Gait and Ovulation…A sexier saunter…
Welcome to Monday morning folks. Here’s something to get you going for the week. Nope, not a post about orangutans, but even BETTER!
Remember, you probably saw it here 1st. You always wondered (at least we did) why women walk differently around the time of ovulation (yes, they REALLY do) , and now here’s the proof. A recent article in Gait and Posture confirms that women walk slower and with what is judged to be a “sexier” gait around ovulation (Go Zsa Zsa Gabor!), which is believed to reinforce their attractiveness and make them more likely to be noticed and attract a partner.
We knew there was a reason we liked gait so much…..
Ivo and Shawn. Bald. Middle aged…Good looking…The Gait Guys
If you know, recognize that you know,
If you don’t know, then realize that you don’t know:
That is knowledge.
Confucius
True knowledge is when one knows the limitations of one’s knowledge.
Neuromechanics on Saturday?
We have long been talking about the importance of the cerebellum in gait and motor activity (see here).
Here is a study (Non-Invasive Brain Stimulation Shown to Impact Walking Patterns) that looks at a new technique for using electrical stimulation of the brain’s cerebellum (trans cranial direct current stimulation to be exact) to change gait on a split belt treadmill (a double treadmill where each leg moves a slightly different speed). The study found that during the electrical stimulation the anode (negative charge) seems to speed up the learning process (our theory: more electrons, possibly creating a temporary electrical gradient which depolarizes (excites) the cells to a greater degree). And the cathode seemed to slow things down (our theory, it hyperpolarizes the cell and makes it less excitable).
Take home message? There are new neurologic studies and experiments that may be proving helpful in retraining gait function. Stimulating the brain’s cerebellum seems to speed up learning or slow it down, depending on your client’s needs. We are sure we will be seeing more of this kind of stuff at technology advances.
Maybe Larry Niven wasn’t that far off. (We loved the story “The Long Arm of Gil Hamilton”). This could be a great, non invasive tool for rehab (or maybe improving performance!)
The Gait Guys…taking you deeper down the rabbit hole…
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In Part 1 of this two part series (Part 1, link here) we wrote about the need to not omit observations of gluteal function when it came to the utilization of foot orthotics to control the knee. We felt that a tunnel vision perspective on just the foot was only telling half the story. Admittedly, we made the comment that research articles can look at isolated issues if it pleases them, but that it was our mission not to let tunnel visioned biases enter into things. Tunnel vision leads to assumptions that some problems have simple solutions. Our clients get evaluated through the entire kinetic chain when looking at foot and knee issues. Heck, even arm swing and opposite leg swing impact the function of the stance phase knee.
Here is again is the original article by Katie Bell over at LER (Lower Extremity Review) that brought up the initial PART 1 dialogue back in January and that is spurring Part 2 here today. It was good information but left some gaps in theory and application in our opinion.
The gap in our opinion is in failing to mention that perhaps this landing mechanics problem is present because of intrinsic foot weakness and kinetic chain cooperation of the entire limb and pelvis-core. One must remember that if the foot can be corrected or merely strengthened in a more functionally neutral manner that it should be a first line intervention. Merely inserting an orthotic, custom or off the shelf pre-fab does nothing to correct intrinsic and extrinsic weaknesses. They are an external device to correct alignment issues. Just because you put an orthotic in a shoe does not mean that the foot must function properly afterwards. A flat weak foot might just sit flat and weak upon the orthotic and nothing more. Sure it will be on a new platform and with different alignment, but there are no guarantees it will function better. The foot might just figure out a new way to compensate in another manner. Even worse, the foot and lower limb might be completely foreign in strategy, skill, endurance and strength in this new position and thus at even greater increased risk for injury than the one you tried to correct with the device in the first place. Just because you toss an intervention at something that should make a difference or create a result, does not mean it will occur. Just because you put a beer in someone’s mug does not guarantee they will drink it. That is the intention, but the outcome is not guaranteed, they might drink it but they also might not. Heck, they could even spill it (ie. compensation … undesirable outcome !). Just because the platform is different, new and possibly more optimal does not guarantee they will have the Skill, Endurance or Strength (S.E.S. - the mantra of The Gait Guys) to function any differently than before. This is why, when we choose to reach for an orthotic, that we educate the client on what it is doing, and how to treat it like any other piece of therapy. Meaning that it is to help reach an end goal, and when possible it is weaned away or minimalized to the new levels of S.E.S.
Now, back to the topic at hand.
This article talks about the hip adduction in females and mentions that it is not present in males but fails to even talk about possible reasoning behind this gender specific finding. Why wasn’t changed Q-angle in females talked about here ? Perhaps that was a discussion in the studies and merely not mentioned here.
