Medial knee pain in a skier.   Considering an orthotic?  You had better know what you are doing! 

Can you guess why this gal has pain in both knees? Especially when skinning up a hill and skiing down? 

 Take a close look at the photos above and notice the orientation of her knee with her foot. Now look at you tuberosity and drop a line straight downward.  This line should pass through or slightly lateral to the second metatarsal shaft. Can you see how it falls to the outside of this? Perhaps even between the third and fourth metatarsal?

This gal has bilateral internal tibial torsion.  When she wears a standard foot bed (creates a level surface for the right for the foot) or an orthotic without appropriate posting, it pushes her knee outside of the saggital plane. This creates abnormal patellofemoral tracking  and appears to be a major contributor to her pain. 

 You will notice that we placed a valgus post under the orthotic(  a post that is canted from lateral to medial) which pushes her knee to the midline as the first ray descends.  You can see her alignment is better with her boots on and the changes. 

 The bottom line? Know your torsions and versions.  Posting a patient like this incorrectly could result in a meniscal disaster!

Lower limb muscle strategies in low back pain patients.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. It is possible that your client may be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired. This problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges.

So you have sporadic low back pain and knee pain. Could they be linked ?

It has been a long believed rule that it is “all about the core”.  We have learned in recent years that this should be a very loosely accepted rule. 

In an old blog post (link) we stated some deeper truths:

Dr. McGill discusses the basic tenet that the hips and shoulders are used for power production and that the spine and core are used for creating stiffness and stability for the ultimate power transmission through the limb.  He makes it clear that if power is generated from the spine, it will suffer.  As gait experts, you should never forget this principle, if the spine and lumbopelvic interval is not strong/stiff and stable enough, the limbs can over power them and thus your gait, your running, your sport, could be causing you pain as the forces are poorly managed as they attempt to traverse the spine. 

Here we find a study referenced below that suggests that when the lumbopelvic interval is fatigued, that the lower limb muscles may step up activity.  This is a neat concept, not earth shaking by any means, but it nice to have studies that help solidify knowledge of compensation strategies.

“Individuals with low back pain (LBP) have been shown to demonstrate decreased quadriceps activation following lumbar paraspinal fatigue. The response of other lower extremity muscles is unknown. The purpose of this study was to determine changes in motoneuron pool excitability of the vastus medialis, fibularis longus, and soleus following lumbar paraspinal fatigue in individuals with and without a history of LBP.” 

What this study attempted to do was perform a controlled laboratory study designed to compare motoneuron pool excitability before and after a lumbar paraspinal fatiguing exercise. Twenty individuals (10 with history of low back pain) performed isometric lumbar paraspinal exercise until a 25% shift in paraspinal muscle surface electromyography median frequency occurred. 

What they discovered was that the soleus motoneuron pool excitability increased following lumbar paraspinal fatigue independent of group allocation and occurred in the absence of changes in vastus medialis or fibularis longus muscles. 

The authors propose that “increased soleus motoneuron pool excitability may be a postural response to preserve lower extremity function”.

When your client comes in with knee or foot/ankle issues do not dismiss the history of intermittent or exercise induced low back issues. They very well could be coming in with a loss of ankle rocker/dorsiflexion.  And, from your physical exam and screens, you may be at a loss as to why their ankle rocker is impaired.The problem further down the chain may simply be a compensation strategy to maintain function and postural integrity due to lumbar functional/fatigue challenges. 

Dr. Shawn Allen, one of the gait guys.

Reference:

J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain.Bunn EA¹, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

http://www.ncbi.nlm.nih.gov/pubmed/21388827

What have we listened to lately? Patello Femoral Pain!

The David pope Physioedge PODcast with  Dr Micheal Rathleff talking about adolescent patellofemoral knee pain, which has a prevalence of 6 to 7%. 

Here is our summary: 

Two thirds of the population do sports five times per week and often do the sports with pain. This group (adolescents) has usually been doing one sport their entire life and has had pain on and off. The other third of the population are adolescents who do not play sports at all. This group often are going from primary secondary school and encounter a lot of stairs or increased amounts of activity which is believed to contribute to the condition. So the majority are increased intensity or frequency of load whereas the other one is increased load only.

For the first group, playing in identifying with the sport is part of their social network and they would rather play with pain than be excluded.

One of the questions was “is there a different treatment protocol for each group”? 

The short answer is no. Many times and adolescent in the “overuse” group is given additional exercises. Often this just contributes to increasing load. Education appears to be key in the rehab process. Males with the shortest duration of pain and lowest intensity seem to be the best responders to this program. Females with longest duration and highest intensity of pain seem to respond the least.

Not surprisingly, compliance with treatment protocol can be difficult with a teenager. In a recent RCT that they performed, 55% of folks that did their exercises three times per week were recovered in one year whereas those that did less were at 20%.  These statistics are often put on the chart, laminatedand shown to the patients. This seems to improve compliance.

