Plantar Plate Gait

This girl has a (healing) plantar plate lesion on the left hand side at the head of the second met. She also has an anatomical short leg on the same side. Her second metatarsal of both feet or longer than the first

A few things I hope you notice about the video:

  • Can you see how she “reaches“ to get to the ground with her left foot?

  • Can you see how her left foot is more inverted that strikes in the right, creating a greater amount of forefoot pronation that needs to be controlled?

  • Can you see how poor her motion control is of her pronation on the left foot with the sudden “crash” at impact?

  • Have you noticed her “crossover“ gait?


Does it make sense that because of her anatomy and running style, that the constant reach, increased forefoot inversion and lack of pronation control (which causes more abduction of the forefoot at toe off); this drives the force to the second metatarsal head which is longer and more prominent and is more than likely what led to her plantar plate lesion in the first place?


Remediation?

  • A 3 mm full length sole lift for the left foot

  • Foot intrinsic strengthening exercises

  • Hip abduction strengthening exercises/drills

  • Moving her more to a “midfoot strike” running gait with toes extended to engage the windlass


Dr Ivo Waerlop, one of The Gait Guys


#plantarplate #gaitanalysis #crossovergait #leglengthdifference #thegaitguys


You won't read this. So send it to a colleague who will.

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Beating a point to near-death. Consider this our Thursday Rant.

Yes, we won't let this go, and, you should not either.

We highlight the word ADAPTIVE below, because it is the key to all of this.

"The observed postural responses could be viewed as an ADAPTIVE process to cope with an unilateral alteration in the hip neuromuscular function induced by the fatiguing exercise for controlling bipedal stance. The increase in CoP displacements observed under the non-fatigued leg in the fatigue condition could reflect enhanced exploratory "testing of the ground" movements with sensors of the non-fatigued leg's feet, providing supplementary somatosensory inputs to the central nervous system to preserve/facilitate postural control in condition of altered neuromuscular function of the dominant leg's hip abductors induced by the fatiguing exercise."-*Vuillerme N1, Sporbert C, Pinsault N.

When one prescribes or chooses a corrective exercise for a client, one based sheerly on what is visualized as an "apparently" faulty movement pattern or aberrant screen, one is making many assumptions. Assumptions that are likely not entirely correct (we are being kind, most assumptions made based on partial fragmented information are incorrect to a high degree).

Here is comes again, . . . . what you SEE and TEST in your client's movement is not what is wrong with them most of the time. What you see is how your client is ADAPTING to the variables they can engage, avoiding the ones that are painful or perceived as unstable, or finding ways around immobility and as the article as quote above suggests. This was a basic tenet of Karel Lewit's and Janda's work to not focusing on the area of pain, rather to seek out the root cause, we are just saying it in a different manner.

Continuing, we also adapt around fatigue which can take place even in everyday tasks and how we move around our world, yes, even in our gait. Yes, you are seeing a client's best attempts, ones that are likely deeply rooted and now their new norm, their baseline to base all other patterns off of. Their attempts can be based off of immobility, instability (true or functional), lack of skill, proprioceptive deficits, fatigue (lack of baseline endurance), lack of strength or power. For some clients, forget challenging screens that really test them, heck, we find some athletes do not even have the requisite baseline endurance or strength in a few primary fundamental patterns of which they have built more robust patterns atop of. We all to often read about "robustness" of a skill and pattern and interpret it as a good thing. Robustness can also be build atop of a bad pattern of movement, atop of poor stability patterns.

Thus, asking a client to change that ADAPTIVE norm, based off of what you visualize, based on the working parts available to them, without rooting out the cause, is asking them to compensate around their new norm base of compensation. When done this way, we are merely giving our client armor to their dysfunction, faulty robustness if you will. We are in fact moving further from the remedy. To correctly play this multi-layered game of helping people, one has to examine the client, not just put them through screens and assessments that show us (and them) what they can and cannot do.

