Do you have enough Ankle Dorsiflexion to do this ? Some clues ?
Two guys pulling 40,000 pounds over one mile in just over an hour !
Watch the video above and then check out this link.
Look at the fellas left foot in the video compared to his right. Notice the turn out (the increased progression angle as it is referred to as) ? Now look at the photos from the article link above, again the fella in the red shirt has his left foot turned out again. Why is he doing this ?
Because he does not likely have enough ankle dorsiflexion (ankle rocker) to get into this far of a forward lean. Have you seen this in people or your students doing squats ? Lunges ? Will this present in his normal gait ? Perhaps, but if he has enough for normal gait (~15 degrees past vertical 90 degrees) he shouldn’t need to turn it out.
Turning out the foot will allow you to pronate through the midfoot to gain more dorsiflexion. It is why some people do it. Look for it.
It is also possible that he has a painful big toe or a hallux rigidus/limitus (ie. turn toe) and thus cannot toe off sagittally like on the other foot or like the other fella. This turn out will avoid loading that joint as much.
Regardless, you must examine this fella and figure out why he is using this strategy only on one side. This is just one theory, but we did not want to pollute this post with a few others. We can do that another time.
Ankle rocker dorsiflexion. It is critical for some activities.
Shawn and Ivo
from a FAcebook reader:
Question: Most sources allow for a small amount of turnout as “normal” in gait – about 7 degrees on average. Should feet point straight ahead? What is the repercussion of turnout, even a small amount? I think in barefoot societies the feet are pointing straight ahead so I wondered where this belief comes from and if it is correct. Perhaps people are losing dorsiflexion from wearing positive heels and are turning out in response? Thanks.
The Gait Guys You are correct. zero degrees progression angle is not considered normal….. 5-20 degrees is more “normal”……but it depends on the source. Keep in mind that femoral torsion and tibial torsion will be big players in this foot angle. The more the foot is turned out the more pronation (more than normal) can sneak in. IT will challenge the foot tripod. Weakness in the glutes, (particlarly g. medius from frontal plane challenges ) may ask the limb and foot to turn out to engage a more stable foot tripod. meaning, if you engage another plane (ie. more frontal plane) via more foot/limb turn out you can gain the help from other muscles such as the quadriceps. Reducing the heel height can force one to adapt to the use of more ankle dorsiflexion, you are correct. Hence why the literature suggests less injuries from more minimialist shoes. Hope this helps.
Gait analysis case study: A runner with achilles pain.
Please watch this clip a few times and pay special attention to the lateral views. This client had persistent Left Achilles pain which has improved with care and foot exercise, but is developing Left soleus pain.
Lets try something new. Lets test your gait auditory skills. Run the video and listen. Listen to the foot falls. Can you hear one foot slap harder than the other on strike ? Can you hear the right forefoot slap harder than the left ? It is there, it is subtle, keep re-running the video until you are convinced. The left foot just lands softer. Take your gait assessment to the next level, listen to your clients gait. Use all your senses. This finding should ask you to assess the anterior compartment of the right lower limb (tibialis anterior and toe extensors). And if they are not weak then you should begin to ask yourself why they may be loading the right foot abruptly. Perhaps it is because they are departing off of the left prematurely, in this case possibly because of a short leg that has a shorter stride length.
From clinical examination he has a 10mm anatomically short left leg (not worn in these videos), bilateral uncompensated forefoot varus deformities, bilateral internal tibial torsion and tibial varum ( 10 degrees Left, less on Right).
- weakness of the fourth and fifth lumbricals (small intrinsic foot muscles to the 4th and 5th toes) left greater than right. This will afford some lateral foot weakness during stance phase.
- weakness of all long toe extensors bilaterally (their weakness will allow dominance of toe flexors)
- weakness of the extensor hallucis brevis bilaterally
- weak left iliacus (a hip flexor muscle)
- slight pelvic shift to the left when testing the right abdominal external obliques
- weakness bilaterally of the quadratus femoris (a deep hip stabilizing muscle)
- weakness superior and inferior gemelli left, superior right (again, more deep hip stabilzer muscles)
So, what gives?
