A return to "the Kickstand Effect". So your foot is turned out, externally rotated ?

Amputee War Veteran Sergeant Christopher Melendez Became a Pro Wrestler Read more at http://www.craveonline.com/mandatory/1053779-standing-tall-how-amputee-war-veteran-christopher-melendez-beca#XeD2LrZ2xmtXQ6um.99

Amputee War Veteran Sergeant Christopher Melendez Became a Pro Wrestler
Read more at http://www.craveonline.com/mandatory/1053779-standing-tall-how-amputee-war-veteran-christopher-melendez-beca#XeD2LrZ2xmtXQ6um.99

Why is my foot turned out ?  A 3rd return to the solitary externally rotated foot.

Below you will find our 2 prior articles on this topic, but this is a relatable concept to other thing which we have embedded in many of our blog posts and podcasts over the last decade of sharing what we know.

In the photo above the brave Army Veteran Sergeant Melendez one can see the concept brilliantly as he only has one limb.  One can see the concept in full play, he must balance his body mass over one point, not two like the rest of us lucky folk.  In trying to balance over one point, if the foot is straight forward (if one is blessed with close to neutral torsional bone alignment) one will have good stability in the sagittal plane (forward /back) but will be at risk to fall, drift or sway into the frontal plane. Here Sergeant Melendez displays the foot and limb turn out into the frontal plane so that he can use the quadriceps to help him protect into that frontal plane, plus, by situating his base posture in more of an externally rotated position (likely losing internal rotation capability over time, unless forcibly maintained through specific exercises) he can more fully and skillfully engage all 3 divisions of the gluteus maximus and medius, and perhaps hamstrings and adductors and who knows what else, to maintain a more stable and likely less fatiguable posture. Go ahead, try it for yourself, this is easier to balance and maintain that a straight sagittal foot posturing. The one trouble he might have, is not deviating too much, or too often, into a frontal plane drift hip-pelvis posture. This will put much aberrant compressive load onto the roof of the femoral head-acetabular interval, where most of us begin a degenerative hip arthritis journey, unfortunately. 

Side note:   So you might think your client has FAI ?  Maybe start here, our thinking might lead you done a helpful path to get started. Search our blog for FAI as well.

here are the 2 prior articles on the topic, with video.  Watch for this one, it is everywhere out in the world, walking amongst us.  
Thank you for your service Sergeant Melendez.  Here is the article written by K. Thor Jensen, on Crave Online.  

https://thegaitguys.tumblr.com/post/14262793786/gait-problem-the-solitary-externally-rotated

https://thegaitguys.tumblr.com/post/40617674450/a-return-to-the-solitary-externally-rotated-foot

Shawn & Ivo, The Gait Guys

The extra-articular hip impingements

There continues to be a plethora of research and dialogue on the femoral acetabular impingements (FAI), the intra-articular impingements.  But we must not forget about the extra-articular impingements about the hip. A common one we see is the Ischiofemoral variety whereby the quadratus femoris muscle gets pinched between the ischial tuberosity and the femur.  We wrote about it, see the link below.  This one gets mistake for proximal hamstring tendonopathies by some we suspect. We suspect, however this is pure speculation, that the two most common are #1 and #3.

This article outlines some of the common extra-articular impingement syndromes:

 1) Ischiofemoral impingement: as we discuss in our article

 "2) Subspine impingement: mechanical conflict occurs between an enlarged or malorientated anterior inferior iliac spine and the distal anterior femoral neck.

3) Iliopsoas impingement: mechanical conflict occurs between the iliopsoas muscle and the labrum, resulting in distinct anterior labral pathology.

4) Deep gluteal syndrome: pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space.

5) Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis. "

Ischiofemoral Impingement
https://thegaitguys.tumblr.com/post/110564772099/ischial-femoral-impingement-you-have-to-know-what

Current concepts in the diagnosis and management of extra-articular hip impingement syndromes.  Nakano N1, Yip G1, Khanduja V2.
Int Orthop. 2017 Jul;41(7):1321-1328. doi: 10.1007/s00264-017-3431-4. Epub 2017 Apr 11.
https://www.ncbi.nlm.nih.gov/pubmed/28401279

 

 

 

