Neuroma! Triple Threat....

Can you guess why this patient is developing a neuroma on the left foot, between the 3rd and 4th metatarsals?

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This gal presented to the office with pain in the left foot, in the area she points to as being between the 3rd and 4th metatarsals. It has been coming on over time and has become much worse this spring with hiking long distances, especially in narrower shoes. It is relieved by rest and made worse with activity.

Note the following:

  • She has an anatomical short leg on the left (tibial)

  • internal tibial torsion on the left

  • left forefoot adductus (see the post link below if you need a refresher)

Lets think about this.

The anatomical short leg on the left is causing this foot to remain in relative supination compared the right and causes her to bear weight laterally on the foot.

The internal tibial torsion has a similar effect, decreasing the progression angle and again causing her to bear weight laterally on the foot, compressing the metatarsals together.

We have discussed forefoot adductus before here on the blog. Again, because of the metararsal varus angle, it alters the forces traveling through the foot, pushing the metatarsals together and irritating the nerve root sheath, causing hypertrophy of the epineurium and the beginnings of a neuroma.

In this patients case, these things are additive, causing what I like to a call the “triple threat”.

So, what do we do?

  • give her shoes/sandals with a wider toe box

  • work on foot mobility, especially in descending the 1st ray on the left

  • work on foot intrinsic strength, particularly the long extensors

  • treat the area of inflammation with acupuncture

Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #metatarsusadductus #neuroma #gaitanalysis #thegaitguys #internaltibialtorsion

3 things

Its subtle, but hopefully you see these 3 things in this video.

I just LOVE the slow motion feature on my iPhone. It save me from having to drag the video into Quicktime, slow it down and rerecord it.

This gal has a healing left plantar plate lesion under the 2nd and 3rd mets. She has an anatomical leg length deficiency, short on the left, and bilateral internal tibial torsion, with no significant femoral version. Yes, there are plenty of other salient details, but this sketch will help.

  1. 1st if all, do you see how the pelvis on her left dips WAY more when she lands on the right? There is a small amount of coronal plane shift to the right as well. This often happens in gluteus medius insufficiency on the stance phase leg (right in this case), or quadratus lumborum (QL) deficiency on the swing phase leg (left in this case) or both. Yes, there are other things that can cause this and the list is numerous, but lets stick to these 2 for now. In this case it was her left QL driving the bus.

  2. Watch the left and right forefeet. can you see how she strikes more inverted on the left? this is a common finding, as the body often (but not always) tries to supinate the shorter extremity (dorsiflexion, eversion and adduction, remember?) in an attempt to “lengthen” it. Yes, there is usually anterior pelvic tilt accompanying it on the side, because I knew you were going to ask : )

  3. Look how her knees are OUTSIDE the saggital plane and remain there in her running stride. This is commonly seen in folks with internal tibial torsion and is one of the reasons that in our opinion, these folks should not be put medially posted, torsionally rigid, motion control shoes as this usually drive the knees FURTHER outside the saggital plane and can macerate the meniscus.

Yep, lots more we could talk about on this video, but in my opinion, 3 is a good number.

Dr Ivo Waerlop, one of The Gait Guys

#thegaitguys #gaitanalysis #footpain #gaitproblem #internaltibialtorsion #quadratuslumborum #footstrike

https://vimeo.com/329212767

Things seem to come in 3's...

Things tend to occur in threes. This includes congenital abnormalities. Take a look this gentleman who came in to see us with lower back pain.

Highlights with pictures below:

  • bilateral femoral retrotorsion

  • bilateral internal tibial torsion

  • forefoot (metatarsus) adductus

So why LBP? Our theory is the lack of internal rotation of the lower extremities forces that motion to occur somewhere; the next mobile area just north is the lumbar spine, where there is limited rotation available, usually about 5 degrees.

Dr Ivo Waerlop, one of The Gait Guys.

#tibialtorsion #femoraltorsion #femoralretrotorsion #lowbackpain #thegaitguys #gaitproblem

this is his left hip in full internal rotation. note that he does go past zero.

this is his left hip in full internal rotation. note that he does go past zero.

full internal rotation of the right hip; note he does not go past zero

full internal rotation of the right hip; note he does not go past zero

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

ditto for the keft

ditto for the keft

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

less adductus but still present

less adductus but still present

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

Ditto!

