Bend-AR 30 Hour Adventure Race

One of our clients, is a badass. He just completed, and successfully we might add, right behind the world's best we are told, just finished this mind boggling race. 

This 30-hour race is now in its sixth year, BEND-AR is quickly becoming a “must do” race and has drawn teams from as far away as the east coast, central Canada and SoCal.  Though the exact course is kept secret up until right before the race date, the event is held near Bend, Oregon. It is touted as being “the must-do race for the Pacific Northwest”.

Disciplines: Mountain biking, whitewater paddling, trekking, and navigation.

That is a long day's work. Congrats to you Luis and to your sponsors !

A unique version of the circumducting gait.

It is Rewind Friday:
Chef and general overall badass Anthony Bourdain's gait.
A unique variation on the Circumducting Gait. You will see this one is many people, if you look for it.

https://thegaitguys.tumblr.com/post/21713480315/the-chef-another-abnormal-gait-pattern-in

The Chef: Another abnormal gait pattern in celebrity chef and The Travel Channel’s Anthony Bourdain.

It was just a few nights ago after a 13hour day with patients that I got home and climbed into bed, looking forward to flipping through channels to find something to alter my brainwave state. I needed to find something that would allow me to dial down into a slumber.  Much to my happiness I found one of my favorite shows, “No Reservations” with my favorite chef.  I get a real kick out of Tony. This is one smart dude. He is pretty slick with the english language.  Did you ever get to read his New
York Times best seller “Kitchen Confidential”?  What a killer book. We recommend the audio book read by the author himself.  It turned the restaurant scene upside down.  Has anyone ever told you not to order fish Monday through Thursday ? It is all in the book.  Why else do I love Bourdain?  His command of the english language is exceptional, and creative.  For example, he once said, “what would it be like to be a meat-filled Pinata at a Pit Bull convention?”.  Things like that stick with you.

Anyhow, so there I am lying in bed dozing off, listening to Bourdain talk about Mozambique and there he is in all his slender glory walking down the street with his sidekick Samir.  “Red Alert, Red Alert ! "  The clinical brain snaps back on.  Dammit !  Knowing very well I had to rewind the cable box to see it again, but knowing I was slowly descending into deeper brainwaves, I quickly rewind and grab my iphone to record the gait you see above.  You see, when you are a gait nerd like us, nothing escapes you when it is this obviously wrong. It is a disease; trust us.  We cannot go anywhere anymore without noticing pathologic gait.  It appears we cannot even watch a cooking show. And since we live on a planet where everyone walks, it must be a penance for something we must have done in another life.

Onto Bourdain’s gait. 

Look at Tony’s circumducting feet compared to Samirs (on the right).  Samir clearly engages pelvis lift on the swing leg side which is typically brought on by engagement of the hip abductors (g. medius) on the stance leg side. This lift on the swing side allows the swing leg to have ample room to pendulum through without having to prostitute the knee or foot posturing.  The knee and foot simply sagittally hinge through, this is economical gait.

Bourdain on the other hand shows little if any swing side pelvis lift driven by stance leg hip gluteus medius engagement.  This creates a clearance problem for the pendulum swing leg.  So now the problem becomes how to get the leg to swing through without catching the toes and foot. You must create clearance. Clearance can be obtained by:

generating oppositehip abduction forcing the swing leg hemi-pelvis to lift
increasing hip flexion which will initiate a steppage gait. This will be combined with increased knee flexion. This is productive and necessary if you are climbing stairs or trying to unload a painful turf toe near the end of stance phase push off.  When seen in normal walking gait it may represent neurologic pathology.  But folks with hip problems or weakness will use it to get around to avoid tripping.
circumduct the swing leg hip. The act of swinging the leg outward and around will eat up the leg length.
circumduct the foot.

Bourdain is doing #4. It is a pretty lazy gait strategy, you can see it is lazy. It probably requires very little energy to flip the foot outside the normal ankle dorsiflexion foot swing progression.  What must be the cost to activating the peronei and the lateral toe extensors to flip that foot around like that ? Sure you can see that the knees are for a moment carried outside the sagittal plane but who cares, right ? 

There are a couple of concerns. One is that failure on a single step to generate sufficient foot/ankle circumduction will result in a foot catch and a fall.  Another is the trouble in always getting that circumducting foot to land precisely in the near sagittal plane. When you move the foot on an arc you really only have a narrow target to land the foot within the 5-15degree landing zone. Circumduct too far and the foot is in-toed and more rigid due to it being supinated during midstance, circumduct too little and the foot is more out-toed and increased pronation risk increases.  This goes for running as well.

Go back and watch Samir’s walk. Clean and done right, the swing leg is a passive pendulum. Tony’s is obviously different. Who knows, maybe he has bad hips ? Maybe it was always a struggle to walk normally. He is 6'4” so we cannot blame it on excessive height unless he lives in a house that has 6 foot ceilings, because then his strategy would be our gait of choice. It would be the only one that would effectively work !  Maybe that is it. Maybe he lives in Smallville ?

We don’t think so.  The only for sure way to know would be to get him on our exam table and see what parts he is not using. We would put big money on weak gluteus medius, bilaterally.  It is the one we see most often in this abnormal gait pattern.

Shawn and Ivo, tortured gait observers in a world of ambulatory pathology.

Welcome to our hell.

Another way to alter loading rates and potentially reduce injuries?

