Pronating around internal hip rotation loss.

This is a remedial principle, but it is always nice to capture it on video like this. Watch this clients left foot. On initial impressions you might just say too much foot pronation, and you would be right. Some of you might say abductor-adductor twist of the foot. These are all correct. But, if we told you that this was a hip complaint client, and lack of internal hip rotation this foot action should be a simple 60Watt “light bulb moment” (translation: “epiphany”), certainly not a 100Watt moment (but for some it might be).  

This client cannot internally rotate through the hip adequately, so they have found the opposite end of the limb to internally rotate through.  They collapse through the arch/tripod, which essentially in the crudest of analogies “internally screws the limb” into the ground.  They are finding internal femur rotation through foot pronation.  Internal hip rotation is being achieved from a bottom up process if you will. Pronation through the foot complex is adduction, medial rotation and plantarflexion of the talus which will carry the tibia (and thus the femur) with it into internal rotation.  There is a problem in many clients who find that extra little bit of rotation at the hip via a foot/ankle cheat.  That problem is one of corruption of the pelvis antiphasic motion of the pelvis, they will most often dump the same hip laterally and thus drift into the frontal plane instead of achieving the antiphasic motion of the pelvis.  This will decouple the rotation of the torso in the opposite rotation of the pelvis, and thus begin the corruption of arm swing.  Want to take it another level deeper ? Ok, eat this for lunch……. asymmetrical thoracic rotation from side to side will set up. This will mean more work through scapulothoracic stabilization and cervical rotation on the side of the thoracic rotation deficit.  Still not deep enough ? Ok, evaluate their respiration symmetry.   Too many are doing respiratory work before hip rotation is clean and symmetrical, especially during gait that necessitates 1000′s of engraining steps a day.  If the hips are not clean, gait is not clean, and that means repetitive arm swing-thoracic-respiratory mechanics are not clean.

If you want to truly fix someones rooted problems, you have to be willing and able to go down the rabbit hole. 

Shawn Allen, one of the gait guys

Here is a great case from a reader.

“Hey guys, I absolutely love the show, especially as it becomes less and less over my head.

Due to your love of gait-altering absurdly thick EVA midsoles, I thought you might like to check out this Hoka incident that occurred at the Marathon des Sable across the Sahara in Morocco, a 6 day 251km event. It was posted by Ian Corless at Talk Ultra Podcast. Apparently the medial side of the midsole collapsed—on DAY 2! This guy finished the race, and as you have to carry 100% of your gear and nutrition, I guess he only had the one pair. It looks like this runner should fly out to CO or IL asap, because if he didn’t have gait issues before, he is sure to have them now.”

This brings up some scary thoughts when it comes to the amount of EVA foam and quality of foam (EVA or otherwise) being used in some shoes.  ”The more foam there exists, the greater one can break down into their compensation or deforming strategy.” What do we mean by this ?  Well, two things should be on one’s mind:  1. all foam breaks down into the vector of the deforming forces and 2. most of us do not have perfectly clean biomechanics, thus an abnormal loading vector is most likely present. These aberrant biomechanics are eventually reflected into our shoes as a “wear pattern”.  In this case, the EVA foam had progressively broken down into their rearfoot pronation (and likely mid and forefoot pronation). In this case, even if the person had enough tibialis posterior and other medial pronation-decelerating structure strength at the start, the acceleration of their foot into this issue is now even more abrupt, brisk, excessive etc.  A new pair of shoes would not be broken down into this deformity and so a newer pair of shoes is preventive. This is why we recommend new shoes often, and the cycling in of another pair (or several pair) into the mix so that one is never driving the same shoes into the potentially destructive compensation patterns that most of us  have.  At least with a fresh pair of shoes brought into the mix at the 200 mile wear point, you would only be in the more destructive shoes every other run, giving the body time to recuperate more. 

As for this pair of shoes, this runner either has a terrible right foot problem or this was a brutally flawed right shoe from the get go, or both. We can only imaging how painful the medial knee might be at this point.  Furthermore, imagine the abrupt nature of the hip internal rotation mechanics ! IF they do not have hip labrum impingement yet, they will soon !  And with that amount of internal limb spin, can you imagine how inhibited the glutes would be from constantly having to eccentrically control that excessive rotation? 

As a whole, are not huge fans of the HOKA shoe family, we just cannot fathom the need for this much foam under the feet. If you have been with us long enough you will have heard on our podcast and blog talk about increased impact forces with increasing EVA foam thickness (want that info, here is the link and references). Just because some EVA foam is good, doesn’t mean more is better.  Remember, to propulse off of a foam infrastructure you must bottom out/compress the foam sufficiently to find a firmness to propulse from. The Hoka’s have plenty of foam making this our concern, and we are not picking on just them. There are other companies doing this “super sizing/super stacking” such as Brooks, Altra, and New Balance to name just a few.  Sure they have added a greater forefoot rocker/toe spring on the front of the shoe to help (they have to because the foam thickness is so great that there is no flexing of the forefoot of the shoes), but is it enough for you? Remember, every biomechanical phase of the gait cycle is necessary and timely to engage the natural joint, ligament, muscle components of joint loading, mobility, stability and movement. If you spend too much time in one phase (perhaps because you are waiting for foam to decompress) you may wait a moment too long and miss the opportunity for another critical phase to begin in the sequence.  This is the root cause of many injuries, aberrant biomechanics leading to aberrant mobility or stability. 

