Remember this kiddo?

We have been following the natural development of this little guy for some time now. For a review, please see here (1 year ago) and here (2 years ago) for our previous posts on him.

In the top 2 shots, the legs are neutral. The 3rd and 4th shots are full internal rotation of the left and right hips respectively. The last 2 shots are full external rotation of the hips.

Well, what do you think now?

We remember that this child has external tibial torsion and pes planus. As seen in the supine photo, when the knees face forward, the feet have an increased progression angle (they turn out). We are born with some degree / or little to none, tibial torsion and the in-toeing of infants is due to the angle of the talar neck (30 degrees) and femoral anteversion (the angle of the neck of the femur and the distal end is 35 degrees).  The lower limbs rotate outward at a rate of approximately 1.5 degrees per year to reach a final angle of 22 degrees….. that is of course if the normal de rotation that a child’s lower limbs go through occurs timely and completely.

He still has a pronounced valgus angle at the the knees (need a review on Q angles? click here). We remember that the Q angle is negative at birth (ie genu varum) progresses to a maximal angulation of 10-15 degrees at about 3.5 years, then settles down to 5-7 degrees by the time they have stopped growing. He is almost 4 and it ihas lessend since the last check to 15 degrees.

His internal rotation of the hips should be about 40 degrees, which it appears to be. External rotation should match; his is a little more limited than internal rotation, L > R. Remember that the femoral neck angle will be reducing at the rate of about 1.5 degrees per year from 35 degrees to about 12 in the adult (ie, they are becoming less anteverted).

At the same time, the tibia is externally rotating (normal tibial version) from 0 to about 22 degrees. He has fairly normal external tibial version on the right and still has some persistent internal tibial version on the left. Picture the hips rotating in and the lower leg rotating out. In this little fellow, his tibia is outpacing the hips. Nothing to worry about, but we do need to keep and eye on it.

What do we tell his folks?

  • He is developing normally and has improved significantly since his original presentation to the office
  • Having the child walk barefoot has been a good thing and has provided some intrinsic strength to the feet
  • He needs to continue to walk barefoot and when not, wear shoes with little torsional rigidity, to encourage additional intrinsic strength to the feet
  • He should limit “W” sitting, as this will tend to increase the genu valgus present
  • We gave him 1 leg balancing “games” and encouraged agility activities, like balance beam, hopping, skipping and jumping on each leg individually

We are the Gait Guys, promoting gait and foot literacy, each and every post.

Usain… Again!!! How good are your powers of observation?

Take a look at this video again. Yes, we have shown it many times before. It is from a 2001 race in Monaco.

These are all incredible athletes. What can we note about the fastest of the fast?

  • Most of them have excellent hip extension (ok, the gent immediately to Usain’s right does not appear to be optimal)
  • the fastest of the pack have a upright head posture with the neck neutral or in slight extension (gents in lanes 1, 3 and 6; notice the head forward posture of the others)
  • minimal heel rebound (see our last post on this here)
  • minimal torso motion (note the increased torso motion  with arm swing of the gents in lanes 1, 3, 4 and 5)
  • symmetrical hip flexion, with the thigh parallel or nearly parallel to the ground in float phase
  • what else?

Watch it a few more times. It took us a while too…

Really, go watch it again…

Did you see it?

Watch the vertical oscillation of the runners. At this level (or any level for that matter), outside of improving biomechanics and neuromechanics, there are really only a few things you can do to run faster. One is to have a faster cadence and another is to have a longer stride length. You can control both, but if not done concurrently, one gets better at the expense of the other.

If your cadence is slower and you try and increase stride length, you increase your vertical oscillation (ie: how much you bounce up and down). Note the handrail at the far side of the track. It makes a convenient marker for vertical oscillation. Watch this bar and watch the video again. Usain and the gent in lane 6 (Nesta Carter) have little vertical oscillation compared to the rest of the pack. Note also the close finish. difficult to say if Usain’s knee or Carters foot crossed 1st. Usiain’s time was 9.88 and Nesta’s 9.90.

Decreased cadence = Increased vertical oscillation = Less horizontal motion = Slower speeds

How about watching this video a few more times and telling us what else is up?

The Gait Guys. We are trying to help you improve your powers of observation while stretching your mind. Are we succeeding? We hope so!

Ivo and Shawn

Want more stability when trail running? Try this…

While running the other morning through about 6-8” of fresh snow (yes, it is snowing here already at 9000 feet), something occurred to me as I almost fell several times due to the undulating surface beneath my feet and the terrain to match under that.

