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Use a wider base of gait for medial tibial stress syndrome

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Craig Payne, Nov 6, 2012.

  1. Craig Payne

    Craig Payne Moderator


    Members do not see these Ads. Sign Up.
    In a previous thread on medial tibial stress syndrome, there was a lot of discussion of a potential risk factor for MTSS was the higher bending moments in the tibia due to the narrower base of gait (ie the runners varus). Using medial wedge to counteract this by all reports works well.

    In that thread I made the observation that:
    and Kevin responded:
    Now we have this abstract that is due to be presented at the Jan 2013 APTA conference in San Diego:

    Step Width and Tibial Stresses during Running
    Meardon, Stacey A.; Derrick, Timothy R.
    What say you?
  2. Admin2

    Admin2 Administrator Staff Member

  3. NewsBot

    NewsBot The Admin that posts the news.

    Now published:
    Effect of step width manipulation on tibial stress during running
    Stacey A. Meardon, Timothy R. Derrick
    Journal of Biomechanics; Available online 21 May 2014
  4. RobinP

    RobinP Well-Known Member

    Anyone got the full paper. Good tool in the arsenal if this study is OK?
  5. Griff

    Griff Moderator

    Will email it over.

    Been using this cue for a while now (as just one small part of the bigger rehabilitation strategy of course) and getting some good clinical success.
  6. Ian Linane

    Ian Linane Well-Known Member

    Hi Ian
    Me to if possible, please.
  7. RobinP

    RobinP Well-Known Member

    Thanks Griff - similar results clinically but with much smaller numbers of patients so difficult to say if definitely related to the altered base of running gait. This paper potentially makes it a definite inclusion in the treatment protocol
  8. Griff

    Griff Moderator

    You make a good point... On reflection if I'm being scientific about things my comment about using it and getting good clinical success may be a bit of a stretch given I seldom use it in isolation (but instead concurrent with other running re-education cues, proximal control/recruitment drills and orthoses)

    That said I have seen a few individuals who already had orthoses from elsewhere which looked fit for purpose but they were still symptomatic, and when we then made some minor adjustments to their base of gait when running certainly experienced a positive result. Definitely feel it has a place in the management of MTSS and will often mention when discussing other running stride parameters with my patients.
  9. RobinP

    RobinP Well-Known Member

    Like you, I use glut med and glut max recruitment exercises as another staple in the treatment protocol. However, like many exercise programs, it lacks a tangible element and I think people really get that with widening base of gait. It is often easier for them to persevere with increased base of gait when it is not happening as quickly as they would like when recruitment exercises seem very slow and long term.
  10. Using a wider base of gait in running is doing nothing more than decreasing the limb varus that occurs with running. Trying to teach a runner to run with a wider base of gait is just another form of gait retraining. Unfortunately, even though gait retraining is being used with limited success, we really don't know how long-lasting it is or whether it may unload one tissue at the expense of increasing the loading on another tissue.

    Retraining a runner to run with their feet wider apart may be very difficult for some runners to do, will feel very unnatural to many runners and may cause other problems. Instead of having a runner change their gait, I prefer to simply add more varus forefoot and rearfoot wedging to their shoes/orthoses and generally get very good results. This is much easier for me to do, much easier for the runner and much less mental work for the runner who is often using running as a way to clear their mind of their daily worries.

    Why do you all think a runner chooses to place their feet more under the center of mass of their body as they run faster? There is a reason for this change in frontal plane alignment of the lower extremities as one progresses from walking to faster running!
  11. Griff

    Griff Moderator

    Hey Kevin

    Don't disagree with the mechanism behind widening the base of gait (decreasing limb varus and subsequent tibial bending moments). Also suspect you are right regarding the potential for it to possibly be at the expense of other tissues (it is after all a zero sum game). This is all part of the discussion with the athlete/patient beforehand where they are counselled about potential benefits, limitations and risks.

    Although it is easier to just add more varus wedging to their devices do you not find yourself in scenarios where doing so is just not feasible or well tolerated? I certainly do. Usually those with a corking great varus morphology of their tibia and maybe even a previous ATFL injury thrown in for good measure. In these individuals I find it useful to have another tool to use to try and manipulate their loading patterns.

    Maybe it is more of a narrative of the personality traits of many of my patients (Type A, City of London workers, usually analysts) but it is not my experience at all that they are looking to clear their mind when running. Most of them pretty much demand running technique advice and cues on their technique and cadence. They way I see it I'd rather be part of that rather than them reading something on a blog or in Runners World.