Another chart is made with these bullet points: 

• Low hip strength
• low quadricep strength
• different movement pattern. 

The anatomy is then shown and explained to the patient and an attempt is made to tie it all together.

Differentiation is made between: patellofemoral pain, Osgood-Schlatter’s disease, and patellar tendinopathy. The differentiating factors are with patellofemoral pain, the pain is diffuse; with Osgood-Schlatter’s it’s located over the tibial tuberosity and with patellar tendinopathy it is more at the inferior patellar pole.

Differentiation is always made between Sinding-Larsen-Johannsen disease and the others by the fact that this is mostly pain at the inferior patellar pole and relatively rare and adolescent population.

Differentiation between patellofemoral pain and Osgood-Schlatter’s disease usually involves the latter having locking in addition to pain. These conditions are usually confirmed with ultrasound or MRI.

There don’t appear to be specific reliable tests to rule in patellofemoral pain so the process becomes one of ruling out.

Palpation in the diagnostic process of course please large role. Also specific localization by the patient can be helpful. Dimension and “app” that the patient can draw on to show the examiner where the knee pain is. We really like this idea. 

Exclusionary tests include the patellar fat pad compression test, but it is emphasize that this is more generalized rather than specific to the Tele femoral pain and a brief discussion as to its anatomy ensues. 

Treatment includes 3 main steps

1. patient education as to activity limitations. 
2. Patient refrains from activities a check of the pain for approximately four weeks and then his gradually reintroduce as long as they can keep their VAS scores below three. 
3. Exercise can begin at the four-week timeframe, again depending upon the patient’s symptoms. A gentle progression with pain as a guide is advised with a return to activity previous activity as early as 5 to 6 weeks. Frequency of training is increased first and then duration of training.

Exercise initially is confined to the more proximal joints such as the core and hips.  They begin with open chain, theraband exercises (which we do not necessarily agree with). They also do RM testing 10 to 12 reps.some standardization is done with regards to therapy and length and amount of travel.

Compliance is discussed as adolescence often have an extensive social network. Exercise in 15 minute intervals is encouraged. Prognostically it shows that patients that can control their loads earlier tend to do better longitudinally.

Foot orthoses are discussed but it is pointed out that there is not a lot of data and research on their efficacy in an adolescent population for the telephone real pain. He goes on to talk about how a foot orthoses “takes your brain out of the equation” and can provide some degree of increased compliance albeit, passive. The orthotics are left in until they are “worn out” (they use a great expression:”until the natural mortality of the orthotic runs its course” which we loved ! and then see how the patient does.

Hip strengthening is discussed. It appears that adolescents develop weaknesses after patellofemoral joint pain,  not as a result of it. 

Other treatment modalities included “fat pad unloading tape”. A “v”  pattern is done with crossing at the tibial tuberosity. The Chris Barstann method is given in a YouTube link is provided. Plane “white tape” can be utilized for adolescents who hyper extend their knees, with the tape running behind the knee a few hours at a time.David talks about an anchor above and below the knee with an X pattern crossing at the middle of the popliteal fossa and having the knee in slight flexion.

So after the progression of one activity modification, two taping three therapy and exercises they then move onto hip strengthening with close chain exercises such as squatting and lunches.backpacks with different amount of weight totaling there 10 or 12 RM are then employed. Care is exercised to keep them in a pain-free range. When they can accomplish this then they move onto one legged work

Stretching was deemphasized because of the increased compression at the patellofemoral joint.

Guidance as to speed, frequency and ranges of motion of exercise are carefully given to each patient. Eight seconds of time under tension for each repetition using a thorough band (three second concentric, two second isometric hold, three second eccentric) adding up to 80 seconds for each 10 repetitions. This allows good proprioceptive control because of the long contraction and increased exercise dose. They often use a “smart phone” to video the exercise for the patient (with the doing this for years and it’s a great way to assist in compliance; a person may lose a sheet of paper or their keys but they will not lose their phone).

All in all, an informative PODcast for those who have a deeper interest in treating PFP in the adolescent population.

The Gait Guys

link to PODcast:  http://physioedge.com.au/physio-edge-039-patellofemoral-pain-adolescents-dr-michael-rathleff/

Heat Exertion and Gait Decline

Changes in gait characteristics are found when exertional heat stress is experienced during prolonged load carriage.  As heat stress increased, step width decreased while percent crossover steps increased. Reduced stance time variability, step width variability, and percent crossover step were observed.  These are frontal plane gait parameters for the most part. 

Think about these things during your long summer run or as you go deeper into those last miles of your long run.  Simple muscular fatigue in the frontal plane hip-pelvis stabilizers are going to render the same results.  This is quite possibly why many problems and injuries crop up in the latter miles of your run. 

Reference:

Gait Posture.

