Ode to the Popliteus

Remember the popliteus? To recap, it contracts at the initial contact phase of the walking gait cycle, to act as an accessory PCL (look HERE

https://www.thegaitguys.com/search?q=popliteus&f_collectionId=57d4982c91b18610c6ee3e0f

to read about that), then contracts eccentrically to slow the rate of internal rotation of the femur on the tibia until midstance, so as not to macerate the meniscus; It then contracts concentrically to accelerate the external rotation of the femur on the tibial plateau so it rotates faster then the tibia, to protect the meniscus as well. So, internal rotation of the femorotibial complex from initial contact to midstance and external rotation of the complex from midstance to preswing. Got it?

Now look at the video of this gal with L sided medial knee pain and past history of a left tibial plateau fracture in her youth. Do you see it? Hmmmm; doesn’t look like internal rotation does it? Don’t see it? Remember that the whole complex SHOULD be internally rotating until the swing phase leg passes the stance pase leg. See it now? Considering that the popliteus tested weak on the clinical exam, does this surprise you?

Agreed that there are many factors initiating internal rotation (and thus pronation) of the stance phase leg from initial contact to midstance, like plantar flexion, adduction and eversion of the talus, contraction of the lower leg anterior compartment muscles, eccentric contraction of the quads and hamstrings, just to name a few, can you see how (a least theoretically) one bad player can ruin the team?

Yes, popliteus rehab, along with abdominal core and foot core endurance exercises are in her future.

Dr Ivo Waerlop, one of The Gait Guys

#popliteus #kneepain #kneeproblem #thegaitguys #gaitanalysis

Tricks of the trade: Backward walking

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

image credit: https://pixabay.com/vectors/slide-sliding-falling-stickman-151861/

A single event can generate asynchronous sensory cues due to variable encoding, transmission, and processing delays. Robert Peterka talks about this, along with posture compensation and system apportionment when it comes to balance and coordination of the visual, vestibular and proprioceptive systems. We have talked about that here on the blog in the past.

We are often looking for ways to “highlight” pathology and make it more visible in the clinical exam. Having your patient/client walk backwards is one of those tools.

Walking and remaining upright in the gravitational plane requires 3 integrated systems to work in concert with one another: the visual, vestibular and proprioceptive systems. Backwards walking requires a more coordinated effort AND IF there is a “hiccup” or extra demand on the system (the proprioceptive in this case), neurological processing can take a little longer, efforts can be delayed and the end result is a greater compensation is needed; this often makes pathology more evident.

Try having your client walk backwards when you are doing your exam and see what we mean. We think you will be surprised with the results : )

Dr Ivo Waerlop, one of The Gait Guys

Peterka RJStatler KDWrisley DMHorak FB. Postural compensation for unilateral vestibular loss. Front Neurol. 2011 Sep 6;2:57. doi: 10.3389/fneur.2011.00057. eCollection 2011.

temporal Shayman CSSeo JHOh YLewis RFPeterka RJHullar TE.Relationship between vestibular sensitivity and multisensory temporal integration. J Neurophysiol. 2018 Oct 1;120(4):1572-1577. doi: 10.1152/jn.00379.2018. Epub 2018 Jul 18.

Hawkins KABalasubramanian CKVistamehr AConroy CRose DKClark DJFox EJ. Assessment of backward walking unmasks mobility impairments in post-stroke community ambulators. Top Stroke Rehabil. 2019 May 12:1-7. doi: 10.1080/10749357.2019.1609182. [Epub ahead of print]

#backwardwalking #clinicalexam #thegaitguys #gaitpathology #clinicaltricksofthetrade

On the subject of manual muscle work…

image credit: https://commons.wikimedia.org/wiki/File:Muscle_spindle_model.jpg

image credit: https://commons.wikimedia.org/wiki/File:Muscle_spindle_model.jpg

Here is an older article that may seem verbose, but has interesting implications for practitioners who do manual muscle work with their clients. We would invite you to work your way through the entire article, a little at a time, to fully grasp it’s implications.

Plowing through the neurophysiology, here is a synopsis for you:

Tactile and muscle afferent (or sensory) information travels into the dorsal (or posterior) part of the spinal cord called the “dorsal horn”. This “dorsal horn” is divided into 4 layers; 2 superficial and 2 deep. The superficial layers get their info from the A delta and C fibers (cold, warm, light touch and pain) and the deeper layers get their info from the A alpha and A beta fibers (ie: joint, skin and muscle mechanoreceptors).

So what you may say

The superficial layers are involved with pain and tissue damage modulation, both at the spinal cord level and from descending inhibition from the brain. The deeper layers are involved with apprising the central nervous system about information relating directly to movement (of the skin, joints and muscles).

Information in this deeper layer is much more specific that that entering the more superficial layers. This happens because of 3 reasons:

  1. there are more one to one connections of neurons (30% as opposed to 10%) with the information distributed to many pathways in the CNS, instead of just a dedicated few in the more superficial layers

  2. the connections in the deeper layers are largely unidirectional and 69% are inhibitory connections (ie they modulate output, rather than input)

  3. the connections in the deeper layers use both GABA and Glycine as neurotransmitters (Glycine is a more specific neurotransmitter).

Ok, this is getting long and complex, tell me something useful...

