External Tibial Torsion as expressed during gait.

So, last week we watched this young lad doing some static ankle and knee bends, essentially some mini squats.  Here was what we found (LINK). It is IMPERATIVE that you watch this LINK first before watching today’s video above.

Now that you have watched that link here is what you should be seeing today.

You should see that the left foot is extremely turned out. We talked about why in the linked post from last week. It is because of the degree of external tibial torsion.  When it is present the knee rides inside the foot progression line (the knee bends into the forward / sagittal plane when the ankle bends into its more lateral /coronal / frontal plane (they all mean the same thing) ie. when the foot points outwards.

Remember, the knee has only one choice of motion, to hinge forward and backward. When the knee is asked to hinge in any other direction once the foot is locked to the ground there is torque placed upon the knee joint and thus shear forces.  Menisci do not like shear forces, nor does articular joint cartilage.

So, once again we see the rule of “you cannot beat the brain” playing out. The brain took the joint with the least amount of tolerance, the knee, and gave it the easy job.  The foot was asked to entertain another plane of motion as evidenced here in this video with significant increased foot progression angle. 

When the foot progression angle is increased but the knee still must follow the forward body progression (instead of following the foot direction) the motion through the foot will be directly through the medial longitudinal foot arch.  And as seen here, over time this arch will fail and collapse. 

Essentially this lad is hinging the ankle sagittally / forward through the subtalar and midtarsal joints, instead of through the ankle mortise joint where ankle hinging normally should occur.

This is a recipe for disaster. As you can see here.  You MUST also know and see here that there is an obvious limp down onto that left limb. It appears the left limb is shorter. And with this degree of external tibial torsion and the excessive degree of foot pronation, the limb will be shorter. You need to know that internal limb spin and pronation both functionally shorten the limb length.  This fella amongst other functional things is going to need a full length sole lift. We will start with 3mm rubber infused cork to do so. And let him accomodate to that to start.

We will attempt to correct as much foot tripod (anti-pronation) control as possible to help reduce leg shortness as well as to help reduce long term damage to the foot from this excessive pronation. We will also strengthen the left gluteus medius (it was very weak) to help him engage the frontal/lateral/coronal plane better. This may bring that foot in a little. But remember, the foot cannot come in so far that it drives the knee medially. Remember who is ruling the roost here !…… the knee.  It only has one free range, the hip and foot have 3 ! 

Shawn and Ivo

Foot Landing Mechanics: Part 2 of 2 (Gait and Running)

Foot orthoses and landing mechanics

_________________

In Part 1 of this two part series (Part 1, link here) we wrote about the need to not omit observations of gluteal function when it came to the utilization of foot orthotics to control the knee. We felt that a tunnel vision perspective on just the foot was only telling half the story. Admittedly, we made the comment that research articles can look at isolated issues if it pleases them, but that it was our mission not to let tunnel visioned biases enter into things. Tunnel vision leads to assumptions that some problems have simple solutions. Our clients get evaluated through the entire kinetic chain when looking at foot and knee issues. Heck, even arm swing and opposite leg swing impact the function of the stance phase knee.

Here is again is the original article by Katie Bell over at LER (Lower Extremity Review) that brought up the initial PART 1 dialogue back in January and that is spurring Part 2 here today. It was good information but left some gaps in theory and application in our opinion.

The gap in our opinion is in failing to mention that perhaps this landing mechanics problem is present because of intrinsic foot weakness and kinetic chain cooperation of the entire limb and pelvis-core.  One must remember that if the foot can be corrected or merely strengthened in a more functionally neutral manner that it should be a first line intervention.  Merely inserting an orthotic, custom or off the shelf pre-fab does nothing to correct intrinsic and extrinsic weaknesses. They are an external device to correct alignment issues.  Just because you put an orthotic in a shoe does not mean that the foot must function properly afterwards.  A flat weak foot might just sit flat and weak upon the orthotic and nothing more.  Sure it will be on a new platform and with different alignment, but there are no guarantees it will function better.  The foot might just figure out a new way to compensate in another manner.  Even worse, the foot and lower limb might be completely foreign in strategy, skill, endurance and strength in this new position and thus at even greater increased risk for injury than the one you tried to correct with the device in the first place. Just because you toss an intervention at something that should make a difference or create a result, does not mean it will occur.  Just because you put a beer in someone’s mug does not guarantee they will drink it.  That is the intention, but the outcome is not guaranteed, they might drink it but they also might not. Heck, they could even spill it (ie. compensation …  undesirable outcome !).  Just because the platform is different, new and possibly more optimal does not guarantee they will have the Skill, Endurance or Strength (S.E.S. – the mantra of The Gait Guys) to function any differently than before.  This is why, when we choose to reach for an orthotic, that we educate the client on what it is doing, and how to treat it like any other piece of therapy.  Meaning that it is to help reach an end goal, and when possible it is weaned away or minimalized to the new levels of S.E.S.

Now, back to the topic at hand.

This article talks about the hip adduction in females and mentions that it is not present in males but fails to even talk about possible reasoning behind this gender specific finding. Why wasn’t changed Q-angle in females talked about here ? Perhaps that was a discussion in the studies and merely not mentioned here.

