The “Standing on Glass” Static Foot/Pedograph... PART 2

The “Standing on Glass” Static Foot/Pedograph... PART 2
We hope you find this case presentation dialogue interesting.

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon.

Here is the case . . .

Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there.

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left. The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ? Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings. Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern.

Remember this critical fact. After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively. Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow. We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation. See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations. Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining. The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

The “Standing on Glass” Static Foot/Pedograph... PART 1
We hope you find this case presentation dialogue interesting.

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon.

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations. Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining. The big questions should be, “why do i see this, what could be causing these observances ?”

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot. Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level. If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg. In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg. Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ? Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation. Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings. Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact. After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively. Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ? What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption. See you tomorrow friends !

Shawn and ivo, the gait guys

Here is the case link.......

https://thegaitguys.tumblr.com/post/99409232289/the-standing-on-glass-static-footpedograph?fbclid=IwAR3gd3d81Gwt3ywAB7BcTwXqST2Z_5nmieODzSb8rJQYBcJFhTs6rS_9auA

What does a pedograph of a person with hallux limitus look like?

Take a good look at the pedographs above. Can you figure out which side has the hallux limitus from the pictures? 

You would think that with hallux limitus there would be increased printing over the distal phalanx of great toe and possibly over the distal metatarsal as seen in the print of the right foot. This would make sense as if you have limited motion here and the pressure will be more forward. However, often times Hallux limitus is painful and the patient develops a compensation to NOT load the joint, as we see on the print of the left foot. We see the lack of printing under the first metatarsal head and increased printing laterally in the foot from avoidance of that joint. Also notice a slight increased printing in the right heel teardrop (hash marks are more filled in) and slight widening of it anteriorly. He has a right sided leg length discrepancy and we would normally expect an increased amount of pronation on the longer leg side, however because of the weight shift to the left we are seeing increased pronation on the right. Now, with this valgus moment of the right foot do you understand why the printing is so heavy under the first metatarsal and distal phalanx. Note also the increased printing at the distal phalanx of toes number two, three and five on the right hand side in an attempt to stabilize as his center of gravity shifts to the right.

And now you know!

Dr Ivo, one of The Gait Guys

#halluxlimitis, #gaitanalysis, #pedograph, #leglengthdiscrepancy, #LLD

The Beef on the EDL.....

We have long been promoting appropriate function of the long extensors of the toes  here, in our practices, our lectures, on Youtube, in our book......You get the idea. Lets take a closer look at this often weakened and overlooked muscle.

We remember that the EDL lies mostly in the superior and somewhat lateral part of the anterior compartment of the lower leg, comprising approximately the upper 2/3 from under the lateral tibial plateau and fibula, and from the interosseus membrane. It lies under the tibialis anterior, and the extensor hallucis longus lies below it. Its tendons pass inferiorly and travel under the extensor retinaculum and attaches to the base of the distal phalanges of toes 2-4. These muscles act from initial contact to loading response to help eccentrically lower the foot to the ground and ensure smooth heel rocker and most likely attenuate the speed of initial pronation as the talus glides anteriorly on the calcaneal facets and again from terminal stance through initial swing to provide compression of the metatarsal phalangeal and interphalangeal joints, to offset the long flexors (which are often overactive) and create clearance for the toes during swing.  

What does it look like when the long extensors don’t work so well? Have a look at the pedograph on the right (pair J howard r). what do we see? First we notice the lack of printing under the head of the 1st metatarsal and increased printing of the second metatrsal head. Looks like this individual has a forefoot supinatus, or possibly a forefoot varus (cannot get the head of the 1st metatarsal to the ground, and thus a weak medial tripod, possibly insufficient extensor hallucis brevis, peroneus longus, flexor digitorum brevis, or all of the above). Next we see increased printing of the distal phalanges of digits 2-4. Looks like the long flexors are dominant, which means the long extensors are inhibited. What about the lack of printing of the 5th toe? I thought the flexors were overactive? They are, but due to the supinatus, the foot is tipped to the inside and the 5th barely contacts the ground!

How do you fix this?

