The Glute Max does that?

-There’s lots of talks about glutes and glute function. When was the last time you thought about the gluteus maximus has an internal rotator of the hip? We did a recent podcast and talked about this during climbing. 

-As the thigh flexes to 90° or greater, the internal rotational power of both the gluteus maximus and medius increases exponentially. Think about this when prescribing your rehabilitation exercises and get creative!

For a lot more information on this as well as other fun things with the glutes join us tomorrow evening for our monthly third Wednesdays Teleseminar on onlinece.com biomechanics 328 tomorrow night, 7 central 

Come join us for an hour of talking about peoples butts and how to make them work better :-)

#gluteus #gluteusmaximus #glute #glutes #muscleaction #muscleactions #rehab #rehabilitation #exercise #gluteexercise #gluteexercises 

The smell of napalm in the morning: Your gait and trouser coughs, a clinical entity no one talks about.

Written by Dr. Shawn Allen

This is our very last gait guys blog post. Yes, all good things come to an end, even this trusted blog.
But, keeping in good faith, we will finish on a strong note ……. One of gardenia and lavender. Thanks for the last 10 years our dear gait brethren, is has been a great ride. Shawn and Ivo
_______________________________
The technical title of this blog post should have been, “The reactive influence of non-normopressure bowel distention and spontaneous high vapor dissipation on bipedal locomotion.” but no one but true gait nerds would have read it had we stuck with this pubmed-type title. Yes, we are talking about farts and gait here today folks, buckle up.

One biomechanical principle we will link to this entity of “off-gassing“ is that excessive or sustained ankle plantarflexion could inhibit dorsiflexion and certainly, at the very least, works against it. We have talked about this often here on the blog and how the lack of ample ankle dorsiflexion can impair many of the biomechanical events higher up into the human frame. So, how can someone’s bowel gas translate into gait problems ?

Think about this … to squeeze out a right “cheek sneak” (fart) with optimal crowd pleasing pitch and peak vibrato, some elevation and relaxation of the lower and middle gluteus maximus divisions (coccygeal and sacral) seems imperative to optimally control off-gassing . Seemingly, to do this, a significant degree of right ankle plantarflexion may be necessary to lift the right hemipelvis driving a subsequent intentional clockwise pelvic distortion assisting in the relaxation of these gluteal divisions. This consciously driven right side of the body “lift” via the right ankle plantarflexion can also be met and assisted via ipsitlateral abdominal and contralateral gluteus medius contraction to further enable the optimal right hemipelvis elevation. Go ahead, stand up and mimic the posture and note these biomechanical pieces. Recall our mantra,

“when the foot is on the ground, the glutes are in charge, when the foot is in the air, the abdominals are in charge”.

These coordinated motor patterns might be considered dual/multi tasking. This honed series of biomechanical events is one often perfected in frat houses and basement gaming rooms. But make no mistake, there is a biomechanical danger lurking here if this becomes a habitual compensation pattern, one common in large volume legume consumers (beware vegans). Habituation of this motor task, or demonstrating poor technique over time can render right quadratus lumborum shortening and weak lower abdominals rendering an anterior pelvic tilt. This tilt may lead to gluteal inhibition/weakness (because it is difficult to contract the gluteals in an anterior pelvic tilt, go ahead stand up again and try it) which over time can impair stance phase gait mechanics. However, relating to the off-gassing, this physical posturing might optimize low frequency gluteal vibrations that can optimize vibrato during gas dissipation if pressurization is in fact optimal for an “audible”. It is important to note that conscious variable control of the tonus of the muscular anal sphincter complex plays a big part in the pitch and vibrato. There is always a drawback it seems, it does truly come down to motor control it seems, doesn’t it always ?

This is not to say that avoiding “audibles” through holding “one” in doesn’t have consequences. The exotic gas (nitrogen, carbon dioxide, hydrogen, methane, oxygen) induced gut distention that could only make your collage roommate proud can inhibit the abdominal wall and thus the lower thoracic canister and disable normal breathing mechanics. This could be a serious complication to the coupled events of respiration and thoracic mobility. So, holding that big one in for your friends rather than engaging the compensatory Trendeleburg-type off-gassing posture as described above is also fraught with problems. We know that functional disconnection of the thoracic canister from the pelvic core can disrupt the normal anti-phasic mechanics of the contralateral upper and lower limbs as well as possibly impair the normal spinal cord mediated central pattern generators.

Farts…..Call them what you want, those ear pleasing, nose hair curling, trouser coughs that only a teenage boy can truly relish and recognize as a function of boyhood success. All joking aside, they truly should be your biggest concern in your gait analysis evaluation, bar none. Ask your patients about their bowels and off-gassing, it should be part of your clinical history intake. Maybe even consider taking out the discomfort of open dialogue, and put it on your intake forms. We found that a stick figure diagram in a good biomechanical squat posture with a mushroom cloud formation hanging overhead eases dialogue tension about this sensitive topic. We even give the young children crayons to they can color the cloud. What fun !

Dare us to write a part two on this topic. “Blue Angels” (unfamiliar with this clinical phenomenon? look it up). Go ahead, dare us for a part 2.

By now, if you haven’t realized that The Gait Guys just punked you (happy April Fools day) , then you likely haven’t had your cup of morning coffee. Yes, we have no clue what we were talking about on this blog post, well, ok maybe, after all we do have that y-chromosome. Yes, we are NOT ending the blog either :)

Are you now considering us juvenile ? Ok maybe we are a little, but don’t deny it, you thought about some unique and honest body biomechanics for a moment here and it is these mental gymnastics that will take your creative thinking about gait to the next level. If you are upset, so be it. There will be no apologies here in this growing PC world. "Off-gassing" is a human thing, we all do it. We have been writing serious stuff daily for 5 years here on The Gait Guys. It was time for us to write something a little lighter. We can only hope that you will think of us and the complexities of the gait cycle the next time you sneak one out while having dinner at the in-laws or before you blame the dog for any "something wicked this way comes" gaseous event. Try not to giggle when you do, but for certain, think about your body mechanics when you do, we can’t be responsible for off-gassing injuries.

