neuromusculoskeletalneuromusculoskeletalneuromusculoskeletal

[thegaitguys]

Movement, can it make us better humans ?

This will be the last blog post you read from us …  for 2017. Happy New year wishes to you all !

This is a rehash of some old stuff, and some new, it seems to bring together many good points and thoughts of our work this past year. We hope you agree. If this seems familiar for those who have been with us for the last 9 years, it is our typical year end post, but it is worth your time

We have an amazing video for you today, a testament to how amazing the human frame is and how amazing movement can be.  But first … . it has been an amazing year for both of us here at The Gait Guys. Through this year, we have bridged further chasms. Our podcasts went into high gear and our numbers continue to grow globally, we were blessed to know our voices spanned the miles into 90+ countries. The National Shoe Fit Certification Program continues to bring us deep gratitude emails from all professions. We blogged weekly , added some new videos and have made plans for more. We also made many new friends while learning much on our own end in our relentless research and readings. We appreciate every one of you who has followed us, and we thank you for your friendship.

As we find ourselves here at the end of another year, it is normal to look back and see our path to growth but to look forward to plan for ways to further develop our growth.  Many of you who read our blog are runners, but many of you are in one way or another involved with a sport or activity that incorporates running and gait. Hey, we all walk !  Even in the video above the dancers are seen running and walking. What we mean is that many of you are coaches or trainers or movement experts who develop those who run or move in one way or another in various sports, but many of you are also in the medical field helping those to run and move to get out of pain or improve performance.  And still yet we have discovered that some of you are in the fields of bodywork such as yoga, pilates, dance, martial arts and movement therapies.  It is perhaps these fields that we at The Gait Guys are least experienced at (but are learning) and like many others we find ourselves drawn to that which we are unaware and wish to know more in the hope that it will expand and improve that which we do regularly.  For many of you that is also likely the case. For example, since a number of you are runners we would bet to say that you have taken up yoga, pilates, lifting or cross training to improve your running and to reduce or manage injuries or limitations in your body. But why stop there ? So, here today, we will try to slowly bring you full circle into other fields of advanced movement. As you can see in this modern dance video above the grace, skill, endurance, strength, flexibility and awareness are amazing and beautiful. Wouldn’t you like to see them in a sporting event ? Wouldn’t you like to see them run ? Aren’t you at least curious ? Their movements are so effortless. Are yours in your chosen sport ? How would they be at soccer for example ? How would they be at gymnastics ? Martial arts ? Do you know that some of the greatest martial artists were first dancers ? Did you know that Bruce Lee was the Cha Cha Dance Champion of Hong Kong ? He is only one of many. Dance, martial arts, gymnastics …  all some of the most complex body movements that exist. And none of them are simple, some taking decades to master, if that, but most of which none of us can do. In 2018 we will continue to expand your horizons of these advanced movement practices as our horizons expand.  There is a reason why some of the best athletes in the NBA, NFL and other sports have turned to almost secret study of dance and martial arts because there is huge value in it.  Look at any gymnast, martial artist or dancer. Look at their body, their posture, their grace.  It is as if their bodies know something that ours do not.  And so, in 2018 The Gait Guys will dive even deeper into these professions to learn principles and bring them back to you. After all, everything we do is about movement. Movement is after all what keeps the brain alive and learning.

Below are excerpts from a great article from Kimerer Lamothe, PhD. She wrote a wonderful article in Psychology Today a few years ago  on her experience with McDougall’s book “Born to Run” and how she translated it into something more.  At some point, take the time to read her whole article.  But do not cut yourself short now, you only have a little more reading below, take the next 2 minutes, it might change something in your life.

We leave you now with our 2017 gratitude for this great growing brethren and community that is unfolding here at The Gait Guys. We have great plans for 2017 so stay with us, grow with us, and continue to learn and improve your own body and those that you work with.  Again, read Kimerer’s most excellent excerpts below, for now, and watch the amazing body demonstrations in the video above. It will be worth it.

Shawn and Ivo, the gait guys

_____________________

Can Running Make us Better Humans ?….. excerpts from the artcle by Kimerer LaMothe.

http://www.psychologytoday.com/blog/what-body-knows/201109/can-running-make-us-better-humans

“The Tarahumara are not only Running People, they are also Dancing People. Like other people who practice endurance running, such as the Kalahari Kung, dancing occupies a central place in Tarahumara culture. Or at least, it has. The Tarahumara dance to pray, to celebrate life passages, to mark seasonal and religious events. They dance outside where Father God and Mother Moon can see, in patterns consisting of steps and shuffles, taps and hops, performed in a line or a circle with others. And they dance the night before a long running race, while the native corn beer, or tesguino flows.

