One point and 1 treatment can profoundly influence gait

When talking about the lower extremity and gait (as I have been know to do at more that one seminar), I often talk about the “reverse engineering” principle. This is looking at a muscle or muscle group from a “ground up” perspective, as it would be functioning during the gait cycle. This, along with knowing when a muscle should be firing in the gait cycle, can provide clues to what may be going on and how you may be able to help.

When discussing the quads, we often employ this principle. It can be a little difficult to think of the vastus medialis as a lateral rotator of the thigh and the rectus femoris as a flexor (anterior nutator) of the pelvis, but if you put your foot on the ground and think about it, you will see what I mean.

The VMO is often implicated in patello femoral syndromes but cannot be selectively activated. The ratio between vastus medialis and vastus lateralis does seem to be alterable and perhaps is a siginificant factor.

How about if we look at the vastus lateralis instead?

The vastus lateralis is the largest and most powerful portion of the quadriceps. One paper reports that the muscle volume of the the vastus lateralis was 674 cm3 followed by the vastus intermedius at 580 cm3, vastus medialis 461 cm3 and lowest in the rectus femoris 339 cm3.  This makes the vastus lateralis is twice the volume of the rectus femoris!

Studies of muscle fiber orientation show that VL force component is directed approximately 12-15° laterally with respect to the longitudinal axis of the femoral shaft. This would mean it has a tremendous mechanical advantage and could (should?) pull the patella directly laterally compared to the VMO force, whose component is directed approximately 55 ° medially.   The muscle “balance” between the VMO and the VL, along with the periarticular soft tissue structures acting on the patella, is considered major component in the control of normal patellar alignment and function. The VL is often considered to be the “overactive” one by many clinicians, particularly in cases of patellofemoral dysfunction. It turns out that from an EMG standpoint, they may be correct. 

The vastus lateralis arises posteriorly from the femur along the linea aspera and circumnavigates the thigh in a counterclockwise fashion to attach laterally to the patellar tendon.   Because of its size and fiber orientation, it would stand to reason that needling it would have more cortical representation than say the vastus medialis.

There is an interesting paper where they needled a single acupuncture point: Stomach 34. For those who haven’t studied acupuncture (or don’t remember) this point is located on the thigh, in a small depression about 2.5 inches (63 mm for the metric folks) lateral to and above lateral border of the patella. In other words, it is in the vastus lateralis (see above).

The results showed statistically significant improvement in velocity, cadence, stride length, cycle time, step time and single/double leg support after treatment. The effect was small, but positive.

Think about where the trigger points are for this muscle (see above) ; fairly close to this point, sometimes (depending on the trigger point), even directly over this point. Needling has many effects on muscle and its trigger points and we like to think that needling “normalizes” function of a muscle; perhaps it influences the apparent “dominance” of this muscle and allows the patella to track more medially?

So, in this popultion of patients of elderly individuals, 1 acupuncture (needling) treatment  had a positive influence on their gait. Perhaps if the folks in the knee study were treated a few more times, we would have seen a change. Imagine what could have happened if aditional treatment modalities, like exercise, proprioceptive work and gait retraining were added! 

What a great, cost effective alternative or addition to your rehabilitation this could be. Consider adding this modality (and point!) to your current clinical toolbox, not only for older patients but for any patients that may have a gait abnormality.

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Boucher JP, King MA, Lefebvre R, Pépin A. “Quadriceps femoris muscle activity in patellofemoral pain syndrome.” Am J Sports Med. 1992 Sep-Oct;20(5):527-32. Web. 17 Nov 2012.

Souza DR, Gross MT. “Comparison of vastus medialis obliquus: vastus lateralis muscle integrated electromyographic ratios between healthy subjects and patients with patellofemoral pain.” Phys Ther. 1991 Apr;71(4):310-6. Web. 25 Nov 2012.

Cowan SM, Bennell KL, Crossley KM, Hodges PW, McConnell J. “Physical therapy alters recruitment of the vasti in patellofemoral pain syndrome.” Med Sci Sports Exerc. 2002 Dec;34(12):1879-85. Web. 26 Nov 2012.

Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG. “Outcomes of a weight-bearing rehabilitation program for patients diagnosed with patellofemoral pain syndrome.” Arch Phys Med Rehabil. 2006 Nov;87(11):1428-35

Kim, H. H., & Song, C. H. (2010). Effects of knee and foot position on EMGactivity and ratio of the vastus medialis oblique and vastus lateralis during squatexercise. Journal of Muscle and Joint Health, 17(2), 142-150.

