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So a patient presents to your office with a recent history of a L total knee replacement 8 weeks ago AND a recent history of a resurgence of low back pain, supra iliac area on the L side. Hmmmm. Hope the flags went up for you too!

His global lumbar ROM’s were 70/90 flexion with low back discomfort at the lumbo sacral junction, 20/30 extension with lumbosacral discomfort, left lateral bending 10 degrees with increased pain (reproduction); right lateral bending 20 degrees with a pulling sensation on the right. Extension and axial compression of the lumbar spine in left lateral bending reproduced his pain.

Neurologically he had an absent patellar reflex on the left, with diminished sensation over the knee medially and laterally. Muscle strength 5/5 in LE; sl impaired balance in Left single leg standing. There was incomplete extension of the left knee, being at 5 degrees flexion (right side was zero).

He has a right sided leg length deficiency (or a left sided excess!) of 5 mm. Take a look at the tibial lengths in the 1st 3 pictures. See how the left is longer? In the next shot, do you see how the knee cannot completely extend? Can you imagine that the discrepancy would probably be larger if it did?

Now look at the x rays. We drew a line across from the non surgical leg to make things clearer.

Now, think about the mechanics of a longer leg. That leg will usually pronate more in an attempt to shorten the leg, and the opposite side will supinate to attempt to lengthen. Can you see how this would cause clockwise pelvic rotation (in addition to anterior pelvic rotation)? Can you see this patients in the view of the knees from the top? Do you understand that the lumbar spine has very limited rotation (about 5-10 degrees, with more movement superiorly (1)  ). Does it make sense that the increased range of motion could effect the disc and facet joints and increase the patients low back pain?

So, how do we fix it? Have you seen the movie “Gattica”? Hmmm….A bit extreme. How about a full length 3mm sole lift to start, along with specific joint manipulation to restore normal motion and some acupuncture to reduce inflammation? We say that is a good start.

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, please send it to someone else for them to enjoy and learn. 

(1) Three-Dimensional In Vivo Measurement of Lumbar Spine Segmental Motion Ruth S. Ochia, PhD, Nozomu Inoue, MD, PhD, Susan M. Renner, MS, Eric P. Lorenz, MS, Tae-Hong Lim, PhD, Gunnar B. Andersson, J. MD, PhD, Howard S. An, MD Spine. 2006;31(15):2073-2078.

Podcast 67: Biotech of Running's Future, Rothbart's Foot, 100 Ups

A. Link to our server:

Direct Download:

http://traffic.libsyn.com/thegaitguys/pod_67finals.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-67

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

______________

Today’s Show notes:

The cyborg era begins next week at the World Cup
 
The One Exercise That Just Might Change Your Running Forever
 

What Foot Strike Photos From 10K Olympic Trials Say About Barefoot Running by 

A Serious Gait Problem: Pancompartmental Compromise of the Lower Leg.

“Pan” is a prefix (combining form) meaning all, entire, everything, everywhere 

This was a case we discussed during a more recent podcast, perhaps pod 63 or 64? This doctor had fallen asleep with the left leg dangling over the side of his bed. The issue was that the leg not only dangled over the mattress, but also over a wooded side bed frame, so there was a firm upward compression into the posterior/popliteal compartment. He awoke the next day with complete loss of function of the foot and ankle.  This video is 8 weeks after the compressive event and there has been a significant improvement in function, but there are still some deficits here.  Can you see them ?  We will show you come other video clips in a future blog post discussing some other components of his gait but lets get you familiar with the case today.

What you should see here:

1- Left heel shows a staggered drop. He cannot hold heel rise because of compromise to the posterior compartment strength (gastrocsoleus complex). This was a drastic improvement from his complete inability to heel rise at all at on his initial visit. You can easily see the fatiguability of the calf after just a few steps. 

2- There is a pathetic attempt at heel walking; gross function testing of the anterior compartment. What appears to be an attempt at just right heel walking is actually an attempt to do it on both sides, there is just still so much weakness in the left anterior compartment that you cannot even see his attempts to dorsiflex the foot/ankle or toes. But, what we do not show here is that he has non-weight bearing dorsiflexion now, which was completely absent for the first 6 weeks.  

Neuronal regeneration is possible. It takes time.  Depending on your referenced source the numbers vary. But in his case, in 8 weeks there is progressive improvements and he can say for certain that in the last 2 weeks they are exponential.  The time to restoration of neuronal function is said to be directly proportional to the measurable length of nerve damage.  

What is interesting in this case, is that there is anterior and posterior compartment neurologic compromise. This was a case of vascular and mechanical compression to the neurovascular bundle at the popliteal/knee level. 

Wallerian degeneration is a process that results when a nerve is severely damaged. The axon of the nerve which is separated from the neuron cell body degenerates distal to the injury. The part of the axon distal to the injury begins its degeneration within 24-36 hours of the lesioning event and is followed by myelin sheath degradation. Somewhere around 4 days from the time of the injury, the distal end of the portion of the nerve fiber proximal to the lesion begins sprouting in an attempt to regrow and fill the gap along the length of axonal damage. Sources vary, but many seem to indicate a 1mm per day reinnervation. 