This supports that much of what we do when we do manual therapy on a patient or client is we stimulate inhibitory neurons or interneurons which can either (directly or indirectly)

  • inhibit a muscle

  • excite a muscle because we inhibited the inhibitory neuron or interneuron acting on it (you see, 2 negatives can be positive)

So, much of what we do is inhibit muscle function, even though the muscle may be testing stronger. Are we inhibiting the antagonist and thus strengthening the agonist? Are we removing the inhibition of the agonist by inhibiting the inhibitory action on it? Whichever it may be, keep in mind we are probably modulating inhibition, rather than creating excitation.


Semantics? Maybe…But we constantly talk about being specific for a fix, not just cover up the compensation. Is it easier to keep filling up the tire (facilitating) or patching the hole (inhibiting). It’s your call


Yan Lu Synaptic Wiring in the Deep Dorsal Horn. Focus on Local Circuit Connections Between Hamster Laminae III and IV Dorsal Horn Neurons J Neurophys Volume 99 Issue 3

March 2008 Pages 1051-1052 link: http://jn.physiology.org/content/99/3/1051

Music to my ears. Movement to my steps...

https://en.wikipedia.org/wiki/Music

https://en.wikipedia.org/wiki/Music

"The applicable contribution of these novel findings is that music tempo could serve as an unprompted means to impact running cadence. As increases in step rate may prove beneficial in the prevention and treatment of common running-related injuries, this finding could be especially relevant for treatment purposes, such as exercise prescription and gait retraining."

Van Dyck E, Moens B, Buhmann J, Demey M, Coorevits E, Dalla Bella S, Leman M. Spontaneous Entrainment of Running Cadence to Music Tempo. Sports Med Open. 2015;1(1):15. Epub 2015 Jul 14.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526248/

image credit: http://pressplay.pbworks.com/w/page/82954552/Loebner%20Keith%20HW%203

Perhaps we need to change how we are are rehabbing X (insert your favorite weight bearing joint)

image credit: https://en.wikipedia.org/wiki/StrongBoard_balance

image credit: https://en.wikipedia.org/wiki/StrongBoard_balance

We have recently run across some research that has changed the way we look at some of the rehab we do, especially proprioceptive rehab. Perhaps it will do the same for you.

Traditionally, we present increasing balance requirements to the weight bearing structure by changing one or more of the three parameters that keep us upright in the gravitational plane: vision, the proprioceptive system (which include the muscles, joints and ligaments) and the vestibular system (the utricle, saccule and semicircular canals). We have discussed them extensively in multiple articles here on the blog. We generally would make the rehab task more difficult by removing a stimulus (closing your eyes, having someone stand on foam) or challenging (standing on one leg, putting someone on a wobble board, BOSU, extending the head, etc) the to make it more durable and "educated". More difficult task + better balance = more stable joint and better outcomes. 

The importaat thing is to think about how much of each system is apportioned; we often (wrongly) assume it is pretty equally divided between the three. It turns out, that it really depends on the surface you are standing on and the circumstances.

On flat planar surfaces, the division of labor looks something like this:

  • proprioceptive system 70%
  • vestibular system 20%
  • visual system 10 %

On uneven or unstable surfaces (like a BOSU, dynadisc, foam, Swiss ball, etc), it looks like this:

  • vestibular system 70%
  • visual system 20%
  • proprioceptive system 10%

So, if we are rehabbing an ankle, it would make the most sense to do most of the rehab (and additional challenges) on a flat planar surface, perhaps incorporating things like forward, backward and side lean, toe and heel work and closed chain strengthening. WE could also close the eyes to make them more dependent on the proprio system, or extend the head 60 degrees to dampen the influence the lateral semicircular canals. We can put them on a BOSU or unstable surface but we need to remember that in that case, we will be rehabbing the vestibular system AND PERHAPS teaching THAT SYSTEM to compensate more, than the "broken" system. Yes, they get better BUT we are not fixing the system that is injured. 

You could make the argument, that your athletes/clients run/walk/exercise on uneven surfaces and use their vestibular system more.Maybe so, but is the actual injury to the vestibular system or to the musculoskeletal one?

Armed with this information, try and think of the system that is compromised and focus your efforts on that system, rather than the other two. Yes, people have vestibular dysfunction and refractive errors and need therapy, exercises and/or corrective lenses, but many of us are not vestibular or opticokinetic therapists (kudos to those of you who are!)

 

 

 

Peterka RJ, Statler KD, Wrisley DM, Horak FB. Postural Compensation for Unilateral Vestibular Loss. Frontiers in Neurology. 2011;2:57. doi:10.3389/fneur.2011.00057.

Horak FB. Postural Compensation for Vestibular Loss. Restorative neurology and neuroscience. 2010;28(1):57-68. doi:10.3233/RNN-2010-0515.

This simple screening test becomes a form of exercise.

Today we look at a simple CNS screen for your “central pattern generators” or “CPG’s”. If you do not pass, then the exercise becomes the rehab exercise. If you (or your client) does not have good coordination between the upper and lower extremity, then they will not be that efficient, physiologically or metabolically. 

The “cross crawl” or “step test” looks at upper and lower extremity coordination, rather than muscular strength. If performed for a few minutes, it becomes a test that can look at endurance as well. 

It is based on the “crossed extensor” response, we looked at last week. That is, when one lower limb flexes, the other extends; the contralateral upper limb also flexes and the ipsilateral upper limb extends. It mimics the way things should move when walking or running. 
 