Lam, P. L., & Ng, G. Y. (2001). Activation of the quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain. American Journal of Physical Medicine & Rehabilitation, 80(11), 804-808.

Erskine, R. M., Jones, D. A., Maganaris, C. N., & Degens, H. (2009). In vivo specific tension of the human quadriceps muscle. European journal of applied physiology, 106(6), 827-838. [PubMed]

Grabiner MD: Current Issues in Biomechanics (9th ed). Champaign, Human Kinetics Publishers, 1993.

http://www.orthobullets.com/anatomy/10058/vastus-lateralis

Hauer K, Wendt I, Schwenk M, Rohr C, Oster P, Greten J. Stimulation of acupoint ST-34 acutely improves gait performance in geriatric patients during rehabilitation: A randomized controlled trial. Arch Phys Med Rehabil. 2011 Jan;92(1):7-14. doi: 10.1016/j.apmr.2010.09.023.

Peter Deadman, Mazin Al-Khafaji, Kevin Baker: A Manual of Acupuncture (2nd Edition) Journal of Chinese Medicine Esat Sussex, England 2007

Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual: The Lower Extremities. Vol.2 . Baltimore, Md: Williams & Wilkins;1992

 http://www.medscape.org/viewarticle/521494_3

New research on Non-motorized treadmills.

Facts:

•Non-motorised treadmill locomotion creates large reductions in tibial acceleration.
•Non-motorised treadmill locomotion increases lower limb muscular activation.
•Non-motorised treadmill locomotion decreases cycle time/increases step frequency.

Keep these things in mind when you are doing a treadmill gait analysis. We have discussed over and over again of the severe and misleading information gleaned from gait analysis, that it shows strategies around problems, often not the problem at hand. But, this is yet one more factor to keep in mind when you are doing such studies, that changing the surface and how and why any given work is being performed on a given surface/device, that the information can be tainted if you do not know exactly what you are dealing with.   

Few studies are perfect, look at all of the parameters they likely should, and understand the complexity of the model they examine in their entirety. None the less, there is information to glean from most studies that help to debate, refute or clarify working concepts presently proven or unproven. This study provides some conclusions as well, that should be take in, digested and then determined where, when and if appropriate for a client.

Tibial impacts and muscle activation during walking, jogging and running when performed overground, and on motorised and non-motorised treadmills

Montgomery, Dobson, Smith & Ditroilo

http://www.gaitposture.com/article/S0966-6362(16)30116-3/abstract?platform=hootsuite

A clear cut case of Form follows Function.  Leave a deforming force long enough and the body will accommodate. 

When the lateral quadratus plantae (QP) is weak and the flexor digitorum longus pulls unopposed (relying on the QP to properly orient the long flexor pull) for too long the 4th and 5th toes and drift medially and spin inwards toward the midline of the foot (as seen in the photo). Then, as the 4th toe presses down on the fleshy pad of the 5th toe, over time the fleshy pad is pancaked and triangulated. Then, with repeated pressure a corn like hardness becomes of the tip of that triangluted tissue, it resembles a hard callus. A corn is a coalescing of the skin cells into a tighter formation, a reaction to fend off repeated pressure and friction.  Form follows prolonged function.  Shave these things down and they will come back, unless you get to the root source of the problem, which could be all the way up the chain. 

-Dr. Allen

A marathon a day, for over 120 days…..on one leg, battling cancer.

So you think you are tough ? This guy was tough. A marathon a day for over 120 days…..on one leg, battling cancer. 

Rest in Peace Terry. You are not forgotten. You made a mark on my life, thank you for that. Watching you skip on the good leg, giving your prosthetic enough time to swing through mesmerized me, the biomechanics of it all. If i look back, this was the first time I payed attention with great detail to someone’s gait. I was in awe, you moved me, your mission moved me, your heart and spirit moved me. Your life made a difference in mine, so I may help others.Dr. Allen
Today, June 28th, every year here on The Gait Guys, I remember Terry Fox. Every year I post a reminder of perhaps one of the toughest dudes who ever lived. Today , this day, 1981 Terry Fox died. I grew up in Canada. I was barely a teenager when Terry began his plight, The Marathon of Hope. 

His mission, 26 miles a day, every day, until he had crossed the expanse of Canada to raise awareness for cancer. He made it an amazing 120+ days in a row, 3339 miles, one one leg, before his cancer returned. The whole country stood cheering watching him do something no mortal man would attempt, let along with one leg, and cancer. Today we pay a tribute to this true rockstar.
Let this video move you, just in case you think you are having a rough day.

https://www.youtube.com/watch?v=xjgTlCTluPA

Global body compensations in ACL deficient knees.