More on this case next time, but the stage has been set.

Shawn and Ivo

Another IFGEC Certified Doc!
Here is what Dr Brad Hochstein has to say about the National Shoe Fit Certification Program.
“Taking the National Shoe Fit Certification course has introduced me to many things that I didn’t take into consideration…

Another IFGEC Certified Doc!

Here is what Dr Brad Hochstein has to say about the National Shoe Fit Certification Program.

“Taking the National Shoe Fit Certification course has introduced me to many things that I didn’t take into consideration when working with my patients. The depth of information introduced is very helpful and presented more clearly than other courses I have taken in the past. I have studied a lot of the concepts that are introduced through the program in the past but struggled to put everything together. This certification did just that for me. It has helped me to link things together and look “outside the box” more than I had in the past.


I am a chiropractor with an extensive functional/biomechanics background and this has added another level of depth to my practice assessment and treatment. I am excited to incorporate the knowledge I have gained through this certification into my practice to give my patients an even better experience!”

Is it time to up your knowledge base and separate yourself from other clinicians, coaches, trainers, therapists and retailers?

Want to know more? Email us at : thegaitguys@gmail.com

Can you see it?
Here we are again. We have looked at this picture before; once about head tilt, and another about flip flops and form.
Take a good look at this picture and what is different about the child in blue all the way to the right and all th…

Can you see it?

Here we are again. We have looked at this picture before; once about head tilt, and another about flip flops and form.

Take a good look at this picture and what is different about the child in blue all the way to the right and all the others with the exception of the boy in pink, that we really cannot see?

Can you see it? No, we don’t mean the flip flops (but if you caught that all the boys were in sneakers and all the girls are in flip flops, you are good!)

How about looking at arm swing? Remember this post on arm swing and crossover gait, with the simple cue for correction? All of the children EXCEPT the boy in blue, are drawing their arms ACROSS their body (ie: flexion, internal rotation and adduction). Take a look at their legs. Yep, crossover gait (flexion, internal rotation and adduction). Little boy blues arms are going relatively straight and going in the saggital plane, where the others are going in the coronal plane.

We are not saying that blue does not have some gait challenges, like his torso shift to the left (or pelvic drift to the right), most likely do to gluteus medius weakness or inappropriate firing of the gluteus medius on the left stance phase leg; or his head tilt to the right, which most likely represents a compensation for the right pelvic drift and left body lean.

Arm swing. A very important clue to the puzzle we call gait and compensation. It is more prevalent than you think, and, in some cases, easily corrected with a simple cue.

The Gait Guys. Making it real and pertinent, in each and every post.

Podcast 66: Stem Cells, Running Form, Dartfish & Case Studes

A. Link to our server:

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_66final.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-66-stem-cells-running-form-dartfish-case-studes-0

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

______________

Today’s Show notes:

Duke researchers have found a new type of neuron in the adult brain that is capable of telling stem cells to make more new neurons.

 
2. A closer look at iOS 8′s Health app (video)http://9to5mac.com/2014/06/02/a-closer-look-at-ios-8s-health-app-video/
new HealthKit platform aggregator will allow developers of various health and fitness apps to have all related data populate within the Health app in iOS 8.
 
3. something fun bc it is from the onion……but there is some truth to the placebo right ?
American Medical Association Introduces New Highly Effective Placebo Doctors
American Medical Association announced Thursday the introduction of new placebo doctors to administer general practice medical care to the American public. 
4. a beautiful example from our blog post today June 4th on what you see isnt always the problem
The Right Form For Running - Dartfish
“The video showed that his right foot was … .
 
some random talk we can do on asymetries and symmetry– 
 
6. Case studies on posture, pronation, osteitis pubis and more.

Correcting a cross over gait with arm swing? Is it really THAT easy? Sometimes, yes!

We noticed this patient had a cross over gait while running (1st few seconds of video. need to know more about crossover gait? click here). We noted she was crossing her arms over her body as well. We than had her run her hands and arms straight out. See the crossover disappear? Need to know more about arm swing? click here

We the had her do the same while walking. Easier to see, eh? That’s because it is often easier to “fudge” things when you are moving faster (ie: the basal ganglia of nervous system can interpolate where the body part is supposed to be, and because of momentum, there is less need for precision). When we do things slowly (like the 3 second Test), more precision is needed. Watch this short video clip a few more times.

The arms are essentially adducting when the arms cross over. The arms are reciprocally paired with the contralateral lower extremity. When you make a change in one, you often will make a change in the other.

Subtle. Yes. Easier to see when the task becomes more difficult. Yes. Pay attention, the answer is often right there if you look closely enough.

Providing the clues to help you be smarter, better, faster, stronger; we are The Gait Guys

special thanks to “Q” for allowing us to publish this video : )

The 5 Point Turn (in a human).  Do you know this gait problem ?

Here is a video link for the full video case study with diagnosis and more details on this client’s gait but our point here today is to look at the uniquely pathologic turning motor pattern deployed by this patient.

