Medial or lateral foot placement ?

Foot placement matters. We have repeatedly beaten this topic in our dialogues on “the cross over gait” for years now.
Lack of Stability often, if perhaps not always, limits mobility.
Mediolateral stability can be efficiently controlled through appropriate foot placement. This study hypothesized that humans control mediolateral foot placement through swing leg muscle activity, basing this control on the mechanical state of the contralateral stance leg. Thus, obviously, if thestance phase limb has sensory-motor deficiencies, which might be easily translated into “balance” or control issues in single leg stance evaluation, this will impact the swing leg and thus subsequent foot placement.
In this study, “During Unperturbed walking, greater swing-phase gluteus medius (GM) activity was associated with more lateral foot placement.”
“The Perturbed walking results indicated a causal relationship between stance leg mechanics and swing-phase GM activity. Perturbations that reduced the mediolateral CoM displacement from the stance foot caused reductions in swing-phase GM activity and more medial foot placement." 

The swing leg is taking cues from the stance leg mechanics. If stance phase has challenges, the swing limb will be forced to accommodate and adapt, and that means altered foot placement.  

Once again, remember, (broken record moment)……. "what you see is not your client’s problem, it is their strategy to get around/compensate for the problem”. Don’t you dare correct your client’s foot placement without examining why they are doing what they are doing. Get to the root of the problem you are “seeing”.

-Dr. Shawn Allen

J Neurophysiol. 2014 Jul 15;112(2):374-83. doi: 10.1152/jn.00138.2014. Epub 2014 Apr 30.A neuromechanical strategy for mediolateral foot placement in walking humans.Rankin BL1, Buffo SK1, Dean JC2.

Foot Progression Angle Exaggeration: External Tibial Torsion

Take a look at the tibial tuberosity and then where you think the 2nd metatarsal head would be. What do you see? The 2nd metatarsal is lateral to the tibial tuberosity. You are looking at external tibial torsion. 

Lets see how this external tibail torsion behaves during a knee bending. Observe the medial drift of the knee during weight bearing knee flexion. Many folks would say that the problem here is the increased foot prontation, but that is not where the problem lies, that is where many of the forces are funneling though. The client is pronating more because the external tibial torsion that is creating this appearance has put the knee inside the foot tripods region of stability.

In external tibial torsion there is an external torsion or a “twist” along the length of the tibia (diaphysis or long section). This occurs in this example to the degree that the ankle joint (mortise joint) can no longer cooperate with sagittal knee joint.  When taking a client with external tibial torsion and pre-postioning their foot in a relatively acceptable/normal foot progression angle there is a conflict at the knee, meaning that the knee cannot hinge forward in its usual sagittal plane. In this case with the foot progression angle smaller than what this client would posture the foot, the knee the knee will be forced to drift medially.

Are you looking for torsions of the lower limb in your clients ?

Are you forcing them into foot postures that look better to  you but that which are conflicting to your clients given body mechanics ?  Would you correct this client’s foot turn out (increased progression angle) ? IF you did you would likely cause them knee pain in time.  Would you put them into a stability shoe to try and control the pronation ? Again, you are likely to draw their knee outside the saggital knee hinge that is presently pain free. There is more to shoe fit that just looking at the foot. First do no harm is our mantra ! 

Remember, telling someone to turn their foot in or out because it doesn’t appear correct to your eyes can significantly impair either local or global joints , and often both. Torsions can occur in the talus, the tibia and the femur.

Furthermore, torsions can have an impact on foot posturing at foot strike and affect the limbs loading response, from foot to core and even arm swing can be altered.  Letting your foot fall naturally beneath your body does not mean that you have the clean anatomy to do so without a short term or long term cost. 

This is some of the toughest stuff you will deal with clinically. The fence is narrow, if you do to little correction you fall off the fence into the wrong yard and create problems. If you do to much correction you get the same result. These torsional issues are a delicate balancing act many times. You first have to know what you have, then you have to know where the fix is, and then how much is safe.  Tricky stuff. This is exactly why in some folks a stability shoe can be magic or tragic and in others dropping into zero drop minimalism can be magic or tragic.  

Want more on torsion and versions ?  Type the words into the search box on our blog. We have plenty of good info for you.

Shawn and Ivo, The Gait Guys

Video case: The King’s Preference: Short and Sweet. A quick and easy case demonstrating the patellar tracking struggles with external tibial torsion.

Our favorite functional evaluation piece of equipment as well as our favorite piece of therapy equipment is the Total Gym.  Here we clearly demonstrate, to us and the client, in partial weight bearing load, the effects of external tibial torsion.  

Remember, the knee is sort of the King of all joints when it comes to the lower extremity.  The knee is a sagittal plane hinge, and so all it wants to do is hinge forward, freely without binding from deficits at the hip or knee. But we cannot ignore the simple fact that pre-pubescent kids the long bone derotation process is still undergoing, and in adults the process may have been corrupted or insufficient.  

