1st MTP Pain?
It may not be a trigger point. In this capsule summary, Dr Ivo discusses an interesting and perhaps revolutionary, theory on trigger point pain that refers to the 1st metatarsal phalangeal articulation. The anatomy of the joint and responsible muscles are also discussed
Got Motion Control? Sometimes too much of a good thing is a bad thing!
Welcome to Monday and News You can Use, Folks.
Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.
You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.
The Banana Toe: The Force has to go somewhere. It’s a Jedi Gait Rule.
* note: there are 4 photos to today’s blog post. Be sure you click through all 4.
When you toe off, you have to toe off from somewhere in the foot unless you like an apropulsive hip flexion gait, where you just lift you foot off the ground from foot flat, kind of like a true neurologic “foot drop” gait client would. But, if you are lucky enough not to have a true foot drop, you are going to push off somewhere in the foot. You can do it off the lateral foot (low gear toe off) and lesser toes, or you can do it off the big toe (high gear) the way we were built to do it.
The above pictures show a nasty dorsal crown of osteophytes that is limiting hallux (big toe) extension/dorsiflexion. This is true hallus rigidus and hallux limitus. When this client attempts to toe off, the joint cannot normally partake in the activity, there is no Windlass effect, no posturing up over the sesamoids for mechanical advantage etc.
In this scenario, there are two places you can put it, up into the next proximal joint(s) meaning the met-cuneiform joint or further down into the interphalangeal joint. In other words. the loads go proximal or distal to the limited joint, and they eventually play out there, over and over and over gain. The former option would basically mean you are pronating/dorsiflexing through the midfoot which is never good (can you say Saddle exostosis ! ouch !) or the latter option is to dorsiflex through the interphalangeal joint and over time that toe begins to attenuate plantar ligamentous structures and extend beyond its normal limits resulting in the “Chiquita” toe (a upward bent toe resembling a banana shape). This will disable the long flexor of the great toe (FHL: flexor hallucis longus).and inhibit mechanical advantage of the extensor digitorum brevis. If you struggle with the “how and why” behind this sentence in terms of restoration attempts, you need to watch my video here. It will offer you deeper insights.
Will this toe become painful ? yes, in time it is quite possible. Is there much you can do? Sure, a rocker bottomed shoe will help take the load at toe off instead of forcing it into this toe or the midfoot. Will an orthotic help ? Well, this is a loaded question. If you are putting the forces into the midfoot choice as described above, the orthotic will block that motion and you will likely default option into the toe presentation above. So you are merely just moving loading forces around. It can be helpful, but you are quite possibly “robbing Peter to pay Paul” as they say. The video I asked you to watch can be helpful but it will force that metatarsophalangeal joint into extension, a range it does not have, so it is not a remedy and not recommended. Perhaps some awareness and slight increase in FHL(long toe flexor) use can be attained however. These are tricky cases, simple in theory, but execution can be fussy and requires patient awareness and education. We like the rocker bottomed shoe as a nice easy solution and some increased FHL use awareness. Help them find a little more FHL use by putting a pencil under the crease of the toe and help them to drive the tip of the toe down just a little out of that banana extension posture. It can help them control the overloading of the dorsal aspect of the interphalangeal joint.
As always, lets carry this forward into gait thoughts. How is hip extension going to be in this client ? How is glute strength ? Hip joint range ? Hip extension motor patterning ? Will the client go into anterior pelvic tilt to borrow the last range of hip extension ? Will the hamstrings have to accommodate ? Lots of yummy biomechanical and neurological mental gymnastics here. Bottom line answer to all the above ? “ it depends, they will have to accommodate and compensate”. And as the Jedi Gait Rule goes, “the Force as to go somewhere”.
Shawn Allen, one of the gait guys
Carry a backpack?
Unless you are a great compensator, like some limb amputees seem to be (see yesterdays post), be prepared for some changes in your gait. During some of our “backpack” research for yesterdays post, we turned up this full text article:
“In conclusion, college students currently carry too much weight in their backpacks. The average weight carried by UVU students caused an increase in trunk flexion regardless of age, gender or year in school. The load carried in the backpacks also slowed gait velocity, increased time spent in double support, and with the messenger bags caused a change in the right foot angle implying that the hip was rotated due to the contralateral bag placement. In an effort to avoid such potentially harmful conditions, college students should avoid using messenger bags, should always follow the manufacturer settings for proper bag positioning, and carry less weight in their backpacks.”
https://www.western.edu/sites/default/files/page/docs/jensen.et_.al_.spring.2014.pdf
Carry a pack?
