WEBVTT 00:00:00.069 --> 00:00:00.569 this thing off. 00:00:00.649 --> 00:00:03.350 Kelly, welcome to the podcast. 00:00:04.110 --> 00:00:05.049 Thanks so much for having me. 00:00:05.509 --> 00:00:06.650 You're in the Mile High State. 00:00:06.669 --> 00:00:09.391 You're a physical therapist at UC Health. 00:00:09.430 --> 00:00:10.250 Do I have that right? 00:00:10.730 --> 00:00:11.471 Yeah, that's correct. 00:00:11.791 --> 00:00:12.111 Look at that. 00:00:12.191 --> 00:00:12.891 I can Google. 00:00:12.971 --> 00:00:14.211 Congratulations. 00:00:15.291 --> 00:00:17.352 You're presenting at the AMT Conference, 00:00:17.391 --> 00:00:18.792 which is far from Colorado. 00:00:18.832 --> 00:00:19.672 It's at sea level. 00:00:19.772 --> 00:00:21.092 Are you going to be okay? 00:00:21.112 --> 00:00:22.112 Are you going to adjust to 00:00:22.152 --> 00:00:23.233 that coming from Colorado? 00:00:23.312 --> 00:00:24.073 I'm going to feel great. 00:00:24.092 --> 00:00:24.993 You're going to feel good. 00:00:25.013 --> 00:00:25.754 That's what you learned. 00:00:25.873 --> 00:00:26.754 Minus the humidity. 00:00:27.713 --> 00:00:28.814 Right, right. 00:00:29.013 --> 00:00:29.774 But it's October. 00:00:29.893 --> 00:00:32.335 That's October, November, December. 00:00:32.835 --> 00:00:33.975 That's when you want to be in Florida. 00:00:34.634 --> 00:00:35.814 That's the way to do it, Kelly. 00:00:35.835 --> 00:00:36.314 You're smart. 00:00:36.335 --> 00:00:38.335 You train, live in Colorado, 00:00:38.375 --> 00:00:38.956 come to sea level, 00:00:38.975 --> 00:00:39.756 and you can blow us away. 00:00:40.415 --> 00:00:41.415 So you're presenting at the 00:00:41.515 --> 00:00:42.337 AOMT conference, 00:00:42.536 --> 00:00:44.137 and we want to give a little teaser. 00:00:44.176 --> 00:00:45.676 So let's just start from the start. 00:00:45.837 --> 00:00:47.017 What do you get to share? 00:00:47.057 --> 00:00:48.076 What do you get to teach 00:00:48.116 --> 00:00:49.497 people this year at AOMT? 00:00:49.518 --> 00:00:50.338 And we'll learn a little bit. 00:00:50.618 --> 00:00:51.957 This is the tease before the tease. 00:00:53.037 --> 00:00:54.057 Yeah, good question. 00:00:54.158 --> 00:00:56.018 So I will be presenting with 00:00:56.039 --> 00:00:56.918 two of my colleagues. 00:00:57.957 --> 00:00:59.378 on an out-of-the-box 00:00:59.459 --> 00:01:00.259 approach to regional 00:01:00.298 --> 00:01:02.759 interdependence specific to 00:01:02.920 --> 00:01:03.881 the lower extremity. 00:01:03.901 --> 00:01:06.701 So the title of our presentation, 00:01:06.721 --> 00:01:07.781 it's going to be two parts. 00:01:08.281 --> 00:01:09.343 The first part is going to 00:01:09.362 --> 00:01:11.302 be talking about a top-down approach, 00:01:11.563 --> 00:01:12.603 and the second part will be 00:01:12.623 --> 00:01:14.885 talking about a bottom-up approach, 00:01:15.025 --> 00:01:15.625 and in both, 00:01:15.724 --> 00:01:17.406 we'll be giving case scenarios, 00:01:17.846 --> 00:01:19.966 showing videos of gaits 00:01:20.027 --> 00:01:21.766 from different patient presentations, 00:01:21.887 --> 00:01:23.207 and then, you know, giving some 00:01:23.536 --> 00:01:24.936 attendees some different 00:01:24.977 --> 00:01:26.737 ideas of techniques they 00:01:26.757 --> 00:01:28.438 can use to treat those deviations. 00:01:28.679 --> 00:01:29.498 You've got to mention your 00:01:29.539 --> 00:01:31.319 co-presenters or they would be, 00:01:31.420 --> 00:01:32.081 they would feel left out. 00:01:32.100 --> 00:01:32.781 They're not here right now, 00:01:32.801 --> 00:01:33.281 but who are they? 00:01:33.301 --> 00:01:34.141 Yeah, they would. 00:01:34.162 --> 00:01:36.143 So it's Dr. Laura Baum and 00:01:36.343 --> 00:01:37.944 also Dr. Mary Beth Geiser. 00:01:38.424 --> 00:01:38.823 Now you're good. 00:01:38.903 --> 00:01:39.745 You've got them in there. 00:01:39.784 --> 00:01:40.444 You've snuck them in. 00:01:40.465 --> 00:01:41.504 We got them in. 00:01:42.006 --> 00:01:43.385 So let's give a little tease. 00:01:43.626 --> 00:01:44.846 The presentation with your 00:01:44.906 --> 00:01:45.707 co-presenters is going to 00:01:45.727 --> 00:01:47.108 be a little more robust and 00:01:47.128 --> 00:01:48.049 that's how we get you, right? 00:01:48.069 --> 00:01:48.728 We're going to teach you 00:01:48.828 --> 00:01:49.810 right now while you listen 00:01:49.829 --> 00:01:50.870 on the podcast or watch 00:01:50.890 --> 00:01:51.771 them on the video. 00:01:52.643 --> 00:01:53.222 But you're going to learn 00:01:53.242 --> 00:01:54.784 more when you come in person. 00:01:55.004 --> 00:01:56.444 And I've been to the AM conference, 00:01:56.743 --> 00:01:57.524 pretty robust. 00:01:57.843 --> 00:01:59.183 So go to the website link in 00:01:59.203 --> 00:02:00.284 the show notes in the bio 00:02:00.344 --> 00:02:01.885 to to find out more. 00:02:02.305 --> 00:02:03.084 But let's start with this. 00:02:03.745 --> 00:02:04.786 Help us understand the 00:02:04.825 --> 00:02:06.165 importance of gait analysis 00:02:06.206 --> 00:02:07.186 and physical therapy. 