and what have we been saying about loss of ankle rocker and achilles tendon problems for years now?

Here is a FREE, FULL TEXT article talking all about it

“A more limited ankle Dorsi Flexion ROM as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendinopathy among military recruits taking part in intensive physical training.”

J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study.Rabin A1, Kozol Z, Finestone AS.

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243387/

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.

Screens are valuable. But, only if they screen all the pertinent areas, only if the screener knows what to look for, and only if one realizes they are just a screen and not a platform for corrective exercise prescription. Guys like us and Gray Cook have been saying this for years.

Eliminating the fake out of ample ankle rocker through foot pronation in the squat and similar movements:  How low can you go ? 

This is a simple video with a simple concept. 

* Caveat: To avoid rants and concept trolling, am blurring lines and concepts here today, to convey a principle. Do not get to tied up in specifics, it is the principle I want to attempt to drive home.  What you see in this video is clearly more lunge/knee forward flexion rather than hip hinge movement. However, keep in mind, that this motion does occur at the bottom of many movements, including the squat. 

You can achieve or borrow what “appears” to be more ankle dorsiflexion, a term we also loosely refer to as ankle rocker, through the foot, foot pronation to be precise. Do not mistaken this extra forward tibial progression range as ankle rocker mobility however. When you need that extra few degrees of ankle dorsiflexion deep in your squat, or similar activities, you can get it through your foot. Often the problem is that you do not think that is where it is coming from, you might just think you have great ankle mobility.  Many deep squatters are borrowing those last few degrees of the depth of the squat from the foot. This is not a problem, until it is a problem.  Watch the video above.  Why ? Because when the foot pronates and begins to collapse (hopefully a controlled collapse/pronation) the knee follows. Forcing the knees outward in a squat like some suggest is a bandaid, but I assure you, the problem is still sitting on the table. 

Go do a body weight squat with the toes up like in this video. Toes up raises the arch from wind up of the windlass and increased activity of the toe extensors and some assistance from the tibialis anterior and some other associated “helper” muscles.  When the arch is going up, it cannot go down. So, you raise your toes and do your squat. This will give you a better, cleaner representation of how much mobility in your squat/lunge/etc is from ankle dorsiflexion, knee flexion and  hip flexion. You can cheat and get some from the foot. The foot can be prostituted to magnify the global range, and like I said, this is not a problem until it IS a problem.   We know that uncontrolled and unprotected increases in foot pronation can cause a plethora of problems like plantar tissue strain, tibialis posterior insufficiency and tendonopathies, achilles issues, compression at the dorsum of the cuneiform bones (dorsal foot pain) to name a few. This dialogue however is not the purpose of this blog post today. You can read more about these clinical entities, proper foot tripod skills and windlass mechanics on other blog posts on this site. 

Today, we just wanted to bring this little “honesty” check to your awareness. Has been a staple in my clinic for over a decade, to help me see where limitations are and to show folks how they can cheat so much through the foot. Go ahead, try it yourself, see how much you use your foot to squat further if you have end range mobility issues in the hips, knees or ankles.  The foot is happy to give up the goat, it just doesn’t know the repercussions until they show up. 

So, lift your toes, do a full squat. Go as low as you can with good form with the toes up.  Then, at the bottom of the squat or the bottom of  your clean mobility, suddenly drop your toes and let the arch follow if it must. Here is the moment of truth, at that moment the toes go down, feel what happens to the foot, ankle, tibial spin, knee positioning, pelvis posture changes. Careful, these are subtle. You may find you are using foot pronation more that you should, more than is safe.  Now try this, bottom out your cleanest squat as you regularly would, and at the bottom, raise your toes and try to reposition the foot arch and talus height. In other words, reposture your foot tripod, see how difficult this is if you can do it at all. Perhaps you will find your toe extensors are too weak to even get there.  This is how we cheat and borrow. We should not make it a habit, it should be used when we need it, but it should not be a staple of your squatting diet, it should not be a regular event where you prostitute sound biomechanics.  Unless you wish to pay for it in some way.  What should happen is that you should be able to bring your toes down and not let the arch follow, but that is a skill most have not developed. It is a staple move in your clients’ movement diets.

