Video Gait Case: A troubled Youth.
This is a video of a teenage girl with chronic posterior knee pain. What do you see in her gait. Don’t cheat yourself. Before you read below see what you can see first and then drop your eyes down to our work below.
- Heavy rear foot lateral strike. This is rearfoot inversion at its worst. This is considered rearfoot varus. Hyperpronators will often display the opposite, a rearfoot valgus. In this case, a heavy lateral strike leads to sustained lateral foot weightbearing which will mean she stays on the outside or lateral aspect of her foot too long and thus stays in supination.
- The heavy lateral foot strike will often lead to knee hyperextension during initial contact and often continues throughout stance phase, as this is a position of stability for the joint. At the end of the video as her knees come into view you can see the degree of knee hyperextension (somewhat). This may remind you of our blog post months ago on anterior knee pain (Anterior Meniscofemoral Impingement Syndrome). Such an anterior pitch of the pelvis and lumbar extension can obviously lead to shortness and shortness-weakness of the psoas and rectus femoris to name just a few.
- This type of gait will often lead to an accentuated lumbar spine lordosis curve (functional usually) with an accentuation of the anterior pelvic tilt and resultant inhibition of the lower abdominals. This furthers the knee hyperextension and thus the cycle continues (the knee hyperextenion perpetuating the anterior pelvis and weak abdominals which then drive continued knee extension). Bringing these topics and blending them with items in #2 will naturally limit the degree of hip extension (since the extension of the limb is occurring in the lumbar spine) and lead to inhibition and weakness of the gluteus maximus.
- Quite frequently a heavy lateral rear foot strike results in a heavy pronation event at the forefoot loading period (forefoot pronation) particularly when the foot progression angle (turn out) of the feet is large. We DO NOT see this here. However, in these cases one had better have exceptional medial foot tripod skill, endurance and strength (S.E.S once again) as well as great strength in the long and short big toe flexors (FHL, FHB) to help anchor that medial tripod because the forces that are coming into the forefoot in those case are like a rhino at feeding time. However, in this case, there is a plantar flexed 1st ray posturing of the forefoot. A trained eye can see some of the functional characteristics of this forefoot type, but you really must confirm its presence on a clinical examination mainly because you want to know if it is a rigid or flexible forefoot variant. A plantarflexed 1st ray is sometimes found paired with a rearfoot varus, as the foot is trying to find the medial tripod. A forefoot valgus is also possible, but this usually results in the medial foprefoot striking the groung 1st, as opposed to the lateral, as we see here. These people often have great difficulties getting off of the outside of the foot and onto the medial foot to adequately toe off the big toe. This is sometimes referred to as an apropulsive gait.
Wow, all this from some bad gait skills and some minor foot variances huh ?! Yup.
Which brings us to shoes. Wouldn’t it be nice to be well versed on all these issues before you slap her into a neutral shoe ? Because she clearly does not need a stability shoe; pronation is absent in these feet. So, do you pick a neutral shoe with a soft lateral heel crash zone ? How about one with a lateral rearfoot cut out (or “entry” as it is often called? What about no cut out ? Would she do better in a straight lasted shoe or curved ? There are plenty of questions, more than just these. But for this case…….lets stop here and answer just these few for now.
- no soft lateral heel impact crash zone with this type of rear foot
- use a shoe with no cut out (the beveled cut out at the lateral heel will promote more sustained lateral foot weightbearing). Shoes without a cut out (or entry) will help to drive that heel into eversion and pronation but you had better make sure you have changed their gait and ensured adequate medial foot tripod strength, because remember those types of feet will be driving into that medial forefoot in a major hurry with aggression…… but, thankfully this is not the case here.
- Choose a Straight lasted shoe in this case. A more curve lasted shoe will promote more and faster pronation into that forefoot, there is already enough !
There is so much more to this game that simply promoting natural running form or natural walking form. So much more than simply dropping someone to a zero drop or minimal shoe. As we say, it is often not the shoe but the thing you put in the shoe……. but you have to know what shoe you put on the foot and how it is going to react to the foots abilities and its challenges.
Our Shoe Fit program is getting closer and closer to a release date. Those that have been through our program, formally or informally will have the knowledge and skills to dissect a case like this and make some good assessments and choices.
Shawn and Ivo. Gait Geeks, Shoe nerds, Running form teachers, …….. and halfway decent doctors too.