Sometimes, you just need to add a little pressure….

Cyclists are no different than runners; often when the effort is increased (or the conditions reproduced), the compensation (or problem) comes out.

Take a good look at this video of a cyclist that presented with right sided knee pain (patello femoral) that begins at about mile 20, especially after a strong climb (approx 1000 feet of vertical over 6 miles through winding terrain).

The first 7 seconds of him are in the middle chain ring, basically “spinning” ; the last portion of the video are of him in a smaller (harder) gear with much greater effort.

Keep in mind, he has a bilateral forefoot varus, internal tibial torsion, L > R and a right anatomically short leg of approximately 5mm. His left cycling insole is posted with a 3mm forefoot valgus post and he has a 3mm sole lift in the right shoe.

Can you see as his effort is increased how he leans to the right at the top of his pedal stroke of the right foot and his right knee moves toward the center bar more on the downstroke? Go ahead, stop it a few time and step through it frame by frame.  The left knee moves inward toward the center bar during the power stroke from the forefoot valgus post.

So what did we do?

·      Worked on pedal stroke. We gave him drills for gluteal (max and medius) engagement on the down stroke (12 o’clock to 6 o’clock) to assist in controlling the excessive internal spin of the right leg. Simple palpation of the muscle that is supposed to be acting is a great start.

·      Did manual facilitation of the glutes and showed him how to do the same

·      Worked on abdominal engagement during the upstroke (the abs should initiate the movement from 6 o’clock to 12 o’clock)

·      Manually stimulated the external oblique’s

·      Placed a (temporary, hopefully) 5mm varus wedge in his right shoe to slow the internal spin of the right lower extremity

·      Taught him about the foot tripod and appropriate engagement of the long extensors; gave him the standing tripod and lift/spread/reach exercise (again to tame internal spin and maintain arch integrity)

Much of what you have been learning (for as long as you have been following us) can be applied not only to gait, but to whenever the foot contacts anything else.

The Gait Guys. Experts in human movement analysis and providing insight into biomechanical faults and their remediation.

All material copyright 2013 The Gait Guys/The Homunculus Group. Please use your integrity filter and ask before using our stuff. 

Photo: Where is your knee joint hinge point ?  Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing.  He has the cleanest lines of the bunch. How is that for cruel irony ?  Sometimes it ain’t what you got, it is what you do with what you got.  Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations.  Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.  

Today’s Lesson:  Get in line, and get in line early. (just kidding of course)

The Gait Guys.  Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination.  We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.  "Seeing may be believing" but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

*Photo courtesy of BIG EAST Conference

Bipedal vs. Quadrupedal. A Navy Seal vs. Chimp

Next week we have a short series on quadrupedal gait. You won’t want to miss this one. We are gonna show you something that will freak you out ! But as always, we have lessons and teachings with it, important ones.  

Here is a primer.  Enjoy

Midfoot Striking Monsters.  That’s right, a gorgeous HD video for you today. Reminds us of a Joseph Campbell storyline.  A beautiful video and an Angus Young-ish young boy with perfect midfoot strike, along with his monster buddies.

Something a little lighter today for the gait brethren here on The Gait guys.  Proof that it doesn’t always have to be cerebral here on the Gait Guys. Today just sit back, go full screen HD on this one, and turn it up loud !

This kid should give form running clinics. Its simply a beautiful running form.

Shawn and Ivo.

___________________

credits:

RUN BOY RUN EP ON I-TUNES : itunes.apple.com/fr/album/run-boy-run-remixes-ep/id522665628

WOODKID - RUN BOY RUN - Video directed by Yoann Lemoine

Produced By ICONOCLAST with the help of Picseyes
Produced by Roman Pichon 
Art director / Chef Decorateur : Pierre Pell 
Post Production by OneMore Prod
VFX SUPERVISOR : Gregory Lanfranchy
FLAME ARTIST : Herve Thouement
FLARE ARTISTS : Laura Saintecatherine & Romain Leclerc
3D : Olivier Junquet & Priscilla Clay
MATTE PAINTING : Arnaud Philippe Giraux
POST PRODUCER : Raminta Poskute
Label & Video commissioner Pierre Le Ny

P & C 2012 GREEN UNITED MUSIC ICONOCLAST / GREEN UNITED MUSIC / SEIZE ZÉRO TROIS
label-gum.com/

Trojan horses for knee menisci.

 Orthotics and internal tibial torsion. Good? Bad? or Ugly? It depends…

Hopefully you remember about torsions, especially internal tibial torsion (see above). Tibial torsions are deviations (in this case, in the transverse plane) of the long axis of the bone. The bone is basically twisted along its long axis, like wringing out a wet towel. They are measured by drawing an imaginary line through the medial and lateral malleoli, as well as through the two halves of the tibial plateau, and measuring the angle between them (see 2nd picture above). For a more complete review of torsions, click here.

 At birth there should be little to no angular difference between the proximal and distal tibia, and this changes to about 19-22 degrees in the adult; the shaft of the tibia rotates outward (externally) with growth resulting in a normal tibial external version (see 3rd picture above).  Sometimes, the angular difference is less than zero at birth and the tibia does not rotate outward (externally) resulting in internal tibial torsion.

Internal tibial torsion usually results in a decreased progression angle (more on those here). This often causes a “toed in gait” and the foot remains in supination for a longer period of time (supination is adduction, inversion and plantar flexion), making the foot a rigid lever. When we examine the person in a standing position with the knees in the coronal plane, the feet point inward. When we move the feet to a more normal posture, the knees rotate outward from the coronal plane.

