What have we here?

Take a look at the tibial tuberosity and then where you think the 2nd metatarsal head would be. What do you see? The 2nd metatarsal is lateral to the tibial tuberosity. You are looking at external tibial torsion.

Lets see how this external tibail torsion behaves during a knee bend on a total gym. Observe the medial drift of the knee during weight bearing knee flexion. 

In external tibial torsion there is an external torsion or a “twist” along the length of the tibia (diaphysis or long section) (need a review? click here). This occurs in this example to the degree that the ankle joint (mortise joint) can no longer cooperate with sagittal knee joint.  When taking a client with external tibial torsion and pre-postioning their foot in a relatively acceptable/normal foot progression angle as seen here, there is a conflict at the knee, meaning that the knee cannot hinge forward in its usual sagittal plane. In this case with the foot progression angle smaller than what this client would posture the foot, you an see that as they bend the knee the knee is forced to drift medially and as soon as the heel is unloaded a pure “adductory twist” is noted (you can see the heel jump medially in an attempt to find a more tolerable sagittal knee bend).

Are you looking for torsions of the lower limb in your clients ?

Are you forcing them into foot postures that look better to  you but that which are conflicting to your clients given body mechanics ?  Remember, telling someone to turn their foot in or out because it doesn’t appear correct to your eyes can significantly impair either local or global joints , and often both. Torsions can occur in the talus, the tibia and the femur.

Furthermore, torsions can have an impact on foot posturing at foot strike and affect the limbs loading response, from foot to core and even arm swing can be altered.  Letting your foot fall naturally beneath your body does not mean that you have the clean anatomy to do so without a short term or long term cost. 

Want more on torsion and versions ?  Type the words into the search box on our blog. We have plenty of good info for you.

Shawn and Ivo, The Gait Guys

Twisted, Part 4

 

Hopefully you have been keeping us with us. If you missed the 1st 3 of this series, go back 3 weeks and start reading again, or do a search on the blog page for “torsion”.

The final chapter of developmental versions involves the femur. The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas  or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait.  In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up,  and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. See the person with external tibial torsion in the above picture?

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  •  FNA values that exist one to two standard deviations outside the range are considered “torsions”
  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”
  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation
  • Ante torsion causes an increase in available internal rotation  of the hip and decrease in external rotation
  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)
  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 

Stay tuned for a case tomorrow to test your learning over the last few weeks.

 

We remain: Bald, good looking and intelligent…The Gait Guys

 

 

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.  Please ask to use our stuff!

Step width alters iliotibial band strain during running.

More substantiation that “the cross over gait” is a pathologic process.

Did you get to hear podcast #23 yet ?  Here is the link (iTunes).  In podcast #23 we talked at length about the effects of step width in runners.  Reducing ones step width will result in a progression into what we have been referring to for years as “the cross over gait”.  We have been reducing this phenomenon in our runners, and many walkers, for over a decade now to reduce many of the lower limb pathologic processes that ensue when the cross over is left unchecked and worse yet, strength and endurance is loaded upon the faulty pattern.  Everyone’s gait in this realm will differ because of pelvis width, femoral and tibial torsion, genu posturing (knee valgum, varum)  and foot structure and type. All of these factors must be taken into account when deciding upon the degree of step width correction.  Ultimately the goal in a perfect world would be to have the foot and knee stack pristinely under the centrated hip joint proper, but we all know that ideal biomechanics are the unicorn when it comes to humans. Anatomic variation is the known norm and this must not be forgotten, this was pounded into all of our heads in medical school.
As this article from the Nov 2012 J. of Sports Biomechanics clearly states, iliotibial band strain and strain rate is significantly greater in narrow based gait scenarios and that increasing step width during running, particularly in those who tend towards the lazier narrower step width, may be beneficial in not only the treatment but the prevention of future lateral hip and knee biomechanical syndromes such as IT band syndrome.  So, if you are a slave to your foam roller and need your IT band foam roller fix daily, you might want to look a little deeper at your biomechanics and make some changes.  Our videos here will be helpful to you and our writings on the Cross Over gait  and link here will be helpful as well.
In  summary, there is just so much more to good running form than just following the mantra “let my feet fall under my body mass and everything will be just fine”.  We wish it was this easy, but it is not. Unfortunately, too many of the sources on the internet are maintaining that good running form is mostly just that simple. Sadly, we find it our mission to bring the bitter tasting truth to the web when it comes to these things.  One just cannot ignore the factors of pelvis width, femoral and tibial version and torsion, genu posturing (knee valgum, varum) and foot structure and foot type (and we mean so much more than are you a pronator or supinator).  These factors will alter lower limb biomechanics and may drive even the runner with heightened awareness of foot strike and running form into less than optimal foot strike positioning and loading response. Furthermore, one needs to be acutely aware that merely taking the cooked down under-toned postulation of this journal article, that being increasing step width will resolve their IT band problems, may not resolve their problem. In fact, without taking the issues of pelvis width, torsion, version, foot type and the like into account, making these changes could bring about more problems.  Seeking the advise of a knowledgeable physician in this complicated field of human locomotion is paramount to solve your chronic issues.
There is more to clean running than just a
midfoot-forefoot strike under the body mass, a good forward lean and high cadence. And we are here to bring those other issues to light, for the sake of every injured and frustrated runner.  Remember, uninjured does not always mean efficient. And efficient does not always mean uninjured.

