#hyperpronation

[thecaptain-steverogers]

I just bought myself another present in the form of running shoes

Because hyperpronation sucks and I'm trying to be fit, not in pain. Back problems and shin splints are only the start of it, I'm developing plantar fasciitis and that's not good for a girl who has to stand for 7-8 hours a day 5 days a week and then exercise for an hour or so.

So.

tl;dr i bought new running shoes because reasons. 

[thegaitguys]

External Tibial Torsion as expressed during gait.

So, last week we watched this young lad doing some static ankle and knee bends, essentially some mini squats.  Here was what we found (LINK). It is IMPERATIVE that you watch this LINK first before watching today's video above.

Now that you have watched that link here is what you should be seeing today.

You should see that the left foot is extremely turned out. We talked about why in the linked post from last week. It is because of the degree of external tibial torsion.  When it is present the knee rides inside the foot progression line (the knee bends into the forward / sagittal plane when the ankle bends into its more lateral /coronal / frontal plane (they all mean the same thing) ie. when the foot points outwards.

Remember, the knee has only one choice of motion, to hinge forward and backward. When the knee is asked to hinge in any other direction once the foot is locked to the ground there is torque placed upon the knee joint and thus shear forces.  Menisci do not like shear forces, nor does articular joint cartilage.

So, once again we see the rule of "you cannot beat the brain" playing out. The brain took the joint with the least amount of tolerance, the knee, and gave it the easy job.  The foot was asked to entertain another plane of motion as evidenced here in this video with significant increased foot progression angle. 

When the foot progression angle is increased but the knee still must follow the forward body progression (instead of following the foot direction) the motion through the foot will be directly through the medial longitudinal foot arch.  And as seen here, over time this arch will fail and collapse. 

Essentially this lad is hinging the ankle sagittally / forward through the subtalar and midtarsal joints, instead of through the ankle mortise joint where ankle hinging normally should occur.

This is a recipe for disaster. As you can see here.  You MUST also know and see here that there is an obvious limp down onto that left limb. It appears the left limb is shorter. And with this degree of external tibial torsion and the excessive degree of foot pronation, the limb will be shorter. You need to know that internal limb spin and pronation both functionally shorten the limb length.  This fella amongst other functional things is going to need a full length sole lift. We will start with 3mm rubber infused cork to do so. And let him accomodate to that to start.

We will attempt to correct as much foot tripod (anti-pronation) control as possible to help reduce leg shortness as well as to help reduce long term damage to the foot from this excessive pronation. We will also strengthen the left gluteus medius (it was very weak) to help him engage the frontal/lateral/coronal plane better. This may bring that foot in a little. But remember, the foot cannot come in so far that it drives the knee medially. Remember who is ruling the roost here !...... the knee.  It only has one free range, the hip and foot have 3 ! 

Shawn and Ivo

[thegaitguys]

The Solitary Turned out Right foot in a Barefoot Runner: Part 2

Here is a perfect example why we sometimes cringe when someone comes into our office with pain or problems and wearing minimalist shoes or worse yet, claims to be a barefoot runner.  This is a perfect example of a client, whether they are in your shoe store or in a medical office, that needs to be convinced to remain in their more stable trainers until the problem is unwound. 

In this video it is plain for anyone to see that the right foot/lower limb is clearly externally rotated and pronating excessively when compared to the left side.  This could be from weakness of the gluteus medius, loss of internal rotation or one of several other biomechanical flaws (be sure to review Dec 15th blog post on these topics ). However, it could also be anatomic.  This could be from external tibial torsion or a torsion at the femur.  Regardless, it is likely creating a functional short leg on the right because when we pronate heavily like this, the height of the talus and arch drops further than normal, and in this case further than the other side.  However, one could argue the opposite, meaning that this person is pronating heavily on the right to shorten that leg to be equal to an already shorter left leg. In order to know, and not guess, you have to assess your client.  As indicated above, the internal limb spinning pronation could be a compensation to gain more entire limb internal rotation from a loss of hip rotation. Yes, there could be many causes. In this latter case, prescribing an orthotic to dampen this pronatory excess would be a mistake for the hip even though it would be a logical intervention at the foot level.  Our direction would be to find the cause of the right limb turn out and hyperpronation.  Video gait analysis and guessing will not get you there.  You have to assess your clients neuromuscular ability and deficits.  If one were to bet on impaired internal hip rotation, a fairly high probability bet, then how many internal rotators of the lower limb can you name immediately without looking them up ? You will need this info at the tips of your fingers in an exam if you are going to prove or disprove the internal hip rotation theory.  Here are a few to get you started:

vastus lateralis

TFL-ITB

anterior head of gluteus medius

reflected head of rectus femoris

adductor brevis

coccygeal division of gluteus maximus

how many others can you name and accurately test so that you are not guessing when it comes time to assess your client ?