In this case it should be obvious that the knee is sagittal and free to hinge when the foot is at a large foot progression angle.  This allows the knee to hinge cleanly. But when the foot is corrected to the sagittal plane, as you see in the second half of the video, the knee tracks inward and this can cause patellofemoral pain syndromes, swelling, challenges to the menisci (and possible eventual tears) and challenges to the ACL and other accessory restraints.  Additionally, this medial drift is a longer and more difficult challenge to the eccentric phase external rotators such as the gluteus maximius not to mention many of the other muscles and their optimal function.  

So, the next time you see a large foot progression angle in a client or in their walk (duck footed if you will) try to resist the natural urge to tell them to corrrect the foot angle. They are likely doing it to keep the King happy.  And furthermore, be careful on your coaching recommendations during squats, olympic lifts, lunges and running.  Just because you do not like the way the foot looks doesn’t mean you should antagonize the King of joints.  

External tibial torsion, its not something you want to see, but when you do see it, you have to know its degree, its effects at the knee, hip and foot as well as how it might impact hip extension, pelvic neutrality, foot strike, foot type, toe off and so many other aspects.

Whoever said gait analysis was easy was a liar. And if all they use is a video camera and fancy analysis software they have show up with only part of the team. And if they said they were an expert  in gait only a few years into practice, you had better also look for a jester’s hat somewhere hiding in the corner. After all, the King would want to know !

Shawn and Ivo, your court jesters for the last 3+ years.  Maybe we will get a promotion from the King someday soon !

Photo: Where is your knee joint hinge point ?  Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing.  He has the cleanest lines of the bunch. How is that for cruel irony ?  Sometimes it ain’t what you got, it is what you do with what you got.  Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations.  Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.  

Today’s Lesson:  Get in line, and get in line early. (just kidding of course)

The Gait Guys.  Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination.  We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.  ”Seeing may be believing” but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : 

Gait Guys online /download store:

*Photo courtesy of BIG EAST Conference

OK, quiz time. The Powers of Observation.

Perhaps you have been following us for a while, perhaps you are just finding us for the 1st time. Here is some back ground on this footage. Let’s test you observation skills.

Watch this gait clip a few times and come back here to read on.

This triathlete presented with low chronic low back pain of about 1 years duration. The   pain gets worse as the day goes on; it is best in the early am. Running and biking do not alter its intensity or character and swimming makes it worse. Rest and analgesics provide only temporary relief.

Physical exam findings include limited internal rotation of both hips (zero); a left anatomical short leg (tibial and femoral, 5mm total); diminished proprioception with 1 leg standing (<30 seconds). MRI reveals fatty infiltration of the lumbar spinal paraspinals and fibrotic changes within the musculature; degenerative changes in the L4 and L5 lumbar facet joints, degeneration of the L5-S1, L3-L4 and L2-L3 lumbar discs.

Now watch his gait again and come back here for more.

Did you see the following?

  • torso lean to left during stance phase on L?
  • increased progression angle of both feet?
  • decreased arm swing on L?
  • circumduction of right leg?
  • clenched fist on L?(esp when standing on either leg)
  • body lean to R during L leg standing?

How did you do? If you didn’t see all those things, then you are missing pieces of the puzzle. Remember, often what you see is not what is wrong, but the compensation

The powers of observation of the subtle make the difference between good results and great ones.

Try some of these tips.

  • break down the gait into smaller parts by watching one body part at a time: right leg, left leg, right arm, left arm, etc
  • watch for shifts in body weight in the coronal plane (laterally) and saggital plane (forward/backward) as weight transfers from one leg to another
  • watch for torso rotation (watch his shoulders. Did you notice he brings his torso more forward on the left than right when walking toward us?)

We are (and have been) here to help you be a better observer and a better clinician, coach, athlete, sales person, etc. If you haven’t already, join us here for some insightful posts each week; for our weekly (almost) PODcast on iTunes; follow us on Twitteror on Facebook: The Gait Guys

Running Technique Video with Complications:

Here we have a good running video with a nice teaching component to it.

We found this on the web on some random site.  Nice to see others are helping to spread our good word.  Here is what the website said, and below that are our comments.

FROM: 30, 2011 11:18 AM

You should send your video to The Gait Guys:

Actually, they did a 3 part video on crossover gait recently. I looks like you’ve got a bit of crossover going on (hips are swinging side to side). Most people do some crossover. Another thing The Gait Guys always say is that what you can see in the video is usually not the problem (the right foot turning out), it is usually the compensation you are seeing…the problem is somewhere else.

Thank you Nate. I will see what The Gait Guys say.