Shawn and Ivo, The Gait Guys


_______________________________
Sports Biomech.
2012 Nov;11(4):464-72.Meardon SA, Campbell S, Derrick TR.

Step width alters iliotibial band strain during running.

Abstract
excerpted:

“Greater ITB strain and strain rate were found in the narrower step width condition (p < 0.001, p = 0.040). ITB strain was significantly (p < 0.001) greater in the narrow condition than the preferred and wide conditions and it was greater in the preferred condition than the wide condition. ITB strain rate was significantly greater in the narrow condition than the wide condition (p = 0.020). Polynomial contrasts revealed a linear increase in both ITB strain and strain rate with decreasing step width. We conclude that relatively small decreases in step width can substantially increase ITB strain as well as strain rates. Increasing step width during running, especially in persons whose running style is characterized by a narrow step width, may be beneficial in the treatment and prevention of running-related ITB syndrome.”

Podcast #24: Chronic achilles issues, beer recovery drink and case studies.

podcast link: http://thegaitguys.libsyn.com/pod-24-the-chronic-achilles-beer-cases

iTunes link: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Show notes:

Gait Guys online store:

http://store.payloadz.com/results/results.aspx?m=80204

Today’s show notes:

1. J Trauma Acute Care Surg. 2013 Mar;74(3):946-7. doi: 10.1097/TA.0b013e31828272ad.
Achilles’ death: Anatomical considerations regarding the most famous trauma of the Trojan War.
2. J Foot Ankle Surg. 2001 May-Jun;40(3):132-6.Saxena A, Bareither D.

Magnetic resonance and cadaveric findings of the “watershed band” of the achilles tendon.
3. http://www.sciencedaily.com/releases/2013/02/130212112019.htm

Fallout from Nuclear Testing Shows That the Achilles Tendon Can’t Heal Itself
4. K. M. Heinemeier, P. Schjerling, J. Heinemeier, S. P. Magnusson, M. Kjaer. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb 14C. The FASEB Journal, 2013; DOI: 10.1096/fj.12-225599

5.  http://www.washingtontimes.com/news/2013/feb/10/scientists-suggest-beer-after-workout/#.USRSIq-QMnw.facebook

Scientists suggest beer after a workout
6. Sports Biomech. 2012 Nov;11(4):464-72.

Step width alters iliotibial band strain during running.
7. _http://skorarunning.com/confessions-of-an-overpronator

Over-Pronation

8. http://www.championseverywhere.com/why-gait-analysis-doesnt-work-future-of-the-shoe-industry

Why gait analysis doesn’t work (future of the shoe industry

Podcast #24: Chronic achilles issues, beer recovery drink and case studies.

podcast link: http://thegaitguys.libsyn.com/pod-24-the-chronic-achilles-beer-cases

iTunes link: https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Show notes:

Gait Guys online store:

http://store.payloadz.com/results/results.aspx?m=80204

Today’s show notes:

1. J Trauma Acute Care Surg. 2013 Mar;74(3):946-7. doi: 10.1097/TA.0b013e31828272ad.
Achilles’ death: Anatomical considerations regarding the most famous trauma of the Trojan War.
2. J Foot Ankle Surg. 2001 May-Jun;40(3):132-6.Saxena A, Bareither D.

