The Toe Waving Exercise: Part 1

Welcome to Friday, Folks. A little exercise here for you today that we use all the time.

There are at least 3 muscles important in forming and maintaining the foot tripod. The short flexors of the lesser digits (Flexor Digitorum Brevis or FDB) are one of the important component sfor creating and maintaining the foot tripod (the tripod between the head of the 1st metatarsal, head of 5th metatarsal and center of calcaneus).

It arises by a narrow tendon from the medial process of the calcaneal tuberosity the plantar aponeurosis, and from the connective tissue between it and the adjacent muscles. As it passes forward, and divides into four tendons, one for each of the four lesser toes which divide into 2 slips ( to allow the long flexor tendons to pass through), unite and divides a second time, inserting into the sides of the second phalanx.

Because the axes of the tendons passe anterior to the metatarsal phaalngeal joint (MTP), they also provide an upward (or dorsal) movement of the MTP joint complex, moving it posterior (or dorsal) with respect to the 1st metatarsal heal (thus functionally moving the 1st met head “down”). This is a boon for people with a forefoot varus, as it can help create more mobility of the 1st ray, as well as help descend the head of 1st ray to form the medial tripod (and assist the peroneus longus in anchoring the base of the big toe). It also helps the lumbricals to promote flexion of the toes at the MTP, rather than the distal interphalangeal joint.

In this brief video, Dr Ivo explains the exercise to a patient (Thank you N, for allowing us to use this footage).

The Toe Wave: try it. Use it with your patients. Spread the tripod. We know you want to….

Ivo and Shawn

all material copyright 2012: The Homunculus Group/The Gait Guys

Using a Pedograph to get Dynamic Answers to Foot Dysfunction:

Pedograph topic: One quick topic here. Note the hot spot (ink concentration) at the big toe and note that the ink is proximal on the toe pad. We would like to see the pressure point at the center of the pad. This spot means this person walked across the Harris Ink mat with increased FHB (flexor hallucis brevis) use and not enough FHL (flexor hallucis longus);  too much short flexor, not enough long flexor. There is loss of synergy between the two. This will likely mean there is something going on in the extensors as well, something abnormal.

Need a review? Look at Monday’s video again on the EHB (extensor hallucis brevis) where we discuss all of the toes muscles.

Clinically this patient had a hallux limitus/rigidus (could not dorsiflex great toe) which complicated the mechanics at the joint and forward into the great toe, sadly also at the foot’s medial tripod as well. You cannot get an accurate read from a static (standing only) pressure mapping. Don’t rely on them for dynamic info !

Too much FHB with not enough FHL means EHB (as well as long extensors of the lesser toes) is going to be impaired. Impair the EHB and you ask the EHL  to work differently as well.  Here’s a hint, look at all the printing under the lesser digits distally, there is too much flexor activity here as indicated by intense inking from toe clenching / hammering.  They are likely doing this to add more stability since the great toe cannot from what we discussed above. There are problems that come from these issues as well but we want to stay focused on the big toe today.

Now, go back and review Mondays blog video post (here is the link).

Treatment:

In a case where there is some loss of the 1st MPJ range of motion (metatarsaphalangeal joint) (depending on the source, 45 degrees is typically needed) there will be impairment of the long and short toe flexor/extensor pairing and synergy.  In this case above there is highly suspected increased short flexor (FHB) activity (hence the ink at the proximal big toe) and this means that the long flexor is usually submissive.  And, when the long flexor (FHL) is submissive the long extensor is dominant. When the long extensor is dominant the short extensor is submissive. Can you now see the beautiful symphony and harmony we need here. This is why we loosely say that the FHB and the EHL are paired and the FHL and EHB are paired.  It is not exactly the case but hopefully you catch our drift. 

So, in this case, with a hallux limitus/rigidus when the 45 degrees of dorsiflexion is lost these pairing can be challenges and the synergy is lost.  The symphony of these muscles is “off tune”.  This can further provoke the 1st MPJ and it can also be the slow brewing initiation of the problem. It can be a vicious cycle when it gets going. And, when the 1st MPJ is limited the dorsiflexion that is supposed to occur at the joint can be shunted proximally into the midfoot or ankle and cause pain/pathology there.  It can also impair the normal pronation-supination cycles. The big toe when it goes sour makes the whole orchestra angry and play off tune.

Doing your best to normalize and maximize muscle harmony and function many times will dampen the pathology and pain and get the person going again.  Of course the problem is still lurking under the surface.  Test the muscles, try to isolate them but remember that your muscle tests need to be as specific as you can. Nothing is isolated in the body, but do your best.

Of course there are many other scenarios but this is the one we chose to teach today from this pedographing of the big toe. We will explore other options and challenges another time.

Shawn and Ivo.    Gait geeks promoting gait literacy and competency everywhere we can get an open ear.

EHB: Extensor Hallucis Brevis

Did you know that the EHB (extensor hallucis brevis) the topic of today’s video tutorial, originates off of the forepart of the medial aspect of calcaneus & lateral talocalcaneal ligament. It is just above the bulk origin of the EDB (extensor digitorum brevis). It is frequently torn/strained in ankle inversion sprains and frequently goes undiagnosed. It can be torn/avulsed from the bone if the inversion sprain is focused below the lateral ankle joint. This occurs mostly when the foot is more plantarflexed before the inversion event. A foot cannot afford to have an impaired big toe ! Don’t miss this one !

