The opposite upper and lower limbs model each other. Today we discuss adduction. See the photo.

Screen Shot 2019-04-10 at 2.17.04 PM.png

The opposite upper and lower limbs model each other. Today we discuss adduction. See the photo.

This is a discussion we had last March 11 and 12, 2019 on this photo. Today, lets look closer at the photo.

Runners, athletes . . . Even in your drills, do it correctly !
Last week we discussed this and its relation to the Bird Dog exercise. This is no where near the same pattern as Bird Dog, as we discussed, the Bird Dog is neurologically incorrect. Today, Adduction is the topic at hand.

This runner is performing a skill, a proper neurologic skill when it comes to patterning limbs the way we repeatedly move in walking, running, and often (but not always) sports. If you want to know why Bird Dog is an outlier neurologically, go back and find our post last week on the topic.

Today, look at the right knee, he has allowed it to adduct. We discussed why this is a lazy pattern, unless he has a purpose for not abducting the hip (possibly addressing something we are unaware of). Now look at the left arm, it too is adducted towards the midline. When left to its patterned and balanced based ways, the brain will use balance and patterning to model the limbs with their counterpart. This is the neurologic "shaping" we have discussed previously. The upper limb can help to shape the movement of the lower, but we know there is the opposite effect as well. We also know that the lower limb has a higher "leading" affect, it runs the show more. This is why we feel coaching arm swing is not the best way to go about changing someone's gait issues/form.

Try what he is doing, stand up and try it. You will see that the upper limb and lower limb better follow the modeling and shaping when they are both doing the same things (in this case, hip and shoulder flexion, and adduction). Now, keep the right thigh flexed and adducted, and ABduct the arm, you will find a subtle balance challenge and it will feel like there is a slight disassociation, because you have taken one limb away from the midline. Now, instead, adduct the left shoulder, but abduct the right thigh/hip. It is harder to do, again. Not leaps and bounds harder, but you had to think about it, because one limb is moving toward the midline and the other is not , all the while in a static balance position. Now yes, some will argue that this was not hard at all, and this kind of thing happens in sport all the time, agreed. Sometimes balance and proprioception (i.e. the vestibular system) trumps neurological patterning because of the hierarchy in the CNS. BUT don't miss our point, that there are underlying neurologic patterns and principles that dictate limb function when we are not paying attention to it. This is our point, and you will see it in your clients when they walk and run. And you see it in this guys case, because we would bet that he was not doing this left shoulder left hip adduction on purpose. He was doing it because it felt right, felt normal, felt balanced, and it is neurologically sound. But, he could do better, if he abducted the left arm and right hip, he be earning a more pattern as a runner. And, he would reduce the tendency of the cross over gait pattern, because, as you can see here, if that right foot heads to the ground, he is going to be very narrow step width in his gait, and that COULD mean potential problems and power leaks.
One more thing, do not be surprised that the right arm is abducting while it is extending, this is spin off of the adduction of the other limbs we discussed today. If he likely remedies them, the right arm will no longer abduction, likely.
And, these same concepts play out if you are adducting your arms across your body when walking or running, if the arm is pulling hard across the midline, do not be surprised if your step width is narrow. Hence, if you wish to run with more glutes and a wider more powerful gait, reduce the arm adduction and the legs will have to follow from the "shaping" influence of the arms.

The Cross Over Running Technique: A Quick Case Study

Walk on a piece of string or along a seam in the concrete or walk on the lane dividing lines on your local high school or college track. What happens ? If you walk on a single line you will find yourself more unstable as compared to walking with a foot fall directly under your hips and knees the way it is supposed to occur. The limbs are a pendulum and economy and biomechanical efficiency as well as injury reduction will occur when the parts operate in the most effective manner.

We have all of our cross over runners, as you see her doing in the first half of this video before she corrects to anti-cross over (ie. natural), first walk on a line. In our case we use the metal drainage grate outside our office that you see in the video for just that purpose, they walk the grate. Then they run the grate. We ask them to feel how unstable they are in the frontal plane walking the grate. Then we have them walk with their feet only touching the outer edges of the grate, now not crossing over. They can feel the difference, the increased stability. They all say it is easier to walk with the thighs, knees and feet all barely scuffing past one another but after they feel the other most will comment that they can see and feel how lazy their gait and running gait have become. They can feel the better posture, more gluteals and more power that an anti-cross over gait affords them. Then they run the grate again. Then they run the edges of the grate. You see this skill builder in the video above.

In this video clip, after 60 seconds of coaching, this top NCAA distance track athlete (often injured) was able to make the change immediately. You can see after just a few strides the immediate and dramatic change in her gait. We then had her drift back and forth between lazy cross over and the corrected anti-cross over gait. We do this so that on her long runs, when she notices the inside shoes scuff past one another, when they notice the feet begin to run on a line, when the thighs begin brushing past each other that she can immediately make the correction. It will happen often during the beginning stages of developing the new neurologic skill pattern. Motor pattern learning takes up to 12 weeks before the neuroplasticity becomes more worthy of the dominant pattern of choice.

We have all of our athletes head over to the oval track and run not in the lanes, but on the line. To be precise, they run with their feet on either side of the line, making sure they have that visual feedback for the correction. They run over the line. We drove past a local high school the other day and saw the entire girls cross country team on the track running not in the lanes, but over the lines. We smiled big, and long. We know the coach, he follows our stuff, and he will prevent so many injuries this year in his runners. They have a 15 minute pre-run warm up and skill building for their runners. They will be competitive at the State level once again because they will show up with everyone healthy and free of injury, we can only hope. They will have a better chance than others who keep doing what they did last year, and the year before that, and the year before that.

If you are doing what you did last year in your training, expect last years results.

Want to know more? Join Dr Allen this Wednesday evening on onlineCE.com, Biomechanics 316

Childhood Long Bone Torsions: Neurodevelopmental Considerations

Key Tag words:  torsions, gait, long bone torsions, femoral torsion, tibial torsion, neuromotor, neuroscience, locomotion, DNS, ambulation, walking, running, gait analysis, infant gait, childhood gait, jiu jitsu, crossover gait, cross over, vestibular, Parkinson's disease

We hit some good topics today, from childhood torsional issues, fix or leave alone ? What to look for when first observing and examining your client's gait plus Balance and vestibular function in gait and bike riding, exercise and neurodegenerative disorders and diseases and even developing proper neuromotor patterns, and inhibiting improper ones.
Plus we hit a favorite topic, the cross over gait and Ivo hits some highlights on gating inhibitory pathways.


