It is Friday Follies on The Gait Guys and we have something a little different for you. Not something gait related but more movement related. Enjoy the short video.

Guillaume Blanchet spent 382 days riding his bike through the streets of Montreal living what appears to be a normal everyday life on his bike. He dedicates the short film to his father, Yves Blanchet where he first got his love for riding a bike.

Man spends 382 days living his life while on a bike

By: Nate Hoppes

Everyday something original and entertaining pops up on the internet and today is no exception as a 3 minute short film titled “THE MAN WHO LIVED ON HIS BIKE” is captivating peoples attention.

Here’s a quick breakdown of the film-
Original= Absolutely
Creative= Definitely
Quality= Well done
Odd= Very, especially when he’s shaving naked while riding a bike.
Entertaining= Well worth watching the whole 3 minutes

Need more muscle activation? How about a crouched gait?→

Muscle contributions to support and progression during single-limb stance in crouch gait

J Biomech. 2010 Aug 10;43(11):2099-105. Epub 2010 May 20.

You have heard us talk about crouch gait as a rehabilitative exercise (see another post here). Here is some proof that you are working harder

“The results of this analysis indicate that children walking in crouch gait have less passive skeletal support of body weight and utilize substantially higher muscle forces to walk than unimpaired individuals.”

and

“… during crouch gait, these muscles are active throughout single-limb stance, in contrast to the modulation of muscle forces seen during single-limb stance in an unimpaired gait.”

...and working the right muscles

“Crouch gait relies on the same muscles as unimpaired gait to accelerate the mass center upward, including the soleus, vasti, gastrocnemius, gluteus medius, rectus femoris, and gluteus maximus.”

and

“Subjects walking in crouch gait rely more on proximal muscles, including the gluteus medius and hamstrings, to accelerate the mass center forward during single-limb stance than subjects with an unimpaired gait.”

Yup, crouched gait gives you more bang for the buck. Try it….You’ll like it!

Yes, we are the Geeks of Gait…. sifting through and synthesizing the research so you don’t have to

Muscle contributions to support and progression during single-limb stance in crouch gait

J Biomech. 2010 Aug 10;43(11):2099-105. Epub 2010 May 20.

Steele KM, Seth A, Hicks JL, Schwartz MS, Delp SL.

Source

Departments of Mechanical Engineering, Clark Center, Stanford University, Stanford, CA 94305-5450, United States. ksteele@stanford.edu

Abstract

Pathological movement patterns like crouch gait are characterized by abnormal kinematics and muscle activations that alter how muscles support the body weight during walking. Individual muscles are often the target of interventions to improve crouch gait, yet the roles of individual muscles during crouch gait remain unknown. The goal of this study was to examine how muscles contribute to mass center accelerations and joint angular accelerations during single-limb stance in crouch gait, and compare these contributions to unimpaired gait. Subject-specific dynamic simulations were created for ten children who walked in a mild crouch gait and had no previous surgeries. The simulations were analyzed to determine the acceleration of the mass center and angular accelerations of the hip, knee, and ankle generated by individual muscles.

The results of this analysis indicate that children walking in crouch gait have less passive skeletal support of body weight and utilize substantially higher muscle forces to walk than unimpaired individuals.  

Crouch gait relies on the same muscles as unimpaired gait to accelerate the mass center upward, including the soleus, vasti, gastrocnemius, gluteus medius, rectus femoris, and gluteus maximus.

However, during crouch gait, these muscles are active throughout single-limb stance, in contrast to the modulation of muscle forces seen during single-limb stance in an unimpaired gait. Subjects walking in crouch gait rely more on proximal muscles, including the gluteus medius and hamstrings, to accelerate the mass center forward during single-limb stance than subjects with an unimpaired gait.

Copyright 2010 Elsevier Ltd. All rights reserved.

Neuromechanics Weekly: Installment 2 (Now aren’t you lucky to have so much neuro in 1 week!)

FEEL THE PAIN: PART 2

The Character of Pain

In today’s post we hope to help you better understand your pain or the pain that someone else describes to you. The character of the pain can tell you much about what tissues are involved and what might be going on behind the scenes. Understanding the anatomy and physiology of the parts is critical.  Thus, this post is going to be a little latin/medical word heavy for some of you….. but trust us, if you spend just a few extra minutes championing these words and owning the concepts below you will forever be better at what you do. Or at the very least, better understand your own pain.

