A symptomatic tendon affects more than the local area it finds itself, it "affects the neuromuscular control on the involved side but not the non-involved side. The muscle–tendon unit on the tendinotic side exhibits a lowered temporal efficiency, which leads to altered CNS control. The altered CNS control is then expressed as an adapted muscle activation pattern in the lower leg". - Yu-Jen Chang and Kornelia Kulig
Rewind Video Friday.
If you ever were unclear on how the sesamoids, 1st MET and FBH (flexor hallucis brevis) and others party together, this video will help you get up to speed.
As we begin the process of generating new videos, we came across this little gem from 8 years ago. Who is this younger punk ? Its Dr. Allen, showing some foot skills and sharing knowledge, stuff that will serve you well as we move forward with new videos.
Your holiday homework . . . . look for the gait clues Ivo and Shawn have talked about this year (*see below)
Dual tasking and neurocognitive decline.
Mild cognitive impairment (MCI) is considered a predementia state associated with a 10-fold increased risk of progression to dementia. Dual tasking during gait may help predict neurocognitive decline.
So, When you are around aging family this holiday season, pay close attention to them when moving about around them. Dual tasking during gait should not be difficult for most healthy folks, but if you add in things that the aging population are challenged with (things like physical weaknesses, mild vestibular challenges, visual challenges , mild neuropathy, cold feet, proprioceptive losses) and then throw in some dual tasking (talking, carrying bags) we can often bring out predictors of future decline.
Remember, falls in the elderly are huge predictors of near term morbidity.
* Look for the clues during dual tasking or during intimidating situations (ie, crossing a busy street), look for things like slowing of gait, wider or narrower step width, shorter steps, frustration, confusion, reaching for support (grapping your hand or arm), stopping, shuffling, arresting of talk to negotiate an area, etc.
"A dual-task gait test evaluating the cognitive-motor interface may predict dementia progression in older adults with MCI (mild cognitive impairment)."
Association of Dual-Task Gait With Incident Dementia in Mild Cognitive Impairment
Results From the Gait and Brain Study. Manuel M. Montero-Odasso et al.
JAMA Neurol. 2017 Jul; 74(7): 857–865.
The “Standing on Glass” Static Foot/Pedograph... PART 2
We hope you find this case presentation dialogue interesting.
* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon.
Here is the case . . .
Part 2: “Standing on Glass” Static Foot/Pedograph Assessment
* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.
Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there.
We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left. The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ? Only a competent clinical examination will enlighten us.
Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings. Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern.
Remember this critical fact. After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively. Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.
Come back tomorrow. We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation. See you tomorrow friends !
Shawn and ivo, the gait guys
* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations. Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining. The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?
tag/key words: gait, gaitproblems, gaitanalysis, forefootrunning, forefootstrike, achilles, heelstrike, elastography, thegaitguys, microvascularity, rockeredshoes, HOKA, metarocker, gaitretraining,
Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".
Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
shawnallen.net
Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Where to find us, the podcast Links:
iTunes page:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
Google Play:
https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast
Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_150.2_-_42719_5.00_PM.mp3
Permalink URL: http://thegaitguys.libsyn.com/forefoot-running-achilles-loads-gait-retraining
Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/9555122
Show notes:
Ultrasound elastographic assessment of plantar fascia in runners using rearfoot strike and forefoot strike. Tony Lin-WeiChen et al
https://www.sciencedirect.com/science/article/pii/S0021929019302775
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 S et al
https://www.ncbi.nlm.nih.gov/pubmed/24636129/
The increase in muscle force after 4 weeks of strength training is mediated by adaptations in motor unit recruitment and rate coding. Alessandro Del Vecchio et al
https://physoc.onlinelibrary.wiley.com/doi/10.1113/JP277250
Learning new gait patterns is enhanced by specificity of training rather than progression of task difficulty. ChandramouliKrishnan et al
https://www.sciencedirect.com/science/article/pii/S0021929019301927
The microvascular volume of the Achilles tendon is increased in patients with tendinopathy at rest and after a 1-hour treadmill run. Pingel J et al
Am J Sports Med. 2013 Oct;41(10):2400-8. doi: 10.1177/0363546513498988. Epub 2013 Aug 12.
https://www.ncbi.nlm.nih.gov/pubmed/23940204/
*** Our PODcast disclaimer:
This podcast is for general informational purposes only. It does not constitute the practice of medicine, nursing, rehab, treatment, therapy recommendations or anything of the sort. This podcast should not replace proper medical advise that should only be attained through proper medical channels that would entail a full medical and/or biomechanical physical examination and/or appropriate diagnostic testing. No doctor-patient relationship is formed by listening to this podcast or any information gleaned from our writings or social media work.
