Arm swing asymmetry: It can be a huge window of education into your client.

Arm swing asymmetry: It can be a huge window of education into your client, if you can get past the dumb stuff we’ve all done (and believed) for decades.
I have beaten you down with arm swing principles over the past few years, sorry about that, but, the beating will continue because it is important to know what arm swing tells you, and what it does not tell you (hint hint for all those improperly coaching arm swing changes). We did an entire tele seminar on the Stage 1 principles of of arm swing (#218) on www.onlinece.com and www.chirocredit.com if you wish to take that archived lecture. Heck $19, how can you lose (see photo).  Arm swing is intimately dependent upon scapular stability, thoracic mobility, breathing, cervical spine function, pelvis stability and clearly ipsilateral and contralateral leg swing not to forget to mention spinal stability. The first signs of spine pain or instability and the counter rotation of the shoulder and pelvic girdles become more phasic, instead of their normal anti phasic nature (moving in opposite directions). This phasic nature reduces spinal shear loads.

Neurologic diseases in their early, middle and late phases can give us a clearer window into how the nervous system is tied together.
Arm swing asymmetry during gait may be a sensitive sign for early Parkinson’s disease.

Here is what this Plate et al study found :
-Arm swing amplitude as well as arm swing asymmetry varied considerably in the healthy subjects.
-Elderly subjects swung their arms more than younger participants. -Only the more demanding mental load caused a significant asymmetry
-In the patient group, asymmetry was considerably higher and even more enhanced by mental loads.
-Evaluation of arm swing asymmetry may be used as part of a test battery for early Parkinson’s disease.

Some facts you should consider:
Parkinson’s Disease will be well advanced before the first signs of motor compromise occurs. So early detection and suspicion should be acted upon early when possible. Reductions or changes in arm swing may be the first signs of neuralgic disease expression and progression. Dual tasking may bring out neurologic signs early, so talk to your clients or have them count backwards to distract the motor programs. Look for one sided arm swing impairment, and when present, be sure to examine all limbs, especially the lower limbs, for impaired function. After all, the arms are like balasts, they can help with postural stability simply by abducting or modifying their swing.  Arm swing changes can include:
– crossing over the body
– more forward sagittal swing and less posterior swing
– more posterior sagittal swing and less anterior swing
– shoulder abduction during swing (and with attributes of the prior two mentioned above)
– less swing with adduction stabilized with torso
– modified through accentuations or dampening of shoulder girdle rotation oscillations, thus less arm swing but more torso swing to protect the glenohumeral and other joints
– and others of course

Arm swing and arm swing symmetry matter. Don’t be a dunce and just train it out or tell your client to do things to change it before you identify the “why” behind it. If it were that simple Ivo and I would have long grown tails and begun eating more bananas. Or maybe we would have already moved to the islands by now. That was random wasn’t it. That’s what Jimmy Buffett said.

“Now he lives in the islands, fishes the pilin’s
And drinks his green label each day
He’s writing his memoirs and losing his hearing
But he don’t care what most people say.
Through eighty-six years of perpetual motion
If he likes you he’ll smile then he’ll say
Jimmy, some of it’s magic, some of it’s tragic
But I had a good life all the way.
And he went to Paris looking for answers
To questions that bother him so.”  -Jimmy Buffett

Hope this helps, now back to that rum.
-Shawn Allen

Gait Posture. 2015 Jan;41(1):13-8. doi: 10.1016/j.gaitpost.2014.07.011. Epub 2014 Aug 8.
Normative data for arm swing asymmetry: how (a)symmetrical are we?  Plate A1, Sedunko D2, Pelykh O3, Schlick C4, Ilmberger JR5, Bötzel K6.
http://www.ncbi.nlm.nih.gov/pubmed/25442669

 Why does this gal have so much limited external rotation of her legs? 

 We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.

 Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.

Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion.   This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation.  She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.

 So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius,  gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient. 

confused? Did you miss our awesome post on femoral torsions: click here to learn more.

Wow!  Can you figure out why this person at the distal end of her first metatarsal under her medial sesamoid.

She recently underwent surgery for a broken fibula (distal with plate fixation) and microfracrure of the medial malleolus. You are looking at her full range of dorsiflexion which is improved from approximately 20° plantarflexion. She is now at just under 5°.

She has just begun weight-bearing and developed pain over the medial sesamoid.

