Toes Spacers, anyone?

Less pain through better mechanics?

We have been using toe separators for various foot problems like hallux valgus, hammer toes and flexor dominance/extensor weakness. Our reasoning is that through changing the angle of attachment of the muscle, you alter the mechanical advantage of that muscle and help it to work more efficiently. This seems implied in the literature with respect to foot orthoses (1-3) but we could not find any data regarding toe separators. Toe separators DO seem to reduce pain and increase function (4-6). Perhaps this is through better biomechanics, mechanical deformation, proprioceptive changes, or most likely a combination of all these factors and more.  We think clinical results speak volumes. It is nice to see more data coming out on these easy to implement clinical tools. 

What is you clinical reasoning or rationale for using these devices? We would love to hear and if you have an article for reference you could share, that would be great. 

1. Scherer PR, Sanders J, Eldredge DE, Duffy SJ, Lee RY. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc. 2006 Nov-Dec;96(6):474-81.

2. Halstead J, Chapman GJ, Gray JC, Grainger AJ, Brown S, Wilkins RA, Roddy E, Helliwell PS, Keenan AM, Redmond ACFoot orthoses in the treatment of symptomatic midfoot osteoarthritis using clinical and biomechanical outcomes: a randomised feasibility study. Clin Rheumatol. 2016 Apr;35(4):987-96. doi: 10.1007/s10067-015-2946-6. Epub 2015 Apr 28.

3. Bishop C, Arnold JB, May T. Effects of Taping and Orthoses on Foot Biomechanics in Adults with Flat-Arched Feet. Med Sci Sports Exerc. 2016 Apr;48(4):689-96. doi: 10.1249/MSS.0000000000000807.

4. Chadchavalpanichaya N, Prakotmongkol V, Polhan N, Rayothee P, Seng-Iad S. Effectiveness of the custom-mold room temperature vulcanizing silicone toe separator on hallux valgus: A prospective, randomized single-blinded controlled trial. Prosthet Orthot Int. 2017 Mar 1:309364617698518. doi: 10.1177/0309364617698518. [Epub ahead of print]

5. Tehraninasr A, Saeedi H, Forogh B, Bahramizadeh M, Keyhani MR. Effects of insole with toe-separator and night splint on patients with painful hallux valgus: a comparative study. Prosthet Orthot Int. 2008 Mar;32(1):79-83. doi: 10.1080/03093640701669074.

6. Tang SF, Chen CP, Pan JL, Chen JL, Leong CP, Chu NK. The effects of a new foot-toe orthosis in treating painful hallux valgus. Arch Phys Med Rehabil. 2002 Dec;83(12):1792-5. 

Is swinging the arms worth it ? The metabolic cost of running.

The metabolic cost of human running: is swinging the arms worth it?
(precursor: *photo depicts a nice wide antiphasic gait, when that narrows, possibly for spine protection, limb swing becomes more phasic. In these senarios, forcing more arm swing action in a runner is foolish. One is not likely smarter than their client's body's protective mechanisms, so one needs to stop forcing things when they don't know what they are dealing with).

There remains scant info regarding the metabolic benefit of arm swing during human running. We have written about arm swing many times in the past, the concepts of phasic and antiphasic upper and lower limb swing (and their impact on spine loading) are critical for one to understand if they are working with runners. Without the understanding of these principles, coaching runners on form change adds risk to the plate of your client. Feel free to search our blog on these topic. But while you read on, please keep in mind all those strange unilateral compensatory arm swing things you see, such as an abducted arm on one side, a circumducting arm, one arm swinging more than the other, or less than the other, sports where we are carrying something (ie. a football) or throwing (ie javelin), or running with a water bottle. And please consider going back and re-reading all of our arm swing posts discussing why coaching a different arm swing, certainly a corrective arm swing, might be a bad idea because it could be a compensation from the lower limbs since the arms are positioned to be such good postural ballasts.

Here Arellano & Kram "compared the metabolic cost of running using normal arm swing with the metabolic cost of running while restricting the arms in three different ways: (1) holding the hands with the arms behind the back in a relaxed position (BACK), (2) holding the arms across the chest (CHEST) and (3) holding the hands on top of the head (HEAD)."

They hypothesized that "running without arm swing would demand a greater metabolic cost than running with arm swing." What the found in comparing with running using normal arm swing, a net metabolic power demand was 3, 9 and 13% greater for the BACK, CHEST and HEAD conditions, respectively (all P<0.05).

They also discovered that "when running without arm swing, subjects significantly increased the peak-to-peak amplitudes of both shoulder and pelvis rotation about the vertical axis, most likely a compensatory strategy to counterbalance the rotational angular momentum of the swinging legs."
In conclusion, Arellano and Kram's findings "support a general hypothesis that swinging the arms reduces the metabolic cost of human running". Their findings also "demonstrate that arm swing minimizes torso rotation". We infer that actively swinging the arms provides both metabolic and biomechanical benefits during human running. (Our big question is, when said clients come in for an upper quarter limb problem , is it because they may have been coached to actively swing the arms, or swing them differently?). Those who coach arm swing changes without a physical examination to determine why one arm has an aberrant swing may be driving new compensations onto old compensations, which could very well be the source of the problem.

