#gait problem

In the continuing series of this virtual gait analysis. remember that this is just we are seeing and conjecture, we have not examined these folks....

A look at # 245......

Look at the position of his knee with respect to his foot. Both are pointing outward into external rotation. They are in the same plane so a torsion is unlikely, but he is probably trying to gain some stability as his center of gravity moves across his body.

Now look at his pelvis and see how it is tilted (or dropped) down on the left. We would definitely want to check his right gluteus medius and his left quadratus lumborum.

the 1st in a series of “virtual” gait analysis

Whoa! What's wrong with #172?

Where do we start? Look at all of that tibial and genu varum! Notice how his knee is outside the sagittal plane? This means that he also has internal tibial torsion and he is rotating his foot out to create the requisite 4-6° internal rotation needed to move forward. It also looks like he has limited internal rotation of the thigh by the positioning of his body. This could be due to femoral retroversion as this commonly occurs with internal tibial torsion. 

Check out the interesting hand posturing bilaterally. Notice the extended thumb and wrist on the left? He may be trying to fire into his extensor pool to help gain more hip extension. I sure wish we had a sideview. 

Thankfully his pelvis is relatively level, isn't it? No, it actually isn't. That's just his shirt. Look closely at the tops of the iliac crests and you will see what I am talking about. Did you catch the slight head tilt to the right? With that much tibial and genu varum his center of gravity is moving to the left and he needs to tilt his head to the right to equalize things out. What about the posterior rotation of the left shoulder? Again probably this is due to a lack of or failure to use internal rotation of the left hip.

and what have we been saying?

Gait problems leave clues. Asymmetry is a BIG clue

"Asymmetrical lower extremity neuromuscular control is predictive of repetitive stress injury in recreational runners, according to findings presented at the Combined Sections Meeting of the American Physical Therapy Association in February in Anaheim."

Lets make a resolution...Or not...

Cool guy, cool picture, cool scenery. Motivational? He is the fitness guru the developed the "Insanity" workout series, amongst others.

But looks may be deceiving.  

For reference, draw a line from the philitrium, interpec interval, symphisis pubis to area bisected between feet. 

Did you notice the following?

crossing arms across midline; look how far that left arm is abducted.

look at pelvis list to left. If you bring that arm in, you need to compensate somewhere

did you notice the hip hike on the left? That may have something to do with the excessive internal rotation of the thigh on the left. Is that because of the pelvis shift to the left (to compensate) or is he making up for limited internal rotation of the right hip?

what about the subtle head tilt to the right? is that driving the compensation or is it another compensation?

Questions, questions, questions...

A profound loss of hip extension...

While sitting on the beach, our mind never rests. Even when on vacation we continue to watch how people move.

Luckily today, I had the gait cam (Dr Allen is holding down the Gait Guys Fort), so live from Sunset Beach, it's Sunday night. See of you can see what I saw.

Sitting with my wife and watching the kids dig in the sand, this gal with the flexed posture caught my eye.

Why is she so flexed forward? The profound loss of hip extension made it impossible for her to stand up straight! It was difficult to say if she has bilateral hip osteoarthritis, or possible bilateral THR's (total hip replacements), maybe just really tight hip flexors, painful bunions that do not like toe off, or even all of the above. She may have a leg length discrepancy, as she leans to the left on left stance phase; of course she could have weak hip abductors on the left. It does not appear she has good control of her core.

What do we see?

flexion at the waist

loss of hip extension

body lean to left at left midstance

shortened step length

loss of ankle rocker

premature heel rise

decreased arm swing (she is carrying something in her left hand)

No one is safe from the gait cam! Stay tuned for more beach footage this week!

So you want to do a Gait Analysis: Part 4

This is the 4th in a multi part series. If you missed part 1, click here. For part 2, click here, part 3, click here. 

These are the basics, folks. We hope this is a review for many.

A quick review of the walking gait cycle components:

There are two phases of gait: stance and swing. 

