The knee follows the arch/ankle.

*in the video, watch the left knee
Hopefully this video and post will make you think deeper about patellofemoral tracking, runners knee, meniscal issues and anterior knee pain syndromes as a whole.

This is subtle, but in this case, this is relevant to the LEFT knee complaints of this client.
When the foot complex is a little weak, the arch can collapse more than it should, rendering too much pronation, this means the talus will adduct, plantarflex and medially rotate more than it should. Since the tibia sits on top of this talus it must follow. This will allow more internal tibia spin (medial rotation) and this will drag the knee medially (it appears in the video to be a valgus load but it is more internal/medial rotation than valgus).
So, what the foot-ankle complex does, the knee follows. Conversely, when the knee moves medially or valgus because of a hip weakness (poor external rotation control) the foot will move medially.
So, are you going to "fix" this with an orthotic ? A stability shoe? Or are you going to actually help the client gain better control ?
You can see that our "raise the toes, to raise the arch" helps the client find the more appropriate arch posture with the help of more anterior compartment engagement and windlass effect at the 1st MPT-hallux joint. This is where our reteaching of the component parts via "motor chunking" via the Shuffle Walk (see our youtube channel) can help them control the rate and amount of arch "collapse" and thus control the rate of medial knee spin.
i say it on our podcast all the time, the knee is a simple sagittal hinge joint between 2 multiaxial joints. It is often a follower, not a leader.
Or you can bandaid this client with an expensive orthotic and never fix their problem. This keeps them coming back over and over for symptom management. It is a good business model (insert sarcasm), but helping this client learn and remedy their deficiency is a better one. Happy people talk to their friends, even strangers.

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #ovepronation, #archcollapse, #valgusknee, #tibialspin, #internalhiprotation, #thegaitguys, #kneepain, #runnersknee, #patellapain, #anteriorkneepain

"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."

We say this so often in our offices.
"You do not have a shoe problem, you have a "thing in the shoe problem", meaning, it is you."
Translation: compromised mechanics leading to tissue overloading.
But we all have to strongly consider that injury is a result of the loading you have not trained gradually into, failure to adapt and accommodate, excessive mileage without adequate tissue recovery,

From the article:
"So Napier and co-author Richard Willy from the University of Montana reviewed the highest-quality research featuring randomized controlled trials and systematic reviews.
"What we see is that there's really no high-level evidence that any running shoe design can prevent injuries," Napier said."

Now, to be honest, in our (the gait guys) opinion, there are times we do recommend a change in the foot wear for a client, and it is often because it appears to be working against someone mechanics and is a contributory factor in their injury or complaint. And sometimes that shoe recommendation is a temporary one, and sometimes a permanent one. We can use a shoe to help us get to a better/faster end point. After all, when we sprain an ankle sometime a brace or crutches are helpful and protective, of temporary value. A wisely chosen shoe can act the same if we are dealing with an acute achilles tendinopathy or a painful bunion for example. And in those cases we might recommend a shoe that can give us an assist. Sometime, when appropriate perhaps it is a shoe with a stronger medial post, perhaps one with a higher or lower heel drop/delta, or more or less stack height, or perhaps a mid/forefoot rocker built into the shoe. The truth is, people come in with functional or "fixed" pathology and sometimes pairing up a shoe to help us around some conflicting biomechanics can be temporarily, and sometimes permanently, helpful. But, the shoe is never the only answer, a wise clinician has many things they can utilize, all the way up the kinetic chain sometimes.
The more you know, the better you can assist someone.

Shawn Allen, one of the gait guys

#Nigg, #barefoot, #shoes, #stackheight, #heeldrop, #achillestendinitis, #bunion, #pronation, #supination, #running, #gait, #thegaitguys, #gaitanalysis, #gaitproblems, #gaitcompensation

Can the design of a running shoe help prevent injury? A B.C. researcher says he has the answer

Kelly Crowe · CBC News · Posted: Dec 15, 2018 9:00 AM ET

https://www.cbc.ca/news/health/running-shoe-injury-prevention-second-opinion-1.4947408?fbclid=IwAR3XaGPdgfQ68wj2N0tHqIamDdpYuxTIIL2LeudUd-doYN8YqQrIZI9-s9E

The Alex Honnold climb you haven’t heard about.

On janurary 15, 2014 Alex Honnold, Free-Soloed El Sendero Luminoso (The Shining Path) in El Potrero Chico, Mexico in a little over 3 hours. The climb rises 2500 feet to the summit of El Toro. At the time, it was considered to possibly be the most difficult rope-less climb in history, . . . until El Capitan.

An Alternate View of Crawling and Quadrupedal Motor Patterns: A Correlation to Free Solo Mountain Climbers ?

snippet from our redux blog post (link below):
"The interlimb coordination in climbing and crawling biomechanics shares similar features to other quadrupeds, both primate and non-primate, because of similarities in our central pattern generators (CPG’s). New research has however determined that the spaciotemportal patterns of spinal cord activity that helps to mediate and coordinate arm and leg function both centrally, and on a cord mediated level, significantly differ between the quadruped and bipedal gaits."

Blog link:

https://www.thegaitguys.com/thedailyblog/2019/2/10/an-alternate-view-of-crawling-and-quadrupedal-motor-patterns-a-correlation-to-free-solo-mountain-climbers-?fbclid=IwAR314kcjj6_KCnIczXksa6_5qUDQfy30NEPseH_RBmgVYEzNRSHcm8hq-IQ

What do the hip flexors have to do with the knee extensors ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment."