Important: this study likely did not look at the aberrant arm swing habits that develop when there is a lower limb mechanical aberrancy. The literature has suggested that arm swing motor patterns are subservient to the leg swing motor patterns, and so coaching arm swing changes seems a bit foolish if the literature is in fact correct. Also, this study does seem to mention asymmetries in arm swing, and how these, though when different may change metabolic cost, may be necessary because of impairments in the antiphasic relationship of the upper and lower limb action.

J Exp Biol. 2014 Jul 15;217(Pt 14):2456-61. doi: 10.1242/jeb.100420.
The metabolic cost of human running: is swinging the arms worth it? Arellano CJ1, Kram R2.

What ischial-femoral impingement might look like as aberrant shoe wear.

Can a cross over occur on one side of the body ? Sure, this case is a perfect example. The heavy lateral shoe wear on the left is a huge clue. But remember, what you see is not the problem, it is the result of their problem(s).

. . . a talented marathoner came into our office complaining of a long standing deep posterior right hip pain and an equally longstanding left chronic lateral ankle and foot pain. The ankle had been treated regularly for chronic peroneal tendonitis with various manual therapy modalities and yet the right hip seemed to be left out of the equation in terms of treatment.

After taking a detailed history this runner unknowingly pretty much told us they had all the qualifications of ischial-femoral impingement (IFI). What they did not realize was that they had a cross over gait style that was a significant contributor to the clinical problem.

Here is a nice rewind case for your Friday read.

____________________

link:  https://thegaitguys.tumblr.com/post/116468620969/what-ischial-femoral-impingement-might-look-like

What ischial-femoral impingement might look like as aberrant shoe wear.

A few weeks ago we wrote an article on ischial-femoral impingement. For you to best understand today’s blog post you really should go back and review this interesting clinical phenomenon, here is the link to that piece.

Three weeks ago a talented marathoner came into our office complaining of a long standing deep posterior right hip pain and an equally longstanding left chronic lateral ankle and foot pain.  The ankle had been treated regularly for chronic peroneal tendonitis with various manual therapy modalities and yet the right hip seems to be left out of the equation in terms of treatment.

After taking a detailed history this runner unknowingly pretty much told us they had all the qualifications of ischial-femoral impingement (IFI).  What they did not realize was that they had a cross over gait style that was a significant contributor to the clinical problem.  

Lets now have a look at the shoe wear patterns above. On the left shoe, (a shoe we love, New Balance Fresh Foam (find your next pair at NewBalance Chicago)) we see that the entry zone or crash zone of rear foot impact is heavily worn, especially laterally. Heavy entry zone wear can be from several things, but one thing we always check for and assume until proven otherwise is a cross over gait. It can also just be from excessive rearfoot inversion at foot strike but when excessive there is usually a reason for it, especially when unilaterally as seen here. This foot is not stacking under the knee and hip, it is striking more midline to a plumb line dropped from the hip joint. This creates a steep medial angle of attack. The question is why ? Well, in the history the right hip pain began first and then the left ankle pain, so one should at least consider a compensatory timeline, that being the foot is a compensation in the gait cycle from the painful hip.

This client on examination tested pretty obviously for a right frontal plane drift, meaning when the right foot impacts there is not enough lateral line support to hold the hip/pelvis over the foot and so the pelvis drifts laterally to the right in this case. This can be fought by inverting the foot. This is a strategy to try and stop the lateral drift.  In this case, excessive wear is seen on the entire lateral side of the right shoe to represent this compensation. Changing this clients foot wear, shoe, orthotic is not fixing the problem, in fact it is impairing their ability to compensate and could create more problems, and even another deeper layer of compensation. Again, the inverted/supinated right foot moves the weightbearing line laterally, by moving the foot’s center of pressure from within the confines of the foot tripod towards the lateral border of the foot tripod, in attempt to restack the loading over the laterally drifted hip (hence the right lateral shoe wear pattern). Unfortunately this does not solve the reason for the lateral drifted pelvis. That solution has to come from improved stablization of the hip, pelvis and core and since they tested weak on the right side abdominals, gluteus medius, gluteus max and other  accessory lateral stabilizers,  work must be done there. Interestingly, this runner is stuck into a vicious cycle. The lateral drift to the right is allowing the left hemi-pelvis to dip and this is challenging rotational control of the stance limb and it is causing ischial-femoral impingement (suspecting of the quadratus femoris).  It was clear on examination that there was impairment of the quadratus femoris and obturator externus upon detailed testing and deep palpation was pin point tender over these structures.  Resistance to rotational challenges to the limb, especially iso and eccentric internal rotational challenges, were very poor when it came to coordination, endurance and certainly strength.