Does all this mean you should squat with your toes up ? No, but it may serve you well in awareness, evaluation, and looking for potholes and power leaks. At the very least, give it some thought and consideration. You may see some smiles and have some lightbulb moments between you and your athletes and clients. 

Plan on blocking this foot pronation range with an orthotic ? How dare you ! At least try to do it through reteaching this and the tripod skill first. Give your a client a chance to improve rather than a bandaid to cope. 

Dr. Shawn Allen, one of the gait guys

Ankle Dorsiflexion stretching ?

Are we the only ones that did a “face palm” after reading this study? I mean, “duh”. Or are we missing something ?
Pronation gets more dorsiflexion all on its own so how in the world can this be a translatable study ?
Besides, in the pronation posture, length if achieved was perhaps mostly medial gastrocoleus divisions.
And……was the knee bend or straight? Hint: This matters, both those posterior muscles do not cross the knee, only one does.

Conclusion: After a 3-wk gastrocnemius-stretching program, when measuring dorsiflexion with the STJ positioned in supination, the participants who completed a 3-wk gastrocnemius stretching program with the STJ positioned in pronation showed more increased dorsiflexion at the ankle/rear foot than participants who completed the stretching program with the STJ positioned in supination.

Gastrocnemius Stretching Program: More Effective in Increasing Ankle/Rear-Foot Dorsiflexion When Subtalar Joint Positioned in Pronation Than in Supination
2015, 24, 307 – 314

http://journals.humankinetics.com/jsr-current-issue/jsr-volume-24-issue-3-august/gastrocnemius-stretching-program-more-effective-in-increasing-anklerear-foot-dorsiflexion-when-subtalar-joint-positioned-in-pronation-than-in-supination

Pod #93: Ankle Rocker, Sacroiliac Joint symmetry , Landing mechanics

Ankle Rocker, Sacroiliac Joint symmetry , Landing mechanics, Gait Tech, Gray Cook theories, movement and music and so much more !

A. Link to our server:
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Direct Download:  http://thegaitguys.libsyn.com/pod-93-ankle-rocker-sacroiliac-joint-symmetry-landing-mechanics

Sponsor: www.newbalancechicago.com

-Other Gait Guys stuff
B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
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https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
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Show notes:

-Landing mechanics
http://www.ncbi.nlm.nih.gov/pubmed/26117159

-Shock absorbing landing loads
J Athl Train. 2015 Jun 11. [Epub ahead of print]
Weight-Bearing Dorsiflexion Range of Motion and Landing Biomechanics in Individuals With Chronic Ankle Instability. Hoch MC1, Farwell KE1, Gaven SL2, Weinhandl JT1.

-Neuroscience:
Trying to reteach your client’s CNS new sensory-motor patterns so they can move better ?
New connections and pathways are fragile and only through repetition and practice and focused attention can those connections be established enough to become habitual or default behaviors.
Neuroscience for Leadership: Harnessing the Brain Gain Advantage (The Neuroscience of Business). Tara Swart

-Does variability in muscle activity reflect a preferred way of moving or just reflect what they’ve always done?
http://esciencenews.com/articles/2014/03/14/motion.and.muscles.dont.always.work.lockstep.researchers.find.surprising.new.study

-Context-dependent changes in motor control and kinematics during locomotion: modulation and decoupling. Foster and Higham
http://www.ncbi.nlm.nih.gov/pubmed/24621949

-gait technology problems 😕
http://www.buzzfeed.com/stephaniemlee/who-owns-your-steps#.twn1Bg28P

-Dance video discussed, Alvin Ailey Dance Company
https://vimeo.com/36286106

-SI joint anatomy/rehab piece: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3512279/
more rehab strategies here: http://lermagazine.com/article/music-therapy-and-gait-rehab-to-a-different-beat

-a few minutes on Gray Cook quotes. pick a few we can talk about (pic attached)

movement patterns talk: http://www.anatomy-physiotherapy.com/28-systems/musculoskeletal/lower-extremity/knee/1191-altered-movement-patterns-in-individuals-with-acl-rupture

