#pedograph

The “Standing on Glass” Static Foot/Pedograph... PART 1 We hope you find this case presentation dialogue interesting.

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon.

The “Standing on Glass” Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client’s strategies around clinical problems or compensations. Today’s photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client’s presentation and to help open up the field to questions the observer should be entertaining. The big questions should be, “why do i see this, what could be causing these observances ?”

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot. Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level. If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg. In that same client, they may try to meet the process part way by pronating the other foot to functionally “shorten” that leg. Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ? Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation. Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings. Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook’s turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact. After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively. Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ? What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption. See you tomorrow friends !

Shawn and ivo, the gait guys

Here is the case link.......

Time for a pedograph, folks. What do we have here?

To review :

Let’s divide the foot into 3 sections: the rear foot, the mid foot and the fore foot.

First of all, are they symmetrical? Look carefully at the fore foot on each side. NO! the right foot looks different than the left, so we are looking at asymmetrical pathology.

Let’s start at the rear foot: The heel teardrop is elongated on both sides, slightly more on the right; this means incraesed calcaneal eversion (or rearfoot pronation) bilaterally, R > L. The right heel shows increased pressure (more ink = more pressure).

Next up, the mid foot. Similar shapes, more pressure and printing on the left. Did you notice the “tail” of the 5th metatarsal printing, giving it a wider print? This person is staying on the outside of their foot longer than normal, right (more ink) more than left.

How about the fore foot? Lots going on there.

Lets start on the left

Notice the mild increased printing of the 5th and 4th metatarsal heads. Force should be traveling from lateral to medial here, as the foot goes into supination. A relatively normal amount of pressure on the head of the 1st metatarsal.

Now look at the toes. Notice that space between the 2nd and 3rd? This gal had an old fracture and has an increased space between them.

Now how about the right?

Increased pressure on most of the heads with a concentration on the 1st metatarsal. Hmmm…what would cause that? this is typical of someone who has a 1st ray (cunieform and metatarsal) that is hypomobile, such as with someone with a forefoot valgus (as this person does) or a dropped 1st metatarsal head (which is usually rigid, as is NOT the case here).

Did you see that rpinting at the medial aspect of the proximal phalanyx of the hallux (ie. big toe)? This gal externally rotates the lower extremity to push off the big toe to propel herself forward. This is because the 1st metatarsal head hits the ground BEFORE the 5th (as we would normally expect to see, like in the left foot), and because the weight is now on the outside of the foot, she need to push off SOMETHING.

Getting better at this? We hope so. Keep reading the blog and look at some of our past pedograph posts here.

Nothing like a little 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!

 Have you ever studied footprints on the beach or looked at the print left by a wet foot when you get out of the water? These are some of the most primitive types of pedographs.

The pedograph, 1st described by Harris and Beath in 1947 is a rubber mat surface with multiple protruding, small grid lines on one side, which, when covered with ink, imprints an underlying sheet of paper when weight (usually a foot) passes over it. Relative plantar pressures are indicated by the size and density of the inked area, creating a “footprint” reflecting passages of force through the foot at that instance in time.  They have fallen into and out of usage over the years, often discarded for more expensive technology such as pedobarographs, individual pressure sensors, and pressure sensitive mats, which have computer interfaces and can provide many useful measurements and calculations to assist the clinician with rendering a diagnosis. These systems, though more precise in some ways (provided a controlled, reproducible testing procedure) are often thousands of dollars, require a computer and the necessary skills, and have a substantial learning curve.  

The pedograph in contrast is simplistic, inexpensive, and reliable and only requires that the user have an intact visual pathway and cerebral cortex and knowledge of the events occurring in the gait cycle. With some practice and a good knowledge base, the subtle nuances detected by the sensitive pedograph (nuances that can be undetected with high end computer driven plantar pressure devices) can offer information critical to a precise diagnosis and give solid clues to gait flaws and compensations.  With minimal training using a pedograph, reproducible “prints” can be produced for analysis, in light of your findings clinically. They also make wonderful educational tools for your patients and clients!

An essential part of a comprehensive patient evaluation should include examination of the entire kinetic chain both in a static and dynamic fashion. Often what you see statically is either directly translated to or compensated for in the dynamic evaluation. (It is important to note that many of the available foot scan units available from orthotic companies scan a patient in a static standing position and give little information on how the feet and lower limb dynamically engage the ground during movement.) The pedograph is a useful visual tool representing a 2 dimensional image of tridimensional motion, and you are seeing the end product and compensation (or lack thereof) of the individuals mechanics at that point in time. Because of the specificity of what you are seeing refers to a particular point in time, technique and reproducibility are of paramount importance. Prints should be performed several times to insure what you are looking at is what you are looking at, and not movement artifact, because of the way the patient stepped on to or off of the mat.