How about providing something a simple as visual and auditory cues?

In his particular study they cued people to either
1. Forefoot strike
2. Decrease average vertical loading by 15% or
3.Decrease step length by 7-1/2 per cent (ie increase step frequency)

All 3 decreased eccentric knee joint work; but increased ankle joint work. Forefoot strike as well as cues to decrease average vertical loading (which would cause you to forefoot strike) increased ankle joint work. I guess that if you steal from Peter you need to pay Paul! Decreasing step length had no adverse effects.

What are you trying to accomplish? If it is decreased knee joint loading, such as in patients with patellofemoral problems, then this could be a very good thing. If you have a patient with a raging achilles tendinitis, then perhaps not.

Having someone decrease their step length (effectively increasing their cadence) can be one of the safest ways to decrease vertical loading rates.

Baggaley M, Willy RW, Meardon S. Primary and secondary effects of real-time feedback to reduce vertical loading rate during running Scand J Med Sci Sports. 2016 Mar 19. doi: 10.1111/sms.12670. [Epub ahead of print].

A Metabolic Cost to the Cross over gait.

Here is what we know, when we put our foot on the ground, we, as humans who sit too much and tend to get into sagittal plane activities too often, things like swimming, biking, walking, running -- and do not challenge the frontal/lateral plane enough earn our way into functional problems:  "Walking appears to be passively unstable in the lateral direction, requiring active feedback control for stability. The central nervous system may control stability by adjusting medio-lateral foot placement, but potentially with a metabolic cost. This cost increases with narrow steps and may affect the preferred step width." -Donelan study

For well over 6 years now I have been working on solidifying my thoughts and theories on the cross over gait. I did our 3 part video series back in 2011 and Ivo and I have built our theories to deepen the roots on this concept since then. Since then, the more research I come across continues to serve these initial theories well and help me to hone them for my clients and runners. Some still dismiss the concept because "many professional runners have a very narrow step width and they are fine" -- that is not the point, it is deeper than that. More recently I have found it more helpful to explain it as, "a narrow step width, like all things off of the mechanical norm, have a place and some value when the environment requires it. However, it comes down to a challenge between the two issues of Economy and Liability, perhaps better put, Economy vs Stability. A  narrow step width may be more economical for moving through the sagittal plane in many ways, if they have sufficient lateral (frontal plane) endurance, but if one goes too far or for too long, that economy can become a liability and injury risk can build as one begins to tease that lateral plane."  I will ask my athletes, "how long can you be in this running economical place before you run out of gas and liabilities start to mount into the more metabolically demanding frontal plane?".  Endurance and strength are the major factors, built on skillful movement. The question remains for many athletes, "how long can you run with a narrower step width, with your present lateral hip-pelvis-core endurance and stability, before you exhaust the endurance of your protective mechanisms and expose the liabilities of those more risky frontal plane mechanics ?"

Again, from the Donelan study:
"Walking appears to be passively unstable in the lateral direction, requiring active feedback control for stability. The central nervous system may control stability by adjusting medio-lateral foot placement, but potentially with a metabolic cost. This cost increases with narrow steps and may affect the preferred step width. 
These results suggest that (a). human walking requires active lateral stabilization, (b). body lateral motion is partially stabilized via medio-lateral foot placement, (c). active stabilization exacts a modest metabolic cost, and (d). humans avoid narrow step widths because they are less stable."

- Dr. Shawn Allen, one of the gait guys

J Biomech. 2004 Jun;37(6):827-35.  Mechanical and metabolic requirements for active lateral stabilization in human walking.  Donelan JM1, Shipman DW, Kram R, Kuo AD.
 

Welcome to the posterolateral corner (PLC) of the knee: The Dark Sleepy Hollow of post ACL knees.

Although perhaps more commonly thought to be found in PCL injuries, i personally cannot tell you how many cases of ACL repair I have seen over the years that turned into a failed surgical response because damage and laxity in the posterolateral corner of the knee was missed. 
 I have sent enough knees back to surgeons with detailed explanations of a discovered PLRI (posterolateral rotatory instability), some impressed that it was found, others dismissing it (and eventually surgery by another doctor). These are frustrating cases and they cannot be missed.  One must not just assess for the ACL tear, post event tear is an optimal time to determine if there is BOTH a positive drawer phenomenon and a pivot shift. The majority of PLC injuries do not occur in isolation and are part of a more complex injury pattern that typically involves other vital supporting structures. Do not dismiss the restraining capabilities of the capsular and non-capsular secondary restraints in this far corner of the knee. Finding the pivot shift after the ACL reconstruction is just too late, you must catch it before it heads to surgery and make sure the surgeon knows that the posterolateral corner restraints were also trashed. They likely need repaired as well. otherwise the client will have a great tight drawer test post surgery but will have rotational instability, which is arguably worse if you ask me.  If you find PLRI on the exam make a strong note of it on the MRI request, be sure the radiologist has the clinical functional info in mind when they get the static images coming up on the screen.
Too many clinicians do not know how to assess this area, and the pivot shift phenomenon is also overlooked and misunderstood. If you have never likely had someone walk you through what a positive pivot shift feels like on a ACL knee you will not know what it feels like in a post ACL reconstruction that is failing rehab.
"Although rare, posterolateral corner (PLC) injuries can result in sustained instability and failed cruciate ligament reconstruction if they are not diagnosed. The anatomy of the PLC was once thought to be perplexing and esoteric-in part because of the varying nomenclature applied to this region in the literature, which added unnecessary complexity. "- Rosas
"More recently, three major structures have been described as the primary stabilizers of the PLC on the basis of biomechanical study findings: the lateral collateral ligament, popliteus tendon, and popliteofibular ligament. " 

Do not miss this one gang. Know how to test and feel for PLRI, you will find it if you start looking for it. And, you will likely fail in rehabilitating these knees, it usually need surgical correction of that corner.