This is just a small example of how I approach a client through small assessment window.
As best as I am able, knowing the absolute limitations of a supine examinations translation to vertical loading, I will approach a client's ability to stabilize in all 3 planes of movement. Today, i will micro-dissect a thought process.

The straight leg resistance test (SLR):
just a few incomplete thoughts on a SAGITTAL perspective (so as to avoid writing a book).
I will do it looking at **pelvis posture (anterior, posterior, oblique), lumbar spine posture (incr/decr lordosis), if they can keep their knee locked in a position, does the pelvis rotate, do they want to deviate into internal or external rotation at the hip, do they plantar or dorsiflex their ankle or toes. Lots to see here in how a client will recruit, and this is just a small snapshot of things they might do. Yes, head position, arm position were left out , again, to avoid a longer post today.
I will add consistent (as best as possible) resistance in the SLR test , with full locked knee, at hip 30, 45 and then full straight leg SLR (at the client's hamstring tension limit), then again at 45 degree knee lock with partial hip flexion, 90 degree hip and knee. I am changing loading vectors frequently to see if their is a directional loading failure. I am looking for their ability to provide ample resistance, and how they might cheat (see above).
But here is how my mind works through the test on the most basic level, which will give me insight on the above cheats** the client may employ.
* In the MOST SIMPLEST thought of the assessment, can they EFFECTIVELY stabilize the pelvis to the lumbar spine, can they stabilize the femur into the pelvis, can they stabilize the tibia onto the femur? It is how they choose to engage the system that matters, and that might be partly why their "Screen" shows up shoddy and may be a window into their pain.
The question is, if they fail, where are they failing and what tissues are overburdened or over protecting ? Where is the load, and where NOT is the load, going ?

"It is not about your test, it is what your client displays in your test that matters. They will try to find a way. The load has to go somewhere, and they will find a place to put it, they always do. Finding out how your client cheats, compensates, recruits and fails is the value of the assessment. This is how you need to be thinking when you perform many of the mostly useless orthopedic tests in the textbooks.

This is key,
a SLR screen will not show you any of this, it will just show you their range of motion, nothing more, not how they did it, what parts worked harder than other parts, and which parts are weak, injured or inhibited, for example. It is not what a client does, it is how they go about it that has the most value to you in helping them.

Today's article below is what spurred my rant today. It gives light that most already know, that everything is connected. And perhaps we can translate it into deeper thoughts for our clients, namely, what part is not doing its job, and where are they not connecting the parts, and where are they putting the loads ?

From the Ema study:
"Our findings indicate that hip flexion training results in substantial neuromuscular adaptations during knee extensions similar to those induced by knee extension training."-Ema et al.

We need a stable and strong core-spine-pelvis connection to display powerful knee extension, and, we need a stable and strong femur-pelvis connection as well. So, where is your client doing more or less of the work, and is it related to their hip, low back or knee pain? Or are they tossing it into the ankle perhaps? This is the beauty of the game we all play every day, if we are actually paying attention.

Now, remember my discussion last week about "adding strength to dysfunction" ? Where is your client going to put the load?, the answer, where they can/able. And that doesn't exactly mean where they should be putting it. Mindless prescription of corrective exercises is a real problem in my opinion.

Shawn Allen, the other gait guy.

#gait, #gaitproblems, #gaitanalysis, #correctiveexercises, #running, #hipflexors, #kneeextension, #SLR, #corestrength, #thegaitguys

Scand J Med Sci Sports. 2018 Mar;28(3):947-960. doi: 10.1111/sms.13008. Epub 2017 Nov 22.
Neuromuscular adaptations induced by adjacent joint training.
Ema R1,2, Saito I3, Akagi R1,3.

Imposter syndrome and careful what you say, and read.

Why most published research findings are false.
Ioannidis JP1.
PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30.

"Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research."

Artwork:
from what we can tell, a rework of @rundavidrun artwork, reworked by @MatthewJDalby. Thank you gentlemen.

People received an incomplete picture from a small slice of a clinical exam pie yesterday and made some bold , yet reasonable judgements admittedly. We admit they are germane points and arguments, though easily biased on this small slice video, and unfair in the bigger picture. I will always back Ivo, he is one of the smartest clinicians i know, and if you have listened to our podcast it should be clear to anyone that he can run circles around most with his deep well of knowledge. Dr. Ivo showed a video that discussed some of the things he likes to consider on an exam, not his entire exam, to discuss some things he likes to think about and incorporate into his exam sometimes, things that have become reliable patterns that work for him in practice. Many of us have gone through these exam methods at one time if we have been in the fields long enough, and many of us know that "i do not feel a darn thing that they say i am supposed to" BUT, when put into a full complete exam, for Ivo, these things meshed with other exam inputs honed over a 25+ year history in the field mean something to him. And bottom line, results speak. That is all that matters because a lot of research is often full of holes. I too have some old tricks in my bag that are admittedly somewhat unsupported, but in a bigger picture when all the exam intake variables are brought together, decades of experience allow us to use deeper clinical experience to bring forth some ideas on the client's pain and problems. If we were all to abandon all of our older tricks that have proven valuable, who suffers ? And for what? a few studies that question validity? Everyone's educational past is full of holes and ignorance that has been disproven (yes, even your high school physics knowledge has been rewritten, but it does not mean that the broader insights that have grown from said knowledge is wrong. For example, even today's Low back pain research is becoming more and more untenable in some studies as to the true source of the pain, this has been a huge topic of discussion on some forums by very intelligent people. We are all reading small pieces of new research that tell us "this thing" or that thing is of low reliabilty and we question ideas of old. Some new research is now suggesting that ACL tears do not need surgery, so do we just stop doing ACL repairs? No, that is foolish, but just because the new doesn't support the old doesn't mean the old is useless and without clinical value. Here is what matters, can you help the person in front of you ? That is what matters. How you assess and go about it is not what matters to your patient. Ivo is top shelf, period. There are few people that have the depth and breadth of his knowledge in neurology and if you knew his depth of physiology was even deeper you'd be fully blown away. Listen to one of our podcasts if you do not believe me, he can run circles around me, for what little that might be worth. Productive comments can be made to create a debate without being snide. You only show you are a turd and your true colors (brown) when you cannot be professional. We work hard here, if you can't be professional, go somewhere else, please.

