Leg Pain? Are you SURE its a disc?

Gluteus minimus dysfunction is often present in gait disorders, including stance phase mechanical problems, since it fires from initial contact through pre swing, like it better known counterpart, the gluteus medius. It is interesting that the trigger point referral pattern of the gluteus minimus has a sciatic distribution, whereas the gluteus medius is more in the local area of the hip. 

 There are several, well known effects of dry needling:

decreased central sensitization

increased range of motion

changes in muscle activation

changes in the chemical environment surrounding a trigger point

changes in local and referred pain

and now we can add (not surprisingly), changes in autonomic function. The mechanism probably has something to do with pain and the reticular formation sending information down the cord via the lateral cell column (intermediolateral cell nucleus) or pain (nociceptive) afferents sending a collateral in the spinal cord to the dysfunctional muscle (Dr Ivo talks about these mechanisms in his dry needling and acupuncture lectures). 

Conclusions

The presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. Every TrPs-positive sciatica patient presented DN related vasodilatation in the area of referred pain. The presence of vasodilatation suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism.

BMC Complement Altern Med. 2015; 15: 72. Published online 2015 Mar 20. doi:  10.1186/s12906-015-0587-6PMCID: PMC4426539 Intensive vasodilatation in the sciatic pain area after dry needling

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426539/

When was the last time you thought about the pairing of your glutes and your quadratus? This is an important mechanism, especially when ascending and descending stairs,

Here is a great exercises to help with that:

Heat Exertion and Gait Decline

Changes in gait characteristics are found when exertional heat stress is experienced during prolonged load carriage.  As heat stress increased, step width decreased while percent crossover steps increased. Reduced stance time variability, step width variability, and percent crossover step were observed.  These are frontal plane gait parameters for the most part. 

Think about these things during your long summer run or as you go deeper into those last miles of your long run.  Simple muscular fatigue in the frontal plane hip-pelvis stabilizers are going to render the same results.  This is quite possibly why many problems and injuries crop up in the latter miles of your run. 

Reference:

Gait Posture.

2016 Jan;43:17-23. doi: 10.1016/j.gaitpost.2015.10.010. Epub 2015 Oct 23.Using gait parameters to detect fatigue and responses to ice slurry during prolonged load carriage. Tay CSLee JKTeo YSQ Z Foo PTan PMKong PW

Ankle spains and hip abductors

We see it ALL THE TIME. But sometimes it is nice to point out the obvious, just in case you are not looking for it.
“Conclusions: Our subjects with unilateral chronic ankle sprains had weaker hip abduction strength and less plantar-flexion range of motion on the involved sides. Clinicians should consider exercises to increase hip abduction strength when developing rehabilitation programs for patients with ankle sprains.”-Friel et al
Dr. Allen: if the hip abductors are weak, the leg will posture more adducted (ie, cross over type pattern) and this places the foot more directly below the body midline plumb, this will posture the foot in inversion and thus at greater risk for future inversion sprains.  This sets up the vicious cycle of hip abductor weakness, frontal plane drift of pelvis, inversion of the foot and more ankle sprain risks/events.  The cycle must be broken. The hip must be addressed. That lateral chain must be restored all the way up from the foot.  All stuff you likely already know, but good to find another study to validate.

Dr. Allen

J Athl Train. 2006; 41(1): 74–78.PMCID: PMC1421486Ipsilateral Hip Abductor Weakness After Inversion Ankle SprainKaren Friel,Nancy McLean,Christine Myers, and Maria Caceres
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421486/

How relaxed, or shall we say “sloppy” is your gait ?

Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion. 

Now, visualize a line up from that right foot through the spine. You will see that it is clearly under the center/middle of the pelvis. But of course, it is easier to stand on one leg (as gait is merely transferring from one single leg stance to the other repeatedly) when your body mass is directly over the foot.  To do this the pelvis has to drift laterally over the stance leg side.  Sadly though, you should be able to have enough gluteal and abdominal cylinder strength to stack the foot and knee over the hip. This would mean that the pelvis plumb line should always fall between the feet, which is clearly not the case here.  This is sloppy weak lazy gait. It is likely an engrained habit in most people, but that does not make it right. It is pathology, in time something will likely have to give. 

