Sounds like a bad idea

Orthotics, can be useful adjunct to care. They can be used to give people biomechanics that they do not have while you were trying to improve them and help to make up for ranges of motion which do not seem attainable.

From the gate cycle we know that after initial contact and loading response the calcaneus should start to evert. The calcaneus will continue to evert until it encounters something (like the lateral heel counter of the shoe). At mid stance it should be fully everted and as the opposite leg comes in to swing, begin to invert. The lateral heel counter assists in the inversion/supination process.

To our knowledge, flip-flops, even if they have an increased arch, do not have a lateral heel counter and therefore will promote further lateral excursion of the calcaneus while the medial longitudinal arch is collapsing  (i.e.: midfoot pronation). Go ahead and place your foot into inversion and see what happens to your heel. It’s slides laterally.

It’s also well-established that flip-flops, through flexion of the distal toes and engagement of the long flexor tendons, inhibits ankle rocker. It is often necessary to engage these muscles to keep the flip-flop from coming off. Lack of ankle rocker usually will inhibit hip extension and that can cause a constellation of problems.

Though engagement of the long flexors of the toes will have a partial anti-pronatory effect, this is not enough to counter the excessive heel  eversion which is happening.

We generally do not think the flip-flops are a great idea and telling someone that it’s “OK” to wear flip-flops as long as it has appropriate arch support, is silly.

Riding the inside edge of the sandal. Mystery hunting with Dr. Allen.

You can see it in the photo above, the heel is a third of the way off the sandal. (there are 2 photos provided today, find the arrow and tab to see both)

You either have it or have seen it. It is frustrating as hell if you have it. Your heel rides on only half of your flip flop or summer sandals. You do not notice it in shoes, only in sandals, typically ones without a back or back strap.  This is because the heel has no controlling factors to keep it confined on the rear of the  sandal sole. But there is a reason this happens to some, but not everyone. It is best you read on, this isn’t as simple as it might seem. 

These clients have restricted ankle rocker (dorsiflexion), restricted hip extension and/or adductor twist (if your reference is the direction the heel is moving towards). I could even make a biomechanical case that a hallux limitus could result in the same scenario. So what happens is that as the heel lifts and adducts it does not rise directly vertically off the sandal, it spins off medially from the “adductor twist” event. This event is largely from a torque effect on the limb from the impaired sagittal mechanics as described above, manifesting  at the moment of premature heel rise resulting in an slightly externally rotating limb (adducting heel). The sandal eventually departs the ground after the heel has risen, but the sandal will rise posturing slightly more laterally ( you can clearly see this on the swing leg foot in the air, the sandal remains laterally postured). Thus, on the very next step, the sandal is not entirely reoriented with its rear foot under the heel, and the event repeats itself. The sandal is slightly more lateral at the rear foot, but to the wearer, we believe it is our heel that is more medial because that is the way it appears on the rear of the sandal or flip flop.  Optical illusion, kind of… . . a resultant biomechanical illusion is more like it.

You will also see this one all over the map during the winter months in teenagers who swear by their Uggs and other similar footwear, as you can see in the 2nd photo above. This is not an Ugg or flip flop problem though, this is often a biomechanical foot challenge that is not met by a supportive heel counter and may be a product of excessive rear foot eversion as well.  This does not translate to a “stable” enough shoe or boot, that is not what this is about. This is about a rearfoot that moves to its biomechanical happy place as a result of poor or unclean limb and foot biomechanics and because the foot wear does not have a firm stable and controlling heel counter.  The heel counter has several functions, it grabs the heel during heel rise so that the shoe goes with the foot, it give the everting rearfoot/heel something to press against, and as we have suggested today, it helps to keep the rearfoot centered over the shoe platform.  To be clear however, the necessary overuse and gripping of the long toe flexors to keep flip flops and backless sandals on our feet during the late stance and swing phases of gait, clearly magnifies these biomechanical aberrations that bring on the “half heel on, half heel off” syndrome.

There you have it. Another solution to a mystery in life that plagues millions of folks. 

Dr. Shawn Allen, mystery hunter, and one of the gait guys.

Looking for the subtle clues will help you. You should have hypotheses and work to prove or disprove them. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

We used to call this a “windswept” presentation. It is not that it is incorrect, but it is so vague.  

Look at these fippy floppers. Look closely at the dark areas, where foot oils and whatnot have played their changes in the leather upper of the flops. The right f.flop displays more lateral heel loading, rear foot inversion if you will. You can even see that there is less big toe pressure on this right side and even some increased lateral forefoot loading. This client appears to be more supinated clearly. You can even see there is more lightness to the arch leather on the right, again, more supination is suggested.