Oh, and still want to question things, good, you should, we all should. So, here, question EVERYTHING then.
Then again, there are those that will question this too, as they should. And so, if we just left our selves to decide to only use things deemed valid per today's thin research standards (what is your predatory journal count up to these days?) , then we dismiss much of what we used in our past that we used to actually help people. Do i dare ask those slinging stones to remember this post when 20 years from now the then research might dismiss many of the things they presently deem "law" and solid research?

Bottom line, judge softly, with open eyes, a touch of wisdom and skepticism, and self honesty in the knowledge that much of what we do, and think we do, is also rubbish, but sometimes yet still seems to help people.
And for those who still think they know it all, look at today's art work.

Shawn Allen, humble partner of a wise man, wiser than most. Dr. Ivo

PLoS Med. 2005 Aug;2(8):e124. Epub 2005 Aug 30.
Why most published research findings are false.
Ioannidis JP1.
"Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research."

Comment in

Modeling and research on research. [Clin Chem. 2014]
The clinical interpretation of research. [PLoS Med. 2005]
Minimizing mistakes and embracing uncertainty. [PLoS Med. 2005]
Truth, probability, and frameworks. [PLoS Med. 2005]
Power, reliability, and heterogeneous results. [PLoS Med. 2005]
Why most published research findings are false: problems in the analysis. [PLoS Med. 2007]
When research evidence is misleading. [Virtual Mentor. 2013]
The Value of P. [Am J Transplant. 2016]

https://www.ncbi.nlm.nih.gov/pubmed/16060722

another Patreon video cast study

Adding strength to dysfunction ?

Are you adding strength to dysfunction? Will you be apologizing?
We have been saying this for at least a decade now, glad Michael Boyle feels the same way (see his tweet below).
See ? we are not alone and crazy ! Other smart people are thinking the same things. This is just logic to us and seems Mike feels the same way. We do not fully understand the nay-sayers and push back on this topic.
And so, if you are not examining your client, rather just "movement screening" them and then making corrective exercise prescriptions based off of mere screen outcomes, you are likely, in our strong opinion, risking merely building strength on top of how they already are moving, which is quite possibly dysfunction.
Now, many will argue, a more durable pattern, even if it is dysfunctional, is less likely to be injured. And we can agree with that. But, if you are going to spend all that time, why not just fix the darn problem and then add durability on top of that sound loading pattern in the first place?

Are you going to leave that spare tire on the car just because it drives fine? There is a reason you don't tow a trailer with a spare tire on, and there is a reason you do not drive it at 100mph either. Get the original tire fixed darnit ! Do not settle with, "hey it works fine right now! Leave it alone!" (doh !)

Adding compensations to compensations can have ramifications down the road.
Do you want to be apologizing down the road? Scratching your head asking, "is this a result of what i recommended?"

hmmmmm
It should make you think more about what you are doing, everyday. It sure keeps us in line, everyday.
Makes you ask the hard question of why you are recommending something.
Sorry for the continuous 10 year rant on this. But it is nice to know we are not alone.

shawn allen, one of the gait guys.

#gait, #gaitcompensations, #gaitproblems, #dysfunction, #compensations, #strengthfirst

Knee pain and the the semitendinosis?

image source: https://commons.wikimedia.org/wiki/File:Slide2DADE.JPG

The semitendinosus hails from the posterior compartment.

During an ideal gait cycle, the semitendinosus from mid swing through nearly loading response, with a brief firing at toe off.

We remember that the abdominals should initiate thigh flexion with the iliopsoas, rectus femoris, tensor fascia lata and sartorius perpetuating the motion. Sometimes, when the abdominals are insufficient, we will substitute other thigh flexors, often the psoas and/or rectus femoris, but sometimes sartorius, especially in people with excessive midfoot pronation. Think about all of the medial rotation occurring at the knee during excessive midfoot pronation and when overpronation occurs, the extra compensatory external rotation that must occur to try and bring the knee back into the sagittal plane. The sartorius is positioned perfectly for this function, along with the semitendinosus which assists and external rotation and closed chain.

The semitendinosis is the most superficial of the hamstrings and originates between the biceps femoris, with which it shares a common tendinous attchment, which is anterior and slightly lateral and the semimembranosis which is just beneath it and slightly medial. It is fusiform and the muscle body ends about mid thigh, before becoming a long "piano string" and ultimately inserting most inferiorly of the trio, below the gracilis, on the pes anserine.

