Gait and Climbing (and DNS): Part 2.  Introducing 14 year old Ashima Shiraishi.

14 year old “sends” V15 , a 30 move roof climb in Hiei, Japan, called “Horizon”.

“the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.” - 2005 Shapiro and Raichien

I am flipping the script a little today for DNS’ers (Dynamic Neuromuscular Stabilization). Watch the video if you wish, but the point I will be drawing your attention to is the 2:15 mark when she goes inverted on the roof of this apparently “more simple” V9 route. Note, this is not a video of her historic ~30 move V15 route. Stay tuned for that, it is not available yet.

Look closely. In the video, a then 9 year old Ashima is climbing upside down, a roof climb, defying gravity’s push. Spin this picture 180 and she is crawling, finding points of “fixation” or “punctum fixum”. What is neat about climbing is that you can have one, two, three or four points of fixation, unlike walking (one or two points) and crawling (two, three or four points of fixation). The difference in climbing is that gravity is a bear, wearing you down, little by little. A deep similarity in climbing to any variety of crawling is that both involve pulling and pushing, compressing and extending over fixation points. Other common principles are those of fixation, stability, mobility and neurologic crawling patterns in order to progress.

Ashima just recently, in early 2016, was the first female to complete a V14d (it is said it may even be upgraded to a V15a, maybe even a V16). Not many pros of any gender can say they can complete a V15 so this is a real big deal for a 14 year old. Stay tuned for that video.

DNS, Kolar and Climbing

I took my first DNS course with Prof. Kolar 10 years ago. It was an interesting eye opener and I had just enough clinical experience (9 years at that point) to grasp just enough to take it back to my practice and integrate it. Since that time, it has been fun to see it grow and see young practitioners excited to get their first face palm epiphanies. I have been returning to it often, blending it into my rehab work much of the time. There are few hip, shoulder, spine, breathing or global stabilization exercises I prescribe that do not have a DNS component to them, with my own flare and alterations and amendments as necessary. If you have taken a DNS course you will know why I am bring the topic into climbing. If you have not taking a course, you will be a little lost on the conceptual spill over.

As you can see in the video above, start really paying attention at the 2:15 mark in the video when she goes inverted on the roof. Cross crawl patterns, concepts of fixation, compression, expansion, crossing over, and tremendous feats of shoulder and hip stability on spinal stiffness and rotation.  Now add breathing, oy !  Now add doing all of this by mere finger tip and toe tip fixation ! When you consider all of this, it becomes almost incomprehensible what she and other climbers are doing when they go inverted like this. Amazing stuff, finger pulling/compression and foot pushing to compressively attach the body to the wall and progress forward.

Lucid Dreaming, A climb in the Buttermilks

Last year I wrote a piece on Lucid Dreaming, the name of a rock (another V15 climb) in the Buttermilks of Bishop, California. Here is that blog post. Lucid Dreaming is no ordinary rock.  To summit this rock is basically only three moves off of three holds, from your fingertips, starting from a sitting position. The remainder of the climb is sliced bread. If you can do the three, you can get to the top. The problem is, only a handful of people in the world can accomplish the feat. In the piece I outlined many principles of crawling, quadruped and climbing from a neuro-biomechanical perspective. Here is a excerpt from what i wrote in Gait and Climbing, Part 1:

In climbing there is suspicion of a shift in the central pattern generators because of the extraordinary demand by pseudo-quadrupedal gait climbing due to the demand on the upper limbs and their motorneuron pools to mobilize the organism up the mountain.  We know these quadrupedal circuits exist. In 2005 Shapiro and Raichien wrote “the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.”