While McDougall notes the irony of “partying” the night before a race, he doesn’t ask the question: might the dancing actually serve the running? Might it be that the Tarahumara dance in order to run—to ensure the success of their run—for themselves and for the community?

At the very least, the fact that the Tarahumara dance when and how they do is evidence that they live in a world where bodily movement matters. They believe that how they move their bodies matters to who they are and to how life happens. They have survived as a people by adapting their traditional method of endurance hunting (running animals to exhaustion) to the challenges of fleeing Spanish invaders, accessing inaccessible wilderness, and staying in touch with one another while scattered throughout its canyons. As McDougall notes, they have kept alive an ancient genetic human heritage: to love running is to love life, for running enables life.

Yet McDougall is also clear: even the Tarahumara are not born knowing how to run. Like all humans, they must learn. Even though human bodies are designed to flourish when subject to the stresses of long distance loping, we still need to learn how to coordinate our limbs to allow that growth to happen. We must learn to run with head up, carriage straight, and toes reaching for the ground. We must land softly and roll inwardly, before snapping our heels behind us. We must learn to glide—easy, light, smooth—uphill and down, breathing through it all. How do we learn?

How do we learn to run? We learn by paying attention to other people, and taking note of the movements they are making. We learn by cultivating a sensory awareness of our own movements, noting the pain and pleasure they produce, and finding ways to adjust. We learn by creating and becoming patterns of movement that release our energy boldly and efficiently across space. We learn, in a word, by dancing.

While dancing, people open up their sensory selves and play with movement possibilities. The rhythm marks a time and space of exploration. Moving with another heightens the energy available for it. Learning and repeating sequences of steps exercises a human’s most fundamental creativity, operating at a sensory level, that enables us to learn to make any movement in any realm of endeavor with precision and grace. Even the movements of love. Dancing, people affirm for themselves and with each other that movement matters.

In this sense, dancing before the night of a running race makes perfect sense. Moving in time with one another, stepping and stretching in proximity to one another, the Tarahumara would affirm what is true for them: they learn from one another how to run.  They learn to run for one another. They run with one another. And when they race, they give each other the chance to learn how to be the best that they each can be, for the good of all.

It may be that the dancing is what gives the running its meaning, and makes it matter.

Yet the link with dance suggests another response as well. In order for running to emerge in human practice as something we are born to do, we need a culture that values movement—that is, we need a general appreciation that and how the bodily movements we make matter. It is an appreciation that our modern western culture lacks.

Those of us raised in the modern west grow up in human-built worlds. We wake up in static boxes, packed with still, stale air, largely impervious to wind and rain and light. We pride ourselves at being able to sit while others move food, fuel, clothing, and other goods for us. We train ourselves not to move, not to notice movement, and not to want to move. We are so good at recreating the movement patterns we perceive that we grow as stationary as the walls around us (or take drugs to help us).

Yet we are desperate for movement, and seek to calm our agitated senses by turning on the TV, checking email, or twisting the radio dial to get movement in a frame, on demand. It isn’t enough. Without the sensory stimulation provided by the experiences of moving with other people in the infinite motility of the natural world, we lose touch with the movement of our own bodily selves. We forget that we are born to dance and run and run and dance.

The movements that we make make us. We feel the results. Riddled with injury and illness, paralyzed by fears, and dizzy with exhaustion, our bodily selves call us to remember that where, how, and with whom we move matters. We need to remember that how we move our bodies matters to the thoughts we think, the feelings we feel, the futures we can imagine, and the relationships we can create with ourselves, one another, and the earth.

Without this consciousness, we won’t be able to appreciate what the Tarahumara know: that the dancing and the running go hand in hand as mutually enabling expressions of a worldview in which movement matters.”

Thanks for a great article Kimerer. (entire article here)http://www.psychologytoday.com/blog/what-body-knows/201109/can-running-make-us-better-humans

*oh, and want a little more of these performers in the video, check this out……. it will move you.

http://youtu.be/CvQBUccxBr4

Wishing a Happy New Year to you all, from our hearts……. Shawn and Ivo

The Gait Guys

[thegaitguys]

The Tib Posterior...Revisited...

Posterior tibialis tendinitis is a primary soft tissue tendinopathy of the posterior tibialis that leads to altered foot biomechanics. Although the natural history of posterior tibialis tendon dysfunction is not fully known, it has mostly been agreed that it is a progressive disorder.(1)

The tibialis posterior originates from the proximal posterior tibia and fibula and interosseous membrane; it is deep in the posterior compartment of the leg and changes its line of pull from the vertical to horizontal at the medial malleolus. The musculotendinous junction is in the distal third of the leg and the tendinous portion turns 90 degrees at the medial malleolus. It has a broad insertion into the plantar surface of the midfoot, largely into the navicular tuberosity with branches to the sustentaculum tali, and the remainder inserting into the entire plantar midfoot except for the 5th metatarsal(1-3).

