High Heels and …..Orthotics?

What better way to end the year than to talk about something that some of you have worn last evening. Not only clean underwear, but also high heels!

You have heard all about high heels here on the blog (if not, click here). Now here is some info that may be surprising! This study found that increased heel height caused increased plantar pressures (no surprises) BUT the use of an orthotic or arch pad, attenuated impact forces. IOHO not a reason to wear heels (though we DO like the way they look : )) but if you need to wear them (really? you need to wear them?), then maybe consider an insert to make it more bearable.

Ivo and Shawn                                              

                           

Appl Ergon. 2005 May;36(3):355-62.

Effects of shoe inserts and heel height on foot pressure, impact force, and perceived comfort during walking.

Source

Department of Industrial Management, National Taiwan University of Science and Technology, No. 43, Kee-Lung Road, Sec IV, Taipei, Taiwan, 106 ROC. yhlee@im.ntust.edu.tw

Abstract

Studying the impact of high-heeled shoes on kinetic changes and perceived discomfort provides a basis to advance the design and minimize the adverse effects on the human musculoskeletal system. Previous studies demonstrated the effects of inserts on kinetics and perceived comfort in flat or running shoes. No study attempted to investigate the effectiveness of inserts in high heel shoes. The purpose of this study was to determine whether increasing heel height and the use of shoe inserts change foot pressure distribution, impact force, and perceived comfort during walking. Ten healthy females volunteered for the study. The heel heights were 1.0cm (flat), 5.1cm (low), and 7.6cm (high). The heel height effects were examined across five shoe-insert conditions of shoe only; heel cup, arch support, metatarsal pad, and total contact insert (TCI). The results indicated that increasing heel height increases impact force (p<0.01), medial forefoot pressure (p<0.01), and perceived discomfort (p<0.01) during walking. A heel cup insert for high-heeled shoes effectively reduced the heel pressure and impact force (p<0.01), an arch support insert reduced the medial forefoot pressure, and both improved footwear comfort (p<0.01). In particular, a TCI reduced heel pressure by 25% and medial forefoot pressure by 24%, attenuate the impact force by 33.2%, and offered higher perceived comfort when compared to the non-insert condition.

Excessive Supination in a marathoner: Shoe Photos !

Simple visual case today.

Look at the right shoe, can you see how it is canted laterally? Can you see the inversion of the rear foot ?  Without a foot in that shoe it means that “the last”, the heel counter and the EVA foam are all destroyed and deformed into this great runner’s compensation pattern. 

They did not have pain however can you determine the problem here from the photos ? We hope your answer is no.  We did a teleseminar last night on www.onlineCE.com on pedograph foot mappings and we talked long and hard about the possible limitations of determining foot problems from foot pressure mappings from things like pedographs and pedobarographs.  Do you use foot scanners ? If so, user beware !  They gather vital and valuable information that you absolutely need but you need the critical clinical information from the client examination to bring the foot issue info full circle.

In this case there was a significant limitation in hip rotation. Which one ? Can you theorize ?  If you said internal rotation you are right. There was a notable loss of internal right hip rotation in his marathoner.  And it is represented in his shoe photo above. Someone who has a loss of internal hip rotation will often (but not always) have difficulties achieving the normal foot pronation required for clean foot mechanics, they will be stuck in a supination tendancy.  If loss of internal rotation can mean loss of pronation then in this case ample external rotation meant excessive supination (or at the very least rear foot inversion). Hence the shoe presentation described at the beginning of this post. (Note: this is what we would refer to as a “Flexible” Rear foot Varus posturing).

So, is this the wrong shoe prescription for this runner ? No, the shoes were prescribed correctly. This is a biomechanical breakdown of a shoe because of a hip functional problem.

