Got Arm Swing?

We have written many times about arm swing. Click here for some of our posts here on Tumblr.

Here we are again at the beach. Look at the beautiful difference in arm swing from side to side in the guy carrying the bag. Makes you want to tell him to use a backpack, eh?

Never mind what it does to his gait

  • decreased arm swing on the carrying side
  • increased step length on the left side
  • increased thigh flexion of the left side
  • increased body lean and head tilt to right side (Take a look at this paper)

think about the increased metabolic cost. Think about what this  type of input (increased amplitude of movement unilaterally) is doing to your cortex!

keep your movements symmetrical, folks!

The Gait Guys

A profound loss of hip extension…

While sitting on the beach, our mind never rests. Even when on vacation we continue to watch how people move.

Luckily today, I had the gait cam (Dr Allen is holding down the Gait Guys Fort), so live from Sunset Beach, it’s Sunday night. See of you can see what I saw.

Sitting with my wife and watching the kids dig in the sand, this gal with the flexed posture caught my eye.

Why is she so flexed forward? The profound loss of hip extension made it impossible for her to stand up straight! It was difficult to say if she has bilateral hip osteoarthritis, or possible bilateral THR’s (total hip replacements), maybe just really tight hip flexors, painful bunions that do not like toe off, or even all of the above. She may have a leg length discrepancy, as she leans to the left on left stance phase; of course she could have weak hip abductors on the left. It does not appear she has good control of her core.

What do we see?

  • flexion at the waist
  • loss of hip extension
  • body lean to left at left midstance
  • shortened step length
  • loss of ankle rocker
  • premature heel rise
  • decreased arm swing (she is carrying something in her left hand)

No one is safe from the gait cam! Stay tuned for more beach footage this week!

We remain, The Gait Guys, even on vacation.

Podcast 77: Gait analysis, Forefoot Running & more.

Plus, the 5 neurologic gait compensation expressions.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-77

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Google X acquires ‘tremor-canceling spoon’ startup
http://venturebeat.com/2014/09/10/google-x-acquires-tremor-canceling-spoon-startup/

The 5 expressions of neurologic gait decomposition,
Last week we did an online teleseminar … . .
An acoustic startle alters knee joint stiffness and neuromuscular control
http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract
Effectiveness of Off-the-Shelf, Extra-Depth Footwear in Reducing Foot Pain in Older People: A Randomized Controlled Trial
http://biomedgerontology.oxfordjournals.org/content/early/2014/09/08/gerona.glu169.abstract
reader:
I really appreciate learning from you!! I have a bit of a loaded question that I will try to explain clearly to the best of my ability. About 2 years ago, I broke my left shin (hairline-fibula) in a MMA fight. After it healed, a few things have been happening that I assume are connected but can’t quite put my finger on. My ankle mobility on my left ankle is worse than my left. I seem to have permanent turf toe as well. My right glute, ham, and erector are hyperactive.
Additionally, many times when sprinting, pushing a sled, etc, my right quad will become fatigued much more than my left. I believe it’s because I’m not fully extending my left ankle, and relying on my right leg more. Whenever I squat or deadlift, I feel similar too. The right glute and erectors get much more of a “pump” than my left. With all of this, is there anything you would recommend? I truly appreciate it!! It is very frustrating. Thank you again!

Podcast 77: Gait analysis, Forefoot Running & more.

Plus, the 5 neurologic gait compensation expressions.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-77

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

Google X acquires ‘tremor-canceling spoon’ startup
http://venturebeat.com/2014/09/10/google-x-acquires-tremor-canceling-spoon-startup/

The 5 expressions of neurologic gait decomposition,
Last week we did an online teleseminar … . .
An acoustic startle alters knee joint stiffness and neuromuscular control
http://onlinelibrary.wiley.com/doi/10.1111/sms.12315/abstract
Effectiveness of Off-the-Shelf, Extra-Depth Footwear in Reducing Foot Pain in Older People: A Randomized Controlled Trial
http://biomedgerontology.oxfordjournals.org/content/early/2014/09/08/gerona.glu169.abstract
reader:
I really appreciate learning from you!! I have a bit of a loaded question that I will try to explain clearly to the best of my ability. About 2 years ago, I broke my left shin (hairline-fibula) in a MMA fight. After it healed, a few things have been happening that I assume are connected but can’t quite put my finger on. My ankle mobility on my left ankle is worse than my left. I seem to have permanent turf toe as well. My right glute, ham, and erector are hyperactive.
Additionally, many times when sprinting, pushing a sled, etc, my right quad will become fatigued much more than my left. I believe it’s because I’m not fully extending my left ankle, and relying on my right leg more. Whenever I squat or deadlift, I feel similar too. The right glute and erectors get much more of a “pump” than my left. With all of this, is there anything you would recommend? I truly appreciate it!! It is very frustrating. Thank you again!

