May 05, 2019

Premature heel rise: Part 2

May 05, 2019/ The Gait Guys

VIDEO: an atypical case of Premature heel rise. A follow up video for yesterdays discussion on the topic.

You should easily see premature heel rise here in this video. We will discuss this case at length with other video projections on our Patreon site next week, if you wish to dive further.

But here you should see, lets focus on the right limb, premature heel rise (again, stick with just watching the right foot/leg). This is, in-part, because this person does not achieve adequate hip extension, you should clearly be able to see that. Loss of terminal hip extension means premature heel rise, no exceptions. Train your eye to see this, you do not need expensive video software to see this.

So, Why inadequate hip extension? Well, just look at the amount of right knee flexion going into terminal stance, it is still heavily flexed and this forces them to prematurely heel rise, avoiding terminal hip extension, and prematurely load the forefoot. Without a knee that extends sufficiently, the hip cannot extend sufficiently, and thus premature heel rise is inevitable. And, trying to solve this issue down at the foot/ankle level is foolish in this case. Stretching this calf day after day until aliens come visit earth will still not be enough stretch time to fix this premature heel rise (ie. get that heel to stay down longer). There is a good reason why this is happening in this person, and it is a neurologic one, one we will discuss on the Patreon site for our Patrons. And, the reason does not matter for the concept I am teaching here today.

For today, you need to be able to see premature heel rise, and know all of the issues behind it, including causes, so that you can direct your phyiscial examination to solve your client's puzzle.
I have included yesterday's post below so you can review and bring this further together.
This is the kind of stuff we will do at Dr. Allen's Friday night Gait Lab, over some beverages. A unique, clinically curious and hungry 25 people need only apply. If you want to get to the next level of your human movement game, this is a way to get there.

Yesterday's post: We know that early/premature heel rise (PHR) leads to premature loading of the forefoot.
We know that premature heel rise (PHR) speeds us through many of the timely mechanical events that need and should occur for to get to safe and effective toe off during walking and running gaits.
This is why there are so many variables that need to be assessed and checked before instituting care to address the premature heel rise, because many times the problem is not even near the heel.
Consider, examine, assess (this is not an exhaustive list either) of causes of PHR
-short calf complex
-short quad (limits hip extension)
- short hip flexors
-anterior pelvis tilt as one's deviated norm posture
- prolonged or excessive rearfoot inversion
-lack of appropriate pronation (sustained supination)
-hallux limitus, rigidus
- weak anterior compartment lower leg
-lack of hip extension/weak glutes
-knee flexion contracture
- neurologic (toe walking gait from youth)
-painful achilles tendon mechanism
- loss of ankle rocker (which has its own long list)
. . . . to name a few

This is why you need to examine your clients, even after a gait analysis. Because, as we like to say, what you see is not your clients gait problem, it is their work around to other mechanical deficits.
After all, telling someone they just need to lengthen/stretch their calf to keep that heel down longer is utterly foolish.

*want to learn more about this stuff, you can join the upcoming Dr. Allen, Friday night Gait Lab series that he will be having in his office one Friday a month, in his Chicagoland office. Stay tuned for that notice. I will take only 25 people per session. We will dive into videos, cases, concepts, white-board rabbit holes, and enjoy some beverages and learn together. Stay tuned. The first 25 to pay and sign up are in !

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #heelrise, #PHR, #prematureheelrise, #achilles, #achillestendinitis, #anklerocker, #heelrocker, #forefootpain, #halluxlimitus, #halluxrigidus, #heelpain

May 05, 2019

Premature heel rise: Part 1

May 05, 2019/ The Gait Guys

We know that early/premature heel rise (PHR) leads to premature loading of the forefoot.
We know that premature heel rise (PHR) speeds us through many of the timely mechanical events that need and should occur for to get to safe and effective toe off during walking and running gaits.
This is why there are so many variables that need to be assessed and checked before instituting care to address the premature heel rise, because many times the problem is not even near the heel.
Consider, examine, assess (this is not an exhaustive list either) of causes of PHR
-short calf complex
-short quad (limits hip extension)
- short hip flexors
-anterior pelvis tilt as one's deviated norm posture
- prolonged or excessive rearfoot inversion
-lack of appropriate pronation (sustained supination)
-hallux limitus, rigidus
- weak anterior compartment lower leg
-lack of hip extension/weak glutes
-knee flexion contracture
- neurologic (toe walking gait from youth)
-painful achilles tendon mechanism
- loss of ankle rocker (which has its own long list)
. . . . to name a few

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #heelrise, #PHR, #prematureheelrise, #achilles, #achillestendinitis, #anklerocker, #heelrocker, #forefootpain, #halluxlimitus, #halluxrigidus, #heelpain

April 12, 2019

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

April 12, 2019/ The Gait Guys

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

Most likely this is common knowledge for most followers here on The Gait Guys and our podcast (another one will launch this weekend btw).

Screen Shot 2019-04-12 at 8.43.42 AM.png

But reducing the plantar flexion moment in the late stance phase of running and walking can make notable changes in the loading response to the posterior plantarflexor mechanism (the gastroc-soleus-achilles complex). A rocked shoe, according to this study, can reduce the plantarflexor moment without substantial adaptations in triceps surae muscular activity.
This of course brings to mind the HOKA family of shoes that have purposefully added a gentle rocker mechanism to some of their shoe line, some with an early and some with a late stage metarocker built in. Are you a HOKA hater? We were not fans in their early development because of the volume of stack height foam, but they have many more options in their line up now. But do this for us, do not pass judgement until you put one of these metarockered shoes on, and you will understand the function of it, and their place for your chronic posterior compartment clients. Don't reflexively judge until you try them. It is good to have options for your clients, because "stop running" is not an option for runners, for our runners, unless all else has failed.