Welcome to the complex game we play every day with our athletes and "every day Joe's". It is a brain knocking game, and  you have to juggle many factors while sorting it out. ! Tomorrow we will talk a little about possible problems of Functional Screens and how they can be used to help assess, but also how they can fool you.

Have a good Monday gang..... and watch for the rampant spreading plague of the turned out foot.  It is nationwide already !

Shawn and Ivo, The Gait Guys

[thegaitguys]

"Risk Factors that may adversely modify the natural history of the pediatric pronated foot."  Clin Podiatr Med Surg. 2000 Jul;17(3):397-417. Napolitano C, Walsh S, Mahoney L, McCrea J.Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois, USA.

This article is a nice follow up to the video post from yesterday. The article talks about the flexible and rigid flat foot.  In yesterday's video example we are dealing with a flexible flat foot deformity.  When he was non-weightbearing (which wasn't seen in the video) he formed an arch.  As you can see in the video upon weightbearing the arch disappears but you can see that with the correct patterning employed, he can find an arch.  This is what we term a flexible flat foot deformity.  These types of feet have potential if there is sufficient muscular ability and if hyperlaxity in the ligamentous system can be overcome by neuromuscular support. If not, an orthotic may need to be utilized and be assistive.  The rigid flat foot, is one that does not form a competent arch, ever.  These feet are what they are, flat.  But, keep in mind...... some genetics do render a competent flatter foot.  Some of the strongest feet we have seen are on very low arched people / runners.  So, flatter does not always mean weak, be careful.  What you see is not necessarily what you get, even a rusted out Ford Pinto might have a Ferrari engine in it....... you just don't know by looking, you have to test the competency of the foot (another example, look at Arnold Palmer's golf swing, it isn't the prettiest swing by any means...... but you probably wouldn't bet a penny against him even these days, if you get our drift.)

As the abstract says. "Normally developing infants have a flexible flatfoot and gradually develop a normal arch during the first decade of life."  The key word is NORMALLY.   You must consider risk factors that may affect the foot in its overall development.  The risk factors include ligamentous laxity, obesity, rotational deformities, tibial influence, pathological tibia varum, equinus, presence of an os tibiale externum, and tarsal coalitions.

Again, this is a nice follow up to our video from yesterday and brings home some additional good points to cogitate over. We knew we had a flexible flat foot with potential.  Knowing what you are starting with it vital for your success in treating the problem, and vital in determining long term success. 

We are, The Gait Guys .......... and even a bit geeky in neurodevelopmental physiology. (Yes, we have no life.) 

Shawn and Ivo

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Abstract of the Journal Article....... the link to the article is at the top of the blog post if you wish to obtain the article for further study.

Here is their abstract:

"Flatfoot is one of the most common conditions seen in pediatric podiatry practice. There is no universally accepted definition for flatfoot. Flatfoot is a term used to describe a recognizable clinical deformity created by malalignment at several adjacent joints. Clinically, a flatfoot is one that has a low or absent longitudinal arch. Determining flexibility (physiologic) or rigidity (pathologic) is the first step in management. A flexible flat foot will have an arch that is present in open kinetic chain (off weight-bearing) and lost in closed kinetic chain (weight-bearing). A rigid flatfoot has loss of the longitudinal arch height in open and closed kinetic chain. According to Mosca, "The anatomic characteristics of a flatfoot are excessive eversion of the subtalar complex during weight-bearing with plantarflexion of the talus, plantarflexion of the calcaneus in relation to the tibia, a dorsiflexed and abducted navicular and a supinated forefoot." Normally developing infants have a flexible flatfoot and gradually develop a normal arch during the first decade of life. When evaluating an infant for a pronated condition, the examiner must also consider other risk factors that may affect the foot in its overall development. These contributing factors will play a role in the development of a treatment plan. The risk factors include ligamentous laxity, obesity, rotational deformities, tibial influence, pathological tibia varum, equinus, presence of an os tibiale externum, and tarsal coalitions. The authors realize other less significant factors exist but are not as detrimental to the foot as the primary ones discussed in depth. The primary risk factors that affect the pronated foot have been outlined. The clinician should always examine for these conditions when presented with a child exhibiting pronatory changes. A thorough explanation to the parents as to the consequential effects of these risk factors and their effects on the pediatric pronated foot is paramount to providing an acceptable comprehensive treatment program. Children often are noncompliant with such treatments as stretching and orthotic maintenance. The support of the parents is crucial to maintaining an effective treatment program continued at home."