Have you seen this?

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

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

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

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

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

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

Dr Ivo Waerlop, one of The Gait Guys

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

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

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

Correcting movement problems : the power of opening a neurological window to change the brain's cortical representation.

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Show notes:

Hop strength
https://www.ncbi.nlm.nih.gov/pubmed/30844991
J Strength Cond Res. 2019 May;33(5):1201-1207. doi: 10.1519/JSC.0000000000003102.
Reactive Strength Index and Knee Extension Strength Characteristics Are Predictive of Single-Leg Hop Performance After Anterior Cruciate Ligament Reconstruction.Birchmeier T1, Lisee C1, Geers B2, Kuenze C


https://www.ncbi.nlm.nih.gov/pubmed/28605231

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110230/pdf/jpts-30-1069.pdf

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You might think your shoe is doing more to control motion of your foot than it is actually doing.

You might think your shoe is doing more to control motion of your foot than it is actually doing.

"The measurement of rearfoot kinematics by placing reflective markers on the shoe heel assumes its motion is identical to the foot’s motion."
The results of this study revealed that "calcaneal frontal plane ROM was significantly greater than neutral and support shoe heel ROM. Calcaneus ROM was also significantly greater than shoe heel ROM in the transverse and sagittal planes. No change in tibial transverse plane ROM was observed."

It is easy to underestimate the calcaneal ROM across all planes of motion. Motion is going to occur somewhere, hopefully you can help your client control the excessive ROMs that are occurring and causing their symptoms. But just do not think that a shoe is going to markedly help, it might, but let your interventions and your client's feedback on pain lead you.

Calcaneus range of motion underestimated by markers on running shoe heel.
Ryan S. Alcantara'Correspondence information about the author Ryan S. AlcantaraEmail the author Ryan S. Alcantara
, Matthieu B. Trudeau, Eric S. Rohr
Human Performance Laboratory, Brooks Running Company, 3400 Stone Way N, Suite 500, Seattle, WA 98103 United States

The rigid flat foot. Why an orthotic may not work well at all.

Just because the foot is flat (arch collapsed) does not mean you have a right to try and lift it !
This is a perfect example of a foot that is troubled. It is a rigid flat foot deformity. This acquired over a long period of time. Sometimes tibialis posterior insufficiency over time finally gives way to an incompetent tib posterior, with eventual arch gradual collapse into a pes planus flat deformity, and then time takes its effect to contracture and shorten tissue and arthritic change makes it permanent.
This arch will no longer lift, it is a rigid pes planus. IT will not tolerate an orthotic, SO DO NOT PRESCRIBE ONE ! Even a mild orthotic lift will feel like a golf ball under this arch.
And, to take this one step further, a rockered shoe is, in part, the right idea, but not when the foot does not sagittally toe off. This foot is permanently locked into a full limb external rotation because of hip arthritic change. The point is that his foot progression angle is 45 degrees++, and the rocker will not work if it cannot rocker in the sagittal plane.
This guy wanted an orthotic, and i would not give it to him, and you shouldn't either. He will wear it for 1 minute and throw it away.

Shawn Allen, the other gait guy

#gait, #anklerocker, #forefootrocker, #footprogression, #archcollapse

Sometimes you may need to put the cart before the horse...The knees, the glutes and reverse engineering ?

Footnotes 7 - Black and Red.jpg

We have talked about looking at things “from the bottom” up in the past, so we can understand things like why the vastus medialis is an external rotator in closed chain as are the semi membranosis and tendinosis. Perhaps we need to think more about this traveling proximally, where the knee effects the glutes. We found this paper looking at women with patello femoral problems and gluteal inhibition. Prospective studies have not found gluteal weakness to be a risk factor for patello femoral problems, but perhaps it is the other way around and patello femoral problems are a risk factor for gluteal weakness? It makes sense, especially if you consider the vastus lateralis like we talk about here and here.

“We hypothesize that muscle inhibition is present in the gluteal muscles of females with PFP compared to healthy controls and it is associated with both decreased subjective function and longer duration of symptoms.”

Dr Ivo Waerlop, one of The Gait Guys

Glaviano NRBazett-Jones DMNorte G. Gluteal muscle inhibition: Consequences of patellofemoral pain? Med Hypotheses. 2019 May;126:9-14. doi: 10.1016/j.mehy.2019.02.046. Epub 2019 Feb 27.

