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.

Hip Biomechanics: Frontal Plane Part 3

This diagram (Figure 3)  also shows a balanced HAM x D1 = D2 x BW equation.  The BW is larger than the HAM but this is offset in the rules of the teeter-totter.  Shifting the pivot point towards the larger mass is offset by the smaller D2 and larger D1 moment arms.  This is a typical compensatory mechanism used by obese patients to ambulate effectively.  It does render significant frontal plane movement of the pelvis instead of the more desirable silent frontal plane pelvis.  In this compensation, even large body weights can be somewhat offset by the degree of contralateral hip hiking to reduce the D2 moment arm and increase the D1 moment arm however this compensation has its limits.  When the limits of alteration of moment arm length are reached the body’s only compensation at that point is to increase the HAM forces which increases joint compression and thus cartilage wear since the cyclical loading and unloading of the cartilage is much less.  This is also the same mechanism used by patients with a osteoarthritic painful hip joint.  We are not referring to increasing BW, rather we are suggesting that to reduce pain the patient will want less joint compression and thus a reduced HAM.  To do this we want to increase the D1 moment arm. The only way other than surgery to achieve this increase in D1 is to take the existing body weight and shift it closer to the pivot point. Ideally you would want to lean so far over the affected painful hip as to get your body weight (BW) immediately over the pivot point. This is what is done with a walking cane in the opposite hand of the stance leg, to help lift the swing phase leg and pelvis and to push the body mass over the hip WITHOUT using more HAM (glute medius contraction generated compression, which would generate pain). This would effectively reduce D2 to nil and significantly increase D1 thus allowing HAM to be minimal; thus reducing painful joint compression.  (In teeter-totter verbiage, put the small child on the long part of the teeter-totter arm and you can move large forces with little effort at the pivot point.) 

Clinical Video Case Study: Tibial Varum with added Post-op ACL complications.

This is a case of ours. This young man had a left total knee reconstruction (Left ACL and posterolateral compartment reconstruction; allograft ligaments for both areas). This video is roughly 3 months post surgery.

Q: What anatomical variants are seen in this individual?

A: Note the genu and tibial varum present. This results in an increased amount of pronation necessary (right greater than left, because of an apparent Left sided short leg length;

* NOTE: post-operatively at this point the client had still some loss of terminal left knee extension. thus the knee was in relative flexion and we know that a slightly flexed knee appears to be a shorter leg. Go ahead, stand and bend your left knee a few degrees, the body will present itself as a shorter leg on that left side with all the body compensations to follow such as right lateral hip shift and left upper torso shift to compensate to that pelvic compensation.)

Normally, in this type of scenario (although we have corrected much of it at this point by giving him more anterior compartment strength and strategy as evidenced by his accentuated toe extension and ankle dorsiflexion strategies, these are conscious strategies at this point for the patient), the functionally shorter left leg has a body mass acceleration down onto it off of the longer right leg stance phase of gait. This sagittal (forward) acceleration is met by a longer stride on the right with an abrupt heel strike (in other words, the client is moving faster than normal across the left stance phase so there is abrupt and delayed heel strike on the right because of a step length increase. (again, this is just commentary, had we videoed this client weeks before this, you would have seen these gait pathologies. This video shows him ~70% through a gait corrective phase with us.)

Again, this client has bilateral tibial varum. You can see this as evidence due to the increased calcaneal valgus (ie. rearfoot pronation; look at the achilles valgus presentation).
He increases his arm swing on the Left to help bring the longer Right lower extremity (relative) through.
if you look closely you can also see early right heel departure which is driven by the increased forward momentum of the body off of the short left limb. In other words, the body mass is moving forward faster than normal onto the right limb (because of the abbreviated time spend on the left “short” leg) and thus the forward propulsed body is pulling the right heel up early and the heel is spinning inwards creating a net external rotation on the right limb (look for the right foot to spin outwards/externally ever so slightly in the second half of the video).

Early heel departure means early mid and forefoot weight bearing challenges and thus reduced time to cope well with pronation challenges. As we see in this case where the right foot is pronating more heavily than the left. You can think of it this way as well, the brain will try to make a shorter leg longer by supinating the foot to raise the arch, and the longer leg will try to shorten by creating more arch collapse/pronation.