Some research has determined that in quadrupeds the lower limbs displayed reduced orientation yet increased ranges of kinematic coordination in alternative patterns such as diagonal and lateral coordination.  This was clearly different to the typical kinematics that are employed in upright bipedal locomotion. Furthermore, in skilled mountain climbers, these lateral and diagonal patterns are clearly more developed than in study controls largely due to repeated challenges and subsequent adaptive changes to these lateral and diagonal patterns.  What this seems to suggest is that there is a different demand and tax on the CPG’s and cord mediated neuromechanics moving from bipedal to quadrupedal locomotion. There seemed to be both advantages and disadvantages to both locomotion styles. Moving towards a more upright bipedal style of locomotion shows an increase in the lower spine (sacral motor pool) activity because of the increased and different demands on the musculature however at the potential cost to losing some of the skills and advantages of the lateral and diagonal quadrupedal skills. Naturally, different CPG reorganization is necessary moving towards bipedalism because of these different weight bearing demands on the lower limbs but also due to the change from weight bearing upper limbs to more mobile upper limbs free to not only optimize the speed of bipedalism but also to enable the function of carrying objects during locomotion.

The take home seems to suggest the development of proper early crawling and progressive quadruped locomotor patterns. Both will tax different motor pools within the spine and thus different central pattern generators (CPG). A orchestration of both seems to possibly offer the highest rewards and thus not only should crawling be a part of rehab and training but so should forward, lateral and diagonal pattern quadrupedal movements, on varying inclines for optimal benefits. 

Dancing, Jiu Jitsu and Climbing. Bringing things together.

So, what am I doing with all this information? As some of you may know, I have been expanding my locomotion experiences over the years. First there was three years of ballroom and latin dance, some of the hardest stuff I have ever done, combining complex combined body movements to timing and music at different speeds, each time changing to different rhythms or genres of music. Some of my deepest insights into foot work and hip, pelvis and core stability and spinal mobility originated from my dance experiences, particularly Rumba, Cha Cha, Jive, Waltz and Foxtrot. On a side note, some of my greatest epiphanies about the true function of the peroneal-calf muscle complex came during a private session on a difficult Waltz step concept. It was such an epiphany I sat down and wrote scratch notes on the enlightenment for 20 minutes right there in the ballroom. Next I moved into the very complex martial art of Brazilian Jiu Jitsu, and after three years it is clear it is an art that you could do for a lifetime and never get to the end of the complex algorithms of defense and offense. This art will stay in my wheelhouse to the end if I am able to keep it there.

Rock climbing, this one is the next on the list. After years of sharing my hands on peoples physical problems I know I already have above average grip and finger strength, so this could either prove to be a blessing or a “career ender” in terms of finally finishing off my hands for good. But it is on the list, and it won’t leave my head, so for me that is the tipping point. Climbing is next. I need to understand and experience this, so I can understand human locomotion better.

I will have the video of Ashima “sending” V15+ when they put it up, stay tuned. I have a feeling it is going to be a jaw dropper, I hear the whole send is inverted which boggles my mind. We will dissect her roof crawling and I will try to have some new research for you.

If you want to come down my rabbit hole, come read some of my other related articles:

Part 1: Gait and Climbing. Lucid Dreaming

and my 3 part series on Uner Tan Syndrome. The people who walk on all fours.

Dr. Shawn Allen, one of the gait guys

___________

References:

Shapiro L. J., Raichien D. A. (2005). Lateral sequence walking in infant papio cynocephalus: implications for the evolution of diagonal sequence walking in primates. Am. J. Phys. Anthropol.126, 205–213 10.1002/ajpa.20049

Scand J Med Sci Sports. 2011 Oct;21(5):688-99. Idiosyncratic control of the center of mass in expert climbers. Zampagni ML , Brigadoi S, Schena F, Tosi P, Ivanenko YP

J Neurophysiol. 2012 Jan;107(1):114-25. Features of hand-foot crawling behavior in human adults. Maclellan MJ, Ivanenko YP, Cappellini G, Sylos Labini F, Lacquaniti F.

What Are Motion Control Features, anyway?

