Gait re-training in runners

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I'm increasingly involved these days with gait re-training in athletes and non-athletes along with the Physios.

Does anyone know of any good courses concerning an element of gait re-training?

Many thanks!

 

Its still early days in this concept, but looks real promising. Irene Davis from Delaware has presented at several conferences on this recently. Check this.

 

No sooner than I posted the above message and this arrives in my inbox:

Jitka Bad'urova I, Samsonova H: Appropriate exercise and correct gait as a needful supplement in treatment of excessive pronation and flat foot. Comput Methods Biomech Biomed Engin. 2005 Sep;Supplement(1):15-16.

It has no abstract, so will order monday -- get back to you..

 

Thanks Craig and Admin!

I think the other thread reflects a discussion of either orthotics or physical therapy, which is a little different, as I work with Physios and/or surgeons, sports massage therapists, orthotists, shoemakers and sports shoe retailiers for practically all of my patients.

I don't actually find that I can progress 1/2 as well with my patients, without taking a MDT approach (perhaps that's a reflection of my own abilities!).

However, I think 'gait re-training' is in a realm of it's own and is something traditionally, I think, in the role of personal coaches of athletes, or Pilates/Yoga instructors.

What I'm really looking for is the sort of stuff Irene Davis is doing as I'm fortunate enough to be working with live video feedback etc and within a MDT, so we've just been doing as much as we can based on general gait and antomical/pathology knowledge.

Surely though, Physios or someone who works with neuro rehab has been doing this for years, but just not as sporty-orientated?

Really I was just looking for some sort of 'technique' guide for therapists to help me and my team deliver the best package and get people rehab'd that one stage further, which could be, in some cases, lifetime maintenence?

Thanks for the up-coming extract Craig.

 

Gait retraining in runners

Irene has got permision to reproduce this paper of hers on Gait Retraining in Runners. I have attached it as a PDF.

I was originally published as:
Davis I: Gait Retraining in Runners. Orthopaedic Practice Vol. 17;2:05 8-14 2005. It is reproduced with permission from the Orthopaedic Section, APTA, Inc.

Very very very grateful to Irene for this as there is some very very very good information in this paper.

 

Here is the abstract:
The article reports on a study that monitored the impact of exercise on the shape of children's feet. The dependence of frequency of excessive pronation and flat foot on the age of children suggests that there might be some features having positive impact on those deformities. It is shown that suitable exercise should be an important part of foot deformities treatment. Efforts have to be always focused on the whole body and good gait.

 

The paper by Irene brings up many good points. However, I worry a little about "gait retraining" since much of the research on stride length has pointed to the fact that runners tend to self-select their most metabolically efficient stride length. Therefore, it also stands to reason that a runner trying to run differently than is "natural" for them may become less metabolically efficient at running than they had been previously. In addition, the new gait pattern adopted by the runner may cause injury due to increased stress on the structures that are being "used more" to achieve that new kinematic pattern of gait. Who is to say that adopting this gait style may not cause a new injury to occur? I think it will in many cases.

Having been a long distance runner for many years, I know that when I have tried to change my natural gait style a significant amount, this felt awkward or led to new injuries. However, small changes in arm swing, stride length, and footstrike were tolerable for the most part. Therefore, I believe that small changes may be acceptable as long as the runner can adapt to it without injury or a loss of performance. However, forcing an experienced runner to make large changes to their gait pattern just doesn't seem to make sense to me since I assume they have already pre-selected a relatively efficient gait pattern for their given structural and functional makeup.

 

Hi

I cant open the attatchment, is it me or a is there a problem?

 

mucha gracias amigo

 

If an athlete is able to perform well with their choosen style, injury free, then one would suggest it should be left that way. I come from a sprinting background where depending on the time of year 30-70% of the work load is on specific technique. All runners have there own groove so to speak, but there are basic fundamentals that need to be followed.

I doubt most joggers/runners upto just below a competitive level have ever spent much time on their actual running style. Just getting legs and arms to move in a relatively straight sagital plane will increase efficiency and reduce the chances of injury.

Gait retraining or adjusting is something I'm certainly going to look into more and incorporate where possible. Would be interesting to incoporate it into the walking gait retraining as well, rather than just jogging/running.


