So you think you are an iliotibial band syndrome guru ?  This study has some interesting provoking thoughts about the mechanics we have all previously assumed. It is good to challenge established teachings, for it is only through interrogating old ways that we may see the true light of things.
The iliotibial band (ITB) syndrome is a common overuse injury that is commonly misunderstood. It has been regarded as a friction syndrome where the ITB rubs against he lateral femoral epicondyle because of its previously assumed variable function, below 30 degrees knee extension it has been though to act as an extensor of the knee, and above 30 degrees (ie more knee flexion) it has been thought to act as flexor.  It is thought to be a culprit (with the biceps femoris) of the shift phenomenon in the “pivot shift test” for posterolateral rotatory instability of the knee (PLRI).  Here is an interesting perspective from a 2006 journal article.
“In all cadavers, the ITB was anchored to the distal femur by fibrous strands, associated with a layer of richly innervated and vascularized fat. In no cadaver, volunteer or patient was a bursa seen. The MR scans showed that the ITB was compressed against the epicondyle at 30° of knee flexion as a consequence of tibial internal rotation, but moved laterally in extension. MR signal changes in the patients with ITB syndrome were present in the region occupied by fat, deep to the ITB. The ITB is prevented from rolling over the epicondyle by its femoral anchorage and because it is a part of the fascia lata. We suggest that it creates the illusion of movement, because of changing tension in its anterior and posterior fibres during knee flexion. Thus, on anatomical grounds, ITB overuse injuries may be more likely to be associated with fat compression beneath the tract, rather than with repetitive friction as the knee flexes and extends.”
We found this article interesting because it challenges many thoughts about its actual movement, (“it creates an illusion of movement”) because of changing of tension in the anterior and posterior fibres. As this article suggests, it is unlikely that there is any forward and backward motion of the band over the epicondyle during flexion and extension, rather the illusion of movement is from a gradual shifting of load to and from the anterior and posterior fiber bundles during flexion/extension. It is also an interesting article to us because it suggests and challenges that the clinical phenomenon is associated with fat compression rather than friction over the epicondyle.  The authors go into discussion of how the fat beneath the distal ITBand at the knee level is well vascularized and that Pacinian corpuscles can be present in adipose tissue supporting the view that fat compression may have a proprioceptive role and a roll in pain production when the corpuscles undergo hypertrophy in such a clinical setting.
Just remember what we have been saying all along when treating what you think are lateral chain problems, the ITBand receives most of the tendon of the gluteus maximus so do not forget to examine the hip and pelvis function, but so not forget the critical contribution that impaired foot and ankle function can have proximally at the knee.
This study has some interesting provoking thoughts about the mechanics we have all previously assumed. It is good to challenge established teachings, for it is only through interrogating old ways that we may see the true light of things.
If you are looking for more of our thoughts on this topic, we discussed a clinical case in our last podcast (link here). 
Shawn and Ivo, 
the gait guys
Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. Journal of Anatomy 2006;208(3):309-316. doi:10.1111/j.1469-7580.2006.00531.x

Saucony: Line Running and Crossing Over

We are big fans of the Saucony line of shoes. We have recommended them to our novice and serious runners for decades now. Currently one of our favorite shoes for our runners is the Saucony Mirage, a beautiful 4mm ramp shoe with no bells and whistles.  It is as close to a perfect zero drop that  you will find without going zero, in our opinion.  That is not to say there are not other great 4mm shoes out there, the Brooks Cadence and the New balance minimus are other beautiful 4mm’s out there.  The Mirage has never failed a single client of ours.  

This was a photo we screen captured from the Saucony Facebook page (we hope that for the sake of educating all runners and athletes that we can borrow this picture for this blog post, please contact us if you would like us to remove it). It is a good page, you should follow it as well.  This picture shows not only a nice shoe but something that we have been talking about forever.  The cross over; this runner is running in such a line that it could be argued that the feet are crossing the mid line. In this case, is the line queuing the runner to strike the line ? Careful of subconscious queues when you run, lines are like targets for the eyes and brain.  One thing we like to do with our runners is to use the line as training however, a form of behavioral modification.  When you do a track workout, use the line underneath you, but keep the feet on either side of the line so that you learn to create that little bit of limb /hip abduction that helps to facilitate the hip abductor muscles.  This will do several things, (and you can do a search here on our blog for all these things), it will reduce the reflexive tightening of the ITBand (pay attention all you chronic IT band foam rolling addicts !), it will facilitate less frontal plane pelvis sway, optimal stacking of the lower limb joints, cleaner patellofemoral tracking and help to reduce excessive pronation /internal limb spin effects.  