- Dr. Shawn Allen, one of the gait guys

Radiographics. 2016 Oct;36(6):1776-1791. Unraveling the Posterolateral Corner of the Knee. Rosas HG1.
 

Acute tendon changes in intense CrossFit workouts

Study: Acute tendon changes in intense CrossFit workout

Habitually overloaded tendons often thicken and increase the tendonopathy risks -- nothing new here.
However as this study points out "it remains unknown whether acute overload caused by strenuous, high-intensity exercise will exert changes in tendons and if these changes can be detected and described by ultrasonography."

This study (note: Achilles, and plantaris tendon ultrasounds were performed before and after a specific workout in 34 healthy subjects)
. . . .noted "a significant increase in the thickness of the patellar and Achilles tendons" in response to strenuous, highly intense CrossFit exercises. Cross fit is not the culprit here, it is the load and load rate. None the less, it is good to know that an aggressive workout can leave us more vulnerable. This is why adequate rest and recovery must be part of your regular weekly workouts. One cannot keep fully stomping on the gas pedal over and over, workout after workout, and not expect problems to creep in if adequate recovery time has not been afforded to the working parts. This study showed changes after just one workout. No rocket science here today, we should see changes, load was applied. This is just good old fashioned "well duh, that makes sense". Here is the problem, we don't always listen to logic, nor do our clients who have goals and timeframes. We live in the "more is better" world now, so stay vigilant on logic gang. Dial your foolish clients in a little, save them some grief.  Yes, this goes for runners and all other venues of activity, there is a reason why we see problems in people with speed workouts more frequently than base miles.

Acute tendon changes in intense CrossFit workout: an observational cohort study. F. Y. Fisker et al
http://onlinelibrary.wiley.com/doi/10.1111/sms.12781/full

More foot exercise studies to confuse you.

Don't necessarily believe all that you read. Please to not take away from this study that these 4 exercises: short-foot exercise, toes spread out, first-toe extension, second- to fifth-toes extension are golden goose exercises to rehab your athlete. On first glance if one is not thinking, that could be a mistake in translation.

"The intrinsic foot muscles maintain the medial longitudinal arch and aid in force distribution and postural control during gait."  That is a pretty bold statement by the study's authors. We would argue that a far less misleading statement would be that "the intrinsic foot muscles are a piece of the puzzle, just a piece, and to dismiss the powerhouse tibialis anterior, tibialis posterior, long and short toe flexors and particularly the extensors is a glaring oversight".  Yes, I know, the authors just wanted to study the intrinsics, I get it, -- one just has to be careful of the conclusions made when the study is so microscopic compared to the global perspective at hand.  Please, read on.

This study tried to correlate the effects of these 4 exercises: short-foot exercise, toes spread out, first-toe extension, second- to fifth-toes extension on activation of the foot intrinsics muscles they chose to observe (abductor hallucis, flexor digitorum brevis, abductor digiti minimi, quadratus plantae, flexor digiti minimi, adductor hallucis oblique, flexor hallucis brevis, the interossei, and lumbricals).

They looked at the activation before and after exercise in just 8 athletes. They did not look at non-athletes and yes, this is a terribly small N sampling and the study only used T2 weighted MRI to make these conclusions.

The study's conclusion was "Each of the 4 exercises was associated with increased activation in all of the plantar intrinsic foot muscles evaluated.".  

Here is my concern*. 
Did they consider the various foot typings ? (*Caveat, I have not read the entire study, I am trying to get it). There are many variables to consider including arch integrity, forefoot type, rearfoot type, foot flexibility, step width, step length, client weight amongst other things. Yes, that makes for a near impossible study, I get it. And, it does not appear they had a control study that looked at what happened right after walking. Wouldn't it be fair, and wise,  to see what the study showed after barefoot walking for 1-2 minutes ? I bet many of these muscles show significant activation there as well, after all, they were weight bearing and stepping down on the foot which requires the muscles to be activated and utilized.  So, does that then mean these 4 exercises are any better than walking ? Does that mean they will suffice for homework for your client ? Does that mean they will strengthen these muscles ? And, does activation mean proper pattern utilization of these muscles, meaning, is there functional translation over to functional use ? Yes, that is not what the study was looking at, but for darn sure that would have been nice info to know. Just take the study for what it found, and do not step beyond those tiny boundaries. We hope that is what they will go for in the next stage of study.  To be fair, they also concluded, "These results MAY have clinical implications for the prescription of specific exercises to target individual intrinsic foot muscles."  Safe words. Yes, I capitalized the word MAY.

- Dr. Shawn Allen, one of the gait guys.

