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Welcome to Neuromechanics, a regular weekly feature here at The Gait Guys. Join Dr Waerlop on this neurological journey as he discusses the corticospinal system and how flexor dominance occurs and how that leads to many common injuries.

The Cross-Over Gait: Slow Motion barefoot video analysis.

Thanks to Runblogger.com for once again providing materials on their blog for us to peck away at clinically.

Before we get into our findings from this clip we need to jump up on our soapbox once again on our typical rant on video analysis.  Here we go again, ……. What you see on video analysis is quite often not what is wrong with your client.  What you are seeing is their strategy to run or walk with the parts that are available for them to use.  You are seeing a compensation pattern.  If a gluteus medius is notably weak or inhibited you will not see its functional expression on the analysis, rather you will see your clients neuromuscular strategy with the parts that are available.  Sure you can hypothesize some things, but without proper muscle testing and evaluation, even if you are screening with “functional pattern tests”, there is no guarantee that your suspicions are correct.  Not until you can get them on the table and assess their anchoring musculature, stabilizers and prime movers with more specific muscle tests.  Without this component as part of our client evaluation, you must leave room for the cognitive reality that you are  basing your next thoughts and direction on some assumptions, and we all know what can happen when you do that.  It would be a crime to prescribe or train your client further into assumed patterns, not knowing that you are building skill, endurance and strength on an improper compensation/cheating pattern. Take these thoughts to your next gait evaluation expert, and ask these hard questions. 

(people like examples, so below you will see an example of this thought process)

OK, now, back to our visual findings (assumptions or concerns) in the video above. There is good midfoot strike for the most part. In keeping this simple for today, lets just focus on the stability problem in the frontal plane.  We can easily see a cross over gait here.  This chap is literally running on a line, it is an example of poor biomechanics… 1) it is not biomechanically correct or efficient and 2) it requires a ton of gluteus medius and abdominal core support to hold midstance correctly (which is far from what we see here).  We see evidence of this mechanical collapse and insufficiency here.  The foot should be under the knee, the knee should be under the hip, the opposite side pelvis should be horizontal or show a little hike and the pelvis should be quiet for the most part.  In this case, there is a suspicion (yes, an assumption that we would manually test) that he does not have enought gluteus medius and abdominal strength to stop the obvious lateral deviation of the hip/pelvis during stance phase. 

“But how can you say this Gait Guys ? We cannot even see the pelvis in the video ! ?”

Here is how. We know that the opposite hip has to be dropping, evidence of the lack of stance stability, because in everyone, when the swing phase hip drops it allows the limb to adduct…….. thus driving the swing phase knee towards the stance phase knee.  This drives the cross over gait , or “line runners” as we like to call them.  Just as we see here ! This one is a dead ringer for the need of hip/pelvis/ core evaluation.  Who is driving it ? We do not know, and you cannot know either, not without testing.  Perhaps it is the abdominal oblique as the primary, or maybe the primary is the gluteus medius, , maybe it is the adductors.  There is no way to know. And basing your training or homework or therapeutic exercises for this client from a gait evaluation is about as silly as prescribing a shoe for this foot that looks like it is pronating too much.  When the truth is that it could be doing so to make up for the suspected faulty mechanics above.

In this scenario, telling this guy he should not be in Vibrams is just about as silly as telling him he needs a stability shoe, even though the two thoughts are directed at the same thing.  That thing being the increased pronation appearance that you do not like.  In this case, we need to get to the root of the problem and that means you have to have the clinical skills to do so.  Perhaps this guy is pronating so much through the foot because he does not have enough internal hip rotation. And in order to complete the stance phase of gait the internal rotation has to occur somewhere to get his body mass past the foot so he can get to his glutes to propulse forward.

What you see is not what is wrong most of the time, as in this case.  This client should not be told he should not be in Vibrams, nor should he be told he should be in a stability shoe.  What he should be told is…….” Look buddy, there may be some issues here you. You might want to have some of this stuff looked at a little deeper”

Video Gait analysis……. it is not just for breakfast, lunch or dinner anymore……..it is the fork you use to help you eat those meals.  Its a tool ! ……….. just like The Gait Guys…….. yup, 2 tools…….. Shawn and Ivo

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A Case of Hip pain in a Young Runner: Perthes Disease

here is a nice little short video of a young girl with a healed Perthe’s Disease (full name, Legg-Calve-Perthes Disease) that came to see us a few years ago with right hip pain.  After an examination and a very brief treatment stint films were obtained and found an early stage Perthe’s Hip.  Early diagnosis is always important in this disorder that affects the vascularity of the head of the femur. Failure to make an early diagnosis is a disaster which leads to deformity and permanent disability for the patient.  Perthe’s affects mostly male boys under the age of 10. There is really no clear etiology but many studies point to a period of increased pressure within the joint from an inflammatory process. A term “Transient Synovitis” has been labeled by some.  In this case, the disorder was caught in its first stage and the hip revascularized, did not collapse and it is doing well.  Collapse is the most devastating outcome of this disease process, it is why you do not mess around with children with unresolving hip pain, obtain imaging early.  The main problem, as is seen here, is that she cannot get to her gluteal muscles to stablize the hip in the frontal plane.  Here you see a classic Trendelenberg Sign when she steps onto the right leg. 

When she steps onto the left hip the hip,knee and foot are well aligned in the frontal plane and the right hemipelvis rises above the left hip joint line.  Comparatively, when she steps on the right, there is a significant lateral pelvic and body mass shift beyond a line drawn up from the foot-knee line.  Consequently the left hip drops and she looks like she has a short right leg.  Measurements (as unreliable as they are)  do not show a leg length discrepancy.  However, this type of mechanical behavior can put undue stress on a healing femoral head.  Using a sole lift to help regain pelvic leveling during gait help maintain balanced femoral head pressures and cartilage coverage during the last stages of joint formation in this adolescent.  The problem is that there will be dependency on the lift so regular daily exercises with guaranteed compliance is imperative.  She must regain use of the glute in gait and stance or this hip will be a problem in later years, guaranteed.  So, this is a difficult case.  It is not for the faint of heart.  Bottom line, do not mess with kids with hip pain for long without imaging to rule out terrible problems like this.  There are so many gait problems that will ensue if the gluteal stability is not regained.  To name just a few, the right foot will always be supinated and this means risk for bunions (see last weeks Dr. Ivo video on bunions and the adductor hallucis muscle) and other disorders that are caused by an unanchored first metatarsal.  Additionally, the knee can degenerate the lateral compartment quickly not to mention the plethora of muscular problems (low back pain, knee pain etc) and strategies (ie. pelvic distortion patterns) that will ensue from such a gait.  There is so much more to Perthes Disease than we have mentioned here, but this is not the venue for such complicated topics.  The important thing is to beware of systemic problems that can compromise the integrity of the neuromusculoskeletal system that can have short and long term effects on one’s gait. Here is a link to some more info on Perthes Disease …… but even this is scant info (http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002244/)….. make sure you do your reading if you are in the clinical world and see young patients. 

It is not always just about muscles and shoes and orthotics. You have to always be on your toes (no pun intended).

we are…….. so much more…….. than just Gait Guys.