Toe off: medial or lateral ? The hip matters, and do does forefoot loading.

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.

Screen Shot 2019-01-13 at 8.06.45 PM.png

running gait: the contralateral pelvis drop

Great visual here, Nice work @ylmsportscience !
This is from the AJSM 2018 article Bramah et al.

Nothing new here for our Gait brethren, we have been talking about this contralateral pelvis drop for a long time. Our soap box rant on many of our podcasts and teaching courses of, "when the foot is on the ground the glutes are in charge, and when the foot is in the air, the abdominals are in charge" comes to this article as well. Sure, that is a loose quote, filled with caveats and many other components, but it is globally valid and runners get it when it is kept in simplest terms. Just do not forget that this process can be a top down problem, a bottom up problem from poor foot control, or both (which it often is).
None the less, this is a good article to keep in mind, and a great info-graphic by @ylmsportscience. Thank you to both !

https://www.ncbi.nlm.nih.gov/pubmed/30193080

"found injured runners to run with greater peak CPD (contralateral pelvic drop) and trunk forward lean as well as an extended knee and dorsiflexed ankle at initial contact. CPD appears to be the variable most strongly associated with common running-related injuries."

https://ylmsportscience.com/2018/12/03/is-there-a-pathological-gait-associated-with-common-soft-tissue-running-injuries/?fbclid=IwAR0vR51_13m-xs3q8ucurKmZvzbCagBCZ_WJkVNUW0qGFq8focLTRd3zm8k

#gait, #gaitprobems, #gaitcompensation, #hippain, #gluteweakness, #hipdrop, #archcollapse, #pronation

The case of the sneaky aberrant heel rise.

If you are not careful, as shown in this video case on Patreon, you can easily miss this aberrant heel rise clue.

Screen Shot 2019-03-30 at 7.18.08 AM.png

This has been a challenging case. Without the patience of someone with a strong heart that really wants to get back to running, sometimes things do not get fixed because they are so deeply layered. This has been a rough case, but i have learned to be patient in unlayering things when things are not changing. I think for this great lady and great runner, teamwork and communication regularly was the key to getting to what i feel is the tipping point. come hell or high water, i will get her running again. Enjoy the long talk and steps into our head on this one.

Join us on Patreon (and soon another platform) for deeper gait insight and complex case "Work throughs". You might call these, "exercises in clinical gymnastics".

https://www.patreon.com/thegaitguys

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

IMG_0185.JPG

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 . . .

IMG_0182.JPG

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

Why we have a problem with web-based gait analysis recommendations. What is Visual Parallax and how does it affect gait analysis?

Screen Shot 2019-04-04 at 1.30.29 PM.png

Is your video gait analysis really telling you what you think it is telling you ?


We recently were asked by a student at a physical therapy school to help with a teaching case. They asked us to look at a gait video to assist in outlining some things in the case. Here was our response.
“Hello Jane Doe
We are happy to look at the video for you so you and others can learn.
Just please know, as we say all the time here on the Gait Guys, that without an examination that what we are all seeing is not the problem rather the persons compensatory strategy around the dysfunctional parts.
Plus, video negates binocular and parallax viewing so things that would stand out in in a exam where we are physically present will be masked quite a bit in/on video or on a computer screen. We try to minimize these visual losses by getting multiplanar gait video views (sagittal from front and back and coronal from left and right sides) but even these will not fill the visual gap from transferring data from 3D to 2D and then trying to interpret a 3D answer from the 2D. But it is the best one can do with our technology today unless you use a body suit sensor system, and then you still have the limitations of "what you see is not the problem, its their compensation” so one still needs the physical exam to put the puzzle together.
Here…….. read this if you are wondering what we mean.
*This blog article below which we wrote 6 years ago is the heart of what we wanted you to read today. Visual parallax and binocular vision both need to be understood so that you can better understand why what you see on your gait analysis video might not be what you think you are seeing. Seeing is one thing, knowing what you are seeing is another, knowing the limitations and the “why” of what you are seeing is yet another.

So, we can tell you what we see………but without an exam we cannot tell you with great accuracy why you are seeing what we see. Does that make sense ?“

Read on . . . .



What is Visual Parallax and how does it affect gait analysis? : Is your video gait analysis really telling you what you think it is telling you ?


Have you ever watched someone’s gait, only to reach for your camera to capture a gait deficit digitally, and then later re-watch the video and have a difficult time seeing the same deficit? There is a logical answer.

Vision exists with both eyes open (binocular), or with only one open eye (monocular). Our visual system uses all available depth cues to determine distances between objects, called physiological cues (actual or perceived differences), and psychological cues (experiential; or derived from past experience, or logical deduction).

