Podcast 150: Subtalar joint control? Plus Heel raise effects on low back pain

Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
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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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

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Apple podcasts:
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http://thegaitguys.libsyn.com/subtalar-joint-control-plus-heel-raise-effects-on-low-back-pain

http://directory.libsyn.com/episode/index/id/10909609


Show notes


The HyProCure proceedure

https://images.search.yahoo.com/yhs/search;_ylt=AwrEeBmEH0RdlDUAiAUPxQt.;_ylu=X3oDMTByMjB0aG5zBGNvbG8DYmYxBHBvcwMxBHZ0aWQDBHNlYwNzYw--?p=hyprocure+sinus+tarsi+implant&fr=yhs-sz-001&hspart=sz&hsimp=yhs-001

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4621198/
https://www.ncbi.nlm.nih.gov/pubmed/21106413
https://www.ncbi.nlm.nih.gov/pubmed/29786228

High-heeled walking decreases lumbar lordosis.EdenyBaaklini et al.
https://www.sciencedirect.com/science/article/pii/S096663621730108X

The effect of high-heeled shoes on lumbar lordosis: a narrative review and discussion of the disconnect between Internet content and peer-reviewed literature. Brent S. Russell
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206568/

Prolong Wearing of High Heeled Shoes Can Cause Low Back PainFarjad Afzal1* and Sidra Manzoor
https://pdfs.semanticscholar.org/afb4/641b8ed6450fcbdfa8ff99029d935c2bdc88.pdf

Relation between Wearing High-Heeled Shoes and Gastrocnemius and Erector Spine Muscle Action and Lumbar Lordosis. Cezar Augusto Souza Casarin
https://www.medscitechnol.com/download/index/idArt/892352

A flatter foot approach?
https://twitter.com/IzzyMoorePhD/status/1157034538192855041

Thoughts: titrate into speed work just like doing the same for longer and longer runs
Creating a "speed base"
https://www.fastrunning.com/?p=26410&preview=true

"monster walks"
Hip-Muscle Activity in Men and Women During Resisted Side Stepping With Different Band Positions. Lewis CL, et al. J Athl Train. 2018.
https://www.ncbi.nlm.nih.gov/m/pubmed/30615490/

Physical findings differ between individuals with greater trochanteric pain syndrome and healthy controls: A systematic review with meta-analysis.
Plinsinga ML1, Ross MH1, Coombes BK2, Vicenzino B3.
Musculoskelet Sci Pract. 2019 Jul 25;43:83-90. doi: 10.1016/j.msksp.2019.07.009. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/31369906

Low back pain and asymmetry.

Screen Shot 2019-04-07 at 10.00.54 AM.png

Do oarsmen have asymmetries in the strength of their back and leg muscles?
IF these oarsmen were more symmetrical would they not be in pain?

From the study below:
"Patterns of asymmetry of muscle activity were observed between the left and right erector spinae muscles during extension, which was significantly related to rowing side (P < 0.01). These observations could be related to the high incidence of low back pain in oarsmen."

Here we have a supported study of asymmetry and injury/pain. This is what we have been saying (asymmetry matters) in the last few days with our posts on asymmetry. This study eludes to a finding that strength can test normal and symmetrical, but EMG activity can show patterns of asymmetry that can result in problems/pain.

Have you ever rowed? I mean truly rowed, in a shell, on the water, not on land or on a Concept 2 rower? It is just not the same, especially if you have an unilateral asymmetrical loading arc, like an oarsman pulling from port or starboard. I have rowed on the water just like this, briefly, one summer in a camp for young teens. I rowed on my home town course, on the World famous Royal Canadian Henley Regatta. I was the 2nd seat, starboard, in an 8 man shell. 8 oars in the water, 8+1 guys, one oar a piece, alternating port and starboard. I was behind the stroke. I hated it. Perhaps the hardest thing I had ever done sport wise to that point, largely because this dude setting the pace was jacked on caffeine, or something else, I think. No one works harder than rowers if you ask me, they are some of the fittest athletes in the world. Why? because it is a whole body effort.
Ok, enough of the fluff.

Now imagine rowing like this for many years in high school, college and/or competitively. Forcefully pulling on one oar, across an arc of pull out one side of the boat, thousands of times a day for many years. If that isn't something that will develop asymmetry I do not know what might. Oarsman are under near constant high end effort pushing and pulling loads (push with the legs, pull with the arms). There are few, if any, sports with such high end constant effort than rowing.

