Is there a need for "Gait Retraining'?...We think so

Some hip OA patients walk the way they do because of pain, actually most do because of the pain.  In doing so, they alter loading patterns. As we discussed last week in podcast 161 (Central Pattern Generators) over time this re-wires a central pattern generator, and we get new automated plastic loops of neurologic recruitment. If hip OA patients in pain can do this, so can you, in fact you will. In fact, you already have in many ways if you are a few decades into your life.

“This study below (3) documents alterations in hip kinematics and kinetics resulting in decreased hip loading in patients with hip OA. The results suggested that patients altered their gait to increase medio-lateral stability, thereby decreasing demand on the hip abductors. These findings support discharge of abductor muscles that may bear clinical relevance of tailored rehabilitation targeting hip abductor muscles strengthening and gait retraining.”

There seems to be some controversy with regards to gait retraining. Some folks seem to believe that it should be “left to itself” and they are fully compensated already (1). Perhaps this is true…or not. We have not seen any studies that compare gait retraining vs non gait retraining as a whole, but there seems to be plenty for specific conditions (2). We all see folks AFTER THE FACT and seek to correct the problems and reverse, halt or slow the progression of further pathology. That seems to be what many of us do.

There is substantial evidence that hip pathomechanics lead to osteoarthritis (4, 5). Wouldn’t it make sense to assist in altering motor patterns and correct those biomechanical faults before it becomes a problem? Lets change our focus (if we haven’t already) and concentrate on skill, endurance and strength, in that order for the betterment of ourselves, our patients and humanity.

Meyer CAG, Wesseling M, Corten K, Nieuwenhuys A, Monari D5, Simon JP, Jonkers I, Desloovere K. Hip movement pathomechanics of patients with hip osteoarthritis aim at reducing hip joint loading on the osteoarthritic side. Gait Posture. 2018 Jan;59:11-17. doi: 10.1016/j.gaitpost.2017.09.020. Epub 2017 Sep 22.

image source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

full references, links to free full text on the blog: https://www.thegaitguys.com/thedailyblog/2018/9/12/is-there-a-need-for-gait-retrainingwe-think-so

Cortical Repatterning

Cortical Repatterning

We have been talking this week about what we all cortical repatterning or “motor programming”. Here I run through simple marching exercise for a patient with dystopia, giving some salient points and cues along the way.

A simple test for motor programming

Marching, a rudimentary motion, is a great screening for people with motor programming difficulties. This gal has left lower extremity dystonia and we were looking to see if it was more peripheral or central in origin.

You can see how her movement breaks down after a few simple steps of attempted coordinated movement. Use this simple marching screen next time you suspect a central programming issue in your patients :-) 

Podcast 161: Central pattern generators: Why and how movement goes bad

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Calf Size Matters

Calf size matters. Truly, and here is why.