Ditto!

Motion control Shoes + Internal Tibial Torsion = Knee Pain

Thinking about putting a motion control shoe under that foot to control pronation? You had better make sure you make friends with the knee, as it will often (depending on the compensation) be placed OUTSIDE the SAGGITAL PLANE. Like Dr Allen has said many times before , the knee is basically a hinge joint placed between 2 ball and socket joints, and it is usually the one to start grumbling...

Learn more as Dr Ivo Waerlop of The Gait Guys explains in this brief video

#gait #Gaitanalysis #gaitguys #thegaitguys #kneepain #motioncontrolshoes #internaltibialtorsion

https://vimeo.com/154496722

A primer on tibal torsions and versions....

We get tired of reading posts on squats, lifting, lunges and the whole “have your toes in”, “Have your tires pointing out”, “keep your feet straight” sort of advice for best performance. The truth of the matter is, when the knee is in the saggital plane, you will have the best results and cause the least amount of damage to the knee and menisci. In our opinion, if you are not paying attention to femoral and tibial torsions and versions, you are missing the boat.

This is not a post for the faint of heart, but hopefully will help clear up some questions you may (or may not) have had. Grab a cup of your favorite beverage and enjoy...

The tibia and femur are more prone to torsional defects, as they are longer lamellar (layered) bones as opposed to the cancellous bone that makes up the talus. These often present as an “in toeing” or “out toeing” of the foot with respect to the leg; changing the progression angle of gait.

Tibial versions and torsions can be measured by the “thigh foot angle” (the angulation of the foot to the thigh with the leg bent 90 degrees: above right) or the “transmalleolar angle” (the angle that a line drawn between the medial and lateral malleoli of the ankle makes with the tibial plateau).

At a gestational age of 5 months, the fetus has approximately 20° of internal tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 1.5 degrees per year until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°).

Sometimes the rotation at birth is excessive. This is called a torsion. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure (on the lower legs) in the uterus (an unstretched uterus in a first pregnancy causes greater pressuremaking the first-born child more prone to rotational deformities. Growth of the unborn child accelerates during the last 10 weeks and the compression from the uterus thus increases. As you would guess, premature infants have less rotational deformities than full-term infants. This is probably due to decreased pressure in the uterus. Twins take up more space in the uterus and are more likely to have rotational deformities.

Of interesting note, there is a 2:1 preponderance of left sided deformities believed to be due to most babies being carried on their backs on the left side of the mother in utero, causing the left leg to overlie the right in an externally rotated and abducted position.

Normal ranges of versions and torsions are highly variable. Ranges less than 2 standard deviations are considered internal tibial torsion and greater external tibial torsion.

Internal tibial torsion (ITT) usually corrects 1 to 2 years after physiological bowing of the tibia (ie tibial varum) resolves. External tibial torsion (TT) is less common in infancy than ITT but is more likely to persist in later childhood and NOT resolve with growth because the natural progression of development is toward increasing external torsion.

Males and females seem to be affected equally, with about two thirds of patients are affected bilaterally and the differences in normal tibial version values are often expected to be cultural, lifestyle and posture related.

The ability to compensate for a tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot and/or by externally rotating at the hip. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hip. Both can decrease walking agility and speed if severe. With an external tibial torsion deformity of 30 degrees , the capacities of soleus, posterior gluteus medius, and gluteus maximus to extend both the hip and knee were all reduced by over 10%.

So, there you have it. Ina nutshell, the basics that will take you far and wide on your journey to better performance and biomechanics for yourself and your patients/clients.

 

So, you do weighted carries?

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

 

Nothing earthshaking here (1) , but a few takeaways:

  • Asymmetric loading of L5-S1 will most likely become more significant if the individual has a L5-S1 facet tropism, where one (or both) of the facets is (are) facing saggitally, as loading will be be even greater.  This has been associated with disc derangement (2) and degeneration (3).