From the Parkin et al study:
"The aim of this study was to establish whether asymmetry of the strength of the leg and trunk musculature is more prominent in rowers than in controls. Nineteen oarsmen and 20 male controls matched for age, height and body mass performed a series of isokinetic and isometric strength tests on an isokinetic dynamometer. These strength tests focused on the trunk and leg muscles. Comparisons of strength were made between and within groups for right and left symmetry patterns, hamstring: quadriceps ratios, and trunk flexor and extensor ratios. The results revealed no left and right asymmetries in either the knee extensor or flexor strength parameters (including both isometric and isokinetic measures). Knee extensor strength was significantly greater in the rowing population, but knee flexor strength was similar between the two groups. No difference was seen between the groups for the hamstring: quadriceps strength ratio. In the rowing population, stroke side had no influence on leg strength. No differences were observed in the isometric strength of the trunk flexors and extensors between groups, although EMG activity was significantly higher in the rowing population. Patterns of asymmetry of muscle activity were observed between the left and right erector spinae muscles during extension, which was significantly related to rowing side (P < 0.01). These observations could be related to the high incidence of low back pain in oarsmen."- Parkin et al.

Extra sauce:
I "caught a crab" many times when a novice oarsman and was nearly vaulted out of the boat on one fatal event. A crab is the term rowers use when the oar blade gets “caught” in the water. It is caused by a momentary flaw in oar technique and the paddle end of the oar is pulled into the depths instead of skimming just below the surface. Catching a crab has happened to anyone who has ever rowed. A crab may be minor, allowing the rower to quickly recover, or it may be so forceful that the rower is ejected from the boat as the handle end catches the oarsman under the arms lifting them out of the boat.

J Sports Sci. 2001 Jul;19(7):521-6.
Do oarsmen have asymmetries in the strength of their back and leg muscles? Parkin S1, Nowicky AV, Rutherford OM, McGregor AH.

Low back tightness in runners. Spinal muscle fatigue.

Do you as a runner, or a helper of runners, ever experience low back tightness on a run, particularly a long run ? These muscles can fatigue just like any other muscle; we just generally do not think of them in this manner. Be sure to endurance/fatigue test your runner's lumbar erector muscles. Sure, we need a strong durable core, but in an endeavor like running, where there are constant acceleration/deceleration as well as impact loading forces over long distances, we need these muscles to be just as durable as any other.
And, do not forget that we have to control the constant anterior and posterior pelvis oscillations in the sagittal plane (APT and PPT) that correspond to the acceleration and deceleration phases of gait.

"Previous EMG studies of running have shown the lumbar extensor muscles to be active at foot contact and during early stance (Thorstensson, Carlson, Zomlefer, & Nilsson, 1982). This early activation of the back extensors will act to limit forward flexion of the trunk as energy is absorbed in the lower limbs and the CoM decelerates. During this deceleration phase, the thorax moves into forward flexion and there is a small corresponding posterior tilt of the pelvis as gluteus maximus acts to extend the hip."
S.J. Preece et al. / Human Movement Science 45 (2016) 110–118

Podcast 145: Tendons, Heel Drop and their impacts on the posterior chain,

Heel lifts, Sole lifts and their impact on the EMG of the posterior chain.

Keywords: gait, gait analysis, gait problems, running, ankle, tendinopathy, heel lifts, sole lifts, EMG, paraspinal activity, gluteal inhibition, posterior chain, anterior pelvic tilt, tight quads, diagnostic ultrasound

Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".

Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:

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

Google Play:
https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_149raw_-_31619.mp3

Permalink URL: http://thegaitguys.libsyn.com/podcast-tendons-heel-drop-and-their-impacts-on-the-posterior-chain

Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/9027890

Show notes:

Current trends in tendinopathy management
Tanusha B.Cardosoa, TaniaPizzarib, RitaKinsellab, DanielleHopec, Jill L.Cook
https://www.sciencedirect.com/science/article/pii/S1521694219300233

https://www.jospt.org/doi/full/10.2519/jospt.2015.5880


Insightful paper on how tendon adapts to loading and unloading. Discusses a lack of evidence supporting eccentric training as the treatment of choice for injury and notes that tendon response to loading is not normalized until ~6-12 months after injury
https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP275450
The impact of loading, unloading, ageing and injury on the human tendon
S. Peter Magnusson, Michael Kjaer

Effects of heel lifts on lower limb biomechanics and muscle function: A systematic review
Chantel L.Rabusinac, Hylton B.MenzacJodie A.McClellandbcJade M.TanacGlen A.WhittakeracAngela M.EvansaShannon E.Munteanuac
https://www.sciencedirect.com/science/article/pii/S0966636218310075?dgcid=coauthor

