So you prescribe and fit orthotics you say ?

"It all matters, and quite possibly, if you do not know it all, you cannot help your client."

How about this then, you have someone with a rearfoot valgus with internal tibial torsion.  How are they going to load now? What if you throw in a valgus knee and femoral torsion variant?  Are they going to pronate more or less ? What if that person had just internal tibial torsion on one leg and not the other, yet they had 2 rearfoot valgus feet presentations.  Now what?

Ouch, that is a strong statement. It likely needs softened, but, there is some truth within those words. 

Last night we did our monthly lecture on www.onlineCE.com.  We had a packed room, biggest audience to date.  It is likely because people are realizing that the small stuff matters.  We talked for an hour on foot types and  how they present, how they potentially load, and how other mechanical issues above can impact how a foot type loads. 

We have all seen the pedographs like in the photo. The unwise depend on a static pedograph mapping for diagnostic help and God forbid that is all you use for making orthotics (that may only help if your client is  a professional stander), the more wise use the dynamic pedograph mapping to see how their client moves across the ground, and the wise use it as a mere piece of the data, combine it with a clinical exam, look far up into the biomechanical chain for other locomotive challenges that could change the dynamic loading pattern across the foot and ground.  What do we mean exactly ?  Well, a client with a rearfoot valgus foot type will load the heel and rest of the foot one way if they are doing a good job stacking the hip over the knee, and knee over the foot. But, if they have weakness in the hip affording a frontal plane drift of the pelvis over the foot, that is going to magnify the rearfoot valgus loading pattern (addendum: they could also tip into rearfoot varus posturing as well). That is just one example, of many.  In otherwords, it is the same foot type, but both of these are going to show a dynamic change in the loading pattern response. So, said another way, you cannot diagnose a foot type by the pedograph mapping. Nor should one make an orthotic for someone based off of a pedograph mapping, nor without an examination of the entire kinetic change.  What is your client able, and unable, to do? That is a big question, and when you start by asking those 2 questions, you get closer to the prize.  The pedograph only shows the static or dynamic pressures from the superincumbent load, it does not tell you if it is good or bad, and it does not tell you what they are doing, or why they are loading that way. It only shows the loading. Your job is to find out why they are loading that way, and then determine if that is part of their problem they have sought you out for.

So, does  your head spin now ? Does this suddenly make you sweat ? Do you realize you are missing pieces of the pie in helping your client?  Not yet maybe ?  How about this then, you have someone with a rearfoot valgus with internal tibial torsion. How are they going to load now? What if you throw in a valgus knee and femoral torsion variant? Are they going to pronate more or less ? What if that person had just internal tibial torsion on one leg and not the other, yet they had two rearfoot valgus feet presentations. Now what? Suddenly the loading is different in both feet and up the chains. There is likely going to be different challenges to limb spin control from side to side. This aberrant and asymmetrical loading is going to come up to a pelvis, upon which a single spinal column is trying to find a sound base of support and mobility to work and transfer loads from. 

And, what if this client also has some tibial varum on that same side ? What if they had external tibial torsion or some femoral torsional presentation on one side ?  You can see now how complicated this gets. And that is just on the structural components. What about the dynamic components ?  We here at The Gait Guys feel that this is all critical stuff to take into consideration and it is sometimes the stuff that is the tipping point between a successful management of a clients complaints, and unsuccessful.  

In closing, think about this. If you are sending out your orthotics for fabrication, have you conveyed this all to your fabricator ?  All they know is what a pedograph might show, and what the foot mold looks like. You have to provide them with all this other information, because essentially they are blind (this of course assumes your fabricator can mind juggle all the torsions, valgus/varus, pelvis drift loads etc,  oy vey ! That is hard to do !) This is why we do all of our modifications in office, in the rare case we need a temporary orthotic modification. But, we will aim to just correct what mechanics are aberrant and avoid the whole orthotic crutch when we are able. But lets face it, sometimes, for a period of time, we all need a crutch to get through a problem, to find better mechanics where we can strengthen from or gain protecting from temporarily.  That is what splints do, taping, crutches, braces, one might even argue what corrective exercises do. It is a path on the journey for your client, and sometimes they need help through the muddy parts.