Gait analysis is so much more than watching someone move on a treadmill. Forward momentum at a normal speed can blur out many of a person’s gait pathologies.  We discussed this in detail in this blog post on slowing things down with the “3 second gait challenge”.  Furthermore, most gait analysis assessments do not start seated, then watching the client progress to standing, and then initiating movement.  Watching these intervals can show things that simple “gait analysis” will not.  Finding stability over one’s feet and then initiating forward motion can be a problem for many.  Those first moments after attaining the standing position afford momentum to carry the person sideways just as easily as carrying them forward. In other words, once momentum forward begins, a normal paced gait can make it difficult to see frontal plane deficits.  Our point here, transitional movements can show clues to gait problems and turning to change direction is no different.

Typically when we turn we use a classic “plant and pivot” strategy.  We step forward on a foot (right foot for example here), transfer a majority load on that forward right foot, we then pivot the left foot in the next anticipated direction of movement, and then push off the right foot directionally while spinning our body mass onto that left foot before initiating the right limb swing through to continue in the new direction.  This is not what this patient does. Go ahead, stand up and feel these transitions, if you are healthy and normal they are subconscious weight bearing transitions but for some one who is old and losing strength and proprioception/balance or some one with neurologic decline for one reason or another, these directional changes can be extremely difficult as you see in this video here. A full 180 degree progression is often the most difficult when things get really bad.  And more so, if one leg is more compromised than the other, turning one way a quarter turn (a 90 degree directional change) might be met with an alternative 270 degree multiple-point turn in the opposite direction over the more trusted limb to get to the same directional change. When there is posterior column disease or damage this seemingly simple “plant/weight shift/ pivot and push off” cannot be trusted. So a 5 point (or more) turn is deployed to be sure that small choppy steps maximize minimal loss of feel and maximal ground contact feel. This can be seen clearly in this video above.

Full video case link here:https://www.youtube.com/watch?v=AYmzQL_NSeI

Just some more things to think about in  your gait education.  Watch your clients move from sit to stand, from stand to initiating gait, and then watch closely their turning strategies. At the very least, have them make several passes making their about-face turns both to the right and the left. You will often see a difference.  Watch for unsteadiness, arm swing changes, cross over steps, reaching for stability (walls, furniture etc), moving of the arms into abduction for a ballast effect and the like. Then correlate your examination findings to your gait analysis.  Then, intervene with treatment and rehab, and review their gait again. Remember, explaining their deficiencies is a huge part of the learning process. Make them aware of their 5 point turns, troubles pivoting to the right or the left, and make them understand why they are doing the goofy one-sided rehab exercises. Understanding what is wrong is a huge part of fixing your client’s problems.

* Remember: if your client is having troubles on a stable surface (ie. the ground) then they should engage some rehab challenges on the ground. Giving them a tilt board or bosu or foam pad (ie. making the ground more unstable) will make things near impossible.  This is not a logical progression, we like to say, “if you can’t juggle one chainsaw we won’t give you 3”. Improve their function on a stable surface first, then once improvements are seen, then progress them to unstable surfaces.  

Shawn and Ivo

The gait guys.  

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Spanking the orthotic: The effects of hallux limitus on the foot’s longitudinal arch.

But the issues do not stop at the arch. If you have been with us long enough, you will have read about the effects of the anterior compartment (namely the tibialis anterior, extensor digitorum and hallucis and peroneus tertius muscles) strength and endurance on the arch.

Here we have a very troubled foot. This foot has undergone numerous procedures, sadly. Today we will not talk about the hallux varus you see here, a virtual unicorn in practice  (and acquired in this case) nor do we want to discuss the phalangeal varus drift. We want to draw your attention to the obvious impairment of the 1st MTP (metatarsophalangeal joint) dorsiflexion range.  You can see the large dorsal crown of osteophytes, a dorsal buttress to any hallux dorsiflexion.  There is under 10 degrees of dorsiflexion here, not even enough worth mentioning.  We have said it many times before, if you lose a range at one joint usually that range has to be accommodated for proximal or distal to the impaired joint. This is a compensation pattern and you can see it here in the hallux joints themselves.

Here you can see that some of the dorsiflexion range has been acquired in the proximal phalangeal joint.  We like to call this “banana toe” when explaining it to patients, it is a highly technical term but you are welcome to borrow it. This occurred because the joint was constantly seeing the limitation of dorsiflexion of the 1st MTP joint and seeing, and accommodating to, the demands of the need for more dorsiflexion at toe off. 

But, here is the kicker. You have likely seen this video of ours on Youtube on how to acquire a foot tripod from using the toe extensors to raise the arch.  Video link here  and here.  Well, in his patient’s case today, they have a limitation of 1st MTP dorsiflexion, so the ability to maximally raise the arch is impaired. The Windlass mechanism is broken; “winding” of the plantar fascia around the !st MTP mechanism is not sufficiently present. Any limitations in toe extension (ie dorsiflexion) or ankle dorsiflexion will mean that :

1. compensations will need to occur

2. The Windlass mechanism is insufficient

3. gait is impaired at distal swing phase and toe off phases

4. the anterior compartment competence will drop (Skill, endurance, strength) and thus injury can be more easily brought to the table.

