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” : )
Two photos above, toggle the red bar on the right. What do you see ?
Here is a case of a young football star we saw last night. He came in with a fresh right mid-belly quadriceps strain. This is a simple case if you know what the visuals are telling you. Just be sure you test your visuals (which are ASSUMPTIONS !), in other words, prove or disprove your hunches. What you SEE is not always what is present as the problem.
You can see clearly that in a prone position this chap has significant right gluteal underdevelopment compared to his left. This is a “quick peak” method of screening that i do on every patient when they turn over prone on the table as he is positioned.
There are many nuiances to this case, but here is what i was thinking the moment he told me about the injury…. “Doc, we were doing short 40 sprints, and my right quad just seized up?”.
I thought, hummmm….. i wonder if he was anchoring his thigh into his glutes and abdominals. Lets test his glutes first. If the glute is weak then i can assume he is quadriceps dominant and not anchoring the limb into the pelvis and core correctly. If he is gluteal inhibited, that means he will have underdeveloped glute if it has been there long enough. And if so, the glute cannot power hip extension so that range will be deficient. Sagittal extension will occur the next level above (lumbar spine) and inhibit the lower abdominals on the right. The hamstrings can also be called in to drive hip extension (welcome to the world of chronic hamstring issues in athletes). And if hip extension is limited, then internal rotation is likely somewhat limited. And if internal hip rotation and hip extension are limited then ankle dorsiflexion (“ankle rocker”) will be impaired and limited during midstance thus creating early heel rise during push off thus forcing the calf muscles to create more body mass lift than forward propulsion.
I put him on the table……saw the atrophied right gluteal……and proceeded to confirm all of the above. Treatment is based on figuring out who started this whole mess and reversing the functional pathologies in the pattern that makes sense to that patient’s neurologic system. It can be different for each person. You cannot “cook book” good manual medicine.
Prove or disprove your differential diagnoses or hunches……. make sure your direction is the right one. We all know what ASSUMING lead us to ……. it makes a donkey out of all of us.
We are….. The Gait Guys……. just a couple of donkeys.
A brief gait analysis of a pretty famous barefooter from a pretty famous study…
OK so we know this rather famous person is on a treadmill, so yes, there is a component of preload to the hip extensors, as well as an increased deceleration component (but those are topics for another post!), but there is some great stuff to look at here.
1st off, note the great technique: mid to forefoot strike, good toe dorsiflexion (although it could stand to be a bit increased to help prepare for even better tripod contact), and good ankle rocker. You can see his excellent shock absorption, through midfoot pronation, ankle dorsiflexion, knee flexion and hip flexion. Also check out the awesome action of his peroneals on his L leg, driving that 1st ray down to the ground for a great foot tripod and prelude to supinaion
But did you notice something else? How about the lack of hip extension? He barely gets past zero. How about the flexion at the waist? We bet his hip flexors are tight! Is some of this caused by the treadmill? Probably, but we would need to see some non-treadmill footage to be sure.
What the Gait Guys have to say about this article:
This article highlights some of the differences in gait between males and females on treadmills. Though treadmills don’t necessarily represent real life, they are an approximation. While reading this article, please keep the following in mind:
1. the treadmill pulls the hip into extension and places a pull on the anterior hip musculature, especially the hip flexors including the rectus femoris, iliopsoas and iliacus. This causes a slow stretch of the muscle, activating the muscle spindles (Ia afferents) and causing a mm contraction (ie the stretch reflex). This acts to inhibit the posterior compartment of hip extensors (especially the glute max) through reciprocal inhibition, making it difficult to fire them.
2. Because the deck is moving, the knee is brought into extension, with stretch of the hamstrings, the quads become reciprocally inhibited (same mechanism above).
3. The moving deck also has a tendency to put the ankle in dorsiflexion, initiating a stretch reflex in the tricep surae (gastroc/soleus) facilitating toe off through here and pushing you through the gait cycle, rather than pulling you through (with your hip extensors).
4. the moving deck forces you to flex the thigh forward for the next footstrike (ie footstance), firing the RF, IP and Iliacus, and reciprocally inhibit the g max
If your core isn’t engaged, the pull of the rectus femoris and iliopsoas/iliacus pulls the ilia and pelvis into extension (ie increases the lordosis) and you reciprocally inhibit the erectors and increase reliance on the multifidus and rotatores, which have short lever arms and are supposed to be more proprioceptive in function. Can you say back pain?
