November 30, 2015 November 30, 2015/ The Gait Guys

Welcome to Monday folks and news you can use! Have a patient with weak hip abductors? Here is another great closed chain gluteus medius/ Maximus/minimums exercise we utilize all the time called “"hip helicopters” Try it in yourself, then try it on your patients and clients, then teach others : )

November 27, 2015

Pod #100: Hill Running + Cortical Brain Changes in Injuries

November 27, 2015/ The Gait Guys

Pod #100 Hill Running + Cortical Brain Brain Changes in Injuries, Plus leg length challenges, Sole vs Heel lifts, Varying your Running Surface, Frontal plane biomechanics, Baker Cyst and Popliteal Muscle problems and more !

Show Sponsors:
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Other Gait Guys stuff

A. Podcast links:

direct download URL: http://traffic.libsyn.com/thegaitguys/pod_100f.mp3

permalink URL: http://thegaitguys.libsyn.com/podcast-100-hill-running-cortical-brain-brain-changes-in-injuries

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

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

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

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

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

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

Show Notes:

1 Cortical change in chronic low back pain

http://www.anatomy-physiotherapy.com/articles/other/nervous/1329-cortical-change-in-chronic-low-back-pain
-Chronic low back pain is characterised by a range of structural, functional and neurochemical changes within the brain. Functional changes in individuals with chronic low back pain are reflected in a cortical reorganization, altered cortical activity and altered cortical responsiveness.

2 Lifting weights can change the brain
http://www.techvibes.com/blog/lifting-weights-can-beneficially-change-structure-of-brain-2015-10-27

3 Importance of varying running surfaces
http://triathlon.competitor.com/2015/05/training/importance-varying-running-surfaces_100995

4 Emergence of postural patterns as a function of vision and translation frequency.
http://www.ncbi.nlm.nih.gov/pubmed/10322069
J Neurophysiol. 1999 May;81(5):2325-39.
Our results suggest that visual information was important to maintaining a fixed position of the head and trunk in space, whereas proprioceptive information was sufficient to produce stable coordinative patterns between the support surface and legs. *The CNS organizes postural patterns in this balance task as a function of available sensory information, biomechanical constraints, and translation frequency.

5 Previous hamstring injury is associated with altered kinematics.
“Previously injured athletes demonstrated significantly reduced biceps femoris muscle activation ratios with respect to ipsilateral gluteus maximus, ipsilateral erector spinae, ipsilateral external oblique, and contralateral rectus femoris in the late swing phase. We also detected sagittal asymmetry in hip flexion, pelvic tilt, and medial rotation of the knee effectively putting the hamstrings in a lengthened position just before heel strike.”

The biomechanics of running in athletes with previous hamstring injury: A case-control study. C. Daly1, U. McCarthy Persson2, R. Twycross-Lewis1, R. C. Woledge1,† andD. Morrissey1,

November 23, 2015 November 23, 2015/ The Gait Guys

Have a patient with weak hip abductors? Here is a great closed chain gluteus medius exercise called “"hip airplanes” we utilize all the time. Try it in yourself, then try it on your patients and clients, then teach others : )

November 23, 2015

Starting and stopping your gait. How we do it gracefully.

November 23, 2015/ The Gait Guys

Can you imagine being unable to stop moving graciously? Imagine that every attempt to halt your walking or running was like smacking into a wall or stumbling to a halt ? Kind of like that amateur driver who uses no grace or finesse, every start is a stomp on the gas and every stop is a slamming on the brakes. Or can you imaging suffering from FOG (freezing of gait) as in some Parkinson’s patients ?
When we are healthy, we take locomotion for granted. When we are in pain, movement can become labored and challenging; when we have a neurologic disease to the locomotor centers, we can find it almost impossible. On occasion, it can be the seemingly simplest of things that can cause the greatest of difficulties, for example, we take stopping for granted and we underestimate the complexity of initiating movement. It is one of those things in life, you do not know what you have until you lose it. When was the last time you even thought about starting or stopping your movements ? It is so natural that the thought doesn’t even reach the surface of our conscious thought. When was the last time you walked towards your kitchen sink to wash the dishes and you consciously thought,

“ok, we are about 3 more steps from the sink, you had better slow down … . ok, 2 more steps … 1 more step, this is the last one … . ok, that is it, you have arrived at the sink, both feet stop moving … . . initiate double stance support, 50% weight on both feet… . . begin standing mode.”