The use of this information and the materials linked to the podcast is taken at the users own risk. This podcast and the content shared is not intended to replace or be a substitute for appropriate professional medical advise diagnosis or treatment. Users should not disregard or delay obtaining medical advice for any condition they have and should seek the advice and assistance from their providers for any such conditions.
Soapbox rant today: So forget repairing your ACL tear huh?
Just give it some deep thought before you decide rehab is enough for you. Don't get fully sucked into the non-surgery hype, sometimes there is value and purpose. We are not necessarily saying that we are pro-ACL surgery, but it does have a place when we are talking about a major ligament with many functions beyond articular vector restraint.
*Here is where we see the present problem with the "newer" rehab-only hype for ACL tears . . . . the follow up time frames of the research pieces that suggest that ACLR is sufficient, in our opinion are not long enough into the future (years) to substantiate that secondary instability is not occurring or not a risk. In fact, there are enough articles to substantiate that secondary instability (often deeply rotational) will occur if no ACL repair occurs.
But, other bad things can happen if the joint is not cinched up tightly.
"Increases in TFI (time from injury) are associated with medial meniscal tears, including irreparable medial meniscal tears, medial femoral condyle chondral damage, and early medial tibiofemoral compartment degenerative changes at time of ACLR. These findings highlight the importance of establishing a timely diagnosis and implementing an appropriate treatment plan for patients with ACL injuries. This approach may prevent further instability episodes that place patients at risk of sustaining additional intra-articular injuries in the affected knee. "
*in this study 47.2% were classified as playing competitive or professional sports versus recreational sport
There have been some therapists in the field around the world that have been promoting that ACL surgeries ** are seemingly becoming more and more unnecessary. Their stance seems to be that with hardcore rehab that the knees do just as well, that performance is not lost. Sure, this is possible this or next season, but what about in 2 years? 5 years ? And what will the consequences be then? This article outlines some thoughts.
So, lets just all be careful of the strong points of view we put out there for the consumer. We get their point, but it is foolish to dismiss that the ligament doesn't have a function and is never necessary to replace/repair as this article (and many others report). SECONDARY instability is a real thing, rotational instability in non-ACL repaired** knees is a real thing. Attenuation of secondary joint restraints over time is a real thing, and the cost that comes with those changes. The consequences to the joint structure as secondary instability sneaks in, are a real thing, they are most likely to occur, even if you rehab your client's knee deeply. So be sure that you educate your client, that without their ACL their knee will never be as good, even if you are a champion rehab guru, you are just not that good that you and your rehab can negate all of the rotational vectors of loading in your high level athletes. Time and load will win, just be honest. Just because you do not see consequences tomorrow, just because your top-tier athlete continues to perform this season at top levels without compliant, doesn't mean they will not be present next year. Just be up front with your clients.
And here is another thought to chew on. 24 months ago my Jui-jitsu master Prof Carlos Lemos Jr. tore his ACL. We rehabed and he did well, he even won his 4th world championship without his ACL. But, we had these talks, and he knew that even though he was able to perform at the top level, he knew that the leg was not like the other. He decided 6 weeks ago to have it repaired because we discussed many times the above kinds of long term possibilities. I placed what facts and experiences I have had over 20+ years, the research that is presently out there, and let him decide. He decided that "hope" only goes so far, that he knows he will not be exceptionally as strong on the long term rehab to the degree it was initially performed, and he did not want to risk subsequent internal joint damage that might ensue.
Yes, not everyone needs ACL surgery, especially those who are not highly active or sporting, or the aging/elderly, but we can make a case that just rehabing and dismissing repair is also going to miss some vital points. We are not saying that we are pro-ACL surgery, but it does have a place.
Just educate your client honestly, then let them decide the direction, and do good work.
If anyone wishes to debate here, lets do it. But come at us with 5-10 year post-rehab no-ACL surgery cases with MRI's showing no intra-articular cost. (Good luck with that.) But if you find such unicorns, we definitely want to see them so we can share it and adjust our stance more softly. We want to be as smart and accurate on our rants as possible, it is important.
**corrected/ammended 10:57central time
photo credit: pixabay.com. thank you !
Orthop J Sports Med. 2018 Dec 11;6(12):2325967118813917.
Relationship Between Time to ACL Reconstruction and Presence of Adverse Changes in the Knee at the Time of Reconstruction.
Sommerfeldt M1,2, Goodine T2, Raheem A3, Whittaker J1,4, Otto D
You cannot change one thing, and not expect the other parts to change, have to adapt, and possibly complain at some point.
The loads are going to go somewhere.
Too much pronation means the arch may be reduced in height, but it also means that the first ray complex (the 1-2 metatarsals essentially) is dorsiflexing more than normal. This means they will not likely get to their adequate plantarflexion by the time the foot is ready to heel rise and toe off at supination. In other words, if you have pronated and dorsiflexed too long and too much, you will eat up the time you needed to plantarlfex and supinate.
