Since the world did not end, you should probably think twice about those motion control shoes….

WE can all agree that there is a time and a place for motion control shoes. For people with chronic ankle sprains or lateral instability (ie, an incompetent lateral compartment; peroneus longus, brevis or tertius), it is neither the time, nor the place.

The lateral ankle is stabilized by both static (ligaments: above lower left) and dynamic (muscles above, lower right) elements. This is often called “the lateral stabilizing complex” The lateral ankle (ie the lateral malleolus) also projects more inferiorly than the medial. This means that when push comes to shove, the ankle is more likely to invert (or go medially) than evert (or go laterally). What protects it? The static component consist of three main ligaments (seen above) the posterior and anterior talofibular ligaments and the calcaneofibular ligaments. The dynamic components are the peroneii muscles. These muscles not only stabilize but also exert an eversion (brings the bottom of the foot to the outside) force on the ankle.

So what you say?

according to one study we found “Using an in-shoe plantar pressure system, chronic ankle instability subjects had greater plantar pressures and forces in the lateral foot compared to controls during jogging.”

Hmmm. Remember the midsole? (If not click here and here for a review) Motion control shoes are medially posted. That means they provide more support medially or  have a tendency to tip the foot laterally. SO, motion control shoes shift forces laterally.

A person with chronic ankle instability has weakness of either the static, dynamic, or both components of the lateral stabilizing complex.

bottom line? make sure folks have a competent lateral stabilizing complex and if they don’t, you may want to think twice about using a motion control shoe.

Ivo and Shawn. Increasing your shoe geekiness coefficient on daily basis!                                                                                                                                                    

Foot Ankle Int. 2011 Nov;32(11):1075-80. Increased in-shoe lateral plantar pressures with chronic ankle instability. Schmidt H, Sauer LD, Lee SY, Saliba S, Hertel J. Source University of Virginia, 2270 Ivy Road, Box 800232, Charlottesville, VA 22903, USA.

Abstract BACKGROUND:

Previous plantar pressure research found increased loads and slower loading response on the lateral aspect of the foot during gait with chronic ankle instability compared to healthy controls. The studies had subjects walking barefoot over a pressure mat and results have not been confirmed with an in-shoe plantar pressure system. Our purpose was to report in-shoe plantar pressure measures for chronic ankle instability subjects compared to healthy controls.

METHODS:

Forty-nine subjects volunteered (25 healthy controls, 24 chronic ankle instability) for this case-control study. Subjects jogged continuously on a treadmill at 2.68 m/s (6.0 mph) while three trials of ten consecutive steps were recorded. Peak pressure, time-to-peak pressure, pressure-time integral, maximum force, time-to-maximum force, and force-time integral were assessed in nine regions of the foot with the Pedar-x in-shoe plantar pressure system (Novel, Munich, Germany).

RESULTS:

Chronic ankle instability subjects demonstrated a slower loading response in the lateral rearfoot indicated by a longer time-to-peak pressure (16.5% +/- 10.1, p = 0.001) and time-to-maximum force (16.8% +/- 11.3, p = 0.001) compared to controls (6.5% +/- 3.7 and 6.6% +/- 5.5, respectively). In the lateral midfoot, ankle instability subjects demonstrated significantly greater maximum force (318.8 N +/- 174.5, p = 0.008) and peak pressure (211.4 kPa +/- 57.7, p = 0.008) compared to controls (191.6 N +/- 74.5 and 161.3 kPa +/- 54.7). Additionally, ankle instability subjects demonstrated significantly higher force-time integral (44.1 N/s +/- 27.3, p = 0.005) and pressure-time integral (35.0 kPa/s +/- 12.0, p = 0.005) compared to controls (23.3 N/s +/- 10.9 and 24.5 kPa/s +/- 9.5). In the lateral forefoot, ankle instability subjects demonstrated significantly greater maximum force (239.9N +/- 81.2, p = 0.004), force-time integral (37.0 N/s +/- 14.9, p = 0.003), and time-to-peak pressure (51.1% +/- 10.9, p = 0.007) compared to controls (170.6 N +/- 49.3, 24.3 N/s +/- 7.2 and 43.8% +/- 4.3).