In prior post in this series we talked about the pain producing tissues being derived from one of the primordial tissues, the endoderm, ectoderm or mesoderm. And if it is from  the mesoderm, from which of the 3 layers of the somite is it originating ? The sclerotome, the dermatome or myotome? (The mesoderm is the middle embryonic germ layer from which connective tissue, muscle, bone, and the urogenital and circulatory systems develop.)

As we discussed yesterday, pain usually has one of four qualities: burning, aching/throbbing, sharp/stabbing, or electric/shooting. Each one tells us something about where it is coming from.

Remember the Krebs cycle? How about glycolysis? What was one of the end products of glycolysis? Lactic acid. Your ability to recycle it and make it into oxaloacetic acid and stuff it back into the Krebs cycle determines your aerobic capacity. When lactic acid builds up, we get muscular inefficiency due to the drop in pH (initially this helps, but too much of a good thing creates a problem), The result? Burning pain. Burning pain is the burn of glycolysis, or muscular overuse.

Aching/ throbbing pain is that deep, boring pain, like a toothache in a bone. It is the pain of the mesoderm, or what is often called sclerotogenous pain. Aching/Throbbing pain is the pain of connective tissue dysfunction (remember that connective tissue is bone, cartilage and collagenous structures like ligaments and tendons). Throbbing pain can sometimes be vascular in origin, as the connective tissue elements of the vessels (the tunica adventitia to be exact) is stretched (which contains a perineural plexus; think about the pain of a migraine headache).

Shooting/electric pain is the pain of the ectoderm. Think about when you hit your ulnar or peroneal nerves and get that “electric shock” sensation. If you ever have had a herniated disc, you know this pain first hand; sharp and shock like. This pain often travels in the distribution of a nerve root or peripheral nerve. 

Sharp/ stabbing pain is the pain of acute tissue damage to one of the 3 layers of the somite (the dermatome, sclerotome or myotome). Think of a sprain (sclerotome) or strain (myotome), or the pain of a shingles outbreak (dermatome). Sharp/stabbing pain is the pain of acute tissue damage.

Keep in mind there is often overlap of pain types, which mean that there is more than one tissue crying out for help (the burning pain in the left hip from gluteus medius insufficiency, combined with the dull, achy pain in the medial knee, from poor control of internal rotation of the thigh).

Pay attention to the character of pain, as it often provides clues to the tissue of origin.

The Gait Guys. Explaining it so you can understand it, one pain free stride length at a time.

Ivo and Shawn

Neuromechanics Weekly:

FEEL THE PAIN: PART 1

Pain Producing Tissues

What usually brings people in to see you or us? Sometimes, it is the desire for better performance, but most often it is pain. We see it daily in our offices. You see it daily in yours. In this installment of Neuromechanics, how about we characterize some of what we are seeing?

We like to think of pain as having one of four qualities: burning, aching/throbbing, sharp/stabbing, or electric/shooting. Each one tells us something about where it is coming from. Before we talk about that, we need to assess  “What is the pain producing tissue?"  To understand this further, we must delve deeper into tissue types.

We may remember from embryology, around the 3rd week of development, the embryo becomes trilaminar (three layers) forming, the endoderm, the mesoderm and the ectoderm. The endoderm becomes most of our organs (called the splanchnotome), the ectoderm becomes the nervous system, and the mesoderm becomes the muscles, ligaments and bones. The mesoderm coalesces and becomes blocks or segments of tissue called somites.  These somites have 3 distinct parts: the dermatome, the myotome and the scerotome.

The dermatome becomes the skin, with it’s segmental innervation (the spinal cord level that supplies that area of skin). Think about when someone has an outbreak of shingles, which often follows a spinal nerve root distribution. We often test sensation along both dermatomal distributions (segmental) and peripheral nerve distributions (with contriobutions from many segmental nerves).

The myotome becomes the muscle and the segmental nerves which supply it. Each segmental level usually corresponds to a function (S1 does plantarflexion of the foot, L5 does dorsiflexion of the foot, etc). This is one of the reasons we muscle test, to tell us which segments may be involved in a problem.

The sclerotome becomes the bone, ligament and tendon supplied by one segmental level (ex. C5 does most of the upper humerus, lateral scapula and clavicle and shoulder capsule). It is what causes the pain associated with sprains or fractures. This is the pain of connective tissues (remember, connective tissues connect muscle to bone AND make up the ultrastructure of the muscle itself!) This is one of the most common pains we encounter in a clinical setting.

Knowing the tissue of origin often leads to a more specific diagnosis etiology of why your client/patient (or YOU) are having a problem.

Next time we delve deeper into pain. Until then, we remain, 2 good looking, aging, nerdy bald guys, Ivo and Shawn.

