and what have we been saying?

Gait problems leave clues. Asymmetry is a BIG clue

“Asymmetrical lower extremity neuromuscular control is predictive of repetitive stress injury in recreational runners, according to findings presented at the Combined Sections Meeting of the American Physical Therapy Association in February in Anaheim.”

http://lermagazine.com/issues/march/years-after-achilles-tear-injured-limb-demonstrates-elevated-knee-loading

The Banana Toe: The Force has to go somewhere. It’s a Jedi Gait Rule.

* note: there are 4 photos to today’s blog post. Be sure you click through all 4.

When you toe off, you have to toe off from somewhere in the foot unless you like an apropulsive hip flexion gait, where  you just lift you foot off the ground from foot flat, kind of like a true neurologic “foot drop” gait client would.  But, if you are lucky enough not to have a true foot drop, you are going to push off somewhere in the foot.  You can do it off the lateral foot (low gear toe off) and lesser toes, or you can do it off the big toe (high gear) the way we were built to do it. 

The above pictures show a nasty dorsal crown of osteophytes that is limiting hallux (big toe) extension/dorsiflexion. This is true hallus rigidus and hallux limitus. When this client attempts to toe off, the joint cannot normally partake in the activity, there is no Windlass effect, no posturing up over the sesamoids for mechanical advantage etc.   

In this scenario, there are two places you can put it, up into the next proximal joint(s) meaning the met-cuneiform joint or further down into the interphalangeal joint. In other words. the loads go proximal or distal to the limited joint, and they eventually play out there, over and over and over gain. The former option would basically mean you are pronating/dorsiflexing through the midfoot which is never good (can you say Saddle exostosis ! ouch !) or the latter option is to dorsiflex through the interphalangeal joint  and over time that toe begins to attenuate plantar ligamentous structures and extend beyond its normal limits resulting in the “Chiquita” toe (a upward bent toe resembling a banana shape). This will disable the long flexor of the great toe (FHL: flexor hallucis longus).and inhibit mechanical advantage of the extensor digitorum brevis.  If you struggle with the “how and why” behind this sentence in terms of restoration attempts, you need to watch my video here. It will offer you deeper insights.

Will this toe become painful ? yes, in time it is quite possible.  Is there much you can do? Sure, a rocker bottomed shoe will help take the load at toe off instead of forcing it into this toe or the midfoot.  Will an orthotic  help ? Well, this is a loaded question. If you are putting the forces into the midfoot choice as described above, the orthotic will block that motion and you will likely default option into the toe presentation above. So you are merely just moving loading forces around. It can be helpful, but you are quite possibly “robbing Peter to pay Paul” as they say.  The video I asked you to watch can be helpful but it will force that metatarsophalangeal joint into extension, a range it does not have, so it is not a remedy and not recommended.  Perhaps some awareness and slight increase in FHL(long toe flexor) use can be attained however.  These are tricky cases, simple in theory, but execution can be fussy and requires patient awareness and education. We like the rocker bottomed shoe as a nice easy solution and some increased FHL use awareness.  Help them find a little more FHL use by putting a pencil under the crease of the toe and help them to drive the tip of the toe down just a little out of that banana extension posture. It can help them control the overloading of the dorsal aspect of the interphalangeal joint.

As always, lets carry this forward into gait thoughts.  How is  hip extension going to be in this client ? How is glute strength ? Hip joint range ? Hip extension motor patterning ? Will the client go into anterior pelvic tilt to borrow the last range of hip extension ? Will the hamstrings have to accommodate ? Lots of yummy biomechanical and neurological mental gymnastics here. Bottom line answer to all the above ?  “ it depends, they will have to accommodate and compensate”.  And as the Jedi Gait Rule goes, “the Force as to go somewhere”.