The influence of high and low heeled shoes on EMG timing characteristics of the lumbar and hip extensor complex during trunk forward flexion and return task
AnnaMikaa, Brian C.ClarkbcŁukaszOleksy
https://www.sciencedirect.com/science/article/abs/pii/S1356689X13000428


The effect of heel lifts on trunk muscle activation during gait: A study of young healthy females
Christian J.Bartonac, Julia A.CoyleaPaulTinley
https://www.sciencedirect.com/science/article/pii/S1050641108000424

A Systematic Review and Meta-Analysis of Crossover Studies Comparing Physiological, Perceptual and Performance Measures Between Treadmill and Overground Running
https://link.springer.com/article/10.1007/s40279-019-01087-9

Plantarflexor strength and endurance deficits associated with mid-portion Achilles tendinopathy: The role of soleus - ScienceDirect
https://www.sciencedirect.com/science/article/pii/S1466853X18305017

Could your low back pain be related to your big toe?

Ok, he has low back pain. But i can also see that high gear (1st toe off) is impaired from loss of terminal dorisflexion at that 1st MTP joint.

Ok , so this means heel rise will be premature and when it does happen the toe off will be towards the lesser toes, low gear toe off.
This means the knee will be carried laterally as opposed to the more desirable sagittal tracking/hinging.
And, if heel rise is premature, this means the knee will likely flex and hinge sagittally just a little, when it should actually be extending and coupling with the gastroc and glute to produce propulsion.
And, when the knee flexes, I know the hip flexes, when we should again be moving into hip extension for propulsion.
And when the knee and hip flex, the vertical length of the leg is shorter functionally, which means a subtle lateral pelvis dip and compensatory thoracolumbar lateral bend to the other side to compensate. This leads to imbalance in the lumbar spine musculature and more work in some areas, and less in others.

So, doc, are you telling me my low back pain is from my big toe? It could be Sir. Lets get into it and find out.
Game ?
Game . . . .

One has to be able to quickly juggle normal known gait biomechanics with pathologic biomechanics. You don't have all day with your patient. Play these games in your head, often.
Example: So, if the knee doesn't terminally extend, what could this mean to the rest of the system ?

Stop treating the area of pain, is might not be the problem.

Shawn Allen, one of the gait guys.

#gait, #thegaitguys, #gaitproblems, #gaitcompensations, #halluxlimitus, #turftoe, #hipextension, #prematureheelrise

Why are you putting your internal hip rotation into your low back (pain).

Why are you putting your internal hip rotation into your low back (pain).

On October 12th, 2018 I wrote about utilizing the gluteals in internal hip rotation. You will have to go back and search FB for that article and video.
Assessing Internal hip rotation (in various ranges of hip flexion, extension, abduction and adduction) is a basic exam principle I examine on nearly every patient and athlete that comes to see me, regardless of their complaint. Other than breathing, walking is the next most under appreciated movement we undertake, and take for granted.
Lack of adequate internal hip rotation, in my clinical experience (20+ years), is all too often a fundamental parameter in hip, knee and low back pain. It is necessary to have unrestricted internal hip rotation during gait. Adequate internal hip rotation in the mid to late stance phases of gait is critical and is also paired with hip extension, in fact, one has to pass through adequate internal hip internal rotation to get to adequate hip extension. Without one, we do not get the other. And, if the internal rotation is not imparted in the hip when the hip is supposed to be the one internally rotation, that demand is going to move up or down, caudally or rostrally, low back or knee. Of interesting note, taking things deeper, the opposite arm is also going to go through internal rotation and extension at the same time. Impair one limb, and we can make a case, often enough, that the contralateral upper or lower limb is also challenged. This fundamental fact is one of the fascinating reasons Dr Ivo and I get so geeked out by gait and human movement. Because, it is very complicated. And if one is not looking close enough, paying enough attention with enough fundamental knowledge, things are going to get overlooked and missed when solving for "X" in a client's pain/problems/movement. Compensation will ensue, all too easily. Build strength on said compensations and we are off to the races in driving neuronal pasticity into potential asymmetries. If one is strength training a client without examining them and making specific corrections along the way, well, we reap what we sew. Ok, enough soap-boxing. -Dr. Allen
Here, don't take our word for it, . . . . .

"Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review."
Ortop Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
Sadeghisani M1, Manshadi FD1, Kalantari KK1, Rahimi A1, Namnik N2, Karimi MT3, Oskouei AE4.