• Help make a better foot tripod using the toe wave, tripod standing and extensor hallucis brevis exercises.
• Make sure the articulations are mobile with joint mobilization, manipulation and massage.
• How about dry needling and acupuncture to improve function?
• Make sure the knee and hip are functioning appropriately.
• Put them in footwear that will allow the foot to function better (a less rigid, less ramp delta shoe).
• As a last resort, if they cannot make an adequate tripod because of lack of motivation, anatomical constraints or both, use a foot leveling orthotic.

Club Foot, anyone?

This gent came in to see us for a new orthotic prescription. As you can imagine, or are probably aware, these cases present a challange becuase of both the anatomy and pathomechanics, especially the plantar flexed foot and loss of ankle rocker.

This gent had his left foot is 20 degrees plantar flexion. He has bi-lateral rigid forefoot valgus, bi-lat. femoral retrotorsion and bi-lat. internal tibial torsion.  

We built him an othotic with a modified UCB (deep heel cup) with 20 degrees of plantar flexion (ie ramp delta or "drop") into the left orthotic as well as bilateral forefoot valgus posts.

If you would like to read up on clubfoot (or talipes equino varus, as it is called) , here is a nice, full text review.

Anand A, Sala DA. Clubfoot: Etiology and treatment. Indian Journal of Orthopaedics. 2008;42(1):22-28. doi:10.4103/0019-5413.38576.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2759597/

A Tale of 2 Footies

Time for a pedograph, folks. What do we have here?

To review :

Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.

First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.

Let’s start at the rear foot: The heel teardrop is elongated on both sides, slightly more on the right; this means incraesed calcaneal eversion (or rearfoot pronation) bilaterally, R > L. The right heel shows increased pressure (more ink = more pressure).

Next up, the mid foot. Similar shapes, more pressure and printing on the left. Did you notice the “tail” of the 5th metatarsal printing, giving it a wider print? This person is staying on the outside of their foot longer than normal, right (more ink) more than left.

How about the fore foot? Lots going on there.

Lets start on the left

Notice the mild increased printing of the 5th and 4th metatarsal heads. Force should be traveling from lateral to medial here, as the foot goes into supination. A relatively normal amount of pressure on the head of the 1st metatarsal.

Now look at the toes. Notice that space between the 2nd and 3rd? This gal had an old fracture and has an increased space between them.

Now how about the right?

Increased pressure on most of the heads with a concentration on the 1st metatarsal. Hmmm…what would cause that? this is typical of someone who has a 1st ray (cunieform and metatarsal) that is hypomobile, such as with someone with a forefoot valgus (as this person does) or a dropped 1st metatarsal head (which is usually rigid, as is NOT the case here).

Did you see that rpinting at the medial aspect of the proximal phalanyx of the hallux (ie. big toe)? This gal externally rotates the lower extremity to push off the big toe to propel herself forward. This is because the 1st metatarsal head hits the ground BEFORE the 5th (as we would normally expect to see, like in the left foot), and because the weight is now on the outside of the foot, she need to push off SOMETHING.

Getting better at this? We hope so. Keep reading the blog and look at some of our past pedograph posts here.

The Gait Guys. Teaching you about the importance of gait, each and every day!

What’s up, Doc?

Nothing like a little brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let’s start at the rear foot:

• limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.
• note the increased pressure at the  medial calcaneal facets on each side with the increased printing
• very little fat pad displacement overall

Now let’s look at the mid foot:

• decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

• increased printing under the met heads bilaterally; L >> R
• increased printing of 1st met head L >> R
• increased printing at medial proximal phalynx of hallux  L >> R
• increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

• short leg on L
• more rigid foot on L
• increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot?

Here is what is going on:

• there is no appreciable leg length deformity, functional or anatomical
• The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

• Can you feel how when your foot is supinated
• can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction
• Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?
• now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What’s the fix?

• create a more supple foot with manipulation, massage, muscle work
• increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)
• have them walk with their toes slightly elevated
• we are sure you can think of more ways as well!

The Gait Guys. Increasing your gait literacy with each and every post. I

The pedograph as a window to the gait cycle

Have you ever studied footprints on the beach or looked at the print left by a wet foot when you get out of the water? These are some of the most primitive types of pedographs.

