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Foot Progression Angle Exaggeration: External Tibial Torsion

Take a look at the tibial tuberosity and then where you think the 2nd metatarsal head would be. What do you see? The 2nd metatarsal is lateral to the tibial tuberosity. You are looking at external tibial torsion. 

Lets see how this external tibail torsion behaves during a knee bending. Observe the medial drift of the knee during weight bearing knee flexion. Many folks would say that the problem here is the increased foot prontation, but that is not where the problem lies, that is where many of the forces are funneling though. The client is pronating more because the external tibial torsion that is creating this appearance has put the knee inside the foot tripods region of stability.

In external tibial torsion there is an external torsion or a “twist” along the length of the tibia (diaphysis or long section). This occurs in this example to the degree that the ankle joint (mortise joint) can no longer cooperate with sagittal knee joint.  When taking a client with external tibial torsion and pre-postioning their foot in a relatively acceptable/normal foot progression angle there is a conflict at the knee, meaning that the knee cannot hinge forward in its usual sagittal plane. In this case with the foot progression angle smaller than what this client would posture the foot, the knee the knee will be forced to drift medially.

Are you looking for torsions of the lower limb in your clients ?

Are you forcing them into foot postures that look better to  you but that which are conflicting to your clients given body mechanics ?  Would you correct this client’s foot turn out (increased progression angle) ? IF you did you would likely cause them knee pain in time.  Would you put them into a stability shoe to try and control the pronation ? Again, you are likely to draw their knee outside the saggital knee hinge that is presently pain free. There is more to shoe fit that just looking at the foot. First do no harm is our mantra ! 

Remember, telling someone to turn their foot in or out because it doesn’t appear correct to your eyes can significantly impair either local or global joints , and often both. Torsions can occur in the talus, the tibia and the femur.

Furthermore, torsions can have an impact on foot posturing at foot strike and affect the limbs loading response, from foot to core and even arm swing can be altered.  Letting your foot fall naturally beneath your body does not mean that you have the clean anatomy to do so without a short term or long term cost. 

This is some of the toughest stuff you will deal with clinically. The fence is narrow, if you do to little correction you fall off the fence into the wrong yard and create problems. If you do to much correction you get the same result. These torsional issues are a delicate balancing act many times. You first have to know what you have, then you have to know where the fix is, and then how much is safe.  Tricky stuff. This is exactly why in some folks a stability shoe can be magic or tragic and in others dropping into zero drop minimalism can be magic or tragic.  

Want more on torsion and versions ?  Type the words into the search box on our blog. We have plenty of good info for you.

Shawn and Ivo, The Gait Guys

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 (see above)

For more cool info on the peroneus longus, see our blog post here.

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.

The Gait Guys. Improving your GQ (Gait Quotient) each and every day with every post we write.

Podcast 69: Advanced Arm Swing Concepts, Compensation Patterns and more

Plus: Foot Arch Pathomechanics, Knee Pivot Shift and Sesamoiditis and more !

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D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1. “Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”
What happens when we change the length of one leg? How do we compensate? Here is a look at the short term consequences of a newly acquired leg length difference.
http://www.ncbi.nlm.nih.gov/pubmed/24857934
2. Medial Longitudinal Arch Mechanics Before and After a 45 Minute Run
http://www.japmaonline.org/doi/abs/10.7547/12-106.1

3. Several months ago we talked about the pivot-shift phenomenon. It is frequently missed clinically because it can be a tricky hands on assessment of the knee joint. In this article “ACL-deficient patients adopted the … .* Remember: what you see in their gait is not their problem, it is their strategy around their problem.
http://www.clinbiomech.com/article/S0268-0033(10)00264-0/abstract

4.Do you know the difference between a forefoot supinatus and a forefoot varus?
"A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation. ”
http://www.ncbi.nlm.nih.gov/pubmed/24980930

5. Pubmed abstract link: http://www.ncbi.nlm.nih.gov/pubmed/24865637
Gait Posture. 2014 Jun;40(2):321-6. Epub 2014 May 6.
Arm swing in human walking: What is their drive?
Goudriaan M, Jonkers I, van Dieen JH, Bruijn SM

6. This is Your Brain On Guitar
http://www.the-open-mind.com/this-is-your-brain-on-guitar/

So you want to do a Gait Analysis: Part 4

This is the 4th in a multi part series. If you missed part 1, click here. For part 2, click here, part 3, click here. 

