More on landing mechanics.
Here is a recent article on landing mechanics. This article talks about the landing mechanics far past where I feel the first stage of vulnerability is, which is initial forefoot load, as i discuss in the video pertaining to landing from a jump or if sprinting (forefoot loading). IF landing occurs in low gear (lateral half of the forefoot), inversion risks are higher.
The medial foot tripod, high gear toe off (1st and 2nd mets) is where we should be taking off from, and landing initially upon. Anything lateral is vulnerable without the lateral column strength (lateral gastrocsoleus complex, peronei longus/brevis).
This article talks about knee flexion angles and ACL vulnerability, far after this initial loading response. The article some valid conclusions in that phase.

– Dr. Shawn Allen

Posture specific strength and landing mechanics.

http://lermagazine.com/article/posture-specific-strength-and-landing-mechanics

https://www.youtube.com/watch?v=8T9UzOaYxmo

Podcast 84: Toe Walkers, Hip Impingment & Olympic Lifting Shoes

Plus: pulmonary edema syndrome in Triathlete swimmers, truths about olympic lifting shoes and more !

Show sponsors:

www.newbalancechicago.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_84f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-84

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 and 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”

Show notes:

Are Triathletes Really Dying of Heart Attacks?

 
We had some stuff on FB last week about head positioning during running.  Alot of people tried to simplify it.  There is more to it. Here is another perspective.
 
Toe Walking children
 
Olympic lifting shoes ? or Converse Chuck Tailors ?
 
Journal of Foot and Ankle Research | Abstract | The associations of leg lean mass with foot pain, posture and function in the Framingham foot study
http://www.jfootankleres.com/content/7/1/46/abstract
 
Hip Impingements
 
Achilles oddity: Heeled shoes may boost load during gait | Lower Extremity Review Magazine
http://lermagazine.com/news/in-the-moment-rehabilitation/achilles-oddity-heeled-shoes-may-boost-load-during-gait
 

Toe Walking in Children. Do you know what you are dealing with ? Part 2

So you have now ruled out possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy) in your young toe walking individual.  Now you have been left with the aftermath foggy diagnosis of “Idiopathy Toe Walking”, that doesn’t leave you as a parent or clinician with much to work with or likely to be confident about. Let us try to help make things clearer and give you some other cognitive options to entertain. New research in recent years has brought new light onto the issue and we wanted to use today’s blog post as a platform to share it with you. 

In a previous week’s “Part 1” blog post & video (link) you can see in the gait on the video that nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing.  This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles) not to mention the sustained forefoot loading response on the foot bones and joints. Remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius).  Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) abd posterior compartment length to avoid functional pathology not to mention the timely coordination of all these events. 

Idiopathic toe walking is suggested to be as prevalent as 12%. Toe walking is categorized when there is an absence, or at least a limitation, of heel strike during initial walking gait contact phase. We are not referring to, at all, forefoot running principles. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems.  With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes.  Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become skilled and permanent.  It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some deeper thoughts to your mind right now.  Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share. 

In the literature and clinics a plethora of things have been tried and discussed (ie. serial casting, botulinum toxin, surgical tendon lengthening, gait retraining, orthoses/orthotics, night splints, day splints and the like). Keep in mind that only one of the above is addressing a functional change via cognitive and higher brain center demand, “gait retraining”. The others are passive forced attempts.  But is gait training enough ? And how far back into primitive and postural gait pattern training do you have to go? Gait training certainly does something as eluded to by two research papers we posted on our Facebook page in previous weeks. See those references below.

“For both feet, contact time of the heel was increased after the training period, whereas contact time of the forefeet decrease. Also positive changes in the active range of joint motion of the ankle (dorsal extension) were observed in both feet. These positive effects were visible also in the follow—up assessment.” -Pelykh study

Daily intensive gait training may influence the elastic properties of ankle joint muscles and facilitate toe lift and heel strike in children with CP. Intensive gait training may be beneficial in preventing contractures and maintain gait ability in children with CP.” – Willerslev-Olsen study

So what else could be going on here ? Is this neurodevelopmental ? Yes, for sure.  But where did things go awry ?  And how do we fix it ? Remember, the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot).

