Mirror Neurons: We are gonna piss off ALOT of people today with this post.  

How closely do your kids watch you? If you are a guy, how closely did you study the sporting greats like Michael Jordan, Joe Thiesman, Magic Johnson, Nolan Ryan, Carl Lewis, etc ? And ladies, who did you mirror yourself after?  When we are young we idolize, mimic and mirror that which we are surrounded by or that which we aspire to.  Every kid in my neighborhood had a Kareem Addul Jabar Sky-hook.  Heck, why not ?!

When it comes to gait, we model there too. In our practice we have seen, enough times to know it is not coincidence, a father walk into the office and his son have the same limp and swagger.  Kids pay attention, they just don’t model our 4 letter words.  Actions speak loudly and imitation is a strong method of learning and communication.

Humans have always observed other humans.  Observation, modeling and imitation are a form of survival.  If we want to socially understand, interact and survive we have to understand the actions of others and learn to assimilate, interact and react to others. Mirror neurons and the mirror-neuron mechanism are fundamentally human and necessary to complete these tasks of social interaction.

To this end, it is imperative to understand the gait cycle, both the walking and running cycles. The observer must know the normal cycles in order to identify the abnormal components of someone’s gait cycle. Once this can be identified one must know how to determine the cause of what is observed and know how to remedy the cause of the abnormality, not the remedy of the observed abnormality.  And just as importantly, the observer must help the client see and feel the pathologic pattern, correlate the causitive factor and help model a cleaner motor pattern. We find it very helpful to be able to mimic the client’s pathology to help them see and recognize it outside of their own body and then help them better feel their pathology (which is often an epiphany to them), model a remedy, and help them remedy the problem fitting the new pattern into a new non-pathologic gait pattern.  Once a client sees their problem, recognizes it, feels it in their own gait, feels the cleaner remedied pattern then they can cycle in a new neurologic pattern.  Then the clock begins to tick, and a new pattern will develop in 10+ weeks once a new myelinated pattern is engrained with conscious practice.  

* But one thing is clear, if you do not identify the source or cause of the abnormal gait pattern first (with remedy to follow), and you skip this critical diagnostic first step, deciding to go directly into showing your client how they SHOULD walk or run then you merely have helped them to develop a new gait cycle on top of the faulty old gait pattern which was a compensatory strategy to begin with around the underlying neuromechanical pathology (ie. immobility, hypermobility, instability, weakness etc). Whew ! That was mouthful.

Go for the root level of the problem, forget about the grass level appearance of the problem. Dig deep, don’t be a shallow digger. Be part of the solution, not part of the problem.  Think about all of this the next time you goto a running clinic that is teaching what is supposed to be “better form”. First of all, better form for whom ? The elite running? The upper quartile athlete?  The mean? The median? Or, the first timer amateur ?  Telling people how running should look and feel, rather than looking for the cause as to why someone runs less than optimally is a big mistake.  The body doesn’t decide to run poorly and inefficiently, it chooses to do so because some of the parts are either twisted (ie. osseous torsions), there are remnants of old injuries unresolved completely, they are in the wrong shoes for their foot type, they have physical limitations from underlying weakness (which then predicate the development of tightness or altered patterns to compensate) or lack of body awareness. Think about all this the next time you start to ponder form running clinics and treadmill gait analysis at your local store or therapists office.

Examine your client, test their motor patterns, test their muscle strength, find the cause of that gimpy gait or running technique.

Shawn and Ivo, The Gait Guys…….. likely pissing off a whole lot of people today with science, logic and neuro-mechanical principles. And, not intentionally pissing folks off, just suspecting that a bunch of people just had a light bulb moment and are pissed at the messenger.

Another video link:   http://youtu.be/6s1ON7ZZQxQ   Family Performance by Warren & Kristi Boyce – Glenn Richard Boyce & Kayleigh Andrews @ 3rd Surabaya International Dancesport Championship 2013 (8th June 2013)

Reference Links:

http://www.ncbi.nlm.nih.gov/pubmed/15217330

http://www.ncbi.nlm.nih.gov/pubmed/19129788

Sometimes, you just need to add a little pressure….

Cyclists are no different than runners; often when the effort is increased (or the conditions reproduced), the compensation (or problem) comes out.

