Podcast 88: interpreting Shoe Wear patterns & Running Surface Effects

Show sponsors:
www.newbalancechicago.com

Plus: Biometrics in Pro Sports, Epigenetics and How Exercise changes our DNA, Hip Dysplasia„ Pavlik harnesses.

We hope you find today’s show helpful. Remember, we don‘t know everything, and we do not expect everyone else to know everything either. We are just bringing our logic and knowledge and hopefully truth to the web … . . Please, Correct us when we are sharing inaccuracies, as we try to do the same. There is alot of misguided info on the web and in the wrong hands, people can get hurt … . we feel we are doing our part to carve a safe path. But, when we go astray, please our dear brethren……call us out on it ! We insist. -Shawn and Ivo

Other Gait Guys stuff

Download links:

A. http://traffic.libsyn.com/thegaitguys/pod_88_solid.mp3

B. http://thegaitguys.libsyn.com/podcast-88

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

Gait Guys online /download store (National Shoe Fit Certification and more !) :
http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

New biometric tests invade the NBA
http://espn.go.com/nba/story/_/id/11629773/new-nba-biometric-testing-less-michael-lewis-more-george-orwell

How Exercise Changes Our DNA
http://well.blogs.nytimes.com/2014/12/17/how-exercise-changes-our-dna/

An integrative analysis reveals coordinated reprogramming of the epigenome and the transcriptome in human skeletal muscle after training. Lindholm ME
Epigenetics. 2014 Dec 7:0. [Epub ahead of print]

Hip Dysplasia
http://journals.lww.com/pedorthopaedics/Abstract/2015/01000/Back_carrying_Infants_to_Prevent_Developmental_Hip.11.aspx

Journal of Pediatric Orthopaedics:
January 2015 – Volume 35 – Issue 1 – p 57-61
Back-carrying Infants to Prevent Developmental Hip Dysplasia and its Sequelae: Is a New Public Health Initiative Needed? Graham, Simon M.

Plus: Pavlik harness
https://www.google.com/webhp?sourceid=chrome-instant&ion=1&espv=2&ie=UTF-8#q=pavlik%20harness

Does Correct Head Positioning Make You Run Faster?http://runnersconnect.net/running-injury-prevention/running-form-proper-head-position/

Running surfaces
http://www.slowtwitch.com/Training/Running/Concrete_or_Asphalt__4793.html

How to Read and Interpret the Wear Pattern on Your Running Shoes
http://runnersconnect.net/running-tips/read-wear-pattern-running-shoes/

Do you know your stuff? Would you correct this child’s gait ? Give them orthotics, exercises, force correction, leave them alone ? 

Is he Internal Tibial torsioned ? Is he “pigeon toed” ,if that is the only lingo one knows, 😦  Does he have femoral torsion ?  A pronation problem locally at the foot or an internal spin problem through the entire limb ? Or a combination of the above ? 

What’s your solution?

It MUST be based on the knowledge necessary to fix it, not the limits of YOUR knowledge. You can never know what to do for this lad from his gait evaluation, no matter how expensive your digital, multi-sensor, 3D multi-angle, heat sensor, joint angle measuring, beer can opening, gait analysis set up is. You can never know what to do for this lad if you do not know normal gait, normal neuro-developmental windows, normal biomechanics, know about torsions (femoral, tibial, talar etc), foot types etc.  It is a long list.  You cannot know what to do for this kid if you do not know how to accurately and logically examine them. 

Rule number 1. First do no harm.

If your knowledge base is not broad enough, then rule number one can be easily broken ! Hell, if you do not know all of the parameters to check off and evaluate, you might not even know you are breaking rule number one !  If everything looks like a weak muscle, every solution will be to “activate” and strengthen and not look to find the source of that weakness.  Muscles do not “shut down” or become inhibited because it is 10 minutes before practice or because it is the 3rd Monday of the month. You are doing your client a huge disservice if you think  you are smarter than their brain and activate muscles that their brain has inhibited for a reason. What if it were to prevent joint loading because of a deeper problem ?  If every foot looks flat and hyper pronated, and all you know is orthotics or surgery or shoe fit, guess what that client is prescribed ? If all you see is torsions, that is all you will look to treat. If all you see is sloppy “running form” and all you know is “proper running form” forcing your client into that “round peg-square hole” can also lead to injury and stacking of compensation patterns.  