Call it pes anserinus bursitis or pes anserine tendinitis but they both add up to medial knee pain when the thigh needs help flexing. Look to this troublesome trio the next time you have recalcitrant medial knee pain.

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #gaitdysfunction, #thegaitguys, #pesanserine, #semitendinosis

Imani F, Rahimzadeh P, Abolhasan Gharehdag F, Faiz SH. Sonoanatomic variation of pes anserine bursa. Korean J Pain. 2013;26(3):249-54. 

Gupta, Aman & Saraf, Abhinesh & Yadav, Chandrajeet. (2013). ISSN 2347-954X (Print) High-Resolution Ultrasonography in PesAnserinus Bursitis: Case Report and Literature Review. 1. 753-757. 

Gray H:  Anatomy of the Human Body  Lea and Febiger, Phildelphia and New York 1918

https://www.anatomy-physiotherapy.com/knee/articles/systems/musculoskeletal/lower-extremity/knee/test-your-knowledge-the-pes-anserinus

 Michaud T: in Foot Orthoses and Other Forms of Conservative Foot Care Williams & Wilkins, 1993 Pp. 50-55

 Michaud T: in Human Locomotion: The Conservative Management of Gait-Related Disorders 2011

Climbing and quadrupedal patterns . . .

video: 14 year old “sends” V15 , a 30 move roof climb in Hiei, Japan, called “Horizon”.

Look closely. In the video, a then 9 year old Ashima is climbing upside down, a roof climb, defying gravity’s push. Spin this picture 180 and she is crawling, finding points of “fixation” or “punctum fixum”. What is neat about climbing is that you can have one, two, three or four points of fixation, unlike walking (one or two points) and crawling (two, three or four points of fixation). The difference in climbing is that gravity is a bear, wearing you down, little by little. A deep similarity in climbing to any variety of crawling is that both involve pulling and pushing, compressing and extending over fixation points. Other common principles are those of fixation, stability, mobility and neurologic crawling patterns in order to progress. This is one of the reasons why I respect and love Jiu jitsu so much, rolling, tumbling, crawling, pulling and pushing, compressing and extending over fixation points.

“the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.” - 2005 Shapiro and Raichien

In climbing there is suspicion of a shift in the central pattern generators because of the extraordinary demand by pseudo-quadrupedal gait climbing due to the demand on the upper limbs and their motorneuron pools to mobilize the organism up the mountain. We know these quadrupedal circuits exist. In 2005 Shapiro and Raichien wrote “the present work showed that human QL (quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.”

read our whole piece here, on our site . . . .

https://www.thegaitguys.com/thedailyblog/gait-and-climbing-and-dns-part-2-introducing?fbclid=IwAR1RtpRJyVzpd5EZ-lv-2vvI76nBjcRcW-KZANN7_wFzAYENtscDPNLBwLU

Do her hips get weak, fatigue, or both when she runs?

“ Both healthy and injured runners demonstrated decreased gluteus medius strength following the run to fatigue (p = 0.01), but there was no interaction between groups (p = 0.78). EMG onset activation timing did not differ between groups for the gluteus medius (P = 0.19) and tensor fascia latae muscles (P = 0.52). Injured runners demonstrated decreased gluteus medius initial median frequency values suggestive of fatigue (P = 0.01). These findings suggest that the gluteus medius muscle of female runners with ITBS does not demonstrate gross strength impairments but does demonstrate less resistance to fatigue. Clinicians should consider implementation of a gluteus medius endurance training regimen into a runner's rehabilitation program. “

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #fatigue, #gluteusmedius, #gluteusminimus, ITB, #ITbandsyndrome, #thegaitguys

Brown AM, Zifchock RA, Lenhoff M, Song J, Hillstrom HJ. Hip muscle response to a fatiguing run in females with iliotibial band syndrome. Hum Mov Sci. 2019 Feb 8;64:181-190. doi: 10.1016/j.humov.2019.02.002. [Epub ahead of print]

House MD. : Is he using his cane on the correct side ?

House MD. : Is he using his cane on the correct side ? (hint: vascular infarct to the quadriceps muscle)

*disclaimer: Note to listeners…. there is controversy over the lyrics, there always has been and always will be …..but they are listed below at the end of the post.)

When can you ever go wrong with AC/DC ? Combine that with Hugh Laurie from HOUSE MD and you have a great mix.

So, watching this video, why is he using his cane incorrectly? We all know that House’s has a problem with the right hip and leg. “The Rules” state that with a hip problem the cane should always be used on the opposite side to change the D2 lever arm (great lesson on this:https://www.youtube.com/watch?v=FLFQOKVO6X4&feature=youtu.be). After watching this Gait Guys videos you will clearly understand (perhaps to a better level than most of your therapists and doctors who gave you the cane) why it is used on the opposite side.

So, why in the world is the brilliant Dr. House using it on the same side ? We have received this question more than once. And the answer is quite simple. His problem is likely extracapsular. In the pilot episode of House MD it was explained that he suffered a vascular infarct to the quadriceps muscle. Like bone infarcts, muscular infarcts can be painful. If he contracts the quadriceps when loading the leg there will be pain. Just like if the infarct were osseous, the loading of the cortical bone and stress on the trabecular infrastructure in that case, axial loading of the limb (muscular or osseous) will drive pain. So, to lessen the issue he uses the cane on the same side to literally share his body mass load over the length of the cane and splinting of his body mass through that right arm and the cane. He is essentially attempting to use the cane as his weight bearing limb, same as if using crutches. The cane use on the opposite side is best used when you are attempting to unload the muscular compressive forces across the hip (acetabulofemoral) joint. Contraction of the gluteus medius generates the greatest joint compressive loading of all of the hip muscles because of its orientation during gait. Thus, utilizing the cane on the opposite side acts as a hydraulic lift necessitating a shift in body mass closer to the joint and reducing the compressive demands on the gluteus medius muscle.

