Loss of medial tripod

It is Rewind Friday.
Today, we are reaching back to a brief 2009 lecture I did for the local NSCA chapter on the patterns of kinetic chain compensation that match with loss of medial and lateral foot tripod. (video starts at 49 seconds, for some reason)
https://www.youtube.com/watch?v=yeCBGZkNaeM

Loss of medial tripod

Eating up a cardinal plane.

Simple post, simple principle today.  We found this case on the web, somewhere. Wish we could remember so we could give credit. 

Looks like simple right leg length discrepancy but the point we wanted to make is that any time you deviate into a plane, you eat up length. In this case, the right knee is severely valgus and that has at least in part contributed to a shorter limb and unleveling of the pelvis. And, it is not uncommon that rotation axis are changed when frontal or sagittal planes are compromised. It is easy to see this on the x-rays, if the foot posturing isn’t at least noted, look at the spacing between the tibia and fibula .  .  .  . rotational planes have changed as well. Is it from the femur or tibia? That is the topic of another day. 

In the larger photo you will notice that even with the right foot lifted there is still a pelvis unleveling. How can that be, unless it was further unleveled that what we are seeing ?  Well, just because you lift to fix doesn’t mean the lift will not enable further collapsing into the weakness and deformity.  We have described this principle on the topic of EVA shoe foam deformation.  When the foot presses the foam into the deformation, it leaves more room for possibly further and faster deformation loads (perhaps more so than had a new shoe been prescribed). So in some cases, more lift can allow more deformation.  How far, well as in this photo, at least until the right knee slams into the left knee and stops further deformation.

So, seeing a plane deficit clues you into possible unleveling of the pelvis and abnormal joint loading responses. It should clue you into looking for another cardinal plane compromise as well. But make no mistake, just adding a lift doesn’t mean the deformation is remedied and not enabling further deformation. It is possible that you can make your client worse if you do not teach them how to find the appropriate motor patterns with the lift so they can learn to protect the parts. Often teaching these types of clients how to control their deformities (when and if possible) is where the gold lies, not in just leveling out the foundation. 

One more “beating of the dead  horse”, lift the whole foot, heel and forefoot with a sole lift when you are “lifting and leveling”. Lifting only the heel puts them into ankle plantar flexion and can often facilitated earlier and faster forefoot loading and even earlier knee flexion.  Save the heel lift as a possible consideration when there are posterior compartment contractures or inflammation.  Certainly we could have gone into functional and structural leg length discrepancies, but we have blogged excessively on that topic in the past. Go ahead and search our blog if you want more on those topics.

Take home point, “just because you lift, doesn’t mean you are truly lifting, you may enable the opposite”.

Shawn Allen, one of the gait guys

Rearfoot to Hip Pathomechanical considerations.

In normal gait, the rearfoot strikes in slight inversion and then quickly moves through eversion in the frontal plane to help with the midfoot through forefoot pronation phases of gait. Some sources would refer this rearfoot eversion as the rearfoot pronatory phase, after all. pronation can occur at the rear, mid or forefoot. As with all pronation in all areas, when it occurs too fast, too soon or too much, it can be a problem and rearfoot eversion is no different.  If uncontrolled via muscles such as through tibialis posterior eccentric capabilities (Skill, endurance, strength) or from a structural presentation of Rearfoot Valgus pain can arise. 

From a scenario like in the video above, where a more rearfoot varus presentation is observed,  where the lateral to medial pronation progression is excessive and extreme in terms of speed, duration and magnitude this can also create too much lateral to medial foot, ankle and knee movement.  This will often accompany unchecked movements of internal spin through the hip. So one should see that these pronation and spin issues can occur and be controlled from the bottom or from the top, and hopefully adequately from both in a normal scenario.  It is when there is a biomechanical limitation or insufficiency somewhere in the chain that problems can arise. And remember, pain does not have to occur where the failure occurs, in fact it usually does not. So when you have knee pain from an apparent valgus posturing knee, make sure you look above and below that knee.  Also, keep in mind that as discussed last week in the blog post on ischiofemoral impingment syndrome (link), these spin scenarios can be quite frequently found with ipsilateral frontal plane lateral deviations (bumping of the hip-pelvis outside the vertical stacking of the foot-knee-hip stacking line). This stacking failure can also be the source of many of the issues discussed above, so be sure you are looking locally and globally. And remember, what you see is not the problem, it is their compensation around their deeper problem quite often.