00:02:07.325 --> 00:02:07.525 You know, 00:02:07.585 --> 00:02:08.866 how does it impact patient outcome? 00:02:08.907 --> 00:02:09.586 Like what's the outcome? 00:02:09.806 --> 00:02:10.467 Patient outcomes, 00:02:11.146 --> 00:02:12.467 particularly in your area, 00:02:12.526 --> 00:02:13.807 orthopedics and lower 00:02:13.848 --> 00:02:15.587 extremity amputee care. 00:02:16.862 --> 00:02:17.043 Yeah, 00:02:17.062 --> 00:02:19.063 so gait analysis is an extremely 00:02:19.123 --> 00:02:20.663 important tool in our 00:02:20.683 --> 00:02:22.585 toolbox as physical therapists. 00:02:22.724 --> 00:02:25.366 And this is certainly true in orthopedic, 00:02:25.526 --> 00:02:28.467 but other areas of PT practice as well. 00:02:28.907 --> 00:02:29.187 You know, 00:02:29.247 --> 00:02:31.388 we use it as an assessment in 00:02:31.467 --> 00:02:32.868 terms of how does someone 00:02:33.028 --> 00:02:35.409 use their range of motion, their strength, 00:02:35.449 --> 00:02:36.710 their flexibility, right, 00:02:36.729 --> 00:02:37.491 all those good things, 00:02:38.131 --> 00:02:39.371 and execute a very 00:02:39.450 --> 00:02:41.032 necessary functional task. 00:02:41.723 --> 00:02:43.024 And I think sometimes we 00:02:43.104 --> 00:02:44.585 forget about movement 00:02:44.664 --> 00:02:45.865 observation as an 00:02:45.905 --> 00:02:47.925 assessment tool that 00:02:48.165 --> 00:02:48.966 actually provides more 00:02:49.026 --> 00:02:50.366 meaningful information for 00:02:50.406 --> 00:02:52.187 me than a single special 00:02:52.227 --> 00:02:54.647 test when it comes to assessment. 00:02:55.407 --> 00:02:56.807 As for the patient outcomes 00:02:56.888 --> 00:02:58.568 part of your question, you know, 00:02:58.688 --> 00:02:59.489 I can't tell you how many 00:02:59.528 --> 00:03:00.788 times a week patients tell 00:03:00.829 --> 00:03:02.210 me their goal for therapy 00:03:02.370 --> 00:03:03.210 is to walk again. 00:03:04.150 --> 00:03:06.031 Whether it's they want to walk pain-free, 00:03:06.091 --> 00:03:07.290 they want to walk further, 00:03:07.350 --> 00:03:08.831 they want to walk faster, right, 00:03:09.111 --> 00:03:10.431 or walk periods. 00:03:11.138 --> 00:03:12.679 And what better way to help 00:03:12.718 --> 00:03:14.600 them meet that goal than to 00:03:14.640 --> 00:03:15.622 provide specialized 00:03:15.701 --> 00:03:17.644 intervention based on the way they walk? 00:03:18.304 --> 00:03:19.405 And I think that's 00:03:19.465 --> 00:03:20.466 especially true when you're 00:03:20.545 --> 00:03:21.667 working with individuals 00:03:21.747 --> 00:03:22.788 following limb loss, 00:03:23.548 --> 00:03:24.688 but the added layer is 00:03:24.830 --> 00:03:26.131 figuring out whether their 00:03:26.151 --> 00:03:27.972 gait deviations are driven 00:03:28.051 --> 00:03:30.153 by musculoskeletal impairments, 00:03:30.614 --> 00:03:32.056 prosthetic alignment issues, 00:03:32.276 --> 00:03:33.616 or a combination of the two. 00:03:34.656 --> 00:03:35.915 All right, so we mentioned top-down, 00:03:35.996 --> 00:03:37.356 bottom-up, right? 00:03:37.377 --> 00:03:38.717 Burning the candle at both ends. 00:03:39.597 --> 00:03:40.877 Go a little deeper, elaborate. 00:03:41.276 --> 00:03:41.717 Top-down, 00:03:41.777 --> 00:03:43.117 bottom-up approaches you mentioned. 00:03:44.018 --> 00:03:45.078 How do those strategies 00:03:45.217 --> 00:03:47.699 differ besides the top and bottom, 00:03:47.818 --> 00:03:48.218 obviously? 00:03:48.239 --> 00:03:49.878 And in what situations would 00:03:49.959 --> 00:03:51.340 each be most effective? 00:03:52.479 --> 00:03:52.639 Yeah, 00:03:52.659 --> 00:03:54.539 so both strategies are based in 00:03:54.580 --> 00:03:56.781 concepts of regional interdependence, 00:03:57.100 --> 00:03:57.621 right? 00:03:57.721 --> 00:03:59.480 And so I think in school we've all learned, 00:03:59.580 --> 00:04:00.262 or in the clinic, 00:04:00.282 --> 00:04:01.822 we have all learned some element of 00:04:02.622 --> 00:04:02.842 You know, 00:04:02.882 --> 00:04:04.763 your knee pain may be related to 00:04:04.782 --> 00:04:07.123 impairments at the hip or, you know, 00:04:07.144 --> 00:04:09.305 foot and ankle pain might 00:04:09.344 --> 00:04:11.324 be related to impairments up at the hip. 00:04:12.045 --> 00:04:12.945 Our presentation is just 00:04:12.966 --> 00:04:13.925 going to be providing a 00:04:13.985 --> 00:04:15.347 more systematic way of 00:04:15.407 --> 00:04:17.026 looking at that and treating that. 00:04:17.588 --> 00:04:19.427 So, for a top-down approach, you know, 00:04:19.468 --> 00:04:20.389 that term is going to be 00:04:20.449 --> 00:04:21.809 referring to starting at 00:04:21.848 --> 00:04:22.910 the hip and then 00:04:22.949 --> 00:04:23.970 systematically going down 00:04:23.990 --> 00:04:25.031 to the knee and then this 00:04:25.071 --> 00:04:26.130 to the foot and ankle. 00:04:26.559 --> 00:04:28.660 And bottom up will just be vice versa. 00:04:28.759 --> 00:04:29.899 Start at the foot and ankle, 00:04:29.959 --> 00:04:30.759 then work your way more 00:04:30.800 --> 00:04:33.040 proximally up the kinetic chain. 