 The tibialis posterior (TP) is one of the more important extrinsic arch stabilizing muscles. It is a stance phase muscle that fires from the loading response through terminal stance, acts eccentrically to loading response to mid stance to slow pronation and concentrically from mid stance to terminal stance to assist in supination.(4) Its recruitment seems to be increased with slower walking speeds (5).

Since the foot is usually planted when it fires, we must look at its closed chain function (how it functions when the foot/insertion is fixed on the ground), which is predominantly maintenance of the medial longitudinal arch, with minor contributions to the transverse metatarsal and lateral longitudinal arches (6) ; flexion and adduction of the tarsal’s and metatarsals and eccentric slowing of anterior translation of the tibia during ankle rocker. It is also an external rotator of the lower leg and is the prime muscle which decelerates internal rotation of the tibia and pronation. As the origin and insertion are concentrically brought towards each other during early passive heel lift it becomes a powerful plantarflexor and inverter of the rearfoot.  There is also a  component of ankle stabilization via posterior compression of the tarsal’s and adduction of the tibia and fibula.

Alas, there is much more than the typical open chain functions of plantar flexion, adduction and inversion. Perhaps it is some of these other, closed chain functions, that cause the “progressive nature of posterior tibial tendon dysfunction"(7)?

This muscle is easily accessed through the posterior compartment, lying deep in the midline to the gastroc and soleus (8,9). Care should be taken to avoid the sural nerve, often found between the heads of the gastroc and becoming superficial (and palpable) in the midline where it exits from the inferior junction of the 2 heads of the gastroc (10). The posterior tibial artery, vein and nerve lie on top of the tibialis posterior for the upper 2/3 of its route through the calf, becoming superficial (and palpable) in the distal 1/3 of the lower leg (11). I find starting laterally or medially and angling your fingers, instrument or the needle medially or laterally seems to work best. Make sure to count your layers!

 1. Ling SK, Lui TH. Posterior Tibial Tendon Dysfunction: An Overview.  Open Orthop J. 2017 Jul 31;11:714-723. doi: 10.2174/1874325001711010714. eCollection 2017. link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620404/

2. Blake R.L., Anderson K., Ferguson H. Posterior tibial tendinitis. A literature review with case reports. J. Am. Podiatr. Med. Assoc. 1994;84(3):141–149. doi: 10.7547/87507315-84-3-141. [PubMed] [Cross Ref]

3. Supple K.M., Hanft J.R., Murphy B.J., Janecki C.J., Kogler G.F. Posterior tibial tendon dysfunction. Semin. Arthritis Rheum. 1992;22(2):106–113. doi: 10.1016/0049-0172(92)90004-W. [PubMed] [Cross Ref]

4. Semple R, Murley GS, Woodburn J, Turner DE. Tibialis posterior in health and disease: a review of structure and function with specific reference to electromyographic studies. Journal of Foot and Ankle Research. 2009;2:24. doi:10.1186/1757-1146-2-24.

link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2739849

5. Murley GS1, Menz HB2, Landorf KB2.  Electromyographic patterns of tibialis posterior and related muscles when walking at different speeds. Gait Posture 2014 Apr;39(4):1080-5. doi: 10.1016/j.gaitpost.2014.01.018. Epub 2014 Feb

6. Kaye RA1, Jahss MH.  Tibialis posterior: a review of anatomy and biomechanics in relation to support of the medial longitudinal arch. Foot Ankle. 1991 Feb;11(4):244-7.

7. Rabbito M, Pohl MB, Humble N, Ferber R. Biomechanical and Clinical Factors Related to Stage I Posterior Tibial Tendon Dysfunction.  J Orthop Sports Phys Ther, Epub 12 July  2011.doi:10.2519/jospt.2011.3545.

 8. Howitt S, Jung S, Hammonds N. Conservative treatment of a tibias posterior strain in a novice triathlete: a case report. J Can Chiropr Assoc. 2009 Mar;53(1):23-31.   link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2652628/

9.   Lou XF, Yang XD, Jiang SH, Sun CY, Zhang RF.[Study on angle and depth of needle insertion in acupuncture at Zusanli (ST 36)]. Zhongguo Zhen Jiu. 2006 Jul;26(7):483-6

10. https://functionalanatomyblog.com/2009/11/26/the-sural-nerve-anatomy-and-entrapment/

11. Enrique Ginzburg, … Norman M. Rich VASCULAR ANATOMY OF THE EXTREMITIES in Current Therapy of Trauma and Surgical Critical Care, Mosby; Pages 467–472 2008

[thegaitguys]

Lets take another look at the tibialis posterior

As cinincians , we often  treat the tibialis posterior for posterior tibial tendon dysfunction, platar fasicits, patellofemoral joint pain, and a host of other conditions. Lets take a look at some of the anatomy and see why it is a big player in these conditions.