In this patient’s case, they came in complaining of burning at the top of the foot and stiffness in the anterior ankle mortise area.  This would only come on after a long brisk walk.  If the walk was brisk yet short, no problems. If the walk was long and slow, no problems.  They clearly had an endurance problem and an endurance challenge in the office showed an immediate failure in under 30 seconds (we will try to shoot a quick video so show our little assessment so be patient with us). The point here today is that if there is a joint limitation, there will be a limitation in skill, strength or endurance and very likely a combination of the 3. If you cannot get to a range, then any skill, endurance or strength beyond that limitation will be lost and require a compensation pattern to occur.  This patient’s arch cannot be restored via the methods we describe here on our blog and it cannot be restored by an orthotic. The orthotic will likely further change, likely in a negative manner, the already limited function of the 1st MPJ. In other words, if you raise the arch, you will shorten the plantar fascia and draw the 1st MET  head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … .  but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ……..yes, exactly !  So use your head  (and spank the orthotic when you see it used in this manner.  ”Bad orthotic, bad orthotic !”)

So think of all of this the next time you see a turf toe / hallux rigidus/ hallux limitus. Rattles your brain huh !?

This is not stuff for the feint of heart. You gotta know your biomechanics.

Shawn and Ivo … .the gait guys

Addendum for clarity:

a Facebook reader asked a question:

From your post: “if you raise the arch, you will shorten the plantar fascia and draw the 1st MET head towards the heel (part of the function of the Windlass mechanism) and by doing this you will plantarflex the big toe … . but weren’t we praying for an increase in dorsiflexion of the limitus big toe ? ” I always thought when the plantar fascia is shortened, it plantar flexes the 1st metatarsal (1st ray) and extends (dorsiflexes) the 1st MTP joint….

Our response:  

We should have been more clear, our apologies dear reader.  Here is what we should have said , ” The plantar fascia is non-contractile, so it does not shorten. We meant conceptually shorten. When in late stance phase, particularly at toe off when the heel has raised and forefoot loading is occurring, the Windlass mechanism around the 1st MET head (as the hallux is dorsiflexing) is drawing the foot into supination and thus the heel towards the forefoot (ie passive arch lift). This action is driving the 1st MET into plantarflexion in the NORMAL foot.  This will NORMALLy help with increasing hallux dorsiflexion. In this case above, there is a rigid 1st MTP  joint.  So this mechanism cannot occur at all. In this case the plantar fascia will over time retract to the only length it does experience. So, if an orthotic is used, it will press up into the fascia and also plantarflex the 1st MET, which will carry the rigid toe into plantar flexion with it, IN THIS CASE.”

What’s up, Doc?
Nothing like a little Monday morning brain stretching and a little Pedograph action.
This person had 2nd metatarsal head pain on the left. Can you figure out why?
Let’s start at the rear foot:
limited calcaneal eversion (…

What’s up, Doc?

Nothing like a little Monday morning brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let’s start at the rear foot:

  • limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.
  • note the increased pressure at the  medial calcaneal facets on each side with the increased printing
  • very little fat pad displacement overall

Now let’s look at the mid foot:

  • decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

  • increased printing under the met heads bilaterally; L >> R
  • increased printing of 1st met head L >> R
  • increased printing at medial proximal phalynx of hallux  L >> R
  • increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

  • short leg on L
  • more rigid foot on L
  • increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot?

Here is what is going on:

  • there is no appreciable leg length deformity, functional or anatomical
  • The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

  • Can you feel how when your foot is supinated
  • can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction
  • Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?
  • now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What’s the fix?

  • create a more supple foot with manipulation, massage, muscle work
  • increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)
  • have them walk with their toes slightly elevated
  • we are sure you can think of more ways as well!

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, tell others and spread the word. If you didn’t like this post, tell us! We value your constructive feedback.

Running Ugly Sometimes Wins Marathons.

There are many running gurus out there. There are numerous running form clinics out there.  Everyone knows someone that can tell you how to run better and show you things you should be doing to improve your running.  But should you listen ?  That is the problem, should we listen ?  There is the old adage that “if it ain’t broken, don’t fix it”.  Sometimes that is true as well. But lets face a fact, most people that come into our offices do not come in with the request to make them a better runner, rather they come in asking us to help them resolve a problem or injury that is stopping them from becoming a better runner.  

In this video, the two elite runners are clearly not made from the same mold.  There is no question, even to the uneducated eye, as to who is the more comfortably appearing and “cleaner” runner.  The fella in the orange represents much of what we are all told a runner should look like posturally.  But, it is clear that the fella in the blue is having no problems keeping a comfortable stride with the guy in the orange even though is form looks labored from a postural stand point.  But remember what we always say, what you see in someone’s gait is quite often not their problem, it is their compensation to cope with a problem.  And compensations are needed because we are all never 100% clean and biomechanically efficient. Back to our point, telling Mr. Blue to retract his head and lift his chest may not be what the run doctor ordered.  Changing this one glaring fact could be the thing that injures him or reduces his efficiency amongst other things.  Just because you don’t like what you see doesn’t mean it is wrong for that person or that it needs to be changed. This is why a clinical examination along with a gait analysis is imperative for solid advice. For example, what if this guy has a scoliosis or some other structural problem that has made his thoracic spine more kyphotic  thus producing a more accentuated cervical lordosis and an extended and protracted head carriage ?  Changing in this case that posturing may not be possible for him or may create problems elsewhere.  AGain, just because you do not like it doesn’t mean you should change it.  

