GAIT DYSFUNCTIONS

Gait dysfunctions are changes in your normal walking pattern, often related to a disease or abnormality in different areas of the body. Gait dysfunctions are among the most common causes of falls in older adults, accounting for approximately 17% of falls. This guide will help you better understand how gait dysfunctions are categorized, and how treatment by a physical therapist can help you regain a healthy gait. Physical therapists are experts at identifying the root causes of gait dysfunctions, and designing treatments that restore gait.

What are Gait Dysfunctions?

Gait dysfunctions make the pattern of how you walk (ie, your gait) appear “abnormal." Most changes in gait are related to underlying medical conditions. Gait dysfunctions can be related to disorders involving the inner ear; nervous system disorders such as Parkinson's disease; muscle diseases such as muscular dystrophy; and musculoskeletal abnormalities such as fractures. In many cases, treatment of the underlying medical condition will help normalize the gait pattern.

Common classifications of gait dysfunction include:

• Antalgic. This type of gait dysfunction is often caused by bearing weight on a painful leg. It can be related to arthritis or a traumatic injury, and is what many people refer to as a "limp." People with this dysfunction take slow and short steps, and quickly try to shift their weight off of the sore leg, ankle, or foot, and back onto the unaffected leg.
• Cerebellar Ataxia. This gait dysfunction is often seen in individuals who have a condition of the cerebellum (a region of the brain), drug or alcohol intoxication, multiple sclerosis, or have experienced a stroke. The affected individual will have a wide-based stance (feet wide apart), and display inconsistent and erratic foot placement.
• Parkinsonian. This type of gait dysfunction is often related to Parkinson’s disease and is characterized by short, shuffled steps.
• Steppage. This dysfunction occurs in people with "foot drop" (an inability to lift the ankle), which is related to conditions, such as lumbar radiculopathy and neuropathy. Because the ankle will "slap" off of the ground, the individual will often lift the leg higher at the knee and hip, to clear the foot when taking a step./li>
• Vestibular Ataxia. This pattern is often related to vertigo, Meniere’s disease (an inner-ear condition), and labyrinthitis (a type of inner-ear disorder in 1 ear). It causes people to walk unsteadily, often falling toward 1 side. 
• Waddling. This pattern often arises from muscular dystrophy and myopathy, and causes individuals to walk on their toes, while swaying side-to-side.

Note: These are only a few of the many possible gait dysfunctions. If you suspect you are walking differently, call your physical therapist for a gait assessment.

How Is It Diagnosed?

There are many different strategies and tools that can help a physical therapist diagnose a gait dysfunction. While other health care professionals are educated in the screening for potential conditions related to the gait abnormality, a physical therapist is the expert in diagnosing the actual type of gait dysfunction. Your physical therapist will ask you questions, such as:

• When did you notice you were walking differently?
• Is the problem getting better or worse?
• Has it resulted in a fall or any additional problems?
• Are you in pain while you walk?
• Have there been any recent changes in your medical history, including changes in medications?

Your physical therapist will also conduct certain tests to learn more about your condition. Your assessment may include:

• Observation. Your physical therapist will ask you to walk back and forth, to observe any abnormalities in your gait pattern. 
• Gait speed measurements. Your physical therapist will time your walking speed. Studies have shown that complications like falling are related to how fast you walk.
• Balance tests. Your physical therapist may also assess your balance to determine your risk of falling.
• Strength and range-of-motion measurements. These tests can help determine whether the dysfunction is due to musculoskeletal limitations. A physical therapist may utilize tools, such as a goniometer to measure your joint motion, or dynamometer to measure your strength. 
• Reflex and sensation screenings. These measurements will help your physical therapist determine whether a neurological (brain or nervous system) condition is present.

How Can a Physical Therapist Help?

Physical therapists play a vital role in helping individuals improve their gait. Your physical therapist will work with you to develop a treatment plan to help address your specific needs and goals. Your physical therapist will design an individualized program to treat your specific condition.

The treatment strategy may include:

Pre-Gait Training. Your physical therapist may begin your treatment by having you perform activities and exercises that will help you understand how to improve your gait, without taking a single step. These exercises may include simple activities, such as having you stand and lift your leg in place, to more complex strategies like stepping in place and initiating contact with your heel to the ground, prior to other portions of the foot. 

Gait Training. Your physical therapist will help you focus on retraining the way you walk. Because the underlying condition may be vestibular, neurological, or muscular, variations in the training exist. Your physical therapist will design the safest and best training for your specific condition.

Balance and Coordination Training. Your physical therapist may prescribe balance activities for you to perform to help stabilize your walking pattern.

Neuromuscular Reeducation. Your physical therapist may employ neuromuscular reeducation techniques to activate any inactive muscle groups that may be affecting your gait.

Bracing or Splinting. If the gait dysfunction is due to significant weakness or paralysis of a ligament, your physical therapist may teach you how to use adaptive equipment, like a brace or splint, to help you move.