There is a brainstem pathway specifically dedicated to control locomotor arrest. Activating this pathway stops locomotion, while inhibiting the pathway enables locomotion.

In the study below, researchers Julien Bouvier and Vittorio Caggiano together with Professor Ole Kiehn and colleagues studied how the complex brainstem neuronal circuits control locomotion in mice. What they found was this,

Neuronal populations in the Reticular Formation of the brain “constitute a major excitatory pathway to locomotor areas of the ventral spinal cord. Selective activation of these neurons (V2a) of the rostral medulla stops ongoing locomotor activity, owing to an inhibition of premotor locomotor networks in the spinal cord. Moreover, inactivation of such neurons decreases spontaneous stopping in vivo. Therefore, the V2a “stop neurons” represent a glutamatergic descending pathway that favors immobility and may thus help control the episodic nature of locomotion.”-Bouvier et al.

Human locomotion is an extremely complex task. It is one that requires all sensory and motor pathways to be intact and reflexive controls such as central pattern generators to function properly. Gait is a complex task that requires synchrony, rhythmicity, balance, coordination, endurance and strength to name a few. Initiating gait is highly complex, as is arresting one’s gait. We take for granted how complex these task are at coordinating muscles, joints, limbs, vision, proprioception, vestibular inputs and many other components not to forget the cerebral connection bring it all together to get us from one place to the next is a safe fashion. It is only when things go wrong that we realize how fragile, and how complex, the system truly is. Don’t believe us ? Well then, try to over ride the system next time you are coming to a curb at the corner of the busiest street in your town. Try to over ride the coordinated stop mechanism that enables you to suddenly stop perched on the curb, observing oncoming traffic, standing safely without falling into the lane.

Shawn Allen, one of The Gait Guys

“Descending command neurons in the brainstem that halt locomotion” by Julien Bouvier, Vittorio Caggiano, Roberto Leiras, Vanessa Caldeira, Carmelo Bellardita, Kira Balueva, Andrea Fuchs, and Ole Kiehn in Cell. Published online November 19 2015 doi:10.1016/j.cell.2015.10.074

This brief blog post was inspired from this article on the same topic. http://neurosciencenews.com/v2a-neurons-locomotion-neuroscience-3119/

November 16, 2015 November 16, 2015/ The Gait Guys

Now THERE”S some internal tibial torsion!

So, this gent came in to see us with L sided knee pain after it collapsed with an audible “pop” during a baseball game. He has +1/+2 laxity in his ACL on that side. He has subpatellar and joint line pain on full flexion, which is limited slightly to 130 (compared to 145 right)

We know he has internal torsion because a line drawn from the tibial tuberosity dropped inferiorly does not pass through or near the plane of the 2nd metatarsal (more on tibial torsions here)

What would you do? Here’s what we did:

acupuncture to reduce swelling
took him out of his motion control shoes (which pitch him further outside the saggital plane)
gave him propriosensory exercises (1 leg balance: eyes open/ eyes closed; 1 legged mini squats, BOSU ball standing: eyes open/eyes closed)
potty squats in a pain free range
ice prn
asked him to avoid full flexion

Is it any wonder he injured his knee? Imagine placing the FOOT in the saggital plane, which places the knee FAR outside it; now load the joint an twist, OUCH!

November 14, 2015

Podcast #99: How foot placement, the glutes and cross over gait all come together and make sense.