Take a good look at this video of a cyclist that presented with right sided knee pain (patello femoral) that begins at about mile 20, especially after a strong climb (approx 1000 feet of vertical over 6 miles through winding terrain).

The first 7 seconds of him are in the middle chain ring, basically “spinning” ; the last portion of the video are of him in a smaller (harder) gear with much greater effort.

Keep in mind, he has a bilateral forefoot varus, internal tibial torsion, L > R and a right anatomically short leg of approximately 5mm. His left cycling insole is posted with a 3mm forefoot valgus post and he has a 3mm sole lift in the right shoe.

Can you see as his effort is increased how he leans to the right at the top of his pedal stroke of the right foot and his right knee moves toward the center bar more on the downstroke? Go ahead, stop it a few time and step through it frame by frame.  The left knee moves inward toward the center bar during the power stroke from the forefoot valgus post.

So what did we do?

·      Worked on pedal stroke. We gave him drills for gluteal (max and medius) engagement on the down stroke (12 o’clock to 6 o’clock) to assist in controlling the excessive internal spin of the right leg. Simple palpation of the muscle that is supposed to be acting is a great start.

·      Did manual facilitation of the glutes and showed him how to do the same

·      Worked on abdominal engagement during the upstroke (the abs should initiate the movement from 6 o’clock to 12 o’clock)

·      Manually stimulated the external oblique’s

·      Placed a (temporary, hopefully) 5mm varus wedge in his right shoe to slow the internal spin of the right lower extremity

·      Taught him about the foot tripod and appropriate engagement of the long extensors; gave him the standing tripod and lift/spread/reach exercise (again to tame internal spin and maintain arch integrity)

Much of what you have been learning (for as long as you have been following us) can be applied not only to gait, but to whenever the foot contacts anything else.

The Gait Guys. Experts in human movement analysis and providing insight into biomechanical faults and their remediation.

All material copyright 2013 The Gait Guys/The Homunculus Group. Please use your integrity filter and ask before using our stuff. 

Photo: Where is your knee joint hinge point ?  Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing.  He has the cleanest lines of the bunch. How is that for cruel irony ?  Sometimes it ain’t what you got, it is what you do with what you got.  Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations.  Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.  

Today’s Lesson:  Get in line, and get in line early. (just kidding of course)

The Gait Guys.  Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination.  We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.  ”Seeing may be believing” but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

*Photo courtesy of BIG EAST Conference

Bipedal vs. Quadrupedal. A Navy Seal vs. Chimp

Next week we have a short series on quadrupedal gait. You won’t want to miss this one. We are gonna show you something that will freak you out ! But as always, we have lessons and teachings with it, important ones.  

Here is a primer.  Enjoy

Midfoot Striking Monsters.  That’s right, a gorgeous HD video for you today. Reminds us of a Joseph Campbell storyline.  A beautiful video and an Angus Young-ish young boy with perfect midfoot strike, along with his monster buddies.

Something a little lighter today for the gait brethren here on The Gait guys.  Proof that it doesn’t always have to be cerebral here on the Gait Guys. Today just sit back, go full screen HD on this one, and turn it up loud !

This kid should give form running clinics. Its simply a beautiful running form.

Shawn and Ivo.

___________________

credits:

RUN BOY RUN EP ON I-TUNES : itunes.apple.com/fr/album/run-boy-run-remixes-ep/id522665628

WOODKID – RUN BOY RUN – Video directed by Yoann Lemoine

Produced By ICONOCLAST with the help of Picseyes
Produced by Roman Pichon 
Art director / Chef Decorateur : Pierre Pell 
Post Production by OneMore Prod
VFX SUPERVISOR : Gregory Lanfranchy
FLAME ARTIST : Herve Thouement
FLARE ARTISTS : Laura Saintecatherine & Romain Leclerc
3D : Olivier Junquet & Priscilla Clay
MATTE PAINTING : Arnaud Philippe Giraux
POST PRODUCER : Raminta Poskute
Label & Video commissioner Pierre Le Ny

P & C 2012 GREEN UNITED MUSIC ICONOCLAST / GREEN UNITED MUSIC / SEIZE ZÉRO TROIS
label-gum.com/

Trojan horses for knee menisci.