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Show Notes:

Training out a crossover gait?

This gal came to see us with right-sided hamstring insertional pain. During gait analysis we noted that she has a crossover gait as seen in the first two sections of this video. In addition to making other changes both biomechanically (manipulation, gluteus medius exercises) and in her running style (“Rounding out her gait” and making her gait more “circular”, running with less impact on foot strike, extending her toes slightly in her shoes) she was told to run with her arms at her sides rather than across her body. You can see the results and the third part of this.

Because of her bilateral gluteus medius weakness that is seen with the dipping and lateral shift of the pelvis on the footstrike side, she moves her arms across her body to move her center of gravity over her feet.

Yes, there is much more work that needs to be done. This is one simple step in the entire process.

“When you run up a hill, most of the cross over gait disappears. Runners will tend toward beautifully stacked lower limb joints.”- Dr. AllenAre people running up a hill more likely to tend towards a cross over gait style, in other words tend toward …

“When you run up a hill, most of the cross over gait disappears. Runners will tend toward beautifully stacked lower limb joints.”- Dr. Allen

Are people running up a hill more likely to tend towards a cross over gait style, in other words tend toward a more narrow gait step or a wider gait step ?

Watch people run up hill closely. Even if they are cross over (narrow foot fall) runners, when running up hills a few things will negate much of the narrow foot fall.

1- Running up hill requires more gluteals, more power is needed for all that extra required hip extension to power up the hill. More gluteal max use can, and will, spill over into the posterior fibers of the gluteus medius and this will tend to abduct the leg/hip and reduce some of the cross over tendency.

2- When one runs up a hill, there is a forward pitch of the upper torso, often with a some degree of forward pitch occurring at the hips. More importantly, because one is running up hill, they are stepping up and so more than normal hip flexion is necessary than in normal running. The forward pitch of the body and the greater degree of hip flexion is the culprit here. If the hip/leg is adducted in a cross over style, adding this to a more than normal flexing hip, it will create a scenario for anterior hip impingement and risk of femoral acetabular impingement (FAI) syndromes. Go ahead, test it for yourself. Lie on your back and flex your hip, drawing your knee straight up towards your shoulder.  Pretty good range correct ?  Now, flex the hip drawing your knee towards your navel, adducting it a little across your body. Feel the abrupt range of motion loss and possible pinch in the front of the hip ?  FAI.  This is what would happen if you utilized a cross over gait, narrow foot strike gait. The goes for mountain/sleep hill hikers as well. 

This is why, if you are a narrow foot striker, a near-cross over type of runner, you will see it disappear when you run up hills.  

If you get anterior hip pain running up hills, force a wider step width and reduce the possible impingement at the anterior hip joint. Just make sure you have enough ankle dorsiflexion to tackle the hill in the first place. If not, you may welcome some foot and ankle stuff to the table along with the hip.  

Likely obvious stuff to most of the readers here, but sometimes it is nice to point out the obvious.  Hills, just because they are there, doesn’t mean you have the parts to run them safely.

Dr. Shawn Allen

Podcast 82: Phasic vs Antiphasic Gait, Cross Over Gait & more.

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Show notes:

 
Blog posts we reviewed:
 

Muscle Activity Differences in Forefoot and Rearfoot Strikers
http://www.runresearchjunkie.com/muscle-activity-differences-in-forefoot-and-rearfoot-strikers/

www.runnersworld.com/injury-treatment/forward-lean-while-running-might-reduce-knee-pain?cid=social33696857

Weight-Bearing Ankle Dorsiflexion Range of Motion—Can Side-to-Side Symmetry Be Assumed?
http://www.natajournals.com/doi/abs/10.4085/1062-6050-49.3.40

extras for this piece:

and you can use this to substantiate it: http://www.ncbi.nlm.nih.gov/pubmed/23997389

Effect of step width manipulation on tibial stress during running. J Biomech. 2014 Aug 22;47(11):2738-44. doi: 10.1016/j.jbiomech.2014.04.047. Epub 2014 May 21.

Hip muscles and postural control related to ankle function.

Hip exercises boost postural control in individuals with ankle instability
http://lermagazine.com/news/in-the-moment-sports-medicine/hip-exercises-boost-postural-control-in-individuals-with-ankle-instability

-“Four weeks of hip external rotator and abductor strengthening significantly improves postural control in patients with functional ankle instability (FAI) and may be useful for preventing recurrent instability, according to research from Indiana University in Bloom­ington.”

Nothing new here, at least not here on The Gait Guys blog. We have been talking about these kinds of issues for a long time. We  have long discussed the necessary control of the glutes (and their anchoring abdominals) to eccentrically control the loading response during the stance phase of gait, we especially like to discuss the control of the rate of internal rotation (read: eccentric ability of external rotators as a component) of the leg with the glutes. It is why we think it is so important to eccentrically test the glutes and the core stabilizers (all of them !) when the client is table assessed because it is a huge window for us as to what is happening when there is ground interface. Sure one is open chain and the other is closed, but function is necessary in both. 
What this article is again, like others, telling us is that the ability to stack the joints (knee over foot, hip over knee, level stable pelvis over hip) improves postural control, especially when there is a risky environment of ankle functional or anatomical instability. 
And yes, we are talking Cross over gait and frontal plane challenges and faulty patterns here.  Failure to stack the joints usually leads to cross over gait challenges (type in “cross over or cross over gait into our blog SEARCH box). Remember though, you must selectively strengthen the weak muscles and weak motor patterns, if you are not specific you can easily strengthen the neuro-protective tight muscles and their patterns because they have been the only available patterns to your client. If you are not careful, you will help them strategize and compensate deeper, which in itself can lead to injury.  This is a paramount rehab principle, merely activating what appears weak does not mean you are carrying them over to a functional pattern. Just because you can show a change on the table doesn’t mean it carries over to the ground and sport or training. 
Shawn and Ivo, the gait guys
Can you see it?
Here we are again. We have looked at this picture before; once about head tilt, and another about flip flops and form.
Take a good look at this picture and what is different about the child in blue all the way to the right and all th…

Can you see it?