The left f.flop suggests the opposite. More medial heel pressures and more over the medial forefoot and arch. 

Now this clients f.flops tell a story.  So, this client is being windswept to the right we used to say, appearing to pronate more on the left and supinating more on the right.  Why are they doing this? Is the left leg functionally longer and by pronating they reduce the functional length of the leg (yet, increase internal spin of the limb and the host of naughty things that come with that). Is the right leg shorter, and by supinating they are raising the ankle mortise and arch which helps reduce the length differential ?  MAybe a bit of both, finding common ground for a more symmetrical pelvis ?  Who knows. This is where you need your physical exam, but, now you have some hypotheses to prove or disprove. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

Is there some right hip pain from the right frontal pelvis drift creating some aberrant loading on the greater trochanter from ITB tension ? Perhaps a painful right hallux big toe, and they are unloading it to avoid pain? Maybe some knee pain or low back pain ? Who knows? Take your history and start putting the pieces together, it is your job. Just don’t screen them and throw corrective exercises at them, you owe it to them to examine them, take their history, watch them walk, teach them about what you see, and then sit down, spread the puzzle pieces out, look for the straight edges and corner pieces, and begin to build their puzzle. 

Clues, they are everywhere, if you look for them.

Dr. Shawn Allen, one of the gait guys

The Abductor Heel Twist: Look carefully, it is here in this video.

This should be a simple “piece it together” video case study for you all by this point. This young lad came into our office with left insertional achilles pain of two weeks duration after starting some middle distance running.

What do you see here ? It is evident on both the right and the left, but it is a little more obvious on the left and can be seen on the left when he is walking back toward the camera as well.  You should see rearfoot eversion, it is excessive, and a small rearfoot adductor twist. Meaning, the heel pivots medially towards the midline of his body.  Some sources (Michaud) call this an Abductory Twist, but the reference there is typically the forefoot.  Regardless, to help our patients, we sometimes refer to this is “cigarette butt” foot. It is like stepping on a lit cigarette to put it out via twisting/grinding it into the ground. 

So, now that you can see this, what causes it? 

The answer is broad but in this case he had a loss of ankle dorsiflexion range.  The ankle mortise clearly did not have enough of ankle rocker range during midstance so as that limitation was met, the heel raised up prematurely during the moments when the opposite leg is in full swing imparting an external rotation on the stance limb (hence the external foot spin (adducting heel/abducting foot……depending on your visual reference)). There is a bit more to it than that, but that will suffice for now because it is not the central focus of our lesson today.

What can cause this ? As we said, a broad range of things:

  • hallux limitus
  • flexion contracture of the knee (swelling, pain, joint replacement etc)
  • short calf-achilles complex
  • weak tib anterior and extensor toe muscles
  • Foot Baller’s ankle
  • limited/impaired hip extension
  • weak glute (minimizing hip extension range)
  • sway back (lower crossed syndrome-type biomechanics)
  • short quadriceps (similarly impairing hip extension)
  • flip flop excessive use (or any other motor strategy that imparts more flexor compartment dominance (read: calf-achilles, FDL)
  • excessive pronation
  • impaired foot tripod mechanics
  • etc

The point is that anything impairing TIMELY (the key word is timely) forward sagittal gait mechanics can, and very likely will, impair ankle rocker.  Even the wrong shoe choice can do this (ie. someone who suddenly drops from a 12 mm heel ramped shoe into a 0-4mm ramped heel shoe and who thus may not have earned the length of the calf-achilles complex as of yet).

The abductor-adductor twist phenomenon is not a normal visual gait observation. It is a softly seen, but screaming loud, pathologic gait motor pattern that must be recognized.  But, more importantly, the source of the problem must be found, confirmed and resolved.  In this fella’s case, he has some weakness of the tib anterior and extensor toe muscles that has lead to compensatory tightness of the calf complex. There was no impairment of the glutes or hip extension, as this was just 2 weeks old or so, but if left unaddressed much longer the CNS would have likely begun to dump out of hip extension and gluteal function to protect……another compensation pattern. Remember, ankle rocker and hip extension have a close eye on each other during gait.

Clinical pearl for the true gait geeks…… if you see someone with a vertically bouncy forefoot-type gait (you know, those people that bounce up and down the hallway at work or school) you can usually suspect impaired ankle rocker and if you look closely, you will usually see a quick abductor-adductor twist.

