increased cushioning = increased impact forces (GRF)
increased impact forces = increased injuries?
possibly not...
footwear can impact injury and biomechanics but may not be the primary factor
a nice recap of the state of what we currently know about shoes, design and cushioning.
http://lermagazine.com/cover_story/running-shoes-and-injury-risk-rethinking-the-importance-of-cushioning-and-pronation
Got Muscle activation? Looking for some EMG data on what fires when in walking vs running gait? The conclusion and point of the study are good, but the EMG data and diagrams are awesome for those of you seeking a greater understanding of what goes on when
"The major difference between walking and running was that one temporal component, occurring during stance, was shifted to an earlier phase in the step cycle during running. These muscle activation differences between gaits did not simply depend on locomotion speed as shown by recordings during each gait over the same range of speeds (5–9 km/h). The results are consistent with an organization of locomotion motor programs having two parts, one that organizes muscle activation during swing and another during stance and the transition to swing. The timing shift between walking and running reflects therefore the difference in the relative duration of the stance phase in the two gaits."
A great read and FREE FULL TEXT
http://jn.physiology.org/content/95/6/3426
Zombies are a peculiar lot. Not wanting to limit our analysis to the living, we have begun to examine the undead.
In this entertaining and educational clip, we note that a common characteristic seems to be partial paralysis of an lower and/or upper extremity, along with the peculiar behavior of keeping their upper extremities in a flexed posture, similar to a stroke. They also seem to have an exaggerated gag reflex and difficulty with phonation (talking). We believe this is a neurological phenomenon, based on the fact that the only way to truly kill a zombie is to kill their brain.
Have a great Halloween!
Beyond the Trigger Point...
Many clinicians needle. We are taught to dry needle trigger points and to needle the segmental innervation of the muscle involved. But should we do more? I think so, and here is one paper on incorporating needling myofascial meridians along with trigger points that supports that notion (1).
Since most of us treat patients that are ambulatory, we should be thinking of how a patient moves, especially through the gait cycle. Think of the kinetic chain in what I like to call “reverse engineering”, that is, from the ground up, rather from the torso down, in a closed chain fashion. This will profoundly effect the way you look at muscle function, for example: thinking of the vastus lateralis as a medial rotator of the thigh (yes, you read that right; think about it and try and get your head wrapped around it), or of the peroneus longus as an abductor of the lower leg and external rotator (assisting supination) during the latter half of the gait cycle. Reverse engineering gives you a whole new outlook on locomotion and human movement.
Tom Myers was insightful enough to write a great text talking about myofascial meridians or “lines of tissue stress ” describing the fascial connections of muscles utilized in a chain during movement (2). This built upon the original work of Valdimir Janda and his concepts of “loops and slings” (3), as well as the work of Paoletti (4) and Vleeming (5).
In neurology, we have the conjoint concepts of temporal and spacial summation that can lead to some action on the part of the nervous system. They describe 2 ways that receptors or neurons can reach threshold and fire an action potential (6) .
Temporal summation is when a receptor or neuron is stimulated repetetively over time, with each potential bulding upon the previous, making the stimulus effectively larger and larger. If you were in a movie theater and the person seated behind you kept hitting the back of your seat repetitively (temporal summation), it would only be a matter of time before you turned around and said some thing to them(ie, you reached threshold).
Spacial summation is when a receptor or neuron is stimulated at multiple locations over time, with the potentials building and bringing the receptor or neuron closer to threshold. Taking the same scenario as before, if many people began hitting your chair from multiple directions (spacial summation), it would be only a matter of time before you said something (ie: reached threshold).
These two things can work together as well, usually eliciting a result much faster, since the receptor or neuron is being hit multiple times from multiple directions and it can usually reach threshold faster.
Since one of our goals in needling is not only to reduce or eliminate the trigger point, but also to reduce pain and increase function, wouldn’t it make sense to take advantage of as much neurology as possible? How about more real estate (spacial summation) in a reasonable time frame from point to point (temporal summation)?
Needling appears to cause pain modulation, as well as many of its other effects, through both peripheral and central mechanisms (7,8). Having our therapy stimulate more of these mechanisms should theoretically make our therapy more effective and improve outcomes. So, more needles may be a good thing, no?
Getting back to the paper (1), they needled tender points (satellite trigger points?) along the lower portions of the “superficial back line” or “SBL”, along with points on the foot for plantar fascitis. The SBL contains plantar fascia, Achilles tendon, gastrocnemius,hamstrings, sacrotuberous ligament, and erector spinae. It continues to the suboccipital muscles and ends at the suboccipital muscles, galea aponeurotica of the skull and ultimately the frontalis muscle (2). They could have incorporated more, and perhaps had even better results, as the upper cervial spine contains one of the highest densities of mechanoreceptors in the body (9, 10), and afferent information from the upper 4 cervical neuromeres feed directly into the flocculonodular lobe of the cerebellum (11, 12).
So, how about incorporating myofascial meridians into your needling toolbox? The next time you see someone with a problem area, think about the kinetic chain that gets you there, starting from the ground up, and incorporate THAT into your treatment protocol.
references:
1. Akhbari B, Salavati M, Ezzati K, Mohammadi Rad S: The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis Journal of Chiropractic Medicine (2014) 13, 43–48
2. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists. 2nd ed. Philadelphia: Churchill Livingstone; 2009.
3. Janda V, Vavrova M, Hervenova A, et al. Sensory motor stimulation. In: Liebenson C. ed Rehabilitation of the spine: a practitioner’s manual. 2nd edn. Lippincott Williams & Wilkins, 2006.