There is really nothing negative about correcting your cross over, IF it truly needs correcting.  That is the key question.  Some people may have anatomic reasons as to why the cross over is their norm, but you have to know  your anatomy, biomechanics and neuromechanics and bring them together into a competent clinical examination to know when the correction will lead to optimal gait and when it will drive suboptimal gait. Just because you see it and think it is bad, does not make it so.  

New to this cross over stuff ? Head over to the search box here on our blog and type in “cross over” or “cross over gait” and you will find dozens of articles and some great videos we have done to help you better grasp it. 

* you will also note that this runner is in an excessive lateral forefoot strike posturing.  This means that excessive and abrupt prontation will have to follow through the mid-forefoot in order to get the medial foot tripod down and engaged.  The question is however, is what you are seeing a product of the steep limb angle from the cross over, or does this runner have a forefoot varus (functional or anatomic, rigid or flexible)?  Are the peronei muscles weak, making pre-contact foot/ankle eversion less than optimal ? This is an important point, and your clinical examination will define that right away … . . if you know what these things are.  And if you don’t ? Well, you have found the right blog, one with a SEARCH box. Type in “forefoot varus”, if you want to open up the rabbit hole and climb down it … . . we dare ya ! 🙂

Podcast 55: Cold Joints, Gluten Brain & Toilets

-The Neurophysiology of your Joint Pain and Problems

A. Link to our server:

Direct Download: http://traffic.libsyn.com/thegaitguys/pod_55final.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-55-cold-joints-gluten-brain-toilets

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”

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* Today’s show notes:

3 neuroscience pieces this week:

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‘Gluten Brain’: Wheat Cuts Off Blood Flow To Frontal Cortex 

http://www.greenmedinfo.com/blog/research-wheat-cuts-blood-flow-brains-frontal-cortex

Influence of midsole hardness of standard cushioned shoes on running-related injury risk

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blishahead/Running_Shoes_Increase_Achilles_Tendon_Load_in.98153.aspx
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Case From a blog reader
Hello, 

I’m a swedish elite cross-country skier and newly graduated physio and I find your podcasts very interesting and informative! I have a question about something I’ve never heard you talk about, and which has been a problem for me for the last year.
It’s about the IP-joint of the big toe. I’ve had discomfort/pain in the joint for the last year, mostly after my workouts. It’s a bit swollen and there is crepitus to some degree(especially when I manually flex the toe while compressing it and at the same time have a pressure downwards/ventrally of the distal phalanx. I think it may be coming from a trauma I had 4-5 years ago when I stubbed my big toe really hard in a rock in an orienteering competition, which caused me to rest from running for a week or two.
So, my question to you is if you have any suggestion for me or others in my situation? Treatment? Which types of shoes to use? How would a future joint-fusion affect my running?
I’m only 23 years old and I’m really worried that this ache/discomfort will just get worse and worse.. I’ve asked a lot of great physios here in Sweden, but most of them don’t know much about what to do.
I’d be really grateful if you could take the time to give this a thought and share it.
Thanks!
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Another reader case:
 

Good morning. I am a former collegiate runner, I competed at Eastern Michigan University and Grand Valley State University, my father is a Chiropractor in northern Michigan. While in school I was recalled to active duty in the reserves after 9/11 and was unable to finish my eligibility. I am now 32, living in North Carolina, and trying to make a comeback to running and competing in Triathlons. At 6’2” and 170lbs. during college  I was competitive at the collegiate level  but always a step behind the true elites in the distance races in college, probably just because of my size, etc. competing against guys carrying 30 less lbs.

I train with a team called Without Limits  (iamwithoutlimits.com ) in Wilmington NC. My coach had mentioned that I had a really long loping stride which felt normal to me, but I cannot remember if I ran this way in college or not. When I finally counted, I had a cadence of 140 steps per minute rather then the optimal 180…

Long story short, I got really out of shape, now getting into pretty good form again, but I am having problems with the IT band and pain in the knee on the right leg. I never ever had this in college training at very high levels (90-100 mile weeks in the off and early parts of each season) …so now I have the bike component that I am working on, but being a larger distance runner I am trying to fine tune my gait/stride and see if I can improve my running that way and also figure out what is going on with this IT band issue as I am only running 30-40 miles/week now but on the bike and in the pool a lot. I am back down to 175 and pretty lean but carrying a little extra muscle from biking and swimming.

