What ischial-femoral impingement might look like as aberrant shoe wear.

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Can a cross over occur on one side of the body ? Sure, this case is a perfect example. The heavy lateral shoe wear on the left is a huge clue. But remember, what you see is not the problem, it is the result of their problem(s).

. . . a talented marathoner came into our office complaining of a long standing deep posterior right hip pain and an equally longstanding left chronic lateral ankle and foot pain. The ankle had been treated regularly for chronic peroneal tendonitis with various manual therapy modalities and yet the right hip seemed to be left out of the equation in terms of treatment.

After taking a detailed history this runner unknowingly pretty much told us they had all the qualifications of ischial-femoral impingement (IFI). What they did not realize was that they had a cross over gait style that was a significant contributor to the clinical problem.

Here is a nice rewind case for your Friday read.

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link:  https://thegaitguys.tumblr.com/post/116468620969/what-ischial-femoral-impingement-might-look-like

What ischial-femoral impingement might look like as aberrant shoe wear.

A few weeks ago we wrote an article on ischial-femoral impingement. For you to best understand today’s blog post you really should go back and review this interesting clinical phenomenon, here is the link to that piece.

Three weeks ago a talented marathoner came into our office complaining of a long standing deep posterior right hip pain and an equally longstanding left chronic lateral ankle and foot pain.  The ankle had been treated regularly for chronic peroneal tendonitis with various manual therapy modalities and yet the right hip seems to be left out of the equation in terms of treatment.

After taking a detailed history this runner unknowingly pretty much told us they had all the qualifications of ischial-femoral impingement (IFI).  What they did not realize was that they had a cross over gait style that was a significant contributor to the clinical problem.  

Lets now have a look at the shoe wear patterns above. On the left shoe, (a shoe we love, New Balance Fresh Foam (find your next pair at NewBalance Chicago)) we see that the entry zone or crash zone of rear foot impact is heavily worn, especially laterally. Heavy entry zone wear can be from several things, but one thing we always check for and assume until proven otherwise is a cross over gait. It can also just be from excessive rearfoot inversion at foot strike but when excessive there is usually a reason for it, especially when unilaterally as seen here. This foot is not stacking under the knee and hip, it is striking more midline to a plumb line dropped from the hip joint. This creates a steep medial angle of attack. The question is why ? Well, in the history the right hip pain began first and then the left ankle pain, so one should at least consider a compensatory timeline, that being the foot is a compensation in the gait cycle from the painful hip.

This client on examination tested pretty obviously for a right frontal plane drift, meaning when the right foot impacts there is not enough lateral line support to hold the hip/pelvis over the foot and so the pelvis drifts laterally to the right in this case. This can be fought by inverting the foot. This is a strategy to try and stop the lateral drift.  In this case, excessive wear is seen on the entire lateral side of the right shoe to represent this compensation. Changing this clients foot wear, shoe, orthotic is not fixing the problem, in fact it is impairing their ability to compensate and could create more problems, and even another deeper layer of compensation. Again, the inverted/supinated right foot moves the weightbearing line laterally, by moving the foot’s center of pressure from within the confines of the foot tripod towards the lateral border of the foot tripod, in attempt to restack the loading over the laterally drifted hip (hence the right lateral shoe wear pattern). Unfortunately this does not solve the reason for the lateral drifted pelvis. That solution has to come from improved stablization of the hip, pelvis and core and since they tested weak on the right side abdominals, gluteus medius, gluteus max and other  accessory lateral stabilizers,  work must be done there. Interestingly, this runner is stuck into a vicious cycle. The lateral drift to the right is allowing the left hemi-pelvis to dip and this is challenging rotational control of the stance limb and it is causing ischial-femoral impingement (suspecting of the quadratus femoris).  It was clear on examination that there was impairment of the quadratus femoris and obturator externus upon detailed testing and deep palpation was pin point tender over these structures.  Resistance to rotational challenges to the limb, especially iso and eccentric internal rotational challenges, were very poor when it came to coordination, endurance and certainly strength.