Shawn Allen, one of the gait guys

What were they thinking? Oh, they weren’t thinking…

Here is a simple case of knowing your anatomy. 

make sure to use the toggle bar to the right and left of the picture to see all the pictures : )

This woman came in with right sided lateral knee pain with hiking and skiing; worse with fatigue, better with rest. The pain was localized at the lateral joint line and at the tibial fibular joint. 

She had been previously been diagnosed with tibial fibular hypermobility and subsequently had an arthrodesis (fusion) performed at that joint for knee pain. The surgery helped for a short time and a newer, slightly different pain developed. 

Yes, she has a moderate genu valgus, R > L. Yes, she has a left, anatomically short (tibial) Left leg. Yes, she has has NO MOBILITY at the tib/fib articulation and the focus of pain is just above at the joint line and at the lateral aspect of the patello femoral joint. 

The tibial fibular joint is a syndesmosis (not a true synovial or diarthrodial joint) that is supposed to have a a superio/inferior gliding motion (see diagram) with ankle dorsiflexion, due to the wedge shape of the talar dome and talo crural articulation. It also is supposed to have an anterior/posterior gliding movement at the superior aspect of the joint and a reciprocal movement in the opposite direction at the ankle (see diagram).

Whenever we take away movement in one area, it needs to occur somewhere else; in this case, at the femoral tibial joint and patello femoral joints.

Does it make sense that her left sided leg would cause hypermobility on the right side with a supinatory moment of the foot on the left to attempt to lengthen the leg and a pronatory movement of the foot on the right, in addition to valgus angulation of the joint on the right to attempt to “shorten” that extremity? Would this increased valgus angluation of the knee, in turn, cause abnormal, lateral, tracking of the patella? Wouldn’t the increased pronatory moment cause a more supple foot on that side with increased requirements for “push off” on that side with increased calf recruitment? Do you think that may impair proprioception on that side?

What if you put a sole lift in the left shoe (like we did) to help to alleviate some of the discrepancy and gave her some anterior compartment exercises (toes up walking, lift/spread/reach exercises, heel walking, simple balance on 1 leg exercises? Her world becomes a much better place to live in and she can return to the activities she loves to do with her 65 year old friends, like hiking 14′ers, skiing and mountain biking,

What we do to one joint affects all the others. You cannot make one change without expecting others. Be on the lookout and know your anatomy! This case was relatively straight forward. Many are not. Do a thorough exam and expect the unexpected. 

How well do you understand stance phase mechanics?

Here is a recent question we fielded and thought it would make a great post. 

Question/Comment: I’m slightly confused about closed chain hip motion in the stance leg.


Maybe if I explain what my thought process is you can correct me.  Lets use
left stance phase with the right leg swinging through.

After right mid-swing, the pelvis will be rotating towards the left.  The
motion of the pelvis on the left femur would be relative femur internal
rotation.  I understand that the right leg is externally rotating
(supinating) and that normal open chain kinematics of hip extension is
coupled with external rotation.  But if the pelvis is moving towards the
left AND the left femur externally rotates, wouldn’t that create too much
rotation?  So what I’m saying is that a pelvis that is oriented to the left
with a left femur that externally rotates creates an odd motion in my head
(which may be where the problem lies).  If you’ve ever seen a western where
the gun slingers do that weird walk to a shoot out…that’s what an
externally rotating femur during terminal stance looks like to me.

I’ve discussed this with other clinicians.  Some are in agreement with me,
some think it’s externally rotating, and some don’t know what I’m talking
about.  In my patients I also see a loss of hip IR more than hip ER.  These
patients that lose hip IR seem to have more difficulty in terminal
stance/toe-off phase more than the ones that lose hip ER.

If you could help me understand these kinematics and clear this up for me I
would greatly appreciate it.

Thank you, A

our reply: 

Taking your example with the L leg in stance:
When the L heel contacts the ground, the friction of the ground (hopefully) slow the calcaneus and the talus slide anteriorly on the calcaneus. 