People tend to forget about the peroneal muscles. This is what it looks like when the brain forgets.

This client came to see us for obvious reasons but the case details are not what we are focusing on today. Gait gets pretty messed up when a critical component or phase is lost or forgotten.  

In last weeks teleseminar on www.onlineCE.com we discussed several gait cases. In these cases 5 things kept coming up when it came to looking at (specifically) neurologic gait compensations:

  1. slowing of gait
  2. wider based gait
  3. increased ancillary movements 
  4. utilizing support when needed or available
  5. shorted step length and stride length

In this video, it is clear that this person has some serious neurologic problems engaging the peroneal muscles and controlling ankle and foot function and as a consequence you see evidence of some of the itemized issues above, namely, calculated movements, nearly zero arm swing and step length from left to right is abbreviated. 

It can go both ways. The neurologic problem can affect one’s gait, but one’s resultant gait can then affect cortical function, driving an endless loop. Recently, five studies presented at the Alzheimer’s Association International Conference in Vancouver Canada provided striking evidence that when a person’s walk gets slower or becomes more variable or less controlled, his cognitive function is also suffering.(2)  

A person’s gait and their neurologic function cannot be separated. The stuff just run’s too deep.  This is why we love gait so much, because to fully understanding someone’s clinical problems we must understand how and why they move.  There are clues in everyone’s gait that can help you clinically. The question is, will you notice them ? Do you know what normal gait is to begin with ? Will you understand what you are seeing and realize it is a compensation? Will you fix what you see or look deeper to find the cause of what you see ? 

Shawn and Ivo,

The Gait Guys

Gait Posture. 2013 Jul;38(3):549-51. doi: 10.1016/j.gaitpost.2013.02.008. Epub 2013 Mar 11.

Altered gait termination strategies following a concussion.

Buckley TA1, Munkasy BATapia-Lovler TGWikstrom EA.

2.  http://www.nytimes.com/2012/07/17/health/research/signs-of-cognitive-decline-and-alzheimers-are-seen-in-gait.html?_r=1&

This is part 2 of a 2 part post; with the video from the case previously discussed

please note the following in the video:

  • body lean to left during left stance phase (to clear right longer leg)
  • circumduction of right lower extremity  (to clear right longer leg)
  • lack of arm swing bilaterally (cortical involvement)
  • patient looking down while walking (decomposition of gait)
  • shortened step length (decomposition of gait)
  • increased tibial varum bilaterally

ASSESSMENT:  This patient’s short leg and internal tibial torsion impediments to her full recovery. She has increased tibial varum noted which is complicating the picture. This is causing pathomechanics and an abductory moment not only at the knee but also in the lumbar, thoracic and cervical spines.

WHAT DID WE DO?:                    

  • We attempted to do the one leg standing exercise. She needed to hold on and did not feel stable on the left hip while performing this.  This is probably more of confidence rather than ability issue. 
  • We gave her the stand/sit exercise to try to improve gluteal recruitment.
  • We also gave her the lift/spread/reach exercise to attempt to strengthen her feet.
  • A full-length 5 mm lift was cut for the left shoe  She felt more stable when walking on this.
  • She was treated with IC, PIR and manipulative therapy and neuromuscular stim of the knee as well as left hip area above, below and at the joint line of the knee as well as gluteus medius and minimus.   
  • We may need to consider building a more aggressive orthotic with a forefoot varus post depending upon her progress and response to care  

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn

Wow! What would you do?

This is part 1 of a 2 part post. Look for the other one a few minutes after this one with a video up top for the conclusion

PRESENTING PROBLEM: This 54 YO female patient presents with with left sided knee pain.  She had a total knee replacement (TKR) done in 2011.  She’s had a significant amount of discomfort on the medial aspect of the knee since then. She had an MRI of the hip done thinking the problem was there, and found nothing.   She is walking with a bad limp, left leg is half inch shorter than the right.  Pain is worse at night, changes with weather. 

She has knee pain on the lateral aspect (points to tibial plateau and joint line) with swelling that goes down to the ankle left side.  She has been wearing a “Good Feet” OTC orthotic on the left side which she states helps quite a bit.

Generally speaking, stretching and analgesics make the discomfort better.    Ibuprofen 400 mg. b.i.d. can take the edge off  Soft sided brace (neoprene sleeve) makes a difference as well. The hard sided brace gives her difficulty.

WORK HISTORY: She works for a preschool.  Her job involves standing and getting up and down a lot.  

FAMILY HISTORY:  She has left sided lid ptosis, this evidently is familial.  

PHYSICAL EXAM:  She stood 5’ 1” and weighed approx. 150 pounds.

Viewing the knees bi-lat., the left knee is markedly externally rotated.

