Podcast 167: Is symmetry important for biomechanics and energy utilization?

Podcast 167: Is symmetry important for biomechanics and energy utilization? Plus, things that mimic plantar fasciitis. Including trigger points you never thought might be implicated.

This podcast is way more interesting than the title !

join us each month on the Masterclass in Gait

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Join at the $40 monthly level and get the masterclass each month, bonus material and the detailed monthly content we only share on Patreon.

The Masterclass is a formal LIVE presentation of slides, videos, demos, deep dives on topics you will not hear anywhere but here ! We hit the gait, biomechanics, neurology and orthopedics of all of the gait topics we present. This is not for the weak and timid, this is the deep dive you have been waiting for. Join us while we turn our normal 50 minute presentations into 3.5 hours on a regular basis ! The 40$ Patreon level will give you the Masterclass and also get you the $20, $10, and 5$ Patreon level content. What a deal ! It will not be here forever so lock in now !

Or, you can get less for your money (why would you do that?) and just buy our Monthly $40 Masterclass at our VIMEO on demand page: https://vimeo.com/ondemand/thegaitmasterclass


Links to find the podcast:
Look for us on Apple Podcasts, Google Play, Podbean, PlayerFM, RADIO and more.
Just Google "the gait guys podcast".
_______________________________________________________________________________
Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).

Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:
Apple podcasts:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

Google Play:

https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

Links for today's show:

https://traffic.libsyn.com/secure/thegaitguys/167_Dec_4_2020_.mp3

https://thegaitguys.libsyn.com/is-symmetry-important-for-biomechanics-and-energy-utilization

https://directory.libsyn.com/episode/index/id/17322929

Association between trigger points in hamstring, posterior leg, foot muscles and plantar fasciopathy: A cross- sectional study
J Bodyw Mov Ther. 2020 Oct;24(4):373-378. doi: 10.1016/j.jbmt.2020.07.018. Epub 2020 Aug 7. Ravindra C Thummar 1 , Sannasi Rajaseker 2 , Ranjith Anumasa 3


https://physoc.onlinelibrary.wiley.com/doi/abs/10.1113/JP280509
Journal of Physiology.
The human preference for symmetric walking often disappears when one leg is constrained
Michael G. Browne, Cameron S. Smock, Ryan T. Roemmich, Nov 24, 2020

Podcast 166: Senile Degeneration of afferent mechanoreceptors.

Podcast 166: Senile Degeneration of afferent mechanoreceptors.

This podcast is way more interesting than the title !

join us each month on the Masterclass in Gait

https://www.patreon.com/thegaitguys

Join at the $40 monthly level and get the masterclass each month, bonus material and the detailed monthly content we only share on Patreon.

The Masterclass is a formal LIVE presentation of slides, videos, demos, deep dives on topics you will not hear anywhere but here ! We hit the gait, biomechanics, neurology and orthopedics of all of the gait topics we present. This is not for the weak and timid, this is the deep dive you have been waiting for. Join us while we turn our normal 50 minute presentations into 3.5 hours on a regular basis ! The 40$ Patreon level will give you the Masterclass and also get you the $20, $10, and 5$ Patreon level content. What a deal ! It will not be here forever so lock in now !

Or, you can get less for your money (why would you do that?) and just buy our Monthly $40 Masterclass at our VIMEO on demand page: https://vimeo.com/ondemand/thegaitmasterclass


Links to find the podcast:
Look for us on Apple Podcasts, Google Play, Podbean, PlayerFM, RADIO and more.
Just Google "the gait guys podcast".
_______________________________________________________________________________
Our Websites:
www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
shawnallen.net

Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).

Our podcast is on iTunes and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:
Apple podcasts:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2

Google Play:

https://play.google.com/music/m/Icdfyphojzy3drj2tsxaxuadiue?t=The_Gait_Guys_Podcast

https://traffic.libsyn.com/secure/thegaitguys/pod_166final_Dec11_launch_-_121120_2.34_PM.mp3

https://thegaitguys.libsyn.com/podcast-166-senile-degeneration-of-afferent-mechanoreceptors

https://directory.libsyn.com/episode/index/id/17160167


Eight-Week Inspiratory Muscle Training Alters Electromyography Activity of the Ankle Muscles During Overhead and Single-Leg Squats: A Randomized Controlled Trial

J Appl Biomech. 2020 Oct 12;1-8. doi: 10.1123/jab.2019-0315. Online ahead of print.
Behnam Gholami-Borujeni 1 , Ali Yalfani 1 , Leila Ahmadnezhad 1

Why Don't Runners' Knees Fail More Often?

Biology suggests that decades of running should invariably blow out your knees. Scientists are trying to understand why that doesn’t happen.