November 14, 2015/ The Gait Guys

Topics: Plus, How foot placement, the glutes and cross over gait all come together and make sense. Plus, discussions on vibration,proprioception, cerebellum and movement.

Show Sponsors:

*newbalancechicago.com

*Rocktape.com

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_99final.mp3

Podcast Direct Download: http://thegaitguys.libsyn.com/podcast-99-how-foot-placement-the-glutes-and-cross-over-gait-all-come-together-and-make-sense

Other Gait Guys stuff

Evaluating the Differential Electrophysiological Effects of the Focal Vibrator on the Tendon and Muscle Belly in Healthy People ARTICLE in ANNALS OF REHABILITATION MEDICINE · AUGUST 2014 DOI: 10.5535/arm.2014.38.4.494 · Source: PubMed

J Neurophysiol. 2014 Jul 15;112(2):374-83. doi: 10.1152/jn.00138.2014. Epub 2014 Apr 30. A neuromechanical strategy for mediolateral foot placement in walking humans. Rankin BL

J Neurophysiol. 2015 Oct;114(4):2220-9. doi: 10.1152/jn.00551.2015. Epub 2015 Aug 19.

Hip proprioceptive feedback influences the control of mediolateral stability during human walking.

Roden-Reynolds DC1, Walker MH1, Wasserman CR1, Dean JC2.

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

Prog Brain Res. 2004;143:353-66. Role of the cerebellum in the control and adaptation of gait in health and disease. Thach WT1, Bastian AJ.

You’d have to be smart to walk this lazy, and people are

Research suggests that humans are wired for laziness

http://www.sciencedaily.com/releases/2015/09/150910131451.htm#.VfWquNKaf3s.facebook

Jessica C. Selinger, Shawn M. O’Connor, Jeremy D. Wong, J. Maxwell Donelan. Humans Can Continuously Optimize Energetic Cost during Walking. Current Biology, 2015; DOI: 10.1016/j.cub.2015.08.016

