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, ūüė¶ ¬†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

Podcast 78: Step Width Gait, Training Asymmetries & more

Show sponsors: 

www.newbalancechicago.com

www.lemsshoes.com

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_78ff.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-78

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, ¬†‚ÄĚBiomechanics‚ÄĚ

______________

Today’s Show notes:

24-year-old woman missing entire cerebellum exemplifies the amazing power of brain plasticity

Brain scans reveal ‘gray matter’ differences in media multitaskers

Who are we: Ivo talk a bit about yourself and your educational history and what is your website ?
Shawn…..do the same
and……lets keep each interesting but to just a few minutes
Effect of step width manipulation on tibial stress during running
Does Limited Internal Femoral Rotation Increase Peak Anterior Cruciate Ligament Strain During a Simulated Pivot Landing?
http://ajs.sagepub.com/content/early/2014/09/22/0363546514549446.abstract
Quadriceps Muscle Function After Exercise in Men and Women With a History of Anterior Cruciate Ligament Reconstruction
http://natajournals.com/doi/abs/10.4085/1062-6050-49.3.46

Foot Progression Angle Exaggeration: External Tibial Torsion

Take a look at the tibial tuberosity and then where you think the 2nd metatarsal head would be. What do you see? The 2nd metatarsal is lateral to the tibial tuberosity. You are looking at external tibial torsion. 

Lets see how this external tibail torsion behaves during a knee bending. Observe the medial drift of the knee during weight bearing knee flexion. Many folks would say that the problem here is the increased foot prontation, but that is not where the problem lies, that is where many of the forces are funneling though. The client is pronating more because the external tibial torsion that is creating this appearance has put the knee inside the foot tripods region of stability.

In external tibial torsion there is an external torsion or a ‚Äútwist‚ÄĚ along the length of the tibia (diaphysis or long section). This occurs in this example to the degree that the ankle joint (mortise joint) can no longer cooperate with sagittal knee joint.¬† When taking a client with external tibial torsion and pre-postioning their foot in a relatively acceptable/normal foot progression angle there is a conflict at the knee, meaning that the knee cannot hinge forward in its usual sagittal plane. In this case with the foot progression angle smaller than what this client would posture the foot, the knee the knee will be forced to drift medially.

Are you looking for torsions of the lower limb in your clients ?

Are you forcing them into foot postures that look better to¬† you but that which are conflicting to your clients given body mechanics ? ¬†Would you correct this client’s foot turn out (increased progression angle) ? IF you did you would likely cause them knee pain in time. ¬†Would you put them into a stability shoe to try and control the pronation ? Again, you are likely to draw their knee outside the saggital knee hinge that is presently pain free. There is more to shoe fit that just looking at the foot. First do no harm is our mantra !¬†

Remember, telling someone to turn their foot in or out because it doesn’t appear correct to your eyes can significantly impair either local or global joints , and often both. Torsions can occur in the talus, the tibia and the femur.

Furthermore, torsions can have an impact on foot posturing at foot strike and affect the limbs loading response, from foot to core and even arm swing can be altered.  Letting your foot fall naturally beneath your body does not mean that you have the clean anatomy to do so without a short term or long term cost. 

This is some of the toughest stuff you will deal with clinically. The fence is narrow, if you do to little correction you fall off the fence into the wrong yard and create problems. If you do to much correction you get the same result. These torsional issues are a delicate balancing act many times. You first have to know what you have, then you have to know where the fix is, and then how much is safe.  Tricky stuff. This is exactly why in some folks a stability shoe can be magic or tragic and in others dropping into zero drop minimalism can be magic or tragic.  

Want more on torsion and versions ?¬† Type the words into the search box on our blog. We have plenty of good info for you.

Shawn and Ivo, The Gait Guys

Limitations: The powers of observation will help you.

Physical examination, FMS, DNS, gait analysis … . . these are all very important tools for the coach, trainer, therapist, clinician. ¬†They will all offer information and lead the “therapy giver” in a direction for intervention. ¬†But when something doesn’t match up with the basic standard protocols, you have to go outside the standard box. ¬†We have all been there and today is just a little reminder not to get caught up in the “proceedures” and merely running through protocol without an engaged brain putting the pieces together. ¬†

Here we see 2 classic examples of deviations from the mean, the client on the left has drifted further outside the frontal plane because of tibial varum and a little genu varus. ¬†The client on the right has imploded deep into the frontal plane via rigid pes planus foot collapse and genu valgum. ¬†These will both affect your physical screenings for these clients. And keep in mind, and this is probably the most important point of today’s blog post, either client may have good or bad strategies around their anatomy. ¬†In other words, some clients will have great compensations to limit further functional pathology, and some will have poor compensation strategies, and thus, both will have different physical exam findings, different screenings and different neuromotor patterns embedded deep into their CPGs (central pattern generators). ¬† Put yet another way, all of the scenarios discussed may/will have varying screening assessment outcomes but for different reasons. ¬†If you know the cause of these faults and the impaired neuro-recruitment patterns that are likely, your assessments will make more sense, and so will your exercise/therapy/rehab prescriptions. ¬†If you do not understand the fundamental differences (ie long bone torsions or various femoral-neck shaft angles, foot types such as an uncompensated forefoot valgus etc) , one could prescribe therapies that will not address the underlying problems, rather they might address the compensations and strategies found with these client’s challenges.

It can get sloppy messy.  Wear a bib.

Dig for the roots, don’t mow the grass…… Shawn and Ivo, The Gait Guys

Photo: Where is your knee joint hinge point ? ¬†Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing. ¬†He has the cleanest lines of the bunch. How is that for cruel irony ? ¬†Sometimes it ain’t what you got, it is what you do with what you got. ¬†Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations. ¬†Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out. ¬†

Today’s Lesson: ¬†Get in line, and get in line early. (just kidding of course)

The Gait Guys. ¬†Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination. ¬†We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.¬†¬†”Seeing may be believing” but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ? ¬†Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com¬†

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

*Photo courtesy of BIG EAST Conference

If you do not undestand limb torsions, you are quite possibly screwing up your runners.

You must understand all 3 of these (see below) to understand funky gaits that you see, and to clean up your physical exams with clients. If you are making gait or running form recommendations on this stuff without understanding Torsions you are quite possibly making very bad form recommendations and could be putting forces and torque into foot, ankle, knee or hip that are detrimental. Trust us. We know what we are talking about.

In light of our teleseminar on Chirocredit.com last night we will re-run the 5 Part series on limb Torsions and Versions.

Remember, there are three areas this needs to be considered in:

1. torsion of the talus

2. tibial torsion

3. femoral torsion

here is the link to our old post on this topic, part 1a

http://thegaitguys.tumblr.com/post/30799942620/torsions-this-gentleman-has-2-excellent-examples

Shawn and Ivo

If you do not undestand limb torsions, you are quite possibly screwing up your runners.

You must understand all 3 of these (see below) to understand funky gaits that you see, and to clean up your physical exams with clients. If you are making gait or running form recommendations on this stuff without understanding Torsions you are quite possibly making very bad form recommendations and could be putting forces and torque into foot, ankle, knee or hip that are detrimental. Trust us. We know what we are talking about.

In light of our teleseminar on Chirocredit.com last night we will re-run the 5 Part series on limb Torsions and Versions.

Remember, there are three areas this needs to be considered in:

1. torsion of the talus

2. tibial torsion

3. femoral torsion

here is the link to our old post on this topic, part 1a

http://thegaitguys.tumblr.com/post/30799942620/torsions-this-gentleman-has-2-excellent-examples

Shawn and Ivo