If you have not read the blog post from last week on ischiofemoral impingement syndrome you might not know where the components of the cross over gait come in to play here nor how a rearfoot problem can present with a hip impingement scenario, so I can recommend that article one more time.

One last thing, just in case you think this stuff is easy to work through, remember that these rearfoot varus and valgus problems, and pronation rates. and limb spin rates are all highly variable when someone has varying degrees of femoral torsion, tibial torsion or talar torsion. Each case is different, and each will be unique in their presentation and in the uniqueness of the treatment recipe. I just thought I would throw that in to make your head spin a little in case it wasn’t already.

For example, a case where the rearfoot is a semi rigid varus, with tibial varum, and frontal plane lateral pelvic drift with components of cross over gait (ie. the video case above) will require a different treatment plan and strategy than the same rearfoot varus in a presentation of femoral torsion challenges and genu valgum. Same body parts, different orientations, different mechanics, different treatment recipe.  

So, you can fiddle with a dozen pair of shoes to find one that helps minimize your pains, you can go for massages and hope for the best, you can go and get activated over and over, you can try yet another new orthotic, you can go to a running clinic and try some form changes, throw in some yoga or pilates, compression wear, voodoo bands and gosh who knows what else. Sometimes they are the answer or stumble across it … or you can find someone who understands the pieces of the puzzle and how to piece a reasonable recipe together to bake the cake just right. We do not always get there, but we try.  

Want more ? Try our National Shoe Fit certification program for a starter or try our online teleseminars at www.onlinece.com (we did a one hour course on the RearFoot just the other night, and it was recorded over at onlineCE.com).

Dr. Shawn Allen,  of the gait guys

Reference:

Man Ther.  2014 Oct;19(5):379-85. doi: 10.1016/j.math.2013.10.003. Epub 2013 Oct 29.Clinical measures of hip and foot-ankle mechanics as predictors of rearfoot motion and posture.  Souza TR et al.

Health professionals are frequently interested in predicting rearfoot pronation during weight-bearing activities. Previous inconsistent results regarding the ability of clinical measures to predict rearfoot kinematics may have been influenced by the neglect of possible combined effects of alignment and mobility at the foot-ankle complex and by the disregard of possible influences of hip mobility on foot kinematics. The present study tested whether using a measure that combines frontal-plane bone alignment and mobility at the foot-ankle complex and a measure of hip internal rotation mobility predicts rearfoot kinematics, in walking and upright stance. Twenty-three healthy subjects underwent assessment of forefoot-shank angle (which combines varus bone alignments at the foot-ankle complex with inversion mobility at the midfoot joints), with a goniometer, and hip internal rotation mobility, with an inclinometer. Frontal-plane kinematics of the rearfoot was assessed with a three-dimensional system, during treadmill walking and upright stance. Multivariate linear regressions tested the predictive strength of these measures to inform about rearfoot kinematics. The measures significantly predicted (p ≤ 0.041) mean eversion-inversion position, during walking (r(2) = 0.40) and standing (r(2) = 0.31), and eversion peak in walking (r(2) = 0.27). Greater values of varus alignment at the foot-ankle complex combined with inversion mobility at the midfoot joints and greater hip internal rotation mobility are related to greater weight-bearing rearfoot eversion. Each measure (forefoot-shank angle and hip internal rotation mobility) alone and their combination partially predicted rearfoot kinematics. These measures may help detecting foot-ankle and hip mechanical variables possibly involved in an observed rearfoot motion or posture.

Holy Hand Grenades! What kind of shoe do I put these feet in?

Take a look at these feet. (* click on each of the photos to see the full photo, they get cropped in the viewer) Pretty bad, eh? How about a motion control shoe to help things along? NOT! OK. but WHY NOT? Let’s take a look and talk about it.

To orient you:

  • top photo: full internal rotation of the Left leg
  • 2nd photo: full internal rotation of the Right leg
  • 3rd photo: full external rotation of the Left leg
  • last photo: full external rotation of the Right leg

Yes, this gal has internal tibial torsion (yikes! what’s that? click here for a review).