"There is a hypothesis which suggests that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.

"Asymmetrical (right versus left, lead versus non-lead) and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetrical total hip rotation was also observed in patients with LBP. However, none of the studies explicitly reported limited hip external rotation ROM."

CONCLUSION: "The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be included in the examination of patients with LBP symptoms."

Photo credit: courtesy of Pixabay

Part 2: The amputated hallux & the complex biomechanical fall-out from it.

Screen Shot 2018-08-10 at 8.10.05 AM.png

Last week we promised Part 2 to this case, the amputated big toe.
Here is part 2. These are the complicated biomechanical fall-outs, so grab a big mug o' coffee and have at it !

In review, this person (all photos and case premissioned in swap for insight) had the distal hallux removed because of a progressive melanoma on the big toe. Can you believe that ! This is one more reminder that the sun and regular dermatologist screenings are wise.
This person had a complaint of progressing right gluteal and QL pain, spasm, tone and some persistent pain now in the 2nd metatarsal as well as some shoe challenges. We discuss this case briefly in and upcoming podcast, #139 or #140 we believe.

Screen Shot 2018-08-10 at 8.10.19 AM.png

Before we add our final thoughts to this case, lets cap our post from last week.

-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- More internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will likely be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree).
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities
- These factors are likely related to his complaints in the right gluteal and low back/QL area.

Now, onto our next thoughts.

- when the hallux is incompetent, in this case absent, there are few other choices to gain forefoot purchase on the ground other than more flexion gripping of the 2nd toe (then the 3rd, then 4th). This is a progressing "searching" phenomenon for forefoot stability and without the function of the big fella, the 2nd toe will begin a hammering phenomenon, often, but not always. We would not be surprised to see hammer toe development in this case, but this person is now very aware of it, and can at least now fight that battle with increased awareness. There is some mild evidence of this on the side lateral photo.

- We are happy to see that the proximal phalange was spared. The adductor hallucis is inserted medially there, and this will help to reduce bunion generation risk (medial metatarsal drift). Comparing the photo and the radiograph is a great example of how far back/proximal the 1st MTP joint is. One could easily assume that the entire hallux was resected from the photo, but the radiograph shows otherwise.

Screen Shot 2018-08-10 at 8.22.36 AM.png

- Toe off is obviously going to be compromised. The patient cannot adequately stabilize the 1st metatarsal (MET) and this will mean a compromised foot tripod, medial foot/tripod splay, arch pronation control challenges but toe off stabilization is going to have to be met by the 2nd and 3rd digits, as discussed above. They are not suited to be the major players here, they are synergistic to this end. Do not be surprised to see one of 2 strategies at toe off here:

1. heavy medial foot tripod toe off, dropping into the void and this maximize the internal spin challenges and minimizing the requisite foot supination stiffness generation phase that should be normal at toe off

2. avoidance of the above, with a forced conscious forefoot lateral toe off, a supinatory strategy, to avoid internal limb spin, more toe hammering, and the lurch heavily and abruptly off of the right foot and onto the left limb.

Screen Shot 2018-08-10 at 8.10.27 AM.png

3. taking #2 further, any time there is perceived challenges or deficits in strength, endurance, proprioception, balance, power and the like, the brain often will create a premature departure off of said limb, creating a requisite premature loading onto the opposite limb. This can cause a phenomenon well loosely refer to "catching" in the contralateral quadriceps mechanism. These clients, with their abrupt loading pattern onto the opposite limb will most often have troubles getting into initial gluteal hip stabilization strategies, and thus default into a quadriceps strategy, that in time can lead to quad shortness and increased tone, which can cause more compression across the patellofemoral joint and cause knee pain. This is more of a compression/loading response issue rather than tracking phenomenon, which we see at the typical diagnosis. We often look for causes in the opposite limb for contralateral knee pain. IT is quite often there if you are looking hard enough for it. Fix the problem, not the symptom.
There is a long host of other things than can arise from here, including heavy contralateral (in this case left sided) foot loading challenges, often more forefoot initial loading, and all of the problems than can arise when this pattern is cyclical, but that would take this post far too deep and long. So, . . . . another time.

Screen Shot 2018-08-10 at 8.09.47 AM.png

4. Shoe fit, we could make the case that a shoe that nicely hugs the forefoot, as opposed to a wide toe box'ed shoe, could help fight off the risk of 1st metatarsal abduction and thus bunion formation risk. However, one cannot dismiss the wider toe box giving the remaining toes a better environment to engage without hammering with over use of long flexors. We might suggest a trial of an elastic sleeve, one often used for plantar fascitis symptom management, placing a snug one around the forefoot when ambulating. This could help keep that metatarsal snug and stop the bunion-like drift we would be watching for.

have at it gang, cases like this are far and deep and require deep understanding of normal and abnormal biomechanics, and the rabbit hole deep myriad of compensations that can be engaged.

have a great weekend !