* Rule breaker: sure, you can still use the cane on the same side to reduce the gluteus medius forces, it is just a bit more awkward and arguably less efficient from a physics persective. But it can be done. Think about and elderly folk who had a weaker opposite arm, they would feel more comfortable using House’s strategy. The rules are not hard pressed.

* So, House is using the cane correctly for his condition. Of course, he is no dummy !

Rules are meant to be broken. When you are as smart as House you know when to break the rules.

Thanks for the reminder AC/DC ……lyrics

https://thegaitguys.tumblr.com/post/17823193087/house-md-is-he-using-his-cane-on-the-correct?fbclid=IwAR1pAHFxhByiSr1orgIKIkOqwj9W1F-dd-4jQ8BEPntlEztgrolwrT60mos

“Living easy, living free
Season ticket on a one-way ride
Hey Momma, look at me

"Four puckered anuses and a heel strike."

So you say you do "gait analysis" and "movement screens" huh ?
If you glaze past this post, well, that would be sad to us, we put a lot of time into sharing what we feel are important (and not necessarily right) thought experiments and thoughts.

In our opinion, and this upsets some folks, screens do not tell you much of anything beyond how someone is moving. They do not tell you why they are moving that way. They do not tell you what is wrong, or right, about a person's body or why they move, or why they screen the way they do. We could even put up a darn good debate of why they could be a waste of time, when uncoupled with a clinical examination.

Much like the excessive wear on this left heel (see photo) it merely tells you that the person is, FOR SOME REASON, impacting/scuffing that heel too much. It too does not tell you why they are moving that way. (The shoe case explained in a moment).

Giving someone a "corrective homework exercise or stretch" or new movement because you "think" they are failing a screening procedure is nothing more than confirmation bias on your existing knowledge base (which for ALL of us is limited, yet hopefully expanding). Your confirmation bias might be, "I know what this screen should look like, I know what my gurus have told me it should tell me, and this client just failed the screen, so here is what you need to do to make the screen look and test better and here is what will make the client "better" (whatever that is)."

It just cannot, and is not, that simple.

Similarly, it would be like telling this person not to heel strike so hard, "Stop heel striking, stop scuffing your heel !". It is just not that simple and it is foolish to think so. We need to get to the bottom of the problem, the root cause. This means we need to hands-on examine our client, and correlate said findings to the screens. Collectively, we are just gathering information to put together a cause effect for any of our patient's problems. But you cannot just make assumptions that stroke your confirmation bias. There is logical process in place, for a good reason.

Now, why is this guy scuffing his left heel? He has no left heel pain, no left leg pain, clean foot, ankle and hip mechanics on that left side (from detailed coupled screens correlated with a detailed hands on exam including neuromuscular strength, length, skill, length-tension relationships, endurance assessments etc).

And if you think we are not guilty or above all of these mistakes we are calling out, you are mistaken. WE are on the same bus as everyone else. WE are human, we have biases, so we have to check them everyday. Just the other day I told a patient he wasn't getting better because i made and assumption based off of what i saw in his gait, and i assumed he wasn't going to fail my hop test, that it was a different problem, so i looked elsewhere, found something that confirmed my bias, and they came back 2 weeks later saying "i did my homework, i am no better." I took them into the hallway, had them go through my hop screen, and damn if i wasn't ashamed of myself, i followed with some hands on exam, and dang if I wasn't a confirmed moron. So, we screw up too, more than we like to. Some people will say "that is why we call it a medical practice". That is a soft let down. Sure, it happens, but laziness and confirmation bias happens way more often in all of us we believe.

Look at the cartoon below, the parents think the kid loves the animal mobile. From their perspective, from their limited experience lying under an animal mobile, how could they know the kid was smiling because he/she was looking up at 4 anuses? Four puckered anuses (yes, the plural is not ani. We had to look it up, too !). Go ahead, laugh, we did.
*And so, if you do make corrective exercise recommendations off of a screen, without clinical hands-on exam correlation, may your kids paint animal anuses on your bedroom ceiling to remind you of their tortured infant years.
Perspective, like this infant here staring at buttholes of stuffed animals, is amazing. It is all too often how you approach things, and with the limited (or expansive) knowledge and experience you approach it with, as to what confirmation biases you lay on things, and how you go about solving things.

*Oh, as promised, this dude in the shoes, has markedly weak RIGHT hip abductors and RIGHT lateral core (from our hands on exam and then specific loaded screens to assess and help confirm these things). This means, right lateral pelvis drift. This confirmed the visual drop of the left hemipelvis during swing phase, which allowed the left foot to have challenged clearance (he could hear the heel scuff when walking). Yes, slight left cross over gait too. The corrective exercise is to improve the right hip and lateral core stability, and establish gait awareness homework to learn how to reengage those areas. The corrective exercises were not to force more LEFT hip flexion and knee flexion to gain more clearance and stop the heel scuff. A monkey could figure that out. But that would seem logical if no examination had been done.