ALERT: Ok, this is big.
It is a huge comment on what the brain and reflexive patterns impart on posture and gait when perceived functional instability is present.
This study aimed to investigate the gait modification strategies of trunk over right stance phase in patients with right anterior cruciate ligament deficiency.
* Here is what you need to ABSOLUTLY keep in mind when you read it. The 3D capture it telling you what they are DOING to strategize, not what is WRONG or what needs CORRECTING (our mantra it seems, sorry to keep beating this concept to death). This again hits home what I have been preaching for quite some time, that arm swing (and you can translate that to trunk movements, thorax, head posture, breathing etc) should not be coached or corrected unless you are absolutely sure there are clean symmetrical lower limb biomechanics (yes, you can easily and correctly argue that you can concurrently work on all parts). IF there is something going awry in a lower limb, compensations will occur above, they have to occur. So be absolutely sure you are not making therapeutic interventions above without making therapeutic corrections below. If you are working on a shoulder/upper quarter problem and are not looking for drivers in the lower limbs or in gait, well … . . good luck making lasting effects. Other than breathing, it can be argued well that gait locomotion is our 2nd most engaged motor pattern that we have driven to subconscious levels , and compensations are abound (but not without a cost), so we can dual++ task.
If you want to dive deeper into this, search our blog and look for my articles on Anti-phasic gait. This is essentially what this study was looking at, and confirming, that there is a distortion in the NORMAL opposite phase movements (anti-phasic) of the “shoulder girdle” and “pelvic girdle” when something goes wrong in a lower limb.
– Dr. Allen

Findings from Shi et al when there was a chronic right ACL deficiency:
-trunk rotation with right shoulder trailing over the right stance phase was lower in all five motion patterns
– trunk posterior lean was higher from descending stairs to walking when the knee sagittal plane moment ended
– trunk lateral flexion to the left was higher when ascending stairs at the start of right knee coronal plane moment when descending stairs at the maximal knee coronal plane moment and when descending stairs at the end of the knee coronal plane moment
– trunk rotation with right shoulder forward was higher at the minimal knee transverse plane moment and when the knee transverse plane moment ended
– during walking, trunk rotation with right shoulder trailing was lower at other knee moments during other walking patterns

http://www.ncbi.nlm.nih.gov/pubmed/27131179

Feature: Arterial disease and cycling – VeloNews.com

“That offseason, his symptoms worsened. Before, it might have taken 20 minutes of riding at 400 watts to feel the sensation. Now, if he rode for five minutes at 350, he’d be riding with one good leg and one numb, powerless appendage.”

Iliac artery endofibrosis is a circulatory condition affecting the legs and is sending more and more cyclists under the knife.
If you are a bike geek like i am (been watching the Tour de France since i was 15) you may take interest in this. If you are a avid bike rider or triathlete you may take interest in this.
But do not stop at the bike when you have symptoms in front of you that sound vascular. If your leg is doing numb on a long walk or run, dead or heavy during exertion, something is going on that needs evaluated. Get evaluated.

Feature: Arterial disease and cycling – VeloNews.com

Obesity and Base of Support

Recently we have been speaking and writing about “base of support” and how a narrow base of support will render a small comfort and control zone of balance in single leg tasking (walking, running, sports etc). We do not notice these things if we are standing on both feet or when walking or running per se, but all one needs to do is test a 30 second single leg stance to see how crappy one’s single limb base of support actually is. Most people will drift the pelvis laterally to get the single foot under the center of the body mass. This is a false support, it is a demonstration of weak support, unless you like to walk on a line/cross over gait. We should not have our knees rubbing together, scuffing our ankles or shoes together. If you do, you have a narrow base of support, have engrained a lazy style of locomotion, and you will wish and attempt to put the center of your body mass over the foot at all times. This is good if you are walking on ice, but that is about it. This is an epidemic, hence the prevalence of cross over gait out in the world. Increasing balance ability will help to increase base of support and hence help with reducing cross over gait (narrow step width gait and running) tendencies. Obesity seems to make this worse. Obesity in our world is wrecking our people, especially our kids.

“Alterations were detected in the intermittent postural control in obese children. According to the results obtained, active anticipatory control produces higher center of pressure displacement responses in obese children and the periods during which balance is maintained by passive control and reflex mechanisms are of shorter duration.”
“Differences in intermittent postural control between normal-weight and obese children ” Israel Villarrasa-Sapiña, Xavier García-Massó

http://www.gaitposture.com/article/S0966-6362(16)30091-1/abstract?platform=hootsuite