Remember, when you are spending time going sideways (right frontal plane drift), you are not spending time moving forwards. This could cause an early right departure and force and early left stance engagement.  But it goes deeper than that in this case.  Here, the right frontally drifting pelvis will pull the left swing leg across the midline with it, creating a left cross over gait.  This will make more sense if you watch our popular video here. Link

So, when this left swing leg is forced into the cross over gait variant, it will force a strong lateral heel strike, as evidenced on the left shoe wear. This is a compensation to what is going on in the right side body mechanics.

Can a cross over occur on one side of the body ? Sure, this case is a perfect example.

Can a cross over gait on the left in this case, cause a vicious cycle and in itself create an environment whereby a right ischio-femoral impingment occurs ?  Sure, neuronal plasticity can be a bitch, it can work in your favor, and against you.

This is not a tough case, if you have seen the beast before and you recognize all of its parameters. If you have not seen the beast before, this case is a nightmare with all these pieces (deep buttock pain, impingement, frontal drift, cross over, strange shoe wear pattern, opposite ankle peroneal pain etc).  Do you have to get this right every time with a bulls eye diagnosis and remedy? Heck no, we flounder every day with new things and variants of old. Sometimes the layers of compensations are so deep that it takes weeks before a recognizable layer presents itself. Patience on both the client and the doctor are necessary.  

So what we have here is a fairly classic shoe wear pattern of a right laterally drifting pelvis and a cross over left leg. In this case it was from a weak right core and pelvis drift creating an environment for the generation of a right ischial-femoral impingement syndrome, driving a left peroneal tendonopathy scenario from the ensuing left cross over gait.  

Remember, don’t fix your clients shoe wear pattern and certainly do not make shoe recommendations from what you see in their shoe wear pattern. Recommending a different shoe to fix this clients problem is a mistake. As is prescribing an orthotic, different foot bed, adding wedges and postings to the shoe or foot bed can also be  mistake. Define the source of the problem, before you go start tinkering around with the bottom of the kinetic chain. Want more ? Try taking our National Shoe fit program to get deeper into this kind of stuff.

We were lucky enough to get this runner’s problem spot on. After many failed attempts by others, this case was 50-75% resolved in one session with the right homework and a great understanding by the runner of their problem. They fully engaged themselves in the understanding of the problem and what they needed to be aware of in their walking and running gait. They were diligent with their homework and understood how it would help the presentation. They presented again to the clinic this week for a focused session to drive the problem further out of town and they are now on their way to the Boston Marathon with a smile and tools to fix the problem. There is a little more fine tuning to do here, but we can wait until they return from Boston.

Good luck in Boston everyone !

We hope this case helps you help someone else, that is the point after all.

Shawn and Ivo, the gait guys

 

Can you spot the problem?

Take a look at the pictures before proceeding, knowing that this gal presented with L sided outside knee pain and see if you can tell what may be wrong. She does wear orthotics. 

Take a good look at the lateral flare on each of these shoes. Yes, it is a Brooks Pure series with a 4mm drop. Yes the shoe has a medial (sl larger) and lateral flare, posteriorly and anteriorly.

Do you see the discoloration and increased wear on the lateral heel counter on the left compared to the left? There is also increased wear of the lugs on the outside of this left shoe. The forefoot is also worn into slight varus, but this difficult to see. The shoe, especially in combination with her orthotic, is keeping her in varus (ie inverted) for too long, taking her knee outside the saggital plane and contributing to her knee pain. 

ROTATE YOUR SHOES!

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“Too much tripping, soles worn thin. Too much Trippin and my soul’s worn thin.”

Scott Weiland


Take a look at these shoes which are basically a leather glove for the foot. Look at the wear pattern and how the lines of force travel from the heel, of the lateral aspect of the foot, across the metatarsal heads and out the great toe. To have you wear on the right is due to a left-sided leg length discrepancy.  She has a higher lateral longitudinal arch as evidenced from the absence of where just anterior to the heel.  Looks like she’s getting her first Ray to the ground, Eh?

Podcast 88: interpreting Shoe Wear patterns & Running Surface Effects

Show sponsors:
www.newbalancechicago.com

Plus: Biometrics in Pro Sports, Epigenetics and How Exercise changes our DNA, Hip Dysplasia,, Pavlik harnesses.