There is an awful lot of armchair doctoring going on out there, thankfully it all comes from a good place in the heart's of many good folk. We have so many people come in to see us who have problems and a list of corrective exercises that have been prescribed to them, exercises that clearly have been based off of correcting what is seen in their screens and movements. We discuss their workout patterns, their activities, and hear about how they are attempting to build up their bodies for the apparent good. But all to often, with a client in front of us in pain, we hear the clues that the problem is being exercised around. Meaning, building robustness on top of a dysfunctional base somewhere in their system. Many of these people have been given these exercises as part of their corrective work and strengthening programs at their place (gym, box, trainer, coach etc). Many times there was no in depth hands on examination coupled with screens and gait to root out the cause of why they are moving the aberrant way that they are. We all must commit ourselves to a complete process for our clients. Screens and tests and exercises are not enough. Please read yesterdays post if you have not already, we make our point once again in a video case.

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To close this post, we fully acknowledge regularly that we are on the same bus to the same temple of higher wisdom as everyone else that reads these kinds of posts. We write to share, but we write to learn, to dive deeper into our thoughts, to challenge our biases and rooted assumptions through thought experiments, challenging thoughts and old ways that get us into troubled automated patterns of approaching all things. Again, we write to learn. And, part of that learning is accepting our limitations and hearing from others who are wiser in other areas than us, so, please comment and add insight below if you wish. Debates are good, for us all.  Pull up a chair, grab a pint, join us around the hearth for some gab.

Shawn Allen, . . .  the other gait guy.    www.doctorallen.co    &    www.shawnallen.net

"One of the few ways I can almost be certain I'll understand something is by sitting down and writing about it. Because by forcing yourself to write about it and putting it down in words, you can't avoid having to come to grips with it. You might be wrong, but you have to think about it very intensely to write about it. So I use writing as a learning tool. " - Hunter S. Thompson

*Postural adaptation to unilateral hip muscle fatigue during human bipedal standing.

Gait Posture. 2009 Jul;30(1):122-5. doi: 10.1016/j.gaitpost.2009.03.004. Epub 2009 Apr 28.

Vuillerme N1, Sporbert C, Pinsault N.

Want more stability, NOW?

balancing-stones.jpg

Try this...

While walking or running running (or watching a client walk, amble or run) you may be thinking  “I need to do something to improve my (their) proprioception, or they are going to fall (again)” If you were to increase your (their) surface area, and make yourself (theirself)vless top heavy, I (they) would be more stable. How can we accomplish that?

Here is what you can do:

First, spread your toes.; why not maximize the real estate available to your feet?

Next,  widen your stance (or base of gait). Spreading your weight over a larger surface area would be more stable and provide stability.

Third, raise your arms out from your sides (no don't try to fly) to provide more input from your upper extremities to your proprioceptive system (more input from peripheral joint and muscle mechanoreceptors = more input to cerebellum = better balance)

Lastly, Slow down from your blistering pace. this will give your (aging) nervous system more time to react.

All these actions were all “primitive” reactions of the nervous system when learning to walk. We did a post on that when my youngest son was learning to walk.

Want to have better balance?

  • Spread your toes
  • Widen your stance
  • Raise your arms
  • Slow down

Notice I didn’t say this would make you faster. Who is more likely to fall on a corner when being chased by a predator; the tortoise or the hare?

A little practical neurology for you this morning brought to you by the geeks of gait. Ivo and Shawn.

Podcast 98: Stability, Mobility and The Brain

Topics: Plus, the central nervous system’s effects on Chronic Tendonopathies and Gait Problems.

Show Sponsors:

*newbalancechicago.com

*Rocktape.com

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_98f.mp3

Podcast Direct Download:  http://thegaitguys.libsyn.com/podcast-98-stability-mobility-and-the-brain

Other Gait Guys stuff

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

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

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

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

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

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

Show notes:

Stability, Mobility and The Brain plus, the CNS and Chronic Tendonopathies and Gait Problems. We have done 98 podcasts, it is easy to miss one or two, but this is not one of those ones you should pass up. Hope you will join us on the podcast today !