  • Stand (or have your client stand) in a place where you will not run into anything.
  • Begin marching in place.
  • Observe for a few seconds. When you (or your client) are flexing the right thigh, the left arm should flex as well; then the left thigh and right arm. Are your (their) arms moving? Are they coordinated with the lower extremity?
  • What happens after a few minutes? Is motion good at 1st and then breaks down?
  • Now speed up. What happens? Is the movement smooth and coordinated? Choppy? Discoordinated?
  • now slow back down and try it with your (their) eyes closed


If  movement is smooth and coordinated, you (they) pass

If movement is choppy or discoordinated, there can be many causes, from simple (muscle not firing, injury) to complex (physical or physiological lesion in the CNS).

  • If movement is not smooth and coordinated, try doing the exercise for a few minutes a day. You can even start sitting down, if you (they) cannot perform it standing. If it improves, great; you were able to help “reprogram” the system. If not, then you (they) should seek out a qualified individual for some assistance and to get to the root of the problem.

Arm swing and instability. To train or not to train... Should we do it?

We have long talked about arm swing and whether to change it, encourage it or just observe it. It appears to be an indicator of potential instability as well as a portent for more dire neurological problems (Alzheimers, Parkinson's)

This study looks at altered arm swing in kids with CP; how it is an indicator that there is a problem and how it can profoundly effect their gait and stability. Cerebral palsy may be an extreme case, but how does it differ REALLY (other than severity) from someone who has a mild neurological impairment, such as movement patterning disorders, that we see each and every day in our friends, family, clients and patients? Try and think out of the box and investigate the implications.

"Observational research suggests that in children with cerebral palsy, the altered arm swing is linked to instability during walking. Therefore, the current study investigates whether children with cerebral palsy use their arms more than typically developing children, to enhance gait stability. Evidence also suggests an influence of walking speed on gait stability. Moreover, previous research highlighted a link between walking speed and arm swing. Hence, the experiment aimed to explore differences between typically developing children and children with cerebral palsy taking into account the combined influence of restricting arm swing and increasing walking speed on gait stability. Spatiotemporal gait characteristics, trunk movement parameters and margins of stability were obtained using three dimensional gait analysis to assess gait stability of 26 children with cerebral palsy and 24 typically developing children. Four walking conditions were evaluated: (i) free arm swing and preferred walking speed; (ii) restricted arm swing and preferred walking speed; (iii) free arm swing and high walking speed; and (iv) restricted arm swing and high walking speed. Double support time and trunk acceleration variability increased more when arm swing was restricted in children with bilateral cerebral palsy compared to typically developing children and children with unilateral cerebral palsy. Trunk sway velocity increased more when walking speed was increased in children with unilateral cerebral palsy compared to children with bilateral cerebral palsy and typically developing children and in children with bilateral cerebral palsy compared to typically developing children. Trunk sway velocity increased more when both arm swing was restricted and walking speed was increased in children with bilateral cerebral palsy compared to typically developing children. It is proposed that facilitating arm swing during gait rehabilitation can improve gait stability and decrease trunk movements in children with cerebral palsy. The current results thereby partly support the suggestion that facilitating arm swing in specific situations possibly enhances safety and reduces the risk of falling in children with cerebral palsy."

Front Hum Neurosci. 2016 Jul 15;10:354. doi: 10.3389/fnhum.2016.00354. eCollection 2016.
Restricted Arm Swing Affects Gait Stability and Increased Walking Speed Alters Trunk Movements in Children with Cerebral Palsy.
Delabastita T, Desloovere K, Meyns P.

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4945643/

The Beef on the EDL.....

We have long been promoting appropriate function of the long extensors of the toes  here, in our practices, our lectures, on Youtube, in our book......You get the idea. Lets take a closer look at this often weakened and overlooked muscle.

We remember that the EDL lies mostly in the superior and somewhat lateral part of the anterior compartment of the lower leg, comprising approximately the upper 2/3 from under the lateral tibial plateau and fibula, and from the interosseus membrane. It lies under the tibialis anterior, and the extensor hallucis longus lies below it. Its tendons pass inferiorly and travel under the extensor retinaculum and attaches to the base of the distal phalanges of toes 2-4. These muscles act from initial contact to loading response to help eccentrically lower the foot to the ground and ensure smooth heel rocker and most likely attenuate the speed of initial pronation as the talus glides anteriorly on the calcaneal facets and again from terminal stance through initial swing to provide compression of the metatarsal phalangeal and interphalangeal joints, to offset the long flexors (which are often overactive) and create clearance for the toes during swing.  

jhowardL.gif
jhowardR.gif

What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right (pair J howard r). what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has a forefoot supinatus, or possibly a forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod, possibly insufficient extensor hallucis brevis, peroneus longus, flexor digitorum brevis, or all of the above). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the supinatus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

  • Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises.
  • Make sure the articulations are mobile with joint mobilization, manipulation and massage.
  • How about dry needling and acupuncture to improve function?
  • Make sure the knee and hip are functioning appropriately.
  • Put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe).
  • As a last resort, if they cannot make an adequate tripod because of lack of motivation, anatomical constraints or both, use a foot leveling orthotic.

 

Want to be faster?

superhero.jpg

Take this simple test. 