In this brief video, Dr Ivo talks about common motion control features found in many shoes shoes. terms like “medial posting” “dual density midsoles” and “lateral flares” are discussed

SoftScience “The Terrain Ultra Lyte” shoe update:

Introducing “The Terrain Ultra Lyte”.  Fresh off the UPS truck today and just unboxed ! Uber excited. Wearing them right now. Dang, zero drop with good cush. I could run in these babies ! And I will just to try, even thought that is likely not their intended purpose.  Gorgeous roomy toe box. True to fit. These feel like a favorite pair of worn in favorite leather gloves …  they are soft cotton canvass right out of the box.  I don’t think i even need to wait a few days, they should have a label that says “pre-worn in”. I may have just found yet another new favorite weekend casual shoes, I will save my Altra Everyday’s for work. I can see where the thinking came when the partners brought their wisdom over from Crocs (only the best parts were brought, the materials, from what i can see).  
Removable, washable Trileon™ insole, non-marking, slip-resistant outsole
Ultra lightweight, a pair in size 10 weighs just 1.6 lbs. (that is per pair !)

*Welcome to Soft Science. one of our Podcast sponsors. Because we believe in them.

Update one day later:

Some have been asking about this shoe. I think they have done something unique here. This shoe is about 6 oz, yes, that is seriously uber light. That means there is no room for stabilizing rigidity factors in this shoe. It appears to be a well thought out “outsole” and a soft cotton canvas upper. That is it. If you need control, this shoe may not be for you. The outsole however offers a nice wide foot print with some flare of the sole out from the foot (look at their website, look at the shoe from behind), and that in itself offers stabilizing over something compared to like a glove type shoe.
Now, on to the insole:
I know what the website says, a “minimal heal to toe elevation”. I emailed the guru over as Soft Science. I have been told they are zero drop and after wearing i believe they are, and if not, maybe a millimeter ? I have sensitive feet, I wear zero drop all day long at work because I can. Not everyone can and this is important to note.
I do not have any info outsole thickness of this particular shoe, the foot does recede somewhat into the outsole that you see, so there is not a tremendous amount of stack height as portrayed in photos, some of that is the outsole lipping up to grab onto the shoe’s upper.
TRileon Insole:There is a VERY mild arch contour, not as much as in crocs (as one person asked) but it is present and mild. If you have a flatter arch, you will feel it, but, Trileon is uber cush so it is not offending at all. If you have a normal arch posture, you may not even notice it, it is that subtle.
Insole: there feels like a 1-2 degree or 1-2 mm varus forefoot post, i have pretty sensitive feet and can tell these things readily, i may choose to grind this down on the insole, it wouldn’t take much to do this. If you take out the insole and put it on a hard floor and stand on it, you will notice the subtle forefoot varus posting of the foam. And if you put the insole in your hands and pinch finger tips together at the 1st metatarsal head and 5th met. head you will notice the thickness difference. * It is not much, but it is there. Some people can really benefit from it since many feet are have a slight FF varus. Some may not notice it at all. I did notice it because my forefoot is not varus’d at all.  I noted it less so when the insole was in the shoe so it may be off setting a slight depression in the outsole shell. I am not sure, so do not quote me on this. For most folks, this is “princess and the pea” subtle jibber jab talk and is not worthy of noting.  But we are shoe geeks and some of you want to know about peas.
To be clear, I like this shoe so far, very much actually. It will be on my feet all week and all weekend……..many weekends.  Soft, uber light, no break in, zero drop, good looks, minimal, wide platform, ….. things i like and things that are important to me. The question is, “is it for you ?” That is up to you.  Nice work Soft Science.
-Dr. Allen

http://www.softscience.com/mens/the-terrain-ultra-lyte.html

Great, FREE FULL TEXT article on the hip.

an EXCELLENT review with some great rehab tips at the conclusion like this

“Once isolated contraction of the deep external rotator muscles
is successfully achieved, progression can be made to the
rehabilitation of secondary stabilisers and prime movers of the
hip, particularly the gluteus maximus, initially using nonweight
bearing exercises and progressing to weight bearing
exercises once motor control and strength allows. Pre-activation
of the deep external rotators may make these exercises
more effective. Deficits in flexibility and proprioception
should also be addressed at this stage. Once adequate hip muscle
strength and endurance is achieved, functional and sports
specific exercises can then be implemented. ”

Can local muscles augment stability in the hip?: A narrative literature review T.H. Retchford, K.M. Crossley, A. Grimaldi , J.L. Kemp, S.M. Cowan J Musculoskelet Neuronal Interact 2013; 13(1):1-12

http://www.ismni.org/jmni/pdf/51/01RETCHFORD.pdf

image from: https://www.researchgate.net/…/258427127_fig12_Fig-11-Anato…

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

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

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

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

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

List all the letters that apply first.