Here we are again. We have looked at this picture before; once about head tilt, and another about flip flops and form.

Take a good look at this picture and what is different about the child in blue all the way to the right and all the others with the exception of the boy in pink, that we really cannot see?

Can you see it? No, we don’t mean the flip flops (but if you caught that all the boys were in sneakers and all the girls are in flip flops, you are good!)

How about looking at arm swing? Remember this post on arm swing and crossover gait, with the simple cue for correction? All of the children EXCEPT the boy in blue, are drawing their arms ACROSS their body (ie: flexion, internal rotation and adduction). Take a look at their legs. Yep, crossover gait (flexion, internal rotation and adduction). Little boy blues arms are going relatively straight and going in the saggital plane, where the others are going in the coronal plane.

We are not saying that blue does not have some gait challenges, like his torso shift to the left (or pelvic drift to the right), most likely do to gluteus medius weakness or inappropriate firing of the gluteus medius on the left stance phase leg; or his head tilt to the right, which most likely represents a compensation for the right pelvic drift and left body lean.

Arm swing. A very important clue to the puzzle we call gait and compensation. It is more prevalent than you think, and, in some cases, easily corrected with a simple cue.

The Gait Guys. Making it real and pertinent, in each and every post.

Correcting a cross over gait with arm swing? Is it really THAT easy? Sometimes, yes!

We noticed this patient had a cross over gait while running (1st few seconds of video. need to know more about crossover gait? click here). We noted she was crossing her arms over her body as well. We than had her run her hands and arms straight out. See the crossover disappear? Need to know more about arm swing? click here

We the had her do the same while walking. Easier to see, eh? That’s because it is often easier to “fudge” things when you are moving faster (ie: the basal ganglia of nervous system can interpolate where the body part is supposed to be, and because of momentum, there is less need for precision). When we do things slowly (like the 3 second Test), more precision is needed. Watch this short video clip a few more times.

The arms are essentially adducting when the arms cross over. The arms are reciprocally paired with the contralateral lower extremity. When you make a change in one, you often will make a change in the other.

Subtle. Yes. Easier to see when the task becomes more difficult. Yes. Pay attention, the answer is often right there if you look closely enough.

Providing the clues to help you be smarter, better, faster, stronger; we are The Gait Guys

special thanks to “Q” for allowing us to publish this video : )

Saucony: Line Running and Crossing Over
We are big fans of the Saucony line of shoes. We have recommended them to our novice and serious runners for decades now. Currently one of our favorite shoes for our runners is the Saucony Mirage, a beautiful …

Saucony: Line Running and Crossing Over

We are big fans of the Saucony line of shoes. We have recommended them to our novice and serious runners for decades now. Currently one of our favorite shoes for our runners is the Saucony Mirage, a beautiful 4mm ramp shoe with no bells and whistles.  It is as close to a perfect zero drop that  you will find without going zero, in our opinion.  That is not to say there are not other great 4mm shoes out there, the Brooks Cadence and the New balance minimus are other beautiful 4mm’s out there.  The Mirage has never failed a single client of ours.  

This was a photo we screen captured from the Saucony Facebook page (we hope that for the sake of educating all runners and athletes that we can borrow this picture for this blog post, please contact us if you would like us to remove it). It is a good page, you should follow it as well.  This picture shows not only a nice shoe but something that we have been talking about forever.  The cross over; this runner is running in such a line that it could be argued that the feet are crossing the mid line. In this case, is the line queuing the runner to strike the line ? Careful of subconscious queues when you run, lines are like targets for the eyes and brain.  One thing we like to do with our runners is to use the line as training however, a form of behavioral modification.  When you do a track workout, use the line underneath you, but keep the feet on either side of the line so that you learn to create that little bit of limb /hip abduction that helps to facilitate the hip abductor muscles.  This will do several things, (and you can do a search here on our blog for all these things), it will reduce the reflexive tightening of the ITBand (pay attention all you chronic IT band foam rolling addicts !), it will facilitate less frontal plane pelvis sway, optimal stacking of the lower limb joints, cleaner patellofemoral tracking and help to reduce excessive pronation /internal limb spin effects.  

There is really nothing negative about correcting your cross over, IF it truly needs correcting.  That is the key question.  Some people may have anatomic reasons as to why the cross over is their norm, but you have to know  your anatomy, biomechanics and neuromechanics and bring them together into a competent clinical examination to know when the correction will lead to optimal gait and when it will drive suboptimal gait. Just because you see it and think it is bad, does not make it so.  

New to this cross over stuff ? Head over to the search box here on our blog and type in “cross over” or “cross over gait” and you will find dozens of articles and some great videos we have done to help you better grasp it. 

* you will also note that this runner is in an excessive lateral forefoot strike posturing.  This means that excessive and abrupt prontation will have to follow through the mid-forefoot in order to get the medial foot tripod down and engaged.  The question is however, is what you are seeing a product of the steep limb angle from the cross over, or does this runner have a forefoot varus (functional or anatomic, rigid or flexible)?  Are the peronei muscles weak, making pre-contact foot/ankle eversion less than optimal ? This is an important point, and your clinical examination will define that right away … . . if you know what these things are.  And if you don’t ? Well, you have found the right blog, one with a SEARCH box. Type in “forefoot varus”, if you want to open up the rabbit hole and climb down it … . . we dare ya ! :-)

The Cross Over Gait
Did you miss our teleseminar presentation on this topic last night on www.onlinece.com ?
Here is a sample of one of our slides.  The cross over gait is potentially a real problem for some. The question is always, how much cross o…

The Cross Over Gait

Did you miss our teleseminar presentation on this topic last night on www.onlinece.com ?

Here is a sample of one of our slides.  The cross over gait is potentially a real problem for some. The question is always, how much cross over (running or walking) is too much for a client ? When does it need corrected ? Does it need corrected ? Leave it alone ?  We answered these hard questions in our teleseminar.  