CONCLUSION:

Using an in-shoe plantar pressure system, chronic ankle instability subjects had greater plantar pressures and forces in the lateral foot compared to controls during jogging.

CLINICAL RELEVANCE:

These findings may have implications in the etiology and treatment of chronic ankle instability.

 

all material copyright 2012 The Homunculus Group/ The Gait Guys. Don’t rip off our stuff. PLEASE ASK 1st!

EHB: Extensor Hallucis Brevis

Did you know that the EHB (extensor hallucis brevis) the topic of today’s video tutorial, originates off of the forepart of the medial aspect of calcaneus & lateral talocalcaneal ligament. It is just above the bulk origin of the EDB (extensor digitorum brevis). It is frequently torn/strained in ankle inversion sprains and frequently goes undiagnosed. It can be torn/avulsed from the bone if the inversion sprain is focused below the lateral ankle joint. This occurs mostly when the foot is more plantarflexed before the inversion event. A foot cannot afford to have an impaired big toe ! Don’t miss this one !

Runners . . . On Your Mark, Ready, Set…..Swim.

For many of the years of my youth I watched just about every NBA basketball game I could get my eyes on.  When I wasn’t dreaming of playing ball in the big time I was at the local YMCA in my small town shooting jump shots, working on my fading jumper (because i was a small guard with no vertical, the worst of combinations), and working on my ball handling techniques. I was not a great player, not by any means, but I could play in pretty competitive pick up games and at least be somewhat respectable (note that ‘somewhat’ is highlighted).  But I still dreamed big about the NBA until I became old enough to realize that I was just too short and not blessed with the natural talent for the game that others obviously had been blessed. No matter how much I dreamed, being 5 foot 8 inches wasn’t going to ever get me to the big dance.  Body type, form, physiology and your anatomy have a big part in what sport you will be good at. There just are not too many 5’8” NBA guards, there never were minus Mugsy and Spud. They were an exception, obvious outliers. 

Are you a runner with runner’s anatomy ?  Do you have bowed legs ? Forefoot varus flat feet ? Anteverted hips ? Excessive tibial torsion ?  These are not great traits for runners. They tend to lead to many biomechanical issues that provoke injury at a much higher incidence than someone like my friend Charlie Kern , the USA masters mile champion.  Charlie is like Tiger Woods. Charlie has straight lower limb bones, no bony versions or torsions, great feet, he is slender, excellent muscle structure, and has tons of natural ability.  If you have ever seen him run it is like watching water flow. Charlie is as a runner just like Tiger is as a golfing Ferrari. They both happened to pick a sport that their body’s were perfectly suited for, then they had the passion for that sport, were lucky to have found it at a young age, and they worked harder than anyone else at their sport.  Anatomy, a bit of luck in sport choice early on, a physiology that paired well with the anatomy, and a work ethic to trump anyone. Being the best is a combination of things. You can have all the desire in the world as a runner or athlete but if you do not have the magic mixture of all things necessary you might just be average instead of extraordinary. 

Do you get injured all the time when you run ? How are your feet, are they competent or are they flat ? Do your tibias bow like a weathered piece of lumber ?  Are your knees kinked inwards (genu valgum) ? Are you tall and thin or are you build like a line backer ?  In other words, are you suited to be a distance runner or marathoner ? Or should you be happy with three to four 5k runs a week and be happy you can run those smaller distances rather than spend every 2 weeks in the therapists office getting a foot fixed, an orthotic tweaked, kinesiotape on a knee, more rehab. Do you spend more time icing your injuries and doing pre-run theapeutic exercises and foam rolling than you do running ? 

If this is you. God bless your dedicated heart. But maybe you should put on your Speedo and go for a swim.  I put my NBA dreams on hold long ago after realizing that at 5’8” it just wasnt going to happen. I picked up golf and did much better at that game in a shorter period of time than all the work on my hoop dreams.  I would fathom to say I should have picked up ping-pong long ago as a child. Perhaps I would be world champ by this time.

