Spring 2014

Pulse

Pulse Spring 2014

SMCA Board of Directors Ray Kardas - President

Dexter Nelson - Past President

Steve Johnson - Vice-President

Alex Yaworski - Secretary

Miranda Sallis - Treasurer

Stephane Simard - Member at Large

Heather Brady - Member at Large

SMCA Employees Barb Adamson - Executive Director

Penelope Beardsley - Bookkeeper

Pulse Magazine Published by: Sport Medicine Council of Alberta

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Website: www.sportmedab.ca

Contents copyright 2014 by SMCA.

Articles/abstracts may not be reprinted

without permission. The opinions are

those of the respective authors and are

not necessarily those of the SMCA.

ISSN: 1181-9812

Publication agreement no. 40038086

2 Spring 2014

Inside this issue:

K2A Conference 4

Mental Health and Athletic Performance 6

Knee Pain - Patellofemoral Pain Syndrome 8

Multidisciplinary Approach to Nutritional Physiology 10

3D Gait Anaylsis 12

A New Look at Pes Planus from the Perspective of a Really Pronated Physical Therapist

14

Inside Pulse…

3 sportmedab.ca

The Sport Medicine Council of Alberta would like to Thank our Partners for

their ongoing Support:

Sport Nutrition Level 1 10:00 a.m. - 4:00 p.m.

April 26, 2014 Edmonton

Athletic Injury Management 8:30 a.m. - 4:30 p.m.

March 8, 2014 Calgary/Airdrie

March 15, 2014 Edmonton April 12, 2014 Edmonton

May 3, 2014 Edmonton

June 7, 2014 Edmonton

Sport Taping & Strapping 8:30 a.m. - 4:30 p.m.

March 9, 2014 Calgary/Airdrie

March 16, 2014 Edmonton April 13, 2014 Edmonton

May 4, 2014 Edmonton June 8, 2014 Edmonton

Sport Trainer 8:30 a.m. - 4:30 p.m.

*Combination of Athletic Injury Management and

Taping & Strapping

March 8 - 9, 2014 Calgary/Airdrie

March 15 - 16, 2014 Edmonton April 12 - 13, 2014 Edmonton

May 3 - 4, 2014 Edmonton June 7 - 8, 2014 Edmonton

For more information on any of the above courses or to

register, visit sportmedab.ca/courses

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Dr. Reed Ferber, Ph.D., CAT(C), ATC Dr. Ferber holds a Ph.D. in sports medicine and gait biomechanics from the Univer-

sity of Oregon in addition to being a Certified Athletic Therapist. He is an Associate

Professor in the University of Calgary's Faculty of Kinesiology, as well as the Director

of the Running Injury Clinic in Calgary, Alberta, which serves as a public facility for the

clinical assessment of musculoskeletal injuries for walkers and runners as well as a

dynamic research laboratory. He is internationally recognized as an expert in running

injuries, clinical biomechanics, and rehabilitation research on topics including patel-

lofemoral pain syndrome in runners, iliotibial band syndrome and foot biomechanics.

Dr. Bahram Jam, D.Sc.PT, M.PHty, B.Sc.PT, FCAMT Bahram Jam graduated from the University of Toronto, Canada in 1992 with a Bachelors of

Science in Physical Therapy. In 1999 he completed a Clinical Masters in Manipulative

Physiotherapy at the University of Queensland, Australia and in 2009 he completed his

Doctorate in Science in Physical Therapy at Andrews University, USA. He has the Canadian

Diploma of Advanced Manual and Manipulative Physiotherapy and is also credentialed

with the McKenzie Institute International. He is the founder and director of Advanced

Physical Therapy Education Institute (APTEI) and has been a chief instructor for over six

hundred post-graduate Orthopedic clinical courses across Canada and internationally. He

continues to practice and has had extensive clinical experience with direct patient care.

He is presently practicing at Athlete's Care Clinic Located at York University Campus,

Toronto, Ontario.

Spring 2014 4

K2A - Knowledge to Action

Conference

May 15 - 17, 2014

Canmore, AB

Sessions include: Prevention and Treatment of Common Running Injuries, Fuelling for Activity, Lower Extremities Massage Techniques, Patellofemoral Pain Syndrome and Patellar

Instability, Risk and Re-injury in Ankle Sprains and ACL Injuries, The Achilles’ Heel of Achilles Tendon Rupture, Intrinsic Foot Muscles,

Gait/Foot Assessment & Prescription of Footwear, and More!