This means that "Increased foot pronation may compromise ankle plantarflexion moment during the stance phase of gait, which may overload knee and hip."-Resende et al
If you cannot plantarflex the foot-ankle complex sufficiently, or in a timely manner, you should understand that you are carrying this fault forward while moving into heel rise during the forefoot rocker stance phase of gait, and you are doing it over a less stable, less rigid foot-ankle complex because it is still in relative pronation. This means you are placing higher propulsive loads over an unprepared ankle-foot complex. This means different/altered posterior compartment function, which can mean altered knee and hip function. Sagittal plane function, to name the most obvious, will have to create and endure compensatory loads. Sure, they may be fine for a time, but perhaps there will be a cost over time. Now, many might say, "if it is not a problem now, it is not a problem", let them build robustness on their chosen pattern; that can be very hopeful and shortsighted thinking in our opinion. Why not change things that are obviously aberrant and build robustness on a pattern and correction that is suspected to be more sound? This can be a cyclical argument that no one wins, EVER, we all see it all the time. After all, the arguments become silly after time, and we resist our own silly comments like "well, why change the oil in your car right now, nothing bad is happening at this time. Or, well that front right tire, though bald and nearly flat, is still rolling along so why bother changing it out?" But that stuff gets no one anywhere, other than pissed off, so we hold back. The debate never gets furthered along, because no one can see the future.
So, we will leave this rant with this thought, we cannot change one thing, and not expect the other parts to change, have to adapt. And adaptation can be both good OR bad. Or maybe we should say, good AND bad.
The loads are going to go somewhere. Lets leave it at that.
photo: credit pixabay.com
Gait Posture. 2018 Oct 23;68:130-135. doi: 10.1016/j.gaitpost.2018.10.025. [Epub ahead of print]
Effects of foot pronation on the lower limb sagittal plane biomechanics during gait.
Resende RA1, Pinheiro LSP2, Ocarino JM3.
Toe off.
How we off load can affect the tragectory of the knee sagittal hinging and it can affect the frontal, sagittal and rotational planes at the hip.
We can see here that a nice high gear medial foot toe off will draw the knee in a more sagittal direction (knee over foot, hip over knee) where as a lateral foot toe off, low gear off the lateral metatarsals could easily encourage the knee into the frontal plane, and the hip into the frontal and lateral rotational planes (knee outside the foot, hip outside the knee).
Lack of strength or awareness or endurance on a long run to endure the "more normal" medial toe off could lead to some knee tracking challenges and pathomechanical set up at the knee and hip, or elsewhere for that matter.
It is the clinicians job to find out if this is a factor, whether it is anatomic (torsion of long bones), weakness, lake of proprio/awareness or a combination of them.
Sometimes the smallest of details in how your client moves can get you the answers you need as to why your client may be in pain.
Attached is an older video from a few years back , it is very similar in execution to the heel-rise ball squeeze exercise which is the precursor to this more functional engagement as shown in this video today.
The important premise is that you have to have command of the entire posterior compartment if you are to get safe, effective, efficient and adequate ankle plantarflexion. As we have discussed many times, if you do not have the requisite skills as shown in this video you are in trouble and ankle sprains and other functional pathologies are not unlikely to visit you. Additionally, without requisite posterior compartment endurance and an ability to engage what I like to refer to as "top end" strength in the heel rise is an asymmetrial loading issue and can lead to compensatory adaptations up the kinetic chain. Make no mistake, the load will go somewhere, and thus the work will be done somewhere. In this video you should be able to clearly see and understand that one must be able to achieve top end posturing and have command of lateral and medial forefoot loading responses and challenges if clean forward function and power is to be achieved, and injuries from extremes of motion medially and laterally are to be avoided. Furthermore, as eluded to here and in several of our podcasts (and in the study included below), an inability to achieve top end posturing will lead to changes in forefoot loading, may spill over into endurance challenges prematurely in the posterior mechanism, and create changes in the timing of the gait cycle (things like premature or delayed heel rise, premature or delayed forefoot loading, recruitment of other components of the posterior chain just to name a few). This parsing and sharing of loads and responsibilities is laid out in the Kulmala study referenced today. The study could be extrapolated to say, I believe, that particularly in sprinting, a failure to achieve top end heel rise through effective posterior mechanism contraction, will change the load sharing between the posterior compartment and the quadriceps. After all, if the calf is weak, the ankle is not in as much plantarflexion, this could mean more knee flexion and thus raise demands on the quadriceps, logically changing knee mechanics. This is exactly why we spend so much time at every patient visit looking for full range of motion at the joints and then determine the skill, endurance and strength of the associated muscles in supporting that range. Then, of course, comparing this function to the opposite limb. Symmetry is not everything, but it is definitely a major factor in safe efficient and injury free locomotion.