-suggests that 98% of knees should fail after three decades of running. But they don't, and the big question is why not. One possibility: contrary to the usual view, cartilage adapts to repeated loading.
https://www.outsideonline.com/2417356/runners-knee-cartilage-study-2020?utm_medium=social&utm_source=twitter&utm_campaign=onsiteshare

Lengthening of the gastrocnemius-soleus complex: an anatomical and biomechanical study in human cadavers
Gregory B Firth 1 , Michael McMullan, Terence Chin, Francis Ma, Paulo Selber, Norman Eizenberg, Rory Wolfe, H Kerr Graham. JBJS Am.: 2013 Aug 21;95(16):1489-96

GHS: Generalized Hypermobility Syndrome

GHS: Generalized Hypermobility Syndrome

We have all seen these types of clients/patients. They have joints that have more than ample full range. It is easy for them to hyperextend their elbows and knees. They can fold over and touch their toes, everything seems lax and flexible. What they need is help gaining more control of their joints. But what about their gait ? Albeit a focal study, finally someone has looked at how these people interface the ground,

The forefoot region received higher loading in GHS clients.

So what could this mean? Does it mean they have challenges transitioning from rearfoot to forefoot? Does it mean their center of pressure is more foreward biased ? Does it mean they have to impart heavier loads through the forefoot during gait to feel stable? Are they premature heel raisers thus showing the forefoot bias increase? There are many questions here, too broad for this study, but they are the keys to understanding how the GHS body interprets movement. Regardless, it is highly suspect that these clients dominate their gait with the calf muscle complex doing plenty of extra work. We suspect they will be toe clenchers/grippers ( ie, have increased toe flexor dominance) and this can have long term impact on things like metatarsal loads, neuroma formation, bunions, lumbrical weakness, fat pad displacement, hammer toes and many other related issues that occur with premature or excessive forefoot loading. They may even have a little of that vertical bouncy gait we often discuss. We will keep our eyes open for this stuff and keep you in the loop.

J Back Musculoskelet Rehabil. 2018 Nov 2. doi: 10.3233/BMR-170973. [Epub ahead of print]

Generalized hypermobility syndrome (GHS) alters dynamic plantar pressure characteristics.

Simsek IE1, Elvan A1, Selmani M2, Cakiroglu MA2, Kirmizi M2, Angin S1, Bayraktar BA3.
We have all seen these types of clients/patients. They have joints that have more than ample full range. It is easy for them to hyperextend their elbows and knees. They can fold over and touch their toes, everything seems lax and flexible. What they need is help gaining more control of their joints. But what about their gait ? Albeit a focal study, finally someone has looked at how these people interface the ground,
The forefoot region received higher loading in GHS clients.
So what could this mean? Does it mean they have challenges transitioning from rearfoot to forefoot? Does it mean their center of pressure is more foreward biased ? Does it mean they have to impart heavier loads through the forefoot during gait to feel stable? Are they premature heel raisers thus showing the forefoot bias increase? There are many questions here, too broad for this study, but they are the keys to understanding how the GHS body interprets movement. Regardless, it is highly suspect that these clients dominate their gait with the calf muscle complex doing plenty of extra work. We suspect they will be toe clenchers/grippers ( ie, have increased toe flexor dominance) and this can have long term impact on things like metatarsal loads, neuroma formation, bunions, lumbrical weakness, fat pad displacement, hammer toes and many other related issues that occur with premature or excessive forefoot loading. They may even have a little of that vertical bouncy gait we often discuss. We will keep our eyes open for this stuff and keep you in the loop.

J Back Musculoskelet Rehabil. 2018 Nov 2. doi: 10.3233/BMR-170973. [Epub ahead of print]
Generalized hypermobility syndrome (GHS) alters dynamic plantar pressure characteristics.
Simsek IE1, Elvan A1, Selmani M2, Cakiroglu MA2, Kirmizi M2, Angin S1, Bayraktar BA3.

The loads are going to go somewhere.

You cannot change one thing, and not expect the other parts to change, to have to adapt, and possibly those parts to complain at some point.

The loads are going to go somewhere.

Too much pronation means the arch may be reduced in height, but it also means that the first ray complex (the 1-2 metatarsals essentially) is dorsiflexing more than normal. This means they will not likely get to their adequate plantarflexion by the time the foot is ready to heel rise and toe off at supination. In other words, if you have pronated and dorsiflexed too long and too much, you will eat up the time you needed to plantarflex and supinate.