 

  • The body does seem to adjust for the load, but it takes at least to the second step. We need to make sure the proprioceptive feedback loops (joint and muscle mechanoreceptors and their associated pathways) are functioning well. Manipulate, mobilize, facilitate, inhibit as appropriate.

 

  • The increased varus moment and hip abduction on the unweighted side are most likely to move the center of gravity more to the midline, which makes sense. This may become problematic with folks with increased internal tibial torsion, especially with femoral retroversion/torsion as they already have limited internal rotation available to them at the hip

 

 

 

 

 

 
1. Wang J, Gillette JC. Carrying asymmetric loads during stair negotiation: Loaded limb stance vs. unloaded limb stance. Gait Posture. 2018 Jun 19;64:213-219. doi: 10.1016/j.gaitpost.2018.06.113. [Epub ahead of print]
2. Chadha M, Sharma G, Arora SS, Kochar V. Association of facet tropism with lumbar disc herniation. European Spine Journal. 2013;22(5):1045-1052. doi:10.1007/s00586-012-2612-5.
3. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J (1998) Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J 7: 376-380.

 

Abstract

BACKGROUND:

Individuals often carry items in one hand instead of both hands during activities of daily living. Research Question The purpose of this study was to investigate low back and lower extremity frontal plane moments for loaded limb stance and unloaded limb stance when carrying symmetric and asymmetric loads during stair negotiation.

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

RESULTS:

Peak L5/S1 contralateral bending moments were significantly higher when carrying a 20% BW unilateral load as compared to a 20% BW bilateral load for both stair ascent and stair descent. In addition, peak L5/S1 contralateral bending moments were significantly higher during step one than for step two. Peak external knee varus and hip abduction moments were significantly higher in unloaded limb stance as compared to loaded limb stance when carrying a 20% BW unilateral load.

SIGNIFICANCE:

General load carriage recommendations include carrying less than 20% BW loads and splitting loads bilaterally when feasible. Assessment recommendations include analyzing the first stair step and analyzing both the loaded and unloaded limbs.

The Adductor Magnus; Not just for adduction anymore...

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Yet another paper (1) to support the notion that the adductors (particularly the adductor magnus, in this paper), act as external rotators (especially eccentrically), not internal rotators as is commonly purported in many anatomy texts (2) . Remember that the lower extremity is internally rotating (as a whole) from initial contact to midstance and externally rotating from midstance to pre swing. SOMETHING needs to help attenuate some of that internal rotation (and pronation) that occurs during the 1st part of stance phase and assist in external rotation (and supination); now you can add the adductor magnus to the popliteus, deep six external rotators, anterior and posterior compartments of the lower leg to the hamstrings and quads.

"This study suggests that adductor magnus has at least two functionally unique regions. Differences were most evident during rotation. The different direction-specific actions may imply that each segment performs separate roles in hip stability and movement. These findings may have implications on injury prevention and rehabilitation for adductor-related groin injuries, hamstring strain injury and hip pathology."

 

1. Benn ML, Pizzari T, Rath L, Tucker K, Semciw AI1 . Adductor magnus: An emg investigation into proximal and distal portions and direction specific action. Clin Anat. 2018 Mar 9. doi: 10.1002/ca.23068. [Epub ahead of print]

2. Leighton RD. A functional model to describe the action of the adductor muscles at the hip in the transverse plane.Physiother Theory Pract. 2006 Nov;22(5):251-62.



 

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How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Full internal rotation

Full internal rotation

full external rotation

full external rotation

full internal rotation

full internal rotation

full external rotation

full external rotation

neutral

neutral

neutral

neutral

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

  • Top: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
  • second picture: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
  • third picture: normal internal rotation of the left hip; internal tibial torsion
  • 4th picture: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
  • last 2 pictures: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle. If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist androtating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limitinghis follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

  • we treated the injured joint locally, with manipulation of the pathomechanical segments
  • we reduced inflammation and muscle spasm with acupuncture
  • we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
  • we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
  • we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

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.

When the wrong shoe, meets the right foot

Is it any wonder that this gentleman has pain on the dorsum of this his feet?