So the next time you are at your local store or some marathon event tent and getting form running advice from an “expert”, take it with a grain of salt because there are so many pieces of the puzzle that they are not seeing or understanding.  This is the big problem with the internet and all of its guru’s and their advice.  The next time someone says, here is our go to video for resolving shin splints, take it with a grain of salt. Even if it is us giving the advice on one of our podcasts, because without the examination probably 90% ?? of the information is absent.  If you make a change in someones form, there must be a reason and a goal and you must be prepared to catch any fall out from those changes and know what to do with them.  This is where clinical experience comes in.  So the next time your favorite running site or running magazine gives what appears to be sound advice for chronically tight IT bands, think it over, take it with a grain of salt, and make a sound judgement based on what your body is doing with its unique limitations and pay attention to the results and possible positive and negative outcomes.  Change is inevitable, but is it good for you ?  That is the question.

Oh, and by the way,these were the marathon’s leaders, Benjamin Bitok and Nixon Machichin, both of Kenya. Bitok (in blue) went on to win in 2:13:21, 46 seconds up on Machichin.  

It just goes to prove that what good running looks like ,and should be better in our perfect little world, and of what the websites and magazines tell us about what is right, doesn’t always lead to improved performance.  However, we wouldn’t suggest you start running with Bitok’s form because he is awesome (even though some kids in his home land may do just that because modeling is the greatest form of compliment.)  But, what do we know ? We are just two more self-proclaimed guru’s trying to set the record strait, from our experience and perspective. 

Shawn and Ivo, 

the gait guys

More Power Leaks: Part 3


Good Morning peoples! A few weeks ago, we introduced posts about potential areas for power leaks. click here for #1, click here for #2

The common areas for leaks are:
great toe dorsiflexion
mm strength test
loss of ankle rocker
loss of knee flexion/extension
loss of hip extension
loss of balance/ proprioception

let’s take a look at a video of the next 2, with Dr Ivo and his partner in SCR, Dr John Asthalter:

Power leak 2: Muscle strength test

you need adequate strength in both the short and long extensors of the toes, for arch integrity, the windlass mechanism as well as appropriate ankle rocker

Common compensations include:

externally rotating the foot and coming off the inside of the great toe. this often causes a callus at the medial aspect of the toe. This places the foot in more pronation (plantar flexion, eversion and abduction) so it is a poorer lever.

lifting the foot (and bending the knee) excessively (knee flexion > 60 degrees) to create clearance of the toes for swing phase. This is sometimes referred to as a steppage gait.

hiking of the hip, again to create clearance for the foot

Power leak 3: ankle rocker

ankle rocker is needed to move the body mass forward in the gravitational plane. It is one of the 3 rockers (for a rocker review, click here).

Compensations for loss of ankle rocker can include:

premature heel rise

shortened step length

excessive pronation through the mid foot

external rotation of the lower extremity and “rolling off” the inside of the great toe

forefoot strike gait

Ivo and Shawn. Giving you the information you need to make informed clinical decisions and build better runners, wherever you go! Spread the word of gait literacy!

Podcast 64: Baby Walker Risks, Achilles Asymmetry & Too Much Exercise

A. Link to our server:

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_64final.mp3

Permalink: 

http://thegaitguys.libsyn.com/podcast-64-baby-walker-risks-achilles-asymmetry-too-much-exercise 

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

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Today’s Show notes:

1. The post-Oculus boom: Survios raises $4M for free-moving virtual reality

http://venturebeat.com/2014/05/19/the-post-oculus-boom-survios-raises-4m-round-for-free-moving-virtual-reality/

2. This treadmill lets you walk in any direction

http://www.engadget.com/2014/05/20/this-treadmill-lets-you-walk-in-any-direction/?ncid=rss_truncated

3. Dangers of baby walkers in the home:

http://consults.blogs.nytimes.com/2010/02/22/the-dangers-of-baby-walkers/?_php=true&_type=blogs&_r=0
NYTimes:  there are 3 days of neuromotor developmental delay for every day of their use.  Promote upright motor patterns and gait patterns before those neurologic windows are actually open and ready……..this goes back to expression of BDNF 
4.The Influence of Hip Strength on Lower Limb, Pelvis, and Trunk Kinematics and Coordination Patterns During Walking and Hopping in Healthy Women : Journal of Orthopaedic & Sports Physical Therapy
5. Individuals with chronic ankle instability exhibit decreased postural sway while kicking in a single-leg stance
6. Asymmetry of Achilles tendon mechanical and morphological properties between both legs
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Some times there is not an easy answer.