Thomas M. Gooding, Mark A. Feger, Joseph M. Hart, and Jay Hertel (2016) Intrinsic Foot Muscle Activation During Specific Exercises: A T2 Time Magnetic Resonance Imaging Study. Journal of Athletic Training In-Press. 
http://natajournals.com/doi/abs/10.4085/1062-6050-51.10.07
http://dx.doi.org/10.4085/1062-6050-51.10.07

Impact matters: How you put your foot on the ground matters.

Impact matters. For years Ivo and I have been telling our clients this obvious fact. Over and over we hear the heavy heel strike of our barefoot clients on the floors of our office. We are constantly drawing their attention to this unnecessary impact load.  They hear it, feel it, and make immediate notable changes and realize that they are a big part of their own problem.  (Recently, an onslaught of Sever's "disease" cases have been coming into our office and the parents confirm a herd of elephants live on the upper floors of their homes, if you catch our drift. Impact matters.  Kids with heel growth plate issues should not be pounding their heels into the floors.)  We like to say, the heel can touch down first, that is ok, it is normal in walking gait, just please "kiss the floor" with the heel instead of driving nails.  But, to be fair, all those high heel EVA foam cushioned shoes have brought us to where we are, and minimalism is trending us out -- a little.  

Here in this study, they "aimed to determine if a quantifiable relationship exists between the peak sound amplitude and peak vertical ground reaction force (vGRF) and vertical loading rate during running."

They used the same queuing in the study that we use in our offices, participants were verbally instructed to run quietly compared to their normal running. What is interesting is that "simple linear regressions revealed no significant relationships between impact sound and peak vGRF in the normal and quiet conditions and vertical loading rate in the normal condition." But, read carefully. There is a subtlety in this study, there were changes when the runners were queued to run more quietly, consciously.  This was different compared to those who just unconsciously ran quieter. 

"During the normal running condition, 15.4% of participants utilized a non-rearfoot strike technique compared to 76.9% in the quiet condition, which was corroborated by an increased ankle plantarflexion angle at initial contact. "

"This study demonstrated that quieter impact sound is not directly associated with a lower peak vGRF or vertical loading rate. However, given the instructions to run quietly, participants effectively reduced peak impact sound, peak vGRF and vertical loading rate."

J Sports Sci. 2016 Sep 3:1-7. [Epub ahead of print]

Running quietly reduces ground reaction force and vertical loading rate and alters foot strike technique.

Phan X1,2, Grisbrook TL1, Wernli K1,3, Stearne SM1, Davey P1, Ng L1.

GOT ENDURANCE?

We all realize the importance of endurance work, especially when it comes to core work. If we had a dollar for every patient that lacked lower back extensor endurance that had a gait problem......

In this video, Dr Ivo demonstrates his adaptation of Dr Eric Goodman's "Founders" sequence, along with some clinical commentary. Try this on yourself or with your patients/clients today. It's easy and effective.

Acupuncture/Dry Needling and Proprioception. A Winning combination.

What a great combination of therapies for folks with chronic ankle instability, or almost any injury for that matter! Taking 2 modalities that emphasize afferent input from the peripheral mechanoreceptor system, which has such a large influence on the cerebellum as well as the segmental and descending pain inhibition pathways.

Did you notice they used the trigger points in the peroneus longs muscle to needle? Though they didn't say it, did you remember that that the point correlates to a great point: Gallbladder 34, which is an empirical point for musculoskeletal pain? Interesting how this muscle influences both frontal and saggital plan stability. 

Though the techniques of exercise could use some refinement (check out the gents posture in the photo, sure looks like he could use some gluteus medius work!), this is a good overview that provides evidence that utilizing spacial summation (combining multiple techniques that provide afferent input to more than one modality to cause an effect) has better outcomes than one alone. Put this one on your reading list : )

Salom-Moreno J, Ayuso-Casado B, Tamaral-Costa B, Sánchez-Milá Z, Fernández-de-Las-Peñas C, Alburquerque-Sendín F.Trigger Point Dry Needling and Proprioceptive Exercises for the Management of Chronic Ankle Instability: A Randomized Clinical Trial. Evid Based Complement Alternat Med. 2015;2015:790209. doi: 10.1155/2015/790209. Epub 2015 Apr 30.

link to FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430654/

Who Rules -- The glutes or the quads? Well, it is complicated.

We have often talked about how important it is to be able to achieve terminal hip extension for an athlete, and arguably for everyone. This means one must have strength of the glutes into that terminal range so one can actually achieve the range of motion and access it functionally. If one does not, then extension movements may occur in the lumbar spine via some anterior pelvic tilt. However, one must not dismiss that upright posture needs sufficient quadriceps strength as well -- meaning, hip extension and knee extension get us to an upright posture and make locomotion possible. If we make the hip flexors or quadriceps tight, due to weakness of the lower abdominals or glutes,  we get anterior pelvic posturing and less hip extension (these are admittedly very rough principles, we all know it is far more complex that this).  What I am saying is that there is an interaction amongst groups of muscles, functional patterns of engagement, recruitment and whatnot. 

One must clearly realize how much knee and hip motions are coupled and work with and off of eachother.  If we bend over in a squatting type motion, we are in hip flexion and knee flexion. When we stand, hip and knee extension. These guys play off of eachother.  One must consider these issues when movements are more advanced and loading and loading rates are magnified, such as in squatting type lifting.  

