Grab a Beer and Watch this Heel Strike Flick !
Wow, only one mid-forefoot striker in the whole bunch …….everyone else is a heavy heel striker. ……. and so the epidemic continues……… until this plague ends runners will always have injuries and guys like Ivo and myself will never be able to retire ! …….. until then…….. we remain dreamers of Boats, Beaches, Bars and Ballads (a great Jimmy Buffett box set !)
“Fins to the left, fins to the right, ….. We’re the only GAIT in town”
Even though it isn’t winter, we could resist showing you these “toasty” slippers…
Have a fun Friday,
Ivo and Shawn
Correlating various foot problems to hip function and limitations. This is something we have been shouting about for years now.
One of the very first things we do after watching one’s gait on any patient visit is to have them supine on the table and check passive external and internal hip rotation (IR) ranges. At this time paying particular attention to the topic of INTERNAL HIP ROTATION, we do this particularly with the limb straight (lying flat on the table) to mimic what the range might be with them standing in midstance phase of gait/running (ie. the pelvis and body mass directly over the foot). We do this supine because checking IR in variations of hip flexion does not make much sense when it comes to gait pathology. We compare the ranges left and right. They should be symmetrical and sufficient. According to Michaud’s work, 4-6 internal rotation degrees is necessary, 45 is normal.
As we move through midstance the stance limb is converting from external hip rotation to internal rotation as the contralateral hemipelvis transitions forward during that leg’s swing phase. A major key for normal biomechanics moving downwards through the kinetic chain is that sufficient hip internal rotation is present. If there is a deficit functionally (and sometimes that is different from what the books say is necessary), the internal rotation has to occur somewhere. Quite frequently it occurs through more aggressive and faster internal tibial rotation which will challenge the amount of foot pronation that occurs (it usually causes more). [* please keep in mind if your solution for this local increased pronation at the foot is an orthotic to block the excess motion keep in mind that the body now has to find another place to put this internal spin and sadly it quite often has to go back to the hip and this can cause the hip labral problems that we have talked about all week. *Now you see why we set the week up this way preempting this discussion with the pathologies.]
Continuing our thoughts a bit further, if internal hip rotation is not sufficient as the body moves over the limb then the next succession, hip extension, is going to be compromised. This sets up a whole cascade of problems. here we go with some (but not all) …….
And so …. if you follow this whole lineage, you will see a completion of a vicious cycle. So now, the entire gait pattern is disrupted. From internal hip rotation, to hip extension, to glute mediation, to pelvic instability, to impaired limb spin, to impaired pronation-supination cycle and thus …… gait pathology. And in time, but hopefully not, hip labral and knee meniscal pathologies to go with the gait pathology.
Remember what they always say…….. FORM FOLLOWS FUNCTION.
But here at The Gait Guys, we like to say……..FORM FOLLOWS DYSFUNCTION.
we ain’t no Gait Fools !
What have we been saying all along ?………. everyone’s foot morphology is different…… no one just fits into the old pronator or supinator foot types. There is so much more to it.
From the brief newsreel……
“Ms Baxter’s PhD supervisor, Associate Professor Stephan Milosavljevic, of Otago’s School of Physiotherapy, says the study highlights that everyone’s foot morphology is different.
Previous studies have shown that Pacific Island and Maori people tend to have flatter, wider feet that are better designed for dexterity while bare-foot.
“So the ‘one-size-fits-all’ philosophy does not necessarily work because everybody’s feet are different, and this has implications for learning how best to protect against injuries down the line,” he says.”
Tomorrow, in Part 4 (the last part), we will talk about functional hip problems in runners and cyclists but today we will finish up this little topic on some of the internal hip derangements. For tomorrow, remember our key words from the other day, INTERNAL HIP ROTATION range……. it is important stuff when we discuss gait and the hip problems that result from pathologic gait patterns.
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Labral detachments and tears are the most common clinically significant abnormalities to be identified. To date it still seems that evaluation of the patient with chronic mechanical hip pain remains somewhat of a diagnostic dilemma for physicians. The differential diagnosis is diverse including common entities such as osteoarthritis, fracture, and avascular necrosis, as well as less common entities including pigmented villonodular synovitis, synovial osteochondromatosis, snapping hip syndrome, and hemorrhage into the ligamentum teres. Childhood disorders such as Perthes disease and dysplasia also need to be considered with adolescents. Similar to findings in the knee and shoulder, radiographs appear normal in the vast majority of patients with internal derangement as a cause for hip symptoms. In one study, labral lesions were identified at arthroscopy in 55% of patients with intractable hip pain.