4. Paoletti S. The fasciae: anatomy, dysfunction & treatment. Eastland Press; 2006.
5. Vleeming A, Snijders C, Stoeckart R, Mens J. The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming A, et al, editor. Movement, stability and low back pain. Churchill Livingstone; 1997. p. 53–71
6. Levin & Luders (2000). Comprehensive Clinical Neurophysiology. New York: W.B. Saunders Company.
7. Dommerholt j Dry needling — peripheral and central considerations Journal of Manual and Manipulative Therapy 2011 VOL. 19 NO. 4 223-237
8. Li-Wei Chou, Mu-Jung Kao, Jaung-Geng Lin ProbableMechanisms of Needling Therapies for Myofascial Pain Control Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 705327, 11 pages doi:10.1155/2012/705327
9. Kulkarni V1, Chandy MJ, Babu KS Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India. 2001 Dec;49(4):355-9
10. Bogduk N Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001 Aug;5(4):382-6.
11. Luan H1, Gdowski MJ, Newlands SD, Gdowski GT Convergence of vestibular and neck proprioceptive sensory signals in the cerebellar interpositus. J Neurosci. 2013 Jan 16;33(3):1198-210a. doi: 10.1523/JNEUROSCI.3460-12.2013.
12. Seaman D Winterstein Dysafferentation: A Novel Term to Describe the Neuropathophysiological Effects of Joint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation J Manipulative Physiol Ther 1998 (May); 21 (4): 267-280
More on asymmetries from a neurologic perspective, The neurophysiologic process that actually occurs during an injury. Plus, Should you change your clients running form? It is a big debate, and we think many of the experts get this wrong.
Key Tagwords:
ankle sprains, knee pain, patellar tracking, isometric loading, gait, gait analysis, neurology, thegaitguys, analgesia, tendonopathy, movement disorders, running form
Links to find the podcast:
iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
http://traffic.libsyn.com/thegaitguys/pod_130f.mp3
http://thegaitguys.libsyn.com/podcast-130-concepts-around-ankle-knee-injuries
http://directory.libsyn.com/episode/index/id/5887731
Our Websites:
www.thegaitguys.com
summitchiroandrehab.com doctorallen.co 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, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Show Notes:
Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Ebonie Rio, Dawson Kidgell, Craig Purdam, Jamie Gaida, G Lorimer Moseley, Alan J.Pearce, Jill Cook
http://bjsm.bmj.com/content/early/2015/05/15/bjsports-2014-094386
The constant switching between steady state cortical neuron discharge and and non-steady state discharge.
Takakusaki , Neurophysiology of Gait: From the Spinal Cord to the Frontal Lobe. Movement Disorders, Vol. 28, No. 11, 2013
I was reminded again yesterday, after yet another foot pain client came in to see me, that many do not understand the absolute and deeper ramifications of putting an orthotic into a shoe (and onto a foot) and what effects of doing so can have on changing a necessary adaptation.
This client had medial heel pain, not plantar heel pain, not the posterior calcaneal area, the medial edge (see photo). The edge where the inside/medial edge of the calcaneus/heel meets the ground. This client could reproduce the pain on palpation and could reproduce it if they stood up, and everted the heel just a tiny bit.
This client had a healthy appearing foot and arch. But, as often is the case, appearances are deceiving.
Here was the major problem:
So, what is happening here, and often happens with the above limitations, the client does not have the muscular ability to maintain the arch sufficiently from the big players, as noted. In other words, the ankle has lost mobility and the foot has lost stability, a common pattern. To make up for a loss of ankle dorsiflexion we often collapse the arch a sufficient amount to pitch the talus medially and forward to help the tibia progress forward the requisite amount needed for forward locomotion across the foot-ankle complex. This is a normal compensation, and in time there may be a pathologic cost. This medial approach of the talus and arch collapse, requires calcaneal eversion. This eversion means more medial calcaneal loading into the shoe, orthotic or ground, including medial soft tissue (mostly fat pad) loading between the ground and the everting calcaneus.
This is a normal compensatory strategy to move forward over a restricted ankle dorsiflexion range. However, the doctor this client saw previously (for plantar fascitis), felt that this motion was a problem they needed to block with an orthotic. One that resisted the heel eversion and more than normal arch collapse/pronation cycle. This remedy resolved the plantar fascial pain. But, the medial heel pain began shortly thereafter.
So, here we have a client that is compensating, and finding a way (though there are biomechanical costs to this way), to get past a limitation, loss of ankle rocker in this case. But, the doctor put an orthotic in the shoe that stopped this "way". Now the client has to evert the heel even harder, because of the presence of the orthotic preventing it) and it is causing a "bite" or friction plus compression of the medial soft tissues.
So, this client now still cannot compensate well, in the manner they have attempted to do so, because of the orthotic. So, where are the loads going to go now ? Yes, some are being rammed into the medial aspect of the orthotic, but some are likely going to so elsewhere. Remember, the client is trying to progress their mass over and past the limited ankle rocker, and more pronation was their strategy. But, the orthotic is preventing that. So, the loads are very likely going to move up the chain (because the orthotic is muting loads down into the foot).
______
Me: "Oh, wait, "Mr. Jones", didn't you say you were just recently beginning to have some posterior knee pain ? Let me tell you why you are hyperextending your knee a little more than normal and taxing out your gastrocneumius.* One way you can progress forward, if you cannot do it through ankle rocker, is to extend your knee a little by contracting your quadriceps a small amount at midstance. Lets discuss why the orthotic is not helping you, not solving your problem, and creating some new issues for you. Then lets get down to fixing the root problem."