Remember, when you are spending time going sideways (right frontal plane drift), you are not spending time moving forwards. This could cause an early right departure and force and early left stance engagement.  But it goes deeper than that in this case.  Here, the right frontally drifting pelvis will pull the left swing leg across the midline with it, creating a left cross over gait.  This will make more sense if you watch our popular video here. Link

So, when this left swing leg is forced into the cross over gait variant, it will force a strong lateral heel strike, as evidenced on the left shoe wear. This is a compensation to what is going on in the right side body mechanics.

Can a cross over occur on one side of the body ? Sure, this case is a perfect example.

Can a cross over gait on the left in this case, cause a vicious cycle and in itself create an environment whereby a right ischio-femoral impingment occurs ?  Sure, neuronal plasticity can be a bitch, it can work in your favor, and against you.

This is not a tough case, if you have seen the beast before and you recognize all of its parameters. If you have not seen the beast before, this case is a nightmare with all these pieces (deep buttock pain, impingement, frontal drift, cross over, strange shoe wear pattern, opposite ankle peroneal pain etc).  Do you have to get this right every time with a bulls eye diagnosis and remedy? Heck no, we flounder every day with new things and variants of old. Sometimes the layers of compensations are so deep that it takes weeks before a recognizable layer presents itself. Patience on both the client and the doctor are necessary.  

So what we have here is a fairly classic shoe wear pattern of a right laterally drifting pelvis and a cross over left leg. In this case it was from a weak right core and pelvis drift creating an environment for the generation of a right ischial-femoral impingement syndrome, driving a left peroneal tendonopathy scenario from the ensuing left cross over gait.  

Remember, don’t fix your clients shoe wear pattern and certainly do not make shoe recommendations from what you see in their shoe wear pattern. Recommending a different shoe to fix this clients problem is a mistake. As is prescribing an orthotic, different foot bed, adding wedges and postings to the shoe or foot bed can also be  mistake. Define the source of the problem, before you go start tinkering around with the bottom of the kinetic chain. Want more ? Try taking our National Shoe fit program to get deeper into this kind of stuff.

We were lucky enough to get this runner’s problem spot on. After many failed attempts by others, this case was 50-75% resolved in one session with the right homework and a great understanding by the runner of their problem. They fully engaged themselves in the understanding of the problem and what they needed to be aware of in their walking and running gait. They were diligent with their homework and understood how it would help the presentation. They presented again to the clinic this week for a focused session to drive the problem further out of town and they are now on their way to the Boston Marathon with a smile and tools to fix the problem. There is a little more fine tuning to do here, but we can wait until they return from Boston.

Good luck in Boston everyone !

We hope this case helps you help someone else, that is the point after all.

Shawn and Ivo, the gait guys

Imaging things can make them better.

Imagining can make things better.

Visualization is a key in most sports and activities if one wants to improve their skill and performance. Gait retraining through visualization should thus work as well. This study which has yet to be executed, hypothesizes that we should be able to change and improve our gait through visualization of changes. Motor imagery, envisioning motor actions without actual execution, has been used to improve gait in Parkinson's disease and post-stroke. In this study subjects will be asked to specifically imagine walking, imagine talking and imagine walking while talking. It will be interesting to see what they discover, but we suspect that this should be like improving any other motor task, that visualization improves the task. Learning occurs on several levels. One should also consider not only asking clients to do their prescribed corrective exercise homework and movements, but also visualize them even when actual physical execution is not feasible.

Neurodegener Dis Manag. 2017 Nov 22. doi: 10.2217/nmt-2017-0024. [Epub ahead of print]
Motor imagery of walking and walking while talking: a pilot randomized-controlled trial protocol for older adults. Blumen HM1, Verghese J1.

A bit about the QL...

As we have said in previous posts,  though they can’t act independently we like to think to think of the QL as having two divisions. The lower division arises from the medial portion of the iliac crest and adjacent iliolumbar ligament and inserts onto the transverse processes of the lumbar vertebrae, in the coronal plane from lateral to medial and in the saggital plane from posterior to anterior. The upper division arises from the lumbar transverse processes of the upper 4 lumbar vertebrae and insert into the inferior border of the 12th rib, running in the coronal plane from medial to lateral and in the saggital plane from anterior to posterior; about half of the fascicles of this second division act on the twelfth rib and the rest act on the lumbar spine.