Shawn and Ivo

Internal hip rotation and low back pain.

Internal hip rotation and low back pain.

No brain surgery here if you have been on our station for the last several years. We pound home the critical importance of internal hip rotation all the time, here and in our clinic.
When the foot is on the ground, loading, the opposite leg is in swing. Part of this swing phase requires the hemipelvis on that swing side to also advance forward as well. This means that the stance phase leg will see the pelvis rotating atop of the static femoral head, this rotation is internal hip rotation. If one does not have sufficient internal hip rotation then the heel will be lifted prematurely, the foot might undergo an adductory twist (the heel moves medially into adduction which can look like the foot spinning "relatively" outward into external rotation) to name just a few (of many possible) pattern consequences. The loads can also move up into the lumbar spine, because, if the rotation is not there in the hip, or not buffered there, it either moves down into the limb or up into the pelvis and spine, or both. There are many strategies and patterns of loading responses available to the framework, it is your job to find them, source out the problem, and remedy. One must look for and understand the importance of sufficient internal hip rotation in your client, and the ramifications when it is not sufficiently present.
This study brings this principle to mind.

https://www.ncbi.nlm.nih.gov/pubmed/26751745

Not moving.

Not moving: the fundamental but neglected motor function.

Have you ever had a client tell you that prolonged standing is their biggest challenge ? "My feet kill me when I have to just stand in a booth at a trade show !" , or "My low back kills me when I stand for 2 hours at a cocktail party". In many of these cases, if they start to move, they feel better. I have plenty of trade show folks complaint of foot pain from the sustained standing. The muscles are under a constant sustained load, there is little to no joint movement, the ligamentous support systems undergo creep, and other things. So, i have them walk back and forth the 5-6 steps within the confines of their trade show booth. Movement is medicine. Sustaining a postural position and thus a fixed joint position over time, even with modest load, is fatiguing and eventually leads to multi-tissue failure. Sustained loading, even when suboptimal, is a problem. The nervous system becomes cranky too as discussed in the abstract below.

Here is an interesting article we are trying to get our hands on (please share if you have access to it). It is not a strong correlation to the discussion above, but there is some conceptual spill over we hope to dive deeper into, perhaps on an upcoming podcast.

Abstract

"The function of the motor system in preventing rather than initiating movement is often overlooked. Not only are its highest levels predominantly, and tonicaly, inhibitory, but in general behavior it is often intermittent, characterized by relatively short periods of activity separated by longer periods of stillness: for most of the time we are not moving, but stationary. Furthermore, these periods of immobility are not a matter of inhibition and relaxation, but require us to expend almost as much energy as when we move, and they make just as many demands on the central nervous system in controlling their performance. The mechanisms that stop movement and maintain immobility have been a greatly neglected area of the study of the brain. This paper introduces the topics to be examined in this special issue of Philosophical Transactions, discussing the various types of stopping and stillness, the problems that they impose on the motor system, the kinds of neural mechanism that underlie them and how they can go wrong.This article is part of the themed issue 'Movement suppression:brain mechanisms for stopping and stillness'."

Philos Trans R Soc Lond B Biol Sci. 2017 Apr 19;372(1718). pii: 20160190. doi: 10.1098/rstb.2016.0190.

Not moving: the fundamental but neglected motor function.
Noorani I1, Carpenter RH2.

Arm Swing and dynamic stability of the system.

Screen Shot 2017-10-16 at 1.33.03 PM.png

We have discussed the arm swing issue so many times over the years that we have lost count. By many sources, arm swing is a product of lower limb action and a product of the effective, or ineffective, relationship between the shoulder "girdle" (maybe thoracic rotation component) and the pelvic girdle (lumbopelvic rhythm) during gait.  This is the concept of phasic and anti-phasic limb swing. If you want to dive into that, and you should if you are unfamiliar with the concept, you can look it up on our blog using the search box.  We are not to forget that the arms, and thus arm swing, is a major factor in maintaining balance. We have used the term "ballast" many times to describe the effects of arm swing, rotation, abduction, circumduction etc on assisting balance maintenance of the body during various locomotion strategies. These are largely subconscious actions, hence why we agree with the research suggesting that arm swing is secondary, compensatory, and takes its queues off of the activity of the lower limb motor actions. In essence, arm swing variants are necessary compensations to assist in maintaining things like balance, center of pressure, equilibrium and the like. 