Some things to think about. Orthotics are not bad, but the user has to know when they are a device to help a client progress through a problem, and when they are inappropriate. Not all increased pronation is bad, particularly when it helps a client get through a problem. But, fix the root problem, and then help them regain proper amounts of pronation.
Oh, and one more thing, all you "drive more ankle rocker and dorsiflexion" people out there. Are you driving more ankle dorsiflexion, or are you merely pressing the talus into more medial posturing, plantarflexion and adduction? These are the talar motions in pronation. And when you pronate, you get more ankle rocker, faked out ankle rocker. So, are you truly helping your client get more ankle rocker and dorsiflexion ? Is this increased pronation what they are doing during their squats, to "apparently" get enough ankle rocker/dorsiflexion? Be careful all those new found ankle rocker mobility drills are not just making your client pronate more than normal. We know it happens, we see all the time. Loss of ankle mobility and loss of foot stability are often a paired phenomenon, they are trying to talk to you and tell you to treat the root cause.
-Dr. Allen, one of the gait guys
Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, rostrally to the lower 3 or 4 ribs and inferior angle of the scapula, to travel superiorly and laterally to the attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements.
It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically during walking gait (1,2) until speed increases or you are running (2-4). The latissimus dorsi is THE functional link between the upper and lower extremity, particularly though its connections with the thoracolumbar fascia (5,6). Latissimus activity, through gait and arm swing seems to profoundly influence and be influenced by gluteal activity, through the posterior oblique sling system (3,4), consisting of the latissimus dorsi, thoracolumbar fascia and contralateral gluteus maximus (7). The posterior oblique sling system provides trunk stability and power delivery to the upper extremity from the contralateral lower extremity and promotes mutual gait patterns between the upper and lower extremities (8), while creating joint contraction in running, turning and walking (9,10). Recent studies conversely show that arm swing can, in turn, effect lower extremity movement as well (3,4).
Given the importance of the latissimus, it would stand to reason we would want it to function at its best. Dry needling is one modality we seem to be able to use to change its function,not only reducing central sensitization, but reducing local and referred pain, improves range of motion and muscle activation patterns (11-13). There are other modalities, including supportive exercises, that can be used to both activate and rehabilitate the lat as well (14-17)
Here is one method we like to use to needle the latissimus dorsi. Consider adding this to your clinical toolbag.
references:
1. Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558
2. G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006
3. Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.
4. Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.
5. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.
6. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy, function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.
7. Mooney V, Pozos R, Vleeming A, Gulick J, Swenski D Exercise treatment for sacroiliac pain. Orthopedics. 2001 Jan; 24(1):29-32.
8. Page P, Frank C, Lardner R: Assessment and treatment of muscle imbalance. Champaign: Human Kinetics Pub, 2010, pp 30–37.
9. Bergmark A Stability of the lumbar spine. A study in mechanical engineering. Acta Orthop Scand Suppl. 1989; 230():1-54.
10. Collins SH, Adamczyk PG, Ferris DP, Kuo AD A simple method for calibrating force plates and force treadmills using an instrumented pole. Gait Posture. 2009 Jan; 29(1):59-64.
11. Dar G, Hicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.
12. Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.
13. Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.
14. Youdas JW, Coleman KC, Holstad EE, Long SD, Veldkamp NL, Hollman JH. Magnitudes of muscle activation of spine stabilizers in healthy adults during prone on elbow planking exercises with and without a fitness ball. Physiother Theory Pract. 2017 Sep 18:1-11. doi: 10.1080/09593985.2017.1377792. [Epub ahead of print]
15. Crane P, Ladden J, Monica D. Treatment of axillary web syndrome using instrument assisted soft tissue mobilization and thoracic manipulation for associated thoracic rotation dysfunction: A case report. Physiother Theory Pract. 2017 Aug 30:1-5. doi: 10.1080/09593985.2017.1368755. [Epub ahead of print]
16. Massé-Alarie H, Beaulieu LD, Preuss R, Schneider C. Influence of paravertebral muscles training on brain plasticity and postural control in chronic low backpain. Scand J Pain. 2016 Jul;12:74-83. doi: 10.1016/j.sjpain.2016.03.005. Epub 2016 May 11.
17. Snarr RL, Hallmark AV, Casey JC, Esco MR. Electromyographical Comparison of a Traditional, Suspension Device, and Towel Pull-Up. J Hum Kinet. 2017 Aug 1;58:5-13. doi: 10.1515/hukin-2017-0068. eCollection 2017 Sep.
How we do one thing, is how we do all things.
I was sitting having my morning coffee earlier than normal this morning, which left me time to ponder some things.
Look at this picture, is this not a magnification of the "cross over gait" x100 ? Thus, is that planted foot not inverted ? Yes, it has to be, to a degree, a high degree. There is a reason why soccer players have a great affinity for ankle sprains.
When we have a narrow based gait, we are most likely going to strike more laterally on the foot, more supinated, if you will. If you widen step width, less inversion, less lateral forces (typically) and less supination (typically) compared to a narrow based gait.
If we descend stairs with our feet in a more narrow based gait, we are not only going to be inverted more, but striking at the ball of the foot, thus, more on the lateral foot tripod. This is the typical inversion sprain injury position.
When we jump, we should be trying to land with our feet more abducted, certainly not narrow based, because if we are too narrow we are at more risk for the same lateral forefoot landing and thus ankle inversion event. Just like descending stairs.
We see plenty of ankle inversion events. Why?
Because most people do not have enough hip abduction or peroneal skill, strength, endurance and they are unaware of their weak gait patterns or their ankle spatial awareness. Many have lazy narrow based gaits and insufficient proprioceptive awareness. And, they carry these things over into running, walking, jump landing (ie. volleyball, basketball, etc), and descending stairs, just to name a few.
