Bunions

Dear Gait Guys:

if treated when still a child can you change a bunion without surgery? I have a young kid, 12, with a bilateral forefoot varus and bilateral bunions, he has started to compensate even through his hip and core already which I have been working on but wondered if, by retraining the foot, tripod exercises, lumbricals, interossei, can we actually change his foot? And do you have any other ways that I might be able to attack this foot in order to change it?

Thanks

J

Dear J

As we sure you are aware, bunions form from unopposed activity of the adductor hallicus. Normally, with an appropriate tripod, it serves to assist in forming the transverse and longitudinal arches of the foot during the stance phase of gait. When the 1st ray (in basic terms, the medial aspect of the foot) isn’t anchored, it acts unopposed and adducts the hallux instead, forming an abductovalgus deformity over time. This causes a medial shift of weight in the foot and the metatarsals to abduct to compensate for this. In other words, the big toe and medial tripod are supposed to be well anchored so that the lateral foot is pulled towards it. This forms the forefoot’s transverse arch. But when the medial tripod is not anchored, the lateral foot serves as the anchor and thus the big to is pulled towards that lateral anchor by the adductor hallucis muscle.

It is imperative that you restore function (and the ability) to fully descend the 1st ray (your child must relearn how to anchor that metatarsal head aspect of the tripod).  This is imperative for success.  We have a youtube video of a young child demonstrating how they learned this. You can often accomplish this with manual methods, mobilization, appropriate footwear and most importantly exercises to descend the 1st ray , particularly toe extensor exercises (both the EHB and the EHL which descend the head of the 1st). Sometimes, if the 1st ray is rigid and won’t descend, you will need to use an orthotic or a cork addition to their footbed with a Mortons toe extension to bring the ground up to the base of the 1st metatarsal.

It sounds like you are strengthening the core, which provides stability from above down. Pay close attention to the external rotators, as they will often be lengthened due to excessive internal rotation of the extremity.  But the key is restoring the skill, endurance and strength of those muscles that descend the head of the 1st metatarsal and that help reengage the medial tripod.

We hope this helps. PLease let us know

Ivo and Shawn

Think about what you are doing

“The bottom line is this. ….

For every impairment we detect, and for every altered movement pattern we see in our people (ie. more arm swing on one side, one shoulder dropped, one foot turned out etc…..) ……there is a good reason.

After 15 years of practice, here is what I have concluded.

There is a reason……and that reason must be one of avoidance of pain or threat (weakness, pending damage …..such as a subclinical developing tendonitis, cuff tear, tumor, infection etc) or, what you are seeing is the person’s strategy to compensate to avoid the above.  So, quite frequently, what you see is not the problem.  So, when you see your athlete/client doing something funky, or you lie them down and see an impaired ankle rocker or hip rotation, your VERY NEXT question should be "fact or fiction”….. Is this a true cause or is this a compensation ?  If what you do does not change it PERMANENTLY it was likely a secondary compensation, if you keep having to return to the same issue, you are not on the button so stop wasting your time.  That is not where the problem is most likely (unless some reasonable improvements in skill strength and endurance (SSE) make the change)……but……but…..BUT…..if you do work on the SSE and it improves the problem……the wise, savvy and awake coach, therapist etc must ask the hard question, “OK, so, did I really fix that or just lay enough SSE to mask the problem.  You can see that this can be a vicious cycle of self questioning.  So if any of you wonder why our hair has fallen out then you now know the true frustrations we go through every 45 minutes of very day with our clients.  "Did i fix it or mask it ?????"  Only time has the answer.

Here is a clue to help you……

If your client stops the homework and the improvements remain long term, without the development of NEW compensations and new injuries, then you got it.  But, if your client’s response was, "this tightened up today, and this was sore today, and this hurt during the first 10m…..etc” then you have to cast a jaundiced eye at what you did, and ask the hard questions.

For in reality if  you are doing the right things for  your client for the right reasons they should get healthier and less injury prone and have fewer complaints.  You should have a brethren of athletes that are all injury free, top shape, top of their game, and each workout should show improvements in skill strength and endurance in a balanced fashion…..“super athletes” if you will.  Some might argue that a hard workout can trigger any injury but I disagree.  A hard workout should trigger physiological advancements, not neurophysiological and neuromuscular setbacks.  The more appropriate muscle tone, range of motion in a joint and its accessory joints, the more competent the regional anchoring muscles are, and  when each component is doing its thing correctly, not borrowing things from others beside it, then this body should be humming like a new motor with freedom to tromp of the accelerator and push it to the floor without hesitation or risk.

But, if you keep cycling injuries, and new ones keep cropping up despite more exercise homework, more rehab, more stretching , more warm-up, etc then you are just MANAGING the issue and adding layers of compensation to your athlete/client.  You effectively raise the capacity of the compensated system but you do not narrow the gap between the asymmetries in the body that drove the compensation and the injury.

All we ask is for you all to think.  Think often, think deeply. Think about what you are doing.  And always ask, “Did I fix that or did I help them to add another layer of compensation ?”.  The body is pretty amazing and resilient, it will make fast immediate and profound changes if given the right recipe and it will complain if it does not like it.  Pain and altering its strategies (weakness, inhibition, loss of ROM etc) are its only ways to communicate with you and its owner.   If you are not listening to its silent dialogue, paying attention its detailed expressions (range of motion loss, tightness, soreness, weakness) then you are doomed to be just like all the others in your field…..and frankly mediocrity doesn’t get you or your client the gold medal !