The pedograph, 1st described by Harris and Beath in 1947 is a rubber mat surface with multiple protruding, small grid lines on one side, which, when covered with ink, imprints an underlying sheet of paper when weight (usually a foot) passes over it. Relative plantar pressures are indicated by the size and density of the inked area, creating a “footprint” reflecting passages of force through the foot at that instance in time.  They have fallen into and out of usage over the years, often discarded for more expensive technology such as pedobarographs, individual pressure sensors, and pressure sensitive mats, which have computer interfaces and can provide many useful measurements and calculations to assist the clinician with rendering a diagnosis. These systems, though more precise in some ways (provided a controlled, reproducible testing procedure) are often thousands of dollars, require a computer and the necessary skills, and have a substantial learning curve.  

The pedograph in contrast is simplistic, inexpensive, and reliable and only requires that the user have an intact visual pathway and cerebral cortex and knowledge of the events occurring in the gait cycle. With some practice and a good knowledge base, the subtle nuances detected by the sensitive pedograph (nuances that can be undetected with high end computer driven plantar pressure devices) can offer information critical to a precise diagnosis and give solid clues to gait flaws and compensations.  With minimal training using a pedograph, reproducible “prints” can be produced for analysis, in light of your findings clinically. They also make wonderful educational tools for your patients and clients!

An essential part of a comprehensive patient evaluation should include examination of the entire kinetic chain both in a static and dynamic fashion. Often what you see statically is either directly translated to or compensated for in the dynamic evaluation. (It is important to note that many of the available foot scan units available from orthotic companies scan a patient in a static standing position and give little information on how the feet and lower limb dynamically engage the ground during movement.) The pedograph is a useful visual tool representing a 2 dimensional image of tridimensional motion, and you are seeing the end product and compensation (or lack thereof) of the individuals mechanics at that point in time. Because of the specificity of what you are seeing refers to a particular point in time, technique and reproducibility are of paramount importance. Prints should be performed several times to insure what you are looking at is what you are looking at, and not movement artifact, because of the way the patient stepped on to or off of the mat.

With a pedograph, seeing is believing. When you have objective data about how an individual moves through space and how their joints and motor system help them to accomplish that, you have a better appreciation for the type or form of therapy which may be most appropriate. In the hands of a skilled clinician, seeing abnormal plantar pressures tells you where the biomechanical fault lies, and thus where manipulation may be appropriate, which muscles need strengthening and where neuromotor coordination is lacking and gait rehabilitation is needed.  

excerpted from the 1st edition of our Book “Pedographs and Gait Analysis: Clinical Pearls and Case Studies” Trafford Publishing

“Too much tripping, soles worn thin. Too much Trippin and my soul’s worn thin.”

Scott Weiland

Take a look at these shoes which are basically a leather glove for the foot. Look at the wear pattern and how the lines of force travel from the heel, of the lateral aspect of the foot, across the metatarsal heads and out the great toe. To have you wear on the right is due to a left-sided leg length discrepancy.  She has a higher lateral longitudinal arch as evidenced from the absence of where just anterior to the heel.  Looks like she’s getting her first Ray to the ground, Eh?

Can you guess why this person has left-sided plantar fasciitis?

This question probably seem somewhat rhetorical. Take a good look at these pedographs which provide us some excellent clues.

First of all,  note how much pressure there is over the metatarsal heads. This is usually a clue that people are lacking ankle rocker and pressuring these heads as the leg cantilevers forward.  This person definitely have a difficult time getting the first metatarsal head down to the ground.

Notice the overall size of the left foot compared to the right (right one is splayed or longer). This is due to keeping the foot and somewhat of a supinated posture to prevent excessive tension on the plantar fascia.

The increase splay of the right foot indicates more mid foot pronation and if you look carefully there is slightly more printing at the medial longitudinal arch. This is contributing to the clawing of the second third and fourth toes on the right. Stand up, overpronate your right foot and notice how your center of gravity (and me) move medially.The toes will often clench in an attempt to create stability.

