The next time they have gait asymmetry, try changing out the insole...

or putting a textured one in there...or maybe putting a some sand or dirt in their shoe...

image credit: https://torange.biz

image credit: https://torange.biz

Textured insoles change (we like to think for the better) proprioceptive input and can improve balance and gait performance, both statically and dynamically. We have seen this in folks with parkinsons (1) as well as stroke (2), though it can be used in the elderly (3), in diabetes and neuropathy (4), as well as healthy individuals (5,6). Changes from postural stability, to changes in anterior/posterior sway, to medial/lateral sway, to step length and height, the research is there.

These results support the hypothesis that enhanced somatosensory feedback to the sensory system, both through the spinocerebellar and dorsal column pathways, as well as the vestibular system, results in an improved motor output (and most likely coordination) of gait.

  1. Qiu F, Cole MH, Davids KW, et al. Effects of textured insoles on balance in people with Parkinson's disease. PLoS One. 2013;8(12):e83309. Published 2013 Dec 12. doi:10.1371/journal.pone.00833

  2. Ma CC1, Rao N2, Muthukrishnan S3, Aruin AS4. A textured insole improves gait symmetry in individuals with stroke. Disabil Rehabil. 2017 Aug 7:1-5. doi: 10.1080/09638288.2017.1362477. [Epub ahead of print]

  3. Annino G1,2,3, Palazzo F2, Alwardat MS4, Manzi V5, Lebone P2, Tancredi V1,2,3, Sinibaldi Salimei P2,6,7, Caronti A2, Panzarino M2,3, Padua E2,3. Effects of long-term stimulation of textured insoles on postural control in health elderly. J Sports Med Phys Fitness. 2018 Apr;58(4):377-384. doi: 10.23736/S0022-4707.16.06705-0. Epub 2016 Sep 15.

  4. Paton J, Glasser S, Collings R, Marsden J. Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy. J Foot Ankle Res. 2016;9:40. Published 2016 Oct 5. doi:10.1186/s13047-016-0172-3

  5. Steinberg N1, Tirosh O, Adams R, Karin J, Waddington G. Influence of Textured Insoles on Dynamic Postural Balance of Young Dancers. Med Probl Perform Art. 2017 Jun;32(2):63-70. doi: 10.21091/mppa.2017.2012.

  6. Collings R1, Paton J2, Chockalingam N3, Gorst T2, Marsden J2. Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking. Foot (Edinb). 2015 Sep;25(3):159-63. doi: 10.1016/j.foot.2015.05.003. Epub 2015 May 11.

The Knee and Macerating Menisci

Take a good look at the above 2 slides.

Notice that, during pronation, there is a medial rotation of the lower leg and thigh. We remember that, during pronation, the talus plantar flexes, adducts, and everts. This anterior translation and medial rotation of the talus causes the tibia and subsequently the femur to follow. This, if everything is working right, results in medial rotation of the knee.

From the slides, it should also be evident that the medial condyle of the femur and a medial tibial plateau are larger than the lateral. This allows for an increased amount of internal and external rotation of the knee. We remember that the meniscus, like a washer, is between the tibia and femur. We if you think about this kinematically, it would make sense that the tibia, during pronation (which occurs from initial contact to mid stance) would have to rotate faster than the femur otherwise the meniscus would be caught "in between". If there is a mismatch in timing, the meniscus is "caught in the middle", which causes undue stress and can cause fraying, degeneration, etc.

Likewise, during supination (from mid stance to pre swing) the femur must externally rotate faster then the tibia, otherwise we see this same "mismatch". This is a scenario we commonly see in folks who over pronate at the mid foot and remain in pronation for too omg a period of time. 

We think of pronation as being initiated from the movement described above by the talus, and it is attenuated by the popliteus muscle as well as some of the deep flexors of the foot, which fire mostly during stance phase. You will notice that the popliteus  is eccentrically contracting at this point.

Supination, initiated by swing phase of the opposite leg and momentum, is assisted by concentric contraction of the popliteus muscle, internal rotation of the pelvis on the stance phase leg, contraction of the vastus medialis, deep flexors of the foot and peroneii.