00:04:33.060 --> 00:04:35.901 For simplicity purposes, right, 00:04:35.922 --> 00:04:36.661 this is a teaser. 00:04:37.322 --> 00:04:38.742 You might choose a top-down 00:04:38.802 --> 00:04:40.103 approach when you're 00:04:40.122 --> 00:04:41.142 treating an individual who 00:04:41.182 --> 00:04:44.463 has low back pain, hip pain, pelvic pain, 00:04:44.483 --> 00:04:45.225 right? 00:04:45.264 --> 00:04:47.745 Because looking at the hip more proximally, 00:04:47.964 --> 00:04:49.586 that might be the most plausible, 00:04:49.605 --> 00:04:50.206 you know, 00:04:50.286 --> 00:04:52.067 explanation for their symptoms 00:04:52.127 --> 00:04:53.266 or their gait deviations. 00:04:54.521 --> 00:04:55.663 but maybe the patient isn't 00:04:55.723 --> 00:04:57.564 improving the way you thought they would, 00:04:58.225 --> 00:05:00.165 or their gait deviation isn't changing. 00:05:00.346 --> 00:05:01.826 And then you could start to consider, 00:05:01.966 --> 00:05:02.848 following our approach, 00:05:03.247 --> 00:05:04.129 looking at the knee and 00:05:04.168 --> 00:05:05.288 then the foot and the ankle. 00:05:05.990 --> 00:05:08.391 As for bottom-up, you know, same idea, 00:05:08.411 --> 00:05:09.791 it might be most relevant 00:05:09.851 --> 00:05:11.252 for a patient experiencing 00:05:11.312 --> 00:05:12.353 foot and ankle pain, right? 00:05:12.374 --> 00:05:13.555 That kind of makes sense to us. 00:05:14.334 --> 00:05:15.596 But kind of as I was mentioning, 00:05:15.855 --> 00:05:16.617 if they don't respond to 00:05:16.637 --> 00:05:17.898 the way you're expecting them to, 00:05:18.057 --> 00:05:18.697 you have to start 00:05:18.757 --> 00:05:20.680 considering contributors more proximally, 00:05:21.040 --> 00:05:21.920 because the foot and ankle 00:05:21.980 --> 00:05:23.922 is really just the first contact point 00:05:24.380 --> 00:05:26.262 on the ground in the gait cycle. 00:05:26.783 --> 00:05:27.903 And then a lot happened from there. 00:05:27.923 --> 00:05:28.865 All right. 00:05:28.884 --> 00:05:28.964 Well, 00:05:28.985 --> 00:05:30.526 we've got to bring in some sort of 00:05:30.625 --> 00:05:32.608 manual therapy technique, right? 00:05:32.627 --> 00:05:33.747 Because you're presenting it 00:05:33.889 --> 00:05:36.269 and that's sort of a common thread. 00:05:36.750 --> 00:05:39.213 So help us understand, 00:05:39.252 --> 00:05:40.473 maybe give us an example of 00:05:40.514 --> 00:05:41.735 a few techniques that you 00:05:41.774 --> 00:05:42.855 might use and explain how 00:05:42.896 --> 00:05:44.536 they address gait-related 00:05:44.596 --> 00:05:46.137 problems specifically. 00:05:47.278 --> 00:05:47.579 Sure. 00:05:47.639 --> 00:05:48.439 So let's start at the head. 00:05:49.175 --> 00:05:50.776 So let's say you see a 00:05:50.836 --> 00:05:52.877 patient who is having a 00:05:52.916 --> 00:05:54.278 really short stride length, 00:05:54.838 --> 00:05:56.077 meaning they're not getting 00:05:56.098 --> 00:05:57.759 into full hip extension at 00:05:58.059 --> 00:06:00.401 that terminal stance phase of gait. 00:06:01.300 --> 00:06:03.021 Maybe you try going to a 00:06:03.341 --> 00:06:05.583 prone P to A or posterior 00:06:05.622 --> 00:06:07.524 to anterior mobilization to 00:06:07.543 --> 00:06:09.324 the hip to improve extension. 00:06:10.074 --> 00:06:11.254 And I think we would maybe 00:06:11.334 --> 00:06:12.774 all logically start there. 00:06:13.595 --> 00:06:14.855 Also looking at, you know, 00:06:15.076 --> 00:06:15.855 I know you asked about 00:06:15.896 --> 00:06:16.896 manual therapy techniques, 00:06:16.915 --> 00:06:17.976 but also looking at hip 00:06:18.016 --> 00:06:19.276 flexor length and kind of 00:06:19.336 --> 00:06:20.557 other contributors to that 00:06:20.598 --> 00:06:21.697 limited mobility. 00:06:22.358 --> 00:06:23.519 But a more out-of-the-box 00:06:23.598 --> 00:06:25.059 approach to that specific 00:06:25.098 --> 00:06:27.019 gait deviation would be to 00:06:27.060 --> 00:06:28.500 maybe use the sideline 00:06:28.560 --> 00:06:30.581 lumbopelvic mobilization or 00:06:30.620 --> 00:06:32.742 even manipulation to build 00:06:32.762 --> 00:06:35.642 more anterior rotation of that innominate, 00:06:35.702 --> 00:06:36.963 which is a very necessary 00:06:37.043 --> 00:06:38.283 part of hip extension. 00:06:39.040 --> 00:06:40.281 So kind of thinking out of 00:06:40.341 --> 00:06:42.583 just that femoroacetabular joint. 00:06:44.184 --> 00:06:45.125 At the knee, 00:06:45.144 --> 00:06:47.666 a common deviation I see is 00:06:47.766 --> 00:06:49.048 patients remain in slight 00:06:49.088 --> 00:06:50.608 knee flexion throughout the 00:06:50.649 --> 00:06:52.471 entire gait cycle, 00:06:52.490 --> 00:06:53.612 which would be abnormal 00:06:53.732 --> 00:06:54.773 into stance phase. 00:06:54.872 --> 00:06:56.254 Very important that patients 00:06:56.374 --> 00:06:57.795 be able to access that 00:06:57.855 --> 00:06:59.216 terminal knee extension. 