The Gait Guys Podcast #7: S1E7

This one will get you to the show player of all of our podcasts.
http://directory.libsyn.com/shows/view/id/thegaitguys

And this link will get you a nicely laid out “show notes”.
http://thegaitguys.libsyn.com/webpage/2012/08

Show Notes: The Gait Guys Podcast, Season 1, Episode 6

1- CPR:  neurscience story

http://www.bbc.co.uk/news/health-15552957

 

Correctly performed CPR  triples survival rates. The UK Resuscitation Council recommends that the chest should be compressed by 5-6 cm and at a rate of 100-120 compressions per minute. A study published in 2009 showed that using a familiar song as an AID did increase the number of people getting the right rate. But there was a drop in those hitting the correct depth.

 

2. - more lectures available  on www.onlineCE.com 13 hours of courses there !  Go there and look up our lectures

3. - EMAIL CASE:
off our FB page, from Lisa

I’m so hoping you can help me out with a patient. He is a military runner (Army) who hope to compete his first full Tri this year. In a nutshell: He has been plagued with peroneus Longus pain on his slightly longer side with running. This now occurs only with running in the combat boots and he uses a Nike Free Boot. I have checked all shoes for manufacturer defects.
Barefoot running, ankle rocker exercises, Glu. med strengthening for cross-over gait have helped his out of boot running experience, but he is frustrated by calf pain in the boots and so am I. I do have a video gait barefoot that I can send you. We have discussed the problem of trying to be a midfoot striker in a boot.
He does the waddle gait w/ theraband, squats with toes up, shuffle gait and moonwalk backwards. As far as i know, the military has banned VFFs for training and maybe all minimalist shoes. Scratching head…

4. Have you ever wondered why people who walk together quickly synchronize their gaits ?

What is thought to happen is that one partner dominates the lead in the gait, just as in dancing, one person is the leader and the other is the follower. The lead partner’s lower limbs determine the movement of their arms, which in turn when holding hands, sets the arm movement pattern in the partner then determining the leg swing and stance phases. Thus, synchrony is achieved. 

References used:
J Neuroengineering Rehabil. 2007; 4: 28. The sensory feedback mechanisms enabling couples to walk synchronously. An initial investigation.  Ari Z Zivotofsky and Jeffrey M Hausdorff  Published online 2007 August 8. doi:  10.1186/1743-0003-4-28

Hum Mov Sci. 2012 Jun 22. [Epub ahead of print] Modality-specific communication enabling gait synchronization during over-ground side-by-side walking. Zivotofsky AZ, Gruendlinger L, Hausdorff JM.Gonda Brain Research Center, Bar-Ilan University, Ramat-Gan 52900, Israel.

5 - Payloadz.com

-pedographs on FB and blog

LEMINGS new shoe line www.lemingfootwear.com

6.-EMAIL CASE

The gait guys,

My name is Nathaniel and i am e-mailing from the UK having found you through my endless googling of my injury. I  was hoping you might be able to give me a helping hand.

• So a bit of background, i am a 28 year old very keen amateur (2.23 marathon) who has a 5 year history of heavy run training (80-120 miles per week) having been a triathlete prior to that and a swimmer from the age of 8. I had no injury history prior to this except, perhaps crucially, in 2006 i twisted my right ankle into supination, several times over the course of 2-4 months, I never had to stop running for more than a day or two at this time but it was very swollen and for at least 6 months was very unstable, but i ran through it.
• so current injury is a 2.5 years of vague right posterolateral gluteal pain which is constantly there but progresses with running to a spasm, over the area i believe to be the glute medius and some mild adductor pain on the same right hand . . i can usually get through easy mileage but the pain is always there and speed work/racing is a no no. I had bilateral sports hernia surgery on the 3rd january in the belief that it would cure the problem , it helped and certainly reduced the abdominal/adductor aspect but i still cant race and I know think the sports hernias were a product of the problem and not the problems route cause.
• I have no problems on the left. my right foot are some callouses on the right on the medial aspect of the arch.just proximal to the 1st MTP
• the navicular is much more prominent on the right.
  the foot wear pattern on the right shoe is different, there appears to be a far heavier heel strike on the right lateral side, greater wear under where the right 1st MTP joint would be.
• on the left there is far more “toe off” wear on the shoe after periods of inactivity it feels as though the foot needs to warm up before it will pronate sufficiently to allow toe off. like im walking on the outside of the foot.
• the right hip has more internal rotation and less external rotation than the left,
• flexion and extension at the hip are stiff but within i believe normal limits.
• the hallux tests i have found online dont appear to show any restricton although i was initially cheating on the right with foot pronation.
•  the podiatrist said I had bilateral forefoot varus with it being worse on the right. he noted my prominent naviculars, he initially thought I had accesory bones but confirmed that i did not. he said that on the right (my bad leg) had a restriction/fixed at the midtarsal joint so the increased required pronation to get the first ray down had to come from sub-talar pronation.
• onto the walking pressure pad analysis,

-on the right (bad leg) i had alot of lateral edge mid foot loading, the right foot was much more externally rotated than the left.

-on my left leg the peak force/pressure was very unusally right under the tip if the hallux 

-on the right the forces were much less throught the heel strike, stance, and push off phase

onto the video analysis.

when you slow down my gait the left (my good, pain free leg) looks incredibly odd.

on the “swing through” phase (so when my right was on the floor) my left knee points laterally and appears to circumduct through rather than progress straight in the saggital (?) plane. as the left foot approached foot strike is looks much more supinated than the right.

 -this is in contrast to my right (painful leg) which swung though perfectly in the saggital plane,

-no movement laterally in the frontal plane, no cicumduction, approached foot strike with much less supination and just looked mor normal.