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

.

.

.

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

.

.

.

.

.

.

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

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

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

Dr. Shawn Allen

The Pitfalls of Motion Control Features.

Welcome to Monday, folks. Today Dr Ivo discusses why not all shoes are created equal and why you need to understand and educate your peeps about shoes!

Internal tibial torsion is when the foot is rotated internally with respect to the tibia. When the foot is straight (like when you are walking, because the brain will not let you walk too internally rotated because you will trip and fall), the knee will rotated OUTSIDE the saggital plane (knee points out). Putting a medially posted shoe on that foot rotates the foot EVEN FURTHER laterally. Since the knee is a hinge joint, this can spell disaster for the meniscus.

need to know more? email us or send us a message about our National Shoe Fit Program.

Yes, Virginia. Dizziness and Vertigo are costly

I had a Parkinson’s pt that came in this morning and had fatigue (more than usual) related to a recent onset of dizziness. He was trying to figure out why and It got me to thinking about the metabolic costs of disequilibrium.

A quick pub med search found me having to try multiple search terms and all I was able to turn up was a few papers on the topic. I found that surprising, considering the prevalence of fatigue complaints with dizziness and vertigo.
It makes sense to think of as proprioception is impaired (or altered), it would have a greater energy cost to get normal tasks done. I was able to turn up a few full text papers (below), and yes, the short answer is it does cost more to have impairment. 

Gait Posture. 2015 Feb;41(2):646-51. doi: 10.1016/j.gaitpost.2015.01.015. Epub 2015 Jan 24.Metabolic cost of lateral stabilization during walking in people with incomplete spinal cord injury.Matsubara JH1, Wu M2, Gordon KE3.

Arch Phys Med Rehabil. 2013 Nov;94(11):2255-61. doi: 10.1016/j.apmr.2013.04.022. Epub 2013 May 20.Effect of balance support on the energy cost of walking after stroke.Ijmker T1, Houdijk H, Lamoth CJ, Jarbandhan AV, Rijntjes D, Beek PJ, van der Woude LH.

Dragging your tongue ? When the tongue of your shoe keeps getting pulled to the side. Do you know what it means ? It means plenty, if you are sharp.

By: Dr. Shawn Allen

This one pisses off most people it happens to. Why does it typically happen only on one side, on one shoe ? Look at the photo case above. Look closely to the left foot, the tongue of the shoe is pulled laterally compared to the right, or shall I say, dragged.

This is a fairly common phenomenon, and there is a reason for it, several actually. So, no, you do not need to staple the tongue to the shoe upper, or tighten your shoe laces, or stitch the tongue to the medial shoe upper. You need to stop externally spinning your foot in your darn shoe.  What ?!

Yes, you very well may be avoiding normal internal rotation progression of the pelvis over the fixated limb. Loss of internal hip rotation is often a common finding clinically. As one passes the swing leg forward, the forward progressing pelvis eventually meets this loss of internal rotation over the fixated leg and femoral head. The swing leg none the less progresses further forward to get to its’ heel strike and the stance phase leg has to externally spin over the ground (I like to give the analogy of putting out a cigarette butt on the ground or squishing a bug (PETA don’t come after me)). This is called an Abductory or Adductory twist (good video demo here) depending on whether your reference point is the forefoot or rear foot. Regardless, the heel is spinning inward, the forefoot is relatively spinning outward. This spin of the foot inside the shoe (this happens minutely just before the shoe spins on the ground) and pulls the tongue laterally with it.  