Have a LLD or other gait altering condition like a lower limb amputation? Carrying a pack may not necessarily change your center of gravity.
Yes, we were surprised as well…
“There are many scenarios where it becomes necessary to carry a load, and a back pack is often the most realistic option to carry this load. The additional load is thought to lead to changes in kinematics of the persons movement. This hypothesis, however, is not supported by results of this study. Asymmetry in movement did not significantly alter centre of pressure (COP) parameters for an amputee carrying a loaded backpack.”
Abstract
Understanding how load carriage affects walking is important for people with a lower extremity amputation who may use different strategies to accommodate to the additional weight. Nine unilateral traumatic transtibial amputees (K4-level) walked over four surfaces (level-ground, uneven ground, incline, decline) with and without a 24.5 kg backpack. Center of pressure (COP) and total force were analyzed from F-Scan insole pressuresensor data. COP parameters were greater on the intact limb than on the prosthetic limb, which was likely a compensation for the loss of ankle control. Double support time (DST) was greater when walking with a backpack. Although longer DST is often considered a strategy to enhance stability and/or reduce loading forces, changes in DST were only moderately correlated with changes in peak force. High functioning transtibialamputees were able to accommodate to a standard backpack load and to maintain COP progression, even when walking over different surfaces.
Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.
Appl Ergon. 2016 Jan;52:169-76. doi: 10.1016/j.apergo.2015.07.014. Epub 2015 Jul 31.Center of pressure and total force analyses for amputees walking with a backpack load over four surfaces. Sinitski EH, Herbert-Copley AG, et al
Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe.
What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head.
This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals. This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint. What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.
So, they wanted to know about their gait and what to watch out for. Off the top of your head, without thinking, you should be able to rattle off the following:
There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.
* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus. They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … . you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).
If you know the complicated things, then the simple things become … … . . simple.
Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left.
… . sorry for the rant, too much coffee this morning, obviously.
Shawn Allen, one of the gait guys
What are we listening to this week? The Plantaris…
Thanks to Karly Foster of Twin Bridges Physiotherapy the: Physioedge podcast with David Pope
Imagine if you were able to dedicate a large portion of your life to the study of one individual muscle. That’s exactly what the main person interviewed here has done Dr. Kristof Spang from Sweden has done. a lot of research on Achilles tendon tendinopathy.This podcast looks at the role of the plantaris muscle in mid tendon tendinopathy, with an emphasis on anatomy.
This muscle needs to be considered in recalcitrant cases of Achilles tendon apathy which of not respond to conservative means.
Dr Spang goes through some of the anatomical variations of attachment of the plantaris, with 10 to 20% attaching into the Achilles tendon. Since there seems to be at least nine different anatomical variations in attachment that can occur; this can often explain the variety of symptoms associated with plantaris issues.
The plantaris attaches from the lateral aspect of the femoral condyle downward to its insertion point within deli near its origin at the knee. The area of attachment distally can be between two and 5 mm and this “area attachment” may be part of the source of the pain. Phylogenetically the tendon attaches into the plantar fashia, similar to the palmaris. One theory is due to the small muscle size it may actually act as a proprioceptive sentinel for the knee and ankle. The peritendonous tissue may interfere with the gliding of the tendon in this is believed to be one of the ideologies of this recalcitrant problem.
Of the diagnostic imaging available, ultrasound seems to provide the most clues. In the absence of imaging, recalcitrant medial knee tendon Achilles tendon pain seems to also be a good indicator.
Our takeaway was that most often the problem seems to be had a conjoined area between the planters and Achilles tendon midcalf lead to most problems. Treatment concentrated in this area may have better results. If this is unsuccessful, surgery (removal of the plantaris, extreme, eh?) may need to be considered.
Regarding specific tests for plantaris involvement, people who pronate seem to be more susceptible than those who supinate. This is not surprising since the tendon runs from lateral to medial it would be under more attention during predatory forces
It seems that plantaris tendonopathy can exist separately from an conjoint tendinopathy and it may be that people of younger age may suffer from plantaris tendinopathy alone. This may indicate that the problem may begin with the plantaris and that the planters is actually stronger and stiffer than the Achilles!
