When runner do you want to be? 2 photos

Who do you want to be ? The guy loading his head over his foot
(narrow step width), or the gal loading the head and COM inside the foot (less narrow step width) ?

It is not hard to suspect who is gonna be faster and more powerful from these photos. This however does not mean on is more durable, more or less injured, more or less efficient but logical debates and thought experiments can be made here.

The lady is stacking the knee over the foot, the hip over the knee and stabilizing the hip and pelvis sufficiently and durably to keep the pelvis level for the next powerful loading step, and the other is flexion collapsing into the stance phase knee, insufficiently loading the hip and thus dropping the opposite side pelvis. He is not stacking the joints, there is a pending cross over (look at the swing leg knee approaching midline with barely any knee spacing, thus guaranteeing a cross over step or at the very least a very narrow step width.)
Sure, some one is going to say one is a distance runner and the other is a sprinter. Yes, and our point is that the sprinter is not head-over-foot, the one with all the highly suspect flaws is head over foot ! Wider step width means more glutes. Go ahead, walk around right now with a very narrow step width and see how little efficient glute contraction you get, then walk with a notably wider step width, and you will see wider means more glutes. Keep your COM moving forward, not oscillating back and forth sideways over each stance foot, that is a power leak.

The distance runner appears to be demonstrating less optimal in technique, appears is the key word here. Say what you want, but a decent argument might be made as to one of these runners being weak and very likely at greater risk for injury, the other is suspect to be strong and durable, and likely at less risk for injury.
If you ask us, but what do we know . . . . it is all a thought experiment, but based on some pretty decent ideas.
So, again, was ask . . . . which one do you want to be ?

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.

The “Dodgy Foot”, a UK runner’s dilemma.

We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK, The runner was frustrated, explaining a “dodgy foot”. We like the word.

We can guarantee you that the solution here to this runner’s form issue is not wholly at the foot which appears “in toed” and slanted and appears ready to kick the back of the right heel, not to mention the knees that are about to brush together. Thus, merely working on their foot strike would be so remedial and corrupt that it would a crime.

Ivo and I do not take on cases via the internet because we cannot give all the information because we cannot examine the client, many do offer such services but people are not being given the whole story and we pledged long ago not to be part of the problem. Anyone who recommends exercises from things they see on a video gait analysis are basically doing the same disservice in our opinion. But sometimes, as in this case, their inquiry is simple, there is a photo or video and it allows us to highlight an important component of an individuals gait which can lead them on a road to appropriate discovery. This is one of those cases. I will not be presenting a solution, because I do not have the examination information I need, but I will propose a solid thought process that further investigation may afford progress towards resolution.

This is a non-pathologic cross over gait in my mind until proven otherwise, there may be other sources, causes and components, but when it quacks like a duck you’d be silly not to check for webbed feet. This runner even confirmed upon questioning that the left foot scuffs the inside of the right ankle/shin often, both sides scuff in fact but more left shoe on right shin. No Einsteinian epiphany there. After all, the thigh adduction on the left is what gives the foot posturing appearance, but it is likely driven by poor stabilization on the stance side leg (the right):

This means a narrow swing through (adducting) left limb.
This means stance and swing phase gluteus medius communication problems.
This means swing leg foot targeting problems.
This often suggests right, but sometimes both right and left, frontal plane pelvis sway problems which means pelvis control is challenged which means core lumbar stability control is challenged.
This means adaptive arm swing changes from the clean norm.
This does NOT mean this runner has pain, or pain yet, or maybe never will have pain but there are many determinants of that which I will discuss below.

But, make no mistake, this is flawed gait mechanics. The left swing leg is clearly targeting a more medial placement, meaning limb adduction (active or passive or both is to be determined) and this is a product of the cross over gait (unfamiliar with the cross over gait ? SEARCH our blog for the term, you will need a few hours of free time to get through it all). Some would call the cross over gait a lazy gait, but I would rather term it an efficient gait taken too far that it has now become a liability, a liability in which they can no longer stabilize frontal plane sway/drift. A wider gait on the other hand, as in most sprinters, is less efficient but may procure more power and the wider base is more stable affording less frontal plane drift. Just go walk around your home and move from a very narrow line walking gait to a wide gait and you will feel a more powerful engagement of the glutes. Mind you, this is not a fix for cross over gaits, gosh, if it was only that simple !