With a pedograph, seeing is believing. When you have objective data about how an individual moves through space and how their joints and motor system help them to accomplish that, you have a better appreciation for the type or form of therapy which may be most appropriate. In the hands of a skilled clinician, seeing abnormal plantar pressures tells you where the biomechanical fault lies, and thus where manipulation may be appropriate, which muscles need strengthening and where neuromotor coordination is lacking and gait rehabilitation is needed.  

"Too much tripping, soles worn thin. Too much Trippin and my soul’s worn thin."

Scott Weiland

Can you guess why this person has left-sided plantar fasciitis?

This question probably seem somewhat rhetorical. Take a good look at these pedographs which provide us some excellent clues.

First of all,  note how much pressure there is over the metatarsal heads. This is usually a clue that people are lacking ankle rocker and pressuring these heads as the leg cantilevers forward.  This person definitely have a difficult time getting the first metatarsal head down to the ground.

Notice the overall size of the left foot compared to the right (right one is splayed or longer). This is due to keeping the foot and somewhat of a supinated posture to prevent excessive tension on the plantar fascia.

The increase splay of the right foot indicates more mid foot pronation and if you look carefully there is slightly more printing at the medial longitudinal arch. This is contributing to the clawing of the second third and fourth toes on the right. Stand up, overpronate your right foot and notice how your center of gravity (and me) move medially.The toes will often clench in an attempt to create stability.

The patient's pain is mostly at the medial and lateral calcaneal facets, and within the substance of the quadratus plantae with weakness of that muscle and the extensor digitorum longus. She has 5° ankle dorsiflexion left and 10 degrees on the right and hip extension which is similar.

The lack of ankle rocker and hip extension or causing her to pronate through her midfoot, Tensioning are plantar fascia at the insertion. The problem is worse on the left and therefore that is where the symptoms are.

Test your Mental Clinical Thinking Skills with this pedograph case. 

A few months ago, we discussed this case in great detail. There is likely little chance you will see our thinking progression with these final conclusions without sitting down with a warm cup of coffee and going over these 2 prior blog posts on this case (part 1 and part 2).  Besides, it will be a good review for you and it is great mental gymnastics.  This kind of analysis gets easier each time you do it but we have to through out our standard warning. This is the kind of stuff one needs to be able to go through on the fly in one's practice, it is something to aspire to.

First of all, caveats:

Our discussions on this case were all theoretical.  What we went through was an exercise in static assessment and clinical thinking. 

One cannot, and must not, make clinical decisions from a static assessment. 

As in all assessments, information is taken in, digested and then MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. 

Gait analysis or pedograph-type assessment are helpful tools, but not the final answer.

Our static exam proposal on this case came up with the following theories (please stand up and mimic as we discuss, trust us, it will help you). *Remember: the foot on YOUR LEFT is the RIGHT foot for the purposes of this discussion. And remember, this is all theoretical, this is an exercise in biomechanical and clinical thinking, nothing more.

Suspect Counter-clockwise pelvis distortion pattern (causes relative internal rotation on LEFT and external rotation on RIGHT), this will drive Left knee hyperextension and Right knee flexion (hence foot plantar pressures as we discussed in previous 2 blog posts linked above). This of course cannot be seen, but we are extrapolating from our clinical experiences.

poor pronation and internal limb spin control on the left (hence longer foot and toe hammering). Obviously, we would see a dramatic shift of the pressures to the medial foot if this were truly the case.  Perhaps this is because of the greater lateral left pelvis drift forcing the glute and foot pronatory controls to have to work harder and longer, and maybe even quicker, to control the internal spin and pronation. Over time, they fatigue and fail rendering a flatter, more pronated and longer heel:toe ball length ratio. This would also give credence to the left toe hammering/gripping response.

static increased left limb weight bearing (left hip drift)

abrupt right foot loading pattern (more mid-forefoot strike), perhaps as reflected by the static forefoot loading. Again, supposition.

with all of the above, it is suspect that this client will appear to have a subtle limp, coming off the left quickly or prematurely as they speed through uncontrolled pronation and resulting in an abrupt right limb loading response that mostly skips through heel strike and results in a more aggressive mid-forefoot loading response.  This, sort of, creates a catching of the loading response by the quadriceps more than the gluteals. This can cause medial knee drift (valgus loading) if the medial knee stabilizers are not up to task, this also creates a sudden patellofemoral compresson event and unappreciated sudden tension on the extensor mechanism (the quad-patella-patellar tendon complex).  Can you say generic anterior knee pain ?