It was emphasized that this condition only exists in a small percentage of mid Achilles tendon apathy patients. And that conservative means should always be exhausted first.
All in all, an interesting discussion for those who are interested in pathoanatomy. Check out part 2 in this series for more.
link to PODcast: http://physioedge.com.au/physio-edge-041-plantaris-involvement-in-midportion-achilles-tendinopathy/
Podcast 102: Thermic adaptation, gait, running, odometer neurons, your brain’s GPS, rehab for cartilage, plantar fascitis and more.
Show Sponsors:
Softscience.com
Other Gait Guys stuff
A. Podcast links:
direct download URL: http://traffic.libsyn.com/thegaitguys/pod_102ff.mp3
permalink URL: http://thegaitguys.libsyn.com/podcast-102-thermic-adaptation
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:
‘Odometer neurons’ encode distance traveled and elapsed time
http://www.eurekalert.org/pub_releases/2015-11/cp-ne102815.php#.Vj5xCP01e5w.facebook
Our GPS loss
http://www.fastcoexist.com/3053172/these-beautiful-mental-maps-of-cities-help-your-brain-regain-what-it-has-lost-to-gps?partner=superfeed
Athletic adjustments to the heat http://www.runnersworld.com/sweat-science/how-long-does-it-take-to-adjust-to-heat
Hyperthermic conditioning http://fourhourworkweek.com/2014/04/10/saunas-hyperthermic-conditioning-2/
The newest craze? or a temp fad ? http://sproingsport.com
Muscle strength in Plantar fascitis http://www.runresearchjunkie.com/intrinsic-muscle-strength-in-plantar-fasciitis/
Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis
RTH Cheung, L.Y. Sze, N.W. Mok, G.Y.F. Ng
Journal of Science and Medicine in Sport ; Article in Press
What does stretching do to a joint ?http://www.greglehman.ca/2015/11/11/what-does-stretching-do-to-a-joint-we-really-have-no-idea-part-i/
Rehabing cartilage ?
http://www.thestudentphysicaltherapist.com/home/rehabing-cartilage-defects
Music piece: why you need good earphones to run with.
http://www.openculture.com/2015/10/the-neuroscience-of-bass-new-study-explains-why-bass-instruments-are-fundamental-to-music.html
Dry Needling and Proprioception. What a great combination.
Since dry needling and proprioception both have such profound effects on muscle tone, why not combine them to treat chronic ankle instability? We do all the time and here is a FREE FULL TEXT article that ties the two together nicely!
And what better to muscle to use than the peroneii? These babies help control valgus/varus motions of the foot and influence plantar and dorsiflexion AND the longus descends the 1st ray. We call that a triple win!
“This study provides evidence that the inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the end of the therapy in individuals with ankle instability. Our results may anticipate that the benefits of adding TrP-DN in the lateral peroneus muscle for the management of ankle instability are clinically relevant as large between-groups effect sizes were observed in all the outcomes.”
link to full text
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/
photo from this past weekends Dry Needling Seminar: working on the dorsal interossei
Toe sardines. What have we done to our feet ?
Note that form follows function. If you are observant, you will see the deformation of the 5 digit, just like in this case as the quadratus weakens and the long flexors dominate. The toe begins to spin laterally, and thus the plantar toe pad begins to deform medially, look closely, you can see that here in the video.
Does this look like your foot ? There are a few subtle issues here.
In the foot, the toe that delineates abduction and adduction of the toes is the 2nd toe. The 2nd toe is considered the anatomic middle of the digits and forefoot. Any toe or movement that moves away from the 2nd toe is abduction and any movement towards the 2nd toe is adduction. This is obviously different than in the hand where the 3rd digit, the one you use during road rage, is the reference digit. Next time you are questioned, tell them you threw them your reference finger, not “the bird”, it is a more accurate descriptor.
In this foot, note how neatly and tightly packed the cute little toes are, all snuggled up to their brothers and sisters. Remember, form follows function. Obviously function has been low on these fellas, at least in abduction. This often comes from snug toe box footwear and lack of abduction (toe spread) use. But make no mistake, this is a weak foot.