And, don't be "that guy" that says orthotics are useless. They are a crutch , a tool. A small tool, one might argue that it should only be pulled out when the other tools are not working to get the job done.  Do not make them your first line of defense, except when that is called for.  After all, not all people were blessed with sufficient anatomical  and mechanical parts to avoid needing a crutch, so don't be "that guy" that preaches from that extreme, because it is not honest. Or, maybe, you just do not see the biomechanical messes we see in our clinics, that is quite the realistic possibility. 

Want to learn more about this kind of stuff? Keep up with our blog here. OR take some of our lecture recorded classes on www.onlineCE.com . We have a library of classes there for you to take anytime. And meet us once a month over there, every 3rd Wednesday. And, stay tuned for some new teaching gigs we have coming your way.

-Shawn and Ivo,  the gait guys

 

 

Podcast 123: The Rear foot: Understanding your RearFoot type

Key tag words:
foot types, rearfoot, forefoot, pronation, supination, shoe fit, forefoot varus, forefoot supinatus, rearfoot inversion, ankle rocker, injuries, rehab, corrective exercises

Rearfoot varus and Rearfoot valgus. Knowing the anatomy of your rear foot and its anatomic and functional posturing can lead to many problems in anyone. If you do not know the rearfoot type and posturing, you will not understand the rest of the foot mechanics. Without this knowledge, you will not know the reason for midfoot or forefoot problems, not understand what shoe you are in, or even why the shoe, footbed, orthotic you have chosen is either not fixing your problems, or causing them.  Join us on a journey down the rearfoot rabbit hole over the next hour.  Plus a few funny stories to lighten the biomechanics-heavy dialogue.
 

Show links:
http://traffic.libsyn.com/thegaitguys/pod_123final_cut.mp3

http://thegaitguys.libsyn.com/podcast-123-the-rear-foot-understanding-your-rearfoot-type

Show sponsors:
www.newbalancechicago.com

www.thegaitguys.com
That is our website, and it is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

https://www.ncbi.nlm.nih.gov/pubmed/27134364

https://www.ncbi.nlm.nih.gov/pubmed/25364132

RearFoot positions:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3588658/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990938/

Powers CM, Maffucci R, Hampton S. Rearfoot posture in subjects with patellofemoral pain. J Orthop Sports Phys Ther. 1995 Oct;22(4):155-60.

Power V, Clifford AM. The Effects of Rearfoot Position on Lower Limb Kinematics during Bilateral Squatting in Asymptomatic Individuals with a Pronated Foot Type. J Hum Kinet. 2012 Mar;31:5-15. doi: 10.2478/v10078-012-0001-0. Epub 2012 Apr 3.

Shultz SP, Song J, Kraszewski AP, Hafer JF, Rao S, Backus , Mootanah R, Hillstrom HJ. An Investigation of Structure, Flexibility and Function Variables that Discriminate Asymptomatic Foot Types. J Appl Biomech. 2016 Dec 19:1-25. [Epub ahead of print]

 

Rearfoot to Hip Pathomechanical considerations.

In normal gait, the rearfoot strikes in slight inversion and then quickly moves through eversion in the frontal plane to help with the midfoot through forefoot pronation phases of gait. Some sources would refer this rearfoot eversion as the rearfoot pronatory phase, after all. pronation can occur at the rear, mid or forefoot. As with all pronation in all areas, when it occurs too fast, too soon or too much, it can be a problem and rearfoot eversion is no different.  If uncontrolled via muscles such as through tibialis posterior eccentric capabilities (Skill, endurance, strength) or from a structural presentation of Rearfoot Valgus pain can arise. 

From a scenario like in the video above, where a more rearfoot varus presentation is observed,  where the lateral to medial pronation progression is excessive and extreme in terms of speed, duration and magnitude this can also create too much lateral to medial foot, ankle and knee movement.  This will often accompany unchecked movements of internal spin through the hip. So one should see that these pronation and spin issues can occur and be controlled from the bottom or from the top, and hopefully adequately from both in a normal scenario.  It is when there is a biomechanical limitation or insufficiency somewhere in the chain that problems can arise. And remember, pain does not have to occur where the failure occurs, in fact it usually does not. So when you have knee pain from an apparent valgus posturing knee, make sure you look above and below that knee.  Also, keep in mind that as discussed last week in the blog post on ischiofemoral impingment syndrome (link), these spin scenarios can be quite frequently found with ipsilateral frontal plane lateral deviations (bumping of the hip-pelvis outside the vertical stacking of the foot-knee-hip stacking line). This stacking failure can also be the source of many of the issues discussed above, so be sure you are looking locally and globally. And remember, what you see is not the problem, it is their compensation around their deeper problem quite often.