Would you be interested, if I could send you several high quality videos from different angles, in taking a look at my gait (or even riding the bike on the trainer) and see if you notice anything ? I have been working on improving my cadence since the IT band issues began, and found your videos online while doing research.  I understand this would be better done on a treadmill or in the parking lot at your office where you could watch up close, but if you are interested, please let me know. I look forward to hearing from you.

 Sincerely,

 Tim

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The sedentary life affects your neurons !

http://www.outsideonline.com/news-from-the-field/Sitting-Still-Is-Bad-For-Your-Neurons.html

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A 3rd case this week, on Dystonia

Do you guys have any recommendations for analysis and treatment of acquired focal and gait dystonia?
It started as a splinting mechanism with a very loose right si and some L5 radiculopathy over 5 years ago.  The dystonia would come and go then eventually stuck all the time.
All the dystonia is on the right side and I don’t have any systemic neurological disease.
Forward walking, stair climbing, running (although barefoot running in grass and in particular undulating surfaces is ok in small amounts, asphalt or treadmill
brings on dystonia within seconds) are all a problem. Can cycle, run in water for 40 minutes or so no problem, so I think Si may still be hypermobile.  Walking backwards no problem.
Dystonia presents as stiff right leg with knee hyperextension, right eccentric weak, right glute medius weak, sticky posterior weight shift, but full and
painless movement through complete range of hip and knee.  I do have some focal dystonia as well mostly knee extension with hip flexion and foot supination and eversion with hip and knee flexed.

There must be someone who deals with this somewhat locally to me, Virginia Beach, VA.  Hoping you all may have some contacts on the east coast.
Thanks,
Sally

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http://www.entrepreneur.com/article/231344

Approaching joint assessment from the perspective of “cylinders”.

Our approach to every joint assessment has long been to visualize and assess the joint(s) as a cylinder since the body parts are cylindrical in form. This has been our approach, and they way we teach, for many years. At each number on the clock (cylinder) there is a theoretical muscle that provides stability to the joint in that vector during loading. The most accurate assessment would be one that investigates the ability of each muscle around the clock (cylinder) to see if it has sufficient S.E.S. (Skill, Endurance, Strength) as well as how well that muscle(s) participates with the synergists, antagonists and agonists (ie. motor patterns for stability and mobility).  We do this at each joint along the kinetic chain when assessing someone with a clinical or functional problem.  

When dealing with a frontal plane drift, as in the 3rd photo above where you see the person’s (black shorts) pelvis drift laterally outside the perpendicular foot line, one could naturally assume that the gluteus medius is weak (9 o’clock) but the wise clinician would also look at the other side of that cylinder to see if the adductors were involved (3 o’clock) since that is 180 degrees through the joint axis.  (Note: Runners are sagittal athletes so frontal plane weaknesses are often seen. This is not desirable however, this is a perfect example why runners should cross train more into lateral and angular sports to ensure that the sagittal plane does not dominate.) Obviously the foot and the knee also need a similar cylindrical assessment approach. We have spoken loudly many times  here and on our podcasts over the years that quite often there are multiple flaws in a presentation, typically a focal cause and one if not several compensations as a functional adaptation strategy around that central flaw. In this runner’s case there could be medial knee weakness or foot weaknesses that are affording too much medial drift and spin of the limb resulting in the lateral pelvic drift compensation.  But, just because the gluteus medius shows up weak does not mean that it is the focal point of clinical intervention. If one facilitates the gluteus medius and does not address the causative lower cylinder issues then they are quite possibly empowering the compensation and enabling the aberrant activity to continue. Knowingly or unknowingly layering armor or inappropriate strength to a pathologic compensation pattern at a focal joint level that is not the focal cause should be a clinical crime, but it is done every day by people who do not know better even though their efforts are well intended.

Ok, we got on a bit of a soap box rant there, sorry. Back to the case at hand.  

Your assessment should not stop at the frontal plane in this case. If there is an imbalance in the sagittal plane in this sagittal athlete this can be a causative problem as well, which is why the cylinder approach should not stop at the frontal plane or when you find that first major weakness. In frontal pelvic drift cases, there is quite often an anterior pelvic tilt where the lower abdominals can be weak, the low back is slightly extended and the paraspinals are more active. This is the classic “impaired hip extension pattern” and sets up a Janda/Lewitt style “Layered Syndrome”. Most of the time, resolving this sagittal flaw will show immediate improvement of the frontal plane deficits.  But, do not think it is as simple as re-facilitating these 2 patterns. Remember, neuromotor reprogramming and patterning takes 8-12 weeks by some sources. And remember, the initial strength gains in the first few weeks are from neuroadaptation (ie, skill gains in coordination), these gains are not the true physiological endurance and strength gains that we desire for an athlete.  Those gains take time but they are the ones that we need for sport performance and joint power.