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Celeste Lavallee, RD, IOC Dip Sports Nutr, ISAK Level 1 Celeste is a Registered Dietitian specializing in nutrition for sport performance. She completed the In-

ternational Olympic Committee Diploma in Sports Nutrition and continues to strengthen her knowl-

edge through practice and professional development. Celeste works with athletes competing at rec-

reational to international levels. She has experience with athletes from a variety of sports such as swim-

ming, skiing, bodybuilding, triathlon, sledge hockey, mixed martial arts, gymnastics, soccer and ultra-

endurance racing, as well as many more. She has consulted as the head sport dietitian to the Alberta

Sport Development Centre (ASDC) – Capital Region since its inception in 2009. Other clients of

Celeste’s include the Sport Medicine Council of Alberta, ASDC Northwest, and various club and provin-

cial sport teams and organizations. Celeste draws on her personal experience as a mountain biker, ul-

tra-trail runner, climber and past triathlete when counselling in sport nutrition. She is an avid outdoor

enthusiast, enjoying activities from canoeing and backcountry camping to hiking and golfing.

Brad Schneider, RMT SMT (cc) Brad Schneider is a graduate from Wellington College of Massage Therapy in Regina

Saskatchewan. Brad is currently the Alberta Chapter President of the Canadian Sport

Massage Therapist Association. His primary treatment focus includes therapeutic mas-

sage, sports injury rehabilitation and injury prevention education. He is a Massage Thera-

pist at River Valley Health which is a Sport Performance base clinic in Edmonton Alberta.

Currently the team therapist for the NLL Edmonton Rush and the Canadian Freestyle Ski

Team, Brad has had the privilege of traveling worldwide with a number of organizations,

treating members of the CFL, NHL, WHL, and CACC as well as many Olympic athletes.

Sarah Kerslake, PT

Sarah received her Physiotherapy degree from the University of Queensland, and completed a Clini-

cal Research thesis comparing outcomes of neuromuscular stretching techniques. She has worked

as Research Coordinator for the Banff Sport Medicine Clinic for the past four years. In collaboration

with the team of orthopaedic surgeons, Sarah has developed an extensive ACL reconstruction data-

base that is providing informative data regarding post-operative rehabilitation, functional perform-

ance outcomes, quality of life scores and the risk factors for surgical failure. Working in collabora-

tion with Dr. Laurie Hiemstra, Sarah has developed pre and post-operative rehabilitation programs

for patients with patella instability, analysed the presenting complaints and functional characteris-

tics of patella instability patients (WARPS/STAID), and participated in the development and valida-

tion of a quality of life instrument for this patient population (Banff Patella Instability Instrument).

Sarah also works as a sessional lecturer for the Faculty of Rehabilitation at the University of Alberta

and regularly mentors students on clinical placements.

Visit www.sportmedab.ca

for more information and registration.

6 Spring 2014

This is such an interesting area of sports medicine and yet, it is often ignored or dis-patched to the fine print by the many that are involved in high performance sport. Often mental health is assumed. To even contemplate that your mental health is at risk is often perceived as a personal weak-ness (such as an excuse to exit from train-ing or even an excuse for poor perform-ance). Within the context of a sport envi-ronment, it is nebulous in that there is no ‘legitimate’ injury, or no ‘known’ or ‘acceptable’ limited medical illness such as infection or diabetes or thyroid disorders.

Mental wellness, as opposed to mental illness, is something we all strive for and, at times, battle to achieve. Often mental well-ness is assumed and, in this respect, not a conscious goal. Mental wellness is regularly seen as something we don’t actually choose to invest in and nurture and train as we do with other aspects of our health and wellbeing.

When we attempt to look at mental health in the sphere of high performance sport, there is a real paucity of literature. We have publications on goal setting and skill acqui-sition that are related specifically to sports performance and mind management. Of-ten research in this area is targeted to pin-nacle events and how to deal with the pres-

sure of per-forming ‘on the day’. Over the last decade or so, we have seen the burgeon-ing of sports ps y ch ol og y as a disci-pline, with athlete sup-port teams often having a designated person deliv-ering services on a regular basis.

However, mental health is not purely about how an athlete copes with training loads, and the pressure of high performance events. Mental health is also how the ath-lete is coping with their day to day lives, their relationships (both personal and pro-fessional). It must acknowledge family his-tory and known mental health traits. All these aspects cannot be ignored if you are involved in providing holistic sports medi-cal care.

The nature of high performance sport, from an athlete’s perspective, means peo-ple and multiple factors impact on them at one time. These people and multiple fac-tors all influence and perceive claim and even ownership of the athlete at times – almost like they are property or an invest-ment.

You will not only have the elite athlete to develop rapport and understanding with, but also her entire support team (coach, strength and conditioner, physiotherapist and so on). The appreciation of the nature of high performance sport and its impact on athletes and those in the support team is fundamental, as is understanding your athlete and the environment they live and train in, when delivering holistic sports medicine care. The mental health of your athlete cannot be ignored and is unlike any

other aspect of sports medicine care that you deliver.