2016 Jan;43:17-23. doi: 10.1016/j.gaitpost.2015.10.010. Epub 2015 Oct 23.Using gait parameters to detect fatigue and responses to ice slurry during prolonged load carriage. Tay CS, Lee JK, Teo YS, Q Z Foo PTan PM, Kong PW

We had a great PODcast in the studio last Friday, talking about tendon vascularity and compression vs tension therapies for tendinopathies.

Here is a great FULL TEXT article on tendon vascularity that can serve as a catalyst for designing your treatment programs

“Conclusions
Neovascularization is critical to tissue repair and wound healing. Therefore, strategies to enhance vascularization to promote regeneration are considered promising treatment modalities, i.e., the use of platelet rich plasma (PRP) to restore functional bone (Zhang et al., 2013) or skin (Kakudo et al., 2011). However, in acute or chronic tendon injuries hypervascularity often does not pave the way to functional recovery of the tissue. Therefore, to overcome the limited intrinsic regeneration capacity of tendon and to achieve scarless healing will most likely require a balanced manipulation of the angiogenic response in tendon tissue. For a variety of treatment methods, such as the use of PRP, the availability of clinical data is limited, due to heterogeneity in application (Khan and Bedi, 2015). In order to develop rational strategies to achieve a well-balanced angiogenic response following tendon injury, we need a thorough understanding of the molecular and cellular networks driving tendon vascularization and regeneration—a challenge for years to come.”

image from: http://www.slideshare.net/ShoulderPain/rotator-cuff-repair-23326992

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650849/

Ankle spains and hip abductors

We see it ALL THE TIME. But sometimes it is nice to point out the obvious, just in case you are not looking for it.
“Conclusions: Our subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar-flexion range of motion on the involved sides. Clinicians should consider exercises to increase hip abduction strength when developing rehabilitation programs for patients with ankle sprains.”-Friel et al
Dr. Allen: if the hip abductors are weak, the leg will posture more adducted (ie, cross over type pattern) and this places the foot more directly below the body midline plumb, this will posture the foot in inversion and thus at greater risk for future inversion sprains.  This sets up the vicious cycle of hip abductor weakness, frontal plane drift of pelvis, inversion of the foot and more ankle sprain risks/events.  The cycle must be broken. The hip must be addressed. That lateral chain must be restored all the way up from the foot.  All stuff you likely already know, but good to find another study to validate.

Dr. Allen

J Athl Train. 2006; 41(1): 74–78.PMCID: PMC1421486Ipsilateral Hip Abductor Weakness After Inversion Ankle SprainKaren Friel,Nancy McLean,Christine Myers, and Maria Caceres
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421486/

Why don’t some folks pay attention to anatomy?

Movement isn’t important…until you can’t…

Grey Cook

Manipulation of a joint appears to change the instantaneous axis of rotation of that joint (1). It would stand to reason that this change would effect muscle activation patterns (2). Can this be applied to the lower extremity? Apparently so, at least according to this paper (3). 

“…The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.”

So, what does this mean?

The peroneus longus contracts from just after midstance to pre swing to assist in descending the 1st ray and assist in supination. The soleus contracts from loading response (medial portion, eccentrically, to slow calcaneal eversion) until just after midstance (to assist in calcanel inversion and supination). 

The tibiofibular articulation is a dynamic structure during gait, and the fibula appears to move downward during the stance phase of gait (rather than upward, as previously thought from cadaver studies)(4), with the distal articulation having a rotational moment (5). 

Consider checking the integrity of these joints, and asuring their proper ranges of motion, particularly in patients with chronic ankle instability (6). A little joint motion can go a long way : ) 

1. The Effect of Lateral Ankle Sprain on Dorsiflexion Range of Motion, Posterior Talar Glide, and Joint LaxityCraig R. Denegar, Jay Hertel, Jose FonsecaJournal of Orthopaedic & Sports Physical Therapy 2002 32:4, 166-173 

2. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee painSuter, Esther et al.Journal of Manipulative & Physiological Therapeutics , Volume 22 , Issue 3 , 149 - 153

3. Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability.Grindstaff TL, Beazell JR, Sauer LD, Magrum EM, Ingersoll CD, Hertel J. J Electromyogr Kinesiol. 2011 Aug;21(4):652-8. doi: 10.1016/j.jelekin.2011.03.011. Epub 2011 May 4.

4.  Dynamic function of the human fibula. Weinert, C. R., McMaster, J. H. and Ferguson, R. J. (1973), Am. J. Anat., 138: 145–149. doi: 10.1002/aja.1001380202

5. Kinematics of the distal tibiofibular syndesmosisAnnechien Beumer , Edward R Valstar , Eric H Garling , Ruud Niesing , Jonas Ranstam , Richard Löfvenberg , Bart A Swierstra  Acta Orthopaedica Scandinavica  Vol. 74, Iss. 3, 2003

6. Effects of a Proximal or Distal Tibiofibular Joint Manipulation on Ankle Range of Motion and Functional Outcomes in Individuals With Chronic Ankle InstabilityJames R. Beazell, Terry L. Grindstaff, Lindsay D. Sauer, Eric M. Magrum, Christopher D. Ingersoll, Jay HertelJournal of Orthopaedic & Sports Physical Therapy 2012 42:2, 125-134 

What are we listening to lately?