Cheers

Tom

 

Craig,

Thank you for the paper. I haven't read it yet, but will. I just wanted to respond to agree completely with Kevin's concerns, based on ill-effects I have seen from gait re-training in the past, namely one experience as follows:

Patient presented to me with pain from the majority of her feet, but especially TA, peroneals, plantar fascia and 1st mtpj's. She was an international level sprinter and high-level ballerina. She was referred from another Podiatrist who has been treating with Orthoses for a second opinion. After assessment I found: Pernoneal tendons bilaterally dislocating over lateral malleoli, elongated and chronically inflammed TA's, complete antalgic gait in pronation mostly (as you would see someone walking who'd just run a Marathon!), lumbar pain, bilateral plantar fasciitis and hypermobility.............Her pathological history? Given her propensity to ballet and sprinting, it is unsurprising that she was a toe runner/walker, but PAIN-FREE. She decided to run the Gt. North Run as she was winding down from her sprinting career and wanted a new challenge. She sought the advice of a personal trainer who immediately instructed her to run heel/toe. She did this in typical competitive fashion, resulting in 2 stress fractures to her left tibia and one stress fracture to the right, plus the soft tissue pain she was still left with. Needless to say, she didn't run the race. In fact, she can't even run anymore!!!!!!!

This experience is what led me to ask some of these questions about gait re-training. I woul agree that minor changes would seem relatively harmless and possibly helpful (such as pelvic tilt), but worry about larger changes that I feel should be dealt with on a symptom led basis and then mainly with exercises to strengthen/stretch certain muscle groups, pilates techniques and possibly orthoses.

I attended a 1/2 marathon once of an international field and the man who came 3rd had bilaterally fused ankle joints. He presented only with mild calf pain after the race and professed to being injury-free!

Another aspect that I am looking at is 'pilates goes vertical', a weekend course of which is running soon, which combines essential pelvic stability with motion in gait. If anyone wants details of the course (this is not publicity!!), I can let them have the details via a PM.

Sorry this is all subjective rambling! I'll go and read that paper now!

 

Gait Retraining

Hi,

This is my first post to this group. I wanted to thank you all for your responses to the gait retraining article that I submitted to Craig. I can certainly appreciate concerns voiced regarding the effect of altering one's gait pattern. I believe that it is vital to have a strong basis upon which one makes the decision to alter a gait pattern. Thus we have conducted numerous studies on the mechanics associated with two of the most common injuries runners sustain: Patellofemoral pain syndrome (PFPS)and tibial stress fractures. While we realize that the etiology of these injuries is multifactorial, I think most would agree that mechanics play a role. If faulty mechanics are evident, and these faulty mechanics are associated with the injury the runner has experienced, then it makes sense to change those mechanics. For example, we have shown that high loading is associated with stress fractures. This provides a basis upon which to train individuals to run with lower loading (ie. consistent with non-injured runners). In our runners with PFPS, we have identified a pattern of hip add and IR, that is associated with PFPS. When we train individuals to run more well-aligned, their pain resolves. The idea is that the malaligned posture is what is causing the problem. By placing the limb in a more aligned posture, we are hopefully reducing abnormal loads - seems to be supported by the reduction in symptoms we are seeing.

It is important to monitor the changes closely so that runners do not maladapt to a pattern that will cause a problem. We have not had this happen to date, but we see the runners 3x/week and they are not allowed to run outside of the lab during the retraining.

Regarding efficiency, I would agree that, in the beginning, the runners are likely less efficient (although we are not actually measuring this) However, we have runners who have returned to competition and surpassed previous bests - an indication that efficiency may return once the pattern becomes natural. Although, admittedly, our focus is not to perfect running style for performance, but to address faulty mechanics associated with injury.

We truly are in the early phases of this work and look forward to having more data to support or refute our ideas.

Irene Davis

 

Irene,

Good to see you posting to the Podiatry Arena forum. Your research in this area is very interesting and may be enough to make me change my ideas on how I treat runners with injuries.

However, my question is will insurance companies pay for "gait retraining" treatments? And, if they don't, how much would you need to charge through your laboratory facility to the patient to be assured that they are being diagnosed and retrained properly? How would this method of treatment compare to simply altering their gait with custom foot orthoses in regards to cost?