The podiatrist thinks all my problems are coming from my left foot, despite that being my good leg. so he gave me a knocked up orthotic to use in my left shoe which basically pushes me more into supination at the arch and calcaneus, nothing in the forefoot. he thought there was nothing to do in the right foot.he told me to try it for 6 weeks and if it worked he would prepare a more robust permanent version.

 

This is where my questions came from the things I have learnt from the gaitguys, Basically i questioned why if I have a forefoot varus is there nothing in the forefoot to bring the ground up to the first ray. and help attenuate the subtalar pronation on the right and mid tarsal/subtalar joint on the left. he said through years of experience, which is fair enough of an answer as I dont have any experience or qualifications of my own!

 

I enjoyed the assessment and I thought it was enlightening but cant help but feel he mar be very good at detecting/ diagnosing but im not convinced that his remedy is the way forward.

Despite the abberent movements of the left leg Im still convinced the right is the problem and what i see in the left in swing though is a product of poor mechanics of the right foot when its on the floor.

 

Thanks again. Nathaniel , United Kingdom

The Gait Guys www.onlineCE.com courses.

https://chirocredit.com/courses/index.php?catid=124&pid=1

Biomechanics

Biomechanics 208 Case Studies in Gait Analysis: Challenges to the Knee during Gait
Credit Hour(s): 1.0

Educational Objectives:

Review the pertinent anatomy of the knee

• Review the kinematics and kinetics of knee function during the gait cycle
• View and discuss case studies involving knee function
• Predict pathomechanics that will arise from the gait abnormalities presented
• Propose remedies for the gait abnormalities seen

Format(s):Adobe PDF Download Android Compatible

Ipad/Iphone compatible using Puffin Browser
Slides with audio

Price:$20.00 USD

Biomechanics 207  A case study in gait analysis: focus on torsions and versions

Credit Hour(s):1.0

Educational Objectives:

• Assess actions of the lower kinetic chain during gait
• Predict pathomechanics that will arise from gait abnormalities presented
• Propose remedies for the gait abnormalities seen
• Review the gait cycle and gait cycle biomechanics
• View and discuss case studies of gait

Format(s):

Adobe PDF Download
Android Compatible
Ipad/Iphone compatible using Puffin Browser
Slides with audio

Price:$20.00 USD

Biomechanics 206  A Case Study in Gait Analysis

Credit Hour(s): 1.0

Educational Objectives:

• Review the gait cycle and gait cycle biomechanics
• View and discuss case studies of gait
• Assess actions of the lower kinetic chain during gait
• Predict pathomechanics that will arise from gait abnormalities presented
• Propose remedies for the gait abnormalities seen

Format(s):

Adobe PDF Download
Android Compatible
Ipad/Iphone compatible using Puffin Browser
Slides with audio

Price:$20.00 USD

Biomechanics 205: Barefoot Running and Gait: What you need to know

Credit Hour(s):1.0

Educational Objectives:

• Explore barefoot running from a position of biomechanical efficiency
• Contrast the differences in shod vs unshod running
• Predict problems that can arise from shod and barefoot running
• Apply visual analysis skills to barefoot running technique
• Describe how to introduce barefoot running to your patient population

Format(s):

Adobe PDF Download
Android Compatible
Ipad/Iphone compatible using Puffin Browser
Slides with audio

Price:$20.00 USD

Biomechanics 204: Shoe selection and the effect and impact on gait

Credit Hour(s):1.0

Educational Objectives:

• Describe and identify how the parts of a running shoe affect running biomechanics
• Compare and contrast different shoe constructions to the biomechanical needs of an individual
• Determine the appropriate last shape for different foot types
• Discuss the biomechanical consequences of improper vs. proper selection of last types
• Predict which features in a shoe are necessary to correct faulty gait patterns

Format(s):

Adobe PDF Download
Android Compatible
Ipad/Iphone compatible using Puffin Browser
Video Presentation

Price:$20.00 USD

Biomechanics 203:Gait Analysis: Normal and Abnormal Gait and factors affecting them

Credit Hour(s):3.0
Educational Objectives:

• Discuss the normal walking gait cycle
• Apply the biomechanics of the pelvis and lower kinetic chain during walking to clinical practice
• Predict and discuss problems and clinical strategies that can arise from altered lower extremity biomechanics
• Apply visual analysis skills
• Evaluate case studies in gait analysis
• Clinically apply solutions for gait abnormalities

Format(s):Adobe PDF Download

Android Compatible
Ipad/Iphone compatible using Puffin Browser
Video Presentation

Price:$60.00 USD

Biomechanics 202:Foot Function and the Effects on the Core and Body Dynamics

Credit Hour(s):1.0
Educational Objectives:

• Describe how the motor and sensory homunculus relate to the foot and are integral to training and rehabilitation
• Discuss the 3 rockers of the foot
• Give examples of problems that result from a loss of the 3 rockers of the foot
• Explain the concept of pelvis neutrality and its effect on training
• Describe and examine the tripod of the foot
• Breakdown most movement into 2 basic rules or tenets
• Give examples of the problems which can arise if the 2 basic rules or tenets of movement are not followed
• Discuss the clinical consequences of loss of the medial and lateral tripods of the foot

Format(s):

Android Compatible
Ipad/Iphone compatible using Puffin Browser
Video Presentation

Price:$20.00 USD

Biomechanics 201: Introduction to Gait: Pedographs and Gait Analysis

Credit Hour(s):4.0
Educational Objectives:

• Explain the phases of human walking gait
• Discuss the biomechanical events associated with stance phase of gait
• Discuss the biomechanical events associated with swing phase of gait
• Explain biomechanically what is happening during each phase of gait in the foot, ankle, knee and hip
• Discuss the 3 rockers of the foot and how they apply to the gait cycle
• Understand the calcaneocuboid locking mechanism and defend it’s importance in the stance phase of gait
• Summarize the ranges of motion of the foot, ankle, knee and hip and their importance in normal gait
• Explain how stance phase abnormalities would impact the gait cycle
• Demonstrate competency in obtaining a reproducible Pedograph print
• Interpret rearfoot, midfoot and forefoot mechanics as seen on a pedograph print
• Identify and interpret problem areas in a pedograph print
• Identify stance phase abnormalities on a Pedograph print
• Extrapolate pathomechanics which would occur rostrally in the kinetic chain during pathomechanics occurring in the gait cycle
• Evaluate the impact of gait abnormalities on human locomotion

Format(s):

Android Compatible
Iphone/Ipad Compatible

Price:$80.00 USD

Runners . . . On Your Mark, Ready, Set.....Swim.

For many of the years of my youth I watched just about every NBA basketball game I could get my eyes on.  When I wasn’t dreaming of playing ball in the big time I was at the local YMCA in my small town shooting jump shots, working on my fading jumper (because i was a small guard with no vertical, the worst of combinations), and working on my ball handling techniques. I was not a great player, not by any means, but I could play in pretty competitive pick up games and at least be somewhat respectable (note that ‘somewhat’ is highlighted).  But I still dreamed big about the NBA until I became old enough to realize that I was just too short and not blessed with the natural talent for the game that others obviously had been blessed. No matter how much I dreamed, being 5 foot 8 inches wasn’t going to ever get me to the big dance.  Body type, form, physiology and your anatomy have a big part in what sport you will be good at. There just are not too many 5'8" NBA guards, there never were minus Mugsy and Spud. They were an exception, obvious outliers. 

Are you a runner with runner’s anatomy ?  Do you have bowed legs ? Forefoot varus flat feet ? Anteverted hips ? Excessive tibial torsion ?  These are not great traits for runners. They tend to lead to many biomechanical issues that provoke injury at a much higher incidence than someone like my friend Charlie Kern , the USA masters mile champion.  Charlie is like Tiger Woods. Charlie has straight lower limb bones, no bony versions or torsions, great feet, he is slender, excellent muscle structure, and has tons of natural ability.  If you have ever seen him run it is like watching water flow. Charlie is as a runner just like Tiger is as a golfing Ferrari. They both happened to pick a sport that their body’s were perfectly suited for, then they had the passion for that sport, were lucky to have found it at a young age, and they worked harder than anyone else at their sport.  Anatomy, a bit of luck in sport choice early on, a physiology that paired well with the anatomy, and a work ethic to trump anyone. Being the best is a combination of things. You can have all the desire in the world as a runner or athlete but if you do not have the magic mixture of all things necessary you might just be average instead of extraordinary. 

Do you get injured all the time when you run ? How are your feet, are they competent or are they flat ? Do your tibias bow like a weathered piece of lumber ?  Are your knees kinked inwards (genu valgum) ? Are you tall and thin or are you build like a line backer ?  In other words, are you suited to be a distance runner or marathoner ? Or should you be happy with three to four 5k runs a week and be happy you can run those smaller distances rather than spend every 2 weeks in the therapists office getting a foot fixed, an orthotic tweaked, kinesiotape on a knee, more rehab. Do you spend more time icing your injuries and doing pre-run theapeutic exercises and foam rolling than you do running ? 

If this is you. God bless your dedicated heart. But maybe you should put on your Speedo and go for a swim.  I put my NBA dreams on hold long ago after realizing that at 5'8" it just wasnt going to happen. I picked up golf and did much better at that game in a shorter period of time than all the work on my hoop dreams.  I would fathom to say I should have picked up ping-pong long ago as a child. Perhaps I would be world champ by this time.

Run, bike, swim, hoops, golf…..whatever your passion. There is nothing wrong with having heart and grinding it out daily to be a runner or do whatever your sport happens to be.  Just never lose sight of the obvious. Maybe you need to look past your heart and look in the mirror and your mounting therapy bills and make some adjustments to your running dreams. Some of my best Triathletes were awesome runners at one time … .  when we could get them healthy to a start line line.  The problem was that they had more unused race bibs than completed races. They were in my office regularly pleading me to fix them up so they could get their training in so they could get to race day. However, after much psychoanalysis and reality talking we finally got through to some of the best athletes. Once we switched them to triathlons where they could moderate the runs and hit some alternative sports that did not play up their challenged race anatomy, they rose to the top and rarely had to hand off a race bib to a friend who was healthy.  And they are happier.  I see them far less in my office and far more at the finish lines with a huge smile.

Do some honest inventory of your body.  Sometimes a Speedo just makes sense, well, sort of. If you catch our drift.

Dr. Shawn Allen, The Gait Guys

Did you know that the EHB (extensor hallucis brevis) the topic of today’s video tutorial, originates off of the forepart of the medial aspect of calcaneus & lateral talocalcaneal ligament. It is just above the bulk origin of the EDB (extens

or digitorum brevis). It is frequently torn/strained in ankle inversion sprains and frequently goes undiagnosed. It can be torn/avulsed from the bone if the inversion sprain is focused below the lateral ankle joint. This occurs mostly when the foot is more plantarflexed before the inversion event. A foot cannot afford to have an impaired big toe ! Don’t miss this one !