Shawn and Ivo

the gait guys

Podcast #13: Caffeine, Nicotine & Lance

here is the link for podcast 13

http://thegaitguys.libsyn.com/webpage

______________________________

1- Malcolm gladwells piece on drug doping (PEDs) in sports:

“Gladwell argued that we should think about cycling the same way we think about auto racing — where teams should be rewarded for using science and bending the rules to their breaking point to succeed.
“When you look at what Lance is alleged to have done. Basically he was better than everyone else at using PEDs,” Gladwell said. “He was the guy who sat down and was rigorous and focused and thoughtful and intelligent and cutting edge in how to use them, and apply them and make himself better. Like, I don’t know, so is that a bad thing?”

Read more: http://www.businessinsider.com/malcolm-gladwell-lance-armstrong-2012-10#ixzz29QBKJpAJ

2- Caffeine: A PED ?
Mens health online magazine, also found in our Sunday edition Oct 14th, 2012 newspaper:

http://news.menshealth.com/chew-gum-before-races/2012/04/12/

Chew on this: Caffeinated gum can improve your athletic performance—if you start chewing it at the right moment, finds a new study from Kent State University.

NICOTINE: http://www.t-nation.com/free_online_article/most_recent/50_hits_of_nicotine
Nicotine has been used in energy drinks in Japan for years.
stimulates the release of acetylcholine, providing a sense of increased energy. Arnold used to do commercials for them.
Nicotine can improve reaction time.
Nicotine can be addictive, much like caffeine. But addiction to nicotine gum, lozenges, or patches is rare, if not unheard of.
MAYO clinic: http://www.mayoclinic.org/medical-edge-newspaper-2009/apr-24b.html

3- DISCLAIMER:We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors !

4: Maryland Guy Running a marathon in flip flops:

“Some of the rules: It can’t be a heal strap. There can’t be any other means to hold the flip flop on your shoe besides just the normal thing between your toes,” Levasseur said. “I don’t know what happens if I get a blowout.”

Read more: http://www.wbaltv.com/news/sports/Man-to-run-Baltimore-marathon-in-flip-flops/-/9379464/16917220/-/remeou/-/index.html#ixzz29QDIyW4d

5-Managing Ankle Sprains:
http://www.running-physio.com/anklesprain/

6- HIIT
 http://www.the15minutes.info/2012/10/12/what-is-hiit-and-what-can-it-do-for-you/

http://sportsmedicine.about.com/od/anatomyandphysiology/a/Deconditioning.htm
Studies have shown that you can maintain your fitness level even if you need to change or cut back on you exercise for several months. In order to do so, you need to exercise at about 70 percent of your VO2 max at least once per week.

7- EMAIL FROM A Blog follower:

middleagedathlete asked you:
I searched the site and didn’t see anything on bow-leggedness (if that’s a word) and it’s impact on gait. I have mild to moderate bow legs and never even knew it until I started running and it was pointed out to me by a PT I was seeing for knee pain. Is there an optimal (or at a minimum least bad) strategy for running with bow legs? I am 6’0” tall and have a gap of about 2” between my knees when standing with my ankles together and my legs straight. I am curious to hear your thoughts.

8- from the newspaper:
from Barefoot Running University.com
Article: Running up Hill

 http://barefootrunninguniversity.com/2012/10/12/uphill-running-technique/
9- Blog post we liked recently: October 5th, Gait Running and Sound. Are you listening to your body ?
 
 
10- Random topic: Wednesday october 10th Peter larson who runs Runblogger did a review of the following article:

Minimalist Running Results in Fewer Injuries?: Survey Suggests that Traditionally Shod Runners are 3.41 Times More Likely to Get Hurt

we have not gotten through the research article yet but we will, and we will try to address out thoughts on it and pete’s in the next 1-2 podcasts.  We want to make sure our thoughts are heard as well.  We bet Pete did a phenomenal job but we like to see things for ourselves, just like pete does. He is a stickler to details like we are, which is why we like alot of his work.  So, stay tuned !

11- Our dvd’s and efile downloads
Are all on payloadz. Link is in the show notes.
Link: http://store.payloadz.com/results/results.asp?m=80204

Podcast #11: Walking and Ozzy

http://thegaitguys.libsyn.com/podcast-11-walking-and-ozzy

Topics and Show Notes:

– Flips Flops, Walking Biomechanics, Minimalism Shoe Formula

Payloadz link for our DVD’s and efile downloads: http://store.payloadz.com/results/results.asp?m=80204

1- NEUROSCIENCE PIECE: Walking Statistics

2- Email from a Facebook Follower:
Hey guys, I was wondering if you had any links to articles about the effects of open back shoes on gait?  All I can seem to find are articles about flip flops, which I know have the similar effect, however some of my collegues don’t agree with that, so I was hoping to help inform them on the effects of the open back shoes/sandals on gait function.
 Thanks for your time,Tyler

http://www.ncbi.nlm.nih.gov/pubmed/22185067
http://www.webmd.com/healthy-beauty/features/worst-shoes-for-your-feet?page=3

3- DISCLAIMER:
We are not your doctors so anything you hear here should not be taken as medical advice. For that you need to visit YOUR doctors and ask them the questions. We have not examined you, we do not know you, we know very little about your medical status. So, do not hold us responsible for taking our advice when we have just told you not to !  Again, we are NOT your doctors !

