BACKGROUND AND HISTORY
Male, 47 years at time of first assessment, long-distance runner and triathlete.
Patient had history of chronic and recurring bilateral and Achilles injuries. At time of the assessment he reported progressive calf tightness that worsened with increased running speed. Previous rehabilitation involved soft tissue massage and calf stretching.
INITIAL 3D GAIT ANALYSIS MAIN OBSERVATIONS
• Power Generation: There is high (++) anterior pelvic tilt, and as a result high hip flexion and low hip extension. Low knee flexion at FS bilaterally, although dorsiflexion normal.
• Control: There is general asymmetry with low pelvic obliquity, hip adduction and rotation on the left compared to right.
• Ankle: Ankle dorsiflexion is within normal range. There is low inversion at FS and slightly high peak eversion. Time to peak eversion is high (++) bilaterally and low tibial rotation on left.
• Gait Parameters: High foot progression angle on left and higher over-stride on left compared to right. Very low cadence.
The results suggest power is being produced elsewhere than the hips. Further investigation into the kinematic curves confirmed high plantarflexion throughout the second half of stance and therefore an ankle dominant gait. The combination of an excessive anterior pelvic tilt and low hip extension, plus reduced dorsiflexion from mid-stance through to toe-off indicates that the calves are being over-worked. The function of the glutes reduces significantly in an anterior pelvic tilt. Furthermore, as the pelvis moves more into increased anterior tilt with increased speed, the problem will be exacerbated at faster running speeds.
It is likely that there is a limitation of the anterior muscle groups (quads / hip flexors), creating a structural limitation to the position of the pelvis and this should be worked on in addition to gait retraining .
Cadence is very low, reflected in low knee flexion at foot-strike and encouraging an over-stride.
On the control side of things, there is significant asymmetry with stiffening happening in the left hip/pelvis that could be explored further, as well as reduced tibial internal rotation on the left. High knee abduction and right knee internal rotation are possibly a result of poor hip and pelvic control (seen in the high hip adduction and high pelvic obliquity on the right).
RECOMMENDATIONS AND PLAN
1. Gait Retraining: Based on the results of the gait analysis, a faded feedback protocol to address: excessive anterior pelvic tilt (also high hip flexion and low hip extension) and low cadence was implemented. Strength, neuromotor and flexibility work to complement the proposed gait retraining cues were included in the plan.
2. Strength and Neuromotor: Key areas to target: Hip abductors, hamstrings, glute activation, single-leg squat.
3. Flexibility: Key areas to target: Hip flexors, quadriceps and calves.
GAIT RETRAINING PROTOCOL
A gait retraining protocol was implemented, comments and results are shown on the next pages.
Retraining session were carried-out weekly. Patient also ran a minimum of 2x per week between sessions focussing on the cues. 3x Physiotherapy session were included to improve hip flexor mobility, hip mobility and guide through the exercise programme described above.
GAIT RETRAINING SUMMARY:
• Power Generation: The gait retraining was targeted to increase cadence, reduce anterior pelvic tilt and increase hip extension at toe-off, with the aim of reducing the ankle dominant gait that was observed in the initial assessment. A minor reduction in anterior pelvic tilt was achieved in all gait retraining sessions (apart from Session 3, which was explained by the patient feeling unwell). Further review of the kinematic curves revealed that this change was accompanied by a reduction in plantarflexion through the second-half of stance, thereby having the desired effect of off-loading the gastro-soleus complex. The minor improvements in pelvic tilt position were not coupled by increased hip extension at toe-off and it was recommended that other biomechanical factors (hip flexor tightness and glute function) need to be addressed first. Knee flexion at foot-strike increased as a result of the increased cadence, but there was clear asymmetry (right more flexed than left at FS) . Peak dorsiflexion decreased when the footwear was changed in Session 3.
• Control: Whilst not directly targeted by gait retraining, some minor improvements in frontal and transverse plane movements and symmetry were observed.
• Ankle: Rear-foot inversion at foot-strike and time of peak rear-foot eversion improved when the footwear was changed in Session 3.
• Gait Parameters: Cadence was increased from 156 to 166 - 177 throughout the gait retaining sessions and the patient was able to maintain this increase relatively comfortably. A slight increase in step-width and decrease in foot progression angle were observed after the new shoes were introduced in Session 3.
SUMMARY AND PLAN
The gait retraining targeted reducing anterior pelvic tilt and increasing cadence in order to off-load the plantar-flexors and reduce the patient’s ankle dominant gait pattern. The patient successfully maintained an increased cadence and minor improvements in pelvic tilt, resulting in the desired effect of reducing plantarflexion through the second-half of stance. No improvements in hip extension at toe-off were achieved and the patient was advised to focus on improving hip flexor range of motion and glute function.
Minor improvements in control and symmetry in the frontal and transverse planes were observed and foot kinematics improved after introducing the Mizuno Wave Riders.
Patient able to run slowly, three times per week without pain following the initial gait retraining protocol. He was advised to continue with HEP and physiotherapy programme to help improve ankle dorsiflexion limitations, knee flexion, pelvic positioning and hip control (through hip flexor mobility work, and single leg balance exercise progressions).
Plan to follow-up in 1-month to review if patient is able to maintain current gait changes and improve further. Also, follow up in 6 months and 1-year (case-study to be updated as appropriate).