Taking moment to "wrap your head around" this concept. Now you can see how complicated it can be when we started to throw in femoral and tibial torsions as well as possibly some orthotic therapy. For example, in an individual with internal tibial torsion, if you do not valgus post the forefoot of the orthotic, the knee is placed at outside the sagittal plane in external rotation further by the orthotic and this thwarts the function of his mechanism, leaving the meniscus holding the bag. 

Know your anatomy and know what is supposed to be firing when, your patients and clients knees depend on it!

 

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Pain on the outside of the leg? Could it be your orthotic? What you wear on your feet amplifies the effect of the orthotic.

This woman presented with right-sided pain on the outside of her leg after hiking approximately an hour. She noticed a prominence of the arch in her right orthotic. She hikes in a rigid Asolo boot ( see below). Remember that footwear amplifies the effect of an orthotic!

In the pictures below you can see the prominent arch. The orthotic has her “over corrected” so that she toes off in varus on that side. The rigid footwear makes the problem worse. The peroneus group is working hard (Especially the peroneus longus)  to try and get the first Ray down to the ground.

The “fix” was to soften the arch of the orthotic and grind some material out. Look at the pictures where the pen is pointing to see how some of the midsole material was taken out. Notice how I ground it somewhat medial to further soften the arch.

She felt better much better after this change and is now a “happy hiker” :-)

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1st met pain in an orthotic?

This patient came in with pain at the base of the first metatarsal that she believed was related to her orthotic. The first picture shows the foots relationship to the orthotic. Notice how the sesamoid bones and distal aspect of the first metatarsal under lap the orthotic shell. In other words, the shell is longer than her foot. When she dorsiflexes her big toe, she’s hitting the distal of the orthotic.

The next view shows the orthotic with a typical first ray cutout. Notice how far forward the shell of the orthotic goes (next picture). I have placed a pen pointing to the area where the orthotic shell is too long.

In addition to reviewing her first ray descending exercises, a simple fix was to grind back the orthotic shell and be careful to bevel the edge so that it was not hitting the sesamoids and it did not impinge upon the descending first ray. I have placed a pen where the cut out now is (pre and post gluing in the pictures). The cork underlying the base of the first ray was also ground away (last picture)

A simple fix for a common problem. Make sure that your orthotic shell lengths fall just short of the 1st ray and not impinge on the sesamoids!

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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.

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.   This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not.  A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.  Hmmm..  We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?  Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB.  Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial. Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.

This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not.  A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.

Hmmm..

We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?

Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB.  Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.

Orthotics and Foot beds, What’s the Difference?  
  
 Welcome to rewind Friday Folks. Here is an oldie but a goodie, with lots of great information. Rememeber; if you use or prescribe orthotics, hopefully you are using exercises as well and hopefully, the prescription is changing over time and you are removing correction from the device! 

 Orthotics and footbeds, they’re the same thing, right? This is a question that is often posed to us.    No, they’re not the same, but oftentimes one or the other can be appropriate. To explain the difference, we need to understand a little bit about foot mechanics. 
 The foot is a biomechanical marvel.    It is composed of 26 bones and 31 articulations or joints.    The bones and joints work together in concert to propel us through the earth’s gravitational field.    It is a dynamic structure that is constantly moving and changing with its environment, whether it is in or out of footwear.    Problems with the bones or joints of the foot, or the forces that pass through them, can interfere with this symbiosis and create problems which we call diagnoses.    They can range from bunions, plantar fasciitis, shin splints, TFL syndrome, abnormal patellar tracking, and lower back pain just to name a few. 
  Before we go any further, we should talk a little bit about gait (ie walking pattern). Normal walking can be divided into 2 phases,  stance and swing .   Stance   is the time that your foot is in contact with the ground. This is when problems usually occur.   Swing   is the time the opposite, non weight bearing foot is in the air.   
     