In this recent 2017 study, we have another suggesting arm swings function in assisting, even improving, dynamic stability. We are reminded of MdGill's suggestion, and the concepts of phasic and antiphasic torso-pelvis counter rotational movements, of how spinal loads can be affected by changes or differences in arm position.  Even arm position changes in sitting and standing can alter spinal loads, so during movement it is a virtual guarantee. 

This study looked at "how arm swing could influence the lumbar spine and hip joint forces and motions during walking." In this study, the researchers had each subject perform walking with different arm swing amplitudes and arm positions. Here is a comment from the researchers on what they found, it is pretty much what we have been writing about for several years based off of other research"

"The range of motion of the thorax with respect to the pelvis and of the pelvis with respect to the ground in the transversal plane were significantly associated with arm position and swing amplitude during gait. The hip external-internal rotation range of motion statistically varied only for non-dominant limb. Unlike hip joint reaction forces, predicted peak spinal loads at T12-L1 and L5-S1 showed significant differences at approximately the time of contralateral toe off and contralateral heel strike."

Thus, we find yet another study confirming what many will say is obvious, that being arm position and movements have notable effects on whole body kinetics and spinal loads. This study suggested that arm variations did not have an effect on spinal loads during walking. We find this curious; it is something we will be looking into, and pondering. We hope you do as well.

Effect of arm swinging on lumbar spine and hip joint forces. Lorenza Angelini et al. Journal of Biomechanics, Sept 2017
http://www.sciencedirect.com/science/article/pii/S0021929017304670

Subtle clues. Helping someone around their anatomy

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This patient comes in with low back pain of years duration, helped temporarily with manipulation and activity. Her exam is relatively benign, save for increased lumbar discomfort with axial compression in extension and extension combined with lateral bending. Believe it or not, her abdominal and gluteal muscles (yes, all of them) test strong (no, we couldn’t believe it either; she is extremely regular with her exercises). She has bilateral internal tibial torsion (ITT) and bilateral femoral retro torsion (FRT). She has a decreased progression angle of the feet during walking and the knees do not progress past midlilne. There is a loss of active ankle rocker with gait, but not on the exam table; same with hip extension. 

We know she has a sweater on which obscures things a bit, but this is what you have to work with. Look carefully at her posture from the side. The gravitational line should pass from the earlobe, through the shoulder, greater trochanter and through or just anterior to the lateral malleolus.

In the top picture, can you see how her pelvis is anterior to this line? Do you see how it gets worse when she lifts her hands over her head (yes, they are directly over head)? This can signify many things, but often indicates a lack of flexibility in the lumbar lordosis; in this case, she cannot extend her lumbar spine further so she translates her pelvis forward. Most folks should have enough range of motion from a neutral pelvis and enough stability to allow the movement to occur without a significant change. Go ahead, we know you are curious, go watch yourself do this in a mirror and see if YOU change.

Looking at the this picture, can you pick out that she has a genu valgus? Look at the hips and look at the tibial angle.

Did you note the progression angle (or lack of) in her feet? This is a common finding (but NOT pathognomonic) in patients with internal tibial torsion. Notice the forefoot adductus on the right foot?

So what do we think is going on?

  • ITT and FRT both limit the amount of internal rotation of the thigh and lower leg. Remember you NEED 4 degrees of each to walk normally. Most folks have significantly more
  • if you don’t have enough internal rotation of the lower extremity, you will need to “create” it. You can do this by extending the lumbar spine (bottom picture, right) or externally rotating the lower extremity
  • Since her ITT and FRT are bilateral, she flexes the pelvis and nutates the pelvis anteriorly.
  • the lumbar facet joints should only carry 20% of load
  • she is increasing the load and causing facet imbercation resulting in LBP.

What did we do?

  • taught her about neutral pelvic positioning, creating more ROM in the lumbar spine
  • had her consciously alter her progression angle of her foot on strike, to create more available ROM in internal rotation
  • encouraged her to wear neutral shoes
  • worked on helping her to create more ankle rocker and hip extension with active drills and exercise (ie gait rehabilitation); shuffle walks, Texas walk, toes up walking, etc

why didn’t we put her in an orthotic to externally rotate her lower extremity? Because with internal tibial torsion, this would move her knee outside the saggital plane and create a biomechanical conflict at the knee and possibly compromising her meniscus.