Folks with internal tibial torsion often have a forefoot varus (the forefoot is inverted with respect to the rear foot) because of the amount of supination they are in, which we talked about in the previous paragraph, (see also here). When folks have a forefoot varus, they have a tendency to pronate more through the forefoot, and when people pronate more other folks like to typically put them in orthotics to “get rid of that pronation”(because we all know that pronation is the scourge of humanity, and if there were less pronation in the world, there would probably be fewer wars, famine and poverty : )

 So what happens to the knee when we place an orthotic in the shoe? Most orthotics are designed to slow pronation of the midfoot, so they basically supinate the foot, causing the talus to dorsiflex, abduct and invert. This rotates the leg (and thus the knee) externally. With internal tibial torsion, often the knee is already externally rotated because your brain will not allow you to progress forward with your toes in too far, you would trip. So, the orthotic rotates the knee out further, bringing it outside the sagittal plane. This does not bode well long term, as it creates a rotational and friction conflict at the knee (remember the knee is basically a hinge between two ball and socket joints). Guess where the conflict manifests itself? At the meniscus. This, over time, is a great way to macerate a meniscus and create a problem.

Does this mean an orthotic is never indicated? No it does not. It means that if you use one, you should probably make sure the part of the orthotic anterior to the styloid of the 5th metatarsal has a valgus post built into it. This valgus moment will help to bring the knee back to the midline during the propulsive phase of gait. See our recent post here about forefoot valgus posting. Do you think this is ever considered in stores when dispensing foot beds for shoes ?  Not all foot beds are evil or a problem mind you, but we have seen some in stores that are real risky business if you ask us.

The bottom line? Know how to use the tools you have available, or someone is going to get hurt. When in doubt, exercise is usually a safer alternative and often has less likelihood of creating a Trojan Horse.  

Want to learn more about these kinds of things, foot beds, foot types etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

The Gait Guys. Raising questions and providing answers and guidance, with each and every post.

all material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our wares. 

What is your gait filter ? This blog post may be the most important one we have ever written.

Are you a biomechanist ? A high school or college coach ? A physical therapist ? Chiropractor ? Self-proclaimed running guru ? Running shoe store shoe fitter ? Researcher ?

We all are going to approach gait and gait analysis through our biased filter. There is no way you can avoid it. And the more diverse your background, the deeper your education levels and the deeper your experience level in practicing your trade the better your filter will be.  But in many ways this article is more than just about your gait analysis filter, it is about your life filters, your outlook and opinions that have shaped your life.

Are you assessing your client’s gait ? Maybe you think you are. Maybe you are doing a great job and are seeing things that are truly there, and maybe you are making them up.  Is your filter clogged ? And, if you are doing gait analysis and your gait knowledge is thin, then you are also limiting and possibly biasing the information of one of the most deeply repetitive and engrained motor and movement patterns that a human will do on a daily basis. If you are not looking for honest gait pathomechanics, and if you are giving exercises to your client without cleaning up those pathomechanics (*not what you see but what has caused what you see) you are further driving your clients neurologic faulty motor patterns deeper into a rut.  This can lead to injury locally and possibly globally.

Just remember, in gait analysis and in life, if you disagree with someone it is likely because of the detail and depth of the filter you or they are observing things through.  Once your education stops, formal or experiential, your filter will no longer change and life and gait will be judged based on that stagnant filter (and we all know a “rigid in their ways” parent or grandparent who is stuck in their ways).  And, when it comes to progress or lack there of,  so does the potential benefit to every client you help from this day forward. Keep refining that filter, keep making it deeper and more pristine. Keep cleaning it out regularly and look for ways to improve upon it.  The more you know the better your filter, the better you will filter out the assumed, the lies and the fake outs from the truth.  

Ivo and I have have filters too. And when it comes to gait, our individual filters force us to see other sides but these filters we each bring to the table create conflicts at times.  We do not always see a case the same way and sometimes we argue from one side of the fence, until we realize to put on the other guys filtered glasses. Ivo has a strong neurological, rehab, acupuncture/Eastern medicine filter. These are weak filters for me and I will always default to him on these issues. Likewise, I have an
orthopedic, sports med, muscle activation filter and they too can be a blessing and curse. But when we come together and layer our filters we get a clearer extract from what is being pressed through our filters. And, when we play nicely with each other, putting our two brains together and let a case filter down through the filters of neurology, orthopedics, acupuncture, rehab, sports medicine, movement pattern systems, muscle activation/inhibition techniques and the like we often get a pure and honest extract at the other end. Our filters help us remove the biases in a case that inexperience or a lack of expertise or knowledge on a particular disorder will cloud.

There is much to this filter theory. As we eluded to earlier, filters dictate how we see the world. Whether it be gait analysis or how we raise our kids filters affect how we see our world and the actions we take based on that filtered information.  Gait analysis is no different than anything else in our lives. When it comes to rearing children for example we often act subconsciously and reactively on many of the filters handed to us by our parents, from our life experiences, from our religous views, political views and many others. These actions and reactions do not mean your filter is always right either. Learning about another side or perspective through some else’s filter can help clear or solidify yours. Gait analysis is no different and it is subject to the biases passed down to you from all that you have learned or experienced.

Are you keeping your clinical and gait filters pure and unbiased? We question this all the time about our work to keep us honest. If all someone does is look at something through the same filter you can get lost at seeing the world only through that filter. Be careful if all you do is go to the same seminars and follow the same people around because they are the top chef guru right now. Every theory has holes and limits, just ask Einstein. It’s when we try to press a square peg into a round hole based on “the guru or theory of the moment” perspective that we get ourselves into the problems of a clogged filter. We have all done it, yes all of us. We get stuck in our ways as well. We are creatures of habit. We have all been to a great seminar only to return the next Monday into our routines of old slowly drifting back to ways of old in a few weeks. It’s easy to settle back in to a narrow clogged filter because change asks something more of us. It’s easier to slide down that hill of comfort and familiarity, but it asks something more and something bigger of us when we have to trudge up that steep hill that is cursed with questions, unfamiliarity and discomfort. But, that’s where the gold is found. 