Run, bike, swim, hoops, golf…..whatever your passion. There is nothing wrong with having heart and grinding it out daily to be a runner or do whatever your sport happens to be.  Just never lose sight of the obvious. Maybe you need to look past your heart and look in the mirror and your mounting therapy bills and make some adjustments to your running dreams. Some of my best Triathletes were awesome runners at one time … .  when we could get them healthy to a start line line.  The problem was that they had more unused race bibs than completed races. They were in my office regularly pleading me to fix them up so they could get their training in so they could get to race day. However, after much psychoanalysis and reality talking we finally got through to some of the best athletes. Once we switched them to triathlons where they could moderate the runs and hit some alternative sports that did not play up their challenged race anatomy, they rose to the top and rarely had to hand off a race bib to a friend who was healthy.  And they are happier.  I see them far less in my office and far more at the finish lines with a huge smile.

Do some honest inventory of your body.  Sometimes a Speedo just makes sense, well, sort of. If you catch our drift.

Dr. Shawn Allen, The Gait Guys

More research on Forefoot Running: Forefoot Varus and the toe extensor muscles.

Lately we have all seen much in the news about the forefoot strike loading in runners and many of the proposals and rebuttals regarding injury rates.  Our dialogue less than 2 weeks ago on some of Lieberman’s recent comments (our blog article “Dear Dr. Lieberman”, click here) seem to be ringing true again. Here are just two more insightful and important studies when it comes to looking at some of the proposed ideas and causes of forefoot varus. Naturally, a thinking mind would wonder if some of these weaknesses in anterior and posterior tibialis muscles as well as extensor toe musculature, as proposed in just these 2 articles, are causal to the forefoot injuries that seem inevitable as Lieberman seems to suggest (again, see our blog post). Naturally, weaknesses and poor motor patterns of some or all of these muscles is going to create and insufficient and possibly inefficient and pathologic forefoot loads because of the forefoot varus foot type these muscular imbalances can functionally produce.  We have been pounding sand on this issue for years but still no one listens.  The medial research, as evidenced here is supportive of our theories and everyday clinical findings.

To summarize, ONCE AGAIN, not everyone is suited or possibly ready for forefoot load/contact/strike running.  And if you have injury or problems in doing so, don’t blame your minimalist shoe……. it is either a foot type that needs functional repair or a foot type that is fixed an must opt for midfoot strike.

There is SO MUCH MORE to this game than just strap on some minimalist shoes and start forefoot loading your way on your next run.  Buyer beware !

Shawn and Ivo…….. the gait guys……..two guys who are “Gandhi’d” regularly. 

“First they ignore you, then they laugh at you, then they fight you, then you win.”

– Mahatma Gandhi

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http://www.ncbi.nlm.nih.gov/pubmed/20307453

Foot (Edinb). 2009 Jun;19(2):69-74. Epub 2008 Dec 31.

Foot varus in stroke patients: muscular activity of extensor digitorum longus during the swing phase of gait.

Reynard F, Dériaz O, Bergeau J.

Clinique romande de réadaptation, SUVA Care, Av. Gd-Champsec 90, Sion, Switzerland. fabienne.reynard@crr-suva.ch

Abstract

CONCLUSIONS: The activity of extensor digitorum longus muscle during the swing phase of gait is important to balance the foot in the frontal plane. The activation of that muscle should be included in rehabilitation programs.

_______________

http://www.ncbi.nlm.nih.gov/pubmed/16882899

J Bone Joint Surg Am. 2006 Aug;88(8):1764-8.

The contributions of anterior and posterior tibialis dysfunction to varus foot deformity in patients with cerebral palsy.

Michlitsch MG, Rethlefsen SA, Kay RM.

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA.

Abstract

RESULTS: The muscular contributor to varus deformity was the anterior tibialis in thirty feet, the posterior tibialis in twenty-nine feet, both the anterior tibialis and the posterior tibialis in twenty-seven feet, and another contributor in two feet. Seventy feet had varus deformity during both stance phase and swing phase. Of these seventy feet, twenty-five exhibited dysfunction of the anterior tibialis, twenty exhibited dysfunction of the posterior tibialis, and twenty-three exhibited dysfunction of both muscles. Therefore, the timing of varus was not predictive of the contributing muscle or muscles.