We have been getting into David Pope and the “Physioedge” podcast.

This particular title piqued our interest talking all about plantar fasial pain. It is an interview with Michael Rathleff from Denmark. Michael works in the areas of patellofemoral research, plantar fascia research, and exercise.  

Approximately 10% of the population from 840 to 60 suffers from some sort of plantar fasciopathy. These people usually have jobs where they are upright and standing on her feet for extended periods of time.

Plantar fascial pain seems to respond better to loading-based therapies rather than stretching-based therapies,  due to the similarities between tendons and fascia . He emphasizes not to overlook educating the patient about their condition and taking the time to explain what’s going on. He then goes on to talk about activity modification in the treatment plan.

He classifies two major types of people who develop planter for shop: runners and people that are overweight ( repetitive loading versus constant loading).

Pain patterning is often threefold: 

1. pain during the workday

2. pain when they get home

3. pain after they get up after taking a rest for any length of time. 

So, how much can you reduce the loading and, how much does that reduce their symptoms?  With runners it’s a little easier as you can just tell them to reduce their mileage.

Some “rules of engagement” are given: runners need to be able to walk a 10K briskly, without pain before during or after or at three time frames when they had pain before. After this baby can begin a running program eight weeks of five k’s of continued running. Ching that yes this can take some time is important and offering the patient alternative means of exercise (cycling, swimming etc.) is important.

Running should begin with one minute running, two minute walking and repeating the cycle and a pain-free patch fashion. Pain should never exceed a 3/10 on the analog scale.

The distinction is made between plantar fasciopathy and plantar fasciitis with the former being more of a degenerative condition and the latter an inflammatory one. Palpation and thickening of the central portion of the planter fascia is emphasized in fasciopathy.

A link to some downloads with handouts, instruction, etc. is also provided within the podcast. 

Rehabilitative exercises focus on increasing loads. A simple calf raise with the toes of dorsiflexion using a town introduced. The patient begins with three sets of 12 RM done every other day for a few weeks with increased to an eight RM as they get stronger. Repetitions are three seconds up, hold for two seconds, three seconds down, hold for two seconds.

The pros and cons of this exercise are discussed: in short if you need high tensile loads across the plantar fashion then this exercise is key. This would be more for chronic conditions rather than acute ones which would probably require rest rather than loading. Up to six months the high load strengthening exercises seem to be superior to stretching and simple he’ll inserts, but after six months there appeared little difference between the two. Speculation was that most people probably discontinue the exercises because they were feeling better.

People that were more active or engaged in sports, at least in this RCT, seem to do better than folks that had the fascia apathy due to having a high BMI.

One study they cite looks at intrinsic musculature of the feet and legs as a contributing component to chronic plantar fasciopathy. It’s emphasized that an individualized program be designed for each patient.

All in all a nice evidence-based lecture/interview with some great clinical pearls. Consider adding a progressive loading program to your planter fasciopathy patients and perhaps consider adding intrinsic muscle exercises well.

http://physioedge.com.au/pe-038-plantar-fasciopathy-loading-programs-michael-rathleff/

Fatigue and exercise.

Do your clients do their home program exercise before activity ? We warn our clients about fatigue/endurance all the time. We will build capacity and durability on skills before we hit strength parameters all the time. We like to ensure that we get a durable pattern engrained before we challenge it with more strength challenges.
*However, do not let your clients do their home program to fatigue before activity. It is ok to prime the movement patterns with corrective exercise, but just a few reps before activity. This study suggests why:
“We conclude that 20min is not enough to see full recovery of gait after exhaustive quadriceps muscle fatigue.”-Barbieri FA et al.\

addendum:  Keep in mind, that during exercise, say a 7 mile run, if you fatigue some critical joint stabilizers at the 5 mile mark, ……. you will begin to run a comensatory sub-motor program.  You hope !   Just don;t do that too often !  How do  you know ?  You don’t, until you get pain from that pattern failing quite possibly !

Gait Posture. 2016 Jan;43:270-4. doi: 10.1016/j.gaitpost.2015.10.015. Epub 2015 Oct 25.Recovery of gait after quadriceps muscle fatigue.Barbieri FA¹, Beretta SS², Pereira VA³, Simieli L², Orcioli-Silva D², Dos Santos PC², van Dieën JH⁴, Gobbi LT².

http://www.ncbi.nlm.nih.gov/pubmed/26531768

Is the “Short Foot” exercise dead ? Dr. Allen thinks it is at the very least, floundering on wobbly premises.