Part 2 of the EHB: Bringing the Extensor Hallucis Brevis of the Foot Back to Life.

Today we show you a proprietary exercise we developed here at The Gait Guys. It was developed out of necessity for those clients who are too EHL dominant (long big toe extensor muscle) and big toe short flexor dominant (FHB). These two muscles are what we call a foot functional pair.  Big toes like these will be dysfunctional and will not be able to gain sufficient purchase on the ground to produce stability and power without impacting the joint (1st metatarsophalangeal joint).  Imbalances like these lead to altered joint loading responses and can be a possible predictor for premature damage to the joint over time. These imbalances are also what lead to injuries to the big toe, the arch and other areas of the foot. After all, when the big is weak or dysfunctional gait will be compensated.  When imbalance at this joint occurs because of EHB weakness the medial tripod anchor (the head of the 1st metatarsal) is compromised possibly transmitting stress into the foot, arch and medial stabilizers such as the tibialis posterior for example.

This exercise is to be weaned back to less and less yellow band resistance until the EHB can be engaged on its own. Then the gait retraining must begin. Simply reactivating and strengthening the skill and muscle is not enough. The pattern must be then taken to the floor and learned how to be used in the gait cycle.

Do we need to mention the critical function this muscle plays in extension of the 1st MPJ, of its importance in hallux rigidus/limitus, in bunions, hallux valgus, toe off function, arch height and function ? We hope not.

It is a process restoring gait. All too often the “Devil is in the Details”.
If you liked this video, visit our daily blog: www.thegaitguys.tumblr.com
or our website: www.thegaitguys.com
See our other free videos here on youtube on our “The Gait Guys Channel”.
Or our other videos here: http://store.payloadz.com/results/results.asp?m=80204

Shawn and Ivo
The Gait Guys

all material copyright 2012 The Gait Guys/ The Homunculus Group: all rights reserved.

Welcome to Friday Follies Folks.

A funny Fila commercial on tap for you here. Hope you have a great weekend

Ivo and Shawn

Classic Crossover Gait Case.

Here is a client with a uncompensated forefoot varus (ie: the forefoot is inverted with respect to the rearfoot) and a cross over gait, secondary to incompetence of the medial tripod of the foot (he cannot descend the head of his 1st metatarsal to form the medial tripod due to the uncompensated forefoot varus) and weak right lower abdominal external obliques which we discovered on examination (perhaps you can detect a subtle  sag of the right side during stance phase on that side).

Note how he circumducts the lower extremities around each other. This takes the cross over to another level and it can occur when a client is pronating through the medial tripod such as in this forefoot varus case (we know this from the examination, it cannot be detected for sure from the video with the foot in the shoe, that would be an assumption).

How do you fix this?

• tripod standing exercises
• core stabilization exercises with attention to the right lower oblique (see our core series available for download on Payloadz here and here
• foot manual therapy to improve motion of the 1st ray
• see our crossover gait series on youtube here: part 1, part 2, and part 3
• form running classes such as Chi Running

The Gait Guys. Bringing you the meat, without the fat.

all material copyright 2012 The Gait Guys/ The Homunculus Group: all rights reserved

READY

The Gait Guys Case of the week: What do you see?

This individual presents with Right achilles tendonitis, bilateral foot pain and a history of plantar fascitis. What do you think?

Take a look at his foot type, particularly the forefoot to rearfoot orientation. Hmmm….Asymmetrical. Notice the dropped 1^st metatarsal on the left that is not present on the right. He has a forefoot valgus on the left with a quasi flexible 1^st ray (1^st ray = medial cuneiform, 1^st metatarsal and associated phalanges) which is dropped and an uncompensated forefoot valgus on the right, with an inflexible 1^st ray.

He has bilateral external tibial torsion (which you cannot see in these pictures) right greater than left (OK, you can see that), as well as a Left anatomically short leg (tibial) of approximately 7mm.

Now look at the pedographs. BIG difference from left to right. Good tripod on right with clear markings over the calcaneus, the head of 5^th metetarsal and the head of 1^st metatarsals.  But I thought you said he had an UNCOMPENSATED forefoot valgus ?  Look at the shape of the forefoot print. It is very different from right to left. Remember, with a forefoot valgus, the medial side of the foot hits the ground before the lateral side most of the time,

How about the left? Look at all that metatarsal pressure. Looks like a loss of ankle rocker. Think that might be causing some of that left sided foot pain? Notice the print under the 1^st metatarsal is even greater; and look at all that printing of the 5^th metatarsal head. Remember, this is the shorter leg side, so this foot will have a tendency to supinate more, thus he increased pressures laterally.

Achilles tendonitis?  Stand on one leg on your foot tripod and rock between the head of your 1^st metatrsal and head of the 5^th.  Where do you feel the strain? The gastroc/soleus and peroneals. Now put all your weight on the lead of the 1^st metatarsal. What do you notice? The foot is everted. What everts the foot? The peroneals. So, if the foot is everted (like in the forefoot valgus), what muscle is left to shoulder the load? Remember also, that the gatroc/soleus group contracts from mid to late stance phase to invert the heel and assist with supination of the foot.

The Gait Guys. Your guiding light to gait literacy and competency.

Want to know more about pedographs? Get a copy of our book here.

All material copyright 2012 The Gait Guys/The Homunculus Group.

