Take good look at these gals. The gal on the left (in blue) looks like she has a level pelvis, but look at the upper body. She’s leaning to the left and has a great deal of torso rotation backward. One of the clues is the abduction of her left arm. Also note how her right arm crosses across her body. We wonder how she looks in right foot stance.

The gal on the left (in red) has a subtle dip of the right side of her pelvis and also has over rotation of her upper body. Her right on crossing the body is a good reason to believe she will have a crossover gait if viewed from straight on.

While both of these gals may have adequate strength, we question how much endurance they have as well as available rotation in the hips and lumbar spine.

This is an excellent, referenced review of some of the current literature and controversy of strength and injury risk. A good read and certainly worth your time to get caught up on what’s current. We would love to see you study on endurance and injury risk.

“While muscle strength may improve tolerance of loads during running, another reason for inconsistencies in the reported relationships between strength and injury risk may be that strength is typically assessed isometrically. It’s unclear how much of an influence peak isometric strength has on the dynamic task of running, and specifically on prolonged running in the presence of muscular fatigue. Schmitz et al found that, while isometric hip strength values were similar between novice and experienced runners, hip internal rotation motion during running was higher in the novice runners, suggesting isometric strength may not correlate strongly with muscular control and kinematics during running.”

http://lermagazine.com/article/lower-extremity-strength-and-injury-risk-in-runners

Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

Do you know your stuff? Would you correct this child’s gait ? Give them orthotics, exercises, force correction, leave them alone ? 

Is he Internal Tibial torsioned ? Is he “pigeon toed” ,if that is the only lingo one knows, 😦  Does he have femoral torsion ?  A pronation problem locally at the foot or an internal spin problem through the entire limb ? Or a combination of the above ? 

What’s your solution?

It MUST be based on the knowledge necessary to fix it, not the limits of YOUR knowledge. You can never know what to do for this lad from his gait evaluation, no matter how expensive your digital, multi-sensor, 3D multi-angle, heat sensor, joint angle measuring, beer can opening, gait analysis set up is. You can never know what to do for this lad if you do not know normal gait, normal neuro-developmental windows, normal biomechanics, know about torsions (femoral, tibial, talar etc), foot types etc.  It is a long list.  You cannot know what to do for this kid if you do not know how to accurately and logically examine them. 

Rule number 1. First do no harm.

If your knowledge base is not broad enough, then rule number one can be easily broken ! Hell, if you do not know all of the parameters to check off and evaluate, you might not even know you are breaking rule number one !  If everything looks like a weak muscle, every solution will be to “activate” and strengthen and not look to find the source of that weakness.  Muscles do not “shut down” or become inhibited because it is 10 minutes before practice or because it is the 3rd Monday of the month. You are doing your client a huge disservice if you think  you are smarter than their brain and activate muscles that their brain has inhibited for a reason. What if it were to prevent joint loading because of a deeper problem ?  If every foot looks flat and hyper pronated, and all you know is orthotics or surgery or shoe fit, guess what that client is prescribed ? If all you see is torsions, that is all you will look to treat. If all you see is sloppy “running form” and all you know is “proper running form” forcing your client into that “round peg-square hole” can also lead to injury and stacking of compensation patterns.  

One’s lack of awareness and knowledge, are one’s greatest enemies. If you don’t know something exists, because you’ve never studied or learned it, how can you be aware of it ? If you’re not spending enough time examining a client, you might not be aware of an issue even though you may be knowledgeable about the issue.
One must have both awareness and knowledge. One must also be aware that compensations are the way of the body. What you see is not your client’s problem. It is their strategy to cope.

Are you helping your client ? Hurting them ?  Adding risk to their activity ? Are you stepping beyond your skill set ?  

Rule Number 1: First do no harm. 

Shawn and Ivo

PS: we will get to this case another time, we just wanted to make a point today about the bigger problems out in the world.

the gait guys

How injury and pain reorganize the brain.

Gait, Arm Swing and Reorganizing the Brain

When we injure a body part there is a price to pay, how expensive it will be is entirely up to you. Upon injury, the brain takes note and typically dives into a backup plan of neurologic inhibition, neuro-protective tightness and alteration of motor patterns to protect that injured area and allow it to heal. Moderating and altering the forces and demands upon said tissues is the goal to enable healing, if we as humans, don’t get in the way first (“I have to get that run in, I am behind in my training with all these injuries !” or “Ah, its still not that bad, the pain wasn’t worse on Tuesday’s run, I will be ok.”). The bigger question for most folks is, will you listen to what your body is asking of you? Heed the warnings and messages, and your injury will come and go in a timely manner, ignore the messages and welcome to a chronic festering problem.