- another blog article by Dr. Shawn Allen

Stand and raise your toes. Where does your arch go ? It should elevate, the arch should increase in height/width/volume thanks to several biomechanical principles, the Windlass mechanism to name one.

Many therapeutic approaches to foot posture correction at some point implement the “Short foot” exercise. In some respects, perhaps many, I think that model may be poorly grounded fundamentally and functionally. My protocols and approach are to restore as functional a foot as possible, during both static and dynamic stance phases of gait, and that means restoring rear and forefoot alignment on a neutral strong competent arch. To be clear, an arch does not need to be high, at whatever its’ height, it just needs to be competent. It is quite possible that I have not truly used the “short foot” exercise in over 10 years in correcting my client’s biomechanics, not in its’ traditionally taught methodology (ie, I have never taught the exercise with the toes flush on the ground, that a mistake in my opinion). I see some limitations in it, and some flaws. These are purely experiential on my part, yet grounded in my successes and failures with many hundreds of clients. This however does not mean I am always right, but i go with what works in my clients. 

When I ask a client to stand up and raise their toes (this is truly how a “short foot” is achieved), pointing out that their arch raised as the toes elevated, they often look puzzled. I often put their orthotic under their foot and again ask them to raise the toes again, thus lifting their apparently “fallen” incompetent arch off the orthotic. I then ask the question, so, are we going to continue to use this device to “Fix” your foot ? Are we going to use a hydraulic push approach restore your foot, or are we going to exercise the muscle that are already there to lift (I like to use a crane analogy) the arch and restore the rear and forefoot relationships ?  Clients always answer this question for me, and they do so quickly.  I am quick to reply that this will take time, repetition, obsession, awareness and homework.  This does not mean every case is successful. Some people have attenuated the ligamentous and tendon structures so badly that a deconstructed arch or weight bearing navicular is just too far gone. There are also those folks who have zero body awareness and that is their rate limiting step.  There are many rate limiting steps in attempting to restore function. We just cannot save everyone. 

I am sure you want answers, protocols, “the order” and “the exercises” I use. Ivo and i have outlined some of them on our blog and on our youtube videos. Somewhat purposefully, we have not prescribed an “order” for them to be done, because each person has their own unique problems and their own order and that is were clinical knowledge must come in to play. You just cannot throw exercises at people and see what sticks, too many people do this already.  I also know that many prescribe the “Short Foot” exercise as homework. That is not a problem for some, but it may have limited value if the prescriber does not realize that 

the exercise has a retrograde approach and a prograde approach. 

What I mean is, with this exercise as it is traditionally taught by many (not all), that you are weight bearing first with the toes down, then shortening the rear-forefoot interval by reacting into the ground, and this is exactly opposite from what truly happens in functional prograde weight bearing. In functional weight bearing the arch and foot need to somewhat splay to load adapt, and more importantly, this has to be a skilled eccentric endurance task. This first portion of the arch splay occurs with the toes off of the ground and so forgetting to teach this part while only teaching the “reacting off the ground, flexor muscle driven approach” is flawed. The toes when on the ground utilize the flexor muscles help to resist the latter phase of arch accommodation, but again to be clear, this does not occur in the initial weight bearing phase where eccentrics of the anterior compartment muscles rule the roost. What I am trying to say is that there is never a point in the functional stance phase of the gait cycle where the rearfoot and forefoot are approximating, other than at terminal toe off, it just does not occur.  Hopefully you can see the point of my argument, that this exercise if done improperly (as taught by many) is not functional. 

So is the short foot exercise dead ? Well, to be honest everything has its’ place in this world. Value can sometimes be obtained from the most corrupt of tasks, but there has to be a correlation and transference to the end purpose.  

None the less, this is a pretty prehistoric exercise if you ask me, it needs to be dusted off and updated and retaught correctly, and that is one of my near term missions in the coming weeks. Again, if anything, if there is one morsel of value , the eccentric phase of “letting go” of the short foot posture into a controlled splay is the part of it that has much of any functional relevance.  Teaching your client how to attain a short foot posture, and then to stand and learn to slowly eccentrically release the short foot posture is its main functional value. But, the toes are critical, and a video is key to helping drive this point home, so that is my short term commission. Again, this does not mean there is not value here, so lets not start a social media rant taking my words out of context.  

To summarize, as we are bearing weight down on the foot the arch should be in a controlled pronatory deformation to shock absorb. There is no time to be reacting off the floor into a short foot, that opportunity moment is lost at contact, actually it really never occurs once the ground is met whether one is in initial rearfoot, midfoot or forefoot strike.  The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure.  The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact).  Failure to procure a competent foot will put your client at risk for all of the juicy pathologies we talk about here on The Gait Guys, things like bunions, hammer toes, pes planus, plantar fascitis, tibialis posterior insufficiency and a multitude of various tendonopathies to name just a few.

Need an exciting primer on the types of things a foot should be able to do ? Here are 2 videos. Video link. Video 2 link.