This means that "Increased foot pronation may compromise ankle plantarflexion moment during the stance phase of gait, which may overload knee and hip."-Resende et al

If you cannot plantarflex the foot-ankle complex sufficiently, or in a timely manner, you should understand that you are carrying this fault forward while moving into heel rise during the forefoot rocker stance phase of gait, and you are doing it over a less stable, less rigid foot-ankle complex because it is still in relative pronation. This means you are placing higher propulsive loads over an unprepared ankle-foot complex. This means different/altered posterior compartment function, which can mean altered knee and hip function. Sagittal plane function, to name the most obvious, will have to create and endure compensatory loads. Sure, they may be fine for a time, but perhaps there will be a cost over time. Now, many might say, "if it is not a problem now, it is not a problem", let them build robustness on their chosen pattern; that can be very hopeful and shortsighted thinking in our opinion. Why not change things that are obviously aberrant and build robustness on a pattern and correction that is suspected to be more sound? This can be a cyclical argument that no one wins, EVER, we all see it all the time. After all, the arguments become silly after time, and we resist our own silly comments like "well, why change the oil in your car right now, nothing bad is happening at this time. Or, well that front right tire, though bald and nearly flat, is still rolling along so why bother changing it out?" But that stuff gets no one anywhere, other than pissed off, so we hold back. The debate never gets furthered along, because no one can see the future.

So, we will leave this rant with this thought, we cannot change one thing, and not expect the other parts to change, have to adapt. And adaptation can be both good OR bad. Or maybe we should say, good AND bad.

The loads are going to go somewhere. Lets leave it at that.

photo: credit pixabay.com

Gait Posture. 2018 Oct 23;68:130-135. doi: 10.1016/j.gaitpost.2018.10.025. [Epub ahead of print]

Effects of foot pronation on the lower limb sagittal plane biomechanics during gait.

Resende RA1, Pinheiro LSP2, Ocarino JM3.

Fatigue matters. Why a quick treadmill analysis of someone's gait will lie to you.

This is why i think gait analysis, on a treadmill with all the sensors, the visual captures , there are so many lies and fake outs.

Driving to work today and I saw this 40 something lady running. It just might have been the most tortured running i have seen in ages. It made me wonder, when we see our clients at the office and we ask them to run, they are typically in a fresh state, they're going to give us their best running, they are naturally going to put out their best for us, even if we ask them to "just run".

The truth is, they haven't been out there for 10-15 miles slogging it out in the heat and the pain and in the dysfunction. They haven't been out in the elements slowly fatiguing stabilizers, slowly layering neuro-protective tightness and strategies to offset the fatiguing structures. Even if that lady came in to see me tomorrow, i am not going to see what i saw in here on the side of the road. The clues i might see will be the muscular inhibition, the neuro-protective tightness, the compensations, the things on the hands on examination. This is why gait analysis has to have a hands on examination. And if i put her through a screening method, i am going to see her strategies in the screen to get around all that i mentioned above.

This is why i think gait analysis, on a treadmill with all the sensors, the visual captures , there are so many lies and fake outs. That process has significant limitations. Do not get me wrong, everything has value, but do we know what that value is, and what the lies are?

I think my question for my clients needs to be, be honest with me how ugly does your run get in the later miles when you're in pain? But then again, that is an impossible question isn't it !? Self awareness has its limitations. After all, we are human.

When asked to run at my doctors office, i am still gonna put on my best run for them. I will hide my flaws, my weaknesses, my tightness, my soreness, and give them the best run i have. The game is on them. Lets see how good they are.

Good luck today comrades, see what you can find and solve in all those who come begging for help, yet doing their best to hide their worst.

We often say that arm swing should not be coached early on.

From Canton: "Relating shoulder muscle activities to upper limb kinematics suggested these muscles mainly acted eccentrically, providing evidence that passive elements are a significant factor in arm swing control. However, the conserved muscle activity patterns and temporal coupling of limb movements when pelvis motion was reduced are suggestive of an underlying active maintenance of the locomotor pattern via linked upper and lower limb neural networks."