Stance consists of:

Initial contact

Loading response

Midstance

Terminal stance

Pre-swing

Swing consists of:

initial (early) swing

mid swing

terminal (late) swing

today, lets explore Terminal stance

Terminal stance is one of the last stages of stance phase. Following midstance, where maximal pronation should be occurring, the stance phase foot should now begin supinating, initiated by the the opposite foot in swing phase moving forward of the center of gravity. 

Lets look at what is happening here at the major anatomical areas:

Foot

Supination begins from the opposite, swing phase leg (see above)

 the calcaneus inverts to neutral

 the center of gravity of the foot raises from its lowest point at midstance

The lower leg should begin externally rotating (as it follows the talus)

The thigh should follow the lower leg and should also be externally rotating; sometimes to a greater extent due to the shape and size of the medial condyle of the femur (which is larger than the lateral)

these actions are perpetuated by the gluteus maximus and posterior fibers of the gluteus medius, as well as posterior compartment of the lower leg including the flexor digitorum longus, flexor hallucis longus, peroneus longus and tibialis posterior

Ankle

The ankle should be 5 degrees dorsiflexed and in ankle rocker

the calcaneocuboid locking mechanism should be engaging to assist the peroneus longus in getting the head of the 1st metatarsal to the ground

Knee

near or at full extension. This is perpetuated by the quadriceps and biceps femoris, contracting concentrically and attenuated by the semi membranosis and tendonosis. The popliteus contracts eccentrically as soon as the knee passes midstance to keep the rates of external rotation of the tibia and femur in congruence.

Hip

The hip should be extending to 10 degrees.

Can you picture what is happening? Try and visualize these motions in your mind. Can you understand why you need to know what is going on at each phase to be able to identify problems? If you don’t know what normal looks like, you will have a tougher time figuring out what is abnormal.

Ivo and Shawn. Gait and foot geeks extraordinaire. Helping you to build a better foundation to put all this stuff you are learning on.

What's up, Doc?

Nothing like a little Monday morning brain stretching and a little Pedograph action.

This person had 2nd metatarsal head pain on the left. Can you figure out why?

Let's start at the rear foot:

limited calcaneal eversion (pronation) L > R. The teardrop shape is more rounded on the left. This indicates some rigidity here.

note the increased pressure at the  medial calcaneal facets on each side with the increased printing

very little fat pad displacement overall

Now let's look at the mid foot:

decreased mid foot pronation on the L. See how thin the line is going from the rear foot to the forefoot along the lateral column? This indicates a high lateral longitudinal arch

Now how about the fore foot?

increased printing under the met heads bilaterally; L >> R

increased printing of 1st met head L >> R

increased printing at medial proximal phalynx of hallux  L >> R

increased printing of distal phalanges of all toes L >> R

 Figure it out?

What would cause increased supination on the L?

short leg on L

more rigid foot on L

increased pronation on the R

Did you notice the elongated 2nd metatarsals (ie: Morton's toe) on each foot?

Here is what is going on:

there is no appreciable leg length deformity, functional or anatomical

The Left foot is more rigid than the Right, thus less rear, mid and fore foot pronation, thus it is in relative supination compared to the right foot

do this: stand and make your L foot more rigid than the right; take a step forward with your right foot, what do you notice?

Can you feel how when your foot is supinated

can you see how difficult it is to have ankle rocker at this point? remember: supination is plantar flexion, inversion and adduction

Can you feel the weight of the body shift to the outside of the foot and your toes curl to make the foot more stable, so you do not tip to the left?

now, how are you going to get your center of mass forward from here? You need to press off from your big toe (hallux)

Wow, does that make sense now?

What's the fix?

create a more supple foot with manipulation, massage, muscle work

increase ankle rocker by training the anterior compartment (shuffle walks, lift/spread/reach exercise, heel walking, Texas walk exercise, etc)

have them walk with their toes slightly elevated

we are sure you can think of more ways as well!

Welcome to Rewind Friday. Today we review a video we did on toe box sizing. Lots of great info here. Check it out!

Have a great weekend (not that we are telling you what to do)