Is there a need for "Gait Retraining'?...We think so

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

There seems to be some controversy with regards to gait retraining. Some folks seem to believe that it should be “left to itself” and they are fully compensated already (1). Perhaps this is true…or not. We have not seen any studies that compare gait retraining vs non gait retraining as a whole, but there seems to be plenty for specific conditions (2). We all see folks AFTER THE FACT and seek to correct the problems and reverse, halt or slow the progression of further pathology. That seems to be what many of us do.

This recent study (3) looks ate altered loads and muscle recruitment patterns in patients with osteoarthritis. they conclude:

“This study documents alterations in hip kinematics and kinetics resulting in decreased hip loading in patients with hip OA. The results suggested that patients altered their gait to increase medio-lateral stability, thereby decreasing demand on the hip abductors. These findings support discharge of abductor muscles that may bear clinical relevance of tailored rehabilitation targeting hip abductor muscles strengthening and gait retraining.”

There is substantial evidence that hip pathomechanics lead to osteoarthritis (4, 5). Wouldn’t it make sense to assist in altering motor patterns and correct those biomechanical faults before it becomes a problem? Lets change our focus (if we haven’t already) and concentrate on skill, endurance and strength, in that order for the betterment of ourselves, our patients and humanity.

1. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: “preferred movement path” and “comfort filter” Br J Sports Med. 2015 Jul; doi: 10.1136/bjsports-2015-095054. bjsports - 2015-095054. 

2. Davis IS, Futrell E. Gait Retraining: Altering the Fingerprint of Gait. Physical medicine and rehabilitation clinics of North America. 2016;27(1):339-355. doi:10.1016/j.pmr.2015.09.002. FREE FULL TEXT

3. Meyer CAG, Wesseling M, Corten K, Nieuwenhuys A, Monari D5, Simon JP, Jonkers I, Desloovere K. Hip movement pathomechanics of patients with hip osteoarthritis aim at reducing hip joint loading on the osteoarthritic side. Gait Posture. 2018 Jan;59:11-17. doi: 10.1016/j.gaitpost.2017.09.020. Epub 2017 Sep 22.

4. Christian Egloff, Thomas Hügle, Victor Valderrabano: Biomechanics and pathomechanisms of osteoarthritis Swiss Med Wkly. 2012;142:w13583 FREE FULL TEXT

5. https://www.the-rheumatologist.org/article/get-out-of-your-oa-box/?singlepage=1&theme=print-friendly

More Flip Flop Madness. Can a flip flop reduce impact forces?

Flip Flop Madness. Can a flip flop reduce loading/impact force? Maybe...

We agree that the increased ankle dorsiflexion moment is to try and keep the flip flop on.  This particular flip flop, the Fit Flop, has different gait parameters (see figure 2 in the article) compared to normal flip flops and barefoot. We hypothesize this is most likely due to the semi rockered design along with the heel cup. Rockered shoes reduce the amount of hallux dorsiflexion needed for forefoot rocker and reduce plantar pressures in the forefoot (1) What surprised us most were the decreased impact forces.

"The current study identified increased ankle dorsiflexor activity in flip-flop style footwear compared to barefoot, coupled with increased dorsiflexion in swing, assumed to be a mechanism to hold the shoe on the foot. The FitFlop limited foot motion in the frontal plane and significantly reduced loading at impact, compared to flip-flop and barefoot. However, it is not clear whether the reductions in these parameters are enough to reduce any potential injury or overuse injuries associated with flip-flop footwear and further, longitudinal, research would be needed to clarify this relationship." (2)

More on the subject with a free, full text below.

 

1. Sobhani S, van den Heuvel E, Bredeweg S, Kluitenberg B, Postema K, Hijmans JM, Dekker R. Effect of rocker shoes on plantar pressure pattern in healthy female runners. Gait Posture. 2014 Mar;39(3):920-5. doi: 10.1016/j.gaitpost.2013.12.003. Epub 2013 Dec 9.

2.  Price C, Andrejevas V, Findlow AH, Graham-Smith P, Jones R. Does flip-flop style footwear modify ankle biomechanics and foot loading patterns? Journal of Foot and Ankle Research. 2014;7:40. doi:10.1186/s13047-014-0040-y.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4182831/

Footwear IS Medicine

We always have said that "Shoes ARE medicine" Here's an article that supports that.

"Footwear plays an integral role in force distribution on the lower extremities, and choosing appropriate footwear is one of many strategies people can use to manage knee pain caused by joint disorders. When footwear is properly fit, force and stress can be shifted away from weaker parts of the knee, and the leg stabilized. This may lead to a significantly better quality of life for patients with knee problems, such as osteoarthritis (OA) and patellofemoral pain syndrome."

http://lermagazine.com/article/the-effect-of-footwear-on-the-management-of-pain-caused-by-disorders-of-the-knee-joint

increased cushioning = increased impact forces (GRF)

increased impact forces = increased injuries?

possibly not...

footwear can impact injury and biomechanics but may not be the primary factor

a nice recap of the state of what we currently know about shoes, design and cushioning.

http://lermagazine.com/cover_story/running-shoes-and-injury-risk-rethinking-the-importance-of-cushioning-and-pronation

We’ve got an angle….. The Progression Angle

1st of a non sequential series

The progression angle is the angle to foot makes with the ground at initial contact of gait to loading response, and it is often carried through the gait cycle to toe off (see left image above). It is something we often look at to see how a patient may be compensating. It often represents how forces are traveling through the foot (see right image above).

The normal line of force through the foot during a gait cycle should begin at the lateral aspect of the heel, travel up the lateral column of the foot, across the metatarsal heads from the 5th to the 1st, and then through the hallux (see L part of right picture above.

We remember that the foot strikes the ground in a supinated posture, then pronates from initial contact through the middle of midstance (to provide shock absorption and initiate medial spin of the lower extremity: see picture bottom left); the foot should then supinate, to make the foot into a rigid lever, with this being initiated by the opposite limb going into swing and externally rotating the stance phase lower extremity (se picture bottom right)

The progression angle is determined by many factors, both anatomical and functional, and is often a blend of the 2.

Anatomical factors include:

• subtalar joint positioning
• tibial torsion
• femoral torsion
• acetabular dysplasia

and functional causes can include:

• compensation for a hallux limitus or rigidus
• weak glutes (of course we wouldn’t leave our favorite muscle out)
• loss of ankle rocker
• over or under pronation
• and the list goes on….

Next time we begin breaking this down into bite sized chunks to aid digestion.

Ivo and Shawn. Bald. Good Looking. Middle Aged. Definitive Foot and Gait Geeks : )