The tibialis posterior takes its origin from the proximal posterior tibia, fibula and interosseous membrane. It is deep to the tricep surae and more superior than the flexors hallucis and didgitorum longus. The tendon descends medially, travels around the medial malleolus and divides into 3 portions: plantar, main and recurrent components. It inserts into all the tarsals and metatarsals 2-4.(1) Note that it DOES NOT insert into the 1st. There must be a good reason for this, no?

The tibialis posterior acts to plantar flex and invert the foot as well as help eccentrically control eversion of the foot. It fires from initial conact to almost terminal swing. This assists in plantart flexion of the foot from initial contact to loading response, eccentric slowing of the foot during pronation from loading response to misdstance and concentric contraction to assist in and speed up supination from midstance to terminal stance.  When you look at the EMG studies for walking (2,3) , you will see that it starts ramping down activity just after midstance as the peroneus longus starts to ramp up more (firing from just after loading response to pre swing, with a bust of activity from midstance on).

So, with all this talk, there has to be a reason, right? Think about this. In order to move forward in the gravitational plane and have high gear push off (ie, pushing off the base of the hallux), the 1st ray needs to descend to gain purchase on the ground (2,4, 5) . This is largely through the actions of the peroneus longus, extensor hallucis brevis and flexor digitorum brevis (6,7). The function of the peroneus longus should be obvious with its attachment to the base of the 1st metatarsal. The extensor hallucis brevis moves the axis of the 1st MTP downward when it contracts, as discussed here and here (8, 9). The flexor digitorum brevis moves the axis of metatarsal  phalangeal joints 2-5 dorsally and posterior which effectively moves the axis of the head of the 1st metatarsal phalangeal joint ventral and anteriorly. This is requisite for you to have adequate hallux dorsiflexion of about 60 degrees to toe off normally.

OK, so what about the tibialis posterior?

Remember that the tib posterior attaches to most of the proximal bottom of the foot with the exception of the 1st metatarsal base? In the area of the 1st ray, the tib posterior attaches to the navicular. When it contracts, it will pull the navicular posterior and inferior, effectively rasing the base of (and lowering the head of) the 1st metatrsal. If it attached to the 1st metatarsal, its base would be pulled posterior and inferior which would raise the head of the 1st ray, exactly what we are trying NOT TO DO.

Armed with this clinical tidbit, can you see how posterior tibial tendon dysfunction can be involved with so many foot and therefore lower kinetic chain problems? If you can’t descend the 1st ray, the foot will need to toe off its lateral aspect, with less effectiveness of the calcaneocuboid locking mechanism (more on that here (10) and here (11)), so problems with propulsion off of an “unlocked” foot. Can you see how the forefoot may be somewhat more everted in this situation? Can you see how this would contribute to more calcaneal eversion and sustained midfoot pronation from midstance through the rest of the gait cycle?  What muscle is sitauted to help maintain the arch as well as decelerate pronation? Tibialis posterior. What muscle will be called into play to assist the gastroc/soleus to help propel you forward? Tibialis posterior. You get the picture.

The tibialis posterior. An important player in the gait game. A great muscle to needle that  pays clinical dividends in more ways than you can imagine.

Dr Ivo

1. Bubra PS, Keighley G, Rateesh S, Carmody D. Posterior Tibial Tendon Dysfunction: An Overlooked Cause of Foot Deformity. Journal of Family Medicine and Primary Care. 2015;4(1):26-29. doi:10.4103/2249-4863.152245.

2. Michaud T. Foot Orthoses and Other Forms of Conservative Foot Care. Thomas Michaud Newton, MA 1993

3. Valmassey  R. Clinical Biomechanics of the lower extremities. Mosby, St Louis, Philadelphia. 101-107: 1996

4. Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore, Williams and Wilkins, 1981

5. Scranton PE, et al. Support phase kinematics of the foot.  In Bateman JE, Trott AW (eds). The Foot and Ankle. New York, Thieme-Stratton, 1980

6. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, NJ, Slack 1992

7. The Pathokinesiology Service and the Physical Therapy Department. Observational Gait Analysis. Rancho Los Amigos National Rehabilitation Center Downey, CA 2001

8. https://tmblr.co/ZrRYjxFOn2hk

9. https://tmblr.co/ZrRYjxFSJ4Yz

10. https://tmblr.co/ZrRYjx1MjeIVN

11. https://tmblr.co/ZrRYjxToM8SI

[thegaitguys]

Difficult hip presentations. Coordination of deep hip muscle activity is often altered in symptomatic femoroacetabular impingement (FAI).

