Your Walking Book

Walk your way to better health

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Your homework:

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Your OPTM physical therapy program will consist of several phases. Your program has been designed to allow you to meet your goals safely and efficiently. Pain may have multiple causes. You may have damaged tissue due to trauma or surgery. Perhaps, you have developed some habits which irritate your tissues. Or, perhaps you have developed pain that is considered ‘centrally mediated pain’ which doesn’t have a cause and effect relationship but rather is a malfunction of your nervous system.

Together, we will determine a program which works best for you. You are in charge of how we work together. You should not have increasing symptoms but you may feel low levels of discomfort, about a 3-4/10 level during your exercises. If you have more pain, stop the activities until we can alter your program. You need to be a very active participant in your recovery. Your program will be most effective if you perform your exercises daily and be mindful of your body mechanics, postures and ergonomics throughout the day.

Think of reasons why you want to feel better and how your life will improve if you are able to perform your desired activities of daily and recreational living more comfortably. This mindfulness process actually helps you regain your health. How we think affects how we feel and how life presents itself to us. Perhaps 20 minutes of mindfulness meditation each day would be useful to help you control your stress and improve your immune system. We function as one unit and our health is dependent upon all body systems functioning optimally.

This is a general outline of your program.

Phase 1: Your will learn techniques which will always be useful as first aid for pain.a. Behaviors which provoke your symptoms. b. How to change these pain provoking activities and positions.c. Movements which will allow you to perform your daily activities safely.d. Exercises to begin conditioning your tissues to tolerate activities and

increase the strength of weak muscles.

Phase 2: You will continue to avoid provocative activities. a. Increase your strength and coordination to enhance your activity tolerance.

b. Improve your range of motion in order to be able to move comfortably.

Phase 3: a. Progression of your exercise program to include more demanding functional

activities.

Phase 4:a. Begin a return to sport or specific activity program with specific exercises which

will allow you to safely return to higher levels of activity.

Phase 5: Specific sports training.

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A healthy life:Our body parts work together as one functional unit and movement is the best medicine for our body. When we to do something supposedly healthy for one body part, e.g. our back, we should ensure that what we are doing is healthy for our whole body. The healthier we are in general, the more resilient we will be when we are ill or injured. We will improve our stress tolerance and our recovery from painful episodes will be enhanced. Our general health and emotional well-being are essential to our recovery. Recovery is not a light switch, it is more of a rheostat. We improve a little at a time.

Every day you need to remind yourself to do good things for yourself: eat the right portions of good food, get plenty of sleep. Your body needs energy to recover, so don’t cheat on your sleep, get at least 7-8 hours every night. Think positive thoughts and develop healthy coping strategies. You will recover, but it is a journey.

Healthy advice:

1. Modify your postures and activities to keep your spine healthy.2. Change positions frequently to alter tissue stress. Even the best positions

become painful if we don’t move occasionally. 3. Move daily. Include walking and a few exercises as instructed to keep your

body strong and limber. If standing is comfortable, try standing at least 60% of your day.

4. Unload your spine by elongating it like a spring throughout the day.5. Work healthy movements into your daily life to improve your circulation,

flexibility, muscle function and comfort.6. Eat a healthy diet and maintain a healthy weight. Eat 30-40 mg of fiber daily.7. Get 7-8 hours of sleep daily.8. Improve your health with positive thoughts and meditation. Use your

exercise time to clear your mind and enhance your immune system.

You are your own best doctor.

The first step to health and happiness is to stop hurting yourself.

Keep moving and think positive thoughts!

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WALKING AND OUR QUALITY OF LIFE

Walking, or your gait, is our most frequent action. The average sedentary adult walks nearly 5,000 steps per day. Aside from being our primary mode of independent transportation, walking has also been proven to be an excellent method for exercising our body and maintaining health. The Surgeon General recommends that every adult should perform at least 10,000 steps per day in order to remain in good physical condition and combat disease.