Today we wish to really focus your attention to an old topic, just a revisit. We can see the 4th and 5th toes curl under from the probably weak lateral head of the quadratus plantae thus encouraging unopposed oblique pull of the long flexors of the digits (FDL). See this post here for an explanation of this phenomenon. There is also obvious imbalance between the long and short flexors and extensors in these toes, the long flexors are expressing more tone, and that means the long extensors are deprived.
Note that form follows function. If you are observant, you will see the deformation of the 5 digit, just like in this case as the quadratus weakens and the long flexors dominate. The toe begins to spin laterally, and thus the plantar toe pad begins to deform medially, look closely, you can see that here in the video. This spin can carry the toe nail so far laterally sometimes that the nail can begin to touch the ground during gait and cause painful nail lifting with even some losing the nail.
There is plenty of life left in this foot, but you have to get to it quickly and get them in lower heeled shoes if tolerable and ones with a wider toe box. The client needs to be retaught how to access the toe extensors and abductors. Lumbrical retraining, which is a recurrent topic here on our blog, should also be instituted.
Shawn Allen, one of the gait guys
What are we listening to this week?
Therapy Insiders interview with Stu McGill entitled “the mechanics of a treatment approach with Dr. Stuart McGill"This was an interesting interview with some nice clinical pearls. Anyone who has had the opportunity to see Dr. McGill speak will certainly appreciate his humor and candor.
After a lengthy discussion on mustaches, they began to talk about competency of therapists. Dr. McGill then explains some salient points in his three hour evaluation of patients. His goals are to "precisely define The pain triggers to that patient” and then to “remove them”. Pretty simple but effective. We think the keyword here is “precisely”.He then talks about utilizing your clinical knowledge based in the powers of observation.
His assessment begins with a patient interview to determine The character of the patients pain. He’s very careful to listen to “exactly” what the triggers and really are for a patient’s pain. He then goes on to offer some nice clinical diagnostics pearls that we will leave for you to listen to the podcast to glean.
He then again emphasizes observing the patients movement and movement habits to establish their stability/mobility continuum. His examination consists of three parts: provocative motions, neural tests, and tissue specific tests. He looks for provocative motions postures and loads. Once the pain should use identified, he then seeks to find positions postures or movements which will alleviate it. He then does neural tests, looking for things like neural or root tension. Finally he discusses some tissue specific diagnoses.
There’s an interesting discussion on pain and pain science. Dr. McGill emphasizes that people need to avoid the movement which causes pain not moving in general. He then goes on to talk about Central sensitization and how, if you can teach people to not invoke their “pain trigger” motion, that they will actually improve and central sensitization will decrease. in other words, don’t move “through” pain but find ways to work around the trigger.
There’s been a series of “Twitter” questions that are answered with an interesting discussion on Core stability and superimposed axial movement. All in all a informative interview with some clinical pearls.
you can give it listen here:
http://updocmedia.com/mediacast/the-mechanics-of-a-treatment-approach-w-dr-stuart-mcgill/
Hmmm..What’s going on here? Can you see it?
Welcome to Monday, Folks, and News You Can Use! Sometimes, it’s the subtle things that make all the difference.
Take a look at this patients right leg versus left legs (knees in particular). What do you see? Can you notice the subtle bend in the right knee? Can you see how she hyperextends the left? Can you see that she has an anatomical deficiency (Tibial) of the left tibia? This is a common finding if you look for it.
Noticing subtle changes like these in your examination can make all the difference in your outcomes. This particular patient happens to have right-sided knee pain. On examination (difficult to see from the photos) she has increased amounts of mid foot pronation. She presented with right sided back pain running from the supra iliac region up along the right lumbar paraspinal’s. You can manipulate this patient forever and her problem is not going to improve until you address the cause.
Develop keen sense of observation. Become a “student of the obvious”. Keep your eyes and ears open. Expand your clinical skill set. Sometimes, when all we have is a hammer, everything starts to look like a nail.
From the study:
“From these indexes it was established that the postural capacity needed just to control balance with the leg muscles was not attained before 4-5 years of independent walking, i.e., at about 5-6 years of age.” -Breniere
reference link:
Exp Brain Res. 1998 Aug;121(3):255-62.Development of postural control of gravity forces in children during the first 5 years of walking.Brenière Y1, Bril B.