1st of all, how about his internal tibial torsion? It is bilateral, L > R. This places the majority of his weight on the outside of his feet, keeping him somewhat supinated most of the time.

2nd: he has an anatomical leg length discrepancy on the right which is tibial (see pictures 2 and 3). This will place EVEN MORE weight on the outside of the right foot, as it will often remain in supination in an attempt to "lengthen" itself.

3rd, take a look at his shoes. Is this particular model supposed to be rear foot posted in varus? Talk about adding insult to injury! This will place this guys feet into EVEN MORE supination and EVEN MORE on the outside of his feet. maybe the right shoe is worn into more supination because of his right sided LLD?

And if that wasn't enough, this particular shoe has increased torsional rigidity through the midfoot, slowing or arresting any hope of shock absorption that he may have. 

Yikes! We sure wish more folks knew more about feet and shoes! Maybe they should think about taking the National Shoe Fit Program? Email us for more info.

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 Every foot has a story. 

 This is not your typical “in this person has internal tibial torsion, yada yada yada” post.  This post poses a question and the question is “Why does this gentleman have a forefoot adductus?”

The first two pictures show me fully internally rotating the patients left leg. You will note that he does not go past zero degrees and he has femoral retroversion. He also has bilateral internal tibial torsion, which is visible in most of the pictures. The next two pictures show me fully internally rotating his right leg, with limited motion, as well and internal tibial torsion, which is worse on this ® side

 The large middle picture shows him rest. Note the bilateral external rotation of the legs. This is most likely to create some internal rotation, because thatis a position of comfort for him (ie he is creating some “relief” and internal rotation, by externally rotating the lower extremity)

 The next three pictures show his anatomically short left leg. Yes there is a large tibial and small femoral component. 

 The final picture (from above) shows his forefoot adductus. Note that how, if you were to bisect the calcaneus and draw a line coming forward, the toes fall medial to a line that would normally be between the second and third metatarsal’s. This is more evident on the right side.  Note the separation of the big toe from the others, right side greater than left. 

Metatarsus adductus deformity is a forefoot which is adducted in the transverse plane with the apex of the deformity at LisFranc’s (tarso-metatarsal) joint. The fifth metatarsal base will be prominent and the lateral border of the foot convex in shape . The medial foot border is concave with a deep vertical skin crease located at the first metatarso cuneiform joint level. The hallux (great toe) may be widely separated from the second digit and the lesser digits will usually be adducted at their bases. ln some cases the abductor hallucis tendon may be palpably taut just proximal to its insertion into the inferomedial aspect of the proximal phalanx (1)

Gait abnormalities seen with this deformity include a decreased progression angle, in toed gait, excessive supination of the feet with low gear push off from the lesser metatarsals. 

 It is interesting to note that along with forefoot adductus, hip dysplasia and internal tibial torsion are common (2) and this patient has some degree of both. 

 His forefoot adductus is developmental and due to the lack of range of motion and lack of internal rotation of the lower extremities, due to the femoral retrotorsion and internal tibial torsion.  If he didn’t adduct the foot he would have to change weight-bearing over his stance phase extremity to propel himself forward. Try internally rotating your foot and standing on one leg and then externally rotating. See what I mean? With the internal rotation it moves your center of gravity over your hip without nearly as much lateral displacement as would be necessary as with external rotation. Try it again with external rotation of the foot; do you see how you are more likely displace the hip further to that side OR lean to that side rather than shift your hip? So, his adductus is out of necessity.

Interesting case! When you have a person with internal torsion and limited hip internal rotation, with an adducted foot, think of forefoot adductus!


1.  Bleck E: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatric Orthop 3:2-9,1983.

2. Jacobs J: Metatarsus varus and hip dysplasia. C/inO rth o p 16:203-212, 1960

The Pitfalls of Motion Control Features.

Welcome to Monday, folks. Today Dr Ivo discusses why not all shoes are created equal and why you need to understand and educate your peeps about shoes!