Cool case, eh? We thought so. Keep on learning so your brain keeps expanding. If you are not growing your brain, you are shrinking it!

The Gait Guys

Not quite the QL, but close....

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We all see folks with low back pain and gait abnormalities. It is active during single limb support during stance phase of gait on the contralateral side (along with the external oblique) to elevate the ilium. This is coupled with the ipsilateral anterior fibers of the gluteus medius and minimus pulling the iliac crest toward the stable femur.

We found this FREE FULL TEXT while doing some quadratus lumborum research. It reminds us about things like scleratogenous pain (pain arising from tissues of like embryological origin with a common nerve innervation, like tendon, bone, muscle, etc) and other triggers for low back pain. We have needled this ligament with good result. Remember that this is an individual ligament making up a portion of the middle layer of the thoracolumbar fascia, and is not an aponeurosis of the lumbocostal fibers of the quadratus lumborum.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5226660/

photo from: https://musculoskeletalkey.com/treatment-of-the-patient-with-chronic-pain/

Those Multifidi   The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.    Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.    RESULTS and CONCLUSION: &ldquo;Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.&rdquo;    see also our post  here .    J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print] The immediate effect of dry needling on multifidus muscles&rsquo; function in healthy individuals. Dar G1,2, Hicks GE3.

Those Multifidi

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:
“Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.”

see also our post here.

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print]
The immediate effect of dry needling on multifidus muscles’ function in healthy individuals. Dar G1,2, Hicks GE3.

Low back pain and quadriceps compensation. A study.

“Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.“- Hart et al.

Recently I discussed a paper (link below) about how soleus  motoneuron pool excitability increased following lumbar paraspinal fatigue and how it may indicate a postural response to preserve lower extremity function.
Today I bring you an article of a similar sort.  This paper discusses the plausibility that a relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation and the subsequent changes in hip and knee function when running fatigue ensued. 


"Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.”- Hart et al.

Whether this or any study was perfectly performed or has validity does not matter in my discussion here today. What does matter pertaining to my dialogue here today is understanding and respecting the value of the clinical examination (and not depending on a gait analysis to determine your corrective exercise prescription and treatment). When an area fatigues and cannot stabilize itself adequately, compensation must occur to adapt. Protective postural control strategies must be attempted and deployed to stay safely upright during locomotion. The system must adapt or pain or injury may ensue, sometimes this may take months or years and the cause is not clear until clinical examination is performed. Your exam must include mobility and stability assessments, motor pattern evaluation, and certainly skill, coordination, ENDURANCE and strength assessments if you are to get a clear picture of what is driving your clients compensation and pain. 

So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles and bash them and other similar ones into your brain. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. In today’s discussion, impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) may also be related to low back pain, in this case, paraspinal fatigue.  

Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If only it were as simple as, “you need to work on abdominal breathing”, or “you need to strengthen your core”.  If only it were that simple. 

Dr. Shawn Allen, one of the gait guys


References:
J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.
Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain. Bunn EA1, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

J Electromyogr Kinesiol. 2009 Dec;19(6):e458-64. doi: 10.1016/j.jelekin.2008.09.003. Epub 2008 Dec 16. Jogging gait kinetics following fatiguing lumbar paraspinal exercise.
Hart JM1, Kerrigan DC, Fritz JM, Saliba EN, Gansneder B, Ingersoll CD

Lower limb muscle strategies in low back pain patients.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. It is possible that your client may be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired. This problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges.

So you have sporadic low back pain and knee pain. Could they be linked ?

It has been a long believed rule that it is “all about the core”.  We have learned in recent years that this should be a very loosely accepted rule. 

In an old blog post (link) we stated some deeper truths:

Dr. McGill discusses the basic tenet that the hips and shoulders are used for power production and that the spine and core are used for creating stiffness and stability for the ultimate power transmission through the limb.  He makes it clear that if power is generated from the spine, it will suffer.  As gait experts, you should never forget this principle, if the spine and lumbopelvic interval is not strong/stiff and stable enough, the limbs can over power them and thus your gait, your running, your sport, could be causing you pain as the forces are poorly managed as they attempt to traverse the spine. 

Here we find a study referenced below that suggests that when the lumbopelvic interval is fatigued, that the lower limb muscles may step up activity.  This is a neat concept, not earth shaking by any means, but it nice to have studies that help solidify knowledge of compensation strategies.