Yes, it is worse on the Left side

Yes, she has a moderate genu valgus, bilaterally.

If someone has internal tibial torsion, the foot points inward when the knee is in the saggital plane (it is like a hinge). The brain will not allow us to walk this way, as we would trip, so we rotate the feet out. This moves the knee out of the saggital plane (ie. now it points outward).

What happens when we place a motion control shoe (with a generous arch and midfoot and rearfoot control) under the foot? It lifts the arch (ie it creates supination and it PREVENTS pronation). This creates EXTERNAL rotation of the leg and thigh, moving the knee EVEN FURTHER outside the saggital plane. No bueno for walking forward and bad news for the menisci.

Another point worth mentioning is the genu valgus. What happens when you pick up the arch? It forces the knee laterally, correct? It does this by externally rotating the leg. This places more pressure/compression on the medial aspect of the knee joint (particularly the medial condyle of the femur). Not a good idea if there is any degeneration present, as it will increase pain. And this is no way to let younger clients start out their life either.

So, what type of shoe would be best?

  • a shoe with little to no torsional rigidity (the shoe needs to have some “give”)
  • a shoe with no motion control features
  • a shoe with less of a ramp delta (ie; less drop, because more drop = more supination of the foot (supination is plantarflexion, inversion and adduction)
  • a shoe that matches her sox, so as not to interfere with the harmonic radiation of the colors (OK, maybe not so much…)

Sometimes giving the foot what it appears to need can wreak  havoc elsewhere. One needs to understand the whole system and understand what interventions will do to each part. Sometimes one has to compromise to a partial remedy in one area so as not to create a problem elsewhere. (Kind of like your eye-glass doctor. Rarely do they give you the full prescription you need, because the full prescription might be too much for the brain all at once.  Better to see decent and not fall over, than to see perfectly while face down in the dirt.) 

Want to know more? Consider taking the National Shoe Fit Certification Program. Email us for details: thegaitguys@gmail.com.

We are the Gait Guys, and yes, we like her sox : )

Limitations: The powers of observation will help you.

Physical examination, FMS, DNS, gait analysis … . . these are all very important tools for the coach, trainer, therapist, clinician.  They will all offer information and lead the “therapy giver” in a direction for intervention.  But when something doesn’t match up with the basic standard protocols, you have to go outside the standard box.  We have all been there and today is just a little reminder not to get caught up in the “proceedures” and merely running through protocol without an engaged brain putting the pieces together.  

Here we see 2 classic examples of deviations from the mean, the client on the left has drifted further outside the frontal plane because of tibial varum and a little genu varus.  The client on the right has imploded deep into the frontal plane via rigid pes planus foot collapse and genu valgum.  These will both affect your physical screenings for these clients. And keep in mind, and this is probably the most important point of today’s blog post, either client may have good or bad strategies around their anatomy.  In other words, some clients will have great compensations to limit further functional pathology, and some will have poor compensation strategies, and thus, both will have different physical exam findings, different screenings and different neuromotor patterns embedded deep into their CPGs (central pattern generators).   Put yet another way, all of the scenarios discussed may/will have varying screening assessment outcomes but for different reasons.  If you know the cause of these faults and the impaired neuro-recruitment patterns that are likely, your assessments will make more sense, and so will your exercise/therapy/rehab prescriptions.  If you do not understand the fundamental differences (ie long bone torsions or various femoral-neck shaft angles, foot types such as an uncompensated forefoot valgus etc) , one could prescribe therapies that will not address the underlying problems, rather they might address the compensations and strategies found with these client’s challenges.

It can get sloppy messy.  Wear a bib.

Dig for the roots, don’t mow the grass…… Shawn and Ivo, The Gait Guys

Podcast 36: Heel lift lies, the Exercise Drug & Malcolm Gladwell’s 10,000 hours.

http://thegaitguys.libsyn.com/podcast-36-heel-lift-lies-and-the-exercise-drug

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen  Biomechanics

Today’s show notes:

Neuroscience piece:

Description
1. Health Scanner Scanadu Scout: the future of medical info gathering ?