Just some thoughts. Please go back to the prior 2 blog posts to delve deeper into the conclusions we have brought about here, we have other good reasoning to suspect the above as the scenario. But remember, what you see is not the problem, we see people's compensations, their strategies. This was just an exercise in "what ifs", nothing more. But you will see it in your clinic, just substantiate it with an exam, not what you necessarily see in your clients gait or static assessment. Static assessments are for fools, don't be a fooled fool.  What  you see is not the problem.

Remember this critical fact.  After an injury or a long standing problem, the job of muscles and motor patterns is to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries often leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is often a culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury. There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives. Is the compensation top down, bottom up, or both ?

Don;t be a fooled fool. Get the facts.

The "Standing on Glass" Static Foot/Pedograph Assessment: Part 1

* note: This is a static assessment dialogue. One cannot, and must not, make clinical decisions from a static assessment. As in all assessments, information is taken in, digested and them MUST be confirmed, denied and/or at the very least, folded into a functional and clinically relevant assessment of the client before the findings are accepted, dismissed and acted upon. As we always say, a gait analysis or pedograph-type assessment is never enough to make decisions on treatment to resolve problems and injuries. What is seen and represented on either are the client's strategies around clinical problems or compensations.  Today's photo and blog post are an exercise in critical clinical thinking to get the juices flowing and to get the observer thinking about the client's presentation and to help open up the field to questions the observer should be entertaining.  The big questions should be, "why do i see this, what could be causing these observances ?"

* note the right and left sides by the R and L circled in pink.

ORANGE lines: The right foot appears to be shorter, or is it that the left is longer (see the lines and arrows drawing your attention to these differences)? A shorter foot could be represented by a supinated foot (if you raise the arch via the windlass mechanism you will shorten the foot distance between the rear and forefoot). A longer foot could be represented by a more pronated foot.  Is that what we have here ? There is no way to know, this is a static presentation of a client standing on glass. What we should remember is that the goal is always to get the pelvis square and level.  If an anatomically or functionally short leg is present, the short leg side MAY supinate to raise the mortise and somewhat lengthen the leg.  In that same client, they may try to meet the process part way by pronating the other foot to functionally "shorten" that leg.  Is that what is happening here ? So, does this client have a shorter right leg ? Longer left ?  Do you see a plunking down heavily onto the right foot in gait ? Remember, what you see is their compensation.  Perhaps the right foot is supinating, and thus working harder at the bottom end of the limb (via more supination), to make up for a weak right glute failing to eccentrically control the internal spin of the leg during stance phase ? OR, perhaps the left foot is pronating more to drive more internal rotation on the left limb because there is a restricted left internal hip rotation from the top ? Is the compensation top-down or bottom up ? These are all viable possibilities and you must have these things flowing freely through your head during the clinical examination as you rule in/rule out your hands-on findings.  Remember, just going by a FMS-type screen to drive prescription exercises from what you see on a movement screen is not going to necessarily fix the problem, it could in fact lead one to drive a deeper compensation pattern. You can be sure that Gray Cook's turbo charged brain is juggling all of these issues (and more !) when he sees a screen impairment, although we are not speaking for him here.

Remember this critical fact.  After an injury or a long standing problem, muscles and motor patterns jobs are to stabilize and manage loads (stability and mobility) for adequate and necessary movement. Injuries leave a mark on the system as a whole because adaptation was necessary during the initial healing phase. This usually spills over during the early movement re-introduction phase, particularly if movement is reintroduced too early or too aggressively.  Plasticity is the culprit. Just because the injury has come and gone does not mean that new patterns of skill, endurance, strength (S.E.S -our favorite mnemonic), stability and mobility were not subsequently built onto the apparently trivial remnants of the injury.  There is nothing trivial if it is abnormal. The forces must, and will, play out somewhere in the body and this is often where pain or injury occurs but it is rarely where the underlying problem lives.

Come back tomorrow, where we will open your mind into the yellow, pink, blue and lime markings on the photo. Are the hammering toes (lime) on the left a clue ? How about the width of the feet (yellow) ? The posturing differences of the 5th toe to the lateral foot border ?  What about the static plantar pressure differences from side to side (blue)? Maybe, just maybe, we can bring a logical clinical assumption together and then a few clinical exam methods to confirm or dis-confirm our working diagnostic assumption.  See you tomorrow friends !