And by the way, for those who don't know you and your work as well as I do, I want to publicly acknowledge that your contributions to foot and lower extremity and foot orthosis biomechanics research is some of the best in the world. Thanks for all your hard work and your support of the podiatry profession.

 

Gait Retraining

Kevin,

These are good questions. In terms of PT, 3 visits/week for four weeks - or 12 visits - is not unreasonable for PFPS - could be billed under gait training codes. At $60-70/visit X12 visits - that equals approx $800 - which is likely less than a pair of orthotics. However, the patients we are currently targeting have increased hip add and IR and may not have any problems at the foot. Some may have excessive pronation as well, but have not received enough relief from orthotics. I still use orthotics if I think a patient has a foot related problem. In terms of the stress fracture group, we have demonstrated that cushioning running shoes (ms in press) do reduce shock by 10-15%, however, we can reduce shock by 50% with the retraining. Thus, I believe individuals have an untapped potential to change their own mechanics - perhaps to a greater degree than we can do with external means (orthoses, shoes). We don't even blink about the idea of changing movement pattners for activities such as golf, pitching, and tennis. However, running is thought to be an automatic function that cannot/should not change. I do not believe that individuals always self-select the best pattern of locomotion for themselves. If this were the case, we would all be out of business!

I need to say that we are quite far from making recommendations of optimal gait retraining protocols. However, the notion of changing movement patterns to minimize injury risk is not new to therapists - neuromuscular re-education is a big part of what they do every day. I am hoping that this research will eventually provide therapists with an evidence-based treatment approach to gait abnormalities. While runners are a great group to use for this research because they are so motivated, I do think that eventually some of these techniques can be used with other populations.

thanks for your kind comments....

Irene

 

Yes I agree Irene that gait training in both running and walking should be strongly considered in combination with appropriate stretching and strengthening exercises in minimising injuries.
Most people have bad gaits (walking and running). Remember that we tend to find (as Kevin indicated) a metabolically efficient gait naturally. HOWEVER these naturally developed gaits tend to be lazy gaits dependent on high joint stresses and less muscle activity and tone. That is why people's stance consists of only one leg held in extension by the popliteal muscle AND why your sitting reading this message with very bad posture (yes that's right..straightened up). Due to the fact that we develope these 'skeletal dependent' gaits with minimal muscle activity, we become prone to injuries and although they are usually metabolically effecient they are not always the MOST metabolically efficient and certainly not biomechanically efficient.

I understand Irene's comparison of retraining in other sports. As a squash coach I see many players who suffer from injuries like 'tennis' or 'golfer's' elbow due to poor technique. I have never seen a professional squash or tennis player suffer from tennis elbow although they hit balls all day everyday.

I saw a 18 year old male (walker) 2 weeks ago who was concerned about his 'flat feet' and 'knocked knees' with R medial knee pain. OK a pair of orthoses may help BUT his proximal positioning and wide base of gait meant that the internal rotating forces of legs were IMMENSE. He made eventually need orthoses but for now I am working in collaboration with a physio in retraing his walking gait with the aid of MBT shoes as a training device.

It is only logical and that is the way I see it.
Cheers
Con

 

whats causing the muscle weakness in the patients in the study?

 

Con:

If I knew what your definition of "bad" is, then I could either agree or disagree with your observation that "most people have bad gaits". If you mean that "bad" means "imperfect", then I would agree with you. However if you mean "bad" to mean "exceedingly mechanically inefficient" then I would disagree with you.

I disagree with your statement that "naturally developed gaits tend to be lazy gaits dependent on high joint stresses and less muscle activity and tone". First of all, I have no clue what you mean by a "lazy gait". I would say that naturally developed gaits are generally the most metabolically efficient gait pattern for that individual but are also influenced by other factors such as pain-avoidance and central nervous system excitation parameters. Second, if you could provide research evidence that self-selected gait tends to cause "high joint stresses" then I won't just believe that this statement is pure conjecture on your part.