00:07:00.257 --> 00:07:01.538 And so I would start by 00:07:01.617 --> 00:07:03.680 assessing various accessory 00:07:03.740 --> 00:07:04.961 motion around the knee 00:07:05.000 --> 00:07:06.281 joint or the knee complex. 00:07:07.283 --> 00:07:09.083 But we have to think about, you know, 00:07:09.142 --> 00:07:10.843 not only a posterior glide 00:07:10.863 --> 00:07:12.324 of the femur on the tibia 00:07:12.603 --> 00:07:14.064 or an anterior glide of the 00:07:14.124 --> 00:07:15.245 tibia on the femur, 00:07:15.805 --> 00:07:17.024 but think about the screw 00:07:17.064 --> 00:07:18.485 home mechanism of the knee 00:07:18.845 --> 00:07:20.446 and that combination of 00:07:20.505 --> 00:07:22.665 that glide and rotation that happens, 00:07:23.406 --> 00:07:24.826 as well as that proximal 00:07:24.886 --> 00:07:26.747 tibiofibular joint, right? 00:07:26.807 --> 00:07:28.826 Is that joint moving as well? 00:07:29.307 --> 00:07:30.947 We could also consider doing 00:07:30.966 --> 00:07:32.048 some interventions for 00:07:32.148 --> 00:07:33.708 superior patellar glide. 00:07:34.110 --> 00:07:34.911 But we have to kind of 00:07:34.971 --> 00:07:36.552 figure out why isn't that 00:07:36.572 --> 00:07:38.473 patient able to access knee extension? 00:07:38.494 --> 00:07:39.334 Well, do they have it? 00:07:39.995 --> 00:07:41.956 And then are they able to access it? 00:07:42.478 --> 00:07:43.038 And, you know, 00:07:43.098 --> 00:07:44.019 our presentation 00:07:44.218 --> 00:07:45.339 particularly is going to be 00:07:45.379 --> 00:07:46.740 really incorporating a lot 00:07:46.800 --> 00:07:48.463 of themes from that screw 00:07:48.502 --> 00:07:49.744 home mechanism and more of 00:07:49.803 --> 00:07:51.505 those combined movement patterns. 00:07:53.387 --> 00:07:53.608 Next, 00:07:53.648 --> 00:07:55.588 kind of going down to the foot and ankle, 00:07:55.608 --> 00:07:57.350 the most common thing I see, 00:07:57.370 --> 00:07:58.112 and I'm sure other 00:07:58.151 --> 00:07:59.112 therapists when they hear 00:07:59.153 --> 00:08:00.533 this are going to be like, yeah, me too. 00:08:01.480 --> 00:08:03.062 is limited ankle dorsiflexion. 00:08:03.083 --> 00:08:04.923 That's, you know, by and large, 00:08:04.963 --> 00:08:06.404 the most common deviation 00:08:06.464 --> 00:08:07.646 at the foot and ankle. 00:08:07.706 --> 00:08:09.127 And so that might look like 00:08:09.166 --> 00:08:11.389 an early heel rise in gait, 00:08:11.728 --> 00:08:13.350 or they may externally 00:08:13.410 --> 00:08:14.531 rotate their foot that 00:08:14.550 --> 00:08:15.411 they're avoiding 00:08:15.831 --> 00:08:17.452 dorsiflexion and great toe 00:08:17.473 --> 00:08:19.055 extension and midfoot 00:08:19.074 --> 00:08:20.536 pronation altogether. 00:08:22.317 --> 00:08:23.237 We've all learned that 00:08:23.257 --> 00:08:25.637 talocral distraction manipulation. 00:08:25.658 --> 00:08:26.978 I also like to treat the 00:08:27.017 --> 00:08:28.298 subtalar joint for that 00:08:28.358 --> 00:08:29.658 with a similar technique, 00:08:29.699 --> 00:08:31.060 but just changing the 00:08:31.220 --> 00:08:33.200 pre-positioning of the foot 00:08:33.240 --> 00:08:35.600 and the ankle to bias one over the other. 00:08:35.620 --> 00:08:37.860 And then I like to follow 00:08:37.900 --> 00:08:39.461 that with a talonavicular 00:08:39.601 --> 00:08:40.422 joint treatment. 00:08:40.942 --> 00:08:41.701 So whether that's a 00:08:41.743 --> 00:08:43.883 mobilization or a manipulation, 00:08:43.903 --> 00:08:45.222 I typically treat that in 00:08:45.283 --> 00:08:47.583 prone because we know that 00:08:47.604 --> 00:08:49.445 dorsiflexion and pronation 00:08:49.605 --> 00:08:50.644 are coupled movements. 00:08:51.331 --> 00:08:51.490 Right. 00:08:51.530 --> 00:08:52.693 Especially, you know, 00:08:52.734 --> 00:08:55.158 applicable to that stance phase of gait. 00:08:56.080 --> 00:08:58.043 And keep in mind that in mid stance, 00:08:58.063 --> 00:08:59.145 we also need controlled 00:08:59.206 --> 00:09:00.427 internal rotation at the hip. 00:09:00.488 --> 00:09:02.150 So going right back up the chain. 00:09:02.171 --> 00:09:02.250 Yeah. 00:09:03.192 --> 00:09:03.934 Bottom up, top down. 00:09:04.423 --> 00:09:06.024 Your presentation at the M 00:09:06.063 --> 00:09:07.125 Conference this year is 00:09:07.144 --> 00:09:08.306 going to emphasize the 00:09:08.365 --> 00:09:09.366 collaboration and 00:09:09.427 --> 00:09:10.408 synergistic movements 00:09:10.969 --> 00:09:12.089 within that lower extremity 00:09:12.129 --> 00:09:12.809 in the kinetic chain. 00:09:13.269 --> 00:09:14.431 How can physical therapists 00:09:14.471 --> 00:09:15.131 ensure that they're not 00:09:15.331 --> 00:09:16.732 missing critical links? 00:09:16.793 --> 00:09:17.634 PTs are always scared. 00:09:17.653 --> 00:09:18.375 What are we missing? 00:09:18.394 --> 00:09:20.076 Should we record it and have 00:09:20.096 --> 00:09:20.576 them do it again? 00:09:20.596 --> 00:09:21.837 So how can you make sure PTs 00:09:21.878 --> 00:09:22.697 ensure they're not missing 00:09:22.738 --> 00:09:23.538 critical links in the chain 00:09:23.578 --> 00:09:25.380 when assessing and treating 00:09:25.400 --> 00:09:25.841 their patients? 