BAREFOOT AND MINIMALIST RUNNING: WHAT DO WE KNOW?

Barefoot running and running in minimalist shoes have received much attention in the scientific literature and media over the past few years. However, only 25%-30% of runners have reported using minimalist footwear on a regular basis 1, 2, and only 2% run barefoot on a regular basis 1. In fact, only 20% have reported trying to run barefoot 2.

Advocates of barefoot/minimalist-shoe running suggest that changes in mechanics, foot strength, and impact have a direct relationship to injury reduction. A March 2014 article in the British Journal of Sports Medicine 3 reviews current research regarding barefoot running, and concludes that running injuries are the result of many factors, and running without your shoes is least likely to be the mitigating factor.

But research and debate on barefoot and minimalist running are likely to continue, in light of various reported benefits.

The most common justifications for barefoot running are:

1. It is the "natural" way of running.
2. It prevents injury.
3. It makes you run faster.
4. It strengthens the muscles of your feet.

Are these claims supported by evidence?
Let's explore each one:

Natural Running

While it is likely that humans' gait mechanics have evolved over eons, the evidence of the relationship between shoes and these changes is lacking. Shoes have been worn for thousands of years. More recently, the running boom of the 1970s resulted in distinct changes in shoes. Interestingly, since the change in shoe construction has changed dramatically over the past 40 years, the rate of injuries among runners has not. It would seem possible that this is due to 2 potential reasons 3:

1. Shoes are not related to the injuries, or
2. The features of shoes are addressing the wrong factors.

These facts should not lead one to believe that no shoes are the answer.

Prevents Injury

The theory for how barefoot running will prevent injury are based on 2 primary findings:

1. It reduces impact, and
2. It reduces the load at the knee.

Both of the above claims presume changes in mechanics occur with barefoot running, that running without shoes should result in a midfoot or forefoot strike pattern, rather than a heel strike gait. However, only 40%-50% of individuals who run barefoot adopt a midfoot or forefoot strike pattern.

Impact has been associated with stress related injuries to the tibia. By changing the strike pattern, the impact is potentially removed from the lower leg, but those impact forces are likely moved to the foot as a result. In fact, foot stress fractures have been related to increased loads.

While midfoot or forefoot striking reduces the impact forces at the knee, it concurrently increases the demand on the ankle muscles. If the logic is that reducing load in 1 structure will decrease injury, then increasing load in another structure should increase risk of injury. It is yet to be determined if either of these is true.

Faster Running

This appears to be a classic case of backwards logic. Runners adopt more of a midfoot strike pattern as they run faster. In fact, 73% of competitive runners in the 800 m and 1500 m events have a midfoot or forefoot strike pattern 11. However, during a marathon or half marathon, 88.9% of runners are rearfoot strikers 12.

It is often suggested that midfoot or forefoot striking is more economical (uses less energy) so therefore, you can run farther and faster. However, research suggests that forefoot runners and heel-strike runners demonstrate the same running economy at various speeds 13. So, faster runners are more likely to adopt a midfoot or forefoot pattern, but adopting a midfoot or forefoot pattern does not necessarily make you faster.

Muscle Strength

Evidence suggests that short foot exercises do increase the size of the foot intrinsic muscles; however, there is no evidence to suggest that barefoot walking or running has the same effect. There is little rationale given as to the reason for the foot strengthening 14.

• Are stronger feet less likely to be injured? Or,
• Are stronger feet more likely to protect other structures in the lower extremities from injury?

It is also important to remember that there are muscles originating outside the foot (extrinsic muscles) that play a significant role in foot and ankle control during running and walking. These muscle are longer and have greater force-producing capabilities than the muscles originating inside the foot. Finally, recent findings suggest little change in foot intrinsic muscle activity after running (with or without shoes), and no difference between shoes on and shoes off 10.

Conclusion

Barefoot/minimalist running is a popular topic of discussion that is, in reality, not very prevalent among runners. There is little data to support its use as a training tool or treatment for injury. Continued study on the potential risks and benefits of this technique is necessary to determine its usefulness.

 

References

1. Goss DL, Gross MT. Relationships among self-reported shoe type, footstrike pattern, and injury incidence. US Army Med Dep J. 2012;Oct-Dec:25-30. Article Summary on PubMed.

2. Rothschild CE. Primitive running: a survey analysis of runners' interest, participation, and implementation. J Strength Cond Res. 2012;26(8):2021-2026. Article Summary on PubMed.

3. Tam N, Astephen Wilson JL, Noakes TD, Tucker R. Barefoot running: an evaluation of current hypothesis, future research and clinical applications. Br J Sports Med. 2014;48(5):349-355. Free Article.

4. Trinkaus E, Shang H. Anatomical evidence for the antiquity of human footwear: Tianyuan and Sunghir. J Archaeol Sci. 2008;35(7):1928–1933. Article Summary.