In a recent study in the Journal of Child Neurology,  

“for the first time, motor and sensory challenges presenting in healthy children with an idopathic toe walking gait have been identified.These challenges imply an immaturity or mild impairment at the cerebellum or motor cortex level.”

As the article suggested, the research did not render direct cause(s) for the gait pattern, rather some very viable theories on the topic. They found that only the areas of balance, upper body coordination and bilateral coordination were areas found to be problematic in the toe walkers. These 3 components require the integration of the tactile, vestibular and proprioceptive systems as a team. Diving deeper into how these 3 outputs are linked, there is a required “mix of occulomotor control and cues together with subtle and gross postural adjustments” (3). As Williams et al (3) suggested, “they are skills requiring the coordination of movements in which each side of the body moves simultaneously or in sequence”.  Kind of sounds like some topics on Arm Swing/Leg swing and also on the topic of phasic/antiphasic gait we have discussed over and over again here on TGG and in recent podcasts (82) doesn’t it ?  It was proposed that perhaps idiopathic toe walkers negotiate their sensory challenges by unconsciously engaging toe walking behavior to change or challenge these inputs.  Here were some of the proposed thoughts from the Williams study.

“The tactile receptors of the skin may be stimulated through pressure at the ball of the foot or lessened by a reduction of surface contact by raising the heel off the ground. Proprioceptive input may be changed at the knee, ankle and even toe joints by unconsciously repositioning of the foot posture.  The vestibular input may be increased by the vertical stimulation of the bouncy type gait that results from toe walking.”(3) Williams

It seems clear from the Williams study that these children demonstrate a number of sensory needs that motivate toe walking to alter (increase or decrease) or improve sensory input.  The study also suggests that the toe walking gait is an attempt to modify input on postural stimuli during gait to serve diminished postural and position awareness.

The findings of this study are important.  Our most recent blog posts and podcasts (Nov 2014) have discussed some of the components to build, control and coordinate gait on a higher neurologic level. The Williams article seems to support these discussions, that some pathologic gaits are initiated on a neurologic level as opposed to biomechanical at the foot and ankle level.  This sounds like the work offered by “the functional neurologist”, graduates of the Carrick Institute for Graduate Studies ! (carrickinstitute.com)

Have a great day gait brethren !

Shawn and Ivo, The Gait Guys

References:

1. Eur J Phys Rehabil Med. 2014 Oct 9. [Epub ahead of print]

Treatment outcome of visual feedback training in an adult patient with habitual toe walking.

NeuroRehabilitation. 2014 Oct 15. [Epub ahead of print]

2. Gait training reduces ankle joint stiffness and facilitates heel strike in children with Cerebral Palsy.

3. Is idiopathic toe walking really idiopathic ? The motor skills and sensory processing abilities associated with idiopathic toe walking gait.  J Child Neurol 2014, 29:71 Williams, C. , Curtin, Wakefield and Nielsen

The Bouncy Gait: Premature heel rise gait. Taking another look.

This is a great video example of a premature heel rise during gait. You should be able to clearly see it on the left foot (and this was toned down after we brought it to his awareness!).  The heel rise occurs early in the stance phase of gait, instead of the late stance phase.

We have talked about this bouncy type vertically oriented gait many times in blog posts and in our podcasts.  This is a pretty prevalent problem in the world, mostly because so many people have impaired ankle rocker/dorsiflexion from weak anterior compartments and short/tight posterior compartments.  None the less, for the majority, this is a pathologic gait pattern and it will impart undue stress into the posterior mechanism (calf-achilles complex). Just think about it, this person is going vertical at or prior to the tibia achieving 90degrees (perpendicular to the ground) instead of continuing to progress the tibia to 110+ degrees to enable normal timely pronation and foot biomechanical events.  This is not a normal gait. Period. This will change the function of the entire posterior chain upward. 

If you want to see another great example  from the frontal plane, check out this cute video representation of a vertial/premature heel rise bouncy gait. 