The eccentric aspect of the shuffle walk

Hey guys,
I’m an Osteopath from Australia and am a keen follower of your work. I just had a quick question about your tib ant training via the shuffle gait. I am comfortable with the theory behind it, my only issue is that clinically, tib ants role as an eccentric controller of pronation is significant. Therefore, shouldn’t we develop an exercise which trains it in an eccentric fashion? perhaps there is some controlled pronation in the shuffle gait that I have missed, but i’m interested to hear your thoughts as they are thoughts I respect!
Thanks very much for all your work, it’s great to see practitioners using evidence based practice in a creative and practical way.
Cheers,
D

________

our response:

Hi D. Good question and it is a major point.. If you think about the exercise, you are slowly putting the ball of the foot back on the ground AND maintaining the arch as best as possible. In essence, the arch will drop a bit as your weight is born on the foot, so it will pronate, but you are trying to hold it up, so in a manner of speaking you are controlling the arch descent, so you are eccentrically focusing on the activity. If we were to reshoot the video, this would be part of teh dialogue, because we do have our clients focus on this.  Remember, we are giving this exercise to many folks who have pronation control issues (yes, and ankle rocker issues) so we are kinda hitting the aspect you are questioning.  How this helps a bit.  As they get better, they take bigger steps in the shuffle walk, so that means more acceleration of the prontation, so they will have to try to maintain the arch under greater loads…….hence, more eccentric focus.  That is the way we see it anyways.  

Achilles Tendonitis

The motion needs to occur somewhere…Make sure you look at the whole picture

Since the knee was bent, perhaps we should be looking at the soleus? And the talo crural articulation?

“A more limited ankle Dorsi Flexion Range Of Motion as measured in Non Weight Bearing with the knee bent increases the risk of developing Achilles Tendonitis among military recruits taking part in intensive physical training.”

J Foot Ankle Res. 2014 Nov 18;7(1):48. doi: 10.1186/s13047-014-0048-3. eCollection 2014.
Limited ankle dorsiflexion increases the risk for mid-portion Achilles tendinopathy in infantry recruits: a prospective cohort study.
Rabin A1, Kozol Z1, Finestone AS2.

Tom Purvis hits some strong points in this video about squatting, hip hinges, ankle dorsiflexion, and movement as a whole.  * Keep in mind, this is all sagittal plane stuff….. it gets far more complicated when there are lateral (frontal) plane or rotational (axial) considerations ….. these are the “knees out” dialogues and debates you have read over and over on the web in the last year.

Dr. Shawn Allen

addendum:

Food for thought after posting today’s Tom Purvis squat video.

Could this study below translate into the statement/question: 

“attempting to achieve sufficient dorsiflexion through the combined ‘foot pronation-ankle dorsiflexion’ mechanism, as opposed to just dorsiflexion from the ankle mortise joint alone, may change the dynamics of the entire limb…. in this case, hip flexion range observation. Is this because when dorsiflexion is cheated via foot pronation, instead of just ankle dorsiflexion, there is more internal tibia/femoral spin than would normally occur from just sagittal ankle hinging which can in turn impair terminal hip flexion range via impingement type action ? I think so. It would be cool to see what would have happened in the study had the pronating clients been shown my foot tripod restoration exercise (it’s on youtube).   -Dr. Allen

here is some new research on this point, for what it is worth.  It keeps the mind thinking though.

J Phys Ther Sci.  2015 Jan;27(1):285-7. doi: 10.1589/jpts.27.285. Epub 2015 Jan 9.The kinematics of the lower leg in the sagittal plane during downward squatting in persons with pronated feet.  Lee,Koh da,  Kim 

Abstract

[Purpose] This study aimed to examine changes in lower extremity kinematics in the sagittal plane during downward squatting by subjects with pronated feet. [Subjects and Methods] This study selected 10 subjects each with normal and pronated feet using a navicular drop test. The subjects performed downward squatting, in which the knee joints flex 90° in a standing position. We recorded the angles of the hip, knee, and ankle joint in the sagittal plane through motion analysis. For the analysis, the squatting phase was divided into phase 1 (initial squat), phase 2 (middle squat), and phase 3 (terminal squat) according to the timing of downward squatting. [Results] In the pronated foot group comparison with the normal group, thehip joint flexion angle decreased significantly in phases 2 and 3. The dorsiflexion angle of the ankle joint increased significantly in phase 3. The flexion angle of the knee joint did not differ between groups in any of the phases. [Conclusion] The pronated foot group utilized a different squat movement strategy from that of the normal foot group in the sagittal plane.