These are the basics, folks. We hope this is a review for many.

A quick review of the walking gait cycle components:

There are two phases of gait: stance and swing. 

Stance consists of:

• Initial contact
• Loading response
• Midstance
• Terminal stance
• Pre-swing

Swing consists of:

• initial (early) swing
• mid swing
• terminal (late) swing

today, lets explore Terminal stance

Terminal stance is one of the last stages of stance phase. Following midstance, where maximal pronation should be occurring, the stance phase foot should now begin supinating, initiated by the the opposite foot in swing phase moving forward of the center of gravity. 

Lets look at what is happening here at the major anatomical areas:

Foot

• Supination begins from the opposite, swing phase leg (see above)
  

•  the calcaneus inverts to neutral

•  the center of gravity of the foot raises from its lowest point at midstance

• The lower leg should begin externally rotating (as it follows the talus)

• The thigh should follow the lower leg and should also be externally rotating; sometimes to a greater extent due to the shape and size of the medial condyle of the femur (which is larger than the lateral)

• these actions are perpetuated by the gluteus maximus and posterior fibers of the gluteus medius, as well as posterior compartment of the lower leg including the flexor digitorum longus, flexor hallucis longus, peroneus longus and tibialis posterior

Ankle

• The ankle should be 5 degrees dorsiflexed and in ankle rocker
• the calcaneocuboid locking mechanism should be engaging to assist the peroneus longus in getting the head of the 1st metatarsal to the ground

Knee

• near or at full extension. This is perpetuated by the quadriceps and biceps femoris, contracting concentrically and attenuated by the semi membranosis and tendonosis. The popliteus contracts eccentrically as soon as the knee passes midstance to keep the rates of external rotation of the tibia and femur in congruence.

Hip

• The hip should be extending to 10 degrees.

Can you picture what is happening? Try and visualize these motions in your mind. Can you understand why you need to know what is going on at each phase to be able to identify problems? If you don’t know what normal looks like, you will have a tougher time figuring out what is abnormal.

Ivo and Shawn. Gait and foot geeks extraordinaire. Helping you to build a better foundation to put all this stuff you are learning on.

pictured used with permission from Foot Orthoses and Other Conservative Forms of Foot Care

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Subtle Clues to Ankle Rocker Pathology: How good are your powers of observation ?

There are clues showing you there is motor pathology to ankle dorsiflexion, if you are paying close enough attention.

When we see motor pathology in ankle dorsiflexion we immediately begin to think about impairment to hip extension range of motion, gluteal strength, motor coordination and many other issues.

Here is a simple case. Observation skills are your greatest superpower when it comes to figuring out many gait and movement problems. But, you have to know what to look for and know what they mean before you can even hope to know how to fix things.
This is a simple video. It shows active ankle dorsiflexion in supination. We asked the client (a runner with right heel and persistent sesamoid pain following a healed sesamoid fracture) to perform simple ankle dorsiflexion. This is what we saw.

It should be clear to the observer that the end of the video shows attempted right dorsiflexion pulls the 2-5 toe extensors into the pattern quite aggressively and as a dominating faction. One can see toe abduction and extension with surprisingly little help from the long hallux toe extensor (EHL).  Dorsiflexion also fatigued early on the right. There is only one reason that the lesser toe extensors (EDL & EDB) are being over recruited, it’s because the EHL and tibialis anterior are weak and/or inhibited or have been pattern corrupted for one reason or another. Depending on this smallest of anterior compartment muscles over the EHL and tib anterior will mean that ankle rocker (dorsiflexion) is impaired. It also means that abnormal forefoot valgus posturing is expected (we could make a case for valgus or varus depending on other variables present). Passive ROM assessment confirmed the impaired ankle rocker with barely greater than 90 degrees ankle dorsiflexion ROM. This impairment will possibly do many things including:

• premature heel rise
  
• premature gastrocsoleus engagement
• accentuated rear foot eversion (Rearfoot pronation)
• midfoot pronation
• strain of plantar fascia
• premature forefoot loading response (strong clue for clients sesamoid fracture and persistent pain)
• anterior/ posterior shin splints
• hallux VALgus /bunion formation
• long toe flexor dominance and many other things.