Think of us, 2 juveniles at times, when the world needs us the most.

Shawn and Ivo, remaining here, for the duration.

disclaimer: we cannot be responsible for injuries that might be sustained by improper off-gassing events. Keep your work area a no smoking or vaping zone please when off-gasing. We also do not recommend attempts at performing Blue Angels, this is a potentially dangerous activity and could cause great bodily harm (seriously). :)

Loaded Carry, Addendum idea

Recently, Jan 13th, 2018, we posted 2 photos of the Farmer's carry, in that specific case how to use it to drive more load into the hip stabilizers as opposed to the lateral abdominals. Here is how we progress someone from wide step walking corrections, we add the step up. The next progression is to be sure they do not lose the hip hike as they try to return the foot to the ground, which you do not see here. Note the kettlebell in the LEFT hand. They will have to do that (return the RIGHTfoot to the ground) through a knee bent knee mini-squat-lunge, to keep the gmedius on. Or, they can just do a controlled eccentric, but that is even more attention. Most people just let the RIGHT glutes go entirely to get the LEFT swing leg back to the ground, no bueno ! This is not normal gait, but it is what most people do because they do not have command of the glutes in the 3 phasese: early, mid and late stance. In fact, most people fail through all 3 phases, but certainly the Early and Late phases are the toughest, with the Late phase being the most challenging. The glutes should remain active through the next foot contact phase.

Part 2: The amputated hallux & the complex biomechanical fall-out from it.

Last week we promised Part 2 to this case, the amputated big toe.
Here is part 2. These are the complicated biomechanical fall-outs, so grab a big mug o' coffee and have at it !

In review, this person (all photos and case premissioned in swap for insight) had the distal hallux removed because of a progressive melanoma on the big toe. Can you believe that ! This is one more reminder that the sun and regular dermatologist screenings are wise.
This person had a complaint of progressing right gluteal and QL pain, spasm, tone and some persistent pain now in the 2nd metatarsal as well as some shoe challenges. We discuss this case briefly in and upcoming podcast, #139 or #140 we believe.

Before we add our final thoughts to this case, lets cap our post from last week.

-Without the hallux, we cannot wind up the windlass and shorten the distance between the first metatarsal and heel, thus the arch will splay (more permanently over time we suspect) and we cannot optimize the arch height.
This will promote more internal spin on that limb because of more midfoot pronation and poor medial foot tripod stabilization.
- More internal limb spin means more internal hip spin, and more demand (which might not be met at the glute level) and thus loads that are supposed to be buffered with hip stabilization, will likely be transferred into the low back, and or into the medial knee. Look for more quad protective tone if they cannot get it from the glutes. Troubles arise when we try to control the hip from quadriceps strategies, it is poorly postured to do so, but people do it everyday, *hint: most cyclists and distance runners to a large degree).
- anterior pelvis posturing on the right, perhaps challenging durability of the lower abdominals, hence suspect QL increased protective tone, possible low back tightness or pain depending on duration of activities
- These factors are likely related to his complaints in the right gluteal and low back/QL area.

Now, onto our next thoughts.

- when the hallux is incompetent, in this case absent, there are few other choices to gain forefoot purchase on the ground other than more flexion gripping of the 2nd toe (then the 3rd, then 4th). This is a progressing "searching" phenomenon for forefoot stability and without the function of the big fella, the 2nd toe will begin a hammering phenomenon, often, but not always. We would not be surprised to see hammer toe development in this case, but this person is now very aware of it, and can at least now fight that battle with increased awareness. There is some mild evidence of this on the side lateral photo.

- We are happy to see that the proximal phalange was spared. The adductor hallucis is inserted medially there, and this will help to reduce bunion generation risk (medial metatarsal drift). Comparing the photo and the radiograph is a great example of how far back/proximal the 1st MTP joint is. One could easily assume that the entire hallux was resected from the photo, but the radiograph shows otherwise.

- Toe off is obviously going to be compromised. The patient cannot adequately stabilize the 1st metatarsal (MET) and this will mean a compromised foot tripod, medial foot/tripod splay, arch pronation control challenges but toe off stabilization is going to have to be met by the 2nd and 3rd digits, as discussed above. They are not suited to be the major players here, they are synergistic to this end. Do not be surprised to see one of 2 strategies at toe off here:

1. heavy medial foot tripod toe off, dropping into the void and this maximize the internal spin challenges and minimizing the requisite foot supination stiffness generation phase that should be normal at toe off

2. avoidance of the above, with a forced conscious forefoot lateral toe off, a supinatory strategy, to avoid internal limb spin, more toe hammering, and the lurch heavily and abruptly off of the right foot and onto the left limb.

3. taking #2 further, any time there is perceived challenges or deficits in strength, endurance, proprioception, balance, power and the like, the brain often will create a premature departure off of said limb, creating a requisite premature loading onto the opposite limb. This can cause a phenomenon well loosely refer to "catching" in the contralateral quadriceps mechanism. These clients, with their abrupt loading pattern onto the opposite limb will most often have troubles getting into initial gluteal hip stabilization strategies, and thus default into a quadriceps strategy, that in time can lead to quad shortness and increased tone, which can cause more compression across the patellofemoral joint and cause knee pain. This is more of a compression/loading response issue rather than tracking phenomenon, which we see at the typical diagnosis. We often look for causes in the opposite limb for contralateral knee pain. IT is quite often there if you are looking hard enough for it. Fix the problem, not the symptom.
There is a long host of other things than can arise from here, including heavy contralateral (in this case left sided) foot loading challenges, often more forefoot initial loading, and all of the problems than can arise when this pattern is cyclical, but that would take this post far too deep and long. So, . . . . another time.