This is the cross over gait we have beaten to a pulp here at The Gait Guys over and over … . . and over.   This gait this gait, this single photo, means this client is engaging movement into the frontal plane too much, they have drifted to the right. We call it frontal plane drift. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain, this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, a compensation in arms swing or thoracic spine rotation or head tilt  … … something has to give, something has to compensate. 

So, how sloppy is your gait ? 

Do you kick or scuff the inside of your opposite shoe ? Can you hear your pants rub together ? Just clues. You must test the patterns, make no assumptions, please.

Shawn Allen, one of the gait guys

Have a patient with weak hip abductors? Here is a great closed chain gluteus medius exercise called “"hip airplanes” we utilize all the time. Try it in yourself, then try it on your patients and clients, then teach others : )

Podcast #99: How foot placement, the glutes and cross over gait all come together and make sense.

Topics: Plus, How foot placement, the glutes and cross over gait all come together and make sense. Plus, discussions on vibration,proprioception, cerebellum and movement.

Show Sponsors:

*newbalancechicago.com

*Rocktape.com

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_99final.mp3

Podcast Direct Download: http://thegaitguys.libsyn.com/podcast-99-how-foot-placement-the-glutes-and-cross-over-gait-all-come-together-and-make-sense

Other Gait Guys stuff

B. iTunes link:
https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138
C. Gait Guys online /download store (National Shoe Fit Certification & more !)
http://store.payloadz.com/results/results.aspx?m=80204
D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com type in Dr. Waerlop or Dr. Allen, ”Biomechanics”

-Our Book: Pedographs and Gait Analysis and Clinical Case Studies
Electronic copies available here:

-Amazon/Kindle:
http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

-Barnes and Noble / Nook Reader:
http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

-Hardcopy available from our publisher:
http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

Evaluating the Differential Electrophysiological Effects of the Focal Vibrator on the Tendon and Muscle Belly in Healthy People ARTICLE in ANNALS OF REHABILITATION MEDICINE · AUGUST 2014 DOI: 10.5535/arm.2014.38.4.494 · Source: PubMed

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 BL

J Neurophysiol. 2015 Oct;114(4):2220-9. doi: 10.1152/jn.00551.2015. Epub 2015 Aug 19.

Hip proprioceptive feedback influences the control of mediolateral stability during human walking.

Roden-Reynolds DC1, Walker MH1, Wasserman CR1, Dean JC2.

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

Prog Brain Res. 2004;143:353-66. Role of the cerebellum in the control and adaptation of gait in health and disease. Thach WT1, Bastian AJ.

You’d have to be smart to walk this lazy, and people are

Research suggests that humans are wired for laziness

http://www.sciencedaily.com/releases/2015/09/150910131451.htm#.VfWquNKaf3s.facebook

Jessica C. Selinger, Shawn M. O’Connor, Jeremy D. Wong, J. Maxwell Donelan. Humans Can Continuously Optimize Energetic Cost during Walking. Current Biology, 2015; DOI: 10.1016/j.cub.2015.08.016

The “Dodgy Foot”, a UK runner’s dilemma.

We get “help me” emails from all over the world on a regular basis. Recently we received this photo from a runner in Oxford, UK,  The runner was frustrated, explaining a “dodgy foot”.  We like the word. 

dodg·y    däjē/

-dishonest or unreliable; potentially dangerous; of low quality.

We can guarantee you that the solution here to this runner’s form issue is not wholly at the foot which appears “in toed” and slanted and appears ready to kick the back of the right heel, not to mention the knees that are about to brush together.  Thus, merely working on their foot strike would be so remedial and corrupt that it would a crime. 

Ivo and I do not take on cases via the internet because we cannot give all the information because we cannot examine the client, many do offer such services but people are not being given the whole story and we pledged long ago not to be part of the problem.  Anyone who recommends exercises from things they see on a video gait analysis are basically doing the same disservice in our opinion. But sometimes, as in this case, their inquiry is simple, there is a photo or video and it allows us to highlight an important component of an individuals gait which can lead them on a road to appropriate discovery. This is one of those cases.  I will not be presenting a solution, because I do not have the examination information I need, but I will propose a solid thought process that further investigation may afford progress towards resolution.