If you have not read the blog post from last week on ischiofemoral impingement syndrome you might not know where the components of the cross over gait come in to play here nor how a rearfoot problem can present with a hip impingement scenario, so I can recommend that article one more time.

One last thing, just in case you think this stuff is easy to work through, remember that these rearfoot varus and valgus problems, and pronation rates. and limb spin rates are all highly variable when someone has varying degrees of femoral torsion, tibial torsion or talar torsion. Each case is different, and each will be unique in their presentation and in the uniqueness of the treatment recipe. I just thought I would throw that in to make your head spin a little in case it wasn’t already.

For example, a case where the rearfoot is a semi rigid varus, with tibial varum, and frontal plane lateral pelvic drift with components of cross over gait (ie. the video case above) will require a different treatment plan and strategy than the same rearfoot varus in a presentation of femoral torsion challenges and genu valgum. Same body parts, different orientations, different mechanics, different treatment recipe.  

So, you can fiddle with a dozen pair of shoes to find one that helps minimize your pains, you can go for massages and hope for the best, you can go and get activated over and over, you can try yet another new orthotic, you can go to a running clinic and try some form changes, throw in some yoga or pilates, compression wear, voodoo bands and gosh who knows what else. Sometimes they are the answer or stumble across it … or you can find someone who understands the pieces of the puzzle and how to piece a reasonable recipe together to bake the cake just right. We do not always get there, but we try.  

Want more ? Try our National Shoe Fit certification program for a starter or try our online teleseminars at www.onlinece.com (we did a one hour course on the RearFoot just the other night, and it was recorded over at onlineCE.com).

Dr. Shawn Allen,  of the gait guys


Reference:

Man Ther.  2014 Oct;19(5):379-85. doi: 10.1016/j.math.2013.10.003. Epub 2013 Oct 29.Clinical measures of hip and foot-ankle mechanics as predictors of rearfoot motion and posture.  Souza TR et al.

Health professionals are frequently interested in predicting rearfoot pronation during weight-bearing activities. Previous inconsistent results regarding the ability of clinical measures to predict rearfoot kinematics may have been influenced by the neglect of possible combined effects of alignment and mobility at the foot-ankle complex and by the disregard of possible influences of hip mobility on foot kinematics. The present study tested whether using a measure that combines frontal-plane bone alignment and mobility at the foot-ankle complex and a measure of hip internal rotation mobility predicts rearfoot kinematics, in walking and upright stance. Twenty-three healthy subjects underwent assessment of forefoot-shank angle (which combines varus bone alignments at the foot-ankle complex with inversion mobility at the midfoot joints), with a goniometer, and hip internal rotation mobility, with an inclinometer. Frontal-plane kinematics of the rearfoot was assessed with a three-dimensional system, during treadmill walking and upright stance. Multivariate linear regressions tested the predictive strength of these measures to inform about rearfoot kinematics. The measures significantly predicted (p ≤ 0.041) mean eversion-inversion position, during walking (r(2) = 0.40) and standing (r(2) = 0.31), and eversion peak in walking (r(2) = 0.27). Greater values of varus alignment at the foot-ankle complex combined with inversion mobility at the midfoot joints and greater hip internal rotation mobility are related to greater weight-bearing rearfoot eversion. Each measure (forefoot-shank angle and hip internal rotation mobility) alone and their combination partially predicted rearfoot kinematics. These measures may help detecting foot-ankle and hip mechanical variables possibly involved in an observed rearfoot motion or posture.

Podcast 70: Achilles Solutions and Foot Cases

The Achilles and Calf: Achieve Posterior Length via Anterior Strength

A. Link to our server: 

Direct Download: 

http://traffic.libsyn.com/thegaitguys/pod_70final_was71.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-70-0B. 

iTunes link:

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

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

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

D. other web based Gait Guys lectures:

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

______________

Today’s Show notes:

*Show sponsor: Lems Shoes.  www.lemsshoes.com
Mention GAIT15 at check out for a 15% discount through August 31st.
 
