So you say your client needs more ankle rocker? Faking out ankle dorsiflexion and ankle rocker.

I was reminded again yesterday, after yet another foot pain client came in to see me, that many do not understand the absolute and deeper ramifications of putting an orthotic into a shoe (and onto a foot) and what effects of doing so can have on changing a necessary adaptation.

This client had medial heel pain, not plantar heel pain, not the posterior calcaneal area, the medial edge (see photo). The edge where the inside/medial edge of the calcaneus/heel meets the ground. This client could reproduce the pain on palpation and could reproduce it if they stood up, and everted the heel just a tiny bit.

This client had a healthy appearing foot and arch. But, as often is the case, appearances are deceiving. 

Here was the major problem:

- client had loss of terminal ankle dorsiflexion from prior fracture immobilization

- top end calf weakness * (see later)

- client had clear fatiguability of the anterior shin compartment muscles, and mild toe extensor weakness

- the client had high arched supportive orthotics

So, what is happening here, and often happens with the above limitations, the client does not have the muscular ability to maintain the arch sufficiently from the big players, as noted. In other words, the ankle has lost mobility and the foot has lost stability, a common pattern. To make up for a loss of ankle dorsiflexion we often collapse the arch a sufficient amount to pitch the talus medially and forward to help the tibia progress forward the requisite amount needed for forward locomotion across the foot-ankle complex. This is a normal compensation, and in time there may be a pathologic cost. This medial approach of the talus and arch collapse, requires calcaneal eversion. This eversion means more medial calcaneal loading into the shoe, orthotic or ground, including medial soft tissue (mostly fat pad) loading between the ground and the everting calcaneus.  

This is a normal compensatory strategy to move forward over a restricted ankle dorsiflexion range. However, the doctor this client saw previously (for plantar fascitis), felt that this motion was a problem they needed to block with an orthotic. One that resisted the heel eversion and more than normal arch collapse/pronation cycle. This remedy resolved the plantar fascial pain. But, the medial heel pain began shortly thereafter. 

So, here we have a client that is compensating, and finding a way (though there are biomechanical costs to this way), to get past a limitation, loss of ankle rocker in this case. But, the doctor put an orthotic in the shoe that stopped this "way".  Now the client has to evert the heel even harder, because of the presence of the orthotic preventing it) and it is causing a "bite" or friction plus compression of the medial soft tissues. 

So, this client now still cannot compensate well, in the manner they have attempted to do so, because of the orthotic. So, where are the loads going to go now ? Yes, some are being rammed into the medial aspect of the orthotic, but some are likely going to so elsewhere. Remember, the client is trying to progress their mass over and past the limited ankle rocker, and more pronation was their strategy. But, the orthotic is preventing that.  So, the loads are very likely going to move up the chain (because the orthotic is muting loads down into the foot). 

______

Me:     "Oh, wait, "Mr. Jones", didn't you say you were just recently beginning to have some posterior knee pain ?  Let me tell you why you are hyperextending your knee a little more than normal and taxing out your gastrocneumius.* One way you can progress forward, if you cannot do it through ankle rocker, is to extend your knee a little by contracting your quadriceps a small amount at midstance.  Lets discuss why the orthotic is not helping you, not solving your problem, and creating some new issues for you. Then lets get down to fixing the root problem."

Some things to think about.  Orthotics are not bad, but the user has to know when they are a device to help a client progress through a problem, and when they are inappropriate. Not all increased pronation is bad, particularly when it helps a client get through a problem. But, fix the root problem, and then help them regain proper amounts of pronation.

Oh, and one more thing, all you "drive more ankle rocker and dorsiflexion" people out there. Are you driving more ankle dorsiflexion, or are you merely pressing the talus into more medial posturing, plantarflexion and adduction? These are the talar motions in pronation. And when you pronate, you get more ankle rocker, faked out ankle rocker. So, are you truly helping your client get more ankle rocker and dorsiflexion ? Is this increased pronation what they are doing during their squats, to "apparently" get enough ankle rocker/dorsiflexion?  Be careful all those new found ankle rocker mobility drills are not just making your client pronate more than normal. We know it happens, we see all the time. Loss of ankle mobility and loss of foot stability are often a paired phenomenon, they are trying to talk to you and tell you to treat the root cause.