The QL is primarily a coronal plane stabilizer causing lateral bending to the ipsilateral side when the foot is planted as well as posterior rotation of the lumbar spine on the weight bearing side.   When acting unilaterally without the ipsilateral foot fixed on the ground, it can raise the ilia on the side of contraction. It is active during single limb support during stance phase of gait on the contralateral side (along with the external oblique) to elevate the ilium. This is coupled with the ipsilateral anterior fibers of the gluteus medius and minimus pulling the iliac crest toward the stable femur. Sahrmann states “the QL is optimally situated to provide control of lateral flexion to the opposite side via its eccentric contraction to provide control of the return from lateral flexion via its concentric contraction. The muscle is also positioned to play a role in the rotation that occurs between the pelvis and spine during walking”.

Acting bilaterally, it extends the lumbar spine, deepening the lordosis and acting to limit anterior shear of the vertebral bodies.

It is also able to stabilize the 12th rib during forced expiration, thus acting as an accessory muscle of respiration. This fixation is important when we need to superimpose pelvic movements upon it. Furthermore, it increased activation in response to increasing compression in static upright standing postures.

Here is a video of a low back screen we often use

How is your foot is connected to your butt....?

If you have been following us for any length of time, you have heard us talk about how the lower kinetic chain is connected, how ankle rocker effects hip extension and how important hallux (great toe) extension is. 

What can we conclude from this study?

toe spreading exercises are important for reducing navicular drop (and thus mid foot pronation, at least statically)
In addition to increased abductor hallucis recruitment in ascending and descending stairs, when hip external rotation exercises were added along with toe spreading exercises folks had more recruitment of the vastus medialis (a closed chain external rotator of the leg and thigh)
 
Keep in mind:

the exercises given were all non weight bearing and open chain for the external rotators. Imagine what might have happened if they were both closed chain AND weight bearing!
They concentrated on the effects of toe spreading (AKA  lift/spread/reach) on the abductor hallucis. It also has far reaching effects on the dorsal interossei, long and short extensors of the toes. 

Abstract: The purpose of the present study was to examine the effects of toe-spread (TS) exercises and hip external rotator strengthening exercises for pronated feet on lower extremity muscle activities during stair-walking. [Subjects and Methods] The participants were 20 healthy adults with no present or previous pain, no past history of surgery on the foot or the ankle, and no foot deformities. Ten subjects performed hip external rotator strengthening exercises and TS exercises and the remaining ten subjects performed only TS exercises five times per week for four weeks. [Results] Less change in navicular drop height occurred in the group that performed hip external rotator exercises than in the group that performed only TS exercises. The group that performed only TS exercises showed increased abductor hallucis muscle activity during both stair-climbing and -descending, and the group that performed hip external rotator exercises showed increased muscle activities of the vastus medialis and abductor hallucis during stair-climbing and increased muscle activity of only the abductor hallucis during stair-descending after exercise. [Conclusion] Stair-walking can be more effectively performed if the hip external rotator muscle is strengthened when TS exercises are performed for the pronated foot.

Goo YM, Kim DY, Kim TH. The effects of hip external rotator exercises and toe-spread exercises on lower extremity muscle activities during stair-walking in subjects with pronated foot. J Phys Ther Sci. 2016 Mar;28(3):816-9. doi: 10.1589/jpts.28.816. Epub 2016 Mar 31. 
link to  FREE FULL TEXT: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4842445/

Do you really understand what it takes to control the 1st Metatarsal during loading ?

Do you have dorsal (top) foot pain, at the peak of the arch? Think you are tying your shoes too tightly and that is the cause? Do you have pain over the dorsal or plantar mid foot on heel rise or jumping/landing or going up stairs ?

Just because you raise your heel and load the ball of the foot does not necessarily mean you have adequately plantarflexed the 1st metatarsal and loaded it soundly/stable with the medial tarsal bone. Heel rise, and thus loading onto the medial foot tripod, must be met with ample, stable, durable, 1st metatarsal plantarflexion and the associated medial tarsal bones. Also, without this, loading of the sesamoids properly cannot occur, and pain may ensue.

The first ray complex can be delicate in people who are symptomatic. In some people who do not have a good tibialis posterior-peroneus sling mechanism working harmoniously, in conjunction with a competent arch tripod complex to achieve a compentent arch complex (ie, EDL, EHL, tib anterior and some of the other foot intrinsics) this tarsometatarsal interval can become painful and instead of the 1st ray complex being stable and plantarflexing as the heel departs and the 1st ray begins taking load, it may not do so in a stable plantarflexed posturing. In some people it can momentarily dorsiflex as the arch subtly collapses (when it should be stable and supinated in heel rise).