Magnetic resonance and cadaveric findings of the “watershed band” of the achilles tendon.
3. http://www.sciencedaily.com/releases/2013/02/130212112019.htm

Fallout from Nuclear Testing Shows That the Achilles Tendon Can’t Heal Itself
4. K. M. Heinemeier, P. Schjerling, J. Heinemeier, S. P. Magnusson, M. Kjaer. Lack of tissue renewal in human adult Achilles tendon is revealed by nuclear bomb 14C. The FASEB Journal, 2013; DOI: 10.1096/fj.12-225599

5.  http://www.washingtontimes.com/news/2013/feb/10/scientists-suggest-beer-after-workout/#.USRSIq-QMnw.facebook

Scientists suggest beer after a workout
6. Sports Biomech. 2012 Nov;11(4):464-72.

Step width alters iliotibial band strain during running.
7. _http://skorarunning.com/confessions-of-an-overpronator

Over-Pronation

8. http://www.championseverywhere.com/why-gait-analysis-doesnt-work-future-of-the-shoe-industry

Why gait analysis doesn’t work (future of the shoe industry

Yet another IFGEC certified individual, and our 1st in Asia! Congrats, Andy! Here’s what he has to say:

My name is Andy Neo aka Dee. I work as the regional senior tech rep for a distributor shoe company managing Singapore, Malaysia, Thailand & Indonesia. Additionally I graduated with a Bachelor degree in Sports & Outdoor from Monash University and an avid distance runner.   

I’m a keen learner about exercise physiology & human movement but there is no course for shoe fitting since I started working in the footwear industry few years back. A lot of knowledge was self learnt through trial & error because there are no industrial standards across the running shoes market. Fortunately I happened to tumble The Gait Guy’s blog & Facebook and was a keen follower of their regular posts. I was overjoyed when Dr Ivo & Dr Shawn in 2012 announced the opportunity to participate the National Shoe Fit Certification Examination online especially for me coming from another continent. The extensive 3hr lecture did helps to bridge the gap between health science, sports science & footwear education (seriously lacking in modern shoe industry). The lecture video was downloaded and studied at my own pace was really beneficial for working adults like myself. My advice to future IFGEC candidates is to have a good read up of human anatomy, shoe anatomy and human biomechanics for better understanding because the extensive 3hours lecture use technical terminology that can be jargon but definitely worthy information.

The quality of  examination questions required critical thinking & hence raise the standard of the certificate. Passing the IFGEC examination would elevate my profession so now I can better impart the knowledge to my retail staffs across 4 countries for a holistic shoe-fit service.

I recommend representative from performance footwear company & medical healthcare professions to spend quality time to sign up for this level 1 course because the contents will narrow the gap between health science & shoe industry.”

 

For more information on IFGEC certification, please email us at thegaitguys@gmail.com

http://thegaitguys.tumblr.com/post/21713480315/the-chef-another-abnormal-gait-pattern-in

Last night we caught a DVR’d season show of Bourdain’s new show “the Layover” on the Travel Channel.  Great new show, we love his diatribes, rants and command of the English language. It reminded us of this post we did last year where we looked in depth at his unique gait flaw, the circumducting foot.

Join us again for this great gait dissection, see the link at the top. Even if you have been with us for over a year and still somewhat remember this gait pattern and our explanation of it, you will likely pick up another layer of  understanding after our last year of teaching  here on The Gait Guys blog.

Shawn and Ivo, The Gait Guys

http://thegaitguys.tumblr.com/post/21713480315/the-chef-another-abnormal-gait-pattern-in

Last night we caught a DVR’d season show of Bourdain’s new show “the Layover” on the Travel Channel.  Great new show, we love his diatribes, rants and command of the English language. It reminded us of this post we did last year where we looked in depth at his unique gait flaw, the circumducting foot.

Join us again for this great gait dissection, see the link at the top. Even if you have been with us for over a year and still somewhat remember this gait pattern and our explanation of it, you will likely pick up another layer of  understanding after our last year of teaching  here on The Gait Guys blog.

Shawn and Ivo, The Gait Guys

Yes, we are all twisted. Part 3 continued.

If you missed yesterdays post, this one will make more sense if you go back and read it.Today we talk about compensations for tibial torsions.

As discussed in previous posts, there are at least 3 reasons we need to understand  tibial torsions and versions:

1. They will often alter the progression angle of gait.  In internal tibial torsion, there will often be a decreased progression angle of the foot and with external, an increased angle of progression. A decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width.