CONCLUSIONS: The current study demonstrated a higher prevalence of anterior tibialis dysfunction, both alone and in combination with posterior tibialis dysfunction, as a contributor to pes varus in patients with pes varus and cerebral palsy than had been reported previously. Dynamic electromyography provides clinically useful information for the assessment of such patients.

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 of the Week: Rib Pain While Running: Part 1

Case of the Week: Rib Pain while Running: Part 1

This 39 year old woman presents with with rib pain, pointing to right ribs. First time it “went out” 1 ½ year ago, second time a year ago and recently two weeks ago. It is usually related to running with pain the day of and day after it is acute; it hurts to lie on her back or roll onto that side or breathe deep. She seems to do best when she is semiflexed on her knees.  Stretching can take the edge off.  When she has an acute episode, it usually lasts about a day.

She is very physically active and works out almost everyday. She runs triathlons and Ironman’s (or Ironwoman’s in this case), and generally is in good shape.

Above is what you see physically (hover mouse over each picture) and here are her exam findings:

She is 5’ and weighs approx. 105 pounds.BP 100/72 left, pulse ox 94, pulse 52. Lungs auscultate clearly, normal heart sounds, abdomen non tender and normal to percussion and auscultation.

Viewed from posterior in a standing position, she had increased tibial varum bi-lat., right greater than left, right hip had posterior rotation, less space between iliac crest and rib margin right hand side. No tenderness noted over the obliques or lower ribs left hand side. She had a loss of lateral bending to the left L2 through L4 negative theta-z stress.

She has a L  left short leg (tibial) 5 mm, bi-lat. external tibial torsion left greater than right. There is weakness of the abdominal internal and external obliques bi-lat. as well as iliopsoas, R > L. There was point tenderness at the R lesser trochanter; active and passive hip extensoin was 10 degrees right, 15 degrees left.

Question: What is your assessment and what are you going to do?

a. do not know, go have a beer

b. do not know, go have 2 beers

c. do not know, do not drink beer, have a double latte after reading Fridays post and try not to spill it

d. reply to this post,  think about it and check back later to see what The Gait Guys have to say

Injury and Repair

Injury and Repair?

It appears injury and repair are the yin and yang of healing. Injury may be necessary for nerve regeneration to occur, at least in mice. Talk about neural learning! So injuries (from a neurological perspective) may be a good thing!  Perhaps this is why acupuncture, dry needling and intramuscular therapy work so well for these conditions. ( Watch for a Live Gait Guys course in dry needling and intramuscular stimulation this fall in Chicago and Denver!)    
A protein abbreviated DLK (which stands for dual leucine zipper kinase) apparently is necessary to activate nerve regeneration after an injury.    
“DLK is a key molecule linking an injury to the nerve’s response to that injury, allowing the nerve to regenerate,” says Aaron DiAntonio, MD, PhD, professor of developmental biology. “How does an injured nerve know that it is injured? How does it take that information and turn on a regenerative program and regrow connections? And why does only the peripheral nervous system respond this way, while the central nervous system does not? We think DLK is part of the answer.”    
Most injuries have a neurological component, whether it be the inflammatory process, a change in muscle tone or activity, the perception of pain or proprioceptive abnormality. If this mechanism is not triggered, the nervous system may not heal. This may provide clues as to why nerve injuries heal so slowly or are less responsive. Learning more about this protein may provide clues and answers to this commonly encountered dilemma.    
The original paper was published in Neuron and a nice summary can be found here.    
The Gait Guys: sorting out the literature and giving you the latest information so you can make more informed clinical decisions.

Running barefoot: Saving money or spending it on the doctor ? & How to Cycle shoes !

Running barefoot: Saving money or spending it on the doctor ? & How to Cycle shoes !