Endocanabioids
http://metro.co.uk/2015/10/07/runners-high-triggers-the-same-brain-receptors-as-getting-stoned-on-weed-5426140/

Exercise Pill
http://www.huffingtonpost.com/entry/exercise-pill_56128c64e4b0768127028b16

Swagger gait in primates
http://news.discovery.com/human/evolution/tree-climbing-extinct-human-had-swagger-151007.htm

Should we instruct changes in client’s gait ?
http://www.anatomy-physiotherapy.com/articles/musculoskeletal/lower-extremity/knee/1311-kinematic-variation-and-pain-in-dynamic-knee-collapse

The Brain and chronic tendonopathies
http://www.anatomy-physiotherapy.com/articles/musculoskeletal/1313-tendon-neuroplastic-training

Want more stability when trail running? Try this…  

  
 While running the other morning through about 6-8” of fresh snow (yes, it is snowing here already at 9000 feet), something occurred to me as I almost fell several times due to the undulating surface beneath my feet and the terrain to match under that. 

  
 “I need to do something to improve my proprioception, or I am going to fall (again)” I thought (yes, we both think about this stuff while running or exercising! No, I was not listening to music on this run, though cranking up some AC/DC was tempting..). If I were to increase my surface area on the snow, and make myself less top heavy, I would be more stable. How could I accomplish that? 

  
 Here is what I did, and it worked great! 

  
 First,  I spread my toes . No, I wasn’t barefoot, but in my Altra Lone Peak 1.5’s; why not maximize the real estate available to my feet in these roomy shoes? 

 Next,  I widened my stance  (or base of gait). My massive 145# spread over a larger surface area would be more stable and provide stability from my weight distributed over a larger surface area. 

 Third,  I raised my arms out from my sides  (no I didn’t try to fly) to provide more input from my upper extremities to my proprioceptive system (more input from peripheral joint and muscle mechanoreceptors = more input to cerebellum = better balance) 

 Lastly,  I slowed down  from my blistering 10 min mile pace. Though this did not improve my surface area, it did give my aging nervous system more time to react. 

  
 It occurred to me that these actions were all “primitive” reactions of the nervous system when learning to walk. We did  a post  on that when my youngest son was learning to walk a few years ago. 

  

   Want to have better balance?   

  Spread your toes 
 Widen your stance 
 Raise your arms 
 Slow down 
   

  
 Notice I didn’t say this would make you  faster . Who is more likely to fall on a corner when being chased by a predator; the tortoise or the hare? 

   

 A little practical neurology for you this morning brought to you by the geeks of gait. Ivo and Shawn. 

  

Want more stability when trail running? Try this…

While running the other morning through about 6-8” of fresh snow (yes, it is snowing here already at 9000 feet), something occurred to me as I almost fell several times due to the undulating surface beneath my feet and the terrain to match under that.

“I need to do something to improve my proprioception, or I am going to fall (again)” I thought (yes, we both think about this stuff while running or exercising! No, I was not listening to music on this run, though cranking up some AC/DC was tempting..). If I were to increase my surface area on the snow, and make myself less top heavy, I would be more stable. How could I accomplish that?

Here is what I did, and it worked great!

First, I spread my toes. No, I wasn’t barefoot, but in my Altra Lone Peak 1.5’s; why not maximize the real estate available to my feet in these roomy shoes?

Next, I widened my stance (or base of gait). My massive 145# spread over a larger surface area would be more stable and provide stability from my weight distributed over a larger surface area.

Third, I raised my arms out from my sides (no I didn’t try to fly) to provide more input from my upper extremities to my proprioceptive system (more input from peripheral joint and muscle mechanoreceptors = more input to cerebellum = better balance)

Lastly, I slowed down from my blistering 10 min mile pace. Though this did not improve my surface area, it did give my aging nervous system more time to react.

It occurred to me that these actions were all “primitive” reactions of the nervous system when learning to walk. We did a post on that when my youngest son was learning to walk a few years ago.

Want to have better balance?

  • Spread your toes
  • Widen your stance
  • Raise your arms
  • Slow down

Notice I didn’t say this would make you faster. Who is more likely to fall on a corner when being chased by a predator; the tortoise or the hare?