Difficult hip presentations. Coordination of deep hip muscle activity is often altered in symptomatic femoroacetabular impingement (FAI).   If your clinic is anything like ours, you are regularly seeing failed therapy cases of hip pain walk into your clinic. Many of these cases have been diagnosed clinically or with imaging as FAI (femoral acetabular impingement (syndrome)). FAI can give all kinds of hip pain presentations around the front, side or back of the hip, groin and pelvis, even with referral into the knee. Lets make no mistake, these are difficult cases. The attached study suggests that these often difficult cases are fraught with undefined parameters. These cases can be difficult for us all, particularly if one do not have the clinical examination skills to tease out what muscles are not working, which ones are over working, what has happened to joint centration, how the client loads the hip, what the pelvis posturing attitude is and what motor stabilization strategies are being deployed. Lumbar, pelvis and hip posturing and stabilzation is key in understanding FAI and these often vague and frustrating cases. Determing how the client deploys stacking of the lower limb joints and how they then deploy these strategies in gait and running is paramount to your success in assisting these client cases. This is a deeply multifactorial problem and often why these issues do not get resolved.   Recently I just closed yet another case with a 21 year old female who had FAI and labral tear surgery 2 years ago. She had been told she would always have some pain and never run again. As many of these cases often proceed, after defining all of the issues above, it was clear she had many unaddressed components postoperatively. It appeared many components had not been addressed preoperatively, and had they been addressed, I suspect she may have not needed surgery. These multitudes of dysfunctional components can lead to FAI and labral damage. Many torn labrums do not need surgery, as evidenced by how many clients come out of surgery still having the same pre-operative pain as well as how many improve or resolve by a non-surgical approach to addressing all of the components above.  This study, by Diamond et al compared coordination of deep hip muscles between people with and without symptomatic FAI using analysis of muscle synergies (i.e. patterns of activity of groups of muscles activated in synchrony) during gait. The study utilized intramuscular fine-wire and surface electrodes EMG activity of selected deep and superficial hip muscles.   This study found a significant correlation with the quadratus femoris muscle, one we have repeatedly found problematic over the years. This study was nice to read, it confirmed many of the issues we have found rooted in these often difficult cases. The study surmised that      “coordination of deep hip muscles in the synergy related to hip joint control during early swing differed between groups. This phase involves movement towards the impingement position, which has relevance for the interpretation of synergy differences and potential clinical importance. ”     We strongly refer you back to our  podcast #99  to look into the gluteus medius during swing phase. This is a key component to one’s deeper understanding of how complex the hip works, during both stance and swing. We all tend to get too caught up in stance phase mechanics because that is the one we can see and assess most clearly, however, if one does not understand how vital the gluteus medius is in swing phase limb targeting through the sagittal plane, one is likely missing a big piece of a client’s clinical puzzle. One can do all the dynamic and functional movement and stabilization therapy they wish, but if one does not understand the swing phase mechanics, and perhaps most importantly, if one does not reteach a client how to make the necessary adaptive gait changes to employ the therapeutic work the changes remain on the therapy table and never cross over into functionally using them. The clinician must address the client’s previously deeply rooted gait motor program. A client may have in their bank account the new functional abilities they have been taught, but they likely have not been taught how to deploy them in a new more appropriate gait strategy.   -Dr. Shawn Allen   1. Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement. Laura E Diamond, Wolbert Van den Hoom, Kim L Bennell, Tim V Wrigley, Rana S Hinman, John O’ Donnell, Paul Hodges  2. J Neurophysiol. 2014 Jul 15;112(2):374-83. doi: 10.1152/jn.00138.2014. Epub 2014 Apr 30. A neuromechanical strategy for mediolateral foot placement in walking humans.  Rankin BL   3. Podcast 99: How foot placement, the glutes and cross over gait all come together and make sense.  4.  https://thegaitguys.tumblr.com/post/133206339519/podcast-99-how-foot-placement-the-glutes-and

Difficult hip presentations. Coordination of deep hip muscle activity is often altered in symptomatic femoroacetabular impingement (FAI).


If your clinic is anything like ours, you are regularly seeing failed therapy cases of hip pain walk into your clinic. Many of these cases have been diagnosed clinically or with imaging as FAI (femoral acetabular impingement (syndrome)). FAI can give all kinds of hip pain presentations around the front, side or back of the hip, groin and pelvis, even with referral into the knee. Lets make no mistake, these are difficult cases.
The attached study suggests that these often difficult cases are fraught with undefined parameters. These cases can be difficult for us all, particularly if one do not have the clinical examination skills to tease out what muscles are not working, which ones are over working, what has happened to joint centration, how the client loads the hip, what the pelvis posturing attitude is and what motor stabilization strategies are being deployed. Lumbar, pelvis and hip posturing and stabilzation is key in understanding FAI and these often vague and frustrating cases. Determing how the client deploys stacking of the lower limb joints and how they then deploy these strategies in gait and running is paramount to your success in assisting these client cases. This is a deeply multifactorial problem and often why these issues do not get resolved. 

Recently I just closed yet another case with a 21 year old female who had FAI and labral tear surgery 2 years ago. She had been told she would always have some pain and never run again. As many of these cases often proceed, after defining all of the issues above, it was clear she had many unaddressed components postoperatively. It appeared many components had not been addressed preoperatively, and had they been addressed, I suspect she may have not needed surgery. These multitudes of dysfunctional components can lead to FAI and labral damage. Many torn labrums do not need surgery, as evidenced by how many clients come out of surgery still having the same pre-operative pain as well as how many improve or resolve by a non-surgical approach to addressing all of the components above.