Here are some of our deeper thoughts as to why we stand firm on this, not coaching arm swing early on.
Look at this photo, there are lots of different arm swings in every group of runners. These differences are not choices for the most part, the arms are just doing what they must, based off of many parameters in a runner, things that are working right, and not so right.
To be more clear, aberrant arm swing is often a compensation to cope with other flawed mechanics elsewhere, things such as a weak core on one side, loss of thoracic lateral bend or rotation, altered limb stability patterns, hip stability challenges etc. Thus, it is almost foolish to change an arm swing that you do not like in you or your client, because often that is not the problem. Arm swing is a power producer, but it is also a huge ballast like appendage that is used to help maintain balance changes. So, look for all possible causes of what you so, that which looked aberrant, and fix those mechanical flaws first.
From Canton: "Current research has yet to determine how passive dynamics and active neural control contribute to upper limb swing during human locomotion. The present study aimed to investigate these contributions by restricting pelvis motion during walking, thereby altering the upward energy transfer from the swinging lower limbs."
Here at The Gait Guys we have discussed for years the principles of the antiphasic nature between the pelvis "girdle" and shoulder "girdles" in that they should move in opposite rotational planes, and yet be equal in their amplitude, and that when this occurs, arm and leg swings are mostly symmetrical, equal in amplitude and symmetrical in their swing planes. This study found that when the pelvis was restricted, that the ranges of motion of the shoulder and trunk, as well as the vertical trunk center of mass movement, were also reduced, as we have said many times in our writings and in quoting the research over the years. This study also supported our long standing position that arm swing is more of a passive phenomenon, yet with complex coupling of the upper and lower limb neural networks, but also strongly taking its queues from the trunk, pelvis and leg swing.
One final thought from us, coaches, especially sprint coaches, are still going to coach arm swing and force arm swing drills, the ones they want to see, to achieve more power. . . . sigh (we get it, speed is important, but there could be a cost to making the body do what is it naturally struggling to do cleanly). So, if you are going to employ these arm swing sprint drills, get someone to fix the aberrant patterns first, if you want to see fewer injuries. Otherwise, don't be surprised if you see in your runners more thoracic lean to one side, a head tilt to one side, athletes complaining of mid or low back or neck pain, tightness, shoulder pain and the list goes on. Forcing your desired coached arm swing pattern on a clients already compensated physiology may have some unwanted costs.
-Dr. Allen (of the gait guys)

From the -Canton and MacLellan paper:
"Relating shoulder muscle activities to upper limb kinematics suggested these muscles mainly acted eccentrically, providing evidence that passive elements are a significant factor in arm swing control. However, the conserved muscle activity patterns and temporal coupling of limb movements when pelvis motion was reduced are suggestive of an underlying active maintenance of the locomotor pattern via linked upper and lower limb neural networks."
Active and passive contributions to arm swing: Implications of the restriction of pelvis motion during human locomotion.Canton S1, MacLellan MJ2. Hum Mov Sci. 2018 Feb;57:314-323. doi: 10.1016/j.humov.2017.09.009. Epub 2017 Sep 25.

What do the hip flexors have to do with the knee extensors ?

What do the hip flexors have to do with the knee extensors ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment."

This is just a small example of how I approach a client through small assessment window.

As best as I am able, knowing the absolute limitations of a supine examinations translation to vertical loading, I will approach a client's ability to stabilize in all 3 planes of movement. Today, i will micro-dissect a thought process.

The straight leg resistance test (SLR):

just a few incomplete thoughts on a SAGITTAL perspective (so as to avoid writing a book).

I will do it looking at **pelvis posture (anterior, posterior, oblique), lumbar spine posture (incr/decr lordosis), if they can keep their knee locked in a position, does the pelvis rotate, do they want to deviate into internal or external rotation at the hip, do they plantar or dorsiflex their ankle or toes. Lots to see here in how a client will recruit, and this is just a small snapshot of things they might do. Yes, head position, arm position were left out , again, to avoid a longer post today.

I will add consistent (as best as possible) resistance in the SLR test , with full locked knee, at hip 30, 45 and then full straight leg SLR (at the client's hamstring tension limit), then again at 45 degree knee lock with partial hip flexion, 90 degree hip and knee. I am changing loading vectors frequently to see if their is a directional loading failure. I am looking for their ability to provide ample resistance, and how they might cheat (see above).

But here is how my mind works through the test on the most basic level, which will give me insight on the above cheats** the client may employ.

* In the MOST SIMPLEST thought of the assessment, can they EFFECTIVELY stabilize the pelvis to the lumbar spine, can they stabilize the femur into the pelvis, can they stabilize the tibia onto the femur? It is how they choose to engage the system that matters, and that might be partly why their "Screen" shows up shoddy and may be a window into their pain.

The question is, if they fail, where are they failing and what tissues are overburdened or over protecting ? Where is the load, and where NOT is the load, going ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment. This is how you need to be thinking when you perform many of the mostly useless orthopedic tests in the textbooks.

This is key,

a SLR screen will not show you any of this, it will just show you their range of motion, nothing more, not how they did it, what parts worked harder than other parts, and which parts are weak, injured or inhibited, for example. It is not what a client does, it is how they go about it that has the most value to you in helping them.

Today's article below is what spurred my rant today. It gives light that most already know, that everything is connected. And perhaps we can translate it into deeper thoughts for our clients, namely, what part is not doing its job, and where are they not connecting the parts, and where are they putting the loads ?

From the Ema study:

"Our findings indicate that hip flexion training results in substantial neuromuscular adaptations during knee extensions similar to those induced by knee extension training."-Ema et al.