If you want to be faster, you had better incorporate some proprioceptive training into your plan. It is the 1st part of our mantra: Skill, Endurance, and Strength (in that order). Proprioceptive training appears to be more important that strength or endurance training from an injury rehabilitation perspective injury rehabilitation perspective as well part of an injury prevention program

 What is proprioception? It is body position awareness; ie: knowing what your limbs are doing without having to look at them.

Take this simple test:

  • Stand in a doorway with your shoes off. Keep your arms up at your sides so that you can brace yourself in case you start to fall. Lift your toes slightly so that only your foot tripod remains on the ground (ie the base of the big toe, the base of the little toe and the center of the heel.). Are you able to balance without difficulty? Good, all 3 systems (vision, vestibular and proprioceptive) are go.
  • Now close your eyes, taking away vision from the 3 systems that keep us upright in the gravitational plane. Are you able to balance for 30 seconds? If so, your vestibular and proprioceptive systems are intact.
  • Now open your eyes and look up at the ceiling. Provided you can balance without falling, now close your eyes. Extending your neck 60 degrees just took out the lateral semicircular canals of the vestibular system (see here for more info). Are you still able to balance for 30 seconds? If so, congrats; your proprioceptive system (the receptors in the joints, ligaments and muscles) is working great. If not, looks like you have some work to do. You can begin with exercises we use every day by clicking here.

Proprioception should be the 1st part of any training and/or rehabilitation program. If you don’t have a good framework to hang the rest of your training on, then you are asking for trouble. 

 

 

Timothy E. Hewett, PhD, , Kevin R. Ford, MS, Gregory D. Myer, MS, CSCS Anterior Cruciate Ligament Injuries in Female Athletes: Part 2, A Meta-analysis of Neuromuscular Interventions Aimed at Injury Prevention The American Journal of Sports Medicine Vol 34, Issue 3, pp. 490 - 498   link to free full text: http://journals.sagepub.com/doi/abs/10.1177/0363546505282619

Lephart SM1, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med. 1997 Jan-Feb;25(1):130-7.

 

You can only take so many whacks to the head before it starts to show...

In addition to vision and the vestibular system, proprioceptive information is gathered by primarily 2 sources: The peripheral joint mechanoreceptors left (type 1, type 2, type 3, and type 4 ), as well as the muscle mechanoreceptors: Muscle spindles and golgi tendon organs. This information is transmitted to the cortex via the dorsal column and spinocerebellar pathways. The information is then integrated in the parietal lobe (for information in the dorsal columns) and cerebellum. The information is then relayed to the motor cortex, basal ganglia, and vestibular system. The interplay of these 3 systems, vision, the vestibular system, and the joint/muscle mechanoreceptors is what allows us to keep our bodies up right and functioning in the gravitational field. When integration is compromised, at either a peripheral or cortical level, proprioception suffers.

" Measures of cumulative subconcussive head impacts during a men’s lacrosse season are associated with decreases in balance scores from pre- to postseason, according to findings from Sacred Heart University in Fairfield, CT, that could have implications for lower extremity injury risk. The findings suggest that, even in the absence of a concussion, repetitive subconcussive impacts can negatively affect an athlete’s balance, which in turn can increase the risk of lower extremity injury"

http://lermagazine.com/news/in-the-moment-sports-medicine/subconcussive-subtleties-lacrosse-study-links-balance-impacts

Miyashita TL, Diakogeorgiou E, Marrie K. Correlation of head impacts to change in balance error scoring system scores in Division I Men’s lacrosse players. Sports Health 2017 Jan 1. [Epub ahead of print]

Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther 2006;36(12):911-919.

Where do you do YOUR gait retraining?

It may seem like we are stating the obvious, but visual contrast seems to matter more than visual acuity. When we look at light contrast in lower frequencies (red ranges), we start to see some decomposition of gait with regards to step length, but not necessarily cadence or speed in this study of over 4,000 folks over 50 (hey, that’s us!). What are your patients wearing on their feet? What color is your floor? How about the walls?

Do your gait retraining in a well lit area with lots of contrast between the floor and your patients shoes, as well as the surroundings.

 

Duggan E, Donoghue O, Kenny RA, Cronin H, Loughman J, Finucane C. Time to Refocus Assessment of Vision in Older Adults? Contrast Sensitivity but Not Visual Acuity Is Associated With Gait in Older Adults. J Gerontol A Biol Sci Med Sci. 2017 Feb 28. doi: 10.1093/gerona/glx021. [Epub ahead of print]

 

More on that post operative foot

This is part 2 of a series following a case. If you missed part 1, please go back here and read what we found.

The patient returns 1 week later and reports being approximately 25% improved. She has been performing her "toes up" exercises while walking all the time. She is having some difficulty still with balance. She has been performing her toe waving exercises a few times daily.

X-rays performed 2/17 reveal screw fixation of the navicular. I cannot find evidence of a previous cuboid fracture. The ankle mortise is clear.

She still has 4/5 weakness of the long and short toe extensors; long greater than short. She has tenderness to palpation along the anterior aspect of the deltoid ligament on the left hand side which is made worse with eversion of the ankle. There is a loss of long axis extension at the talocrural and talonavicular articulations. Less tenderness is noted in the inter metatarsal intervals and the interossei musculature.

There is significant improvement over last time. Lack of fixation of the navicular to other articulations will allow us to perform manipulation/mobilization of the foot.