This study, by Diamond et al compared coordination of deep hip muscles between people with and without symptomatic FAI using analysis of muscle synergies (i.e. patterns of activity of groups of muscles activated in synchrony) during gait. The study utilized intramuscular fine-wire and surface electrodes EMG activity of selected deep and superficial hip muscles.  
This study found a significant correlation with the quadratus femoris muscle, one we have repeatedly found problematic over the years. This study was nice to read, it confirmed many of the issues we have found rooted in these often difficult cases. The study surmised that 

“coordination of deep hip muscles in the synergy related to hip joint control during early swing differed between groups. This phase involves movement towards the impingement position, which has relevance for the interpretation of synergy differences and potential clinical importance. ”

We strongly refer you back to our podcast #99 to look into the gluteus medius during swing phase. This is a key component to one’s deeper understanding of how complex the hip works, during both stance and swing. We all tend to get too caught up in stance phase mechanics because that is the one we can see and assess most clearly, however, if one does not understand how vital the gluteus medius is in swing phase limb targeting through the sagittal plane, one is likely missing a big piece of a client’s clinical puzzle. One can do all the dynamic and functional movement and stabilization therapy they wish, but if one does not understand the swing phase mechanics, and perhaps most importantly, if one does not reteach a client how to make the necessary adaptive gait changes to employ the therapeutic work the changes remain on the therapy table and never cross over into functionally using them. The clinician must address the client’s previously deeply rooted gait motor program. A client may have in their bank account the new functional abilities they have been taught, but they likely have not been taught how to deploy them in a new more appropriate gait strategy. 

-Dr. Shawn Allen


1. Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement.
Laura E Diamond, Wolbert Van den Hoom, Kim L Bennell, Tim V Wrigley, Rana S Hinman, John O’ Donnell, Paul Hodges

2. J Neurophysiol. 2014 Jul 15;112(2):374-83. doi: 10.1152/jn.00138.2014. Epub 2014 Apr 30. A neuromechanical strategy for mediolateral foot placement in walking humans.  Rankin BL

3. Podcast 99: How foot placement, the glutes and cross over gait all come together and make sense.

4. https://thegaitguys.tumblr.com/post/133206339519/podcast-99-how-foot-placement-the-glutes-and


Does hill running equate to biking when it comes to pathomechanics ?Think about it, when  you are hill running, one leg is in extension while the lead leg is in more extremes (compared to road running) of hip flexion reaching up the hill for the next step. Isn’t this similar to biking ? On the bike one is bent over leaning forward, the lead leg is in extremes of flexion while the foot on the bottom crank has that same hip in extension.  So does hill running equate to biking ? Well, no. But then it comes to approximating anterior hip structures, there are some similarities. You cannot deny that there seems to be some similarities to pathomechanics.This was a post from a few weeks ago, but this week in our online teleseminar class we went over these principles.  We talked about some of the same biomechanical principles and vulnerabilities in hill running and when in biking.Might be a good time to revisit this brief blog post and see why we had hill running and biking in the same conversation.  Dr. Shawn Allen  Here is the hill running blog post where we mentioned a few things.  http://thegaitguys.tumblr.com/post/143841190479/when-you-run-up-a-hill-most-of-the-cross-over

Does hill running equate to biking when it comes to pathomechanics ?Think about it, when  you are hill running, one leg is in extension while the lead leg is in more extremes (compared to road running) of hip flexion reaching up the hill for the next step. Isn’t this similar to biking ? On the bike one is bent over leaning forward, the lead leg is in extremes of flexion while the foot on the bottom crank has that same hip in extension.  So does hill running equate to biking ? Well, no. But then it comes to approximating anterior hip structures, there are some similarities. You cannot deny that there seems to be some similarities to pathomechanics.This was a post from a few weeks ago, but this week in our online teleseminar class we went over these principles.  We talked about some of the same biomechanical principles and vulnerabilities in hill running and when in biking.Might be a good time to revisit this brief blog post and see why we had hill running and biking in the same conversation.

Dr. Shawn Allen

Here is the hill running blog post where we mentioned a few things.
http://thegaitguys.tumblr.com/post/143841190479/when-you-run-up-a-hill-most-of-the-cross-over

Podcast 73: Cross Fit and Squatting. Knees out ?

Podcast 73: Femoral and Tibial Torsions and Squatting: Know your Squatting Truths and Myths

*Show sponsor: www.newbalancechicago.com

Lems Shoes.  www.lemsshoes.comMention GAIT15 at check out for a 15% discount through August 31st, 2014.

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_74f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-73-cross-fit-squatting-knees-b. out

iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

______________

Today’s Show notes:

1. Bioengineers create functional 3D brain-like tissue   http://www.nih.gov/news/health/aug2014/nibib-11.htm

2.  A Novel Shear Reduction Insole Effect on the Thermal Response to Walking Stress, Balance, and Gait
 
3.  Hi Shawn and Ivo, There is a lively debate in the Crossfit community about “knees out” during squatting. I have attached a blog post. It might be a good blog post or podcast segment. 
 
4. Shoe Finder ?
 
5.  Michael wrote: “I know this is too broad a topic for facebook, but I was wondering what your general recommendation would be for someone with flat feet and exaggerated, constant over-pronation. I’ve tried strengthening my calves and ankles, but have seen no noticeable reduction in the automatic "rolling in” of my feet whenever walking or standing. I can consciously correct the over-pronation, of course, but as soon as I stop tensing my arch muscle, everything flops back down.“