How we do one thing, is how we do all things (mostly).
-Dr. Allen
Addendum:
Rickie Lovell : As he struck the ball it would been everted. The momentum of the follow through will have off loaded the everted foot as the energy moves in a similar line to that of the ball. It is extremely rare for a footballer to get a sprain from this, I certainly didn't see over several years working in professional football.
On a side note, find some footage of David Beckham taking free kicks - the mechanics are astounding!
The Gait Guys: possibly everted, but no guarantee.It still looks pretty inverted to me.But we see your point, and is a real good one, real good. Super good. We will check our the bender-man thanks for chiming in with such great insight !
The Gait Guys: yes, the momentum of the leg kicking across the body would externally spin the stance leg. The picture is likely showing the offloading phase, not the loading. Bueno !
Rotate your shoes more often? Maybe not, if you are concerned about plantar pressures. But do increased plantar pressures actually cause injuries? That is the million dollar question, isn't it?
from this paper:
"Walking plantar pressures in running shoes need to be investigated. There are no pedobarographic studies in the literature that compare new with old running shoes. We hypothesized that old running shoes transmitted higher plantar pressures as compared to new running shoes. If so, are old running shoes detrimental to our feet? The purpose of this study was to see whether the mean peak pressures & pressure-time integrals exerted at the plantar surface of feet were higher when using old running shoes as compared to new running shoes.
Plantar pressure measurements in general were higher in new running shoes. This could be due to the lack of flexibility in new running shoes. The risk of injury to the foot and ankle would appear to be higher if running shoes are changed frequently. We recommend breaking into new running shoes slowly using them for mild physical activity.
Rethnam U, Makwana N. Are old running shoes detrimental to your feet? A pedobarographic study. BMC Research Notes. 2011;4:307. doi:10.1186/1756-0500-4-307. link to FREE FULL TEXThttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228510/
references:
Threshold foot drop.
Do you see it in this gait? No. There is a clue though, the EHL on the right (extensor hallucis longus) does not seem to be all that hearty and robust during gait, the toe is not as extended/dorsiflexes as on the left foot. A Clue ? Yes.
This client had true blatant foot drop, but it was caught relatively immediately, and the source resolved and recovery ensued. There is still some residual weakness, as you see at the end of the video, but making steady gains. Previously, gait showed obvious foot drop, foot slap, abrupt knee flexion (the "catch" response as we call it as the client's knee suddenly flexed forward as foot slap occurs). But, as you can see , the gait is pretty much normal now except for a little EHL strength lag. But, at the end of the video, when they heel walk, one can see the weakness, they cannot keep the ball of the foot off the ground during attempted heel walk. We like to call this "threshold weakness", it is just hovering below the surface, when taxed, it can be seen, but doesn't show up in gait. But, it does show up in longer endurance based walking events. This may be when your client's symptoms show up, as fatigue expresses limitations in the system. It just goes to show you, if you are not testing and looking for these things, you just might not find the source of your clients knee pain, foot pain, hip or low back pain. Heel and toe walking takes 10 seconds, do not forget to check them off. It just might be the "big reveal" for you, and them !
-Shawn and Ivo, the gait guys
We have discussed the arm swing issue so many times over the years that we have lost count. By many sources, arm swing is a product of lower limb action and a product of the effective, or ineffective, relationship between the shoulder "girdle" (maybe thoracic rotation component) and the pelvic girdle (lumbopelvic rhythm) during gait. This is the concept of phasic and anti-phasic limb swing. If you want to dive into that, and you should if you are unfamiliar with the concept, you can look it up on our blog using the search box. We are not to forget that the arms, and thus arm swing, is a major factor in maintaining balance. We have used the term "ballast" many times to describe the effects of arm swing, rotation, abduction, circumduction etc on assisting balance maintenance of the body during various locomotion strategies. These are largely subconscious actions, hence why we agree with the research suggesting that arm swing is secondary, compensatory, and takes its queues off of the activity of the lower limb motor actions. In essence, arm swing variants are necessary compensations to assist in maintaining things like balance, center of pressure, equilibrium and the like.
In this recent 2017 study, we have another suggesting arm swings function in assisting, even improving, dynamic stability. We are reminded of MdGill's suggestion, and the concepts of phasic and antiphasic torso-pelvis counter rotational movements, of how spinal loads can be affected by changes or differences in arm position. Even arm position changes in sitting and standing can alter spinal loads, so during movement it is a virtual guarantee.
This study looked at "how arm swing could influence the lumbar spine and hip joint forces and motions during walking." In this study, the researchers had each subject perform walking with different arm swing amplitudes and arm positions. Here is a comment from the researchers on what they found, it is pretty much what we have been writing about for several years based off of other research"
"The range of motion of the thorax with respect to the pelvis and of the pelvis with respect to the ground in the transversal plane were significantly associated with arm position and swing amplitude during gait. The hip external-internal rotation range of motion statistically varied only for non-dominant limb. Unlike hip joint reaction forces, predicted peak spinal loads at T12-L1 and L5-S1 showed significant differences at approximately the time of contralateral toe off and contralateral heel strike."
Thus, we find yet another study confirming what many will say is obvious, that being arm position and movements have notable effects on whole body kinetics and spinal loads. This study suggested that arm variations did not have an effect on spinal loads during walking. We find this curious; it is something we will be looking into, and pondering. We hope you do as well.