#gait #foot #patellofemoralpain #PFP #quadriceps #thegaitguys #glutes #gluteal muscles

Unique adaptations to arm swing challenges: the one armed runner. Welcome to Luke Ericson, an amazing athlete, and man

Luke Ericson is tough as nails.

Human gait is cyclical. For the most part, when one limb is engaged on the ground (stance phase), the other is in swing phase. Before I continue, you should recall that there is a brief double limb support phase in walking gait, that which is absent in running gait. Also, I wish to remind you of our time hammered principle that when the foot is on the ground the glutes are heavily in charge, and when the foot is in the air, the abdominals are heavily in charge.  

For one to move cleanly and efficiently one would assume that the best way to do that would be to ensure that the lower 2 limbs are capable of doing the exact same things, with the same timing, same skill, same endurance and same strength. This goes for the upper 2 limbs as well, and then of course the synchronizing of the 4 in a cohesive effort. For this clean seamless motor function to occur, one must assume that there would be no injuries that had left a remnant mark on one limb thus encouraging a necessary compensation pattern in that limb (and one that would then have to be negotiated with the opposite limb as well as the contralateral upper or lower limb).  

Removing a considerable mass of tissue anywhere in the body is going to change the symmetry of the body and require compensations. One can clearly see the effects of this on this athletes body in the video above. He even eludes to the fact that he has a scoliosis, no surprise there.  There is such an unequal mass distribution that there is little way the spine had any chance to remain straight.  Not only is this going to change symmetry from a static postural perspective (bulk, weight, fascial plane changes, strength etc) but it will change dynamic postural control, mobility and stability as well as dynamic spinal kinematics.  I have talked about this previously in a blog piece I wrote on post-mastectomy clients display changes in spatiotemporal gait parameter such as step length and gait velocity.

-mastectomy post: http://tmblr.co/ZrRYjx1XB8RhO

If you have been with The Gait Guys for awhile you will know that impairing an arm swing will show altered biomechanics in the opposite lower limb (and furthermore, if you alter one lower limb, you begin a process of altering the biomechanical function and rhythmicity of the opposite leg as well.) You can search the blog for “arm swing part 1 and part 2″ for those dialogues.

Arm swing impairment is a real issue and it is one that is typically far overlooked and misrepresented. The intrinsic effects of altering the body through subtraction of tissue are not all that dissimilar to extrinsic changes into the system from things like  walking with a handbag/briefcase, walking with a shoulder bag, walking and running with an ipod or water bottle in one hand. And do not forget other intrinsic problems that affect spinal symmetry, for example consider the changes on the system from scoliosis as in this case.  It can cycle back on its own feedback loop into the system, either consciously or unconsciously altering arm swing and thus global body kinematics.  

There is a reason that in our practices we often assess and treat contralateral upper and lower limbs as well as to address remnants from old injuries whether they are symptomatic or not. It all comes together for the organism as a concerted effort in optimal locomotion.

Here on TGG, and in dialogues with Ivo on our podcast, I have long talked about phasic and anti-phasic motions of the arms and shoulder-pelvic blocks during gait and locomotion/sport activity.  I have written several times about the effects of spine pain and how spine pain clients reduce the anti-phasic rotational (axial) nature of the shoulder girdle and pelvic girdle. In the video above, you can see anything but anti-phasic gait, to be clear, this is a classic representation of a phasic gait. The shoulder block and the pelvic block show little if any counter rotation, they are linked together which is not normal gait. Furthermore, if you look carefully, the timing of the right arm swing is variable and cyclically changing in its timing with the left leg. Look carefully, you will see the cyclical success and failure at the beginning of the video.  This is pathologic gait, he must be constantly fighting frontal plane sway because there is no axial anti-phasic motion. He is also constantly fighting the unidirectional rotation that the absence of an entire limb and limb girdle is presenting, you can see him struggle with this if you have looked at enough gait samplings. There is essentially frozen torso movements.  Want to see more of our work on arm swing ? search the gait guys blog.

There is so much more here to discuss, so I will likely return to this video another time to delve into those other things on my mind. Luke is an amazing athlete, he gets much respect from me.

I hope this dialogue helps you to get a deeper grip on gait and gait problems. I have written many articles on the topics of arm swing, phasic and anti-phasic gait, central pattern generators. The are all archived here on the blog. I try to write a new original thought-process article each week for the blog amongst the other “aggregator” type stuff we share from other folks social media. My weekly article serves to go deeper into things, sometimes they are well referenced and in this case, I am basing today’s discussion on the referenced work in the other pieces I have written on arm swing, phasic and anti-phasic gait, central pattern generators etc. So please do your readings there before we begin debate or dialogue, which i always welcome !