"Subtle hypermobility of the first tarsometatarsal joint can occur concomitantly with other pathologies and may be difficult to diagnose. Peroneus Longus muscle might influence stability of this joint. Collapse of the medial longitudinal arch is common in flatfoot deformity and the muscle might also play a role in correcting Meary's angle."-Duallert et al

Soon, I hope to show you a video of how to watch for this problem, how to train it properly, how we do it in my office.
Dr. Allen

Reference:

Clin Biomech (Bristol, Avon). 2016 May;34:7-11. doi: 10.1016/j.clinbiomech.2016.03.001. Epub 2016 Mar 10.  The influence of the Peroneus Longus muscle on the foot under axial loading: A CT evaluated dynamic cadaveric model study. Dullaert K1, Hagen J2, Klos K3, Gueorguiev B4, Lenz M5, Richards RG6, Simons P7.

https://www.ncbi.nlm.nih.gov/pubmed/27015031

When one foot is shorter, and smaller. Gait thoughts to consider.

This person had a congenital “club foot” at birth also know as congenital talipes equinovarus (CTEV). It is a congenital deformity involving one or both feet. In this case it affected the right foot (the smaller one).
Foot size is often measured with the Brannock device in shoe stores, you know, the weird looking thing with the slider that measures foot length and width. In this case, the right heel:ball ratio, the length from the heel to the first metatarsal head, is shorter. The heel:toe length is also shorter, nothing like stating the obvious ! IF they are shorter then the plantar fascia is shorter, the bones are shorter, the muscles are smaller etc.

So, the maximal height of the arch on the right when the foot is fully supinated is less than that of the left side when also fully supinated (ie. during the second half of the stance phase of gait). Even with maximal strength of the toe extensors which we spoke of yesterday will not sufficiently raise the arch on the right to the degree of the left.

Thus, this client is very likely to have a structural short leg. Certainly you must confirm it but you will likely see it in their gait if you look close enough.
Also, you must remember that the shorter foot will also spend fractionally less time on the ground and will reach toe off quicker than the left. This may also play into a subtle limp.
This client may have a mal-fitting shoe, the right foot will swim a little in a shoe that fits correctly on the left. You may be easily able to remedy all issues with a cork full length sole insert lifting both the heel and forefoot. This can negate the shoe size differential, change the toe off timing and remedy much of the short leg issue. You will know that the right foot at the metatarsal-phalangeal joint bending line will not be flexing where the shoe flexes on that right foot. The Right foot will be trying to bend proximal to the siping line where the shoe is supposed to naturally bend. This will place more stress into that foot. This brings up the rule for shoe fit: never size a persons shoe by pinching the toebox to see if there is ample room, the shoe should be fit to meet the great toe bend point to the flex point of the shoe.
Strength of muscles is directly proportional to the cross sectional area of the muscle. With smaller muscles, this right limb is very likely to be underpowered when compared to the left.
All of these issues can cause a failure of symmetrical hip rotation and pelvic distortion patterning.
Altered arm swing (most likely on the contralateral side) is very likely to accommodate to the smaller weaker right lower limb. Do not be surprised to hear about low back pain or tightness or neck/shoulder issues.
A shorter right leg, due to the issues we have discussed above, will place more impact load into the right hip ( from stepping down into the shorter leg) and more compressive load into the left hip (due to more demand on the left gluteus medius to attempt to lift the shorter leg during the right leg swing phase). This will also challenge the pelvic symmetry and can cause some minor frontal plane lumbar spine architecture changes (structural or functional scoliosis…… if you want to drop such a heavy term on it).

Gait plays deeply into everything. Never underestimate any asymmetry in the body. Some part as to take up the slack or take the hit.

post link:

https://thegaitguys.tumblr.com/post/23230149195/we-could-have-easily-made-this-a-blog-post-about

The over extended knee, genu recurvatum. Watch your kids.

In 2011, in our infancy here at The Gait Guys, we were at the airport. And we saw this . . . .

What do you see here in this young lady ? What you should see here matters. They are just visual things, and lead to visual hypotheses, but it is your job to prove or disprove them. If you like to play these kinds of mental gymnastic games, this is valuable work. This is the work that sets you up to move skillfully, quickly and confidently in the exam and treatment room.
Join us for a rewind, back to 2011.

A young lady with knee recurvatum. Even at the airport you are not safe from The Gait Guys !

Standing waiting for my parents luggage I had to do a double take when i saw this excessive genu recurvatum of the knees. Of course it was much worse in person because of the added dimension that a photo cannot give.  This poor gal probably doesn’t even know she needs us. 

What do we see here and what assumptions can we extrapolate (assumptions from mere standing of course)  ?:

We are going to keep it to things from pelvis down or we will be here all day.

1. Anterior pelvis tilt. She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  Combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis.
2. The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extennsion.
3. The knees are likely locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis.
4. She will be in relative ankle plantarflexion instead of balancing the tibia neutrally over the talus.  Relative constant plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. This gal will likely have problems controlling pronation we suspect because of such assumed imbalances.

These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. I was going to walk behind to take a pic so we could make some assumptions about the frontal plane, but people all around were already getting suspicious of me snap photos of so many of them. 

Remember, these are just assumptions from a single static photo. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us.