Effect of arm swinging on lumbar spine and hip joint forces. Lorenza Angelini et al. Journal of Biomechanics, Sept 2017
http://www.sciencedirect.com/science/article/pii/S0021929017304670
So, is it the effects on calcium and nerve function (neurotransmitter release), the effects on calcium and muscular contraction, the antioxidants properties, some other function? Supplementing Vitamin D and getting people more sun exposure are easy things to do...
"These findings reveal an important new relationship between parathyroid hormone and gait stability parameters and add to understanding of the role of 25-OHD in motor control of gait and dynamic balance in community-dwelling women across a wide age span."
Bird ML, El Haber N, Batchelor F, Hill K, Wark JD. Vitamin D and parathyroid hormone are associated with gait instability and poor balance performance in mid-age to older aged women. Gait Posture. 2017 Sep 28;59:71-75. doi: 10.1016/j.gaitpost.2017.09.036. [Epub ahead of print]
https://www.ncbi.nlm.nih.gov/pubmed/29017107
Links to find the podcast:
iTunes page: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138?mt=2
http://traffic.libsyn.com/thegaitguys/pod_129final.mp3
http://thegaitguys.libsyn.com/podcast-129
Key Tagwords:
usain bolt, gait, gait asymmetry, isometrics, isotonics, RF ablation, COOLIEF, OA, deafferentation, knee arthritis, ibuprofin, kidney damage, NSAIDS, heel drop, achilles, tendonitis, heel pain,
Our Websites:
www.thegaitguys.com
summitchiroandrehab.com doctorallen.co 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, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
Show Notes:
Healing Tech in Neuroscience:
New device can heal with a single touch
https://www.usatoday.com/story/news/nation-now/2017/08/07/miracle-device-can-heal-single-touch-and-even-repair-brain-injuries/537326001/
Cool radiofrequency ablation
http://www.nbcnews.com/health/health-news/cool-new-knee-procedure-eases-arthritis-pain-without-surgery-n771221
Updates on Ibuprofin in runners
http://womensrunning.competitor.com/2017/07/news/ibuprofen-risks-endurance-runners_78580#EyIoMyAdkPW9UBpP.97
PeerJ. 2017 Jul 19;5:e3592. doi: 10.7717/peerj.3592. eCollection 2017.
Sonographic evaluation of the immediate effects of eccentric heel drop exercise on Achilles tendon and gastrocnemius muscle stiffness using shear wave elastography.
Leung WKC1, Chu KL1, Lai C1.
Front Physiol. 2017 Feb 28;8:91. doi: 10.3389/fphys.2017.00091. eCollection 2017.
Quantification of Internal Stress-Strain Fields in Human Tendon: Unraveling the Mechanisms that Underlie Regional Tendon Adaptations and Mal-Adaptations to Mechanical Loading and the Effectiveness of Therapeutic Eccentric Exercise.
Maganaris CN1, Chatzistergos P2, Reeves ND3, Narici MV4.
Oman Med J. 2010 Jul; 25(3): 155–1661.
An Overview of Clinical Pharmacology of Ibuprofen
Rabia Bushra* and Nousheen Aslam
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191627/
Pharm Biol. 2014 Feb;52(2):182-6. doi: 10.3109/13880209.2013.821665. Epub 2013 Sep 30.
Zizyphus jujuba protects against ibuprofen-induced nephrotoxicity in rats. Awad DS1, Ali RM, Mhaidat NM, Shotar AM.
https://www.ncbi.nlm.nih.gov/pubmed/24074058
Gait asymmetry ?
https://www.ncbi.nlm.nih.gov/pubmed/28759127
Scand J Med Sci Sports. 2017 Jul 31. doi: 10.1111/sms.12953. [Epub ahead of print]
Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters.
Haugen T1, Danielsen J2, McGhie D2, Sandbakk Ø1,2, Ettema G2.
It was a great Chicago marathon this year. I worked with some amazing athletes this year and I am so very excited for them, they did amazing ! So amazing in fact that 3 of them were the top Illinois finishers, and all Olympic qualified !
Congratulations to some fine runners, this one, someone who has become a good friend, Kristen Leigh (Kristen Heckert) was the top Illinois finisher and again, PR'd ! 2:38 ! and her husband and coach Michael Lucchesi , a long time friend and one of the best coaches i know was instrumental (he had 10 athletes run this year, helped them to 7 PRs and 3 under olympic trial standard, the 3 top ladies). Kristen, how can someone run that fast ? She finished 27th at the Olympic trials last round, shocking many who had underestimated her. I am excited for you Kristen, for the next round. Huge shout out to Chirine and Alyssa as well ! Congrats ! 1, 2, 3 ! And of course, to all the others I was able to help along the way, too many to mention here, I followed you all, and I am sending my sincere congratulations ! -Dr. Allen
Kristen Heckert 2:38 PR (Top finisher in Illinois)
Chirine Njeim 2:39 PR (2nd IL)
Alyssa Schneider 2:42 PR/Debut (3rd IL)
https://www.runnersworld.com/chicago-marathon/this-teacher-has-an-amazing-marathon-pr-and-a-mind-boggling-wakeup-call?utm_campaign=Runner%E2%80%99s+World&utm_medium=Social&utm_source=facebook.com&utm_term=1103204175
We speak often about the 3 foot rockers, with particular attention often to ankle rocker (ankle mortise). But one must not forget about the rear and forefoot rockers, they have their important place as well.
But, we all too often only think of these parameters when the foot is on the ground. The truth is, the swing limb is very important as well. How we swing, how the foot prepares for initial contact is also critical.
Last week Ivo wrote about toe walkers, a topic we have written about several times previously on our blog "The Gait Guys".