The Gait Guys Podcast #6 : S1E6

The Gait Guys Podcast #6 : S1E6

This one will get you to the show player of all of our podcasts.
http://directory.libsyn.com/shows/view/id/thegaitguys

And this link will get you a nicely laid out “show notes”.
http://thegaitguys.libsyn.com/webpage/2012/08

Show Notes: The Gait Guys Podcast, Season 1, Episode 6

1-  Cannabinoids and the Runners High
 http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=151936266&m=152175552

http://www.npr.org/blogs/health/2012/05/07/151936266/wired-to-run-runners-high-may-have-been-evolutionary-advantage

Endurance athletes sometimes say they’re “addicted” to exercise. In fact, scientists have shown that rhythmic, continuous exercise — aerobic exercise — can in fact produce narcoticlike chemicals in the body.

2-  more lectures available  on www.onlineCE.com   Go there and look up our lectures. New www.PAYLOADZ.COM lectures.
 
3- A lot of people cycle either as a less stress option to running or in conjunction with it (tri-athletes). No biomechanics-minded gait gurus are analyzing cycling posture, gait and cadence and putting it out there for us all to learn from. What can you teach us gait gurus?
Sincerely,
Ben, A lifelong student

4-   Cuboid Syndrome
Hi Gait Guys,I’m doing research on cuboid syndrome and wanted to know your thoughts on addressing the strength of the arch and how it might influence recovery.  Also, what impact would retraining/changing  the reflexive action of the of the peroneus longus may have on reducing the reoccurrence  of cuboid syndrome.  Any thoughts or feedback would be very helpful.
Thank you,Chase in Mooresville, NC

5- Part 2 on the LISA foot case , the suspect neuroma, seroma, tarsal tunnel case. We discussed her initial case in podcast 5
 DVDs , website, email,

6- Shoe talk / product talk

7-  EMAIL CASE
 Hi - I have been watching your videos for 2 years and find them very informative.  Here’s my problem:
I have had foot/ankle pain for more than 3 years.  The pain is traveling up/down my kinetic chain on the left side.  I’ve been diagnosed with:

        PTTD
        Achilles Tendinopathy
        Ankle instability
        Possible Tarsal Tunnel Syndrome
        Equinus
        Gluteal Medial Tendinopathy

I’ve seen 11 foot/ankle specialists (the BEST in Philadelphia).  I’ve seen orthopedic doctors for my glute problem.   I’ve seen 2 physiatrists to determine if this is a problem with my back.  I’ve had 4 surgical procedures on my ankle.  Had a tenotomy on my glute med tendon.  Gone thru 5 rounds of physical therapy for my foot/ankle.  4 months of therapy for my glute med tendinopathy.  I have 5 pairs of custom orthotics; 1 UCBL; 1 Arizona AFO.  Countless OTC devices.

hope you will join us for  Lorraine’s case.

8- Discussion on who controls individual cell control/coordination (and email from Jesse in Luxembourg). We dicuss several things including the effects of neuropepties.

Gait analysis case study: A runner with achilles pain.

Please watch this clip a few times and pay special attention to the lateral views. This client had persistent Left Achilles pain which has improved with care and foot exercise, but is developing Left soleus pain.

Lets try something new. Lets test your gait auditory skills. Run the video and listen. Listen to the foot falls. Can you hear one foot slap harder than the other on strike ? Can you hear the right forefoot slap harder than the left ?  It is there, it is subtle, keep re-running the video until you are convinced. The left foot just lands softer. Take your gait assessment to the next level, listen to your clients gait. Use all your senses. This finding should ask you to assess the anterior compartment of the right lower limb (tibialis anterior and toe extensors).  And if they are not weak then you should begin to ask yourself why they may be loading the right foot abruptly. Perhaps it is because they are departing off of the left prematurely, in this case possibly because of a short leg that has a shorter stride length. 

From clinical examination he has a 10mm anatomically short left leg (not worn in these videos), bilateral uncompensated forefoot varus deformities, bilateral internal tibial torsion and tibial varum ( 10 degrees Left, less on Right).

Exam reveals:

• weakness of the fourth and fifth lumbricals (small intrinsic foot muscles to the 4th and 5th toes) left greater than right. This will afford some lateral foot weakness during stance phase.
• weakness of all long toe extensors bilaterally (their weakness will allow dominance of toe flexors)
• weakness of the extensor hallucis brevis bilaterally
• weak left iliacus (a hip flexor muscle)
• slight pelvic shift to the left when testing the right abdominal external obliques
• weakness bilaterally of the quadratus femoris (a deep hip stabilizing muscle)
• weakness superior and inferior gemelli left, superior right (again, more deep hip stabilzer muscles)

So, what gives?

Did you pick up the nice ankle rocker present?  There is good ankle dorsiflexion. What is missing? Look carefully at the hip (in the lateral/ side video views). There is not much hip extension going on there. So, the question is how does he get the ankle rocker he is achieving ? Look at the knees. He is getting it through knee flexion! It would be more effective and economical to achieve this kind of ankle dorsiflexion from a nice hip extension and utilize the glutes for all they can provide.

Remember, he has an uncompensated forefoot varus. This means he has trouble making the medial part of his foot tripod get to the ground. This means that the foot tripod will be challenged when the foot is grounded and when combined with the clinical foot weaknesses we noted on examination this is a foregone conclusion.  With all that knee flexion which muscle will be called upon to control the foot? The soleus  (which DOES NOT cross the knee).

The answer to helping this chap ? Achieve more hip extension! How? Gluteal activation through some means (acupuncuture, dry needling, MAT, K tape, rehab and motor skill patterns etc), conscious dorsiflexion of the toes, conscious activation of the glutes and anything else you might find useful from your skill set. Gain more from the hips and  you will gain more control from that area and ask for the soleus to do just its small job.