We need a stable and strong core-spine-pelvis connection to display powerful knee extension, and, we need a stable and strong femur-pelvis connection as well. So, where is your client doing more or less of the work, and is it related to their hip, low back or knee pain? Or are they tossing it into the ankle perhaps? This is the beauty of the game we all play every day, if we are actually paying attention.

Now, remember my discussion last week about "adding strength to dysfunction" ? Where is your client going to put the load?, the answer, where they can/able. And that doesn't exactly mean where they should be putting it. Mindless prescription of corrective exercises is a real problem in my opinion.

Shawn Allen, the other gait guy.

#gait, #gaitproblems, #gaitanalysis, #correctiveexercises, #running, #hipflexors, #kneeextension, #SLR, #corestrength, #thegaitguys

Scand J Med Sci Sports. 2018 Mar;28(3):947-960. doi: 10.1111/sms.13008. Epub 2017 Nov 22.

Neuromuscular adaptations induced by adjacent joint training.

Ema R1,2, Saito I3, Akagi R1,3.

Why are you putting your internal hip rotation into your low back (pain)?

On October 12th, 2018 I wrote about utilizing the gluteals in internal hip rotation. You will have to go back and search FB for that article and video.
Assessing Internal hip rotation (in various ranges of hip flexion, extension, abduction and adduction) is a basic exam principle I examine on nearly every patient and athlete that comes to see me, regardless of their complaint. Other than breathing, walking is the next most under appreciated movement we undertake, and take for granted.

Lack of adequate internal hip rotation, in my clinical experience (20+ years), is all too often a fundamental parameter in hip, knee and low back pain. It is necessary to have unrestricted internal hip rotation during gait. Adequate internal hip rotation in the mid to late stance phases of gait is critical and is also paired with hip extension, in fact, one has to pass through adequate internal hip internal rotation to get to proper hip extension. Without one, we do not get the other. And, if the internal rotation is not imparted in the hip when the hip is supposed to be the one internally rotating, that demand is going to move up or down, caudally or rostrally, low back or knee.

Of interesting note, taking things deeper, the opposite arm is also going to go through internal rotation and extension at the same time. Impair one limb, and we can make a case, often enough, that the contralateral upper or lower limb is also challenged. This fundamental fact is one of the fascinating reasons Dr Ivo and I get so geeked out by gait and human movement. Because, it is very complicated. And if one is not looking close enough, paying enough attention with enough fundamental knowledge, things are going to get overlooked and missed when solving for "X" in a client's pain/problems/movement. Compensation will ensue, all too easily. Build strength on said compensations and we are off to the races in driving neuronal pasticity into potential asymmetries. If one is strength training a client without examining them and making specific corrections along the way, well, we reap what we sew. Ok, enough soap-boxing. -Dr. Allen

Here, don't take our word for it, . . . . .

"Correlation between Hip Rotation Range-of-Motion Impairment and Low Back Pain. A Literature Review."
Ortop Traumatol Rehabil. 2015 Oct;17(5):455-62. doi: 10.5604/15093492.1186813.
Sadeghisani M1, Manshadi FD1, Kalantari KK1, Rahimi A1, Namnik N2, Karimi MT3, Oskouei AE4.
"There is a hypothesis which suggests that a limited range of hip rotation results in compensatory lumbar spine rotation. Hence, LBP may develop as the result. This article reviews studies assessing hip rotation ROM impairment in the LBP population.
"Asymmetrical (right versus left, lead versus non-lead) and limited hip internal rotation ROM were common findings in patients with LBP. Reduced and asymmetrical total hip rotation was also observed in patients with LBP. However, none of the studies explicitly reported limited hip external rotation ROM."
CONCLUSION: "The precise assessment of hip rotation ROM, especially hip internal rotation ROM, must be included in the examination of patients with LBP symptoms."

Sacroiliac joint dysfunction and asymmetrical gait.

"Walking is often compromised in individuals with low back and hip disorders, such as sacroiliac joint dysfunction (SIJD). The disorder involves reduced coactivation of the gluteus maximus and contralateral latissimus dorsi, which together provide joint stability during walking."- Feeney et al. 2018

This study, 2018, seems to reconfirm some ideas of old, and these are muscular patterns of weakness and dysfunction we see all the time. Read on . . .