The patient’s pain is mostly at the medial and lateral calcaneal facets, and within the substance of the quadratus plantae with weakness of that muscle and the extensor digitorum longus. She has 5° ankle dorsiflexion left and 10 degrees on the right and hip extension which is similar.

The lack of ankle rocker and hip extension or causing her to pronate through her midfoot, Tensioning are plantar fascia at the insertion. The problem is worse on the left and therefore that is where the symptoms are.

Pedographs can be useful tool in the diagnostic process and provide clues as to biomechanical faults in the gait cycle.

Congenital clubfoot anyone?

This gentleman, a longtime patient came in for new orthotics, as his old ones were 10 years old. From the pedographs above, you can see it is his LEFT foot. 

Note the following:

• shortened apparent foot length left compared to right (the foot is merely deformed and plantarflexed)
  
• The increased plantar pressures laterally, from the foot being supinated 
  
• increased arch height L > R
  
• clawing of digits 2-4 to provide stability
  

This case made me think about some common issues that you may be wondering about if you see these folks. 

There are several things you should think about:

• People with clubfoot generally have a high arched, rigid, cavus foot. 
  

• These folks generally are fixed in some degree of plantar flexion.
  

• Because of the plantar flexed posture of their foot, they generally have a loss of a ankle rocker
  

• If you utilize an orthotic with these patients, you need to make sure that there is significant ramp delta (heel higher than the 1st metatarsal)
  

• Clubfoot can often be unilateral.
  

• Clubfoot is usually not congenital
  

• Gait training and balance (proprioceptive) work can be especially helpful in these cases. 

Abductory twist in your gait ?

Last night on our www.onlinece.com teleseminar we discussed some clinical applications and critical thinking of gait parameters and pathology. We discussed the dynamic gait pedograph below. Possible evidence of Abductory Twist gait pathology (video linkhttps://youtu.be/F3DHRoHrYOs). In this case, client had loss of internal hip rotation, but they sure love external rotation pivot at the ground interface, as the pedo shows here (more details were provided on the teleseminar last night).
*Fix the problem, retrain normal gait skills, add endurance and strength to the new gait pattern and you have a solution. Add an orthotic to treat what you see on the pedograph and you have a bandaid (and potentially/probably a problem down the road). You can’t fix a motor pattern compensation by forcing a compensatory fix. Get to the root of the problem, in this case hip and pelvic biomechanics ! It is all about mobility and stability ! 

Sometimes it is easy and straight forward.

HISTORY: A 56 YO 200 # male construction worker presents with pain at the bottom of his right foot, worse in the am, getting better as the day goes on till midday, then getting worse again. Better with rest and ice. More supportive shoes and a heel gel pad offer him some relief. Past history of plantar fascitis. 

OBJECTIVE:           Tenderness at medial calcaneal facet right side;  tenderness also in the arch and over the flexor hallucis longus tendon and short flexors of the toes. Ankle dorsiflexion is less than 5 degrees on the right, and 15 on the left.  Hip extension was less than 10 degrees bilaterally. He has mild bi-lat. external tibial torsion.

Gait evaluation reveled an increased progression angle right greater than left.  Very limited ankle dorsiflexion noted bi-lat (decreased ankle rocker). 

There is weakness of the short flexors (FDB) and long extensors (EDL) of the toes on the right. Poor endurance of the intrinsic musculature of the arch as well as interossei musculature during standing arch test.

PEDOGRAPH FINDINGS: 

ASSESSMENT:       From history and exam, plantar fascitis.

PLAN:           He was given the following exercises:  lift/spread/reach, the one leg balancing, shuffle walks and toes up walking. These were filmed via ipad and sent to him.  We are going to build him a medium heel cup, full length orthotic made out of acrylic.  We will see him again later this week.  We will do some symptomatic treatment utilizing manual stimulation techniques, pulsed ultrasound and additional exercises aimed at improving dorsiflexion as well as hip extension. 

Test your Mental Clinical Thinking Skills with this pedograph case. 