 

A little practical neurology for you this morning brought to you by the geeks of gait. Ivo and Shawn.

 

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Since the world did not end, you should probably think twice about those motion control shoes….

WE can all agree that there is a time and a place for motion control shoes. For people with chronic ankle sprains or lateral instability (ie, an incompetent lateral compartment; peroneus longus, brevis or tertius), it is neither the time, nor the place.

The lateral ankle is stabilized by both static (ligaments: above lower left) and dynamic (muscles above, lower right) elements. This is often called “the lateral stabilizing complex” The lateral ankle (ie the lateral malleolus) also projects more inferiorly than the medial. This means that when push comes to shove, the ankle is more likely to invert (or go medially) than evert (or go laterally). What protects it? The static component consist of three main ligaments (seen above) the posterior and anterior talofibular ligaments and the calcaneofibular ligaments. The dynamic components are the peroneii muscles. These muscles not only stabilize but also exert an eversion (brings the bottom of the foot to the outside) force on the ankle.

So what you say?

according to one study we found “Using an in-shoe plantar pressure system, chronic ankle instability subjects had greater plantar pressures and forces in the lateral foot compared to controls during jogging.”

Hmmm. Remember the midsole? (If not click here and here for a review) Motion control shoes are medially posted. That means they provide more support medially or  have a tendency to tip the foot laterally. SO, motion control shoes shift forces laterally.

A person with chronic ankle instability has weakness of either the static, dynamic, or both components of the lateral stabilizing complex.

bottom line? make sure folks have a competent lateral stabilizing complex and if they don’t, you may want to think twice about using a motion control shoe.

Ivo and Shawn. Increasing your shoe geekiness coefficient on daily basis!                                                                                                                                                      

Foot Ankle Int. 2011 Nov;32(11):1075-80. Increased in-shoe lateral plantar pressures with chronic ankle instability. Schmidt H, Sauer LD, Lee SY, Saliba S, Hertel J. Source

University of Virginia, 2270 Ivy Road, Box 800232, Charlottesville, VA 22903, USA.

Abstract BACKGROUND:

Previous plantar pressure research found increased loads and slower loading response on the lateral aspect of the foot during gait with chronic ankle instability compared to healthy controls. The studies had subjects walking barefoot over a pressure mat and results have not been confirmed with an in-shoe plantar pressure system. Our purpose was to report in-shoe plantar pressure measures for chronic ankle instability subjects compared to healthy controls.

METHODS:

Forty-nine subjects volunteered (25 healthy controls, 24 chronic ankle instability) for this case-control study. Subjects jogged continuously on a treadmill at 2.68 m/s (6.0 mph) while three trials of ten consecutive steps were recorded. Peak pressure, time-to-peak pressure, pressure-time integral, maximum force, time-to-maximum force, and force-time integral were assessed in nine regions of the foot with the Pedar-x in-shoe plantar pressure system (Novel, Munich, Germany).

RESULTS:

Chronic ankle instability subjects demonstrated a slower loading response in the lateral rearfoot indicated by a longer time-to-peak pressure (16.5% +/- 10.1, p = 0.001) and time-to-maximum force (16.8% +/- 11.3, p = 0.001) compared to controls (6.5% +/- 3.7 and 6.6% +/- 5.5, respectively). In the lateral midfoot, ankle instability subjects demonstrated significantly greater maximum force (318.8 N +/- 174.5, p = 0.008) and peak pressure (211.4 kPa +/- 57.7, p = 0.008) compared to controls (191.6 N +/- 74.5 and 161.3 kPa +/- 54.7). Additionally, ankle instability subjects demonstrated significantly higher force-time integral (44.1 N/s +/- 27.3, p = 0.005) and pressure-time integral (35.0 kPa/s +/- 12.0, p = 0.005) compared to controls (23.3 N/s +/- 10.9 and 24.5 kPa/s +/- 9.5). In the lateral forefoot, ankle instability subjects demonstrated significantly greater maximum force (239.9N +/- 81.2, p = 0.004), force-time integral (37.0 N/s +/- 14.9, p = 0.003), and time-to-peak pressure (51.1% +/- 10.9, p = 0.007) compared to controls (170.6 N +/- 49.3, 24.3 N/s +/- 7.2 and 43.8% +/- 4.3).