November 11, 2015 November 11, 2015/ The Gait Guys

The “Dodgy Foot”, a UK runner’s dilemma.We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK, The runner was frustrated, explaining a “dodgy foot”. We like the word. dodg·y… — **The “Dodgy Foot”, a UK runner’s dilemma.**
We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK, The runner was frustrated, explaining a “dodgy foot”. We like the word.
**dodg·y däjē/**
***-dishonest or unreliable;* *potentially dangerous;* *of low quality.***
We can guarantee you that the solution here to this runner’s form issue is not wholly at the foot which appears “in toed” and slanted and appears ready to kick the back of the right heel, not to mention the knees that are about to brush together. Thus, merely working on their foot strike would be so remedial and corrupt that it would a crime.
Ivo and I do not take on cases via the internet because we cannot give all the information because we cannot examine the client, many do offer such services but people are not being given the whole story and we pledged long ago not to be part of the problem. Anyone who recommends exercises from things they see on a video gait analysis are basically doing the same disservice in our opinion. But sometimes, as in this case, their inquiry is simple, there is a photo or video and it allows us to highlight an important component of an individuals gait which can lead them on a road to appropriate discovery. This is one of those cases. I will not be presenting a solution, because I do not have the examination information I need, but I will propose a solid thought process that further investigation may afford progress towards resolution.
This is a non-pathologic cross over gait in my mind until proven otherwise, there may be other sources, causes and components, but when it quacks like a duck you’d be silly not to check for webbed feet. This runner even confirmed upon questioning that the left foot scuffs the inside of the right ankle/shin often, both sides scuff in fact but more left shoe on right shin. No Einsteinian epiphany there.
This means a narrow swing through (adducting) left limb.
This means stance and swing phase gluteus medius communication problems.
This means swing leg foot targeting problems.
This often suggests right, but sometimes both right and left, frontal plane pelvis sway problems which means pelvis control is challenged which means core lumbar stability control is challenged.
This means adaptive arm swing changes from the clean norm.
This does NOT mean this runner has pain, or pain yet, or maybe never will have pain but there are many determinants of that which I will discuss below.
But, make no mistake, this is flawed gait mechanics. The left swing leg is clearly targeting a more medial placement, meaning limb adduction (active or passive or both is to be determined) and this is a product of the cross over gait **(unfamiliar with the cross over gait ? SEARCH our blog for the term, you will need a few hours of free time to get through it all)**. Some would call the cross over gait a lazy gait, but I would rather term it **an efficient gait taken too far that it has now become a liability**, a liability in which they can no longer stabilize frontal plane sway/drift. A wider gait on the other hand, as in most sprinters, is less efficient but may procure more power and the wider base is more stable affording less frontal plane drift. Just go walk around your home and move from a very narrow line walking gait to a wide gait and you will feel a more powerful engagement of the glutes. Mind you, this is not a fix for cross over gaits, gosh, if it was only that simple !
This runner must investigate whether there is right frontal plane drift, and if it is in fact occurring, find the source of the drift. It can come from many places on either limb. (This client says they are scuffing both inside ankles, which is not atypical and so we likely have drift on both right and left). We have discussed many of them here in various places on the blog over the years. Now as for “Why” the foot looks in toed, well that can also come from many places. Quite simply the adducted limb once it leaves toe off can look like this. But, perhaps it is also a product of insufficient external rotation maintenance occurred during that left stance phase, affording more internal rotation which is being unchecked and observed here during early swing. Remember though, if this is in fact a cross over gait result, in this gait the limb approaches the ground unstacked (foot is too far inside a left hip joint plumb line) the foot will greet the ground at a far lateral strike and in supination. Pronation will thus be magnified and accelerated, if there is enough time before toe off. However, and you can try this on your own by walking around your home, put yourself in terminal stance at toe off. Make sure you have the foot inverted so you are toeing off the lateral toes (low gear toe off). Does this foot not look like the one in the photo ? Yes it does, now just lift the foot off the ground and you have reproduced this photo. And when combined with a right pelvis drift, the foot will sneak further medially appearing postured behind the right foot.
Keep this in mind as well, final pronation and efficient hallux (big toe) toe off does often not occur in someone who strikes the ground on a far lateral foot. I am sure this runner will now be aware of how poorly they toe off of the big toe, the hallux. They will tend to progress towards low gear toe off, off the lesser toes. This leaves the foot inverted and this is what you are seeing in her the photo above. That is a foot that is inverted and supinated and it carried through all the way through toe off and into early swing. It is a frequently component of the cross over gait, look for it, you will find it, often.
Final thoughts, certainly this can be an isolated left swing phase gluteus medius weakness enabling an adducted swing limb thus procuring a faulty medial foot placement, but it is still part of the cross over phenomenon. Most things when it comes to a linked human frame do not work in isolation. But i will leave you with a complicating factor and hopefully you will realize that gait analysis truly does require a physical exam, and without it you could be missing the big picture problem. **What if she has a notable fixed anatomic internal tibia torsion on that left side. Yup, it could all be that simple, and that is not something you can fix, you learn to manage that one as a runner.**
* Side bar rant: Look at any google search of runners photos and you will see this type of swing limb foot posturing often, far too often. And yes, you can take the stance that “I do it as well and i have no injuries or problems so what is the big deal?”. Our response is often “you do have an issue, it may be anatomic or functional, but you do have an asymmetrical gait and you think it is not a problem, YET”. And maybe you will run till you are 6 feet under and not have a problem because you have accomodated over many years and you are a great compensator, yes, some people get lucky. Some people also do not run enough miles that these issues express themselves clinically so lets be fair. But some of these people are reality deniers and spend their life buying the newest brace or gadget, trying a different shoe insert, orthotic or new shoe of the month and shop over and over again for another video gait analysis expert who can actually fix their pain or problem. And then there are those who have a 45 minute home exercise program that they need to do to keep their problems at bay, managing, not fixing anything. Or, they spend an hour a week on the web reading article after article on what are the top 4 exercises for iliotibial band syndrome for example. They shop for the newest Graston practitioner, the newest kinesio taping pattern, Voodoo bands, breathing patterns, compression socks etc. And sometimes they are the ones that say they still dont have a problem.You get the drift. Gosh darn it, find someone who knows what the hell they are doing and can help you fix the issues that are causing the problem. And yes, some of the above accoutrements may be assistive in that journey.
I have dealt with this unique toe off issue way too many times not to roll my eyes at it any longer. It is to the point that it is an automated evaluation and solution program that begins to run in my head. Once you see something enough times, you learn all of the variations and subtle nuiances that a problem can take on. But, trying to fit everyone into a similar solution model is where the novice coach, trainer or clinician will get into trouble. Trust us, it all starts with an examination, a true clinical physical examination. If one leaves the investigatory process to a series of screens or functional movement patterns, “activation” attempts, digital gait analysis or strength tests one is juggling chainsaws and the outcome you want is often not likely to occur. There is nothing wrong with making these components part of the investigation process, but on their own, they are not enough to get the honest answer many times. Of course, Ivo and i were not able to jump the pond and examine this runner with our own eyes and hands so today’s dialogue was merely to offer this runner some food for thought to open their mind to our thought process, in the hopes that they can find someone to help them solve the underlying problem and not merely make the gait look cleaner. Making someone’s walking or running gait look cleaner is not hard, but making it subconsciously competent and clean (without thought or effort) requires a fix to the underlying problem. We can ALMOST guarantee you that the solution here to this runner’s form issue is not wholly at the foot that looks in toed and slanted. Merely working on their foot strike would be so remedial and corrupt that it would a crime.
Dr. Shawn Allen, one of the gait guys