2. They affect available ranges of motion (ROM) of the limb. We remember that the lower leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance:

ROM changes that may occur with internal tibial torsion

  • If it is already fully internally rotated (as it may be with internal tibial torsion), that range of motion must be created or compensated for elsewhere.
  • This can result in external rotation of the affected lower limb to create the range of motion neede
  • Circumduction of the lower limb, because the foot is already in a supinated posture, and the decreased range of motion of the foot needs to be compensated for.
  • A shortened step length, due to increased compressive forces at the medial knee
  • And alteration of vertical and medial lateral ground reactive forces
  • A rolling off the lateral aspect of the foot, due to it being in a more supinated posture

ROM changes that may occur with external tibial torsion          

  • external tibial torsion often results in the increased midfoot pronation, through the deformity, because more range of motion is possible both at the hip and foot at the subtalar joint

3. They often can effect the coronal plane orientation of the lower limb.

In internal tibial torsion, due to the foot being more rigid and the deformity often being accompanied by increased tibial varum, the knee often falls outside the plane of the foot (rather than being “stacked”), resulting in a decreased step width and often a cross over gait pattern (click here for more info on crossover)

In external tibial torsion, the foot is often more pliable. This often results in an increased step width and well as the knee falling inside (or medially) to the plane of the foot. Because of the increased hip and foot ranges of motion available,  the foot is not an adequate lever, shortening step length and sometimes requiring increased pelvic motion to “get around” the stance phase leg.

Whew! This stuff can be tough, Thanks for hanging in there! Next stop: Femoral Torsions and Versions!

Ivo and Shawn; your torsioned friends : )

 

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.  Ask before you lift our stuff, Lee is watching……

Yes, we are all twisted; Part 3

 

In the last 2 posts we discussed the differences between torsions and versions, as well as talar version and torsion, 1 of the 3 major versional events that occur during normal development (missed out? Click here and here to re read them).

In this post we discuss tibial versions and torsions.

The tibia and femur are more prone to torsional defects, as they are longer lamellar (layered) bones as opposed to the cancellous bone that makes up the talus. These often present as an “in toeing” or “out toeing” of the foot with respect to the leg; changing the progression angle of gait (click here for more on progression angles).

Tibial versions and torsions can be measured by the “thigh foot angle” (the angulation of the foot to the thigh with the leg bent 90 degrees: above right) or the “transmalleolar angle” (the angle that a line drawn between the medial and lateral malleoli of the ankle makes with the tibial plateau: above left). 

At a gestational age of 5 months, the fetus has approximately 20° of internal tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°). 

Sometimes the rotation at birth is excessive. This is called a torsion. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure (on the lower legs) in the uterus (an unstretched uterus in a first pregnancy causes greater pressuremaking the first-born child more prone to rotational deformities. Growth of the  unborn child accelerates during the last 10 weeks and the compression from the uterus thus increases. As you would guess, premature infants have less rotational deformities than full-term infants. This is probably due to decreased pressure in the uterus. Twins take up more space in the uterus and are more likely to have rotational deformities. 

Of interesting note, there is a 2:1 preponderance of left sided deformities believed to be due to most babies being carried on their backs on the left side of the mother in utero, causing the left leg to overlie the right in an externally rotated and abducted position.

Normal ranges of versions and torsions are highly variable (see chart above: right). Ranges less than the values are considered internal tibial torsion and greater external tibial torsion.

Internal tibial torsion (ITT) usually corrects 1 to 2 years after physiological bowing of the tibia (ie tibial varum) resolves. External tibial torsion (TT) is less common in infancy than ITT but is more likely to persist in later childhood and NOT resolve with growth because the natural progression of development is toward increasing external torsion.

Males and females seem to be affected equally, with about two thirds of patients are affected bilaterally and the differences in normal tibial version values are often expected to be cultural, lifestyle and posture related.

 The ability to compensate for a tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot and/or by externally rotating at the hip. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hip. Both can decrease walking agility and speed if severe. With an external tibial torsion deformity of 30 degrees , the capacities of soleus, posterior gluteus medius, and gluteus maximus to extend both the hip and knee were all reduced by over 10%.

Well, that was probably more than you wanted to know about tibial torsions, and we could go on for many more pages and perhaps cure any insomnia you may have. Take a while to digest this, as it is important to gait, shoe selection, and rehabilitation. Torsions are an acquired taste and we hope we have whetted your appetite! Tomorrow we talk about compensations!

 

Ivo and Shawn; two twisted guys!

 

 

 

 

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.  Ask before you lift our stuff, Lee is watching……