The fact of the matter is this…..if it was easy to fix things on this human body (Hey, Mr. Jones….when you walk just keep thinking about turning in that right foot and swing that left arm a little more.“) I would like to think that guys like us would have figured it out by now and would have stopped making things more difficult. We would have written "the Bible” on this stuff and with its worldwide proceeds we would be sailing on a nice big yacht in the middle of the Caribbean drinking beer with Jimmy Buffet.  But since you have not seen that book yet and because Ivo and I are still pasty white with meager sized livers you can only assume that we are still on the journey just like you guys.  But, each day we hope to be one step closer.  Hang with us, we hope to get there before we are too old or before Jimmy is 6 feet under !

Cheers

Shawn and Ivo

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Another day at the zoo. What do you see?

Fashion faux paus? Interesting tattoo? A man and a wagon?

OK, did you see this in these 3 pictures above (scroll through them) ?

  • Left calcaneal valgus
  • pelvic dip/rop on right
  • hip cruise (shifting of the pelvis) to left (weak gluteus medius anyone?); look at the 3rd picture; when the leg is supported, all is well
  • possible Left functional short leg with right bent consistently?

What are you thinking?

  • Wow, where can I get a pair of shorts like that?
  • That tattoo over the achilles must have hurt
  • Does my butt make these shorts look too big?
  • Left weak gluteus medius driving left pelvic shift; weakness of posterior fibers of the gluteus medius allowing too much internal spin of the Left leg
  • notice in shot 3 how supporting the Right leg rotates the pelvis counterclockwise and corrects the “pelvic dip”

The Gait Guys….no one is safe from the gait cam. Yes…when you look in the dictionary under the word “geeks” our picture is there.

Why you should have a picture similar to this of Sandra Bullock in your shoe store….  Because of the story it tells to all runners (and walkers)….. we guess that means everyone then doesn’t it ?
Note what the lovely Sandra is wea…

Why you should have a picture similar to this of Sandra Bullock in your shoe store….  Because of the story it tells to all runners (and walkers)….. we guess that means everyone then doesn’t it ?

Note what the lovely Sandra is wearing.

Your eyes may be first drawn to the accentuation of her buttocks and calf as well as her lifted chest.  In actual fact, that is what high heel shoes are designed to do.

What you might not see because you are drunk on her beauty and figure is the cost on her body from those illusion driving high heel shoes. Here is what they are doing behind the scenes:

  1. creating a perpetually plantarflexed foot with excessive and unnatural forefoot loading and likely increased use of long toe flexors
  2. sustaining tension in her quadriceps because she is purchased forward on the balls of her feet
  3. hyperextension loading the knees with increased lumbar lordosis which is making it a challenge to maintain adequate abdominal tone, in fact, likely inhibiting the abdominals.  

Who cares right ? It all frame her glutes nicely and accentuates her bosom right ? 

Blame it on Sex and the City or blame it on men who like to see women in high heels, but there is blame to dish out.

Put Sandra in some Newtons or Altra’s ……or some other zero-drop minimalist shoes and watch:

  1. Her heels drop redistributing normal rear : forefoot loading 
  2. Foot intrinsic muscles begin to re-engage as the long toe flexors settle down now that she is off the forefoot
  3. Achilles and calf muscles lengthen to their normal state
  4. Tone normalizes in anterior shin compartment and toe extensors
  5. The foot mechanics we were born with are restored because they are in the environment we were born with…… that being that the forefoot and rearfoot are both on the same plane (flat on the ground) and thus the mechanics they were designed to engage are once again available and possible.  (But it will take time to restore the lost function. Even men’s every day shoes, including traditional running shoe trainers have a ramp-delta heel lift.)
  6. Lumbar spine lordosis reduces, abdominals engage easier
  7. Psoas returns to normal length from its shortened state
  8. Cervical spine returns to neutral
  9. patellofemoral joints compressively unloads making for some happy knees
  10. Gluteals re-engage and take the extension from the lumbar spine and put it back into the hips where it is supposed to be achieved.

And that my friends, is why you need a picture of Sandra Bullock in your shoe store now that you know what heeled shoes are doing in the background of your body mechanics.

Bammmmm…….. The Gait Guys…….. critics of even the most beautiful actresses in Hollywood.  Ivo and Shawn…….risking it all, even a dinner date with Sandra, to bring you the facts.  Our only question now is, “Why Jessie James? Why ?”

Shawn and Ivo

How robust is human gait to muscle weakness?

Below you will find a link for the 2012 article in Gait Posture entitled “ How Robust is Human Gait to Muscle Weakness?”
Today’s Take Home Points are:
  1. Proper technical form in walking and running is critical. Everyone talks about it at the ground level assuming we are all idiots.  No one is getting down to the roots of the problems and solutions like we try to do.  This means reducing Cross Over gait pathologies which we have shown you previously. 
  2. Attempt to maintain clean movement patterns free from compensations. For one,  make sure you have sufficient ankle rocker (dorsiflexion bend). 
  3. Make sure your abdominal muscles and core are symmetrical and strong. Obliques are key but not exclusively so.  They will make sure that your initial hip flexion comes from them and not the hip flexors !
  4. Do your glute work to ensure your glutes are in charge of hip extension and not your quadriceps.
  5. Make sure you are not a victim of compensations such as overactive hip flexors, weak hip abductors and premature calf engagement.