Our 2 eyes see the world from slightly different locations (or different lines of sight), so the images transmitted to the visual cortex (in the occipital lobe) by the eyes are slightly different (see left picture above, compliments of Wikipedia). This difference in the perceived images is called binocular parallax. The amount or angle can be measured by the angle or semi-angle of inclination between those two lines. The term is derived from the Greek parallaxis, meaning “alteration”.

Our visual system is very sensitive to these “differences”, and binocular parallax is the most important depth cue for medium viewing distances (see right picture above, compliments of www.cns.nyu.edu). The sense of depth can be achieved using binocular parallax even if all other depth cues are removed.

Nearby objects have a larger parallax than more distant objects when observed from different positions, so parallax can be used to determine distances. Usually video provides us with confirmation of we are actually seeing in 3D. Beware, visual parallax may be playing tricks with you, as there is a discrepancy when translating 3D to 2D (cameras have one lens and are therefor monocular). Yes, binocular effect is lost in video; there is little depth perception with 2D and everything on the web, at this point, is 2D. A different vantage point (ie multiple camera angles: front, back and side) often offer a different perspective which is why we always suggest 3 views, but that too, is having 3 videos which are all 2D !

So this is why when you watch someone’s gait, even when LIVE on Skype or FACETIME, you have a difficult time seeing the same deficit that you might have seen had you been there in person enabling the components of binocular and parallax to come into play. Trust us, we are astonished all the time when we see something in a client's gait, and we reach for our phone or ipad, only to have it be barely present on the video because of the 2D capture limitations.


Remember, what you see (actually or on video) IS their compensation, NOT the problem, but it can often lead you to the problem. Pelvic drift to right during stance often means weak Gluteus medius on that side. Is that the problem? Maybe. However, “Why” is the bigger question. Is it from the foot? The Knee? the hip? Or maybe central and involving the vestibular apparatus? We examine, try to make a change, and see if it sticks.

So, in the future, keep in mind some of these limitations of what you are diagnosing off of video analysis because what you are seeing is a monocular interpretation of the real thing. Some information has been lost in the process of monocular motion capture. We are sure that in time video analysis will reach the 3D realm, and solve this problem.

Binocular Parallax. 2 different views of the same thing. Kind of like us…The Gait Guys…Ivo and Shawn

Things seem to come in 3's...

Things tend to occur in threes. This includes congenital abnormalities. Take a look this gentleman who came in to see us with lower back pain.

Highlights with pictures below:

  • bilateral femoral retrotorsion

  • bilateral internal tibial torsion

  • forefoot (metatarsus) adductus

So why LBP? Our theory is the lack of internal rotation of the lower extremities forces that motion to occur somewhere; the next mobile area just north is the lumbar spine, where there is limited rotation available, usually about 5 degrees.

Dr Ivo Waerlop, one of The Gait Guys.

#tibialtorsion #femoraltorsion #femoralretrotorsion #lowbackpain #thegaitguys #gaitproblem

this is his left hip in full internal rotation. note that he does go past zero.

this is his left hip in full internal rotation. note that he does go past zero.

full internal rotation of the right hip; note he does not go past zero

full internal rotation of the right hip; note he does not go past zero

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

ditto for the keft

ditto for the keft

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

less adductus but still present

less adductus but still present

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

Ditto!

Ditto!

The smell of napalm in the morning: Your gait and trouser coughs, a clinical entity no one talks about.

Written by Dr. Shawn Allen


This is our very last gait guys blog post. Yes, all good things come to an end, even this trusted blog.
But, keeping in good faith, we will finish on a strong note ……. One of gardenia and lavender. Thanks for the last 10 years our dear gait brethren, is has been a great ride. Shawn and Ivo
_______________________________
The technical title of this blog post should have been, “The reactive influence of non-normopressure bowel distention and spontaneous high vapor dissipation on bipedal locomotion.” but no one but true gait nerds would have read it had we stuck with this pubmed-type title. Yes, we are talking about farts and gait here today folks, buckle up.

One biomechanical principle we will link to this entity of “off-gassing“ is that excessive or sustained ankle plantarflexion could inhibit dorsiflexion and certainly, at the very least, works against it. We have talked about this often here on the blog and how the lack of ample ankle dorsiflexion can impair many of the biomechanical events higher up into the human frame. So, how can someone’s bowel gas translate into gait problems ?

