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

Remapping the Cortex: How Rehab Exercise does it.

Below are two studies that we recently incorporated into 2 neurologic gait cases during one of our global teleseminars on www.onlineCE.com.  You can find that lecture there in a few weeks but we have dozens of our other presentations available there presently. 

Injury to a body part starts a reorganization of the brain cortex. We know this occurs from a plethora of studies but most of them are based on injury induced changes and not from treatment-induced means.  These studies support the treatment induced changes that occur in the central nervous system, and they are profound and give us comfort and validity in our work. The findings of these studies should not be a shock to you if you are in the work of manual therapy and rehab. 

The one study used transcranial magnetic stimulation to map the cortical motor output area of a hand muscles on both sides in 13 stroke patients in the chronic stage of their illness before and after a 12-day-period of constraint-induced movement therapy.

What they found was “post treatment the muscle output area size in the affected hemisphere was significantly enlarged, corresponding to a greatly improved motor performance of the paretic limb”. As the study showed, this suggested a recruitment of adjacent brain areas. Even at 6 month follow up examinations “the motor performance remained at a high level, whereas the cortical area sizes in the 2 hemispheres became almost identical, representing a return of the balance of excitability between the 2 hemispheres toward a normal condition.”

The second study (2) looked at limb immobilization in 10 right-handed subjects with right upper extremity injury that required at least 14 days of limb immobilization. Subjects underwent 2 MRI examinations post injury, 48 hours and 16 days post immobilization. Cortical thickness of sensorimotor regions and FA of the corticospinal tracts was measured.  The findings showed “a decrease in cortical thickness in the left primary motor and somatosensory area as well as a decrease in FA in the left corticospinal tract. In addition, the motor skill of the left (noninjured) hand improved and is related to increased cortical thickness and FA in the right motor cortex.”

These studies suggest the findings are associated with skill transfer from the right to the left hand. It was suggested that immobilization induces rapid reorganization of the sensorimotor system. 

Rehab works, but everyone here on The Gait Guys already knew that. It is just nice to know the specifics of “how”.  

Please go to these articles and get the specifics for yourself. Don’t take our word for it ! 

references:

1. Stroke. 2000 Jun;31(6):1210-6.Treatment-induced cortical reorganization after stroke in humans. Liepert J1, Bauder H, Wolfgang HR, Miltner WH, Taub E, Weiller C.

2. Langer N, et al “Effects of limb immobilization on brain plasticity”Neurology 2012; 78: 182–188.

 

Steppage gait ? Or just a runway model ?  Take the thinking farther.
Today we have a short blog post for you. You may take the topic simply on the surface or cogitate over it and find some deeper epiphanies from the well of knowledge we have tried to present here on our blog for the past 4+ years.  
It is clear that in this video that the model has a consciously driven steppage gait. Meaning, she is lifting her limb/foot via exaggerated hip flexion and knee flexion to clear the foot.  This is often seen unilaterally in a foot drop case where the client has a neurologic lesion that for one reason or another has impaired the client’s ability to extend the toes or dorsiflex the ankle sufficiently to clear the foot (so they do not drag toes and trip/fall).  
But, why is she doing this steppage gait ? It is highly unlikely that she has bilateral lesions.  Sure, she was asked to walk this way by her mentor but again, take it further.  Is there a factor making this gait necessary regardless of the coaching ? 
Obviously the answer is yes or we wouldn’t be doing a blog post on this topic.  She is wearing ridiculously high heels. This is forcing her into an extreme plantarflexed foot and ankle posture. IF she were to swing her leg normally during the swing phase she would drive the foot and ankle into dorsiflexion (a normal gait event) and the long pointed heel would be made more prominent as it was driven forward and downward. This would surely catch on the ground, immediately driving the foot into sudden violent forefoot loading and pitch her into a forward fall.  Yes, you have seen this on the run way videos on youtube, and yes we know you laughed too ! You see, when wearing heels this high, one must deploy a certain degree of steppage gait to clear the heel because ankle plantarflexion is fraught with the risk we just discussed above, the heel is too prominent and will catch. How much steppage (knee flexion and hip flexion to clear the foot) is necessary ? Well, to a large degree it depends on how much of a heel is present.  If you are wearing a small heeled shoe, lets say 1 inch, then a small steppage is necessary.
None the less, there is a bigger problem lurking and brewing underneath when heels are a regular occurrence. Slowly and gradually the disuse of the anterior compartment muscles (Extensor dig., Ext. hallucis, peroneus tertius, tibialis anterior) will weaken and the posterior compartment will shorten respectively. IF left too long, it will result in tightness (yes, there is a difference between tightness and shortness, one is a neurlogical protective mechanism, the other is a more permanent change.) We have said this many times here and in our videos, much of posterior compartment problems (ie achilles tendonitis, Sever’s, Hagglunds etc) are related to a degree of anterior compartment weakness, skill deficits or endurance challenges.  Wearing high heels often will often, but not always, increase this risk. 
If you are an athlete, but someone who wears high heels often, you may have to do extra work to keep your anterior compartment competent on several levels.  Eccentric strength is just as important as concentric in this region. Remember, many gait problems come on slowly, a slow simmering smoldering fire. And remember this last point about heeled shoes, your forefoot is always being loaded initially in ankle plantarflexion, this is not normal and in time this will have a cost in many people.  
One last thing. We are not necessarily talking about dress shoes, although they are a greater culprit.  Many running shoes still have accentuated rear foot stack heights where the heel will be many millimeters above the plane of the forefoot.  Do not discount these shoes as a possible contributor of your problem, remember, physiological adaptation takes time to express into a biomechanical symptom creating problem, and it may take quite some time to resolve your compensations and adaptations.
PS: drive that “cross over gait” lady.  Fools.
Shawn and Ivo
the gait guys