Solution: Dump the shoes for a new pair and quickly restore hip function. Keeping these shoes in the mix will promote the bad pattern.  In this case, functional movement and muscle tested assessments revealed specific weakness of the right lower transverse abdominus, right internal abdominal oblique, right TFL, right vastus lateralis and coccygeal division of the g. max.   Yes, all INTERNAL HIP ROTATORS  or stabilizers or synergists of internal hip rotation.  Immediate post treatment remedy revealed near full internal hip rotation and homework was prescribed to ramp those said muscles up further to support the new movement. 

If he had remained in this shoe, the breakdown in the shoe would continue to promote the biomechanical deviations into the previously engrained faulty motor compensatory pattern. 

Shoes, sometimes they are the problem, sometimes the solution and sometimes caught somewhere in between.

Need to get better at this stuff ? Just follow us daily here on The Gait Guys or consider adding the National Shoe Fit Program to your repertoire !  Email us if you are interested or need some help with your interesting cases !

Shawn and Ivo, The Gait Guys

Shoe News You can Use…

The Heel Counter– the back of the upper

This is the back of the shoe that offers structure (just squeeze the back of a shoe. this is the rigid part you feel between your thumb and 1st finger, unless of course, you are using your teeth). This is often part of or integrated with the upper.

A strong, deep heel counter with medial and lateral support is important for motion control; It offers something for the calcaneus (heel bone) to bump up against when as it is everting (moving laterally) during pronation. Look at folks that have a bump on the outside of their heel (particularly the ladies(sorry, true); this is often called a “pump bump”). Now look at the inside of their shoes. See that worn away area on the inside of the back of the shoe? Now you know where that worn away area is coming from!

Lateral support especially for people who invert a great deal or when you’re going to place an orthotic in the shoe which inverts the foot a great deal.  The lateral counter provides the foot (or orthotic) something to give resistance against.  The lateral counter needs to extend at least to the base of the fifth metatarsal, otherwise it can affect the foot during propulsion. A deep heel pocket in the shoe helps to limit the motion of the calcaneus and will also allow space for an orthotic. The heel counter should also grip right above the calcaneus, hugging the Achilles tendon.

We know you want to know more. We can help. Take the National Shoe Fit Certification Program. If you like, sit for the exam and get certified as well. Email us for details thegaitguys@gmail.com

The Gait Guys. We’re your heel counter!


all material copyright 2012 The Homunculus Group/ The Gait Guys. All rights reserved. If you want to use our stuff, please ask. If not, Captain Cunieform may pay you a visit…

The Great Myth of Rotating your Shoes : Here are the Actual Facts as we see them.

Everyone has heard the rules, rotate into new shoes about every 400-500 miles.  We disagree, kind of, and we have talked about it on previous blog posts in the past and on our podcasts.  Many shoe reps have agreed with the methods we employ for our runners.

The EVA foam often used in shoe manufacturing has a lifespan, or better put, a given number of compression and shear cycles. It can go through a rather fixed number of compression cycles before it loses its original structural properties, the older the foam gets the faster the degradation process and the more risks it poses for runners.  It is known that EVA foam compressed into a focal vector or area over and over again becomes softer and more giving into that vector/area over time.  Hence, if you have a compensation pattern or a known foot type (forefoot varus, forefoot valgus, rearfoot varus, rearfoot valgus or a combination of these 4) you will break down a certain region or zone of the shoe’s EVA foam. For example a forefoot varus foot type will often drive some heavy focal compression into the foam under the first metatarsal. However, if you combine it with a rear foot valgus it will drive shear forces and compression into the  EVA foam along the entire medial aspect of the shoe (see the 2 pictures attached, you can see the evidence of excessive medial compression and medial shear in a foot that has severe rearfoot valgus and forefoot varus. This is a very poor shoe prescription for the foot type involved).

Here is what you need to do / know:

1- Know your athletes foot type so you can make more informed decisions.