A few months ago, we discussed this case in great detail. There is likely little chance you will see our thinking progression with these final conclusions without sitting down with a warm cup of coffee and going over these 2 prior blog posts on this case (part 1 and part 2).  Besides, it will be a good review for you and it is great mental gymnastics.  This kind of analysis gets easier each time you do it but we have to through out our standard warning. This is the kind of stuff one needs to be able to go through on the fly in one’s practice, it is something to aspire to.

First of all, caveats:

• Our discussions on this case were all theoretical.  What we went through was an exercise in static assessment and clinical thinking. 
• One cannot, and must not, make clinical decisions from a static assessment. 
• As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. 
• Gait analysis or pedograph-type assessment are helpful tools, but not the final answer.

Our static exam proposal on this case came up with the following theories (please stand up and mimic as we discuss, trust us, it will help you). *Remember: the foot on YOUR LEFT is the RIGHT foot for the purposes of this discussion. And remember, this is all theoretical, this is an exercise in biomechanical and clinical thinking, nothing more.

• Suspect Counter-clockwise pelvis distortion pattern (causes relative internal rotation on LEFT and external rotation on RIGHT), this will drive Left knee hyperextension and Right knee flexion (hence foot plantar pressures as we discussed in previous 2 blog posts linked above). This of course cannot be seen, but we are extrapolating from our clinical experiences.
• poor pronation and internal limb spin control on the left (hence longer foot and toe hammering). Obviously, we would see a dramatic shift of the pressures to the medial foot if this were truly the case.  Perhaps this is because of the greater lateral left pelvis drift forcing the glute and foot pronatory controls to have to work harder and longer, and maybe even quicker, to control the internal spin and pronation. Over time, they fatigue and fail rendering a flatter, more pronated and longer heel:toe ball length ratio. This would also give credence to the left toe hammering/gripping response.
• static increased left limb weight bearing (left hip drift)
• abrupt right foot loading pattern (more mid-forefoot strike), perhaps as reflected by the static forefoot loading. Again, supposition.
• with all of the above, it is suspect that this client will appear to have a subtle limp, coming off the left quickly or prematurely as they speed through uncontrolled pronation and resulting in an abrupt right limb loading response that mostly skips through heel strike and results in a more aggressive mid-forefoot loading response.  This, sort of, creates a catching of the loading response by the quadriceps more than the gluteals. This can cause medial knee drift (valgus loading) if the medial knee stabilizers are not up to task, this also creates a sudden patellofemoral compresson event and unappreciated sudden tension on the extensor mechanism (the quad-patella-patellar tendon complex).  Can you say generic anterior knee pain ?

Just some thoughts. Please go back to the prior 2 blog posts to delve deeper into the conclusions we have brought about here, we have other good reasoning to suspect the above as the scenario. But remember, what you see is not the problem, we see people’s compensations, their strategies. This was just an exercise in “what ifs”, nothing more. But you will see it in your clinic, just substantiate it with an exam, not what you necessarily see in your clients gait or static assessment. Static assessments are for fools, don’t be a fooled fool.  What  you see is not the problem.

Remember this critical fact.  After an injury or a long standing problem, the job of muscles and motor patterns is to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries often leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is often a culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. Is the compensation top down, bottom up, or both ?

Don;t be a fooled fool. Get the facts.

Shawn and Ivo, the gait guys

Part 2: “Standing on Glass” Static Foot/Pedograph Assessment

* note (see warning at bottom): This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. The right and left sides are indicated by the R and L circled in pink. There are 4 photos here today.

Blue lines: Last time we evaluated possible ideas on the ORANGE lines here, it would be to your advantage to start there. 