The three rockers, depicted above from Thomas Michauds book, or necessary for normal gait.  This patient clearly has a loss of ankle rocker. Because of this loss her foot will cantilever forward and put pressure on the head of the first metatarsal.  This is resulting in excessive forefoot rocker.  Her other option would have been to pronate through the midfoot. Hers is relatively rigid so, as Dr. Allen likes to say, the “buck was passed to the next joint. ”

There needs to be harmony in the foot in that includes each rocker working independently and with in its normal range. Ankle rocker should be at least 10° with 15° been preferable and for footlocker at least 50° with 65 been preferable.

 If you need to know more about rockers, click here.

Yay for the lift, spread and reach exercise!

Toe spreads and squeezes are aimed at strengthening specific intrinsic foot muscles—the dorsal and plantar interrosei, according to Irene S. Davis, PhD, PT, director of the Spaulding National Running Center and a professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School in Boston. Doming or foot shortening exercises contract most of the muscles on the plantar side of the foot, and help to strengthen the abductor hallucis muscle

see our post here: https://tmblr.co/ZrRYjx1iuSYMM

Goo YM, Heo HJ, An DH. EMG activity of the abductor hallucis muscle during foot arch exercises using different weight bearing postures. J Phys Ther Sci 2014;26(10):1635-1636.

A visual example of the consequences of a leg length discrepancy.

This patient has an anatomical (femoral) discrepancy between three and 5 mm. She has occasional lower back discomfort and also describes being very “aware” of her second and third metatarsals on the left foot during running.

You can clearly see the difference in where patterns on her flip-flops. Note how much more in varus wear on the left side compared to the right. This is most likely in compensation for an increased supination moment on that side. She is constantly trying to lengthen her left side by anteriorly rotated pelvis on that side and supinating her foot  and trying to “short” the right side by rotating the pelvis posteriorly and pronating the foot.

With the pelvic rotation present described above (which is what we found in the exam) you can see how she has intermittent low back pain. Combine this with the fact that she runs a daycare and is extremely right-handed and you can see part of the problem.

Leg length discrepancies become clinically important when they resulting in a compensation pattern that no longer works for the patient. Be on the lookout for differences and wear patterns from side to side.

Loss of medial tripod

It is Rewind Friday.
Today, we are reaching back to a brief 2009 lecture I did for the local NSCA chapter on the patterns of kinetic chain compensation that match with loss of medial and lateral foot tripod. (video starts at 49 seconds, for some reason)
https://www.youtube.com/watch?v=yeCBGZkNaeM

Loss of medial tripod

Leg length discrepancies and total joint replacments.

5mm cut off ?  MaybeYou are likely to come across hip and knee arthroplasty clients (total joint replacements). When they take a joint out and replace it with a new one, it can be a true challenge to restore leg lengths to equality side to side. Problems often arise down the road once gait is resumed and rehabilitation is completed. It can take time for the leg length discrepancy (LLD) to begin to create compensatory problems. This article seems to suggest that 5mm is the tipping point where gait changes becoming a problem are founded. Other sources will render different numbers, this article found 5mm. The authors found that both over- and underrestoration of leg length/offset showed similar effects on gait and that Gait analysis was able to assess restoration of biomechanics after hip replacement.  I would chose to use the word “change” over restore, since the gait analysis is merely showing the deployed strategies and compensations, never the problem.  But it is a tool, and gait analysis can be a decent tool to show “change”.*Remember, it is not always a product of true length, it can come from the pelvis posturing and/or from the acetabular orrientation, which can be a postoperative sequella. One cannot over look  acetabular inclination, anteversion and femoral component anteversion/retroversion issues.Just remember, before you start making LLD changes with inserts, cork, orthotics etc be sure that you have restored as best as possible, pelvis-hip-spine mechanics because changes here can reflect as a mere leg length discrepancy. And it goes the other way as well, a LLD can cause those changes above.

* Just use your brain and don’t just lift the heel, give them a full sole lift. Heel lifts for this problem are newbie mistakes. Don’t be a newbie.

– Dr. Shawn Allen

Leg length and offset differences above 5 mm after total hip arthroplasty are associated with altered gait kinematicsTobias Renkawitz, Tim Weber, Silvia Dullien, Michael Woerner, Sebastian Dendorfer, Joachim Grifka,Markus Weber
http://www.gaitposture.com/article/S0966-6362(16)30148-5/abstract?platform=hootsuite