*What The Gait Guys have to say:

The most obvious thing we see is that the right foot is spun out (this is more evident on the video clips running away from the camera). This is referred to as the “foot progression angle” and here it is increased.  Depending on the source you reference, the upper limit of normal can be 25degrees. But, it is more important to do a case by case comparison.  Without the advantages of a hands on exam this case seems to indicate that the right foot progression is increased beyond the left, assuming the left is normal.  (yes, it is possible that the right is this chaps normal and that the left foot progression angle is decreased. But the usual presentation is that of increased, usually.)

What we do like is the great form his is displaying. Great natural barefoot technique. Pure barefoot technique does not allow heel strike to occur. Do not believe us? Go try it yourself, just don’t email or call us afterwards and complain !  His strike is midfoot, cadence is high, and body posture is clean and upright.  There is a minor cross over gait here. The readers were right.  Good eyes, good call !

The increased right foot progression angle will often accelerate pronation and increase its degree. This can also increase and accelerate the rate of internal spin of the tibia and limb, all the way into the hip and pelvis.  This can challenge the eccentric capabilities of the gluteals and other external hip rotator muscles and in time this can represent itself and mechanical hip joint pain or low back/Sacroiliac joint symptoms.  The increased pronation amount and rate can challenge other structures at the foot, namely the posterior tibial tendon, abductor hallucis muscle and the first ray stabilizers such as long and short hallux muscles (EHL, EHB, FHL, FHB) and thus loss of longitudinal arch capabilities and stabilizers. 

We also see, if you look closely particularly on the running away from camera views, that the left arm seems to cross the body more than the right. We always look for this in the opposite upper limb to try and help confirm or suggest which of the lower limbs is the problem.  Since the left upper arm is crossing the body, it is neurologically matched up with the right limb during swing and stance.  It can act like a ballast. This fella would most likely have some pelvic asymmetry because of this cross body deficit. 

PS: the issue can be reversed.  We have had plenty of frozen shoulder clients present with biomechanical deficits in the opposite lower limb so beware of the total body complexities and compensations.  We have also have had runners who always carry a water bottle in the same hand showing changes in the opposite lower limb. Our treatment success with one runner did not occur until we convinced this ultra trail runner to go with a camel back water supply.

Nice little case. Wish we had more information on the runner and what is bothering him.

Maybe in time we will hear from him and update him.

To get the most out of this case you should watch the 3 part cross over gait series on our youtube channel. Just type in thegaitguys and it will be right there.  You should also goto the search box in our tumblr blog and type in “arm swing” and read some of our writings on this topic.  We think it is fascinating stuff.

Shawn and Ivo……….. world wide web gait geeks……. and victims of radical hackers everywhere…… ok, just in Algeria.

External Tibial Torsion as expressed during gait.

So, last week we watched this young lad doing some static ankle and knee bends, essentially some mini squats.  Here was what we found (LINK). It is IMPERATIVE that you watch this LINK first before watching today’s video above.

Now that you have watched that link here is what you should be seeing today.

You should see that the left foot is extremely turned out. We talked about why in the linked post from last week. It is because of the degree of external tibial torsion.  When it is present the knee rides inside the foot progression line (the knee bends into the forward / sagittal plane when the ankle bends into its more lateral /coronal / frontal plane (they all mean the same thing) ie. when the foot points outwards.

Remember, the knee has only one choice of motion, to hinge forward and backward. When the knee is asked to hinge in any other direction once the foot is locked to the ground there is torque placed upon the knee joint and thus shear forces.  Menisci do not like shear forces, nor does articular joint cartilage.

So, once again we see the rule of “you cannot beat the brain” playing out. The brain took the joint with the least amount of tolerance, the knee, and gave it the easy job.  The foot was asked to entertain another plane of motion as evidenced here in this video with significant increased foot progression angle. 

When the foot progression angle is increased but the knee still must follow the forward body progression (instead of following the foot direction) the motion through the foot will be directly through the medial longitudinal foot arch.  And as seen here, over time this arch will fail and collapse. 

Essentially this lad is hinging the ankle sagittally / forward through the subtalar and midtarsal joints, instead of through the ankle mortise joint where ankle hinging normally should occur.

This is a recipe for disaster. As you can see here.  You MUST also know and see here that there is an obvious limp down onto that left limb. It appears the left limb is shorter. And with this degree of external tibial torsion and the excessive degree of foot pronation, the limb will be shorter. You need to know that internal limb spin and pronation both functionally shorten the limb length.  This fella amongst other functional things is going to need a full length sole lift. We will start with 3mm rubber infused cork to do so. And let him accomodate to that to start.

We will attempt to correct as much foot tripod (anti-pronation) control as possible to help reduce leg shortness as well as to help reduce long term damage to the foot from this excessive pronation. We will also strengthen the left gluteus medius (it was very weak) to help him engage the frontal/lateral/coronal plane better. This may bring that foot in a little. But remember, the foot cannot come in so far that it drives the knee medially. Remember who is ruling the roost here !…… the knee.  It only has one free range, the hip and foot have 3 ! 

Shawn and Ivo