10,000 steps! That is roughly 5 miles of walking per day. Aside from walking being a great form of exercise, the speed at which we are able to walk is often referred to as the “sixth vital sign.” This means that many medical professionals consider walking speed to be a measurement that is just as important as monitoring our heart rate, blood pressure, respiratory rate, body temperature, and body weight when assessing the condition of our health. Just as having a blood pressure higher than 120mmhg/80mmhg is predictive of a higher risk for heart disease and stroke, being unable to walk faster than 2.2 mph is predictive of our risk for developing various disease, for falling, becoming disabled, becoming hospitalized or reliant on assisted care, and even for death. About 76% of the people under the age of 65 were unable to walk at or above a speed of 2.2 mph. looking at people over the age of 65, the percentage increased to 85%. To provide a reference for how fast we need to be able to walk in order to be functional, we must be able to walk at a speed of 3 mph in order to cross a crosswalk within the allotted time.

Most commonly, people begin to stop walking, or walk more slowly either because our work becomes more sedentary as we get older and we get out of shape and then walking becomes painful we become unstable and are unable to walk at a faster speed.

The following sections of this book will serve to provide a detailed yet simple method we can evaluate your gait, determine the necessary steps to correct the deviations in your gait, and provide a reference to create a training program to restore normal gait mechanics and alleviate your pain and/or improve your stability.

A pain free life is now literally just steps away!

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PHASES OF GAIT

STANCE: Period of gait where the foot is on the ground. This period accounts for 60% of your gait cycle.

Initial Contact: Moment when double leg stance begins. The knee is straight and contact is made with the heel to allow for forward progression, as well as to set the leg in position to prepare for shock absorption. At initial contact, your hamstrings, quadriceps, and tibialis anterior muscles are active.

Loading Response: Phase of gait that allows for shock absorption, continued forward progression, and dynamic stance stability as the foot lowers to be flat on the ground and the knee and hip bend as weight is being transferred onto the front leg. At loading response, your gluteus maximus, hamstrings, quadriceps, and tibialis anterior muscles are active.

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Mid-Stance: The beginning of single leg stance and period of continued forward progression and dynamic stance stability. The hip and knee will extend while the ankle rocks forward over the foot. At early mid-stance, the gluteus maximus, hip abductors, quadriceps, and calf muscles are active. At late mid-stance, the hip abductor and calf muscles are active.

Terminal Stance: During this phase, the body advances forward in front of the leg. The objective is continued forward progression. The ankle continues to move forward over the foot, while the knee and hip will continue to extend. At terminal stance, the hip abductor and calf muscles are active.

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Pre-swing: Phase of gait where the body returns to double leg stance. Weight is being unloaded from the leg to prepare for swing as the ankle extends and the knee and hip begin to flex. It is the active hip flexion the drives the passive knee flexion. At pre-swing, the rectus femoris, adductor longus, and calf muscles are active.

SWING: Period of gait where the foot is not contacting the ground. This period accounts for 40% of your gait cycle.

Initial Swing: In this phase of gait the objective is to clear the foot from the ground as the leg swings forward. To accomplish this, the hip and knee will continue to flex, and the ankle will move from an extended position toward a neutral position. At initial swing, the iliopsoas, biceps femoris short head, and tibialis anterior muscles are active.

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Mid-Swing: The leg continues to swing forward, with the knee now moving toward extension. The hip continues to bend and the ankle will flex to a neutral position to maintain foot clearance. At mid-swing, the iliopsoas, biceps femoris, and tibialis anterior muscles are active.

Terminal Swing: The objective of this phase is to continue to advance the leg forward and prepare the leg to contact the ground. The knee will extend to a straitened position, while the ankle and hip will remain flexed to allow for heel contact. At terminal swing, the gluteus maximus, hamstrings, quadriceps, and tibialis anterior muscles are active.

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FOOT AND ANKLE ROCKERS

Think of your foot like the rocking rail on a rocking chair. Your foot should roll as you walk, much like the rail rolls when you rock the chair. Your foot strike should be smooth and quiet when you walk without any slapping sound.

HEEL ROCKER

The heel rocker begins when your heel contacts the ground and ends when your foot is flat on the ground. This occurs through the initial contact and loading response phases of gait. The purpose of using the heel rocker is to aide with forward progression. Typically, people will discontinue using the heel rocker in order to improve their stability when they feel unbalanced during gait, or if they lack full knee extension. The consequences of not using a heel rocker are increased energy expenditure during gait, which will cause early fatigue with walking, along with decreased gait speed, which will make walking in the community more challenging.