Since when did the popliteal muscle become the muscle of the lower extremity that exerts the greatest magnitude of knee extension moment to hold the knee "in extension"?! The popliteus tendon originates nearly on top of the knee joint axis, is a very small muscle and has very little, if any, ability to exert a knee extension moment. Also, more importantly, the center of mass of the body is normally positioned anterior to the knee joint axis during relaxed bipedal stance so that a passive knee extension moment is produced by the action of gravitational acceleration on the center of mass of the body (as long as the knee can come to full extension). Therefore,your statement that "people's stance consists of only one leg held in extension by the popliteal muscle" is a misleading and mechanically flawed statement.

If you are concerned about making a pair of orthoses for this patient then why not add some medial heel and arch padding to his shoe sockliners to see if his medial knee pain resolves as a clinical test? I would bet that his pain would resolve and his apparent genu valgum would also improve even with simple adhesive felt padding. Custom foot orthoses with a medial heel skive, made of deformation-resistant materials would have even a better chance of making significant improvements in the kinetics and kinematics of his gait without the need of repeated physio visits or MBT shoes.

I suppose that there are many ways to skin a cat, but certainly, in my hands, the use of shoe and orthosis modifications, along with stretching and strengthening protocols are a very predictable and relatively cost-efficient method of allowing individuals with mechanically-related foot and lower extremity athletic and non-athletic injuries to become pain free in a relatively short period of time.

 

Just wanted to weigh in on this discussion. I have worked with elite athletes in track for several years and work closely with physical therapists and coaches. Orthoses have been an integral part of gait retraining, but certainly are not a substitute for retraining musculoskeletal and vice versa. It is our opinion that it is most often the integration of disciplines that produce the most success.

One of the issues that has not been looked at in great detail is the biofeedback that foot orthoses provide to a patient. When improving run technique through muscle activation patterning is the goal, then using a device to give the appropriate positioning of the foot and limb will give the musculature the opportunity to get strongest in that position.(specificity of training principle)

We have been using some non-traditional techniques (muscle testing, applied kinesiology) to evaluate the change in biafeedback but they are not quantifiable. Does anyone knowof any papers, periodicals etc that have looked at the biofeedback of foot orthoses and how that pertains to movement patterns?

I know that Dr Nigg at U of C in Calgary Alberta is doing work on a similar, parallel topic(matching shoe attenuation frequency with joint and soft tissue attenuation frequency) but I don't know of any other simialr work,

Bob

 

Hi Kevin,

1) Yes the term 'bad' can be interpreted as 'imperfect'

2) a) Yes 'lazy' gaits are usually metabolically efficient. (Use the least amount of energy). Why would anyone want to use more energy to walk from point A to point B? Why would anyone walking try and activate core stability muscles, think about pelvic tilt, think about pelvic rotation, hold up correct spinal position, co-ordinate healthy rotation in shoulders, correct medially rotated shoulder position,...and so on...and so on. Yes not very efficient metabolically but I dare say mechanically more sound.

2) b) Yes your right, almost pure conjecture on my part that these 'lazy gaits' produce higher stress on joints. But the fact that correct technique in squash and tennis prevents tennis and golfer's elbow is also conjecture. (could not find any studies). It makes sense to me however that a joint that has little uniform muscle tone surrounding it would be subject to more stress in particularly if it is positioned (the joint) in a less congruent position.

3) Yes your right the popliteal muscle has never been 'the muscle of the lower extremity that exerts the greatest magnitude of knee extension'. However I never said that. It helps to hold the knee in the extended position. And of course is not the only muscle that does that but this small muscle was mentioned to underline my point that we attempt to do things (like stand) with minimal muscle activity. Interesting however is the fact that you mentioned that "the center of mass of the body is normally positioned anterior to the knee joint axis during relaxed bipedal stance". Yes what is 'normal'. Maybe if we corrected our stance it would not be as anteriorly positioned(if anterior at all). Food for thought.

3) I placed medial heel wedge during first visit and pain has subsided. Of course I will always treat the problem at hand for pt relief with time and cost in mind. I think we also have to keep the whole picture in mind. This pt also has always had lower back problems. If you could see the gait you could understand why. And I have a responsibility to give this pt the full picture.