This is a non-pathologic cross over gait in my mind until proven otherwise, there may be other sources, causes and components, but when it quacks like a duck you’d be silly not to check for webbed feet. This runner even confirmed upon questioning that the left foot scuffs the inside of the right ankle/shin often, both sides scuff in fact but more left shoe on right shin. No Einsteinian epiphany there. 

  • This means a narrow swing through  (adducting) left limb. 
  • This means stance and swing phase gluteus medius communication problems. 
  • This means swing leg foot targeting problems. 
  • This often suggests right, but sometimes both right and left, frontal plane pelvis sway problems which means pelvis control is challenged which means core lumbar stability control is challenged. 
  • This means adaptive arm swing changes from the clean norm.  
  • This does NOT mean this runner has pain, or pain yet, or maybe never will have pain but there are many determinants of that which I will discuss below. 

But, make no mistake, this is flawed gait mechanics. The left swing leg is clearly targeting a more medial placement, meaning limb adduction (active or passive or both is to be determined) and this is a product of the cross over gait (unfamiliar with the cross over gait ? SEARCH our blog for the term, you will need a few hours of free time to get through it all).  Some would call the cross over gait a lazy gait, but I would rather term it an efficient gait taken too far that it has now become a liability, a liability in which they can no longer stabilize frontal plane sway/drift. A wider gait on the other hand, as in most sprinters, is less efficient but may procure more power and the wider base is more stable affording less frontal plane drift. Just go walk around your home and move from a very narrow line walking gait to a wide gait and you will feel a more powerful engagement of the glutes. Mind you, this is not a fix for cross over gaits, gosh, if it was only that simple !

This runner must investigate whether there is right frontal plane drift, and if it is in fact occurring, find the source of the drift.  It can come from many places on either limb. (This client says they are scuffing both inside ankles, which is not atypical and so we likely have drift on both right and left). We have discussed many of them here in various places on the blog over the years. Now as for “Why” the foot looks in toed, well that can also come from many places. Quite simply the adducted limb once it leaves toe off can look like this. But, perhaps it is also a product of insufficient external rotation maintenance occurred during that left stance phase, affording more internal rotation which is being unchecked and observed here during early swing.  Remember though, if this is in fact a cross over gait result, in this gait the limb approaches the ground unstacked (foot is too far inside a left hip joint plumb line) the foot will greet the ground at a far lateral strike and in supination.  Pronation will thus be magnified and accelerated, if there is enough time before toe off. However, and you can try this on your own by walking around your home, put yourself in terminal stance at toe off. Make sure you have the foot inverted so you are toeing off the lateral toes (low gear toe off). Does this foot not look like the one in the photo ? Yes it does, now just lift the foot off the ground and you have reproduced this photo. And when combined with a right pelvis drift, the foot will sneak further medially appearing postured behind the right foot. 

Keep this in mind as well, final pronation and efficient hallux (big toe) toe off does often not occur in someone who strikes the ground on a far lateral foot. I am sure this runner will now be aware of how poorly they toe off of the big toe, the hallux.  They will tend to progress towards low gear toe off, off the lesser toes. This leaves the foot inverted and this is what you are seeing in her the photo above. That is a foot that is inverted and supinated and it carried through all the way through toe off and into early swing. It is a frequently component of the cross over gait, look for it, you will find it, often. 

Final thoughts, certainly this can be an isolated left swing phase gluteus medius weakness enabling an adducted swing limb thus procuring a faulty medial foot placement, but it is still part of the cross over phenomenon.  Most things when it comes to a linked human frame do not work in isolation.  But i will leave you with a complicating factor and hopefully you will realize that gait analysis truly does require a physical exam, and without it you could be missing the big picture problem.  What if she has a notable fixed anatomic internal tibia torsion on that left side. Yup, it could all be that simple, and that is not something you can fix, you learn to manage that one as a runner.  