This gait style is caused by a premature heel rise from joint range limitation and/or from premature engagement of the gastrosoleus (and sometimes even the long toe flexors, you will see them hammering and curled in many folks). It can be a learned habitual pattern and nothing more, we have even seen it even in child-parental gait modeling in our offices. These people will never get to NORMAL full late-midstance of gait (without biomechanical compromise) and thus never achieve full hip extension nor adequate ankle dorsiflexion / ankle rocker. The gait cycle is an orchestrated symphony of timely events and when one or several timely events are omitted or impaired the mechanics are passed into other areas for compensation. This vertical gait style is very inefficient in that the gluteals cannot adequately power into hip extension into a forward progression drive, because the calf is prematurely generating vertical movement through ankle plantarflexion.  This strategy is sometimes deployed because the person actually is significantly ankle dorsiflexion (ankle rocker) deficient.  Meaning, they hit the limitations of dorisflexion and in order to progress forward they first have to go vertical.  This vertical motion, because they are moving into ankle plantarflexion, re-buys more ankle dorsiflexion range which then can be used if they so choose. Obviously, the remedy is to find the functional deficit, remove it and retrain the pattern.  There are a whole host of other problems that go with this compensation pattern but we wanted our mission to stay focused today.  Remember, this is usually a subconscious motor pattern compensation. Is it like the toe walking issue we talked about last week (post link here) ? It is similar in some ways and can have primitive and postural motor pattern implications. We will follow up the “Idiopathy Toe Walking Gait: Part 2” shortly but we wanted to strategically put this blog post ahead of it, because there are similar characteristics and implications. Trust us, there is a method to our madness 🙂

Shawn and Ivo

The Gait Guys

Toe Walking in Children. Do you know what you are dealing with ?

In the literature this condition typically has prompted thoughts of possible Autism-spectrum, possible CMT (Charcot-Marie Tooth Disease), CP (Cerebral Palsy), MD (Muscular Dystrophy).  Those are ominous diagnoses to consider if you are a parent with a toe walking child. There will be long sleepless nights without answers. When these types of disorders can clearly be ruled out, a diagnosis of “Idiopathy Toe Walking” is claimed.  But, the research in recent years has brought new light onto the issue and we wanted to use today’s blog post to be a brief introduction. We will be doing another post in the coming week to look more deeply into this clinical phenomenon, but today will just serve as an introduction to wet your palate and get your head in the right direction. 

As you can see in this gait, nothing appears to be terribly abnormal in the foot structure (from what we can tell), the client is merely remaining in the plantarflexed posture and forefoot weight bearing.  This is highly ineffective gait and can be very fatiguing let alone to mention the sustained loading into the posterior compartment and plantarflexor mechanism (gastrosoleus-achilles). And remember, the tibialis posterior and long toe flexors are close neighbors with capabilities of plantarflexion moments, so there are possible clinical manifestations there as well not to mention the obvious (especially to long-time Gait Guys readers) deficits that will be found in functional ankle dorsiflexion, ankle rocker and S.E.S. (skill, endurance, strength) of the anterior compartment mechanism (tibialis anterior, long toe extensors, peroneus tertius).  Even if this client were to go into normal heel strike and stance phases right now, they would have lots of work to do to restore the anterior-posterior compartment balance, the 3 foot rockers (heel, ankle and forefoot) to avoid functional pathology. 

Idiopathic toe walking is suggested to be as prevalent as 12%. Neuromotor maturation comes about via the suppression of the primitive reflexes/windows and appearance of the postural reflexes and responses. Delays or subtractions of these windows/reflexes may cause challenges in the normal development and maturation of the central and/or peripheral nervous systems.  With toe walking, the clinical window most studies suggest is to begin investigation after 3 years of age when the primitive motor patterns should have solidified and the gait and postural patterns have begun to layer on top of those primitive reflexes.  Remember though, the primitive patterns are not sequentially fixed, meaning that infants move in and out of these reflexes until they become permanent.  It is not until they are fixed that the postural patterns, which are volitional, can be gradually built. This should bring some thoughts to your mind right now.  Is toe walking behavior a missed primitive window or a non-volitional postural window? These kids are not doing this by choice, anyone who has worked with these types of cases knows this very well, and we have seen our share. 