Subtle? Maybe. Now that you know what you are looking at it is pretty easy isn’t it ? It’s like the “invisible gorilla in the room” we talked about in our previous Podcast.  Unless someone brings it to your attention your focus will be on what you are accustomed to looking for and what you have seen before. Sometimes we just need someone to direct our vision.  There is a difference between seeing something and recognizing something. In order to recognize something you have to go beyond seeing it, the brain must be engaged to process the vision.

The Gait Guys. Let us be your Peter Frampton and “Show you the Way” : )

Big Toe Exercise: Regaining Control of the Extensor Hallucis Brevis.

Exercise Anyone?

Here Dr Ivo briefly talks about the 1st part of the famous “Extensor Hallucis Brevis” or “EHB” exercise (Part 1) with a patient. More of this to follow after we launch the shoe program (yes, we know, it has been a long time coming. We would have had it out earlier had our site not been hacked). We plan on a foot muscle testing and Exercise DVD this winter.

Special thanks to our patient or letting us use the footage, and his wife to film the clip!

Ivo and Shawn

Welcome to Friday folks! Here is a funny commercial that lets us know why some people run : )

See you next week

Ivo and Shawn

Proprioceptive effects of aging: It’s all in the details

Here is a brief video of a gentleman that presented to us with neck discomfort and limited range of motion. Step through it several times before proceeding.

Hopefully, you noted the following:

Increased arm swing on the right (or, decreased on Left)

Pelvic shift to the left on Left stance phase

Decreased step length on the left

Hip hike on Left during Right stance phase

The patient does not have a leg length deficiency.

We remember that there are 3 systems that keep us upright in the gravitational plane:

1. vision

2. vestibular system

3. proprioceptive system

We also remember that as one of these systems become impaired, the others will usually increase their function to help maintain homeostasis. All these systems are known to decline in function with aging. So we have 3 systems breaking down simultaneously.

Did you also note the head forward posture, to move the center of gravity forward? How about the subtle head tilt to the right and “bobble” right and left? Motions which have to do with the head are functions of the vestibular system. He is attempting to increase the input to these areas (by exaggerating movements) to increase input.

How about the glasses? Presbyopia (hardening of the lens) makes it more difficult to focus. Movement (detected largely by rods in the eyes have a much higher density than cones, which are for visual acuity). By moving the head, he provides more input to the visual (and thus nervous system)

Amplified extremity movements provide greater input to the proprioceptive system (muscle spindles and golgi tendon organs (GTO’s), as well as joint mechanoreceptors).

Think of the cortical implications (and effects on the cerebellum, the queen of motor activity and important component for learning).  You are witnessing the cognitive effects of aging playing out on the ability to ambulate and its effect on gait.

 So what do we do?

Improve quality of joint motion, whether that is mobilization or manual methods to improve motion where motion is lost. Perhaps acupuncture to help establish homeostasis and improve muscular function. There are many options.

Postural advice and exercises

Core work

Proprioceptive exercises (like head repositioning accuracy, heel to toe and heel to shin)

Gait retraining

 You get the idea. Providing some of that increased input for him and helping the system to better process the information will be the key to improving his function and helping to counteract and maybe slow the effects of aging on the locomotor system.

We are the Gait Guys. Two geeks, giving you the info so we can all make a difference, every day

Special thanks to RM, who allowed us to use this video for this discussion.

Copyright 2012 , The Gait Guys/Homunculus Group

Materials and content cannot be used, copied or distributed without proper author credit /reference or without prior written consent.

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Doing Squats, Lunges as well as Walking and Running using the Big Toe Ineffectively.

This is an important video.
Here in the initial frames you should see that this fella is using his big toe muscles incorrectly.  There is a long flexor and short flexor of the big toe, just like there is a long and short extensor muscle.
You should clearly see that the big toe sort of curls upwards in the early frames before he is coached to correct in the later frames. In these early frames his medial tripod stabilizing strategy is to use the short toe flexor (FHB - flexor halucis brevis) and more long toe extensor (EHL- extensor hallucis longus). This is what is giving the upward curl presentation. The problem with this strategy is that it is ineffective and uneconomical. It does not help to engage the medial tripod of the foot (ie. keep the big toe knuckle, the metatarsal head, down and purchased well on the ground) nor does it effectively assist the arch posturing of the foot.

You can see at the 17 second mark, with our coaching, he begins to learn and teach himself about the differing uses of the long and short hallux flexors. You can see him over correct from too much short flexor (FHB) into too much long flexor (FHL) where he claws the toe into the ground. You can then see in subsequent frames that he begins to play with the relationship to find a balance between the two. Then, you see that he loses the purchase of the medial tripod at 21 seconds where you see our hand enter the picture and queue the metatarsal head/knuckle down. When done correctly a double arch will form, one in the longitudinal arch of the foot and a second one just under the big toe. This big toe arch should be subtle but visible. If the client collapses this “toe arch” as we call it, they are driving the toe down with abundant short flexor (FHB). This can be easily seen on a pedograph mapping or foot scan represented by too much ink or pressure mapping at the proximal toe and little to no pressure distally through the pad of the big toe. These folks will struggle with adequate anchoring and purchase of the medial tripod (the 1st metatarsal head) and will challenge the longitudinal arch of the foot and thus the tibialis posterior as well as other structures. They can pronate too much and challenge the ankle mortise dorsiflexion range.  Rear foot eversion can become abundant as well. 