When working with high performance ath-letes, you have to first acknowledge that the essence of being elite requires heroic dedication and focus. You could be ex-cused as an outsider looking in. The traits of obsessive compulsive disorder, for ex-ample, are well and truly exhibited on a daily basis by some athletes, and very often with the whole of the support team!

How an athlete copes, however, with changing training loads, both physically and mentally, can determine if an athlete will exhibit symptoms of ‘illness’ or ‘overtraining’. Changing training loads can also determine injury patterns of ‘overuse’ as the athlete strives to squeeze every ounce of effort out of their highly tuned bodies, into their performance. The chal-lenge for us as health professionals is to ensure that the athlete’s mental wellness is not overlooked in the pursuit of perform-ance excellence. To do so is at both your, and the athlete’s, peril.

So, what does the literature tell us? We understand that the prevalence of mental illness amongst high performance athletes is at least the same as the general popula-tion. Therefore, being regularly exercising individuals, often in the public eye and well regarded by the respective communities nationally and internationally does not con-fer any superhuman immunity to mental illness. We have seen recent papers discuss the importance of unrecognised recurrent head injury as an antecedent to mental illness (notable in many high profile con-tact sports around the world).

Of major increasing concern is the area of substance abuse disorders. We have abuse of legal and illegal substances, abuse of prescription medication, over the counter medication, and, also the use of perform-ance enhancing medication and treatment. Fortunately, heightened awareness is an asset in not only recognition but also treat-ment and involvement from the profes-sional help that our elite athletes need. As sports medical clinicians, we need to be

Mental Health and Athletic Performance Dr. Lynne Coleman

7 sportmedab.ca

awake to these issues presenting as otherwise ‘legitimate’ ill-nesses. Being able to accurately diagnose the fundamental issues involved with our troubled elite athletes ensures unhelpful behav-iours are worked on and reversed, and healthy alternative behav-iours are instilled and reinforced.

As clinicians, we have to stay abreast of current treatment trends and allied services that assist our athletes and support teams once a diagnosis is made. Being alert and aware and having a good network or support services and agencies enables you to truly make a difference with your troubled athlete.

My challenge to you, the sports support personnel and especially the sports medical community, is to be alert, have good sound systems for enquiry, consequent diagnostic tools, and access to services for your elite athletes. Assist athletes in embracing re-sponsibility for their personal mental wellness just as they do all the other areas of their athletic performance. By being up-skilled and knowledgeable, and by feeling comfortable in conversing with your athletes about such important issues, you assist in re-moving the stigma attached to mental illness, and assist the change toward emphasizing mental wellness as just as an impor-tant ‘work on’ as muscle strength and speed training.

8 Spring 2014

Many athletes and non-athletes battle with chronic knee pain. Often it develops insidiously and cannot be attributed to a single traumatic event. This type of knee condition can be very difficult to diagnose and treat for the practitioner, and as a result can be very frustrating for the affected person. First and foremost, it’s important that a practitioner rule out intra-articular damage to any ligaments, menisci, or even the patella itself. Once ruled out, the practitioner then must assess the func-tion and kinetic chain of the entire lower extremity.

What is Patellofemoral Pain Syndrome? Patellofemoral pain syndrome simply refers to the improper tracking of the patella on the femur. This abnormal tracking pat-tern is often a result of abnormal forces from the muscles throughout the kinetic chain of the lower extremity, resulting when there’s a lack of diversity in the athlete’s training program. Many repetitive activities such as running and cycling consist of linear movements that may lead to imbalanced muscle develop-ment. The entire lower extremity kinetic chain can contribute to the problem. Muscular imbalances all the way from the hip down to the ankle can contribute to pain felt in the knee, therefore it’s important for any clinician to assess the Q-Angle of the knee when assessing a patient’s complaint. The Q-Angle is simply the angle that the femur (thigh bone) sits at in relation to the tibia (shin bone). Females typically have an in-creased Q-Angle in comparison to males due to anatomical differ-ences through the pelvic bowl. However, an increased Q-Angle for both men and women leads to abnormal wear of the anatomi-cal structures of the knee and initial onset of pain is often an early

warning sign. Patients with an increased Q-Angle can present with slight to severe genu valgum (knock knees).

Treatment Options An increased Q-angle can either be addressed structurally or func-tionally. It’s important again to have a practitioner assess which line of treatment is most warranted. Structural problems refer to Problems that typically must be addressed surgically. These are

Knee Pain - Patellofemoral Pain Syndrome Dr. James Young, DC

often present from birth or occur due to trauma. The functional problems refer to the kinematic muscular imbalances that occur from activity, training, and sedentary lifestyle. These are the problems that can be addresses through proper soft tissue and manual therapies.