Imaging: As with other joints in the body, magnetic resonance (MR) arthrography of the hip has emerged as a technique for diagnosis of internal derangement of the hip. In addition to depicting labral lesions, MR arthrography may also depict intraarticular loose bodies, osteochondral abnormalities, and abnormalities of the supporting soft-tissue structures. Radiographs in patients with labral tears are typically unremarkable. If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.
Labral lesions have a strong correlation with symptoms such as: anterior inguinal pain, painful clicking, transient locking. “giving way” of the hip. Pain may be reproduced with flexion and internal rotation of the hip. An audible click may also be present at times. The patient history usually does not reveal significant trauma. The onset of pain may be related to sports and may involve a mild twisting or slipping injury. Major trauma such as dislocation may result in labral tear.
Patients with developmental dysplasia of the hip are at increased risk for labral tears and abnormalities of the labral rim. The Rim syndromes are categorized by two types of acetabular dysplasia; one being the incongruent oval shaped acetabulum the other being the congruent, spherical acetabulum with poor lateral coverage of the femur head which leads to fatigue fractures of the acetabulum socket and articular and interosseous cyst formation. In patients with developmental dysplasia, the acetabular rim and the labrum are placed under increased stress.
The possibility of a pathologic labral condition should be considered in individuals with developmental dysplasia of the hip in whom the pain is disproportionate to the radiographic changes, as well as in patients who have not experienced significant improvement after osteotomy. The fact that a detached labrum increases the risk of failure of treatment has been recognized.
Summary:
Mechanical hip pain can be a real enigma unless your doctor really knows their stuff. Not many studies talk about neuromuscular support, muscular function and movement patterns of the hip largely because the education in this area is poor, in our opinion. Physician skill level with years of experience is also a real challenge when dealing with mechanical hip pain and the causes (as we have discussed here) of anatomic pathology that might occur when the normal hip mechanics are challenged. Add an abnormal gait pattern to the mix and it is no wonder why some hip problems go undiagnosed in the early stages of problem.
A pathologic labral conditions, detachments or tears, are a common cause of chronic hip pain, and MR arthrography of the hip is the imaging procedure of choice for identifying an abnormal labrum. Detachments are more common than tears and are identified on the basis of the presence of contrast material interposed at the acetabular-labral junction.
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There is not a ton of literature out on the Rim syndromes, since some of you have been asking about it. Here is an article we found. Link for article purchase is at the header of today’s blog.
J Bone Joint Surg Br. 1991 May;73(3):423-9.
The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.
Klaue K, Durnin CW, Ganz R.
Abstract
The acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or ‘os acetabuli’ as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.
ARS: Acetabular Rim Syndromes. Hip Pain.
Some examples of MOI’s (Mechanism of Injury)
-An athlete complains of a gradual onset of pain deep within his or her anterior groin.
-Forceful kicking a ball with the medial border of the foot may cause a sharp pain with a catching sensation.
-A case involving a ballerina with 10 months of left hip pain originated during a high kick in the abducted position; she felt a sudden catching sensation in the anterior left groin.
-A car accident with knee dashboard impact forcing femur posteriorly.
-A wrestler in a quadruped position forced back onto heels (buttock to heels)
Labral lesions have a strong correlation with
anterior inguinal pain
painful clicking
transient locking
giving way of the hip
Pain may be reproduced with flexion and internal rotation of the hip
An audible click may also be present
The patient history usually does not reveal significant trauma
The onset of pain may be related to sports and may involve a mild twisting or slipping injury
Radiographs in patients with labral tears are typically unremarkable.
If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.
While the pain is usually in the groin, it could also be in the trochanteric and buttock region. A significant trauma is not necessary to disrupt the labrum - twisting or falling may be causative. The injury is usually caused by the hip joint being stressed in rotation. The pain could be acute or insidious. The most common complaint is discrete episodes of sharp pain precipitated by pivoting or twisting. Clicking or catching is common but not always present. Activities that involve forced adduction of the hip joint in association with rotation in either direction tend to aggravate. The majority of labral tears (up to two-thirds) are located anteriorly.
Their hip pain is often nonspecific regarding symptoms.
Radiological findings may be negative.
It is important to rule out early any possibility of fractures, infections, inflammation or ischemic necrosis; laboratory tests of blood, urine and at times synovial fluid may be necessary.
Acetabular dysplasia, considered pre-osteoarthritic by some, is a valid clinical entity that must be considered. Some references are calling this disorder dysplastic acetabular rim syndrome (DARS).
