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” : )
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
*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.
- 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!
Acupuncture can be effective for many types of sports injuries and rehabilitation of gait related disorders. One such study can be found here.
The effect of needling is though to be 3 fold: local, segmental and cortical.
The local effect of needling occurs at the site of the needle insertion. Local tissue damage causes cytokines to be released and this stimulates both the inflammatory and healing process, as well as increasing local circulation.
The segmental affect is thought to be at the spinal cord level (the dermatome or sclerotome) where inhibition of pain impulses occur (pre synaptic inhibition for you neuro nerds out there)
The cortical or “long loop” effect is thought to be due to activation of higher brain centers which cause descending inhibition of pain and activation of the hypothalamic-pituitary axis (which appears to be one of the reasons acupuncture can be effective for colds and other problems).
You can view many of our posts on pain and its physiology here to gain a better understanding of the pain pathway and pain modulation.
The Gait Guys: yes, sometimes we are a pain, but we offer solutions to help and give you the research to back it up
Neuromechanics Weekly: How does appropriate movement diminish pain?
We talk about proper (or should we say appropriate) movement (including gait) inhibiting or diminishing pain. So, how does that happen?
Above on the left is a great diagram that we will work through.
You are looking at a cross section of a spinal cord (We can hear the groans already!) We remember that the dorsal horn (posterior part) is sensory and the ventral horn (front) is motor. In between them (the lateral horn) is autonomic (this runs automatized body functions such as your heart, lung, guts, etc).
Small nerve fibers subserve pain. These are the A delta and C nerve fibers. “Small” refers to fiber diameter of the nerve. These nerves are where pain stimuli enters the spinal cord; they enter the sensory dorsal horn and synapse/connect there with the next neuron in line that takes the sensory message up the spinal cord to the brain to tell you about the pain including its intensity, location etc. Pain can result from tissue damage or injury (which can be due to, or the result of, poor biomechanics).
Large diameter nerve fibers subserve sensations like touch, pressure, vibration, muscle spindles (muscle length) and golgi tendon organs (muscle tension/load). These fibers also enter the sensory dorsal horn, but they do not synapse immediately, unlike pain fibers. They ultimately travel up to the top of the brainstem or cerebellum to coordinate information with other data your brain is processing. They send a branch (or collateral) to an inhibitory neuron, which excites the inhibitory neuron. Thus, if you excite an inhibitory neuron, it does it’s job and inhibits the propagation of an impulse. In this case, it inhibits the pain impulse from traveling to the cortex. So pain is inhibited. Appropriate biomechanics excite the largest population of receptors and provide the most effective response.
Now look at the diagram on the right. It is a simplified schematic of the one on the left, with detail of the connections. Note that the LARGE FIBERS (from joint mechanoreceptors, spindles, muscles, etc) EXCITE the inhibitory interneuron (which would inhibit it). Also note that the SMALL FIBERS INHIBIT the inhibitory internuron (which would excite it!)
There you have it. Clear as mud? Go through some of our old posts on receptors and FEEL THE PAIN (parts 1, 2, 3+4) and come back to this and read it again. You know you want to be a geek, so go ahead!
The Gait Guys: Geeks on many levels. helping you to presynaptically inhibit pain on a daily basis, through better movement.
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.
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.
Arm swing in gait and running. Why it is crucial, and why it must be symmetrical.
It becomes clear that once you get the amazing feats seen in this video out of your head, and begin to watch just the variable use of the arms that you will begin to appreciate the amazing need for arm swing and function in movement.
We have written many articles on arm swing and its vital importance in gait and running. Have you missed all these articles ? If so, go to our blog main page, type in “arm swing” in the search box and you will have a solid morning of readings at your fingertips. We are still not done writing about this most commonly forgotten and overlooked aspect of gait and running analysis, and we probably never will be done. Why is no one else focusing on it ? We think it is because they do not see or understand its critical importance.
Without the presence and use of the arms in motion things like acceleration, deceleration, directional change, balance and many other critical components of body motion are not possible.
What is perhaps equally important for you to realize, as put forth in:
Huang et al in the Eur Spine Journal, 2011 Mar 20(3) “Gait Adaptations in low back pain patients with lumbar disc herniation: trunk coordination and arm swing.”
is that as spine pain presents, the shoulder and pelvic girdle anti-phase begins to move into a more in-phase favor. Meaning that the differential between the upper torso twist and pelvic twist is reduced. As spine pain presents, the free flowing pendulum motions of the upper and lower limbs becomes reduced to dampen the torsional “wringing” on the spine. When this anti-phase is reduced then arm swing should be reduced. The central neural processing mechanisms do this to reduce spinal twisting, because with reduced twist means reduced spinal motor unit compression and thus hopefully less pain. (Yes, for you uber biomechanics geeks out there, reduced spine compression means increased shear forces which are favorite topics of many of our prior University instructors, like Dr. Stuart McGill). The consequence to this reduced spinal rotation is reduced limb swing. And according to
Collins et al Proc Biol Sci, 2009, Oct 22 “Dynamic arm swinging in human walking.”
“normal arm swinging requires minimal shoulder torque, while volitionally holding the arms still requires 12 % more metabolic energy. Among measures of gait mechanics, vertical ground reactive moments are most affected by arm swinging and increased by 63% without arm swing.”
So, it is all about efficiency and protection. Efficiency comes with fluid unrestricted movements and energy conservation but protection has the cost of wasting energy and reduced mobility through a limb(s) and spine.
In past articles we have carried these thoughts into historical functional needs of man such as carrying spears and of modern day man in carrying briefcases. Today we show a great high functioning video of another parkour practitioner. Parkour is a physical discipline and non-competitive sport which focuses on efficient movement around obstacles. Watch closely the use of the arms. The need for arm use in jumping, in balance, in acceleration etc. It becomes clear that once you get the amazing feats seen in this video out of your head, and begin to watch just the use of the arms that you will begin to appreciate the amazing need for arm swing and function in movement.
There is a reason that in our practices we treat contralateral upper and lower limbs so much. Because if you are paying attention, these in combination with the unilateral loss of spinal rotation are the things that need attention.
Yup, we are The Gait Guys….. we have been paying attention to this stuff long before the functional movement assessment programs became popular. If you just know gait, one of the single most primitive patterns other than crawling and breathing and the like, you will understand why you see altered squats, hip hinges, shoulder ROM screens etc. You have to have a deep rooted fundamental knowledge of the gait central processing and gait parameters. If you do not, every other screen that you put your athlete or patient through might have limited or false leading meaning.
Shawn and Ivo … combining 40 years of orthopedics, neurology, biomechanics and gait studies to get to the bottom of things.
And once again…… another study validating the fact of weak hip stabilizing muscles in causing knee pain. The study showed that increased activation of the gluteus maximus in individuals with patellofemoral knee pain suggests that these subjects were attempting to recruit a weakened muscle, perhaps in an effort to stabilize the hip joint.