One’s lack of awareness and knowledge, are one’s greatest enemies. If you don’t know something exists, because you’ve never studied or learned it, how can you be aware of it ? If you’re not spending enough time examining a client, you might not be aware of an issue even though you may be knowledgeable about the issue.
One must have both awareness and knowledge. One must also be aware that compensations are the way of the body. What you see is not your client’s problem. It is their strategy to cope.

Are you helping your client ? Hurting them ?  Adding risk to their activity ? Are you stepping beyond your skill set ?  

Rule Number 1: First do no harm. 

Shawn and Ivo

PS: we will get to this case another time, we just wanted to make a point today about the bigger problems out in the world.

the gait guys

Podcast 87: Podcast 87: The Kenyan’s Running Brain & “The” Anterior Compartment.

Plus, Some unknown facts about going minimalism and barefoot. We POUND anterior compartment strength today gang ! Hope you enjoy !

Show sponsors:
www.newbalancechicago.com

A. Link to our server: 
http://traffic.libsyn.com/thegaitguys/pod_87final.mp3

Direct Download: 
http://thegaitguys.libsyn.com/podcast-87

Other Gait Guys 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:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

On high heels and short muscles: A multiscale model for sarcomere loss in the gastrocnemius muscle

http://www.sciencedirect.com/science/article/pii/S0022519314006262

The Brain Needs Oxygen

Maintained cerebral oxygenation during maximal self-paced exercise in elite Kenyan runners.

http://www.runnersworld.com/racing/the-brain-needs-oxygen
http://www.ncbi.nlm.nih.gov/pubmed/25414248
J Appl Physiol (1985). 2014 Nov 20:jap.00909.2014. doi: 10.1152/japplphysiol.00909.2014. [Epub ahead of print]

The texting lane in China
http://www.theguardian.com/world/shortcuts/2014/sep/15/china-mobile-phone-lane-distracted-walking-pedestrians

Dialogue on endurance training,
NeuroRehabilitation. 2006;21(1):43-50. 
http://www.ncbi.nlm.nih.gov/pubmed/16720937

Effects of dorsiflexor endurance exercises on foot drop secondary to multiple sclerosis.  Mount J1, Dacko S.

APOS Therapy
we were asked out opinion on this
http://apostherapy.com/

Foot instrinsic dialogue
Motor Control. 2014 Jul 15. [Epub ahead of print]

Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.
Okai LA1, Kohn AF.

There are many factors in adults that impair gait. It is not all biomechanical. This is part of our ongoing dialogue on the aging population and why gait impairments and falls are so prevalent.
Acta Bioeng Biomech. 2014;16(1):3-9.
Differences in gait pattern between the elderly and the young during level walking under low illumination.
Choi JS, Kang DW, Shin YH, Tack GR.


Podcast 86: The Best of The Gait Guys Podcast: Part 1

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_87_Best_of_Part_1.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-87-the-best-of-the-gait-guys-part-1

Other Gait Guys 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:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Test your Mental Clinical Thinking Skills with this pedograph case. 

A few months ago, we discussed this case in great detail. There is likely little chance you will see our thinking progression with these final conclusions without sitting down with a warm cup of coffee and going over these 2 prior blog posts on this case (part 1 and part 2).  Besides, it will be a good review for you and it is great mental gymnastics.  This kind of analysis gets easier each time you do it but we have to through out our standard warning. This is the kind of stuff one needs to be able to go through on the fly in one’s practice, it is something to aspire to.

First of all, caveats:

  • Our discussions on this case were all theoretical.  What we went through was an exercise in static assessment and clinical thinking
  • One cannot, and must not, make clinical decisions from a static assessment. 
  • As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. 
  • Gait analysis or pedograph-type assessment are helpful tools, but not the final answer.

Our static exam proposal on this case came up with the following theories (please stand up and mimic as we discuss, trust us, it will help you). *Remember: the foot on YOUR LEFT is the RIGHT foot for the purposes of this discussion. And remember, this is all theoretical, this is an exercise in biomechanical and clinical thinking, nothing more.