How do you know if your orthotic is working?

Foot orthotics are easy, no? You get casted, it gets built, you put it in your shoe and you’re good to go, right? Wrong!

Orthotics or Orthotic Therapy as we like to call it in our offices, is an ongoing process. If an orthotic is doing it’s job, your foot should change (for the better) and your prescription should become less. At least in an ideal world.

Remember, orthotics are designed to help you adapt to your environment better. Unlike a footbed (which merely creates a level playing field for the foot), they change the biomechanical function of your foot. A lot should go into getting fit for an orthotic, otherwise they can actually cause some of the problems they are purported to fix!

First of all, there should be a comprehensive history of you and whatever is going on, with an inventory of all your past injuries. That appendectomy or laporoscopy which invaded the abdominal wall could be a culprit for future problems. Next you should have a thorough examination of your lower kinetic chain, including the feet, ankles, knees, hips and low back. This should include range of motion, muscle strength, muscle recruitment patterns and joint function, along with reflexes, sensation and balance or proprioception. Next there should be an analysis of your gait, preferably with stop motion video which allows you to slow down movements and assess subtle abnormalities that may not be visible during normal speeds of movement.

At this point, it should be obvious to both you and your orthotic provider whether or not an orthotic is needed. If so, a non weight bearing cast (weight bearing casts show you what the problem or compensation is, why would you want to cast someone in their pathology and perpetuate it?) The non  weight bearing cast is usually done in a mid to terminal stance position of the foot. This should be followed by the prescription of appropriate stretches and exercises, specific to your condition. Shoe recommendations should also be given, since different foot types require different footwear characteristics (good news for the ladies who like shoes!).

So, if you need an orthotic (remember, the prescription should become less over time AND should be accompanied by appropriate exercises), these are the steps we feel are imperative, otherwise, you may just have a really expensive doorstop….

The Gait Guys….Promoting Gait Literacy, one stride length at a time.

Textured insoles:What's your take?

One of our readers writes:

I saw the video on cross over running, it was very good. It appeared the glute Med was inhibited and that the penguin walk assisted in activating it. My question is what your philosophy is regarding slightly textured insoles and if this may affect hip and abdominal function and cross posture syndrome?

 Our Response:

Thanks for the kudos. Textured insoles are probably a good thing, as they can help provide more proprioception from the feet (which have a tremendous amount of cortical representation).  They could conceivably affect hip and abdominal function. The research out there seems to be focused on people with MS, but here is another supporting study: http:// www.ncbi.nlm.nih.gov/pubmed/18246902

The Gait Guys…Texturing your mind with new ideas….

Gait Issues: When Proprioception is Lost … What we lose when we wear “the wrong” shoes …

You have heard us use this word proprioception a million times (OK, some, maybe not a million). Proprioception is our ability to be aware of and orient our body or a body part in space.  Poor proprioception can result in balance and coordination difficulties as well as being a risk factor for injury (Like this poor pooch). *Note: there is no such thing as a “proprioceptor”. All receptors have a more specific name but there are no receptors in the body actually called a proprioceptor, it is a rough classification if that.

Think about people with syphilis, who lose all afferent (sensory) information coming in through the dorsal root ganglia at the spine level. This ultimately leads to a wide based ataxic gait (due to a loss of position and tactile sense) and joint destruction (due to loss of position sense and lack of pain perception). The same consequences can occur, albeit on a smaller scale, when we have diminished proprioception from a joint or its associated muscle spindles.  Just like when we put shoes on our feet, proprioception is lost. Just as it would be lost if we wore oven mitts on our hands all day long; there is a cost to optimal functioning of those muted joints.

To review, proprioception is subserved by both cutaneous receptors in the skin (pacinian coprpuscles, Ruffini endings, etc.), joint mechanoreceptors (types I,II,III and IV) and from muscle spindles (nuclear bag and nuclear chain fibers) . It is both conscious and unconscious and travels in two main pathways in the nervous system.

Conscious proprioception arises from the peripheral mechanoreceptors in the skin and joints and travels in the dorsal column system to ultimately end in the thalamus, where the information is relayed to the cortex. Unconscious proprioception arises from joint mechanoreceptors and muscle spindles and travels in the spino-cerebellr pathways to end in the midline vermis and flocculonodular lobe of the cerebellum.

Conscious proprioceptive information is relayed to other areas of the cortex and the cerebellum. Unconscious proprioceptive information is relayed from the cerebellum to the red nucleus to the thalamus and back to the cortex, to get integrated with the conscious proprioceptive information. This information is then sent down the spinal cord to effect some response in the periphery. There is a constant feed back loop between the proprioceptors, the cerebellum and the cerebral cortex. This is what allows us to be balanced and coordinated in out movements and actions.