Because of the shape of the calcaneal facets, the talus plantar flexes, adducts and everts. This sets the stage for pronation to occur: the calcaneus everts and the lower leg internally rotates, with the thigh following. The right side of the pelvis is moving to the L (counter clockwise rotation). This should occur (ideally) until midstance. At midstance, the opposite ® foot begins to enter swing phase; this should initiate supination of the stance phase leg (L). At this point, the L foot should be beginning to supinate the the leg and thigh beginning external rotation. It (thigh and leg) should reach maximal external rotation at toe off (maximal counter clockwise rotation of the pelvis) and remain in external rotation until heel strike/initial contact on the L side again. At this point, the pelvis begins clockwise rotation.

It is necessary for the thigh and leg to externally rotate while the pelvis is rotating counter clockwise, because of the constraints of the iliofemoral, pubeofemoral and ishiofemoal ligaments.

We too often see a loss of internal rotation of the hip in symptomatic populations more often than external rotation.

We hope this clarifies things for you.

Thank you again for the question and taking the time to write.

The Gait Guys

Lets make a resolution…Or not…

Cool guy, cool picture, cool scenery. Motivational? He is the fitness guru the developed the “Insanity” workout series, amongst others.

But looks may be deceiving.  

For reference, draw a line from the philitrium, interpec interval, symphisis pubis to area bisected between feet. 

Did you notice the following?

  • crossing arms across midline; look how far that left arm is abducted.
  • look at pelvis list to left. If you bring that arm in, you need to compensate somewhere
  • did you notice the hip hike on the left? That may have something to do with the excessive internal rotation of the thigh on the left. Is that because of the pelvis shift to the left (to compensate) or is he making up for limited internal rotation of the right hip?
  • what about the subtle head tilt to the right? is that driving the compensation or is it another compensation?

Questions, questions, questions…

We are choosing to make a resolution without him for the time being : ) More on this photo another day.

Lets make a resolution…Or not…

Cool guy, cool picture, cool scenery. Motivational? He is the fitness guru the developed the “Insanity” workout series, amongst others.

But looks may be deceiving.  

For reference, draw a line from the philitrium, interpec interval, symphisis pubis to area bisected between feet. 

Did you notice the following?

  • crossing arms across midline; look how far that left arm is abducted.
  • look at pelvis list to left. If you bring that arm in, you need to compensate somewhere
  • did you notice the hip hike on the left? That may have something to do with the excessive internal rotation of the thigh on the left. Is that because of the pelvis shift to the left (to compensate) or is he making up for limited internal rotation of the right hip?
  • what about the subtle head tilt to the right? is that driving the compensation or is it another compensation?

Questions, questions, questions…

We are choosing to make a resolution without him for the time being : ) More on this photo another day.

Whoa!  It is amazing what the human frame can withstand…

This 300 pound individual is retired from working with tow trucks from a towing company as well as a service station.   He believes working with the tow trucks, particularly jumping out of them contributed to the O.A. of the ankles.

He has osteoarthritic ankles, a rear foot varus of 15 degrees left side, 5 degrees right.  He is currently in the New Balance 1040 shoe.  He would like some new orthotics built. He Fowler tests positive on his current orthotic set up (with the foot on the ground, dorsiflex the foot at the 1st metatarsal phalangeal joint (ie big toe joint), simulating terminal stance; the orthotic should hug the arch through the range of motion; ie about 45-60 degress of great toe dorsiflexion, which he incredibly has). He is unable to one leg stand because of the O.A. on the ankles and pain.

He has bi-lat. internal tibial torsion, Left > Right and moderate tibial varum, L > R. He has very little internal rotation of the hips bi-lat. Ankle dorsiflexion is about 5 degrees bilaterally.

He is currently in an older New Balance motion control shoe. You can see how he has worn the shoes into varus. More neutral shoes hurt his feet; attempts to put his rear foot into valgus causes increased ankle pain. Exercise compliance is minimal.

WHAT WOULD YOU DO?

The Gait Guys. Teaching and educating with each post.