Compressing the Distal Tib-Fib joint. Really ?!
If you do not know your biomechanics, this could be a road to problems for your client. 

Many who viewed this video will not know the “Caveat emptor” we will expand upon below. 

Here is the meat of today’s blog post:
The distal tibia-fibular syndesmosis is supposed to separate during ankle dorsiflexion to accommodate for the wider ankle mortise anteriorly, compressing the two bones could nullify this range.

There are new ideas on the web every day; through new ideas come new innovations. These bands (some call them Voodoo bands) are all the rage right now, and they may have value depending on their use (and the wisdom of the user), but from what we can tell even the innovators are at a bit of a loss as to what the heck is truly happening with their use. All we have right now is theories, but understandably things have to start somewhere. We propose some logical thoughts on this video implementation here today.  
Some people are using the bands over larger muscle masses, perhaps using the compression and shear between tissue layers to act as a kind of “flossing” or “active release” to the muscle and myofascia. The goal seems mostly to gain more joint range and thus greater function through that joint. Some think the vascular/ischemic challenge is creating partial effects. Others appear to be using the band to change joint compression to change stability to change mobility. We suspect others are using them to manage joint shear, we hope they realize they are impacting that component. One must keep in mind that a joint that is cylindrically compressed (such as in the video) and then subsequently loaded may still undergo motion and shear at the opposing joint surfaces. The question is, are you getting what you want?  The even bigger question is have you the earned stability on that new mobility if you are about to go add activity on this new range? New “borrowed” range, meaning mobility that has been acquired but not been earned via the muscles that were supposed to achieve and maintain it, may be a recipe for injury risk. One must also not forget that with a primary motion there is an accessory motion (ie. roll and glide are in opposite directions for concave/convex joint relationships). This is a concept of joint centration, and when there is excessive uncontrolled shear there cannot be adequate centration. Too much axial compression may limit primary motion while minimizing shear but could impact accessory motion, a mulit-edged sword. There is really no good and certain way to do all this except intrinsically via the muscles surrounding the cylinder. Any extrinsic attempts must be met with the realization and understanding of the true mechanics of compression, shear, primary motion and accessory motions. So just keep in mind that things like impingement, shear and peripheral joint loading (as opposed to centrated loading) are risk factors when these components are not well understood.

That all said, we bring these concerns to light today in regards to the above mobilization video.  Many who viewed this video will not know the “Caveat emptor” we have eluded to above and will expand upon below. That caveat should have (in our opinion) been mentioned. We are not trying to pick on folks, trolling or being pricks, we know everyone is just trying to help contribute to the mass knowledge base here on the web but one has to understand biomechanics in order to deliver a clean honest method without tipping the risk reward scale. We think our caveat is very much worth mentioning so that the knowledge is available to everyone. We bet the doctor in the video knows all about what we are writing here today, but many others will not, and so by debating and critiquing we all raise the bar, for the good of all mankind. In turn, we expect the same critique should happen to our material, after all, the collective mind is more powerful than the individual mind.