Balance of the long and short flexors of the big toe in concert with the long and short extensors. Too much short flexor usually couples with too much long toe extensor (hence the upward curl of the toe as we saw in the early video frames). Too much long flexor couples with too much short extensor, forming a claw-hammer toe presentation. There is a science to this. Balance must be achieved.  Just running barefoot or in minimalism does not guarantee a stronger foot or better form. It may in fact get you a more strength in a bad pattern (as you saw in the first few seconds of the video) which leads to injury  and it may get you stronger into many bad running and walking forms, both at the foot and higher up into your body.

There is more to this game than shoes and random exercises. This is a specific science, if you care to look beyond the basics that allow alot of injuries.  This is how detailed our game is with our athletes and patients, because it is the way the game should be played.

The devil is in the details
Shawn and Ivo………Uber gait geeks.

The Cross Over Running Technique (again):  A New Quick Case Study

Walk on a piece of string or along a seam in the concrete or walk on the lane dividing lines on your local high school or college track.  What happens ?  If you walk on a single line you will find yourself more unstable as compared to walking with a foot fall directly under your hips and knees the way it is supposed to occur.  The limbs are a pendulum and economy and biomechanical efficiency as well as injury reduction will occur when the parts operate in the most effective manner.

We have all of our cross over runners, as you see her doing in the first half of this video before she corrects to anti-cross over (ie. natural),  first walk on a line. In our case we use the metal drainage grate outside our office that you see in the video for just that purpose, they walk the grate. Then they run the grate.  We ask them to feel how unstable they are in the frontal plane walking the grate.  Then we have them walk with their feet only touching the outer edges of the grate, now not crossing over.  They can feel the difference, the increased stability.  They all say it is easier to walk with the thighs, knees and feet all barely scuffing past one another but after they feel the other most will comment that they can see and feel how lazy their gait and running gait have become. They can feel the better posture, more gluteals and more power that an anti-cross over gait affords them. Then they run the grate again. Then they run the edges of the grate.  You see this skill builder in the video above.

In this video clip, after 60 seconds of coaching, this top NCAA distance track athlete (often injured) was able to make the change immediately. You can see after just a few strides the immediate and dramatic change in her gait.  We then had her drift back and forth between lazy cross over and the corrected anti-cross over gait.  We do this so that on her long runs, when she notices the inside shoes scuff past one another, when they notice the feet begin to run on a line, when the thighs begin brushing past each other that she can immediately make the correction. It will happen often during the beginning stages of developing the new neurologic skill pattern. Motor pattern learning takes up to 12 weeks before the neuroplasticity becomes more worthy of the dominant pattern of choice.

We have all of our athletes head over to the oval track and run not in the lanes, but on the line. To be precise, they run with their feet on either side of the line, making sure they have that visual feedback for the correction. They run over the line. We drove past a local high school the other day and saw the entire girls cross country team on the track running not in the lanes, but over the lines.  We smiled big, and long. We know the coach, he follows our stuff, and he will prevent so many injuries this year in his runners.  They have a 15 minute pre-run warm up and skill building for their runners.  They will be competitive at the State level once again because they will show up with everyone healthy and free of injury, we can only hope.  They will have a better chance than others who keep doing what they did last year, and the year before that, and the year before that.

If you are doing what you did last year in your training, expect last years results.
Have you watched the cross over series we put together on youtube ? The 3 part video series ?  It is worth your time to watch it.

Here are the links:
Part 1: http://youtu.be/LG-xLi2m5Rc
Part 2: http://youtu.be/WptxNrj2gCo
Part 3: http://youtu.be/oJ6ewQ8YUAA

Shawn and Ivo……… still pounding the floor on eradicating the modern day plague in running…… The Cross Over Gait.  You don’t want to catch this illness !

Slow Your Gait & Shorten Your Stride and Your Brain May Slow

Slow Your Gait & Shorten Your Stride and Your Brain May Slow

Well, you have heard it here before, the receptors drive the brain, and here is another study that backs this up. Remember that receptors, which include not only joint mechanoreceptors, but also muscle mechanoreceptors (muscle spindles and golgi tendon organs) and tactile receptors in the skin (Merkels discs, paccinian corpuscles, etc) feed into the brain cortex (via the dorsal column system) and the cerebellum (via the spino cerebellar system). This afferent (sensory information) input is important for proper coordination as well as cognition and learning.

Remember, your brain is always remodeling. Here, the old adage “if you don’t use it, you will lose it” applies. More input = more synapses = more neuronal growth. So less motion = less input=synaptic atrophy = fewer connections and thus slower brain function.

Increased speed and length of stride stretches receptors more; decreased speed and shorter stride lengths decrease receptor activation. So, take big steps quickly, or you may turn into a zombie ! There is a reason why they walk slowly !

In July 2012 at the Alzheimer’s Association International Conference in Vancouver, British Columbia Mayo Clinic researchers presented research indicating that walking problems such as a slow gait and short stride are associated with an increased risk of cognitive decline. Computer assessed gait parameters (stride length, cadence and velocity) in study participants at two or more visits roughly 15 months apart. They revealed that participants with lower cadence, velocity and length of stride experienced significantly larger declines in global cognition, memory and executive function.

references:

http://www.aansneurosurgeon.org/2012/08/02/slow-gait-short-stride-linked-to-increased-risk-of-cognitive-decline/

http://www.newswise.com/articles/view/591437/?sc=dwhn

Welcome to Friday Follies

Here is a funny sketchers commercial to ease you into the weekend. Have a good one!

Ivo and Shawn