Lastly Kevin, I can see why you would have been an A+ student. Your attention to detail gives rise to a good scientific mind. So forgive my loose termilogy i.e. popliteal muscle.

Cheers
Con

 

Good last post Conp.

As for 'popliteus', Kevin's explaination was correct, but I think he missed what you were trying to suggest; which was that this muscle, along with the posterior knee capsule and other posterior joint structures, become taut in the end-range knee extension position. If this did not occur, the anteriorly positioned COM would be unopposed and the knee would extend beyond function.

As you said Conp, it takes effort/control/endurance/support etc. to keep the joint position away from end range.

 

Gait Retraining

Con and Kevin,

I think we all recognize that no one treatment cures all things. We all have our own approaches - based on our own experiences. Since I have the opportunity, I use my research, as well, to guide me.

Back to gait retraining, which began this discussion. I have data to support that mechanics are related to injury, and that runners (the only group I've studied), have a greater capacity to change their own mechanics than a shoe or orthotic. In some cases, an orthotic device may be all one needs. But my approach has changed over the years and I use orthotics less and retraining more. My reasons for this warrant a longer discussion than I can enter into now.

Watch out - I'll be retraining pronation next!

Irene

 

Irene,

When you can retrain dorsiflexion of the forefoot on the rearfoot (longitudinal arch flattening) during late midstance then I will be really impressed.

 

Commencing gait-retraining

Yes, nice work Irene on taking this topic to the research and coming up with some good starting evidence for us to chew on...

I have been working alongside physios/podiatrists that have been attempting to delve into gait-retraining with a good amount of success. Less PFPS, less patella tendon irritation (tendinopathy sufferers) even with basic stride length shortening.

One thing that I haven't seen mentioned which I (and others) feel is the corner stone to starting the process off. Why are the joints/forces being created in the first place. Muscles to tight/flexible, weak/strong. I leave this to the rehab physio's to work out and once strengthened/stretched then commence gait retraining.

Should we not be trying to accertain why the knee in a deeply flexed position at midstance, or internally rotated...is it because hip flexors are tight with ant tilt at the pelvis, putting a stretch reflex on the glut medius, along with tight hamstrings causing little or no resistance to internal rotation/increase in flexion at the knee joint at midstance with an inability to move out of this mechanically inefficient position causing injury...

Lots of others could be mentioned but keen to get some further opinions...

 

Gait Retraining Problems

Here are the potential problems that I envision with increased use of gait retraining as a method of treating running injuries:

1. Personal experience with my own running gait and hundreds of patients that I have treated has been that when a natural, self-selected gait style (e.g. trying to supinate or pronate more or less than usual) is changed even slightly due to a current injury that this has often produced injuries that take longer to heal from than the original injury that they had changed their gait style for.

2. To perform gait retraining technique in the most scientific way, a significant capital outlay will be required by the clinician to purchase treadmill equipment, video analysis equipment and computer software.

3. The potential cost to the patient will probably be as much (if not higher) as treating the runners with foot orthoses and more traditional techniques. This is especially true if it is found that the "new gait pattern" is producing new injuries and the whole process of gait retraining has to be started over again.

4. How often will the runner need to return to the clinician to see if their gait is properly maintained in the "retrained" position? Will it be assumed that since they don't have injury that the gait retraining has been successful, even if, in fact, their gait has eventually returned, over time, to what they originally had? In other words, do we have any evidence that gait retraining is long-lasting? Or is gait retraining going to be an transient effect that will then be gradually "forgotten" so that the runner to eventually relapse into their old "bad" gait style?

5. How does constantly having to "think" about running correctly, versus just "doing it", affect the pleasure of running? This gets down to whether this new "style" of running is something that the runner can learn to do automatically, or is it a movement that is so unnatural for them that they have to constantly think, with each running stride, to run differently. Again, this brings us back to the question of how long does "gait retraining" last for the runner without having to have their gait "checked" again by the clinician.

It should not be inferred from my comments/questions above that I think that gait retraining may not be a valuable technique to use in treating runners. In fact, I have been using gait retraining for over 20 years in treating runners. However, this has involved showing them proper stride length (overstriding is very common in beginners), how to keep their center of mass from "bouncing" during long runs ("survival shuffle technique"), and adjusting their arm swing. I have never tried to advise runners to run with their knees closer or farther apart or to pronate or supinate their feet more or less since I felt that this would lead to increased risk of injury (based on personal and patient experience).