The Achilles tendon (AT) moment arm transforms triceps surae muscle forces into a moment about the ankle which is critical for functional activities like walking and running. The achilles tendon moment arm changes continuously during walking. It changes as movement occurs and as the triceps surae contracts. But, it also changes as the muscle grows in size, or shrinks. This has relevance to exercise, strengthening, and atrophy of the calf compartment. When the muscle contracts, its cross sectional area changes, and this can change the pull angle on the achilles. One might think of the achilles tendon as being "tented" away from the tibia slightly, and one can feel this on their own foot when palpating the soft tissue space between the tendon and the tibia on plantarflexion even when sitting. Better yet, sit down, your foot on the ground. Now, palpate the soft tissue space between the achilles and tibia. Now raise your heel, thus forefoot loading. You will feel the space gap open, the moment arm has increased because of this, thus changing its moment arm. On dorsiflexion the moment arm shortens, on plantarflexion it lengthens. Sure, this does not create a monstrous line of pull change, but by the time we get down to the pivot point at the ankle mortise, a small change in moment arm can translate to significant changes in torque and force production. This is why a foot that does not supinate in time for heel off, or supinate sufficiently, meaning the rear foot isn't inverted optimally, means that the ankle mortise (talus position) might change/shorten that moment arm. This is not efficient mechanics. Want to jump higher ? You have to get that excessive pronation in ankle dorsiflexion under control and convert it to supination, and rearfoot inversion. Jumping from a collapsed foot tripod is a power leak and you will not optimize the triceps surae-achilles complex and their lever arm. This also goes for toe off in walking and especially running, particularly sprinting where you are up on that forefoot. Said another way, when the arch is more collapsed and the talus is thus more plantarflexed the moment arm is sorter for the achilles. Strength, power, torque all suffer. One does not want to engage heel rise and calf contraction from this ineffective position of pronation taken too far, or heel rise while still pronated. This can also put undue load, and angle of pull, through the achilles. Meaning, the linear pull one desires through the achilles, can be through a calcaneal insertion that is not oriented optimally. One might postulate, rightly so we believe, that the lateral bundles/fascicles of the achilles tendon might see more loading than the medial. At the very least, we might postulate that the medial and lateral achilles tensile loads are offset and unequal. This could create problems over time, meaning changes in tendon morphology.

In the below Rasske & Franz article, they posit that aging negatively effects the architecturally complex AT moment arm during walking, which thereby contributes to well-documented reductions in ankle moment generation during push-off. They looked at the "AT moment arms of young (23.9 ± 4.3 years) and older (69.9 ± 2.6 years) adults during walking, their dependence on triceps surae muscle loading, and their association with ankle moment generation during push-off. Older adults walked with 11% smaller AT moment arms and 11% smaller peak ankle moments during push-off than young adults. Moreover, as hypothesized, these unfavourable changes were significantly and positively correlated (r2 = 0.38, p < 0.01). More surprisingly, aging attenuated load-dependent increases in the AT moment arm (i.e., those between heel-strike and push-off at the same ankle angle); only young adults exhibited a significant increase in their AT moment arm due to triceps surae muscle-loading. Age-associated reductions in triceps surae volume or activation, and thus muscle bulging during force generation, may compromise the mechanical advantage of the AT during the critical push-off phase of walking in older adults. Thus, strategies to restore and/or improve locomotor performance in our aging population should consider these functionally important changes in musculoskeletal behavior."

Great article spawning deeper thoughts, here at The Gait Guys blog.
More to come on this most likely.

Aging effects on the Achilles tendon moment arm during walking. Kristen Rasske, Jason R.Franz
Journal of Biomechanics
Volume 77, 22 August 2018, Pages 34-39

Photo credit: Image by Huei-Ming Chai, National Taiwan University School of Physical Therapy as found on www.runsmartproject.com

The Calcaneo Cuboid Locking Mechanism

Do you know what this is? You should if you walk or run!

It is the mechanism by which the tendon of the peroneus longus travels behind the lateral malleolus of the ankle, travels underfoot, around the cuboid to insert into the lateral aspect of the base of the 1st metatarsal and adjacent 1st cunieform.

When the peroneus longus contracts, in addition to plantar flexing the 1st ray, it everts the cuboid and locks the lateral column of the foot, minimizing muscular strain required to maintain the foot in supination (the locked position for propulsion). Normally, muscle strength alone is insufficient to perform this job and it requires some help from the adjacent articulations.

In addition, the soleus maintains spuination during propulsion by plantar flexing and inverting rear foot via the subtalar joint. This is assisted by the peroneus brevis and tertius which also dorsflex and evert the lateral column, helping keep it locked. Can you see why the peroneii are so important?

Signs of a faulty calcaneo cuboid locking mechanism:

-weak peroneus longus, brevis and or tertius

-excessive rear or midfoot pronation

-low arch during ambulation-poor or low gear “push off”

-subluxated cuboid

The calcaneo cuboid locking mechanism. Essential for appropriate supination and ambulation. Insufficiency, coming to a foot you will soon examine.