Dr. Shawn Allen, one of the gait guys

Muscle Contraction and Antibacterial Soap.

Using antibacteria soaps and gels? New study suggests you think twice. We knew of its alleged endocrine disrupting properties, but this one shocked us.“triclosan disrupted communication between two proteins crucial for proper muscle functioning, causing failure in both the heart and skeletal muscle cells.”
“triclosan penetrates the skin and enters the bloodstream more easily than previously thought. A new paper, (Triclosan impairs excitation–contraction coupling and Ca2+ dynamics in striated muscle) published today in the Proceedings of the National Academy of Sciences, indicates that triclosan impairs muscle function in both animals and humans. The study found that the chemical hinders human muscle contractions at the cellular level and inhibits normal muscle functioning in both fish and mice.

Reference:
http://www.smithsonianmag.com/science-nature/triclosan-a-chemical-used-in-antibacterial-soaps-is-found-to-impair-muscle-function-22127536/?no-ist

Study: http://www.pnas.org/content/109/35/14158.abstract

Triclosan impairs excitation–contraction coupling and Ca2+ dynamics in striated muscle

Asymmetries in limbs

Repetitive loading of limb asymmetries may have a cost down the road in terms of bone mass and bone structure. This can impact loading responses and musculoskeletal function.

Study purpose: “Asymmetrical loading patterns are commonplace in football sports. Our aims were to examine the influence of training age and limb function on lower-body musculoskeletal morphology.” -Hart et al.

“Conclusion: Asymmetries were evident in athletes as a product of limb function over time. Chronic exposure to routine high-impact, gravitational loads afforded to the support limb preferentially improved bone mass and structure (cross-sectional area and cortex thickness) as potent contributors to bone strength relative to the high-magnitude, muscular loads predominantly afforded to the kicking limb.” -Hart et al.

From:

Musculoskeletal Asymmetry in Football Athletes: A Product of Limb Function over Time.

Hart, Nicolas H.; Nimphius, Sophia; Weber, Jason; Spiteri, Tania; Rantalainen, Timo; Dobbin, Michael; Newton, Robert U.

Medicine & Science in Sports & Exercise:Post Acceptance: February 11, 2016

1st MTP Pain?

It may not be a trigger point. In this capsule summary, Dr Ivo discusses an interesting and perhaps revolutionary, theory on trigger point pain that refers to the 1st metatarsal phalangeal articulation. The anatomy of the joint and responsible muscles are also discussed

Got Motion Control? Sometimes too much of a good thing is a bad thing!

Welcome to Monday and News You can Use, Folks.

Today we look at short video showing what someone with internal tibial torsion looks like in a medially posted (ie motion control) running shoe. Note how the amount of internal rotation of the lower leg decreases when the shoe is removed and when he runs. Be careful what shoes you recommend, as a shoe like this is likely to cause damage down the road.

You can follow along listening to Dr Ivo’s commentary. This was filmed at a recent seminar he was teaching.

The Banana Toe: The Force has to go somewhere. It’s a Jedi Gait Rule.

* note: there are 4 photos to today’s blog post. Be sure you click through all 4.

When you toe off, you have to toe off from somewhere in the foot unless you like an apropulsive hip flexion gait, where  you just lift you foot off the ground from foot flat, kind of like a true neurologic “foot drop” gait client would.  But, if you are lucky enough not to have a true foot drop, you are going to push off somewhere in the foot.  You can do it off the lateral foot (low gear toe off) and lesser toes, or you can do it off the big toe (high gear) the way we were built to do it. 

The above pictures show a nasty dorsal crown of osteophytes that is limiting hallux (big toe) extension/dorsiflexion. This is true hallus rigidus and hallux limitus. When this client attempts to toe off, the joint cannot normally partake in the activity, there is no Windlass effect, no posturing up over the sesamoids for mechanical advantage etc.   

In this scenario, there are two places you can put it, up into the next proximal joint(s) meaning the met-cuneiform joint or further down into the interphalangeal joint. In other words. the loads go proximal or distal to the limited joint, and they eventually play out there, over and over and over gain. The former option would basically mean you are pronating/dorsiflexing through the midfoot which is never good (can you say Saddle exostosis ! ouch !) or the latter option is to dorsiflex through the interphalangeal joint  and over time that toe begins to attenuate plantar ligamentous structures and extend beyond its normal limits resulting in the “Chiquita” toe (a upward bent toe resembling a banana shape). This will disable the long flexor of the great toe (FHL: flexor hallucis longus).and inhibit mechanical advantage of the extensor digitorum brevis.  If you struggle with the “how and why” behind this sentence in terms of restoration attempts, you need to watch my video here. It will offer you deeper insights.

