Have you seen this?

Patterns. That’s what it’s about a lot of times. Dr Allen and I are always looking for patterns or combinations of muscles which work together and seem to cause what appear to be predictable patterns; like a weak anterior compartment and a weak gluteus maximus, or a weak gluteus medius and contralateral quadratus lumborum.

Here is an interesting story and a new combination that at least I have never seen before

I had a 11-year-old right footed soccer player from my son’s soccer team coming to see me with bilateral posterior knee pain which began during a soccer game while he was “playing up” on his older brothers team. He did need to do a lot of jumping as well as cutting. He is generally a midfielder/Forward. Well experienced player and “soccer is his life“.

My initial thoughts were something like a gastroc dysfunction or a Baker’s cyst. On examination, no masses or definitive swelling noted behind either knee. He did have tenderness to moderate degree over the right plantaris and tenderness as well as 4/5 weakness of the left popliteus. There was a loss of long axis extension of the talo crural articulations bilaterally with the loss of lateral bending to the right and left at L2-L3.

If you think about the mechanics of the right footed kicker (and try this while kicking a soccer ball yourself) it would be approximately as follows: left foot would be planted near the ball and the tibia/femur complex would be internally rotating well the foot is pronating and the popliteus would be eccentrically contracting to slow the rotation of the femur and the tibia. The right foot will be coming through and plantarflexion after a push off from the ball of the foot firing the triceps surae and plantaris complexes. He would be “launching“ off of the right foot and landing on his left just prior to the kick, causing a sudden demand on the plantar flexors; with the plantaris being the weak link. As the kicking leg follows through, the femur of the stance phase leg needs to externally rotate (along with the tibia) at a faster rate than the tibia (otherwise you could injure the meniscus) the popliteus would be contracting concentrically. A cleat, because it increases the coefficient of friction with the ground would keep the foot on the ground solidly planted and The burden of stress would go to the muscles which would be extremely routine leg and close chain which would include the semimembranosus/tendinosis  complex as well as the vastus medialis and possibly gracilis and short adductor, along with the popliteus.

I have to say and all of my years of practice I’ve never seen this combination type of injury before involving these two muscles specifically and am wondering if anyone else has seen this?

Dr Ivo Waerlop, one of The Gait Guys

#footproblem #gait #thegaitguys #soccerinjury #bilateralkneepain #popliteus #plantaris

image credit: https://commons.wikimedia.org/wiki/File:Slide2ACCA.JPG

image credit: https://commons.wikimedia.org/wiki/File:Slide2ACCA.JPG

Barefoot vs Shoes...It's about the strike pattern


Footnotes 7 - Black and Red.jpg

“The influence of strike patterns on running is more significant than shoe conditions, which was observed in plantar pressure characteristics. Heel-toe running caused a significant impact force on the heel, but cushioned shoes significantly reduced the maximum loading rate. Meanwhile, although forefoot running can prevent impact, peak plantar pressure was centered at the forefoot for a long period, inducing a potential risk of injury in the metatarsus/phalanx. Plantar pressure on the forefoot with RFS was lesser and push-off force was greater when cushioned shoes were used than when running barefoot.”


takeaways from the study?

  • forefoot strike reduces heel impact

  • rear foot strike reduces forefoot impact

  • forefoot strike increases and prolongs pressures (in shoes) on the forefoot which could potentially cause forefoot problems

  • cushioned shoes do not really change impact force but change (reduce) the rate of loading

  • in a forefoot strike, pressures are shifted more to the mid foot

want to know more? Join us this Wednesday, December 19th on online.com: Biomechanics 303







Sun XYang YWang LZhang XFu W. Do Strike Patterns or Shoe Conditions have a Predominant Influence on Foot Loading? J Hum Kinet. 2018 Oct 15;64:13-23. doi: 10.1515/hukin-2017-0205. eCollection 2018 Sep.

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6231350/





People who are injured move differently

Like we have said before, often times when folks are injured they often lose cortical function (afferent input) from a particular area, and their gait becomes more primitive, often taking a broader base, slower movement, increased amplitude of movement and sometimes requiring assistance or something to help them balance, like our post here

"Findings suggest that movement variability in those with a musculo-skeletal injury differs from uninjured individuals. Interestingly, there was an overall trend toward greater movement variability being associated with the injured groups, although it should be noted that this trend was not consistent across all subcategories (eg, injury type). "

Baida SR, Gore SJ, Franklyn-Miller AD, Moran KA. Does the amount of lower extremity movement variability differ between injured and uninjured populations? A systematic review. Scand J Med Sci Sports. 2018 Apr;28(4):1320-1338. doi: 10.1111/sms.13036. Epub 2018 Feb 14. (

What specific movement pattern(s) does a person with chronic ankle instability have?

image source: https://en.wikipedia.org/wiki/Ligament

image source: https://en.wikipedia.org/wiki/Ligament

...it is unique and depends on their compensation

 

"The researchers concluded that multiple distinct movement patterns were found in a high percentage of CAI subjects and each person likely incorporates unique positions and loads that contribute to the chronic nature of instability. Additionally, the data revealed distal joint stiffness was lower in those with CAI than controls generally, while proximal joint stiffness was greater than controls. These data support the theory that the hop plays a vital role in controlling lower extremity movement in CAI subjects."