* Side bar rant: Look at any google search of runners photos and you will see this type of swing limb foot posturing often, far too often.  And yes, you can take the stance that “I do it as well and i have no injuries or problems so what is the big deal?”.  Our response is often “you do have an issue, it may be anatomic or functional, but you do have an asymmetrical gait and you think it is not a problem, YET”. And maybe you will run till you are 6 feet under and not have a problem because you have accomodated over many years and you are a great compensator, yes, some people get lucky. Some people also do not run enough miles that these issues express themselves clinically so lets be fair. But some of these people are reality deniers and spend their life buying the newest brace or gadget, trying a different shoe insert, orthotic or new shoe of the month and shop over and over again for another video gait analysis expert who can actually fix their pain or problem. And then there are those who have a 45 minute home exercise program that they need to do to keep their problems at bay, managing, not fixing anything.  Or, they spend an hour a week on the web reading article after article on what are the top 4 exercises for iliotibial band syndrome for example. They shop for the newest Graston practitioner, the newest kinesio taping pattern, Voodoo bands, breathing patterns, compression socks etc.  And sometimes they are the ones that say they still dont have a problem.You get the drift.  Gosh darn it, find someone who knows what the hell they are doing and can help you fix the issues that are causing the problem.  And yes, some of the above accoutrements may be assistive in that journey. 

I have dealt with this unique toe off issue way too many times not to roll my eyes at it any longer. It is to the point that it is an automated evaluation and solution program that begins to run in my head. Once you see something enough times, you learn all of the variations and subtle nuiances that a problem can take on. But, trying to fit everyone into a similar solution model is where the novice coach, trainer or clinician will get into trouble. Trust us, it all starts with an examination, a true clinical physical examination.  If one leaves the investigatory process to a series of screens or functional movement patterns, “activation” attempts, digital gait analysis or strength tests one is juggling chainsaws and the outcome you want is often not likely to occur. There is nothing wrong with making these components part of the investigation process, but on their own, they are not enough to get the honest answer many times.  Of course, Ivo and i were not able to jump the pond and examine this runner with our own eyes and hands so today’s dialogue was merely to offer this runner some food for thought to open their mind to our thought process, in the hopes that they can find someone to help them solve the underlying problem and not merely make the gait look cleaner. Making someone’s walking or running gait look cleaner is not hard, but making it subconsciously competent and clean (without thought or effort) requires a fix to the underlying problem. We can ALMOST guarantee you that the solution here to this runner’s form issue is not wholly at the foot that looks in toed and slanted. Merely working on their foot strike would be so remedial and corrupt that it would a crime.

Dr. Shawn Allen, one of the gait guys

The smell of napalm in the morning: Your gait and trouser coughs, a clinical entity no one talks about.

This is our very last gait guys blog post. Yes, all good things come to an end, even this trusted blog.
But, keeping in good faith, we will finish on a strong note ……. One of gardenia and lavender.  Thanks for the last 5 years gait brethren, is has been a great ride.  Shawn and Ivo
_______________________________
The technical title of this blog post should have been, “The reactive influence of non-normopressure bowel distention and spontaneous high vapor dissipation on bipedal locomotion.”  but no one but true gait nerds would have read it had we stuck with this pubmed-type title. Yes, we are talking about farts and gait here today folks, buckle up.

One biomechanical principle we will link to this entity of “off-gassing“ is that excessive or sustained ankle plantarflexion could inhibit dorsiflexion and certainly, at the very least, works against it. We have talked about this often here on the blog and how the lack of ample ankle dorsiflexion can impair many of the biomechanical events higher up into the human frame. So, how can someone’s bowel gas translate into gait problems ?

Think about this …  to squeeze out a right “cheek sneak” (fart) with optimal crowd pleasing pitch and peak vibrato, some elevation and relaxation of the lower and middle gluteus maximus divisions (coccygeal and sacral) seems imperative to optimally control off-gassing . Seemingly, to do this, a significant degree of right ankle plantarflexion may be necessary to lift the right hemipelvis driving a subsequent intentional clockwise pelvic distortion assisting in the relaxation of these gluteal divisions.  This consciously driven right side of the body “lift” via the right ankle plantarflexion can also be met and assisted via ipsitlateral abdominal and contralateral gluteus medius contraction to further enable the optimal right hemipelvis elevation. Go ahead, stand up and mimic the posture and note these biomechanical pieces. Recall our mantra, 

“when the foot is on the ground, the glutes are in charge, when the foot is in the air, the abdominals are in charge”.  