Here is the meat of today’s blog post:

The distal tibia-fibular syndesmosis is supposed to separate during ankle dorsiflexion to accommodate for the wider ankle mortise anteriorly. More gently stated, as dorsiflexion progresses at the ankle mortise complex, the distal tibia-fibula must be able to change to accept the wider anterior mortise engagement. This is normal ankle biomechanics, for everyone ! So, why would you want to compress the distal tib-fib and attempt at arresting or limiting the normal spreading process during ankle dorsiflexion? What about the ligamentous structures that depend upon clean terminal dorsiflexion and congruent tib-fib-mortise orchestration ? Cylindrical compression could impair or limit terminal dorsiflexion range.  Wasn’t this the purpose of the mobilization in the first place?  This mobilization is just not something that we will be recommending you start tossing out in your rehab or training room unless you can justify on a case by case basis a reason for possibly working against normal clean biomechanics, unless of course you are sure to stay within reasonable compression limits.  If you compress these bones too much, you are potentially creating mid or end range joint impingement.  
We are sure the argue point will be that the band is not applied tightly enough to create sufficient compression to limit this normal range. This may be true. But, 

  • “Think of how stupid the average person is, and realize half of them are stupider than that.” -George Carlin

All joking aside now, but for the “average Joe” who might think that more is better, our caveat is worthy in our opinion especially when you see the volume of band used in some other videos.  

SIDEBAR: Dear Gait Guys brethren, as members of those on the web who are supposed to know better, we all have a responsibility to act and portray truth and accuracy to those that are not in our lines of profession and knowledge. There are videos on line demonstrating a cavalier approach to using these bands (we are not at all referring to today’s video), we beg you to think about who is seeing these videos, possibly herds of runners and athletes looking for quick answers to their problems.  Know that you may be the first line of intervention to help direct these folks to an informed way to implement self-treatment.

Back to the video for one final point.

We see that after some cylinder compression is rendered by the band, as terminal ankle dorsiflexion is mobilized we see end range mobilizing of internal and external rotation. Remember, if the compression is too much (and again, it may not be in this case if band tension application is reasonable), as dorsiflexion is attempted we will have more closed pack-type joint compression binding mid-range, and this may mean risk to articular cartilage. Just something to keep in mind. Listen to your client feedback when they do this or you instruct them, pain is obviously not a welcome outcome when you are performing potentially impinging therapies.

Here on The Gait Guys we previously shared our mnemonic , “anterior strength achieves posterior length to drive ankle dorsiflexion range”. That does not in any way mean that mobilizations are not worthy efforts at any time during a treatment.  As a clinician, sometimes you have to address the tissue length of the posterior compartment tissues, but if that is not the primary cause of loss of dorsiflexion you are commissioned to look elsewhere.  Also, remember that ankle dorsiflexion can be disguised through foot pronation and this in itself can enable pathology. This is perhaps one of the biggest omissions in ankle dorsiflexion mobilization videos across the board.

Make no mistake, you can mobilize all you want but at the end of the day you must improve skill, endurance and strength (S.E.S.) as well as functional stability and capacity on these new patterns of mobility if you are to do your client justice. Failure to do these things will result in loss of the gained mobility and risk for injury. Almost anyone can gain more joint motion, we have all been doing this various ways for decades. Can you earn enough capacity to keep the new mobility on a clean and correct motor pattern without corruption is the bigger question. Remember, just because you force a joint range, as opposed to earning it, doesn’t mean it is wise. Try this logic on any adhesive capsulitis shoulder patient, you will surely receive a five finger death punch in return. 

There is much in the way of innovation and free thinking out there today and everyday the internet opens our collective eyes and minds to new ideas and possibilities. We all must keep in mind that many of these new things are in their infancy, some will survive with validation and some will wither away without it. It is up to the practitioner to take their client’s case to heart, do the best they can with the knowledge they have, accept when their scope of knowledge and practice has been met, and always first “do no harm”.  Most things can be fixed, or at the very least improved upon but the tough cases often require deep wells of knowledge and experience. Sometimes we have to tread into uncharged waters, we just have to make sure we do no harm and try to work around a framework of science based knowledge.

We talk about this concept and video in greater depth in Podcast 90. Feel free to listen in,

here is that link

Dr, Shawn Allen

… . just two guys trying to provide logic to things we do not have complete answers for at this time.

 

For your reading pleasure, here is another fella who has gone through some  similar internal dialogue trying to find answers regarding this Voodoo band stuff. We respect his thoughts and dialogue, very much so.  He covers many thoughts and theories, it is worth your time if you are using this type of therapy. 

http://valeohealthclinic.com/voodoo-floss-really-voodoo/