Dr. Shawn Allen, the other gait guy

PRP, platelet-rich plasma for patellar tendinopathy: No more effective than saline (in this first study).

"Combined with an exercise-based rehabilitation program, a single injection of LR-PRP or LP-PRP was no more effective than saline for the improvement of patellar tendinopathy symptoms.:"

*this is the First randomized controlled trial comparing PRP (platelet-rich plasma) injection to saline, for patellar tendinopathy.

Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline

Alex Scott, PhD*, Robert F. LaPrade, MD, PhD, Kimberly G. Harmon, MD,

Link: https://journals.sagepub.com/doi/abs/10.1177/0363546519837954?journalCode=ajsb&fbclid=IwAR2p8pj3cugbIafBLaUj8zoaKm3hHyBfIIw6m3rBfDVgBDVKBj73s4jaK30

Premature heel rise: Part 2

VIDEO: an atypical case of Premature heel rise. A follow up video for yesterdays discussion on the topic.

You should easily see premature heel rise here in this video. We will discuss this case at length with other video projections on our Patreon site next week, if you wish to dive further.

But here you should see, lets focus on the right limb, premature heel rise (again, stick with just watching the right foot/leg). This is, in-part, because this person does not achieve adequate hip extension, you should clearly be able to see that. Loss of terminal hip extension means premature heel rise, no exceptions. Train your eye to see this, you do not need expensive video software to see this.

So, Why inadequate hip extension? Well, just look at the amount of right knee flexion going into terminal stance, it is still heavily flexed and this forces them to prematurely heel rise, avoiding terminal hip extension, and prematurely load the forefoot. Without a knee that extends sufficiently, the hip cannot extend sufficiently, and thus premature heel rise is inevitable. And, trying to solve this issue down at the foot/ankle level is foolish in this case. Stretching this calf day after day until aliens come visit earth will still not be enough stretch time to fix this premature heel rise (ie. get that heel to stay down longer). There is a good reason why this is happening in this person, and it is a neurologic one, one we will discuss on the Patreon site for our Patrons. And, the reason does not matter for the concept I am teaching here today.

For today, you need to be able to see premature heel rise, and know all of the issues behind it, including causes, so that you can direct your phyiscial examination to solve your client's puzzle.
I have included yesterday's post below so you can review and bring this further together.
This is the kind of stuff we will do at Dr. Allen's Friday night Gait Lab, over some beverages. A unique, clinically curious and hungry 25 people need only apply. If you want to get to the next level of your human movement game, this is a way to get there.

Yesterday's post: We know that early/premature heel rise (PHR) leads to premature loading of the forefoot.
We know that premature heel rise (PHR) speeds us through many of the timely mechanical events that need and should occur for to get to safe and effective toe off during walking and running gaits.
This is why there are so many variables that need to be assessed and checked before instituting care to address the premature heel rise, because many times the problem is not even near the heel.
Consider, examine, assess (this is not an exhaustive list either) of causes of PHR
-short calf complex
-short quad (limits hip extension)
- short hip flexors
-anterior pelvis tilt as one's deviated norm posture
- prolonged or excessive rearfoot inversion
-lack of appropriate pronation (sustained supination)
-hallux limitus, rigidus
- weak anterior compartment lower leg
-lack of hip extension/weak glutes
-knee flexion contracture
- neurologic (toe walking gait from youth)
-painful achilles tendon mechanism
- loss of ankle rocker (which has its own long list)
. . . . to name a few

This is why you need to examine your clients, even after a gait analysis. Because, as we like to say, what you see is not your clients gait problem, it is their work around to other mechanical deficits.
After all, telling someone they just need to lengthen/stretch their calf to keep that heel down longer is utterly foolish.

*want to learn more about this stuff, you can join the upcoming Dr. Allen, Friday night Gait Lab series that he will be having in his office one Friday a month, in his Chicagoland office. Stay tuned for that notice. I will take only 25 people per session. We will dive into videos, cases, concepts, white-board rabbit holes, and enjoy some beverages and learn together. Stay tuned. The first 25 to pay and sign up are in !

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #heelrise, #PHR, #prematureheelrise, #achilles, #achillestendinitis, #anklerocker, #heelrocker, #forefootpain, #halluxlimitus, #halluxrigidus, #heelpain

Top end heel raises. The top end might matter.