4. Shoe fit, we could make the case that a shoe that nicely hugs the forefoot, as opposed to a wide toe box'ed shoe, could help fight off the risk of 1st metatarsal abduction and thus bunion formation risk. However, one cannot dismiss the wider toe box giving the remaining toes a better environment to engage without hammering with over use of long flexors. We might suggest a trial of an elastic sleeve, one often used for plantar fascitis symptom management, placing a snug one around the forefoot when ambulating. This could help keep that metatarsal snug and stop the bunion-like drift we would be watching for.

have at it gang, cases like this are far and deep and require deep understanding of normal and abnormal biomechanics, and the rabbit hole deep myriad of compensations that can be engaged.

have a great weekend !

Shawn and Ivo

Hamstring injuries and their gluteal relationship, the dialgoue.

Yesterday we talked about hamstring tears. One of the frequent findings we see in our hamstring injured clients is under performance of the gluteal group. We all are well aware that the hamstrings can be an assistive piece of the posterior chain hip extension pattern in gait. When the glutes are underperforming, under protecting hip stability or underperforming in pelvis control, that the hamstrings can be called upon to do more. The loads an move into the low back or into the leg, or both, when the glutes are underperforming. This study is supportive in an indirect manner.

Sagittal trunk flexion and extension in patients with chronic low back pain.
The study found the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Nothing new here for many of our followers, but it is always worth discussing.

We have talked about the fatigue factor and endurance factor of the paraspinals in low back pain in previous podcasts, maybe a year or two ago. But, in looking for something else in particular today, I came across this article from 2000.
It once again suggests the critical function of the glutes, all 3 divisions and that they do play multiple parts other than just hip stability and movement. We see plenty of clients who have poor development of the upper iliac and sacral divisions of the glute max. This could be from anterior pelvis tilt presentations, faulty movement patterning, or even failure to get to end range hip extension to work on developing that portion of the muscle. Regardless, this once again proves that we are an under-developed glute species and all this sitting is a problem, and even the standing desk trend, will not fix this. The body must move, it must be loaded through to the full range of motion and we must incorporate compound movements with load if we are to get even close to the opportunity to see folks with healthy glutes and thus healthy hips and spines.

"RESULTS:
During early flexion, lumbar paraspinal and biceps femoris were activated simultaneously before gluteus maximus. At the end of flexion and during extension all investigated muscles were activated and relaxed in order. Lumbar paraspinal and biceps femoris muscles were activated in a similar order in low back pain patients and healthy controls during flexion and extension. However, the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Active rehabilitation did not change the muscle activities of lumbar paraspinal and biceps femoris in the back pain patients, but in the measurements after rehabilitation the onset of gluteus maximus activity occurred later in flexion and earlier in extension."

"CONCLUSIONS:
The activity of the gluteus maximus muscle during the flexion-extension cycle was reduced in patients with chronic low back pain. The gluteal muscles should be taken into consideration in the rehabilitation of these patients." - Leinonen et al

Arch Phys Med Rehabil. 2000 Jan;81(1):32-7.
Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation.

Leinonen V1, Kankaanpää M, Airaksinen O, Hänninen O.
https://www.ncbi.nlm.nih.gov/pubmed/10638873

Glute fatigue in low back pain.

Sagittal trunk flexion and extension in patients with chronic low back pain.

The study found the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Nothing new here for many of our followers, but it is always worth discussing.

We have talked about the fatigue factor and endurance factor of the paraspinals in low back pain in previous podcasts, maybe a year or two ago. But, in looking for something else in particular today, I came across this article from 2000.
It once again suggests the critical function of the glutes, all 3 divisions and that they do play multiple parts other than just hip stability and movement. We see plenty of clients who have poor development of the upper iliac and sacral divisions of the glute max. This could be from anterior pelvis tilt presentations, faulty movement patterning, or even failure to get to end range hip extension to work on developing that portion of the muscle. Regardless, this once again proves that we are an under-developed glute species and all this sitting is a problem, and even the standing desk trend, will not fix this. The body must move, it must be loaded through to the full range of motion and we must incorporate compound movements with load if we are to get even close to the opportunity to see folks with healthy glutes and thus healthy hips and spines.

"RESULTS:
During early flexion, lumbar paraspinal and biceps femoris were activated simultaneously before gluteus maximus. At the end of flexion and during extension all investigated muscles were activated and relaxed in order. Lumbar paraspinal and biceps femoris muscles were activated in a similar order in low back pain patients and healthy controls during flexion and extension. However, the duration of gluteus maximus activity was shorter in the back pain patients than in controls during the trunk flexion (p<.05), and it ended earlier during extension. Active rehabilitation did not change the muscle activities of lumbar paraspinal and biceps femoris in the back pain patients, but in the measurements after rehabilitation the onset of gluteus maximus activity occurred later in flexion and earlier in extension."

"CONCLUSIONS:
The activity of the gluteus maximus muscle during the flexion-extension cycle was reduced in patients with chronic low back pain. The gluteal muscles should be taken into consideration in the rehabilitation of these patients." - Leinonen et al

Arch Phys Med Rehabil. 2000 Jan;81(1):32-7.
Back and hip extensor activities during trunk flexion/extension: effects of low back pain and rehabilitation.

Leinonen V1, Kankaanpää M, Airaksinen O, Hänninen O.
https://www.ncbi.nlm.nih.gov/pubmed/10638873

Labral tears and altered motion during loading.

"One might argue, that we sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum. This becomes particularly suspect when in a conforming chair, such as a "bucket" seat in a car." -Shawn Allen

This article follows nicely with yesterday's post about hip joint control and anterior hip pain.