This clinical find plays nicely into the clients multiple symptoms (plantar pain and sesamoid problems) and functional gait pathology.
Restoring proper motor hierarchy and synchrony to the ankle dorsiflexion team (tib anterior, peroneus tertius, EDL, EHL) will reduce the need for solitary group overuse and impart forces where they should be when they need to be present. Impair the synchrony and problems ensue.

Help your client achieve the motion at the ankle mortise and they do not have to pass the buck into the foot.  Always test for skill, endurance and strength. Endurance is the most often forgotten assessment.  If endurance is lost early, the brain will begin to block out that end range of motion because it cannot be trusted, and thus posterior compartment tightness will be detected. This is an often common source of regional achilles and para-achilles tendonopathy. If your clients symptoms take time during activity to develop looking at the endurance of motor patterns may give the clue to your solution. 

Simple case, but you have to know your normal gait parameters, know functional anatomy and know how impaired mechanics factor into injury. 

Shawn and Ivo

The gait guys

Spine pain and arm swing. Do you truly get this ? You had better.

We have all seen that runner who swings the one  arm more than the other, they may even violently thrust the one arm across the front of the torso. If you have been a spectator half way through any race you have seen this person. And, if you are watching carefully in your gym, lab, office or gait lab  you have seen the accentuated arm swing on one side (or is it the loss of arm swing on the opposite, we discussed some of these games in last weeks blog post here). You have also see the person who is running with a water bottle in their hand and altering their neurological arm-leg swing opposite pairing and thus their anti-phasic shoulder-pelvic girdle pairing (see attached photo). (If you are lost when we discuss the terms phasic and anti-phasic you will want to go and read this previous blog post.) 

Knowing that which you are seeing in your client is their highest level of neurologic motor compensation, and not likely their problem, represents a higher thought process in a diagnostician. Unfortunately, it also opens a whole bunch of clinical thought process mental gymnastics. 

Our purpose of today’s blog post is to revisit an important aspect of the clinical examination, observation.  Listening and watching (and knowing what you are seeing, and not seeing) are two of the biggest pieces of a clinical exam other than the hands on assessments. One has to be good at all of the pieces.  But then their is the knowledge base that is needed to base the information and choices upon so that the proper path to remedy can be chosen.  Without the knowledge the actions and choices can be dramatically incorrect and devastating to an athlete or client/patient.  Make the wrong choice for a patient and they do not get better, perhaps even get worse. Make the wrong choice for an athlete and you deepen their compensation and increase their risk for injury.  This is one of our pet peeves because we recognize that we have a deep knowledge base and yet we find ourselves without the certainty and answers on a regular basis and yet we see people making similar choices for clients and athlete with only a small piece of the knowledge necessary on their table to make those choices.  If you don’t know what you don’t know, and yet your still swimming in the risky waters, you are already in deep trouble. 

Here are two articles that you should be familiar with. We talk about them in depth in our “arm swing” online course #317 here.  These articles talk about phasic and antiphasic motions of the arms and shoulder-pelvic blocks.  They talk about spine pain and how spine pain clients reduce the antiphasic rotational (axial) nature of the shouder girdle and pelvic girdle. They elude to the subcortial pattern of choice to rotate them as a solid unit to reduce spine rotation, axial loading and compression and that spine pain disables the normal arm-leg pendulums.  If you do not know and  understand these principles, and you are training, treating or coaching people, you are a problem waiting to happen for your client. You, are the problem and your choices could likely hurt your client.  IF you do not know how to address them or fix them safely, it is your job to send them to someone who does. 

So the next time you see an aberrant arm swing, during your exam, your observations and your history better delve into all things relevant. How about that 20 year “healed” ankle fracture that your client dismisses as “oh, but that was 20 years ago, its not part of this problem i am having now”.  How about that episode of frozen shoulder that was “fixed” 15 years ago or that episode of hip or knee pain from falling on ice or the random big toe pain or the headaches ?  If they dismiss all of this because they are just coming to see you for spine pain or because their running partner says their arm swing stinks on the right you had better sit down for a longer ride, because you  know better now.  Unless you prefer to see life through tunnel vision. Sure it is easier, but don’t you want more for your client ?

Sorry for the rant.

Shawn and Ivo, …… the gait guys.

