Hiya Gait Guys! I have cross over gait…watched your vids on adopting new style of running (imaginary lines etc) and want to introduce the new way of running i.e. not running on a tightrope!! How quickly can I introduce this new method? I currently run 20 miles per week, generally 3-6 mile runs. I am doing some hip and glute medius strengthening at the same time. Do I introduce it a few miles at a time as I realise it will be working new muscles and how cautious should I be? Thanks

hi !

We will answer this in podcast 19

should launch this week !

thanks for your great question

The Gait Guys

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Case of the Week: Rib Pain while Running: Part 2

Welcome back. Glad you picked choice d (or maybe you had a pint anyway)

Assessment:This patient has a significant difference in the length of her legs; her left leg being short, right leg being longer. The…

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BIKE FIT: Case Study

Along the vein of bike fit, to go with Thursday and Friday’s posts last week, here is gentleman with right sided low back pain ONLY when ascending hills on his mountain bike. Can you figure out why?

*Stop, watch the video and think about it before we give you the answer… .

____________________________

This gentleman presented with low back pain, only on his mountain bike, only on long ascents.

He measures out with an 83 cm inseam which should put him on a 44 to 45.5 cm frame (measured via our method). His frame has a dropped top tube and measures 55 cm.

He has a knee bend angle of 20 degrees at bottom dead center. Knee is centered well over pedal axis.

His stem falls far in front of his line of sight with respect to his hub. Stem is a 100 mm stem with a 6 degree rise.

There is a 2” drop from the seat to the top of the handlebars.

He has an anatomically short Left leg (tibial)

Here is some additional video of him with a 3 mm lift in the left shoe. Look at the tissue folds at the waist and amount of reach with each leg during the downstroke in this one as well as the last. no changes were made to the seat height, fore/aft position of seat. or handlebars.

The frame, though he is a big dude (6’+), is too big and his stem is too long. He is stretched out too far over the top tube, causing him to have an even more rounded back (and less access to his glutes; glutes should rule the downstroke and abs the upstroke). This gets worse when he pushes back (on his seat) and settles in for a long uphill. Now throw in a leg length discrepancy and asymmetrical biomechanics.

Our recommendations:

  • smaller frame (not going to happen)
  • lower seat 5-7mm
  • shorter stem (60-75mm) with greater than 15 degree rise
  • lift in Left shoe


We ARE the Gait Guys, and we do bikes too!

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MORE compensations for short legs…

We remember from 2 weeks ago, the week before, AND last week, there at least SIX common compensations for a short leg.

We spoke about circumducting the long leg last time. Once again, here is the list

  •  pronation of the longer side, supination of the shorter
  • leaning to he shorter leg side
  • circumduction of the longer leg around the shorter
  •  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive ankle plantar flexion on short side
  •  excessive knee bend on the long leg side

Lets look at “hip hiking” of the longer extremity today. Hiking the hip allows one to create enough room (hopefully) to get that long leg through without dragging on the ground. Again,  it makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the longer leg.

This gal in the video has cerebral palsy (CP), affecting the left side. She has a short R leg and hikes the L pelvis pelvis up to get it to clear (she has L g med weakness due to the CP)

Watch the above video a few times to see what we are talking about. You can really see it when she is walking toward you.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Hip Hiking. Not quite the “Walk in the Woods” Bill Bryson was talking about, but yet another compensation for a short leg.

Ivo and Shawn. …bald, good looking, geeky…… The Gait Guys

Case of the Week: Rib Pain while Running: Part 2

Welcome back. Glad you picked choice d (or maybe you had a pint anyway)

Assessment: This patient has a significant difference in the length of her legs; her left leg being short, right leg being longer. The right ilia is rotated posteriorly (thus the tissue fold) in an attempt to shorten the extremity and the left ilia is rotated anteriorly, in an attempt to lengthen the leg. This is putting the abdominal external obliques in a  lengthened and shortened position, respectively. The right is short weak and the left is long (stretch).  The obliques attach to the lower ribs 5-12 (for external) and ribs 10-12 (for the internals).

The psoas muscle takes its origin form the lumbar vertebral bodies and inserts on the lesser trochanter of the femur. Due to the poterior rotation of the right ilia, it has been lengthened over time (thus the difference in hip extension) and is stretch weak on the right.

So why only on the right and during running?

due to the anatomical leg length difference, the right oblique has shortened over time. Running (forced inspiration and expiration) causes us to use some of our accessory muscles of respiration (obliques, intercostals, serratus posterior superior and inferior, sternocleidomastoid, scalenes. Remember that for quiet respiration, only the diaphragm is used for inspiration; passive tension in muscles for expiration).