  • Suspect Counter-clockwise pelvis distortion pattern (causes relative internal rotation on LEFT and external rotation on RIGHT), this will drive Left knee hyperextension and Right knee flexion (hence foot plantar pressures as we discussed in previous 2 blog posts linked above). This of course cannot be seen, but we are extrapolating from our clinical experiences.
  • poor pronation and internal limb spin control on the left (hence longer foot and toe hammering). Obviously, we would see a dramatic shift of the pressures to the medial foot if this were truly the case.  Perhaps this is because of the greater lateral left pelvis drift forcing the glute and foot pronatory controls to have to work harder and longer, and maybe even quicker, to control the internal spin and pronation. Over time, they fatigue and fail rendering a flatter, more pronated and longer heel:toe ball length ratio. This would also give credence to the left toe hammering/gripping response.
  • static increased left limb weight bearing (left hip drift)
  • abrupt right foot loading pattern (more mid-forefoot strike), perhaps as reflected by the static forefoot loading. Again, supposition.
  • with all of the above, it is suspect that this client will appear to have a subtle limp, coming off the left quickly or prematurely as they speed through uncontrolled pronation and resulting in an abrupt right limb loading response that mostly skips through heel strike and results in a more aggressive mid-forefoot loading response.  This, sort of, creates a catching of the loading response by the quadriceps more than the gluteals. This can cause medial knee drift (valgus loading) if the medial knee stabilizers are not up to task, this also creates a sudden patellofemoral compresson event and unappreciated sudden tension on the extensor mechanism (the quad-patella-patellar tendon complex).  Can you say generic anterior knee pain ?

Just some thoughts. Please go back to the prior 2 blog posts to delve deeper into the conclusions we have brought about here, we have other good reasoning to suspect the above as the scenario. But remember, what you see is not the problem, we see people’s compensations, their strategies. This was just an exercise in “what ifs”, nothing more. But you will see it in your clinic, just substantiate it with an exam, not what you necessarily see in your clients gait or static assessment. Static assessments are for fools, don’t be a fooled fool.  What  you see is not the problem.

Remember this critical fact.  After an injury or a long standing problem, the job of muscles and motor patterns is to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries often leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is often a culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. Is the compensation top down, bottom up, or both ?

Don;t be a fooled fool. Get the facts.

Shawn and Ivo, the gait guys

The case of the dropped (plantarflexed) metatarsal head. Or, “How metatarsalgia can happen”.

This gentleman came in with fore foot pain (3rd metatarsal head specifically), worse in the AM upon awakening, with first weight bearing that would improve somewhat during the day, but would again get worse at the end of the day and with increased activity. The began insidiously a few months ago (like so many problems do) and is getting progressively worse.

Rest and ice offer mild respite, as does ibuprofen. You can see his foot above. please note the “dropped” 3rd metatarsal head (or as we prefer to more accurately say, “plantarflexed 3rd metatarsal head”) and puffiness and prominence in that area on the plantar surface of the foot. 

To fully appreciate what is going on, we need to look at the anatomy of the short flexors of the foot. 

The flexor digitorum brevis (FDB) is innervated by the medial plantar nerve and arises from the medial aspect of the calcaneal tuberosity, the plantar aponeurosis (ie: plantar fascia) and the areas bewteen the plantar muscles. It travels distally, splitting at the metatarsal phalangeal articulation (this allows the long flexors to travel forward and insert on the distal phalanges); the ends come together to divide yet another time (see detail in picture above, yes, we are aware it is the hand, but the tendon structure in the foot is remarkably similar)) and each of the 2 portions of that tendon insert onto the middle of the middle phalanyx (1) 

As a result, in conjunction with the lumbricals, the FDB is a flexor of the metatarsal phalangeal joint, and proximal interphalangeal joint (although this second action is difficult to isolate. try it and you will see what we mean). In addition, it moves the axis of rotation of the metatasal phalangeal joint dorsally, to counter act the function of the long flexors, which, when tight or overactive, have a tendency to drive this articulation anteriorly (much like the function of the extensor hallucis brevis above in the drawing from Dr Michauds book, yes, we are aware this is a picture of the 1st MTP).

Can you see the subtle extension of the metatarsal phalangeal joint and flexion of the proximal interphalangeal joint in the picture?

We know that the FDB contracts faster than the other intrinsic muscles (2), playing a tole in postural stability (3) and that the flexors temporally should contract earlier than the extensors (4), assumedly to move this joint axis posteriorly and allow proper joint centration. When this DOES NOT occur, especially if there is a concomitant loss of ankle rocker, the metatarsal heads are driven into the ground (plantarflexion), causing irritation and pain. Metatarsalgia is born….