A patient came in with intermittent pain in his feet, bilateral and symmetrical of approximately 1 months duration.  It is bothering him in the arches and the ends of the toes. He can akin it to no singular precipitaIng event. The discomfort is sharp at times, and he can sometimes get cramping. He has been taking good care of his feet, washing his feet as of late. There are no alleviating factors; lots of activity can sometimes cause more pain but not consistently.  It seems to happen in all different types of shoes, so shod or unshod makes no difference. He is unable to reproduce the pain or discomfort.

The feet were normal in appearance. Arches were normal to slightly cavus. He had a mild, uncompensated forefoot varus. No global redness. Mild redness noted at medial and lateral nail beds of the great toe. He had a loss of long axis extension of the metatarsophalangeal arIculaIons and talonavicular arIculaIons bi-­‐lat. No tenderness to palpation of the dorsal or plantar surfaces of the feet are noted. No difference in neurological integrity with respect to sensaIon, motor strength or deep tendon reflex on either side. Nail bed filling was normal. Feet were cool
and moist to touch.  He did have weakness of the short extensors of the great toes, somewhat of the long extensors of the remainder of the digits. Ankle dorsiflexion is 10 degrees on each side.

Gait was tandem with a slight crossover. 

Hmm. Pretty boring, eh?

This is what we thought the differential should include:

1.   Early Gouty arthropathy.  This would be rare in a bilateral situation but possible.
2.   Athlete’s foot. This usually presents with more redness or this could be a variant.
3.   Lack of arch support during the day and his feet are fatiguing.
4.   Lumbar spinal canal stenosis; note that he has no change with squatting or sitting, so this is unlikely.


This is what we recommended:

 He is going to try either TinacIn or Lotrimin on his feet for 2 weeks, twice per day applicaIons, changing his socks between, making his feet wet and moist before application. Will switch to a boot that breathes batter and is more supporIve for work (he is a mason), to see if this works well. Foot strengthening exercises for the muscular deficiencies were prescribed. If this does not alleviate the discomfort, we will consider running labs and imaging looking at the possibility of gouty arthropathy and/or stenosis.

The Gait Guys. Showing that we don’t always have all the answers, but have a pretty good idea of how to get them.

The Naked Foot: The Soft Neurology behind Barefoot.

The Naked Foot: Thoughts for the Shoe Minimalist

This may be one of the very first articles we ever wrote for The Gait Guys. It must be 7-8 years old now, before the barefoot-minimalist craze ever started. It is a bit dated, but we think that it was time to revisit its contents. You will see that many of our early core principles have not changed and you can see the thought process of where the fads and trends were projected to go.  Wind your mind back a near decade, and read on !

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If you want to follow the fad craze these days, just look to companies like Vibram and Nike. Vibram is the company that has brought you the soles and treads of many of the shoes you have worn over the years and of course Nike are the people who first brought you the “running shoe” as we know it today. Nike first brought us the waffle bottom trainer, the cross trainer, air pockets, “shocks” and, the Air Jordan and now their barefoot minimalist series, the Nike Free. Now, we are sure not many of you have heard of the “Vibram Five Fingers” barefoot slip-on ‘shoe’ but virtually everyone who runs in some manner has seen and heard about the Nike Free. What initially stymied us when they first came out was the obvious question of “Why would the same people who sell us the shoes, and give us so many varieties and categories to choose from, now be advocating that we train barefoot, or close to it? ” Or are they ?

  • (Addendum:  this article was originally written long ago, at the start of this fad, the fad that has become a trend.  The article traveled fast around the internet and garnered us much attention including a gig with Vibram as consultants.  But that was then, this is now.  We, and the trend have come a long way, and so has the research.  Some supportive for the trend, some disagreements and plenty of controversy.  The remainder of this article has been unedited, hence its tense and outdated verbiage, shoe types and research.  But we thought it was time to review before moving ahead.)

The Nike version they are pushing, first the Nike Free 5 and now down to the Nike Free 3, has a light weight thin flexible sole and thin vamp top cover material whoís purpose is to merely hold the shoe onto the foot. The Vibram device, which is a fascinating yet simple slipper, is even more simplistic but has some brilliance built right into its heart. It is merely a rubber sock with compartments for each individual toe but that is part of its brilliance. So why would Nike and now Vibram go against their own creations and advocate that we begin walking and running barefoot, or at least become more “shoe-minimalists” after decades of building shoe and sole lines that previously were designed for various conditions, foot types and activities ? There appears to be sound moral reasoning if you delve into the research, but you have to look closely and you have to be careful you do not have one of those foot types that could lead to problems with this type of footwear (but that is a topic for another article to come soon, see Part II).

Barefoot theories are nothing new. In 1960 Abebe Bikila, perhaps the greatest barefoot runner of all time, won the first of his consecutive gold medals without shoes setting a world record of 2:15:17. Englandís Bruce Tulloh was setting overseas records into the 1960’s running unshod, skin to the ground. Today Ken Bob Saxton is one of the most visible barefoot marathoners, long beard and all, and is an advocate of the technique.

