch in the front of the hip ?  FAI.  This is what would happen if you utilized a cross over gait, narrow foot strike gait. The goes for mountain/sleep hill hikers as well. 

This is why, if you are a narrow foot striker, a near-cross over type of runner, you will see it disappear when you run up hills.  

If you get anterior hip pain running up hills, force a wider step width and reduce the possible impingement at the anterior hip joint. Just make sure you have enough ankle dorsiflexion to tackle the hill in the first place. If not, you may welcome some foot and ankle stuff to the table along with the hip.  

Likely obvious stuff to most of the readers here, but sometimes it is nice to point out the obvious.  Hills, just because they are there, doesn’t mean you have the parts to run them safely.

Dr. Shawn Allen

Hip Abduction moment?

This was a great question we received, so we thought we would make a post of it, so everyone could benefit.

“@GregLehman: @KineticRev @TheGaitGuys do you guys have a link to your thoughts on how an ER leg allows the quads to create a hip abductor moment? Thanks”

First of all, What IS a hip abduction moment?

In posts, we often refer to a “moment”, meaning almost literally, a few seconds where a certain motion occurs. When are watching someone from behind and see their heel adduct as they get to terminal stance and pre swing (just before they toe off), you are seeing an “adductory moment” of the heel, sometimes referred to as an “adductory twist”.

Now lets think about the hip. Have you ever seen a framing square used by a carpenter? It is an “L” shaped device to make sure things are square (like hanging a door). The hip is kind of like this. It is shaped like an “L” with the neck and head forming the shorter side of the “L” and the femoral shaft forming the longer side. If you imagine the short side of the square attached to the pelvis and now hinging that away from the body, you have abduction of the hip. Normally, this task is tended to (primarily) by the middle fibers of the gluteus medius and posterior fibers of the gluteus minimus, assisted by the quadratus lumborum on the opposite side.

How can the quad be involved?

We remember that the quadriceps has four parts, the vastus lateralis, vastus intermedius and vastis medialis (collectively called “the vasti’) and the rectus femoris.

The rectus femoris proximal attachments are at the anterior inferior iliac spine (this is called the straight or anterior head) and the superior lip of the acetabulum (called the reflected or posterior head) Please see the top of the 2^nd picture above, you can see the 2 heads. The distal attachment, after blending with the vasti, is into the patellar tendon and ultimately the tibial tuberosity.

The rectus is an accessory hip flexor and knee extensor, though it not normally a prime mover for either of these motions. It’s amount of action depends on the position of both the knee and hip.  When the knee is flexed, the rectus has less mechanical advantage, because it is placed in a lengthened position; same goes if the hip is extended.  It will be shortened if the hip is flexed and if the knee is extended at the same time, will have a mechanical disadvantage.

Now think about the direction of travel of each of the heads.

The “straight” head actually runs more obliquely from lateral to medial from its proximal attachment (AIIS) to the distal attachment (blending with vasti and patellar tendon); the refelected head runs a similar course, but not as oblique. If you were to externally rotate the thigh (remember, some folks may have an externally rotated foot due to external tibial torsion), it would actually give these heads more mechanical advantage (when the knee is relatively extended, such as at heel strike/ initial contact and toe off/ preswing) as abductors (remember to think from the ground up, closed chain, so the distal attachments are acting more like the origin); thus, the abductor moment we have talked about.

There you have it @Greglehman. Thanks for the great question.

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More proof for the Cross Over Gait for the non-believers and debaters.

For those of you who have been with us for a few years, you are no stranger to our articles and videos on the web for piecing together many aspects of the CROSS OVER GAIT in a manner more comprehensive and more clear.  If you are not familiar with our work on this, please click here.

Today we add a little more “proof to our pudding”.

“Changing step width alters lower extremity biomechanics during running.” Brindle et al.
http://www.gaitposture.com/article/S0966-6362(13)00291-9/abstract

• Step width influences frontal plane biomechanics of all body parts
• Changes in step width affects arm swing symmetry and often creates arm abduction
• Hip and knee biomechanics change from their normal predicted path and mechanics
• Hip adduction, rearfoot eversion and internal tibial spin decrease as step width increases
• Knee adduction/valgus stress decreases as step width increased.
• Increased step width improves cephalad stacking of all lower extremity joints
• The swing limb is a hinging pendulum. Striving for a level pelvis and normal step width promotes a normal sagittal pendulum path and improves the likelihood of a recurring sagittal pendulum swing for the opposite leg. 

