a happy cerebellum = better learning

We are not sure how many of these (little) guys you treat, but this article is germane.

4 hours per day, 5 days per week. It takes time to recannalize (or re create) new (or rejuvenate old) neurological pathways.

"After only two weeks, the children in the experimental group demonstrated a significant increase in locomotor and object control skills and in gross quotient (a composite measure of both skills categories). Participants’ locomotor improvements plateaued between weeks four and eight, and object control skills improved during the first two weeks but demonstrated nonsignificant changes between weeks two and four, four and six, and six and eight. A significant gain in locomotor skills also occurred between weeks four and eight."

...and don't forget about the "neurological windows" we are always talking about. Aggressive, early intervention is indicated

"Early childhood is a sensitive time in development, and motor researchers have an opportunity to improve motor skills very early—even as young as 2 years, said Ketcheson. Early intervention may give children with ASD the ability to play and interact in age-appropriate ways with their peers entering kindergarten. Early intense motor skills instruction within a CPRT framework can be a valuable addition to practitioners’ intervention strategies aimed at improving social success for children with ASD, she said."

Get them up, get them moving!

Testing the Spinocerebellar Pathways

Though we know about the importance of the neck and gait function, like where we discussed here and here, we cannot leave out the integrity of the spincerebellar pathways. Can you test them and discern their functions? This quick video demonstrates how. Some great clinical pearls in this short segment.

Dr Ivo, one of the Gait Guys

#spinocerebellar, #pathways, #clinicaltesting, #gait, #gaitanalysis

Loaded Carry, Addendum idea

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Recently, Jan 13th, 2018, we posted 2 photos of the Farmer's carry, in that specific case how to use it to drive more load into the hip stabilizers as opposed to the lateral abdominals. Here is how we progress someone from wide step walking corrections, we add the step up. The next progression is to be sure they do not lose the hip hike as they try to return the foot to the ground, which you do not see here. Note the kettlebell in the LEFT hand. They will have to do that (return the RIGHTfoot to the ground) through a knee bent knee mini-squat-lunge, to keep the gmedius on. Or, they can just do a controlled eccentric, but that is even more attention. Most people just let the RIGHT glutes go entirely to get the LEFT swing leg back to the ground, no bueno ! This is not normal gait, but it is what most people do because they do not have command of the glutes in the 3 phasese: early, mid and late stance. In fact, most people fail through all 3 phases, but certainly the Early and Late phases are the toughest, with the Late phase being the most challenging. The glutes should remain active through the next foot contact phase.

Details matter in a Loaded Carry.


Last night I lectured on the Cross over gait. I discussed at one point using one sided carries, a heavy farmer's carry, to stimulate more activity on the stance leg , particularly focusing on driving more hip stability. But, it matters how you do it.

Screen Shot 2018-11-11 at 9.48.18 AM.png

The photos i have attached are both technically a farmers carry unilaterally. One I am working my gluteus medius and hip stabilizers more, and the other i am using my lateral abdominal chain more (more of a compensated Trendeleberg type gait, and we know that hip pain patients lean in a Trendeleberg gait to reduce the activity of the glute medius to reduce compression across the joint (2/3 reduction)). If you are trying to help your client reduce their cross over gait with more hip stability building, one of them is going to hit the mark far better than the other.
So, if your clients are walking a line in their Farmer's carry, think about what you/they are actually doing (likely less hip stability stimulation).
The exercise should fit your goal. Have them walk feet on either side of a wider balance beam to get more stance phase glute activity (try it yourself, the wider your step width the more hip loading you get), or, have them walk a line and lean more into the frontal plane to get more abdominal. It is not a perfect science, but you do get a different feel from how you do it.

But, it matters how you do it.

Pateon subscriber post.

Understanding a strange leg swing problem.
This is an olympic hopeful in the marathon from Australia who came to see us to help with some chronic injuries that she hasn't been able to get help with. We discuss the issue here in the video.

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LLD's and Achilles Tendinopathy

Sometimes, it doesn't matter whether it is long or short.

 Achilles tendinopathy .. there are many factors that can contribute. Have you considered leg length inequality? Generally speaking, People have a tendency to overpronate on the longer leg side and under prone only shorter leg side with strain on the medial and lateral aspects of the Achilles tendon respectively. It would make sense that this could be a contributing factor.

 "The mean inequality in length of legs (ILL) was 5 +/- 4 mm. Among the 48 patients with ILL > or = 5 mm, the side affected with ruptured tendon was longer in 48% of cases and shorter in 52%. "

Age and pathology can play a role with younger, healthy tender and having greater compliance.

Proprioception is impaired on the affected side of folks with Achilles tendinopathy. This is a "chicken and the egg" scenario. Did impaired proprioception cause the tendinopathy or is the tendinopathy causing the impaired proprioception? Probably, a little bit of both.

Dr Ivo, one of The Gait Guys

Leppilahti J, Korpelainen R, Karpakka J, Kvist M, Orava S. Ruptures of the Achilles tendon: relationship to inequality in length of legs and to patterns in the foot and ankle. Foot Ankle Int. 1998 Oct;19(10):683-7.

Scholes M, Stadler S, Connell D, Barton C, Clarke RA, Bryant AL, Malliaras P. Men with unilateral Achilles tendinopathy have impaired balance on the symptomatic side. J Sci Med Sport. 2018 May;21(5):479-482. doi: 10.1016/j.jsams.2017.09.594. Epub 2017 Oct 6.