The article also fails to talk about failed landing mechanics at forefoot load. When we load returning to the ground from a jump, we first load the forefoot. If the peronei and lateral calf are not strong enough to hold the rearfoot and forefoot in eversion at landing, making sure that the forefoot bipod is squared up at initial contact, the foot will be at a huge risk of inverting and spraining ligamentous tissues (esp. lateral restraints) as the load transitions from forefoot to rearfoot upon landing.
Think about all of this the next time your foot is in the air and quickly approaching the ground. If you are into a forefoot landing technique in your running, how is your forefoot landing platform ? is it flat ? Are you hitting laterally and risking injury or faulty mechanics ? Is your foot landing too medially and challenging the foot tripod prematurely ? Are you falling into the orthotic if you are using one ? Or are you merely using it as a crutch to improve your landing mechanics ? And……. do you even truly need an orthotic at all ? Or did your $ 500+ merely make for a nice mortgage payment on someone’s new boat ?
Orthotics …. they have value at times. Do you know when and how to implement them and when to hold off ? It is a tough game, you have to know the rules.
Shawn and Ivo
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The Secrets to Running Downhill Fast. -
Please hit the link here for the entire great article by Jene Shaw. There is lots more here. LINK
http://triathlon.competitor.com/2012/05/training/the-secrets-to-running-downhill-fast_54031
Lean forward from the hips, not the shoulders. Gravity naturally pulls you downhill. Avoid the urge to lean back and focus on keeping your body perpendicular to the ground. “As you increase speed, move your center of gravity forward with you; not enough and your feet are sliding out from under you, too much and you’re on your face,” Waerlop says.
Think of your foot as a tripod, with the three points being the heads of the big and little toes (at the ball line) and the heel. This tripod needs to be level for the foot to function optimally. If you are too much on your heel, your shins need to slow the descent of the foot, which can lead to shin splints. If you land too much on your forefoot, your calves have to work harder to lower your heel and will exaggerate any forefoot abnormality you have in your gait; this will place additional stress on your knees. —The Gait Guys, Drs. Ivo Waerlop and Shawn Allen
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Here are some other things to remember when running down hill:
Be a drop of water: The Zen of watching water run downhill can teach us much. Taking the path of least resistance often is the least stressful for our bodies. Though terrain features like rocks, grass and dirt mounds can be useful to control speed, they also cause deceleration of our bodies, which means you need to reaccelerate them (remember Newtons 1st law?). This costs energy and wear and tear on our chassis. If you need to regulate speed on your descent, use the terrain options as described or angle your approach to one side or another zigzagging the descent. Taking the descent on an angle enables you to get 2 legs of your foot tripod on the ground almost immediately for added stability and it shifts your center of gravity to a more vertical or stable position, it also puts your body mass closer to the hill. A slip when descending on an angle is a better controlled slip. As you gain skill, you can point your feet more progressively down hill.
Do your homework: In the simplest explanation, muscles contract two ways: concentrically and eccentrically. Concentric contractions explain how the muscle shortens as it contracts, like picking up something. Eccentric contractions explain how the muscle lengthens as it contracts, like putting something you picked up back down. Eccentric contractions are much more costly from an energy and wear and tear perspective, as it takes more energy to break bonds between muscle fibers than make them. Running down hill requires lots of eccentric contraction of muscle, especially the quadriceps and muscles on the front of the shins, as there is a shift from glute drive to quadriceps loading. Running hills requires more (or extra) training particularly the eccentric phase for hill descents because of the increased demand.
The faster you go, the more perpendicular to the ground your body needs to be: Because of gravity, you are pulled down a hill. Our instinct may tell us to lean away (or backward) as we descend and pick up speed, but that could spell out disaster and perhaps your last run for quite some time. As you increase speed, you need to have your center of gravity move forward with you; not enough and your feet are sliding out from under you, too much and you are on your face. Again, if speed control is getting challenging, like in backwoods steep descents, zigzag your descent. Managing speed but covering more terrain safely is better than being the first down the hill while the last to get out of the first aid tent.
Look down the hill, not at your feet: Your brain works best pre-planning the next thing it should do, and works better when multitasking. Looking down at you feet actually facilitates your flexor muscles (the muscles which make you bend forward). This does two things: it makes you tend to fall forward and it turns off your extensor muscles (glutes, hams, back muscles) which are (or should be) the muscles in charge to keep you upright.
Engage your core: Think of your core as your engine and your legs as your transmission. An engine needs to drive the transmission. Your core muscles (abs, glutes) provide a stable platform for the other limb muscles to work upon. Not having the core engaged makes you more susceptible to injury, just like if your engine mount were broken.
Relax: Your mind is like a parachute; it works best when open. Stiffening up elicits protective reflexes that could be dangerous while running downhill. Imagine trying to drive your car with the airbag inflated. Let go and follow the flow.