So what could be going on here ? Is this neurodevelopmental ? Yes, for sure.  But where did things go awry ?  And how do we fix it ? We will get into all of this next week but in the mean time remember that the development of primitive and postural reflexes is supposed to occur proximal to distal (ie. from core to hand/foot). This must be a motor-sensory deficit or mismatch, and we will go into that next week on the blog. In the meantime, consider the definition:

Idiopathic: Of unknown cause. Any disease that is of uncertain or unknown origin may be termed idiopathic. 

That definition should only occur if further research does not render sufficient answers and theories. Next week we will propose some new ideas in the research up to 2014, ideas and proposals that will hopefully lead us to answers and dropping of “idiopathic” from this disorder. 

Have a great day gait brethren !

Shawn and Ivo, The Gait Guys

Podcast 37: Anandamide & Body Work, 3D Printed Shoes and Case Studies

Our show notes should interest you today. We have another great podcast ready for you today !

Link to our server:

http://thegaitguys.libsyn.com/podcast-37-anandamide-body-work-3d-printed-shoes-and-case-studies

iTunes link:

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

Gait Guys online /download store:

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

other web based Gait Guys lectures:

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

Today’s show notes:

Neuroscience piece:

McPartland et al (2005) measured Anandamide (AEA) levels pre- and post, Myofascial Release, Muscle Energy Technique, High velocity manipulation all of which load fascia patients experienced analgesic/euphoric cannabimimetic effects, which correlated with an increase in serum AEA levels (more than double pre-treatment evels). 
Neither cannabimimetic effects, nor changes in AEA levels, occurred in control subjects.

McPartland, J et al 2005.. Jnl. American Osteopathic Association 105, 283–291 
http://leonchaitow.com/2008/01/30/bodywork-high

2. Vibrating shoes could be the future of navigation and wearable tech

http://www.wired.co.uk/magazine/archive/2013/09/start/vibrating-shoes-the-new-navigation-tool

3. Tim Ferriss (@tferriss)

9/2/13 9:25 PM
Malcolm Gladwell: “Man and Superman” The New Yorker buff.ly/174jruO Drugs, genetics, and the fallacy of a level playing field.

 
4.FB reader sent us a message:

Hi Guys: Not quite sure how I came across your podcasts but really enjoying them, even if I’m only slowly starting to understanding them. I was catching up on some old ones during my marathon training and the ones on evolution reminded me of some of my musing on the arch in the foot (well I guess correctly that should be the medial longitudinal arch). I though you might be able to give me the answers or point me in the right direction

Are we only species with this?
What is the advantage?
When and how does it develop and why isn’t it formed in utero?
Are flat feet then a genetic or developmental issue and why?
Thanks 
Alex
5. off the web:
The imprecise art of foot orthoses
6. off the web:
3D-Printed Shoes Mean You’ll Never Need to Buy Another Pair
http://mashable.com/2013/08/20/3d-printed-shoes/
7. Another TUMBLR reader asks question about:
Hi Gait Guys,

I am currently a third year podiatry student needing some biomechanics and orthotic-making training. I enjoy your youtube videos but was wondering if you offer or could recommend a dvd that I could purchase to further my education. The way the information is presented it in class is not as good as the way you do it! I am also interested in the biomechanics of shoes… I am having trouble finding information about how walking in a cushioned/plantarflexed sneaker effects function (Does is help us get to forefoot running or hinder us?). I enjoyed your blog on different curved lasts as well. How would I be able to apply the way the shoe is lasted to a patient? For example, if the patient is rigid and I want them to be wearing a shoe that is lasted like a slipper how do I guide them into buying a shoe constructed as such? Do I just tell them to go for a shoe made with a straight toe box? Is there such a thing as a toe box curved laterally? 