00:09:26.994 --> 00:09:27.754 Yeah, great question. 00:09:27.774 --> 00:09:29.495 I think the main message 00:09:29.554 --> 00:09:30.674 that we want to send with 00:09:30.715 --> 00:09:31.635 our presentation is 00:09:31.816 --> 00:09:32.956 consider impairments in 00:09:33.056 --> 00:09:34.496 other areas of the kinetic 00:09:34.557 --> 00:09:36.277 chain that might contribute 00:09:36.317 --> 00:09:37.557 to symptom development. 00:09:37.577 --> 00:09:40.859 I think in PT school or 00:09:40.899 --> 00:09:42.318 maybe in residencies or if 00:09:42.359 --> 00:09:43.659 you pursue fellowship, 00:09:43.720 --> 00:09:45.200 you really get hammered 00:09:45.240 --> 00:09:46.841 home with more of that look 00:09:46.941 --> 00:09:48.020 elsewhere approach. 00:09:48.681 --> 00:09:49.861 But it's easy to get into 00:09:49.881 --> 00:09:51.142 the clinic and start seeing 00:09:51.182 --> 00:09:52.263 patients and get into a 00:09:52.322 --> 00:09:53.523 rhythm and you kind of 00:09:53.562 --> 00:09:54.663 start to forget about 00:09:54.702 --> 00:09:56.484 things that are outside of that patient's 00:09:56.913 --> 00:09:58.115 pain zone, right, 00:09:58.195 --> 00:10:00.537 or their exact location of symptoms. 00:10:01.017 --> 00:10:03.058 But the human body is complex, right? 00:10:03.119 --> 00:10:04.700 Gait is a complex movement 00:10:04.759 --> 00:10:05.520 and something that we're 00:10:05.600 --> 00:10:07.081 all doing every single day. 00:10:07.101 --> 00:10:08.363 You know, 00:10:08.423 --> 00:10:10.083 I would also argue that looking 00:10:10.205 --> 00:10:12.626 at some of the impairments outside of, 00:10:13.067 --> 00:10:13.307 you know, 00:10:13.346 --> 00:10:14.988 that exact area of pain could 00:10:15.008 --> 00:10:16.450 also explain ongoing or 00:10:16.490 --> 00:10:17.649 persistent symptoms. 00:10:18.191 --> 00:10:18.350 You know, 00:10:18.390 --> 00:10:19.831 maybe that is that missing link 00:10:19.871 --> 00:10:21.273 to why someone keeps coming 00:10:21.312 --> 00:10:22.934 back to you with the same 00:10:23.014 --> 00:10:24.416 symptoms once a year. 00:10:25.071 --> 00:10:25.350 right? 00:10:25.390 --> 00:10:26.272 Or maybe it's every two 00:10:26.312 --> 00:10:27.793 years or something like that. 00:10:27.812 --> 00:10:28.493 And, you know, 00:10:28.533 --> 00:10:30.154 we do have evidence support 00:10:30.215 --> 00:10:31.294 that when someone has 00:10:31.394 --> 00:10:32.556 experienced low back pain, 00:10:32.576 --> 00:10:33.777 they're at an increased 00:10:33.856 --> 00:10:35.057 risk for recurrent back 00:10:35.097 --> 00:10:36.339 pain again in the future. 00:10:36.359 --> 00:10:38.500 And so I would offer that if 00:10:38.539 --> 00:10:39.581 we begin to consider those 00:10:39.640 --> 00:10:41.903 other areas and think about, you know, 00:10:41.942 --> 00:10:43.703 how someone moves more generally, 00:10:43.724 --> 00:10:45.404 I think we might be able to 00:10:45.445 --> 00:10:46.546 decrease that risk and 00:10:46.806 --> 00:10:48.626 fully return people to function. 00:10:48.647 --> 00:10:51.068 I think it's also helpful to 00:10:51.408 --> 00:10:52.908 I think I may have mentioned this already, 00:10:52.947 --> 00:10:54.028 but when you get stuck with 00:10:54.087 --> 00:10:55.448 a patient and you're just like, 00:10:55.629 --> 00:10:56.589 I do not know what else to 00:10:56.629 --> 00:10:57.528 do for this person. 00:10:57.589 --> 00:10:59.328 I assessed their foot and ankle. 00:10:59.688 --> 00:11:01.750 I treated what I found and I 00:11:01.809 --> 00:11:03.029 don't understand why it's 00:11:03.049 --> 00:11:03.909 not getting better, right? 00:11:03.929 --> 00:11:05.269 We've all been there where 00:11:05.309 --> 00:11:07.051 we get frustrated and you 00:11:07.071 --> 00:11:08.171 run out of treatment ideas. 00:11:08.230 --> 00:11:09.390 And so I would say turn 00:11:09.410 --> 00:11:11.130 towards function and start 00:11:11.150 --> 00:11:12.312 to assess their gaze. 00:11:12.751 --> 00:11:14.131 And one way you can really 00:11:14.172 --> 00:11:14.912 make sure you're not 00:11:14.991 --> 00:11:16.192 missing more subtle 00:11:16.272 --> 00:11:18.173 deviations or asymmetries 00:11:18.413 --> 00:11:20.052 is to use video analysis. 00:11:20.693 --> 00:11:20.894 You know, 00:11:20.913 --> 00:11:22.115 there's a lot of really great 00:11:22.235 --> 00:11:23.255 apps out there that are 00:11:23.296 --> 00:11:25.216 totally free or just the 00:11:25.317 --> 00:11:27.639 iPhone camera has that slow-mo feature. 00:11:27.839 --> 00:11:29.120 And sometimes that gives me 00:11:29.179 --> 00:11:31.201 enough of a brief look and 00:11:31.782 --> 00:11:33.003 I'll even record it on the 00:11:33.023 --> 00:11:34.484 patient's phone, right? 00:11:34.524 --> 00:11:35.663 So they can see it. 00:11:35.744 --> 00:11:37.085 And then you get that buy-in 00:11:37.105 --> 00:11:38.385 and you can record it again 00:11:38.446 --> 00:11:39.486 on their phone a few months 00:11:39.527 --> 00:11:41.148 from now and they can 00:11:41.187 --> 00:11:42.369 compare their progress. 