She does have a left short leg; tibial and femoral.  She has bilateral tibial torsion (look at the tibial tuberosities and drop a line straight down; it should pass through the 2nd metatarsal head) and marked internal tibial torsion on the left side (>60 degrees) with femoral retrotorsion (less than 8 degree angle of femoral head with the shaft) on this side.  There is no rotation of the thigh or leg past zero degrees midline. .  She had 10 degrees of tibial varum on the left hand side.  Her Q-angle is 10 degrees on that side.  There is plantar flexion inversion of the foot.  Left lower extremity has less sensation secondary to the her TKR  surgery.

Gait evaluation reveals a fair amount of midfoot pronation noted on the left hand side in addition to an intoed gait.  She has to lean her body over to the left to get the right leg to clear.

Some mild weakness noted of hip abduction musculature left hand side gluteus medius, middle and anterior fibers. Knee stability tests were negative.

Neurologically, otherwise, she had full integrity with respect to sensation, motor strength and deep tendon reflexes in the upper and lower extremities.

Please see part 2 of this post for additional info including our assessment and what WE did.

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn

Podcast 76: The FMS™ screen and Injuries, Impact Loading & more.

Podcast 76: Association of Functional Movement Screen™ With Injuries, Wool workout gear, landing softly and more !

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77.1_76final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-76

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

 
Last week on our social media sites we posted this article that garnered 9000+ hits:
Runner? LONG DISTANCE runner? Better be careful out there!
http://www.sciencedaily.com/releases/2012/06/120604093108.htm
 
then this news this week:
Well-Regarded Endurance Athlete Chad Denning Dies While Running Appalachian Trail | Valley News
 
Association of Functional Movement Screen™ With Injuries in Division I Athletes
 
from a reader:
Hey guys, great site, sometimes a bit more than I know at this point. Just graduated from massage school in april. I have been diagnosed with tendonosis of the Achilles heel. Also finding that my leg doesn’t fully extend while walking, anything I can do besides hamstring and calf stretches. It really happened after a 30 mile hike with a 40 lb backpack, Help 
Thanks, sincerely Hector
Synthetic Workout Gear Smells Worse Than Cotton Gear
 
 Land Softly And Carry Less Injury Risk

http://running.competitor.com/2014/07/injury-prevention/land-softly-and-carry-less-injury-risk_11174

 
 

Podcast 76: The FMS™ screen and Injuries, Impact Loading & more.

Podcast 76: Association of Functional Movement Screen™ With Injuries, Wool workout gear, landing softly and more !

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_77.1_76final.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-76

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

 
Last week on our social media sites we posted this article that garnered 9000+ hits:
Runner? LONG DISTANCE runner? Better be careful out there!
http://www.sciencedaily.com/releases/2012/06/120604093108.htm
 
then this news this week:
Well-Regarded Endurance Athlete Chad Denning Dies While Running Appalachian Trail | Valley News
 
Association of Functional Movement Screen™ With Injuries in Division I Athletes
 
from a reader:
Hey guys, great site, sometimes a bit more than I know at this point. Just graduated from massage school in april. I have been diagnosed with tendonosis of the Achilles heel. Also finding that my leg doesn’t fully extend while walking, anything I can do besides hamstring and calf stretches. It really happened after a 30 mile hike with a 40 lb backpack, Help 
Thanks, sincerely Hector
Synthetic Workout Gear Smells Worse Than Cotton Gear
 
 Land Softly And Carry Less Injury Risk

http://running.competitor.com/2014/07/injury-prevention/land-softly-and-carry-less-injury-risk_11174

 
 

It is marathon season in Chicago. Time for this old reader-favorite blog post on Black toe nails !  

The Black Plague (ok, kinda sort of)……Subungal Hematomas in Runners. Blood under the toe nail.  It is not exactly what you think it is !

There are two pictures here, cursor to the right and see the slider that will toggle between the two photos. The photo with bandaid credit given towww.healthandrunning.com the other photo……is a runner client of ours with both a callus pattern on the tip of the 2nd toe and an early small subungal hematoma (read on !)

__________________________________________________________________________

We get inquiries about the black toe nail “Syndrome”……aka…..blood under the toe nails in our runners, and how to avoid them. Lets look at this phenomenon as it pertains to the foot.

This problem has a clinical name, “subungual hematoma”. It means a collection of blood under the finger or toe nail.  There are many causes of the subungal hematoma (SH for short as we move forward here).  Here are a few, but we have yet to find any good journal articles for one cause that we are seeing as a possible cause…one we will discuss here shortly. 

One cause is obvious, the crush injury where someone steps on your toe, you drop something onto it or smash it into something.  This is something we have all done at some time. 