So what is the fix? Getting the FDB back on line for one. 

  • How about the toe waving exercise? 
  • How about the lift spread reach exercise? 
  • How about retraining ankle rocker and improving hip extension?
  • How about an orthotic with a metatarsal pad in the short term? 
  • How about some inflammation reducing modalities, like ice and pulsed ultrasound. Maybe some herbal or enzymatic anti inflammatories?

The Gait Guys. Increasing your gait and foot literacy with each and every post. 

1. http://en.wikipedia.org/wiki/Flexor_digitorum_brevis_muscle

2. Tosovic D1, Ghebremedhin E, Glen C, Gorelick M, Mark Brown J.The architecture and contraction time of intrinsic foot muscles.J Electromyogr Kinesiol. 2012 Dec;22(6):930-8. doi: 10.1016/j.jelekin.2012.05.002. Epub 2012 Jun 27.

3.Okai LA1, Kohn AF. Quantifying the Contributions of a Flexor Digitorum Brevis Muscle on Postural Stability.Motor Control. 2014 Jul 15. [Epub ahead of print]

4. Zelik KE1, La Scaleia V, Ivanenko YP, Lacquaniti F.Coordination of intrinsic and extrinsic foot muscles during walking.Eur J Appl Physiol. 2014 Nov 25. [Epub ahead of print]

Learning and being humbled.

There is a quote out there by someone that suggests that in the moments of talking and teaching one will learn nothing, for one is merely spouting off the limits of what one already knows, some of which is likely outdated or incorrect. One cannot teach that which one has not previously heard, experienced and mastered.
*Learning is about listening, and evaluating our prior beliefs against the current wisdom. It is about unlearning the false and relearning the latest truths that have come to light. Learning is not about talking.

Dear Gait brethren: Ivo and I do not have all the answers, but we seek and share what we know daily in this realm of The Gait Guys. Through challenging old and current theories, principles and research, one’s insight and wisdom can only grow. We will get things wrong, and we will admit when we do, and thank those who teach us the present truths. We have no single guru we follow, nor should you. No one person or method has all the answers to all of your client’s woes. The day you only trust one guru and one theory and the day you stop seeking, learning, unlearning, and being humbled to the mistakes one has made and been taught, is the day one begins a journey to being left behind and possibly insignificant in time. Thanks to all of you who correct us, teach us, humble us and trust us. It has been a great year here on TGG, thanks for hanging out with us ! 
“The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn.” ~Alvin Toffler.
Enjoy the funny cartoon, it is sort of related to the words above. It is a huge comment on communication, communication in relationships and possibly stuff that gets communicated in seminars. Things get lost in translation everyday, sadly. But perhaps that is a good thing, perhaps that is why theories and principles morph into greater wisdom. Not all change is bad.

Podcast 85: Texting & Walking, 2015 Shoe talk

Plus: Endurance training and the immune system, hamstring endurance, Ampla Fly shoe, 

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_85f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-85-texting-walking-2015-shoe-talk

Other Gait Guys 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:

Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Show notes:

Exercising Too Long Can Hurt Your Immune System
http://www.outsideonline.com/news-from-the-field/Exercising-for-Too-Long-Can-Hurt-Your-Immune-System.html

Future Shoe: New Ampla Fly Shoe Breaks The Mold
http://running.competitor.com/2014/11/video/nov-30-future-shoe-new-ampla-fly-shoe-breaks-mold_118688

How We Test Shoes
http://www.runnersworld.com/running-shoes/how-we-test-shoes?adbid=10152448718631987&adbpl=fb&adbpr=9815486986&cid=socSG_20141203_36589687

Three minutes of all-out intermittent exercise per week increases skeletal muscle oxidative capacity and improves cardiometabolic health
https://www.readbyqxmd.com/read/25365337/three-minutes-of-all-out-intermittent-exercise-per-week-increases-skeletal-muscle-oxidative-capacity-and-improves-cardiometabolic-health

 

The Gait Guys talk about Cerebellar Afferents

http://youtu.be/tP-PvzB-fYM

Texting and Walking

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535903/

 
 
Texting and Walking.  Your gait will change when you are texting on your phone.
You are going to want to put away your cell phone after you read this, or at least hide your parent’s phones.
*(the video link attached here has likely been blocked by ABC News, you should see a forwarded link to their youtube feed. If not, here it is