PS: There is no need to check his pelvic floor (see infant mobile cartoon above to extrapolate that joke). But, if you made assumptions of what homework to give him based only off of a bunch of screens, heck, you might as well check his sphincter. What do you have to lose?

WE would LOVE, love love love to give credit to whoever drew this cartoon. There is no name on it, we NEED to give them credit. It is more than brilliant. IT is an entire lecture on perspective. Send us this genius person's contact if you know who it was ! Please !!!!!!

Shawn Allen, the other gait guy

#gait, #gaitproblems, #gaitanalysis, #movementscreens, #correctiveexercises, #thegaitguys, #heelstrike

A flexed leg is a shorter leg: When loss of knee extension really matters.

A flexed knee is a shorter leg, period.
A knee with any loss of terminal extension, is more bent knee, and thus a shorter leg, period.

Stand up, bend one knee 10 degrees, you have shortened the global top to bottom length of that leg.
So when walking, you will plunk down onto that shorter leg, and there will be a cost.

This is old hat for our long time readers, but it is a good reminder to look for loss of terminal knee extension.

I just saw a lady with a uni-knee replacement of 5 months. Failing some aspects of rehab, they are stuck. There is hip,knee and ankle pain on walking.
She had a loss of terminal knee extension, thus a short leg, true shortness.
I placed a 2mm full sole length rubber-cork lift in the shoe (*DO NOT USE JUST A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts and causing plantarflexion at the ankle. Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, or want to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
She put the shoe back on with the 2mm sole lift in the shoe and walked 20 steps and started to tear up. No pain.

Sometimes things are simple. We more closely restored the leg length by adding more vertical height. Yes, the problem still exists, but its global effects are somewhat muted. She stopped premature heel rise, could feel her glutes, stopped the abrupt plunk onto the leg, *stopped the sudden abrupt knee flexion loading that was crippling her.

I then took it out, "shoe'd" her up again, and she was dumbfounded, all the pain returned as did her awareness of what she was coping with.

Now, sent her away with the sole lift to accommodate for 2 weeks, and we will restart the rehab once things have time to get used to the "new norm". Now the rehab will work, we think. Time will tell

One thing is for sure, and now yesterdays post rings more clear and true, if you build strength on compensation, you earn and own that compensation.

The Gait Guys

#gait, #gaitproblems, #gaitcompensations, #strength, #heellift, #solelift, #TKA, #hippain, #shortleg

Photo courtesy of Pixabay, beautiful photo isn't it !?

Gluteal tendinopathy and the Cross Over gait pattern.

Gluteal tendinopathy, often lateral hip pain at or around the region of the greater trochanter. (note: the pain referral of this problem can dispurse far and wide, from low back and even into groin or to the knee). It is not gluteal bursitis, the research barely supports that. You'd be better off using the term "greater trochanteric pain syndrome" (yes, its an ICD10 code).

The problem often involves the abductors, the gluteus medius and/or gluteus minimus tendons as weakness or poor co-contraction stabilization patterning creates a compressive adduction of the tendons and gr.trochanter. But, know this, mere strengthening is not the entire answer, and it is not supported as the cause or cure, it is just part of the solution. As with most problems, resolution is about load, how we load, load over time, tolerance to load, time under tension, loads we can manage, loads we are unprepared for. These are variables certainly pertinent to novice runners and athletes (though for some everyday folk even walking can be vulnerable) but also high level athletes who either mal-adapt, compensate, over protect or under-recover.
About 10 years ago I began my dive into something I was seeing often, something that did not seem to have a name from what I was able to determine, but one that was fraught with mechanical loading issues that was part of my athletes' symptom collage. I referred to it by what it appeared to be, a "cross over gait", and since then have written a few dozen pieces, at least, that go into the problem, pathomechanics, and correction for my athletes and patients. I have often referred this to as a "failure to stack the lower limb joints", but that is so remedial and non-descript. Almost a decade ago I did the 3 part video series (part 1 is below) and it brought a lot of light to gait problems in runners and a huge variable in unresponsive gluteal tendonopathies, amongst others. One can strengthen the glutes all they want, but if the pattern of pathologic loading is not amended, altered, improved, then the model will fail.
And here is another factor that is interesting brought forth at a recent conference,
"@Bill_Vicenzino Imaging over-estimates compared to clinical presentation - MRI positive for Gluteal Tendinopathy in 77% of cases but clinical presentation only positive in 52%"

Watch my 3 part series, starting with the video below. Get to understand the cross over gait variables and you will get better at remedying gluteal tendonopathy. It is more than just prescribing half a dozen glute exercises.

Shawn Allen, the other gait guy.

#gait, #thegaitguys, #gaitproblems, #gaitanalysis, #glutealtendinopathy, #hippain, #crossovergait, #hipadductors, #hipabduction, #greatertrochanter, #hipbursitis

Hip Abductor Strength In Individuals With Gluteal Tendinopathy: A Cross-sectional Study. Kim Allison et al.
https://bjsm.bmj.com/content/48/Suppl_2/A6.2

Free Solo. The movie, quadrupedal gait, and crapping your pants (all in one blog post).