 The most commonly theory of cause is repetitive trauma, thought to be that of repeated impact of the toe into the top or end of the shoe.  Heim et al  noted this in 2000.  This really got us to thinking.  Why, when we see these SH’s, do the runners never seem to have shoes that are too short / small or shoe signs of friction (wear patterning) of the toe nail into the top of the shoe’s upper ?  Often the runners insist there has been no such contact within the shoe.  So we started our own investigation making sure to ask all our runners what they thought and felt as they ramped up their miles in prep for marathons and 20 mile runs or daily doubles, particularly those who seemed regularly susceptible to SH’s.  We will discuss our findings and thoughts momentarily, but lets get back to some of the more well known information on SH’s.

The medical literature is full of other types of causes or clues of SH’s that must be investigated, such as medication reactions, autoimmune skin disorders, melanoma, blood disorders (dyscracias or clotting problems). These certainly are not the norm.

It is important to know the anatomy of the area because the nail bed is very rich in vasculature (hence the hematoma creation) and nerve endings (hence the pain) when blood collects in the confined area or it gets torn off from trauma.  The nail bed is a derivative of the epidermis containing keratin which gives it its hard nature. The nail grows from a nail root in front of the cuticle and grows distally at a slow but (usually) steady rate.  This area is frequently susceptible to fungal infections which destroy the tissue in the area and possibly make SH’s more common.

We will not get into the aggressive treatment of things here because that is 1) not our purpose here and 2) we do not want to be accountable for people getting infections  from boring a hole into the nail bed (trephine) to release the blood or the consequences of using plyers to yank it off.  We just tend to recommend they be left alone and let nature take its course.  (For those bold and tough gang, who chose the plyers method, you should know that there is no fatty tissue beneath the nail and the underlying bone to cushion the area, the nail is the only protection; furthermore you should know that the extensor tendon attachment is awfully close to the proximal nail bed root area !).  But when pain it too much, we have our people we refer these cases to.  Rather, we tend to look for a cause of the problem. 

In a limited number of cases we do see a shallow toe box where there is little room for toe extension, thus the nail can get rubbed on the roof of the toe box repeatedly causing a lifting action of the nail from its vascular bed.  This a more plausable cause in our opinion over the “toes hitting the end of the shoe” phenomenon put out there by many sources.  Particularly when most people size their shoes sufficiently long enough for the distal foot slip migration that occurs at mid-foot load within the shoe.  In  these cases a close cropping of the toe nail shoe stop the lifting/friction phenomena on the toe box roof. 

However, we seem to be seeing a more frequent trend that we wanted to share  here.  It seems to go hand in hand with the plague of flexor dominance in our society these days.  What we are seeing is a predominance of toe flexion (either a gentle or marked toe flexion ….we sometimes refer to it as toe hammering) in our runners.  This just makes sense because of the posterior compartment dominance in runners.  (The posterior compartment is made up of the gastroc-soleus complex, long toe flexors and tibialis posterior).  So if this compartment is dominant, and there is not sufficient home work to off set the flexor dominance with extensor exercises, then this flexion dominance will continue and possibly worsen.  As you will see either in yourself, our photo here, or on the feet of many of your co-runners is a distal “tip of the toe” callus development (usually most on the second toe, and less moving into the more lateral toes) immediately below the leading edge of the toe nail.  This callus coincides well with a distal gripping phenomenon of the long flexors (Flexor digitorum longus). So, now imagine, to get the callus there must be repeated friction and since the toe is not hitting the end of the shoe it must be friction into the sock liner bed of the shoe. And if this is the case, the skin is pulled at a differential rate over the distal phalange than the nail bed there will be a net lifting response of the nail from its bed as the skin is drawn forward of the backward drawn phalange  (put another way, the callused toe tip is fixed to the sock liner for grip, and then the phalange is drawn backwards from this contact point creating a NET movement of skin forward thus lifting the nail from its bedding).  [For an at-home example of this, put your hand flat on a table top. Now activate your distal long finger flexors so that only the tip of the fingers are in contact with the table top.  Now, without letting the finger tip-skin contact point move at all, go ahead and increase your long flexor tone/pull fairly aggressively. I defy you to not feel some  pressure building under the distal tip of the finger nail as the skin is RELATIVELY drawn forward.]   And with the nail bed being so vascular, micro bleeding can occur.  This bleeding is slow and takes time.  Which brings the big question to light, SH’s seem to mostly occur on very long runs, and never on short runs (where there is not enough nail bed separation repeatedly to create enough damage to bleed, not to mention fatigue of the other toe/foot intrinsic muscles thus necessitating more use of the more powerful long toe flexors.)

There  does not seem to be anything out there in the information on this supposition.  Maybe we are crazy…….but we do see alot of runners.  And once we bring the awareness of the problem to our runners and show them  how to reduce the flexion dominance with exercises to gain more extension balance, do we see an arrest of any further Subungal hematomas. 

We would love to hear your thoughts and experiences with them, both clinically and as a runner. Let us know what you think about our plausable cause.  

we remain……The Gait Guys