This problem can also come from, and often does, a premature heel rise from things like a:

•  loss of ankle rocker
• short calf
• lack of hip extension
  
• hallux rigidus / limitus or even a painful big toe
• etc

There are even several other causes I will not list here today, I could have you waste your whole day on the list and the mental gymnastics of things to consider. Basically, anything that impairs the stance phase mechanics creating a premature heel rise or failure of completing internal hip rotation can cause an Abd/Adductor twist of the foot/heel and drag the tongue laterally. Sure, there are others, but the purpose of my blog post here today was to explain a neat little biomechanical phenomenon that  has huge clinical insight if you know what it means.  You cannot fix this problem if you do not do a physical exam, understand clean and faulty gait biomechanics, and maybe can even find small objects in a dark room.  What I mean is it takes some educated exploration and a curiosity to want to fix things.  

There are clues often right in front of you, all you have to do is pay attention and sometimes ask a simple question. 

“Mr. Jones, when you stick out your tongue, does it drag laterally ?”  

Ok, maybe not that exact question. But, when I see a loss of internal rotation or terminal hip extension in a runner, and when I have time to explain things deeply with a openly receiving client, I might start the conversation with that fun question and then explain what I really meant was the tongue of the shoe on that affected side. 

You can’t swallow bandaids to fix things, as much as you wish it was that easy. Sure, you can avoid all of this fun by buying a shoe that has the tongue of the shoe sewn to the medial upper of the shoe, but then you wouldn’t have to fix anything.  Where would you “get your fun on” then ?  Be brave, go all in, fix the problem dammit.  

These are the things that keep me up at night. Welcome to my nightmares.

Dr. Shawn Allen, one of the gait guys

Photo courtesy of this weartested.org link: http://weartested.org/wp-content/uploads/2015/03/altra-superior-2-top-socks.jpg

Why is that muscle so tight?

We often think of neurological reasons (increased facilitation of the agonist, decreased reciprocal inhibition of the antagonist, increase gamma drive, etc), but how about the series elastic element (ie the connective tissue)? Or perhaps the sarcomere (individual contractile unit of the muscle)? How can we fix that? It is easier than you thought!

An oldie but a goodie. A great FREE FULL TEXT paper on sarcomere loss and how to prevent it. Yep, would you have guessed static stretching? Yes, this study was on mice and it seems plausible that it would be applicable to humans as well.

“When muscle is immobilised in a shortened position there is both a reduction in muscle fibre length due to a loss of serial sarcomeres and a remodelling of the intramuscular connective tissue, leading to increased muscle stiffness. Such changes are likely to produce many of the muscle contractures seen by clinicians, who find that such muscles cannot be passively extended to the full length, which normal joint motion should allow, without the production of muscle pain or injury.

…These experiments show that in addition to preventing the remodelling of the intramuscular connective tissue component daily periods of stretch of ½ h or more also prevent the loss ofserial sarcomeres which occurs in mouse soleus muscles immobilised in the shortened position.”

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1004076/pdf/annrheumd00439-0044.pdf

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1004076/pdf/annrheumd00439-0044.pdf

A great, quick read from one of our fav’s: Dr Tom Michaud.

Here is my favorite excerpt. I had not thought of imaging the ankle quite this way

“Physical examination reveals pinpoint sensitivity over the anteromedial capsule. When the ankle is slightly plantarflexed, the osteophytes on the talus and tibia can be readily palpated. Surprisingly, lateral X-rays only identify approximately 40 percent of the talotibial spurs, because the natural torsion of the distal tibia obstructs direct visualization of the anteromedial tibia. To improve radiographic accuracy, van Dijk, et al., recommend oblique radiographs be taken with a 45-degree craniocaudal angle, with the lower extremity externally rotated 30 degrees. The authors demonstrated that oblique radiographs identify 73 percent of the spurs located on the talus and 85 percent of the spurs located on the distal tibia.”