There are many ways to approach pain and dysfunction at the SI joint interval. This joint has many pain patterns, both locally and peripherally, and everybody's pain pattern is a little different.
Some lean on mobilization, some manipulation, some needling, other distraction, repeated active patient mobilizations, injections, NSAIDS, ice, and the list goes on.
However, do any of these methods truly hit at the heart of the source of the problem? Maybe.
We like to look notably at the muscular component, often first, as we fell that without balance, strength, still, endurance of the active joint stabilizers of this joint, problems can easily arise and perpetuate. This article supports this.
"Walking is often compromised in individuals with low back and hip disorders, such as sacroiliac joint dysfunction (SIJD). The disorder involves reduced coactivation of the gluteus maximus and contralateral latissimus dorsi, which together provide joint stability during walking."- Feeney et al. 2018
"EMG. Non-negative matrix factorization was used to identify patterns of EMG activity (muscle synergies). Individuals with SIJD exhibited less hip extension and lower peak vertical ground reaction forces on the affected side than the unaffected side. In contrast to controls, the SIJD group also displayed a depressed muscle synergy between gluteus maximus on the affected side and the contralateral latissimus dorsi. The results indicate that individuals with SIJD exhibited both reduced activation of gluteus maximus during a loading synergy present in walking and greater asymmetry between legs when walking compared with age-matched controls."-Feeney et al 2018
J Electromyogr Kinesiol. 2018 Sep 22;43:95-103. doi: 10.1016/j.jelekin.2018.09.009. [Epub ahead of print]
Individuals with sacroiliac joint dysfunction display asymmetrical gait and a depressed synergy between muscles providing sacroiliac joint force closure when walking.
Feeney DF1, Capobianco RA2, Montgomery JR3, Morreale J4, Grabowski AM5, Enoka RM6

Is there a linkage between the toes and ankle range of motion ? Yes.

Toe stiffness affects gait.
Awhile back we proposed a thought experiment on toe flexion and MTP joint extension and how the 2 might conflict during toe off in gait, thus producing some flexion plastic changes in the soft tissues.

We all read about ankle rocker and, when it is impaired, how it can wreak havoc on sagittal foot-ankle and gait mechanics. When ankle rocker/dorsiflexion is limited, moving our body mass forward over the foot-ankle complex can be a challenge because we have to compensate elsewhere to move forward (putting loads in places we do not want them, or working harder in areas we don't wish to be working so hard).
This study below suggests a linkage between the toes and ankle range of motion.
The study "characterized the effects of varying toe joint stiffness across a range of different ankle joint stiffness conditions, and the effects of varying toe shape on walking biomechanics. "
As we eluded to above, the study suggests "To our surprise, we found that varying toe joint stiffness affected COM Push-off dynamics during walking as much as, or in some cases even more than, varying ankle joint stiffness. Increasing toe joint stiffness increased COM Push-off work by up to 48% (6 J), and prosthetic ankle-foot Push-off work by up to 181% (12 J)."
Follow this thought experiment:
1. So, yesterday. (Oct. 15, 2018) we proposed a thought that increased toe flexion loads during stance phase loading can impact normal metatarsophalangeal (MTP) dorsiflexion. One will find it a biomechanical challenge to extend the toe when the flexors are trying to flex (yes, eccentric contractions thus come into play in this thought experiment but here today we are referring to those who over grip/clench into toe flexion for one of a myriad of mechanical reasons we will not discuss here today).
2. Note, MTP dorsiflexion (ie, extension) is what happens at the end of ankle rocker and progression thus into heel rise.
3. Heel rise encompasses posterior compartment engagement, in which studies suggest that up to 50% of propulsion comes from the calf-posterior compartment.
4. This study today said that "varying toe joint stiffness affected COM Push-off dynamics during walking as much as, or in some cases even more than, varying ankle joint stiffness. Increasing toe joint stiffness increased COM Push-off work by up to 48% (6 J), and prosthetic anklefoot Push-off work by up to 181% (12 J)."
5. So, is it possible to suggest that plastic changes in flexor tissues, capsule, and ligaments impair MTP function, thus impairing ankle rocker, thus demanding more, and premature calf complex loading work up to 48%?
Do you have a client with toe gripping and to flexion overdrive? Do they also have a loss of ankle rocker/dorsiflexion? Loss of hip extension and gluteal activity? Low back pain? After. all, we are just moving up the posterior chain, . . . we like to say,
. . . . the load has to go somewhere and the work will have to be done somewhere.
http://iopscience.iop.org/article/10.1088/1748-3190/aadf46

Leg exercise is critical to brain and nervous system health: Clues into why motorneuron diseases decline so quickly.

