gait guys

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“The Icelandic horse was a work horse and the nation’s only transportation. Everything that needed moving was packed on a horse and transported over rough terrain and unbridged rivers. Not everyone could afford to own a horse, but for those who did it was a priceless possession for work and travel. It is understandable why the horse was called “the most needed servant”.” (x)

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Keep Digging

We are often asked “What is wrong with this gait?” or “Why do I have pain?”. Sometimes, we are able to provide an explanation which seems too simple, but is often correct. It often corrects the immediate problem, only to have another crop up a few weeks later.

Why?

To paraphrase from the words of SHREK; peoples compensations are like onions; they have layers. Uncovering and remedying one problem often leads us to the next weakest link in the chain.

We still have fond memories of Dr Ted Carrick grilling us in the post graduate neurology program “What is the longitudinal level of the lesion? Most pathologies occur at one locus; if you diagnose more than one, it is usually due to metastasis, multiple vascular occlusions, or clinical incompetence. Is the lesion at the receptor, the effector, the peripheral nerve, the spinal cord, the brainstem, the thalamus, the cerebellum or cerebrum”.

The information to glean here is that often we need to establish and limit our focus to ONE area where the problem could be. This necessitates us thinking through the problem and coming up with ONE problem which could cause all the problems you are seeing. This applies to gait and motion assessment as well.

Think of the patient with r sided knee pain caused by patellar tracking issues. Is the retro patellar inflammation the cause? Not usually (unless there has been direct trauma), it is often the symptom (or compensation). Maybe the cause is a forefoot varus deformity because they cannot descend the 1st ray adequately. Maybe this is due to insufficient extensor hallicus brevis function, or is it the peroneus longus? Maybe it is due to a congenital deformity of the foot. Maybe it is due to a functional (or anatomical)leg length discrepancy. Or maybe it is a problem with the left shoulder…you get the idea.

Keep looking and digging until you have found the 1 THING that can explain what is going on. Maybe it’s the individual; maybe it’s their footwear. maybe something else. If you can’t explain it by a single problem or fault, maybe it is time to run some blood work, send them for a vascular flow analysis, or more often than not; expand our knowledge base.

We are the Gait Guys. Two guys digging deeper and looking for the cause.

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In this Neuromechanics weekly, Dr Waerlop Introduces the cerebellum and talks about its importance clinically, since it contains more than ½ of the neurons in the brain! It’s anatomy and inputs from the periphery are discussed. The take home message is the cerebellum is the key to understanding and directing movement, since it receives feedback from most ascending and descending pathways.

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The Mighty Quadratus: Part 2  The Quadratus and Gait

Acting unilaterally without the ipsilateral foot fixed on the ground, it can raise the ilia on the side of contraction (as in a pull up or side bend on a Roman chair). The quadratus lumborum was more active than other muscles during isometric side support postures where the body is held horizontally almost parallel to the floor as the subjects supported themselves on one elbow on the floor together with both feet. 

It is active during single limb support during stance phase of gait on the contralateral side (along with the external oblique) to elevate the ilium. This is coupled with the ipsilateral anterior fibers of the gluteus medius and minimus pulling the iliac crest toward the stable femur.

Sahrmann states “the QL is optimally situated to provide control of lateral flexion to the opposite side via its eccentric contraction to provide control of the return from lateral flexion via its concentric contraction. The muscle is also positioned to play a role in the rotation that occurs between the pelvis and spine during walking”. This makes you really think about the interplay of this muscle, and another stance phase stabilizer, the psoas major, which attaches opposite the QL on the anterior aspect of the vertebral body, IN FRONT of the transverse process.

Acting bilaterally, it extends the lumbar spine, deepening the lordosis and acting to limit anterior shear of the vertebral bodies.

It is able to stabilize the 12th rib during forced expiration, thus acting as an accessory muscle of respiration. This fixation is important when we need to superimpose pelvic movements upon it. Furthermore, it increased activation in response to increasing compression in static upright standing postures.