Part 2: How relaxed, or shall we say “sloppy” is your gait ? The Cross over gait /Frontal plane drift gait.
In this photo (*credit below) the blurred right swing leg tells you this client has been photographed during gait/running motion. Can you see it ? Have we educating you well ?
Human gait is cyclical. A problem on one side will corrupt the other and the cycle begins, and usually continues until the cycle is broken.
We wish to remind you of our time hammered principle that when the foot is on the ground the glutes are heavily in charge, and when the foot is in the air, the abdominals are heavily in charge. For us to move cleanly and efficiently one would assume that the best way to do that would be to ensure that the lower 2 limbs are capable of doing the exact same things, with the same timing, same skill, same endurance and same strength. This goes for the upper 2 limbs as well, and then of course the synchronizing of the four in a cohesive antiphasic effort. This would be perfect and clean gait, a gait that would unlikely ever suffer pain or problems. Symmetrical durability wins every time.
This photo demonstrates the cross over gait and we are beating it to a pulp here, again. In this running gait photo, this momentary snapshot of global movement, it shows this client is engaging movement into the left frontal plane excessively, they have drifted to the left far outside the vertical plumb line from the foot. The question is, it is excessively enough to present as painful pathology or is it a painless problem at this time? We call what you see here a frontal plane drift, but more so, the cross over gait. You can even see suggestion of the left frontal drift as evidenced by the concavity of the lumbar spine curve to the left. It should be clear that the right pendulum leg will scrape the left calf on its way through its oblique pendulum swing (instead of a pure forward sagittal swing) to a foot strike somewhere near to the line they are closely running on (a theoretical line). This is the cross over gait. After this left frontal plane drift and right cross over, there will likely be a corresponding right frontal plane drift and left cross over to compensate on the very next step. Thus, the cycle begins, each on feeding and compensating off the other. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to have the stability from S.E.S (skill, endurance, strength) to stack the hip, knee and foot over top of each other. You have to have enough ankle stability and a host of other clean and strong and skilled layers to fend it off to be precise. One must be able to find functional stability in the stacked posture, and this can take some training and time. Make no mistake, this is a faulty movement pattern, even if there is not pain (yet), this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, posterior ischeofemoral impingment syndrome, a compensation in arms swing or thoracic spine rotation or head tilt etc … . something has to give, something has to compensate.
To complicate the cyclical scenario, the time usually used to move sagittally will be partially used to move into, and back out of, the frontal plane. This will necessitate some abbreviations in the left stance phase timely mechanical events. Some biomechanical events will have to be abbreviated or sped through and then the right limb will have to adapt to those changes. These are simple gait problems we have talked about over and over again here on the gait guys blog. (Search “arm swing” on our blog and you will find 50+ articles around this topic.) These compensation patterns will include expressed weaknesses in various parts of the human frame as part of the pattern
Are you able to find the problem in the never ending loop of compensations of your clients and find a way to unwrinkle their system one logical piece at a time, or will you just chose to strengthen the wrinkled system and hope that the new strength on top of the compensations is adequate for you or your client ? One should not be forever sentenced to daily or weekly rehabilitative sessions or homework to negate and alleviate symptoms, this is a far more durable machine than that. Fix the problem. Merely addressing things locally can be a crime. If you are seeing an arm swing change, you would be foolish not to look at the opposite lower limb and foot at the very least, and of course assess spinal rotation, lateral flexion and hinging as well as core mobility and stability.
For you neuro nerds, remember what Dr. Ivo says, that the receptors from the central spine and core fire into the midline vermis of the cerebellum (one of the oldest parts of our brain, called the paleo cerebellum); and these pathways, along with other cerebellar efferents, fire our axial extensor muscles that keep us upright in the gravitational plane and provide balance or homeostasis through stability. It is why they assessed and addressed.
Or, if this is too much thinking for you, … you can just train harder and get stronger . . . in all your compensation patterns, after all, it is easier than figuring out why and how a right ankle for example started the whole mess, if in fact that is even the first piece of the puzzle. No one said this would be easy.
So, how sloppy is your gait ?