If your clinic is anything like ours, you are regularly seeing failed therapy cases of hip pain walk into your clinic. Many of these cases have been diagnosed clinically or with imaging as FAI (femoral acetabular impingement (syndrome)). FAI can give all kinds of hip pain presentations around the front, side or back of the hip, groin and pelvis, even with referral into the knee. Lets make no mistake, these are difficult cases. The attached study suggests that these often difficult cases are fraught with undefined parameters. These cases can be difficult for us all, particularly if one do not have the clinical examination skills to tease out what muscles are not working, which ones are over working, what has happened to joint centration, how the client loads the hip, what the pelvis posturing attitude is and what motor stabilization strategies are being deployed. Lumbar, pelvis and hip posturing and stabilzation is key in understanding FAI and these often vague and frustrating cases. Determing how the client deploys stacking of the lower limb joints and how they then deploy these strategies in gait and running is paramount to your success in assisting these client cases. This is a deeply multifactorial problem and often why these issues do not get resolved. 

Recently I just closed yet another case with a 21 year old female who had FAI and labral tear surgery 2 years ago. She had been told she would always have some pain and never run again. As many of these cases often proceed, after defining all of the issues above, it was clear she had many unaddressed components postoperatively. It appeared many components had not been addressed preoperatively, and had they been addressed, I suspect she may have not needed surgery. These multitudes of dysfunctional components can lead to FAI and labral damage. Many torn labrums do not need surgery, as evidenced by how many clients come out of surgery still having the same pre-operative pain as well as how many improve or resolve by a non-surgical approach to addressing all of the components above. This study, by Diamond et al compared coordination of deep hip muscles between people with and without symptomatic FAI using analysis of muscle synergies (i.e. patterns of activity of groups of muscles activated in synchrony) during gait. The study utilized intramuscular fine-wire and surface electrodes EMG activity of selected deep and superficial hip muscles.   This study found a significant correlation with the quadratus femoris muscle, one we have repeatedly found problematic over the years. This study was nice to read, it confirmed many of the issues we have found rooted in these often difficult cases. The study surmised that 

“coordination of deep hip muscles in the synergy related to hip joint control during early swing differed between groups. This phase involves movement towards the impingement position, which has relevance for the interpretation of synergy differences and potential clinical importance. ”

We strongly refer you back to our podcast #99 to look into the gluteus medius during swing phase. This is a key component to one’s deeper understanding of how complex the hip works, during both stance and swing. We all tend to get too caught up in stance phase mechanics because that is the one we can see and assess most clearly, however, if one does not understand how vital the gluteus medius is in swing phase limb targeting through the sagittal plane, one is likely missing a big piece of a client’s clinical puzzle. One can do all the dynamic and functional movement and stabilization therapy they wish, but if one does not understand the swing phase mechanics, and perhaps most importantly, if one does not reteach a client how to make the necessary adaptive gait changes to employ the therapeutic work the changes remain on the therapy table and never cross over into functionally using them. The clinician must address the client’s previously deeply rooted gait motor program. A client may have in their bank account the new functional abilities they have been taught, but they likely have not been taught how to deploy them in a new more appropriate gait strategy. 

-Dr. Shawn Allen

1. Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement. Laura E Diamond, Wolbert Van den Hoom, Kim L Bennell, Tim V Wrigley, Rana S Hinman, John O’ Donnell, Paul Hodges

2. J Neurophysiol. 2014 Jul 15;112(2):374-83. doi: 10.1152/jn.00138.2014. Epub 2014 Apr 30. A neuromechanical strategy for mediolateral foot placement in walking humans.  Rankin BL

3. Podcast 99: How foot placement, the glutes and cross over gait all come together and make sense.

4. https://thegaitguys.tumblr.com/post/133206339519/podcast-99-how-foot-placement-the-glutes-and

[thegaitguys]

What’s your Foot Type?: Part 1

Ready for Monday Morning? This is the 1st of a 5 part series to get your week going and help get you in a “Gait Guys” frame of mind

Rearfoot varus

What if many of your nagging and seemingly un resolvable injuries as an athlete were from an undiagnosed foot type? What if every shoe, insert and orthotic you implemented in an attempt to help manage these problems was not the solution, but rather a means of “band aiding” the problem because your anatomy was compromised from the start? 