We hope you find today’s show helpful. Remember, we don’t know everything, and we do not expect everyone else to know everything either. We are just bringing our logic and knowledge and hopefully truth to the web … . . Please, Correct us when we are sharing inaccuracies, as we try to do the same. There is alot of misguided info on the web and in the wrong hands, people can get hurt … . we feel we are doing our part to carve a safe path. But, when we go astray, please our dear brethren……call us out on it ! We insist. -Shawn and Ivo

Other Gait Guys stuff

Download links:

A. http://traffic.libsyn.com/thegaitguys/pod_88_solid.mp3

B. http://thegaitguys.libsyn.com/podcast-88

iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Gait Guys online /download store (National Shoe Fit Certification and more !) :
http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

New biometric tests invade the NBA
http://espn.go.com/nba/story/_/id/11629773/new-nba-biometric-testing-less-michael-lewis-more-george-orwell

How Exercise Changes Our DNA
http://well.blogs.nytimes.com/2014/12/17/how-exercise-changes-our-dna/

An integrative analysis reveals coordinated reprogramming of the epigenome and the transcriptome in human skeletal muscle after training. Lindholm ME
Epigenetics. 2014 Dec 7:0. [Epub ahead of print]

Hip Dysplasia
http://journals.lww.com/pedorthopaedics/Abstract/2015/01000/Back_carrying_Infants_to_Prevent_Developmental_Hip.11.aspx

Journal of Pediatric Orthopaedics:
January 2015 - Volume 35 - Issue 1 - p 57-61
Back-carrying Infants to Prevent Developmental Hip Dysplasia and its Sequelae: Is a New Public Health Initiative Needed? Graham, Simon M.

Plus: Pavlik harness
https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=pavlik%20harness

Does Correct Head Positioning Make You Run Faster?http://runnersconnect.net/running-injury-prevention/running-form-proper-head-position/

Running surfaces
http://www.slowtwitch.com/Training/Running/Concrete_or_Asphalt__4793.html

How to Read and Interpret the Wear Pattern on Your Running Shoes
http://runnersconnect.net/running-tips/read-wear-pattern-running-shoes/

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What does sustained rearfoot and forefoot inversion look like in terms of shoe wear ?

This is a client who came to us with a history of several months of big toe pain (specifically 1st metatarsophalangeal joint pain). The pain was dorsally located (ie. top of the big toe joint).  It was clear that on examination the pain was being caused by osseous and soft tissue dorsal impingement due to a progressing hallux rigidus/limitus. 

This painful status obviously is creating both a conscious medial toe off pattern during the propulsive phase of late stance phases.  The client is more than obviously steering push off laterally as can be seen in this photo. The grey lateral pods are almost obliterated. This means the foot is perpetually supinated during the entire stance phase of gait and this means that pronation shock absorption is not present.

Remember, a perpetually supinated foot means the talus and arch never descend as part of the pronation/shock absorption cycle and so the same side limb will always remain longer than the other limb which is seeing the internal rotation/pronation effects which functionally shorten the leg during stance phase.  So in this case, we have a pelvic unlevelling and a frontal plane shift to the functionally shorter leg during its stance phase.  It should not surprise you that this client has hip pain contralateral to this abnormal shoe wear/hallux limitus side. 

There are plenty of other issues here to be discussed, like eccentric weakness of the same side g.maximus, patellar tracking issues, lack of hip extension and thus weakening of the glutes and thus resultant shortness of the quadriceps group which will all often be found in this clinical picture. But we will save that all for another time.

Remember, the longer this client stays in this shoe, the easier it is mechanically on them because the eVA foam and the shoe are broken down into their compensatory avoidance behaviour.  But, this is where the pattern becomes subconsciously embedded and thus when the pattern drives many of the other compensatory patterns off of this one since it is the new norm. The faster you address this problem, the sooner you stop the compensatory cascade.  And on that note, if you read our blog post re-run of the Arm Swing last week you will understand why  these folks will begin altering the opposite arm swing phase.