Contributing Factors to Be Assessed and Treated To address a functional increase in Q-Angle we need to look at and treat the muscles, ligaments, and soft tissue structures that contribute to genu valgum. Starting at the hip, two of the main culprits that catch our attention are the gluteus medius and the tensor fascia lata (TFL). The primary action of the gluteus medius is to abduct the leg, or pull the leg away from midline of the body. Weakness in this muscle is a main contributor to allowing the knees to buckle together. Weakness can be caused by scar tissue and adhesions within the muscle or from underdevelopment in comparison to the gluteus maximus from repetitive linear movements. In the same note, the TFL often attempts to compensate for this weakness and be-

comes overactive. This actually changes the axis of rotation of the hip as pure abduction reduces and a combination of abduction and flexion of the hip takes its place. The TFL attaches to the illiotibial band, which runs down the outside of the thigh and is chronically tight in many athletes with knee pain. The tightness of this band is often caused by the over activity of the TFL, be-cause as this band shortens it contributes to the increased Q-Angle by pulling the lat-eral or outside aspect of the knee towards the hip. As this negative pattern continues to de-velop, the lateral quadriceps become more dominant as they are placed in a biome-chanical advantage due to the increased Q-Angle. This in turn causes the medial aspect of the quadriceps to become underdevel-oped in comparison and lose influence on the proper tracking of the patella. Moving past the knee into the lower leg, this pattern can also cause ankle pain and joint dysfunction. The genu valgum caused by the increased Q-Angle causes pronation of the foot and ankle which occurs as the foot and ankle roll inward to maintain bal-

ance and full contact with the ground. The pronation in turn causes muscular imbal-ances with the calves and muscles of the lower leg and may even contribute to fal-ling arches.

Treatment Once the knee is properly assessed, treat-ment is focused on correcting the abnormal movement patterns that exist. This simply consists of breaking up existing muscular adhesions associated with both muscular inactivity and over-activity. This can be done via Active Release, Graston, and Deep Tissue Massage. Specific muscular-focused stretching in conjunction with treatment of adhesions is paramount to ensure a more satisfactory lasting effect of the work done. It’s also important that the muscular imbal-ances and weaknesses are addressed via specific exercises provided by the practitio-ner. Programs need to be designed to spe-cific patient needs and progress as patients gain mobility and earn their stability. When properly assessed, treated, and ac-tively rehabbed, these common knee com-plaints usually resolve within a short period of time.

sportmedab.ca 9

The interaction between exercise and nutrition are much more intimately linked than many realize. At its fundamental level, training adaptation is a balance between energy expenditure (exercise) and energy intake (nutrition), which ultimately dictates the adaptive response of the athlete and, thus, could be coined “nutritional physiology”. Certainly, the exercise stimulus is funda-mental in driving positive training adaptations. But, the proper substrates (nutrition) can optimize this response. In some in-stances, the limits to performance can partially be overcome through the strategic use of several nutrition and supplementa-tion strategies. Accordingly, in recent years a hand-full of nutri-tion and supplement interventions have come to the forefront, with considerable scientific evidence for performance efficacy, especially for the endurance athlete. It is impossible to identify a single factor that causes fatigue and limits performance during endurance events, such as a marathon (Joyner et al., 2008; Joyner et al., 2011). Causes of exhaustion can potentially include central nervous system fatigue, muscle buffer-ing capacity, dehydration, O2 delivery, glycogen depletion and optimal race-day nutrition/energy intakes. More recent research suggests that the brain’s ability to perceive fatigue, pain and the time to the finish (telo-anticipation, or central governor theory; (Noakes, 2011)), are also intimately integrated with physiological limitations to performance. However, whether central governor versus peripheral limitations operate via feed forward or feed-