I have successfully, however, treated thousands of running injuries with foot orthoses and have altered the frontal plane and transverse plane position of their feet and lower extremities with foot orthoses [I first made and dispensed Blake inverted orthoses (under Rich Blake's guidance) in 1982 (when Rich first started using the technique) but have been using medial heel skive orthoses for runners since 1990 to "control" excessive rearfoot pronation.]

This gets me to thinking......it would be fun to get Rich Blake to come on here and recount his experience with his orthoses. Rich did the Biomechanics Fellowship three years before I did and was my instructor in biomechanics, and we did a relay called the "Border to Border Run" from Oregon to Mexico together, along with 9 other podiatry students in 1980. Also Rich and Ron Valmassy ran with me and a bunch of podiatry students in the 39 person-150 foot long "centipede" I put together for our "CCPM Pod Squad Running Club" for the Bay to Breakers race in San Francisco in 1979....a world record at the time. Maybe I will contact Rich and see if he can contribute with his vast experience of treating runners to this forum.

 

Gait retraining

Hi Kevin,

To answer your questions:

1. Good Point. Runners certainly do maladapt (due to pain) to an injury creating another one. However, we are altering the exact mechanic that we have found to be related to the problem (excessive loading or excesive hip add). I believe this actually reduces overall injury risk as the runner's mechanics are improved - not maladapted.

Gait retraining does need to be monitored to be sure the runner doesn't overcompensate or adapt some abnormal pattern. Runners inthe PFPS retraining will experience muscle soreness in their hip abductors in the first few sessions - but that is to be expected when you are changing a neuromuscular pattern. This resolves after the first couple of weeks.

We have yet to create a new injury. We believe this is because we monitor the retraining, watching for any potential maladaptations, and the runners do not run outside of the retraining sessions.

2. While we use an instrumented system because of our research requirements, we have performed gait retraining using a simple mirror and treadmill (as described in the article that Craig posted). If you are treating runners, a treadmill and video camera are a minimal expense and should be readily available.

3. The cost of retraining may be a little more initially than orthotics, but not necessarily any more expensive than a standard course of PT. In the long run, retraining may be less expensive than orthotics. If a runner is trained to run with better alignment or less loading (greater changes than can be attained with orthoses), it seems that they would be less likely to develop other injuries associated with that malalignment or increased loading (needs to be studied as I have no data on this). In addition, orthoses need to be replaced and thus are a recurring expense.

Gait retraining is not simply telling someone to run differently and then letting them do this on their own. They need some form of feedback (mirror, sound, etc) to reinforce their pattern. In addition, based on the motor control literature, feedback must be intermittent to produce lasting changes. In our protocol, runners only run 10 minutes in their first session gradually increasing their time. We gradually remove the feedback intermittently, such that, by the end of their sessions, they are running 30 minutes without feedback and with their new pattern.

4. This is a very good question- and one I cannot yet answer. We do know that 1 runner maintained their mechanics up to 6 months post. We have about 10 runners whose mechanics we have measured 1 month post. All have shown maintenance of their patterns. We are very very early in this research and have much to study regarding maintenance of new patterns.

5. Runners definitely have to "think" about their new mechanics in the beginning. But by the end of the retraining sessions, the subjects are more comfortable with their new pattern than their old pattern - and report they do not have to "think" about it. It is really not any different that someone learning a new tennis serve or golf swing.


While our research is focusing on gait retraining, my clinical approach to runners is much more broad. I use stretching, strengthening, footwear, and orthotics as well. However, I primarily use orthotics when I think the problem is related to abnormal foot mechanics. If the problem is more hip related - and many patellofemoral pain syndromes are - then I address the hip.


Hope that answers your questions!

Irene

 

Hi Kevin,
For what it's worth I think that an activity like nordic skiing is at least similar to walking or running in that it is rythmical "contralaterally symetrical"? involving most of the muscle groups. Many years of teaching these kinds of skills leaves me completely convinced that permanent changes can be achieved in motion patterns.
This will involve a great deal of mental effort intially and over time and repetition with feedback more and more aspects of movement will be incorporated into the "neural template" ....the autopilot gradually takes over and allows you head space for other things as well.