Would you like to know more? Join us for our “third Wednesdays“ online webinar: Biomechanics 313. Wednesday, June 18 at 6 MST. Onlinece.com

Appropriate Placement of Metatarsal Pads

In a follow-up to our last IGTV video, here we look at appropriate place in metatarsal pads. Metatarsal pads can do a great job to lift and separate the individual metatarsal heads and create space for things like neuromas and alter the forefoot mechanics. They are not a substitute for appropriate exercise and strengthening.

This individual had right “sixth toe“ disease and the metatarsal pad was being used by a podiatrist to alter for foot mechanics. It was clearly too far back on the right side. 

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6th Toe Disease

It’s probably fair to say that a good number of us see people with “sixth toe” problems or a Taylor’s bunion more often than not. This problem is often accompanied by internal tibial torsion and sometimes femoral retro torsion. This video reviews a case that came in yesterday.

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#6thtoe #6thtoedisease #tailorsbunion #lateralfootpain #footpain #footproblem #gait

The gluteus medius and low back pain

We see this one ALL the time. We are sure you do as well. “Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP.” It is often more on the side of pelvic frontal plane drift. The abdominals and spinal stabilizers also often test weak on this same side.

We often see compromise of hip rotation stability as well because , since the hip is relatively adducting (because the pelvis is undergoing repeated frontal plane drift, hence no hip abduction) there is often a component of cross over gait phenomenon which can threaten rotation stability of the lower limb (type “cross over gait” into the search box of our tumblr blog for an sample of work we have written on that phenomenon). Eur Spine J. 2015 May 26. [Epub ahead of print]

Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.
http://www.ncbi.nlm.nih.gov/pubmed/26006705

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Part 2 Isometric Force

Finding the right load for a given tendon and a right frequency of loading and duraction of loading is also case by case specific. Part of finding the right loading position is a discovery process as well, as noted in the photos above. Finding the fascicles you want to load, and the ones you do not want to load (painful) can be a challenging discovery process for you and your client. Finding the right slice of the pie to load, and the ones not to load takes experimentation. When it is the achilles complex, finding the safe However, if one is looking for a rough template to build from, brief, often, heavy painfree loads is a good template recipe to start with.

Here, in this Geremia et al article, "ultrasound was used to determine Achilles tendon cross-sectional area (CSA), length and elongation as a function of plantar flexion torque during voluntary plantar flexion." They discovered that, "At the end of the training program, maximum isometric force had increased by 49% and tendon CSA by 17%, but tendon length, maximal tendon elongation and maximal strain were unchanged. Hence, tendon stiffness had increased by 82%, and so had Young’s modulus, by 86%. Effects of high loading by eccentric triceps surae training on Achilles tendon properties in humans.
European Journal of Applied Physiology
August 2018, Volume 118, Issue 8, pp 1725–1736

Part 1 Isomentric Force

Maximum isometric force had increased by 49% and tendon CSA by 17% !
Tendons can change their cross sectional area, if you load them.

Here I show lateral forefoot loading in a heel raise, and a medial forefoot loading in heel raise. This has to be part of the discovery process outlined below.

Isometrics are useful, they have their place. In a recent podcast to load up here in the future, we discuss the place and time to use isometrics, isotonics, eccentrics and concentrics.
One of the goals in a tendonopathy is to restore the tendon stiffness. Isometrics are a safe way to load the muscle tendon complex without engaging a movement that might have to go through a painful arc of movement. With isometrics here is neurologic overspill into the painful arc without having to actually go there.

The key seems to be load. More load seems to get most people further along. Remember, the tendon is often problematic because it is inflammed and cannot provide a stiffness across its expanse. Heavy isometric loading seems to be a huge key for most cases. But, we have to say it here, not everyone fits this mold. Some tendons, in some people, will respond better to eccentrics, and strangely enough, some cases like stretching (perhaps because this is a subset of an eccentric it seems or because there is a range of motion issue in the joint that is a subset of the problem). Now the literature suggests that stretching is foolish, but each case is unique all in its own way, and finding what works for a client is their medicine, regardless of what the literature and research says.