Dr. Shawn Allen, one of the gait guys
________________________
References and Credits
Note: photo linked to this article. Photo credit/property: REUTERS/Eduardo Munoz (Copyright Reuters 2016).
Article: Workouts focused on motor skills may help ease lower back pain
Ishial tuberosity pain that looks like a hamstring but is not responding? Think QF.
We have always have found the quadratus femoris is one of, if not the, 1st hip muscle to become dysfunctional in hip pain patients. Perhaps it is due to it being the southern most stabilizer of the deep 6. Long known as an adductor, but also external rotator, we find it is employed eccentrically when the foot the planted and people rotate to the same side as weight bearing, or people take a “sudden stumble” while running. It often mimics an insertional hamstring strain with regards to location. We were happy to see it is getting some of the attention it deserves : )
You mean a sauna can improve my endurance for running?
Did you know using a sauna can (in some areas) produce better results than exercise? I didn’t believe it either. What are we listening to this week? For 1, one of Dr Ivo’s new favs: Dr Rhonda Patrick
This is an absolutely great, referenced short on some of the benefits of hyperthermic conditioning (ie sauna use). One of the most surprising effects was benefits which exceeded exercising!
Here is one small excerpt:
Being heat acclimated enhances endurance by the following mechanisms:
It increases plasma volume and blood flow to the heart (stroke volume). This results in reduced cardiovascular strain and lowers the heart rate for the same given workload. These cardiovascular improvements have been shown to enhance endurance in highly trained as well as untrained athletes.
It increases blood flow to the skeletal muscles, keeping them fueled with glucose, esterified fatty acids, and oxygen. The increased delivery of nutrients to muscles reduces their dependence on glycogen stores. Endurance athletes often hit a “wall” when they have depleted their muscle glycogen stores. Hyperthermic conditioning has been shown to reduce muscle glycogen use by 40%-50% compared to before heat acclimation. This is presumably due to the increased blood flow to the muscles. In addition, lactate accumulation in blood and muscle during exercise is reduced after heat acclimation.
It improves thermoregulatory control, which operates by activating the sympathetic nervous system and increasing the blood flow to the skin and, thus the sweat rate. This dissipates some of the core body heat. After acclimation, sweating occurs at a lower core temperature and the sweat rate is maintained for a longer period.
waaaayyyyy more in her video. Check it out. I had to listen to it several times to catch all the details.
https://www.youtube.com/watch?v=aHOlM-wlNjM&feature=youtu.be
and what have we been saying for the last several years?
“The development of bone marrow edema after transitioning from traditional running shoes to minimalist footwear is associated with small intrinsic foot muscle size, according to research from Brigham Young University in Provo, UT.
The findings, epublished in late October by the International Journal of Sports Medicine, suggest that runners with small intrinsic foot muscles may benefit from strengthening exercises prior to attempting the transition to minimalist running.
Investigators randomized 37 habitually shod runners to 10 weeks of running in minimalist footwear or their own shoes, and performed magnetic resonance imaging at baseline and after the intervention to detect bone marrow edema and assess intrinsic foot muscle size.
Eight of the runners in the minimalist group had developed bone marrow edema at 10 weeks, as well as one in the control group. Those who developed bone marrow edema had significantly smaller intrinsic foot muscles than those who did not.
In addition, running in minimalist footwear was associated with a 10.6% increase in abductor hallucis cross-sectional area, a statistically significant change”.
Source:
Johnson AW, Myrer JW, Mitchell UH, et al. The effects of a transition to minimalist shoe running on intrinsic foot muscle size. Int J Sports Med 2015 Oct 28. [Epub ahead of print]
yet another cause of impaired ankle rocker. Be sure to do a thorough exam!
“Many pathogenic manifestations of equinus occur due to the center of pressure displacement that is seen in diseased states. Typically, the center of pressure on the foot can be measured 6 cm anterior to the ankle during gait, but with equinus, it is shifted distally and laterally. The pull of the Achilles tendon cannot adequately compensate for the new distal and lateral center of pressure and, as a result, an overall pronatory force remains.”
http://lermagazine.com/article/equinus-its-surprising-role-in-foot-pathologies
“The Deep 6” and their “not so talked about” role in the gait cycle.
Excerpted from a recent Dry Needling Seminar in, listen to this brief video and you will never look at these muscles the same way again.