So you think you are a multi-tasker do you ?  Do you know how much cerebral cortex real estate is necessary to walk or drive and text ? Just try texting while walking for 5 seconds in an unfamiliar environment and see what happens.  Dual tasking is difficult especially when one task is cognitive and the other is spacial and motor. At some point something has to give, especially if you are on the edge of tapping out the executive function centers in the brain because of early disease or age related mental decline.  This has never been more prevalent than in the elderly and the number of mounting studies proving that dual attention tasks lead to a dramatic increase in age related fall injuries.  If you look into the literature the fall rate increases from anywhere from 11 to 50%, these are strong numbers correlating falls and dual attention tasking in the elderly.  Certainly the numbers are worse in the frail and gait challenged and fewer in healthier elderly folks, but the correlation seems to be strong particularly when there are even early signs of frontal cortex demise. We have talked about this on several recent podcasts (check out podcasts 80-85) and this has been rooted even further from one of our neurology mentors, Dr. Ted Carrick.  

Recently in the Journal of Applied Biomechanics, Parr and associated took 30 young able bodied healthy individuals with experience texting on cellular phones. The study used an 11-camera optical motion capture system on a 8m obstacle-free floor. 
The study showed a reduction in gait velocity in addition to significant changes in spatial and temporal parameters, notably, step width, while the double support phase of the gait cycle increased.  Furthermore, and equally disturbing, toe clearance decreased but luckily step length and cadence decreased. 
Thus, it appears that the attention draining texting task generally forced the brain to slow the gait, reduce step length while improving stability via increasing step width and double support phase of gait, keep in mind that these are young healthy experienced individuals with no early cognitive challenges.  This is not the case in aging adults, or in adults with factors that have either challenged gait stability (degrees of impaired balance, vision, vestibular, proprioception etc) or challenged frontal cortex function where that functionality of the brain is already nearing its tipping point for adequate function.  Sadly, these are all factors in the aging adult and they are why falls are increased and riskier for the elderly. Essentially, what the studies are showing is that dual tasking creates a distraction that can amplify any sensory-motor challenges in the system.  Mind you, there are studies that show that if the dual task is remedial such as talking while walking the effects are more muted, however in those who are at the tipping point capacity of mental executive function, mere talking (cognitive linguistic engagement), can also tip the system into deciding whether to focus on the gait or the talk but not both adequately.  Something will have to give in these folks, safe competent dual tasking is beyond the ability of their system. 
As we have eluded to here, there are many factors and variables that can challenge the system. Visual challenges such as low light vision problems or depth perception challenges can act similarly on the system to dual tasking attempts and thus magnify fall risk. What about sensory challenges from a spinal stenosis or peripheral neuropathy such as in advancing diabetes?  Balance and vestibular challenges, let alone factors such as unfamiliar environments (perhaps magnified by vision challenges) as precursors are a foregone conclusion to increase fall risk in anyone let alone the elderly.
By this point in this article it should be a given that texting while doing anything else is a dual tasking brain challenge that could lead to a fall, an embarrassing spill into the public pool or into a fountain at the mall let alone driving off a cliff or into a crowd of people.  But are all of these unfortunate people showing signs of frontal cortex/executive function impairment? Perhaps not, especially if they are healthy.  One has to keep in mind that texting is a high demanding cognitive attention task, even though we think nothing of it as a healthy adult. Think about it, one has to engage a separate screen other than the environment they are trying to walk through. Additionally, one has to think about what they are trying to text, engage a seperate motor program to type, then there is spelling, choosing text recipients, sending the message, watching and listening for a response, and the list goes on meanwhile the person is still trying to run the gait subprograms.  We take it for granted but texting is highly engaging and adding walking can tip the system into a challenge or failure if we are in a crowd, unfamiliar environment, low light etc.  
So if you have ever wondered why elderly people trip and fall in even the most benign environments, it is likely a compounded result of challenges to situation and spatial awareness and working memory with many possible factor challenges. Again, things like poor lighting, vision limitations, unfamiliar environment, vestibular limitations, numbness in the feet, talking or even if they are simply carrying the afternoon tea to the sun room these things all are dual tasking and some require higher demands from the executive function brain centers.   Any factor(s) which tax the already-reducing executive function centers in the elderly subtract from the most basic elements required for upright posture and gait.  If dual-tasking can impair healthy young individuals, the elderly are a forgone conclusion to have magnified risks.  
There can be a plus to all of this however. If the goal were to only reduce falls and fall risks in the elderly, an astute clinician can work this to their favor and do gait challenges and retraining in the office environment while safely stacking dual task challenges to expand and restore some executive function capabilities.  We are never too old to learn and lay down improved motor and cognitive patterns. So, use this information to your advantage to improve function instead of delivering it as a dark cloud to hang over your clients, whether they are elderly or neurologically challenged. 
In summary, put down the darn phone, trust us, that text can wait.  Rather, enjoy the sunshine, the smiling faces, the trees.  If you are driving or walking, dump the phone and pay attention to traffic and your environment. Stop and wave to a friend. Teach your kids about this texting problem, they are likely already oblivious to many risks in the world, and this one likely hasn’t crossed their mind either. At the very least, help the elderly lady or man cross the street. By now you should understand all that they are consciously and subconsciously trying to calculate to negotiate the street crossing. Their declining executive function is often a mental feat all on its own, but having to actually add the physical act of walking (which is likely already showing aspects of age related biomechanical decline) might just be their tipping point leading to a fall.  So offer your arm, a warm smile, and think everything of it, because someday it will be you at that street corner with sweaty palms and great fear.
 