We can see a few noteworthy things here in these photos. We have contrast-adjusted the photo so the pressure areas (BLUE) are more clearly noted. There appears to be more forefoot pressure on the right foot (the right foot is on the readers left), and more rearfoot pressure on the left (not only compare the whiteness factor but look at the displacement of the calcaneal fat pad (pink brackets). There is also noticeably more lateral forefoot pressure on the left. There is also more 3-5 hammering/flexion dominance pressure on the left.  The metatarsal fat pad positioning (LIME DOTS represent the distal boundary) is intimately tied in with the proper lumbrical muscle function  (link) and migrates forward toward the toes when the flexors/extensors and lumbricals are imbalanced. We can see this fat pad shift here (LIME DOTS). The 3-5 toes are clearly hammering via flexor dominance (LIME ARROWS), this is easily noted by visual absence of the toe shafts, we only see the toe pads. Now if you remember your anatomy, the long flexors of the toes (FDL) come across the foot at an angle (see photo). It is a major function of the lateral head of the Quadratus plantae (LQP) to reorient the pull of those lesser toe flexors to pull more towards the heel rather than on an angle. One can see that in the pressure photos that this muscle may be suspicious of weakness because the toes are crammed together and moving towards the big toe because of the change in FDL pull vector (YELLOW LINES). They are especially crowding out the 2nd toe as one can see, but this can also be from weakness in the big toe, a topic for another time. One can easily see that these component weaknesses have allowed the metatarsal fat pad to migrate forward. All of this, plus the lateral shift weight bearing has widened the forefoot on the left, go ahead, measure it. So, is this person merely weight bearing laterally because they are supinating ? Well, if you read yesterday’s blog post we postulated thoughts on this foot possibly being the pronated one because of its increased heel-toe and heel-ball length. So which is it ? A pronated yet lateral weight bearing foot  or a normal foot with more lateral weight bearing because of the local foot weaknesses we just discussed ? Or is it something else ? Is the problem higher up, meaning, are they left lateral weight bearing shift because of a left drifted pelvis from weak glute medius/abdominal obliques ?  Only a competent clinical examination will enlighten us.

Is the compensation top-down or bottom up, or both in a feedback cycle trying to find sufficient stability and mobility ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a screen to drive prescription exercises from what you see on the movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. 

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow.  We will try to bring this whole thing together, but remember, it will just be a theory for without an exam one cannot prove which issues are true culprits and which are compensations. Remember, what you see is often the compensatory illusion, it is the person moving with the parts that are working and compensating not the parts that are on vacation.  See you tomorrow friends !

Shawn and ivo, the gait guys

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or static pedograph-type assessment (standing force plate) is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”right foot supinated ? or more rear and lateral foot……avoiding pronation ?

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations.  Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, “why do i see this, what could be causing these observances ?”

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot.  Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level.  If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg.  In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg.  Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ?  Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation.  Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ?  What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption.  See you tomorrow friends !

Shawn and ivo, the gait guys

Flat Dogs

Take a look at these pedographs. Wow!

• No rear foot heel teardrop.
• No midfoot arch on left foot and minimal on right.
• An elongated 2nd metatarsal bilaterally and forces NOT getting to the base of the 1st metatarsal and stalling on the 2nd: classic sign of an uncompensated forefoot varus.
• increased printing of the lateral foot on the right

Knowing what you know about pronation (need a review? click here) Do you think this foot is a good lever? Do you think they will be able to push off well?

What can we do?

• foot exercises to build the intrinsic and extrinsic muscles of the foot (click here, here, here, and here for a few to get you started)
• perhaps an orthotic to assist in decreasing the pronation while they are strengthening their foot
• motion control shoe? Especially in the beginning as they are strengthening their feet and they fatigue rather easily

The prints do not lie. They tell the true story of how the forces are being transmitted through the foot. For more pedograph cases, click here.

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What’s up, Doc?

Nothing like a little Monday morning brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let’s start at the rear foot:

• limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.
• note the increased pressure at the  medial calcaneal facets on each side with the increased printing
• very little fat pad displacement overall

Now let’s look at the mid foot:

• decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

• increased printing under the met heads bilaterally; L >> R
• increased printing of 1st met head L >> R
• increased printing at medial proximal phalynx of hallux  L >> R
• increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

• short leg on L
• more rigid foot on L
• increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton’s toe) on each foot?

Here is what is going on:

• there is no appreciable leg length deformity, functional or anatomical
• The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

• Can you feel how when your foot is supinated
• can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction
• Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?
• now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What’s the fix?

• create a more supple foot with manipulation, massage, muscle work
• increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)
• have them walk with their toes slightly elevated
• we are sure you can think of more ways as well!