* Please give great thought to the part in the video where I discuss the drop phase in jumping. All too often we at looking for the propulsive mechanics and forget that a failure there will also be represented during the adaptive phase. Ankle sprains rarely occur from propulsive pushing off, they occur from a failure to properly reacquaint the foot to the ground on the following step.
-Dr. Shawn Allen, one of the gait guys.
In this study the authors noted:
"During walking, the relative effort of the ankle extensors was almost two times greater compared with the knee extensors. Changing walking to running decreased the difference in the relative effort between the extensor muscle groups, but still, the ankle extensors operated at a 25% greater level than the knee extensors. At top speed sprinting, the ankle extensors reached their maximum operating level, whereas the knee extensors still worked well below their limits, showing a 25% lower relative effort compared with the ankle extensors."
And concluded that:
"Regardless of the mode of locomotion, humans operate at a much greater relative effort at the ankle than knee extensor muscles. As a consequence, the great demand on ankle extensors may be a key biomechanical factor limiting our locomotor ability and influencing the way we locomote and adapt to accommodate compromised neuromuscular system function."
Med Sci Sports Exerc. 2016 Nov;48(11):2181-2189. Walking and Running Require Greater Effort from the Ankle than the Knee Extensor Muscles. Kulmala JP1, Korhonen MT, Ruggiero L, Kuitunen S, Suominen H, Heinonen A, Mikkola A, Avela J.
https://www.ncbi.nlm.nih.gov/pubmed/27327033
https://youtu.be/8T9UzOaYxmo
the gait guys
#gait, #gaitproblems, #thegaitguys, #gaitanalysis, #heelrise, #calfstrength, #toeoff, #forefootloading, #metatarsalgia, #inversionsprain
Topics:
Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".
Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
shawnallen.net
Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Where to find us, the podcast Links:
iTunes page:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
Google Play:
https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast
Direct download URL: http://traffic.libsyn.com/thegaitguys/pod_143_146old_-_11919_11.11_AM.mp3
Permalink URL: http://thegaitguys.libsyn.com/podcast-143-future-of-movement-running-cadence-and-more
Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/8316341
Show notes:
The future of human movement control ?
https://www.zerohedge.com/news/2019-01-01/zuckerberg-funds-wireless-mind-control-using-game-changing-brain-implants
Really interesting study: in-race cadence data from world 100K champs. Fatigue matters less than expected;
https://www.outsideonline.com/2377976/stop-overthinking-your-running-cadence?utm_medium=social&utm_source=twitter&utm_campaign=onsiteshare
A new study shows a majority (82%) of adolescent patients presenting with FAI syndrome can be managed nonoperatively, with significant improvements in outcome scores at a mean follow-up of two years: ow.ly/GXtC30n49nc pic.twitter.com/dyr4f6pEOU
Gait Rehab
https://academic.oup.com/ptj/article/88/12/1460/2742171
" Rehabilitation of gait in PSP should also include oculomotor training because the ability to control eye movements is directly related to the control of gait and safe ambulation. Vision plays a critical role in the control of locomotion because it provides input for anticipatory reactions of the body in response to constraints of the environment. Anticipatory saccades occur normally in situations that involve changing the direction of walking17 or avoiding obstacles.18 When downward saccades are not frequently generated during obstacle avoidance tasks, there is an increase in the risk for falling. Di Fabio et al19 reported that elderly people at a high risk for falling generated fewer saccades than their low-risk counterparts during activities involving stepping over obstacles. In addition, foot clearance trajectories were asymmetric in the high-risk group, with the lag foot trajectory being significantly lower than the lead foot trajectory. Similar behavior has been observed in patients with PSP during stair-climbing activities. Di Fabio et al20 recently reported that patients with severe oculomotor limitations had a lower lag foot trajectory than those with mild oculomotor limitations. "
Eye movements:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932064/
" The content of the eye movement program was as follows: First, a picture card was shown to the patient, and then mixed with 20 other cards and spread face up on the desk. The patient was instructed to find that one card. This task was repeated approximately 20 times. Second, the therapist moved a baton slowly while drawing curves and the patient was instructed to keep his or her gaze fixed on the tip of the baton. In this task, the distance between the baton and the patient was maintained at approximately 1 m and the task was performed for approximately five minutes. Third, the patient was instructed to shake his or her head laterally as quickly as possible and a letter card with letters written upside down was presented to the patient to read. This task was repeated approximately 10 times. Fourth, the therapist moved a baton slowly from a point approximately 5 cm away from the patient to a point approximately 50 cm away and the patient was instructed to keep his or her eyes on the baton. This task was performed for approximately five minutes. The experimental group underwent eye movement training while the control group underwent gait training for 20 minutes per session, five times per week for six months in total."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259492/
Plantar fascia loads higher when forefoot striking . . . .