With the introduction of the Nike Free, the interest in barefoot running resurfaced at the turn of the century. An article by Michael Warburton, published as an internet paper on barefoot theories, seemed to spark some of the resurgence of the method of running. In his brilliant paper he had some interesting thoughts and pointed out some noteworthy facts. He indicated that research showed that an extra mass of 100 grams attached to the foot diminished the economy of running by one percent. Thus, two 10 ounce shoes (the weight of a lightweight training shoe) could compoundingly cripple you by more than five percent in efficiency. In tangible terms that could be more than six minutes tacked onto a world class marathoner, taking a world record time to a mere first group finishing time. So, it is a question of weight and time, or is there something more ?

To get started with some hard and simple research facts, current research has been conducted showing that plantar (bottom of the foot) sensory feedback plays a central role in safe and effective locomotion, that more shoe cushioning can lead to higher impact forces on the joints and higher risk of injury, that unshod (without shoes) lowers contact time versus shod running, that there are higher braking and pushing impulses in shod versus unshod running, that unshod running presents a reduction of impact peak force that would reduce the high mechanical stress that occurs during repetitive running and that the unshod foot induces a neural-mechanical adaptation which could enhance the storage and restitution of elastic energy at ankle extensor level. These are only some of the research findings but they are some of the more significant ones. These issues will not only support injury management benefits for the unshod runner but increase speed, force and power output.

Stepping backwards in time a little, in the caveman days things were different. The foot was unshod (without shoes) from the moment of the first step until one’s dying day, and thus the foot developed and looked different. The sole of the foot was thicker and callused due to the constant contact with rough and offending surfaces thus preventing skin penetration, the foot proper was more muscular and it may have been wider in the forefoot and the toes were likely slightly separated due to the demands of gripping which would obviously necessitate increase muscular strength and bulk to the foot intrinsic muscles. It was the constant input of uneven and offending surfaces such as rocks, twigs, mud, foliage and debris that stimulated the bottom of the foot, and thus the intrinsic muscles, sensing joint positions and relaying those variations to the brain for corresponding descending motor changes and adaptations to maintain protection and balance. The foot simply worked different, it worked better, it worked more like the engineering marvel that it truly is. The foot was uncovered and the surfaces we walked on were uneven and challenging. However, as time went on, man decided to mess with a good thing. He took a foot that was highly sensitive, a virtual sensory organ with a significant sensory and motor representation in the brain (only the hands and face have more brain representation as represented by the sensory and motor homunculus of the brain) and he not only covered it up with a slab of leather or rubber but he then flattened and then paved not only his world, but also his home, with black hard top, cement, wood or tile thus completing the total sensory information deprivation of the entire foot. Thus, not only did he take away critical adaptive skills from himself and generations to follow, but he began the deprivation of the brain of critical information from which the central nervous system would need to develop and continue to function effectively. It is not unlikely that the man of pre-shod time had a strong competent foot arch (perhaps somewhat flat to increase surface area contact for adaptation), but one that did not need orthotics, stability shoes or rigid shanks and inserts. In other words, the foot and its lower limb muscles were strong with exceptional skills and endurance. But in today’s day and time things are now different. We now affix a shoe to the child’s foot even before he can walk and then when he does, all propriosensory information necessary for the development of critical spinal and central nervous system reflexes is ensured to be virtually absent. Is it any wonder why there are so many people in chronic pain from postural disorders related to central core weakness and inhibition ? Is it any wonder why so many people seem to have flat incompetent feet and arches? Man has done it to himself, but thankfully man has proven that what he can do, he can undo. Thankfully we see modern medical research that has delved into this realm of thought and has uncovered the woes of our ways and to follow, companies like those mentioned earlier are imagining and developing devices that will allow us some protection from modern day offenses such as glass, plastics and metal and thus allow us the slow and gradual return to our healthier foot days, all fashion sense aside.

 Shawn and Ivo, The Gait Guys

Two fellas that were here at the beginning, and two fellas that will be here for the duration.  

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Oh, it is just a simple ankle sprain. It will heal fine. (Not always ! Sometimes we do not know what we should fear, often because we do not even know it exists.)

When an ankle sprain is far more than an ankle sprain.

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Fracture of the Anterior Process of the Calcaneus

We have seen enough of these over our careers that we know they should be on the differential list when an ankle sprain smells fishy. This may be the most frequently missed fracture in the foot because it is not well known and the classic radiographic series often leaves this teeny tiny area poorly laid out on plain film radiographs.  This focal piece of bone, has a critical attachment to the cuboid and navicular so it is critical for stability of the rear-midfoot complex and obviously for mobility of the forefoot on the mid-foot. This Bifurcate ligament (see diagram above) if left unhealed or reattached to its calcaneal base can lead to anatomic instability and serious performance and loading problems. It can be a career ending injury if it is not caught early. This fracture accounts for ~15% of all calcaneal fractures and as we mentioned, it is misdiagnosed as a more severe ankle sprain. The mechanism is a typical inversion sprain mechanism, the most common of ankle sprains, and it can have all of the other typical presentations but with this fracture as a complicating parting gift of the injury. 

Do not miss this one ! When in doubt, refer it out. Don’t leave your client with an unresolving ankle sprain. If you are anxious, as for the imaging and a competent clinical exam. Tenderness over the calcaneocuboid joint that is localized approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus, just distal to the anterior talofibular ligament insertion is of high suspicion.  