Oh, and we must not forget to once again thank Mr. UGG boot for helping add another dimension of challenge to this lovely lady ! Although this assumption would be better made off of a frontal plane photo.

Beware of geeks in the airport and shopping malls snapping photos and video. It is likely us, The Gait Guys.

Shawn and Ivo

rewind: https://thegaitguys.tumblr.com/post/14809328401/a-young-lady-with-knee-recurvatum-even-at-the

Peroneus brevis is a more effective evertor than peroneus longus

"A primary function of the peroneus longus and peroneus brevis is to provide the eversion moment necessary to balance the opposing inversion moments. "
The peronei have to be rehabilitated when injured, and they have to be strong to effectively control that rear and midfoot and work in a balance fashion. This is not a simple task and this will take some specific focused efforts, in our experience. On example we would strongly suggest would be to put far more focus on loaded weight bearing peroneal challenges in various heel heights rather that waste time with non-weight bearing band/theraloop work, it just cannot replicate the loaded rear/mid/forefoot.

Foot and Ankle. 2004 Apr;25(4):242-6.Peroneus brevis is a more effective evertor than peroneus longus.Otis JC1, Deland JT, Lee S, Gordon J.

https://www.ncbi.nlm.nih.gov/pubmed/15132932

Arm swing and Gait Stability

"When discussing the effects of arm swing on gait stability, it is
necessary to start with a definition of gait stability. In steady-state gait, infinitesimally small perturbations are ever present, and the system’s response to such perturbations may be called local stability. When gait is externally perturbed, global stability can be assessed by quantifying the response to such a perturbation. Following Bruijn et al. [12], in human gait, this response may be divided into two phases: an initial phase, which is dependent upon both the steady state of the system (as it was before the perturbation) and the system’s intrinsic mechanical properties (e.g. inertia, stiffness), and a second, reactive phase (‘recovery’), which is mainly dependent on active control and reflexes." - P. Meyns et al. / Gait & Posture 38 (2013) 555–562

*The how and why of arm swing during human walking
Pieter Meyns a,1 , Sjoerd M. Bruijn a,b,1, Jacques Duysens a,c,

Planks for 10 seconds ?

Take this new "McGill'ism" with a grain of salt and in the context it may have been given, ie. for general core strength for the average person.
For what we do however, we do not agree this is a rule to follow. In our clients, when working on functional stability deficits, adhering to a 10 second rule won't often make sense to resolve the issues of planar skill, endurance or strength deficits.

http://www.businessinsider.com/sports-scientist-says-there-is-no-point-in-holding-plank-for-long-time-2018-3

Nose picking and your running form problems.

Nose picking and running form

I use an example, with the appropriate clients, that humidifying one's home in the dry winter to try and break a nose picking behavior that was borne of resultant dry mucous linings doesn't necessarily mean one will break the 3 month habit of nose picking.
Furthermore, just because you decide to humidify the house doesn't mean your brain is going to halt the nose picking that has become a subconscious habit. Similarly, consciously asking someone to turn in their externally rotated foot (increased foot progression angle) or turn in the entire limb during gait, which might have been the result of frontal plane weakness of the ankle from an ankle sprain, isn't going to fix a problem that has now become an adaptive compensatory behavior at the hip. One has to get to the root of the problem, the unaddressed ankle sprain and neurologic behavioral adaptive patterns, at both the ankle and the hip. Plus, it just might get you to stop picking your beak, although, some sources now say that a good digested booger might be good for your immune system (probably a piece written by a happy confident picker).
- a Monday morning Dr. Allen rant

Got Short leg?

Ahhhh. They get it!

Our favorite quote from this article " Understanding limb-length compensation
We encourage you to pay as much attention to any abnormal compensation pattern as you do to the LLD itself. It is well documented that abnormal biomechanics, such as you would find in a compensatory pattern, can result in vibratory forces and microtrauma along the closed kinetic chain (Figure 1). The spinal facet; hip, knee, ankle and foot joints; and their associated muscles may suffer repetitive microtrauma resulting in sprain, strain, or degenerative joint disease. By addressing compensatory neuro-musculoskeletal function, you may be able to assist the patient with a cascade of dysfunction through the musculoskeletal system.

We also encourage you to make use of gait assessment technology to quantify, document, and monitor patients’ progress. Application of reproducible, documented metrics is essential to communicate effectively within a multidisciplinary system that is committed to practicing evidence-based medicine."

http://lermagazine.com/cover_story/assessing-limb-length-discrepenacy

Ruminations on a child with Calcaneal Valgus

Have a young patient with severe calcaneal valgus? Here are some of our thoughts...

So, what attaches to that hip capsule anyway....

I was trying to figure to which muscles attached to the labrum of the hip, as I see many folks where theres has gone south. I had always wondered if the iliopsoas attached, since many people with labral pathology have hip flexor dysfunction, where they use their psoas and iliacus as hip flexion initiators (or sometimes the rectus femoris, TFL and sartorius), instead of the abdominals. It turns out that NO MUSCLES attach to the labrum, but some attach to the capsule. 