A few weeks ago Bret Contreras in conjunction with Strength and Conditioning Research put out an article by Yamashita , yes, a 1988 article.  "EMG activities in mono- and bi-articular thigh muscles in combined hip and knee extension."  What this article looked at was what happened during isolated hip extension and isolated knee extension, and more importantly, what happened to the forces when both joints loaded simultaneously, paired in generating extension at the hip and knee, as in a squat. 

This article suggested that when hip and knee extension forces are generated in conjunction, the knee extensors are more activated than if the same force was generated in isolation. What this seemed to suggest is that during the extension phase of a squat, it is easy for the quad thigh muscles (rectus femoris, vastus medialis in this study) to to try and rule the movement, from an activation perspective -- the hip extensors (g. max and semimembranosus) take second seat.  We have talked many times about the dangers of this principle when we frequently say "the glutes should be in charge of the hip, not the quads, when the quads try to apply dominant control of the hip motion, trouble may ensue." Admittedly, this may not be entirely true and it is very loosely stated, but the principle has some sound value when it is approached from how we intend it to be heard, that many athletes do not have sufficient glute strength, hip extension range of motion, and poor control of pelvic neutral. So, they dump into the quads because as we see here in this study, they are very appropriately positioned to help synergistically drive the positioning for, and activity of, hip extension motor pattern production. Is this why we see small buttocks and large quadriceps in distance runners, and the opposite in sprinters ?  We think so, but we need to dive deeper into the research to prove or disprove it, but the principles seem to make sense.
This is why I like to initially drive my glute and hip extension work with my clients in a more knee flexed position, such as supine bridges.  I cannot say it better than Bret Contreras did when he reviewed this article,  

"So exercises that involve less knee extension (glute bridges, hip thrusts, deadlifts, pull throughs and back extensions) will tend to produce much greater hip muscle activation than those that involve more knee extension (squats, lunges, and leg presses), although there are always other factors involved of course!".  

If you are not following Bret's and Strength & Conditioning Research's work, you are missing out, They are thorough and insightful, they do their homework, learn from them.
We clearly need to dive into some newer research on this topic, we will see if we can squeeze out the time. 

- Dr. Shawn Allen, the other "gait guy"

Here is an embedded code for the beautiful slide that accompanied Strength and Conditioning Research's summary of the study. If you cannot find it above in this post, goto their Facebook page and scroll to Sept 22nd, 2016. You will find it beautifully laid out there.  Beautiful job S&CR!

<iframe src="https://www.facebook.com/plugins/post.php?href=https%3A%2F%2Fwww.facebook.com%2FStrengthandConditioningResearch%2Fposts%2F982124818565207%3A0&width=500" width="500" height="731" style="border:none;overflow:hidden" scrolling="no" frameborder="0" allowTransparency="true"></iframe>

Yamashita  1988. Eur J Appl Physiol Occup Physiol. 1988;58(3):274-7. EMG activities in mono- and bi-articular thigh muscles in combined hip and knee extension.
https://www.ncbi.nlm.nih.gov/pubmed/3220066
 

Podcast 112: Strengthening the foot's arch

Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 

Show links:
http://traffic.libsyn.com/thegaitguys/pod_112f.mp3
http://traffic.libsyn.com/thegaitguys/pod_112f.mp3
* and on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 

Show notes:

Job security, become so good and so unique that Ai cant replace your skills as a doctor
http://www.techinsider.io/age-of-ems-machines-will-take-over-all-jobs-2016-8

How prosthetics are working now, and will in the future
and why you should be scared
http://thenextweb.com/insider/2016/08/04/researches-think-we-may-have-to-protect-our-brains-from-hackers-in-a-few-years/

Open talk about how coordination is the first strength changes someone notes. It comes before true strength is achieved. It is neurologic, and its can feel decievingly safe, but it is a lie.

Foot Strengthening ?
https://drjohnrusin.com/advanced-strength-training-for-feet/

http://www.jospt.org/doi/abs/10.2519/jospt.2016.6482?platform=hootsuite&

Impaired Foot Plantar Flexor Muscle Performance in Individuals With Plantar Heel Pain and Association With Foot Orthosis Use

Tags:
foot arch, foot intrinsics, short foot, yoga toes, gastrocnemius, soleus, heel pain, hammer toes, correct toes, foot exercises, thegaitguys, squatting, gait, gait analysis, gait assessment,  orthotics, prosthetics
 

Rock Your Rehab Process with these simple Proprioceptive Exercises

In this capsule, excerpted from a recent Dry Needling Seminar, Dr Ivo talks about one of his proprioceptive sequences and the neurological reasoning behind it

Today we give away some of the farm with a great proprioceptive exercise sequence that we use ALL THE TIME.

Skill (proprioception), Endurance, Strength. In that order.

Try incorporating this simple and effective sequence into your rehab program and watch your results get even better!

Comparative effects of proprioceptive and isometric exercises on pain and difficulty in patients with knee osteoarthritis: A randomised control study. Ojoawo AO, Matthew O, Mariam HA.Technol Health Care. 2016 Jul 8. [Epub ahead of print]

Efficacity of exercise training on multiple sclerosis patients with cognitive impairments. Chenet A, Gosseaume A, Wiertlewski S, Perrouin-Verbe B. Ann Phys Rehabil Med. 2016 Sep;59S:e42. doi: 10.1016/j.rehab.2016.07.097.