Thankfully a fashion trend of wearing oven mitts on our hands has never hit the runways, but in a way we continue to do a similar disservice to our feet wearing shoes. Watch the video again and think about this next time you are contemplating, at the very least, a motion control shoe for yourself or a client.  If we all walked like this when we put shoes on we would never have done this disservice of footwear to ourselves long ago.

Ivo and Shawn….Good Looking and Proprioceptively different.

Extensor Hallucis Brevis Case Treatment

EHB CASE treatment: For this particular case we used simple stuff. In more complex cases we will add Western Acupuncture methods as well. But in this case we used the simplest of methods ……. a blend of MAT, AMIT, followed by graded iso’s every 15degrees over and over again in multiple vectors integrating larger and further reaching muscle groups. For example, first simple hallux extension at the interphalangeal joint, then combine that with foot dorsiflexion, then combine those 2 with ankle inversion (so all 3 now), then added hip abduction and then lateral trunk flexion (abs, paraspinals, QL etc) to those. This took care of ramping up the local motor pattern and the longer more complex chain motor patterns that were primary in that particular injury (ie. almost pure frontal plane failure in this case, from what showed up weak on the neuromuscular assessment). Just reteaching the brain how to reintegrate that EHB back onto the field with the rest of the team. It came back fast and complete. No need to use a jackhammer when a simple mallet was sufficient this time around. hope that helps.

It is Fun Friday Follies time. Enjoy a great actor moving with finesse and style. Great footwork too. Walken initially trained as a dancer in music theatre at the Washington Dance Studio before moving on to dramatic roles in theatre and then film.

This was a classic on MTV at one time.

Gait / Running Injury: Misdiagnosed Big Toe Extensor Hallucis Brevis tear in a distance runner from a simple ankle sprain.

* Sorry for the less than perfect video. Need some editing time.  Watch from 0:32 onwards for the topic at hand.

This young man, State caliber cross country runner, came in to see us after some unsuccessful treatment for an inversion ankle sprain several weeks prior. Although his swelling and range of motion had improved he was still having pain despite treatment.

On examination it was revealed that there was no loss of integrity of the lateral ligamentous restraints, no joint gapping was noted and the ligaments were non-tender. There was no swelling. Balance was clean. Even the immediate local lateral ankle muscular restraints, largely peronei, were competent with skill, endurance and strength assessment.

After further pointed discussion, after the ankle was cleared as a causative /symptomatic generator, we insisted the patient be more specific with his pain region. After requesting he palpate around to focalize the area of complaint this time he pointed not to his lateral ankle but rather pointed to the lateral dorsum of the foot over the fleshy mass of the short extensor muscle group just distal and anterior to the lateral malleolus. Inversion of the ankle was pain free but inversion of the forefoot on the rearfoot reproduced his pain pin point to the EHB (extensor hallucis origin area).

Upon reassessing his gait it was now obvious that he was unable to engage the left hallux (big toe) extensors. You can clearly see his lack of toe extension (lift) on the video at 0:32 seconds. When consciously requested to do so it immediately reproduced his pain ! If you look very carefully, that the hallux was not extending during swing phase through midstance contact phases of gait.

After specific muscle testing found only the EHB (extensor hallucis brevis) weak and not the EDB at all (extensor digitorum brevis) we began a few minutes of manual therapy to the EHB. Within ~5 -10 minutes the EHB was painfree and he could engage the muscle again actively. The muscle was clearly healed from it low grade strain, he was just unable to reactivate it during the gait cycle. Post treatment, he was able to walk immediately with much less pain and with ability to use the EHB in gait.

We followed up a second visit with him but he was pain free and was discharged from care. There were no gait compensations and screens for functional sensory motor compensations were unremarkable. Case closed.

Good results come from a precision diagnosis which can only come from a sound base of knowledge of anatomy, physiology and biomechanics …. when it comes to this kinda stuff.  Would you have picked this up on someone’s gait ? We didn’t at first.  Use your clinical examination to drive your suspicions in your gait analysis. What you see is not always what you get during gait analysis, this easily could have been a similar presentation of a hallux limitus.

Details, details, details. The devil is in the details, The proof is in the pudding……. etc.

Shawn & Ivo

Of gait, running and waffles: No we are not talking about carb loading today.

define: Waffling (verb):  waf-fle .   To speak or write, esp. at great length, without saying anything important or useful.