In this study, the researchers were appearing to look at plantarflexion posturing of the foot-ankle complex. the noted that"unilateral restricted ankle motion influenced kinematics mainly in the swing phase" as we proposed. Again, swing phase is just as critical as the stance phase of gait. One might recall our mnemonic, "when the foot is on the ground, the glutes are in charge, and when the foot is in the air, the abdominals are in charge". This admittedly is a very loose statement, but it has its place to begin the dialogue. Meaning, there is more to it. Yes, the hip flexors are key, but they have to be active on a precursor, sufficient control of the pelvis, via the abdominals in part. To this point, the researchers noted that, "hip and knee peak flexion in the swing phase were increased on the restricted side". Meaning, that to clear a plantarflexed foot-ankle complex, one might have to accentuate flexion elsewhere. No rocket science here. This is the "foot drop" strategy most of us are all to familiar with. People with foot drop have an inability to dorsiflex the ankle to clear the ground in swing, thus, to avoid tripping, one has to flex the limb higher up the chain, perhaps even hike the pelvis with the opposite leg hip abductors (plus a little frontal plane lean perhaps). This article however discusses restrictions, and not what we just discussed, loss of function.
Furthermore, "Walking with unilateral restricted ankle motion had a negative effect on walking velocity, cadence, step time, and step length."
Gait Posture. 2015 Mar;41(3):835-40.
Immediate effects of unilateral restricted ankle motion on gait kinematics in healthy subjects. Romkes J1, Schweizer K2.
https://www.ncbi.nlm.nih.gov/pubmed/25800648
The extensor hallucis brevis : An overlooked "miracle worker"
The Extensor Hallicus Brevis, or EHB as we fondly call it is an important muscle for descending the distal aspect of the 1st ray complex (1st metatarsal and medial cunieform) as well as extending the 1st metatarsophalangeal joint. It is in part responsible for affixing the medial tripod of the foot to the ground. Its motion is generally triplanar, with the position being 45 degrees from the saggital (midline) plane and 45 degrees from the frontal (coronal) plane, angled medially, which places it almost parallel with the transverse plane. With pronation, it is believed to favor adduction (1).
It arises from the anterior calcaneus and inserts on the dorsal aspect of the proximal phalynx. It is that quarter dollar sized fleshy protruding, mass on the lateral aspect of the dorsal foot. The EHB is the upper part of that mass. It is innervated by the lateral portion of one of the terminal branches of the deep peronel nerve (S1, S2), which happens to be the same as the extensor digitorum brevis (EDB), which is why some sources believe it is actually the medial part of that muscle. It appears to fire from loading response to nearly toe off, just like the EDB; another reason it may phylogenetically represent an extension of the same muscle (2-4).
Because the tendon travels behind the axis of rotation of the 1st metatarsal phalangeal joint, in addition to providing extension of the proximal phalynx of the hallux (as seen in the child above), it can also provide a downward moment on the distal 1st metatarsal (when properly coupled to and temporally sequenced with the flexor hallicus brevis and longus), assisting in formation of the foot tripod we have all come to love (the head of the 1st met, the head of the 5th met and the calcaneus).
Why is this so important?
The central axis of a joint (sometimes called the instantaneous axis of motion) is the center of movement of that articulation. It is the location where the motion will occur around, much like the center of a wheel, where the axle attaches. In an articulation, it usually involves one bone moving around another. Lets look at an example with a door hinge.
A hinge is similar to a joint, in that it has parts with is joining together (the door and the jamb), with a “joint” in between, The axis of rotation of the hinge is at the pivot rod. When the door, hinge and jamb are all aligned, it functions smoothly. Now imagine that the hinge was attached to the jamb 1/4” off center. What would happen? The hinge would bind and the door would not operate smoothly.
Now let’s think about the 1st metatarsal phalangeal joint. It exists between the head of the 1st metatarsal and the proximal part of the proximal part of the proximal phalanyx. Normally, because the head of the 1st metatarsal is larger than the heads of the lesser ones, the center of the joint is higher (actually,almost 2X as high; 8mm as opposed to 15mm). We also remember that the 1st metatarsal is usually shorter then the 2nd, meaning during a gait cycle, it bears the brunt of the weight and hits the ground earlier than the head of the 2nd.
The head of the 1st metatarsal should slide (or should we say glide?) posteriorly on the sesamoids during dorsiflexion of the hallux at pre swing (toe off). It is able to do this because of the descent of the head of the 1st metatarsal, which causes a dorsal posterior shift of the axis of rotation of the joint. We remember that the head of the 1st descends through the conjoined efforts of supination and the coordinated efforts of the peroneus longus, extensor hallucis brevis, extensor hallucis longus, dorsal and plantar interossei and flexor hallucis brevis (which nicely moves the sesamoids and keeps the process going smoothly)(1, 5).
Suffice it to say, if things go awry, the axis does not shift, the sesamoids do not move, and the phalanyx crashes into the 1st metatarsal, causing pain and if it continues, a nice spur you can write home about!
Treating and needling this muscle is easy, as it is very accessible on the dorsum of the foot and due to the decreased receptor density, is not too uncomfortable. We like to needle the peroneus longus and short flexors as well, as they all have the function of lowering the head of the 1st ray. Check it out in this quick how to video.
2. https://www.physio-pedia.com/Extensor_Hallucis_brevis
3. http://www.wheelessonline.com/ortho/extensor_hallucis_brevis
4. Becerro de Bengoa Vallejo R., Losa Iglesias M.E., Jules K.T. Tendon Insertion at the Base of the Proximal Phalanx of the Hallux: Surgical Implications (2012) Journal of Foot and Ankle Surgery, 51 (6) , pp. 729-733.