Also, the stride length will be increased on the longer leg side (ie when the L leg is in swing and R in stance); this put additional stretch on the R iliopsoas and R abdominal obliques.

iliopsoasthe

Treatment Plan: We placed a 3 mm lift in her left shoe. We treated with manipulative therapy of the lumbar spine.  She was given the nontripod, side bridge, cross/crawl quadruped and hip flexor stretch with side bending exercises to perform on a daily basis.  She felt better post treatment.

Case Quiz: Part 2: The Questions

Here was our reply:

She has a cross over gait pattern Right > Left; assumedly due to the amount of tibial varum on the Left; is it that prominent unilaterally? The lateral shift is compromising the LCL (lateral collateral ligament on the Left, combined with poor gluteus medius control. She appears to have an uncompensated forefoot varus bilaterally as well. I would question if she has an LLD (let length discrepancy) on the Right, with more pelvic glide/drift occurring to that side during stance phase of gait. Her arm swing is also greater on the right. With the reconstruction, she has a greater stride length on the Right, as she tries to unload the Left side. Does she look any better in the orthotics ?

Our suspicions are:

  • LLD (leg length discrepancy), short on the right
  • moderate Forefoot varus, uncompensated
  • LCL (lateral collateral ligament) laxity
  • weak Gluteus medius complex bilaterally
  • crossover gait

What could be done?

  • continued acupuncture for muscle facilitation
  • “waddle walks” with theraband around legs (to challenge the gluteus medius), keeping them in some degree of abduction
  • Single leg standing exercises on foot tripod
  • foot intrinsic strengthening (lift, spread, reach exercise; EHB; FDB, EDL)
  • Sole lift if indicated to help with limb length challenge

prolotherapy may help but you need to know WHY the leg translates laterally; otherwise you are just band aiding it

Hope that helps. Let us know how it goes and if she has an LLD (short leg, anatomically).


Ivo and Shawn: asking the tough questions….

Case Quiz: Part 1

Here is a case submitted by a friend of ours, Dr Lance Robbins in Florida. You can see the problem (and a description below). Rather than just give you the answers, we want you to come up with what questions to ask. Tune in later for what we think.

Ivo and Shawn


Dr Robbins notes on the client in the video:

Intermittent left knee pain with a painless limp while walking
Medical History is positive for an ACL reconstruction on the Left many years ago where they used part of the patellar tendon
Currently wears orthotics made by Xtreme Footwerks
Exam:
Gait showed a lateral knee deviation 
Static exam findings showed a marked tibial varus on the left,  bilateral external tibial torsion, along with Bilateral abducto-hallux valgus and mild bilateral forefoot varus.
There is a decrease in the right side ankle rocker, mid and forefoot motion is WNL (within normal limits). 
She presents with unilateral right sided genu recurvatum. During the exam she explained that before her ACL reconstruction she had bilateral genu recurvatum and during the surgery they corrected the left side.
Static palpation reveals a tight hypertonicity in the posterior knee structure on the left. There is also a moderate a,out of swelling along the upper lateral side of the left knee around the insertion of vastus lateralis and the client indicates that this has been there for along time since the surgery. When she tried to reduce the swelling with a TENs unit her knee pain got worse.
Dynamic evaluation showed normal hip ROM (Range of Motion) and ankle ROM except for the decrease in ankle rocker noted above. The right knee ROM is WNL. The left knee has a very slight reduction in flexion compared to the other side but still falls within normal limits. There is a moderate amount of instability in the left knee during the Varus stress test indicating some LCL (lateral collateral ligament) laxity. 
There is a decrease in the Left popliteus, biceps femoris, and glute medius  muscle function.
After one session of CMT (chiropractic manipulative therapy) (L5, Left Sacroiliac joint), acupuncture to facilitate muscle function and kinesiotape to support ligament laxity she had an immediate reduction in the swelling around her knee without any occurrence of pain. This lasted for 4-5 days with a return of some swelling after. 
The ligament laxity was not majorly effected by the treatment. 
Prolotherapy is one alternative we are considering
My hunch is that this has developed as a post-surgical adaptation due to the change in structural orientation of the knee (unilateral correction of genu recurvatum).
Even with prolothery to tighten up ligament structure how do we proceed forward in order to prevent reoccurrence or early onset degenerative processes?