00:11:42.568 --> 00:11:44.049 So I've had good success with that. 00:11:44.110 --> 00:11:45.191 And also, 00:11:45.230 --> 00:11:46.652 if you do record on your own phone, 00:11:46.672 --> 00:11:48.192 just remember with HIPAA to 00:11:48.293 --> 00:11:49.374 delete it because 00:11:49.934 --> 00:11:50.995 and not keep it on your phone. 00:11:51.115 --> 00:11:53.115 But video analysis can be super helpful. 00:11:53.515 --> 00:11:53.635 Yeah. 00:11:53.655 --> 00:11:54.096 All right. 00:11:54.155 --> 00:11:56.517 Well, physical therapists love examples. 00:11:56.557 --> 00:11:58.496 We love the case. 00:11:58.636 --> 00:11:59.658 I was working with this person. 00:11:59.758 --> 00:12:02.258 I'd like to share. 00:12:02.557 --> 00:12:03.619 Give us a real-world case 00:12:03.639 --> 00:12:04.859 study or example where the 00:12:04.958 --> 00:12:05.558 application of the 00:12:05.599 --> 00:12:06.519 techniques you just talked 00:12:06.558 --> 00:12:08.039 about are going to help 00:12:08.299 --> 00:12:09.419 improve a patient's gait. 00:12:09.519 --> 00:12:10.340 And what were the key 00:12:10.379 --> 00:12:11.201 takeaways from that 00:12:11.240 --> 00:12:12.160 particular experience? 00:12:13.499 --> 00:12:13.938 Yeah, 00:12:14.038 --> 00:12:15.639 so the case that kind of stands out 00:12:15.659 --> 00:12:16.681 the most to me where this 00:12:16.721 --> 00:12:18.341 has happened recently is I 00:12:18.461 --> 00:12:19.562 had a patient with a really 00:12:19.621 --> 00:12:21.243 complicated orthopedic history, 00:12:21.683 --> 00:12:22.984 relatively young guy. 00:12:23.684 --> 00:12:25.385 He fractured both of his 00:12:25.505 --> 00:12:27.886 tali with a relatively low 00:12:28.006 --> 00:12:29.008 impact incident. 00:12:29.028 --> 00:12:31.089 He brought his dirt bike to a stop, 00:12:31.469 --> 00:12:32.909 put his feet on the ground 00:12:33.169 --> 00:12:35.311 and broke both of his tali, 00:12:35.390 --> 00:12:37.152 which is kind of crazy. 00:12:37.172 --> 00:12:39.673 So he had a surgery. 00:12:39.754 --> 00:12:41.053 They did an open reduction 00:12:41.094 --> 00:12:42.274 internal fixation and 00:12:42.931 --> 00:12:43.831 For both of them, 00:12:44.130 --> 00:12:45.572 long journey in recovery. 00:12:45.692 --> 00:12:47.032 I did not treat him after 00:12:47.072 --> 00:12:48.332 that original surgery. 00:12:49.173 --> 00:12:49.893 But that surgery was 00:12:49.932 --> 00:12:51.552 successful for his left ankle. 00:12:51.994 --> 00:12:53.553 His right ankle, on the other hand, 00:12:53.634 --> 00:12:55.114 continued to have pain and 00:12:55.173 --> 00:12:56.355 just ongoing mobility 00:12:56.414 --> 00:12:58.554 limitations and felt super stiff. 00:12:59.615 --> 00:13:00.375 So he went back to the 00:13:00.416 --> 00:13:02.056 surgeon and they decided to 00:13:02.076 --> 00:13:03.496 take the hardware out and 00:13:03.576 --> 00:13:06.177 see if that could help with 00:13:06.216 --> 00:13:07.418 his pain and his symptoms. 00:13:08.177 --> 00:13:09.138 And so that's when he was 00:13:09.158 --> 00:13:09.837 then referred to me, 00:13:10.197 --> 00:13:11.918 was after the hardware was taken out. 00:13:12.533 --> 00:13:14.134 So when I looked at his gait 00:13:14.174 --> 00:13:15.556 during the evaluation, 00:13:15.576 --> 00:13:17.397 I noted a few different things. 00:13:17.937 --> 00:13:20.078 So I saw that he had a 00:13:20.139 --> 00:13:21.479 really early heel rise. 00:13:21.499 --> 00:13:22.840 So kind of showing some of 00:13:22.860 --> 00:13:24.301 those signs of that lack of 00:13:24.400 --> 00:13:25.621 ankle dorsiflexion. 00:13:25.642 --> 00:13:27.842 He had decreased midfoot 00:13:27.903 --> 00:13:29.923 pronation in that stance phase, 00:13:30.085 --> 00:13:31.865 a lack of terminal knee extension, right? 00:13:31.926 --> 00:13:33.466 All of those movements go together. 00:13:33.486 --> 00:13:34.787 So that does make sense. 00:13:35.408 --> 00:13:36.347 And then he also had that 00:13:36.629 --> 00:13:37.749 decreased stride length 00:13:37.769 --> 00:13:38.690 that I was talking about, 00:13:38.710 --> 00:13:40.431 a lack of hip extension. 00:13:41.754 --> 00:13:42.995 So in my examination, 00:13:43.015 --> 00:13:44.437 obviously I'm going to look 00:13:44.517 --> 00:13:46.337 at range of motion, strength, right, 00:13:46.378 --> 00:13:47.399 all those bread and butter 00:13:47.479 --> 00:13:50.520 things that we all know and love in PT. 00:13:51.142 --> 00:13:52.903 And in doing so, I cleared his hip. 00:13:53.263 --> 00:13:55.043 So I think most people, when they, 00:13:55.465 --> 00:13:55.664 you know, 00:13:55.684 --> 00:13:56.826 would get that referral for 00:13:56.865 --> 00:13:58.005 someone after hardware 00:13:58.066 --> 00:13:59.067 removal in the ankle, 00:13:59.567 --> 00:14:00.587 they may not go look at the 00:14:00.628 --> 00:14:01.489 hip on day one. 00:14:02.179 --> 00:14:03.461 Um, but I did right. 