These protective mechanisms need to be in place, we just have to listen to them.  Failure to heed their warnings to dial things back and rest, recover and heal, the brain will make alternative changes out of necessity.

In the medpage today article in the references below, the authors discuss several important things.

“Getting a cast or splint causes the brain to rapidly shift its resources to make righties function better as lefties, researchers found.
Right-handed individuals whose dominant arm had to be immobilized after an injury showed a drop in (brain) cortical thickness in the area that controls primary motor and sensory areas for the hand, Nicolas Langer, MSc, of the University of Zurich in Switzerland, and colleagues reported.
Over the same two-week period, white and gray matter increased in the areas that controlled the uninjured left hand, suggesting “skill transfer from the right to the left hand,” the group reported in the Jan. 17 issue of Neurology.
The findings highlight the plasticity of the brain in rapidly adapting to changing demands, but also hold implications for clinical practice, they noted.”

This article highlights the rapid changes in motor programs that occur. It does not take long for the body to begin to develop not only functional adaptations but neurologic changes at the brain level within days and certainly less than 2 weeks.

So how long have you been in this pain ? If someone has to ask you this question, the process has already begun.

We tell our patients, if pain does not go away fairly quickly, that we need to get on top of the injury quickly. That is not to say you need to reach for the phone every time you have pain but you need to heighten your awareness of the injury’s status and  you need to make sure you are not driving session after session of training into a festering injury. If you do not let something heal and recover, the brain will find a way around it.  And it will imprint that new motor pattern into hard wiring, and into the hard wiring of other patterns, if you do not heed the warning signs.  This new wiring is a compensation pattern. And the longer it is there the more the neurologic pattern becomes embedded by layerings of myelin coating.  Which means that in the future, if you fatigue or injury another local tissue, this old compensation pattern is waiting in the shadows looking for an opening to rear its ugly head for old times sake.

Furthermore, on the topic of asymmetry, the above concept holds strongly true. In our clinics, we recognize asymmetry as a strong clinical finding. Despite the  Lathrop-Lambach study below, mentioning that they feel a 10% baseline asymmetry is the norm, if you do not rehab and correct both an injury and its new neurologic hardwiring changes, you have enabled and welcomed asymmetry. We feel, as many others do, that asymmetry can be a major component and predictor to injury. Logically, restoring as much symmetry as possible, both biomechanically and neurologically, is restorative and protective.

Don’t be a stoic knucklehead. Get your stuff fixed by someone who knows what they are doing. And remember, watching your gait on a treadmill or through some high tech gait analysis software and making recommendations from that information is just plain idiotic. Go see someone smart who can correlated it to examination findings. 

This article pertains to athletes and non-athletes of all walks of life. From 5 to 105 years of age, we are all susceptible to the brain’s overriding mechanisms. 

Shawn and Ivo

references:

1. Broken arm can reorganize the brain.

http://www.medpagetoday.com/Neurology/GeneralNeurology/30686

Gait Posture. 2014 Jul 1. pii: S0966-6362(14)00610-9. doi: 10.1016/j.gaitpost.2014.06.010. [Epub ahead of print]
Evidence for joint moment asymmetry in  healthy populations during gait.
“We found a high amount of asymmetry between the limbs in healthy populations. More than half of our overall population exceeded 10% asymmetry in peak hip and knee flexion and adduction moments. Group medians exceeded 10% asymmetry for all variables in all populations. This may have important implications on gait evaluations, particularly clinical evaluations or research studies where asymmetry is used as an outcome. Additional research is necessary to determine acceptable levels of joint moment asymmetry during gait and to determine whether asymmetrical joint moments influence the development of symptomatic pathology or success of lower extremity rehabilitation.”

Making a list and checking it twice…

So you or someone you are treating/coaching/ rehabbing, etc has muscle weakness, either perceived by them or noted by you, by observation or muscle testing. Have you stopped to think what might be causing the weakness?

Cross sectional area is directly proportional to strength. With strength, we are talking predominantly about Type II muscle (remember, Type I is predominantly endurance muscle, due to differing histological structure).  Type II muscle fibers are larger, have fewer capillaries, less myoglobin, fewer mitochiondra . They obtain most of their energy by anaerobic glycolysis, rather than aerobic respiration  (ie the Krebs cycle).  All muscles are made of a mixture of Type I and Type II fibers, but most muscles tend to have a predominance of one over the other. Here we are referring to strength.