CONCLUSION:

Using an in-shoe plantar pressure system, chronic ankle instability subjects had greater plantar pressures and forces in the lateral foot compared to controls during jogging.

CLINICAL RELEVANCE:

These findings may have implications in the etiology and treatment of chronic ankle instability.


all material copyright 2012 The Homunculus Group/ The Gait Guys. Don’t rip off our stuff. PLEASE ASK 1st!

Speed Matters: Brief Thoughts on Gait and Running.


The journal article below sparked a few thoughts for a blog post today.

Have you ever tried to walk slower than your normal pace ? How about running slower than your normal pace (  you know, running with that person who is clearly a minute slower pace) ? Why are both so uncomfortable and labor intensive ? Why does your balance, energy and stability become challenged ? After all, slower should be easier right ?!
There are many reasons and this study hints at a few issues but the bottom line is that speed matters.  Have you ever been driving down the road and you see a big pot hole in the road that you just cannot get around because it is either too big or you do not have time to steer around it ?  What is your first reaction ?  Many will press down on the gas pedal. Why is that ? Well, logic for many is that speeding up will possibly enable you to launch across the void and reduce the impact issues of dropping down into the void.  Men will rationalize the “launch across the pothole” theory, and in some respects they are not wrong.
Running and walking slowly sort of bring out some of the same issues.  When we move slowly the body is more likely to drift into the frontal/coronal (side to side) plane.  Moving more quickly ensures that the dominant path is forward. Slowing down does not ensure that forward will occur. side to side sway enters the picture. And when side to side sway enters as an option we have to spend more time and strategies negotiating the side sway.  This is why we see all kinds of corrections with the limbs and core when we attempt to stand on one foot, but we do not see these issues when we walk or run.  When running we are mostly trying to get the next foot underneath our body so that we do not fall forward flat on our face. Locomotion is a strategy of nothing more than trying to stay upright.  When we run the predominant motion is forward. But when we slow down and reduce the advantage of speed to blur out these issues the challenges begin and other planes of movement become an option and thus planes we need to control. It is much why the elderly have more difficulty moving about, because they have to negotiate and control so many other planes of movement.
So, if you want to bring out some faulty motor patterns, move more slowly and see where your deficits lie. One of our assessments for patients and athletes is to have them walk at a 3second pace meaning each foot fall must be held for 3 seconds before the next step can be initiated. This means stance and swing must be slowed to 3 seconds.  Amazing things will show up if you just slow things down and allow weaknesses to percolate to the surface.  Speed blurs them and keeps them suppressed. It is really a form of cheating and compensation.
So, like in your car, speed matters.
Think about this next time you have to walk or run with a slower person. It may be one of the issues, but there are others and we will eventually get to them.


Gait and Speed on Child Development
J Biomech. 2008;41(8):1639-50. Epub 2008 May 7. The effect of walking speed on the gait of typically developing children. Schwartz MH, Rozumalski A, Trost JP. Abstract

Many gait studies include subjects walking well below or above typical self-selected comfortable (free) speed. For this reason, a descriptive study examining the effect of walking speed on gait was conducted. The purpose of the study was to create a single-source, readily accessible repository of comprehensive gait data for a large group of children walking at a wide variety of speeds. Three-dimensional lower extremity joint kinematics, joint kinetics, surface electromyographic (EMG), and spatio-temporal data were collected on 83 typically developing children (ages 4-17) walking at speeds ranging from very slow (>3 standard deviations below mean free speed) to very fast (>3 standard deviations above mean free speed). The resulting data show that speed has a significant influence on many measures of interest, such as kinematic parameters in the sagittal, coronal, and transverse planes. The same was true for kinetic data (ground reaction force, moment, and power), normalized EMG signals, and spatio-temporal parameters. Examples of parameters with linear and various nonlinear speed dependencies are provided. The data from this study, including an extensive electronic addendum, can be used as a reference for both basic biomechanical and clinical gait studies.