00:14:03.480 --> 00:14:04.361 Just to clear it. 00:14:04.522 --> 00:14:05.783 And so I didn't find any 00:14:05.842 --> 00:14:07.464 substantial impairments at the hip. 00:14:07.845 --> 00:14:09.905 And so that kind of led me towards, 00:14:10.086 --> 00:14:11.267 I think this is really more 00:14:11.346 --> 00:14:12.268 foot and ankle driven, 00:14:12.307 --> 00:14:13.208 which is more kind of 00:14:13.249 --> 00:14:14.669 traditional based on the 00:14:14.710 --> 00:14:15.831 referring diagnosis. 00:14:16.191 --> 00:14:16.390 Right. 00:14:16.410 --> 00:14:20.374 Um, so when I looked at his knee, 00:14:20.394 --> 00:14:22.255 I actually found he had a 00:14:22.355 --> 00:14:23.996 lot of hypo mobility or 00:14:24.037 --> 00:14:25.357 decreased movement at that 00:14:25.477 --> 00:14:27.419 proximal tibiofibular joint. 00:14:28.260 --> 00:14:28.801 which again, 00:14:29.081 --> 00:14:29.881 makes sense when you're 00:14:29.902 --> 00:14:31.082 talking about the ankle complex, 00:14:31.123 --> 00:14:32.263 but might not be something 00:14:32.302 --> 00:14:34.224 you would look at with every, you know, 00:14:34.303 --> 00:14:35.985 post-op foot and ankle patient. 00:14:36.625 --> 00:14:38.046 So I treated that joint with 00:14:38.267 --> 00:14:40.268 manipulation a few times, 00:14:40.408 --> 00:14:41.248 a couple sessions, 00:14:41.307 --> 00:14:42.168 and that actually cleared 00:14:42.208 --> 00:14:43.548 that up pretty quickly. 00:14:43.690 --> 00:14:45.250 And that restored his knee extension. 00:14:45.269 --> 00:14:46.750 So that was pretty cool. 00:14:47.292 --> 00:14:48.731 And then I focused most of 00:14:48.792 --> 00:14:50.133 my time and energy on those 00:14:50.192 --> 00:14:51.793 impairments in the foot and ankle. 00:14:51.854 --> 00:14:53.554 So I did a lot of treatment to his 00:14:53.972 --> 00:14:55.033 talocrural joint, 00:14:55.313 --> 00:14:57.575 the distal tibiofibular joint, 00:14:57.595 --> 00:14:58.615 subtalar joint, 00:14:58.676 --> 00:15:00.035 and then his talonavicular 00:15:00.056 --> 00:15:02.096 joint was just super locked up. 00:15:02.798 --> 00:15:03.857 Makes a lot of sense with 00:15:03.898 --> 00:15:05.399 the injury that he had, 00:15:05.979 --> 00:15:06.639 but I actually think 00:15:06.700 --> 00:15:07.879 treating his talonavicular 00:15:07.940 --> 00:15:09.841 joint restored more of a 00:15:09.902 --> 00:15:11.081 normal gait pattern than 00:15:11.182 --> 00:15:12.442 even treating talocrural, 00:15:13.222 --> 00:15:14.683 which may surprise some people, 00:15:14.764 --> 00:15:16.725 certainly surprised me in this case. 00:15:17.525 --> 00:15:20.086 He benefited from treatment of both areas, 00:15:20.346 --> 00:15:21.707 but ultimately, 00:15:22.335 --> 00:15:23.975 That approach was successful 00:15:24.115 --> 00:15:26.057 in minimizing his gait deviation. 00:15:26.077 --> 00:15:29.000 So the time to his heel rise was delayed. 00:15:29.019 --> 00:15:31.201 It's still not perfect if I'm being picky, 00:15:32.001 --> 00:15:33.283 but he got back full 00:15:33.302 --> 00:15:34.724 pronation in stance phase 00:15:34.803 --> 00:15:36.465 and his drive length is symmetrical. 00:15:36.565 --> 00:15:40.587 So to me, that's a huge win in terms of, 00:15:40.769 --> 00:15:41.028 you know, 00:15:41.048 --> 00:15:42.629 kind of where's his plan of care now. 00:15:43.309 --> 00:15:45.412 His dorsiflexion is still a bit limited, 00:15:45.591 --> 00:15:48.094 but in communication with his surgeon and 00:15:48.479 --> 00:15:49.340 She's kind of said she 00:15:49.360 --> 00:15:50.260 doesn't think further 00:15:50.321 --> 00:15:52.202 improvement is really possible. 00:15:52.263 --> 00:15:53.384 He's certainly developing 00:15:53.445 --> 00:15:54.346 some of that early 00:15:54.405 --> 00:15:56.067 post-traumatic arthritis. 00:15:56.768 --> 00:15:57.509 So we're really in a 00:15:57.568 --> 00:15:59.130 maintenance phase of care now, 00:15:59.230 --> 00:16:00.312 transitioning towards 00:16:00.812 --> 00:16:02.073 independent management with 00:16:02.114 --> 00:16:03.054 a gym program. 00:16:03.355 --> 00:16:03.975 He does a lot of 00:16:04.056 --> 00:16:06.578 self-mobilizations at home, 00:16:06.658 --> 00:16:07.620 which has helped us get a 00:16:07.659 --> 00:16:08.741 lot more carryover. 00:16:09.446 --> 00:16:11.488 And a lot of corrective exercises, right? 00:16:11.508 --> 00:16:12.448 This is certainly a manual 00:16:12.469 --> 00:16:13.910 therapy conference, 00:16:13.990 --> 00:16:15.172 but shameless plug for 00:16:15.211 --> 00:16:16.712 corrective exercise, right? 00:16:17.014 --> 00:16:18.195 You have to do that to get 00:16:18.235 --> 00:16:19.716 those corrections to stick. 00:16:20.336 --> 00:16:20.897 And for him, 00:16:20.937 --> 00:16:23.840 that's been a huge component as well. 00:16:24.000 --> 00:16:24.821 So we're really just trying 00:16:24.841 --> 00:16:26.822 to optimize things as much 00:16:26.863 --> 00:16:29.405 as we can and prolong time 00:16:29.485 --> 00:16:30.807 to another potential surgery. 00:16:31.854 --> 00:16:32.313 That's great. 00:16:32.533 --> 00:16:33.653 I like how you told that in the story. 