Congenital clubfoot anyone?

This gentleman, a longtime patient came in for new orthotics, as his old ones were 10 years old. From the pedographs above, you can see it is his LEFT foot. 

Note the following:

• shortened apparent foot length left compared to right (the foot is merely deformed and plantarflexed)
  
• The increased plantar pressures laterally, from the foot being supinated 
  
• increased arch height L > R
  
• clawing of digits 2-4 to provide stability
  

This case made me think about some common issues that you may be wondering about if you see these folks. 

There are several things you should think about:

• People with clubfoot generally have a high arched, rigid, cavus foot. 
  

• These folks generally are fixed in some degree of plantar flexion.
  

• Because of the plantar flexed posture of their foot, they generally have a loss of a ankle rocker
  

• If you utilize an orthotic with these patients, you need to make sure that there is significant ramp delta (heel higher than the 1st metatarsal)
  

• Clubfoot can often be unilateral.
  

• Clubfoot is usually not congenital
  

• Gait training and balance (proprioceptive) work can be especially helpful in these cases. 

Which sports burn the most calories?→

Photo: Gallo Images/iStockphoto  

Look at this photo. Do you see it ? How much posterior rotation (left rotation) is being driven through that left shoulder/torso rotation. That is nuts! We have a hard time believing that is not a compensation. We would be assessing for stability and mobility issues elsewhere. Heck, the elbow practically crosses the spine posteriorly ! Sheesh ! When you cannot put the movement where it should be, or control it (stabilize) where it should be controlled, sometimes you try to get it or put it elsewhere. We would love to see this lady run, we bet there is a host of clean gait problems down below. We would bet some cross over gait is present as well, after all, that left arm swing is largely predicated off of the right leg swing. Arm swing is far less independent than people think, we have written about that here on our blog numerous times. Just search “arm swing” over on our Tumblr blog.

Remember this, and if you need to go back to read about phasic and anti-phasic gaits head over and search our blog, but the amount of shoulder “girdle” (essentially thoracic rotation) is typically met by the same amount of pelvis rotation. These should be symmetrical. And, when they are not, we can drive it through various means, even as in this case, through more arm swing unilaterally. We wish we could see some axial photos from above to see how much pelvis rotation is noted  here.

Just some brief thoughts from Dr. Allen

Photo link attributed to owner: http://africanspotlight.com/wp-content/uploads/2016/03/CdBVhTzUkAELVp6.jpg

Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

Podcast 103: Effects of Cold on Physiology/Athletes

Using Cold adaptation to your advantage, Walking Rehab “Carries”, Walking and Proprioception.

Show Sponsors:
newbalancechicago.com
Softscience.com

Other Gait Guys stuff

A. Podcast links:

direct download URL: http://traffic.libsyn.com/thegaitguys/pod_103f.mp3

permalink URL: http://thegaitguys.libsyn.com/podcast-103-effects-of-cold-on-physiologyathletes

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show Notes:
Cold
Switching on a cold-shock protein may restore lost connections between brain cells & memory function in aging brain.  
http://www.bbc.com/news/health-30812438

-“Connections between brain cells - called synapses - are lost early on in several neurodegenerative conditions, and this exciting study has shown for the first time that switching on a cold-shock protein called RBM3 can prevent these losses.
http://www.pnas.org/content/111/20/7379.abstract

New study in mice in the inaugural issue of Brain Plasticity reports that new brain cell formation is enhanced by running.
http://neurosciencenews.com/neurogenesis-exercise-memory-3165/

Walking changes our mental state, and our mental state changes our walking.  60 sec audio clip.
http://www.scientificamerican.com/podcast/episode/bouncy-gait-improves-mood/

http://www.sciencedaily.com/releases/2015/…/151119122246.htm

Walking. You don’t have to have the pedal to the metal.
"Those who walked an average of seven blocks per day or more had a 36%, 54% and 47% lower risk of CHD, stroke and total CVD, respectively, compared to those who walked up to five blocks per week.”

http://www.sciencedaily.com/releases/2015/…/151119122246.htm
New proprio study:
http://www.nature.com/neuro/journal/v18/n12/abs/nn.4162.html
Piezo2 is the principal mechanotransduction channel for proprioception
Seung-Hyun Woo et al,
Nature Neuroscience 18, 1756–1762 (2015) doi:10.1038/nn.4162Received 14 July 2015 Accepted 13 October 2015 Published online 09 November 2015

Magnesium intake higher than 250 mg/day associated with a 24% increase in leg power & 2.7% increase in muscle mass.
http://onlinelibrary.wiley.com/doi/10.1002/jbmr.2692/full

Dietary Magnesium Is Positively Associated With Skeletal Muscle Power and Indices of Muscle Mass and May Attenuate the Association Between Circulating C-Reactive Protein and Muscle Mass in Women