And then there is the rotational or axial component, which we did not even begin to discuss here. We have briefly talked about the frontal and sagittal cylinder aspects, and yes, we have just skimmed the surface as there are multiple patterns and issues which we have had to leave out here so that this doesn’t turn into a full fledged chapter for our next book. This stuff gets complicated and can leave you running in mental circles at times.  But these concepts will help you better understand why you often see neuro-protective tightness 180 degrees on the other side of the cylinder from tightness, and when you address the weakness the other side of the cylinder some of that neuro-protective tone is eased.  But again, it is not nearly this simple because you must remember that if your assessment is static or on a table then your findings will be functionally imprecise.  And, not stopping there, there are multiple joints below the joint you are focusing on, and multiple joint complexes above as well. Plus, there are 3 other limbs that can play into the function and dysfunction of a given limb and its joints. There are breathing patterns, postural patterns and many other issues. This is not an easy game to play, let alone play it well or wisely for your athlete.

In today’s photos we wanted to show you 3 runners. One a distance runner with good joint stacking and one sprinter with amazing joint stacking.  And then the runner in the black shorts, who cannot stack the foot, knee or hips even remotely well.  This runner in the back shorts will have the cross over gait and likely have the medial ankle scuff marks to prove it. But remember, there is one component that we often talk about, one we did not discuss here … . . are there also torsional issues in this runner ? Do they have femoral or tibial torsion(s) ? What is their foot type ? Are they in the right shoe for their foot type ? Are some of these components playing into their visibly flawed mechanics ? 

Below is an article we have put up here on the blog previously.  It is a study where the investigators examined hip abductor strength (watch this video here ) in distance runners with iliotibial band syndrome comparing injured limb strength to the unaffected limb to determine whether correction of the strength deficits in the HAM’s (hip abductor muscles) correlates with successful outcomes.  The study showed the obvious, that runners with ITBS have weaker HAM strength compared to the asymptomatic leg.  

But here is our question, did they just strengthen the compensation for an apparently successful outcome, or did they address the problem ? Only time will tell if you actually fixed something or merely enabled the dysfunctional motor pattern by layering it with more armor for the next battle. If it is fixed the problem and all of its associated problems should go away. But if the runner comes back weeks later with knee complaints, foot pain, back pain or the like … . . then the message should be loud and clear.

Shawn and Ivo, The Gait Guys……today with soap on the bottom of our feet.

References:

Clin J Sport Med. 2000 Jul;10(3):169-75. Hip abductor weakness in distance runners with iliotibial band syndrome. Fredericson MCookingham CLChaudhari AMDowdell BCOestreicher N,Sahrmann SADepartment of Functional Restoration, Stanford University, California 94305-5105, USA.

Step width alters iliotibial band strain during running.

More substantiation that “the cross over gait” is a pathologic process.