The article also fails to talk about failed landing mechanics at forefoot load. When we load returning to the ground from a jump, we first load the forefoot. If the peronei and lateral calf are not strong enough to hold the rearfoot and forefoot in eversion at landing, making sure that the forefoot bipod is squared up at initial contact, the foot will be at a huge risk of inverting and spraining ligamentous tissues (esp. lateral restraints) as the load transitions from forefoot to rearfoot upon landing.

Think about all of this the next time your foot is in the air and quickly approaching the ground. If you are into a forefoot landing technique in your running, how is your forefoot landing platform ? is it flat ? Are you hitting laterally and risking injury or faulty mechanics ? Is your foot landing too medially and challenging the foot tripod prematurely ?  Are you falling into the orthotic  if you are using one ? Or are you merely using it as a crutch to improve your landing mechanics ?  And……. do you even truly need an orthotic at all ? Or did your $ 500+ merely make for a nice mortgage payment on someone’s new boat ? 

Orthotics …. they have value at times. Do you know when and how to implement them and when to hold off ?  It is a tough game, you have to know the rules. 

Shawn and Ivo

Foot Landing Mechanics: Part 2 of 2 (Gait and Running)

Foot orthoses and landing mechanics

_________________

In Part 1 of this two part series (Part 1, link here) we wrote about the need to not omit observations of gluteal function when it came to the utilization of foot orthotics to control the knee. We felt that a tunnel vision perspective on just the foot was only telling half the story. Admittedly, we made the comment that research articles can look at isolated issues if it pleases them, but that it was our mission not to let tunnel visioned biases enter into things. Tunnel vision leads to assumptions that some problems have simple solutions. Our clients get evaluated through the entire kinetic chain when looking at foot and knee issues. Heck, even arm swing and opposite leg swing impact the function of the stance phase knee.

Here is again is the original article by Katie Bell over at LER (Lower Extremity Review) that brought up the initial PART 1 dialogue back in January and that is spurring Part 2 here today. It was good information but left some gaps in theory and application in our opinion.

The gap in our opinion is in failing to mention that perhaps this landing mechanics problem is present because of intrinsic foot weakness and kinetic chain cooperation of the entire limb and pelvis-core.  One must remember that if the foot can be corrected or merely strengthened in a more functionally neutral manner that it should be a first line intervention.  Merely inserting an orthotic, custom or off the shelf pre-fab does nothing to correct intrinsic and extrinsic weaknesses. They are an external device to correct alignment issues.  Just because you put an orthotic in a shoe does not mean that the foot must function properly afterwards.  A flat weak foot might just sit flat and weak upon the orthotic and nothing more.  Sure it will be on a new platform and with different alignment, but there are no guarantees it will function better.  The foot might just figure out a new way to compensate in another manner.  Even worse, the foot and lower limb might be completely foreign in strategy, skill, endurance and strength in this new position and thus at even greater increased risk for injury than the one you tried to correct with the device in the first place. Just because you toss an intervention at something that should make a difference or create a result, does not mean it will occur.  Just because you put a beer in someone’s mug does not guarantee they will drink it.  That is the intention, but the outcome is not guaranteed, they might drink it but they also might not. Heck, they could even spill it (ie. compensation …  undesirable outcome !).  Just because the platform is different, new and possibly more optimal does not guarantee they will have the Skill, Endurance or Strength (S.E.S. – the mantra of The Gait Guys) to function any differently than before.  This is why, when we choose to reach for an orthotic, that we educate the client on what it is doing, and how to treat it like any other piece of therapy.  Meaning that it is to help reach an end goal, and when possible it is weaned away or minimalized to the new levels of S.E.S.

Now, back to the topic at hand.

This article talks about the hip adduction in females and mentions that it is not present in males but fails to even talk about possible reasoning behind this gender specific finding. Why wasn’t changed Q-angle in females talked about here ? Perhaps that was a discussion in the studies and merely not mentioned here.

The article also fails to talk about failed landing mechanics at forefoot load. When we load returning to the ground from a jump, we first load the forefoot. If the peronei and lateral calf are not strong enough to hold the rearfoot and forefoot in eversion at landing, making sure that the forefoot bipod is squared up at initial contact, the foot will be at a huge risk of inverting and spraining ligamentous tissues (esp. lateral restraints) as the load transitions from forefoot to rearfoot upon landing.

Think about all of this the next time your foot is in the air and quickly approaching the ground. If you are into a forefoot landing technique in your running, how is your forefoot landing platform ? is it flat ? Are you hitting laterally and risking injury or faulty mechanics ? Is your foot landing too medially and challenging the foot tripod prematurely ?  Are you falling into the orthotic  if you are using one ? Or are you merely using it as a crutch to improve your landing mechanics ?  And……. do you even truly need an orthotic at all ? Or did your $ 500+ merely make for a nice mortgage payment on someone’s new boat ? 

Orthotics …. they have value at times. Do you know when and how to implement them and when to hold off ?  It is a tough game, you have to know the rules. 

Shawn and Ivo

We have talked alot of gait this week, especially this past Wednesday night on our monthly teleseminar on Chirocredit.com. Suffice it to say, it has been a long week

Friday Follies could not be complete with at least one musical reference….

Get out there and Walk Like an Egyptian! (really)

Have a great Friday

Ivo and Shawn