-Dr. Allen, one of the gait guys

Some Basic Tenets of Gait

Initial contact? Loading response? Mid stance? Terminal Stance? pre swing? Are these terms that are familiar to you? Hmmm. How about the wrong orthotic for someone with internal tibial torsion? Join us in this excerpt from a recent Gait and Needling seminar

https://vimeo.com/226733697

Forefoot strike running: Do you have enough calf muscle endurance to do it without a cost ?

Below you will find an article on footwear and running. Rice et al concluded that 

“ When running in a standard shoe, peak resultant and component instantaneous loadrates were similar between footstrike patterns. However, loadrates were lower when running in minimal shoes with a FFS (forefoot strike), compared with running in standard shoes with either foot strike. Therefore, it appears that footwear alters the loadrates during running, even with similar foot strike patterns.

They concluded that footwear alters the load rates during running. No brain surgery here. But that is not the point I want to discuss today. Foot strike matters. Shoes matter. And pairing the foot type and your strike patterns of mental choice, or out of natural choice, is critical. For example, you are not likely (hopefully) to choose a HOKA shoe if you are a forefoot striker. The problem is, novice runners are not likely to have a clue about this, especially if they are fashonistas about their reasoning behind shoe purchases. Most serious runners do not care about the look/color of the shoe. This is serious business to them and they know it is just a 2-3 months in the shoe, depending on their mileage. But, pairing the foot type, foot strike pattern and shoe anatomy is a bit of a science and an art. I will just mention our National Shoe Fit Certification program here if you want to get deeper into that science and art. (Beware, this is not a course for the feint of heart.)

However, I just wanted to approach a theoretical topic today, playing off of the “Forefoot strike” methodology mentioned in the article today.  I see this often in my practice, I know Ivo does as well. The issue can be one of insufficient endurance and top end strength (top end ankle plantar flexion) of the posterior mechanism, the gastrocsoleus-achilles complex. If your calf complex starts to fatigue and you are forefoot striker, the heel will begin to drop, and sometimes abruptly right after forefoot load. The posterior compartment is a great spring loading mechanism and can be used effectively in many runners, the question is, if you fatigue your’s beyond what is safe and effective are you going to pay a price ? This heel drop can put a sudden unexpected and possibly excessive load into the posterior compartment and achilles. This act will move you into more relative dorsiflexion, this will also likely start abrupt loading the calf-achilles eccentrically. IF you have not trained this compartment for eccentric loads, your achilles may begin to call you out angrily. Can you control the heel decent sufficiently to use the stored energy efficiently and effectively? Or will you be a casualty?  This drop if uncontrolled or excessive may also start to cause some heel counter slippage at the back of the shoe, friction is never a good thing between skin and shoe. This may cause some insertional tendonitis or achilles proper hypertrophy or adaptive thickening. This may cause some knee extension when the knee should not be extending. This may cause some pelvis drop, a lateral foot weight bear shift and supination tendencies, some patellofemoral compression, anterior meniscofemoral compression/impingement, altered arm swing etc.  You catch my drift. Simply put, an endurance challenged posterior compartment, one that may not express its problem until the latter miles, is something to be aware of. 

Imagine being a forefoot striker and 6 miles into a run your calf starts to fatigue. That forefoot strike now becomes a potential liability. We like, when possible, a mid foot strike. This avoids heel strike, avoids the problems above, and is still a highly effective running strike pattern. Think about this, if you are a forefoot striker and yet you still feel your heel touch down each step after the forefoot load, you may be experiencing some of the things I mentioned above on a low level. And, you momentarily moved backwards when you are trying to run forwards. Why not just make a subtle change towards mid foot strike, when that heel touches down after your forefoot strike, you are essentially there anyways. Think about it.