So remember these few things:

1. more is not always better for you, it may be for some, but maybe not you.

2. there is a price to pay somewhere in the mechanical system, after all the body is a contained system. What doesn’t happen at one joint often has to be made up at the next proximal or distal joint.

3. Everyone has some aberrant mechanics. No one is perfect. These imperfections will reflect in your shoes, and the longer you are in a pair of shoes the deeper the aberrant mechanics will be reflected in your shoe, thus acting as a steering wheel for the aberrant pattern (the steering is more direct/ more aggressive than in a new pair of shoes). So keep at least 2 pair of shoes rotating in your run cycle, one newer and one half done. We even recommend 3 pairs often.  Trust us, the sudden biomechanical shift from a dead shoe into a new one (even though it is a clean new shoe without bad patterns in it) is still a biomechanical shift and could cause adaptive phase problems, pain or injury.

Lots to consider in this game. It is not just about dropping into barefoot and taking off down your street. Not if you want to be doing this for a long time and stay healthy.

Shawn and Ivo, the gait guys

* next day follow up from our social media pages:

Along the lines of EVA and yesterdays post: 

“Wear of the EVA consistently increased heel pad stresses, and reduced EVA thickness was the most influential factor, e.g., for a 50% reduction in thickness, peak heel pad stress increased by 19%. “

This study looks at a model; it would be interesting to see this study with a large cohort.

Biomed Mater Eng. 2006;16(5):289-99.

Role of EVA viscoelastic properties in the protective performance of a sport shoe: computational studies.

Even-Tzur N1, Weisz E, Hirsch-Falk Y, Gefen A.

http://www.ncbi.nlm.nih.gov/pubmed/17075164

Ankle Dorsiflexion: Even in sprinters who land on the forefoot often heel strike, a retrograde strike if you will.

Many people think of heel strike followed by midfoot/tripod contact phase followed by ankle dorsiflexion, aka ankle rocker.  Heel strike is normal in the walking gait cycle. In some runners, depending on foot type, strength, flexibilty and several other factors, heel strike may be considered normal and may be essential for normal injury free mechanics. However, in recent years we tend to see the media and research investigate a midfoot or forefoot strike pattern. If you have been here with us on TGG for a year or 2-3 you will know we are big advocates of a midfoot strike pattern for several reasons which we will not go into again in this article. (Feel free to SEARCH our blog for MIDFOOT strike articles).  

However, one rarely sees anyone or any source talking about the retrograde heel contact when forefoot strike patterns are used.  Here, in this video, you can see several of these top level athletes who are trying to go forward at top end speed, but who are tapping the heel down on many loading responses. This can be thought of as a retrograde movement and could in a biomechanical way of thinking be considered non-productive. In other words, they are trying to move forward and yet the heel is touching down which is a backwards movement. This point can be argued but that is not the point of this article. The point that we are trying to make is that in order to drop the heel down, and especially if the heel touches, that the runner had better have sufficient ankle rocker/dorsifleixon otherwise the arch may be asked to collapse via excessive pronation (to perform the heel tap) which will drive an internal spin movement when the leg is supposed to be externally rotating to a rigid supinated foot for propulsive toe off. This negative scenario is a huge power leak for a sprinter, or any runner for that matter when they are ramping up speed.  

So, why does this happen ?  Well, for some it can help to load the posterior mechanism, the gastrocsoleus-achilles complex for conservation and power conversion.  It also enables more hip extension and thus more gluteal function. Longer stride means more efficient and greater arm swing which is a huge accessory power source for a sprinter. This also lengthens the stride, they feed off of each other. There are many benefits, if you have sufficient ankle rocker range in the ankle to begin with.  In some runners who do not have the requisite ankle rocker range, you may often see the increased foot progression angle and external limb spin and/or the dreaded adductor twist of the heel (aka  abductory twist of the foot).  These are strategies to get more hip extension and more gluteal function without finding it via the ankle dorsiflexion, where you want to see it.  Remember, the body is a brilliant compensatory and substituter. If the body cannot find a range at one joint it will find it at the next proximal or distal joint. And when that loss is at the ankle, motor patterns options dictate you either find it at foot pronation or hip extension.

Maybe, just maybe we should have called this blog article “Can you hold the foot tripod all the way through the stance phase, even through retrograde heel touch down ? If you cannot, trouble could be on the horizon. ”  But that is a really dumb title.  

Shawn and Ivo

the gait guys

Podcast 47: The Thigh Gap & Medial Tibial Stress Syndrome

Podcast 47 is live !

Topics: Lots of cool stuff for your ears and brains today. Don’t miss this show on Allen’s Rule Part 2, ankle biosensors, Parkinson’s syndrome gait disorder, Medial Tibial Stress Syndrome, The Thigh Gap disorder, and the ever confusing and much debated Abductory Heel Twist in walking and in runners. Don’t miss this show !