https://www.sciencedirect.com/science/article/pii/S0021929018308959
Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis
Tony Lin-WeiChen et al
High pronation was associated with 20-fold higher odds of injury than neutral foot posture
Association between the Foot Posture Index and running related injuries: A case-control study
AitorPérez-Morcillo et al
https://www.sciencedirect.com/science/article/pii/S0268003318304303
movement, gait, thegaitguys, running, cadence, step length, stride length, eye movements, rehab, gait analysis, gait problems, pronation, plantar fascia,
This is a small clip on arm swing from podcast 137.. For the full podcast, head over to our website or iTunes or anywhere that you choose to download your podcasts.
Key words: arm swing, gait, gait analysis, thegaitguys
Links to find the podcast:
iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
Direct Download: http://traffic.libsyn.com/thegaitguys/pod_138.1_arm_swing_-_82718_5.18_PM.mp3
Permalink URL: http://thegaitguys.libsyn.com/podcast-shorts-1381-arm-swing-in-sport
Libsyn URL: http://directory.libsyn.com/episode/index/id/6975092
Our Websites:
www.thegaitguys.com
summitchiroandrehab.com doctorallen.co shawnallen.net
Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Last week we promised Part 2 to this case, the amputated big toe.
Here is part 2. These are the complicated biomechanical fall-outs, so grab a big mug o' coffee and have at it !
In review, this person (all photos and case premissioned in swap for insight) had the distal hallux removed because of a progressive melanoma on the big toe. Can you believe that ! This is one more reminder that the sun and regular dermatologist screenings are wise.
This person had a complaint of progressing right gluteal and QL pain, spasm, tone and some persistent pain now in the 2nd metatarsal as well as some shoe challenges. We discuss this case briefly in and upcoming podcast, #139 or #140 we believe.
Before we add our final thoughts to this case, lets cap our post from last week.
-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- More internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will likely be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree).
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities
- These factors are likely related to his complaints in the right gluteal and low back/QL area.
Now, onto our next thoughts.
- when the hallux is incompetent, in this case absent, there are few other choices to gain forefoot purchase on the ground other than more flexion gripping of the 2nd toe (then the 3rd, then 4th). This is a progressing "searching" phenomenon for forefoot stability and without the function of the big fella, the 2nd toe will begin a hammering phenomenon, often, but not always. We would not be surprised to see hammer toe development in this case, but this person is now very aware of it, and can at least now fight that battle with increased awareness. There is some mild evidence of this on the side lateral photo.
- We are happy to see that the proximal phalange was spared. The adductor hallucis is inserted medially there, and this will help to reduce bunion generation risk (medial metatarsal drift). Comparing the photo and the radiograph is a great example of how far back/proximal the 1st MTP joint is. One could easily assume that the entire hallux was resected from the photo, but the radiograph shows otherwise.
- Toe off is obviously going to be compromised. The patient cannot adequately stabilize the 1st metatarsal (MET) and this will mean a compromised foot tripod, medial foot/tripod splay, arch pronation control challenges but toe off stabilization is going to have to be met by the 2nd and 3rd digits, as discussed above. They are not suited to be the major players here, they are synergistic to this end. Do not be surprised to see one of 2 strategies at toe off here:
1. heavy medial foot tripod toe off, dropping into the void and this maximize the internal spin challenges and minimizing the requisite foot supination stiffness generation phase that should be normal at toe off
2. avoidance of the above, with a forced conscious forefoot lateral toe off, a supinatory strategy, to avoid internal limb spin, more toe hammering, and the lurch heavily and abruptly off of the right foot and onto the left limb.
3. taking #2 further, any time there is perceived challenges or deficits in strength, endurance, proprioception, balance, power and the like, the brain often will create a premature departure off of said limb, creating a requisite premature loading onto the opposite limb. This can cause a phenomenon well loosely refer to "catching" in the contralateral quadriceps mechanism. These clients, with their abrupt loading pattern onto the opposite limb will most often have troubles getting into initial gluteal hip stabilization strategies, and thus default into a quadriceps strategy, that in time can lead to quad shortness and increased tone, which can cause more compression across the patellofemoral joint and cause knee pain. This is more of a compression/loading response issue rather than tracking phenomenon, which we see at the typical diagnosis. We often look for causes in the opposite limb for contralateral knee pain. IT is quite often there if you are looking hard enough for it. Fix the problem, not the symptom.