Did you get to hear podcast #23 yet ?  Here is the link (iTunes).  In podcast #23 we talked at length about the effects of step width in runners.  Reducing ones step width will result in a progression into what we have been referring to for years as “the cross over gait”.  We have been reducing this phenomenon in our runners, and many walkers, for over a decade now to reduce many of the lower limb pathologic processes that ensue when the cross over is left unchecked and worse yet, strength and endurance is loaded upon the faulty pattern.  Everyone’s gait in this realm will differ because of pelvis width, femoral and tibial torsion, genu posturing (knee valgum, varum)  and foot structure and type. All of these factors must be taken into account when deciding upon the degree of step width correction.  Ultimately the goal in a perfect world would be to have the foot and knee stack pristinely under the centrated hip joint proper, but we all know that ideal biomechanics are the unicorn when it comes to humans. Anatomic variation is the known norm and this must not be forgotten, this was pounded into all of our heads in medical school.
As this article from the Nov 2012 J. of Sports Biomechanics clearly states, iliotibial band strain and strain rate is significantly greater in narrow based gait scenarios and that increasing step width during running, particularly in those who tend towards the lazier narrower step width, may be beneficial in not only the treatment but the prevention of future lateral hip and knee biomechanical syndromes such as IT band syndrome.  So, if you are a slave to your foam roller and need your IT band foam roller fix daily, you might want to look a little deeper at your biomechanics and make some changes.  Our videos here will be helpful to you and our writings on the Cross Over gait  and link here will be helpful as well.
In  summary, there is just so much more to good running form than just following the mantra “let my feet fall under my body mass and everything will be just fine”.  We wish it was this easy, but it is not. Unfortunately, too many of the sources on the internet are maintaining that good running form is mostly just that simple. Sadly, we find it our mission to bring the bitter tasting truth to the web when it comes to these things.  One just cannot ignore the factors of pelvis width, femoral and tibial version and torsion, genu posturing (knee valgum, varum) and foot structure and foot type (and we mean so much more than are you a pronator or supinator).  These factors will alter lower limb biomechanics and may drive even the runner with heightened awareness of foot strike and running form into less than optimal foot strike positioning and loading response. Furthermore, one needs to be acutely aware that merely taking the cooked down under-toned postulation of this journal article, that being increasing step width will resolve their IT band problems, may not resolve their problem. In fact, without taking the issues of pelvis width, torsion, version, foot type and the like into account, making these changes could bring about more problems.  Seeking the advise of a knowledgeable physician in this complicated field of human locomotion is paramount to solve your chronic issues.
There is more to clean running than just a
midfoot-forefoot strike under the body mass, a good forward lean and high cadence. And we are here to bring those other issues to light, for the sake of every injured and frustrated runner.  Remember, uninjured does not always mean efficient. And efficient does not always mean uninjured.

Shawn and Ivo, The Gait Guys


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Sports Biomech.
2012 Nov;11(4):464-72.Meardon SA, Campbell S, Derrick TR.

Step width alters iliotibial band strain during running.

Abstract
excerpted:

“Greater ITB strain and strain rate were found in the narrower step width condition (p < 0.001, p = 0.040). ITB strain was significantly (p < 0.001) greater in the narrow condition than the preferred and wide conditions and it was greater in the preferred condition than the wide condition. ITB strain rate was significantly greater in the narrow condition than the wide condition (p = 0.020). Polynomial contrasts revealed a linear increase in both ITB strain and strain rate with decreasing step width. We conclude that relatively small decreases in step width can substantially increase ITB strain as well as strain rates. Increasing step width during running, especially in persons whose running style is characterized by a narrow step width, may be beneficial in the treatment and prevention of running-related ITB syndrome.”

Email from a reader: Chronic IT Band and Plantar Fasciitis

I have been reviewing your Youtube videos and blog posts over the last few weeks, I am a triathlete suffering from plantar fasciitis and ITB issues, and I’m not really close to a major center where I can get treatment so I’m self educating. I’m very interested in the videos you have about function of the foot, and how the toes relate to the arch, fascinating! You mention exercises for the feet, to help the muscles function and learn to work separately. I was wondering if you have any of these exercises posted online, I am not able to hold the arch position or use my toes separately, I think these movements would go a long way to helping me figure why I’m having issues with the PF. Great job on all the info, I love being able to access info like you guys have online, makes me want to learn more… thanks!!
 
 
Becky H
AB, Canada
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Dear Becky:
Sorry to hear about your chronic issues.  Make sure you evaluate your glutes. The pelvis must remain relatively quiet and not tip forward or backward (anterior or posterior tilt) during all forms of ambulation. When it tips more forward the glutes become challenged and can become inhibited. When inhibited internal rotation of the hip minimizes or is lost and the ITBand tightens to attempt to drive that internal rotation. It is a good internal rotator as is the anterior g. medius and coccygeal division of the glute maximus (hence the glute connection).  This will put stain on the patellofemoral joint and may cause tracking issues or lateral knee regional pain (or ELPS….. excessive lateral patellar pressure syndrome).  Additionally, when the foot tries to pronate more to drive more internal limb rotation (because it is obviously not happening at the hip in this scenario) the plantar fascia can become strained because of the pronation lengthening of the longitudinal arch of the foot.
Regarding the foot exercises……. they are coming….. we just need time. We would pay for more time, but we cannot seem to find it on amazon or ebay.  If anyone is selling, we will line up to buy !
thanks for your email question.
Keep the emails coming. Those of you who have emailed us recently or in the past, we  have received them and they are being answered in length in the podcasts we are about to launch. They are coming, you will love them.  It just comes down to editing time.  There is that “time” word again !