 Orthotics and internal tibial torsion. Good? Bad? or Ugly? It depends…

Hopefully you remember about torsions, especially internal tibial torsion (see above). Tibial torsions are deviations (in this case, in the transverse plane) of the long axis of the bone. The bone is basically twisted along its long axis, like wringing out a wet towel. They are measured by drawing an imaginary line through the medial and lateral malleoli, as well as through the two halves of the tibial plateau, and measuring the angle between them (see 2nd picture above). For a more complete review of torsions, click here.

 At birth there should be little to no angular difference between the proximal and distal tibia, and this changes to about 19-22 degrees in the adult; the shaft of the tibia rotates outward (externally) with growth resulting in a normal tibial external version (see 3rd picture above).  Sometimes, the angular difference is less than zero at birth and the tibia does not rotate outward (externally) resulting in internal tibial torsion.

Internal tibial torsion usually results in a decreased progression angle (more on those here). This often causes a “toed in gait” and the foot remains in supination for a longer period of time (supination is adduction, inversion and plantar flexion), making the foot a rigid lever. When we examine the person in a standing position with the knees in the coronal plane, the feet point inward. When we move the feet to a more normal posture, the knees rotate outward from the coronal plane.

Folks with internal tibial torsion often have a forefoot varus (the forefoot is inverted with respect to the rear foot) because of the amount of supination they are in, which we talked about in the previous paragraph, (see also here). When folks have a forefoot varus, they have a tendency to pronate more through the forefoot, and when people pronate more other folks like to typically put them in orthotics to “get rid of that pronation”(because we all know that pronation is the scourge of humanity, and if there were less pronation in the world, there would probably be fewer wars, famine and poverty : )

 So what happens to the knee when we place an orthotic in the shoe? Most orthotics are designed to slow pronation of the midfoot, so they basically supinate the foot, causing the talus to dorsiflex, abduct and invert. This rotates the leg (and thus the knee) externally. With internal tibial torsion, often the knee is already externally rotated because your brain will not allow you to progress forward with your toes in too far, you would trip. So, the orthotic rotates the knee out further, bringing it outside the sagittal plane. This does not bode well long term, as it creates a rotational and friction conflict at the knee (remember the knee is basically a hinge between two ball and socket joints). Guess where the conflict manifests itself? At the meniscus. This, over time, is a great way to macerate a meniscus and create a problem.

Does this mean an orthotic is never indicated? No it does not. It means that if you use one, you should probably make sure the part of the orthotic anterior to the styloid of the 5th metatarsal has a valgus post built into it. This valgus moment will help to bring the knee back to the midline during the propulsive phase of gait. See our recent post here about forefoot valgus posting. Do you think this is ever considered in stores when dispensing foot beds for shoes ?  Not all foot beds are evil or a problem mind you, but we have seen some in stores that are real risky business if you ask us.

The bottom line? Know how to use the tools you have available, or someone is going to get hurt. When in doubt, exercise is usually a safer alternative and often has less likelihood of creating a Trojan Horse.  

Want to learn more about these kinds of things, foot beds, foot types etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

The Gait Guys. Raising questions and providing answers and guidance, with each and every post.

 

all material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. Please ask before lifting our wares. 

What is your gait filter ? This blog post may be the most important one we have ever written.

Are you a biomechanist ? A high school or college coach ? A physical therapist ? Chiropractor ? Self-proclaimed running guru ? Running shoe store shoe fitter ? Researcher ?

We all are going to approach gait and gait analysis through our biased filter. There is no way you can avoid it. And the more diverse your background, the deeper your education levels and the deeper your experience level in practicing your trade the better your filter will be.  But in many ways this article is more than just about your gait analysis filter, it is about your life filters, your outlook and opinions that have shaped your life.

Are you assessing your client’s gait ? Maybe you think you are. Maybe you are doing a great job and are seeing things that are truly there, and maybe you are making them up.  Is your filter clogged ? And, if you are doing gait analysis and your gait knowledge is thin, then you are also limiting and possibly biasing the information of one of the most deeply repetitive and engrained motor and movement patterns that a human will do on a daily basis. If you are not looking for honest gait pathomechanics, and if you are giving exercises to your client without cleaning up those pathomechanics (*not what you see but what has caused what you see) you are further driving your clients neurologic faulty motor patterns deeper into a rut.  This can lead to injury locally and possibly globally.