“Individuals with low back pain (LBP) have been shown to demonstrate decreased quadriceps activation following lumbar paraspinal fatigue. The response of other lower extremity muscles is unknown. The purpose of this study was to determine changes in motoneuron pool excitability of the vastus medialis, fibularis longus, and soleus following lumbar paraspinal fatigue in individuals with and without a history of LBP.” 

What this study attempted to do was perform a controlled laboratory study designed to compare motoneuron pool excitability before and after a lumbar paraspinal fatiguing exercise. Twenty individuals (10 with history of low back pain) performed isometric lumbar paraspinal exercise until a 25% shift in paraspinal muscle surface electromyography median frequency occurred. 

What they discovered was that the soleus motoneuron pool excitability increased following lumbar paraspinal fatigue independent of group allocation and occurred in the absence of changes in vastus medialis or fibularis longus muscles. 

The authors propose that “increased soleus motoneuron pool excitability may be a postural response to preserve lower extremity function”.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. They very well could be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired.The problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges. 

Dr. Shawn Allen, one of the gait guys.


Reference:

J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain.Bunn EA1, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

http://www.ncbi.nlm.nih.gov/pubmed/21388827

Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe.    What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head.   This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my  oral diarrhea of concerns  started.  So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:   impaired toe off   premature heel rise   watchful eye on achilles issues   impaired hip extension and gluteal function   impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)   impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)   lateral toe off which will promote ankle and foot inversion, which will challenge the peronei   frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function   possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)   possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading   impaired arm swing, more notable contralaterally    There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.  * So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags &hellip; .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).     If you know the complicated things, then the simple things become &hellip; &hellip; . . simple.     Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left.   &hellip; .  sorry for the rant, too much coffee this morning, obviously.  Shawn Allen, one of the gait guys

Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe. 

What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head. 

This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.

So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:

  • impaired toe off
  • premature heel rise
  • watchful eye on achilles issues
  • impaired hip extension and gluteal function
  • impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)
  • impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)
  • lateral toe off which will promote ankle and foot inversion, which will challenge the peronei
  • frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function
  • possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)
  • possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading
  • impaired arm swing, more notable contralaterally

There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.

* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).

If you know the complicated things, then the simple things become … … . . simple.

Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left. 

… .  sorry for the rant, too much coffee this morning, obviously.

Shawn Allen, one of the gait guys

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

Topics: Plus, How foot placement, the glutes and cross over gait all come together and make sense. Plus, discussions on vibration,proprioception, cerebellum and movement.

Show Sponsors:

*newbalancechicago.com

*Rocktape.com

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_99final.mp3

Podcast Direct Download: http://thegaitguys.libsyn.com/podcast-99-how-foot-placement-the-glutes-and-cross-over-gait-all-come-together-and-make-sense

Other Gait Guys stuff

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

Evaluating the Differential Electrophysiological Effects of the Focal Vibrator on the Tendon and Muscle Belly in Healthy People ARTICLE in ANNALS OF REHABILITATION MEDICINE · AUGUST 2014 DOI: 10.5535/arm.2014.38.4.494 · Source: PubMed

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

J Neurophysiol. 2015 Oct;114(4):2220-9. doi: 10.1152/jn.00551.2015. Epub 2015 Aug 19.

Hip proprioceptive feedback influences the control of mediolateral stability during human walking.

Roden-Reynolds DC1, Walker MH1, Wasserman CR1, Dean JC2.

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

Prog Brain Res. 2004;143:353-66. Role of the cerebellum in the control and adaptation of gait in health and disease. Thach WT1, Bastian AJ.

You’d have to be smart to walk this lazy, and people are

Research suggests that humans are wired for laziness

http://www.sciencedaily.com/releases/2015/09/150910131451.htm#.VfWquNKaf3s.facebook

Jessica C. Selinger, Shawn M. O’Connor, Jeremy D. Wong, J. Maxwell Donelan. Humans Can Continuously Optimize Energetic Cost during Walking. Current Biology, 2015; DOI: 10.1016/j.cub.2015.08.016

The gluteus medius and low back pain.

We see this one ALL the time. We are sure you do as well.
“Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP.”
It is often more on the side of pelvic frontal plane drift. The abdominals and spinal stabilizers also often test weak on this same side. We often see compromise of hip rotation stability as well because , since the hip is relatively adducting (because the pelvis is undergoing repeated frontal plane drift, hence no hip abduction) there is often a component of cross over gait phenomenon which can threaten rotation stability of the lower limb (type “cross over gait” into the search box of our tumblr blog for a landslide of work we have written on that phenomenon).

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

http://www.ncbi.nlm.nih.gov/pubmed/26006705