Bottom Line?:

Think of the QL, especially during gait abnormalities or recalcitrant low back pain. The more it is stressed, the more it is activated. If someone had mild weakness of the stance leg gluteus medius, it may be called into play to pick up some of the slack. Expect to see increased activity paraspinally, with particular attention paid to the 12 rib attachments.

In our flexor dominant society, the QL may play a role in generating unilateral shear forces on the lumbar spine (along with the ipsilateral psoas), especially in individuals with poor ankle rocker or decreased hip extension.

The QL: it’s not only for breakfast anymore…..

We still are…The Gait guys

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This video pretty much sums up our entire philosophy. Skill, Endurance, Strength; in that order. Why? Skill requires the largest diameter afferent (sensory) nerves to accomplish (Ia and Ib afferents from muscle and joint mechanoreceptors); they are the fastest pathways; Endurance comes from larger sized Type I (and sometimes Type IIa) endurance muscle, which are oxygen dependent (aerobic) and are rich in myoglobin, glycogen, mitochondria and capillaries; Strength last, because it comes from smaller, Type IIb fibers, and is largely glycolytic (depends on anaerobic respiration) and is dependent on the other 2 (skill and endurance).

When you take amazing skill and body awareness and combine it with strength and flexibility and control you can do these kinds of wild things.

Exploring the links between human movement, biomechanics and gait.

The Gait Guys

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Don’t let the title scare you. While watching this excerpt from an acupuncture lecture, think about the implications for gait.

In this installment of Neuromechanics weekly, we discuss how everything we do, smell, see or hear influences muscle tone through the cerebellum. The take home message is environmental cues as well as therapeutic ones will influence muscle tone via the muscle spindles..

You just can’t get away from neurology. It is EVERYWHERE!

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The information you have been waiting for. How do you facilitate a muscle? How do you defacilitate a muscle? Do you already know how? Do you know the mechanism?

Fear not… In this weeks Neuromechanics, Dr Waerlop simplifies the function of Golgi Tendon Organs. Clinical correlations are made throughout the presentation with his usual sense of humor. Neuro and foot geeks around the world are rejoicing…

Wow, we really are geeks!

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So how did they get the skunk into the shoe?

Have a great Friday

Ivo and Shawn

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Something lighter for Friday Follies. 

It just goes to show. You don’t need to be the fastest, just faster than the the slowest guy. Enjoy your Friday!

Ivo and Shawn

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 Splay

Watch this video a few times through. Did you catch the subtle abduction moment of the Hallux (big toe) on impact? Did you see the collapse of the transverse metatarsal arch? No?  Watch it until you do.

What gives? We thought toes were supposed to be stable when they hit the ground (and in fact they are).  Read on…

Think of the adductor hallucis. It has 2 heads. The oblique head arises from the proximal shafts of metatarsals 2-4 and inserts on the MEDIAL aspect of the proximal phalynx of the hallux (along with medial fibers of the flexor hallucis brevis); the transverse head arises from the metatarsophalangeal ligaments of  digits 3-5, and the transverse metatarsal ligament and inserts blending with the oblique head on the proximal phalynx of the hallux.

The action of the adductor hallucis mirrors that of the abductor hallucis (which inserts on the LATERAL side of the proximal phalynx. Together, they act to keep the hallux straight and provide a compressive force which stabilizes the big toe WHEN IT IS ON THE GROUND.

The problem here, is that the base of the Hallux is NOT anchored to the ground. This person has a faulty tripod (most likely an uncompensated forefoot varus) and cannot anchor the big toe, there fore the adductor cannot do it’s job. Is is weak (from lack of use) and we see the result: an abducting big toe AND collapse of the transverse metatarsal arch (which the transverse head of the adductor, under normal conditions maintains).

Looks like this guy needs some exercises to descend the head of the 1st metatarsal and make an adequate tripod. Flexing the distal phalynx of the hallux while extending the metatarsophalangeal joint would be a good start. (see Dr Allen demonstrate this here: http://www.youtube.com/user/TheGaitGuys?feature=grec_index#p/u/11/TyRE9dReVTE )

The Gait Guys…promoting foot literacy here and everywhere.