Will this toe become painful ? yes, in time it is quite possible.  Is there much you can do? Sure, a rocker bottomed shoe will help take the load at toe off instead of forcing it into this toe or the midfoot.  Will an orthotic  help ? Well, this is a loaded question. If you are putting the forces into the midfoot choice as described above, the orthotic will block that motion and you will likely default option into the toe presentation above. So you are merely just moving loading forces around. It can be helpful, but you are quite possibly “robbing Peter to pay Paul” as they say.  The video I asked you to watch can be helpful but it will force that metatarsophalangeal joint into extension, a range it does not have, so it is not a remedy and not recommended.  Perhaps some awareness and slight increase in FHL(long toe flexor) use can be attained however.  These are tricky cases, simple in theory, but execution can be fussy and requires patient awareness and education. We like the rocker bottomed shoe as a nice easy solution and some increased FHL use awareness.  Help them find a little more FHL use by putting a pencil under the crease of the toe and help them to drive the tip of the toe down just a little out of that banana extension posture. It can help them control the overloading of the dorsal aspect of the interphalangeal joint.

As always, lets carry this forward into gait thoughts.  How is  hip extension going to be in this client ? How is glute strength ? Hip joint range ? Hip extension motor patterning ? Will the client go into anterior pelvic tilt to borrow the last range of hip extension ? Will the hamstrings have to accommodate ? Lots of yummy biomechanical and neurological mental gymnastics here. Bottom line answer to all the above ?  “ it depends, they will have to accommodate and compensate”.  And as the Jedi Gait Rule goes, “the Force as to go somewhere”.

Shawn Allen, one of the gait guys

Carry a backpack?

Unless you are a great compensator, like some limb amputees seem to be (see yesterdays post), be prepared for some changes in your gait. During some of our “backpack” research for yesterdays post, we turned up this full text article:

“In conclusion, college students currently carry too much weight in their backpacks. The average weight carried by UVU students caused an increase in trunk flexion regardless of age, gender or year in school. The load carried in the backpacks also slowed gait velocity, increased time spent in double support, and with the messenger bags caused a change in the right foot angle implying that the hip was rotated due to the contralateral bag placement. In an effort to avoid such potentially harmful conditions, college students should avoid using messenger bags, should always follow the manufacturer settings for proper bag positioning, and carry less weight in their backpacks.”

https://www.western.edu/sites/default/files/page/docs/jensen.et_.al_.spring.2014.pdf

Carry a pack? 

Have a LLD or other gait altering condition like a lower limb amputation? Carrying a pack may not necessarily change your center of gravity. 

Yes, we were surprised as well…

“There are many scenarios where it becomes necessary to carry a load, and a back pack is often the most realistic option to carry this load. The additional load is thought to lead to changes in kinematics of the persons movement. This hypothesis, however, is not supported by results of this study. Asymmetry in movement did not significantly alter centre of pressure (COP) parameters for an amputee carrying a loaded backpack.”

Abstract

Understanding how load carriage affects walking is important for people with a lower extremity amputation who may use different strategies to accommodate to the additional weight. Nine unilateral traumatic transtibial amputees (K4-level) walked over four surfaces (level-ground, uneven ground, incline, decline) with and without a 24.5 kg backpack. Center of pressure (COP) and total force were analyzed from F-Scan insole pressuresensor data. COP parameters were greater on the intact limb than on the prosthetic limb, which was likely a compensation for the loss of ankle control. Double support time (DST) was greater when walking with a backpack. Although longer DST is often considered a strategy to enhance stability and/or reduce loading forces, changes in DST were only moderately correlated with changes in peak force. High functioning transtibialamputees were able to accommodate to a standard backpack load and to maintain COP progression, even when walking over different surfaces.

Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.

Appl Ergon. 2016 Jan;52:169-76. doi: 10.1016/j.apergo.2015.07.014. Epub 2015 Jul 31.Center of pressure and total force analyses for amputees walking with a backpack load over four surfaces. Sinitski EH, Herbert-Copley AG, et al

Yes, you are looking INSIDE this toe. That IS a screw and metal plate in that toe. 

What kind of stuff finds its way into your office ? I get all kinds of things it seems, at least once a day something comes in that makes me scratch my head. 

This client just wanted my opinion and thoughts on their toe and their gait once they are ambulating again. They have had multiple surgeries to this poor foot. You can see multiple scars over multiple digits and metatarsals.  This is the 3rd surgery to the big toe, the last 2 have been attempts at correcting failed prior surgeries. This is obviously the last straw surgery, total fusion of the metatarsophalangeal joint.  What is interesting in this case is that this plate was taken out about 4 weeks ago, and the skin was stretched back over and the wound closed up (forgot to take update photo for you). I saw it yesterday, and I was amazed at how healed up the area was. They are months post op now, and they can load the toe heavily now, that is always amazing to me. The body’s healing ability is a miracle. Of course, if you have been with us here long enough you will know that my “concern button” immediately got pushed but the client was proactive and asked the question before my oral diarrhea of concerns started.