  The bones of the foot go through a series of movements while we are in stance phase called  pronation and supination .   Pronation   is when your arch collapses slightly, to make your foot more flexible and able to absorb irregularities in the ground; this is supposed to happen right after your heel hits the ground. As your foot pronates, the leg rotates inward, which causes your knee to rotate in, which causes your thigh to rotate in, which causes you spine to flex forward.   Supination   is when your foot reforms the arch and makes your foot a rigid lever, to help you propel yourself; This is supposed to happen when you are pushing off with your toes to move forward. It is at this time that the entire process reverses itself, and your leg, knee, and thigh rotate outward and your spine extends backward. When these movements don’t occur, or more often, occur too much, is when problems arise. This can be due to many reasons, such as lack of movement between your foot bones (subluxation), muscle tightness, injury, inflammation, and so on.   
 Many people over pronate, due to incompetence of the intrinsic musculature of the lower kinetic chain, genetics, environmental factors or injuries. This means that their arch stays collapsed too long while in stance phase, and they remain pronated while trying to push off. As we discussed, during pronation the foot is a poor lever. This means you need to overwork to propel yourself forward. This can create arch pain, inflammation on the bottom of the foot (plantar fascitis), abnormal pressure on your foot bones (metatarsalgia), knee pain, hip pain and back pain. 
 Lets look at skiing. Skiing is a stance phase sport. While skiing, your foot stays relatively immobile in a ski or snowboard boot (i.e. it is not moving through a gait cycle). A footbed is designed to create a level surface for your feet and keep them in a neutral posture. It accomplishes this by “bringing the ground up to your foot.” They are generally custom designed to an individuals foot through many different methods. They work incredibly well (as long as the foot remains in a static posture) and many people extol the benefits and improvements in their respective sports when using these. 
 Orthotics are  alway s custom made devices. They actually improve the mechanics of your foot (or give you mechanics you didn’t have before) and make it function more efficiently by altering the shape and function of the arch as the foot moves through various activities. They act like a footbed but have the added benefit of functioning while dynamic (i.e. moving) as well. This works as well or better than a footbed, and is usable in other sporting activities, such as Nordic skiing, snow shoeing, hiking, running, or biking. Many people use their orthotic in their everyday shoes, to help prevent some of the problems and symptoms they are experiencing. It should be emphasized that an orthotic IS NOT a substitution for competent musculature. We view them as an aid to assist the rehabilitation process; slowly pulling out correction as the biomechanical competence improves.    We like to call this “Orthotic Therapy”. 
  In summary, a footbed supports the foot in a neutral posture. It is great for activities where your foot is static or held in one position. An orthotic supports the foot in a neutral posture and improves the mechanical function of the foot. It can be used in static or dynamic activities. Remember to always consult with a professional who is well versed with the mechanics of the feet, ankles, knees, hips and back, since footbeds and orthotics have a profound effect on all these structures.  
 Orthotics and footbeds; they can be great assistive devices along the road to foot competence. And they can be great doorstops when you are done using them! 
 We are and remain..The Gait Guys.

Orthotics and Foot beds, What’s the Difference?

Welcome to rewind Friday Folks. Here is an oldie but a goodie, with lots of great information. Rememeber; if you use or prescribe orthotics, hopefully you are using exercises as well and hopefully, the prescription is changing over time and you are removing correction from the device!

Orthotics and footbeds, they’re the same thing, right? This is a question that is often posed to us.  No, they’re not the same, but oftentimes one or the other can be appropriate. To explain the difference, we need to understand a little bit about foot mechanics.

The foot is a biomechanical marvel.  It is composed of 26 bones and 31 articulations or joints.  The bones and joints work together in concert to propel us through the earth’s gravitational field.  It is a dynamic structure that is constantly moving and changing with its environment, whether it is in or out of footwear.  Problems with the bones or joints of the foot, or the forces that pass through them, can interfere with this symbiosis and create problems which we call diagnoses.  They can range from bunions, plantar fasciitis, shin splints, TFL syndrome, abnormal patellar tracking, and lower back pain just to name a few.

Before we go any further, we should talk a little bit about gait (ie walking pattern). Normal walking can be divided into 2 phases, stance and swing. Stance is the time that your foot is in contact with the ground. This is when problems usually occur. Swing is the time the opposite, non weight bearing foot is in the air.