2- Know the type of foam of the shoes you are recommending (ie. Altra uses A-Bound foam instead of EVA just as an example. A-Bound is an environmentally friendly energy-return compound is made of recycled materials. It reduces the impact of hard surfaces while still maintaining ground feedback. Traditional running shoe foam compresses 70-90% while A-Bound™ compresses 2-3x less so it won’t deform over time.).  Cheap shoes use cheap materials.  Altra goes the extra mile for foam quality and many others are beginning to follow suit. If you think you are getting a deal on shoes, know what “the deal” is, it just may be cheaper materials.

3-  500 miles is not the rule for everyone and every shoe.  If you have a relatively neutral forefoot and you are a forefoot or midfoot strike runner you will get far more miles out of a shoe.  If you depend on a stability shoe with dual densities of foam to slow your pronation and control your medial foot because of a rearfoot valgus and/or forefoot varus know that the shoe’s foam will break down less uniformly because of foam interface junctions and whatnot.  This is a science. Engineers call it “the mechanics of material deformation”.  We wonder how many mechanical engineers shoe companies have on board in their R&D divisions ?  We know for a fact that a few do not. There was a reason we snuck quietly into the mechanical engineering departments of our Alma Mater and sat quietly in the “Materials” classes. At the time our roommates just told us it was  cool class, little did we know why it was so interesting to us, until now.

4- Here is what we recommend. Fit the foot type to the right shoe selection. If you are weak in this territory consider taking our intense “National Shoe Fit” program. Fit is everything. Make the wrong choice for your client and the shoes will break down quicker and into poor and risky patterns. Make the right choice and be their hero. If you are looking for a way to improve clientele happiness and store loyalty our Shoe Fit Program is the way. Just read the testimonials here on our blog. Some of the top stores in the Nation have quietly taken the National Shoe Fit Program from us, they have good reason to. They also have good reason to keep it quiet, to get the edge on the competition.

You can email us to get this information and the e-file program download. Why not certify your entire store staff ?

Email us at   thegaitguys@gmail.com.  This program will teach you foot anatomy, functional anatomy, shoe anatomy, foot types and matching foot type to shoe type as well as many other aspects of gait and lower limb biomechanics.

* 5- Try this recommendation.  At 250 miles buy a new shoe to accompany your shoe that already has 250 miles. Now you are rotating 2 shoes. From this 250 mile point moving forward, alternate the newer show with the older shoe. This way you are never in a shoe that is notably more deformed in a specific area of the EVA foam because of your compensations, limitations or foot type. Essentially you are always just a day away from a newer shoe that has less driving force into abnormally compressed EVA foam.  The older the shoe gets the more it accelerates your foot and body into that deformation and hence why many injuries occur as their shoes get older. Continue to alternate shoes on every other run (new, old, new, old).  Once you hit 400-500 miles on the old shoes, ditch them and get a new pair again to restore the cycle once again.  In fact, to be specific here is what we recommend. Monday, old shoe. Tuesday, new shoe. Wednesday do not run, rather, rest or cross train. Thursday go back to the older shoe. Friday new shoe and repeat. This way you are 4 days between runs in the older more deformed shoe. The one day off running in mid week gives tissues that were challenged by the “old shoe run” a bit more time to repair.

6- Dedicate your shoes to running only. Running gait is not the same as walking gait. Why would you want to break down the EVA foam at the rear foot during walking (because heel strike is normal in walking) when in running you are a mid-forefoot striker ?  Keep walking shoes for walking, running shoes for running. Otherwise you are just asking for trouble.

Check out our National Shoe Fit program and certification process here as well as links to our other teaching DVD’s & e-downloads:
 http://store.payloadz.com/results/results.asp?m=80204

Shawn and Ivo. Helping you use your head (and shoe knowledge) better everyday.
The Gait Guys  (have you checked out our RebelMouse page ? https://www.rebelmouse.com/TheGaitGuys/

Keeping up with our awesome informative podcasts ? It is all free stuff ! https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

How about our youtube channel ? http://www.youtube.com/user/thegaitguys

How about our Facebook PAGE ?  https://www.facebook.com/pages/The-Gait-Guys/169366033103080

The Dual Density Foam Running Shoe.