Exercise strategies to protect against the impact of short-term reduced physical activity on muscle function and markers of health in older men: study protocol for a randomised controlled trial. Perkin OJ, Travers RL, Gonzalez JT, Turner JE, Gillison F, Wilson C, McGuigan PM, Thompson D, Stokes KA. Trials. 2016 Aug 2;17:381. doi: 10.1186/s13063-016-1440-z.

Leg and trunk muscle coordination and postural sway during increasingly difficult standing balancetasks in young and older adults. Donath L, Kurz E, Roth R, Zahner L, Faude O.Maturitas. 2016 Sep;91:60-8. doi: 10.1016/j.maturitas.2016.05.010. Epub 2016 May 27.

Hip proprioceptive feedback influences the control of mediolateral stability during human walking. Roden-Reynolds DC, Walker MH, Wasserman CR, Dean JC. J Neurophysiol. 2015 Oct;114(4):2220-9. doi: 10.1152/jn.00551.2015. Epub 2015 Aug 19.

Proprioceptive Training and Injury Prevention in a Professional Men's Basketball Team: A Six-Year Prospective Study. Riva D, Bianchi R, Rocca F, Mamo C.J Strength Cond Res. 2016 Feb;30(2):461-75. doi: 10.1519/JSC.0000000000001097.

Proprioceptive feedback contributes to the adaptation toward an economical gait pattern. Hubbuch JE, Bennett BW, Dean JC. J Biomech. 2015 Aug 20;48(11):2925-31. doi: 10.1016/j.jbiomech.2015.04.024. Epub 2015 Apr 23.

David and Goliath: The calf and the glute.

-by Dr. Shawn Allen

I recently saw yet another bulbous chronically inflamed achilles tendon, this one in an elite runner, a masters 1500 American record holder, so no slouch (this is not their photo, obviously) This thing had been baking for almost a year and they had achieved periods of zero pain and abilities to run and then flare ups would occur. There was a focal bulbous swelling (about 3/4 of inch in size) about one inch above the achilles insertion. The swelling was tendon intra-substance, not pre or post achilles soft tissue, this was clearly the tendon proper, you must be certain of this. There were no tiny nodular densities noted within the tendon proper (this is done slowly, with lotion, and fine palpation to look for nodules that might suggest enlarged microtears, not a full proof exam measure, but one I have made a habit of). The calfs were of equal size and shape.

The length of the posterior mechanism (gastrocsoleus-achilles complex) was good and ankle rocker was good.  Calf strength, especially top end plantarflexion, was obviously and predictably weak. Lying prone it was clear to the naked eye that the same side glute was smaller. We know that a muscles maximal contractile force (strength) is the maximal contractile force produced per square centimeter of the cross sectional area of the muscle.  Now, as a loose and low tech discussion here, moving through  the sagittal universe we like to use our glutes and calf to push. If that glute is weaker, who is going to do all this work moving forward ? The calf is certainly in line to help out, (yes, there are others).  

There was clearly gluteal weakness, same side quad tightness (this is obvious if you look at this from an anterior pelvis posturing perspective), lack of terminal hip extension range amongst other clues. But today, I wanted to just bring this principle forward to look all the way up the chain. Too many achilles tendonopathies get dozens of treatments of ultrasound, e-stim, acupuncture, cold, laser, orthotics, stretching, IASTM and the list goes on.  There is nothing wrong with eccentric loading therapy for this posterior calf-achilles mechanism as long as it is not painful but one must find the reason behind this tissue failure. Local scraping is a silly choice over this tendon, do not be a fool, use your head. But, you must look at other failures along this chain. This client had obvious pain on heel rise in the office, but after 30 minutes of serious motor pattern restoration into hip extension and proper gluteal recruitment in all 3 cardinal planes of loading this client had pain free heel rising. Now, caveat, we tested this 3 times only, obviously this will not hold.  But it gave us a clue, and proof, that restoring the proper posterior chain loading order and patterning, and restoring proper hip and pelvis stability loading patterns was a key parameter.  

These are tough cases these achilles beasts. They will frustrate you to no end because they are frequently slow responders and frequently because there are several failed neuro, ortho and biomechanical components that must be addressed. But, these cases are more about being smart than volume treatments with passive modalities.  And, it is near impossible to ask an elite runner not to run -- if you want to build a running practice, you will have to be smarter than all of the others in your community and not reflexively say "stop running".  Tell them "lets just be a little smarter than we have been Mr. Jones", people want to be smarter and they want to be part of a team.  Runners will find another doctor if you tell them to stop running (though, it is sometimes briefly necessary when they are just being knuckleheads about it), just get smarter, educate them, and spend some time with your client working through the bugs. I have not had ultrasound, e-stim, cold packs, hot packs, laser or any such toys in my office in my 19 years of practice for a reason, I spend 45 minutes with people and work through the bugs.  Sure, go ahead and judge me, tell me I am missing out on tools to help, I am ok with you saying that. But I get results most of the time. Do I sometimes fail though ?  Yes, we all do, I fail from time to time, but I tell my clients, "you will give up on this process before I do". I am just too curious for the deeper answers. I am in it to fix it, not to bandaid it. Anyhow, enough of my egoic rant, that was ridiculous, sorry, I just get really pissed off when I see someone who just fired their therapy place after 20 sessions of ultrasound, laser, e-stim, cook-booked rehab and stretching. We can and must do better than that dear brethren. But I guess that is why you are here with Ivo and myself, a team approach to getting wiser, here at The Gait Guys.