 Gastroc Anyone?

 An interesting and innovative rehab tip for a torn branch of the tibial nerve innervating it, along with some requisite anatomy.

Where your gait might break down.

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. - van der Krogt

In the past few weeks I have shared my thoughts on some articles regarding low back paraspinal musculature fatigue and the subsequent effects on motorneuron pools, specifically excitability of the soleus and quadriceps. These shared thoughts are from recent papers in the literature (search the blog over the last week). These effects are suggested to indicate a postural response to preserve lower limb function. In other words, as paraspinal fatigue set in, lower extremity muscle compensation ramped up to sustain postural locomotion demands.  Obviously, one should think this a step further and translate it all into questions of assessment of ankle dorsiflexion (ankle rocker) and control of progressing knee and hip flexion when pertaining to these muscles. The issues of stability and mobility should heighten. The one big problem in these studies, and you have even likely had these thoughts during your clinical examinations, is that one cannot truly fatigue one muscle group alone especially during activity, nor can one assess a single muscle group during manual testing. Luckily we have EMG testing capabilities in this day and age and we can more easily look into the function and reaction of a muscle and its’ direct response reactions. 

Today I have an article by van der Krogt that we read long ago, but that which one of our readers brought back into our wheelhouse.  This is pretty amazing stuff.

“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.“-van der Krogt

So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles. You may want to consider which muscles are, according to this article, most robust and sensitive to weakness. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. Today’s article seemed to confirm that this muscle group is sensitive to weakness. In today’s discussion, not only is the impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) possibly related to low back pain, in this case, paraspinal fatigue but it may be a muscle group robust to weakness which is a darn good thing when the paraspinals go to nap.

Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If this is all too much for you, in teasing out this quagmire of a system, just throw corrective exercises at your client and hope for the best. What is the worst that can happen if you get it wrong ? Stronger compensations on already present compensations … . . why not, it is good for return business (insert sarcasm emoticon).  But, lets be honest, if it was easy everyone would be doing it the right way. But the truth is that it is a long journey, and we are on the same bus of discovery with you all. 

Dr. Shawn Allen, one of the gait guys.

Reference:

Gait Posture. 2012 May;36(1):113-9. doi: 10.1016/j.gaitpost.2012.01.017. Epub 2012 Mar 3.How robust is human gait to muscle weakness?van der Krogt MM¹, Delp SL, Schwartz MH.

Low back pain and quadriceps compensation. A study.

“Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.“- Hart et al.

Recently I discussed a paper (link below) about how soleus  motoneuron pool excitability increased following lumbar paraspinal fatigue and how it may indicate a postural response to preserve lower extremity function.
Today I bring you an article of a similar sort.  This paper discusses the plausibility that a relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation and the subsequent changes in hip and knee function when running fatigue ensued. 

"Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.”- Hart et al.

Whether this or any study was perfectly performed or has validity does not matter in my discussion here today. What does matter pertaining to my dialogue here today is understanding and respecting the value of the clinical examination (and not depending on a gait analysis to determine your corrective exercise prescription and treatment). When an area fatigues and cannot stabilize itself adequately, compensation must occur to adapt. Protective postural control strategies must be attempted and deployed to stay safely upright during locomotion. The system must adapt or pain or injury may ensue, sometimes this may take months or years and the cause is not clear until clinical examination is performed. Your exam must include mobility and stability assessments, motor pattern evaluation, and certainly skill, coordination, ENDURANCE and strength assessments if you are to get a clear picture of what is driving your clients compensation and pain. 

So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles and bash them and other similar ones into your brain. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. In today’s discussion, impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) may also be related to low back pain, in this case, paraspinal fatigue.  

Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If only it were as simple as, “you need to work on abdominal breathing”, or “you need to strengthen your core”.  If only it were that simple. 

Dr. Shawn Allen, one of the gait guys

References:
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.