This goes along nicely with yesterdays post. Note the photo attached. This is a great example of something we all see everyday. A laterally tipped foot in a stability shoe.  Clearly a shoe that has been mis-prescribed for the wrong reason. Or has it ?

This client is clearly tipped laterally in the shoe, forcing supination.  Did this client self fit the shoe themselves in a discount store ? Were they fitted in a retail running store ? Where did things go wrong ? Or did they ?  The initial knee jerk reaction is to say this is the wrong shoe for this client.  Lets go a little deeper and ask some harder questions and see if you are considering some alternatives.

The assumption is frequently one of, “you are a hyperpronator so you need a stability shoe”. In this case is this person a hyperpronator ?  There is no way to know, not in the shoe.  On initial knee jerk observation this looks like a supinator in a stability shoe, a poor match.  But read on …

1. What if this person has significant flat feet, pes planus with severe pronation problems, but they find the stability they need by standing on the outer edge of the foot in the mechanically locked out position (supination).  Perhaps this is a less fatiguing posture, perhaps a less painful posture. This is often a comfort thing for hyperpronators to display.  What you see is not always what you get because there are two types of feet, those that drop or collapse into the weakness and those that fight the collapse and weakness the whole way via an alternative compensation.  You cannot tell by looking, certainly not from this picture of someone in a shoe. There must be a functional assessment and some gait evaluation. 

2. There exists the high arched flexible foot that pronates excessively, quickly and for a long time (this is the flexible cavus foot) and then there is the high arched rigid foot (the equinovarus foot).  The first described foot may need support from a stability shoe even though they have a high arch on presentation/examination and the later described foot can often go right into a neutral non-supportive shoe.  Can you tell either of these from this picture ? No you cannot.

3. Maybe the person in the photo has tibial varum (bowed lower leg) combined with a rearfoot varus and forefoot varus. This could mean they pronate heavily through the midfoot-forefoot and less so through the rearfoot-midfoot. In this case they are still a heavy pronator but not through what is typically noted or detected by significant medial arch collapse.  In this case the dual density shoe is not going to help all that much because the pronation is occurring mostly after the bulk of the shoe’s dual density stability foam has been passed through by the foot. Can this be detected by this photo ? Again the answer is no. The shoe fitter needs to be clinically aware that this type of client needs a forefoot varus posted shoe to help post up that medial tripod (1st metatarsal head).

4. Maybe, just maybe this is a typical rearfoot-midfoot pronating client, excessive mind you, and all they need is some foot and gait retraining to break their old compensation pattern of lateral weight bearing (standing or walking) and with this correct shoe they can then engage a healthier motor pattern. 

Which is it ?

Do you know how to navigate your way through these issues to make the right decision ?  There is no way to know here without seeing the foot naked and moving across the floor, and with a clinical examination to boot.

You can get all these things through our National Shoe Fit Certification program found here.

LINK:  http://store.payloadz.com/results/results.aspx?advsearch=1&m=80204

Email us and we will share the necessary info to get you started.  thegaitguys@gmail.com

Shawn and Ivo, The Gait Guys

Gait, Running and Sound. Are you listening to your body ?

A few months ago we tried something new.  We tested your gait auditory skills while listening to a video of a runner on a treadmill. We queued you to listen to the foot falls listening for the one foot to slap or impact harder than the other at foot strike. Most of you got it right, we  got plenty of positive feedback on that piece. Here is that piece (link).