So, what are your filters ? Are there enough of them and are they deep enough ? Are they based on good guided and mentored experience or are they based on your self-taught and thus biased experiences ? Our filters here at The Gait Guys have a combined 24+ years of formal medical and medical-related education and 40+ years of clinical experience (and more importantly, failure) with patients. We think our filters run pretty deep but they admittedly have holes that have been stitched with experience and humility, and they likely still have unseen gaping holes and leaks that we struggle to find to this day. But we try to show up everyday in our clinics and here on The Gait Guys blog with an honesty and humbleness in an attempt to learn that which we don’t know and to honestly face that which we think we know, but actually don’t, because our filters are also subject to clogging.

And finally remember one of our biggest catch phrases. “What you see in someone’s gait is not their problem, but rather their strategic compensation around the problem”. 

Don’t make it worse but trying to filter what you see through a clogged or shallow filter. 

And if you do not mind us finishing with a broader brush, it is more than just about GAIT filters, rather it is about every filter through which we approach life and the people in our lives. Whether it be politics, religion, the media, research, guns, war, abortion, gay rights, marriage, our spouses, child rearing and the like, if we just step back from every opinion we have and become aware of our thoughts, feelings and emotions and realize that they are a product of the filters we apply, maybe, just maybe … . . the world will be a better place in that moment. (And if Ivo and I can dream big, maybe a world where everyone walks and runs without pathologic compensations.)

Shawn and Ivo, The Gait Guys.  Getting a little armchair philosophical on you today.

More Foot Rocker pathology Clues.

Is ankle rocker normal and adequate or is it limited ?  Is it limited in early midstance or late midstance ? How about at Toe off?  Is it even possible to distinguish this ? Well, we are splitting hairs now but we do think that it is possible. It is important to understand the pathologies on either end of the foot that can impact premature ankle rocker. 

Look at the photo above. You can see the clinical hint in the toe wear that this runner may have a premature heel rise. However, this is not solid evidence that every time you see this you must assume pathologic ankle rocker. The question is obviously, what is the cause.

Considerations:

1- weak anterior compartment, which is quite often paired with the evil neuroprotective tight calf-achilles posterior complex to offer the necessary sagittal protection at the ankle mortise.  This will cause premature heel rise from a posterior foot aspect.

2- rigid acquired blocked ankle rocker from something like “Footballer’s ankle”. This will also cause premature heel rise from a relatively posterior foot aspect.

3- there are multiple reasons for late midstance ankle rocker pathology. The client could completely avoid the normal pronation/supination phase of gait because of pain anywhere in the foot. For example, they could have plantar fascial pain, sesamoiditis, a weak first ray complex from hallux vaglus, they could have a painful bunion, they could be avoiding the collapse of a forefoot varus. There are many reasons but any of them can impair the timely pronation-supination phase in attempting to gain a rigid lever foot to toe off the big toe-medial column in “high gear” fashion. And when this happens the preparatory late midstance phase of gait can be delayed or rushed causing them to move into premature heel rise for any one of several reasons.  Rolling off to the outside and off of the lesser toes creates premature heel rise.  

4- And now for one anterior aspect cause of premature heel rise. This is obviously past the midstance phase but it can also cause premature heel rise. Turf toe, Hallux rigidus/limitus or even the dreaded fake out, the often mysterious Functional Hallux limitus (FnHL) can cause the heel to come up just a little early if the client cannot get to the full big toe dorsiflexion range.  

We could go on and on and include other issues such as altered Hip Extension Patterning, loss of hip extension range of motion, weak glutes, or even loss of terminal knee extension (from things like an incompleted ACL rehab, Osteoarthritis etc) but these are things for another time. Lets stay in the foot today.

All of these causes, with their premature heel rise component, will rush the foot to the forefoot and likely create Metatarsal head plantar loading and could cause forces appropriate enough to create stress responses to the bone. This abrupt forefoot loading thrust will often cause a reactive hammer toe effect.  Quite often just looking at the resting nature of a clients toes while they are lying down will show the underlying increase in neuro-protective hammering pattern (increased long toe flexor and short toe extensor activity paired with shortness of the opposing pairs which we review here in this short video link).  The astute observer will also note the EVA foam compressing of the shoe’s foot bed, and will also note the distal displacement of the MET head fat pad rendering the MET head pressures even greater osseously. 

Premature ankle rocker and heel rise can occur for many reasons. It can occur from problems with the shoe, posterior foot, anterior foot, toe off, ankle mortise, knee, hip or even arm swing pathomechanics.  

When premature heel rise and impaired ankle rocker rushes us to the front of the foot we drive the front half of the shoe into the ground as the foot plantarflexion is imparted into the shoe.  The timing of the normal biomechanical events is off and the pressures are altered.  instead of rolling over the forefoot and front half of the shoe after our body has moved past the foot these forces are occurring more so as our body mass is still over the foot. And the shoe can show us clues as to the torture it has sustained, just like in this photo case.

You must know the normal biomechanical gait events if you are going to put together the clues of each runner’s clinical mystery.  If you do not know normal how will you know abnormal when you see it ? If all you know is what you know, how will you know when you see something you don’t know ?

Shawn and Ivo, The Gait Guys … .  stomping out the world’s pathologic gait mechanics one person at a time. 

Why alignment of the big toe is so critical to gait, posture, stabilization motor patterns and running.

There are two ways of thinking about the arch of the foot when it comes to competent height.  One perspective is to passively jack up the arch with a device such as an orthotic, a choice that we propose should always be your last option, or better yet to access the extrinsic and intrinsic muscles of the foot (as shown in this video) to compress the legs of the foot tripod and lift the arch dynamically.  Here today we DO NOT discuss the absolute critical second strategy of lifting the arch via the extensors as you have seen in our “tripod exercise video” (link here) but we assure you that regaining extensor skill is an absolute critical skill for normal arch integrity and function.  We like to say that there are two scenarios going on to regain a normal competent arch (and that does not necessarily mean a high arch, a low arch can also be competent….. it is about function and less about form): one scenario is to hydraulically lift the arch from below and the other scenario is to utilize a crane-like effect to lift the arch from above. When you combine the two, you restore the arch function.  In those with a flat flexible incompetent foot you can often regain normal alignment and function.  But remember, you have to get to the client before the deforming forces are significant enough and have been present long enough that the normal anatomical alignments are no longer possible. For example, a hallux valgus with a large bunion (this person will never get to the abductor hallucis sufficiently) or a progressively collapsed arch that is progressively becoming rigid or semi-rigid.