5. Zelik, K.E., La Scaleia, V., Ivanenko, Y.P. et al. Eur J Appl Physiol (2015) 115: 691. https://doi.org/10.1007/s00421-014-3056-x
Photo courtesy of Surestep
Idiopathic Toe Walking in kids..Is it flexor dominance?
You see this at times in the office. Kiddos (or adults) who walk on their toes for no apparent reason. many have shortened heel cords with limited ankle dorsiflexion (1,2). Some studies report an incidence of 7-24% in pediatric populations (3) with an average of about 5% in children that are 5.5 years old (4). It seems to occur in about 2% of normally developing kids aged 5.5 years and 40% of those that have some sort of neuropsychiatric diagnosis or missed a developmental window (5-7), with an increased incidence familialy (8). The question here is why, not what.
We have discussed our opinions of flexor dominance here many times and suffice it to say that increased corticospinal activity seems to have the double whammy effect of increased firing of the distal flexors due to a lack of input to the axial extensors in the rostral and caudal reticular formations respectively(possibly from decreased spindle and /or GTO input and/or mechanoreceptor dysafferentation?) and lack of reciprocal inhibition of the extensors from the increased firing of the flexors segmentally. Is it the cortical abnormailities and missed developmental windows seen in so many of these folks that drives this? These are the sorts of things that keep us up at night....
Physical treatment modalities (2) seem to help, we think most likely to plastic changes in the connective tissue. Orthotics may prove useful due to similar mechanisms, especially if there is an equinus deformity or forefoot to rearfoot abnormaility (9). More agressive (and invasive) measures like Botox, seem to not. An interesting study using whole body vibration (10) produced some immediate but short lived positive results. This really gets you thinking about joint and muscle mechanoreceptors and the cerebellum, and makes us think that perhaps we also should be looking (and treating) north of the foot. We could not find any studies looking at the effects of proprioceptive or vestibular exercises effects on this, but think it could be promising area of therapy and we will continue to employ them until our clinical results tell us otherwise.
1. Barrow WJ, Jaworski M, Accardo PJ. Persistent toe walking in autism. J Child Neurol 2011;26(5):619-621
2. Harris NM. Multidisciplinary approach led to positive results for pediatric patient with idiopathic toe walking. Presented at the Association of Children’s Prosthetic-Orthotic Clinics Annual Meeting, Broomfield, CO, April 15, 2016.
3. Engelbert R, Gorter JW, Uiterwaal C, et al. Idiopathic toe-walking in children, adolescents and young adults: a matter of local or generalised stiffness? BMC Musculoskelet Disord. 2011;12:61.
4. Engström P, Tedroff K. The prevalence and course of idiopathic toe-walking in 5-year-old children. Pediatrics 2012;130(2):279-284.
5. https://tmblr.co/ZrRYjx1VV59rl
6. Williams, C. , Curtin, Wakefield and Nielsen Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait. J Child Neurol 2014, 29:71
7. https://tmblr.co/ZrRYjx1WTNcdK
3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait. J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen
8. Pomarino D, Ramirez Llamas J, Pomarino A. Idiopathic toe walking: tests and family predisposition. Foot Ankle Spec 2016;9(4):301-306
9. Herrin K, Geil M. A comparison of orthoses in the treatment of idiopathic toe walking: a randomized controlled trial. Prosthet Orthot Int 2016;40(2):262-269.
10. Williams CM, Michalitsis J, Murphy AT, et al. Whole-body vibration results in short-term improvement in the gait of children with idiopathic toe walking. J Child Neurol 2016;31(9):1143-1149.
In the 1500's in Western Europe, shoes were different. People wore “turn shoes”, leather shoes that were made inside out then reversed for wear. This was likely the beginning of the use of molds to make shoes, carpenters up until the twentieth century would carve a wooden foot model of various sizes to model the process and standardize it.
These "Turn Shoes" were replaced by shoes with a frame construction as shoes changed to adapt to different environments, as streets changed.
The Turn shoes were basically a slip on or lace up thick leather sock. Thus, they were zero drop, soft, and provided much "feel" for the ground. Proprioception was obviously well appreciated.
We have spoken about the difference between heel strike and heel contact in walking. One can safely heel strike if barefoot on soft grass, but one cannot on the hard concrete or asphalt that we have covered much of our world with. Thus, if one were to wear "turn shoes" in our modern era, one would be forced to adapt to a heel contact or "heel kiss" on the ground, meaning, a more predominant forefoot loading style as described in this video.
What he describes, is largely not a choice, it was because they were in soft thin leather sock all day long, and even on wood or hard dirt packed floors and cart paths all day long, the heels would want some reprieve from heel "strike".
Another way around this, to reduce heel strike, is to do it more naturally, by shortening the step and stride lengths a little, by keeping the body mass over the foot strike. "Chi Running" and "Chi walking" are based off of this principle. By moving the body mass forward with the foot, one has to naturally reduce heel strike. If one lags the body mass behind the foot however, the foot moves out in front, and heel strike begins to naturally (or shall we say, unnaturally) out in front, more heavily. This is not exactly desirable, for many reason. Yet, since most of our shoes have some form of heel lift (a heel to forefoot drop), particular dress shoes (yes, even men's dress shoes, see photo), and even many modern day running shoes, the heel is essentially made more prominent (the heel rise essentially makes the brain think our heel (calcaneus) that much longer. This makes it easier, yet undesirable, to heel "strike" first. Oh what we have done for fashion !