Screen Shot 2019-04-19 at 6.34.09 PM.png

Thought experiment . . .
If top end posterior compartment (loosely, the calf complex) strength is lacking, then heel rise may not be optimized to transfer body mass forward sufficiently and effectively.
This lack of forward progression, fails to move the body mass sufficiently forward enough to reduce the external moment arms and optimize the internal moment arms to take maximal advantage of the calf complex (I am talking about moment arms between the grounded 1st MTP joint and ankle mortise & ankle mortise and achilles tendon).
These are rough thoughts today gang, letting you inside our heads and how we juggle multiple parameters when we are struggling to solve a client's problems.

In the lower heel rise photo, The body mass does not progress forward enough over the grounded first MTP joint at the big toe (during gait, the heel doesn’t just rise up, the axis of the ankle joint moves both up and forward).
In this case, the foot may not be fully rigid in a supinated position to benefit from joint closed-packed positions. Thus, the foot may be more pliable and one might suppose that if not adequately supinated, they are inadequately still too much relatively pronated. This might put more load into the tibialis posterior and other soft tissue mechanical loading scenarios that are less optimally suited to do this job. Over time, might this lead to pathology? Likely.
Thus, when running on a weaker posterior mechanism (often found unilaterally) the higher up posterior chains might be overburdened, the tendon loads and loading response of the achilles, tibialis posterior, and long flexors will be most likely altered, likely negatively, the naturally occurring foot locking mechanisms might be less optimal than desired, subtalar and forefoot loading might be premature (ie. sesamoid malpositioning for one, as a simple example), etc etc. Loading a foot(the mid and forefoot) into heel rise that is still somewhat pronated creates a different moment arm around the subtalar joint axis (that moves through the 1st metatarsal), than a foot that is more supinated.

Now, put these ideas into the 2 photos from yesterday where one might be loading the forefoot laterally or more medially, and now make the top end strength more in one of those scenarios. Is it any wonder why so many struggle with posteiror mechanism tendonopathies ? There are so many parameters to consider and examine. And, if not examined in great detail, the key lacking parameter can be missed.
Hence, just forcing calf strength loading is too simple a solution, there is a needle in that haystack that upset the client's apple cart, it is the job of the clinician to find it and remedy it.

Today, looking into the research and finding some interesting things that are spurring some thoughts.

Shawn Allen, one of the gait guys

More on the scourge of Flip Flops. Riding the inside edge of the sandal. Mystery hunting with Dr. Allen.

Screen Shot 2019-04-19 at 7.53.35 PM.png

Tis the season upon us. Riding the inside edge of the sandal.
You can see it in the photo, the heel is a third of the way off the sandal.

You either have it or have seen it. It is frustrating as hell if you have it. Your heel rides on only half of your flip flop or summer sandals. You do not notice it in shoes, only in sandals, typically ones without a back or back strap. This is because the heel has no controlling factors to keep it confined on the rear of the sandal sole. There is no heel counter on open backed shoes and sandals, the counter keeps the heel central on the back of the footwear. There is a reason this inside edge riding happens to some, but not everyone. It is best you read on, this isn’t as simple as it might seem.

These clients may have restricted ankle rocker (dorsiflexion), restricted hip extension and/or adductor twist (if your reference is the direction the heel is moving towards). I could even make a biomechanical case that a hallux limitus could result in the same scenario. So what happens is that as the heel lifts and adducts it does not rise directly vertically off the sandal, it spins off medially from the “adductor twist” event. This event is largely from a torque effect on the limb from the impaired sagittal mechanics as described above, manifesting at the moment of premature heel rise resulting in an slightly externally rotating limb (adducting heel). The sandal eventually departs the ground after the heel has risen, but the sandal will rise posturing slightly more laterally ( you can clearly see this on the swing leg foot in the air, the sandal remains laterally postured). Thus, on the very next step, the sandal is not entirely reoriented with its rear foot under the heel, and the event repeats itself. The sandal is slightly more lateral at the rear foot, but to the wearer, we believe it is our heel that is more medial because that is the way it appears on the rear of the sandal or flip flop. Optical illusion, kind of… . . a resultant biomechanical illusion is more like it.