A. Link to our server:

http://thegaitguys.libsyn.com/podcast-47-the-thigh-gap-medial-tibial-stress-syndrome

B. iTunes link:

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

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

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

________________________________________

* Today’s show notes:

Neuroscience piece
1. Update on Allen’s Rule blog post:
2. Could a simple ankle sensor help with parkinsons symptoms ?
3. Probiotics Boost Running Performance in Heat
5 Gait Factoid:  the foot abductory twist
6.  Note from melissa on her 9 month leg pain.
Disclaimer 
7 . National Shoe Fit Program
8 . medial tibial stress syndrome
9. from a blog reader:
The thigh-gap obsession is not new but it’s the most extreme body fixation yet

The Solitary Turned out Right foot in a Barefoot Runner: Part 2

Here is a perfect example why we sometimes cringe when someone comes into our office with pain or problems and wearing minimalist shoes or worse yet, claims to be a barefoot runner.  This is a perfect example of a client, whether they are in your shoe store or in a medical office, that needs to be convinced to remain in their more stable trainers until the problem is unwound. 

In this video it is plain for anyone to see that the right foot/lower limb is clearly externally rotated and pronating excessively when compared to the left side.  This could be from weakness of the gluteus medius, loss of internal rotation or one of several other biomechanical flaws (be sure to review Dec 15th blog post on these topics ). However, it could also be anatomic.  This could be from external tibial torsion or a torsion at the femur.  Regardless, it is likely creating a functional short leg on the right because when we pronate heavily like this, the height of the talus and arch drops further than normal, and in this case further than the other side.  However, one could argue the opposite, meaning that this person is pronating heavily on the right to shorten that leg to be equal to an already shorter left leg. In order to know, and not guess, you have to assess your client.  As indicated above, the internal limb spinning pronation could be a compensation to gain more entire limb internal rotation from a loss of hip rotation. Yes, there could be many causes. In this latter case, prescribing an orthotic to dampen this pronatory excess would be a mistake for the hip even though it would be a logical intervention at the foot level.  Our direction would be to find the cause of the right limb turn out and hyperpronation.  Video gait analysis and guessing will not get you there.  You have to assess your clients neuromuscular ability and deficits.  If one were to bet on impaired internal hip rotation, a fairly high probability bet, then how many internal rotators of the lower limb can you name immediately without looking them up ? You will need this info at the tips of your fingers in an exam if you are going to prove or disprove the internal hip rotation theory.  Here are a few to get you started:

  • vastus lateralis
  • TFL-ITB
  • anterior head of gluteus medius
  • reflected head of rectus femoris
  • adductor brevis
  • coccygeal division of gluteus maximus
  • how many others can you name and accurately test so that you are not guessing when it comes time to assess your client ?

Welcome to the complex game we play every day with our athletes and “every day Joe’s”. It is a brain knocking game, and  you have to juggle many factors while sorting it out. ! Tomorrow we will talk a little about possible problems of Functional Screens and how they can be used to help assess, but also how they can fool you.

Have a good Monday gang….. and watch for the rampant spreading plague of the turned out foot.  It is nationwide already !

Shawn and Ivo, The Gait Guys

Hip rotation and knee pain. What we have been saying.

We have been pounding the floor on this topic on and off for the last 6 months it seems.  Lack of internal hip rotation or too much internal hip rotation ……. both abnormal hip kinematics, is a result of reduced hip-muscle performance as opposed to structural issues of the hip (anteversion, retroversion etc).

If you are not assessing for impaired hip muscle function in your knee patients, you could be missing the boat …….. and it is a big boat…… Titanic in size.

Don’t be like so many others and be tunnel visioned when you have a knee patient, expand your vision, at least to the hip and foot. 

We are……. The Gait Guys……. Shawn and Ivo

________________________________________________________________________________

Am J Sports Med. 2009 Mar;37(3):579-87. Epub 2008 Dec 19.

Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain.

Souza RB, Powers CM.

Musculoskeletal and Quantitative Imaging Research Laboratory, Department of Radiology and Biomedical Engineering, University of California, San Francisco, California, USA.

Hip rotation and knee pain. What we have been saying.

We have been pounding the floor on this topic on and off for the last 6 months it seems.  Lack of internal hip rotation or too much internal hip rotation ……. both abnormal hip kinematics, is a result of reduced hip-muscle performance as opposed to structural issues of the hip (anteversion, retroversion etc).

If you are not assessing for impaired hip muscle function in your knee patients, you could be missing the boat …….. and it is a big boat…… Titanic in size.

Don’t be like so many others and be tunnel visioned when you have a knee patient, expand your vision, at least to the hip and foot. 

We are……. The Gait Guys……. Shawn and Ivo

________________________________________________________________________________

Am J Sports Med. 2009 Mar;37(3):579-87. Epub 2008 Dec 19.

Predictors of hip internal rotation during running: an evaluation of hip strength and femoral structure in women with and without patellofemoral pain.

Souza RB, Powers CM.

Musculoskeletal and Quantitative Imaging Research Laboratory, Department of Radiology and Biomedical Engineering, University of California, San Francisco, California, USA.