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ANKLE ROCKER

The ankle rocker occurs as your shin progresses forward over your foot. This occurs during the mid-stance phase of gait. The purpose of the ankle rocker is for continued forward progression through this portion of the gait cycle. Typically, people will discontinue using the ankle rocker due to lack of adequate ankle dorsiflexion. The consequences of not using the ankle rocker are increased energy expenditure, which will cause early fatigue with walking, along excessive loading of the hip and knee extensors, which can cause pain due to muscular strain.

FOREFOOT ROCKER

The forefoot rocker occurs as your heel leaves the ground and the weight of the body is transferred to the ball of the foot. This occurs during the terminal stance phase of gait. The purpose of the forefoot rocker is for continued forward progression during this portion of the gait cycle. There are a number of reasons that people typically discontinue usage of the forefoot rocker. These include pain at the metatarsal heads (ball of the foot), as well as excessive ankle dorsiflexion due to calf weakness. The consequences of not using the forefoot rocker are increased energy expenditure, which will cause early fatigue with walking, along with excessive loading of the calf/Achilles tendon, which can cause pain due to muscular strain.

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WHY DO I HURT WHEN I WALK?

Most of our walking pain results from poor muscle function, flexibility and motor control which adversely affects our ability to absorb shock and properly distribute stress. These impairments are manifested in changes in our gait pattern. Including impaired foot landing, most common of which is ‘cross over stepping’. This is when our foot comes to the midline as if walking on a tight rope, when we walk or run. Most of these pains can be minimized with proper training and lots of practice!

LOW BACK PAIN

Low back pain is a common issue that may limit one’s ability to walk. Back pain problems usually occur during the stance phases of gait, placing excessive loading stress on the trunk and spine. The movement impairments that most commonly contribute to having low back pain with walking include:

1. Poor shock absorption2. Poor stress distribution with asymmetrical trunk positioning3. Poor pelvic motion control

ANTERIOR HIP PAIN

Anterior hip pain with walking occurs due to increased compression of the anterior hip or increased strain of on the muscles of the anterior hip. The most common gait impairments that contribute to increased anterior hip pain with walking include:

1. Femoral internal rotation 2. Femoral adduction3. Anterior pelvic tilt4. Cross over stepping

LATERAL HIP PAIN

Lateral hip pain with walking occurs due to increased strain on the soft tissues of the lateral thigh, including the tensor fasciae latae (TFL) and gluteus medius muscles, the ilio-tibial band (ITB), and the trochanteric bursa. The most common gait impairments that contribute to increased lateral hip pain with walking include:

1. Femoral adduction2. Femoral internal rotation3. Pelvic drop4. Cross over stepping

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POSTERIOR HIP PAIN

Posterior hip pain with walking occurs primarily due to increased strain on the deep rotator muscles that are located at the buttocks. The most common gait impairments that contribute to increased posterior hip pain with walking include:

1. Femoral internal rotation2. Sciatic nerve irritation3. Cross over stepping

LATERAL KNEE PAIN

Lateral (outside) knee pain with walking occurs due to increased friction forces or tension on the soft tissues at the lateral knee, along with increased compression forces on the bone and cartilage at the lateral joint. The most common gait impairments that contribute to increased lateral knee pain with walking include:

1. Femoral internal rotation2. Femoral adduction3. Dynamic knee varus4. Dynamic knee valgus5. Cross over stepping

MEDIAL KNEE PAIN

Medial (inside) knee pain with walking occurs due to increased soft tissue strain at the medial knee due to inward collapse and/or rotation of the thigh. The most common gait impairments that contribute increased medial knee pain with walking include:

1. Femoral internal rotation2. Femoral adduction3. Insufficient ankle dorsi-flexion4. Foot pronation5. Dynamic knee valgus6. Cross over stepping

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ANTERIOR KNEE AND PATELLO-FEMORAL PAIN

Anterior knee and patello-femoral (knee cap) joint pain, PFJP, with walking may occur due to over-use or abnormal compression forces on the patella causing increased compression in the joint. This may be a result of the femur rotating abnormally under the patella when we are weight bearing or the patella moving abnormally on the femur when we extend our knee while non-weight bearing. Deviations in trunk and knee position can increase stress on the quadriceps muscle which will increase the stress on the PFJ or become a source of tendonopathy, which also is a cause of anterior knee pain. The most common gait impairments that contribute increased anterior knee and patella-femoral knee pain with walking include:

1. Femoral adduction2. Femoral internal rotation3. Dynamic knee valgus4. Limited knee extension5. Posterior trunk lean6. Insufficient dorsi-flexion in the ankle7. Foot pronation8. Cross over stepping

CALF AND ACHILLES TENDON PAIN

Calf and Achilles tendon pain with walking occur due to excessive stress on these tissues during the stance phase of gait. The most common gait impairments that contribute to increased calf and Achilles tendon pain with walking include:

1. Excessive or deficient dorsiflexion2. Excessive pronation or eversion of the rear-foot

MEDIAL ARCH AND SHIN PAIN

Medial arch and shin pain with walking occur primarily due to excessive stress on the tibialis posterior muscle during the stance phase of gait. The most common gait impairments that contribute to increased medial arch and shin pain with walking include:

1. Excessive or insufficient dorsi-flexion2. Excessive foot pronation3. External rotation of the foot while walking which causes rolling over the

medial arch instead of the toes.4. Cross over stepping

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PLANTAR FOOT PAIN

Plantar (bottom surface) foot pain with walking occurs due to excessive stress on the plantar fascia and plantar foot muscles. Over-use, activities that demand high forces for which we are not prepared, such as an unaccustomed long uphill walk or run and excessive body weight often contribute to plantar pain. The most common gait impairments that contribute to increased plantar foot pain with walking include:

1. Excessive or insufficient dorsi-flexion2. Excessive pronation3. Poor shock absorption4. Over-use

HEEL PAIN

Heel pain with walking occurs primarily due to excessive loading of the heel at the beginning of the stance phase of gait. The most common gait impairments that contribute to increased heel pain with walking include:

1. Poor shock absorption2. Loss of the heel fat pad

METATARSAL PAIN

Metatarsalgia (ball of the foot pain) with walking occurs primarily due to excessive pressure being placed on the ball of the foot during the stance phase of gait. Hammer toes, poor arch support and tight fitting shoes and socks can contribute to this pain. Common gait impairments that contribute to increased metatarsal pain with walking include:

1. Excessive plantar flexion at mid and terminal stance2. Loss of the forefoot arch3. Tight shoes4. High arched feet, especially with hammer toes5. Loss of the forefoot fat pad.

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LATERAL LEG AND ANKLE / FOOT PAIN

Pain on the outside of your leg and ankle can occur due to tension stress to the lateral muscles and ligaments and impact stress to the bones on the outside of your foot. Often, people with this pain have high arches and walk on the outside of their feet which increases the stress to these tissues. Common gait impairments contributing to include:

1. Walking on the outside part of the foot. Check out the wear on your shoe! 2. Poor pronation shock absorption. 3. Knee varus 4. Contralateral pelvic drop

ANTERIOR SHIN PAIN

Pain in the front of your leg or shin, commonly called shin splints. This pain can result from muscle or tendon irritation, bony pain or excess pressure inside of our muscle compartments. Also, Over-use or unusual activity can contribute to the pain.

Some common gait impairments may include:

1. Insufficient dorsi-flexion 2. Poor shock absorption due to poor pronation / supination function. 3. Poor loading response.

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WHY AM I WALKING SLOWER?

WHAT DETERMINES GAIT SPEED?

Our walking speed is determined by two factors, how long are our steps and how fast we step. In order to be able to walk at a functional speed, we must be able to take large enough steps and take them at a quick enough rate.

WHAT CAUSES PEOPLE TO BEGIN TO WALK MORE SLOWLY?

As we get older, we move less. The less we move, the less inclined we are to move which leads to several functional deficits, especially our stability. Our stability and balance are related to our vision, our vestibular system and our ability to feel our environment with our peripheral sensory system. As these systems slowly decline our stability is impacted.

Stability is a very important aspect of movement. Gait has been called ‘catching a series of falls’ as during normal walking our center of mass is outside of our base of support (where our feet contact the ground) during 80% of each stride. When our stability is compromised we make adjustments to the way we walk in order to make gait a more stable activity.

One adjustment that we can easily make to improve our stability while walking is to shorten our steps. By shortening our steps we can keep our center of mass within our base of support. However, by shortening our step length we lose our foot and ankle rockers which slows our forward progression and we use our hip and thigh muscles less which leads to weakness and impaired ability to balance. We become less able to live safely.