Screen Shot 2019-04-19 at 7.53.46 PM.png


You will also see this one all over the map during the winter months in teenagers who swear by their Uggs and other similar footwear, as you can see in the 2nd photo above. This is not an Ugg or flip flop problem though, this is often a biomechanical foot challenge that is not met by a supportive heel counter and may be a product of excessive rear foot eversion as well. This does not translate to a “stable” enough shoe or boot, that is not what this is about. This is about a rearfoot that moves to its biomechanical happy place as a result of poor or unclean limb and foot biomechanics and because the foot wear does not have a firm stable and controlling heel counter. This is not about too much pronation, so do not make that mistake. And orthotic is not the answer. A heel counter is the answer. The heel counter has several functions, it grabs the heel during heel rise so that the shoe goes with the foot, it give the everting rearfoot/heel something to press against, and as we have suggested today, it helps to keep the rearfoot centered over the shoe platform. To be clear however, the necessary overuse and gripping of the long toe flexors to keep flip flops and backless sandals on our feet during the late stance and swing phases of gait, clearly magnifies these biomechanical aberrations that bring on the “half heel on, half heel off” syndrome.

There you have it. Another solution to a mystery in life that plagues millions of folks.

Shawn Allen, the other gait guy

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

Most likely this is common knowledge for most followers here on The Gait Guys and our podcast (another one will launch this weekend btw).

Screen Shot 2019-04-12 at 8.43.42 AM.png

But reducing the plantar flexion moment in the late stance phase of running and walking can make notable changes in the loading response to the posterior plantarflexor mechanism (the gastroc-soleus-achilles complex). A rocked shoe, according to this study, can reduce the plantarflexor moment without substantial adaptations in triceps surae muscular activity.
This of course brings to mind the HOKA family of shoes that have purposefully added a gentle rocker mechanism to some of their shoe line, some with an early and some with a late stage metarocker built in. Are you a HOKA hater? We were not fans in their early development because of the volume of stack height foam, but they have many more options in their line up now. But do this for us, do not pass judgement until you put one of these metarockered shoes on, and you will understand the function of it, and their place for your chronic posterior compartment clients. Don't reflexively judge until you try them. It is good to have options for your clients, because "stop running" is not an option for runners, for our runners, unless all else has failed.

Shawn Allen, the other Gait Guy

#thegaitguys, #gait, #hoka, #metarocker, #achilles, #tendinitis, #gaitproblems, #gaitanalysis, #calfpain, #running

J Sci Med Sport. 2015 Mar;18(2):133-8. doi: 10.1016/j.jsams.2014.02.008. Epub 2014 Feb 14.

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

Sobhani S1, Zwerver J2, van den Heuvel E3, Postema K4, Dekker R5, Hijmans JM6.

Increased unilateral foot pronation can cause cephalad asymmetries.

Screen Shot 2019-04-07 at 9.44.59 AM.png

Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Nothing earth shaking here, we should all know this as fact. When a foot pronates more excessively, the arch can flatten more, and this can accentuate a leg length differential between the 2 legs. But it is important to note that when pronation is more excessive, it usually carries with it more splay of the medial tripod as the talus also excessively plantarflexes, adducts and medially rotates. This action carries with it a plantar-ward drive of the navicular, medial cuneiforms and medial metatarsals (translation, flattening of the longitudinal arch). These actions force the distal tibia to follow that medially spinning and adducting talus and thus forces the hip to accommodate to these movements. And, where the hip goes, the pelvis must follow . . . . and so much adaptive compensations.
So could a person say that sometimes a temporary therapeutic orthotic might only be warranted on just one foot ? Yes, of course, one could easily reason that out.
-Shawn Allen, one of The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #LLD, #leglength, #pronation, #archcollapse, #orthotics, #gaitcompensations, #hippain, #hipbiomechanics

Gait Posture. 2015 Feb;41(2):395-401. doi: 10.1016/j.gaitpost.2014.10.025. Epub 2014 Nov 3.
Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking.
Resende RA1, Deluzio KJ2, Kirkwood RN3, Hassan EA4, Fonseca ST5.

Habituating a gait correction

We tell our patients all the time that the key to acquiring the gait correctives is the number of times a day they show the nervous system the corrective gait patterns. It is not about 2-3 solid episodes of homework a day, rather, it is an hourly 2-3 minute focused episode driving nothing be the cleaned up motor skill we are trying to neurologically "rewrite".
We have 3 tiers in my office, Gold, Silver and Bronze.
Gold medal homework= 2-3 minutes every hour.
Silver medal homework= 2-3 min every 2 hours
Bronze medal homework= 2-3" every 3 hours (that is still a medal, because it is still 6x a day)

We start with one corrective in their gait and homework to set that pattern up. Then next visit we up the difficultly on that skill/pattern, and introduce another new one that is part of the overall gait correction was want to see. Thus, they are juggling 2 balls, one that is more familiar but a little harder, and now a new one that is at the basic level. The next visit, we add a 3rd ball, upping the demands on the other 2.
Rinse and repeat.
This goes for walking and running gait problems.