I'm sure at least some of this applies to walking and running....but I'm sure you 'd be the first to suggest that no amount of brain power can overcome large undesirable torques resulting from poor boney alignment or joint axis position.

Regards Phill

 

Hi Irene:

Thanks for your answers. Even though hotel managers all know what a good dancer you are, they probably don't also know how smart you are.

The most obvious question that then comes up is as follows: given that we now may have the option to treat patellofemoral syndrome (PFS) with either proximal control of internal hip rotation with gait retraining or with distal control of internal tibial rotation with foot orthoses,which method of controlling internal knee rotation during running is the most energetically efficient? [Energy efficiency being defined as the lowest magnitude of oxygen uptake for a given magnitude of steady state running speed.]

If a properly designed foot orthosis is made that increases the external subtalar joint supination moment, then this orthosis should be able to limit internal knee rotation without the need for increased contractile activity of the external hip rotators, which should not change the oxygen uptake required. However, since it is known that increased shoe mass increases oxygen uptake, then overall, the increased mass of foot orthoses in a shoe will likely cause increased oxygen uptake and, in turn, cause decreased energy efficiency of the runner.

If gait retraining and proximal control of internal hip rotation is the method chosen, then increased contractile activity of the external hip rotators will be necessary which will increase oxygen uptake, even though the shoe weight would remain constant. This would then also cause an overall increase in oxygen uptake and decrease the energy efficiency of the runner.

To me, it would seem like both methods have the potential to not only prevent injury but, in so doing, will decrease the metabolic efficiency of the runner during steady state running, all other things being equal. However, a lightweight foot orthosis may have the potential to alter the kinetics and kinematics of running with minimal increase in oxygen uptake and minimal decrease in energy efficiency of the runner.

Energy efficiency will likely become more important to a runner involved in endurance type events (10K - marathon) where aerobic metabolism is predominant and will be much less important to a runner involved in shorter events where anaerobic metabolism becomes progressively more predominant as the racing distance shortens.

Just some thoughts for the evening....

 

...I remember that conference ... in the ballet shoes

 

I believe they were Irish clogging shoes....maybe Irene remembers.

 

Gait retraining

Kevin,

Efficiency is certainly a consideration, and I do believe it takes more effort on the runner's part in the beginning. However, I am not convinced that efficiency is decreased once they have adapted to their new pattern. We don't collect physiologic data, although we are considering doing a finger prick for a lactate measurement in the future. What I can tell you is that most recently, one of our competitive runners reported back to us that pictures of her most recent race showed her knees straighter - and that she won her division (XC) with a personal best that day. It would be hard to accomplish this with significantly reduced economy. I realize this is only one case study, but most of our runners tell have returned to their previous level of running.

I think that some of the difference in our treatment approaches comes from our professional backgrounds. In addition, people who typically seek out a podiatrist have problems with their feet. I would likely treat these individuals in a similar way as you. However, I honestly cannot believe that all running injuries are related to the foot, and that all are best treated with an orthosis.

Even if your approach is to treat a patient with PFFS and an associated hip problem (excessive hip add and ir) with a foot orthosis, I can provide you with evidence that the effect at the knee (tibiofemoral joint) is greater by addressing the proximal issue. As an aside, we are beginning a project to assess PFJ changes with both a foot orthosis and with altering hip mechanics in runners with PFPS. We have a standing MRI unit here that allows to assess the 3D orientation of the TFJ and PFJ during single leg squats (you know you're a nerd when you get excited about this kind of thing!).

But to answer your initial question, efficiency (reported by the runners, but not tested objectively) hasn't seemed to be a problem.

Irene

ps. Craig - yes they were clogging shoes!

 

Irene:

Of course, a single case report of a personal record is not enough to establish whether the metabolic efficiency of running is affected by gait retraining. The day to day, week to week and month to month variability of running performances is well known to experienced competetive runners so that a PR may occur for unknown reasons that may or may not be affected by a previous intervention parameter. Factors such as hydration level, amount of sleep, stress in daily life, running shoes parameters, timing and intensity of prior training level, diet and emotional well-being, are a few of many things that may affect performance of endurance athletes.