Lucky for you www.onlineCE.com recorded it so you can take the class anytime !  (just give them a few days to process the recording). 

As you can see from just this slide here, we looked at many aspects of the cross over. But we also discussed STEP WIDTH, lateral compartment weakness and tightness as coexisting pathology, and so much more.  Stay tuned, we will be recording this program into an extended and more in depth course for you all in a video format with course notes and more and then have it for you on our Payloadz website (which you can access here for our present offerings).

In the mean time, consider looking for these “Big 6” and when you see them co-existing you might want to look for a cross over pattern in your client, it just might be there sometimes.

- weak gluteus medius

- weak TVA and obliques

- weak adductors

- weak medial quadriceps

- weak tibialis posterior

- excessive foot pronation

Shawn and Ivo, The Gait Guys

Take a look at this gal.
Why does she have a cross over gait?
note how much tibial varum she has (curvature of the tibial in the coronal plane)
how much adduction of the right foot there is, potentially indicating a tight posterior compartment, or p…

Take a look at this gal.

Why does she have a cross over gait?

  • note how much tibial varum she has (curvature of the tibial in the coronal plane)
  • how much adduction of the right foot there is, potentially indicating a tight posterior compartment, or perhaps a loss of internal rotation of the right thigh
  • the excessive posterior rotation of the left shoulder and upper body
  • the subtle abduction of the right arm compared to the left
  • the slight torso lean to the left

The correct answer is we don’t know until we examine her. Maybe is is there out of necessity or perhaps it is a more efficient running style for her. Here are some points:

Technical Issues with the crossover gait

The cross over gait may be:

  • a more efficient running style
  • a potential pathologic musculoskeletal motor pattern
  • better for long distance runners
  • a challenge to balance because of a narrower base of support

It may also be related to:

  • a weak gluteus medius
  • weak adductors
  • excessive foot pronation
  • lower extremity morpholgy (like tibial varum, forefoot varus)
  • a weak vastus medialis
  • a weak tibialis posterior
  • and the list goes on

Join us, tomorrow, Wednesday evening, 8pm EST, 7 CST, 6 MST, 5PCT for an hour of crossover gait on chirocredit.com or onlinece.com for Biomechanics 316. We look forward to seeing you there..

The Gait Guys: Shawn and Ivo

Look at these kids running …  all but one shows poor form, but remember, these kids are still undergoing neurodevelopment and are learning to control their body parts. Remember, the maturation/myelination of the nervous system usually lags be…

Look at these kids running …  all but one shows poor form, but remember, these kids are still undergoing neurodevelopment and are learning to control their body parts. Remember, the maturation/myelination of the nervous system usually lags behind the development of the musculoskeletal system. 

In the photo, lets first focus on the happy lad in the green shirt. He sure looks like he is having fun, which is what running should be about in kids. If you try to make running a chore for kids you just might lose their love of it in the process. But our point here at The Gait Guys is to teach. So here in this photo are some good teaching points. You should see:

1- the stance phase leg (right leg) is spun out into external rotation. Not too much of a big deal because we do not know if he has finished the normal derotation process of the limb, sometimes this can carry into the puberty years even though for most kids the process is largely completed by his predicted age.

2- The pelvis has drifted laterally in the frontal plane past a perpendicular line up from his foot. This could mean alot of things including gluteus medius or abdominal weakness but the point here is that he has broken through the lateral line (frontal plane) of support up through the hip-pelvis-core chain. This is going to set up what the the left knee (swing leg) is doing and will set up #3.

3. Cross over gait is virtually guaranteed because of the lateral pelvis drift as noted in #2. It is virtually guaranteed as well because the swlng leg knee coming inwards is dictating it. IF the knee is coming inwards toward the midline the thing attached to it , the foot, is going to follow. The swing leg is a pendulum, if you shift the pivot point of the pendulum (in this case to his right) the pendulum will swing to the right. This is a self-perpetuating cycle and it will not correct without strengthening, awareness and drilling positive feedback changes.

4. Dr. Allen’s current thought experiment on Ballasts (see podcast 38) is playing out here with the left arm of this fella. If the pelvis drifts far to the right, the arm will move away from the body to move some of the left side body weight outwards to negate the right shift. This is pure balance physics.  Arm swing most of the time cannot be corrected without correcting the thing that causes the aberrant arm swing, and that is often (but not exclusively) aberrant lower limb and pelvis-hip-core or foot mechanics. There are exceptions, but often if you fix the lower limb and pelvis-hip mechanics  you will see an immediate change in the arm swing. If you force changes in arm swing without fixing the problem (and that is not to say there are not local arm swing etiologies) you may be  driving strength into a compensation pattern that you may not want or like.

5. The girl in the pink tights  … . she might have been modelling the boy in the green shirt. Same issues, same concerns.

6. The form we love the most ? The boy in the dark blue shirt and black shorts on the far right. Great form, no major issues here. We bet he didn’t hear the starters gun go off.

On a side note, the fella in the green shirt with that form he would be a champion race walker. He already has the hip action right, the cross over that is loved in that sport and the arm swing.  Maybe some exposure to an alternate sport is a better solution here ? Although we are always an advocate for correcting flawed biomechanics.

It is often painful for us to watch kids run. We know that much of the things we hate are temporary because of the neuro-developmental process. But sometimes, if kids run too much at a young age, and are pressed into long running miles or cross country at too young an age, these aberrant mechanics can become their new norm. This is the danger of plasticity in the nervous system. Repeated stimulation of a pattern engrains that pattern and the extent of a brain’s plasticity is dependent on the stage of neuro-development and the brain region affected.  When an aberrant running form is allowed to perpetuate into the mid-teenage years, when the majority of the synapses are already formed and neurologic “pruning” and myelination are ramping up, then the repeated exposure to the aberrant pattern can get the myelination. This is the most frustrating thing for us. We would rather see some intervention early on with the creation, strengthening and myelinating of correct motor patterns through skill development training rather than mileage training, rather than discarding the more appropriate synapses that could have, might have, should have, been formed. Our bodies and brain will develop depending on the exposures and demands put upon it. And here is the big key, if you do not clean up someone’s gait aberrancy(s) early on, one should not wonder down the road why they developed flat feet, bunions, early degenerative knees and the like. This is a fairly predictable machine, but you have to try to intervene early to prevent the slings and arrows of outrageous misfortune later on.