 

Hopkins JT, Son SJ, Kim J, et al. Joint Stiffness Alterations, Grouped by Movement Strategy, in Chronic Ankle Instability.

http://lermagazine.com/special-section/conference-coverage/identifying-cai-through-specific-movement-patterns

 

Lessons in Gait from Autistic Kids

“Additionally, there is the potential for the cerebellum, which receives sensory information and regulates movements, to have a level of dysfunction as well. Viewed collectively, the potential key contributors for gait asymmetry originate in the brain and specifically, the motor-controlling functions of the brain.” 

“While there is still little known regarding gait impairments in children with ASD, our findings illustrate that gait descriptors may provide insight into furthering working knowledge of ASD and may even enable gait-related symptoms to be treatable through therapies and interventions” 

“Alternative hypotheses suggest that children with ASD exhibit dysfunctional segregation of the motor cortex, which may be the key to uncoordinated movements” 

We often say that "gait is a fingerprint". Gait symmetry is often considered a window to neurologic function. We like to think "normal" gait has minimal asymmetries, while pathological gait does not. 

These are two landmark studies of gait in children with autism spectrum disorder. There were significant kinetic and kinematic differences in gait patterns in the 3 cardinal planes (saggital, coronal and transverse)  in ankle, knee and hip mechanics: The "pattern" is that there is no pattern, only changes. If you have a little time, check out this free, full text article here.

What this article says to us is that

  • We should be looking more carefully at gait asymmetries realizing that
    • These asymmetries are most likely cortical/cerebellar phenomena implying
  • Gait dysfunction equals cortical/cerebellar dysfunction

As clinician's, we should be thinking of altered gait as a window to what is going on north of the feet, knees, hip and pelvis. We remember that the joint and muscle mechanoreceptors feedback to the cerebellum and cortex via the spinocerebellar and dorsal column pathways which feed forward to the lower extremities via the anterior spinous cerebellar pathway as well as cortical spinal, rubrospinal had vestibula spinal pathways. The cortex, particularly the motor portion, has the capacity to alter gait just as abnormal mechanoreception has the capacity to alter cortical and cerebellar function. The two are interrelated and inseparable. Changes over time will altered pathways due to neural plasticity and adaptations will occur.

We need to be prudent and examined people fully and be very careful as to the modalities and exercises that we utilize and prescribed as ultimately they will shape that patients neural architecture.

 

 

Eggleston JD, Harry JR, Hickman R, Dufek JS. Analysis of gait symmetry during overground walking in children with autism spectrum disorder. Gait Posture 2017;55:162-166. 

Dufek JS, Eggleston JD, Harry JR, Hickman R. A comparative evaluation of gait between children with autism and typically developing matched controls. Med Sci 2017;5:1.  link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5635776/

 

So, what DOES cause a change in strike pattern with barefoot running?

We kinda thought so...

"CONCLUSION: Superficial cutaneous sensory receptors are not primarily responsible for the gait changes associated with barefoot running."

So what is? Most likely they play a part, but the joint and muscle mechanoreceptors that we had been talking about here on The Gait Guys for the last several years most likely play a larger role. The cutaneous receptors appear to play a role in general sensation, balance and coordination as well as coordination of upper extremity movements.

Thompson MA, Hoffman KM.Superficial plantar cutaneous sensation does not trigger barefoot running adaptations.Gait Posture. 2017 Jun 27;57:305-309. doi: 10.1016/j.gaitpost.2017.06.269. [Epub ahead of print]

https://www.ncbi.nlm.nih.gov/pubmed/28728130

Dry Needling and Muscle Activation Patterns

A nice study looking at how sequential muscle activation patterns can change with dry needling. Think about the applications for gait?

"Removing LTrPs changes the order of muscle recruitment to a more sequential, stable pattern that is not significantly different to that displayed by the control group prior to fatiguing exercise. This suggests that removing LTrPs may allow subjects to better cope with the effects of fatigue, as evidenced by the reduced variability in activation times and the reduced co-activation of the muscles investigated. "

FREE FULL TEXT here: https://isbweb.org/images/conf/2003/longAbstracts/LUCAS_198-208_SB_LONGE.pdf

Dry Needling and Myofascial Pain

Regardless of the mechanism, dry needling and ischemic compression both seem to reduce myofascial pain. How about some more studies looking at muscle function and activation patterns?

"This study compared these treatment techniques to one another using the Neck Disability Index (NDI), a numeric rating scale (NRS), pressure pain threshold and muscle characteristics. 42 female patients with myofascial neck pain were randomly assigned to a treatment group and the 4 most painful MTrPs were treated using DN or MPT. No difference was found between the two techniques on the short and long term. Both techniques showed an improvement in NDI on the short and long term. "

Dry needling or manual pressure in myofascial pain? - Anatomy & Physiotherapy

The aim of this study was to compare dry needling to manual pressure in patients with myofascial pain.