    Interesting comment regarding the frontal plane kinematic changes (e.g. Running limb varus) being adopted with respect to running. I'd actually love your take on it. I was always of the belief that it was the most efficient way to run - placing the foot/feet directly under the centre of mass surely minimises lateral shift/excursion of the trunk and is therefore more efficient. I had just this chat recently with the running coach I work closely with regarding how we may be (negatively) effecting a runners efficiency by making such changes as widening the stance. Admittedly we are not making huge changes (think running on a running track and the feet landing just outside the lane lines rather than visualising running on say a tram line) but it must have an effect nonetheless. We both agreed that most runners would take running pain free with a wee bit of a performance hit (potentially) over not being able to run at all :)

  12. Craig Payne

    Craig Payne Moderator

    The new edition of Running Medicine includes the advice to do this, ..... but then again Jay Dichary did write that chapter! ... again with no citations to support what he says.

    Even the rationale he uses is about eccentric contractions and not bending moments ... go figure.
  13. Ian:

    I really can't disagree with any of your points above. I have had very good results with increasing forefoot wedging along with increasing varus wedging of patient's orthoses with MTSS to eliminate their pain with running but, as you say, this does not always work. I have experimented on running form manipulation but I do worry about 1) the patient being able to do this wider base of gait and not have to concentrate on it all the time and thus revert back to their more natural base of gait, and 2) another injury occurring which is just as bad, if not worse, than MTSS, due to my instruction to widen their base of gait. I would be interested in how you get along with gait manipulation toward a wider base of gait in your runners to see how it goes for you and your patients.

    Regarding running limb varus, I believe that especially as the runner approaches higher velocities of running (over 6:30/mile pace) they will tend to land with their feet directly under their center of mass as a metabolic energy conservation mechanism. At these running velocities, the runner is spending more time in double float phase and "leaping" from one foot to the next, rather than "shuffling" side to side at slower running velocities where there is a very short double float phase.

    This mechanism to alter varus leg position depending on the velocity of running is driven by the central nervous system (CNS) and seems to be more pronounced in more experienced runners. The CNS will choose to put the feet directly under the center of mass during faster running since this will reduce the side to side accelerations of the center of mass that will occur if the runner places their feet "just outside the lane lines", as you say.

    In other words, the CNS realizes that putting the feet under the center of mass of the runner is the most metabolically efficient way for the runner to run at higher velocities and will tend to fight any tendency to move the feet to a wider base of gait. Of course, if the widening of the base of running gait reduces the pain of running, [pain being another of the key afferent messages which the CNS uses to determine efferent neural activity to the lower extremity muscles and ultimate the runner's gait style], then this may be more easily accomplished by the runner and used as a way to relearn to run with a wider base of gait.

    Here is one of my illustrations which demonstrates how base of gait changes from standing to walking to running.

    Question: Would the metabolic efficiency of running gait be increased by running with a wider base of gait?

    Answer: I doubt it for the vast majority of runners.
  14. Griff

    Griff Moderator

    Thanks for those comments Kevin - that's pretty much where I was at with this. As I say often the trade off of slightly decreased metabolic efficiency is an acceptable one for runners who can otherwise not run at all. Furthermore, approximately 50% of the runners I see are probably not running at a level/speed whereby they care or would even notice. It was interesting to read in the article above that subjects could widen their base of gait without their velocity being negatively affected or altered - this is my observation clinically also (how sustainable this is may be another matter of course).

    Another thought has just come to me and that is regarding a small subset of runners I tend to see (maybe about 20%) which have a cross over gait pattern (which my running coach buddy refers to as 'scissoring'). As I'm sure you know, in this scenario the left foot plants just to the right of the line/CoM and the right foot plants to the left of the line/CoM. Next time I have one in I'll try to remember to upload the video here for all. Often a proximal muscle issue (hip abductors/glutei) is found in these runners which we of course try to work on, and the possible giveaways clinically are those who kick their medial malleoli with the swing leg (particularly when fatigued) or get very muddy in that region during the winter. When cueing these runners to widen their base of gait often we ask them to "run the line" - which of course is widening for them relative to where they started. Perhaps in doing so we are making them more efficient?
  15. N.Knight

    N.Knight Active Member

    Whilst proximal work was spoken about, which is something I use all the time. I would be interested to see if people use Soleus strengthening to help manage MTSS.