IF they want this pattern to be come more habitual faster, one has to go for gold, or gold++.

-Shawn Allen, the other gait guy
#gait, #gaitproblems, #gaitcorrections, #gaitretraining, #gaitanalysis, #thegaitguys, #habits, #runningform

"The findings indicate that the amount of practice in the criterion task is more critical than the difficulty and variations of task practice when learning new gait patterns during treadmill walking."

https://www.ncbi.nlm.nih.gov/pubmed/30905405

Loss of terminal knee extension: How quickly can you process the facts ?

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Some quick thoughts that must go through your mind on your examination. These thoughts must be ingrained, so that you can quickly juggle the other issues you client is coming in with that may very likely be related to the loss of left knee terminal extension.

more knee flexion may likely mean more ankle dorsiflexion , and that means more more anterior shin compartment strength is necessary to stop a quick progression to the forefoot (consider their clinical symptoms), this may mean pronation occurs more quickly (consider their clinical symptoms), it may mean more abrupt quadriceps loading since the loading does not start in more reasonable knee extension which means the quad is short now and that means increased patellofemoral compression possibilities (consider their clinical symptoms), this may mean more hip flexion on initiation of stance phase (consider their clinical symptoms), this may lead to more anterior pelvis tilt posturing and thus increased lordosis (consider their clinical symptoms), this flexed knee means that the leg is shorter which will through off pelvis symmetry (consider their clinical symptoms), this may mean more work for the contralateral hip abductors (consider their clinical symptoms), this may mean more frontal plane pelvis drift to the short leg side (consider their clinical symptoms), it will also mean 2 different step lengths which means 2 different hip extension patterns which means 2 different heel rises, and it will likely mean altered arm swing on both sides which can create changes into thoracic rotation (and of course the cervical spine sits on top of that) etc etc etc, so consider their clinical symptoms . . .

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just wanted to quickly rattle off how fast your brain must juggle things, otherwise your exam is going to be knee-centered and tunnel visioned. Keep in mind, your client may not even have knee complaints, perhaps one or more of the above. But this is a perfect example of why you must examine the WHOLE client.

Perhaps this gives you even deeper understanding (combined with yesterdays "parallax binocular vision 2D post" as to why we will not give online corrective homework or consultations. There is just no way all of these things can be considered over video, Skype, Zoom or anything of the sort. Gait analysis must be done in person and encompass a hands on exam, if you do not want to miss something possible critically important, in our opinion, for what that is worth.

Shawn Allen, the other gait guy

#kneeextension, #gait, #gaitanalysis, #gaitproblems, #gaitanalysis, #gaitcompensations, #correctiveexercises, #thegaitguys

When you run Do you kick or scrape the inside of your ankle with the other foot ?

Do you kick or scrape the inside of your ankle with the other foot ?

Runner's pathologies creep in as the miles go up, fatigue can be a variable in biomechanical breakdown. Some of you who have been with us for years have seen this picture. This young runner had these scuff marks on the inside of the right lower leg and ankle after a cross country meet. So what is going on here and what does it tell you ?

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Some runners notice that they repeatedly will scuff in the inside ankle or inner calf with the opposite shoe when running. This can happen on both sides but it is more often present unilaterally than bilaterally.

This problem, typically, but not always represents one of two things:

1- cross over gait (if you are new to our blog in the SEARCH box type in “cross over” and “cross over gait” and be sure to see our 3 part video on the cross over on our youtube channel found here).

2- negative foot progression angle which may or may not be combined with a degree of internal tibial torsion. Said easier, the runner is “in-toed” or “pigeon toed” but if you have been here with us awhile on The Gait Guys we expect a diagnosis of a higher order so use the former terms, please.

Lets discuss both.

1- Cross over. When the runner is standing on the right leg, right stance phase of gait, the frontal plane is not properly engaged and the pelvis can drift further over the right foot. This drift to the right will drop the pelvis on the left side. This will alter the pendulum movement of the left leg. Since the global pelvis is moving to the right the left swing leg pendulum moves to the right as well and as it swings past the stance leg it strikes a glancing blow to the inside of the right ankle or calf. This is simple biomechanics and physics. To fix this problem, which is clearly inefficient, one has to determine what is causing the right pelvis drift (there are many causes, the most often thought of cause is a weak gluteus medius on the right but if you have been here with us awhile you will know there are other causes) and then fix the drift. Do not assume it is the gluteus medius all the time, for if it is not, and you employ more glute medius exercises you could be ignoring the source and building a deeper compensation pattern. Fix the problem, not what you see.