1. Achilles tendons, loading, and biomechanical changes with different shoes and heel stack heights.
 
2. Aging adults, falls and keeping them and their gait safe.
 
3. Gait and speed evolution of vertebrates.
 
4. Blaise Dubois et al on Barefoot Running. Shod vs unshod.
 
5. Females, pronation, and back pain. The Framingham foot study.
 
6. Your feet and orienteering.
 
7. A case of calcaneal valgus in a youngster.
 
8. Structural integrity is decreased in both Achilles tendons in people with unilateral Achilles tendinopathy
http://www.jsams.org/article/S1440-2440(14)00115-7/abstract

The Case of the Non Rotating Knee

Here is a runner, wanting to be an ultra runner, who recently developed right sided knee pain while running a 50K. He was pacing another individual and developed pain on the outside (lateral patella and knee) on the right, ascending and especially descending hills. The pain is dull and achy. He is able to “push through” the pain, but if he does, it remains painful for a few days.

He has an anatomically short leg on the L (tibial). There is no significant tibial torsion (he has normal external version) and not femoral torsion. There are adequate amounts of internal (>15 degrees) and external (>30 degrees) rotation of the hips.

He has 7 degrees ankle dorsiflexion on the right, 10 degrees on the left. On the table (and in the video) he has 0 degrees of hip extension during passive motion, walking and running. He has weakness of the long extensors of the toes, as well as the abductors.

Take a look at his video. Note the following:

·       the right knee has less medial excursion than the left (watch the dots)

·       rearfoot valgus is noted on the L  (ie. calcaneus is everted)

·       subtle lean to Left on L sided stance phase

·       when barefoot, the problem lessens

Why does the right knee rotate less than the left?

When folks have a short leg, we generally expect that leg to remain in supination (thus external rotation) more and the longer leg to internally rotate more, due to excessive pronation. But here, we see the opposite. You will notice he has a rearfoot valgus on the left. This means the midtarsal joint is in a greater amount of pronation on the shorter side. For every action, there is an equal and opposite reaction. In this case, less pronation (or supination) on the longer leg side. Remember, we said generally folks pronate more on the long leg side. This is one of the exceptions.

So, should he throw away his shoes?

The shoes, which have a certain amount of torsional rigidity, are compounding the problem. The Brooks Cascadia is an excellent trail running shoe, he just needs something with less torsional rigidity. the shoe does  not allow his knee to come midline sufficiently. Since he is a Brooks Fan, we suggested the “Grit” in the Pure line. 4mm drop and less rigid torsionally. He could also work his way into a “Drift” (4mm or zero drop, extremely flexible).

Why does he lean to the left on stance phase on the left?

Most likely, to clear the right long leg on swing phase. This is one of the 5 common strategies. For more strategies, click here.

Why is it better when he is barefoot? It must mean he should be a barefoot runner, right?

He is better, because there is less impediment to the foot pronating (ie. the shoe has less torsional rigidity)

The Gait Guys. Making you a better diagnostician, with each and every post.

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The Great Myth of Rotating your Shoes : Here are the Actual Facts as we see them.

Everyone has heard the rules, rotate into new shoes about every 400-500 miles.  We disagree, kind of, and we have talked about it on previous blog posts in the past and on our podcasts.  Many shoe reps have agreed with the methods we employ for our runners.

The EVA foam often used in shoe manufacturing has a lifespan, or better put, a given number of compression and shear cycles. It can go through a rather fixed number of compression cycles before it loses its original structural properties, the older the foam gets the faster the degradation process and the more risks it poses for runners.  It is known that EVA foam compressed into a focal vector or area over and over again becomes softer and more giving into that vector/area over time.  Hence, if you have a compensation pattern or a known foot type (forefoot varus, forefoot valgus, rearfoot varus, rearfoot valgus or a combination of these 4) you will break down a certain region or zone of the shoe’s EVA foam. For example a forefoot varus foot type will often drive some heavy focal compression into the foam under the first metatarsal. However, if you combine it with a rear foot valgus it will drive shear forces and compression into the  EVA foam along the entire medial aspect of the shoe (see the 2 pictures attached, you can see the evidence of excessive medial compression and medial shear in a foot that has severe rearfoot valgus and forefoot varus. This is a very poor shoe prescription for the foot type involved).