 

The bones of the foot go through a series of movements while we are in stance phase called pronation and supination. Pronation is when your arch collapses slightly, to make your foot more flexible and able to absorb irregularities in the ground; this is supposed to happen right after your heel hits the ground. As your foot pronates, the leg rotates inward, which causes your knee to rotate in, which causes your thigh to rotate in, which causes you spine to flex forward. Supination is when your foot reforms the arch and makes your foot a rigid lever, to help you propel yourself; This is supposed to happen when you are pushing off with your toes to move forward. It is at this time that the entire process reverses itself, and your leg, knee, and thigh rotate outward and your spine extends backward. When these movements don’t occur, or more often, occur too much, is when problems arise. This can be due to many reasons, such as lack of movement between your foot bones (subluxation), muscle tightness, injury, inflammation, and so on.

Many people over pronate, due to incompetence of the intrinsic musculature of the lower kinetic chain, genetics, environmental factors or injuries. This means that their arch stays collapsed too long while in stance phase, and they remain pronated while trying to push off. As we discussed, during pronation the foot is a poor lever. This means you need to overwork to propel yourself forward. This can create arch pain, inflammation on the bottom of the foot (plantar fascitis), abnormal pressure on your foot bones (metatarsalgia), knee pain, hip pain and back pain.

Lets look at skiing. Skiing is a stance phase sport. While skiing, your foot stays relatively immobile in a ski or snowboard boot (i.e. it is not moving through a gait cycle). A footbed is designed to create a level surface for your feet and keep them in a neutral posture. It accomplishes this by “bringing the ground up to your foot.” They are generally custom designed to an individuals foot through many different methods. They work incredibly well (as long as the foot remains in a static posture) and many people extol the benefits and improvements in their respective sports when using these.

Orthotics are always custom made devices. They actually improve the mechanics of your foot (or give you mechanics you didn’t have before) and make it function more efficiently by altering the shape and function of the arch as the foot moves through various activities. They act like a footbed but have the added benefit of functioning while dynamic (i.e. moving) as well. This works as well or better than a footbed, and is usable in other sporting activities, such as Nordic skiing, snow shoeing, hiking, running, or biking. Many people use their orthotic in their everyday shoes, to help prevent some of the problems and symptoms they are experiencing. It should be emphasized that an orthotic IS NOT a substitution for competent musculature. We view them as an aid to assist the rehabilitation process; slowly pulling out correction as the biomechanical competence improves.  We like to call this “Orthotic Therapy”.

In summary, a footbed supports the foot in a neutral posture. It is great for activities where your foot is static or held in one position. An orthotic supports the foot in a neutral posture and improves the mechanical function of the foot. It can be used in static or dynamic activities. Remember to always consult with a professional who is well versed with the mechanics of the feet, ankles, knees, hips and back, since footbeds and orthotics have a profound effect on all these structures.

Orthotics and footbeds; they can be great assistive devices along the road to foot competence. And they can be great doorstops when you are done using them!

We are and remain..The Gait Guys.

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Trojan horses for knee menisci.

 Orthotics and internal tibial torsion. Good? Bad? or Ugly? It depends…

Hopefully you remember about torsions, especially internal tibial torsion (see above). Tibial torsions are deviations (in this case, in the transverse plane) of the long axis of the bone. The bone is basically twisted along its long axis, like wringing out a wet towel. They are measured by drawing an imaginary line through the medial and lateral malleoli, as well as through the two halves of the tibial plateau, and measuring the angle between them (see 2nd picture above). For a more complete review of torsions, click here.

 At birth there should be little to no angular difference between the proximal and distal tibia, and this changes to about 19-22 degrees in the adult; the shaft of the tibia rotates outward (externally) with growth resulting in a normal tibial external version (see 3rd picture above).  Sometimes, the angular difference is less than zero at birth and the tibia does not rotate outward (externally) resulting in internal tibial torsion.

Internal tibial torsion usually results in a decreased progression angle (more on those here). This often causes a “toed in gait” and the foot remains in supination for a longer period of time (supination is adduction, inversion and plantar flexion), making the foot a rigid lever. When we examine the person in a standing position with the knees in the coronal plane, the feet point inward. When we move the feet to a more normal posture, the knees rotate outward from the coronal plane.