We treated with diagnostic manipulation and mobilization of the foot. I reviewed exercises to date and added the shuffle walk exercise. Since acupunture and needling can influence blodd flow (1-4) We utilized acupuncture points stomach 36, spleen 6, gallbladder 41, liver 3, points in the inter metatarsal intervals, bladder 67 and liver 1.Neelding has been shown to improve muscke activation (4-7) so I did origin/insertion stimulation of the long extensors with 3 sets of 10 repetition cocontraction along with origin/insertion stimulation of the short extensors with 3 sets, 10 repetitions cocontraction was performed. She will follow back in approximately 2 weeks because of travel.

So far, so good. We will keep you posted : )

 

1. Sandberg, M., Larsson, B., Lindberg, L.-G. and Gerdle, B. (2005), Different patterns of blood flow response in the trapezius muscle following needle stimulation (acupuncture) between healthy subjects and patients with fibromyalgia and work-related trapezius myalgia. European Journal of Pain, 9: 497. doi:10.1016/j.ejpain.2004.11.002

2.  Cagnie, Barbara et al. The Influence of Dry Needling of the Trapezius Muscle on Muscle Blood Flow and Oxygenation Journal of Manipulative & Physiological Therapeutics , Volume 35 , Issue 9 , 685 - 691

3. Tsuchiya, Masahiko; Sato, Eisuke F.; Inoue, Masayasu; Asada, Akira† Acupuncture Enhances Generation of Nitric Oxide and Increases Local Circulation  Anesthesia & Analgesia: February 2007 - Volume 104 - Issue 2 - pp 301-307

4. Jan Dommerholt Dry needling — peripheral and central considerations Journal Of Manual & Manipulative Therapy Vol. 19 , Iss. 4,2011

5. Zanin, Marília Silva et al. Electromyographic and Strength Analyses of Activation Patterns of the Wrist Flexor Muscles after Acupuncture Journal of Acupuncture and Meridian Studies , Volume 7 , Issue 5 , 231 - 237

6. https://youtu.be/02-M0i6AKAk

7. Fragoso APS, Ferreira AS. Immediate effects of acupuncture on biceps brachii muscle function in healthy and post-stroke subjects. Chinese Medicine. 2012;7:7. doi:10.1186/1749-8546-7-7.

 

Cerebellar impairment = Gait Changes = Happy Patient

This is a fairly info dense post with many links. please take the time to explore each one to get the most out of it. 

If you have been with us here on TGG long enough, you know the importance of the cerebellum and gait. Mechanoreceptor information travels north to the cortex via the dorsal (and ventral) spinocerebellar pathways to be interpreted (and interpolated, in the case of the ventral pathway), with the information relaying back to the motor cortex and vestibular nucleii and eventually back down to the alpha (and gamma) motor neurons that proved the thing you call movement and thus gait. (Cool video on spinocerebellar pathways here and here).

This FREE FULL TEXT paper has some cool charts, like this one, that show the parameters of gait that change with cerebellar dysfunction (in this case, disease, although idiopathic means they really don't know. Anatomical or physiological lesions will behave the same, no? Doesn't the end result of a functional short leg look the same as an anatomical one?)

Looking tat this chart, what do we really see? People with cerebellar dysfunction:

  • a shorter step length
  • a wider base of gait
  • decreased velocity
  • increased lateral sway
  • slower overall gait cycle

Hmmmm...Beginning to sound like a move toward more primitive gait. Just like we talked about in this post on the 5 factors and proprioception here several years ago. We like to call this decomposition of gait. 

They go on to talk about specific anatomic regions of the cerebellum and potential correlation to specific gait abnormalities, like the intermediate zone and interposed nucleii controlling limb dynamics and rhythmic coordination like hypermetria (overshooting a target), especially when walking in uneven surfaces or when gait is perturbed, like walking into something or changes in surface topography, or the lateral zone of the cerebellum, for voluntary limb control, such as where you place your foot. Definitely gait nerd material.

There aren't any direct tips on rehab, but it would stand to reason that activities that activate the cerebellum and collateral pathways would give you the most clinical gains. Lots of propriosensory exercises like here, here, here and here for a start.

Happy cerebellum = Happy patient

The Gait Guys

 

 

 

 

Winfried Ilg, Heidrun Golla, Peter Thier, Martin A. Giese; Specific influences of cerebellar dysfunctions on gait. Brain 2007; 130 (3): 786-798. doi: 10.1093/brain/awl376  FREE FULL TEXT

One of life's great mysteries....Some folks will do what they want anyway....

The origins of the species, gravity and women...Just a few of life mysteries. Reading this article (1) made us sad in many ways. It's like smoking. You know it's bad for you but you keep doing it. Why? The mystery remains to us.

Vanity seems to often trump biomechanics, as we see in pencil skirts (see our post here), droopy pants (see here)  and high heels (here).

Yet, here is yet another study about women, heels and bunion surgery. 

"Almost two thirds (31) of the 50 patients who said they wanted to go back to wearing heels after surgery did so, and 24 of these women said their postoperative use equaled or exceeded the frequency of their preoperative wear. There were no differences between pre- and postoperative heel heights.

In the study, women older than 65 years were more likely than younger women to report high-heel use prior to hallux valgus surgery.

