Gait Gaff Time.
(Gaff: verb tr. (to stand or take the gaff) To receive severe criticism; to endure hardship.
The Foot Slap Gait Style:
This is a funny little video that shows a few important points.
Remember, our purpose here is to help train your eyes to the important things. We used to use slow/stop frame digital gait software programs to slow down the person to look for particular components of failure in the gait or running cycle. After many years of doing this, we found more and more that even before we could fire up the video camera and software that we had trained our eye to see these deficits. This is because, there are multiple clues in every gait compensation. There is head movement (which we will discuss in this case), there is arm swing (is it equal and symmetrical, topics we have posted research articles on in the last 48 hours on this blog), torso rotation, hip lateral sway in the frontal plane, violations of sagittal knee progression, and then the always difficult multiplanar foot and ankle motions as well as so many other parameters we consider. So, when one component goes wrong, with enough experience and skill, one can make predictions as to what is wrong. And, the more flaws (correlative compensations) that are noted, the higher the predictive value of the assumption. Now, many will say to us that there is no way one can do this, and that is ok. To each his/her own. But, after decades of doing this, as with anything, a skill is developed and an art to doing it begins to take shape, as we will see here (without stop frame, without foot mapping devices etc). One begins to form a mental algorithm to the process. We always start with, “is the head silent in the vertical, frontal and sagital plane?”. When a person’s gait is off, the head is almost never silent in space. And arm swing also begins an assymetrical pendulum effect. This could be called an energy conservation mode (as talked about in the article on the blog entitled, Dynamic Arm Swing in Human Walking, (http://www.ncbi.nlm.nih.gov/pubmed/19640879) where it was determined that normal arm swinging required minimal shoulder torque, while volitionally holding the arms still required 12% more metabolic energy. Among measures of gait mechanics, vertical ground reaction moment was most affected by arm swinging and increased by 63% without it.
So, as you do this more and more you will develop the skills of observation to improve the art form of assessing one’s gait. But remember this KEY POINT *** what you see is mere information gathering, it is not always and frequently ever, the problem that you see. You are seeing their compensation pattern around some neurologic, orthopedic or biomechanical problems…..things that are making a silent pristine gait impossible. You MUST then, take this information and correlate it to your clinical findings in terms of neuro-orthopedic-biomechanical limitations during your exam. Things like, joint range limitations, muscle weakness, instabilities and the like. So, you are trying to take what you see, and what you find, and develop a logical algorithm as to where their problem lies and one that tells a logical mechanical story as to the gait pattern you are seeing. For example, a person comes to see you with a lurching forward of their body mass onto the right leg, abruptly skipping over the heel strike phase of gait on the right causing a slap of the right forefoot onto the ground. One option of thought COULD be a deficit in the right tibialis anterior, that being eccentrically weak in that muscle thus delivering an abrupt right foot drop type gait. But your examination on the table, your CLINICAL examination, shows a LEFT hallux limitus with dorsiflexion range shy of the key 45 degrees needed for normal toe off. You then have a clinical epiphany that they are leaving the left foot quickly and prematurely because THEY HAVE NO OTHER CHOICE because it hurts to load that first MTP joint on the left. You then go down, determine the joint is limited in range, it is painful, there is a pinch callus on the medial hallux and the extensor hallucis longus and brevis are weak. Gait analysis is done. What you saw, was not the problem, it was their compensation. Now, you have to try and fix the problem and the compensations…….and treatment begins.
OK, soap box aside………
lets build on that skill set we are trying to develop, the powers of observation and what they COULD mean.
THE SKUNK FU GAIT:
The first thing we see is, the Sagittal head bob.…..each step there is a propulsive head anterior oscillation and then dropping downwards at the end. This can mean there is an apropulsive problem in midstance such as loss of ankle rocker but that is not so in this case, the ankle rocker is great. The head drop in this case coincides with successive heel strikes each time. This in essence means that they are dropping from a height each time. How can this be ? The little fella is on flat ground ! (more on this in a minute). This could mean a lack of core maintenance in the late midstance phase of gait (heel rise-toe off) and subsequent movement onto the next heel strike. This can come from overstriding, as in this case, but it can also come from an aggressive forward lean in a person’s gait style (like walking into a strong head wind). In this case, we have a more reasonable ASSUMPTION, it comes back to the “falling from a height issue”. In this case, lack of adequate anterior compartment lower limb strength (tibialis anterior and the long and short toe extensors, EDL, EDB, EHL, EHB) allows PEPE to move from heel strike to foot flat in an uncontrolled and abrupt fashion. When this occurs, pronation (even the normal amount of pronation) occurs fast. And we know that when a person moves from supination to pronation there is a drop in height of the arch and thus a drop in the body (try this to prove the point, …..stand up straight, look in a mirror and begin raising up your toes and then dropping them. If you do it right, each rise of the toes should raise the arch (The Windlass Effect), and each fall should drop the arch demonstrated in the mirror by a rise and fall of the head vertically.) And so here you have the height differential in this case. So, in a nutshell, PEPE is over-striding (as evidenced by his also aggressive arm swing), and falling hard from heel strike abruptly into foot flat, a double whammy ! There is basically zero eccentric phase activity of the lower anterior compartment musculature and so the foot accelerated to the ground from its starting peak height at heel strike. The poor fella probably has a raging anterior shin splint condition because of this but you would be hard to tell from the smile on the little stinkers face. …………but remember, prove your facts on the table……who knows, maybe he has posterior column spinal cord disease, but an examination will have to be done to confirm your findings and suspicions. In this case, we highly recommend an upwind exam table and plenty of air fresheners.
we remain,… The Gait Guys