Now, lets get into the details, this summary is pretty soft.

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We are ordering this article to see its specifics so stay tuned for any other info. Here we dissect the articles main principles to put it into terms that might serve you well as a walking or running human.
Lets start with a great quote from Basmajian in Muscles Alive,
Locomotion is “the translation of the center of gravity through space along a path requiring the least expenditure of energy. Pathologic gait may be viewed as an attempt to preserve as low a level of energy consumption as possible by exaggerations of the motions of the unaffected levels. When a person loses one of the six determinants of human gait compensation is reasonably effective. Loss of two determinants makes effective compensation impossible; the cost in terms of energy consumption triples adn apparently discourages the patient to the point of his admitting defeat."  Basmajian, 1953, Muscles Alive: Their Functions Revealed by Electromyography.  (Yes, it is 60 year old statement, but we use this book all the time because it is one of a kind and this guy was ahead of his time. His information is frighteningly accurate even on today’s research terms.)
What this article seems to indicate is that weakness in certain muscles has some predictors.  The article inquires, "how much weakness can be tolerated before normal daily activities become impaired?” In theory what they were looking at was a simple principle suggesting that there is a kind of tipping point for muscle weakness before there is sufficient weakness to require a gait compensation pattern to protect the joints and attempt to preserve the motion of gait. 
What the study found is that the muscles of hip extensors and knee extensors (glutes and quadriceps are assumed here) are particularly robust and resist weaknesses. These are sagittal (forward progression) muscles and are quite necessary for gait and running movement. 
In contrast the study indicated that gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors.
So, how might this be interpreted ?  Well, lets start with the hip abductors. These are the gluteus medius muscles for the sake of generality.  These protect the frontal plane and help keep the pelvis neutral. They protect you from the Cross Over gait we have talked about over and over again in previous blog posts and YouTube videos.  Without proper frontal plane stability gait pathologies arise (not to say this is the only source however).
Now lets talk about the hip flexors. This muscle group is every therapists gem to talk about. There always seems to be a runner or patient talking about how their massage therapist,physical therapist or athletic trainer has told them that their hip flexors are tight, weak or filled with trigger points.  We do not dispute their findings here. But what we wish for you is to use logic based on THE FACTS. Most of these people will be alarmed to find out that a main function of the hip flexors is not to initiate hip flexion.  NO ! Say it ain’t so Jack !  Well the truth is that the psoas  muscles are in a big way hip flexor PERPETUATORS, not INITIATORS.  The abdominal muscles are the first muscles to initiate hip flexion via derotating the obliqued pelvis at heel rise.  It is only once the pelvis is moving forward with the pendulum leg following forward that the hip flexors engage to perpetuate the limb flexion at the hip.  Remember, once the leg is in swing phase much of the hip flexion movement is PASSIVE from momentum ! (We will save you from another Newton’s Law diatribe here).  So, it might be safe to say that whatever “your people” are finding are results and consequences to impaired use of the core to INITIATE proper limb/hip flexion. According to this journal source: “Psoas major works phasically: (1) as an erector of the lumbar vertebral column, as well as a stabilizer of the femoral head in the acetabulum at 0 -15 degrees flexion at the hip joint; (2) less as a stabilizer, in contrast to maintaining its erector action, at 15 -45 degrees; and (3) as an effective flexor of the lower extremity, at 45 -60 degrees."  This study seems to support that the psoas is not an initiator of hip flexion, rather it engages at 45 degrees making it a clear perpetuator.
Now lets dialogue briefly on the plantarflexors assuming they mean the gastrocsoleus complex.  All we are willing to say here (because this is a project we are working on) is that when the gastrocsoleus are not used correctly to drive forward progression they may serve to lift the person (this comes with premature heel rise and thus premature calf firing). This can lock out further ankle dorsiflexion range and thus hip extension range. Thus, limiting the ability to gain a sufficient hip extension-pelvic rotation to enable sufficient range for the abdominals to serve as hip flexor initiators and possibly calling on the psoas and other hip flexors to prematurely engage to initiate the motion. 
How do we summarize this article ?  The journal abstract did it nicely for us. "Compensations are generally inefficient, and generate unbalanced joint moments that require compensatory activation in yet other muscles. As a result, total muscle activation increases with weakness as does the cost of walking.” And it will go as well for running in our opinion.
Again, the Take Home Points are:
  1. Proper technical form in walking and running is critical. Everyone talks about it at the ground level assuming we are all idiots.  No one is getting down to the roots of the problems and solutions like we try to do.  This means reducing Cross Over gait pathologies which we have shown you previously. 
  2. Maintain clean movement patterns free from compensations. Thus, make sure you have sufficient ankle rocker (dorsiflexion bend). 
  3. Make sure your  abdominal muscles and core are symmetrical and strong. Obliques are key but not exclusively so.  They will make sure that your initial hip flexion comes from them and not the hip flexors !
  4. Do your glute work to ensure your glutes are in charge of hip extension and not your quadriceps.
  5. Make sure you are not a victim of compensations such as overactive hip flexors, weak hip abductors and premature calf engagement.