In summary, treadmills are not the scourge of humanity, but do have some pitfalls for training, and equal amounts of “backwards” running should be employed (with great caution, mind you)
With that being said, lets look at the results: increased hip internal rotation and adduction, as well as more glute activity for the ladies. Not surprising considering women generally have a larger Q angle (17 +/- 3 degrees for females, 14 +/-3 degrees for males) and greater amounts of hip anteversion (average 14 degrees in females vs 8 in males). The larger Q angle places more stress at the medial knee (compression of the medial femoral condyle and usually increased pronation as the center of gravity over the foot is moved medially) and thus more control needed to slow pronation (from the glutes to control/augment internal rotation). Greater hip anteversion means the angle of the femoral head is greater than 12 degrees to the shaft of the femur. This moves the lower extremity into a more internally rotated position, approximating the origin and insertion of the adductors, making them easier to access. With an increased Q angle and easier access, greater demands are placed on adductors in single leg stance (which is considerably greater in running), This increased adductory moment places more demand on the gluteus medius (and contralateral QL) as well, to stabilize the pelvis and this correlates with speed and incline, also found in the study.
The take home message? Don’t throw away your treadmill! The treadmill can be an excellent diagnostic tool! Gluteal and adductor insufficiencies will be more visible (and probably more prevalent) in females, especially those running or walking on treadmills. The hip extension and ankle dorsiflexion moment created by a treadmill works against some of the stabilizing mechanisms (glute inhibition, ankle dorsiflexor inhibition) and help to highlight some of the subtle gait abnormailities you may miss otherwise.
Gluteal deficiency and Hip Extenion: 5 minute video with rockstar Dr. Ivo Waerlop of The Gait Guys…….flip flop and opened back shoes……flexor dominance can kill ! and a bit about glutes and hip extension
Arm swing provides clues to gait pathology. We always talk about arm swing as a compensation mechanism. Here arm swing is used to increase hip extension in individuals that want to limit rotation of the lumbar spine.
Department of Orthopaedics, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian 35005, People’s Republic of China.
Patients with chronic non-specific low back pain (LBP) walk with more synchronous (in-phase) horizontal pelvis and thorax rotations than controls. Low thorax-pelvis relative phase in these patients appears to result from in-phase motion of the thorax with the legs, which was hypothesized to affect arm swing. In the present study, gait kinematics were compared between LBP patients with lumbar disc herniation and healthy controls during treadmill walking at different speeds and with different step lengths. Movements of legs, arms, and trunk were recorded. The patients walked with larger pelvis rotations than healthy controls, and with lower relative phase between pelvis and thorax horizontal rotations, specifically when taking large steps. They did so by rotating the thorax more in-phase with the pendular movements of the legs, thereby limiting the amplitudes of spine rotation. In the patients, arm swing was out-of phase with the leg, as in controls. Consequently, the phase relationship between thorax rotations and arm swing was altered in the patients.
This is one of our all time favorite gait styles. Aside from the atonic arm swing, what we love about this one is the vertical nature of this gait style. If you look around you will see this one often. These are the bouncy folks. There is a bucket load of vertical body movement when in fact the head should stay static in gait and in running.
This gait style is caused by a premature heel rise from premature engagement of the gastrosoleus (and sometimes even the long toe flexors, you will see them hammering and curled). The person will never get to full late-midstance of gait and thus never achieve full hip extension nor adequate ankle dorsiflexion / ankle rocker. These are timely events and specific things are supposed to happen during these phases of gait that are omitted and thus passed into other areas for compensation. This gait style is very inefficient in that the gluteals cannot power into hip extension into a forward progression drive, because the calf is prematurely generating vertical movement through ankle plantarflexion. This strategy is sometimes deployed because the person actually is significantly ankle dorsiflexion (ankle rocker) deficient. Meaning, they hit the limitations of dorisflexion and in order to progress forward they first have to go vertical. Obviously, the remedy is to find the functional deficit, remove it and retrain the pattern. We will be going over this pattern quite a bit in our new DVD line when we can get to it, because there are other deficits that could drive this one such as short hip flexors and quads to name one.
See you again on Gait Guys Gait Gaffs !…….Shawn and Ivo, we are…….The Gait Guys