Leg exercise is critical to brain and nervous system health
"New research shows that using the legs, particularly in weight-bearing exercise, sends signals to the brain that are vital for the production of healthy neural cells."
This research supports what we already know, but in a new spin, that sensory input is just as important as motor output. This study gives new clues into why people with motorneuron diseases (spinalmuscular atrophy etc) decline so quickly as their movement impairment deepens.
This research might suggest that those who do not continue to weight bear load, such as bedridden or chronically ill patients and even the aging population, are at risk for faster decline. "Not only (do they) lose muscle mass, but their body chemistry is altered at the cellular level and even their nervous system is adversely impacted," says Dr. Raffaella Adami from the Università degli Studi di Milano, Italy.
"Limiting physical activity decreased the number of neural stem cells by 70 percent compared to a control group of mice, which were allowed to roam. Furthermore, both neurons and oligodendrocytes -- specialized cells that support and insulate nerve cells -- didn't fully mature when exercise was severely reduced."
"Reducing exercise also seems to impact two genes, one of which, CDK5Rap1, is very important for the health of mitochondria -- the cellular powerhouse that releases energy the body can then use. This represents another feedback loop."
Bottom line here folks, you have to move, you have to load, especially if you have a neurologic disorder and especially if you are declining in age. At the very least, throw some lunges or body weight squats into your day. Walk the stairs, don't ride the elevator. Move. Lift. Strain.
https://www.sciencedaily.com/rel.../2018/05/180523080214.htm
the gait guys, shawn & Ivo
#gait, #gaitproblems, #exercise, #legstrength, #squats, #lunges, #neuronhealth, #SMA, #neurologicdisease

How you load and off-load your forefoot bipod matters.

If you are a sprinter, how you load the forefoot bipod might be a variable for speed or injury. Tendons can change their cross sectional area, if you load them, but they don't change, if you don't.
Of course this article is not exclusive for sprinters, it pertains to any running sport, even endurance.
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. Forefoot types will play into the loading choice, and unequal strength of the medial or lateral calf compartment will also play into the loading choice made. Where do you need to put your strength ? And is the forefoot competent to take that loading challenge ? Meaning, do they have a forefoot valgus? A forefoot supinatus ? These things matter. If you are a sprinter, how you load the forefoot bipod might be a variable of foot type, asymmetrical posterior compartment strength, or foot strike pattern in the frontal plane (search our blog for cross over gait and glute medius targeting strategies for step width) ,or a combination of several or all of the above. These things matter, and why and where you put your strength matters, if you are even aware of where and how you are putting the loads, and why of course. Of course, then there are people like the recent Outside online article that says how you foot strike doesn’t matter, but it does matter. But of course, if you do not know the things we have just mentioned, it is easy to write such an article.
Isometrics are useful, they have their place. In a recent podcast we discussed the place and time to use isometrics, isotonics, eccentrics and concentrics.
One of the goals in a tendinopathy 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.
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. Jeam Marcel Geremia, Bruno Manfredini Baroni, Maarten Frank Bobbert, Rodrigo Rico Bini, Fabio Juner Lanferdini, Marco Aurélio Vaz
European Journal of Applied Physiology
August 2018, Volume 118, Issue 8, pp 1725–1736

Podcast 165: Chronic ankle problems: A long form discussion on functional neurology and biomechanics.

Chronic Ankle Problems: Neurologic effects in functional ankle instability,

Join at the $40 monthly level and get the masterclass each month, bonus material and the detailed monthly content we only share on Patreon.The Masterclass is a formal LIVE presentation of slides, videos, demos, deep dives on topics you will not hear anywhere but here ! We hit the gait, biomechanics, neurology and orthopedics of all of the gait topics we present. This is not for the weak and timid, this is the deep dive you have been waiting for. Join us while we turn our normal 50 minute presentations into 3.5 hours on a regular basis ! The 40$ Patreon level will give you the Masterclass and also get you the $20, $10, and 5$ Patreon level content. What a deal ! It will not be here forever so lock in now !

Or, you can get less for your money (why would you do that?) and just buy our Monthly $40 Masterclass at our VIMEO on demand page: https://vimeo.com/ondemand/thegaitmasterclass


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Hallux Limitus, anyone?

-This woman presented to our office this morning with a capsular interposition procedure that didn’t go so well (placing material between the distal first Ray and first phalanx to create cushioning and increased hallux dorsiflexion). 

-She has opted for conservative treatment for the time being. We are working on decreasing inflammation to see if we can increase plantar flexion of the distal aspect of the first Ray. She currently has 0° in her shoes and 5° when we planter flex the distal first. 

-Exercises included the lift/spread/reach exercise, short foot exercise, toe waving and one leg standing. 

-We will keep you posted. 

-Look for her x-rays tomorrow

#FootPain #Hallux#halluxlimitus #halluxrigidus #1stmtp #1stmetatarsalphalangealjoint #Gait #ClinicalEvaluation

Toe walking

They usually occur in 3’s... sometimes 4’s

This 12 year old obligate toewalker was brought to our office by his mom for an evaluation. Many times with neurological issues people will have concomitant musculoskeletal abnormalities. It probably has something to do with chromosome 6...