Early symptoms will occur due to overload of the acetabular rim caused by hip motions such as a combination of flexion, adduction and internal rotation.
Getting out of a car or doing the breast stroke are examples of this type of movement stress.
Snapping, locking and clicking are common in ARS, causing the clinician to think of problems related to the labrum or a painless snapping iliopsoas.
Snapping hip complaints must be discriminated from functional hip problems such as anterior femoral glide syndrome and IT Band syndrome.
Symptoms due to hip instability may be related to ARS.
The patient may suffer unexplained falls or the feeling that his or her hip may give way.
With acetabular dysplasia, there may be excessive anteversion of the femoral neck, causing an increase in hip internal rotation on examination. The capsular pattern of the hip that indicates osteoarthritis is almost always a decrease in hip internal rotation. Therefore, as soon as osteoarthritis appears, decreased hip internal rotation will also appear.
We are going to leave things here for today…….we wanted to leave you with 3 words for the day……..INTERNAL HIP ROTATION. Keep these 3 words in your clinical hat for the day, look for its loss and start thinking about your runners, your patients. Look for this loss when the patient is supine and in the straight leg position. Test the hip rotation from spinning the hip (from an ankle contact point) into internal rotation, compare side to side.
More tomorrow ……but remember, sometimes it is not the part……but the anchor for the part….. hence why we will be talking about the lower abdominals as the week goes on. The amount of Internal hip rotation available is only as much as the abdominal wall can support or anchor (ie. a weak abdominal wall cannot support much functional internal hip rotation…….. why ? tune in tomorrow ! as we bring this full circle.)
……….. we are more than…….Just The Gait Guys
We have much to say on this topic. A few years ago I was doing some lectures on Hip Rim syndromes (ARS: Acetabular Rim Syndromes) for an imaging center and realized the lack of clinical knowledge on the topic. Recently, we have been receiving some referrals and emails regarding and we figured it was time to “hit the hip” topic for awhile.
Here is an article to start with. It has some basic info. If you want to be able to follow our progression of Rim Syndromes and labral issues and how to approach them clinically etc start here (and, if you are an athlete with hip issues, there will be understandable and usable info for you as well as the week progresses). We have some nice powerpoint presentations on this stuff too, we are looking for a way to make them available for you as well.
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**** Here is our main problem with the article, as admitted by the authors……… “
** "Clinical Relevance: Although this study does not include muscular forces across the hip joint, it does provide a clue as to the stresses about the labrum through the complete range of motions of the hip, which may help in providing a better understanding of the cause of labral tears and in the protection of labral repairs.”Study:
Am J Sports Med. 2011 Jul;39 Suppl:92S-102S.Check out our take on this classic that we “remade” for The Natural Running Center (www.naturalrunningcenter.com) and Zero-drop.com.
Thanks for the opportunity, guys!
The Gait Guys
Gender differences in walking and running on level and inclined surfaces.
Chumanov ES, Wall-Scheffler C, Heiderscheit BC. Clin Biomech (Bristol, Avon). 2008 Dec;23(10):1260-8. Epub 2008 Sep 6.
What the Gait Guys have to say about this article:
This article highlights some of the differences in gait between males and females on treadmills. Though treadmills don’t necessarily represent real life, they are an approximation. While reading this article, please keep the following in mind:
1. 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 (especially the glute max) through reciprocal inhibition, making it difficult to fire them.
2. Because the deck is moving, the knee is brought into extension, with stretch of the hamstrings, the quads become reciprocally inhibited (same mechanism above).
3. The moving deck also has a tendency to put the ankle in dorsiflexion, 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. 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
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. Can you say back pain?
In summary, treadmills are not the scourge of humanity, but do have some pitfalls for training, and equal amounts of “backwards” running should be employed (with great caution, mind you)
With that being said, lets look at the results: increased hip internal rotation and adduction, as well as more glute activity for the ladies. Not surprising considering women generally have a larger Q angle (17 +/- 3 degrees for females, 14 +/-3 degrees for males) and greater amounts of hip anteversion (average 14 degrees in females vs 8 in males). The larger Q angle places more stress at the medial knee (compression of the medial femoral condyle and usually increased pronation as the center of gravity over the foot is moved medially) and thus more control needed to slow pronation (from the glutes to control/augment internal rotation). Greater hip anteversion means the angle of the femoral head is greater than 12 degrees to the shaft of the femur. This moves the lower extremity into a more internally rotated position, approximating the origin and insertion of the adductors, making them easier to access. With an increased Q angle and easier access, greater demands are placed on adductors in single leg stance (which is considerably greater in running), This increased adductory moment places more demand on the gluteus medius (and contralateral QL) as well, to stabilize the pelvis and this correlates with speed and incline, also found in the study.