Far too often we read articles and blog posts on what could be great topics but all to often they are just another spin on the latest craze or never really amount to anything useful. Our time is valuable, and so is yours. I mean, really, enough barefoot articles already ! If you are going to write something about barefoot running or minimalism it has come time to put a new spin on it. Find something with vitality to add to it. Find the next dimension for God’s sake.  Stop waffling around !

One of our favorite things early every morning before the rest of the world opens their eyes, is to read Seth Godin’s blog. He is short, sweet and to the point. They are skull crushers sometimes, they are reality checks. We got the waffle idea from his blog yesterday. And today, found at the bottom, we paraphrased his mountain discussion.  

We pride ourselves here at The Gait Guys to try and push the limits every day. The two of us, learn from each other with every phone call and every blog post. It is common dialogue to say, “Dude, I learned alot from your blog post today, thanks man !” Sadly it is often followed up with, “Are we the only ones that get excited about this stuff ?”.  Some days we just get frustrated. Clinically, we see stuff missed every day by other therapists, doctors, trainers etc.  And that is ok, we miss stuff too. We are students as well. We try to honor our limits.  The most honest and respectful thing you can do for your patient, your client, or the guy coming in for a new pair of shoes, is to say “Wow, I really do not feel comfortable assisting you. This is a little beyond my expertise level. I am going to refer you to a colleague who will know just what to do with this to help you out."  A referral to the next level is always a relationship builder. it builds trust with your client and with your level-up referral.  It is the right thing to do. It is easy to try to fit every case and client that comes into your store, clinic or gym into the common mold. Into the same things you do day in and day out.  But that is not being honest with yourself or your client and their needs; Seth Godin said it perfectly in his post today, we will get to that in a moment.

Everyone (ok, almost everyone) walks on two feet in this world. They walk into your establishment.  Did you see it ? Did you see how they moved when they were causal and did not think you were looking.  That is the time to grab their gait pattern and imprint it into your head.  That is the time they are showing their best compensation for their problems. That is the time they either have on, or do not have on, their glasses.  How do they carry their purse, their briefcase ? They are in their most natural form.  They are not putting on a show and trying to give you their best interpretation of a good gait.  They are not on a treadmill with a camera on them. In our office we almost always stand at the front desk and turn to watch them saunter down the hall into a treatment room.  They are in their "day shoes” that could be too old, they are not in their new fresh workout shoes. (See the video above of a good friend, physician and just a great guy. He has a rare form of muscular dystrophy. He is an awesome smart doctor but even he was unaware of what his “day shoes” were truly doing to his gait. So we slapped him around a little, lovingly of course, and sent him off for new shoes.) When folks walk into your establishment it is when we  have them at their most natural, most vulnerable.  It is why we both love shopping malls and airports.  The most honest gait comes rising to the top.

Few walk well, many walk poorly. When the first thing that hits the ground does so improperly or does so in the wrong shoe for their foot type or anatomy the rest of the motor pattern is a compensation. Just because they have a flat foot does not mean that foot is weak and incompetent and needs an orthotic or stability shoe.  It just ain’t that simple, trust us.  Watch your people walk. It is the most fundamental movement pattern of all. Forget assessing their shoulder movement pattern looking for the golden key to their problem if their arm swing in gait is altered. Gait is the most repetitive and subconscious motor pattern we do all day long besides breathing (and even that one is done poorly by many folks). It is the one that is done for 4000-8000+ times a day. And if you are doing it wrong, in the wrong shoes, with the wrong skill set then it is part of the fundamental problem. We care that a client might have an impaired upper limb driver problem in a log-roll type motor pattern on your floor……but we often care more if they are not walking like an Egyptian (sorry, couldn’t resist) we mean walking with clean fundamental motor patterns.  Sure, the impaired body rolling could be the driver of the impaired gait, don’t try to catch us on that one.  If it is, then it could be part of the solution. We are just trying to drive home a point here. Thousands of bad steps is a mountain to climb to offset with some home exercises unrelated to the gait issue.  Why not get deeper into their gait, bring their awareness to a higher level, give them hourly corrective queue’s and see their problems unravel ? If the “log rolling” is in fact part of the solution then the gait should begin to clear up, if not, head back to the drawing board. Being good at gait issues is what we do. It is not hard, it just asks something more of you and it takes time. Analogy…  it asks so much more from us to undertake that long difficult arduous painful task of climbing up to the peak of that mountain when it would be so much more fun to turn around half way up and enjoy the effortless ride down on our backsides. Becoming good at gait analysis is first a painful task of 1000’s of hours of time studying anatomy, biomechanics and video footage. You are not offering gait analysis if you just buy a treadmill and a video camera. But after a few years, like anything else worth mastering (thank you Malcolm Gladwell), it becomes an almost effortless art form.

