Increased unilateral foot pronation and its effects upward into the chain.

Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Nothing earth shaking here, we should all know this as fact. When a foot pronates more excessively, the arch can flatten more, and this can accentuate a leg length differential between the 2 legs. But it is important to note that when pronation is more excessive, it usually carries with it more splay of the medial tripod as the talus also excessively plantarflexes, adducts and medially rotates. This action carries with it a plantar-ward drive of the navicular, medial cuneiforms and medial metatarsals (translation, flattening of the longitudinal arch). These actions force the distal tibia to follow that medially spinning and adducting talus and thus forces the hip to accommodate to these movements. And, where the hip goes, the pelvis must follow . . . . and so much adaptive compensations.
So could a person say that sometimes a temporary therapeutic orthotic might only be warranted on just one foot ? Yes, of course, one could easily reason that out.
-Shawn Allen, one of The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #LLD, #leglength, #pronation, #archcollapse, #orthotics, #gaitcompensations, #hippain, #hipbiomechanics

Gait Posture. 2015 Feb;41(2):395-401. doi: 10.1016/j.gaitpost.2014.10.025. Epub 2014 Nov 3.
Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking.
Resende RA1, Deluzio KJ2, Kirkwood RN3, Hassan EA4, Fonseca ST5.

A flexed leg is a shorter leg: When loss of knee extension really matters.

A flexed knee is a shorter leg, period.
A knee with any loss of terminal extension, is more bent knee, and thus a shorter leg, period.

Stand up, bend one knee 10 degrees, you have shortened the global top to bottom length of that leg.
So when walking, you will plunk down onto that shorter leg, and there will be a cost.

This is old hat for our long time readers, but it is a good reminder to look for loss of terminal knee extension.

I just saw a lady with a uni-knee replacement of 5 months. Failing some aspects of rehab, they are stuck. There is hip,knee and ankle pain on walking.
She had a loss of terminal knee extension, thus a short leg, true shortness.
I placed a 2mm full sole length rubber-cork lift in the shoe (*DO NOT USE JUST A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts and causing plantarflexion at the ankle. Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, or want to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
She put the shoe back on with the 2mm sole lift in the shoe and walked 20 steps and started to tear up. No pain.

Sometimes things are simple. We more closely restored the leg length by adding more vertical height. Yes, the problem still exists, but its global effects are somewhat muted. She stopped premature heel rise, could feel her glutes, stopped the abrupt plunk onto the leg, *stopped the sudden abrupt knee flexion loading that was crippling her.

I then took it out, "shoe'd" her up again, and she was dumbfounded, all the pain returned as did her awareness of what she was coping with.

Now, sent her away with the sole lift to accommodate for 2 weeks, and we will restart the rehab once things have time to get used to the "new norm". Now the rehab will work, we think. Time will tell

One thing is for sure, and now yesterdays post rings more clear and true, if you build strength on compensation, you earn and own that compensation.

The Gait Guys

#gait, #gaitproblems, #gaitcompensations, #strength, #heellift, #solelift, #TKA, #hippain, #shortleg

Photo courtesy of Pixabay, beautiful photo isn't it !?

Heel lift or sole lift ?

*DO NOT USE A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts to correct a length length discrepancy, and thus causing plantarflexion at the ankle by raising just the heel. What about raising the forefoot, too ?! Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, unload a barking unresponsive achilles tendonitis, or for some strange reason you wish to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
Besides, many people's problems arise from insufficient ankle rocker/dorsiflexion as it is , so why are you sentencing them to the depths of hell by predisposing them to pre-plantarflexed strategies ? You should love your clients ! Using a heel lift requires smarts, deep smarts, and intimate understanding of the pitfalls of pre-positioning the heel higher than the forefoot and what it may do to your clients mechanics over time. Did decades of high heel ramp, high heel-toe drop shoes or a century of high heeled women's shoes not teach us anything? (ok, we are going overboard here to make our point :)
When do we almost exclusively use a heel lift? Very temporarily in unresponsive achilles tendonopathies, and even that can be argued. But, sometimes you have to use unicorns and black magic.
Use your noggin, daily.

shawn and ivo, the gait guys

#gait, #gaitproblems, #gaitanalysis, #thegaitguys, #heellifts, #solelifts, #anklerocker, #ankleplantarflexion, #ankledorsiflexion, #heeltoedrop, #heelrise, #shortachilles

Where the knee hinges matters.

It is easy to see the big things, but, we sometimes forget that the small things matter.
Sometimes it take an obvious glaring asymmetry to make us appreciate that the small asymmetries can make the same or similar impact over a long period of time. Rivers can carve out canyons over time.