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Foot Arch Question: Sent in from one of our readers

How would one go about “rebuilding” their transverse arch? The latter is pretty much convex. This also accomapnied by very tight long toe extensors (as evidenced by their tendons being very prominent at the top of my foot and my toes being curled at rest) and have suffered on and off from Morton’s neuroma. The ball of my shoes (right in the middle) is where the insoles of my shoes see the most wear. It’s not a huge concern of mine, but I would like to deal with this. I’ve suffered several ankle injuries (as a basketball player) and although I’ve tried orthotics in the past (for the neuroma), I’ve relied mostly on minimalist footwear (except when playing ball of course…). I know some rehab would be in order and would likely work. I’ve “reconditoned” my big toe abductors in the past and can even cross my second to over my big toe, so am just looking for some direction.
Thanks


Our Response:

As you probably are aware, there are 3 arches in the foot: the medial longitudinal (the one most people refer to as the “arch”, the lateral longitudinal (on the outside of the foot) and transverse (across the met heads).

Your collapsed transverse arch seems like it may be compensated for by a rigid, probably high medial and lateral longitudinal arches. This creates rigidity through the midfoot (and often rear foot) and creates excessive motion to try and occur in the forefoot. Depending on how much motion is available, this may or may not occur.

You don’t seem to be able to get your 1st metatarsal head to the ground to form an adequate tripod, so you are trying, in succession, to get some of the other, more flexible ones there (thus the wear in the “ball” of the foot you noted). This results in increased pressure, metatarsal head pain, possibly a bunion and often neuromas.

From your description, you actually have very weak long toe extensors (and possibly some shortening) which is causing the prominence of the tendons, along with overactivity of the long flexors (and thus the clawing) in an attempt to create stability. I am willing to bet you have tight calves as well (especially medially, from overuse of the gastroc to control the foot) and limited hip extension with tight hip flexors.

The foot tripod exercises are a great place to start, as well as heel walking with the toes extended and walking with the toes up (emphasizing extension, which counteracts the flexors). Stay away from open back shoes and flip flops/sandals; continue to go barefoot and get some foot massages to loosen things up. Maybe use one of those golfballs to massage the bottom of the foot when you get off the course and get some golf shoes that aren’t quite so rigid.

Hey everyone. Have a Great 4th of July!

The Gait Guys

A few minutes in our Brains.

We were over at a book store on the weekend and picked up a book called Incognito written by neuroscientist David Eagleman.

The gist of the book was that the majority of brain activity is largely subconscious. That the brain is continuously processing information and working algorithms to questions and problems that we have inquired about either consciously or subconsciously. A conscious example might be pondering which new computer to buy, factoring in price, model, manufacturer, specs, hard drive size, peripherals desired, etc. Over a period of minutes, hours or days you bounce around the issues until you rationalize a best decision for your needs and wallet. On the other end, a subconscious example might be learning a new motor skill in your gait pattern. For example perhaps, a pathologic pattern is the one being learned. In one case the brain may be subconsciously learning to reduce gluteus medius muscle in an attempt reduce hip joint compression forces and thus hip pain due to a degenerative joint cartilage surface (see Dr. Allen’s recent video, Applied Hip Gait Biomechanics, Sept 15). In this scenario the brain was working out the algorithm to solve for the pain. The brain is continuously subconsciously processing to solve these problems, it is always working in the background, in sleep or in a wakeful state. We have all had these epiphany moments where the solution to a problem comes to you seemingly out of the blue. However, it is not the case. The brain had been at it for some time.

Eagleman describes the conscious brain as a CEO who is handed a final product that has been worked on by hundreds of employees for weeks, those employees being the subconscious brain parts. The CEO is the last to know, they only get to see the end success of hundreds of hours of work by the employees, and they often take full credit because they are the CEO afterall. It is a long process to achieve solutions to complicated problems. Afterall, do you really think Steve Jobs made the iPad all by himself ? Some might.