back, or both, remains to be elucidated (Amann et al., 2013). An example of contemporary thinking in nutritional physiology for an endurance athlete is outlined in Figure 1 and has been recently reviewed (Stellingwerff, 2013). The original framework put forth by Joyner and Coyle in 2008 is a physiological-based concept high-lighting the key contributors to endurance velocity and power, based on the aerobic and anaerobic energy systems, coupled with gross mechanical efficiency or economy. Their original published framework in the figure is shown in the white boxes. However, all the black boxes highlight the areas where “nutritional triggers” to adaptation and performance may potentially play an important role in maximizing training adaptation and/or performance out-comes. To further highlight how fast this emerging field of nutri-tional physiology has grown, of all the black nutritional trigger boxes in the figure, five would not have even been on this slide six years ago! In other words, there has been an explosion of re-search into the area of nutritional ergogenics. The last few years have been very exciting for applied sports nu-trition scientists and practitioners. In the last six years alone we have seen new sport nutrition advances such as beta-alanine (Derave et al., 2010; Hobson et al., 2012; Stellingwerff et al., 2012), dietary nitrate supplementation via beetroot juice (Hoon et al., 2013), carbohydrate periodization (e.g. periodically training with low carbohydrate availability (Hawley et al., 2010; Stellingwerff, 2012)), and even efficacy of different proteins (whey vs. casein, timing; (Cermak et al., 2012; Phillips, 2012)) all directly impacting training adaptation and performance. There is also a developing and greater appreciation of the needs to periodize macronutri-ents and dietary caloric intake throughout the periodized training year in athletes as well (Stellingwerff et al., 2007; Stellingwerff et al., 2011). Emerging nutrition and training methods, such as pur-poseful low-glycogen or fasted training (Hawley et al., 2010), do not negate the importance of nutrition, or carbohydrate, around training. Instead, it places more emphasis on the intelligent tim-ing and differential application of altered macronutrient provi-sion, specific to the training bout and desired physiological out-come. It is important to note that this novel research is published in peer-reviewed and evidence based high-quality physiology, nu-trition and medical journals, and where possible, I have cited meta-analysis to support the interventions above. Nevertheless, these novel concepts and value of “nutritional triggers and nutritional physiology” tends to remain unknown to many coaches and ath-letes and even their associated integrated support teams (IST). For athletes, nutrition and training interactions need to be care-fully planned and monitored between coach, athlete and their IST. For example, coaches think about their training stimuli, while physiologists think about their physiological stimuli (e.g. heat, altitude). However, very few coaches and physiologists think

10 Spring 2014

Multidisciplinary Approach to Nutritional Physiology

Dr. Trent Stellingwerff, PhD Canadian Sport Institute - Pacific

11 sportmedab.ca

Figure 1. Overview of physiological and nutritional determinates of endurance per-formance. Adapted from Joyner & Coyle (Joyner et al., 2008). Nutritional ergogenic interventions that may enhance the given physiological adaptation are highlighted in the black boxes. The interventions with question marks require more peer-reviewed evidence-based research before stronger recommendations for or against can be made.

References

Amann, M., Venturelli, M., Ives, S. J., McDaniel, J., Layec, G., Rossman, M. J., & Richardson, R. S. (2013). Peripheral fatigue limits endurance exercise via a sensory feedback-mediated reduction in spinal motoneuronal out put. J Appl Physiol (1985), 115, 355-364.

Cermak, N. M., Res, P. T., de Groot, L. C., Saris, W. H., & van Loon, L. (2012). Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: a meta-analysis. American Journal of Clinical Nutrition, 96, 1454-1464.

Derave, W., Everaert, I., Beeckman, S., & Baguet, A. (2010). Muscle car nosine metabolism and beta-alanine supplementation in relation to exer cise and training. Sports medicine, 40, 247-263.

Hawley, J. A., & Burke, L. M. (2010). Carbohydrate availability and training adaptation: effects on cell metabolism. Exercise and sport sciences re views, 38, 152-160.

Hobson, R. M., Saunders, B., Ball, G., Harris, R. C., & Sale, C. (2012). Effects of beta-alanine supplementation on exercise performance: a meta- analysis. Amino Acids, 43, 25-37.

Hoon, M. W., Johnson, N. A., Chapman, P. G., & Burke, L. M. (2013). The effect of nitrate supplementation on exercise performance in healthy individuals: a systematic review and meta-analysis. International journal of sport nutrition and exercise metabolism, 23, 522-532.

Joyner, M. J., & Coyle, E. F. (2008). Endurance exercise performance: the

physiology of champions. The Journal of physiology, 586, 35-44.

Joyner, M. J., Ruiz, J. R., & Lucia, A. (2011). The two-hour marathon: who and when? Journal of Applied Physiology, 110, 275-277.

Noakes, T. D. (2011). Time to move beyond a brainless exercise physiol ogy: the evidence for complex regulation of human exercise perform ance. Appl Physiol Nutr Metab, 36, 23-35.

Phillips, S. M. (2012). Dietary protein requirements and adaptive advan tages in athletes. British Journal of Nutrition, 108 Suppl 2, S158-167.

Stellingwerff, T. (2012). Case study: nutrition and training periodization in three elite marathon runners. International journal of sport nutrition and exercise metabolism, 22, 392-400.

Stellingwerff, T. (2013). Contemporary nutrition approaches to optimize elite marathon performance. Int J Sports Physiol Perform, 8, 573-578.

Stellingwerff, T., Boit, M. K., & Res, P. T. (2007). Nutritional strategies to optimize training and racing in middle-distance athletes. Journal of sports sciences, 25 Suppl 1, S17-28.