Both the brain and the body will adapt to their environment, whether that is an optimal one or a compensatory one. It can myelinate either pathway. Which one will you choose for your kids ?

Shawn and Ivo, The Gait Guys

Do you kick or scrape the inside of your ankle with the other foot ?
We are moving into the final throws of cross country season now and we are seeing the pathologies creep in and the miles go up. Some of you who have been with us for 3 years  have …

Do you kick or scrape the inside of your ankle with the other foot ?

We are moving into the final throws of cross country season now and we are seeing the pathologies creep in and the miles go up. Some of you who have been with us for 3 years  have seen this picture but we realized we did not have a blog post on the problem represented by this photo.  This young runner had these scuff marks on the inside of the right lower leg and ankle after a cross country meet.  So what is going on here and what does it tell you ?

Some runners notice that they repeatedly will scuff in the inside ankle or inner calf with the opposite shoe when running. This can happen on both sides but it is more often present unilaterally than bilaterally. 

This problem, typically, but not always represents one of two things:

1- cross over gait (if you are new to our blog in the SEARCH box type in “cross over” and “cross over gait” and be sure to see our 3 part video on the cross over on our youtube channel found here).

2- negative foot progression angle which may or may not be combined with a degree of internal tibial torsion.  Said easier, the runner is “in-toed” or “pigeon toed” but if you have been here with us awhile on The Gait Guys we expect a diagnosis of a higher order so use the former terms, please.

Lets discuss both.

1- Cross over.  When the runner is standing on the right leg, right stance phase of gait, the frontal plane is not properly engaged and the pelvis can drift further over the right foot. This drift to the right will drop the pelvis on the left side. This will alter the pendulum movement of the left leg. Since the global pelvis is moving to the right the left swing leg pendulum moves to the right as well and as it swings past the stance leg it strikes a glancing blow to the inside of the right ankle or calf. This is simple biomechanics and physics. To fix this problem, which is clearly inefficient, one has to determine what is causing the right pelvis drift (there are many causes, the most often thought of cause is a weak gluteus medius on the right but if you have been here with us awhile you will know there are other causes) and then fix the drift. Do not assume it is the gluteus medius all the time, for if it is not, and you employ more glute medius exercises you could be ignoring the source and building a deeper compensation pattern.  Fix the problem, not what you see.

2- Negative foot progression angle and/or internal tibial torsion.  In order to fix this you have to know first if you are dealing with a fixed/rigid anatomic tibial or femoral torsion issue which cannot be fixed or if you are dealing with a flexible progression angle issue. Often, “in-toeing” is accompanied with internal tibial torsion, this is because the knee has to progress forward to keep its tracking mechanics clean, if you correct someone’s foot progression back to neutral and they have internal tibial torsion then you have dragged the patellar tracking outside the normal sagittal progression angle, knee pain will ensue. In fact, the foot progression on the ankle is normal, but the tibia or femur are merely torsioned in a manner that drags the foot inwards with the long bone orientation, again, this is driven by a higher order/demand, to normally track the patella sagittally (forward).  However, if this is a pre-puberty individual you have time because the long bone derotation process is still occuring. Give homework to encourage a good foot tripod and work to strengthen the external hip rotators and encourage sagittal knee tracking mechanics. This is a delicate balancing act, but it can be done, but it is a monster of a project for a blog post because each case is different, variable and always changing depending on the client progress. Remember, you can only encourage more appropriate mechanics and hope that the body will embrace some of the change and encourage some of the de-rotation process to occur from the long bone growth plates. 

The “inside scuff”, to identify its solution you have to know the cause. After all, if it was as easy a fix as “stop doing that” no one would be doing it and we would be out of a job.

Shawn and Ivo …… The Gait Guys 

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Approaching joint assessment from the perspective of “cylinders”.

Our approach to every joint assessment has long been to visualize and assess the joint(s) as a cylinder since the body parts are cylindrical in form. This has been our approach, and they way we teach, for many years. At each number on the clock (cylinder) there is a theoretical muscle that provides stability to the joint in that vector during loading. The most accurate assessment would be one that investigates the ability of each muscle around the clock (cylinder) to see if it has sufficient S.E.S. (Skill, Endurance, Strength) as well as how well that muscle(s) participates with the synergists, antagonists and agonists (ie. motor patterns for stability and mobility).  We do this at each joint along the kinetic chain when assessing someone with a clinical or functional problem.  

When dealing with a frontal plane drift, as in the 3rd photo above where you see the person’s (black shorts) pelvis drift laterally outside the perpendicular foot line, one could naturally assume that the gluteus medius is weak (9 o'clock) but the wise clinician would also look at the other side of that cylinder to see if the adductors were involved (3 o'clock) since that is 180 degrees through the joint axis.  (Note: Runners are sagittal athletes so frontal plane weaknesses are often seen. This is not desirable however, this is a perfect example why runners should cross train more into lateral and angular sports to ensure that the sagittal plane does not dominate.) Obviously the foot and the knee also need a similar cylindrical assessment approach. We have spoken loudly many times  here and on our podcasts over the years that quite often there are multiple flaws in a presentation, typically a focal cause and one if not several compensations as a functional adaptation strategy around that central flaw. In this runner’s case there could be medial knee weakness or foot weaknesses that are affording too much medial drift and spin of the limb resulting in the lateral pelvic drift compensation.  But, just because the gluteus medius shows up weak does not mean that it is the focal point of clinical intervention. If one facilitates the gluteus medius and does not address the causative lower cylinder issues then they are quite possibly empowering the compensation and enabling the aberrant activity to continue. Knowingly or unknowingly layering armor or inappropriate strength to a pathologic compensation pattern at a focal joint level that is not the focal cause should be a clinical crime, but it is done every day by people who do not know better even though their efforts are well intended.