I recently crapped my pants at the movie theater. Thanks Alex Honnold.

i have been waiting a year to see Free Solo on IMAX. I saw it on Saturday night. The theater quickly took on a particular odor. Yes, Alex lives, finishes the climb, you know this at the start. But the last 30 minutes of the full length documentary has you riveted, palm sweating, writhing in your seat, saying things inside your head like “he is 3000 feet up, there is no rope, he has nowhere to go, he is doomed”. And then he is not. I promise you this, you will not believe what you see. Please do not see this on anything but IMAX if at all possible, El Capitan and Alex deserve this format if at all possible. I promise, you will get the same pit in your gut that you get when you look over the top of the highest of roller coasters.

Are there possible neurologic differences in climbers such as Alex Honnold as compared to other quadruped species? Primarily, there is suspect of an existing shift in the central pattern generators because of the extraordinary demand on pseudo-quadrupedal gait of climbing because of the demand on the upper limbs and their motorneuron pools to mobilize the organism up the mountain. We know these quadrupedal circuits exist. In 2005 Shapiro and Raichien wrote “the present work showed that human QL(quadrupedal locomotion) may spontaneously occur in humans with an unimpaired brain, probably using the ancestral locomotor networks for the diagonal sequence preserved for about the last 400 million years.”

Some research has determined is that in quadrupeds the lower limbs displayed reduced orientation yet increased ranges of kinematic coordination in alternative patterns such as diagonal and lateral coordination. This was clearly different to the typical kinematics that are employed in upright bipedal locomotion. Furthermore, in skilled mountain climbers, these lateral and diagonal patterns are clearly more developed than in study controls largely due to repeated challenges and subsequent adaptive changes to these lateral and diagonal patterns. What this seems to suggest is that there is a different demand and tax on the CPG’s and cord mediated neuromechanics moving from bipedal to quadrupedal locomotion. There seemed to be both advantages and disadvantages to both locomotion styles. Moving towards a more upright bipedal style of locomotion shows . . . .

Here, read the entire post I wrote several years ago, instead of me piecmeal it here.

https://www.thegaitguys.com/thedailyblog/2019/2/4/gait-and-climbing-part-1

So your patents foot points in or out... Have you considered talar torsion in the differential?

The talus is to the foot, as the lunate is to the hand. It is the only bone that has the entire weight of the body passing through it before being distributed to the foot. It’s motion during pronation should be flexion, adduction and eversion, and in supination: extension,  abduction and inversion.

At birth, the angle between the talar neck and talar dome is 30 degrees adduction. This reduces to 18-20 degrees in the adult (see above). During this reduction of angle, the talar head also everts or “twists” laterally (ie promotes pronation), which helps to correct the supination and adducted position of the forefoot in adults present in infants (Saffarian 2011).

Abnormal talar loading and “untwisting” in development  has been linked to formation of a Rothbart foot type, also known as metatarsus primus elavatus (Rothbart 2003, 2009,2010. 2012). The 1st metatarsal is elevated and inverted with respect to the rest of the foot, with it behaving much like a fore foot varus.

Talar torsion (sometimes called subtalar version) results when there is a 10 degree or greater change in the final position of the talar head. This can cause an adducted position of the forefoot, often mistakenly called “forefoot adductus’, which actually only applies to the metatarsals, and not at all to the talus.

An adducted forefoot provides challenges to gait with many possible compensations. As discussed previously, there are at least 3 reasons we need to understand torsions and versions:

1. They will often alter the progression angle. In talar adduction, there will often be a decreased progression angle of the foot. This causes the individual to toe off in supination.

2. They affect available ranges of motion of the limb. We remember that the lower leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance, If it is already fully internally rotated, that range of motion must be created elsewhere. This may result in external rotation of the affected lower limb, excessive pronation through the deformity (if possible), or rolling off the lateral aspect of the foot.

3. They often can effect the coronal plane orientation of the lower limb. In talar torsion, the head of the talus often does not “untwist” appropriately resulting in a functional forefoot varus, with excessive forefoot pronation occurring at terminal stance and pre swing.

There you have it in a nutshell. Talar tosion: Present in 8% of the population (Bleck 1982) and coming to your clinic (or maybe it has already been there!

We will be talking about talar torsion, as well as many other torsional deformities of the the lower limb this wednesday evening on online.com: Biomechanics 305. Hope to see you there

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #thegaitguys, #talartorsion,#talus, #progressionangle, #toein, #toeout

Shoe flares Medial and lateral. Do you want both.

Wow, this shoe has incredible medial AND lateral flares at the rear foot ! But do you want both ?

Want a shoe that controls rear and midfoot pronation ? This Adidas shoe has features that will do it. Want a shoe that controls rear foot supination, this Adidas shoe also has features that will do it. Want a shoe that SHOULD put that rear foot in a nice tight gutter, and keep the calcaneus on a nice tight fence between pronation and supination, this one has some potential. But, will the foot comply with the mandates of the shoe ? (That is the question, and i will address that tomorrow. ) But, do you even want both in a shoe ? What are the chances that someone pronates AND supinates too much at the rearfoot ? We have never see it that is for sure. But, just look at that wide platform, thing about the potential use of this shoe in someone with neuropathy who cannot "feel" the ground well, hmmmm. Now there is a thought.
We talk about the function of the medial and lateral flares of a shoe, and their effects on rearfoot medchanics in our National Shoe Fit Course
link: (http://store.payloadz.com/results/results.aspx?m=80204)

A lateral flare, grabs the shoe and forces the shoe (and the foot we hope) into a medial direction, pronation. A medial flare, does the opposite, it resists the pronation tendency. Which one does your rear and mid foot need ? Maybe you should consider our Shoe fit course, we take you through hours of material to teach you how, when, why etc. Shoe choices for you and your client is a complex algorithm of knowing your foot type and the right shoe anatomy for that foot type to give you cleaner mechanics. The wrong shoe can be devastating to a foot and to ones gait.