There is a long host of other things than can arise from here, including heavy contralateral (in this case left sided) foot loading challenges, often more forefoot initial loading, and all of the problems than can arise when this pattern is cyclical, but that would take this post far too deep and long. So, . . . . another time.
4. Shoe fit, we could make the case that a shoe that nicely hugs the forefoot, as opposed to a wide toe box'ed shoe, could help fight off the risk of 1st metatarsal abduction and thus bunion formation risk. However, one cannot dismiss the wider toe box giving the remaining toes a better environment to engage without hammering with over use of long flexors. We might suggest a trial of an elastic sleeve, one often used for plantar fascitis symptom management, placing a snug one around the forefoot when ambulating. This could help keep that metatarsal snug and stop the bunion-like drift we would be watching for.
have at it gang, cases like this are far and deep and require deep understanding of normal and abnormal biomechanics, and the rabbit hole deep myriad of compensations that can be engaged.
have a great weekend !
Shawn and Ivo
I blew out my flip flop,
Stepped on a pop top;
Cut my heel, had to cruise on back home.
But there's booze in the blender,
And soon it will render
That frozen concoction that helps me hang on. - Jimmy Buffett
I continue to see more and more people with inadequate toe extension. It is complicated. I see those who do not even have the awareness of toe extension, loss of strength of toe extension, loss of endurance of toe extension, loss of global range of toe extension (dorsiflexion at the MTP joint), more failure of long toe extensor (EHL) strength and more prominence of increased short toe extensor strength (EDB) and more frightening, a lack of disassociation of toe extension (MTP dorsiflexion) and ankle dorsiflexion. Many clients when asked to life their toes, will drive into ankle mortise dorsiflexion; ask them to just purely toe dorsiflex and the mental games begin, a wrinkled brow, intense concentration. If you cannot extended the toes sitting, how are you going to find them in swing phase of gait when balance, and other things, are more important?
Stand and lift your toes. The arch should go up, you have engaged the Windlass Mechanism, that winds up the plantar fascia and raised the arch. If you do not have competent, unconsciously competent, toe extension, your arch is not all that it can, and should, be. If you cannot raise your toes, thus raise the arch, thus plantarflex the first metatarsal, then in gait, when the foot is on the ground, you cannot properly position the sesamoids, properly get safe terminal ranges of hallux dorsiflexion at toe off, properly position the foot for loading and unloading, adequately achieve ankle dorsiflexion, adequately offer the hip a chance for ample hip extension, offer the glutes optimal chance to work in all phases to help control spin of the limb during loading and unloading, and the list goes on and on. I am sure I left much out there, this was written in a few minutes and unedited, just a short rant for the weekend. But if you have not championed toe extension, both in an unloaded and loaded foot (on the ground), achieved control of both long and short extensor muscles to the toes (and paired them well with the long and short toe flexors), disassociated toe extension from ankle dorsiflexion, and then figured out how to properly, timely, engage all these processes into your gait unconsciously, you are working on less of an optimal system than you should be. So, if your feet hurt, hips hurt, or a plethora of other problems that you are trying to fix with orthotics or other toys, maybe start with, "can you lift your toes?". It is a piece of the puzzle, trust me.
Or, you can just stay in your flip flops and perpetuate your toe flexion and wait for bad things to take root After all, tis the season soon !
Yes, toe extension in flip flops (we must flex our toes to keep them on) is as rare as a good multi-tasking man.
Shawn Allen, one of the gait guys.
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.
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.
It is easy to see the big things, but, we sometimes forget that the small things matter.
Sometimes it take an obvious glaring asymmetry to make us appreciate that the small asymmetries can make the same or similar impact over a long period of time. Rivers can carve out canyons over time.
Here we see the gross difference that polio can make in leg size and in leg length. We must remember that changing a leg length also changes the symmetrical relationship of where the 2 knees hinge. A foot that pronates more than the other leg can lower the knee hinge point just a little because the talus drops further from its vertical height. We know very well that it for certain alters the hinge direction, posturing it more medially, but we cannot forget that a cranky knee on a side where the foot is flatter or pronates more excessively than the other is not to be ignored.
In this photo, we have dotted the knee at the same point on the patella. It is clear the knees will not hinge at the same time, thus stride and step lengths will change, and step width will be impacted. The pelvis will also spin more to one side on a pelvis that is lower on one side. This will impact lumbar spine sagittal happiness and stability/mobility. Hip and pelvis drift are real things in this case, and need your attention. *Just like a client that has a painful foot, a more pronated foot, more tibial torsion on one side etc. these things matter, and they often matter years down the road when many thousands of miles have been clocked into the subtle asymmetry. Sometimes these little things matter in our athletes too, who put the pedal to the floor asking the body for more.
Come hear our lecture tonight on www.onlineCE.com. You have to sign up early to get in. We won't disappoint. See you then. 7pm central time.