This is something we do during the initial evaluation for each and every patient that comes to see us, no matter what their issue. We ask them to walk. We ask them do they notice anything. The answer is almost always, “no”.  This is because they are accustomed to their walking habit.  The first queue we notice much of the time is that there is either a bilateral heavy heel strike (because heel strike is normal in walking) or it is  heavier on one side. We ask them to hear and feel that heavier strike once we point it out to them. Not only can they feel it, they can hear it. It is something they have rarely been aware of until that moment.  We then do the same for forefoot loading. If the anterior compartment is a little weaker on one side or if they departed abruptly off the opposite leg for some reason (decreased hip extension, tight calf, loss of ankle rocker etc), a heavier forefoot loading response will be felt and heard as well (opposite side of the mentioned issues).  These are great initial gait queues that anyone can use to gain diagnostic information.  It also draws the client into greater body awareness of their habitual patterns of movement. We then draw out the numbers and forces for them so they understand what several thousand cycles of this event can cause into their body and their clinical problems they are presenting with.  This is typically a new skill they will develop and always be aware of and be able to report to you as they progress through their care with you.  Sound and feeling are key biofeedback tools.

Just remember, they are feeling and hearing what they are doing, not what is wrong ! It is your job to take this information and figure out the “Why” it is happening, and the “how” to fix it.  This is the hard part.

Retail/Coach/Trainer Focus: When a stability shoe does not stop gait or running pronation.

This video is unlisted. You will need this link to view it if it does not show up in the player above this blog post:    http://youtu.be/Lt6RbEtALUY

This is a higher end stability shoe. We know what shoe it is and you can see the significant amount of dual density mid sole foam in the shoe, represented by the darker grey foam in the medial mid sole.  The point here is not to pick on the shoe or the brand. The point here is to:

1. not prescribe a shoe entirely on the appearance of the foot architecture

2. not to prescribe a shoe merely because a person is a pronator

3. not to assume that a stability shoe will prevent pronation

4. not to assume that technique does not play a part in shoe prescription

5. not to assume that all pronation occurs at the mid foot (which is the traditional thinking by the majority of the population, including shoe store sales people)

There you go, plenty of negatives. But there are positives here. Knowing the answers and responses to the above 5 detractors will make you a better athlete, better coach, better shoe sales person, a safer runner, a more educated doctor or therapist and a  wiser person when it comes to human locomotion. 

A shoe prescription does not always make things better. You have heard it here and we will say it again. What you see is not necessarily what you get.  This case is a classic example of how everything done for the right reasons when so very wrong for this young runner.

What do you see ?

Pronation can occur at:

  1. the rear foot (we refer to this as excessive rear foot eversion or calcaneal eversion driven sometimes by rearfoot valgus). This can be structural (congenital) in the bone (calcaneus or talus) or functional from weaknesses in one or several rear foot eversion controlling muscles.
  2. the mid foot as is traditionally assumed (this is often referred to as “arch collapse” ).
  3. the fore foot. (possibly many causes, such as a Rothbart Foot variant, short first metatarsal, a bunion , forefoot varus, hallux valgus, weakness of the hallux controlling muscles etc)

So, in this case you might assume that the stability shoe that is designed to prevent rear and midfoot pronation is:

  1. not doing its job sufficiently OR
  2. the pronation is occuring at the forefoot OR
  3. there is a myriad of of issues (yes, this is the answer)

However, the keen eye can clearly see that this is a case of heavy forefoot pronation but there are also mechanical flaws in technique (driven by weaknesses, hence just working on her running form will not solve her issues, it will merely force her to adopt a new set of strategies around those weaknesses !). The problems must be resolved before a new technique is forced.  This is perhaps the number one mistake runners make that drives new injuries.  They tend to blame the injury on new shoes, old shoes, increased miles, the fartlek they did the other day, the weather, their mom, there spouse, their kids…….runners come up with some great theories. Heck, all of our athletes do ! It keeps things amusing for us and we get to joke around with our athletes and throw out funny responses like, “I disagree, it was more likely the coming precession of the equinox that caused this injury !”. 

Although his individual does not have a fore foot varus deformity (because we have examined  her) it needs to be ruled out because it is  big driver of what you see in many folks.  In FF varus the forefoot is inverted with respect to the rear foot. This can be rigid (cannot descend the 1st ray and medial side of the tripod) or plastic (has the range of motion, but it hasn’t been developed).