Furthermore, this shoe as a dual density built into the medial midfoot. At least they wisely did not waste the dual density on the medial rear foot. It is not necessary with that huge medial rear foot flare. But some companies do not use the flare, they will opt to extend that dual density back into the rear foot to control some of that pronation. (think Brooks Adrenaline shoe for example).
However, you approach should always be to help your client earn better foot mechanics, awareness, skill, endurance, strength and power so that they do not need super duper shoe accoutrements like this shoe has. But, some feet will just never get the gold medal for function, and they will need a little help (or a lot of help in terms of a shoe like this one).
- Dr. Allen

I have knee pain when I run."How we do one thing is how we do all things."

I am not sure who made this statement first, otherwise we would share attributes to it, but it is a good quote. If you saw the back of my truck, you would know what my closet looks like at home. Organization is not a top shelf priority of mine. I can neve remember where i put anything.

IF this is how someone does a double support jump on the up and down loading phases, what do you think is likely to happen in single leg hops ? how about forward hops with movement? Forget about it. Oh wait, that is what running is, forward hops.

Simple principle today, sometimes the best place to start with someone's suspected problematic loading strategies, is to peel it back to the simplest root strategies of the more complex faulty strategy.
All to often we just "run", but we have no idea how to load and unload effectively. If some one cannot double support jump with controllable skill, how then will they single leg hop in place with controlled skill, let alone hop forward progressively with controlled skill, and then do so alternating leg to leg, (running) with controlled skill ?

Sometimes the solution is not an orthotic, or a more stable shoe, or some magical elixer corrective homework seen on a guru's youtube feed.
Sometimes, we just need to start from the beginning. Sometimes it is that simple, start from the start, and build up from there. Sometimes there is no magic, it is just simple progressive loading, which to some will seem too crude and wasteful, and to others who truly "get it", magical.

Sometimes, "how we do one thing, is how we do all things".

Shawn Allen, the other gait guy

Pod 144: Grounded running, Glute fatigue & Stress Fractures

Topics: Grounded running, Glute fatigue, Stress Fractures, Duty Factor, Ankle stiffness & Gait and Concussions

Keywords: gait, gait analysis, gait problems, running, ankle, band, concussions, fatigue, fracture, gait, glutes, grounded, gait guys, glute medius, problems, stiffness, stress, syndrome, time under tension

Links to find the podcast:
Look for us on iTunes, Google Play, Podbean, PlayerFM and more.
Just Google "the gait guys podcast".

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www.thegaitguys.com
Find Exclusive content at: https://www.patreon.com/thegaitguys
doctorallen.co
summitchiroandrehab.com
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 and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.

Where to find us, the podcast Links:

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Permalink URL: http://thegaitguys.libsyn.com/pod-144-grounded-running-glute-fatigue-stress-fractures

Libsyn Directory URL: http://directory.libsyn.com/episode/index/id/8666903

Show notes:

Hip muscle response to a fatiguing run in females with iliotibial band syndrome.
Brown AM1, Zifchock RA2, Lenhoff M3, Song J4, Hillstrom HJ3.
Hum Mov Sci. 2019 Feb 8;64:181-190. doi: 10.1016/j.humov.2019.02.002. [Epub ahead of print]

Balance and Gait Alternations Observed More than 2 Weeks after Concussion: A Systematic Review and Meta-analysis.
Wood TA1, Hsieh KL1, An R1, Ballard RA2, Sonoff JJ1.
Am J Phys Med Rehabil. 2019 Feb 5. doi: 10.1097/PHM.0000000000001152. [Epub ahead of print]

Does Running Faster Put You at Greater Risk of a Stress Fracture?
New research finds that speed might not cause as much strain on the shins as we thought
By Hailey Middlebrook
Feb 12, 2019
https://www.runnersworld.com/health-injuries/a26221848/stress-fracture-speed-study/

Fast Running Does Not Contribute More to Cumulative Load than Slow Running\
Hunter, Jessica G.1; Garcia, Gina L.1; Shim, Jae Kun1,2,3; Miller, Ross H.1,2
Medicine & Science in Sports & Exercise: January 25, 2019

https://journals.lww.com/acsm-msse/Pages/articleviewer.aspx?year=9000&issue=00000&article=96699&type=Abstract

Grounded running Reduces Musculoskeletal Loading.
https://www.ncbi.nlm.nih.gov/pubmed/30480615
Med Sci Sports Exerc. 2018 Nov 21
Bonnaerens S1, Fiers P1, Galle S1, Aerts P1,2, Frederick EC3, Kaneko Y4, Derave W1, De Clercq D1.

Duty factor:
duty-factor. The duration of a gait cycle where each foot is on the ground
https://www.researchgate.net/figure/Illustration-of-the-duty-factor-The-duration-of-a-gait-cycle-where-each-foot-is-on-the_fig2_221908232

Ankle intrinsic stiffness changes with postural sway
PouyaAmiri, Robert E.Kearney
https://www.sciencedirect.com/science/article/pii/S0021929019300387

A deeper dive 30 minute seminar on ankle rocker and ankle dorsiflexion, with Shawn & Ivo

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