It talks about the lesser known, eccentric role of the deep 6 external rotators during gait. This is really important from a rehab perspective, as these muscles are often neglected in the rehab process.
Do yourself and your clients/patients a favor and watch this informative short so you don’t miss out : )
Eliminating the fake out of ample ankle rocker through foot pronation in the squat and similar movements: How low can you go ?
This is a simple video with a simple concept.
* Caveat: To avoid rants and concept trolling, am blurring lines and concepts here today, to convey a principle. Do not get to tied up in specifics, it is the principle I want to attempt to drive home. What you see in this video is clearly more lunge/knee forward flexion rather than hip hinge movement. However, keep in mind, that this motion does occur at the bottom of many movements, including the squat.
You can achieve or borrow what “appears” to be more ankle dorsiflexion, a term we also loosely refer to as ankle rocker, through the foot, foot pronation to be precise. Do not mistaken this extra forward tibial progression range as ankle rocker mobility however. When you need that extra few degrees of ankle dorsiflexion deep in your squat, or similar activities, you can get it through your foot. Often the problem is that you do not think that is where it is coming from, you might just think you have great ankle mobility. Many deep squatters are borrowing those last few degrees of the depth of the squat from the foot. This is not a problem, until it is a problem. Watch the video above. Why ? Because when the foot pronates and begins to collapse (hopefully a controlled collapse/pronation) the knee follows. Forcing the knees outward in a squat like some suggest is a bandaid, but I assure you, the problem is still sitting on the table.
Go do a body weight squat with the toes up like in this video. Toes up raises the arch from wind up of the windlass and increased activity of the toe extensors and some assistance from the tibialis anterior and some other associated “helper” muscles. When the arch is going up, it cannot go down. So, you raise your toes and do your squat. This will give you a better, cleaner representation of how much mobility in your squat/lunge/etc is from ankle dorsiflexion, knee flexion and hip flexion. You can cheat and get some from the foot. The foot can be prostituted to magnify the global range, and like I said, this is not a problem until it IS a problem. We know that uncontrolled and unprotected increases in foot pronation can cause a plethora of problems like plantar tissue strain, tibialis posterior insufficiency and tendonopathies, achilles issues, compression at the dorsum of the cuneiform bones (dorsal foot pain) to name a few. This dialogue however is not the purpose of this blog post today. You can read more about these clinical entities, proper foot tripod skills and windlass mechanics on other blog posts on this site.
Today, we just wanted to bring this little “honesty” check to your awareness. Has been a staple in my clinic for over a decade, to help me see where limitations are and to show folks how they can cheat so much through the foot. Go ahead, try it yourself, see how much you use your foot to squat further if you have end range mobility issues in the hips, knees or ankles. The foot is happy to give up the goat, it just doesn’t know the repercussions until they show up.
So, lift your toes, do a full squat. Go as low as you can with good form with the toes up. Then, at the bottom of the squat or the bottom of your clean mobility, suddenly drop your toes and let the arch follow if it must. Here is the moment of truth, at that moment the toes go down, feel what happens to the foot, ankle, tibial spin, knee positioning, pelvis posture changes. Careful, these are subtle. You may find you are using foot pronation more that you should, more than is safe. Now try this, bottom out your cleanest squat as you regularly would, and at the bottom, raise your toes and try to reposition the foot arch and talus height. In other words, reposture your foot tripod, see how difficult this is if you can do it at all. Perhaps you will find your toe extensors are too weak to even get there. This is how we cheat and borrow. We should not make it a habit, it should be used when we need it, but it should not be a staple of your squatting diet, it should not be a regular event where you prostitute sound biomechanics. Unless you wish to pay for it in some way. What should happen is that you should be able to bring your toes down and not let the arch follow, but that is a skill most have not developed. It is a staple move in your clients’ movement diets.
Does all this mean you should squat with your toes up ? No, but it may serve you well in awareness, evaluation, and looking for potholes and power leaks. At the very least, give it some thought and consideration. You may see some smiles and have some lightbulb moments between you and your athletes and clients.
Plan on blocking this foot pronation range with an orthotic ? How dare you ! At least try to do it through reteaching this and the tripod skill first. Give your a client a chance to improve rather than a bandaid to cope.
Dr. Shawn Allen, one of the gait guys
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