The premise behind this study referenced below was to determine if contact forces and electromyography (EMG) muscle amplitudes were altered during lunging activities in clients with painful labral tears compared to hose who are symptom free.
The unsurprising conclusions of this study ("contact forces and EMG muscle amplitudes are altered during the lunge for patients with symptomatic labral tears") are mostly predictable. But one should, we would hope, propose the chicken or the egg theory here.  Are these clients having pain because they are loading into the labral tear, or is the pain from poor joint stabilitation (and thus possible impaired normal mobility and motion) which incidentally lead to the labral loading and thus tear ?  We propose this one all the time. Why? Because we get a decent population of clients with typical "suspect" anterior hip labral pain and after rehabbing them, the pain resolves. So in these cases, was it a labral tear? Labral irritation? Or just a faulty loading response?
*However, we also get enough clients who present with an MRI in hand that confirms a labral tear, and we take them through the same process, and many of them also stabilize and have pain resolved. This then proposes the end question from them "So, was my pain from the labral tear at all? Or was it because had a poor stabilization capability, which lead to the tear/irritation?" 
And that folks, is the big question that has to be asked in all cases, and that is the unanswerable question.  But, should the process change regardless? If your client is going to head into surgery for the tear, should they not be fully rehabbed in the first place? And if the rehab works, is surgery even necessary ?  In the successful cases, we just stare openly at the client and smile, we let them answer the question. After all, they know the answer anyways.

Make no mistake. not everyone responds to our, or your, care. And, not every labral tear is incidental. Not every labral tear is undamaging to the femoral head and to the longer term health of the joint.  But, taking a few weeks and dedicating some good work into your client's skill, endurance, strength, power and loading responses often either give your client answers or prepare them for a great outcome post-operatively. 

In a nut shell, these can be tricky challenging cases. People sit and use the glutes as a cushion all day. We sit the majority of our days with our femur and thus our femoral head pressed forward into the anterior and roof of the acetabulum (depending on our sitting posture and chair choice).  They load similarly in their cars in challenged ways. They do not move well or often enough. They have weak glutes and abdominals and their ability to control the pelvis in safe loading is poor.  So many patients, and non-patients are on this bus, in fact, the majority of us are on it as well.  It feels like we are seeing more and more of these anterior hip problems, and we are not surprised as the average human moves less, is getting weaker and less durable and robust physically, and they sit more, and drive more.  This anterior hip pain clinical entity should really be no surprise to anyone anymore.
To be thorough, this study did "surface electromyography electrodes were placed over the gluteus medius, gluteus maximus, adductor longus, and rectus femoris muscles of the patients' involved limb and matched limb of asymptomatic controls."  This makes this an incomplete study with incomplete conclusions. As we said yesterday, without information on the mighty psoas and iliacus to name a few other big players, this study is somewhat suspect, but overall, we do not thing the results would come out too terribly different.

-Shawn and Ivo, the gait guys

Do Neuromuscular Alterations Exist for Patients With Acetabular Labral Tears During Function?
Arthroscopy. 2016 Jun;32(6):1045-52. doi: 10.1016/j.arthro.2016.03.016. Epub 2016 Apr 27.  Dwyer MK1, Lewis CL2, Hanmer AW3, McCarthy JC4.

https://www.ncbi.nlm.nih.gov/pubmed/27129378

More anterior hip pain dialogue.

On a recent podcast we discussed complex hip problems, particularly hip stability and mobility issues lending themselves to anterior hip pain.
We have often mentioned ankle rocker being important in the discovery of hip pain, insufficient rocker can cause some impairments and abilities to get to ample hip extension function and range.
Here, this slightly older article mirrors a discussion we had on a recent podcast. We discussed the need for balance in the hip. More so, that focusing only on the glutes and hip extension can get one into trouble. One needs to also consider hip flexion skill, endurance and strength. The glutes and the hip flexors are a team to help maintain hip stability, mobility, and centration of the opposing joint surfaces during roll and glide motions. This is some of Shirley Sahrman's work, and others of course. When these component parts are not in harmony, and a loading force potentiates the femoral head towards the anterior labrum, it is the job of the glutes and hip flexors, to name two of the big players, to centrate that femoral head and keep it from impinging, and applying a forward load especially when this occurs during end motion loading into hip flexion and extension. I came across an article a while back that suggested these anterior directed movement risks are greater when the limb is loaded from being externally rotated, such as when making a strong power move or "cut" off the stance leg into the contralateral direction (we are looking for that source).
The bottom line is pretty simple, create sufficient stability to endure the loading challenge, but have enough strength and skill to still enable safe mobility. That being said, it is the diagnostics and the remedy that can be the tricky and challenging part of this game.

Anterior hip joint force increases with hip extension, decreased gluteal force, or decreased iliopsoas force. Lewis CL1, Sahrmann SA, Moran DW. J Biomech. 2007;40(16):3725-31. Epub 2007 Aug 17.

"Abnormal or excessive force on the anterior hip joint may cause anterior hip pain, subtle hip instability and a tear of the acetabular labrum.

We found that decreased force contribution from the gluteal muscles during hip extension and the iliopsoas muscle during hip flexion resulted in an increase in the anterior hip joint force. The anterior hip joint force was greater when the hip was in extension than when the hip was in flexion."

Podcast 120: Runner's Brains & Glute Rabbit holes

Show links:
http://traffic.libsyn.com/thegaitguys/pod_120_real_final.mp3

http://thegaitguys.libsyn.com/podcast-120-runners-brains-glute-rabbit-holes

Key tag words:
running, running form, running tricks, gait, gait analysis, the gait guys, brain, statins, glutes, runner's brain, 
 
Show sponsors:
newbalancechicago.com
 
www.thegaitguys.com  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.
 
Show Notes:
 
Neuroscience:
 
Statins and exercise
http://www.nytimes.com/2017/01/04/well/move/a-fitness-downside-to-statin-drugs.html?utm_medium=email&utm_source=flipboard&_r=0
 
Cholesterol reference:
http://circ.ahajournals.org/content/early/2016/11/21/CIR.0000000000000461
 
Joe Rogan Experience Podcast: #842, Dr. Chris Kresser
 
Follow Chris Beardsley at "Strength and Conditioning Research" and Bret Contreras, "the glute guy". They always have great research based stuff.
 