“I need to do something to improve my proprioception, or I am going to fall (again)” I thought (yes, we both think about this stuff while running or exercising! No, I was not listening to music on this run, though cranking up some AC/DC was tempting..). If I were to increase my surface area on the snow, and make myself less top heavy, I would be more stable. How could I accomplish that?

Here is what I did, and it worked great!

First, I spread my toes. No, I wasn’t barefoot, but in my Altra Lone Peak 1.5’s; why not maximize the real estate available to my feet in these roomy shoes?

Next, I widened my stance (or base of gait). My massive 145# spread over a larger surface area would be more stable and provide stability from my weight distributed over a larger surface area.

Third, I raised my arms out from my sides (no I didn’t try to fly) to provide more input from my upper extremities to my proprioceptive system (more input from peripheral joint and muscle mechanoreceptors = more input to cerebellum = better balance)

Lastly, I slowed down from my blistering 10 min mile pace. Though this did not improve my surface area, it did give my aging nervous system more time to react.

It occurred to me that these actions were all “primitive” reactions of the nervous system when learning to walk. We did a post on that when my youngest son was learning to walk a few years ago.

Want to have better balance?

  • Spread your toes
  • Widen your stance
  • Raise your arms
  • Slow down

Notice I didn’t say this would make you faster. Who is more likely to fall on a corner when being chased by a predator; the tortoise or the hare?

 

A little practical neurology for you this morning brought to you by the geeks of gait. Ivo and Shawn.

 

The One Cheek Sneak and Your Gait.

Yup. You know what we are talking about.  Out gassing. Passing gas. Trouser coughing. Flatulating (is that a word?) Tooting. Farting.. Call it what you like. Exemplified by Shinta Cho’s classic “The Gas We Pass”. The question is, why is it relevant to gait?

If you have followed us for any length of time, you know how important we think the glutes are.  We have many posts and blog articles on their importance and exercises to strengthen them.  The problem is, when most people do them, they THINK they are contracting their glutes (and some are) BUT they are ALSO contracting their (external anal) sphincter (for you neuro nerds,  the internal sphincter is not under voluntary control). This results in gas retention, which may cause a stomach ache, or in rare instances, distention of the bowel. Chances are, when  you relax, it will come out then (yes, you fart in your sleep, as your bedfellow for an honest answer !).

Try this. Sit down and and contract your glutes and your external sphincter. Now try and contract your external sphincter, ONLY. Contracting the external sphincter also engages the pelvic floor. Not necessarily something you need to do (unless you are treating an incontinence issue but then again that more recently under hot debate, here read our blog post here for some truths and myths on this topic) when running. OK, now just the glutes. You can palpate them (glutes only please) to make sure they are contracting. You are now experiencing isolation of the individual muscles. You should be able to access them individually, as well as together. For an added challenge in your powers of isolation, you can then try this exercise after consuming beans (as you flog your gut with their poisonous lectins) , to test your true abilities.

There are other related issues here to consider, one is the Kegal exercise. As we mentioned in another blog post (link here):

“A Kegel attempts to strengthen the pelvic floor, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF (pelvic floor) gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to pelvic floor disorder (PFD). Zero lumbar curvature (missing the little curve at the small of the back) is the most [we would chose to say a nicely speculative] telling sign that the pelvic floor is beginning to weaken. An easier way to say this is: Weak glutes + too many Kegels = PFD.”-Nicole Crawford (1)

Many exercises are designed to help train your nervous system and create a new motor pattern, in addition to strengthening and or creating endurance in the targeted muscles.  Your external sphincter probably has plenty of strength and endurance.

The Gait Guys.  Bringing you the relevance in the seemingly irrelevant. All Gait; All the time…

 1. Here is Crawford’s article link.

http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-women-and-men

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved. We have Lee and know how to use him

Forefoot Valgus or Plantarflexed 1st ray?

Hmmm. That IS the question, isn’t it?

We remember that Forefoot valgus is a condition where the forefoot is everted with respect to the rearfoot.

With a plantar flexed 1st ray, the forefoot is actually in varus (ie inverted) and the the 1st ray is dropped (thus, plantar flexed).

If you look at the picture, you will see the entire forefoot is everted, thus we are  looking at a true forefoot valgus. The question here, is “does the 1st ray move into dorsiflexion”? This would be the difference between a flexible (plastic or rigid deformity and is a function of the rigidity of the subtalar and midtarsal joints as well as the flexibility of the 1st ray.

The literature states that forefoot valgus is the most commonly seen frontal plane deformity of the foot (McPoil 1988, Burns, 1977). We have not found this in clinical practice, but rather forefoot varus. This may be due to most folks seeing us have an issue, and more issues seem to be caused by rigid varus deformities, since they cause the knee to collapse inward.