The take home message? Don’t throw away your treadmill! The treadmill can be an excellent diagnostic tool! Gluteal and adductor insufficiencies will be more visible (and probably more prevalent) in females, especially those running or walking on treadmills. The hip extension and ankle dorsiflexion moment created by a treadmill works against some of the stabilizing mechanisms (glute inhibition, ankle dorsiflexor inhibition) and help to highlight some of the subtle gait abnormailities you may miss otherwise.
we remain….The Gait Guys
More silly gaits. A take off on the Monty Python classic…In German no less
Have a great Friday!
Shawn and Ivo
In searching our personal archives for neat stuff we came across an oldie but a goodie. One to certainly make your head spin. We do not even know where this came from and how much was our original material and how much was someone else’s. If you can find the reference we would love to give it credit. We do now that we added some stuff to this but we don’t even know what parts were ours ! Regardless, there is a brain twister here worth juggling in your heads. Lets start with this thought……..
When you are sitting the rectus femoris (a quad muscle) is “theoretically” shortened because the hip is in flexion. It crosses the bent knee in the front at it blends with the patellar tendon, thus it is “theoretically” lengthened at the knee. When we stand up, the hip extends and the knee extends, making the R. Femoris “theoretically” lengthen at the hip and shorten at the knee. This, it bodes the question…….did the R. Femoris even change length at all ? And the hamstrings kind of go through the same phenomenon. It is part of the uniqueness of “two joint” muscles. Now, onto Lombard’s paradox with more in depth thought on this topic.
Warren Plimpton Lombard (1855-1939) sought to explain why the quadriceps and hamstring muscles contracted simultaneously during the sit-to-stand motion. He noted that the rectus femoris and the hamstrings are antagonistic, and this coactivation is known as Lombard’s paradox.
The paradox is classically explained by noting the relative moment arms of the hamstrings and rectus femoris at either the hip or the knee, and their effects on the magnitude of the moments produced by either muscle group at each of the two joints.
By virtue of the fact that muscles cannot develop different amounts of force in their different parts, the paradox develops. The hamstrings cannot selectively extend the hip without imparting an equal force at the knee. Thus, the only way for hip extension and knee extension to occur simultaneously in the act of standing (or eccentrically in the act of sitting) is for the net moment to be an extensor moment at both the hip and knee joints. Lombard suggested three necessary conditions for such paradoxical co-contraction:
In 1989, Felix Zajac & co-workers pointed out that the role of muscles, particularly two-joint muscles, was much more complex than has traditionally been assumed. For example, in certain situations, the gastrocnemius could act as a knee extensor. It is clear now that the direction in which a joint is accelerated depends on the dynamic state of all body segments, making it difficult to predict the effect of an individual muscle contraction without extensive and accurate biomechanical models (Zajac et al, 2003).
In fact, back to the gastrocnemius another 2+ joint muscle (crosses knee, mortise and subtalar joints), we all typically think of it as a “push off” muscle. It causes the heel to rise and accelerates push off in gait and running. But, when the foot is fixed on the ground the insertion is more stable and thus the contraction, because the origin is above the posterior joint line, can pull the femoral condyles into a posterior shear vector. It thus, like the hamstrings, needs to be adequately trained in a ACL or post-operative ACL, deficient knee to help reduce the anterior shear of normal joint loading. It is vital to note, that when ankle rocker is less than 90 degrees (less than 90 degrees of ankle dorsiflexion is available), knee hyperextension is a viable strategy to progress forward in the sagittal plane. But in this scenarios, the posterior shear capabilites of the gastrocnemius are brought to the front of the line as a frequent strategy. And not a good one for the menisci we should mention.
Andrews J G (1982) On the relationship between resultant joint torques and muscular activity Med Sci Sports Exerc 14: 361-367.
Andrews J G (1985) A general method for determining the functional role of a muscle J Biomech Eng 107: 348-353.
Bobbert MF, van Soest AJ (2000) Two-joint muscles offer the solution - but what was the problem? Motor Control 4: 48-52 & 97-116.
Gregor, R.J., Cavanagh, P.R., & LaFortune, M. (1985). Knee flexor moments during propulsion in cycling–a creative solution to Lombard’s Paradox. Journal of Biomechanics, 18, 307-16 .