Think about these concepts today as you watch your clients walk, run or exercise.  And then consider this study below on the critical importance of the abductor hallucis muscle after watching our old video of Dr. Allen’s competent foot.  

CONCLUSIONS AND CLINICAL RELEVANCE:

The abductor hallucis muscle acts as a dynamic elevator of the arch. This muscle is often overlooked, poorly understood, and most certainly rarely addressed. Understanding this muscle and its mechanics may change the way we understand and treat pes planus, posterior tibial tendon dysfunction, hallux valgus, and many other issues that lead to a challenge of the arch, effective and efficient gait. Furthermore, its dysfunction and lead to many aberrant movement and stabilization strategies more proximally into the kinetic chains.

*From the article referenced below,  “Most studies of degenerative flatfoot have focused on the posterior tibial muscle, an extrinsic muscle of the foot. However, there is evidence that the intrinsic muscles, in particular the abductor hallucis (ABH), are active during late stance and toe-off phases of gait.“

We hope that this article, and the video above, will bring your focus back to the foot and to gait for when the foot and gait are aberrant most proximal dynamic stabilization patterns of the body are merely strategic compensations.

Study RESULTS:

All eight specimens showed an origin from the posteromedial calcaneus and an insertion at the tibial sesamoid. All specimens also demonstrated a fascial sling in the hindfoot, lifting the abductor hallucis muscle to give it an inverted ‘V’ shaped configuration. Simulated contraction of the abductor hallucis muscle caused flexion and supination of the first metatarsal, inversion of the calcaneus, and external rotation of the tibia, consistent with elevation of the arch.

http://www.ncbi.nlm.nih.gov/pubmed/17559771

Foot Ankle Int. 2007 May;28(5):617-20.

Influence of the abductor hallucis muscle on the medial arch of the foot: a kinematic and anatomical cadaver study.

Wong YS. Island Sports Medicine & Surgery, Island Orthopaedic Group, #02-16 Gleneagles Medical Centre, 6 Napier Road, Singapore, 258499, Singapore. 

"Action Expresses Priorities"- Gandhi

“Action expresses priorities.” -Mahatma Gandhi

So much truth to this statement.  It pertains to gait analysis perfectly.  

For years now you have heard us say, “What you see is NOT what is wrong with someones gait, rather you see their COMPENSATION STRATEGY around what IS wrong." 

The body is always strategizing to negotiate around pain, instability (functional or anatomic) or immobility.  What you see in gait are those strategies. You may not see their immobility for example, you see how they move when increasing mobility in one or multiple areas to cope with immobility in another. 

*Translation= The gait action strategy you see expresses the body’s compensation priority to make gait possible around the underlying problems that are preventing the clean, optimal and primary gait motor pattern from surfacing.

Thanks to Gray Cook for unearthing this Gandhi quote on his twitter.

A Study Supporting much of what we have been saying.

“ Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index.”

This study brings about a few points worth mentioning:

• folks in the Indian population have flatter feet
• the amount of great toe extension is important, especially as it relates to foot pain
• foot prints can tell you a lot about a foot
• foot exercise and footwear modifications achieved the best outcomes

Lets look at some of these points.

folks in the Indian population have flatter feet

foot morphology is not only developmental, but has a genetic component, that can differ in different populations

the amount of great toe extension is important, especially as it relates to foot pain

just how much great toe extension (or dorsiflexion as foot geeks like to say) is necessary? The great toe must extend 40 degrees to walk normally and most folks can dorsiflex 65 degrees. If this is impaired (something called “hallux limitus”) it can:

• shorten your stride length
• make you have difficulty with high gear push off
• will probably give you pain at the metatarsal phalangeal junction

foot prints can tell you a lot about a foot

Gee, we have been saying this for a few years now and have been advocating the use of a pedograph as well. In fact, we wrote the ONLY book about it’s interpretation, available by clicking here.

foot exercise and footwear modifications achieved the best outcomes

We have almost a thousand posts on this blog, and nearly 100 youtube videos, many of which talk about foot exercises, their indications and how to do them

The Gait Guys. Increasing your “Foot IQ” each and every day. If you are new to us, thanks for reading and feel free to “dig in” and search this blog, as well as our youtube channel. Have a question? Want to take your learning to the next level? Consider taking the International Shoe Fit Certification Program and put yourself at the front of the line when it comes to shoe fit. email us at thegaitguys@gmail.com for more info. 

 

J Orthop Surg (Hong Kong). 2013 Apr;21(1):32-6.

Flatfoot in Indian population.

Pandey S, Pal CP, Kumar D, Singh P.

Source

Department of Orthopaedics, Moti Lal Nehru Medical College, Allahabad, India.