Did you pick up the nice ankle rocker present? There is good ankle dorsiflexion. What is missing? Look carefully at the hip (in the lateral/ side video views). There is not much hip extension going on there. So, the question is how does he get the ankle rocker he is achieving ? Look at the knees. He is getting it through knee flexion! It would be more effective and economical to achieve this kind of ankle dorsiflexion from a nice hip extension and utilize the glutes for all they can provide.
Remember, he has an uncompensated forefoot varus. This means he has trouble making the medial part of his foot tripod get to the ground. This means that the foot tripod will be challenged when the foot is grounded and when combined with the clinical foot weaknesses we noted on examination this is a foregone conclusion. With all that knee flexion which muscle will be called upon to control the foot? The soleus (which DOES NOT cross the knee).
The answer to helping this chap ? Achieve more hip extension! How? Gluteal activation through some means (acupuncuture, dry needling, MAT, K tape, rehab and motor skill patterns etc), conscious dorsiflexion of the toes, conscious activation of the glutes and anything else you might find useful from your skill set. Gain more from the hips and you will gain more control from that area and ask for the soleus to do just its small job.
Subtle? Maybe. Now that you know what you are looking at it is pretty easy isn’t it ? It’s like the “invisible gorilla in the room” we talked about in our previous Podcast. Unless someone brings it to your attention your focus will be on what you are accustomed to looking for and what you have seen before. Sometimes we just need someone to direct our vision. There is a difference between seeing something and recognizing something. In order to recognize something you have to go beyond seeing it, the brain must be engaged to process the vision.
The Gait Guys. Let us be your Peter Frampton and “Show you the Way” : )
Tight ankles ? Here we do a short little video for mom.
Gain strength in the anterior compartment to achieve posterior compartment length. Stretching calf is not enough when the calf is tight due to increased neurologic protective tone, possibly an attempt to protect the ankle mortise joint.
So, if stretching is not the solution, look to increase facilitation and strength of the weaknesses in the other compartments. You just might feel the tightness melt away without stretching at all !
Spindle responses and golgi tendon organ responses. The more you know about the nervous system the smarter your treatments will be.
The Gait Guys, using the functioning of the nervous system to get the responses we want.
Gait Parameter: Ankle Rocker during the Squat as a predictor for Shin Splints.
Here is a brief video we shot in our clinic. One of the primary assessments we do with all clients is a basic squat. No a “potty squat” were the tibia remains vertical and the hips press backwards, just a basic squat where the knees come forward. We do this with toes down and toes up.
We shot this video so that we could have some visual to talk about a few things.
1. Why toes up ? You have read it here before on our blog. Raising the toes is done by use of the log and short toe extensor muscles (Extensor digitorum longus and brevis, EDL, EDB and of the hallux extensors EHL, EHB). When we activate the extensors the toes dorsiflex around the metatarsals and the toes elevate. This activates the windlass mechanism. This mechanism tightens the plantar fascia thus shortening the distance between the metatarsal heads and the heel. Thus, the arch is driven up. This is why we harp on gaining toe extensor strength in flat footed and hyperpronators. Go ahead, stand up, raise your toes and feel the arch lift. It is a solid biomechanical phenomenon.
So, why do the squat with the toes up ?
Because when the foot is weaker than it should be a squat can allow the arch to drop too much during the down-squat. If the arch drops the foot could pronate more than necessary. This can drive subtalar joint motion which can fake out the true squat determination and the true determination of available ankle rocker. The client will be able to get deeper into the squat but for assessment purposes this will be a fake out. We want to know true available functional range at the ankle mortise joint (tibial talar joint). With the toes up, the arch is maximized and cannot drop unless the toes drop. As you will see in this video, you can thus see the true ankle rocker in this client is barely sufficient however it is likely enough (100-110 degrees) for normal gait in the sagittal plane.
What if when they do this there is little if any rocker, less than this guy?
Then to get more (100-110, ie. 10-20 degrees past vertical) they will have to compensate. We talk about the strategies in this old video of ours (LINK HERE). One of the best ways to compensate is to pronate through the arch more than normal. This will drop the arch height and carry the tibia forward enough to allow for forward motion. Sadly, this increased pronation can do alot of things. One is to carry the knee medially and this can create patellar tracking issues or IT band tightness, to name just a few.