Ingen-Schenau GJv (1989) From rotation to translation: constraints on multi-joint movement and the unique action of bi-articular muscles. Hum. Mov. Sci. 8:301-37.
Lombard, W.P., & Abbott, F.M. (1907). The mechanical effects produced by the contraction of individual muscles of the thigh of the frog. American Journal of Physiology, 20, 1-60.
Mansour J M & Pereira J M (1987) Quantitative functional anatomy of the lower limb with application to human gait J Biomech 20: 51-58.
Park S, Krebs DE, Mann RW (1999) Hip muscle co-contraction: evidence from concurrent in vivo pressure measurement and force estimation. Gait & Posture 10: 211-222.
Rasch, P.J., & Burke, R.K. (1978). Kinesiology and applied anatomy. (6th ed.). Philadelphia: Lea & Febiger.
Visser JJ, Hoogkamer JE, Bobbert MF & Huijing PA (1990) Length and Moment Arm of Human Leg Muscles as a Function of Knee and Hip Angles. Eur. J Appl Physiol 61: 453-460.
Zajac FE & Gordon MF (1989) Determining muscle’s force and action in multi-articular movement Exerc Sport Sci Revs 17: 187-230.
Zajac FE, Neptune RR, Kautz SA (2003) Biomechanics and muscle coordination of human walking - Part II: Lessons from
dynamical simulations and clinical implications, Gait & Posure 17 (1): 1-17.
Here is some more “vintage” Shawn and Ivo from ‘09 discussing pronation on one of our podcasts.
Follow up post on yesterdays FOOT TRIPOD VIDEO
Good Day Fellow foot geeks !
Yesterday we posted a quick video of a young teenager who came to us for orthotic prescription. As you can see in the early part of the video he had a flat foot posturing and increased foot progression angle (feet pointing too much east and west).
The increased foot progression posturing can be a problem, and accentuate pronation strategies, particularly if it is outside the normative values of 5-15 degrees. This is because during midstance the limb is internally rotating. If the foot progression angle is increased as the limb internal rotation occurs while the body mass is progressing over the foot in midstance, the positioning of the medial tripod of the foot is far off the forward/sagittal progression line (the direction of walk). When the tibia and femur internally rotate on such a foot posturing the degree of pronation is accelerated and accentuated. In another way of explaining it, the subtalar joint is almost falling medially outside of the tripod boundaries and thus cannot be controlled by the tripod. It would be like placing a camera directly on the letter “c” in the triangle diagram above, where the points of the triangle represent the positions of the camera tripod legs. The camera is at risk of tipping over because the mass of the cameral is not within the solid boundaries of the triangle. In the foot, these tripod leg points would be represented by the 1st and 5th Metatarsal heads and the heel forming a triangle. The goal is to stabilize the tripod on level ground and place the camera (foot) in the middle of the tripod for maximal stability. But, when the foot progression angle is increased, the triangle and foot position take on the triangle appearance above, risking pronation excesses.
The problem is that many folks do not know they have developed this problem posturing until symptoms occur. This young lad was brought into our offices by an aware mom who had heard of similar successes we have had with other children and adults.
It took all of 10 minutes to retrain his awareness of the foot tripod and posturing of the feet underneath the body (where he noticed that he could not pronate as much as seen at the end of the video clip). HE did awesome as you can see. For the first time in his life he saw an arch and knew how to correct his foot posturing. He became aware of the use and need for good toe extension to raise the arch (a phenomenon known as The Windlass Mechanism of Hicks). The last stage would be to help him retrain these strategies in gait and various movements.
We will see if we can find that video somewhere.
Bottom line, …….did this kid need an orthotic……. NO ! It would have kept absent the strength development of the muscles needed to make the correction you see in the video. This kid now has a fighting chance to develop normally.
Hope this helps to explain what was going on in yesterdays video.
We are………foot nerds…….
Shawn and Ivo
This is a video follow up to last weeks rockers post. Enjoy!
The Tripod Correction and Your arches
In follow up to yesterdays post, here is a short video showing a tripod correction. See if you can see what is happening.
Reflection:
Sometimes we take for granted our backup systems. In my case, it is Dr. Waerlop. I have known him for the better part of a decade now and two things come to mind: 1) the guy has never let me down and 2) still to this day there are a rare few people i can think of who are more intelligent than this dude. The man is not only a “friend for the duration” but he is just plain old brilliant, ask anyone who knows him or has heard him lecture. It was a no brainer when he approached me with the idea of The Gait Guys (we had been bouncing our knowledge around the web for awhile when it all came together in that big enormous skull of his.) At that moment i knew we had hit a vein/nerve. From that moment on The Gait Guys were cookin.