Here we see the gross difference that polio can make in leg size and in leg length. We must remember that changing a leg length also changes the symmetrical relationship of where the 2 knees hinge. A foot that pronates more than the other leg can lower the knee hinge point just a little because the talus drops further from its vertical height. We know very well that it for certain alters the hinge direction, posturing it more medially, but we cannot forget that a cranky knee on a side where the foot is flatter or pronates more excessively than the other is not to be ignored.
In this photo, we have dotted the knee at the same point on the patella. It is clear the knees will not hinge at the same time, thus stride and step lengths will change, and step width will be impacted. The pelvis will also spin more to one side on a pelvis that is lower on one side. This will impact lumbar spine sagittal happiness and stability/mobility. Hip and pelvis drift are real things in this case, and need your attention. *Just like a client that has a painful foot, a more pronated foot, more tibial torsion on one side etc. these things matter, and they often matter years down the road when many thousands of miles have been clocked into the subtle asymmetry. Sometimes these little things matter in our athletes too, who put the pedal to the floor asking the body for more.

Come hear our lecture tonight on www.onlineCE.com. You have to sign up early to get in. We won't disappoint. See you then. 7pm central time.

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

.

.

.

don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

.

.

.

.

.

.

Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

Falling hard; Using supination to stop the drop.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

This is a case that has been looked at before but today with new video. This is a client with a known anatomic short leg on the right (sock-less foot) from a diseased right hip joint.  

In this video, it is clear to see the subconscious brain attempting to lengthen the right leg by right foot strike laterally (in supination) in an attempt to keep the arch and talus as high as possible.  Supination should raise the arch and thus the resting height of the talus, which will functionally lengthen the leg.  This is great for the early stance phase of gait and help to normalize pelvis symmetry, however, it will certainly result in (as seen in this video) a sudden late stance phase pronation event as they move over to the medial foot for toe off. Pronation will occur abruptly and excessively, which can have its own set of biomechanical compensations all the way up the chain, from metatarsal stress responses and plantar fasciitis to hip rotational pathologies.  It will also result in a sudden plummet downwards back into the anatomic short leg as the functional lengthening strategy is aborted out of necessity to move forward.  

This is a case where use of a full length sole lift is imperative at all times. The closer you get to normalizing the functional length, the less you need to worry about controlling pronation with a controlling orthotic (controlling rate and extent of arch drop in many cases). Do not use a heel lift only in these cases, you can see this client is already rushing quickly into forefoot loading from the issues at hand, the last thing you should be doing is plantarflexing the foot-ankle and helping them get to the forefoot even faster !  This will cause toe hammering and gripping and set the client up for further risk to fat pat displacement, abnormal metatarsal loading, challenges to the lumbricals as well as imbalances in the harmony of the long and short flexors and extensors (ie. hammer toes). 

How much do you lift ?  Be patient, go little by little. Give time for adaptation. Gauge the amount on improved function, not trying to match the right and the left precisely, after all the two hips are not the same to begin with. So go with cleaner function over choosing matching equal leg lengths.  Give time for compensatory adaptation, it is going to take time.  

Finally, do not forget that these types of clients will always need therapy and retraining of normal ankle rocker and hip extension mechanics as well as lumbopelvic stability (because they will be most likely be dumping into anterior pelvic tilt and knee flexion during the sudden forefoot loading in the late midstance phase of gait). So ramp up those lower abdominals (especially on the right) !  

Oh, and do not forget that left arm swing will be all distorted since it pairs with this right limp challenge. Leave those therapeutic issues to the end, they will not change until they see more equal functional leg lengths. This is why we say never (ok, almost never) retrain arm swing until you know you have two closely symmetrical lower limbs. Otherwise you will be teaching them to compensate on an already faulty motor compensation. Remember, to get proper anti-phasic gait, or better put, to slow the tendency towards spinal protective phasic gait, you need the pelvic and shoulder “girdles” to cooperate. When you get it right, opposite arm and leg will swing together in same pendulum direction, and this will be matched and set up by an antiphasic gait.

One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.

“One thing, affects all things. One change necessitates global change. The more you know, the more you will see (and understand).  The more you know, see and understand, the more responsible you will and should feel to get it right and the more global your approach should become. If your head does not spin at times with all the issues that need to be juggled, you are likely not seeing all the issues you should be seeing.” -Dr. Allen (from an upcoming CME course)

Shawn Allen, one of the gait guys.