Who are we ? Shawn and Ivo, The Gait Guys. Two doctors dedicated to challenging the myths and lies out there in the world and on the internet on gait and running from the perspectives of orthopedics, neurology and biomechanics. 

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Gait Posture. 2012 Feb 29. [Epub ahead of print]

How robust is human gait to muscle weakness?

Source

Department of Rehabilitation Medicine, Research Institute MOVE, VU University Medical Center, Amsterdam, The Netherlands; Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands.

Abstract

Humans have a remarkable capacity to perform complex movements requiring agility, timing, and strength. Disuse, aging, and disease can lead to a loss of muscle strength, which frequently limits the performance of motor tasks. It is unknown, however, how much weakness can be tolerated before normal daily activities become impaired. This study examines the extent to which lower limb muscles can be weakened before normal walking is affected. We developed muscle-driven simulations of normal walking and then progressively weakened all major muscle groups, one at the time and simultaneously, to evaluate how much weakness could be tolerated before execution of normal gait became impossible. We further examined the compensations that arose as a result of weakening muscles. Our simulations revealed that normal walking is remarkably robust to weakness of some muscles but sensitive to weakness of others. Gait appears most robust to weakness of hip and knee extensors, which can tolerate weakness well and without a substantial increase in muscle stress. In contrast, gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors. Weakness of individual muscles results in increased activation of the weak muscle, and in compensatory activation of other muscles. These compensations are generally inefficient, and generate unbalanced joint moments that require compensatory activation in yet other muscles. As a result, total muscle activation increases with weakness as does the cost of walking. By clarifying which muscles are critical to maintaining normal gait, our results provide important insights for developing therapies to prevent or improve gait pathology.

Tibialis posterior

A question from one of our readers:

Hi guys,

What are your favourite tib post strengthening exercises or do you usually stay with the anterior strength work?

Thanks

D

Our Response:

Hi,
Thanks for your question. As you know the tibialis posterior muscle from the interosseous membrane, lateral part of the posterior surface of the tibia, and superior two-thirds of the medial surface of the fibula. It travels between the flexor digitorum longus and flexor hallucis longus to insert into the tuberosity of the navicular, cuneiforms, cuboid, and the bases of the 2-4th metatarsals.


The function of the tibialis posterior is one of ankle plantar flexion, calcaneal inversion and plantar flexion as well as stabilization (through compression) of the first ray complex (talus, medial cuneiform, navicular and base of the first metatarsal). It acts additionally to help decelerate subtalar pronation. Further stabilization of the midfoot comes from smaller tendon slips inserting onto the other cuneiforms, metatarsals, the cuboid and the peroneus longus tendon.

The more common problems that can occur with the tibialis posterior complex are those of muscular strain, tendonitis, tendon insufficiency (stretch) and partial or complete tears. Excessive or prolonged pronation causes excessive dorsiflexion of the distal first ray complex, increased pronatory effects, and as discussed above, dysfunction of the 1st MPJ joint. The dorsiflexed 1st toe will compromised the efficiency of the windlass mechanism which “winds up” the plantar fascia, properly positions the paired sesamoids, and thus limit effective dorsiflexion of the 1st MPJ. This dorsiflexion of the first ray requires the tibialis posterior to undergo excessive eccentric load for a longer period of time, thus placing more stress on the tendon and muscle belly.

Clinically we find that more people are flexor driven. Therefore we work quite a bit with increasing extensor function, thus a lot of our rehab protocals involve strengthing Anterior Tib as opposed to Posterior Tib. To this one must ask what is your criterior for strengthening the posterior tib, if over pronation or navicular drop has led you to this conclusion then you may want to reexamine the clinical findings for what muscles may actually be involved.


That being said, there times when it is clinically necessary to strengthen the Posterior Tibialis muscle and we like the following exercises

1. Single Leg Balance with Arch Supports:
Begin standing on one foot. Attempt to raise the medial longitudinal arch and hold in tact while maintaining the body stable over the foot.
2. Single Leg Balance with Arm Swings
Perform the exercise above and add to it multi planar arm swings while maintaining medial arch integrity and balance. Cross body arm swings that generate torso rotation, and simulated axe and pitching motion with each arm are effective motions to use.
3. Seated Forefoot Adduction and Inversion
This exercises utilizes some sort of resistive device such as a theraband that will wrap around the forefoot to attach somewhere lateral to the body creating lateral resistance. while stabilizing the ipsilateral knee with the contralateral hand the exercise is performed by adducting the forefoot against resistance towards the midline.
4. Inverted Calf raises
This exercise is performed standing. it should be started as a double support exercise and can be transitioned into a single support for added challenge. the exercise is performed by performing a standard calf raise with or with out Y-axis resistance and adding an inverted moment at the apex of the raise and then lowering back down.
5. Closed Chain Unilateral Supination
Standing on one leg on a step with the knee slightly flexed and the medial border of the foot over the edge of the step. Exercise is performed by lowering and lifting the arch from pronation to supination.

6. Now perform the sequence with appropriate arch intergrity WITHOUT the arch supports

These exercises should get you started. Good luck and let us know if you have any other questions.

The Gait Guys

In this great little slow mo video we see some things. Do you ? … The Perfect Runner.