I have had other business partners over the decades but i have to say, when you have a backup like this cool cat, business is smooth sailing. I personally wouldn’t hesitate to drive hours for the wisdom and smarts of this guy. Wonder why…..? read this below or check out the link at the top to his website. If you are within a day or two drive of his office, don’t think twice as to whether it will be worth your time. Know a friend within a day’s travel ?,…. don’t hesitate. As we like to say, he has the west coast covered, i have the east and we split the middle !
Thanks for the great partnership dude….i look forward to the next 10 years anticipating the whereabouts of The 2 Gait Guys……..Heck, with just 6 months on Facebook and Social media sites and the tremendous domestic and surprisingly the even bigger international following (collective 30,000 monthly hits !) , i cannot imagine where the next 6 months will leave us, let alone 10 years ! Well, i suppose i can imagine for us……. Perhaps, maybe, just maybe…… someday uploading the day’s blog from our satellite up-link from the bow of our fishin boat (“Big Glutes”) klinking Corona’s and watching the sunset just before pulling up to the pier on St. Barts for a jam session with our new friend-to-be Jimmy Buffet. IF you are gonna dream, dream big !
I wish we could spill the beans on all the stuff in our pipeline for The Gait Guys, but hang tight folks…….there is a bundle to come. We have just gottn’ started !
Check out my brilliant partner below…….and, thanks again for always having my back during the ride man…..
-Shawn
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IVO F. WAERLOP D.C., DABCN, CCRP, CCSP, Lic Acp.
Dr Ivo is a 1986 summa cum laude graduate of the New York Chiropractic College. He received his post-graduate neurology diplomate from Logan Chiropractic College; he became board certified in 1990. Dr Ivo works with a broad base of patients including Olympic level, professional and paraprofessional running, skiing and cycling athletes. He is an adjunct faculty member with the Lincoln School of Post-Professional Education. He is engaged in publishing active research on cycling biomechanics and is involved in gait and lower extremity research. He is a board certified Chiropractic Neurologist, Chiropractic Rehabilitation Physician and certified Chiropractic Sports Physician. He lectures nationally on foot-ankle and gait biomechanics in sports and now in advanced acupuncture techniques. He is co-author of the textbook, Pedographs and Gait Analysis: Clinical Applications and Pearls.
Additional Background
Dr Ivo F Waerlop attended SUNY at Albany for his undergraduate work and graduated from the New York Chiropractic College in 1986. He then joined the Core Science faculty at the college and taught anatomy and cadaver dissection as well as Gonstead and Diversified chiropractic techniques. It was at this time he conducted research performing a serial dissection of alar ligaments in cadavers and completed post graduate work in Sports Medicine, receiving his Certified Chiropractic Sports Physician certification.
Dr Ivo then moved to Gloucester, Massachusetts where he founded Gloucester Chiropractic and Rehabilitation, a medically referral based office complete with CYBEX lab. During his time in Massachusetts, he completed additional post graduate work in rehabilitation and was accepted into the chiropractic neurology program at Logan Chiropractic College in St Louis, Missouri. Here, he was one of the fortunate doctors who studied directly under Dr Ted Carrick, and after 3 years and passing his written and oral board examinations, was awarded his Diplomate in Neurology Degree in May of 1991. At this point in time, Dr Waerlop began his post graduate teaching career, 1st in rehabilitation and later in neurology, lecturing throughout the US and Canada.
In late 1996, Dr Ivo relocated to Summit County Colorado, continuing to teach on a post graduate level and began a private practice in Frisco at the CARE Health Group. He began teaching Anatomy and Physiology locally at the Colorado Mountain College, which he continues to do today. In 1999, he relocated to a larger facility in Silverthorne and founded Summit Chiropractic and Rehabilitation, PC, a rehabilitation and neurology referral based practice, with an emphasis on gait and movement analysis.
In 2004, he became interested in acupuncture, largely because his 150 pound German Shepherd (Atlas) was epileptic, and a Veterinary Acupuncturist from Grand Junction (Dr Shalona McFarland) was able to help him control his seizures. Dr Ivo began his studies shortly thereafter and received his acupuncture license in the summer of 2005. He then studied neuromuscular acupuncture under Dr Yun Tao Ma and currently lecture with and is writing an acupuncture book with him.