J Electromyogr Kinesiol. 2009 Dec;19(6):e458-64. doi: 10.1016/j.jelekin.2008.09.003. Epub 2008 Dec 16. Jogging gait kinetics following fatiguing lumbar paraspinal exercise.
Hart JM1, Kerrigan DC, Fritz JM, Saliba EN, Gansneder B, Ingersoll CD

Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg
In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).

a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°). more cool stuff on torsions here

Wow, cool stuff, eh?

Your client’s strategic, protective compensation patterns are a power leak and costing them greatly in efficiency and energy. There is a greater cost to compensation other than pain avoidance and protection. The cost is a loss in energy and efficiency as these numbers elude to. Think of how many people walking amongst us are in protective pain patterns causing a deep energy suck on the system. So, do your client and yourself a favor… . if you are instructing your clients on how to fix their arm swing on a local (arm/upper quarter) level, please stop. Please don’t use your gait analysis software to coach out arm swing changes, you are missing the boat if you are doing that. Arm swing aberrancies are quite often a manifestation of a greater global problem. Arm swing is largely a passive pendulum effect. Changes in the pendulum are often a sign of something bigger. This takes deep knowledge.

The death of meniscal surgery?

Here is a big one when it comes to gait and clients in our offices.

Here is a big one when it comes to gait and clients in our offices.
We tell our clients all the time that cartilage, at best, has a tenuous blood supply, and just in the peripheral red zone at that, and so true healing is not likely, at least not to any significant degree … . we tell them that their so called surgical “repair” is likely nothing more than debridement, a mere clean up most of the time.  We tell our clients that meniscal tears are likely a dime a dozen after 40 years in most people. The cartilage loses some resilience and pliability with age and does not resist loading and shear as well as it used to making it more prone to loading damage.  
“greater than 90% of the surgeries on the structure are not repairs, as most patients believe, but are instead excisions, or cutting out, of the torn part of the meniscus.”
“The most common orthopedic surgery in America had it’s final epitaph written this month with a level-1 study showing that surgery for meniscus locking is no better than placebo. ”

Mind you, some tears are massive and do create obstruction to joint function. Large tears like bucket handle tears and large free fragments often do need surgery because they are just too obtrusive to safe joint function. However, perhaps for the others one should consider the following:Stabilize the joint and return full symmetrical, balanced, coordinated function with endurance and strength. It may just be the best you can do…….and it seems it is often more than sufficient. 

Reference:

http://www.regenexx.com/should-i-have-meniscus-surgery/#

When was the last time you thought about the pairing of your glutes and your quadratus? This is an important mechanism, especially when ascending and descending stairs,

Here is a great exercises to help with that:

“those with chronic neck pain demonstrated a narrower step width, a shorter step length and slower gait speed during walking with the head movements and at maximum speed” -  Uthaikhup et al. study:

Head movement and Gait Parameters:

By now you should have a good grasp of the global impact of gait and how it presents and translates in everything we do. It is how we move through this world, and everything we do, and everything that has happened to us, impacts our gait. And, our gait impacts things in turn, from our mental state to how we think and act.  

By now, if you have been with us here on The Gait Guys long enough, you know that with the tremendous proprioceptive impact of the system from the cervical spine, that neck pain can influence sensorimotor function and thus motor function. However, little is known about the effects of head movement and walking speed on gait characteristics in patients with neck pain.

From the Uthaikhup et al. study:

Patient sample:  20 women aged between 18 and 59 years with chronic neck pain (>3 months) and 20 healthy controls of similar age, weight and height

Indexes used: Neck Disability Index and Visual Analogue Pain Scale.

“The experiment consisted of two walking sessions. The first session included walking with head straight, head up-down, and head turns from side to side. The second session included walking at comfortable and maximum speeds. Each trial was performed twice. Gait parameters measured using GAITRite walkway system were step length, stride length, step time, stride time, step width, cadence and gait speed.”

According to this study, the clients with chronic neck pain showed several changes in how they implemented their gait. They displayed step width narrowing, a reduction in step length and speed of gait, and even an overall reduction in gait speed when neck movements were induced or encouraged or when there was pain..