Young runners have stronger brain connections
http://www.futurity.org/running-functional-connectivity-1317802-2/
 
Runners and connected brains
http://www.sciencealert.com/runners-brains-are-more-connected-than-most-study-says
 
Runners brains:
http://journal.frontiersin.org/article/10.3389/fnhum.2016.00610/full
 
Early sport diversification vs. late specialization
http://www.humankinetics.com/excerpts/excerpts/late-specialization-is-recommended-for-most-sports

Podcast 117: The glutes in rotation

Key tag words:

running, glutes, climbing, hip rotation, movement patterns, hominids, bone density, gait

Links:

http://traffic.libsyn.com/thegaitguys/pod_117ffinal.mp3

http://thegaitguys.libsyn.com/episode-117

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.

Show Notes:

3D printed talus replacement surgery helps patients regain up to 75% normal ankle function
http://www.3ders.org/articles/20160504-3d-printed-talus-replacement-surgery-helps-patients-regain-up-to-normal-ankle-function.html

http://pubs.rsna.org/doi/full/10.1148/rg.2015140156

Stopping Exercise Decreases Brain Blood Flow
http://neurosciencenews.com/exercise-brain-blood-flow-4927/?utm_medium=email&utm_source=flipboard

Babies Who Walk Earlier May Have Stronger Bones in Their Teens
http://news.health.com/2016/06/02/babys-early-walking-may-mean-stronger-bones-as-teen/

NEW EVIDENCE SUGGESTS OUR HOMINID COUSIN LUCY LOVED CLIMBING TREES
http://www.popsci.com/new-evidence-that-our-hominid-cousin-lucy-loved-climbing-trees

Glutes as internal hip rotators
https://www.thegaitguys.com/thedailyblog/2016/12/7/the-glutes-are-in-fact-great-internal-hip-rotators-too-open-your-mind

Retraining movement patterns, mind or muscles or vision ?
http://www.theglobeandmail.com/life/health-and-fitness/fitness/study-suggests-visual-feedback-doesnt-speed-up-learning-of-new-movements-health/article33142789/

The glutes are in fact great internal hip rotators, too. Open your mind.

I recently got a message from a colleague questioning as to how in the world, that when the hip is in flexion, the glutes and piriformis become internal rotators.  This is again another example of lack of functional anatomy knowledge.  It took me awhile to find a picture to help explain this, but I finally found one reasonable to do so. Many readers who are stuck on this concept are just too stuck on the anatomy as presented in the image to the right, neutral stance-like.  This article today will be all about internal and external moment arms, here, this lecture will help a little, it is on glute medius internal moment arms in stance phase however, so there is little carry over but it will at least get you understanding moment arms more clearly. 

We tend to just think of the glute max as a hip stabilizer and extensor, for the most part. It also decelerates flexion in terminal swing.  The glute medius is mostly thought of as a lateral hip stabilizer and abductor, either of the femur (open chain) or of the pelvis in stance position (closed chain), meaning zero degrees or neutral plus or minus the trivial degrees of engaged hip flexion and extension used in normal gait.

No one I know consciously trains the glutes as an internal rotator, but there are many actions where we need this function, such as in crawling and many high functioning activities such as martial arts grappling and kicking for example. Gymnasts should also know that the glutes are powerful internal hip rotators.  If you are doing quadruped crawling work you also need to know this as your client approaches 90 degrees of hip flexion. No one ever seems to check this critical gluteal function, at least I see it missed all the time from my referring doctors and therapists for unresolving hip pain cases. Patients with hip pain, anterior, lateral or posterior, with lack of internal hip rotation need the glutes checked just as much as the other known internal hip rotators we all seem to know (though some still do not understand how powerful the vastus lateralis is as an internal rotator, but again, those are folks who just have not spend the time in a mental 3D space looking at functional anatomy. I live mentally in that 3D space all day long when working with patients, you should too.) Let me be more clear, the anterior bundle, the iliac bundle of the glute max, is an internal rotator in flexion, the sacral and coccyxgeal divisions are not, they are external hip rotators in flexion. The gluteus medius and minimus are internal hip rotators closing in on 90 degrees hip flexion.  Hence, you must be able to tease out these divisions in your muscle testing, one cannot just test the glutes as external rotators or extensors, you are doing a really sloppy job if that is all you are doing. Nor should someone just train the glutes as hip stabilizers, external hip rotators and extensors (which is probably 90% of the trainers and coaches out there I might assume?). IF one knows the origin and insertions (see the blue and green arrows) and moves those points towards each other in a fashion of concentric contraction (purple arrows) one should be able to easily see that this will orient the femur to spin into internal rotation in the acetabulum (follow the arc of the black arrows). The same goes for eccentric contractions, it is the same game.  If you are doing DNS and crawling work, you should know this stuff cold gang. When you close chain the hip in sitting, or are moving from tall kneeling into flexed kneeling chops, performing high knees in sprint training,  or especially in crawling and climbing type actions, you must understand the mechanisms of internal rotation creation and stabilization -- if the glutes are not present and trained and useful in flexion, you are missing a chunk of something big. Amongst many other things, your client must be capable, stable, strong and skilled in moving from supine to quadruped all in one turning-over motion to teach how to stabilize the hip in the quadruped action and then progress into crawling.  This is a reflexive action learned in the early motor developmental phase of locomotion.  So take your client back through this motor pattern if they have some of the hip problems with internal rotation, it is a small piece of the gluteal puzzle.

I am sure this will show up in someone's seminar at some point, hopefully it is in many already, it has always been in my lectures when going down the rabbit hole of all things glutes. And to be fair, I haven't been to seminars in years as I get too frustrated, so this concept may be everywhere for all I know (lets hope).  But that is something I have to get over, I am sure I still have much to learn.  