This fracture can be serious and lead to prolonged disability and as we said it can be a career ending injury. So do not take that next ankle sprain too lightly. You or your client may pay for it for a lifetime.  

If you do not know it exists, you can’t make the call.  So after today, after reading this short blog post, you are now officially accountable !

Shawn and Ivo

Gait guys and clinical nerds

Saucony: Line Running and Crossing Over
We are big fans of the Saucony line of shoes. We have recommended them to our novice and serious runners for decades now. Currently one of our favorite shoes for our runners is the Saucony Mirage, a beautiful …

Saucony: Line Running and Crossing Over

We are big fans of the Saucony line of shoes. We have recommended them to our novice and serious runners for decades now. Currently one of our favorite shoes for our runners is the Saucony Mirage, a beautiful 4mm ramp shoe with no bells and whistles.  It is as close to a perfect zero drop that  you will find without going zero, in our opinion.  That is not to say there are not other great 4mm shoes out there, the Brooks Cadence and the New balance minimus are other beautiful 4mm’s out there.  The Mirage has never failed a single client of ours.  

This was a photo we screen captured from the Saucony Facebook page (we hope that for the sake of educating all runners and athletes that we can borrow this picture for this blog post, please contact us if you would like us to remove it). It is a good page, you should follow it as well.  This picture shows not only a nice shoe but something that we have been talking about forever.  The cross over; this runner is running in such a line that it could be argued that the feet are crossing the mid line. In this case, is the line queuing the runner to strike the line ? Careful of subconscious queues when you run, lines are like targets for the eyes and brain.  One thing we like to do with our runners is to use the line as training however, a form of behavioral modification.  When you do a track workout, use the line underneath you, but keep the feet on either side of the line so that you learn to create that little bit of limb /hip abduction that helps to facilitate the hip abductor muscles.  This will do several things, (and you can do a search here on our blog for all these things), it will reduce the reflexive tightening of the ITBand (pay attention all you chronic IT band foam rolling addicts !), it will facilitate less frontal plane pelvis sway, optimal stacking of the lower limb joints, cleaner patellofemoral tracking and help to reduce excessive pronation /internal limb spin effects.  

There is really nothing negative about correcting your cross over, IF it truly needs correcting.  That is the key question.  Some people may have anatomic reasons as to why the cross over is their norm, but you have to know  your anatomy, biomechanics and neuromechanics and bring them together into a competent clinical examination to know when the correction will lead to optimal gait and when it will drive suboptimal gait. Just because you see it and think it is bad, does not make it so.  

New to this cross over stuff ? Head over to the search box here on our blog and type in “cross over” or “cross over gait” and you will find dozens of articles and some great videos we have done to help you better grasp it. 

* you will also note that this runner is in an excessive lateral forefoot strike posturing.  This means that excessive and abrupt prontation will have to follow through the mid-forefoot in order to get the medial foot tripod down and engaged.  The question is however, is what you are seeing a product of the steep limb angle from the cross over, or does this runner have a forefoot varus (functional or anatomic, rigid or flexible)?  Are the peronei muscles weak, making pre-contact foot/ankle eversion less than optimal ? This is an important point, and your clinical examination will define that right away … . . if you know what these things are.  And if you don’t ? Well, you have found the right blog, one with a SEARCH box. Type in “forefoot varus”, if you want to open up the rabbit hole and climb down it … . . we dare ya ! :-)

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The case of the focal alopecia. The what?

A focal hair loss. You will see this if you look for it. You will also gain insight into what is (or may be) going on.

Take a good look at these pix. Notice anything about the left anterior lower leg? Besides the varicosity, did you notice the absence of hair? Look again. The devil is in the details, eh?

So, is this a Nair experiment gone wild? No, he never touches the stuff

Shaves just one part of his leg? Really? NOT!

Bad burn resulting in follicular damage? Nice thought, but no.

Weird infection or food allergy? Another good thought but no.

OK. I give up.

So you need to ask the patient a question, what is it?

Do you have a history of chronic low back pain?

Bingo!

Where do you think the problem may be coming from?

Take a look at the dermatomal diagram at the bottom. It represents the area of skin innervated by a spinal nerve. Looks like L5 to us.

How can we confirm it?

muscle test predominantly L5 innervated muscles like the long extensors of the toes and gluteus medius. You could also x ray and look for degenerative changes at the L4-L5 level. Flexion/extension films may reveal some instability at this level as well.

Why does it happen?

Hair growth is influenced by local blood flow and “tropic” influences from the autonomic nervous system and sensory feedback loops, supplied to the area segmentally (ie. by each spinal level). This can be traced back to embryology and development of the musculoskeletal system via the somite and their individual sclerotome (connective tissue elements), dermatome (skin elements) and myotome(muscular elements).

How could this influence his gait?

weakness of the L5 innervated muscles possibly causing:

  • crossover gait
  • lean to one side during stance phase
  • pelvic “cruise” to one side during stance phase on  that limb
  • foot drop and steppage gait (lifting the limb higher on one side to get the foot to clear)

Details, details, details. Pay attention and look carefully. It is all right there if you look hard enough.

The Gait Guys. Balding, yet still neurologically intact