As Uthaikhup et al. summarized, “The results suggest that patients with chronic neck pain have gait disturbances. This supports the notion that assessment of gait should be addressed in patients with persistent neck pain.”

You have to know your gait norms to understand abnormals. We have written about other parameters that affect gait speed, step length and width here on the blog. Here is one more parameter for you to store in your noggin. It is all connected. So, when you goto your gait analysis guru, ask them if they are going to clinically assess your painful neck as part of the gait analysis (be prepared for the “deer in the headlights” look).

Dr. Shawn Allen, one of the gait guys

Reference:

Man Ther. 2014 Apr;19(2):137-41. doi: 10.1016/j.math.2013.09.004. Epub 2013 Sep 27.The effects of head movement and walking speed on gait parameters in patients with chronic neck pain. Uthaikhup S, Sunkarat S, Khamsaen K, Meeyan K, Treleaven J.

What are we listening to this week? 

The Physio edge podcast with David pope. This week they interview Kurt Lisle about anterior knee pain. Here is our synopsis:

One of the things they empahasized right off the bat was that patellofemoral pain not only refers about the knee but also below or most importantly posterior to the knee. The fat pad had a tendency to refer more locally where is other structures can refer to other areas.

Aggravating factors for patello femoral dysfunctional pain tends to be flexion or activities involving flexion as well as compression of the knee and rest is in alleviating factor.

The fat pad pain tends to be to either side of the patellar tendon and sometimes directly under it. This can be aggravated by standing, particularly with the knee and hyperextension, which compresses the fat pad.

Patellar tendon pain tends to remain at the inferior pole of the patella on the tendon whereas patellofemoral pain has a tendency to refer more.

Physical examination pearls:

• Patellar tendonopathy alone generally does not have effusion present where as the patellofemoral or fat pad injury may.
  
• Is there pain in passive hyperextension? This generally can mean fat pad injury or potential he ligamentous injury.
  
• Visually you may palpate a thickened fat pad, particularly in females.
  
• Pain with passive motions generally points away from patellar tendon.
  
• Dialing in as to where and when they are having their pain is an important part of the functional evaluation.

Kurt likes to do a table top examination first to ensure functional integrity of the knee before jumping right to functional tasks. His concerns are (which are valid) is the knee up to the task you’re about to ask it to do? Good advice here.
He emphasizes the need to be systematic and consistent in your examination, no matter how you examine them. Develop a routine that you follow each and every time. He recommends passively looking at the knee in extension and 90° flexion.

There is a discussion on functional movement about the hip and pelvis, knee, and foot and ankle. Emphasis is made, for example at the knee, as to “is the knee moving medially and laterally or are the femur and tibia rotating mediately or laterally” in which is precipitating the pain?

“Catching” of the patella is often due to patellofemoral pathology such as a subchondral defect, slap tear of the chondral surface, or abnormalities of the trochlea of the femur.

Advanced imaging strategies are also discussed with a brief overview of some of the things to look for.

Finally treatment strategies were discussed. It is emphasized that identifying the specific activity or change activities that’s causing any pain he’s made as well as activity modification. We were happy to hear that footwear and its role in knee as well as hepatology was discussed as well as looking at occupational contributions to the pain.

There was emphasis on exercise specificity particularly with respect to if the problem was unilateral not giving “blanket” exercises for both knees but rather concentrating on the symptomatic side.

A discussion on the use of EMG and activation patterns was also entertained with some good clinical pearls here. More marked rather than subtle changes and activation side to side seem to be more clinically significant. In other words, with respect training, can they achieve similar levels of activation on each side with a similar activity (for example isometric knee extension with the leg bent 60°).

The judicious use of tape from a functional testing standpoint was interesting. Emphasis was made that tape is not a cure and will merely a tool.

All in all and informative, concise podcast with some great clinical pearls and a nice review of the knee and patellofemoral pain.

link to PODcast: http://physioedge.com.au/pe-029-acute-knee-injuries-with-kurt-lisle/