Shawn Allen, one of The Gait Guys

Footwear Matters: Influence of Footwear and Foot Strike on Loadrates During Running. Medicine & Science in Sports & Exercise:
Rice, Hannah M.; Jamison, Steve T.; Davis, Irene S.

http://journals.lww.com/acsm-msse/Abstract/publishahead/Footwear_Matters___Influence_of_Footwear_and_Foot.97456.aspx

So you want to do a Gait Analysis: Part 3

This is the third in a multi part series. If you missed part 1, click here. For part 2, click here.

 Again, a quick review of the walking gait cycle components:

There are two phases of gait: stance and swing. 

Stance consists of:

• Initial contact
• Loading response
• Midstance
• Terminal stance
• Pre-swing

Swing consists of:

• initial (early) swing
• mid swing
• terminal (late) swing

today, lets explore Midstance

we remember that midstance is the mid point of the stance phase of the gait cycle. It is when the maximal amount of midfoot pronation should be occurring

Lets look at what is happening here at the major anatomical areas:

Foot

• Pronation begins: The talus should have slid anteriorly on the calcaneus and it then plantar flexed, everted and adducted to its greatest degree. The subtalar joint should have its axes parallel with the calcaneocuboid joint, essentially “unlocking” the midfoot.  This allows the midfoot to assist in absorbing shock, along with knee flexion, hip flexion and a dip of the contralateral pelvis.
  

•  the calcaneus everts to a max of approximately 5-8°

•  the center of gravity of the foot is lowest at this point, and the ankle mortise its deepest. 

• The lower leg should be internally rotated (as it follows the talus) 4-6°

• The thigh should follow the lower leg and should also be internally rotated 4-6°; sometimes to a greater extent due to the shape and size of the medial condyle of the femur (which is larger than the lateral)

• these actions are (still) attenuated by eccentric action of both the long flexors and extensors of the ankle, as well as the foot intrinsics

Ankle

• The ankle should be neutral, as it should be at the mid point of ankle rocker

Knee

• Flexion to 20°. This is attenuated largely by the quadriceps, contracting eccentrically. The popliteus has often concentrically contracting to assist in internal rotation of the thigh up until midstance. It is quiescent at midstance and will begin to contract eccentrically as soon as the knee passes midstance.

Hip

• The hip is at full flexion at loading response, decreasing as it approached midtsnce and now begins to extend. This is facilitated by a brief contraction of the gluteus maximus (which started at initial contact)

Can you see what is happening? Try and visualize this in your mind. Can you understand why you need to know what is going on at each phase to be able to identify problems? If you don’t know what normal looks like, you will have a tougher time figuring out what is abnormal.

Ivo and Shawn. Gait and foot geeks extraordinaire. Helping you to build a better foundation to put all this stuff you are learning on.

Midfoot strike in a non-zero drop shoe. Have you thought about this ?

Here is something to think about. As one midfoot strikes the foot during walking or running the individuals body mass is typically directly over the foot.  When this occurs in a zero drop shoe (ie. flat, your rear and forefoot are on the same plane) the tibia-ankle is at the very least, at 90 degrees. Meaning, the tibia is at the very least at 90 degrees and is at the very least perpendicular to the ground and plane that the foot is on.  And with just a little bit of forward body mass movement over the foot the critical and necessary range of 110-115 plus degrees of ankle dorsiflexion (depending on your reference source) is achieved. This means that one does not have to prostitute the foot into greater than normal pronation to drop the arch further to gain the extra amount of ankle rocker (dorsiflexion) that is necessary to pass over the foot.

However, think about this.  What if that same foot is in a stacked heel shoe.  There are plenty of shoes still out there that have a ramp delta that is above zero drop. So, what we have is a shoe that has the heel higher than the forefoot, a sloped shoe.  IF this same foot midfoot strikes what happens now ?