These coordinated motor patterns might be considered dual/multi tasking. This honed series of biomechanical events is one often perfected in frat houses and basement gaming rooms. But make no mistake, there is a biomechanical danger lurking here if this becomes a habitual compensation pattern, one common in large volume legume consumers (beware vegans). Habituation of this motor task, or demonstrating poor technique over time can render right quadratus lumborum shortening and weak lower abdominals rendering an anterior pelvic tilt. This tilt may lead to gluteal inhibition/weakness (because it is difficult to contract the gluteals in an anterior pelvic tilt, go ahead stand up again and try it) which over time can impair stance phase gait mechanics. However, relating to the off-gassing, this physical posturing might optimize low frequency gluteal vibrations that can optimize vibrato during gas dissipation if pressurization is in fact optimal for an “audible”.  It is important to note that conscious variable control of the tonus of the muscular anal sphincter complex plays a big part in the pitch and vibrato. There is always a drawback it seems, it does truly come down to motor control it seems, doesn’t it always ?

This is not to say that avoiding “audibles” through holding “one” in doesn’t have consequences. The exotic gas (nitrogen, carbon dioxide, hydrogen, methane, oxygen) induced gut distention that could only make your collage roommate proud can inhibit the abdominal wall and thus the lower thoracic canister and disable normal breathing mechanics. This could be a serious complication to the coupled events of respiration and thoracic mobility. So, holding that big one in for your friends rather than engaging the compensatory Trendeleburg-type off-gassing posture as described above is also fraught with problems. We know that functional disconnection of the thoracic canister from the pelvic core can disrupt the normal anti-phasic mechanics of the contralateral upper and lower limbs as well as possibly impair the normal spinal cord mediated central pattern generators.

Farts…..Call them what you want, those ear pleasing, nose hair curling, trouser coughs that only a teenage boy can truly relish and recognize as a function of boyhood success.  All joking aside, they truly should be your biggest concern in your gait analysis evaluation, bar none. Ask your patients about their bowels and off-gassing, it should be part of your clinical history intake. Maybe even consider taking out the discomfort of open dialogue, and put it on your intake forms. We found that a stick figure diagram in a good biomechanical squat posture with a mushroom cloud formation hanging overhead eases dialogue tension about this sensitive topic. We even give the young children crayons to they can color the cloud. What fun !

Dare us to write a part two on this topic. “Blue Angels” (unfamilar with this clinical phenomenon? look it up). Go ahead, dare us for a part 2. 

By now, if you haven’t realized that The Gait Guys just punked you, then you likely haven’t had your cup of morning coffee. Yes, we have no clue what we were talking about on this blog post, well, ok maybe, after all we do have that y-chromosome. Yes, we are NOT ending the blog either 🙂 

Are you now considering us juvenile ? Ok maybe we are a little, but don’t deny it, you thought about some unique and honest body biomechanics for a moment here and it is these mental gymnastics that will take your creative thinking about gait to the next level. If you are upset, so be it. There will be no apologies here in this growing PC world. Off-gassing is a human thing, we all do it. We have been writing serious stuff daily for 5 years here on The Gait Guys. It was time for us to write something a little lighter.  We can only hope that you will think of us and the complexities of the gait cycle the next time you sneak one out while having dinner at the in-laws.  Try not to giggle when you do, but for certain, think about your body mechanics when you do, we can’t be responsible for off-gassing injuries. Think of us.

Shawn and Ivo, remaining here, for the duration.

disclaimer: we cannot be responsible for injuries that might be sustained by improper off-gassing events. We also do not recommend attempts at performing Blue Angels, this is a potentially dangerous activity and could cause great bodily harm (seriously). 🙂

How do your gluteus maximus and gluteus medius exercises stack up?

Looks like side planks (DL=dominant leg) and single leg squats scored big, as did front planks and good old “glute squeezes”

Check out this free full text articlehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201064/

Yes, we know it was surface emg; yes we know they are not necessarily testing functional movements. The EMG does not lie and offers objective data. Note that the one graph is labelled wrong and is the G max, not medius.

Kristen Boren, DPT,1 Cara Conrey, DPT,1 Jennifer Le Coguic, DPT,1 Lindsey Paprocki, DPT,1 Michael Voight, PT, DHSc, SCS, OCS, ATC, CSCS,1 and T. Kevin Robinson, PT, DSc, OCS1 ELECTROMYOGRAPHIC ANALYSIS OF GLUTEUS MEDIUS AND GLUTEUS MAXIMUS DURING REHABILITATION EXERCISES Int J Sports Phys Ther. 2011 Sep; 6(3): 206–223.