However, 58.5% of study participants reported difficulty with heel wear, and 13.9% said they had significant restriction, and couldn’t wear anything without pain but custom orthopedic shoes or slippers. Most women (86%) were able to return to comfortable shoes after surgery with minimal or no discomfort; 27.7% said their footwear choice was unrestricted, meaning they could wear both comfortable shoes and heels with minimal discomfort. The 23 women older than 65 years were twice as likely to report significant restriction as those in the younger cohort; compared by operative type, patients who had the most extensive procedures had the highest rates of restriction. The findings were published in June by the World Journal of Methodology. (2)"

Bunions are believed to be caused by an inability to anchor the 1st ray and the untoward action of the adductor hallucis, acting from the transverse and oblique insertions more proximally on the foot, make the hallux head west. This is under the purview of the peroneus longus, extensor hallucis brevis as well as the short flexors of the lesser toes (see here).

The components of supination are plantar flexion, inversion and adduction. Why would you continue to wear a shoe with a narrow toe box that forces the big toe medially and that puts you in plantar flexion? We won't even begin to talk about the loss of ankle rocker.....

We guess folks will continue to do what they will do....

 

1. Robinson C, Bhosale A, Pillai A. Footwear modification following hallux valgus surgery: The all-or-none phenomenon. World J Methodol 2016;6(2):171-180.

2. http://lerfoothealth.com/archives/2016/most-women-who-want-to-wear-heels-after-bunion-surgery-do-so/

Neuro Hack of the week: using TNR's to your advantage

Have you heard of Asymmetrical Tonic Neck Reflexes? 1st described by Magnus and de Kleyn in 1912, when the head is rotated to one side, there is ipsilateral extension of the upper and lower extremity on that side, and flexion of the contralateral (the side AWAY from where you are rotating) upper and lower extremity. Take a few minutes to see the subtleness of the reflex in the picture above. Now think about how this occurs in your clients/patients.  The reflex is everywhere!

This reflex often persists into adulthood and is modulated by both eye movement and muscular activity. When there is neurological compromise, the reflex can be more prevalent, and it appears to arise from the joint mechanoreceptors in the neck and its connection to the reticular formation of the brainstem.

Let’s say you want to improve hip extension on the right:

actively looking with the eyes to the right and rotating the head to the right facilitates the right tricep, quadricep and glute max and facilitates the left bicep, hamstring and iliopsoas
    
We remember while walking, that the left arm is tied to the right lower extremity neurologically. If you were to rotate your head to the right, you will facilitate extension of the right hip, extension of the right upper extremity (and flexion of the left arm/shoulder and left lower extremity). So, simply put, be like Robocop or the Terminator and rotate your head to the right while your right leg is extending.

Note that the upper extremity is opposite of what we would want to get out of the reflex to take full advantage so you can:

  • do nothing, taking advantage of the lower extremity portion of the reflex. This seems to be fairly effective and is certainly the easiest. This is the way we “normally” walk, and from that perspective, is neurologically sound.
  • uncouple the upper and lower extremity and extend the right upper extremity while the right lower extremity is extending. Uncomfortable and awkward, but effective. Give it a try and see what we mean
  • not swing the arms at all; requires a little practice

Why not try all 3 and see what works best for you and your patient/client?

The Gait Guys. Giving you info you can use in a practical manner, each and every post. Be a gait geek. Spread the word.

 http://www.worldneurologyonline.com/article/arthur-simons-tonic-neck-reflexes-hemiplegic-persons/#sthash.6QS3Eat3.dpuf

Bruijn SM1, Massaad F, Maclellan MJ, Van Gestel L, Ivanenko YP, Duysens J. Are effects of the symmetric and asymmetric tonic neck reflexes still visible in healthy adults?Neurosci Lett. 2013 Nov 27;556:89-92. doi: 10.1016/j.neulet.2013.10.028. Epub 2013 Oct

Le Pellec A1, Maton B. Influence of tonic neck reflexes on the upper limb stretch reflex in man. J Electromyogr Kinesiol. 1996 Jun;6(2):73-82.

Michael D. Ellis, Justin Drogos, Carolina Carmona, Thierry Keller, Julius P. A. Dewal Neck rotation modulates flexion synergy torques, indicating an ipsilateral reticulospinal source for impairment in stroke Journal of NeurophysiologyDec 2012,108(11)3096-3104;DOI: 10.1152/jn.01030.2011

 

Achilles Tendinitis

You should read this study if you haven't already

We all treat different forms of achilles tendinitis and tendonosis. This landmark study uses loaded eccentrics and showed better tendon organization and decreased tendon thickness at follow up. 

Tendons do seem to respond better to tension and loaded eccentrics certainly seems to do the job. 

"Conclusions: Ultrasonographic follow up of patients with mid-portion painful chronic Achilles tendinosis treated with eccentric calf muscle training showed a localised decrease in tendon thickness and a normalised tendon structure in most patients. Remaining structural tendon abnormalities seemed to be associated with residual pain in the tendon."

Ohberg L, Lorentzon R, Alfredson H, Maffulli N. Eccentric training in patients with chronic Achilles tendinosis: normalised tendon structure and decreased thickness at follow up. British Journal of Sports Medicine. 2004;38(1):8-11. doi:10.1136/bjsm.2001.000284.

link to abstract: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724744/

Ankle Sprains...A nice review here

A nice FREE FULL TEXT literature review about the biomechanics, diagnosis, grading and treatment (conservative and non conservative) of acute ankle sprains. There is an interesting section at the end for prevention. Consider this a staple for your library to refer to when needed.