So, enough pseudo-waffling.  See how easy it is ! Sad isn’t it ?  Now spend the rest of the day with honest intent at truly looking at your client’s gait. And if you are a blogger or writer, step up and give us all something new and fresh. If you are trying to get the attention of all of us in the Gait Brethren here at The Gait Guys, with your next barefoot article, you had better start it with “This ain’t just another barefoot article….”. Stop waffling !  Go climb a fresh mountain for God’s sake, that one has been trampled to death !

Seth Godin (paraphrased from his blog today)…

“Repeating easy tasks again and again gets you not very far. Attacking only steep cliffs where no progress is made isn’t particularly effective either. No, the best path is an endless series of difficult (but achievable) hills. The craft of your career comes in picking the right hills. Hills just challenging enough that you can barely make it over. A series of hills becomes a mountain, and a series of mountains is a career.”

We are The Gait Guys…….and after yesterday’s blog post (if you read it) we are SEEING “all things gait” a little clearer.  Are you ? If you read our blog post (1/31/2012) you will know what we mean.  And if not, we have an old mountain out back for you to climb.

Shawn and Ivo ……… waffling and climbing……. at the same time.

More on Gait and Vision:  Along the lines of Binocular Parallax….

Yesterdays post talked about vision and parallax. Today’s explores some adaptations we have to poor visual quality. (Note 3 pictures today, toggle amongst them.)

In the attached study, we see people with poorer vision quality had 3 particular gait parameters (although probably had many more parameters) which changed with vision quality:

1. shorter step length

2. less trunk flexion

3. earlier heel contact with the ground (which goes along with shorter step length.)

If we think about what we know about the nervous system, this all makes sense. There are 3 systems that keep us upright in the gravitational plane: vision, the vestibular system and the proprioceptive system. If we remove one of the systems, the other 2 become enhanced (or better said, they had better become enhanced).

In this study they took away (or impaired) vision. This left the vestibular and proprioceptive systems to take over. The vestibular system affects position of the HEAD ONLY and measures linear and angular acceleration.  It makes sense to say that a more upright posture would do wonders for the stability of the system. The semicircular canals found in the inner ear measure angular motion, or rotation. Placing the body upright shifts the position of the semicircular canals in a different posture (particularly the LATERAL semicircular canal, which sits at 30 degrees to the horizontal; ) and places the utricle and saccule (which measure tilt and linear acceleration) in a better position to appreciate these. Translation, correct upright posture and neutral head positioning are critical for their contribution to detecting and maintaining balance and spacial stability.

The study also suggests that earlier heel contact in gait creates an “exploration” of the ground. This is quite important because the foot has so much cortical representation (see bottom picture) and is important for proprioception owing to its 31 articulations LOADED with joint mechanoreceptors, not to mention 4 LAYERS of muscles, LOADED with spindles and Golgi Tendon Organs.  The foot is a highly dense sensory receptor, the problem is we have had it hibernating in shoes for far too long. Imagine the advantage to balance, gait and posture we might have if we hadn’t dampened the mechano-sensory receptors for the better part of our lives. 

So, bringing this all full circle with the study; If you have poor vision, you had better make up for it with good upright posture and a sensory system that is unimpaired.  Most of us could have better posture and could use some retraining of foot function and sensory reception. Blind people generally have good postural and environmental awareness. They are not slouched over leading their gait head first while wearing oven mits on their hands and rigid steel-toed work boots. They take advantage of these systems and optimize them.

Sometimes the simple answers are not as simple as we like, but it is nice to know there is a reason.

The Gait Guys….Providing both simple answers to complex problems and complex answers to apparently simple ones.

______________________________________________________________________________________

Study: Low vision affects dynamic stability of gait

Gait Posture. 2010 Oct;32(4):547-51. Low vision affects dynamic stability of gait. Hallemans A, Ortibus E, Meire F, Aerts P. Source

Research group of Functional Morphology, Department of Biology, University of Antwerp, Belgium. ann.hallemans@ua.ac.be