Folks with internal tibial torsion often have a forefoot varus (the forefoot is inverted with respect to the rear foot) because of the amount of supination they are in, which we talked about in the previous paragraph, (see also here). When folks have a forefoot varus, they have a tendency to pronate more through the forefoot, and when people pronate more other folks like to typically put them in orthotics to “get rid of that pronation”(because we all know that pronation is the scourge of humanity, and if there were less pronation in the world, there would probably be fewer wars, famine and poverty : )

 So what happens to the knee when we place an orthotic in the shoe? Most orthotics are designed to slow pronation of the midfoot, so they basically supinate the foot, causing the talus to dorsiflex, abduct and invert. This rotates the leg (and thus the knee) externally. With internal tibial torsion, often the knee is already externally rotated because your brain will not allow you to progress forward with your toes in too far, you would trip. So, the orthotic rotates the knee out further, bringing it outside the sagittal plane. This does not bode well long term, as it creates a rotational and friction conflict at the knee (remember the knee is basically a hinge between two ball and socket joints). Guess where the conflict manifests itself? At the meniscus. This, over time, is a great way to macerate a meniscus and create a problem.

Does this mean an orthotic is never indicated? No it does not. It means that if you use one, you should probably make sure the part of the orthotic anterior to the styloid of the 5th metatarsal has a valgus post built into it. This valgus moment will help to bring the knee back to the midline during the propulsive phase of gait. See our recent post here about forefoot valgus posting. Do you think this is ever considered in stores when dispensing foot beds for shoes ?  Not all foot beds are evil or a problem mind you, but we have seen some in stores that are real risky business if you ask us.

The bottom line? Know how to use the tools you have available, or someone is going to get hurt. When in doubt, exercise is usually a safer alternative and often has less likelihood of creating a Trojan Horse.  

Want to learn more about these kinds of things, foot beds, foot types etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

The Gait Guys. Raising questions and providing answers and guidance, with each and every post.

 

all material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our wares. 

Orthotics and Footbeds. What's the difference?

Orthotics and footbeds, they’re the same thing, right? This is a question that is posed to us all the time.  No, they’re not the same, but oftentimes one or the other can be appropriate. To explain the difference, we need to understand a little bit about foot mechanics.

The foot is a biomechanical marvel.  It is composed of 26 bones and 31 articulations or joints.  The bones and joints work together in concert to propel us through the earth’s gravitational field.  It is a dynamic structure that is constantly moving and changing with its environment, whether it is in or out of footwear.  Problems with the bones or joints of the foot, or the forces that pass through them, can interfere with this symbiosis and create problems which we call diagnoses.  They can range from bunions, plantar fasciitis, shin splints, TFL syndrome, abnormal patellar tracking, and lower back pain just to name a few.

Before we go any further, we should talk a little bit about gait (ie walking pattern). Normal walking can be divided into 2 phases, stance and swing. Stance is the time that your foot is in contact with the ground. This is when problems usually occur. Swing is the time the opposite, non weight bearing foot is in the air.

 

The bones of the foot go through a series of movements while we are in stance phase called pronation and supination. Pronation is when your arch collapses slightly, to make your foot more flexible and able to absorb irregularities in the ground; this is supposed to happen right after your heel hits the ground. As your foot pronates, the leg rotates inward, which causes your knee to rotate in, which causes your thigh to rotate in, which causes you spine to flex forward. Supination is when your foot reforms the arch and makes your foot a rigid lever, to help you propel yourself; This is supposed to happen when you are pushing off with your toes to move forward. It is at this time that the entire process reverses itself, and your leg, knee, and thigh rotate outward and your spine extends backward. When these movements don’t occur, or more often, occur too much, is when problems arise. This can be due to many reasons, such as lack of movement between your foot bones (subluxation), muscle tightness, injury, inflammation, and so on.

 

Many people overpronate. This means that their arch stays collapsed too long while in stance phase, and they remain pronated while trying to push off. As we discussed, during pronation the foot is a poor lever. This means you need to overwork to propel yourself forward. This can create arch pain, inflammation on the bottom of the foot (plantar fascitis), abnormal pressure on your foot bones (metatarsalgia), knee pain, hip pain and back pain.