Oh, need research proof ?  Here . . . 

Neuromotor control of gluteal muscles in runners with achilles tendinopathy.   Franettovich Smith MM1, Honeywill C, Wyndow N, Crossley KM, Creaby MW. Med Sci Sports Exerc. 2014 Mar;46(3):594-9. doi: 10.1249/MSS.0000000000000133.

CONCLUSIONS:

"This study provides preliminary evidence of altered neuromotor control of the GMED and GMAX muscles in male runners with Achilles tendinopathy. Although further prospective studies are required to discern the causal nature of this relationship, this study highlights the importance of considering neuromotor control of the gluteal muscles in the assessment and management of patients with Achilles tendinopathy."

Bam ! 

- Dr. Shawn Allen

The Devil is in the Details

While getting ready to board my flight back from teaching a Level 1 dry needling seminar, this gent was in front of me. I couldn’t resist the opportunity to use the “Gait Cam” (yes, the Gait Guys are ALWAYS watching ) and make a few points.

Watch the video a few times through and come back. 

Did you notice his large heavy bag over in his right hand? Can you see (and imagine) how it pulls his center of gravity to the right? Can you also see how he “corrects” and leans to the left during stance phase (on the left) to move his center of gravity over his left foot? ANYTHING that you have in one hand or over one shoulder will alter your center of gravity and cause a simlar reaction, however subtle that may be. I was reminded of this as I took a much needed “post teaching all weekend run” with my friend. Karly Foster, yesterday through some of the beautiful “rain forests” of the Pacific Northwest and was wondering if I should bring a water bottle or not and didn’t have a pack to carry it, so I would have to carry it by hand. I elected not. 

Did you catch the subtle overpronation of the rearfoot on the right side (as evidenced by the valgus angulation) due to the increased load? Can you imagine what this must do to the lower extremity on that side, not to mention the asymmetry of mechanoreception reaching the cortex? Yikes! talk about potential neuroplastic changes!

Be a “student of observation”. Listen, look and think. Pay attention to the subtle details, as they will often provide what may be missing or the clues you are looking for.  

The Circle of Durability.

The article below for some reason inspired today's soft rant. I hope you feel this is worth your time. 
Yesterday I talked about arch height and ankle mortise dorsiflexion and how we can obtain more global dorsiflexion range through some pronation, loosely meaning, some arch compression/drop and splaying apart of the tripod legs of the foot. Global arch flexibility is a piece of that puzzle.  This action of arch compression/drop/tripod splay moves the tibia forward in the sagittal plane and this is global dorsiflexion. Let me be clear however, a reduced ankle mortise dorsiflexion range of sagittal motion which is met by more arch height reduction/prontation/tripod splay, is still dorsiflexion however it is less sagittal dorsiflexion and a little more adduction and medial drift. This can bring the knee into the medial plane and it does promote more internal spin of the limb, this can be a problem.  None the less, it is still global dorsiflexion. It is something we see at the bottom of a squat, we see it because to get there most of us do not have all that dorsiflexion at the mortise. It is not abnormal, the question is, "is it safe for you? Can you do it repeatedly, safely?" It is where we go when we need more sagittal motion, but it may not be ideal, and is often what creates functional pathology. We see it all the time, someone says in an email, "I have plenty of ankle dorsiflexion, that is not my issue".  Do you have plenty? Is it not really your problem? This is fine tuning stuff, it takes a skillful eye and assessment hand. It takes experience to see the whole picture. You cannot get this full 4k experience and understanding from a 2 dimensional youtube video. This arch compression and pronation is normal to occur, it should occur, it must occur. But, how much is too much, for you ? I like to explain it this way, 

"there is a point at which sound, economical, durable, biomechanics becomes a liability. And, at that point where the liabilities begin is in fact where we begin to skirt the edges of that durable skilled movement. Where we begin juggling our liabilities is where the risks begin to mount and begin to whittle away or trump our S.E.S.P (skill, endurance, strength, power). This is where injury often occurs, at that intersection where the gas tank of our S.E.S.P. begins to run low and our liabilities begin to run high." 

Sidebar: 
I have explained this concept many times before when talking about the cross over gait. Moving towards a narrower step width is fine if you have the durability to be there. The question is, how long are you going to be there ? A cross over gait tendency is more economical but you begin to risk liabilities toward injury if that durability becomes challenged. As a runner you must know where your safe zone exists and know how much durability you have at those fringes of your movement. It is when you are there too long, too often, or too much that you empty that durability gas tank which then increases your liabilities towards injury. This is why I give high volume and strength work once a problem is solved, to make sure that they can keep that circle of durability high. It is when we stop keeping our gas tanks large and full that we run on fumes and our risks increase. You might be able to run economically for 5 miles with a narrow step width cross over style running gait. But, can you do it safely at 10 miles ? How about 15?  Is it any wonder why people get injured as they fatigue their safe motor patterns ?  If they have worked hard to keep that circle of durability large (S.E.S.P.) they are bound to be safer and less injured. Injuries occur because we exit our circle of durability, its gas tank has run too low, liabilities now trump economy and durability.