1. Eur Spine J. 2011 Mar;20(3):491-9. doi: 10.1007/s00586-010-1639-8. Epub 2010 Dec 24.

Gait adaptations in low back pain patients with lumbar disc herniation: trunk coordination and arm swing.  Huang YP et al.

2. J Biomech. 2012 Jan 10;45(2):342-7. doi: 10.1016/j.jbiomech.2011.10.024. Epub 2011 Nov 10.

Mechanical coupling between transverse plane pelvis and thorax rotations during gait is higher in people with low back pain.

van den Hoorn W1, Bruijn SM, Meijer OG, Hodges PW, van Dieën JH

You can only “borrow” so much before you need to “pay it back”

How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

• Top left: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
• Top right: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
• Top center:normal internal rotation of the left hip; internal tibial torsion
• 3rd photo down: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
• 4th and 5th photos down: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle (for more on progression angles, click here). If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist and  rotating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limiting  his follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

• we treated the injured joint locally, with manipulation of the pathomechanical segments
• we reduced inflammation and muscle spasm with acupuncture
• we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
• we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
• we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

Podcast 68: Gait , Arm Swing, Neuro-developmental Windows

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C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1.Brain implant helps paralysed man move his hand
http://realitysandwich.com/220399/brain-implant-helps-paralysed-man-move-his-hand-wired-uk/?u=95820

2. Has Science Finally Confirmed the Existence of Acupuncture Points, Validating Chinese Medicine?

http://themindunleashed.org/2014/03/science-finally-confirmed-existence-acupuncture-points-validating-chinese-medicine.html

3.This Tiny, Whip-Tailed Robot Can Administer Meds Anywhere In the Body

http://www.entrepreneur.com/article/235007

4. It matters what you put on your kids feet
“Shoes affect the gait of children. With shoes, children walk faster by…

 http://www.ncbi.nlm.nih.gov/pubmed/21244647

5. Normal gait development.

http://www.oandp.org/jpo/library/1993_02_035.asp

6. Myelination

http://cogweb.ucla.edu/CogSci/Myelinate.html

7. Arm swing in kids.

http://www.ncbi.nlm.nih.gov/pubmed/21531534

8. Arm swing and gait speed.

http://www.ncbi.nlm.nih.gov/pubmed/24396216   and

http://tmblr.co/ZrRYjx1JVgmv_

Arm Swing Truths, and Lies.

We have been reminded over and over again in recent weeks how intimately arm swing is tied to leg swing. We have recently had clients in our practices with strokes (ischemic and hemorrhagic), transverse myelitis, inflammatory neurologic disorder and the plethora of biomechanically pain-mediated gait responses affecting the limbs, including the upper limbs which manifest many variations in these people’s normal gait neuro-mechanics.

We are even reminded of the recent triathlete who had a right hip weakness that was allowing him to drift into the right frontal plane in running and biking. Upon asking about further symptoms he mentioned left hand tingling on longer bike training rides.  We asked if he recalled sliding/shifting onto the right side of the saddle/seat often to find power in the right leg and he mentioned matter of fact that it is a constant awareness. We then suggested that he was having to over pressure into the left handle grips to keep the bike on a straight line because of the right pelvis-saddle shift. He was wide eyed and shocked that it was what he was in fact aware of.  Moral of the story: even in on the bike opposite arm and leg action are intimately tied together.  After testing and assessment it was clear that a function TOS (thoracic outlet syndrome) was in effect because of shortness and increased tone in the left pectoral chest wall compromising neurovascular bundle compression and generating hand paresthesias (numbness/tingling).  A simple fix if you fix the right pelvic frontal plane drift.  If you try to fix the TOS at the shoulder-neck level resistance to progress is likely.

Arm swing is a sneaky thing. There are many variables. We have discussed many of these arm swing variables in 38 previous blog posts (link here) and we have whole lecture here on arm swing (this slide is part of that in depth lecture).

In the pubmed article below there is new research delving into passive and active components of arm swing. There are both, clearly. But what a reader needs to take away is that a clinical examination must be part of every assessment to discover the active components (muscular and neuromuscular) that are missing (ie. weak posterior deltoid, lat dorsi etc) and which need fixing and rehabilitation and the passive components that are inhibitory to the big picture (mobility, stability).