5. Willson JD, Bjorhus JS, Williams DS III, Butler RJ, Porcari JP, Kernozek TW. Short-term changes in running mechanics and foot strike pattern after Introduction to minimalistic footwear. PM R. 2014;6(1):34-43. Article Summary on PubMed.

6. Hatala KG, Dingwall HL, Wunderlich RE, Richmond BG. Variation in foot strike patterns during running among habitually barefoot populations. PLoS One. 2013;8(1):e52548. Free Article.

7. Lieberman DE, Venkadesan M, Werbel WA, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;463(7280):531-535. Article Summary on PubMed.

8. Dixon SJ, Creaby MW, Allsopp AJ. Comparison of static and dynamic biomechanical measures in military recruits with and without a history of third metatarsal stress fracture. Clin Biomech (Bristol, Avon). 2006;21(4):412-419. Article Summary on PubMed.

9. Ridge ST, Johnson AW, Mitchell UH, et al. Foot bone marrow edema after a 10-wk transition to minimalist running shoes. Med Sci Sports Exerc. 2013;45(7):1363-1368. Article Summary on PubMed.

10. Williams DS III, Green DH, Wurzinger B. Changes in lower extremity movement and power absorption during forefoot striking and barefoot running. Int J Sports Phys Ther. 2012;7(5):525-532. Free Article.

11. Hayes P, Caplan N. Foot strike patterns and ground contact times during high-calibre middle-distance races. J Sports Sci. 2012;30(12):1275-1283. Article Summary on PubMed.

DON'T LET YOUR IT BAND HOLD YOU BACK FROM BEATING YOUR NEW YEAR'S RESOLUTIONS

 

January 13, 2016

 
More people each year are participating in local 5k's, 10k's, half-marathons, and beyond in hopes of reaching personal goals and maintaining a healthier lifestyle.  While the summer months usually have the most participants in local races, training for those events will likely begin during the winter months. Icy Kansas City temperatures during the winter months force runners to begin their training indoors on the treadmill, which can cause muscle imbalances that may eventually result in pain. Champion Performance and Physical Therapy would like to take this time to review some prevention and treatment concepts for a common overuse running injury referred to as Iliotibial Band Syndrome (ITBS), and help our local runners accomplish their goals this year!

What is the Iliotibial Band?

The IT band is a part of a group of muscles on the outside of the hip that serve to promote hip stability during running, restraining the leg from crossing midline when the foot hits the ground. The band starts at the hip area (the ilia) and crosses the outside of the knee joint to insert on the tibia (shin bone) of the lower leg.

How does ITBS occur?

If a runner has muscle imbalances due to weakness or tightness, abnormal running mechanics may occur. Altered running mechanics can cause the band to rub over the underlying bone with repeated knee flexion and extension. The resulting friction can lead to inflammation and irritation.

What are the causes of ITBS?

• As mentioned above, ITBS can be caused by muscle imbalances* such as excessive muscle tightness or weakness. 
• Training errors: A runner who increased mileage too quickly, does too many hills, or runs on one side of a beveled road (which is slanted for drainage) is at greater risk for ITBS
• Incorrect shoes: A shoes that does not adequately control pronation or supination can also be a cause of ITBS

*A muscle imbalance would mean that one group of muscles is too tight, too strong, or too weak to match that of it's counterpart/antagonist muscle group. 
A counterpart/antagonist muscle group would be the equivalent of what the triceps are to the biceps - the group of muscles that act on the bone, pulling in the opposite direction.

How can I prevent ITBS?

• Try changing your running routine. Instead of running only on a treadmill or a track, go for a run outdoors (if you can bare the weather), or run on a carpeted surface with more "give". Change the side of the street you run, cross training might also help to alleviate symptoms.
• Stick to a schedule for increasing mileage and remember: not too quickly!
• Stretch, stretch stretch!
• Change your shoes as needed to prevent stress to ankles, hips and knees and maintain integrity of the tread.

How can I treat ITBS if I have it?

• Self soft-tissue mobilization: Foam rollers, tennis balls, and lacrosse balls are good methods of improving soft tissue mobility.
• Include exercises in your training routine that will strengthen your hip abductors
•  If this strategy does not help, contact the experts at Champion Performance and Physical Therapy and we can assess your running shoes, flexibility, and strength and design a program to meet your individual needs.

BEST OF LUCK ACHIEVING YOUR GOALS THIS YEAR!

References
[i] Hamill J, Miller R, Noehren B, Davis I. A Prospective Study of Iliotibial Band Strain in Runners; Clinical Biomechanics [serial online]. April 2008.
[ii] van der Worp M, van der Horst N, de Wijer A, Backx F, Nijhuis-van der Sanden M. Iliotibial Band Syndrome in Runners: A Systematic Review; Sports Med [serial online]. 2012.
[iii] Baker R, Souza R, Fredericson M. Iliotibial Band Syndrome: Soft Tissue and Biomechanical Factors in Evaluation and Treatment; American Academy of Physical Medicine and Rehabilitation [serial online]. June 2011.