1. First clips….. awesome toe extension through the entire swing phase all the way into early contact phase.  You have read here before on our blog entries how critical toe extension is for stable and optimal arch contruction prior to foot loading. Suboptimal arch height can mean that pronation loading occurs in a suboptimal foot tripod posturing and can mean difficulties controlling the normal end point where pronation should stop and convert back into supination to ensure rigid toe off.  (It is kind of like two runners in a 100m sprint. One starts at the line off the blocks and the other gets to start 1 second earlier 10 meters back from the line and gain speed towards the line before the gun goes off.  This is what it is like to start pronation prematurely, or with a suboptimal arch, the starting line where things are fair to all parts has been moved. The foot (the other guy in the race) doesnt have a chance.  Maybe a bad example but you catch the drift we’re surfin’ here.)  Back to our point, Niobe has great running form and great technicals.  Great midfoot strike, yes a little forefoot here but that is what happens when you are barefoot naked on hard surfaces. You have to get good form before you can clean up the technicals.  We spend alot of time on the technicals of running once form is clean. It is what makes the difference between 2nd place and a winner. And it is these little things that mushroom into nagging injuries over time.  We cannot express enough how important toe extension range and strength is for proper foot function and a strong neutral foot tripod.  We rarely have to address long toe flexor strength, short flexor strength yes, but not long.  Toe curls, towel scrunches, picking up stuff is not on our list of homework.

2. Second clip. He is skirting the issue of cross over without going too far. He could do a bit better but all in all pretty decent.

3. Emmanual Pairs, big dude ! No cross over. Awesome form.

4. Krysha Bailey. Long jumper. As with all sprinters, no cross over, beautiful form.

Just some easy topics and viewing for a Saturday blog post.

Have a good day brethren !

Shawn and Ivo

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During a recent trip to the zoo with the family, I noticed this young lady walking in front of me (yes, We ALWAYS have a camera with us and YES, We ALWAYS look at everyone’s gait and YES, we really are that geeky).

Watch the clip a few times and note these points about the gal on the left; keep in mind, she could have hip or muscle pathology as well

  • notice the subtle toeing in (decreased progression angle) of the feet, most likely due to internal tibial torsion
  • notice how she doesn’t have her shoes tied; this would necessitate her clenching or clawing her toes to keep her shoes from falling off. This inhibits the activity of the glutes and causes her to have to extend from the hams and lumbar spine; as a result, note how straight she keeps her legs when ambulating
  • there is little to no ankle rocker; she goes from heel rocker to forefoot rocker
  • premature heel rise
  • due to the lack of hip extension and decreased activity of glute max, note how she “rotates” around each leg
  • how about that cross over gait?

Fixes?

For starters:

  • tie your shoes
  • 1 legged standing exercises, being careful to keep hips level and not have a pelvic shift
  • walk with toes up or slightly extended during all phases except for that brief moment during midstance where you need the toes for balance and ground purchase
  • shuffle exercises to engage glute max
  • never wear pants that are sooooo tight that you cannot generate normal fluid gait

Ivo and Shawn…The Gait Geeks…We leave no gait unanalzed…even at the zoo. Watch it; we may have YOU on film!

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Retail Focus: The Toe Box

(3 photos today, hover over the pic to see the slidebar cursor)

Shoes that are too tight in the fore foot inhibit motion. Just like anything else; “if you don’t use it…you lose it”. That goes for forefoot mechanics as well. Shoes probably do not cause bunions, but they can contribute to bad mechanics, which CAN cause bunions. Today’s retail focus will be on toe boxes.

The toes are designed to work as a team, and that team seems to work best with plenty of room to “stretch out”. We haven’t found a study to say that footwear causes foot problems, but there is at least one that says it can aggravate them. High heels don’t count; we have covered that in other posts,

From our forthcoming shoe fit certification program, we can note the following points:

  • The toe box should have ample room to prevent crowding and pressure on the metatarsal heads.
  • When measuring feet, remember “splay happens”’ the foot is wider and longer when weight bearing (standing) and more so at the end of the day (yes, your feet are larger in the evening).
  • use  the larger of either sole or ball length (when using a Brannocks Device). When in doubt, size up!
  • Make sure the toe break of the shoe (where the shoe bends in the forefoot when pressure is applied to it) is at the joint of the big toe (hallux)
  • Make sure any siping or creases in the sole of the shoe near the forfoot line up with the junction of the metatarsal heads and phalanges (at the base of the toes)

Think about shoes with generous toe boxes: Altra, Keen, some Merrels, or brands that offer width sizing.

The Gait Guys….Yes, we do shoe fit too. Soon to be released; the most comprehensive shoe fit certification program ANYWHERE. Watch the blog, our Facebook page and the  website for the launch announcement….

Pictures compliments of Altra Running and Dr Mark Cucuzzella

Under Armor mouth Guards: Neuromechanics?

This week in neuromechanics weekly, we will look at the concept or preloading motor neuronal pools. A reader asked if we could look at the above link (click title) and offer some clinical commentary and some rather bold statements
Here are our thoughts:


The findings they speak of are not surprising at all…

The Temporomandibular joint (TMJ) is blessed with many mechanoreceptors and receives innervation from Cranial Nerve V (trigeminal nerve) and the upper cervical spine. There is physiological overlap through the trigeminocervical nucleus (in the upper midbrain or mesencephalon, the principal sensory nucleus) which receives the same innervation from the trigeminal nerve distribution and the upper 4 cervical neuromeres(nerve levels) (so double input into same pathway). Nicoli Bogduk published abody of research on this, along with Susan Lord and Leslie Barnsley.