Where are we going with this ?

Unconscious incompetence: you do not know the right foot has turned out during gait.

Conscious Incompetence : someone has brought it to your attention.

Conscious Competence: you find a reasonable motor pattern to turn the foot in, but you must stay conscious of this pattern for the correction to be maintained.

Unconscious Competence: eventually unknowingly achieving the foot alignment correction. Give the brain the correct information … then give it time and the correct supportive exercise and let the brain figure it out. It will bring that foot inline eventually as long as there are not other impeding factors. The key is making sure that the pattern you teach your client , or that you institute yourself, is not a compensation. That’s the hard part ! You have to know what is right before you know what is wrong. Pick the wrong pattern and you find yourself down a fork in the road that is full of potholes and problems. Don’t guess. See someone who KNOWS. We had a guy fly in to see us yesterday and this was exactly the case. Therapy has been prescribed in-part off of a video gait analysis and incorrect physical evaluation. You can’t guess at this stuff. You gotta study!

Coming directly from our temporal lobes, we are…The Gait Guys

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The Mighty Quadratus: Part 1

Today we explore the Quadratus lumborum and its functional anatomy.

It is useful to think of the QL as having two divisions. Though they can’t act independently, it helps when thinking about it from a functional standpoint. The first, or lower division arises from the medial portion of the iliac crest and adjacent iliolumbar ligament, inserting onto the transverse processes of the lumbar vertebrae, running in the coronal plane from lateral to medial and posterior to anterior in the saggital plane. The second, or upper division arises from the lumbar transverse processes of the upper 4 lumbar vertebrae at their upper and lower corners and insert into the inferior border of the 12th rib, running in the coronal plane from medial to lateral and in the saggital plane from anterior to posterir. Approximately half of the fascicles of this second division act on the twelfth rib; the rest act on the lumbar spine.

The QL is primarily a coronal plane stabilizer. Acting unilaterally with the lower body fixed and feet on the ground, it laterally bends the lumbar spine. Normally, with lateral bending of the lumbar spine while in a lordotic posture, we see what is called type I coupled motion, or deviation of the spinous process to the side of lateral bending. The QL would oppose (or perhaps more correctly attenuate) this motion, having a moment of moving the spinous process to the opposite side of contraction. Perhaps it is when the QL become dysfunctional, pulling the ipsilateral transverse process outward (and thus moving the spinous to the opposite side) that we see aberrant (or Type II) motion in the lumbar spine. It is interesting that when the lumbar spine is flexed (as in sitting or forward bending) type II motion is normal, and now the QL becomes prime mover. Due to the angle of attachment here, it can create shear and potentially contribute to injury.

Whew!! Stay tuned for the QL and gait tomorrow!

Yup, if you are reading this, you are a gait geek too!!

Shawn and Ivo

We always think of ourselves as the CSI or NCIS geeks of gait. We were aware of forensic analysis of footprints and this article is just the icing on the cake!

article source: http://www.google.com/hostednews/afp/article/ALeqM5jhIh9jpQmYAgl6Rv0uBjNQgT1ItQ?docId=CNG.4ecd62b490d0f49529b2cfb2c331d332.481

Security first: When a footstep is like a fingerprint

(AFP) – 1 day ago   

PARIS — How a bare foot strikes the ground as one walks reveals your identity almost as well as a fingerprint, according to a study released Wednesday.

The discovery means that one day retinal scans, voice recognition and old-fashioned mugshots may be joined by foot-pressure patterns as a means of confirming ID, it suggests.

Previous research has shown that everyone has a unique stride. Computers can determine “gait patterns” – the way a person walks, saunters, swaggers or sashays – with up to 90-percent accuracy.

Scientists led by Todd Pataky at Shinshu University in Tokida, Japan, looked at enhancing this finding by measuring how the foot hits and leaves the ground during walking.

They used 3-D image processing and a technique called image extraction to analyse the heel strike, roll-to-forefoot and push-off by the toes among 104 volunteers.