To give credit where credit is due, which we always insist upon here at The Gait Guys, this was refreshed in my mind by Greg Lehman in a Facebook post forwarded to me by the inquiring doctor.   Link here  and from the article that spurred him to discuss it, an old article I read long ago just after completing my residency, the article is by Delp et al.  It is worth your time.  Thanks Greg for bringing this back into the dialogue, it is critical base knowledge everyone should already know. 

Variation of rotation moment arms with hip flexion.  Scott L. Delp,*, William E. Hess, David S. Hungerford, Lynne C. Jones  J. of Biomechanics 32, (1999)

-Dr. Shawn Allen, the other Gait Guy

SOUTH LOOP PODCAST #17: DR. SHAWN ALLEN OF THE GAIT GUYS

As promised. Here is Dr. Allen on the Chicago Southloop CrossFit podcast.
Thanks to Todd Nief for a fun interview hour. Always love talking to this smart fella.
Podcast link: http://southloopsc.com/articles/dr-shawn-allen-interview

taken from Todd's Southloop Strength and Conditioning Crossfit site:
Anyone who has ever been to a physical therapist has inevitably been told that they have “weak glutes” and been given Jane Fondas or some other form of band exercise.

Does every human being actually have weak glutes? Is the contractile potential of the muscle limited? Do glutes really not “fire correctly”? Can we actually come up with biomechanical explanations for all of the injuries and issues that we find in athletes?

Dr. Shawn Allen is one half of The Gait Guys along with Dr. Ivo Waerlop – a duo renowned for their information dense podcasts and blog posts in which they dissect the latest research articles in rehab, injuries, nervous system development, and strength training.

Dr. Allen practices not too far from my parents’ house in the suburbs of Chicago, so I made the trek out to see him for some chronic groin issues I’d had from playing soccer. And, it turns out I had some glute issues myself.

However, it’s not as simple as simply contracting the offending muscle group over and over and over again. The pattern in which dysfunction is present must be identified, and then a new pattern must be learned to replace the dysfunctional pattern – which is a higher order way of approaching injuries and movement issues.

Dr. Allen and I have had several interesting conversations about injury mechanisms, the nervous system’s control of movement, and best practices in rehab and training, so we decided to record one of them here.

http://southloopsc.com/articles/dr-shawn-allen-interview

Podcast 114: Pooping your pants

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

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

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

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

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

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

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

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

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

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

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

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

The smell of napalm in the morning: Your gait and trouser coughs, a clinical entity no one talks about.

Written by Dr. Shawn Allen

This is our very last gait guys blog post. Yes, all good things come to an end, even this trusted blog.
But, keeping in good faith, we will finish on a strong note ……. One of gardenia and lavender.  Thanks for the last 5 years gait brethren, is has been a great ride.  Shawn and Ivo
_______________________________
The technical title of this blog post should have been, “The reactive influence of non-normopressure bowel distention and spontaneous high vapor dissipation on bipedal locomotion.”  but no one but true gait nerds would have read it had we stuck with this pubmed-type title. Yes, we are talking about farts and gait here today folks, buckle up.

One biomechanical principle we will link to this entity of “off-gassing“ is that excessive or sustained ankle plantarflexion could inhibit dorsiflexion and certainly, at the very least, works against it. We have talked about this often here on the blog and how the lack of ample ankle dorsiflexion can impair many of the biomechanical events higher up into the human frame. So, how can someone’s bowel gas translate into gait problems ?

Think about this …  to squeeze out a right “cheek sneak” (fart) with optimal crowd pleasing pitch and peak vibrato, some elevation and relaxation of the lower and middle gluteus maximus divisions (coccygeal and sacral) seems imperative to optimally control off-gassing . Seemingly, to do this, a significant degree of right ankle plantarflexion may be necessary to lift the right hemipelvis driving a subsequent intentional clockwise pelvic distortion assisting in the relaxation of these gluteal divisions.  This consciously driven right side of the body “lift” via the right ankle plantarflexion can also be met and assisted via ipsitlateral abdominal and contralateral gluteus medius contraction to further enable the optimal right hemipelvis elevation. Go ahead, stand up and mimic the posture and note these biomechanical pieces. Recall our mantra, 

“when the foot is on the ground, the glutes are in charge, when the foot is in the air, the abdominals are in charge”.  

These coordinated motor patterns might be considered dual/multi tasking. This honed series of biomechanical events is one often perfected in frat houses and basement gaming rooms. But make no mistake, there is a biomechanical danger lurking here if this becomes a habitual compensation pattern, one common in large volume legume consumers (beware vegans). Habituation of this motor task, or demonstrating poor technique over time can render right quadratus lumborum shortening and weak lower abdominals rendering an anterior pelvic tilt. This tilt may lead to gluteal inhibition/weakness (because it is difficult to contract the gluteals in an anterior pelvic tilt, go ahead stand up again and try it) which over time can impair stance phase gait mechanics. However, relating to the off-gassing, this physical posturing might optimize low frequency gluteal vibrations that can optimize vibrato during gas dissipation if pressurization is in fact optimal for an “audible”.  It is important to note that conscious variable control of the tonus of the muscular anal sphincter complex plays a big part in the pitch and vibrato. There is always a drawback it seems, it does truly come down to motor control it seems, doesn’t it always ?

This is not to say that avoiding “audibles” through holding “one” in doesn’t have consequences. The exotic gas (nitrogen, carbon dioxide, hydrogen, methane, oxygen) induced gut distention that could only make your collage roommate proud can inhibit the abdominal wall and thus the lower thoracic canister and disable normal breathing mechanics. This could be a serious complication to the coupled events of respiration and thoracic mobility. So, holding that big one in for your friends rather than engaging the compensatory Trendeleburg-type off-gassing posture as described above is also fraught with problems. We know that functional disconnection of the thoracic canister from the pelvic core can disrupt the normal anti-phasic mechanics of the contralateral upper and lower limbs as well as possibly impair the normal spinal cord mediated central pattern generators.