Shawn and Ivo, “the gait guys”
References :
1. Eur J Neurol. 2009 Jul;16(7):786-95. doi: 10.1111/j.1468-1331.2009.02612.x. Epub 2009 Mar 31.
Stops walking when talking: a predictor of falls in older adults?Beauchet O1Annweiler CDubost VAllali GKressig RWBridenbaugh SBerrut GAssal FHerrmann FR.
2. J Appl Biomech. 2014 Dec;30(6):685-8. doi: 10.1123/jab.2014-0017. Epub 2014 Jul 9. Cellular Phone Texting Impairs Gait in Able-bodied Young Adults. Parr ND1, Hass CJTillman MD.
3. Gait Posture. 2014 Aug 20. pii: S0966-6362(14)00671-7. doi: 10.1016/j.gaitpost.2014.08.007. [Epub ahead of print]  Texting and walking: effects of environmental setting and task prioritization on dual task interference in healthy young adults. Plumer, Apple, Dowd, Keith.
4. Gait Posture. 2012 Apr;35(4):688-90. doi: 10.1016/j.gaitpost.2011.12.005. Epub 2012 Jan 5.  Cell Phones change the way we walk.  Lamberg, Muratori
5. Int J Speech Lang Pathol. 2010 Oct;12(5):455-9. doi: 10.3109/17549507.2010.486446.  Talking while walking: Cognitive loading and injurious falls in Parkinson;s disease. LaPointe LL1, Stierwalt JAMaitland CG.

 

What would you do? This is what we did.

History:

This 7 year old girl is brought in by her mother because of knee misalignment while skiing, L > R. No history of trauma; normal term birth with no complications. No knee pain. Of incidental note, she is deaf in the left ear.

Exam findings:

She has bi-lat. external tibial torsion, left much worse than right (40 degrees transmallolear angle vs 22 degrees. for info on measuring torsions, click here). remember, you should be able to draw a line from the tibial tuberosity down through the 2nd metatarsal head. 

She has a 5mm anatomical leg length deficiency on the right (see top above left).

She has femoral antetorsion right side with very little external rotation, approximately 10 degrees,  internal rotation is in excess of 50.  Left side has normal femoral versions (for a review of femoral versions and torsions, click here).  See last 2 pictures which are full internal and external rotation respectively.

She has a mild uncompensated forefoot varus (cannot really see from the pictures, you will need to take our word for it) with a relatively cavus arch to her foot(see center and last picture on right.

Neurologically, she appeared to have integrity with respect to sensation, motor strength and deep tendon reflexes in the lower extremities.

Assessment:

Pathomechanical alignment as described.  Severe left external tibial torsion. MIld to moderate right. Femoral antetorsion right.

Plan:

We are going to build her a medium heel cup full length modified UCB orthotic inverting the cast bi-lat. left greater than right.  We gave her  balance and coordination exercises, heel walking, lift/spread/reach and one leg balancing. She will follow up for a dispense.  Her mother will try to get a better fitting ski boot as the one she has currently is two sizes too big. She will return for a dispense. She should consider wearing the orthotics in everyday footwear as well. We will do a follow up post in a few weeks. 

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