Think about this … to squeeze out a right “cheek sneak” (fart) with optimal crowd pleasing pitch and peak vibrato, some elevation and relaxation of the lower and middle gluteus maximus divisions (coccygeal and sacral) seems imperative to optimally control off-gassing . Seemingly, to do this, a significant degree of right ankle plantarflexion may be necessary to lift the right hemipelvis driving a subsequent intentional clockwise pelvic distortion assisting in the relaxation of these gluteal divisions. This consciously driven right side of the body “lift” via the right ankle plantarflexion can also be met and assisted via ipsitlateral abdominal and contralateral gluteus medius contraction to further enable the optimal right hemipelvis elevation. Go ahead, stand up and mimic the posture and note these biomechanical pieces. Recall our mantra,

“when the foot is on the ground, the glutes are in charge, when the foot is in the air, the abdominals are in charge”.

These coordinated motor patterns might be considered dual/multi tasking. This honed series of biomechanical events is one often perfected in frat houses and basement gaming rooms. But make no mistake, there is a biomechanical danger lurking here if this becomes a habitual compensation pattern, one common in large volume legume consumers (beware vegans). Habituation of this motor task, or demonstrating poor technique over time can render right quadratus lumborum shortening and weak lower abdominals rendering an anterior pelvic tilt. This tilt may lead to gluteal inhibition/weakness (because it is difficult to contract the gluteals in an anterior pelvic tilt, go ahead stand up again and try it) which over time can impair stance phase gait mechanics. However, relating to the off-gassing, this physical posturing might optimize low frequency gluteal vibrations that can optimize vibrato during gas dissipation if pressurization is in fact optimal for an “audible”. It is important to note that conscious variable control of the tonus of the muscular anal sphincter complex plays a big part in the pitch and vibrato. There is always a drawback it seems, it does truly come down to motor control it seems, doesn’t it always ?


This is not to say that avoiding “audibles” through holding “one” in doesn’t have consequences. The exotic gas (nitrogen, carbon dioxide, hydrogen, methane, oxygen) induced gut distention that could only make your collage roommate proud can inhibit the abdominal wall and thus the lower thoracic canister and disable normal breathing mechanics. This could be a serious complication to the coupled events of respiration and thoracic mobility. So, holding that big one in for your friends rather than engaging the compensatory Trendeleburg-type off-gassing posture as described above is also fraught with problems. We know that functional disconnection of the thoracic canister from the pelvic core can disrupt the normal anti-phasic mechanics of the contralateral upper and lower limbs as well as possibly impair the normal spinal cord mediated central pattern generators.

Farts…..Call them what you want, those ear pleasing, nose hair curling, trouser coughs that only a teenage boy can truly relish and recognize as a function of boyhood success. All joking aside, they truly should be your biggest concern in your gait analysis evaluation, bar none. Ask your patients about their bowels and off-gassing, it should be part of your clinical history intake. Maybe even consider taking out the discomfort of open dialogue, and put it on your intake forms. We found that a stick figure diagram in a good biomechanical squat posture with a mushroom cloud formation hanging overhead eases dialogue tension about this sensitive topic. We even give the young children crayons to they can color the cloud. What fun !


Dare us to write a part two on this topic. “Blue Angels” (unfamiliar with this clinical phenomenon? look it up). Go ahead, dare us for a part 2.

By now, if you haven’t realized that The Gait Guys just punked you (happy April Fools day) , then you likely haven’t had your cup of morning coffee. Yes, we have no clue what we were talking about on this blog post, well, ok maybe, after all we do have that y-chromosome. Yes, we are NOT ending the blog either :)

Are you now considering us juvenile ? Ok maybe we are a little, but don’t deny it, you thought about some unique and honest body biomechanics for a moment here and it is these mental gymnastics that will take your creative thinking about gait to the next level. If you are upset, so be it. There will be no apologies here in this growing PC world. "Off-gassing" is a human thing, we all do it. We have been writing serious stuff daily for 5 years here on The Gait Guys. It was time for us to write something a little lighter. We can only hope that you will think of us and the complexities of the gait cycle the next time you sneak one out while having dinner at the in-laws or before you blame the dog for any "something wicked this way comes" gaseous event. Try not to giggle when you do, but for certain, think about your body mechanics when you do, we can’t be responsible for off-gassing injuries.

Think of us, 2 juveniles at times, when the world needs us the most.

Shawn and Ivo, remaining here, for the duration.

disclaimer: we cannot be responsible for injuries that might be sustained by improper off-gassing events. Keep your work area a no smoking or vaping zone please when off-gasing. We also do not recommend attempts at performing Blue Angels, this is a potentially dangerous activity and could cause great bodily harm (seriously). :)