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A case of the non-resolving ankle sprain. Things to think about when the ankle and foot just do not fully come around after a sprain.
Gait Guys,
A while back I had a severe ankle sprain while trail running. As I stepped on a rock my toes pointed downward, my ankle was rolled in and I felt a pop. This was follow by a lot of swelling and bruising both on the inside and outside of my ankle. Being experienced with ankle sprains, I jumped on the initial treatment immediately. The reduction in swelling and bruising lead me to believe that I was in for a 4-5 week recovery, then I would be back at what I love doing. I was proven wrong:
1. Initial treatment consisted of immobilization, icing, and a very high dose of Ibuprofen (3 days only). After a couple weeks of this I began stretching, massage and trying to get into some modified activities as the pain allowed me to. I was able to do some hiking but running was too painful.
2. After 6 weeks, I was still having pain in the posterior tibial tendon area as well as the deltoid ligament area. I tried running but, I was met with severe pain beginning in the middle of the gait cycle through the push off. I saw a PA at this time and was told to give it more rest. For the next few weeks I wore a soft brace and spent most of my time in a chair.
3. By week 9, there was no improvement. I could walk fine but, I had the same pain when I tried to run. I visited the PA again and was put in a walking cast and had an MRI. The MRI should a low grade deltoid and ATFL sprain as well as a bruised bone. I spent 2 weeks in the walking cast then returned to the soft cast for another week. During this time I did nothing besides give it rest.
4. At week 11, I did not see a noticeable improvement. I still had a sharp pain in my posterior tibial tendon area and deltoid area during the middle of my gait (when trying to run). At this time, I had another visit with the PA. After looking at my MRI more closely, he saw fluid buildup behind my talus. He thinks that I had an impact injury to my Os Trigonum. He also noticed that I had very limited dorsiflexion. He has advised me to stretch and give it a few more weeks. If it’s not going in a positive direction he recommended a cortisone shot.
As it stands today at week 12, in a dorsiflexion position, I have a sharp pain in what feels like my Achilles tendon and posterior tibial tendon area (the MRI shows these are intact). I also have a lot of tenderness in the deltoid area. Walking, I am almost pain free but as soon as I begin to run, the pain starts in the areas described above. This is the first injury I have ever had where I haven’t seen a steady improvement when recovering (maybe I am just getting old). The pain I am having now when trying to running is the same as it was at week 4. This really concerns me.
I guess my question is, where do I go from here? Do I keep doing what I am doing? Should I seek a second opinion? Any help or guidance you could provide would be greatly appreciated.
On a side note, your blog has helped me to get though the last 12 run-less weeks without losing my mind or falling into a deep depression. You guys do some great stuff. Keep up the good work!
Best Regards,
MR
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Dear MR:
Somehow we missed this email. Sorry about that.
Whenever things are not resolving with reasonable intervention one must think of two things: either the injury was severe or the diagnosis is incorrect.
Without seeing you we are unable to determine either. But here are our thoughts.
The Os Trigonum syndrome is a good thought. It seems to be in the correct area of your complaint. These “Os” bones can be embedded in tendon or soft tissue and they can be fixed to the posterior talus by either bone or a cartilagenous bridge. It is possible for this to be your problem if the inversion event was severe enough although it is not that common in this described mechanism.
One must also be suspect of osseous compression of the medial talus against the medial calcaneus, which will bring thoughts of a posterior subtalar facet fracture. We pulled up an article we read a few years ago on this issue (click here), the article is entitled, “Pseudo os trigonum sign: missed posteromedial talar facet fracture”. Obviously this needs to be considered in your case since there are similar components in area and symptom of your complaints. Posteromedial talar facet fracture (PMTFF) is a rare injury, sparsely reported in the literature and it must be chased as a diagnosis of suspicion when all other clinical presentations have not panned out. Damage to the sustentaculum tali must also be assessed, as this too can be fractured. Osteochondral defects are also always on the list in violent inversion events; they are classically seen anteromedially and posteriolaterally at the ankle mortise joint.
Something else that is often missed in ankle inversion sprains is avulsion or rupture of the extensor digitorum brevis on the lateral foot. As the rearfoot inverts and forefoot plantarflexes the EDB is tensioned to the point of tearing. Although you seem to have no symptoms in this area it can never be overlooked. These are easy to discern from the lateral ligamentous structure damage because the areas are clearly separate from eachother. Look for tenderness down into the top of the metatarsals into the forefoot. Also test for weakness and pain of toe extension.
So, lots to consider here in this case. When things to not resolve you have to start looking for less common problems and damage. We would love to hear how you are doing MR. Drop us a line.
Shawn and Ivo……. also geeks of orthopedics. We paid the piper long ago.