Here is what you need to do / know:

1- Know your athletes foot type so you can make more informed decisions.

2- Know the type of foam of the shoes you are recommending (ie. Altra uses A-Bound foam instead of EVA just as an example. A-Bound is an environmentally friendly energy-return compound is made of recycled materials. It reduces the impact of hard surfaces while still maintaining ground feedback. Traditional running shoe foam compresses 70-90% while A-Bound™ compresses 2-3x less so it won’t deform over time.).  Cheap shoes use cheap materials.  Altra goes the extra mile for foam quality and many others are beginning to follow suit. If you think you are getting a deal on shoes, know what “the deal” is, it just may be cheaper materials.

3-  500 miles is not the rule for everyone and every shoe.  If you have a relatively neutral forefoot and you are a forefoot or midfoot strike runner you will get far more miles out of a shoe.  If you depend on a stability shoe with dual densities of foam to slow your pronation and control your medial foot because of a rearfoot valgus and/or forefoot varus know that the shoe’s foam will break down less uniformly because of foam interface junctions and whatnot.  This is a science. Engineers call it “the mechanics of material deformation”.  We wonder how many mechanical engineers shoe companies have on board in their R&D divisions ?  We know for a fact that a few do not. There was a reason we snuck quietly into the mechanical engineering departments of our Alma Mater and sat quietly in the “Materials” classes. At the time our roommates just told us it was  cool class, little did we know why it was so interesting to us, until now.

4- Here is what we recommend. Fit the foot type to the right shoe selection. If you are weak in this territory consider taking our intense “National Shoe Fit” program. Fit is everything. Make the wrong choice for your client and the shoes will break down quicker and into poor and risky patterns. Make the right choice and be their hero. If you are looking for a way to improve clientele happiness and store loyalty our Shoe Fit Program is the way. Just read the testimonials here on our blog. Some of the top stores in the Nation have quietly taken the National Shoe Fit Program from us, they have good reason to. They also have good reason to keep it quiet, to get the edge on the competition.

You can email us to get this information and the e-file program download. Why not certify your entire store staff ?

Email us at   thegaitguys@gmail.com.  This program will teach you foot anatomy, functional anatomy, shoe anatomy, foot types and matching foot type to shoe type as well as many other aspects of gait and lower limb biomechanics.

* 5- Try this recommendation.  At 250 miles buy a new shoe to accompany your shoe that already has 250 miles. Now you are rotating 2 shoes. From this 250 mile point moving forward, alternate the newer show with the older shoe. This way you are never in a shoe that is notably more deformed in a specific area of the EVA foam because of your compensations, limitations or foot type. Essentially you are always just a day away from a newer shoe that has less driving force into abnormally compressed EVA foam.  The older the shoe gets the more it accelerates your foot and body into that deformation and hence why many injuries occur as their shoes get older. Continue to alternate shoes on every other run (new, old, new, old).  Once you hit 400-500 miles on the old shoes, ditch them and get a new pair again to restore the cycle once again.  In fact, to be specific here is what we recommend. Monday, old shoe. Tuesday, new shoe. Wednesday do not run, rather, rest or cross train. Thursday go back to the older shoe. Friday new shoe and repeat. This way you are 4 days between runs in the older more deformed shoe. The one day off running in mid week gives tissues that were challenged by the “old shoe run” a bit more time to repair.

6- Dedicate your shoes to running only. Running gait is not the same as walking gait. Why would you want to break down the EVA foam at the rear foot during walking (because heel strike is normal in walking) when in running you are a mid-forefoot striker ?  Keep walking shoes for walking, running shoes for running. Otherwise you are just asking for trouble.

Check out our National Shoe Fit program and certification process here as well as links to our other teaching DVD’s & e-downloads:
 http://store.payloadz.com/results/results.asp?m=80204

Shawn and Ivo. Helping you use your head (and shoe knowledge) better everyday.
The Gait Guys  (have you checked out our RebelMouse page ? https://www.rebelmouse.com/TheGaitGuys/

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