I believe that the only way that this can be studied with reasonable scientific accuracy would be to measure oxygen uptake of runners on a treadmill at a certain steady state pace, below their anaerobic threshold, both before and after the orthosis or gait retraining intervention. Serum lactate levels would probably be a little less conclusive since it would not give you an accurate objective measure of metabolic efficiency, but would be more a indicator or being more or less efficient, given that the work rate of running is above the individual's lactate threshold. And I don't think that most runners would be able to personally detect the small differences in their own metabolic efficiency that may be caused by foot orthoses or gait retraining since this is very difficult to discern, even for the experienced runner.

I do not use foot orthoses for treating all running injuries. I also use gait retraining, stetching, strengthening, icing, physical therapy, shoe recommendations and shoe modifications. In addition, most of the runners that see me in my office for their injuries do not have problems with their feet but have injuries to their knees, legs, feet, ankles and hips, in that approximate order of anatomical site injury frequency. Therefore, to have a runner-patient come to me with foot pain is not near as common as having a runner come to my office with knee or leg symptoms. However, these runners do seem to know, from word-of-mouth from other runners that I (and other sports podiatrists) have treated here in Northern California for the past 20+ years, that foot orthoses have been highly effective forms of primary treatment of many types of running injuries from the low back to the foot.

As I have said before, there are many ways to skin a cat when it comes to treating running injuries. As long as the clinician is using a treatment method that is effective, long-lasting and has little risk of negative side-effects, then I have no problems with the clinician using that treatment, or combination of treatments, for running injuries. I'm sure we can agree on that.

 

gait retraining

Kevin,

The point I was attempting to make was that the problems that most podiatrists see are related in some way to the foot - which is why someone would seek out a podiatrist. Knee problems, back problems, etc may certainly be related to the foot - and in those cases, foot orthoses would certainly be appropriate. But these problems aren't always related to the foot.

I think that we might have very different ideas about what we are calling gait retraining (see previous post). This may be why we have different opinions about it.

But you are absolutely right in that many treatments lead to resolution of symptoms. And at the end of the day, it is all our patients want!


Irene

 

Irene --- very timely comment:

I am in the middle of preparing a lecture on "Its not the orthotics" (there was this thread we had on hip rotation and PFPS) ... the really fun part of the lecture is that I have a whole lot of images from Dinosaurs -- do you remember that puppet series on TV in which the smart aleck Baby dinosaur would not say the word 'father' or 'dad'? ... Earl used to get upset as he was called "not the muma" ... I have paraphrased that comment and used images from the show to make it into "not the orthotic"

 

I totally agree with you. If I see a patient that I don't think I can help with shoe or foot related adjustments, and I see that I can't suggest improvements in their gait, can't suggest stengthening or stretching exercises, don't think icing protocols or physical therapy prescriptions may be helpful, then I send them for appropriate referral, generally to an orthopedic surgeon for surgical consultation. This happens about with about 1% of my runner patients.

I believe you are right here also. My knowledge of gait retraining, as you perform it, is very limited. That is why I am picking your brain "in public" here, so that you can educate me and the others following along about your expertise in gait retraining in runners.

Keep up the good work, Irene. Hope you continue to contribute to Podiatry Arena since with your considerable research and clinical background, you can add significantly to many of the discussions we have on this forum.

See you at Chicago PFOLA?

 

Just to sidetrack for a moment..... I have to comment on the A and B photograph on the homepage.

Not only is there a difference in the hip and knee (valgus) angles between pictures A and B. There's also quite a difference in the angle of the handrail supports..........

Apologies if anyone else already pointed this out.

Regards,
davidh

 

Update: Gait re-training in runners

Bumping this old thread with this press release from Medical News Today:
Risk For Stress Fractures And Pain Under Kneecap Lowered By Biofeedback On Abnormal Mechanics
04 May 2007

 

Well done Irene,

It shows that the gait can be re-trained. The specific "real time" feedback seems to be the key for the suprisingly 'quick learning' of the new gait.

Keep up the good work.

Cheers

Con