Abstract

PURPOSE. To compare outcomes of different conservative treatments for flatfoot using the foot print index and valgus index. METHODS. 150 symptomatic flatfoot patients and 50 controls (without any flatfoot or lower limb deformity) aged older than 8 years were evaluated. The diagnosis was based on pain during walking a distance, the great toe extension test, the valgus index, the foot print index (FPI), as well as eversion/ inversion and dorsiflexion at the ankle. The patients were unequally randomised into 4 treatment groups: (1) foot exercises (n=60), (2) use of the Thomas crooked and elongated heel with or without arch support (n=45), (3) use of the Rose Schwartz insoles (n=18), and (4) foot exercises combined with both footwear modifications (n=27). RESULTS. Of the 150 symptomatic flatfoot patients, 96 had severe flatfoot (FPI, >75) and 54 had incipient flatfoot (FPI, 45-74). The great toe extension test was positive in all 50 controls and 144 patients, and negative in 6 patients (p=0.1734, one-tailed test), which yielded a sensitivity of 96% and a positive predictive value of 74%. Symptoms correlated with the FPI (Chi squared=9.7, p=0.0213). Combining foot exercises and foot wear modifications achieved best outcome in terms of pain relief, gait improvement, and decrease in the FPI and valgus index. CONCLUSION. The great toe extension test was the best screening tool. The FPI was a good tool for diagnosing and grading of flatfoot and evaluating treatment progress. Combining foot exercises and foot wear modifications achieved the best outcome.

Lateral Foot Pain

Well then, why does this young man have pain on the outside of this foot, near his little toe, when walking for long periods of time, along with cramping of the feet. He recently undertook a “bussing tables” job at a local restaurant and is (suddenly) on his feet for 8-10 hours daily for 7-8 days at a stretch?

Take a good look at the top few photos. What do you see?

You should see:

• windswept biomechanics of the legs (i.e. internal tibial torsion on the left and relative external tibial torsion on the right). missed out on torsions? click here. 

Internal tibial torsion often places extra force on the lateral aspect of the foot. You (often) rotate the extremity internally to maintain the knee in the saggital plane.  

• he has inverted feet bilaterally with (most likely) and forefoot varus (the forefoot is inverted with respect to the rear foot). This is easier to see with exam, as it looks like he may have a forefoot valgus in the picture

for what we hope are obvious reasons, when a person has an uncompensated (cannot form an adequate foot tripod) forefoot varus, this will place extra force on the outside of the foot. 

• he has a left short leg (functional or anatomical)

folks will often (but not always) pronate through the mid foot more on the longer leg side (in an attempt to shorten the leg) and supinate (remember: plantar flexion, inversion and adduction) on the shorter leg side in an attempt to lengthen the limb. 

Now can you see why he has lateral foot pain?

What about the cramping?

Hmmmm. going from almost zero to 8-10 ours daily of standing on hard floors. think the intrinsic muscles of the foot might be called to task? And this is exactly what is happening. Those muscles, which have little endurance capacity, are going through glycolytic pathways to function, this the cramping.

So what do we do?

• for starters, we valgus posted the insoles of his shoes L >>R to try and push him off the lateral aspect of his foot and toward the head of the 1st metatarsal (see pics)
• we gave him a temporary 3mm lift in the L side (a full sole lift). A heel lift only puts the foot in plantarflexion, lift the whole foot.
• we gave him the tripod standing, lift toes, spread toes and reach “shuffle walk” exercises (you can search the blog under “exercise” or “tripod” to see these posts again: 3 sets, 10 reps, 3X daily
• we advised him to stay out of motion control shoes (which would push his L knee too far laterally and outside the saggital plane
• we manipulated his feet to insure his mechanics were biomechanically appropriate
• we did manual stimulation of the tibialis anterior, extensor digitorum longus, interossei, extensor hallucis brevis and tibialis posterior followed by multiangle isometric resistance 

We will see how he does and may need to consider a custom crafted orthotic with intrinsic valgus posting if he does not respond well to therapy. we may need to consider dry needling and/or acupuncture as a supportive modality as well.

We hope you followed our reasoning in this case. If not, maybe search through our blog and youtube channel and catch up on some of this cool stuff!

The Gait Guys: Making you smarter each and every post

Podcast 35: Future-tech of shoe fit, Case studies & technology.

Podcast 35: Future-tech of shoe fit, Case studies & technology.

podcast link:

http://thegaitguys.libsyn.com/podcast-35-future-of-shoe-fit-case-studies-technology

iTunes link:

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

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen  Biomechanics

Today’s show notes:

Neuroscience piece:

 

1- Wearable computers will be inside us

Read more at http://venturebeat.com/2013/07/09/wearable-computers-will-be-inside-us/#QvypWtr2mA3gJkEi.99 

2- First ever head transplants are possible and not far off.

http://qz.com/99413/first-ever-human-head-transplant-is-now-possible-says-neuroscientist/________

3- 3D printed casts for shoe fit. The new future ?

4- FB reader sent us a message:

-Hi Gait Guys,

I have anterior pelvic tilt and overpronation of the right foot.

at gait, LEFT foot does toe off properly and straight.
However, RIGHT foot moves towards my center at toe off. It just sort of caves in & moves in as well.

I managed to really reduce that(i think) from massages and strengthening glutes etc but I would just like to know what causes that so I know what to target.

Once again, congratulations on your work. Not only has it not been done before over the whole internet it is excellent.

-a tormented athlete with postural difficulties

5- Another FB reader asks question about heel spurs, plantar fascitis, ankle biomechanics

6- Questions from a field doc:

Hey guys,

I have a couple questions for you that you could possibly use or you could simply answer them via email. 

1)  Ivo, in one of your videos on muscle function you talk about muscle inhibition.  I always thought the CNS simply chooses not to recruit all of the motor units in a muscle or chain of muscles to protect from injury, compensate, etc.  You mentioned in your video the CNS somehow recognizes the spindles in these motor units are already “turned on” so they will not activate.  I’m not sure I have this correct but I was hoping you could elaborate on this confusing but interesting neurological phenomenon.

7- Patient case yesterday:

Runner comes in and says “i keep landing on the outside of my left foot when i run, it is there a little when i walk, but more prominent when i run. Everywhere i read the armchair experts are saying to just let foot strike happen naturally.  Do i leave this alone ? Oh, and my left hip is always tight.”