4-  Updates and Sponsor talk:

A-  more lectures available  on www.onlineCE.com   Go there and look up our lectures

B- In January we will be taking on sponsors for our podcast.  We have had some interest already but we wanted to work out the quality control issues first. Early in means savings.

Contact us if you would like to be a sponsor……If we believe your product has value to this listener community we will give you a professional and personalized company or product plug and advertisment.  From our lips to our listeners ears ! 
We will basically expose your product to our international fan base.
The sponsors will help make our mission possible, defray costs and time to put out this podcast and blog. These things take is away from our practices a little.  Each week we will have 2 center-Stage sponsors . Your sponsorship can run as long as you want.

5-  Mail from an International Follower of our Blog:

Hi Dr’s,
Im here again. Just a quick question about functional LLD’s again. As you said before, most people who have a LLD are functional, but what causes such an apparent problem? What muscles are affected? Also, what exercises do you do to start to fix a functional LLD?

Thanks again for your reply and the attachment. It would be great if you could put it on a future podcast, I am keeping up with them. I’m a little sad as the first thing I check on facebook each day is what you guys have put on. The seminar over here is still a possibility, I was thinking about coming out to you guys first if that’s a possibility to learn direct? Have you thought about trying to do the fitness conventions? Experts like paul chek, Charles Poliquin, Gary Gray amongst others have been very successful and made a lot of money doing this. Gary Gray has done a huge dvd educational series and offers an internship out of his house, which he does once per year and is always full. I personally know 12 people from this country that have done it. Regarding your comment on facebook, I find the case studies more educational than anything else you put on there as it directly relates to my clients, but I have to keep watching them to fully appreciate what your saying. I can imagine most trainers just want quick fixes and new exercises they can give their clients as they are easy to understand. What are your sales of case studies on the onlice CEC compared to your performance downloads?  I can imagine not as many?   Kind Regards,   Luke

6- EMAIL FROM A Blog follower: 
Dear GaitGuys, on the video “Doing Squats, Lunges as well as Walking and Running using the Big Toe Ineffectively.”, I would like your opinion on the participation of the intrinsic (lumbricals) muscles, in stabilizing the proximal phalanx when we activate the FHL. I would consider it important, would be pleased to hear your opinion on it. Thanks, keep up the good work! Regards,  – Claudio

7- Blog READER EMAIL:
 field100 asked you:
Hi I wondered whether you could point me to the best exercises to increase strength and arch in the foot – I am flat footed. Also would you recommend the use of vivobarefoot shoes or the like to increase overall strength in the foot and ankle. thanks

 8- Blog post we liked recently
Minimalism: Is there a formula?
On one of our many forays into cyberspace, we ran across this easy to understand formula, from one of our friends Blaise Dubois. After we contacted him, he allowed us to reprint it here, for your enjoyment. Thank You Blaise!

Today, we propose a new formula so that you can rate your running shoes on a scale from 1 to 100 (100 being “extremely minimalist” -bare feet- and 1 “extremely maximalist”). The range of variation of your final rating will be more or less 5 points regardless of the comfort criteria, which is subjective. The only thing you need to do is to choose a language, then select the tab of your country at the bottom of the formula page, rate your shoes on the 6 criteria set out and there you go! Please note that we have used average values for criteria to which you don’t have the information. The multiple formats of the formula for every country are represented in accordance with their measuring system, currency and the average selling price of a running shoe for each of these countries.

As for health professionals and scientists, you will see that weighting factors have been applied to all criteria as a function of their importance, which is their effect on the body (biomechanics, tissue adaptation, etc.)
You can now rate your running shoes based upon The Running Clinic’s “TRC Rating” methodology!

12 – Email from a Blog Reader

hoblingoblin asked you:
I have a very strange gait problem that has caused me a great deal of problems in my everyday life. I get a painful, loud snap somewhere in my tarsal tunnel (Post tib, FDL, or something) as I try to control my foot descent from heel strike to midstance and also sometimes as I try to plantar flex at toe off. My ankle also feels kinda loose. I’ve seen multiple ankle specialists who don’t really have answers for me. Any thoughts?        

Category
Educational

Training Tip: Ditch the Flip Flops. Our mention in Triathlete magazine.

Training Tip: Ditch the Flip Flops. Our mention in Triathlete magazine.