November 10, 2015 November 10, 2015/ The Gait Guys

Look at your patients and clients shoes!

Can you see the varus cant to the heel counter of these shoes? This is an Asics Gel Kayano; a shoe we seem to see manufacturers defects in frequently. This could be a good thing for an overpronator, but could be a bad thing for a supinator. With a drop ( ramp delta) of 13 mm, and a narrow toe box, we are not huge fans…

November 09, 2015 November 09, 2015/ The Gait Guys

Ivo and i have a bunch of screens we use to glean information as we move down through the examination tree. Here is one i like to use, it is quick and easy and allows you to check something functionally and quickly while a client turns over. It is a very VERY small piece of a larger puzzle, but it is knowing what to look for and then what to test to verify. You might not have noticed this clients limitations in a passive supine joint assessment, but often when you load them up, mobility and stability challenges start to blossom into something different. If you are thinking, “possible loss of right knee flexion or left hip flexion” you are on the right track, with *caveat. There is more to it, but it is a start. Hope to see you on www.onlinece.com next week for our new course, “thinking through functional pathologic biomechanics”.
* Caveat: The lack of joint flexion range doesn’t necessarily mean they need more flexion, it means their flexion mobility is lost and that might mean they need more stability there or elsewhere for the flexion to present. This is the challenge a screen provides, it doesn’t tell you what’s wrong, it tells you if they can or cannot do the screen. If they cannot, it’s your job to find out why, but giving this particular client flexion work (range or strength work) would have led to a quick demise in their status. Quite often a joint displaying less mobility displays such because it has insufficient stability (from lack of skill, endurance, strength, proprioceptive etc) , but this is not a hard and firm rule. It’s your commission to find out the functional limitation(s) that are leading to these deficits and challenges.

November 04, 2015 November 04, 2015/ The Gait Guys

Sometimes you need to run that valgus post clear back to the heel!

A valgus post assists in pronation. Some fols have modereate to severe internal tibial torsion and need to be able to pronate more to get the knee into the saggital plane for patello femoral conflicts. They usually run from the tail of the 5th metatarsal forward, but sometimes need to run it clear back to the heel to get enough pronation to occur.