This runner must investigate whether there is right frontal plane drift, and if it is in fact occurring, find the source of the drift. It can come from many places on either limb. (This client says they are scuffing both inside ankles, which is not atypical and so we likely have drift on both right and left). We have discussed many of them here in various places on the blog over the years. Now as for “Why” the foot looks in toed, well that can also come from many places. Quite simply the adducted limb once it leaves toe off can look like this. But, perhaps it is also a product of insufficient external rotation maintenance occurred during that left stance phase, affording more internal rotation which is being unchecked and observed here during early swing. Remember though, if this is in fact a cross over gait result, in this gait the limb approaches the ground unstacked (foot is too far inside a left hip joint plumb line) the foot will greet the ground at a far lateral strike and in supination. Pronation will thus be magnified and accelerated, if there is enough time before toe off. However, and you can try this on your own by walking around your home, put yourself in terminal stance at toe off. Make sure you have the foot inverted so you are toeing off the lateral toes (low gear toe off). Does this foot not look like the one in the photo ? Yes it does, now just lift the foot off the ground and you have reproduced this photo. And when combined with a right pelvis drift, the foot will sneak further medially appearing postured behind the right foot.

Keep this in mind as well, final pronation and efficient hallux (big toe) toe off does often not occur in someone who strikes the ground on a far lateral foot. I am sure this runner will now be aware of how poorly they toe off of the big toe, the hallux. They will tend to progress towards low gear toe off, off the lesser toes. This leaves the foot inverted and this is what you are seeing in her the photo above. That is a foot that is inverted and supinated and it carried through all the way through toe off and into early swing. It is a frequently component of the cross over gait, look for it, you will find it, often.

Final thoughts, certainly this can be an isolated left swing phase gluteus medius weakness enabling an adducted swing limb thus procuring a faulty medial foot placement, but it is still part of the cross over phenomenon. Most things when it comes to a linked human frame do not work in isolation. But i will leave you with a complicating factor and hopefully you will realize that gait analysis truly does require a physical exam, and without it you could be missing the big picture problem. What if she has a notable fixed anatomic internal tibia torsion on that left side. Yup, it could all be that simple, and that is not something you can fix, you learn to manage that one as a runner.

* Side bar rant: Look at any google search of runners photos and you will see this type of swing limb foot posturing often, far too often. And yes, you can take the stance that “I do it as well and i have no injuries or problems so what is the big deal?”. Our response is often “you do have an issue, it may be anatomic or functional, but you do have an asymmetrical gait and you think it is not a problem, YET”. And maybe you will run till you are 6 feet under and not have a problem because you have accomodated over many years and you are a great compensator, yes, some people get lucky. Some people also do not run enough miles that these issues express themselves clinically so lets be fair. But some of these people are reality deniers and spend their life buying the newest brace or gadget, trying a different shoe insert, orthotic or new shoe of the month and shop over and over again for another video gait analysis expert who can actually fix their pain or problem. And then there are those who have a 45 minute home exercise program that they need to do to keep their problems at bay, managing, not fixing anything. Or, they spend an hour a week on the web reading article after article on what are the top 4 exercises for iliotibial band syndrome for example. They shop for the newest Graston practitioner, the newest kinesio taping pattern, Voodoo bands, breathing patterns, compression socks etc. And sometimes they are the ones that say they still dont have a problem.You get the drift. Gosh darn it, find someone who knows what the hell they are doing and can help you fix the issues that are causing the problem. And yes, some of the above accoutrements may be assistive in that journey.

