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Walking: Where Things Go Awry – Loss of Mobility


If you have witnessed a baby learn to walk, you know it is a process that takes a full year plus of movement exploration, failure and triumph.


Little ones doggedly push the boundaries of their current function. When you place a baby on her back she is only happy there a short time- eventually she begins to use her hands to maneuver objects, and she explores turning over. If you place a little one on her belly, she starts to lift her chest away from the floor, and eventually pushes onto all fours.


All of these movements are pruning her nervous system for functional upright motion. She is carving out core strength, spinal extension, contralateral control.


By the time a young one takes her first steps, she has been pursuing movement expansion ceaselessly (between feeding and sleeping) for a good 12 months plus.


And yet by the time we are mature adults, we forget all of the work, effort, courage and failure that went into our walking development. We get up in the morning, and walk seemingly effortlessly. We are lulled into a false sense of ease- and even might take our walking for granted.


But make no mistake, walking is a challenging activity that requires our attention and consistent strengthening throughout our lifespan, in order for us to keep doing it successfully.


Those of you with end stage osteoarthritis, those of you with severe balance challenges, those of you with neurologic conditions know how fleeting walking can be.


So how do we preserve this supremely important functional activity across the span of our lifetime?


I must admit, some of it is just dumb luck. If we acquire a neurologic condition or injury, we may be suddenly face to face with limitations in walking, and need to find new, creative methods to practice mobility.


But there are also aspects of moving that are under our control that we can practice as we age.

Below I will highlight the conditions related to loss of mobility that often arise in the orthopedic populations that I work with:


Loss of Mobility


Loss of mobility (specifically at the big toe, ankle and hip joints) is one of the most common reasons for poor/ altered gait mechanics.

Because our feet serve as our foundation when we walk, when we alter our foot/ ankle mobility we severely affect our alignment up our movement chain (extending all the way up through our spine).


The three most common mobility issues I see in the clinic are:


1) Loss of big toe extension in Pre Swing (PSw) Phase of gait:


In order to walk healthfully, there is a point in our Pre Swing phase of gait where we need quite a bit of flexibility in our big toe, in order to maintain healthful foot/ ankle and limb mechanics. In order for this trailing limb, Pre Swing phase of gait to be achieved, Dr. Perry established in her research that 60 degrees of big to extension was required.


If we do not have this mobility at the big toe, a very common compensatory movement is to abduct the foot, pronate the subtalar joint, and push off the lateral aspect of the big toe. This invites forces that can lead to bunion growth, as well as a rotational component to the hinge joint of the knee.

Test your big toe mobility:

Can you draw your big to up away from the ground toward your shin, enough so that you can make a 60-70 degree angle from the floor (brush off those geometry skills! Recall 90 degrees would be perpendicular). This is hallux extension.

When you move the big toe into this extension, does the angle between the toe and metatarsal (the metatarsal is the long bone that starts where your toe ends and projects toward your ankle) change?

Bring your big toe back to the ground. Next check to see if you can move your big toe toward your other big toe (toward your midline)

If all of these mobility tests are clear and easy, move on to checking the mobility at your ankle

If you cannot do either of these, gently work on them by moving exactly the same way you tested. Repeat daily holding for 1.5-2 minutes.


2) Loss of ankle mobility into dorsiflexion in Terminal Stance (TSt) Phase of gait:

For normal gait, Dr. Perry and her team established 10 degrees of dorsiflexion is required during Terminal Stance. Dorsiflexion is the movement your ankle makes when you pull your toes and the top of your foot toward your shin.

Interestingly, just like most adults lack big toe mobility, most of us also lack neutral dorsiflexion range. True dorsiflexion is difficult to test on your own, and may require a provider’s help. But you can get an overall estimate of your dorsiflexion motion by using the movement tests below.

If you are lacking dorsiflexion motion, the body will begin to perform a similar compensatory motion as noted above: foot abduction, loss of big toe push off, and subtalar pronation, with excess rotation in the transverse plane at the knee, hip and up into the spine.

Test ankle dorsiflexion mobility:


Sitting with your legs out in front of you (with support for your back), draw your foot back toward your shin. Can your foot make a 90 degree angle between the shin and foot, with respect to the floor?

Next check right and left side differences at the ankle joint. Stand with your right foot an inch or two away from a wall. Bend your knee, letting your knee move in front of the ankle (I know we are REALLY moving away from this habit, but just for this once!). How far can you move your toes back away from the wall, before you cannot keep your foot flat when your kneecap touches the wall? Notice the distance between your foot and the wall.

Repeat on your second side and compare.


3) Loss of hip extension in Terminal Stance (TSt) Phase of gait


In the Terminal Stance phase of gait, you can see that the trailing limb reaches the maximum of it’s distance behind the hip. This motion is known as hip extension. Dr. Perry observed 20 degrees of apparent hip extension was a prerequisite for this phase of the gait cycle. When you compare this to the motions available at the hip in normal range of motion- it can get a bit confusing, as a normal hip only extends between 10-15 degrees. ‘

The remaining 5 degrees or so of motion is comprised of the rotation at the pelvis, sacrum, and lumbar spine extension.

It is still important to assess the capacity for your hip to achieve about 10 degrees of extension.


Test hip extension mobility:

Kneel on a pillow on the floor

Step your right leg in front, coming into a low lunge position

Gently tuck your pelvis posteriorly, and place your left shin a few inches to the left (bringing your left hip into slight internal rotation)

Can you maintain neutral spine while you gently move your bottom hip toward a slight extension? 10 degrees is not much. You can use a goniometer to help you find 10 degrees

Repeat on the second side and compare


Next up we will look at the largest muscular demands in our walking cycles, and common points where we adults might be missing the mark we need for healthful gait.


Until then, happy moving!


Trina



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