There are many causes of muscle weakness. Here are a few:

  • Injury to the muscle
  • Injury to the joint the muscle crosses
  • Stretch weakness
  • Tight weakness
  • Neurogenic weakness
  • Myopathic weakness
  • Reflexogenic weakness
  • And the list goes on…

The 1st one on the list is an easy one to understand. If you break the machine, it doesn’t work. Torn contractile proteins with leaky sarcoplasmic reticulum (calcium reservoirs) do not allow for efficient contractions.

The second on the list is a bit more complex.

We remember that that the joint capsules are blessed with four types of mechanoreceptors, aptly named Type I, II, III, and IV, which when stimulated physically, chemically, or thermally apprise the nervous system of the forces acting on that joint as well as its position in space. For a great video review of mechanoreceptors, click here

Joint pathology or inflammation will often cause distention of its capsule. The effect of the resulting joint effusion on the actions of the muscles crossing that joint have been examined extensively in the literature. Let’s look at one of the studies and its implications.

Reflex Actions of Knee Joint Afferents During Contraction of the Human Quadriceps

Iles JF, Stokes M, Young A: Clinical Physiology (10) 1990: 489-500

In this paper, the authors infuse hypotonic saline into the knees of eight asymptomatic individuals (including one of the authors) using a 16 gauge needle (ouch!) and studied its effects on the H reflexes and muscle recruitment. An H reflex is like performing a tendon jerk reflex (the involuntary contraction you would check with a neurological hammer) using an electrical stimulus. The onset time (also called the latency) and its amplitude are recorded. Muscle recruitment is the voluntary contraction of that muscle, measured with electromyography (EMG) by having an electrode either over (surface EMG) or within (needle EMG) the muscle and examining how hard the muscle is working based on the amplitude and frequency of the response.

First of all, no one in the study experienced any pain (hmmm, not sure about that) , only the sensation of pressure in their knees (which was considered activation of only the proprioceptors of the joint). The authors found that any pressure increase within the joint capsule depressed the H reflex and inhibited the action of the quadriceps. They hypothesize that this may contribute to pathological weakness after joint injury.

So how does all this apply to us?

As we all know, lots of patients have joint dysfunction. Joint dysfunction leads to cartilage irritation, which leads to joint effusion. This will inhibit the muscles that cross the joint. This causes the person to become unable to stabilize that joint and develop a compensation pattern. Next the stress is transferred to the connective tissue structures surrounding the joint which, if the force is sufficient, will fail. Now we have a sprain and some of the protective reflexes can take over. Abnormal forces can now be translated to the cartilage. This, if it goes on long enough,  can perpetuate degeneration, which causes further joint dysfunction. The cycle repeats and if someone doesn’t intervene and control the effects of inflammation, restore normal joint motion and rehabilitate the surrounding musculature, the patient’s condition will continue its downward spiral, becoming another statistic contributing to the tremendous economic and physical costs of an injury.

And that, my friends, is one mechanism as to how joint effusion disturbs the homeostasis of the musculature surrounding a joint.

In future posts, we will examine other causes of muscle weakness. For now, make a list of possible causes before assuming it is just injured or “turned off”. Compensations happen for a reason, and if you remove someone’s compensation pattern, you had better make sure you have another one up your sleeve and that their system is ready for a change.

The Gait Guys. Giving you the tools so you can be better. Period. 

Just because a muscle tests weak doesnt mean it needs activated.

To Activate or Not Activate: That is the question…

Just because a muscle tests weak does not mean it can, should or needs to be activated.

Muscles become inhibited for many reasons.  Perhaps it is being forced into a substitution or compensation pattern because the primary motor pattern is not accessible.  Perhaps it is because there is a local inflammatory response (ie injury) near by or within the muscle. Perhaps the muscle is lacking in one or several of its primary tenants, S.E.S. (Skill, Endurance, or Strength). Perhaps the joint(s) that muscle crosses are arthritic, inflamed, damaged, remember that an inflamed joint does not like compression/loading. When a muscle contracts it will increase compression across the joint surfaces. Maybe it is being reciprocally inhibited by it’s antagonist, or does not have appropriate sensory feedback from its mechanoreceptors and is neurologically inhibited. The nervous system is wired with many “faults”, which shut things down. Often times, you need to explore the reason why.