 

Skiing is a stance phase sport. While skiing, your foot stays relatively immobile in a ski or snowboard boot (i.e. it is not moving through a gait cycle). A footbed is designed to create a level surface for your feet and keep them in a neutral posture. It accomplishes this by “bringing the ground up to your foot.” They are generally custom designed to an individuals foot through many different methods. They work incredibly well (as long as the foot remains in a static posture) and many people extol the benefits and improvements in their snow sports when using these.

 

Running, hiking and cycling are more dynamic. Sports like these demand a device that changes the biomechanics, so here an orthotic would be most appropriate.

 

Orthotics are always custom made devices. They actually improve the mechanics of your foot and make it function more efficiently by altering the shape and function of the arch as the foot moves through various activities. They act like a footbed but have the added benefit of functioning while dynamic (i.e. moving) as well. This works as well or better than a footbed, and is usable in other sporting activities, such as running, biking, hiking, skiing or snowbaording. Many people use their orthotic in their everyday shoes, to help prevent some of the problems and symptoms they are experiencing.

 

In summary, a footbed supports the foot in a neutral posture. It is great for activities where your foot is static or held in one position. An orthotic supports the foot in a neutral posture and improves the mechanical function of the foot. It can be used in static or dynamic activities. Remember to always consult with a professional who is well versed with the mechanics of the feet, ankles, knees, hips and back, since footbeds and orthotics have a profound effect on all these structures.

The Gait Guys. Bring you info you can use, each and every day.

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.

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OK Folks

Take a look at these pics for a moment, then come back and read.

Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : )  ) They were wondering if the child needed orthotics. What do we see?

top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).

top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).

Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.

Bottom left: I am fully internally rotating the left lower leg. It appears normal  with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.

Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.                               

In summary:

  • External tibial torsion, R > L
  • flattened longitudinal arches
  • Right femoral retrotorsion
  • Left femoral version, NORMAL

Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.                                                                                                           

How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.

The Gait Guys. Twisted in a good way. Versioned but not torsioned.

all material copyright 2013 The Gait Guys/The Homunculus Group. all rights reserved. please don’t use our stuff without asking : )

Running, Einstein, Gravitational Push and Space. What do they have in common ?

WAIT !  Don’t watch the video just yet !  Read this first paragraph first !

Yes, you read it right. Gravitational PUSH.  Did your physics teachers mislead you ?  There is no such thing as Gravitational “Pull”.  Actually it is most accurate to say atmospheric push. Gravity does not pull us to the ground, space (as in the atmosphere) is pushing down on us. Space and time are curved and adjustable, Einstein proved this. You must be saying, “Oh Gait Guys, you are going way too deep now !”.  No, we are not. And you need to know this if you run or walk. It is simple. Your 5th grader will understand this and so should you !   Watch the video for a very nice explanation of what we are going to discuss today, atmospheric PUSH, start at the 3:30 mark for support for our point today.  If you choose not to watch this video today, it is your loss.  You will be depriving yourself of some of the most important information and logic there has ever existed in science. There is a big difference between pull and push.  Ask anyone who has had a car breakdown and had to push it off the road. Ask any weightlifter as well.

What does this have to do with running, walking and gait ?

Well, it is pretty simple.  This is yet another reason why posture is dependent upon the extensors such as the gluteals, the quadriceps, the cervical spine extensors, the thoracolumbar paraspinals, the abdominals etc.  These muscles must be strong enough to resist the push of Space down upon our bodies. Think of it this way, what muscles would have to work harder and be more isometrically and eccentrically strong and endurance trained if you had to carry a 100 pound person on your shoulders all day ?  It is much the same as if you were carrying a bunch of extra winter fat on your body. You will need more of these extensors otherwise you will begin to break down into compensations. 

With the natural motion of pronation during impact loading we need to dampen the internal spin of the hip, femur and tibia to resists the pronatory forces from space pushing down on us. 

So, our neuromuscular system has evolved to resist this push, and that job lies largely with the antigravity extensor muscles, which keep us upright. The elderly eventually begin to lose this battle as they weaken and posturally decompose. These muscles are powered by a special part of our our brain, largely the cerebellum, assisted by the vestibular apparatus (inner ear). Remember that there are 3 systems that keep us upright; vision, the vestibular system and the proprioceptive system. The interplay of these 3 systems is what Newton was trying to figure out and Einstein was eluding to.