The upper 4 cervical nerve root levels also directly input into the flocculonodular lobe of the cerebellum (which coordinates alot of motor activity, especially of axial extensor muscles). This preloads the motor neuronal pool (just like contracting your muscle slightly, or clenching to get a better response from a reflex exam). By optimizing input (through a bite guard), you optimize mechanoreception, which optimizes cerebellar activity, which in turn pre loads the motor neuronal pool.  You would get SIMILAR ( and better tasting!) results with having them clench or bite down on gum, though not as good due to possible imperfect mechanics.

We have not seen all of the research but we are sure it is legit. It’s like an orthotic for the mouth. Keep in mind changing bite mechanics closer to symmetrical occlusion will be helpful ( ie. Orthodontics, invisalign etc).

There you have it. Next time you want to get some extra performance, or are trying to accomplish an especially difficult exercise, try clenching hard to preload those neuronal pools.
Ivo and Shawn…Preloading your neuronal pools to make learning this stuff easier for you….one pathway at a time.
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Running, Einstein, Gravitational Push and Space. What do they have in common ?

WAIT !  Don’t watch the video just yet !  Read this first paragraph first !

Yes, you read it right. Gravitational PUSH.  Did your physics teachers mislead you ?  There is no such thing as Gravitational “Pull”.  Actually it is most accurate to say atmospheric push. Gravity does not pull us to the ground, space (as in the atmosphere) is pushing down on us. Space and time are curved and adjustable, Einstein proved this. You must be saying, “Oh Gait Guys, you are going way too deep now !”.  No, we are not. And you need to know this if you run or walk. It is simple. Your 5th grader will understand this and so should you !   Watch the video for a very nice explanation of what we are going to discuss today, atmospheric PUSH, start at the 3:30 mark for support for our point today.  If you choose not to watch this video today, it is your loss.  You will be depriving yourself of some of the most important information and logic there has ever existed in science. There is a big difference between pull and push.  Ask anyone who has had a car breakdown and had to push it off the road. Ask any weightlifter as well.

What does this have to do with running, walking and gait ?

Well, it is pretty simple.  This is yet another reason why posture is dependent upon the extensors such as the gluteals, the quadriceps, the cervical spine extensors, the thoracolumbar paraspinals, the abdominals etc.  These muscles must be strong enough to resist the push of Space down upon our bodies. Think of it this way, what muscles would have to work harder and be more isometrically and eccentrically strong and endurance trained if you had to carry a 100 pound person on your shoulders all day ?  It is much the same as if you were carrying a bunch of extra winter fat on your body. You will need more of these extensors otherwise you will begin to break down into compensations. 

With the natural motion of pronation during impact loading we need to dampen the internal spin of the hip, femur and tibia to resists the pronatory forces from space pushing down on us. 

So, our neuromuscular system has evolved to resist this push, and that job lies largely with the antigravity extensor muscles, which keep us upright. The elderly eventually begin to lose this battle as they weaken and posturally decompose. These muscles are powered by a special part of our our brain, largely the cerebellum, assisted by the vestibular apparatus (inner ear). Remember that there are 3 systems that keep us upright; vision, the vestibular system and the proprioceptive system. The interplay of these 3 systems is what Newton was trying to figure out and Einstein was eluding to.

This is one of the reasons orthotics (for the long term) often, but not always of course,  do not make sense.  Space pushing down on us and thus space pushing our body mass down onto our tri-arched foot (what we have come to understand as gravitational pull, which is technically misspeaking of the facts) is a large part what creates the pronation; with the musculature of the lower kinetic chain assisting in slowing it.  Slapping an orthotic under the foot to resist this force is not a permanent solution; it is often a temporary fix to a long term problem. This returns us to the hypothesis of today’s post, gravitational pull or Space push. Which is smarter, pushing up against the downward pressure of Space push (orthotic) or finding a better way of using the body’s anatomy to pull up against it ?  Which makes us stronger and a better human and athlete ? Finding better skill, endurance and strength (there it is again, S. E. S.) in the anti-gravitational muscles if you will, such as the toe extensors, tibialis anterior and posterior and foot intrinsics as well as those muscles above that are not dampening internal spin (medial quads, gluteals, lower abdominals)  is the answer if you really want to fix it.  Often times, a stability shoe is much the same as the orthotic; it provides dampening and slows pronation, or “resists” the push of gravity. It can sometimes be helpful in the short term; creating mechanics that you do not have; but is seldom good for the long term (though in some cases they are necessary, we are not negating their occasional beneficial use). We just ask that you, or at least your orthotist,  use your/their brain when making that decision.

As we always say, there are so few people who truly understand the neuro-ortho-biomechanics of the human parts going into the shoe that we get  all caught up in the shoe as the solution.  The solution is S. E. S.  , if you still  have the anatomy to get there.