Ailsa A Welch et al.
http://www.readcube.com/articles/10.1002%2Fjbmr.2692?r3_referer=wol&tracking_action=preview_click&show_checkout=1&purchase_referrer=t.co&purchase_site_license=LICENSE_DENIED

Gray Cook
https://duker2p.wordpress.com/2015/11/16/illuminating-insights-gray-cook-part-1/

Carries, lots of carries
https://www.facebook.com/otpbooks/videos/1004044686323688/

And what have we been saying? parallel processing seems to be OK (balancing and reading), but dual or multitasking has its hazards…

• decreased speed of movement. not surprising because of the dual tasking
• increased ankle dorsiflexion (not necessarily a bad thing. This is probably to create a wider and more stable base through pronation
• reduced cadence
• decreased stride length

we were surprised there was not a increased “base of gait”, as balance requirements increase, gait usually decomposes (see here for a cool post and video we did on this a while ago)

“Numerous studies have analyzed the impact of dual tasks—specifically, tasks that cause cognitive distraction—on gait. With regard to texting as a dual task, many studies have consistently found that it does have an effect on gait, and that’s mostly to slow a person down.

For instance, Italian researchers in the Journal of NeuroEngineering and Rehabilitation assessed 18 healthy young adults who did not have problems with vision, or neurological or musculoskeletal disorders that could affect their gait.3 Barefoot participants walked a straight path of 15 meters (about 50 feet) for three minutes under two conditions: walking alone and walking while texting.

They found that texting while walking differed from walking alone in terms of muscle activation, kinematics, and spatiotemporal variables. Texting was associated with delayed activation of the gastrocnemius lateralis muscle and slightly increased ankle dorsiflexion followed by slightly reduced plantar flexion. It was also associated with a slower gait speed, reduced cadence and stride length, increased flat-foot contact, and decreased push-off. The researchers also found increased co-contraction of the ankle antagonist muscles during what they called the “critical” gait phase—from load response to midstance, corresponding to the transfer of body weight from one leg to the other.”

its a short one. Take the time to check it out…

link to article: http://lermagazine.com/cover_story/texting-while-walking-gait-adaptations-and-injury-implications

Using a boot to heal a bone, tendon, post-op ?  Think deeper please.

Please please, please ! If you are going to put your client in a CAM rocker boot/shoe for a fracture, or post-op can you please try to level out the leg length discrepancy caused by the thickness of the boot’s sole ? Please ? Pretty please with sugar on top?

Some boot brands have a huge midsole thickness. This leads to a functionally longer leg length. If they are barefoot much of the day, there will be a huge leg length discrepancy. If in shoes all day, you can offset this with a sole lift in the healthy foot’s shoe or you can add something like this to the outsole. Use common sense. IF someone is in a CAM boot for 6 weeks and thus a longer leg, this is going to promote a knee flexed posture on the boot side (ie. shortens the leg) and/or hyperextension of the healthy leg’s knee, supination of the foot, more forefoot habitus (sustained calf loads) and even frontal plane lurch pelvis gait mechanics (this is why many folks will get opposite hip pain). These embedded gait flaws must be addressed and remedied after they are out of the boot to reset normal gait. We have seen enough problems come to our offices that are suspect as a result of prolonged boot use and failure to reteach normal gait patterns, meaning, to reduce the learned gait behaviors of being in a boot for prolonged periods. Gait retraining is just as important as the rehab post-boot removal.  Of course, this is rarely done.  Using logic is never a bad thing.   

Dr. Shawn Allen, one of the gait guys

Here is a neat device we found to help.http://www.braceshop.com/procare-evenup-shoe-balancer-walker-system.htm?gdftrk=gdfV28018_a_7c2568_a_7c10961_a_7c32290&gclid=Cj0KEQiA37CnBRChp7e-pM2Mzp0BEiQAlSxQCCeL74AvCkYXbQX_jV1jEP27mfocB87f8pSfbo2PZMIaAsOV8P8HAQ

Medial longitudinal Arch age stablization.

It seems to depend on what source you read as to when the MLA (medial longitudinal arch) stabilizes, but here is a number, between 7-9 years old. 

Conclusions: The MLA of children remained stable from 7 to 9 years old. Gender and the type of footwear worn during childhood may influence MLA development.

Reference:

Medial Longitudinal Arch Development of Children Aged 7 to 9 Years: A Longitudinal Investigation.Jasper W.K. Tong, Pui W. Kong Journal of American Physical Therapy Assoc.   DOI: 10.2522/ptj.20150192 Published February 18, 2016

http://ptjournal.apta.org/content/early/2016/02/17/ptj.20150192