Even before you client walks back to your treatment room, there are several things that we may not be aware of. Gait initiation is a different and more complex motor program than the simple gait motor program.
Here is a little something we do in our clinics, all the time. When the session room is open for the next client, we greet our client in the lobby. We do not have our staff send them back to the room to change and wait for us. We watch them closely, but without them knowing. How does the client stand up? How do they initiate their gait cycle ? How is their balance? How do they carry their bags, purse, backpack ?
We ask them to head back to the session room to get changed, letting them think we are grabbing a drink of water. And then, in a sneaky manner, we watch them stand, initiate gait, and walk back to the room.
We do this, because, gait initiation is separate motor program. It requires several component parts, a squat, weight shift, double support balance acquisition, COP (center of pressure acquisition), step length precalculations, step width precalculation, foot strike targeting, weight shift again, initial weight transition, and then the gait cycle. And gait initiation is different and asymmetrical in people with pain, we know this for a fact in clients with painful osteoarthritis. These clients develop adaptive posturomotor strategies that shorten the monopodal phase on the affected leg.*
For many gait disorders, these are the component parts that will first show up if there is a problem in the system. Gait initiation is more difficult than gait perpetuation. Besides, how we walk when we do not think we are being watched, when we are carrying our things (purse, phone, bottle of water, backpack, etc) is how we typically walk. Clients will show all the goodies we need to see: the turned out foot, the hiked shoulder, the limps, the staggers, stumbles, speed, step width, and the like. We also get to see how they move in the shoes they live in, the heeled ones, the broken down ones, the work shoes.
So, when your client is having a formal treadmill gait analysis, what are you seeing? Their best behavior, or the truth ? One thing is for sure, you do not see the most important program the precedes their treadmill analysis, namely, how they get out of the chair and up onto the treadmill. This stuff matters.
There are clues everywhere, grab all of them, in as natural a manner as possible.
The Gait Guys
*Arch Phys Med Rehabil. 2000 Feb;81(2):194-200.
Asymmetry of gait initiation in patients with unilateral knee arthritis.
Viton JM1, Timsit M, Mesure S, Massion J, Franceschi JP, Delarque A.
Key Tag words: thegaitguys, gait, gait analysis, arm swing, cortisone shots, corticosteroids, leg swing, running injuries
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Show Notes:
Corticosteriods and healing
https://www.eurekalert.org/pub_releases/2017-10/lu-cah101717.php
-steroid full text: https://www.nature.com/articles/s41598-017-12657-0
Can gait retraining prevent injuries ?
https://youtu.be/s8Og2bYsPTM
Exp Gerontol. 2002 May;37(5):615-27.
The reserve-capacity hypothesis: evolutionary origins and modern implications of the trade-off between tumor-suppression and tissue-repair.
Weinstein BS1, Ciszek D.
Arm swing:
Do you remember what Anti-phasic gait is ? If not, this study might not mean much to you. But we have written gobs about it on our blog over the years.
This study looked at "how arm swing could influence the lumbar spine and hip joint forces and motions during walking."
But, we have more to say on this, so, see you on the blog here . . .
https://www.thegaitguys.com/thedailyblog/2017/10/16/arm-swing-and-dynamic-stability-of-the-system
Effect of arm swinging on lumbar spine and hip joint forces
Lorenza Angelini et al. Journal of Biomechanics, Sept 2017
http://www.sciencedirect.com/…/article/pii/S0021929017304670
One more possible piece to the autism issue.
In this study, researchers discovered that between the first and 2 years of age, the brain networks linked to walking change.
"At 12 months, stronger connections between the brain’s motor and default-mode networks were associated with better walking and gross motor skills. By 24 months, brain networks linked to attention and task control also had become engaged in walking and gross motor skills, the research shows."
Scientists have identified brain networks involved in a baby's locomotion systems, and they feel this discovery may help predict autism risks. As this study indicates, building on prior research showing those infants who show skill development delays in coordination and movement are more likely to indicate risk for autism spectrum disorder. The researchers believe they have discovered a root cause in the "default-mode network", a network thought to be very involved in developing one’s own sense of self. The researchers feel it is possible that the brains of children who go on to develop autism are not as adept at making those network connections and processing that data.
“Walking is a huge gross motor milestone, and it’s associated with a child’s understanding of his or her own body in relation to the environment,” said first author Natasha Marrus, an assistant professor of child psychiatry at Washington University School of Medicine in St. Louis.
“Understanding the early development of functional brain networks underlying walking and motor function in infancy adds critically important information to our understanding not only of typical development but also of a key deficit that appears early in the development of a number of neurodevelopmental disorders, such as autism,” says Joseph Piven.