Abstract

The objective of this study was to demonstrate specific differences in gait patterns between those with and without a visual impairment… .  Adults with a visual impairment walked with a shorter stride length (1.14 ± 0.21m), less trunk flexion (4.55 ± 5.14°) and an earlier plantar foot contact at heel strike (1.83 ± 3.49°) than sighted individuals (1.39 ± 0.08 m; 11.07 ± 4.01°; 5.10 ± 3.53°). When sighted individuals were blindfolded (no vision condition) they showed similar gait adaptations as well as a slower walking speed (0.84 ± 0.28 ms(-1)), a lower cadence (96.88 ± 13.71 steps min(-1)) and limited movements of the hip (38.24 ± 6.27°) and the ankle in the saggital plane (-5.60 ± 5.07°) compared to a full vision condition (1.27 ± 0.13 ms(-1); 110.55 ± 7.09 steps min(-1); 45.32 ± 4.57°; -16.51 ± .59°). Results showed that even in an uncluttered environment vision is important for locomotion control. The differences between those with and without a visual impairment, and between the full vision and no vision conditions, may reflect a more cautious walking strategy and adaptive changes employed to use the foot to probe the ground for haptic exploration.

homunculus photo courtesy of : http://joecicinelli.com/homunculus-training/

Left foot pain in a 30 year runner.→

Hi,

I could use some help. I’ve been running/cycling for 30 years. Three years ago, I had surgery on my left knee that realigned my patella (lateral release.) Until recently, I lived in custom orthotics and motion control shoes. I’ve been reading chi-running and natural running and bought a pair of shoes for which I’m transitioning a little a day. My left foot is the problem: it severly overpronates and I have a neuroma. I’ve been walking barefoot and in five-fingers for a while and my feet a definitely getting much better. The natural running style feels much better on my ankles,knees and hips, which used to hurt a lot. Also, cycling hurts only when I get off my bike, my knee is killing me for a while.

My left forefront seems to move too much even with this new style of walking/running. I’m wondering if I have forefront varus that could be helped with a wedge. My real problem is that I currently live in Las Cruces, NM, where there is no running store and no experts on this stuff. Most podiatrists do the same, generic thing for all patients. Is there a little wedge I could try without having it inserted into a custom orthotic? Is there a place to go to analyze my gait/running that would be worth my time and expense to visit? Any advice would be gratefully received.

Thanks for your time,

AT

Thanks for the note AT.

We are glad that the natural style running is helping. remember to go slowly and follow the rules of Skill, Endurance, Strength as you progress into less supportive shoes.

The forefoot motion you are sensing may indeed be a forefoot varus; we would need to see and examine your foot to know for sure. If it is a rigid deformity, it may never totally be gone, though you may be able to increase the range of motion of your foot sufficiently to compensate elsewhere.

Getting a thorough evaluation is paramount. We are not aware of any gait labs in Las Cruces, but Jaqueline Perry’s Pathokinesiology lab is in Rancho Los Amigos (click here for more info). Dr Waerlop is located about 70 miles west of Denver and Dr Allen is in the Chicago suburbs. Only after an evaluation, could exercise suggestions or an orthotic or other device recommendation could be made.

Thanks for your inquiry

Ivo and Shawn

Just going over our FaceBook stats today: 

Did you know a significant part of our readership is international? Current readership= UK, Canada, Australia, Sweden, Brazil, Singapore, Germany, Mexico, Netherlands, India, Ireland, Israel, Pakistan, France, Denmark, United Arab Emirates, Argentina, Spain, USA !!!!!!!!  The Gait Guys, moving towards global gait domination ! www.thegaitguys.tumblr.com  Just wait for the website to launch ! 2 more weeks we hope !

Have a great weekend brethren !

Shawn and Ivo

Gait / Running Talk: Functional Hallux Limitus.

(*2 pictures attached today, toggle between the two and then read on. PS: the subheader for the photo suggests they recommend a Cheilectomy in many cases.. This was typing that came with the photo. This is not our recommendation in many cases.  Please ignore those two lines of type for now. TGG)

It is often though from an evaluation perspective that hallux limitus is a loss of the big toe extending on the forefoot (metatarsal head), such as seen in the picture above.  It is after all the easiest way to assess the joint, however it is not a true functional assessment, rather a passive ROM assessment.  Keen observers will realize that under more functional circumstances, after planting the foot on the ground, the big toe will be affixed to the ground and the limitation will come as the person attempts to move the body over that joint. With a hallux limitus the 1st metatarsal will not be able to roll downwards on the phalanx (big toe) concavity and gain purchase on the ground. This can come from joint arthrosis or some of the functional problems we have discuss in our last 2 blog posts.  This downward roll and glide, plus the body mass moving over the axis, is “functional extension” at that joint (as opposed to passive assessment function of the joint as seen in the first picture above). This joint can be referred to as the Windlass joint. Here we have the concave rounded metatarsal head (see 2nd picture) rolling up but sliding down withing the concavity of the hallux/ big  toe (roll and glide are normally in opposite directions if the axis of joint centration can be held, in functional hallux limitus this centration axis is lost, hence the limitation) . This roll and glide in descending the metatarsal head to the ground is what we refer to as “medial tripod anchoring”. Disruption of this roll and glide at these joint surfaces through this extension movement to get the metatarsal head to the ground can be found with both Functional or Ablative (true) Hallux Limitus (aka “turf toe”).  Failure of this biomechanical mechanism leads to insufficient medial tripod, aberrant toe off mechanics, probably pain, and risk for bunion and hallux valgus formation (because when the medial tripod is not anchored the functional mechanics of the adductor hallucis muscle changes and ends up pulling the hallux laterally). 