Awareness is key

Awareness is key. Does this person know they are doing this ? Do they have pain? If they do not have pain or awareness is it a problem and does it need addressed ? These shoes did not make this person load like this, the person broke the shoes into this pattern. There is something going on, the question is what drove this ? Most likely, this is not a footwear problem, this is a person problem in the footwear.

What we see is not the problem most of the time. We are seeing their strategies , coping mechanics and their ultimate failure to load more cleanly most of the time.

There are people out in the fields that are saying posture doesn't matter, that your next posture is your best posture. This is a bit curious to us. Sure, if you are not in pain then is a given posture a problem? One could argue that, but not with a strong argument, we believe. Take this foot-shoe posturing for example, is this a problem if it is not painful ? Do we leave it alone if it is not painful? Or do we "head this one off at the pass" before possible pathology or pain presents itself? There are certainly no guarantees, however, one can use some educated and calculated logic and make some reasonable decisions that things are going to go off the rails at some point (or in this case, the heel is going to actually go off the shoe!). So, are you going to change this person's footwear ? Bring it to their awareness ? Look for problems in there body mechanics locally and globally? Or are you just going to say, "foot posturing doesn't matter". Saying it is not a problem, until it is a problem, seems awfully negligent, doesn't it?

One cause of hammertoes

One cause of hammertoes

Take a look at this gals left foot. Notice the high, cavus arch as well as increased tone in the long flexors of the toes. Is it any wonder she has weakness of the long extensors on that side?

Look at the other picture and note that she has a shorter leg on the left. Yes, it is anatomical and tibial on clinical exam. She also has limited ankle dorsiflexion and hip extension bilaterally, left greater than right.

When the foot is cavus it puts an increased stretch on the long flexor muscles of the foot because the metatarsalphalangeal joint is in relative extension. More than likely this will activate the Ia afferents from the muscle spindles causing more tone in the flexors. Yes, that will decrease over time but you will also increase the relative length of the long flexor tendons and decrease the length of the long and short extensor tendons.

 More tone in the flexors equals less tone in the extensors. Combine this with a lack of ankle dorsiflexion and hip extension and it’s prescription for more hammertoes. In addition, she has an anatomical short leg on the left putting that foot in relative supination with respect to the right. She will need to claw her toes in an attempt to create stability on that side.

The fix will be getting better control and strength in the long extensors and improving ankle dorsiflexion and hip extension.

What's wrong with the big toe on the right?

So this is what happens when you don’t wear the right shoes as a kid…

This woman came into the office with lower back pain. Do you notice anything peculiar about her feet?

She said that when she was young she was told by the doctor she was “dink toed” and given special shoes (on a sidenote, she has bilateral external tibial torsion and no evidence of forefoot adductus) . The shoes evidently (according to the doctor) were too tight and caused the deformity that you see here. She stated that the shoes were extremely painful while wearing them and then for quite a while when she stopped. This is always been her “problem foot“ with limited toe dorsiflexion and ankle dorsiflexion on that side.

Notice how the distal phalanx of the Halex is stunted and it’s with is increased. Dorsiflexion at the MTP is limited with respect to the other side and dorsiflexion flexion at the IP is limited as well. It appears that the growth plate was damaged resulting in a hypo plastic digit which, due to insufficient length, transfers a lot of weight during terminal stance and preceding ( at the end of her gait cycle, preparing for propulsion) to the second metatarsal head where she gets moderate discomfort.

We can increase the motion of the first ray with mobilization and exercise but unfortunately we are not able to lengthen her digit.

Growth plates are fragile things and what we do to children early on can have a profound impact upon their adult life.
footproblem #toeproblem #hallux #halluxdeformity #bigtoe #gait #gaitanalysis #footexam