    From what I find in clinic is my patients with MTSS can do less bent knee heel raises than those I see without MTSS, I am taking the view that yes I think the bending moment is very important, however I think Kevin touched on it a couple of years back at summer school (I can dig out the reference if required) looking at Soleus fatigue and does this result in an increased bending moment?

    I tend to use this combined with the treatments listed above, so not sure how effective it is or if is the other treatments working.

    Ian - I think I have a video of the type of patient (cross over gait) I saw a few days ago, will try and dig it out (I was having IT issues that day), she is off seeing my physio for proximal work.

  16. RobinP

    RobinP Well-Known Member

    I think the original point was that widening base of gait was a tool in the arsenal. It is not required to be mutually exclusive with varus wedging of the foot.

    Additionally, although there is an element of gait retraining, it is not required to be a permanent solution. In the same way that low dye taping temporarily changes loading patterns to reduce tissue stress, a short period of altered bending moments at the tibia may be enough to allow symptoms to settle (granted this may or may not be a long term solution, but the same could be said for varus wedging)

    I think, when it comes to performance, we have to be aware that (despite the information in the study above) there may well be a reduction in performance for the reasons laid out by Kevin. However, a varus wedge inside a shoe will affect the weight of the shoe to potentially impact upon performance. I accept that one might use high density plastazoate to minimise this effect.

    In my clinical setting, I keep EVA wedge strips that are pre cut at 4 degrees(maybe!) that will cover the full width of the shoe and can be cut out there and then to allow the patient to take away on the day. Like Ian said, perhaps it is the cohort of patients that I see but most will take a small reduction in performance, be it through weight or changes in gait pattern in order to be able to complete the miles required to keep up their marathon training.
  17. N.Knight

    N.Knight Active Member

    I agree, always good to increase the size of the arsenal, to help accomodate for different needs of different patients. Same with my patients, as long as they are running pain free there are a happy bunch.
  18. Interesting, Ian, that you would try to correct someone with a running gait that you deem to be inefficient or wrong. Do you try to correct someone's running gait that is asymptomatic or only those that are symptomatic? Don't you think that an experienced runner is running the way they do because this is the most metabolically efficient way for them to run? What evidence do we have, or do you use, to know that your gait retrainings are really in the best interest of the runner?

    Would you try to instruct Priscah Jeptoo on more "proper" running form to make her a better runner? Something to chew on over the weekend.

    Last edited by a moderator: Sep 22, 2016
  19. Griff

    Griff Moderator

    Can't see anywhere that I suggested I correct gait that I deem to be inefficient or wrong Kevin? Perhaps you have misunderstood - this is all in the context of MTSS...
  20. Perhaps I did misunderstand you, Ian. You said:

    You didn't mention MTSS above in this description so I assumed you were doing this gait retraining on asymptomatic runners also? Please clarify.
  21. Griff

    Griff Moderator

    Ah sorry for the confusion. That was a continuation of the previous comment I made and was in fact supposed to read as 20% of the runners I see that present with MTSS appear to scissor/cross over. I certainly don't suggest widening the base of gait in any other circumstance at present (with the occasional exception of ITB pathology but with less consistent results) and especially not asymptomatic runners. I try to maintain an evidence based approach to gait retraining and at present to my mind that means considering step width for MTSS and stride length/cadence for patellofemoral pain.

    With that in mind and our discussions regarding foot position relative to CoM and running efficiency:

    * Most efficient way to run for most individuals is with feet directly under CoM
    * In individuals with MTSS that run this way if we widen their stride we may improve their symptoms but decrease their efficiency
    * In individuals with MTSS that cross over/scissor if we widen their stride we may improve their symptoms & increase their efficiency

    Sound reasonable and theoretically plausible?
  22. Thanks for that clarification, Ian. I agree.

    Now for a more interesting discussion along the same lines, I am starting a new thread: Should We Retrain the Gait of Asymptomatic Runners?
  23. NewsBot

    NewsBot The Admin that posts the news.

    Walking with wider steps increases stance phase gluteus medius activity
    Samantha N. Kubinski, Christina A. McQueen, Keir A. Sittloh, Jesse C. Dean
    Gait & Posture;Articles in Press
  24. NewsBot

    NewsBot The Admin that posts the news.

    Effects of wide step walking on swing phase hip muscle forces and spatio-temporal gait parameters
    Soheil Bajelan ; Hanatsu Nagano ; Tony Sparrow ; Rezaul K. Begg
    Engineering in Medicine and Biology Society (EMBC), 2017 39th Annual International Conference of the IEEE

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