So, what is our point today ?
- You need to make sure your assessments are telling you what you need them to tell you.
- Sufficient toe extensor strength and range is critical in the gait cycle to ensure sufficient ankle rocker occurs at the tibial-talar joint and not somewhere else you do not want it ( a compensation). Any strength you put into a client who has insufficient true ankle rocker is strength into a compensation pattern. Can you say heightened eventual injury risk ?
- Ability to find the foot tripod is a skill. It needs to be developed in a simple skill like we show here and then the sensation can be carried forward into gait and running.
- A forefoot varus or forefoot valgus (please read our foot type blog posts over the past 3 weeks) can impair the foot tripod and thus the true ankle rocker.
- Make sure the knees hinges straight forward in this ankle rocker-squat test. If it is not a forward bend you must consider foot pronation excess, tibial torsion, hip version or torison, or simply the weak foot issues we are talking about here today.
- This is a form of homework for our clients, just want you see above in the video. We add layers to this as the gain strength. But that is a topic for another day.
This is a huge predictor and problem in chronic shin splints ? You bet ya it is ! It may be the main missed deficit we see in shin splints (both anterior and posterior shin splints). There is lots more to this topic, but we will stop here for today.
Shawn and Ivo…….. you have to know what you are seeing. And as Johnny Nash once said in his song
I can see clearly now, the rain is gone,
I can see all obstacles in my way
Gone are the dark clouds that had me blind
It’s gonna be a bright (bright), bright (bright)
Sun-Shiny day now that i understand ankle rockers better.”
Another Gait variant: The Apropulsive gait style
Here is another important video for all you gait fanatics out there. You will see some of these components in your athletes, patients, family or even yourself if you are paying enough attention.
These animated videos are great because they exaggerate the pathology. Here we see several things:
- excessive forward arm swing: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
- forward head “bobbing”: again, this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
- a heavy forward lurching lean: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
- pronounced knee lift-hip flexion: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
So, what is driving all of these attempts to create more than normal forward propulsion ?
If you look down at the feet you see a lack of ankle rocker (dorsiflexion) as evidenced by early heel departure. This fella puts his foot on the ground and then tries to move across his ankle but he hits a restriction at the range limitation. He cannot move forward sufficiently to normalize a sound effective and efficient propulsive gait. At the moment his ankles lock out from hinging further forward he must go into the above strategies to pull his body mass forward past his foot plant and literally pull the foot off the ground and move forward to the next dysfunctional step. Everything he is doing is to try to create forward propulsion sufficient to move across ankles that do not dorsiflex enough.
* IMPORTANT: Remember: premature heel rise typically leads to premature activation of the calf muscles, gastrocsoleus. And when this happens, the gait becomes vertical and bouncy in nature as the calf muscles are being used to lift the body more than to propulse it forward. This can lead to posterior compartment injury. Additionally, this causes a quick premature forefoot loading response which can create increased burden on the METatarsal head and fat pad but it will also create a grip response of the toes and possible hammering which can disable the lumbricals and other foot intrinsic muscles).
And if that isn’t bad enough, on the sagittal views, we see the knees hinging outside the normal forward progression line and if that isn’t bad enough, on the views from behind he clearly is dipping the contralateral hip-pelvis during stance phase (when standing on the right leg, the left pelvis drops) which is a key sign of suspect gluteus medius weakness.
even the simple cases have nice topics for review. Failure to have sufficient components for effortless forward motion in gait will result in compensations to get the job done.
TAKE HOME POINT: identifying and restoring ankle rocker is pretty darn important. And that does not mean simply via stretching the posterior compartment. Frequently the anterior compartment is the weakness driving the pathology, but not always.
Pixar should call us……… Shawn and Ivo
The Guys of all things Gait
oh look, it appears (but a little hard to tell) ……but it appears we have a casualty !
here is what her ankle is saying …..
“oh no, we do not have enough ankle dorsiflexion to be on this bad boy…….so, who wants to take it guys…….. how about you hyperpronate Mr. Arch, and to help we will drive Mr. Knee medially.” ?
better have enough ankle dorsiflexion if you are gonna play with this monster !
This is a video follow up to last weeks rockers post. Enjoy!