So…What happens if you decide to “activate” the muscle regardless of any of the above, which should have been clearly determined by a clinical examination ?

You very well could be forcing that muscle back on the grid encouraging the muscle to perform in an unsafe or undesirable environment. You may be forcing compressive loading across a joint that is inflamed. You could be forcing compression and shear across a damaged cartilage interface, an osteochondral defect, a ligamentous tear or a combination of the above.  You will also be over riding the nervous systems inherent neuro-protective mechanism and by forcing the muscle to once again activate and work in a faulty movement pattern.  You very likely are reprogramming an unsafe and potentially damaging motor pattern.

Remember, when you “mess around” and over ride neuro-protective inhibition of a motor pattern you reteach a potentially dangerous sensory response telling the joint that the nervous system has been mistaken, that it is actually safe to place load and shear across the joint when in fact it is dangerous. Protective reflexes are there for a reason, to protect you!

We have seen the results of well intentioned or sometimes untrained individuals implementing activation into their clinical practices, coaching, or training.  Without a sound clinical examination to determine the reason for muscle inhibition one is taking a whole pile of warning signs and throwing them to the wind.  Remember, if you force a muscle back into activation despite all of the warning signs and reasons for inhibition, you will get a temporarily stronger muscle. This is not necessarily success.

In fact, what you have done, is enabled your client the ability to once again impart load and shear across a joint(s) and motor chain that was getting clear central nervous system signals to avoid the loading response.  You are essentially forcing a  compensation pattern and we all know where that leads to. 

As clinicians, we take an oath that states: “Primo Non Nocere”, which means “first, do not injure”. Know what you are doing. If you don’t, then get the training or don’t do it.

The Gait Guys. Were are here to help. We are watching. Do us proud and do the right thing.

Just because a muscle tests weak doesnt mean it needs activated.

To Activate or Not Activate: That is the question…

Just because a muscle tests weak does not mean it can, should or needs to be activated.

Muscles become inhibited for many reasons.  Perhaps it is being forced into a substitution or compensation pattern because the primary motor pattern is not accessible.  Perhaps it is because there is a local inflammatory response (ie injury) near by or within the muscle. Perhaps the muscle is lacking in one or several of its primary tenants, S.E.S. (Skill, Endurance, or Strength). Perhaps the joint(s) that muscle crosses are arthritic, inflamed, damaged, remember that an inflamed joint does not like compression/loading. When a muscle contracts it will increase compression across the joint surfaces. Maybe it is being reciprocally inhibited by it’s antagonist, or does not have appropriate sensory feedback from its mechanoreceptors and is neurologically inhibited. The nervous system is wired with many “faults”, which shut things down. Often times, you need to explore the reason why.

So…What happens if you decide to “activate” the muscle regardless of any of the above, which should have been clearly determined by a clinical examination ?

You very well could be forcing that muscle back on the grid encouraging the muscle to perform in an unsafe or undesirable environment. You may be forcing compressive loading across a joint that is inflamed. You could be forcing compression and shear across a damaged cartilage interface, an osteochondral defect, a ligamentous tear or a combination of the above.  You will also be over riding the nervous systems inherent neuro-protective mechanism and by forcing the muscle to once again activate and work in a faulty movement pattern.  You very likely are reprogramming an unsafe and potentially damaging motor pattern.

Remember, when you “mess around” and over ride neuro-protective inhibition of a motor pattern you reteach a potentially dangerous sensory response telling the joint that the nervous system has been mistaken, that it is actually safe to place load and shear across the joint when in fact it is dangerous. Protective reflexes are there for a reason, to protect you!

We have seen the results of well intentioned or sometimes untrained individuals implementing activation into their clinical practices, coaching, or training.  Without a sound clinical examination to determine the reason for muscle inhibition one is taking a whole pile of warning signs and throwing them to the wind.  Remember, if you force a muscle back into activation despite all of the warning signs and reasons for inhibition, you will get a temporarily stronger muscle. This is not necessarily success.

In fact, what you have done, is enabled your client the ability to once again impart load and shear across a joint(s) and motor chain that was getting clear central nervous system signals to avoid the loading response.  You are essentially forcing a  compensation pattern and we all know where that leads to. 

As clinicians, we take an oath that states: “Primo Non Nocere”, which means “first, do not injure”. Know what you are doing. If you don’t, then get the training or don’t do it.

The Gait Guys. Were are here to help. We are watching. Do us proud and do the right thing.