Farts…..Call them what you want, those ear pleasing, nose hair curling, trouser coughs that only a teenage boy can truly relish and recognize as a function of boyhood success.  All joking aside, they truly should be your biggest concern in your gait analysis evaluation, bar none. Ask your patients about their bowels and off-gassing, it should be part of your clinical history intake. Maybe even consider taking out the discomfort of open dialogue, and put it on your intake forms. We found that a stick figure diagram in a good biomechanical squat posture with a mushroom cloud formation hanging overhead eases dialogue tension about this sensitive topic. We even give the young children crayons to they can color the cloud. What fun !

Dare us to write a part two on this topic. “Blue Angels” (unfamilar with this clinical phenomenon? look it up). Go ahead, dare us for a part 2. 

By now, if you haven’t realized that The Gait Guys just punked you, then you likely haven’t had your cup of morning coffee. Yes, we have no clue what we were talking about on this blog post, well, ok maybe, after all we do have that y-chromosome. Yes, we are NOT ending the blog either :) 

Are you now considering us juvenile ? Ok maybe we are a little, but don’t deny it, you thought about some unique and honest body biomechanics for a moment here and it is these mental gymnastics that will take your creative thinking about gait to the next level. If you are upset, so be it. There will be no apologies here in this growing PC world. Off-gassing is a human thing, we all do it. We have been writing serious stuff daily for 5 years here on The Gait Guys. It was time for us to write something a little lighter.  We can only hope that you will think of us and the complexities of the gait cycle the next time you sneak one out while having dinner at the in-laws.  Try not to giggle when you do, but for certain, think about your body mechanics when you do, we can’t be responsible for off-gassing injuries. Think of us.

Shawn Allen, remaining here, for the duration.

disclaimer: we cannot be responsible for injuries that might be sustained by improper off-gassing events. We also do not recommend attempts at performing Blue Angels, this is a potentially dangerous activity and could cause great bodily harm (seriously). :)

Abs on the UP, Glutes on the DOWN

I had the opportunity to go on my 1st mountain bike ride of the season last Sunday morning. Yes, I am aware it is JUNE, but the snow has finally melted (we had over 7 FEET at arapahoe Basin in May) and you need to understand that I am usually a runner). In the cool morning 44 degree air I was reminded of the importance of my gluteal muscles (rather than just my quads) while climbing a technical hill which was clearly pushing my aerobic capacity. We have the opportunity to perform many bike fits in the office and treat many cycling ailments. We also train and retraing pedal stroke and one of our mantras (in addition to skill, endurance and strength) is “Glutes on the downstroke; Abs on the upstroke”. Meaning use your glutes to extend the hip from 12 to 6 o’clock and use your abs to initiate the upstroke. Quadricep (on the downtstroke) and hamstring dominance (on the upstroke) is something we see often and this mantra often proves useful in the “retraining process”.

I have been a fan of Ed Burkes work (“Serious Cycling” and “Competitive Cycling”) for years and have read (and lectured about) these books many times. In my effort to find a basis in the literature for my mantra, I ran across a paper (1) that seemed to substantiate, at least in part, the mantra. It is a small study looked at elite athletes that explores changes that occur in muscle recruitment as the body fatigues after a sub maximal exercise session.

Their conclusion “The large increases in activity for gluteus maximus and biceps femoris, which are in accordance with the increase in force production during the propulsive phase, could be considered as instinctive coordination strategies that compensate for potential fatigue and loss of force of the knee extensors (i.e., vastus lateralis and vastus medialis) by a higher moment of the hip extensors.”

This makes sense, although may be contradicted by this study (2), which showed LESS gluteal activity at higher mechanical efficiency, with increased tricep surae activity. They conclude “These findings imply that cycling at 55%-60% V˙O(2max) will maximize the rider’s exposure to high efficient muscle coordination and kinematics.”  Although this study looks at mechanical efficiency and the 1st lloks at muscle activity.

Being seated on a bike and having your torso, as well as hips flexed is not the most mechanically efficient posture for driving the glutes, but clinical observation seems to dictate that the less quad and hamstring dominant people are on the down and up stroke respectively, then the more pain free they are. This does not always equte to being the fastest, but it does equate to fewer injuries showing up in the office.

1. Dorel S1, Drouet JM, Couturier A, Champoux Y, Hug F. Changes of pedaling technique and muscle coordination during an exhaustive exercise. Med Sci Sports Exerc. 2009 Jun;41(6):1277-86. doi: 10.1249/MSS.0b013e31819825f8.
2. Blake OM1, Champoux Y, Wakeling JM.  Muscle coordination patterns for efficient cycling. Med Sci Sports Exerc. 2012 May;44(5):926-38. doi: 10.1249/MSS.0b013e3182404d4b.

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

Podcast 78: Step Width Gait, Training Asymmetries & more

Show sponsors: 

www.newbalancechicago.com

www.lemsshoes.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_78ff.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-78

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

24-year-old woman missing entire cerebellum exemplifies the amazing power of brain plasticity

http://www.naturalnews.com/047128_cerebellum_brain_plasticity_cerebellar_hypoplasia.html

Brain scans reveal ‘gray matter’ differences in media multitaskers

http://www.sciencedaily.com/releases/2014/09/140924144949.htm

https://www.youtube.com/watch?v=esPRsT-lmw8

Who are we: Ivo talk a bit about yourself and your educational history and what is your website ?