So, they wanted to know about their gait and what to watch out for.  Off the top of your head, without thinking, you should be able to rattle off the following:

• impaired toe off
  
• premature heel rise
  
• watchful eye on achilles issues
  
• impaired hip extension and gluteal function
  
• impaired terminal ankle plantar flexion (because they cannot access the synergists FHL and FHB)
  
• impaired terminal ankle dorsi flexion (because they cannot access the synergists EHL and EHB)
  
• lateral toe off which will promote ankle and foot inversion, which will challenge the peronei
  
• frontal plane hip-pelvis drift because of the lateral toe off and lack of glute function
  
• possible low back pain/tightness because of the  frontal plane pelvis drift and from altered hip extension motor patterning (and glute impairment)
  
• possible knee pain from tracking challenges because they cannot complete medial tripod loading and thus sufficient pronation to internally spin the limb to get the knee to sagittal loading
  
• impaired arm swing, more notable contralaterally
  

There is more, but that is enough for now. You need to know total body mechanics, movement patterns, normal gait cycle events (you have to know normal to know abnormal) and more. You have to know what normal is to understand when you are looking at abnormal.

* So, dial this back to something more simple, a “stubbed toe”, a painful sesamoid, painful pronation or a turf toe or hallux limitus.  They will all have the same list of complications that need to be evaluated, considered and addressed. This list should convey the importance that if your client has low back pain, examining the big toe motion is critical. Also, if you are just looking at the foot and toe in these cases, pack your bags … .  you don’t belong here. If you are just adjusting feet and toes and playing with orthotics while the list above does not constantly file back and forth through your brain, again, pack all your bags, grab your cat and leave town (just kidding, try reading more and get to some seminars).

If you know the complicated things, then the simple things become … … . . simple.

Your local treadmill gait analysis guru should know all of this if they are going to recommend shoes and exercises. Shame on them if there is no physical exam however. The data roadmap from the gait analysis software print out is not going to get you even out of the driveway let alone down the street. The data is going to tell you what you are doing to compensate, not tell you what is wrong. You must know anatomy, biomechanics, neurology, orthopedics and how to apply them to get the recipe right, not just which shoe in a store will unload the medial tripod of the foot or which exercise will lengthen your stride on the left. 

… .  sorry for the rant, too much coffee this morning, obviously.

Shawn Allen, one of the gait guys

What are we listening to this week? The Plantaris…

Thanks to Karly Foster of Twin Bridges Physiotherapy the: Physioedge podcast with David Pope

Imagine if you were able to dedicate a large portion of your life to the study of one individual muscle. That’s exactly what the main person interviewed here has done Dr. Kristof Spang from Sweden has done.  a lot of research on Achilles tendon tendinopathy.This podcast looks at the role of the plantaris muscle in mid tendon tendinopathy, with an emphasis on anatomy.

This muscle needs to be considered in recalcitrant cases of Achilles tendon apathy which of not respond to conservative means.

Dr Spang goes through some of the anatomical variations of attachment of the plantaris, with 10 to 20% attaching into the Achilles tendon. Since there seems to be at least nine different anatomical variations in attachment that can occur; this can often explain the variety of symptoms associated with plantaris issues.

The plantaris attaches from the lateral aspect of the femoral condyle downward to its insertion point within deli near its origin at the knee. The area of attachment distally can be between two and 5 mm and this “area attachment” may be part of the source of the pain. Phylogenetically the tendon attaches into the plantar fashia, similar to the palmaris. One theory is due to the small muscle size it may actually act as a proprioceptive sentinel for the knee and ankle. The peritendonous tissue may interfere with the gliding of the tendon in this is believed to be one of the ideologies of this recalcitrant problem.

Of the diagnostic imaging available, ultrasound seems to provide the most clues. In the absence of imaging, recalcitrant medial knee tendon Achilles tendon pain seems to also be a good indicator.

Our takeaway was that most often the problem seems to be had a conjoined area between the planters and Achilles tendon midcalf lead to most problems. Treatment concentrated in this area may have better results. If this is unsuccessful, surgery (removal of the plantaris, extreme, eh?)  may need to be considered.

Regarding specific tests for plantaris involvement, people who pronate seem to be more susceptible than those who supinate. This is not surprising since the tendon runs from lateral to medial it would be under more attention during predatory forces

It seems that plantaris tendonopathy  can exist separately from an conjoint tendinopathy and it may be that people of younger age may suffer from plantaris tendinopathy alone. This may indicate that the problem may begin with the plantaris and that the planters is actually stronger and stiffer than the Achilles!

It was emphasized that this condition only exists in a small percentage of mid Achilles tendon apathy patients. And that conservative means should always be exhausted first.

All in all, an interesting discussion for those who are interested in pathoanatomy. Check out part 2 in this series for more. 

link to PODcast: http://physioedge.com.au/physio-edge-041-plantaris-involvement-in-midportion-achilles-tendinopathy/