Just taking you through a more functional perspective on hallux limitus. It is not as simple as “the joint is stuck”. And forcing the range won’t make it unstuck ! It will just create more dorsal bony abutment at the top of the joint, and pain.  If you have any chance of fixing this monumentally misunderstood problem, you must understand this blog posting, and the last two blog posts.  To fix this problem, if it is still functional and not ablative (fixed and permanent),  you will have to use your brain and not your fingers ! 

On another day we will talk about the cluffy wedge that you see under the big toe (hallux) in the picture above. We will give you our perspective on the device, how we make our own version of a wedge and some of our concerns for its use.

Alot of our patients joke around when they come in to see us with a problem.  We like humor in our offices.  Their joke frequently is, “must be something wrong with that big toe again !”….. even if it is shoulder or neck pain.  And interestingly, alot of the time they are somewhat right.  If you screw up toe off, the rest of the movement is compensation. 

The Big toe, …… it is often on the menu.

Shawn and Ivo

Welcome to Friday Follies.

Here we see people putting their foot in their mouth….

Have a great day

Ivo and Shawn

The extensor hallucis brevis revisited…or……axes of rotation

In a previous post, we described the attachments and importance of this little, but important muscle. Today we will explore that further.(4 images above, toggle through them)

We recall that the EHB is not only a dorsiflexor of the proximal hallux, but also a descender of the head of the 1st metatarsal . 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 gong smoothly).

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.

Ivo and Shawn….Still Bald…Still good looking…still promoting foot literacy everywhere

Gait / Running: Problems with Big toe pain or power ? The Big toe in motion: another look at a past video we did on EHB and impact on the big toe ! Enjoy this blast from our recent past……. 2.5 years ago……  this video is worth your 5 minutes if you want to get smarter at this stuff !

enjoy…….. Shawn and Ivo

Gait Topic: The Mighty EHB (The Short extensor of the big toe, do not dismiss it !)

Look at this beautiful muscle in a foot that has not yet been exposed to hard planar surfaces and shoes that limit or alter motion! (2 pics above, toggle back and forth)

The Extensor Hallicus Brevis, or EHB as we fondly call it (beautifully pictured above causing the  extension (dorsiflexion) of the child’s proximal big toe) 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 (reference). Did you ever watch our video from 2 years ago ? If not, here it is, you will see good EHB demo and function in this video. click here

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.

*The EDB and EHB are quite frequently damaged during inversion sprains but few seem to ever look to assess it, largely out of ignorance. We had a young runner this past year who had clearly torn just the EHB and could not engage it at all. He was being treated for lateral ankle ligament injury when clearly the problem was the EHB, the lateral ligamentous system had healed fine and this residual was his chief problem.  Thankfully we got the case on film so we will present this one soon for you !  In chronic cases we have been known to take xrays on a non-standard tangential view (local radiographic clinics hate us, but learn alot from our creativity) to demonstrate small bony avulsion fragments proving its damage in unresolving chronic ankle sprains not to mention small myositis ossificans deposits within the muscle mass proper.

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).

Wow, all that from a little muscle on the dorsum of the foot.

The Gait Guys. Definitive Foot Geeks. We are the kind of people your podiatrist warned you about…

This week for neuromechanics, something a little different. A fun video by Mark Gungor about the differences between male and female brains. Sit back, relax and prepare to laugh!

Of interesting historical note; he describes the differences between the male and female brains perfectly as the contrast to early neuronal theory out forth by Ramon Satiago Cajal: Prior to the 1800’s it was thought the nervous system was continuous (much like the female brain wiring) however he (Ramon) proved it was contiguous (ie. there were synapses).

The Gait Guys….Thinking outside the box, even though we have a special “gait box” in our brains.

Ivo and Shawn