As Brinkle et al. say in their paper, “step width is a spatiotemporal parameter that may influence lower extremity biomechanics at the hip and knee joint.”  We would argue that it is even more far reaching than the hip and knee. You have likely learned here at the Gait Guys that arm swing is heavily predicated on the dynamics of contralateral leg function and positioning.

The above video shows a classic cross over gait. The limbs can be seen crossing over the midline thus guaranteeing that the pendulum is moving through an arc and not along a straighter progression. This adduction of the limb virtually guarantees that the foot is striking greater on the lateral heel and forefoot than it should, that the rear foot is going to move through eversion with greater speed and force and internal tibial spin and arch control will need to be controlled better.  And if they are not controlled better, pathology may eventually occur.  Do you want any of this to occur at an accelerated rate as occurs in running ? One doesn’t need to just heel strike to suffer these problems, midfoot strike will still see them if the cross over occurs.

Shawn and Ivo, the Cross Over Guys.

Hip Biomechanics Part 2

Figure 1 shows the condensed version of the parameters (forces and moment arms) affecting movement and stability of the femur-acetabulum complex in the frontal plane during the closed kinetic chain.  (A moment arm such as D1 and D2 is defined as the length of a line that extends from the axis of rotation to a point of right angle intersection with a respective force, in this case HAM or BW.)

In Figure 1 above we see several parameters.  HAM represents the Hip Abductor Muscles, D1 represents the internal moment arm, D2 represents the external moment arm and BW represents the Body Weight of the individual.  These factors all come into play when considering the frontal plane equilibrium of the hip joint.  The equation representing the interaction of all of these parameters is HAM x D1 = D2 x BW.  Both sides of this equation must be equal and balanced in order for the pelvis to remain stable and without movement when in the closed chain stance phase of gait. In this diagram, if the left side of the equation is greater than the right the net effect will be a counterclockwise hip moment and the patient will move their torso over the hip creating a hiking or lifting of the contralateral hip.  This net movement will create abduction at the hip joint.  If the right side of the equation is greater than the left the net effect will be a clockwise hip moment and the patient will move their torso away from the hip creating a dropping of the contralateral hip.  This net movement will create adduction at the hip joint seen here and thus the classic Trendelenberg gait.  We need to keep in mind that this is not a perfect model presented here since we are ignoring acceleration of the body in the forward sagittal plane and rotational planes.  Investigating the equation further should bring the reader to further realization that if the body weight (BW) were to increase, mathematically the D2 external moment arm could decrease to keep the equation balanced.  However, since the length of this D2 moment arm is rather fixed (unless the pelvis were to go through a counterclockwise  rotation which would draw the body weight center closer to the hip joint center effectually abducting the stance hip, thus reducing the D2 moment arm) this is not a more likely scenario. Rather, the response would be to attempt to increase the left side of the mathematical equation thus increasing the HAM forces to attempt to keep the pelvis level and the equation from changing.  In other words, when body weight increases we must increase the gain or contraction in the HAM group during each step to keep the pelvis level and balanced.  Unfortunately the HAM strength has its limits of maximal contraction, sometimes far below any major increases in body weight.  One must keep in mind that with increased HAM contraction there is a corresponding increase in joint compression across the hip articular surfaces which at reasonable levels is well embraced but at unreasonable levels can damage articular cartilage.  One should thus conclude that maintaining a reasonable body weight for one’s bone structure keeps the right and left sides of the mathematical equation at tolerable levels, both for movement, stability and cartilage longevity.  Fortunately the equation has a built in safety mechanism for these counterclockwise hip moments, one that is beneficial.  In such scenarios, as the body is brought over the hip thus decreasing the D2 moment arm, the D1-internal moment arm increases in length and since the equation must be balanced the HAM force can decrease.  Thus, the magnitude of the HAM force is inversely proportional to the length of the D1-internal moment arm.  The whole equation can better be visualized and conceptualized by a teeter totter diagram with a sliding pivot point.

Shawn and Ivo,  The Gait (and biomechanics) Guys