Today, something a little different.  I worked for the world famous Joffrey Ballet Dance company on an off for a few years treating the dancers before shows and productions.  These folks always had the most amazing strength (try this one ! bet you cannot do it……in fact, don’t try it…..you will probably dislocate your MTP (metatarsophalangeal joint; the big knuckle joint) of the big toe.)

These folks also had many problems with their hips, knees and spine mechanics from the demands of turn out, jumping, overuse and the demands of things like en pointe.  This is an example of what is referred to as “en pointe” which means “on the tip”.  There is “demi pointe” which means on the ball of the foot which is much safer and we will do another video on that another time to explain some critical components to it right, there is more to it than just getting up on the ball of your foot.

En Pointe is a  terrible challenge in our opinion. So if you are thinking of putting your darling children in ballet…… just beware of the facts and do some logical thinking on your own.

En pointe or classical point ballet it typically done in point shoes or slippers which have a reinforced toe box that allows a more squared off stable surface to stand in pointe position.  It does not however allow a reduction in the axial loading that you see in this video and it certainly does not help with proper angulation of the big toe, if anything the slipper will gently corral the toes together rendering abductor hallucis muscle function nearly obsolete.   The box will also not stop the valgus loading that typically occurs at the joint as you see occurring here in her right foot if your joint line has a more aggressive angulation (genetics).  You can already see the deforming force that is creating a valgus toe position here. Despite what the studies say, this is one we would watch carefully.  Now, there are studies out there that do not support hallux valgus and bunion formation in dancers (see ** at end of this post).  However, we are just asking you to use common sense.  If you see a bunion forming, if the toe is getting chronically swollen, if the toe is drifting off line then one must use common sense and assume that the load is exceeding joint integrity.  Prolonged and excessive loading of any joint cartilage is likely to create a risky environment to crack, fissure, wear down or damage the cartilage or the bony surface underneath (subchondral bone).  So, if you think that loading your entire body mass axially on the small joint surface of the big toe is a great idea, that is fine, just do not bring your kids to our office and expect to get a happy face sticker at the check out counter.  We are going to read you the risks that are born from logical thinking.  This is not meant in any way to take away from the amazing feat that this is for dancers, but it just is not a smart thing to do if you want a healthy first joint (MPJ – metatarsophalangeal joint) and foot for that matter. After all, if you screw up this joint, toe off will be impaired and thus the windlass effect at the joint will be impaired thus leading to a multitude of other dysfunctional foot issues.

Now, back to the “en pointe” position.  Did you try it yet ? Heed our warning ! Just trust us, this is bloody hard.  Since serious foot deformities can result from starting pointe too early, pre-professional students do not usually begin dancing en pointe until after the age of 10 or so , remember, the adolescent foot has not completed its bone ossification and the bone growth plates have not closed.  Thus, damage and deformity are to be expected if done at too young an age.  If you asked our opinion on this, we would say to wait until at least the mid-teenage years……. but by that point in the dance world a prodigy would miss her or his opportunity.  Thus, we see the problems from going “en pointe” too early in many. In the dance world, there are other qualifications for dancers before En Pointe is begun, things like holding turnout, combining center combinations, secure and stable releve etc. 

 

Achieving en pointe is a process.  There is a progression to get to it.  Every teacher has their own methods but it is not a “just get up on your toes” kind of thing. 

Shawn & Ivo……. Dreaming of Sugar Plum fairies…….. (ok, maybe not)  but knowing your biomechanics of the foot and gait are an integral part of dance as well.

* and after watching this video, if your next thought was……” I wonder what the incidence of posterior ankle impingement injures occur in dancers” or if you said under your breath……. “hey, extreme plantarflexion at the ankle loads the Lisfranc joint pathomechanically ….. I wonder if that joint is ever an issue in dancers……. ?”   then you will clearly be on the route to becoming one of……… The Gait Guys

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** Hallux Valgus in Dancers. A Myth ? 

Abstract: Among dancers it is widely believed that ballet dancing induces hallux valgus. Revision of radiographs of 63 active and 38 retired dancers of both sexes showed no increase in the valgus angulation of the hallux compared with that of nondancers.