 "This paper summarizes the current understanding on acute ankle sprain injury, which is the most common acute sport trauma, accounting for about 14% of all sport-related injuries. Among, 80% are ligamentous sprains caused by explosive inversion or supination. The injury motion often happens at the subtalar joint and tears the anterior talofibular ligament (ATFL) which possesses the lowest ultimate load among the lateral ligaments at the ankle. "

Fong DT, Chan Y-Y, Mok K-M, Yung PS, Chan K-M. Understanding acute ankle ligamentous sprain injury in sports. Sports Medicine, Arthroscopy, Rehabilitation, Therapy, and Technology : SMARTT. 2009;1:14. doi:10.1186/1758-2555-1-14.

link to full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724472/

 

Lets take another look at the tibialis posterior

As cinincians , we often needle and treat the tibialis posterior for posterior tibial tendon dysfunction, platar fasicits, patellofemoral joint pain, and a host of other conditions. Lets take a look at some of the anatomy and see why it is a big player in these conditions. 

The tibialis posterior takes its origin from the proximal posterior tibia, fibula and interosseous membrane. It is deep to the tricep surae and more superior than the flexors hallucis and didgitorum longus. The tendon descends medially, travels around the medial malleolus and divides into 3 portions: plantar, main and recurrent components. It inserts into all the tarsals and metatarsals 2-4.(1) Note that it DOES NOT insert into the 1st metatarsal. There must be a good reason for this, no?

The tibialis posterior acts to plantar flex and invert the foot as well as help eccentrically control eversion of the foot. It fires from initial conact to almost terminal swing. This assists in plantart flexion of the foot from initial contact to loading response, eccentric slowing of the foot during pronation from loading response to misdstance and concentric contraction to assist in and speed up supination from midstance to terminal stance.  When you look at the EMG studies for walking (2,3) , you will see that it starts ramping down activity just after midstance as the peroneus longus starts to ramp up more (firing from just after loading response to pre swing, with a bust of activity from midstance on). 

So, with all this talk, there has to be a reason, right? Think about this. In order to move forward in the gravitational plane and have high gear push off (ie, pushing off the base of the hallux), the 1st ray needs to descend to gain purchase on the ground (2,4, 5) . This is largely through the actions of the peroneus longus, extensor hallucis brevis and flexor digitorum brevis (6,7). The function of the peroneus longus should be obvious with its attachment to the base of the 1st metatarsal. The extensor hallucis brevis moves the axis of the 1st MTP downward when it contracts, as discussed here and here (8, 9). The flexor digitorum brevis moves the axis of metatarsalphalangeal joints 2-5 dorsally and posterior which effectively moves the axis of the head of the 1st metatarsal phalangeal joint ventral and anteriorly. This is requisite for you to have adequate hallux dorsiflexion of about 60 degrees to toe off normally. 

OK, so what about the tibialis posterior? 

Remember that the tib posterior attaches to most of the proximal bottom of the foot with the exception of the 1st metatarsal base? In the area of the 1st ray, the tib posterior attaches to the navicular. When it contracts, it will pull the navicular posterior and inferior, effectively rasing the base of (and lowering the head of) the 1st metatrsal. If it attached to the 1st metatarsal, its base would be pulled posterior and inferior which would raise the head of the 1st ray, exactly what we are trying NOT TO DO

Armed with this clinical tidbit, can you see how posterior tibial tendon dysfunction can be involved with so many foot and therefore lower kinetic chain problems? If you can’t descend the 1st ray, the foot will need to toe off its lateral aspect, with less effectiveness of the calcaneocuboid locking mechanism (more on that here (10) and here (11)), so problems with propulsion off of an “unlocked” foot. Can you see how the forefoot may be somewhat more everted in this situation? Can you see how this would contribute to more calcaneal eversion and sustained midfoot pronation from midstance through the rest of the gait cycle?  What muscle is sitauted to help maintain the arch as well as decelerate pronation? Tibialis posterior. What muscle will be called into play to assist the gastroc/soleus to help propel you forward? Tibialis posterior. You get the picture.

The tibialis posterior. An important player in the gait game. A great muscle to needle thatpays clinical dividends in more ways than you can imagine. 


1. Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior Tibial Tendon Dysfunction: An Overlooked Cause of Foot Deformity. Journal of Family Medicine and Primary Care. 2015;4(1):26-29. doi:10.4103/2249-4863.152245.