One last question- do you recommend a medial FF post for a patient that has a mobile RF varus that causes a FF supinatus? I was told a post like this would limit PF of the first ray and DF of the hallux which would limit toe off and cause other problems. 
Thank you. I appreciate any advice you may have. I am out of my element with biomechanics and really want to improve at it.

8.Another off tumblr: 
sign-life-away asked you:
Is forefoot walking bad for you? Everyone says I walk awkwardly, as if i have something up my bum. I have been trying to walk “naturally” (heel-toe) but I go back to forefoot strike. Does this contribute to why my legs have always been muscular?

Podcast 37: Anandamide & Body Work, 3D Printed Shoes and Case Studies

Our show notes should interest you today. We have another great podcast ready for you today !

Link to our server:

http://thegaitguys.libsyn.com/podcast-37-anandamide-body-work-3d-printed-shoes-and-case-studies

iTunes link:

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

Gait Guys online /download store:

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

other web based Gait Guys lectures:

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

Today’s show notes:

Neuroscience piece:

McPartland et al (2005) measured Anandamide (AEA) levels pre- and post, Myofascial Release, Muscle Energy Technique, High velocity manipulation all of which load fascia patients experienced analgesic/euphoric cannabimimetic effects, which correlated with an increase in serum AEA levels (more than double pre-treatment evels). 
Neither cannabimimetic effects, nor changes in AEA levels, occurred in control subjects.

McPartland, J et al 2005.. Jnl. American Osteopathic Association 105, 283–291 
http://leonchaitow.com/2008/01/30/bodywork-high

2. Vibrating shoes could be the future of navigation and wearable tech

http://www.wired.co.uk/magazine/archive/2013/09/start/vibrating-shoes-the-new-navigation-tool

3. Tim Ferriss (@tferriss)

9/2/13 9:25 PM
Malcolm Gladwell: “Man and Superman” The New Yorker buff.ly/174jruO Drugs, genetics, and the fallacy of a level playing field.

 
4.FB reader sent us a message:

Hi Guys: Not quite sure how I came across your podcasts but really enjoying them, even if I’m only slowly starting to understanding them. I was catching up on some old ones during my marathon training and the ones on evolution reminded me of some of my musing on the arch in the foot (well I guess correctly that should be the medial longitudinal arch). I though you might be able to give me the answers or point me in the right direction

Are we only species with this?
What is the advantage?
When and how does it develop and why isn’t it formed in utero?
Are flat feet then a genetic or developmental issue and why?
Thanks 
Alex
5. off the web:
The imprecise art of foot orthoses
6. off the web:
3D-Printed Shoes Mean You’ll Never Need to Buy Another Pair
http://mashable.com/2013/08/20/3d-printed-shoes/
7. Another TUMBLR reader asks question about:
Hi Gait Guys,

I am currently a third year podiatry student needing some biomechanics and orthotic-making training. I enjoy your youtube videos but was wondering if you offer or could recommend a dvd that I could purchase to further my education. The way the information is presented it in class is not as good as the way you do it! I am also interested in the biomechanics of shoes… I am having trouble finding information about how walking in a cushioned/plantarflexed sneaker effects function (Does is help us get to forefoot running or hinder us?). I enjoyed your blog on different curved lasts as well. How would I be able to apply the way the shoe is lasted to a patient? For example, if the patient is rigid and I want them to be wearing a shoe that is lasted like a slipper how do I guide them into buying a shoe constructed as such? Do I just tell them to go for a shoe made with a straight toe box? Is there such a thing as a toe box curved laterally? 

One last question- do you recommend a medial FF post for a patient that has a mobile RF varus that causes a FF supinatus? I was told a post like this would limit PF of the first ray and DF of the hallux which would limit toe off and cause other problems. 
Thank you. I appreciate any advice you may have. I am out of my element with biomechanics and really want to improve at it.

8.Another off tumblr: 
sign-life-away asked you:
Is forefoot walking bad for you? Everyone says I walk awkwardly, as if i have something up my bum. I have been trying to walk “naturally” (heel-toe) but I go back to forefoot strike. Does this contribute to why my legs have always been muscular?