How to properly regain ankle rocker: A Prince of an Exercise

If you have been with us here at The Gait Guys you will know by now that we like to take Fridays and make them a blog post recycle.  This week we have a beauty and it parlays beautifully into our blog posts from the last 2 days on ankle rocker. We did this video about 3 years ago. We can tell because Dr. Allen hasn’t yet shaved his dome and he looks much younger.  Plus he stopped wearing sweater vests !  Ouch !

Today we show a staple in our in-office and home exercise programs. The Shuffle Walk and the Moon Walk.  We have altered these exercises in the last year or so, thus we really need to get that Foot Exercise DVD done that we have been promising for 2 years+.  

Anyhow, STOP passively stretching your calf muscles !!!!!!

Do the Shuffle walk instead.  We have a rule in our offices. If you are going to participate in a running sport, you must do 2 minutes of Shuffle Walks EVERY SINGLE DAY.  

The size of the anterior compartment muscles is much smaller than the bulbous large posterior compartment so the tug of war is always in the favor of the calf to become too dominant.  Drive some SES (Skill, Endurance and Strength) into the anterior compartment and you will see a stronger arch, control pronation better and very likely see shin splints disappear once and for all. 

Watch the video today and learn why some of our teams can be seen Shuffling around the outdoor track. It is pretty amazing to drive by a school and see an entire team shuffling and know that they are doing it because of The Gait Guys. It is comforting that we do not have to see many shin splint cases in our offices anymore because the teams are being proactive. Shin splints are SOOOOO boring and easy to fix.  

Enjoy gang, From the archives……..

Shawn and Ivo

Pathologic Ankle Rocker: Part 2. “Passing the Buck Proximally”

This was an unexpected follow up blog post from yesterday’s piece we did on the rigid flat foot. We were purging some files from an old computer and came across these 2 videos. We are not even sure where they came from. They were AVI files from probably 2 decades gone by;  they reminded us how long we have been at this gait game and how many great patients have taught us along the way.
Yesterday we learned that if the ankle rocker (dorsiflexion) was impaired that we could ask for the motion to be passed into the midfoot via hyperpronation in order to get the tibia to progress past vertical to enable the body to pass by the rigid ankle mortise rocker.  (Remember from our previous teachings that there are 3 rockers in the foot. First there is heel rocker, then ankle rocker, then forefoot rocker. Each is essential for normal gait. You must understand the 3 rockers to understand gait and to recognize gait pathologies when they present.)
So, yesterday we saw a strategy of pronating excessively through the midfoot to artificially trick us into thinking we have more ankle rocker then we actually truly did. So this was a “pass the buck” into the foot. Today however we are going to show you a very atypical compensatory choice. Today this client shows that with a rigid and/or strong enough arch that the arch doesn’t always need to be the part that gives in to enable more rocker. Today this client chose a vertical strategy.
You are going to have to study these videos closely several times, this is a critical learning and teaching point today. The problem is the left ankle in the video.

This client has chosen to go  VERTICAL when they hit the ankle rocker limitation. Once they achieve their terminal range at the ankle mortise joint (the tibio-talar joint ) their brain realized that moving forward at the ankle was impossible. Since the midfoot did not collapse and give in, as in yesterday’s case, they had no choice but to “pass the buck” proximally into the kinetic chain. In this case we see that the knee was the next vertical joint. Now, they have 2 choices, either hyperextend the knee to enable a forward lurch of the body mass past the ankle rocker axis or “go vertical”. In this case you can see the early heel rise (we refer to is as premature heel rise). Frequently a premature heel rise can force knee flexion but in this case the rise just kept going vertical and forcing them into the use of the gastrocsoleus group and thus forcing a lift of the entire body. If you look hard you can see a greater development of the calf muscles on this side from doing this for years. (Oh, wait, memory data dump here…..we are recalling this case, it was the result of an old motorcycle accident. A student sent us this video back in the 1990’s when we were teaching at the university.)
What is interesting here is that if you think hard, and this will be a new thought process for many readers, that when he goes into heel rise he buys himself more ankle range again. You see, he first met the end range limitation of ankle rocker which appears to be about 90 degrees and then he hits the bony block. If he goes vertical into the calf he is moving back into plantarflexion. This means that even though he is on the forefoot now, he has bought himself more ankle dorsiflexion range again. Now he has the option of holding the posture on the forefoot as rigid and then re-utilizing the new-found extra degrees of ankle dorsiflexion to progress forward OR, he can just move into FOREFOOT ROCKER (the 3rd of the rockers we meantioned earlier).  This client is likely doing a bit of both, perhaps a little more of the forefoot rocker strategy.
You can also kind of see that this slightly shortens the time in the stance phase on this left side and causes an early dumping onto the right limb (which causes a frontal plane pelvis distortion compensation). This gives the appearance of a slight limp.
So, this was a nice follow up from yesterday’s principle of “passing the buck”. You can either ask for the motion from the next distal joint in the kinetic chain, or  you can back up the kinetic chain and dump it into the proximal joint from the pathologic one (the knee in this case). Which one would you want, if you had to choose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns.

Here is a tougher question for you. Would you want this phenomenon on one side and be unilaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*Please do not try to help this client by putting a heel wedge in their shoe. You are just going to rush heel rocker into that bony block sooner and faster and speed up his pathologic stance phase. You will see his vertical strategy come even faster and thus pass the buck into the opposite right hip even stronger. It is a fleeting good initial thought because you are merely trying to help his poor calf muscles get to that heel rise easier, until you think about it for a minute.

When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

The Rigid Flat Foot: Do you know what you are actually dealing with ?

In these 5 photos of a client with a flat arch we see some great opportunity to discuss some of the clinical issues and clinical thinking that needs to occur.  As usual we write our blog posts on the fly with a principle at hand that we want to drive home, or in this case “into the ground”.  There are many more clinical issues with this type of foot and its problems, so today’s list and dialogue is not meant to be exhaustive.  But, if you take one thing away from this case, it should be that not all flat feet can take a stability shoe or an orthotic. So, if you are in the mind set that “when it is flat, jack it up (the arch)” and “when it is high (the arch), cushion it” hopefully you will open your eyes a bit to the reality that it just is not that simple.  IF you want to learn more about these issues we have purposefully put together the National Shoe Fit program for stores and doctors/therapists so they can learn more about the anatomy of the feet and shoes and how to pair them up to create the best recipe for a person.  