Just remember, in gait analysis and in life, if you disagree with someone it is likely because of the detail and depth of the filter you or they are observing things through.  Once your education stops, formal or experiential, your filter will no longer change and life and gait will be judged based on that stagnant filter (and we all know a “rigid in their ways” parent or grandparent who is stuck in their ways).  And, when it comes to progress or lack there of,  so does the potential benefit to every client you help from this day forward. Keep refining that filter, keep making it deeper and more pristine. Keep cleaning it out regularly and look for ways to improve upon it.  The more you know the better your filter, the better you will filter out the assumed, the lies and the fake outs from the truth.  

Ivo and I have have filters too. And when it comes to gait, our individual filters force us to see other sides but these filters we each bring to the table create conflicts at times.  We do not always see a case the same way and sometimes we argue from one side of the fence, until we realize to put on the other guys filtered glasses. Ivo has a strong neurological, rehab, acupuncture/Eastern medicine filter. These are weak filters for me and I will always default to him on these issues. Likewise, I have an
orthopedic, sports med, muscle activation filter and they too can be a blessing and curse. But when we come together and layer our filters we get a clearer extract from what is being pressed through our filters. And, when we play nicely with each other, putting our two brains together and let a case filter down through the filters of neurology, orthopedics, acupuncture, rehab, sports medicine, movement pattern systems, muscle activation/inhibition techniques and the like we often get a pure and honest extract at the other end. Our filters help us remove the biases in a case that inexperience or a lack of expertise or knowledge on a particular disorder will cloud.

There is much to this filter theory. As we eluded to earlier, filters dictate how we see the world. Whether it be gait analysis or how we raise our kids filters affect how we see our world and the actions we take based on that filtered information.  Gait analysis is no different than anything else in our lives. When it comes to rearing children for example we often act subconsciously and reactively on many of the filters handed to us by our parents, from our life experiences, from our religous views, political views and many others. These actions and reactions do not mean your filter is always right either. Learning about another side or perspective through some else’s filter can help clear or solidify yours. Gait analysis is no different and it is subject to the biases passed down to you from all that you have learned or experienced.

Are you keeping your clinical and gait filters pure and unbiased? We question this all the time about our work to keep us honest. If all someone does is look at something through the same filter you can get lost at seeing the world only through that filter. Be careful if all you do is go to the same seminars and follow the same people around because they are the top chef guru right now. Every theory has holes and limits, just ask Einstein. It’s when we try to press a square peg into a round hole based on “the guru or theory of the moment” perspective that we get ourselves into the problems of a clogged filter. We have all done it, yes all of us. We get stuck in our ways as well. We are creatures of habit. We have all been to a great seminar only to return the next Monday into our routines of old slowly drifting back to ways of old in a few weeks. It’s easy to settle back in to a narrow clogged filter because change asks something more of us. It’s easier to slide down that hill of comfort and familiarity, but it asks something more and something bigger of us when we have to trudge up that steep hill that is cursed with questions, unfamiliarity and discomfort. But, that’s where the gold is found. 

So, what are your filters ? Are there enough of them and are they deep enough ? Are they based on good guided and mentored experience or are they based on your self-taught and thus biased experiences ? Our filters here at The Gait Guys have a combined 24+ years of formal medical and medical-related education and 40+ years of clinical experience (and more importantly, failure) with patients. We think our filters run pretty deep but they admittedly have holes that have been stitched with experience and humility, and they likely still have unseen gaping holes and leaks that we struggle to find to this day. But we try to show up everyday in our clinics and here on The Gait Guys blog with an honesty and humbleness in an attempt to learn that which we don’t know and to honestly face that which we think we know, but actually don’t, because our filters are also subject to clogging.

And finally remember one of our biggest catch phrases. “What you see in someone’s gait is not their problem, but rather their strategic compensation around the problem”. 

Don’t make it worse but trying to filter what you see through a clogged or shallow filter. 

And if you do not mind us finishing with a broader brush, it is more than just about GAIT filters, rather it is about every filter through which we approach life and the people in our lives. Whether it be politics, religion, the media, research, guns, war, abortion, gay rights, marriage, our spouses, child rearing and the like, if we just step back from every opinion we have and become aware of our thoughts, feelings and emotions and realize that they are a product of the filters we apply, maybe, just maybe … . . the world will be a better place in that moment. (And if Ivo and I can dream big, maybe a world where everyone walks and runs without pathologic compensations.)

Shawn and Ivo, The Gait Guys.  Getting a little armchair philosophical on you today.