ANATOMY-PHYSIOTHERAPY.COM|BY <A HREF="/AUTHORLIST/3:JOANNA1988" TITLE="VIEW ALL ARTICLES FROM JOANNA TUYNMAN">JOANNA TUYNMAN</A>

 

The debate continues. More support for mid and forefoot strikers. &hellip; 
  &ldquo;Forefoot and midfoot strikers had significantly shorter ground contact times than heel strikers. Forefoot and midfoot strikers had significantly faster average race speed than heel strikers.&rdquo;  
 We are not saying &ldquo;better&rdquo;, but according to this study &ldquo;faster&rdquo;! 
 What is the ideal?  We wish we knew&hellip;Biomechanics seem to point to less impact is better, but what is actually best for the individual is probably due to genetics, training, practice, running surface and  t hat individuals neuromuscular competence and ability to compensate. 
  The Gait Guys. bringing you the facts, even if you or we don&rsquo;t like them&hellip;  
                                                                                                                                           
  J Sports Sci.  2012;30(12):1275-83. doi: 10.1080/02640414.2012.707326. Epub 2012 Aug 2. 
 Foot strike patterns and ground contact times during high-calibre middle-distance races. 
  Hayes P ,  Caplan N . 
 
 Source 
 Department of Sport and Exercise Sciences, School of Life Sciences, Northumbria University, Newcastle-upon-Tyne NE1 8ST, UK. phil.hayes@northumbria.ac.uk 
 
 
 Abstract 
 The aims of this study were to examine ground contact characteristics, their relationship with race performance, and the time course of any changes in ground contact time during competitive 800 m and 1500 m races. Twenty-two seeded, single-sex middle-distance races totaling 181 runners were filmed at a competitive athletics meeting. Races were filmed at 100 Hz. Ground contact time was recorded one step for each athlete, on each lap of their race. Forefoot and midfoot strikers had significantly shorter ground contact times than heel strikers. Forefoot and midfoot strikers had significantly faster average race speed than heel strikers. There were strong large correlations between ground contact time and average race speed for the women&rsquo;s events and men&rsquo;s 1500 m (r = -0.521 to -0.623; P &lt; 0.05), whereas the men&rsquo;s 800 m displayed only a moderate relationship (r = -0.361; P = 0.002). For each event, ground contact time for the first lap was significantly shorter than for the last lap, which might reflect runners becoming fatigued. 
 
 PMID:22857152[PubMed - indexed for MEDLINE] 
  http://www.ncbi.nlm.nih.gov/pubmed/22857152

The debate continues. More support for mid and forefoot strikers.

“Forefoot and midfoot strikers had significantly shorter ground contact times than heel strikers. Forefoot and midfoot strikers had significantly faster average race speed than heel strikers.”

We are not saying “better”, but according to this study “faster”!

What is the ideal?  We wish we knew…Biomechanics seem to point to less impact is better, but what is actually best for the individual is probably due to genetics, training, practice, running surface and that individuals neuromuscular competence and ability to compensate.

The Gait Guys. bringing you the facts, even if you or we don’t like them…

                                                                                                                                     

J Sports Sci. 2012;30(12):1275-83. doi: 10.1080/02640414.2012.707326. Epub 2012 Aug 2.

Foot strike patterns and ground contact times during high-calibre middle-distance races.

Source

Department of Sport and Exercise Sciences, School of Life Sciences, Northumbria University, Newcastle-upon-Tyne NE1 8ST, UK. phil.hayes@northumbria.ac.uk

Abstract

The aims of this study were to examine ground contact characteristics, their relationship with race performance, and the time course of any changes in ground contact time during competitive 800 m and 1500 m races. Twenty-two seeded, single-sex middle-distance races totaling 181 runners were filmed at a competitive athletics meeting. Races were filmed at 100 Hz. Ground contact time was recorded one step for each athlete, on each lap of their race. Forefoot and midfoot strikers had significantly shorter ground contact times than heel strikers. Forefoot and midfoot strikers had significantly faster average race speed than heel strikers. There were strong large correlations between ground contact time and average race speed for the women’s events and men’s 1500 m (r = -0.521 to -0.623; P < 0.05), whereas the men’s 800 m displayed only a moderate relationship (r = -0.361; P = 0.002). For each event, ground contact time for the first lap was significantly shorter than for the last lap, which might reflect runners becoming fatigued.

PMID:22857152[PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/22857152

What is driving our patterned movements such as gait and running ?

ScienceDaily (June 3, 2012) — A new finding that motor cortex is a dynamic pattern generator upends existing theory with broad implications for neuroscience.

Maybe it is actually easier to understand than we thought. A new paper presents some compelling evidence that the motor cortex, rather than being command central, is more like a part of the machine, sending rhythmic signals down the spinal cord to orchestrate movement. 

“The electrical signal that drives a given movement is therefore an amalgam – a summation – of the rhythms of all the motor neurons firing at a given moment.”


This is of course monitored (and modified) by one of our best friends, the cerebellum.

Check it out here: http://www.sciencedaily.com/releases/2012/06/120603191720.htm#.T8yrhOzhvGk.facebook

Ivo and Shawn…Geeky….Cool….Hey, geeky is the new cool. Don’t laugh, you a re a geek as well if you are reading this post : )