This slow and inefficient gait and poor balance can significantly impact our general health. We will become less able to walk longer distances or get up from a chair. We are not be able to cross the street in the required time. We will be more likely to have a fall and walking may become painful due to gait impairments, which will cause us to walk less and contribute to the slow functional decline which will impact our ability to live independently!

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TRAINING DRILLS TO RESTORE NORMAL GAIT

Walking and running comfort is all about optimal shock absorption and stress distribution in the lower extremities. These are a few exercises which will help improve your walking and comfort. Use good form, avoiding cross-over stepping. Your foot strike should be directly in front of your hip. Avoid stepping toward the midline like you are walking a tight rope. Your feet should hit to the side of the rope, not on it!

LOADING RESPONSE LUNGE

These are important cues to remember when performing loading response lunges.

1. Step out with your affected leg with a normal sized step2. Your foot should land heel first3. Shift your weight so that most of your weight is on your front leg4. At the same time, the knee of your front leg should “unlock,” allowing it to

bend slightly5. While your weight shifts to the front leg and the front knee bends, the heel of

your back foot will leave the ground, however, the ball of your foot on your back leg will remain in contact with the ground

6. Repeat for 10-15 repetitions per set, and perform 5-6 sets per day

BAND WALKING

These are important cues to remember when performing band waking.

1. Tie a band tightly around your legs. The band should be tied just above your knees

2. As you walk, think about stretching the band3. Keep your knee caps pointed straight ahead, and do not let them turn inward4. Your goal is to feel your glutes working as you walk5. Walk for 5-10 minutes at a time

RESISTED GAIT

These are cues to remember when performing resisted gait.

1. This drill will require a partner2. Pretend like you are leaning in to a stiff/brisk wind3. Remember to keep your chest up and lean from your hips4. With your partner holding the band from behind, begin to walk while

continuing to think about leaning into a stiff/brisk wind5. Your partner should provide a resistance that you can feel, but does not limit

you from walking with normal mechanics or at a normal speed.

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INCLINE WALKING

Here are the important cues to remember in order to perform incline walking with proper technique:

1. This drill will need to be performed on a treadmill2. Set the treadmill to an incline somewhere between 3 and 5 degrees of incline3. The amount of incline is not important, meaning that more is not better. Your

goal is to use the incline to train you to bring your trunk forward, so use only as much incline as is necessary

4. A band can be used around your knees as described in “band walking” in order to help activate your glutes if necessary

5. Perform for 5-10 minutes at a time

WALKING IN THE HILLS

Walking up hill increases the muscular demand on our hips, knees, ankles and feet. The longer the stride, the more the demand. Also, this is great aerobic work. This is great exercise. But, if this is uncomfortable, try taking shorter steps to decrease the demand on your legs and feet. This will also demand less oxygen so you won’t have to breathe so hard.

Walking down hill increases the impact loading on all lower extremity joints often creating pain in our knees, hips and lower back. Try leaning forward just a touch, taking shorter steps and land with your foot a little flatter than usual to decrease the impact loading. Also, using walking sticks is a great way to decrease the impact stress on our knees and they help with balance.

POWER WALKING

Power walking is simply walking fast. This improves our ability to respond more quickly to unexpected changes in terrain or our stability. Walking on irregular terrain, such as dry sand at the beach or on a dirt path is helpful. As we age, we walk more slowly which slows down our reactions and can increase our potential for falling. Take longer steps and increase your cadence to keep up your aerobic capacity and your muscles and nervous system working and keep yourself safe. Use a walking stick if you feel unsteady or if you have numbness in your feet.

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ROLL YOUR FOOT THROUGH YOUR STEP

When you are walking, think of your foot as the rocking rail on the bottom of a rocking chair. Your foot should land and roll smoothly from your initial contact (A) through lowering your foot flat (B) and rolling over your big toe and second toe (C). Maybe think of a ball rolling and how it rolls easily as opposed to rolling a box, which lands very hard as it pivots from point to point.

A B C

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FOOT ROCKER PRACTICE

This can be performed while walking. Practice landing on the outside of your heel and lower your foot down along a line to your 4th toe. When your weight gets to your forefoot, let your foot roll off of your first 2 toes. You can also think about this while standing. Just center your body weight over the 4th toe line to place your arch in a good position.

Take 10-15 steps with this concept multiple times during a walk until you become aware of how your foot should feel when you do it correctly. You will eventually be more aware of this and will be able to alter your walking pattern to become more comfortable.

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