Internal tibial torsion is when the foot is rotated internally with respect to the tibia. When the foot is straight (like when you are walking, because the brain will not let you walk too internally rotated because you will trip and fall), the knee will rotated OUTSIDE the saggital plane (knee points out). Putting a medially posted shoe on that foot rotates the foot EVEN FURTHER laterally. Since the knee is a hinge joint, this can spell disaster for the meniscus.

need to know more? email us or send us a message about our National Shoe Fit Program.

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Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg
In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).

a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°). more cool stuff on torsions here

Wow, cool stuff, eh?

Got Motion Control? Sometimes too much of a good thing is a bad thing!

Welcome to Monday and News You can Use, Folks.

Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.

You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.

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Now THERE”S some internal tibial torsion!

So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)

 We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)

What would you do? Here’s what we did:

  • acupuncture to reduce swelling
  • took him out of his motion control shoes (which pitch him further outside the saggital plane)
  • gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
  • potty squats in a pain free range
  • ice prn
  • asked him to avoid full flexion

Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!

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Sometimes you need to run that valgus post clear back to the heel!

A valgus post assists in pronation. Some fols have modereate to severe internal tibial torsion and need to be able to pronate more to get the knee into the saggital plane for patello femoral conflicts. They usually run from the tail of the 5th metatarsal forward, but sometimes need to run it clear back to the heel to get enough pronation to occur.

Abdominal Activity and Gait   We came across this cool study today, after a well educated patient asked about abdominal activity during gait.    Here is the bottom line:  low level activity in the rectus abdominis and external oblique throughout the gait cycle, more concentrated activity of the internal oblique at initial contact/loading response (heel strike).    This makes sense, since the external oblique occupies more real estate and has a larger cross sectional area; it most likely has a role in stabilization both in rotational  like emoticon  planes as well as the saggital plane (Z). Perhaps the action of the internal oblique at initial contact is to assist in external rotation of the pelvis on the stance phase leg, as the the opposite leg goes into swing?  “Cluster analysis identified two patterns of activity for the internal oblique, external oblique and rectus abdominis muscles. In the lumbar erector spinae, three patterns of activity were observed. In most instances, the patterns observed for each muscle differed in the magnitude of the activation levels. In rectus abdominis and external oblique muscles, the majority of subjects had low levels of activity (<5.0% of a maximum voluntary contraction) that were relatively constant throughout the stride cycle. In the internal oblique and the erector spinae muscles, more distinct bursts of activity were observed, most often close to foot-strike. The different algorithms used for the cluster analysis yielded similar results and a discriminant function analysis provided further evidence to support the patterns observed”  Clin Biomech (Bristol, Avon). 2002 Mar;17(3):177-84. Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to identify patterns of activity. White SG1, McNair PJ.

Abdominal Activity and Gait

We came across this cool study today, after a well educated patient asked about abdominal activity during gait.

Here is the bottom line:
low level activity in the rectus abdominis and external oblique throughout the gait cycle, more concentrated activity of the internal oblique at initial contact/loading response (heel strike).

This makes sense, since the external oblique occupies more real estate and has a larger cross sectional area; it most likely has a role in stabilization both in rotational like emoticon planes as well as the saggital plane (Z). Perhaps the action of the internal oblique at initial contact is to assist in external rotation of the pelvis on the stance phase leg, as the the opposite leg goes into swing?

“Cluster analysis identified two patterns of activity for the internal oblique, external oblique and rectus abdominis muscles. In the lumbar erector spinae, three patterns of activity were observed. In most instances, the patterns observed for each muscle differed in the magnitude of the activation levels. In rectus abdominis and external oblique muscles, the majority of subjects had low levels of activity (<5.0% of a maximum voluntary contraction) that were relatively constant throughout the stride cycle. In the internal oblique and the erector spinae muscles, more distinct bursts of activity were observed, most often close to foot-strike. The different algorithms used for the cluster analysis yielded similar results and a discriminant function analysis provided further evidence to support the patterns observed”

Clin Biomech (Bristol, Avon). 2002 Mar;17(3):177-84.
Abdominal and erector spinae muscle activity during gait: the use of cluster analysis to identify patterns of activity.
White SG1, McNair PJ.