Now, onto this case.

In this case you should notice a few things. 

1- the rigidity of the flat foot as portrayed in the photo where we are pushing up with our thumb on what once was the peak of the arch (yes, there are 5 photos in this case, click on one to enlarge or scroll) . We are attempting to push up, but the midfoot is completely rigid. This is a classic Rigid Flat Foot Deformity, A Rigid Pes Planus if you will. 

2- There is a prominence at the navicular bone, both top (dorsal) and bottom (plantar) aspects of the foot (see photo of my hand with finger and thumb indicating these areas). The plantar prominence is the actual naviular bone (mostly) that has become weight bearing (termed “weight bearing  navicular” and crudely by some as a dropped navicular, a term we dislike). And the dorsal prominence is a dorsal crown of osteophytes. This means a dorsal ridge of bone has formed at the navicular-1st cuneiform bone/joint interval because of the constant and repetitive compression of the two against each other dorsally as midfoot arch collapse occurred repeatedly and then became a fixed permanent entity.

3- The hyper dorsiflexion range at the 1st MTP joint (the big toe). This range is excessive at actually was able to exceed 90 degrees (see photo) !  Even at rest the hallux (big toe) is extended suggesting the volume of dorsiflexion it gets all the time.  By the way, there was little to no hallux 1st MPJ joint plantarflexion (downward bend), not in a foot this flat. In fact most of that is from the contracture of the short extensors of the toes as noted by the photo showing the hammer toe formation (hammer toe = contractured short extensor myotendon, and to the long flexors as well). Hammer toes are almost always seen in a flat foot presentation, to a degree.

Now, lets put some things together (but a reminder, this is a single principle today, there are many more issues here).

Today’s Principle: Passing the Buck

Normally we need to have just slightly greater than 90 degrees of ankle mortise dorsiflexion to progress the body over the ankle.  Put in other words, we need to be able to get the tibia slightly past vertical (perpendicular to the ground, hence 90+ degrees). Depending on the reference, anywhere from 15-25 degrees past that 90 degree vertical, thus 105 to 120 degrees) is the goal.

If an ankle cannot get that range, the range must be achieved either proximal or distal to that joint, ie. Passing the Buck beyond the ankle mortise joint.  Proximally, one can hyperextend the knee to enable the body mass to pass sagittally over the ankle but a better strategy (arguably) is to compensate distally via collapsing the arch and pronate more than normally through the midfoot putting undue stress and strain into the plantar fascia and over time eventually collapsing the arch and creating the dorsal and plantar bony prominences we mentioned in #2. By dropping the arch, the subtalar joint exceeds its ranges and the talus and navicular collapse medially and plantarwards. 

When the arch drops to the planus stage the tibia is passively thrust forward achieving the necessary forward tibial progression to get body over and past the ankle to enable forward progression. 

Remember, this pes planus will dorsiflex the long metatarsal bone (meaning make it parallel to the ground). This will screw up the 1st Metatarsal-phalangeal joint function and  impair the Windlass Mechanism of Hicks at the big toe (translation, it will impair the sesamoids, possibly leading to sesamoiditis, and change the normal toe function and its tendons.  This is seen both in the pes planus foot and in hallux rigidus turf toe presentations where the big toe loses its  normal ranges as compared to this case here).

So, the normal range can as for the buck to be passed proximally into the kinetic chain or distally. Which one would you want, if you had to chose?  It is a tough choice, luckily the body decides for us.  IF you consider that luck !

Regardless, one has to stand in awe that the body will find a way to get the range elsewhere when it cannot find it in the primary motor pattern.  And when the range has to be gained elsewhere, the muscular function has to change as well and prostitute the normal kinetic chain motor patterns. 

Here is a tougher question for you. Would you want this phenomenon on one side and be uniliaterally compromising (and thus have to compensate on the opposite side) the kinetic chain or bilaterally and have the asymmetry on both sides ?  That is a tough one. There is no good choice however.

*So, a flat RIGID foot.  If you jam an agressive orthotic (or possibly even a motion control shoe) under this foot it could very likely be painful to those rigid bony prominences and it will remove the client’s “passing the buck” compensation. Now the forces may have to revert to the proximal strategy at the knee.  So, when do YOU go with the orthotic or motion control shoe ? When it comes to the feet, use your head.  And, consider the Gait Guys, National Shoe Fit DVD program.  Email us at : thegaitguys@gmail.com

Lets test your visual skills again.

This is a 7 year old with gait abnormalities that has hypertrophied calves and difficulty with attention span (what 7 year old doesn’t) and being “slightly behind in learning”. This young lad was brought in by his mom because other therapists had felt they had reached an end point of care and was offered little from the allopathic physicians they visited.

Watch his gait cycle several times and see if you note the following:

• exaggerated upper body movement
• increased progression angle (r foot particularly)
• toe walking gait
• wide base of gait with running

Physical exam findings reveal

·       cavus foot

·       ankle dorsiflexion at 0 degrees

·       intact lower extremity reflexes, sensation and motor strength

·       general weaker upper body strength (particularly shoulders)

Rather than play “name the pathology”, lets concentrate on what we would do for this young man.

·       Increase ankle dorsiflexion and ankle rocker

·       Increase hip extension and gluteal recruitment

·       Increase proproioception

·       Increase coordination

·       Increase upper body strength

The Gait Guys. Helping you to see things more clearly and find solutions to complex gait challenges.

Special thanks to JM for allowing us to present this teaching case.

What kind of shoe do you put this foot in?

Look carefully at these dogs. Notice anything peculiar? Look at the forefoot to rearfoot relationship. What do you see?