“When a child first learns to walk, a big breakthrough involves just putting one foot in front of the other and learning to control one’s limbs,” Marrus says. “As walking improves, it’s possible the child may begin to think, ‘Where, exactly, do I want to put my foot?’ Or, ‘Do I need to adjust my position?’ And by becoming more or less active, the default-mode network, along with other networks, may help process that information."
Read the original source article here,
http://www.futurity.org/learning-to-walk-autism-1626792-2/
Visualization is a key in most sports and activities if one wants to improve their skill and performance. Gait retraining through visualization should thus work as well. This study which has yet to be executed, hypothesizes that we should be able to change and improve our gait through visualization of changes. Motor imagery, envisioning motor actions without actual execution, has been used to improve gait in Parkinson's disease and poststroke. In this study subjects will be asked to specifically imagine walking, imagine talking and imagine walking while talking. It will be interesting to see what they discover, but we suspect that this should be like improving any other motor task, that visualization improves the task. Learning occurs on several levels. One should also consider not only asking clients to do their prescribed corrective exercise homework and movements, but also visualize them even when actual physical execution is not feasible.
Neurodegener Dis Manag. 2017 Nov 22. doi: 10.2217/nmt-2017-0024. [Epub ahead of print]
Motor imagery of walking and walking while talking: a pilot randomized-controlled trial protocol for older adults. Blumen HM1, Verghese J1.
"One might argue, that we sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum. This becomes particularly suspect when in a conforming chair, such as a "bucket" seat in a car." -Shawn Allen
This article follows nicely with yesterday's post about hip joint control and anterior hip pain.
The premise behind this study referenced below was to determine if contact forces and electromyography (EMG) muscle amplitudes were altered during lunging activities in clients with painful labral tears compared to hose who are symptom free.
The unsurprising conclusions of this study ("contact forces and EMG muscle amplitudes are altered during the lunge for patients with symptomatic labral tears") are mostly predictable. But one should, we would hope, propose the chicken or the egg theory here. Are these clients having pain because they are loading into the labral tear, or is the pain from poor joint stabilitation (and thus possible impaired normal mobility and motion) which incidentally lead to the labral loading and thus tear ? We propose this one all the time. Why? Because we get a decent population of clients with typical "suspect" anterior hip labral pain and after rehabbing them, the pain resolves. So in these cases, was it a labral tear? Labral irritation? Or just a faulty loading response?
*However, we also get enough clients who present with an MRI in hand that confirms a labral tear, and we take them through the same process, and many of them also stabilize and have pain resolved. This then proposes the end question from them "So, was my pain from the labral tear at all? Or was it because had a poor stabilization capability, which lead to the tear/irritation?"
And that folks, is the big question that has to be asked in all cases, and that is the unanswerable question. But, should the process change regardless? If your client is going to head into surgery for the tear, should they not be fully rehabbed in the first place? And if the rehab works, is surgery even necessary ? In the successful cases, we just stare openly at the client and smile, we let them answer the question. After all, they know the answer anyways.
Make no mistake. not everyone responds to our, or your, care. And, not every labral tear is incidental. Not every labral tear is undamaging to the femoral head and to the longer term health of the joint. But, taking a few weeks and dedicating some good work into your client's skill, endurance, strength, power and loading responses often either give your client answers or prepare them for a great outcome post-operatively.
In a nut shell, these can be tricky challenging cases. People sit and use the glutes as a cushion all day. We sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum (depending on our sitting posture and chair choice). They load similarly in their cars in challenged ways. They do not move well or often enough. They have weak glutes and abdominals and their ability to control the pelvis in safe loading is poor. So many patients, and non-patients are on this bus, in fact, the majority of us are on it as well. It feels like we are seeing more and more of these anterior hip problems, and we are not surprised as the average human moves less, is getting weaker and less durable and robust physically, and they sit more, and drive more. This anterior hip pain clinical entity should really be no surprise to anyone anymore.
To be thorough, this study did "surface electromyography electrodes were placed over the gluteus medius, gluteus maximus, adductor longus, and rectus femoris muscles of the patients' involved limb and matched limb of asymptomatic controls." This makes this an incomplete study with incomplete conclusions. As we said yesterday, without information on the mighty psoas and iliacus to name a few other big players, this study is somewhat suspect, but overall, we do not thing the results would come out too terribly different.
-Shawn and Ivo, the gait guys
Do Neuromuscular Alterations Exist for Patients With Acetabular Labral Tears During Function?
Arthroscopy. 2016 Jun;32(6):1045-52. doi: 10.1016/j.arthro.2016.03.016. Epub 2016 Apr 27. Dwyer MK1, Lewis CL2, Hanmer AW3, McCarthy JC4.
https://www.ncbi.nlm.nih.gov/pubmed/27129378
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