November 02, 2015 November 02, 2015/ The Gait Guys

L sided medial knee pain in a TKR patient

So, why does this gals L knee hurt, posterior and medial on the left?

L total knee replacement 6 years ago; she thinks they used too large a size, we would have to agree.
occassional peripatellar discomfort
current pain descending hills and stairs, posterior and medial on the left

Physical findings

tenderness at posterior, medial aspect of knee at the top of the tibial plateau
positive anterior and posterior drawer +2
McMurrays for clicking with valgus and varus stresses
negative valgus/varus stress
all muscles test strong except for one, which one is it?

Read on…

Here is our theory:

This particular muscle fires at heel strike and again from loading response until toe off (you can look at the diagram above if needed). It also acts as an acessory posterior cruciate ligament (PCL).

Think about the forces on the knee while descending hills or stairs. The momentum will carry the femur forward (or anteriorly). There needs to be something to reststrain this; enter the PCL.

Because of the laxity (and instability), the poplitues needs to fire to take up the slack. Palpation confirmed it being tender throughout its course, with most at the tibial attachment. The attachment is largest here, so that makes sense. The muscle also tested weak.

We gave her popliteus and 1 leg balancing exercises in addition to doing acupuncture (origin/insertion work) as pictured. 5 days later she was 60% improved. She may need to return to her ortho, depending on her response to additional care.

Think about the popliteus the next time someone has posterior medial knee pain, especially when descending.

October 30, 2015

Podcast 98: Stability, Mobility and The Brain

October 30, 2015/ The Gait Guys

Topics: Plus, the central nervous system’s effects on Chronic Tendonopathies and Gait Problems.

Show Sponsors:

*newbalancechicago.com

*Rocktape.com

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_98f.mp3

Podcast Direct Download: http://thegaitguys.libsyn.com/podcast-98-stability-mobility-and-the-brain

Other Gait Guys stuff

Stability, Mobility and The Brain plus, the CNS and Chronic Tendonopathies and Gait Problems. We have done 98 podcasts, it is easy to miss one or two, but this is not one of those ones you should pass up. Hope you will join us on the podcast today !

Endocanabioids
http://metro.co.uk/2015/10/07/runners-high-triggers-the-same-brain-receptors-as-getting-stoned-on-weed-5426140/

Exercise Pill
http://www.huffingtonpost.com/entry/exercise-pill_56128c64e4b0768127028b16

Swagger gait in primates
http://news.discovery.com/human/evolution/tree-climbing-extinct-human-had-swagger-151007.htm

Should we instruct changes in client’s gait ?
http://www.anatomy-physiotherapy.com/articles/musculoskeletal/lower-extremity/knee/1311-kinematic-variation-and-pain-in-dynamic-knee-collapse

The Brain and chronic tendonopathies
http://www.anatomy-physiotherapy.com/articles/musculoskeletal/1313-tendon-neuroplastic-training

October 26, 2015 October 26, 2015/ The Gait Guys

Can you believe they missed this? Sometimes you just need to look. This gal has knee pain on the R a “funny gait” and right sided low back pain in the sacro iliac joint fr the last 3 years. She felt like she needed to keep her right leg bent and her left straight all the time. She was unable to hike or walk distances longer than 1 mile or time longer than 30 minutes without slowing down and having pain. She has had reconstructive surgery on the right knee for an ACL/MCL, physical therapy, medication, counseling and even stroke rehabilitation/gait retraining. On exam she has a marked genu varus bilaterally. Knee stability is good anterior/posterior drawer; valgus/varus stress. One leg standing with both eyes open is less than 15 seconds, eyes closed is negligible. She has an anatomically short L leg; at least 2 cm which is both tibial and femoral. She was unaware of this and noone had adressed it in any way. She was given a 10mm sole length lift for the L leg and propriosensory exercises. She was encouraged to walk with a heel to toe gait. She felt 50% better immediately and another 20% after 2 weeks of doing the exercises. She had gone on several 5 mile hikes for over 2 hours with minimal discomfort. Nothing earth shaking here. Just an exam which covered the basics and some common sense treatment. Too bad they are not all that easy, eh? The takeaway? Look and listen. The problem was on the side opposite her complaint, as it can be many times. Look at the area of chief complaint 1st, but then look everywhere else : ).