Stellingwerff, T., Decombaz, J., Harris, R. C., & Boesch, C. (2012). Optimiz ing human in vivo dosing and delivery of beta-alanine supplements for muscle carnosine synthesis. Amino Acids, 43, 57-65.

Stellingwerff, T., Maughan, R. J., & Burke, L. M. (2011). Nutrition for power sports: middle-distance running, track cycling, rowing, canoeing kayaking, and swimming. Journal of sports sciences, 29 Suppl 1, S79-89.

about the substrates (e.g. nutrition/hydration) that optimize the stimuli and how “nutritional triggers” can optimize the train-ing response and performance of the ath-lete. In the modern world of elite sport, we need to break down silos and work across disciplines more than ever before in search of new areas of performance optimization; the combinations of sport science disciplines are most likely where the next break-throughs will arise. We are in an interesting paradox – to become an expert in any field you have to absolutely dedicate and focus yourself to that field, or sub-discipline within that field. In many ways, the modern world-class applied sports practitioner has to be-come an “expert generalist,” being able to access the key experts and then link and ap-ply many interventions across many disci-plines to optimize performance.

If you run in North America you have probably been subjected to a ‘gait analy-sis’ of some kind, whether it consisted of having a shoe salesman give you a verbal report after running you on a treadmill, your friends coaching you in a group run or even using a video camera to show you in slow motion how you run. Runners all seem to want to know if they’re doing it ‘right’! Well, if you’re interested and have a little time, there is a better way!

In started in the field of entertainment, with groups like WETA Digital in New Zea-land. Motion capture technology software can now accurately reproduce how a per-son moves in the minutest detail. Think of the characters in “The Adventures of Tin Tin” or Gollum in the “Lord of the Rings” movie series.

Now thanks to the entertainment industry, at the same high tech level (due largely to software and camera development) run-ning gait analysis is available for use in clinical applications. How does it work? Each person has a unique movement pattern, just like a fingerprint, determined by their structure (which is inherited), their strength (which is change-able), and their range of motion (which is also changeable). Gait analysis captures the motion pattern with the use of high-speed cameras and software.

What can gait analysis do? From measuring improvement in movement control over time to defining trouble areas or signifi-cant asymmetries, gait analysis can give a runner and clinician a lot of useful information to zero in on the target. This can help improve control and help manage injuries. The best and most accurate analysis is 3D gait analy-sis.

Why is 3D gait analysis the best? Move-ment while running is controlled in 3 planes or dimensions: The frontal plane is the plane in which we move side to side (hip abduction, hip adduction, knee col-lapse, ankle inversion, ankle eversion). The sagittal plane is the plane we move for-ward in while running (trunk, hip, knee and ankle flexion and extension). The trans-verse plane is the plane in which we rotate (trunk rotation, femoral rotation, and tibial rotation).

Why use a system with computer technol-ogy? It’s relatively easy to see movement

in the sagittal plane and the frontal plane, but it’s difficult if not impossible to see the amount of trunk rotation, femoral rotation under the pelvis or tibial rotation under the femur. This is where 3D gait analysis

comes in. It exactly measures movement in all 3 planes without guesswork or error and provides complete motion capture. There’s just one more problem: Complete motion capture by itself isn’t enough! We need to know what the range of ‘normal’ is for running gait! This is why the Univer-sity of Calgary under the direction of Dr. Reed Ferber have developed a gender spe-cific database of runners now in the thou-sands to help clinicians determine whether a runner is in fact having trouble control-ling movement. This database is growing daily thanks to the 18 research partners

and 22 clinic partners globally using the same 3D gait analysis system. Runners who go through a gait analysis have their data examined to ensure the cameras and the runner set up is accurate. Then that data is added to the growing database to help further understand what the range of normal actu-ally is for runners. There is no other database like it in the world and it is an innovative approach that helps runners, clinicians and researchers around the world contribute to understanding running better.

Remember, you will always have your own unique ‘fingerprint’ of movement, but how well you control it is really the heart of the issue with good gait analysis. This helps us to reassure runners that they really are doing it the best way

12 Spring 2014

3D Gait Analysis

Craig J. Brososky, B.Sc.,

B.Sc.PT, IMC

13 sportmedab.ca

they can even if they don’t look like someone else. There are, however, certain hallmarks of control that need to present to run well and injury free!

What information do you get from it? The University of Calgary 3D Gait Analysis system provides normative gender specific data that shows how well you control your trunk, hip, knee and foot for both legs. It measures stride-to-stride variability and gives you an ‘injury index’ score that predicts your likelihood of injury and can tell if you are currently running with an injury. The motion cap-ture in conjunction with the clinician’s physical assessment can determine not only exactly how you move but also determine why you move that way.

Why is this so important? Typically rates of injury per year range up to nearly 80% with almost 50% of those injuries being recur-rences (Van Gent, 2007).