Ok, we got on a bit of a soap box rant there, sorry. Back to the case at hand.  

Your assessment should not stop at the frontal plane in this case. If there is an imbalance in the sagittal plane in this sagittal athlete this can be a causative problem as well, which is why the cylinder approach should not stop at the frontal plane or when you find that first major weakness. In frontal pelvic drift cases, there is quite often an anterior pelvic tilt where the lower abdominals can be weak, the low back is slightly extended and the paraspinals are more active. This is the classic “impaired hip extension pattern” and sets up a Janda/Lewitt style “Layered Syndrome”. Most of the time, resolving this sagittal flaw will show immediate improvement of the frontal plane deficits.  But, do not think it is as simple as re-facilitating these 2 patterns. Remember, neuromotor reprogramming and patterning takes 8-12 weeks by some sources. And remember, the initial strength gains in the first few weeks are from neuroadaptation (ie, skill gains in coordination), these gains are not the true physiological endurance and strength gains that we desire for an athlete.  Those gains take time but they are the ones that we need for sport performance and joint power.

And then there is the rotational or axial component, which we did not even begin to discuss here. We have briefly talked about the frontal and sagittal cylinder aspects, and yes, we have just skimmed the surface as there are multiple patterns and issues which we have had to leave out here so that this doesn’t turn into a full fledged chapter for our next book. This stuff gets complicated and can leave you running in mental circles at times.  But these concepts will help you better understand why you often see neuro-protective tightness 180 degrees on the other side of the cylinder from tightness, and when you address the weakness the other side of the cylinder some of that neuro-protective tone is eased.  But again, it is not nearly this simple because you must remember that if your assessment is static or on a table then your findings will be functionally imprecise.  And, not stopping there, there are multiple joints below the joint you are focusing on, and multiple joint complexes above as well. Plus, there are 3 other limbs that can play into the function and dysfunction of a given limb and its joints. There are breathing patterns, postural patterns and many other issues. This is not an easy game to play, let alone play it well or wisely for your athlete.

In today’s photos we wanted to show you 3 runners. One a distance runner with good joint stacking and one sprinter with amazing joint stacking.  And then the runner in the black shorts, who cannot stack the foot, knee or hips even remotely well.  This runner in the back shorts will have the cross over gait and likely have the medial ankle scuff marks to prove it. But remember, there is one component that we often talk about, one we did not discuss here … . . are there also torsional issues in this runner ? Do they have femoral or tibial torsion(s) ? What is their foot type ? Are they in the right shoe for their foot type ? Are some of these components playing into their visibly flawed mechanics ? 

Below is an article we have put up here on the blog previously.  It is a study where the investigators examined hip abductor strength (watch this video here ) in distance runners with iliotibial band syndrome comparing injured limb strength to the unaffected limb to determine whether correction of the strength deficits in the HAM’s (hip abductor muscles) correlates with successful outcomes.  The study showed the obvious, that runners with ITBS have weaker HAM strength compared to the asymptomatic leg.  

But here is our question, did they just strengthen the compensation for an apparently successful outcome, or did they address the problem ? Only time will tell if you actually fixed something or merely enabled the dysfunctional motor pattern by layering it with more armor for the next battle. If it is fixed the problem and all of its associated problems should go away. But if the runner comes back weeks later with knee complaints, foot pain, back pain or the like … . . then the message should be loud and clear.

Shawn and Ivo, The Gait Guys……today with soap on the bottom of our feet.

References:

Clin J Sport Med. 2000 Jul;10(3):169-75. Hip abductor weakness in distance runners with iliotibial band syndrome. Fredericson MCookingham CLChaudhari AMDowdell BCOestreicher N,Sahrmann SADepartment of Functional Restoration, Stanford University, California 94305-5105, USA.

Too much potential gait pathology all in one sport ? Racewalking … . 
Do not underestimate this title, you may learn more about normal running form from today’s blog post than you think.
 
For the best clips start watching at the 4:15 mark. 
The sport of race walking is an interesting one to say the least.  We had the pleasure for years of treating and working closely with one of our countries best race walkers and she taught me so much, not only about the sport but about the strange mechanics of the sport and the functional pathologies the sport drives from its unique requirements driving abnormal gait mechanics on each step.
Racewalking is a long-distance event requiring one foot to be in contact with the ground at all times (and a couple of other unique and wacky rules that we will discuss in a moment). Stride length is thus reduced and so to achieve competitive speeds racewalkers must attain cadence rates comparable to those achieved by Olympic 800-meter runners for hours at a time. Most people cannot truly appreciate how fast these folks are going, most folks will have to move into at the very least a gentle run to keep up with these folks.
 

There are really only two rules that govern racewalking:

1-The first rules states that the athlete’s trailing foot’s toe cannot leave the ground until the heel of the leading foot has created contact. The rule violation is known as "loss of contact". 

2-The second rule specifies that the supporting leg must straighten, essentially meaning knee extension (and for some, terminal extension, ie. negative 5-10 degrees !) from the point of contact with the ground and remain straightened until the body passes directly over it. Again, essentially meaning full range knee extension for the entire stance phase of gait (early, mid and late midstance phases). For those who do not study the details of gait, this may not seem like a huge issue, but it is because full lockout really never occurs in either walking or running.  And there is nothing like impacting a joint in full extension lock and heavy heel strike to take away all of the natural shock absorbing mechanisms of the lower limb. (watch the video at the 4:30 mark, Dang ! the dude in the red looks like his knees are going to fold backward there is so my knee extension !) There is some great slow motion technique breakdown at the 6:28 minute mark of the video. 

In getting around these 2 major rules:

- the hips must rotate a tremendous amount, with full pelvis rotation, to prevent the frontal plane pelvis motion which would be a loss of sagittal power. This produces the visually painful waddle that is classic to the sport.

- the arms are used aggressively to generate power and to help the lower limbs move through the cycle because of the unnaturally apropulsive nature of the overall technique. The arms also often move excessively into the frontal plane since they mirror the lower limb

- excessive lateral heel strike quite often ensues help keep the knee extended and in an attempt to keep the foot on the ground longer, to avoid getting red carded. 