Wouldn’t it be nice to have some answers to all the questions you have as to why your interventions were less than optimal? Wouldn’t life be better if you knew that your anatomy was slightly left of center and that this was the true cause?  Life as an athlete sure would be more tolerable and perhaps, just perhaps, a life with fewer nagging injuries.

The main issue is that the majority of humans have less than perfect feet. The “perfect” neutral foot is one in which the rearfoot and the forefoot lie on the same plane, meaning that the forefoot and the rearfoot lie square on the ground when ankle and subtalar joint mechanics are neutral.  This insures the tripod of the foot (the base of the big toe, the base of the little toe and the center of the heel) remain on equal footing, creating a balance of power between the muscles and articulations.

There are many reasons at to why we do not all have perfect feet with pristine mechanics to run and walk on.  Some are genetic, some congenital, and some developmental. Regardless, as the saying goes “You have what you have, so why not make the best of it?”

In a nutshell, there are 5 basic foot types; two involving challenges to the forefoot, and two challenging the rear foot. These can be rigid and non adapting, flexible and adapting, or somewhere in between. The fifth type is the ideal of what we all hope to have. This 5 part series will help you to understand each and the biomechanics associated with the anatomical variant.

Rearfoot varus.

The rear foot varus is a foot that has the heel inverted, almost appearing as though the ankle is about to roll, like a common ankle sprain. Here the rear of the tripod is compromised. Because of this lateral shift of weight through the contact phase of walking or running, the foot is over supinated  (plantar flexed, inverted and adducted) at toe off.  The owner of this foot type usually has excessive use of the peroneal muscle group to fight this supinated tendency and prevent ankle sprains.  The 4th and 5th metatarsals typically take on more stress, and are often painful. Loading the lateral aspect of the limb shifts the center of gravity and challenges stability in the frontal plane, often leading to hip problems, such as trochanteric bursitits and IT band friction type syndromes and knee/patellar tracking issues.

Confused? Have no fear. Our shoe fit program is almost here! The Shoe fit functional testing module (also available separately from the 3 part program) discusses foot types in more detail. Watch here on Mondays for a different foot type each week!

The Gait Guys: promoting foot and gait competency everywhere!

[thegaitguys]

Take good look at these gals. The gal on the left (in blue) looks like she has a level pelvis, but look at the upper body. She’s leaning to the left and has a great deal of torso rotation backward. One of the clues is the abduction of her left arm. Also note how her right arm crosses across her body. We wonder how she looks in right foot stance.

The gal on the left (in red) has a subtle dip of the right side of her pelvis and also has over rotation of her upper body. Her right on crossing the body is a good reason to believe she will have a crossover gait if viewed from straight on.

While both of these gals may have adequate strength, we question how much endurance they have as well as available rotation in the hips and lumbar spine.

This is an excellent, referenced review of some of the current literature and controversy of strength and injury risk. A good read and certainly worth your time to get caught up on what’s current. We would love to see you study on endurance and injury risk.

“While muscle strength may improve tolerance of loads during running, another reason for inconsistencies in the reported relationships between strength and injury risk may be that strength is typically assessed isometrically. It’s unclear how much of an influence peak isometric strength has on the dynamic task of running, and specifically on prolonged running in the presence of muscular fatigue. Schmitz et al found that, while isometric hip strength values were similar between novice and experienced runners, hip internal rotation motion during running was higher in the novice runners, suggesting isometric strength may not correlate strongly with muscular control and kinematics during running.”

http://lermagazine.com/article/lower-extremity-strength-and-injury-risk-in-runners

[psoastoremember]

Strength vs endurance. Task specific!

[psoastoremember]

[psoastoremember]

"When a dancer turns out properly, it may be possible for dancers to get stability assistance from the Y ligament resulting in less overall muscular effort. A taut Y ligament completely limits any additional hip extension and external rotation. Less muscular effort is needed to stabilize the turned out position when the dancer has found this end range of movement. Dancers may attempt to gain a few degrees of additional rotation by decreasing tension on the Y ligament with slight hip flexion, which lowers the anterior brim of the pelvis into anterior tilt and pulls the lumbar spine into hyperextension. By doing this they sacrifice the stability gained from the Y ligament and alter neutral pelvic and spinal alignment." "The six deep rotators are the muscles closest to the hip joint, the smallest, but most efficient, muscles to turn the leg out. With a fixed femur, they lift the pelvis off the femur.[6] When the six deep rotators are recruited, the dancer may sense “space” deep in the hip joint. The gluteus maximus and the posterior gluteus medius, the larger, superficial rotators, also turn the leg out in hip extension/ hyperextension. However, because they attach above the hip joint on the pelvis and below the hip joint on the femur, when contracted they subject the hip joint to a compressive force. Hence the gluteals do not provide a sense of lift." "The inner thighs (adductor muscle group) help to turn the leg out and balance the pelvis by simultaneously pulling the pelvis forward (anterior tilt/hip flexion) and backward (posterior tilt/hip extension). The outer thigh muscles (abductor muscle group) prevent sitting into the hip and stabilize the joint between the pelvis and sacrum. Balancing the strength and motor organization of these muscles groups is crucial for a dynamically stable hip."