What if the way you move causes your pain? What if you could change the way you move for the better? 3D gait analysis is a fantas-tic tool that helps runners better understand their movement patterns during running. Once you know what your problem areas are you can specifically address and correct them!

Happy Running! Citations: Van Gent, RN, Siem, D, Van Middelkoop, M, Van Os, AG, Bierma-Zeinstra, SMA, Koes, BW. Incidence and Determinants of Lower Extremity Running Injures in Long Distance Runners: A Systematic Review. Br J Sports Med 41:469-480, 2007.

About the author: Craig Brososky is a physiotherapist with a special interest in running and sport performance. He travels regularly to conferences and gives talks, workshops and boot camps on running and roller derby in the U.S.A. and Canada. He graduated with two degrees from the University of Alberta (B.Sc. 1993, B.Sc.PT 1998) and is a keen cyclist, a runner, sometime triathlete and men’s roller derby player. He currently owns West End Physiotherapy in Edmon-ton, Alberta, and is a consultant to several sport and fitness groups in the city and is a clinical instructor at the University of Alberta.

Craig J. Brososky B.Sc., B.Sc.PT, IMC

Owner, Physiotherapist

West End Physiotherapy West End Medical & Professional Bldg.

Room 311, 9509 - 156 Street Edmonton, Alberta T5P 4J5

email: c.brososky@wephysio.com web: http://www.wephysio.com

phone: (780) 484 0514

fax: (780) 484 1347 3D Gait Analysis is available at West End Physiotherapy with our run

specialist Craig Brososky. Call to book yours today!

Spring 2014 14

There are two basic schools of thought when it comes to pes planus (PP): one is that all individuals with PP should wear orthot-ics at all times to prevent potential future lower extremity and spinal injuries. The second is if it ain’t broke don’t fix it. The former school of thought appears to be more prevalent; in the past few decades, health care professionals and the general public have been convincingly made to believe that PP is “evil” and requires intervention.

Nonetheless, industries have seen great opportunities in “fixing” flat footed people by making suppor-tive high arch shoes and orthotics. You would think that by now we would have enough evidence to either support or negate the treat-ment of PP.

A 2013 systematic review by Tonge et al looked at 29 relevant studies and concluded that “High arch and flat-foot foot types are associated with lower extremity injuries but the strength of this relationship is low.”

It seems like review papers can “cherry pick” the studies they in-clude since there are some studies that see a small link while other studies see absolutely no link between foot type and injuries.

Allow me to discuss children before I discuss adults with PP. Ap-proximately 45% of preschool children and 15% of older children (average age 10 years) have flat feet and epidemiological studies show that PP normally improves with age (Evans & Rome 2011). A significant increase in arch height has been shown to occur in boys and girls by age 15 (Pauk et al 2012).

Millions of dollars per year are spent on orthotics for children with PP, even though to date there is little evidence that they actually reduce pain or improve function. A 2007 study by Whitford et al analyzed 160 children between the ages of 7 and 11 years with bi-lateral flexible excess pronation with diagnosis based on calcaneal eversion and navicular drop. The children were randomized into one of 3 groups:

i) Custom-made orthotics Ii) Pre-fabricated soft orthotics Iii) No orthotics

The evaluated outcomes included pain, gross motor proficiency, self-perception and exercise efficiency. They basically found no evidence to justify the prescription of orthotics in children with excessive foot pronation as all three groups had similar outcomes after 3 months and 1 year.

Could it be that pediatric flat foot is often unnecessarily treated? Let us now discuss the relevance of PP in adults. We’ve all heard of the fact that flat footed individuals were once not recruited for

the military due to their high risk of injury. During WWII, the US military disqualified soldiers from active duty simply based on the diagnosis of PP, even though it was revealed that about 15% of military personnel had PP and were asymptomatic (Ifled 1944).

Studies seem to be conflicting; one military study showed that

both PP and pes cavus were risk factors in the development of

lower extremity overuse injuries (Kaufman et al 1999) while an-

other military study showed that foot abnormalities such as

PP, pes cavus, and hallux valgus were not significant factors in the

development of injury during recruit training (Rudzki 1997).

A study followed 230 Royal Australian Air Force recruits over the

course of their 10-week basic training and found that neither flat

feet nor high arched feet were associated with physical function-

ing, injury rates or foot health. If anything, those with flat feet

had a tendency to have fewer injuries (Esterman et al 2005).

Instead of me going on and on presenting conflicting studies

about the risks of PP, let’s just accept that there is a small associa-

tion between PP and lower extremity injuries. So the question

remains: what can be done about it?