I have dealt with this unique toe off issue way too many times not to roll my eyes at it any longer. It is to the point that it is an automated evaluation and solution program that begins to run in my head. Once you see something enough times, you learn all of the variations and subtle nuiances that a problem can take on. But, trying to fit everyone into a similar solution model is where the novice coach, trainer or clinician will get into trouble. Trust us, it all starts with an examination, a true clinical physical examination. If one leaves the investigatory process to a series of screens or functional movement patterns, “activation” attempts, digital gait analysis or strength tests one is juggling chainsaws and the outcome you want is often not likely to occur. There is nothing wrong with making these components part of the investigation process, but on their own, they are not enough to get the honest answer many times. Of course, Ivo and i were not able to jump the pond and examine this runner with our own eyes and hands so today’s dialogue was merely to offer this runner some food for thought to open their mind to our thought process, in the hopes that they can find someone to help them solve the underlying problem and not merely make the gait look cleaner. Making someone’s walking or running gait look cleaner is not hard, but making it subconsciously competent and clean (without thought or effort) requires a fix to the underlying problem. We can ALMOST guarantee you that the solution here to this runner’s form issue is not wholly at the foot that looks in toed and slanted. Merely working on their foot strike would be so remedial and corrupt that it would a crime.

Dr. Shawn Allen, one of the gait guys

Why are you putting your internal hip rotation into your low back (pain).

Why are you putting your internal hip rotation into your low back (pain).

On October 12th, 2018 I wrote about utilizing the gluteals in internal hip rotation. You will have to go back and search FB for that article and video.
Assessing Internal hip rotation (in various ranges of hip flexion, extension, abduction and adduction) is a basic exam principle I examine on nearly every patient and athlete that comes to see me, regardless of their complaint. Other than breathing, walking is the next most under appreciated movement we undertake, and take for granted.
Lack of adequate internal hip rotation, in my clinical experience (20+ years), is all too often a fundamental parameter in hip, knee and low back pain. It is necessary to have unrestricted internal hip rotation during gait. Adequate internal hip rotation in the mid to late stance phases of gait is critical and is also paired with hip extension, in fact, one has to pass through adequate internal hip internal rotation to get to adequate hip extension. Without one, we do not get the other. And, if the internal rotation is not imparted in the hip when the hip is supposed to be the one internally rotation, that demand is going to move up or down, caudally or rostrally, low back or knee. Of interesting note, taking things deeper, the opposite arm is also going to go through internal rotation and extension at the same time. Impair one limb, and we can make a case, often enough, that the contralateral upper or lower limb is also challenged. This fundamental fact is one of the fascinating reasons Dr Ivo and I get so geeked out by gait and human movement. Because, it is very complicated. And if one is not looking close enough, paying enough attention with enough fundamental knowledge, things are going to get overlooked and missed when solving for "X" in a client's pain/problems/movement. Compensation will ensue, all too easily. Build strength on said compensations and we are off to the races in driving neuronal pasticity into potential asymmetries. If one is strength training a client without examining them and making specific corrections along the way, well, we reap what we sew. Ok, enough soap-boxing. -Dr. Allen
Here, don't take our word for it, . . . . .

"Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review."
Ortop Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
Sadeghisani M1, Manshadi FD1, Kalantari KK1, Rahimi A1, Namnik N2, Karimi MT3, Oskouei AE4.

"There is a hypothesis which suggests that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.

"Asymmetrical (right versus left, lead versus non-lead) and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetrical total hip rotation was also observed in patients with LBP. However, none of the studies explicitly reported limited hip external rotation ROM."

CONCLUSION: "The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be included in the examination of patients with LBP symptoms."

Photo credit: courtesy of Pixabay

Hip control, the glutes and centration.

Here at GG we have many mantras. One we have been sharing for 10 years or more is
"when the foot is on the ground, the glutes had better be in charge, and when the foot is in the air, the abdominals better be in charge".
We discuss at length with our athletes, and even non-athletes, that if you do not have sufficient control of the hip-pelvis interface (enough skilled stability of the hip into the pelvis, and of the pelvis onto the hip) and as well, sufficient control of the pelvis-spine interface, problems and injuries are a near forgone conclusion.