Here we explain three common congenital abnormalities occurring together

#gait #gaitevaluation #internaltibialtorsion #femoralretroversion #femoralretrotorsion #forefootadductus #metatarsusadductus #clinicalexam 

Bilateral femoral retro torsion

It’s difficult to see from the angle of the camera that this patient has bilateral femoral retro torsion. It’s pretty obvious he has a difficult time balancing on one leg.  Both of his knees point to the outside when he standing straight. He also has bilateral internal tibial torsion so he needs to turn his feet out to have a normal progression angle for gait.

Notice when he does the one leg standing test how much he has to hike his hips, particularly the right hip when he is weight-bearing on the left side. Also note the position of the knee of the weight bearing side. “Knees pointing out”  is often a telltale sign of femoral retro torsion which often occurs concurrently with internal tibial torsion. This patient also has a Forefoot adductus.

The strategy is he has to get his weight over his hip and it’s very difficult when it has to be externally rotated. Rotate your right foot out and balance on your right leg trying not to lean your torso over the hip and you’ll see what we’re talking about

#gait #gaitexam #internaltibialtorion #femoralretrotorsion #femoralretroversion #forefootadductus #clinicalexam

Flip flops

Flip-flop mechanics are different…

Wearing flip-flops, or open back footwear, changes how we walk. There is increased long flexor tone, often an increased ankle dorsiflexion angle during swing phase, often times increased knee flexion among many other things. The biggest problem is the loss of ankle rocker…

Want to know more? Join us on our monthly “third Wednesdays“ online seminar: biomechanics 329 on onlineCE.com, Tomorrow, September 16 at six mountain time

#flipflops #openbackfootwear #anklerocker #flexortone #gait #gaitanalysis ##thegaitguys 

Leg length discrepancy

Badda Bing Badda Boom 

As you can see, this gal has an anatomical leg length discrepancy on the left side which is tibial. Can you see the other finding?

Look carefully both of her feet. Can you see the bunion on the left but not on the right? This is a common finding on the shorter leg side of a true, anatomical leg length discrepancy it. Because of the leg length discrepancy, that foot is often in supination and the head of the first ray does not make it to the ground thus the pull of the adductor hallucis muscle pulls the great toe west.

Look for bunions on the short leg side of true, anatomical leg length discrepancies.

#lld #leglengthdifference #leglengthdiscrepancy #shortleg #bunions #bunion #gaitevaluation 

Curly toes?

-We have all seen them. We like them, we hate them, we despise them, we scratch our heads.

-The question becomes why?

-it’s pretty obvious from the picture that there is dominance of the flexor muscles and not enough intrinsic strength in the extensor muscles. Look at the prominence of the extensor tendon‘s and posturing of the toes.

– Flexor dominance occurs essentially because of too much activity in the central nervous system, particularly the lower brainstem, over activating the flexors and shutting down (reciprocally inhibiting) the extensors.

-This doesn’t necessarily mean that it is a neurological problem however the nervous system is what’s driving the bus here. Extensor tone is largely regulated by the cerebellum and vestibular system with the flexor tone being regulated by the cortex as well as lower, sub cortical systems.

– The cerebellum and vestibular system get the majority of their input from joint and muscle And joint mechanoreceptors as well as the vestibular apparatus. Their output is predominantly to axial extensor muscles as well as muscles which would be directly affected, from a gravitational standpoint, from those systems as well.

– When we don’t have enough afferent information traveling in from these systems, the flexor systems have a tendency to predominate. Think about protective posture’s and DNS work.

Driving the extensors and working on posture/balance/coordination and perhaps long, sustained stretching of the flexor musculature can help to end the bane of curly toes. 

–so let’s go ahead and make those feet, lower extremity, lower kinetic chain muscles and joints and core more competent and help these folks out.

#curlytoes #flexordominance #toeproblem #toeproblems #footproblem #footproblems 

Can you say Forefoot Adductus?

-Take a look at these tootsies. Draw an imaginary lines for the center of the hill: this should normally pass up through the foot either through the second metatarsal or between the second and third. Can you see how the foot is somewhat banana shaped?

– This is also called metatarsus adductus. The deformity is at the apex of the tarsal/metatarsal joint, also known as Lisfranc joint. The fifth metatarsal base is often prominent in the foot is convex in shape with a higher arch.

-This is usually caused by intrauterine positioning and if caught early will usually spontaneously resolve. Since this gal is over 34, that’s probably not her reality. It is interesting to note that along with this congenital deformity, hip dysplasia and internal tibial torsion (which she has) are extremely common.

– Gait abnormalities seen with this include a decreased progression angle, and a propulsive gait often secondary to poor intrinsic function of the foot musculature

#forefoot #forefootadductus #adductus #foot #footproblem #gait #clinicalexam #thegaitguys