Footstep patterns were matched to the individual with 99.6 percent accuracy, according to their paper, published on Wednesday in Britain’s Journal of the Royal Society Interface.

The study is “proof of concept,” meaning that it was carried out in experimental conditions among volunteers who were barefoot to see whether the theory was sound.

In an email exchange with AFP, said the technology would be useful in security checks.

But it would only work in situations where an individual wants to be recognised, “since anyone can modify their gait,” he explained.

“Automated airport security checks, ATM security, controlled building access – in all these cases, an individual could walk normally to be positively identified.”

Further work is needed to see whether feet that are shod throw up similar telltale patterns.

“We have some pilot data for walking with shoes, but have not yet conducted systematic testing,” Pataky said.

Too cool, eh?

Ivo and Shawn

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Genu valgum in kids: What you need to know

We have all seen this. The kid with the awful “knock knees”.  It is a Latin word “which means “bent” or “knock kneed”. It appears to have 1st been used in 1884.

This condition, where the Q angle angle exceeds 15 degrees, usually presents maximally at age 3 and should resolve by age 9. It is usually physiologic in development due to obliquity of the femur, when the medial condyle is lower than the lateral. Normal development and weight bearing lead to an overgrowth of the medial condyle of the femur. This, combined with varying development of the medial and lateral epiphysies of the tibial plateau leads to the valgus development. Gradually, with increased weight bearing, the lateral femoral condyle (and thus the tibial epiphysis) bear more weight and this appears to slow, and eventually reverse the valgum.

Normal knee angulation usually progresses from 10-15 degrees varus at birth to a maximal valgus angle of 10-15 degrees  at 3-3.5 years (see picture).  The valgus usually decreases to an adult angle of 5-7 degrees.  Remember that in women, the Q angle should be less than 22 degrees with the knee in extension and in men, less than 18 degrees. It is measured by measuring the angle between the line drawn from the ASIS to the center of the patella and one from the center of the patella through the tibial tuberosty, while the leg is extended.

Further evaluation of a child is probably indicated if:

  • The angle is greater than 2 standard devaitions for their age (see chart) 
  • If their height is > 25th percentile 
  • If it is increasing in severity 
  • If it is developing asymmetrically

Management is by serial measurement of the intermalleolar distance (the distance between ankles when the child’s knee are placed together) to document gradual spontaneous resolution (hopefully). If physiologic genu valgum persists beyond 7-8 years of age, an orthopaedic referral would be indicated but certainly intervention with attempts at corrective exercises and gait therapy should be employed. Persistence in the adult can cause a myriad of gait, foot, patello femoral and hip disorders, and that is the topic on another post.

Promotion of good foot biomechanics through the use of minimally supportive shoes, encouraging walking on sand (time to take that trip to the beach!), walking on uneven surfaces (like rocks, dirt and gravel), gentle massage (to promote muscle facilitation for those muscles which test weak (origin/insertion work) and circulation), gait therapeutic exercises and acupuncture when indicated, can all be helpful.

Ivo and Shawn…  The Gait Guys…Promoting foot and gait literacy for everyone.

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Gait, Running and Muscle fiber types & Why you want to train to mimic your sport.

This weeks neuromechanics explores muscle fiber types, the characteristics of each, and what that means for training. How does that relate to gait?

Our lower extremity muscles are a mix of strength and endurance muscles and each must be trained (or retrained) appropriately. If you lack endurance capacity in your gluteus medius (commonly seen with fatigue and manifesting as a pelvic dip), strength training will not help the problem… in fact, it will make it worse! Larger cross sectional area with less mitochondria, fewer capillaries and less myoglobin only fuels more anaerobic glycolysis (read LACTIC ACID PRODUCTION); if you cannot recycle this appropriately, your endurance goes down. Remember, exercise is specific as to the type of contraction (isometric, isotonic, isokinetic) as well as the speed of contraction.

Have your attention? Watch the video!

We Are and will remain The Gait Guys: piecing it together so you don’t have to.