Shawn…..do the same

and……lets keep each interesting but to just a few minutes

Effect of step width manipulation on tibial stress during running

http://www.physiospot.com/research/effect-of-step-width-manipulation-on-tibial-stress-during-running/

Training Asymmetries with FMS Principles
http://charlieweingroff.com/2014/09/training-asymmetries-with-fms-principles/

Does Limited Internal Femoral Rotation Increase Peak Anterior Cruciate Ligament Strain During a Simulated Pivot Landing?
http://ajs.sagepub.com/content/early/2014/09/22/0363546514549446.abstract

Quadriceps Muscle Function After Exercise in Men and Women With a History of Anterior Cruciate Ligament Reconstruction
http://natajournals.com/doi/abs/10.4085/1062-6050-49.3.46

The Abductor Heel Twist: Look carefully, it is here in this video.

This should be a simple “piece it together” video case study for you all by this point. This young lad came into our office with left insertional achilles pain of two weeks duration after starting some middle distance running.

What do you see here ? It is evident on both the right and the left, but it is a little more obvious on the left and can be seen on the left when he is walking back toward the camera as well.  You should see rearfoot eversion, it is excessive, and a small rearfoot adductor twist. Meaning, the heel pivots medially towards the midline of his body.  Some sources (Michaud) call this an Abductory Twist, but the reference there is typically the forefoot.  Regardless, to help our patients, we sometimes refer to this is “cigarette butt” foot. It is like stepping on a lit cigarette to put it out via twisting/grinding it into the ground. 

So, now that you can see this, what causes it? 

The answer is broad but in this case he had a loss of ankle dorsiflexion range.  The ankle mortise clearly did not have enough of ankle rocker range during midstance so as that limitation was met, the heel raised up prematurely during the moments when the opposite leg is in full swing imparting an external rotation on the stance limb (hence the external foot spin (adducting heel/abducting foot……depending on your visual reference)). There is a bit more to it than that, but that will suffice for now because it is not the central focus of our lesson today.

What can cause this ? As we said, a broad range of things:

• hallux limitus
• flexion contracture of the knee (swelling, pain, joint replacement etc)
• short calf-achilles complex
• weak tib anterior and extensor toe muscles
• Foot Baller’s ankle
• limited/impaired hip extension
• weak glute (minimizing hip extension range)
• sway back (lower crossed syndrome-type biomechanics)
• short quadriceps (similarly impairing hip extension)
• flip flop excessive use (or any other motor strategy that imparts more flexor compartment dominance (read: calf-achilles, FDL)
• excessive pronation
• impaired foot tripod mechanics
• etc

The point is that anything impairing TIMELY (the key word is timely) forward sagittal gait mechanics can, and very likely will, impair ankle rocker.  Even the wrong shoe choice can do this (ie. someone who suddenly drops from a 12 mm heel ramped shoe into a 0-4mm ramped heel shoe and who thus may not have earned the length of the calf-achilles complex as of yet).

The abductor-adductor twist phenomenon is not a normal visual gait observation. It is a softly seen, but screaming loud, pathologic gait motor pattern that must be recognized.  But, more importantly, the source of the problem must be found, confirmed and resolved.  In this fella’s case, he has some weakness of the tib anterior and extensor toe muscles that has lead to compensatory tightness of the calf complex. There was no impairment of the glutes or hip extension, as this was just 2 weeks old or so, but if left unaddressed much longer the CNS would have likely begun to dump out of hip extension and gluteal function to protect……another compensation pattern. Remember, ankle rocker and hip extension have a close eye on each other during gait.

Clinical pearl for the true gait geeks…… if you see someone with a vertically bouncy forefoot-type gait (you know, those people that bounce up and down the hallway at work or school) you can usually suspect impaired ankle rocker and if you look closely, you will usually see a quick abductor-adductor twist.

Shawn and Ivo

the gait guys

Unilateral heightened toe extensor tone.

What do we have here ? Well, it is obvious. The left foot is showing increased short extensor tone (EDB: extensor digitorum brevis) and heightened long flexor tone (FDL: flexor digitorum longus). This is the classic pairing for hammer toe development.  We also know from this post (link) and from this post (link) that this presentation is closely related with lumbrical weakness and distal fat pad migration.

So, at an assessment took we like to play games. Mental games to be precise. When we see something like this we immediately begin the mental gyrations of “what could have caused this, and what could this in turn be causing”. Remember, what you see is often not the problem, rather your clients compensation around the problem.  In this case, what goes through your mind ?  Without deep thought, our knee jerk thoughts are:

• possible loss of ankle rocker dorsiflexion (the increased EDB tone can be recruited to help drive more ankle dorsiflexion indirectly)
• plantar intrinsic weakness ?
• flip flops or slip on shoes where the heel is riding up and down inside the shoe/sloppy fit ?  (initiating a gripping response from the FDL)
• weak tib anterior (recruiting EDB to help)
• weak peroneus tertius (recruiting EDB again)
• Ankle /foot instability (more FDL gripping will help gain ground purchase)
• lateral ankle instablity (same thing, more gripping)
• Weak gastrosoleus (since the FDL is a posterior compartment neighbor it can kick into high gear and help with posterior comparment function, we have a whole video case based around this issue, check this out ! )
• premature departure off of the good side leg, and thus an abrupt loading response onto this affected side can challenge the frontal plane of the body and thus require more grip response at the foot level.
• how about simple weakness of the lumbricals or FDB , the short flexors. The long flexors will have to make up for it and present like this.  
• the list goes on and on … .

These are just some quick cursory thoughts, and by NO means a complete exhaustive list.  Just some quick thoughts.

But what about hip function ?  if ankle rocker is blocked in terminal stance and the FDL fire like this what will that do to hip extension ? Well, heel rise will be premature because of the limitation and thus hip extension will be abbreviated. Thus glute function will be impaired to a degree.  This can become a viscous cycle, each feeding off of each other.

This diagnostic stuff is a tricky and difficult game. If you think you can diagnose or fix a problem from just changing what you see you are mistaken, unless you like driving compensation patterns and future injuries into your clients.   There must be a hands on examination and assessment with an intact educated brain attached to the process.

Just some mental gymnastics for you today.  

Shawn and Ivo

the gait guys