Have you noticed that many of the muscles on the list below (not the obturator internus) are internal rotators AND work during the 1st part of stance phase? Remember "glide and roll"? With internal rotation of the hip comes posterior translation of the femoral head. If these are dysfunctional, you may get capsular "pinching". Think about it with the next patient with hip joint pain from initial contact to midstance. 

"An updated knowledge of the intricate relationship of the pericapsular and capsular structures is essential in guiding our treatment of the hip. Following dissection the authors were able to discern that the iliocapsularis, indirect head of the rectus, conjoint tendon (of the psoas and iliacus),  obturator externus and gluteus minimus all have consistent capsular contributions whereas the piriformis did not have a capsular attachment."

Walters BL, Cooper JH, Rodriguez JA New findings in hip capsular anatomy: dimensions of capsular thickness and pericapsular contributions.
Arthroscopy. 2014 Oct;30(10):1235-45. doi: 10.1016/j.arthro.2014.05.012. Epub 2014 Jul 23.

4 ways to fix your running stride ? ummmm

Just too simple and cooked down an article for us.
eh, maybe 2 of these have some value. But we wouldn't head to the bank on them. We have plenty of pro runners who have a decent hallux rigidus and compensate surprisingly well. But, if it ain't broken, and causing other things to become broken, leave it alone. Consider making anatomic anomalies more durable when you cannot fix or change them. As for premature heel rise, "stretch the calf", that is all they were willing to come up with? Our readers know to go a little deeper (anterior compartment assessement, hip extension assessment etc). Zero mention of hip as a cause. He merely touched on the hip drop one in our post yesterday, but that is a goliath of a topic. Read with a jaundiced eye.
 

4 Ways to Fix Your Running Stride

A seasoned biomechanics expert offers his top insights on running-form danger signs

https://www.outsideonline.com/2293286/four-ways-fix-your-running-stride?utm_medium=social&utm_source=facebook&utm_campaign=onsiteshare

Plantar flexion matters, too. Don't get stuck only on ankle rocker/dorsiflexion.

Plantarflexion matters, too.
"one must gain posterior length through anterior strength, lose the strength, lose the length."

We always seem to be harping on ankle rocker and ankle dorsiflexion. But, ankle plantarflexion matters just as much, but in different ways. This study went off of plantarflexion contracture, but we see shortness in the gastroc and soleus all the time, it seems in fact to go with loss of anterior compartment weakness, which is in essence, a functional (if not more truly restricted) loss of ankle rocker. Typically these 2 beasts are both in the same shopping bag. It is why we like to say, "one must gain posterior length through anterior strength, lose the strength, lose the length." This is not to say that shortness, tightness or contracture are the same thing, in fact they are on completely different spectrums. But, losing "posterior mechanism" length (short, tight or contracture), for whatever reason will do many potentially bad things to one's gait cycle and biomechanics. There are too many here of those to name, but, a functionally longer leg, tendency towards knee extension, knee flexion accomodation, early heel rise, abrupt departure from the limb and and abruptly onto the contralateral side, increased forefoot loading problems, toe clenching, loss of hip extension, impaired hip extension, increased quadriceps tone (and thus possible increased PF joint compression), changes in step and stride length and step width are just the start of some of the things your brain needs to start juggling.

The above are some of the thoughts immediately triggered by reading this abstract , , ,

Clinical Biomechanics. Volume 29, Issue 4, April 2014, Pages 423-428
The impact of simulated ankle plantarflexion contracture on the knee joint during stance phase of gait: A within-subject study
Joan Leung, Richard Smith, Lisa Anne Harvey. Anne M. Moseley, JosephChapparo

Do you really understand a runner's hips ? Coaching out things you don't like to see doesn't make it a "fix".

"All the technique in the world doesn't compensate for the inability to notice"- Elliott Erwitt

Excerpt: "So if your remedy for this runner is to just add a "loaded Farmer's carry" on the opposite side, your thinking is right if it is a strength issue in the contralateral hip. IF it is an endurance issue you need a lighter weight and more unilateral Farmer's carrying. If it is a weight management issue, you may be poking the bear. Maybe it is a multitude of issues. "

There are loads of folks taking 'this' seminar series, or 'that' one, striving for 'this' certification or 'that' one. This is trememdous, it keeps the professions moving. But, all the technique in the world doesn't mean a thing if one cannot see, feel, test, or most importantly comprehend and express a client's primary flaw(s) in mobility and stability. The right tools in unskilled hands are useless, and arguably present risks for clients.