[thegaitguys]

Treadmills, motorized or nonmotorized can have some pitfalls. Here are seven of our biggest concerns.

More on non motorized treads from Mike Reinold which came to my attention via Scott Tesoro (thanks!).

1. Watch out for how much ankle dorsiflexion(and great toe extension) your client has to be able to take advantage of the “curve”

2. The treadmill, whether motorized or not, is constantly moving, opposite the direction of travel. With the foot on the ground, this provides a constant rate of change of length of the gastroc/soleus (ie, it is putting it through a slow stretch); so, once the muscle is activated, it contracts for a longer period of time because of the treadmill putting a slow stretch on the gastroc and soleus.

3. The moving deck also has a tendency to put the ankle in dorsiflexion ( see point number one) initiating a stretch reflex in the tricep surae (gastroc/soleus) facilitating toe off through here and pushing you through the gait cycle, rather than pulling you through (with your hip extensors).

4. Likewise, the treadmill pulls the hip into extension and places a pull on the anterior hip musculature, especially the hip flexors including the rectus femoris, iliopsoas and iliacus. This causes a slow stretch of the muscle, activating the muscle spindles (Ia afferents) and causing a mm contraction (ie the stretch reflex). This acts to inhibit the posterior compartment of hip  extensors through reciprocal inhibition, especially the glute max, making it difficult to fire them.

5. Because the deck is moving, the knee is brought into extension, with stretch of the hamstrings, the quads become reciprocally inhibited.

6.  the moving deck forces you to flex the thigh forward for the next footstrike (ie footstance), firing the RF, IP and Iliacus, and reciprocally inhibit the g max

7. If your core isn’t engaged, the pull of the rectus femoris and iliopsoas/iliacus pulls the ilia and pelvis into extension (ie increases the lordosis) and you reciprocally inhibit the erectors and increase reliance on the multifidus and rotatores, which have short lever arms and are supposed to be more proprioceptive in function.

We are not saying they are bad and in fact, we tend to like self-propelled models more than motorized ones  and agree with many of the points made. We are just saying that treadmills are not the same as walking on a flat surface and approximate but do not simulate actual gait.

[thegaitguys]

Video Gait Case: A troubled Youth.

This is a video of a teenage girl with chronic posterior knee pain. What do you see in her gait. Don’t cheat yourself. Before you read below see what you can see first and then drop your eyes down to our work below.

Heavy rear foot lateral strike. This is rearfoot inversion at its worst. This is considered rearfoot varus. Hyperpronators will often display the opposite, a rearfoot valgus. In this case, a heavy lateral strike leads to sustained lateral foot weightbearing which will mean she stays on the outside or lateral aspect of her foot too long and thus stays in supination.

The heavy lateral foot strike will often lead to knee hyperextension during initial contact and often continues throughout stance phase, as this is a position of stability for the joint. At the end of the video as her knees come into view you can see the degree of knee hyperextension (somewhat). This may remind you of our blog post months ago on anterior knee pain (Anterior Meniscofemoral Impingement Syndrome). Such an anterior pitch of the pelvis and lumbar extension can obviously lead to shortness and shortness-weakness of the psoas and rectus femoris to name just a few.

This type of gait will often lead to an accentuated lumbar spine lordosis curve (functional usually) with an accentuation of the anterior pelvic tilt and resultant inhibition of the lower abdominals. This furthers the knee hyperextension and thus the cycle continues (the knee hyperextenion perpetuating the anterior pelvis and weak abdominals which then drive continued knee extension). Bringing these topics and blending them with items in #2 will naturally limit the degree of hip extension (since the extension of the limb is occurring in the lumbar spine) and lead to inhibition and weakness of the gluteus maximus.

Quite frequently a heavy lateral rear foot strike results in a heavy pronation event at the forefoot loading period (forefoot pronation) particularly when the foot progression angle (turn out) of the feet is large. We DO NOT see this here. However, in these cases one had better have exceptional medial foot tripod skill, endurance and strength (S.E.S once again) as well as great strength in the long and short big toe flexors (FHL, FHB) to help anchor that medial tripod because the forces that are coming into the forefoot in those case are like a rhino at feeding time. However, in this case, there is a plantar flexed 1st ray posturing of the forefoot. A trained eye can see some of the functional characteristics of this forefoot type, but you really must confirm its presence on a clinical examination mainly because you want to know if it is a rigid or flexible forefoot variant. A plantarflexed 1st ray is sometimes found paired with a rearfoot varus, as the foot is trying to find the medial tripod. A forefoot valgus is also possible, but this usually results in the medial foprefoot striking the groung 1st, as opposed to the lateral, as we see here. These people often have great difficulties getting off of the outside of the foot and onto the medial foot to adequately toe off the big toe. This is sometimes referred to as an apropulsive gait.