Shawn and Ivo ………. two Uber geeks today.  They are the kind of guys who keep neurology and physics textbooks beside the toliet rather than Sports Illustrated Swimsuit issues.  Hey, we try to keep it simple. We like to pick the low hanging fruit just like everyone else. But it is the higher hanging fruit that are often the gems.  Sure, space pushing down on us all can make it hard to get up that high to the good stuff…….but it is worth it when you get there.  Thanks for tagging along on this journey. If you are a regular reader,  reconsider your bathroom reading material if you haven’t already !

More on the “Earth” shoe

3.7 degrees. Who (besides maybe Kevin Bacon) would have thought a few degrees could make that much of a difference?

We don not doubt that the shoe helps you to burn more energy. You are walking up hill against your normal biomechanics. Inefficiency usually costs more energy.

Remember our friend “PRONATION”? It consists of dorsiflexion, eversion and abduction. SOME PRONATION is requisite for normal gait. It is one of the 4 shock absorbing mechanisms, along with ankle dorsiflexion, knee and hip flexion. (Midfoot) PRONATION begins from initial contact of the heel with the ground (loading response); friction of the heel on the ground causes the talus to slide anteriorly on the calcaneus and it then plantar flexes, adducts and everts to lower the midfoot. This goes on until MIDSTANCE, when the opposite leg begins to go into swing phase which initiates SUPINATION.

We remember PRONATION makes the foot into a “mobile adaptor” for shock absorbtion; SUPINATION makes the foot into a rigid lever for propulsion. The question is: “Why keep the foot in a position that would decrease biomechanical efficiency for ½ of the gait  cycle?”

We do not refute that the shoe does burn more energy. We agree that it will reduce the lordosis of the low back, which can be beneficial for spinal canal stenosis and a few other conditions which demand less stress on the facet joints. We like the wide (though not anatomic) toe box.

Negative ramp delta? We are not convinced this is great idea.

Ivo and Shawn. Triangular, pointy (but beautifuul and bald) heads (like a delta). Bringing you the facts so you can make better decisions.

In our series of questions we get…

Dear Gait Guys
I was reading an article the other day about the foot and intrisic muscles to gain more insight into the function and how to re-train these muscles. I am having a difficult time trying to g…
In our series of questions we get…

Dear Gait Guys

I was reading an article the other day about the foot and intrisic muscles to gain more insight into the function and how to re-train these muscles. I am having a difficult time trying to give patients exercises for intrisic muscles when everyone seems to say something different. The most recent I have read is that the best way to retrain the lumbricals is stand on your toes and walk up steps. I can see some logic in this but also seems a very generic exercise and would encompass alot more flexor driven muscles that are likely already strong. I was wondering if you have a more specific exercise that would be simple and easy for patients to do?

Dear Lumbricals

We would have to agree with you that the exercise is very generic and would cause overuse of the flexors, though it would stimulate lumbrical function.

As you are aware, the lumbricals attach proximally to the sides of adjacent tendons of the flexor digitorum longus (with the exception of the 1st, which only attaches to the medial side) and attach distally to the medial aspect of the head of the proximal phalynx and continue on to the extensor hoods in toes 2-5 .

Their typical function is described as flexion of the proximal phalynx and extension of the proximal and distal interphalangeal joints. They have the unique ability to compress the metatarsal-phalangeal and inerpahlangeal joints. There is also a small adductory moment to counteract abductory shear, due to the tendon passing medial to the metatarsal-phalangeal joints (michaud). These are open chain functions. Unless you are in the habit of waving to people with your toes, they often are used quite differently. But this brings upa good point and excellent exercise we call “waving the toes”.

They are performed by holding the great toe in dorsiflexion (hopefully, without assistance) and flexing the other toes at the MTP joint, while keeping the PIP and DIP in extension. This requires and intact and functional EDL (with good motor control!)

Another exercise is sitting with the foot relaxed and concentrating on flexing the toes (2-5) without clawing (similar to above, without the Hallux extended.

Remember they work from mid to terminal stance, but you need to develop skill before endurance or strength.

We hope this helps, 

The Gait Guys

As a runner: To Cross-Over or not to Cross-Over ?   That is the question. Lets go back and talk about the Cross Over Gait again (yes, again). This is the next level.

*watch this video (link) and notice 2 things: 1. the size of the glutes on these amazing athletes and 2. pay attention to the few seconds at 1:32. No Cross Over gait anywhere.

If you look at any video on the web of ANY sprinter in competition from the front or back (sagittal progression), you will always see the knees and feet falling underneath the hips. Watch video above again and see this. You will never see a sprinter cross over like we see in many distance runners.  Why is that ? Here, look this video (link)  as well, at the 1:30 mark there is a great overhead view of the field, look for one of these fellas crossing over, you will not see it.  Here are starts out of the blocks, clear abduction (link) and no cross over, in fact there is more leg abduction separation coming out of a start to get more glute power (think of a skater, same thing).  Now get on YouTube and watch any distance race and you will have to work at finding non-Cross Over runner or at least someone who is at the tipping point. Everyone does it, but does that make it right ? Does it make it wrong ? Does it make them vulnerable to injury more ?  We think it does.

We believe to reduce injury the cross over needs to be corrected. However, in distance running less brute power is needed, we need to conserve energy so we need to dial to a more reasonable and economical and efficient running gear.  In distance athletes and your typical 20+ mile a week runner less gluteal power is needed, but most runners have just gone past that tipping point and get into under use and begin to cross over.  Lets see if we can expand on this theory a little more.