Intziegianni K, Cassel M, Rauf S, White S, Rector M, Kaplick H, Wahmkow G, Kratzenstein S, Mayer F. Influence of Age and Pathology on Achilles Tendon Properties During a Single-leg Jump. Int J Sports Med. 2016 Nov;37(12):973-978. Epub 2016 Aug 8.

#achilles,#tendon, #achillestendon, #tendinopathy, #proprioception

Got a kid that "toes in"?

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett,  M.D illustration for International Association for Dance Medicine and  Science 2011

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett, M.D illustration for International Association for Dance Medicine and Science 2011

image courtesy: T Michaud

image courtesy: T Michaud

Got a kid that "toes in" during gait? Are you seeing this?

  • smaller foot progression angle

  • greater knee adduction

  • more internally rotated and flexed hips

  • greater anterior pelvic tilt

Wondering what could be causing it?

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is.

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The angle of the femur neck to its shaft diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

There are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. 

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

 

The take home message here about femoral torsions is that no matter what the cause:

  • the angle of the femur neck to shaft values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 

Great paper here

link to full text: http://onlinelibrary.wiley.com/doi/10.1002/jor.22746/abstract;jsessionid=AC848D963DCA526402D71260BDFC91F6.f04t04

Dr Ivo, one of the Gait Guys

#gait,#gaitanalysis,#femoralneckangle, #femoraltorsion, #antetorsion, #retrotorsion, #toein

 

Changing step width alters lower extremity biomechanics during running.

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The Cross over gait. We have been talking about this for years, our theories have been supported by the available research and years of patient care.
Here is another study that goes with our ideas, which gives it deeper clinical relevance.

Changing step width alters lower extremity biomechanics during running. Brindle RA1, Milner CE, Zhang S, Fitzhugh EC. Gait Posture. 2014

"Step width is a spatiotemporal parameter that may influence lower extremity biomechanics at the hip and knee joint. Peak hip adduction and rearfoot eversion angles decreased as step width increased from narrow to wide."
Step width influences lower extremity biomechanics in healthy runners. "When step width increased from narrow to wide, peak values of frontal plane variables decreased.

The Fredericson paper (Hip Abductor weakness in distance runners with iliotibial band syndrome) is also supportive. That paper found that increasing step width reduced the strain on the iliotibial band during running. Greater ITB strain and strain rate were found in the narrower step width condition.

We have said it, and will say it again, because someone will post here, "maybe, but all the pros when you watch then and see photos of them, they all have a very narrow step width, basically qualifying for what you guys call a Cross Over gait. So how can you make such bold statements?"
Our response would be, "every attempt at squeezing out more economy in ones gait, walking that fine line of riskier gait mechanics, is a game of playing ECONOMY vs. LIABILITY. And if you have built enough durability and conditioning into your system that you can nudge right up to that fence of RISK, you can play with those liabilities and squeeze out the economy of your gait (like the pros) with that narrower step width. Just be aware and careful, that when you are losing control, as the runs lengthen, that the LIABILITIES are increasing and thus so is the RISK for injury. Just remember, you are likely not a pro, and have not spend the time building a safe zone of durability on your system to endure narrow step width for 26 miles.

A good runner will train the frontal and rotational planes regularly as they engage in their sagittal sport of running. So that as fatigue sets in and the step width begins to narrow, they have some durability of the lower limb to sustain the risky mechanics of the narrow step width. There is a limit for everyone, when the well goes dry.

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

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

Screen Shot 2018-11-16 at 9.34.48 PM.png

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.

Screen Shot 2018-11-16 at 9.34.29 PM.png

* 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.

Crawling and Bird Dog, a subtle but important difference.Can you see it ?

Screen Shot 2018-11-16 at 9.41.29 PM.png

Crawling and Bird Dog, a subtle but important difference.
Can you see it ?
When we crawl, as in the photo, we use the following pattern:
- the right shoulder is in extension (but it is fixed on the ground, it is the body that is moving forward/extending over this fixated point, it is approximating the flexing right hip as the knee moves up towards the hand)
- the left hip is in extension, pairing appropriately with the right shoulder extension.
- similarly, the left shoulder is in flexion (it is over head in this photo, just like in the other photo of the runner similarly doing the same patterning but standing up, meanwhile the right hip is in flexion.
* take the photo of the runner in the green shirt, and put him in a quadruped crawling pattern as you will see that it is the same pattern as the one of me in the crawling posture.
* This is not bird dog, as seen in the photo, do not confuse them.

Screen Shot 2018-11-16 at 9.34.48 PM.png

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.

This first photo of me in the black shirt is normal, natural, 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.

Screen Shot 2018-11-16 at 9.34.29 PM.png

3 things you can do NOW for patello femoral pain...

 

Recalcitrant PFP? In addition to your treatment regiment AND getting to THE CAUSE of the patello femoral pain (often but not always gluteus medius function), have you tried?

  • forefoot-strike running

  • increasing step rate by 10% (ie cadence)

  • "running softer"

according to this article:

"all modifications were associated with reduced patellofemoral joint force during running, compared with the participants’ normal running gait. But the modifications were also associated with immediate symptom improvement of at least one point out of 10; 62.5% of runners in the study experienced a positive symptomatic response to at least one of the gait modifications."

 

Easy to do, easy to implement

 

Esculier J-F, Bouyer LJ, Roy J-S. Immediate effects of gait retraining on symptoms and running mechanics of runners with patellofemoral pain. J Orthop Sports Phys Ther 2017;47(suppl 1):A9.