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, tell others and spread the word. If you didn’t like this post, tell us! We value your constructive feedback.

And what have we here?

The above is a pedograph, a simple, effective pressure map of the foot as someone is walking across an inked grid. For more info on pedographs, click here.

Did you note the increased ink present under the great toe bilaterally? What could be causing this? If you look carefully, you will note that it is at the base of the proximal phalynx of the great toe. This could be none other than the tendon of the flexor hallucis brevis!

This bad boy arises from the medial part of the under surface of the cuoid and the adjacent 3rd cunieform, with a small slip from the tendon of the tibialis posterior. As it travels forward it splits into two parts, which are inserted into the medial and lateral sides of the base of the proximal phalanyx of the great toe. There is a sesamoid bone present in each tendon, which offers the FHB a mechanical advantage when flexing the toe.  The medial portion is blends with the abductor hallucis and the lateral portion blends with the adductor hallucis.

Had the increased printing on the pedograph been more distal, it most likely would have been due to increased action of the flexor hallucis longus.   Had it been more proximal (under the head of the 1st metatarsal) it would have been due to the peroneus longus.

Cool, eh?

Reading pedographs and making you a sharper clinician/coach/trainer/sales person is just one of the many skills we try to teach here on the blog. Keep up the great work!

The Gait Guys

Lateral Foot Pain

Well then, why does this young man have pain on the outside of this foot, near his little toe, when walking for long periods of time, along with cramping of the feet. He recently undertook a “bussing tables” job at a local restaurant and is (suddenly) on his feet for 8-10 hours daily for 7-8 days at a stretch?

Take a good look at the top few photos. What do you see?

You should see:

• windswept biomechanics of the legs (i.e. internal tibial torsion on the left and relative external tibial torsion on the right). missed out on torsions? click here. 

Internal tibial torsion often places extra force on the lateral aspect of the foot. You (often) rotate the extremity internally to maintain the knee in the saggital plane.  

• he has inverted feet bilaterally with (most likely) and forefoot varus (the forefoot is inverted with respect to the rear foot). This is easier to see with exam, as it looks like he may have a forefoot valgus in the picture

for what we hope are obvious reasons, when a person has an uncompensated (cannot form an adequate foot tripod) forefoot varus, this will place extra force on the outside of the foot. 

• he has a left short leg (functional or anatomical)

folks will often (but not always) pronate through the mid foot more on the longer leg side (in an attempt to shorten the leg) and supinate (remember: plantar flexion, inversion and adduction) on the shorter leg side in an attempt to lengthen the limb. 

Now can you see why he has lateral foot pain?

What about the cramping?

Hmmmm. going from almost zero to 8-10 ours daily of standing on hard floors. think the intrinsic muscles of the foot might be called to task? And this is exactly what is happening. Those muscles, which have little endurance capacity, are going through glycolytic pathways to function, this the cramping.

So what do we do?

• for starters, we valgus posted the insoles of his shoes L >>R to try and push him off the lateral aspect of his foot and toward the head of the 1st metatarsal (see pics)
• we gave him a temporary 3mm lift in the L side (a full sole lift). A heel lift only puts the foot in plantarflexion, lift the whole foot.
• we gave him the tripod standing, lift toes, spread toes and reach “shuffle walk” exercises (you can search the blog under “exercise” or “tripod” to see these posts again: 3 sets, 10 reps, 3X daily
• we advised him to stay out of motion control shoes (which would push his L knee too far laterally and outside the saggital plane
• we manipulated his feet to insure his mechanics were biomechanically appropriate
• we did manual stimulation of the tibialis anterior, extensor digitorum longus, interossei, extensor hallucis brevis and tibialis posterior followed by multiangle isometric resistance 

We will see how he does and may need to consider a custom crafted orthotic with intrinsic valgus posting if he does not respond well to therapy. we may need to consider dry needling and/or acupuncture as a supportive modality as well.

We hope you followed our reasoning in this case. If not, maybe search through our blog and youtube channel and catch up on some of this cool stuff!

The Gait Guys: Making you smarter each and every post