Shawn and Ivo, The Gait Guys

Abnormal wear pattern on a Newton Shoe  
  Understanding what went wrong in this runner to cause unilateral Right shoe “toe off” wear pattern is important.  It happens alot.  Many times it doesn’t get this far but there is evidence on a shoe, more on one side, none the less.  It is quite often “What is wrong with the part/person that goes into a shoe”, than “the shoe itself”. It wasn’t the Newton Shoe in this case (it is almost never a shoe material issue), it was the limb attached to it. The shoes are the window to the gait cycle!   
  This is one of our running clients.  They presented with some right hamstring soreness and pain after longer runs.  There were no foot complaints, the shoe wear pattern was just something that we felt was interesting to share as it made sense with their clinical presentation.    
  Client clinically demonstrated:  
     inhibited right glute max  
  tight right quadriceps  
  weak right lower abdominals  
   Summary:   
  Subsequent to #1-3 above there was a loss of right hip extension, thus shortened right stride. When hip extension is limited the heel rise is premature and the calf engagement can be premature. When premature the calf is asked to lift the person during midstance instead of forward propulsion and its other activities during late midstance.   
  Premature heel rise, premature calf muscle engagement, premature foot plantarflexion all lead to greater pressure at the forefoot and thus through toe off……plus some hamstrings complaining as well !  
   Knowing your gait cycles, knowing which muscles should fire at a given time in the gait cycle, and knowing why they fire and what joints they stabilize is a valuable tool in diagnosis of a runners issues.  Of course, it would be very simple to say “hey, you are toeing off real hard on that right side”.  “BRILLIANT SHERLOCK ! ” would be our first response, there is nothing like stating the obvious.  But the how and why is where the brain actually needs to be engaged, and when it is, things can get very interesting and fun in figuring out what is going on in athletes and patients. Knowing how and why things happen allows you to fix the problem.  And in this case if you are attempting to fix this person at the level of the foot you are missing the true problem originating at the hip.  And when you know the origin of the problem in this case, you also get a new shoe wear pattern for the next shoes and best of all, you conquer a chronic  hamstring problem as well.   
   Shawn and Ivo………. Pipe smoking English sleuths…….. (OK, we are good at the board game CLUE and nothing more, who are we kidding !)

Abnormal wear pattern on a Newton Shoe

Understanding what went wrong in this runner to cause unilateral Right shoe “toe off” wear pattern is important.  It happens alot.  Many times it doesn’t get this far but there is evidence on a shoe, more on one side, none the less.  It is quite often “What is wrong with the part/person that goes into a shoe”, than “the shoe itself”. It wasn’t the Newton Shoe in this case (it is almost never a shoe material issue), it was the limb attached to it. The shoes are the window to the gait cycle!

This is one of our running clients.  They presented with some right hamstring soreness and pain after longer runs.  There were no foot complaints, the shoe wear pattern was just something that we felt was interesting to share as it made sense with their clinical presentation. 

Client clinically demonstrated:

  1. inhibited right glute max
  2. tight right quadriceps
  3. weak right lower abdominals

Summary:

Subsequent to #1-3 above there was a loss of right hip extension, thus shortened right stride. When hip extension is limited the heel rise is premature and the calf engagement can be premature. When premature the calf is asked to lift the person during midstance instead of forward propulsion and its other activities during late midstance.

Premature heel rise, premature calf muscle engagement, premature foot plantarflexion all lead to greater pressure at the forefoot and thus through toe off……plus some hamstrings complaining as well !


Knowing your gait cycles, knowing which muscles should fire at a given time in the gait cycle, and knowing why they fire and what joints they stabilize is a valuable tool in diagnosis of a runners issues.  Of course, it would be very simple to say “hey, you are toeing off real hard on that right side”.  “BRILLIANT SHERLOCK ! ” would be our first response, there is nothing like stating the obvious.  But the how and why is where the brain actually needs to be engaged, and when it is, things can get very interesting and fun in figuring out what is going on in athletes and patients. Knowing how and why things happen allows you to fix the problem.  And in this case if you are attempting to fix this person at the level of the foot you are missing the true problem originating at the hip.  And when you know the origin of the problem in this case, you also get a new shoe wear pattern for the next shoes and best of all, you conquer a chronic  hamstring problem as well.


Shawn and Ivo………. Pipe smoking English sleuths…….. (OK, we are good at the board game CLUE and nothing more, who are we kidding !)