Here is another article to substantiate this concept, this one from a preventative perspective. Nothing new or earth shaking for most of you here, but always a good reminder, for newbies and the grey haired alike here at the GG brethren.

"Muscle activity of the core unit during explosive running appeared to be associated with hamstring injury occurrence in male soccer players. Higher amounts of gluteal and trunk muscle activity during the airborne phases of sprinting were associated with a lower risk of hamstring injuries during follow-up. Hence, the present results provide a basis for improved, evidence-based rehabilitation and prevention, particularly focusing on increasing neuromuscular control of the gluteal and trunk muscles during sport-specific activities (eg, sprint drills, agility drills)."

Proximal Neuromuscular Control Protects Against Hamstring Injuries in Male Soccer Players: A Prospective Study With Electromyography Time-Series Analysis During Maximal Sprinting.

Schuermans J, et al. Am J Sports Med. 2017.

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."

Part 2: How relaxed, or shall we say “sloppy” is your gait ? The Cross over gait /Frontal plane drift gait.

In this photo (*credit below) the blurred right swing leg tells you this client has been photographed during gait/running motion. Can you see it ? Have we educating you well ?

Human gait is cyclical. A problem on one side will corrupt the other and the cycle begins, and usually continues until the cycle is broken. 

We wish to remind you of our time hammered principle that when the foot is on the ground the glutes are heavily in charge, and when the foot is in the air, the abdominals are heavily in charge.  For us to move cleanly and efficiently one would assume that the best way to do that would be to ensure that the lower 2 limbs are capable of doing the exact same things, with the same timing, same skill, same endurance and same strength. This goes for the upper 2 limbs as well, and then of course the synchronizing of the four in a cohesive antiphasic effort. This would be perfect and clean gait, a gait that would unlikely ever suffer pain or problems. Symmetrical durability wins every time. 

This photo demonstrates the cross over gait and we are beating it to a pulp here, again.  In this running gait photo, this momentary snapshot of global movement, it shows this client is engaging movement into the left frontal plane excessively, they have drifted to the left far outside the vertical plumb line from the foot. The question is, it is excessively enough to present as painful pathology or is it a painless problem at this time? We call what you see here a frontal plane drift, but more so, the cross over gait. You can even see suggestion of the left frontal drift as evidenced by the concavity of the lumbar spine curve to the left.  It should be clear that the right pendulum leg will scrape the left calf on its way through its oblique pendulum swing (instead of a pure forward sagittal swing) to a foot strike somewhere near to the line they are closely running on (a theoretical line). This is the cross over gait.  After this left frontal plane drift and right cross over, there will likely be a corresponding right frontal plane drift and left cross over to compensate on the very next step. Thus, the cycle begins, each on feeding and compensating off the other. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to  have the stability from S.E.S (skill, endurance, strength) to stack the hip, knee and foot over top of each other.  You have to have enough ankle stability and a host of other clean and strong and skilled layers to fend it off to be precise. One must be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain (yet), this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, posterior ischeofemoral impingment syndrome, a compensation in arms swing or thoracic spine rotation or head tilt etc … .  something has to give, something has to compensate.

To complicate the cyclical scenario, the time usually used to move sagittally will be partially used to move into, and back out of, the frontal plane. This will necessitate some abbreviations in the left stance phase timely mechanical events. Some biomechanical events will have to be abbreviated or sped through and then the right limb will have to adapt to those changes. These are simple gait problems we have talked about over and over again here on the gait guys blog. (Search “arm swing” on our blog and you will find 50+ articles around this topic.) These compensation patterns will include expressed weaknesses in various parts of the human frame as part of the pattern

Are you able to find the problem in the never ending loop of compensations of your clients and find a way to unwrinkle their system one logical piece at a time, or will you just chose to strengthen the wrinkled system and hope that the new strength on top of the compensations is adequate for you or your client ? One should not be forever sentenced to daily or weekly rehabilitative sessions or homework to negate and alleviate symptoms, this is a far more durable machine than that. Fix the problem.  Merely addressing things locally can be a crime.  If you are seeing an arm swing change, you would be foolish not to look at the opposite lower limb and foot at the very least, and of course assess spinal rotation, lateral flexion and hinging as well as core mobility and stability. 