In August of 2006, Dr John Asthlater joined the practice and the office was moved to our new facility in the Dillon Tech Center, in Dillon. In addition to injury, rehabilitative and preventative care, the new center offers the latest in cutting edge video motion analysis, an orthotic lab, electrodiagnostics, blood glucose and lipid analysis, lactate testing, training programs, expanded hours and many other services.
When Dr Ivo isn’t seeing patients or lecturing, he enjoys spending time tele-skiing, hiking and 4 wheeling with his wife, local photographer Lisa Ortiz, Their son's Vander and Saxxon and their dog, Pons. His hobbies include reading, music and cooking.
Foot Arch Question: Sent in from one of our readers
How would one go about “rebuilding” their transverse arch? The latter is pretty much convex. This also accomapnied by very tight long toe extensors (as evidenced by their tendons being very prominent at the top of my foot and my toes being curled at rest) and have suffered on and off from Morton’s neuroma. The ball of my shoes (right in the middle) is where the insoles of my shoes see the most wear. It’s not a huge concern of mine, but I would like to deal with this. I’ve suffered several ankle injuries (as a basketball player) and although I’ve tried orthotics in the past (for the neuroma), I’ve relied mostly on minimalist footwear (except when playing ball of course…). I know some rehab would be in order and would likely work. I’ve “reconditoned” my big toe abductors in the past and can even cross my second to over my big toe, so am just looking for some direction.
Thanks
Our Response:
As you probably are aware, there are 3 arches in the foot: the medial longitudinal (the one most people refer to as the “arch”, the lateral longitudinal (on the outside of the foot) and transverse (across the met heads).
Your collapsed transverse arch seems like it may be compensated for by a rigid, probably high medial and lateral longitudinal arches. This creates rigidity through the midfoot (and often rear foot) and creates excessive motion to try and occur in the forefoot. Depending on how much motion is available, this may or may not occur.
You don’t seem to be able to get your 1st metatarsal head to the ground to form an adequate tripod, so you are trying, in succession, to get some of the other, more flexible ones there (thus the wear in the “ball” of the foot you noted). This results in increased pressure, metatarsal head pain, possibly a bunion and often neuromas.
From your description, you actually have very weak long toe extensors (and possibly some shortening) which is causing the prominence of the tendons, along with overactivity of the long flexors (and thus the clawing) in an attempt to create stability. I am willing to bet you have tight calves as well (especially medially, from overuse of the gastroc to control the foot) and limited hip extension with tight hip flexors.
The foot tripod exercises are a great place to start, as well as heel walking with the toes extended and walking with the toes up (emphasizing extension, which counteracts the flexors). Stay away from open back shoes and flip flops/sandals; continue to go barefoot and get some foot massages to loosen things up. Maybe use one of those golfballs to massage the bottom of the foot when you get off the course and get some golf shoes that aren’t quite so rigid.
Hey everyone. Have a Great 4th of July!
The Gait Guys
And now for something totally random….
How Much Water should I drink? The basics of hydration
We see many athletes and weekend warriors and are often posed this question; so here you go…
Water is the elixir of life. Too much (hyper hydration) or not enough (dehydration) can both be detrimental to your performance, but how much is enough?
Our bodies consist of about 60-70% water at any point in time. Most men have a higher percentage because they have a higher percentage of muscle mass (unfortunately, adipose tissue contains little water!). We generally lose between 1.5 and 2.5 liters of fluid a day through breathing, urinating and general metabolism. The body must keep a balance of water both inside (intracellular) and outside (extra cellular) your cells. Because the body is in equilibrium, if you sweat, breathe, or urinate too much, you will lose water from your extra cellular compartment. The body will then take water from inside your cells and shift it to outside. Likewise, your brain (hopefully) will stimulate you to drink more and urinate less, helping you to fill up the extra cellular compartment again. The water will then diffuse back into the cells and equilibrium is established again. A lot of this movement of water has to do with electrolytes (charged particles in your blood and body fluids) and their movement across cell membranes. The electrolytes that are most important for us are Sodium (Na+) and Potassium (K+).
When you lose too much water, your blood becomes more viscous (remember, you are losing water, not cells. Less water plus same number of cells equals more viscous liquid). This makes your heart have to work harder to push the blood around. This takes more energy and resultantly your heart rate increases, causing a phenomenon called cardiac drift. An example is when you are exercising for a while at the same intensity and your heart rate increases over time. A loss of 2-3% of your body’s water will decrease your performance by 3-7%! The amount you lose will depend on your exercise intensity and duration as well as temperature. A 20 degree increase in temperature can increase your heart rate as much as 10 beats per minute!!