00:16:33.673 --> 00:16:35.754 A lot of takeaways from that. 00:16:36.754 --> 00:16:38.455 Most importantly for me is I 00:16:38.495 --> 00:16:40.215 now know what the plural of talus is. 00:16:40.995 --> 00:16:41.475 Yeah, I don't know. 00:16:41.495 --> 00:16:42.696 I'm hoping I got that right. 00:16:44.196 --> 00:16:46.697 I didn't take Latin in high school. 00:16:46.876 --> 00:16:48.336 I think you said it on the podcast. 00:16:48.557 --> 00:16:49.437 And since it's recorded, 00:16:49.476 --> 00:16:51.297 no one can change it. 00:16:51.317 --> 00:16:52.057 Yeah, there we go. 00:16:52.798 --> 00:16:53.638 And if they're going to confront you, 00:16:53.658 --> 00:16:54.158 it's going to be when you 00:16:54.197 --> 00:16:55.437 walk off stage at the AM 00:16:55.477 --> 00:16:56.697 conference this year. 00:16:57.298 --> 00:16:58.558 And we had a really fruitful 00:16:58.578 --> 00:16:59.918 discussion about the plural 00:16:59.958 --> 00:17:00.778 form of talus. 00:17:01.265 --> 00:17:02.067 That's the thing to have 00:17:02.147 --> 00:17:04.088 over a drink in the networking hour. 00:17:04.288 --> 00:17:06.990 It's my suggestion for that. 00:17:07.030 --> 00:17:07.371 Kelly, 00:17:07.751 --> 00:17:08.913 last thing we do on the show is 00:17:09.073 --> 00:17:09.673 final thoughts. 00:17:09.753 --> 00:17:10.875 Is there anything you'd want 00:17:10.894 --> 00:17:12.076 to sort of leave with the audience? 00:17:12.096 --> 00:17:12.996 This is your chance for a 00:17:13.056 --> 00:17:15.077 plug to be there for your 00:17:15.117 --> 00:17:16.298 presentation in person. 00:17:16.318 --> 00:17:17.180 But what would you want to 00:17:17.220 --> 00:17:18.421 leave with the audience of 00:17:18.441 --> 00:17:19.481 your colleagues today? 00:17:20.742 --> 00:17:21.183 Yeah, sure. 00:17:21.223 --> 00:17:22.484 I would say just a message 00:17:22.644 --> 00:17:24.866 to continue to look above 00:17:24.906 --> 00:17:26.087 and below the area of the 00:17:26.107 --> 00:17:27.229 patient's pain involvement. 00:17:27.711 --> 00:17:29.372 Think about them as in their 00:17:29.432 --> 00:17:31.173 movement as more generally 00:17:31.233 --> 00:17:32.515 as a human being, right? 00:17:32.595 --> 00:17:34.096 What do they need to execute 00:17:34.115 --> 00:17:34.836 the task that they're 00:17:34.856 --> 00:17:35.856 having trouble with? 00:17:35.978 --> 00:17:37.598 And we could even go on and 00:17:37.679 --> 00:17:38.720 on and on about into the 00:17:38.759 --> 00:17:41.162 trunk and mobility limitations there. 00:17:41.362 --> 00:17:42.883 But I think that's really 00:17:42.903 --> 00:17:43.963 the take home message. 00:17:44.044 --> 00:17:45.724 And then obviously have to say, 00:17:45.785 --> 00:17:47.527 come to the presentation to 00:17:47.727 --> 00:17:48.968 learn more techniques. 00:17:49.188 --> 00:17:50.088 And we're going to be 00:17:50.148 --> 00:17:51.630 creating a video gallery 00:17:51.710 --> 00:17:52.931 and a private YouTube channel 00:17:53.556 --> 00:17:54.817 that people can take with them. 00:17:54.876 --> 00:17:55.656 Cause I don't know about you, 00:17:55.696 --> 00:17:56.738 but sometimes I go to these 00:17:56.778 --> 00:17:57.498 great courses or 00:17:57.538 --> 00:17:59.618 conferences and in the moment I'm like, 00:17:59.719 --> 00:18:01.180 I'm totally going to remember this. 00:18:01.740 --> 00:18:02.921 And I don't, right. 00:18:03.101 --> 00:18:03.300 You know, 00:18:03.320 --> 00:18:04.622 you get back to clinic and you're like, 00:18:04.662 --> 00:18:06.022 how, where were their hands again? 00:18:06.063 --> 00:18:06.522 And you know, 00:18:06.603 --> 00:18:07.383 everyone's trying to take 00:18:07.423 --> 00:18:08.763 videos on their cell phones, 00:18:08.864 --> 00:18:10.105 but you get someone else's 00:18:10.144 --> 00:18:11.505 cell phone and your view 00:18:11.585 --> 00:18:12.526 and it just doesn't work well. 00:18:12.546 --> 00:18:13.286 So we're going to actually 00:18:13.326 --> 00:18:14.426 create a video channel 00:18:14.886 --> 00:18:16.367 afterwards where people can 00:18:16.528 --> 00:18:17.508 go back and look at those 00:18:17.587 --> 00:18:18.909 techniques and hopefully 00:18:19.088 --> 00:18:20.690 use them more consistently 00:18:20.750 --> 00:18:22.451 and successfully in the clinics. 00:18:23.250 --> 00:18:23.991 That's what I like to hear. 00:18:24.771 --> 00:18:27.174 Kelly, I hope to see you in Orlando, 00:18:28.316 --> 00:18:29.416 maybe with Mickey Mouse or 00:18:29.457 --> 00:18:30.317 Minnie Mouse ears. 00:18:30.478 --> 00:18:31.739 You're so close in proximity. 00:18:31.778 --> 00:18:32.640 You've got to kind of touch 00:18:32.759 --> 00:18:33.701 on Disney for the day. 00:18:33.721 --> 00:18:34.461 But thanks so much for 00:18:34.501 --> 00:18:35.082 sharing what you'll be 00:18:35.102 --> 00:18:35.782 talking about with your 00:18:35.823 --> 00:18:38.125 colleagues this October with Amt. 00:18:38.705 --> 00:18:39.767 Yeah, thanks so much for having me. 00:18:41.107 --> 00:18:41.627 And that's it. 00:18:41.788 --> 00:18:42.628 Anything we didn't ask? 00:18:42.669 --> 00:18:43.690 Anything we, you know. 00:18:43.710 --> 00:18:46.353 No, that was easy peasy.