For you neuro nerds, remember what Dr. Ivo says, that the receptors from the central spine and core fire into the midline vermis of the cerebellum (one of the oldest parts of our brain, called the paleo cerebellum); and these pathways, along with other cerebellar efferents, fire our axial extensor muscles that keep us upright in the gravitational plane and provide balance or homeostasis through stability.  It is why they assessed and addressed.  

Or, if this is too much thinking for you, … you can just train harder and get stronger . .  . in all your compensation patterns, after all, it is easier than figuring out why and how a right ankle for example started the whole mess, if in fact that is even the first piece of the puzzle.  No one said this would be easy. 

So, how sloppy is your gait ?

Dr. Shawn Allen, one of the gait guys

________________________

References and Credits

Note: photo linked to this article. Photo credit/property: REUTERS/Eduardo Munoz (Copyright Reuters 2016).  

Article: Workouts focused on motor skills may help ease lower back pain

 http://www.foxnews.com/health/2016/01/14/workouts-focused-on-motor-skills-may-help-ease-lower-back-pain.html

Do I Really Need My Pinky Toe?

Just the other day we saw this article in Popular Science written by Sally Zhang.  Sally obviously does not read our blog, but she got a lot of stuff right.

“If you’re born without a pinky toe or have an accident and it’s removed, you can completely do everything you wanted to do,” Dr. Anne Holly Johnson, instructor in orthopaedic surgery at Harvard Medical School, says.

Above you will see a photo of one of the gait guy’s feet.  It is quite clear from the photo that competent use of the pinky toe is not necessary for adequate, and possibly exceptionally skilled, foot function.  Here, check out this video of our foot in these 2 videos (here and here) for some advanced foot function (sans pinky toe). As you can see in the photo above, this 5th toe has likely never felt the ground, this is a fixed deformity.  Flexor and extensor function of the toe are intact, but it does not reach the ground and so assistance in gaining adequate purchase of the 5th metatarsal on the ground is absent. 

This brings us to a deeper question, what about the 5th metatarsal then? Is it necessary ?  Our answer even without deeper research is a solid “yes”. The foot tripod is severely compromised without the 5th metatarsal. The lateral stability of the foot is impaired without the 5th MET.  The natural locking of the calcaneocuboid joint mechanism will be impaired, the peroneal muscles that provide such critical lateral ankle and foot stability will have fascial planes and tendon attachments disengaged, the natural walking gait lateral to medial foot progression would be impaired, propulsion would be impaired and the list goes on and on. And, not even on the local foot/ankle level. Because, if you take out the function and stability of the lateral foot the hip is very likely to suffer lateral (frontal plane) stability deficits. Meaning, the gluteus medius and abdominal obliques will have more difficulty guarding frontal plane drift when in stance phase rendering all of the “cross over gait” risks (link) highly probable.  

So, not much exciting stuff here today. The presence of a functioning pinky toe does not appear to be critical but don’t take away its big brother neighbor, the 5th Metatarsal or trouble is just around the corner. Don’t believe us? Just ask anyone with a non-union fracture (Jones fracture) of the 5th metatarsal.

The answer goes back to the evolutionary history of humans, explains Dr. Anish Kadakia, assistant professor in orthopaedic surgery at Northwestern University. "Primates use their feet to grab, claw, to climb trees, but humans, we don’t need that function anymore,“ Kadakia says. "Clearly we’re not jumping up and down trees and using our feet to grab. We have toes embryologically, evolutionary for that particular reason because we descended from apes, but we don’t need them as people.”

The gait guys, working with 4 toes on each foot, one step ahead of evolution it seems.

Shawn and Ivo,

The gait guys

reference:

http://www.popsci.com/science/article/2013-05/fyi-do-i-really-need-my-pinky-toe?dom=tw&src=SOC