Subtle clues often provide the answers.

We like yoga as much as anyone else. We saw this picture on the latest cover and couldn’t resist making a few comments on this pose.

Yoga has many benefits. Our understanding is that in addition to the cognitive and spiritual effects of yoga, is that it helps to build your core.

 At first look you may say that this woman has a few issues:

  • she has a right pelvic shift and a left body lean
  • She has slight head rotation to the right and a slight left head tilt
  • you may have noticed that she appears to have more tone in the musculature on the right side of her face than on the left.   Just look at the nasolabial fold as well as the corner of her mouth any area of wrinkling underneath her left orbit.
  •  You may have also noticed the subtle flexion and lack of external rotation of the right hip.

 You may go on and think that she has a week right gluteus medius as well as an overactive quadratus lumborum on the left-hand side which may be causing the pelvic shift. The head tilt may be in compensation for the right side gluteus medius weakness and the subtle rotation may be an attempt to engage a tonic neck response. ( a tonic neck response is  ipsilateral extension of the upper and lower extremity to the side of head rotation with contralateral flexion of the same counterparts.

 You may have also noticed that the toes of the right foot are not dorsiflexed and that her hair appears to be flowing on the right side, and this is not the case at all, but rather she is either standing on a sloped surface or on the downward phase of a jump. According to the magazine it is the latter.  If you caught this at first then congratulations: you are sharper than most. If not remember to always look for subtle clues.

 Like Sir Topham Hat says in Thomas the Train: “  You didn’t get the whole story. What really happened is what really matters.

So why the mild facial ptosis on the left side? She could have had an old Bells palsy, or other form of facial paresis. Note that mostly the lower portions of the (left) face are affected (ie, below the eye). We remember that the upper portions of the face receive bilateral innervation but lower portions of the face unilateral innervation, from the contra lateral facial motor nucleus; this is why it could be a mild upper motor neuron lesion (micro infact, lack of cortical afferent input) and not an lower motor neuron lesion (like Bells Palsy). Why is this germane? Or is it not?

Stand in front of a mirror. Jump up in the air trying to assume the same pose as this woman does and what do you see.  Make sure that you jump up from both legs and then bring one leg over and your hands in front of you in the “praying position”. You may want to have a friend take a snapshot of you performing this. You will notice that you have contralateral head rotation,  a pelvic hike on the side opposite the leg that’s extended and a head tilt to the side that is flexed.  You are attempting to stabilize your core as you’re going up and coming down.

What we are witnessing is a normal neurological phenomena.  This gal merely seems to have some limited external rotation of her left hip. Now perform the same maneuver again but this time don’t externally rotate your leg as far as this woman does and what do you see. You should’ve seen an increase in the aforementioned body postures.

Subtle clues are often the key. Keep your eyes and ears open. 

The Gait Guys. Helping the subtle to become everyday for you, with each and every post.

Podcast 75: Joint Symmetry, Clinical Pearls & Random Thoughts

Lots of good random topics on today’s podcast, including possible causes of leg length discrepancies.

*Show sponsor: www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_true76f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-75-joint-symmetry-cases-stuff

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:


Neurons in human skin perform advanced calculations

http://medicalxpress.com/news/2014-09-neurons-human-skin-advanced.html

RunScribe Is A Wearable For Granular Gait Analysis
Free dialogue on leg length discrepancies.

Evidence for joint moment asymmetry in healthy populations during gait.

Gait Posture. 2014 Jul 1. pii: S0966-6362(14)00610-9. doi: 10.1016/j.gaitpost.2014.06.010. [Epub ahead of print]
The contralateral foot in children with unilateral clubfoot, is the unaffected side normal?

http://www.gaitposture.com/article/S0966-6362(14)00523-2/abstract

Gait guys case on Club foot:

http://thegaitguys.tumblr.com/post/23230149195/we-could-have-easily-made-this-a-blog-post-about