We have said this many times, too many for certain, that what you see in your client is not their problem, it is their means of moving within their present abilities and dysfunctions for whatever reason (ie. lack of skill, endurance, strength, power etc). We have also said that a mere exercise, test or screen doesn't take one to the end zone either, they are also a mere piece of the bigger puzzle. An exercise or test also may only tell you what they are capable (or incapable of), but not why their pain or challenges exist. Thus, taking a failed test, and making it your client's new exercise does not necessarily create an environment for a remedy, it can in fact create one of a more durable compensation. And that is ok, if that is what you are searching for, if that is the emergency bandaid you need before the marathon in 3 weeks, but if you are swinging for the remedy, you may have to trudge the extra yard.

Last week we taught about some basic hip principles during our online class. Take this runner photo for example, below is a basic principle you must glean from the photo. It is a principle based off of remedial joint biomechanics, as incomplete as it is, the thought process should be one you consider and certainly comprehend. In this photo, this runner appears to have insufficient stance phase hip abductor (HAM) strength or endurance. This is in part notable because of the adduction of the contralateral thigh (this is a faulty swing leg pendulum mechanical event, and will undoubtedly lead to a cross over gait and a plethora of other gait problems).

Here is one question that should always come to mind:
Are the stance phase hip abductors strong enough, or have enough endurance, to offset the body mass ? (see the line diagrams). Look at the diagram formula, and let us discuss.
If the pelvis is to remain level (mostly), the D1 and D2 lever arms do not change, the D1 lever arm is always shorter and thus the HAM (Hip abductor muscle strength) will always have to be a large number to offset the BQ (body weight). If BW gets too large, there will be no HAM large enough to offset BW and the pelvis will dip, as in this runner's photo. So, it can be a weight issue, a HAM strength issue, a HAM endurance issue or both. Someone is going to win, and someone is going to pay if the system is not balances and durable. We see this in the failed frontal plane running mechanics all the time in our offices, this is a plague in runners. It is a major source of the spine, pelvis, hip knee and foot issues we see in runners. To fix these clients, you have to understand their mechanics. The latest rehab toy that you bought at after a jazzy seminar pitch doesn't replace the requisite knowledge one needs to have to understand a clients problem. Screens won't get you all the way, tests and pattern assessments won't get you all the way either. You have to do your learning part, the knowledge must precede your interventions.

So if your remedy for this runner is to just add a "loaded Farmer's carry" on the opposite side, your thinking is right if it is a strength issue in the contralateral hip. IF it is an endurance issue you need a lighter weight and more unilateral Farmer's carrying. If it is a weight management issue, you may be poking the bear. Maybe it is a multitude of issues. But, if it is a mobility issue, adding your Farmer's carry doesn't guarantee you will get the client to the promised land, and if it is a stability issue, perhaps you get close.
* This article does not chase down deeper evaluation concepts such as narrow step width, femoral torsions, tibial torsions, swing phase gait mechanic failures, sagittal plane (A-P pelvis control) or rotational plane challenges to the system (failure to control limb rotation at the hip or at the foot) just to name a few. This article ONLY looked at the frontal plane concept, so hopefully one is gleaning how complex these biomechanics are. Hopefully one is gleaning at this point that this is not a spot corrective exercise prescription game, "here is the visually disturbing pattern, here is the exercise to eclipse that pattern". There does need to be some brain engagement in the process to do this right, and this means education and hands on clinical examination.

The Farmer's carry is a beautiful exercise when placed correctly in a client's regimen. There are many who say we take this game too completely, too precisely, too far, that we make this too complex and if one listens to us that one might develop stage fright to execute any intervention. Well, sorry, but we stand our ground. This is not an easy game. Too many people come to see us after intermediate regimens of training and lifting develop problems, problems that were not present at the initiation of their attempts to better they body. If one is being honest with themselves, they should ask themselves, could this have been prevented? Was the work prescribed part of the eventual deliverance? Injuries occur when loads exceed durability, skill, endurance, strength, power etc. One could make the case that if the prescriptions are correct, if the progressions are correct, that injury should be a rare thing. But injuries are not uncommon and those of us who are prescribing corrective exercises and workout regimens have to take self accountability if we are being honest with ourselves.
Don't get us wrong, we are just as much a pupil on this bus as anyone else, we make mistakes all the time. But everyday we force ourselves to pause, consider, double check, reassess, to make sure that the developing patterns are sound, strong, durable and progressive, and ready for more. And when we get it wrong, we reexamine, and try again. It is all one can do.

Stir about your own clinical world with a jaundiced, questioning eye, and you should do just fine. And if you cannot get it right, get it close, prescribe something safe and watch and test for clues of developing problems in the near future. This we all call . . . . learning/ practice.

"All the technique in the world doesn't compensate for the inability to notice"- Elliott Erwitt

Shawn Allen, one of the gait guys

The "most elusive" man in North America

76 runner. Elusive, lives in a bus, running everyday, creating his own trails, calling the shots every minute of his day. Inspiring message.

https://youtu.be/QcJoW9Lwzs0