- there is plenty of cross over gait and severe lack of ankle dorsiflexion for everyone to observe, both of these components combined with the above characteristics give the “Close to the ground” appearance that is attempted by all racewalkers.

- want to see some seriously gut wrenching biomechanics, forward the video to the 7:55 mark. Tell us that won’t cause problems down the road !

Breaking the Rules:

The rules are entirely subjective and enforced by real-time human eye (not video) judges along the course (3 red card violations render an event disqualification). Interestingly, and we have seen this first hand, athletes quite regularly lose contact (meaning initiating a float phase, which is what dictates the difference between running and racewalking) for a few milliseconds per stride.  This float can be detected on film/video which can be caught on film, but such a short flight phase is said to be undetectable to the human eye. Disqualifications (losing contact or bent knee) are routine at the elite level as evidenced by the famous 2000 Summer Olympic case of Jane Saville who was disqualified on her way to a gold medal.

Racewalking … .  a highly technical sport, more so than running.  If you ever get a chance to see someone do this sport first hand, it is truly engaging to a gait geek. Lots of eye candy, gait geek eye candy that is !

Shawn and Ivo… … the gait guys. 

More proof for the Cross Over Gait for the non-believers and debaters.

For those of you who have been with us for a few years, you are no stranger to our articles and videos on the web for piecing together many aspects of the CROSS OVER GAIT in a manner more comprehensive and more clear.  If you are not familiar with our work on this, please click here.

Today we add a little more “proof to our pudding”.

“Changing step width alters lower extremity biomechanics during running.” Brindle et al.
http://www.gaitposture.com/article/S0966-6362(13)00291-9/abstract

  • Step width influences frontal plane biomechanics of all body parts
  • Changes in step width affects arm swing symmetry and often creates arm abduction
  • Hip and knee biomechanics change from their normal predicted path and mechanics
  • Hip adduction, rearfoot eversion and internal tibial spin decrease as step width increases
  • Knee adduction/valgus stress decreases as step width increased.
  • Increased step width improves cephalad stacking of all lower extremity joints
  • The swing limb is a hinging pendulum. Striving for a level pelvis and normal step width promotes a normal sagittal pendulum path and improves the likelihood of a recurring sagittal pendulum swing for the opposite leg. 

As Brinkle et al. say in their paper, “step width is a spatiotemporal parameter that may influence lower extremity biomechanics at the hip and knee joint.”  We would argue that it is even more far reaching than the hip and knee. You have likely learned here at the Gait Guys that arm swing is heavily predicated on the dynamics of contralateral leg function and positioning.

The above video shows a classic cross over gait. The limbs can be seen crossing over the midline thus guaranteeing that the pendulum is moving through an arc and not along a straighter progression. This adduction of the limb virtually guarantees that the foot is striking greater on the lateral heel and forefoot than it should, that the rear foot is going to move through eversion with greater speed and force and internal tibial spin and arch control will need to be controlled better.  And if they are not controlled better, pathology may eventually occur.  Do you want any of this to occur at an accelerated rate as occurs in running ? One doesn’t need to just heel strike to suffer these problems, midfoot strike will still see them if the cross over occurs.

Shawn and Ivo, the Cross Over Guys.

More Proof that the Cross Over Gait has Pathologic Issues for Runners / Athletes.

We have referenced below yet another article in our 2 year long soap box rant that the cross over gait has many negatives to it.  Two weeks ago we discussed the issues in greater depth in podcast # 23 (link: http://thegaitguys.tumblr.com/post/43424418001/podcast-23-neurology-of-walking-babies-dialogues-on) and further in a most recent blog post here (link: http://thegaitguys.tumblr.com/post/44060333371/step-width-alters-iliotibial-band-strain-during).

By this point pretty much everyone should be aware that pelvis width and femoral shaft angle orientation (Q-angle) parlays consistently into knee posturing and thus patellar tracking.  Loosely it goes to say a wider pelvis often makes for a knee tracking challenged environment.  But today’s reference article takes this a little deeper.

Running mechanics always have to be approached from above the knee and below. If the foot collapses too far inwards the internal spin put on the tibia will drag the knee inwards and generate a mal-tracking environment.  And from above, if the gluteal muscles are underperforming they cannot assist in holding the femur in sufficient abduction and external rotation to prevent excessive internal spin from above, thus also enabling a mal-tracking environment from developing.  These are well established theories with plenty of research and years to back them up.  The verbiage “proximal control for distal control” holds. Or, “proximal stability for (proper) distal mobility” also holds true but one needs to never forget about the critical importance of the far distal (foot/ankle) foundational support. 

In today’s study from 2012 there is really nothing earth shatterning to most of our readers but we wanted to again bring these thoughts are results to you and keep the cross over gait in your ever-present mind.  The conclusions of this Harvard study were predictable, that being:

“the finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross sectional studies. These results suggest that runners who develop PFP utilize a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.”

So the study eludes to the fact that not only is it about the anatomy of the parts but also about the functional control of the parts. Without adequate control from above and support from below the knee, it will be difficult to control a largely uni-planar joint (the sagittal flexion/extension of the knee hinge) when the support of a multi-planar joint complex (foot/ankle) from below is insufficient and the control of a multi-planar joint complex above the knee (hip/pelvis) is insufficient.  When one or especially both are compromised the knee will be compromised. It may take weeks or months or even longer for the process to render joint change or pain but without sufficient biomechanics the system is likely to fail. And further more, one needs to realize that shoes and orthotics often are an incomplete (and very often an insufficient and inadequate) remedy.  One must “earn it to own it”. 

If you find you are new to our work and want to catch up on the Cross Over gait topics we have covered previously, try starting here (link: http://thegaitguys.tumblr.com/search/cross+over) and here (link: http://thegaitguys.tumblr.com/search/cross+over+gait).  We are likely to continue to build on this disfunctional paradigm.

Shawn and Ivo
The Gait Guys

Reference:
Med Sci Sports Exerc. 2012 Dec 27. [Epub ahead of print] Prospective Evidence for a Hip Etiology in Patellofemoral Pain. Noehren B, Hamill J, Davis I. Source

1Division of Physical Therapy, University of Kentucky, Lexington, KY 2Department of Exercise Science, University of Massachusetts, Amherst, MA 3Spaulding National Running Center, Harvard University, Cambridge, MA.