October 23, 2015

Effects of prior hamstring injuries

October 23, 2015/ The Gait Guys

Previous hamstring injury is associated with altered biceps femoris associated muscle activity and potentially injurious kinematics.

“Previously injured athletes demonstrated significantly reduced biceps femoris muscle activation ratios with respect to ipsilateral gluteus maximus, ipsilateral erector spinae, ipsilateral external oblique, and contralateral rectus femoris in the late swing phase. We also detected sagittal asymmetry in hip flexion, pelvic tilt, and medial rotation of the knee effectively putting the hamstrings in a lengthened position just before heel strike."

The biomechanics of running in athletes with previous hamstring injury: A case-control study. C. Daly¹, U. McCarthy Persson², R. Twycross-Lewis¹, R. C. Woledge^1,† andD. Morrissey^1,
http://onlinelibrary.wiley.com/d…/10.1111/sms.12464/abstract

October 21, 2015 October 21, 2015/ The Gait Guys

En Pointe, Demi Pointe, Posterior Impingement ?

When we see pictures like this most of us are triggered to look at the toe and the challenges to the 1st MTP joint. But what about all that compression and crowding in the back of the ankle ? Posterior compression is a reality in athletes who spend time at end range plantarflexion or pack much force and load through end range plantarflexion.

This is a photo example of what is referred to as “en pointe” which means “on the tip”. “Demi pointe” means on the ball of the foot which is much safer for many areas of the foot, but this requires adequate 1st MTP (metatarsophalangeal joint range). We discussed this briefly this week on social media regarding hallux limitus and rigidus.

En Pointe is a terrible challenge. So if you are thinking of putting your darling children in ballet…… just beware of the facts and do some logical thinking on your own when it comes to allowing the “en pointe” axially loading of the entire body over a single joint, a type of loading that this joint was never, ever, designed to withstand. This joint is a great problem for a great many in their lives, why start playing with the risk factors so early ? Let them dance, into demi pointe, but pull them once they are being forced in to En Pointe, if you want our opinion on the matter.

En pointe or classical point ballet it typically done in point shoes or slippers which have a reinforced toe box that allows a more squared off stable surface to stand in pointe position. It does not however allow a reduction in the axial loading that you see in this picture and it certainly does not help with proper angulation of the big toe, if anything the slipper will gently corral the toes together rendering abductor hallucis muscle function nearly obsolete. The box will also not stop the valgus loading that typically occurs at the joint. Despite what the studies say, this is one we would watch carefully. Now, there are studies out there that do not support hallux valgus and bunion formation in dancers, we admit that. However, we are just asking you to use common sense. If you see a bunion forming, if the toe is getting chronically swollen, if the toe is drifting off line then one must use common sense and assume that the load is exceeding joint integrity. Prolonged and excessive loading of any joint cartilage is likely to create a risky environment to crack, fissure, wear down or damage the cartilage or the bony surface underneath (subchondral bone). If you screw up this joint, toe off will be impaired and thus the windlass effect at the joint will be impaired thus leading to a multitude of other dysfunctional foot issues in the years to come.

Now, back to the “en pointe” position. Did you try it yet ? Heed our warning ! Just trust us, this is bloody hard. Since serious foot deformities can result from starting pointe too early, pre-professional students do not usually begin dancing en pointe until after the age of 10 or so , remember, the adolescent foot has not completed its bone ossification and the bone growth plates have not closed. Thus, damage and deformity are to be expected if done at too young an age. If you asked our opinion on this, we would say to wait until at least the mid-teenage years……. but by that point in the dance world a prodigy would miss her or his opportunity. Thus, we see the problems from going “en pointe” too early in many. In the dance world, there are other qualifications for dancers before En Pointe is begun. Things like holding turnout, combining center combinations, secure and stable releve, 3rd position, 4th position, 4th croise and 5th position all of which are huge torsional demands on the hips to the feet. Do you want your child undergoing these deforming forces during early osseous development ?