Shawn Allen, the other Gait Guy

#thegaitguys, #gait, #hoka, #metarocker, #achilles, #tendinitis, #gaitproblems, #gaitanalysis, #calfpain, #running

J Sci Med Sport. 2015 Mar;18(2):133-8. doi: 10.1016/j.jsams.2014.02.008. Epub 2014 Feb 14.

Rocker shoes reduce Achilles tendon load in running and walking in patients with chronic Achilles tendinopathy.

Sobhani S1, Zwerver J2, van den Heuvel E3, Postema K4, Dekker R5, Hijmans JM6.

March 02, 2019

"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."

March 02, 2019/ The Gait Guys

We say this so often in our offices.
"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."
Translation: compromised mechanics leading to tissue overloading.
But we all have to strongly consider that injury is a result of the loading you have not trained gradually into, failure to adapt and accommodate, excessive mileage without adequate tissue recovery,

From the article:
"So Napier and co-author Richard Willy from the University of Montana reviewed the highest-quality research featuring randomized controlled trials and systematic reviews.
"What we see is that there's really no high-level evidence that any running shoe design can prevent injuries," Napier said."

Now, to be honest, in our (the gait guys) opinion, there are times we do recommend a change in the foot wear for a client, and it is often because it appears to be working against someone mechanics and is a contributory factor in their injury or complaint. And sometimes that shoe recommendation is a temporary one, and sometimes a permanent one. We can use a shoe to help us get to a better/faster end point. After all, when we sprain an ankle sometime a brace or crutches are helpful and protective, of temporary value. A wisely chosen shoe can act the same if we are dealing with an acute achilles tendinopathy or a painful bunion for example. And in those cases we might recommend a shoe that can give us an assist. Sometime, when appropriate perhaps it is a shoe with a stronger medial post, perhaps one with a higher or lower heel drop/delta, or more or less stack height, or perhaps a mid/forefoot rocker built into the shoe. The truth is, people come in with functional or "fixed" pathology and sometimes pairing up a shoe to help us around some conflicting biomechanics can be temporarily, and sometimes permanently, helpful. But, the shoe is never the only answer, a wise clinician has many things they can utilize, all the way up the kinetic chain sometimes.
The more you know, the better you can assist someone.

Shawn Allen, one of the gait guys

#Nigg, #barefoot, #shoes, #stackheight, #heeldrop, #achillestendinitis, #bunion, #pronation, #supination, #running, #gait, #thegaitguys, #gaitanalysis, #gaitproblems, #gaitcompensation

Can the design of a running shoe help prevent injury? A B.C. researcher says he has the answer

Kelly Crowe · CBC News · Posted: Dec 15, 2018 9:00 AM ET

https://www.cbc.ca/news/health/running-shoe-injury-prevention-second-opinion-1.4947408?fbclid=IwAR3XaGPdgfQ68wj2N0tHqIamDdpYuxTIIL2LeudUd-doYN8YqQrIZI9-s9E

February 03, 2018

Neuromechanical adaptations in achilles tendinosis

February 03, 2018/ The Gait Guys

It is not just about the tendon. A perspective on asymmetry.

We are coming back to this important article again.
When you have a tendon problem, you have other problems. There is the muscle-tendon relationship, there is the CNS component, and there are the other muscles regionally within the related loaded chains. Because of these multiple integrated components, this "illustrates the human body's capacity to adapt to tendon pathology and provide the physiological basis for intervention or prevention strategies".
"If a component in the loop loses its integrity, the entire system has to adapt to that deficiency. "
We have discussed on recent TGG podcasts this important ability of a tendon to have sufficient stiffness, to be more precise, to produce sufficient stiffness. Degenerative tendons exhibit less stiffness and so when this issue is present, we move into the adaptive strategies of the entire system that was alluded to above. Adaptation begins; agonist, synergist, antagonist muscles, CNS, motor pattern adaptive patterns ensue.
It has been suggested by this study that these compensations are unilateral, on the affected side, thus driving asymmetrical neuromechanical adaptations.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553058/

October 29, 2016

Podcast 114: Pooping your pants

October 29, 2016/ The Gait Guys

This podcast is big on the neurology of motor control and movement, plus more on glutes and quads, runners diarrhea and lots of other good stuff. Join us today !

Show sponsors:
newbalancechicago.com
altrarunning.com

www.thegaitguys.com
That is our website, and it is all you need to remember. Everything you want, need and wish for is right there on the site.
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).

Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

* Podcast Links:

http://traffic.libsyn.com/thegaitguys/pod_114f.mp3

http://thegaitguys.libsyn.com/poop
_______________________________________
Show Notes:
Motor control and the immune system.
http://www.thegaitguys.com/thedailyblog/2016/9/12/motor-control-and-the-immune-system

The Exercise Drug is on its way.
http://qz.com/783958/scientists-have-created-a-drug-that-replicates-the-health-benefits-of-exercise/

http://www.cell.com/cell-reports/pdf/S2211-1247(16)31051-8.pdf

Glutes and Achilles.
http://www.thegaitguys.com/thedailyblog/2016/9/28/david-and-goliath-the-calf-and-the-glute

https://www.ncbi.nlm.nih.gov/pubmed/24121244

More glutes and quads
http://www.thegaitguys.com/thedailyblog/2016/10/5/who-rules-the-glutes-or-the-quads-well-it-is-complicated

Runners Diarrhea. What's up with that ?
Am Fam Physician. 1993 Sep 15;48(4):623-7.
Runner's diarrhea and other intestinal problems of athletes. Butcher JD1.

gut and zonulin full text link https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4589170/

2012 article here: http://www.karger.com/Article/Abstract/342169

September 28, 2016

David and Goliath: The calf and the glute.

September 28, 2016/ The Gait Guys

-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