Abstract PURPOSE:

Patellofemoral pain (PFP) is the leading cause of knee pain in runners. Proximal and distal running mechanics have been linked to the development of PFP. However, the lack of prospective studies limits establishing a causal relationship of these mechanics to PFP. The purpose of this study was to prospectively compare running mechanics in a group of female runners who went on to develop PFP compared to healthy controls. It was hypothesized that runners who go on to develop PFP would exhibit greater hip adduction, hip internal rotation, and greater rear foot eversion.

CONCLUSIONS:

The finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross sectional studies. These results suggest that runners who develop PFP utilize a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.

Step width alters iliotibial band strain during running.

More substantiation that “the cross over gait” is a pathologic process.

Did you get to hear podcast #23 yet ?  Here is the link (iTunes).  In podcast #23 we talked at length about the effects of step width in runners.  Reducing ones step width will result in a progression into what we have been referring to for years as “the cross over gait”.  We have been reducing this phenomenon in our runners, and many walkers, for over a decade now to reduce many of the lower limb pathologic processes that ensue when the cross over is left unchecked and worse yet, strength and endurance is loaded upon the faulty pattern.  Everyone’s gait in this realm will differ because of pelvis width, femoral and tibial torsion, genu posturing (knee valgum, varum)  and foot structure and type. All of these factors must be taken into account when deciding upon the degree of step width correction.  Ultimately the goal in a perfect world would be to have the foot and knee stack pristinely under the centrated hip joint proper, but we all know that ideal biomechanics are the unicorn when it comes to humans. Anatomic variation is the known norm and this must not be forgotten, this was pounded into all of our heads in medical school.
As this article from the Nov 2012 J. of Sports Biomechanics clearly states, iliotibial band strain and strain rate is significantly greater in narrow based gait scenarios and that increasing step width during running, particularly in those who tend towards the lazier narrower step width, may be beneficial in not only the treatment but the prevention of future lateral hip and knee biomechanical syndromes such as IT band syndrome.  So, if you are a slave to your foam roller and need your IT band foam roller fix daily, you might want to look a little deeper at your biomechanics and make some changes.  Our videos here will be helpful to you and our writings on the Cross Over gait  and link here will be helpful as well.
In  summary, there is just so much more to good running form than just following the mantra “let my feet fall under my body mass and everything will be just fine”.  We wish it was this easy, but it is not. Unfortunately, too many of the sources on the internet are maintaining that good running form is mostly just that simple. Sadly, we find it our mission to bring the bitter tasting truth to the web when it comes to these things.  One just cannot ignore the factors of pelvis
width, femoral and tibial version and torsion, genu posturing (knee valgum, varum) and foot structure and foot type (and we mean so much more than are you a pronator or supinator).  These factors will alter lower limb biomechanics and may drive even the runner with heightened awareness of foot strike and running form into less than optimal foot strike positioning and loading response. Furthermore, one needs to be acutely aware that merely taking the cooked down under-toned postulation of this journal article, that being increasing step width will resolve their IT band problems, may not resolve their problem. In fact, without taking the issues of pelvis width, torsion, version, foot type and the like into account, making these changes could bring about more problems.  Seeking the advise of a knowledgeable physician in this complicated field of human locomotion is paramount to solve your chronic issues.
There is more to clean running than just a
midfoot-forefoot strike under the body mass, a good forward lean and high cadence. And we are here to bring those other issues to light, for the sake of every injured and frustrated runner.  Remember, uninjured does not always mean efficient. And efficient does not always mean uninjured.

Shawn and Ivo, The Gait Guys

_______________________________
Sports Biomech.
2012 Nov;11(4):464-72.Meardon SA, Campbell S, Derrick TR.

Step width alters iliotibial band strain during running.

Abstract
excerpted:

“Greater ITB strain and strain rate were found in the narrower step width condition (p < 0.001, p = 0.040). ITB strain was significantly (p < 0.001) greater in the narrow condition than the preferred and wide conditions and it was greater in the preferred condition than the wide condition. ITB strain rate was significantly greater in the narrow condition than the wide condition (p = 0.020). Polynomial contrasts revealed a linear increase in both ITB strain and strain rate with decreasing step width. We conclude that relatively small decreases in step width can substantially increase ITB strain as well as strain rates. Increasing step width during running, especially in persons whose running style is characterized by a narrow step width, may be beneficial in the treatment and prevention of running-related ITB syndrome.”

Podcast #23. Neurology of walking babies, dialogues on step width for runners and so much more !

Syndication link:

http://thegaitguys.libsyn.com/podcast-23-walking-babies-step-width-cross-over-running

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Podcast #23. Neurology of walking babies, dialogues on step width for runners and so much more !

1- Newborn babies walk the walk | Body & Brain
http://www.sciencenews.org/view/generic/id/348262/description/Newborn_babies_walk_the_walk

2- 3D printing with stem cells could lead to printable organs - CNET Mobile
http://m.cnet.com/news/3d-printing-with-stem-cells-could-lead-to-printable-organs/57567789

3- our payloadz e-file download site.  http://store.payloadz.com/results/results.aspx?m=80204

4- www.onlineCE.com  

Great TeleSeminar Wed Feb 20th, 2013 8:00 PM Eastern Time Chiropractic TeleSeminar Biomechanics 302 Location: 1 hr by telephone Instructor: Waerlop/Allen, DC Price: 19.00

5- J Biomech. 2004 Jun;37(6):935-8.Owings TM, Grabiner MD.  Step width variability … .

Brach JS.    J Neuroeng Rehabil. 2005 Jul 26;2:21.  Step width variability … .

Sports Biomech. 2012 Nov;11(4):464-72.  IT Band strain and step width … .

6. Rethinking Ice Baths And Ibuprofen pulse.me/s/isg3t Inflammation IS part of the healing process!

7. Bringing the Foot Back To Life: Restoring the Extensor Hallucis Brevis Muscle.

http://youtu.be/1iZg_e4veWk