Well, midfoot strike now occurs in a relatively greater plantarflexed posture (ie. heel is raised higher than the forefoot because of the shoe). This means we are not anywhere near the 115 degrees necessary for normal gait, timely heel departure, timely forefoot load, timely hip extension, timely gluteal activation etc. These timely gait events are paramount to normal gait and when they are altered injury and altered tissue loads can occur.  Altered motor recruitment patterns are likely to ensue.  In the scenario proposed, as the body mass moves over the slightly plantarflexed foot we might now only get to 90 degrees of ankle rocker before the body mass is far enough forward to create the passive heel rise during late-midstance phase of gait. And when the body can only get 90 degrees of ankle dorsiflexion/rocker during midstance the extra amount of dorsiflexion range may need to come from some other joint.  It may come from more than normal midfoot pronation, knee hyperextension, knee valgus etc. This is potentially a long list of compensations.

Our point is simple here and at this time it is just a tip of the iceberg article for us.  But we thought we would put this idea out there to share some of the things we think about on a daily basis, and some of the things that get played out in our clinics each and every day. 

Changing your running form involves so much more than just changing your form. If you change to a midfoot or forefoot strike what kinds of biomechanics are you employing ? Do you have the neuromechanics to accompany these running form changes ? Do you have the necessary ranges of motion ? Do you have strength in potential compensation patterns to fend off both subtle and dramatic running form changes ?  If not, you might find out that your initial response is “ I just cannot do a midfoot or forefoot strike running form. I get foot pain, or knee pain, or hip pain.”

Conversely, think about this regarding our postulation above.  If you have been employing a midfoot strike or forefoot strike pattern in stacked heeled shoes and suddenly try a zero drop shoe you better be aware of symptoms such as pain, tightness or other complications.  Is your body able to adapt to a new (possibly increased) ankle-midfoot rocker or the demand of a greater ankle-midfoot with the newly dropped heel? Is your body immediately adaptive enough after going through that stage of gait with the heel higher than the forefoot for years ?  Just because you went to a running form clinic doesn’t mean  you are ready to make that your new form tomorrow. Change takes time, so be patient with your body and let it adapt.

Food for thought, especially for those who say to others. “Hey dude, chuck your ramped shoes and go minimialism or barefoot. Just go for it. I did and I was fine !”

What is fine for one, is not fine for all.

Shawn and Ivo

The Gait Guys

Gait Cycle Basics: Part 2

Gait Cycle components

Let’s begin today with a typical walking gait cycle.

There are 2 phases: stance and swing. It comprises approximately 62% of the gait cycle. Inman and Scranton use the following classification:

Heel strike: when the heel hits the ground

Full forefoot load: weight is transferred anteriorly to the forefoot

Heel lift: when the heel begins lifting off the ground

Toe off: the beginning of propulsion

They further divide this into a contact period (heel strike to full forefoot load), a midstance period (from full forefoot load to heel lift) and a propulsive period (from heel lift through toe off)

Jaqueline Perry, the Matriarch of gait, uses a slightly more descriptive classification which we prefer:

Initial contact: when the foot 1st touches the floor

Loading response: weight bearing on the loaded extremity from initial contact and continues until the opposite foot is lifted for swing

Midstance: the 1st ½ of single limb support, beginning when the opposite foot is lifted until weight is over the forefoot

Terminal stance: begins with heel rise and continues until the opposite foot strikes the ground

Pre swing: when initial contact of the opposite extremity begins and toes off ends

She also describes 3 tasks to be performed during a gait cycle: weight acceptance (the limb is able to bear weight), single limb support (when weight is supported by one limb with the other in swing phase), and swing limb advancement (moving the opposite limb through space to become the next stance phase leg.

The question is, how do we adequately progress over the stance phase leg? Stay tuned to our next post for a primer on the 3 rockers….

The Gait Guys…Promoting gait literacy and understanding for the clinician and the consumer.