 2. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Thomas Michaud Newton, MA 1993

3. ValmasseyR. Clinical Biomechanics of the lower extremities. Mosby, St Louis, Philadelphia. 101-107: 1996

4. Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore, Williams and Wilkins, 1981

5. Scranton PE, et al. Support phase kinematics of the foot.  In Bateman JE, Trott AW (eds). The Foot and Ankle. New York, Thieme-Stratton, 1980

6. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack 1992

7. The Pathokinesiology Service and the Physical Therapy Department. Observational Gait Analysis. Rancho Los Amigos National Rehabilitation Center Downey, CA 2001

8. https://tmblr.co/ZrRYjxFOn2hk

9. https://tmblr.co/ZrRYjxFSJ4Yz

10. https://tmblr.co/ZrRYjx1MjeIVN

11. https://tmblr.co/ZrRYjxToM8SI

3 points to use with ankle instability

In this study they stimulated 3 points: ST41, BL60 and GB40. Take a look at their locations (above). ST41 is at the base of the long extensor tendons; gee, we never emphasize long extensor function, do we? GB 40 is at the lateral malleolus between the peroneus longus/brevis and peroneus tertius; how important are these for coronal plane stability, not to mention the ability to descend the 1st ray. BL60 is just anterior to the lateral malleolus, right by the peroneus longus and brevis (again). Could they have included K6, under the medial malleolus and near the long flexors? Sure. How about SP4 or 4, in the substance of the flexor hallucis brevis and anterior to the extensor hallucis longus. Of course. You can probably think of other points to include as well.

Do you think it was by accident that their muscle selection included dorsiflexors (excepting the peroneus longus) and everters? How about a muscle that would help descend the 1st ray and complete the medial tripod? Hmmm... There is always a reason and a rationale....

 

"CONCLUSION: Electroacupuncture can effectively improve the proprioception of athletes with FAI and achieves a superior efficacy as compared with the conventional physiotherapy."...or in this case, low level e stim to the medial and lateral malleolus.

How about adding these points, no matter how you would like to stimulate them, to your CAI toolkit?

 

Zhu Y, Qiu ML, Ding Y, Qiang Y, Qin BY. [Effects of electroacupuncture on the proprioception of athletes with functional ankle instability]. Zhongguo Zhen Jiu. 2012 Jun;32(6):503-6.

 

 

Music to my ears....and steps to my cadence

image credit: http://www.holabirdsports.com/blog/which-type-of-music-is-best-for-running/

image credit: http://www.holabirdsports.com/blog/which-type-of-music-is-best-for-running/

This piece is a little different. More of an essay or narrative. We hope you enjoy it...

It was 12° when I woke up. It was mid October and fall is in full swing with the leaves still turning and left on many trees. I looked at the thermometer and it read 12°. When I looked outside I could see that 2 to 3 inches of fresh snow had fallen. Electing not to ride my bike because of the slipperiness of the snow on the roads, I donned my Altra’s and headed out for a run. I grabbed my iPod on my way out the door and queued up Nickelback's "All the Right Reasons".

It's amazing how much music can influence your work out. "Follow You Home" came on came on just as I approached the first hill. The song has a relatively strong beat which made me work harder to get up. This made me think of how much cadence can be influenced by music (1-3) and a few pieces we wrote on music therapy. 

Faster cadences have been associated with shorter step length and decreased vertical impact loading rates, in other words less force and theoretically at least, less injuries (4,5) . 

The snow was soft and forgiving beneath my feet and despite wearing tights and two layers on top, I was quite comfortable. “ Fight for All the right reasons" came on as I started my first set of lunges. I could feel my pace again matching the music.

I was making "first tracks of the season" in the snow. That brought a smile to my face. It was quiet and peaceful (except for my music through the headphones of course) and it was feeling like the beginning of a great run. I begin my ascent of the second large hail and “Photograph” came on which made me think about all things high school and brought a smile to my face. I wondered about some of the people I dated as well as a few that I probably should have dated and those that I definitely should not have dated :-)

My run continued, quite well I might add, with some quick intervals of lunges and squats throughout. “Next Contestant” finished up by brief workout as I came down the home stretch. Another smile came to my face as I know what my next blog piece would be about : )

If you just want the bullet, then here it is: “The applicable contribution of these novel findings is that music tempo could serve as an unprompted means to impact running cadence. As increases in step rate may prove beneficial in the prevention and treatment of common running-related injuries, this finding could be especially relevant for treatment purposes, such as exercise prescription and gait retraining.

  • Music tempo can spontaneously impact running cadence.
  • A basin for unsolicited entrainment of running cadence to music tempo was discovered.
  • The effect of music tempo on running cadence proves to be stronger for women than for men.”

 

 

1. Van Dyck E, Moens B, Buhmann J, et al. Spontaneous Entrainment of Running Cadence to Music Tempo. Sports Medicine - Open. 2015;1:15. doi:10.1186/s40798-015-0025-9. link to full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4526248/

2. Lima-Silva AE, Silva-Cavalcante MD, Pires FO, Bertuzzi R, Oliveira RS, Bishop D.  Listening to music in the first, but not the last, 1.5 km of a 5-km running trial alters pacing strategy and improves performance. Int J Sports Med. 2012 Oct;33(10):813-8. Epub 2012 May 16.

3. Bacon CJ, Myers TR, Karageorghis CI. Effect of music-movement synchrony on exercise oxygen consumption. J Sports Med Phys Fitness. 2012 Aug;52(4):359-65.

4. Baggaley M, Willy RW, Meardon S. Primary and secondary effects of real-time feedback to reduce vertical loading rate during running Scand J Med Sci Sports. 2016 Mar 19. doi: 10.1111/sms.12670. [Epub ahead of print].

5. Lyght M, Nockerts M, Kernozek TW, Ragan R. Effects of Foot Strike and Step Frequency on Achilles Tendon Stress During Running. J Appl Biomech. 2016 Aug;32(4):365-72. doi: 10.1123/jab.2015-0183. Epub 2016 Mar 8.