We, as clinicians, like to assume that MOST FEET have a range of motion that folks are not using, which may be due to muscle weakness, ligamentous tightness, pathomechanics, joint fixation, etc. Our 1st job is to examine test the feet and make sure they are competent. Then and only then, after a trial of therapy and exercise, would you consider any type of more permanent “shoe prescription”.

If the individual has a rigid deformity, then you MAY consider a shoe that “brings the ground up” to the foot. Often time we find, with diligent effort on your and the individuals part, that a shoe with motion control features is not needed.

Sometimes the individual is not willing to do their homework and put in the work necessary to make things happen. This would also be a case where an orthotic or shoe can assist in giving the person mechanics that they do not have.

We have not seen many (or any) shoes that correct specifically for a fore foot varus (ie a shoe with fore foot motion control ONLY). The Altra Provision/Provisioness has a full length varus post which may help, but may over correct the mid foot as well. Be careful of what you prescribe.

Yes, we have been studying, blogging, videoing and talking about this stuff for a long time. Yes, much of it is often subtle and takes a trained eye to see. It is also the stuff that goes the “extra mile” and separates good results from great ones.

We are The Gait Guys. Watch for some seminars on some of our analysis and treatment techniques this fall and winter, and some pretty cool video, soon to be released.

Midfoot strike 5 year old running barefoot in grass.

So, heel strike you say ?  Have  a closer look.  This is a near perfect midfoot strike. What you cannot see is his torso progression. As long as the torso has enough forward lean heel strike cannot occur. Heel contact can occur, but not heel strike or impact.

We have talked about this on many occasions here on The Gait Guys Blog. No one else is talking about this fine line difference between heel strike and heel contact.  Everyone still seems hell bent on talking about forefoot strike. Forefoot strike in distance running is not normal, midfoot strike like you see here in this young child is natural and normal. This 5 year old was likely just asked to run barefoot, he was not likely coached. This is because midfoot strike is natural and normal.  As we said, as long as the torso is directly above or in front of the foot contact position there is no way that heel STRIKE can occur, rather heel CONTACT can only occur (unless you have hamstrings like cirque du soleil acrobats and do not mind going into a posterior tilted pelvis at contact). 

We tell our runners to:

  • lift the chest and lean
  • raise the toes and dorsiflex the ankle  (engage the anterior lower leg compartment) so that the arch is maximally prepared
  • a heel KISS of the ground is fine, just no impact
  • you do not need to forefoot strike to run naturally
  • * and, here is one more reason why we like a midfoot strike over a forefoot strike…. because a midfoot strike means that the body continues forward whereas a forefoot strike that then allows into a heel kiss/touchdown means that there is a posterior progression and eccentric lengthening of the posterior chain (hamstrings and calf muscles). This posterior directed motions is not exactly wise when forward progression is the goal of running !

This little fella is doing it right. Largely because he has not been in shoes long enough to corrupt the natural tissues and mechanisms (both the body parts and the natural neuromotor patterns).

* Addendum: after a really productive FAcebook dialogue with some readers we felt we needed to be more clear on some of our unspoken assumptions here.  If the heel hits first, it will be a STRIKE and not a KISS and the load will be high. The only way the heel can kiss the ground like we mention above is if the heel is absolutely contacting at the same time as the forefoot, one could say that there is a more dominant load on the mid-forefoot but the heel can still strike at this same time.  Striking clearly on the forefoot and then touching down the heel is satisfactory but there is still a retrograde movement which we believe is not as economical yet certainly better than heel impact/strike.  To get the perfect midfoot strike with barely a subtle heel CONTACT (not impact or strike) requires greater skill and more mastery as a runner.  And if you are wearing a shoe that is not minimalist or zero drop developing this skill will be a challenge and you will be misleading yourself.    This ammendment added 1 hour post blog post launch.

Shawn and Ivo…….. the Devil is in the Details.