Well, there are no studies on this. As far as we know we are the only ones trying to solve this mystery of the tipping point cross over gait/run style. Go ahead, search on the web, we seem to be on a solitary voyage all on our own, thankfully we have our Gait Guys brethren (you guys !) with us.  It does however bode the question for us,  “Why are we able to get so many of these chronic distance runners over their injuries by addressing their Cross-Over Gait and its frequent weaknesses (gluteus medius/maximus/medial quadriceps), excessive pronation and their tightness’s (IT band etc). Why do our sprinters have an entirely different injury pattern  ?”  Sure the athletes are different and their events are different, that is the simple answer but it is not good enough.  One athlete is built for speed, the other built for distance and endurance. But there is something big here that needs all of our attention.

Here is the fundamental difference.  We get some vocal challenges particularly from distance runners (but less with time as our theory has yet been refuted) that the cross over is more efficient for a distance runner.  (Example of another great cross over here in case you are new to our work on this topic (video link)). We disagree, for now, until research can disprove our theory which has been several years in development.  The Cross Over Running form challenges the normal pendulum effect of the lower limbs and challenges the biomechanics of the hip frontal plane stabilizers, namely the gluteus medius (need a biomechanics refresher? , click here).  Why would you want to change the natural leg pendulum in a runner ? This is not good running economy, although you will have a fight on your hands if you ask a runner to convert to our anti-cross over gait and drag them from their deeply engrained and comfortable cross over running style ! Beware, they are going to tell you it doesn’t feel right, it is too hard, it feels awkward, “it cannot be right !"  Well, so does brushing your teeth with the opposite hand but that doesn’t make it wrong.  Our 3 part series on Cross Over Running is pretty thorough if you want to learn more, but this is not the place. We feel we have been pounding the floor on those issues long enough.

Here is our question, go and do your own observational work as well. 

Look at the glutes of sprinters (watch the main video with this post again), compare size ratio of glutes to quads. Sprinters have bigger glutes, sure they have massive legs but they have glutes to match that power.  Their glutes are in charge of their hip and pelvic mechanics. When there is mismatch there is often injury.

Distance runners have much smaller glutes, their buttocks are small, in some cases you wonder where it has all gone !  But their quadriceps are massive in comparison in many cases. It is clear that in most of the cases the ratio is not the same as in sprinters.  There is a mismatch. We like to say that their quadriceps are in charge of their hip mechanics, and are certainly not suited to do so.  Now, we know the argument that will arise, that being they are different activities and thus they should be different.  Our only argument there is that the quadriceps should not have such a dominance over the gluteal and hip biomechanics.  Watch our two part hip biomechanics videos on YouTube again.

When we put our distance athletes on our Total Gym slide-squat board to do primitive squat isolations the distance runners have a great deal of difficulty “getting themselves out of the quads and into the glutes”.  The sprinters automatically go right into the glutes, or clearly have a better time of finding the correct pattern in controlling hip extension and eccentric hip flexion during the decent of the squat. 

Here is the bottom line. The glutes should always be in charge over the quadriceps when it comes to hip biomechanics. Mess up this ratio and dominance and problems will occur.  This goes for both distance runners and sprinters, actually all human beings no matter what sport. It has become painfully clear that the cross over gait allows the leg pendulum to shift too far medially and this is controlled largely by the gluteus medius and its synergists on a neutral pelvis and stable core controlling it.  Crossing over is poor gait economy, you must block that faulty cross over collapse.  A good distance runner will come right up to the fence, to the tipping point, but not fall off the proverbial fence.  Go too far, and the injury clock starts ticking.  If you are a runner or even a distance walker and you are crossing over even a little, you need to correct this gait pathology in our humble opinion. You are just not using your glutes correctly and effectively.

( By the way, Here is a drill (link) not to do for a sprinter or any runner for that matter in our opinion, it is driving cross over both mentally and physically. If we had our way he would have run with his foot contact drifting to the outer limits of each marker maintaining a nice vertical pendulum of the limbs from the hip axis, we wouldnt have him run down the line.  We ask our runners to run on either sides of the lanes on the track, not between the lines and in the lane. It is a great place to start. It is just enough to get the feel right.  We know of two coaches doing this from our consultations with them, we know they are on a serious journey to championship seasons. And, when we walk onto their fields and we see all the runners running down the lines and not down the middle of the lanes we smile.  We know it looks crazy.  But sometimes crazy is right !

Shawn and Ivo.  Beating our bloody foreheads against the wall each time we see another cross over runner with hip, knee or foot issues.  You gotta fix the neuromotor pattern problem too !!!!!!!!!!  All the in-clinic rehab and physical therapy in the world will not stave off re-injury if the pattern is not corrected !

whew !  (thanks for hanging in there gang…..long post today !)

Hip Dancing gets this runner to the Olympics

… and some of you thought we might be a few sandwiches short of a picnic when we talked about the value of, and tricks we use, incorporating dance moves into running rehab. Don’t lie, we know you were thinking it ! Remember our last post of 2011 on our experiences with this stuff ?
http://thegaitguys.tumblr.com/
post/15029125468/this-may-be-the-last-blog-post-you-read-from-us

here is a video of the japanese runner doing his Curvy Dancing ?!     http://youtu.be/DvNW4yZNHgM