It’s origin can be multifactorial, ranging from a congenital malformation of the calcaneocuboid joint (more on that joint here) with the absence of a calcanean process, which allows a greater degree of eversion (Bojsen-Moller 1979); over rotation of the talar neck (Sglaraato 1971), or association with a pes cavus foot in compensation to an inverted rearfoot and inflexibilty of the subtalar joint (Lutter 1981). Neuromuscular diseases are believed to cause as many as 95% of these deformities (Dwyer 1975).

The question is, what do we do with it?

  • we insure that the foots mechanics are the best they can be through manipulation and mobilization
  • make sure the joints proximal and distal to the foot are functioning properly
  • muscle test and strengthen weak muscles (think about the poor peroneals in these folks!)
  • make sure they are NOT in a motion control shoe; more flexible is better
  • Make sure their shoe has adequate room in the toe box
  • sometimes, we post the insole of the shoe (or orthotic) in valgus, especially with rigid deformities

A little lost? Take our National Shoe Fit Program, available for instant download 24/7/365 by clicking here.

The Gait Guys. Often a valgus slant on a varus reality. Still bald. Still good looking. Improving your gait competency with each post.

This is a follow up to our last post on forefoot varus, available here.

Remember, ou are looking at a person with an uncompensated, rigid fore foot varus. This individual is not able to get the head of the 1st ray to the ground at all, and he has a Morton’s foot to boot (no pun intended). 

So, what do we see?

  • 1st of all, you will note his 2nd metatarsal is longer than his 1st. When he goes up on his toes, you see his foot invert and will see curling of the toes 3-5 in an attempt to stabilize the foot. 
  • You will also see his foot looks pretty flat. He has an arch (you can see it as he goes up onto his toes) and the “flatness” is actually due to the fore foot varus.
  • You will see a bunion forming bilaterally, due again to the uncompensated fore foot varus, and his inability to anchor the head of the 1st metatarsal. 
  • The posterior view shows relatively vertical calcaneii (no no rearfoot valgus), but you can really see the effects of the fore foot varus, with medial fall of the midfoot.
  • note the prominent “pump bumps” on the lateral calcaneus biaterally, from chronic rubbing on the shoes. 
The Gait Guys. Getting you closer to being a foot nerd with each post.
 

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The Gait Guys. Uber foot geeks. Still bald and good looking. Separating the wheat from the chaff, with each and every post.

Sometimes, you just need to add a little pressure….

Cyclists are no different than runners; often when the effort is increased (or the conditions reproduced), the compensation (or problem) comes out.

Take a good look at this video of a cyclist that presented with right sided knee pain (patello femoral) that begins at about mile 20, especially after a strong climb (approx 1000 feet of vertical over 6 miles through winding terrain).

The first 7 seconds of him are in the middle chain ring, basically “spinning” ; the last portion of the video are of him in a smaller (harder) gear with much greater effort.

Keep in mind, he has a bilateral forefoot varus, internal tibial torsion, L > R and a right anatomically short leg of approximately 5mm. His left cycling insole is posted with a 3mm forefoot valgus post and he has a 3mm sole lift in the right shoe.

Can you see as his effort is increased how he leans to the right at the top of his pedal stroke of the right foot and his right knee moves toward the center bar more on the downstroke? Go ahead, stop it a few time and step through it frame by frame.  The left knee moves inward toward the center bar during the power stroke from the forefoot valgus post.

So what did we do?

·      Worked on pedal stroke. We gave him drills for gluteal (max and medius) engagement on the down stroke (12 o’clock to 6 o’clock) to assist in controlling the excessive internal spin of the right leg. Simple palpation of the muscle that is supposed to be acting is a great start.

·      Did manual facilitation of the glutes and showed him how to do the same

·      Worked on abdominal engagement during the upstroke (the abs should initiate the movement from 6 o’clock to 12 o’clock)

·      Manually stimulated the external oblique’s

·      Placed a (temporary, hopefully) 5mm varus wedge in his right shoe to slow the internal spin of the right lower extremity

·      Taught him about the foot tripod and appropriate engagement of the long extensors; gave him the standing tripod and lift/spread/reach exercise (again to tame internal spin and maintain arch integrity)

Much of what you have been learning (for as long as you have been following us) can be applied not only to gait, but to whenever the foot contacts anything else.

The Gait Guys. Experts in human movement analysis and providing insight into biomechanical faults and their remediation.

All material copyright 2013 The Gait Guys/The Homunculus Group. Please use your integrity filter and ask before using our stuff.