I appreciate that there are several studies demonstrating the effi-

cacy of foot orthoses in preventing and treating lower extremity

injuries (Hume et al 2008). However, should the permanent use

of orthotics be the only solution to PP? We do not treat most indi-

viduals with low back pain

with permanent suppor-

tive back braces but rather

with specific strengthen-

ing and movement exer-

cises. We do not treat indi-

viduals with neck pain with

instructions to wear a neck

collar for the rest of their

life - we prescribe specific

and appropriate exercises.

So here is the question

again: if an individual pre-

sents with PP and poor

pronation control, why is

the first instinct to prescribed permanent orthotics? What about

the crazy idea of strengthening the feet and retraining the intrin-

sic foot muscles (IFM) to improve motor control?

Other than anecdotal evidence, I have no study to date support-

ing the hypothesis that retraining of the IFM can actually change

function or pain related to PP. There is, however, a study showing

that IFM strengthening actually increased the cross sectional area

of the abductor hallucis and the strength of the flexor hallucis

A New Look at Pes Planus from the Perspective of a Really Pronated Physical Therapist

Dr. Bahram Jam, PT e-mail: jam@aptei.com

That’s my left foot and I’ve never had any issues related to my pes planus. I remain asymptomatic, perhaps because I have pretty good lower extremity motor control …pes planus and proud!

15 sportmedab.ca

muscle, where both muscles contribute to pronation control (Jung et al 2011).

Furthermore, another study concluded that a 4-week IFM retraining program was

shown to significantly increase medial longitudinal arch height and improve functional

balance in asymptomatic subjects with PP (Mulligan & Cook 2013). Before you think I

am endorsing the burning of all orthotics and proposing that simple foot strengthening

exercises will resolve all issues related to PP, I’m not. Customized and pre-fabricated

foot orthotics can be very valuable in certain children and adults with obvious foot de-

formities, arthritis, or those in pain and unresponsive to other conservative manage-

ments.

All I have intended to offer in this short article is that perhaps a paradigm shift might be useful, in view of the limited evidence that PP is actually a high risk factor for injuries, and the limited evidence for the efficacy of orthotics in the majority of individuals with PP. I pro-pose the hypothesis that pes planus itself is not the issue; the lack of IFM motor control resulting in uncontrolled pronation is. Alterna-tive approaches to managing pes planus such as the retraining of the IFM, providing proprioceptive feedback and active control of pro-nation, should be considered clinically and in future studies.

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Even with my pes planus, I love hiking and running in my non-supportive shoes.

References:

1. Esterman A, Pilotto L. Foot shape and its effect on functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort study. Mil Med. 2005 Jul;170(7):623-8.

2. Hume P, Hopkins W, Rome K, Maulder P, Coyle G, Nigg B. Effective-ness of foot orthoses for treatment and prevention of lower limb injuries: a review. Sports Med. 2008;38(9):759-79.

3. Ilfeld FW. Pes planus military significance and treatment with simple arching support. JAMA 1944;124:283-286

4. Jones BH, Thacker SB, Gilchrist J, Kimsey CD Jr, Sosin DM. Prevention of lower extremity stress fractures in athletes and soldiers: a system-atic review. Epidemiol Rev. 2002;24(2):228-47.

5. Jung DY, Koh EK, Kwon OY. Effect of foot orthoses and short-foot exercise on the cross-sectional area of the abductor hallucis muscle in subjects with pes planus: a randomized controlled trial. J Back Muscu-loskelet Rehabil. 2011;24(4):225-31.

6. Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal over-use injuries. Am J Sports Med. 1999 Sep-Oct;27(5):585-93.

7. Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. The correlation

between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008 Sep;29(9):910-3.

8. Lakstein D, Fridman T, Ziv YB, Kosashvili Y. Prevalence of anterior knee pain and pes planus in Israel defense force recruits. Mil Med. 2010 Nov;175(11):855-7.

9. Mulligan EP, Cook PG. Effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function. Man Ther. 2013 Oct;18(5):425-30.

10. Pauk J, Ezerskiy V, Raso JV, Rogalski M. Epidemiologic factors affect-ing plantar arch development in children with flat feet. J Am Podiatr Med Assoc. 2012 Mar-Apr;102(2):114-21.

11. Rudzki SJ. Injuries in Australian Army recruits. Part III: The accuracy of a pretraining orthopedic screen in predicting ultimate injury outcome. Mil Med. 1997 Jul;162(7):481-3.

12. Tong JW, Kong PW. Association Between Foot Type and Lower Ex-tremity Injuries: Systematic Literature Review With Meta-analysis. J Orthop Sports Phys Ther. 2013 Jun 11.

13. Whitford D, Esterman A. A randomized controlled trial of two types of

in-shoe orthoses in children with flexible excess pronation of the feet. Foot Ankle Int. 2007 Jun;28(6):715-23.