So, it seems if we drink a lot of water, all will be well. Well, yes… and no. Your body can only absorb about 24-28 ounces of water per hour, any more and it just makes you pee more. You can sweat up to 3 liters (that’s more than 96 ounces!) per hour. Hmm. looks like we will probably be in a deficit. How much we absorb depends on whether we can get the water out of our stomach and into our intestines where it can be absorbed. As you can imagine, there are some things which speed gastric emptying and some which slow it down.
Protein and fat are the 2 main things which slow the trip through the stomach down. If too much of these are in your drink or already in your stomach the water will end up sloshing around and probably leave you not feeling too good. Guess that means lots of protein before or during an endurance workout is probably a bad idea, especially if you are trying to stay hydrated! Small amounts of protein, when combined with carbohydrate can be beneficial, but that’s another subject for another day. So much for all that marketing hype!
Small amounts of carbohydrate (up to 60 grams per hour) can enhance water absorption from the intestines and speed emptying of the stomach. The body can’t process any more than this, and it will actually start to slow stuff down if you do too much.
Sodium (50-70 mg, about a pinch) also helps with water absorption. It has the added bonus of stimulating your hypothalamus to tell you to drink more. If you wait until you are thirsty, it will be too late. You need to drink before you are thirsty!
So, what’s a person to do? Here are some tips:
The Gait Guys…telling it like it is
Gait Cycle Basics: Part 5
Swing Phase
Our final chapter in this series….
Swing phase is less variable in its classification. It begins at toe off and ends at heel strike. It comprises 38% of the gait cycle.There must be adequate dorsiflexion of the ankle, and flexion of the knee and hip to allow forward progression.
The following classification is most commonly used:
Early swing: occurring immediately after toe off. There is contraction of the dorsiflexors of the ankle, and flexors of the knee and hip
Midswing: halfway through the swing cycle, when the swing phase leg is passing the midstance phase extremity. Acceleration of the extremity has occurred up to this point.
Late swing: deceleration of the extremity in preparation for heel strike. There is contraction of the extenders of the thigh and knee, as well as dorsiflexors of the ankle.
Perry defines the phases as:
Initial swing: the 1st third of swing phase, when the foot leaves the round until it is opposite the stance foot.
Mid swing: the time from when the swing foot is opposite the stance foot until the swinging limb is anterior to the stance phase tibia
Terminal swing: from the end of midswing, until heel strike
And there you have it. A nice review of the gait cycle. Probably more than you wanted to know, but we want to give you the facts.
Telling it like it is. We are…The Gait guys
Here is a big topic. Everyone seems to think that stretching makes a big difference, truth is it makes a difference, but it is not big. But is “some” enough ?
The topic comes up in a range we really feel is important, ankle dorsiflexion range. You hear us talk about it all the time as “ankle rocker”. The facts are that you need 100+ degrees of ankle dorsiflexion range to achieve normal biomechanics across the ankle ankle in walking, and near 115 degrees for running (put another way, 10degrees past 90degrees vertical for walking and 25degrees past vertical for running, ref. T. Michaud).
If you do not have these ranges then you must compromise normal biomechanics. This is where functional pathology starts, ie. injuries.
This study found the following:
The meta-analyses showed that calf muscle stretching increases ankle dorsiflexion after stretching for
< or = 15 minutes (WMD 2.07 degrees; 95% confidence interval 0.86 to 3.27),
> 15-30 minutes (WMD 3.03 degrees; 95% confidence interval 0.31 to 5.75), and
> 30 minutes (WMD 2.49 degrees; 95% confidence interval 0.16 to 4.82).
So, what does this mean ?
Well, upon initial impressions it seems that none of them gained more than 3 degrees of dorsiflexion range, even after 30 minutes of stretching. The study suggested that these numbers according to research stats, were “statistically significant”.
But in our mind, if you have 90 degrees range, a “statistically significant” loss in our opinion, then gaining another 3 degrees (ok, lets jump the moon and assume you stretched for 60 minutes and achieved 5degrees)…..well, you are still not at 100 degrees and have to compromise normal mechanics which could mean injury.
Bottom line, you have to find another way to get this range back, stretching is not going to float your boat the whole way. This is why we like the shuffle walks (as seen on our YouTube videos) to engage and strengthen the anterior compartment. This strength will help to reflexively release the tight posterior compartment. You cannot have a relatively normal lengthened posterior compartment if the anterior team is insufficiently strong.
The Gait Guys
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