He gets a few things wrong in the video, in terms of "ease" of walking, but largely it is decently done. One has to be careful if they perch the foot out in front like he does in the slower demonstration, in a plantarflexed ankle and foot, one can easily begin to lock up the knees. We often see this in teenagers in flip-flops.
-Shawn and Ivo, the gait guys
So how many times do we se someone in the clinic who have a problem, but it is not apparent at the time of exam? You know the scenario "I get this low back pain at mile 10" or "My knee hurts on the bike at mile 50". Our questions are
"So, when are you examining your patient?".
The correct answer is "C". We like to say "if we can reproduce the pain, we can most likely figure out what the problem is and can usually come up with a solution or a different compensation".
See your people around the time of the injury. If they get pain at mile 19, then have them run 18 prior to their visit and have them finish up in the office. If the knee pain is at mile 50 on the bike, have them do the last 10 on the trainer under your supervision. People will often have great mechanics until they begin to crumple. Your job is to see them at their worst, or watch their function deteriorate real time and try and come up with a solution.
This concept is used all the time in exercise and stress testing. Why don't we use it with other than cardiovascular evaluations? The question eludes us. We often call this "pre fatigue" and use its all the time. You should too. The factors that separate a good clinician from a great one is outcomes. Be all you can be...
The Gait Guys
Dores H, Mendes L, Ferreira A, Santos JF. Symptomatic Exercise-induced Intraventricular Gradient in Competitive Athlete. Arquivos Brasileiros de Cardiologia. 2017;109(1):87-89. doi:10.5935/abc.20170075. FREE FULL TEXT
Biffi A, Ammirati F, Caselli G, Fernando F, Cardinale M, Faletra E, Mazzuca V, Verdile L, Santini M.Usefulness of transesophageal pacing during exercise for evaluating palpitations in top-level athletes. Am J Cardiol. 1993 Oct 15;72(12):922-6. FREE FULL TEXT: http://www.ajconline.org/article/0002-9149(93)91108-T/pdf
Yesterday we wrote about the importance of endurance acquisition in preventing injuries. It is not a coincidence that many injuries sneak up on athletes in the later part of a game or event. Fatigue can predispose us to the variables that sent up compensation and injury, not always of course, but often.
We felt it would be worthy work to look into a few other journal articles to make our case, not that it truly needed to be hammered out further, but we like to hammer.
We discovered that novice runner's (1) trunk inclination increased and ankle eversion increased with fatigue. Furthermore, as fatigue increased, it was noted to be prominent in the hip external rotators and hip abductors (2). We have discussed this ad nauseam over the years. Failure in these areas impact one's ability to hold sufficient limb rotation to ensure clean sagittal knee mechanics. Challenges in these motions also lead to faults in foot targeting. When these abductors and external rotators fatigue or weaken, hip adduction can often occur leading to undesirable medial foot targeting, hence narrow step width and our favorite soap box topic, the cross over gait. These issues become pronounced at the end of the run according to the Dierks study. However, in the 2nd Dierks (3) study these findings were challenged, "uninjured runners normally experience small alterations in kinematics when running with typical levels of exertion". Similarly, in the García-Pinillos study, (5) no major form failures were noted in endurance athletes that pushed their limits in another type of failure test, the HIIT (high intensity interval) workout. Dierks (3) remarked that "It remains unknown how higher levels of exertion influence kinematics with joint timing and the association with running injuries, or how populations with running injuries respond to typical levels of exertion.".
None the less, these are just two studies, and there are others to refute it. We do however, challenge this. But, this is easy to do, because all day long in our clinics we see and hear the cases where there is correlation, because the people seeking us out are in fact "symptomatic" patients and not uninjured runners, so it is easy to lean in one biased direction from our end. Though, it bodes the bigger question off of this following statement, "uninjured runners normally experience small alterations in kinematics when running with typical levels of exertion", as to whether in time, these small alterations might lead to a symptomatic state. One can easily theorize that it is in fact this time variable that eventually leads these small alterations towards bigger ones that might become symptomatic. After all, every avalanche starts with a single snowflake, no offense to the snowflakes out there.
Shawn Allen, the gait guys
References:
1. J Sci Med Sport. 2014 Jul;17(4):419-24. doi: 10.1016/j.jsams.2013.05.013. Epub 2013 Jun 19.
Kinematic changes during running-induced fatigue and relations with core endurance in novice runners. Koblbauer IF1, van Schooten KS2, Verhagen EA3, van Dieën JH2.
2. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56. doi: 10.2519/jospt.2008.2490. Epub 2008 Aug 1.
Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. Dierks TA1, Manal KT, Hamill J, Davis IS.
3. J Biomech. 2010 Nov 16;43(15):2993-8. doi: 10.1016/j.jbiomech.2010.07.001.
The effects of running in an exerted state on lower extremity kinematics and joint timing. Dierks TA1, Davis IS, Hamill J.
4. Gait Posture. 2014;40(1):82-6. doi: 10.1016/j.gaitpost.2014.02.014. Epub 2014 Mar 4.
Do novice runners have weak hips and bad running form? Schmitz A1, Russo K1, Edwards L1, Noehren B2.
5. J Strength Cond Res. 2016 Oct;30(10):2907-17. Do Running Kinematic Characteristics Change over a Typical HIIT for Endurance Runners?
García-Pinillos F1, Soto-Hermoso VM, Latorre-Román PÁ.
Donate here
Help keep us free ! Make a donation by clicking. here.
Donate to get exclusive content from The Gait Guys
OUR SEARCH BOX IS INTUITIVE, TYPE IN YOUR KEY WORD, WAIT, THEN SCROLL DOWN.
Email us: our email is found under the "Disclaimer" Tab above.
Powered by Squarespace.