This is one of the reasons orthotics (for the long term) often, but not always of course,  do not make sense.  Space pushing down on us and thus space pushing our body mass down onto our tri-arched foot (what we have come to understand as gravitational pull, which is technically misspeaking of the facts) is a large part what creates the pronation; with the musculature of the lower kinetic chain assisting in slowing it.  Slapping an orthotic under the foot to resist this force is not a permanent solution; it is often a temporary fix to a long term problem. This returns us to the hypothesis of today’s post, gravitational pull or Space push. Which is smarter, pushing up against the downward pressure of Space push (orthotic) or finding a better way of using the body’s anatomy to pull up against it ?  Which makes us stronger and a better human and athlete ? Finding better skill, endurance and strength (there it is again, S. E. S.) in the anti-gravitational muscles if you will, such as the toe extensors, tibialis anterior and posterior and foot intrinsics as well as those muscles above that are not dampening internal spin (medial quads, gluteals, lower abdominals)  is the answer if you really want to fix it.  Often times, a stability shoe is much the same as the orthotic; it provides dampening and slows pronation, or “resists” the push of gravity. It can sometimes be helpful in the short term; creating mechanics that you do not have; but is seldom good for the long term (though in some cases they are necessary, we are not negating their occasional beneficial use). We just ask that you, or at least your orthotist,  use your/their brain when making that decision.

As we always say, there are so few people who truly understand the neuro-ortho-biomechanics of the human parts going into the shoe that we get  all caught up in the shoe as the solution.  The solution is S. E. S.  , if you still  have the anatomy to get there.

Shawn and Ivo ………. two Uber geeks today.  They are the kind of guys who keep neurology and physics textbooks beside the toliet rather than Sports Illustrated Swimsuit issues.  Hey, we try to keep it simple. We like to pick the low hanging fruit just like everyone else. But it is the higher hanging fruit that are often the gems.  Sure, space pushing down on us all can make it hard to get up that high to the good stuff…….but it is worth it when you get there.  Thanks for tagging along on this journey. If you are a regular reader,  reconsider your bathroom reading material if you haven’t already !

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How do I know if my orthotic is working?

Foot orthotics are easy, no? You get casted, it gets built, you put it in your shoe and you’re good to go, right? Wrong!

Orthotics or “Orthotic Therapy” as we call it is an ongoing process. If an orthotic is doing it’s job, your foot should change (for the better) and your prescription should become less. and less….Until you no longer need them… At least in an ideal world.

Remember, orthotics are designed to help you adapt to your environment better. Unlike a footbed, they should change the biomechanical function of your foot. A lot should go into getting fit for an orthotic, otherwise they can actually cause some of the problems they are purported to fix!

First of all, there should be a history of you and whatever is going on, with an inventory of all your past injuries. Sometimes there is a pattern that can be recognized and gives your provider clues as to what may be going on with you.

Next you should have a thorough examination of your lower kinetic chain, including the feet, ankles, knees, hips and low back. This should include range of motion, muscle strength, muscle recruitment patterns and joint function, along with reflexes, sensation and balance or proprioception. This gives us a benchmark and defines weaknesses and strengths.

Now there should be an analysis of your gait, preferably with stop motion video which allows us to slow down movements and assess subtle abnormalities that may not be visible during normal speeds of movement. If you are there for cycling orthotics, then a video of your stroke pattern is made. Sometimes, footage of your skiing technique can be helpful as well.

At this point, it should be obvious to both you and your orthotic provider whether or not an orthotic is needed. If so, a non weight bearing cast in terminal stance phase (This is a specific position of your ankle and foot) should be performed. This is usually followed by the prescription of appropriate stretches and exercises, specific to your condition. Shoe recommendations should also be given, since different foot types require different footwear characteristics. This will be good news for the ladies who like many shoes. Most guys just want the pain to stop and won’t care what they look like, as long as they are not pink!

Now you have an idea of what goes into (or should go into) building the perfect orthotic for you. Ask lots of questions of whoever is building them for you and make sure they are answered to your satisfaction. They should be a stepping stone to your recovery and  not a crutch for you to depend on. 

Telling it like it is, we are… The Gait Guys