2- Negative foot progression angle and/or internal tibial torsion. In order to fix this you have to know first if you are dealing with a fixed/rigid anatomic tibial or femoral torsion issue which cannot be fixed or if you are dealing with a flexible progression angle issue. Often, “in-toeing” is accompanied with internal tibial torsion, this is because the knee has to progress forward to keep its tracking mechanics clean, if you correct someone’s foot progression back to neutral and they have internal tibial torsion then you have dragged the patellar tracking outside the normal sagittal progression angle, knee pain will ensue. In fact, the foot progression on the ankle is normal, but the tibia or femur are merely torsioned in a manner that drags the foot inwards with the long bone orientation, again, this is driven by a higher order/demand, to normally track the patella sagittally (forward). However, if this is a pre-puberty individual you have time because the long bone derotation process is still occuring. Give homework to encourage a good foot tripod and work to strengthen the external hip rotators and encourage sagittal knee tracking mechanics. This is a delicate balancing act, but it can be done, but it is a monster of a project for a blog post because each case is different, variable and always changing depending on the client progress. Remember, you can only encourage more appropriate mechanics and hope that the body will embrace some of the change and encourage some of the de-rotation process to occur from the long bone growth plates.

The “inside scuff”, to identify its solution you have to know the cause. After all, if it was as easy a fix as “stop doing that” no one would be doing it and we would be out of a job.

Shawn and Ivo …… The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #gaitcompensations, #hippain, #hipbiomechanics, #crossovergait, #narrowstepwidth, #calfscuff

When the Windlass is lost.

When the Windlass is lost.
Here, this case again (hallux amputation), when the Windlass is lost or at the very least, impaired, what holds up the arch?
Without the winding of the plantar fascia through hallux dorsiflexion (toe extension) and without the FHL (flexor hallucis longus) we lose major engineering advantages to lift/support the arch and control pronation variables.
So what is left ?
Tibialis posterior, tibialis anterior, peroneus longus, mostly, are what is left. So when these guys are suffering (ie, tendinopathy etc) it could be due to the other previously mentioned engineering marvels being impaired.

It is a team effort to keep the foot healthy and functioning without expressible pathology.

*note the heavy flexion attempts of the 2nd toe, the next soldier in line, no surprise there.
Now you should realize why you see this 2nd toe over-flexion attempts when even an existing, yet incompetent, hallux is present.

This slide is part of a new presentation, one we will be doing a WEBEX on that you can all join in on, and it will be a new presentation for our onlineCE Wednesday night seminars.

Now, go read this dudes blog, inspirational journey through big toe cancer. Thanks for sharing your story Kevin, and your case photos. (PS: presentation is almost done, so i will be in touch soon so we can go over it and collaborate).
https://www.theagecoach.com/

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #gaitcompensations, #halluxamputation, #windlassmechanism, #halluxdorsiflexion, #pronation, #FHB, #FHL, #hammertoes, #theagecoach

The Bird Dog rehab exercise is neurologically incorrect. Know what you are asking your client to do, and why..

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Runners, athletes . . . Even in your drills, do it correctly !
Is this Bird Dog standing up? No, look more closely.

Photo #1: pull that right swing leg outwards with your abductors/external rotators. Do not let the knee drift inwards, it will lead to that foot targeting the midline. Plus, because of the neurologic links, it will encourage the left arm to cross the mid line (see yesterdays FB blog post). The upper limb movement can shape lower limb movement. An aggressively narrow cross over gait is undesirable in many aspects, it might be more economical, but it has a wallet full of potential liabilities.
IF you train your machine in a lazy manner, it is not unlikely it will perform as such. Get that knee under the shoulder, not under your head.

Aside from that, this is a good drill. It is neurologically correct. Note that:
- the right arm is in extension and the left hip is in extension
- the left arm is in flexion and the left knee is in flexion.
This is neurologically correct cross crawling.

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* VERY important point:
the Bird Dog exercise is not neurologically correct for the reason of training the proper crossed patterning from a neuro perspective. Note that in the 2nd photo, the bird dog, the same left arm is in flexion, but his left leg is in EXTENSION ! If you want to use the bird dog to teach core engagement, that is one thing, but do not think you are coordinating normal gait patterns or the proper crossed response. This is why we do not use the Bird Dog with our patients, it goes against training fundamental gait patterns.
When we crawl, we use the following pattern:
- the right arm is in extension and the left hip is in extension
- the left arm is in flexion and the left knee is in flexion.