- Dr. Shawn Allen, the gait guys

http://www.japmaonline.org/doi/abs/10.7547/8750-7315-2016.1.Song
 

Toe flexor strength and ankle dorsiflexion ROM during the countermovement jump

This study looked to evaluate the relationships between peak toe flexor muscle strength, ankle dorsiflexion range of motion, and countermovement jump height.

"The results showed (1) a moderate correlation between ankle dorsiflexion range of motion and countermovement jump height and (2) a high correlation between peak first toe flexor muscle strength and countermovement jump height. Peak first toe flexor muscle strength and ankle dorsiflexion range of motion are the main contributors to countermovement jump performance."

There could be variables missing here, and plenty of caveats. We should try to get the full text on this one to be fair. None the less, interesting facts to brain juggle however.
These muscles are posterior compartment muscles so it makes sense, however, when the first great toe (the hallux) is in relative flexion, the arch is easier to drop (conversely, hallux dorslflexion causes the arch to raise and keeps the ankle dorsiflexion more purely in the ankle mortise) where as, with relative toe flexion, the arch can drop, this can generate some pronation and arch splay, which can increase the "appearance" of more ankle dorsiflexion when in fact some could be from the arch drop/pronation. I wonder if the researchers are aware of this variable or if this study took it into consideration. Certainly when someone is dropping into ankle dorsiflexion ready to jump, is is easy to drop the arch. Go ahead, dry doing it with the toes down , and then with the toes up in extension, its very different in the amount of dorsiflexion you can get out of the entire arch-ankle mortise complex combined. IT is these kinds of things that can easily be over looked and skew findings.

Correlation between toe flexor strength and ankle dorsiflexion ROM during the countermovement jump

Sung Joon Yun1) 2), Moon-Hwan Kim2), Jong-Hyuck Weon3), Young Kim4), Sung-Hoon Jung5), Oh-Yun Kwon5)

Journal of Physical Therapy Science
Vol. 28 (2016) No. 8 August p. 2241-2244

link : https://www.jstage.jst.go.jp/article/jpts/28/8/28_jpts-2016-202/_article?platform=hootsuite

https://www.jstage.jst.go.jp/article/jpts/28/8/28_jpts-2016-202/_article?platform=hootsuite

Podcast 111b: Somnambulism. Locomoting when you are still asleep.

Podcast 111b: Sonambulism. Locomoting when you are still asleep. Ultramarathoners know about this one to a degree. Here is what you need to know. Do you ever wonder why you cannot sleep that first night in a new place, like a hotel ? We have answers.

http://thegaitguys.libsyn.com/podcast-111b-shorts-sleepwalking

http://traffic.libsyn.com/thegaitguys/pod_111b_Shorts-_Sleep_walkingg.mp3

Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our website and blog. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).

Are you a control freak?

While working with a post surgical ACL patient that has +2 laxity and  graft pain, I was reminded of something Dr. Allen and I were talking about while discussing this case. 

One of the primary goals post ACL is stated as improving range of motion, particularly getting to full extension. If you look at the mechanics of the anterior cruciate ligament, you'll see that placing the knee in full extension places this ligament under stretch. We often will try to increase range of motion by hyper extending the knee, or using it as a fulcrum, which can cause undue stretch to this ligament. This means the burden of oweness is on the musculature surrounding the joint to provide stability, similar to what we are seeing in my patient.

I asked him to perform a one legged stand keeping his knee over his second metatarsal and just hold it. I then had him perform a mini squat, but rather than a traditional knee forward squad I had him do a potty squat (tibia remains vertical, while flexion occurs at the knee by moving the femur and glutes backward). Note that his foot is in a tripod position and his toes are up. (see video here)  He was able to maintain good control of the knee for about the first 10° of flexion and then his motion started to degrade. Our goal will be to keep him in a range of motion where he has good neuromotor (find the first 10° of motion) and expand upon that. We remember from our principles of exercise that isotonic exercises (like a potty squat) have a physiological overflow of 15° on each side of the point of application. If I can get him to flex to 10° and be in control, I'm actually getting effects up to 25° flexion.

Simple? Yes. Important? Incredibly! If you can't control the range of motion that you have, why should you have more? Remember in your rehab procedures, keep it in a safe range.

Can you see what I see?Or...Can they see what you see?

While making a chickpea and Swiss chard succotash recipe out of the September issue of vegetarian times,  to go with the two racks of ribs and roasted beets and parsnips that I was making, I was reading an article out of August 2016 issue of one of my favorite journals "lower extremity review" by the editor Jordana Foster. Called "Out on a Limb: falling in with feedback". The "out on a limb" section is a monthly regular and always holds some compelling clinical ideas.  This particular one was talking about utilizing "visual feedback" with your patience.

It got me thinking about using visual feedback. The article spoke of some preliminary research from Rosalind Franklin University in Chicago utilizing visual feedback to control tibial acceleration.

It got me thinking. You could utilize some slick software and computer interface in your office or, if you were somewhat text savvy, use a simple video camera with a hook up of the screen real-time to a monitor device. This could be easily accomplished and most offices however there's an even easier for my feedback that could be utilized. A mirror. You can find a very large, great mirror at the local thrift store for a few dollars that you can have in front of your treadmill or Area where you were performing "gate rehab" with your patient or client. The simple tool can be extremely effective and low cost. Nothing like improving your bottom line without increasing your costs.

Try it and let us know what you think

#gait #rehabilitation #gaitrehabilitation #mirrortherapy #visualfeedback #visual #feedback