It should be clear by now, if you have been with us for at least the last year, that what you see in someone’s gait is their compensation, not their problem. Addressing resolution measures to change what you see is a path to deepening the compensation or developing others.  Arm swing is intimately tied to the lower limbs, and powerfully so to the opposite leg. A deficit in the leg will be expressed in some way in the opposite upper limb, which in turn forces a compensatory change in the opposite upper limb and thus down into the “other” opposite lower limb.  One thing affects many. The wrong intervention drives bigger problems, so make sure you know your gait “normal” parameters and be sure a clinical examination is a huge part of your discovery toward the answers for your client.

Shawn and Ivo … . .  the gait guys

Pubmed abstract link: http://www.ncbi.nlm.nih.gov/pubmed/24865637

Gait Posture. 2014 Jun;40(2):321-6. Epub 2014 May 6.

Arm swing in human walking: What is their drive?

Goudriaan M, Jonkers I, van Dieen JH, Bruijn SM

Abstract

The results confirm that passive dynamics are partly responsible for arm swing during walking. However, without muscle activity, passive swing amplitude and relative phase decrease significantly (both p<0.05), the latter inducing a more in-phase swing pattern of the arms. Therefore, we conclude that muscle activity is needed to increase arm swing amplitude and modify relative phase during human walking to obtain an out-phase movement relative to the legs.

Flat Dogs

Take a look at these pedographs. Wow!

• No rear foot heel teardrop.
• No midfoot arch on left foot and minimal on right.
• An elongated 2nd metatarsal bilaterally and forces NOT getting to the base of the 1st metatarsal and stalling on the 2nd: classic sign of an uncompensated forefoot varus.
• increased printing of the lateral foot on the right

Knowing what you know about pronation (need a review? click here) Do you think this foot is a good lever? Do you think they will be able to push off well?

What can we do?

• foot exercises to build the intrinsic and extrinsic muscles of the foot (click here, here, here, and here for a few to get you started)
• perhaps an orthotic to assist in decreasing the pronation while they are strengthening their foot
• motion control shoe? Especially in the beginning as they are strengthening their feet and they fatigue rather easily

The prints do not lie. They tell the true story of how the forces are being transmitted through the foot. For more pedograph cases, click here.

The Gait Guys. Teaching you more about the feet and gait. Spreading gait literacy throughout the net! Do your part by forwarding this post to someone who needs to read it.

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The weeping calf and the deconstructed arm swing.

Last week we showed you this video and blog post of a compressive left lower leg neuropathy and what it looks like when both heel and toe walking are attempted when both are compromised. It was nothing exciting but to see both in a clinical presentation is not all that common.

In today’s videos (the one above and this one here), the videos were all shot on the same day incidentally, we wanted you to see this gentleman’s gait in it’s normal gait pattern attempt.  Because less of the extremes of range and strength are required, it is far more difficult to detect the issues than in last week’s video clip (here).

There are plenty of things to talk about in this video but lets just point out one of them here today.  Remember, the lesion is in the left lower leg.

Absent right arm swing. 

We have been harping about arm swing for a long time.  Go to the search box here on our blog and type in “arm swing” and you will find an abundance of articles on the biomechanics and neurology of arm swing and how it is tied to leg swing.  In this case we have foot drop and impaired calf raise (video link) on the left. Their function is impaired/depressed. We are seeing this matching in the absence of right upper limb swing.  Remember, most of the time the upper limb takes the queue from the opposite lower limb. This is why coaching arm swing changes is not a sound idea most of the time, look for functional opportunities for changes in the opposite lower limb if deficits are present there.  

Part of what you are seeing is the increased activity in the left arm swing.  Why ? Because the client is abruptly lurching off of the left leg because of the stability and strength deficits in that limb. The brain knows that bearing weight on the left limb has challenges.  This causes an abrupt pitch (early departure) forward onto the right leg and this will be met with increased left arm swing (go limb around your home or office, you will see that it is a coupled phenomenon).  So, is it increased left arm swing you are seeing because of this issue we just mentioned or are you seeing decreased right arm swing because of the matching neuro-suppression of left leg ? 

This is where your clinical examination must come into play. Shame on anyone that is making the changes without clinical information. One must see that there rare two (at least) possible scenarios for the differential in arm swing. And one must also see that the arms in this case are not the issue, that it is the left lower limb deficits that are driving the issue.  Guaranteed.

Arm swing……..more to it than you might think.

Shawn and Ivo, The gait guys

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