This is neurologically correct cross crawling. Don't believe us ? Get on the floor and crawl like an infant, it is no where near the bird dog exercise, in crawling the coupled crossed extension and flexion responses are NOT conflicting. So, just because the Bird Dog "sort of looks like crawling" do not get it confused with crawling, because it is not. It is a mere balance exercise, some use it for the core stability, but it is one based on UN-fundamental neurologic patterning we use every day.......something called gait, and running, things we do in our sports. So understand what message you are sending to the CNS.
We are not saying the Bird Dog does not have value, not at all, but if you are not thinking about what it actually is doing, you might be driving patterns you do not want.

The hip flexors do not cause initial hip flexion.

The hip flexors are not responsible for pulling/flexing the swing leg forward in gait or running. The psoas is a mere swing phase perpetuator, not an initiator.
For about 2 decades we have been saying in our lectures, posts and podcasts that it is the reduction of the obliquity of the pelvis during gait from various other tissues and biomechanical events that causes leg swing, meaning the trail leg is brought forward in swing largely by the abdominal muscle linkage to the pelvis (and other loaded tissues) that is responsible for forward swing of the leg. It is not the hip flexor group that does this hip flexion action. Thus it could be considered foolish to train the hip flexors to be the primary swing drivers. Here is another supporting piece of research.

"These experiments also showed that the trailing leg is brought forward during the swing phase without activity in the flexor muscles about the hip joint. This was verified by the absence of EMG activity in the iliacus muscle measured by intramuscular wire electrodes. Instead the strong ligaments restricting hip joint extension are stretched during the first half of the swing phase thereby storing elastic energy, which is released during the last half of the stance phase and accelerating the leg into the swing phase. This is considered an important energy conserving feature of human walking. "

Dan Med J. 2014 Apr;61(4):B4823.
Contributions to the understanding of gait control.
Simonsen EB1.

https://www.ncbi.nlm.nih.gov/pubmed/24814597?fbclid=IwAR3yZQLb2Z0X1LZSVp2hOFLCt3wefsPt4iWEGveswn7-aGaou5OdDqmj4lA

The Mighty Multifidus

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:

"Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity."

see also our post here: https://tmblr.co/ZrRYjx14tXWrD

Dr Ivo Waerlop, one of The Gait Guys

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print] The immediate effect of dry needling on multifidus muscles' function in healthy individuals. Dar G1,2, Hicks GE3.

#gait, #gaitanalysis, #multifidus, #lowbackpain, #proprioception,#thegaitguys

A foot bump. What might this be, and mean?

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A foot bump.
We see this kind of thing all the time. This is a fixed pes planus (flat foot). When we dorsiflex the big toe, the arch does not go up as you see in the photo. That is passive dorsiflexion, if the arch does not go up passively, there is no way you are actively going to achieve this. And, using an orthotic to "attempt" to raise this arch is not only pointless, but it is futile and it will likely cause them pain. This arch does not rise, no matter how hard you put up into it. The bump, that is the navicular bone, and its associated arthritic build up at the adjacent joints, and likely soft tissue accomodation/hypertrophy. You can't needle, ultrasound, tape, adjust or rub this bump away, so stop wasting your and your patient's time selling them that wasteful thinking. It ain't gonna happen.
This is what happens when someone earns a collapsed longitidinal arch, the 1st metatarsal no longer plantarflexes (arch up) and it becomes fixed in dorsiflexion, thus affecting the mechanics at the proximal aspect of the 1st ray complex (navicular-cuneiform-met intervals).
Why? This happened because this client has significantly compromised ankle mortise dorsiflexion, and they chose to find it at the next joint complex distally, as mentioned above. So, they are finding pseudo-ankle rocker at arch collapse? Yes, we discuss this often, more pronation will advance the tibia forward. It is not desirable, but moving forward has to occur, and some people have no choice but to find it from excessive internal rotation and pronation of the limb. And this is what happens when it happens over years. Now the deformity is painful itself in the shoe, it is a new set of problems for this client.
Can this problem occur in reverse ? Yes, a loss of hallux dorsiflexion can afford the same end result.
We have a rule, at the very VERY least, check the joint above and below the area of problem/symptom. Often you will find another piece of the puzzle causing your client's pain.