Normally, we should be able to draw a line from the center of the heel and it should pass between the 2nd and 3rd metatarsal heads. If the line passes through or outside the 3rd metatarsal heads, you have a condition called metatarsus adductus. It occurs from fetal positioning in utero. In children (18 mos to 4 years) it can often be corrected by wearing the shoes on the opposite feet (yes, you read that correctly)

We usually try and distinguish whether the adductus is occurring at the tarsal/ metatrsal articulation or the transverse tarsal joint.

OK, so now what?

Think of the unique biomechanics that happen here. Adduction (along with plantar flexion and inversion) are components of supination. So, the adduction component makes for  a more rigid foot (notice the arch structure in the pedograph). We are not saying this foot does not pronate, only that it pronates less.

Total amount of pronation will be determined by several factors,

• including body weight

• available rear foot motion

• available forefoot motion

• knee angulation (ie genu valgus or varus)

• available internal rotation of the hips (how much ante or retroversion/torsion is present)

• strength of abdominals, particularly the external obliques

• tibial torsion

This individual had

·       markedly increased valgus angle (14 degrees)

·       moderate external tibial torsion

·       femoral antetorsion

this, along with their body weight, explains the rear foot pronation seen on the pedograph.

So, what type of shoe? You should pick a shoe that:

·       does not exaggerate the deformity (ie. a shoe that does not have an excessively curved last)

·       a shoe that does not work (too much) against the deformity (ie. an extremely straight lasted shoe)

·       In this case, a shoe with some motion control features (to assist in controlling some of the increased rear foot motion. This may be something as simple as a dual density midsole

·       a shoe that, upon gait analysis, works to provide the best biomechanics for the circumstances.

As you can see, when it comes to shoe fit and prescription, there are no had and fast rules. You need to examine the individual and have all the facts.

If you are a little lost, or want to know more, you should take our National Shoe Fit Program. Maybe you even should consider getting Level 1 certified by taking the International Foot and Gait Education Council exam. Need more details? Email us at: thegaitguys@gmail.com

The Problematic Cross-over Gait Motor Pattern: Part 1

It seems that many of our newer viewers have come on in the last year, sometime after we did the 3 part series on The Cross Over Gait.  So, we are putting this one up for all those noobs when it comes to The Cross-Over. Remember, it is a 3 part series, just type in “cross over” into our Youtube channel search.  Happy 4th everyone !

Here Dr. Shawn Allen of The Gait Guys works with elite athlete Jack Driggs to reduce a power leak in his running form. The Cross-over gait is a product of gluteus medius and abdominal weakness and leaves the runner with much frontal plane hip movement, very little separation of the knees and a “cross over” of the feet, rendering a near “tight rope” running appearance where the feet seem to land on a straight line path. In Part 2, Dr. Allen will discuss a more detailed specific method to fix this. You will see this problem in well over 50% of runners. This problem leads to injury at the hip, knee and foot levels quite frequently. To date we have not met anyone who had a good grasp on this clinical issue or a remedy quite like ours. Help us make this video go viral so we can help more runners with this problem. Forward it to your coaches, your friends, everyone.
Thanks for watching our video, thanks for your time.
-Dr. Shawn Allen, The Gait Guys
see you daily on the blog ! thegaitguys.tumblr.com

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 ?

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 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 (link below) which we wrote 18 month 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.

http://thegaitguys.tumblr.com/post/16760849274/what-is-visual-parallax-and-how-does-it-affect

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.

that make sense ?“

best
shawn and ivo

Foot “Roll Out” at Toe Off : Do you do this ? And if so, why do YOU do it ?

As we always say, “what you see in someone’s gait is often not the problem, rather a compensatory strategy around the problem”.

What do you see in this case ? We would like to draw your attention at this time to the transition from midfoot stance to toe off on the right foot.  You should watch both feet and note that the right foot tips outward (inverts) as toe off progresses.
What could cause this ?  It is certainly not normal.  Remember, it is highly likely it is not the problem, that something is driving it there or something is not working correctly to drive this client to normal big toe propulsive toe off. Now, there are many other issues in this case, some of which  you can see and many of which you cannot, but do not get distracted here, our point is to talk about that aberrant Right toe off into inversion which prevents the optimal hallux (big toe) toe off. 
A clinical exam will give many answers to joint ranges and what muscles are strong and which are weak and inhibited.  Without the clinical exam and this information about the entire kinetic linkage there is no way to know what is wrong. This thinking should awaken shoe stores when prescribing shoes off of watching clients run or walk on a treadmill.  There is so much to it beyond what one sees. 
So what could be causing this foot to continue its supinatory events from heel strike all the way through lateral toe off ?
The foot could be:
- a rigid high arched cavus foot
- perhaps pronation through the midfoot and forefoot is painful (metatarsal stress pain, painful sesamoiditis, plantar fascitis) so it is an avoidance strategy possibly
- a common one with this gait presentation is perhaps there is a hallux limitus/rigidus (turf toe), painful or non-painful
- weak peronei and/or lateral gastrocsoleus thus failing to drive the foot medially to the big toe during the midstance-to-forefoot loading transition
- contractured medial gastrocsoleus complex (maybe an old achilles tear or reconstruction ?)
-rigid rearfoot deformity not allowing the calcaneus to perform its natural evertion during early stance phases thus maintaining lateral foot pressures the entire time
- presence of a rigid forefoot valgus
- avoidance of the detrimental medial pressures from a forefoot varus

 These and many other issues could be the reason for the aberrant toe off pattern.  This is not an exhaustive list but it should get your brain humming and asking some harder questions, such as (sorry, we have to say it again), “is what you see the problem, or a compensatory strategy to get around the problem ?”

We know you have busy days but we appreciate your time watching our videos and embracing something we are both passionate about.
We are The Gait Guys

Dr. Shawn Allen & Dr. Ivo Waerlop