2. The Exercise Drug:

www.gizmag.com/scripps-drug-sr9009-exercise-mimic/28651

3. FB reader sent us a message:

 am posting this to see if I can get a little bit of help from the best professionals in the area (you). 

I have read some of the information on your site and I think I have quite a problem on my right foot. It happens that the medial part of the foot tripod does not touches the floor at all and I have lack of support in that zone. So it seems like my forefoot is varus. I have also noticed that when I am standing it looks like my rear foot is valgus. So, I can’t really compensate this problem because if the forefoot is varus and I try to put it neutral, the rear foot gets even more valgus, and if it I try to put the rear foot neutral, the forefoot gets even more varus and my big toe does not touch any part of the floor. Can you please help me? I do not know what to do and I am a little bit desperate because nobody I went to could help me. You are probably my last hope. I know I can correct this and I have the will and dedication to pull it off. I bet there are some exercises I can do but I do not really know which at all. 
Thanks in advance. -Jorge

4. Another TUMBLR reader asks question about
Guys what are the possible muscular causes of genu varum during initial swing?
5. Another off tumblr:  Anything  you can talk about on this topic ?
How does running in low-to-no light conditions effect your gait/running/injuries/etc?
6. Topic: step  width

Changing step width alters lower extremity biomechanics during running

7.  heel lift vs. sole lift
why and when would you use only a heel lift…..unilaterally ?
8. National Shoe Fit program: 
Link: http://store.payloadz.com/results/results.aspx?m=80204
9. Questions from a field doc:
Hey guys,

 I have heard you guys say many times that many people who choose to venture into minimalistic footwear have not “earned their right” to do such without increasing their risk for problems.  I was wondering if you could explain what parameters you use to determine if and when they are ready.  
Thanks,
Ryan 
10. Shoes: does pronation matter
11. Shoes #2:
12. Malcolm Gladwell debate, 10,000 hours

Podcast 36: Heel lift lies, the Exercise Drug & Malcolm Gladwell’s 10,000 hours.

http://thegaitguys.libsyn.com/podcast-36-heel-lift-lies-and-the-exercise-drug

iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

Gait Guys online /download store:

http://store.payloadz.com/results/results.aspx?m=80204

other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen  Biomechanics

Today’s show notes:

Neuroscience piece:

Description
1. Health Scanner Scanadu Scout: the future of medical info gathering ?

2. The Exercise Drug:

www.gizmag.com/scripps-drug-sr9009-exercise-mimic/28651

3. FB reader sent us a message:

 am posting this to see if I can get a little bit of help from the best professionals in the area (you). 

I have read some of the information on your site and I think I have quite a problem on my right foot. It happens that the medial part of the foot tripod does not touches the floor at all and I have lack of support in that zone. So it seems like my forefoot is varus. I have also noticed that when I am standing it looks like my rear foot is valgus. So, I can’t really compensate this problem because if the forefoot is varus and I try to put it neutral, the rear foot gets even more valgus, and if it I try to put the rear foot neutral, the forefoot gets even more varus and my big toe does not touch any part of the floor. Can you please help me? I do not know what to do and I am a little bit desperate because nobody I went to could help me. You are probably my last hope. I know I can correct this and I have the will and dedication to pull it off. I bet there are some exercises I can do but I do not really know which at all. 
Thanks in advance. -Jorge

4. Another TUMBLR reader asks question about
Guys what are the possible muscular causes of genu varum during initial swing?
5. Another off tumblr:  Anything  you can talk about on this topic ?
How does running in low-to-no light conditions effect your gait/running/injuries/etc?
6. Topic: step  width

Changing step width alters lower extremity biomechanics during running

7.  heel lift vs. sole lift
why and when would you use only a heel lift…..unilaterally ?
8. National Shoe Fit program: 
Link: http://store.payloadz.com/results/results.aspx?m=80204
9. Questions from a field doc:
Hey guys,

 I have heard you guys say many times that many people who choose to venture into minimalistic footwear have not “earned their right” to do such without increasing their risk for problems.  I was wondering if you could explain what parameters you use to determine if and when they are ready.  
Thanks,
Ryan 
10. Shoes: does pronation matter
11. Shoes #2:
12. Malcolm Gladwell debate, 10,000 hours