Wow, all this from some bad gait skills and some minor foot variances huh ?! Yup.

Which brings us to shoes. Wouldn’t it be nice to be well versed on all these issues before you slap her into a neutral shoe ? Because she clearly does not need a stability shoe; pronation is absent in these feet. So, do you pick a neutral shoe with a soft lateral heel crash zone ? How about one with a lateral rearfoot cut out (or “entry” as it is often called? What about no cut out ? Would she do better in a straight lasted shoe or curved ? There are plenty of questions, more than just these. But for this case…….lets stop here and answer just these few for now.

no soft lateral heel impact crash zone with this type of rear foot

use a shoe with no cut out (the beveled cut out at the lateral heel will promote more sustained lateral foot weightbearing). Shoes without a cut out (or entry) will help to drive that heel into eversion and pronation but you had better make sure you have changed their gait and ensured adequate medial foot tripod strength, because remember those types of feet will be driving into that medial forefoot in a major hurry with aggression…… but, thankfully this is not the case here.

Choose a Straight lasted shoe in this case. A more curve lasted shoe will promote more and faster pronation into that forefoot, there is already enough !

There is so much more to this game that simply promoting natural running form or natural walking form. So much more than simply dropping someone to a zero drop or minimal shoe. As we say, it is often not the shoe but the thing you put in the shoe……. but you have to know what shoe you put on the foot and how it is going to react to the foots abilities and its challenges.

Our Shoe Fit program is getting closer and closer to a release date. Those that have been through our program, formally or informally will have the knowledge and skills to dissect a case like this and make some good assessments and choices.

Shawn and Ivo. Gait Geeks, Shoe nerds, Running form teachers, …….. and halfway decent doctors too.

[thegaitguys]

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

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.

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don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

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Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

[thegaitguys]

What Are Motion Control Features, anyway?

In this brief video, Dr Ivo talks about common motion control features found in many shoes shoes. terms like “medial posting” “dual density midsoles” and “lateral flares” are discussed

[thegaitguys]

This video pretty much sums up our entire philosophy. Skill, Endurance, Strength; in that order. Why? Skill requires the largest diameter afferent (sensory) nerves to accomplish (Ia and Ib afferents from muscle and joint mechanoreceptors); they are the fastest pathways; Endurance comes from larger sized Type I (and sometimes Type IIa) endurance muscle, which are oxygen dependent (aerobic) and are rich in myoglobin, glycogen, mitochondria and capillaries; Strength last, because it comes from smaller, Type IIb fibers, and is largely glycolytic (depends on anaerobic respiration) and is dependent on the other 2 (skill and endurance).

When you take amazing skill and body awareness and combine it with strength and flexibility and control you can do these kinds of wild things.

Exploring the links between human movement, biomechanics and gait.

The Gait Guys

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Fig. 1.

(A) The three longitudinal ligaments of the hip joint form a helical spiral structure around the proximal femur. (B) ILFL. (C) PFL. (D) ISFL.

http://jhps.oxfordjournals.org/content/early/2015/04/20/jhps.hnv017.full

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Hip pain and dysfunction are increasingly recognised as important causes of morbidity in younger and older adults. Pathology compromising the passive stability of the hip joint, including acetabular labral injury, may lead to increased femoral head translation, greater joint contact pressures and ultimately degenerative hip disease. Activation of hip muscles may play an important role in augmenting the stability in the normal and the passively unstable hip. Research at other joints suggests that the local, rather than global, muscles are well suited to provide subtle joint compression, limiting translation, with minimal metabolic cost. Based on the known characteristics of local muscles and the limited research available on hip muscles, it is proposed that the local hip muscles; quadratus femoris, gluteus minimus, gemelli, obturator internus and externus, iliocapsularis and the deep fibres of iliopsoas, may be primary stabilisers of the hip joint. Interventions aimed at restoring isolated neuromuscular function of the primary hip stabilisers may be considered when treating people with passive hip instability prior to commencing global muscle rehabilitation. Finally, further research is needed to investigate the potential association between function of the hip muscles (including muscles likely to have a role in stabilising the hip) and hip pathology affecting hip stability such as acetabular labral lesions.