Achieving en pointe is a process. There is a progression to get to it. Every teacher has their own methods but it is not a “just get up on your toes” kind of thing.

Are you a dancer with posterior ankle pain, impingement or disability. The Os trigonum and protruding lateral talar process are two common and well-documented morphological variations associated with posterior ankle impingement in ballet dancers.

Think this stuff through. If you are going to be treating these things, you have to know the anatomy, loading mechanics and you have to know your sport or art. Dr. Allen was a physician for the world famous Joffrey Ballet for a few years, he knows a thing or two about these issues dancer’s endure. And he still has a few nightmares from time to time over them.

Dr. Shawn Allen

reference:

Clin Anat. 2010 Sep;23(6):613-21. doi: 10.1002/ca.20991.Pathoanatomy of posterior ankle impingement in ballet dancers. Russell JA,Kruse DW, Koutedakis Y, McEwan IM, Wyon M

October 20, 2015 October 20, 2015/ The Gait Guys

Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to whic… — **Custom orthotic or Sham for mid tendon achilles tendonopathy? It doesn’t seem to matter.**
This study prescribed eccentric calf exercises along with either a custom or “sham” foot orthosis for 140 people who were randomized as to which group got the real goods and which one did not. A Victorian Institute Sports Assessment-Achilles questionairre was given at baseline, 1, 3, 6 and 12 months. No statistically significant difference between the groups.
Hmmm..
We wonder just what were the custom and sham like? When we use orthoses, we use full arch contact devices. Perhaps the type of orthosis makes a difference? What has been your experience?
Munteanu SE, Scott LA, Bonanno DR, Landorf KB, Pizzari T, Cook JL, Menz HB. Effectiveness of customised foot orthoses for Achilles tendinopathy: a randomised controlled trial.
Br J Sports Med. 2015 Aug;49(15):989-94. doi: 10.1136/bjsports-2014-093845. Epub 2014 Sep 22.

October 20, 2015

National Shoe Fit Certification Course

October 20, 2015/ The Gait Guys

A quote made by a loyal follower on social media:

“someone asked for the best certification/certificate programs out there, and I posted this with a link to your YouTube promo video, even though I haven’t even went through it, yet. Hopefully this drives a handful of coaches your way. There are over 6k coaches in the group. “National Shoe Fit Program. The most unknown program out there. 2 overwhelmingly smart biomechanical clinicians put together a program to teach people how to integrate foot and shoe anatomy, then apply that to the various foot types to get people standing, walking, running and moving as correctly as they can on a basic level. Good luck trying to correct most of the squatting, deadlifting and Olympic lifting compensations without addressing how the foot interacts with the ground. Good luck trying to improve fitness without addressing gait. Good luck addressing gait without addressing foot types and shoes.”

thanks Michael !

we blush

October 19, 2015

Psoas, iliacus. . . . hip flexors ?

October 19, 2015/ The Gait Guys

How many times have you heard us say, “hip flexion in the swing phase of gait is not driven by the hip flexors. In swing phase, the psoas and iliacus complex is not a hip flexor initiator, it is a hip flexion perpetuator/” ?
More evidence … . .
“These experiments also showed that the trailing leg is brought forward during the swing phase without activity in the flexor muscles about the hip joint. This was verified by the absence of EMG activity in the iliacus muscle measured by intramuscular wire electrodes. Instead the strong ligaments restricting hip joint extension are stretched during the first half of the swing phase thereby storing elastic energy, which is released during the last half of the stance phase and accelerating the leg into the swing phase. This is considered an important energy conserving feature of human walking. ”

http://www.ncbi.nlm.nih.gov/pubmed/24814597