Join us for an exciting episode with Dr. Kelli Baggett, a leading physical therapist at UC Health, as she previews her upcoming presentation at the AAOMPT Conference.
Dr. Baggett, alongside her colleagues Dr. Laura Baum and Dr. Mary Beth Geiser, will discuss innovative approaches to gait analysis and regional interdependence. Learn about their top-down and bottom-up strategies, case scenarios, and practical techniques for treating gait deviations. Don't miss this valuable opportunity to enhance your clinical skills and stay ahead in physical therapy.
Key Points Discussed:
Overview of Dr. Baggett's presentation at the AAOMPT Conference.
Explanation of the top-down and bottom-up approaches to gait analysis.
Case scenarios and video demonstrations of different gait presentations.
Practical techniques for treating gait deviations.
Insights on regional interdependence and its impact on lower extremity function.
00:00:00 --> 00:00:00 this thing off.
00:00:00 --> 00:00:03 Kelly, welcome to the podcast.
00:00:04 --> 00:00:05 Thanks so much for having me.
00:00:05 --> 00:00:06 You're in the Mile High State.
00:00:06 --> 00:00:09 You're a physical therapist at UC Health.
00:00:09 --> 00:00:10 Do I have that right?
00:00:10 --> 00:00:11 Yeah, that's correct.
00:00:11 --> 00:00:12 Look at that.
00:00:12 --> 00:00:12 I can Google.
00:00:12 --> 00:00:14 Congratulations.
00:00:15 --> 00:00:17 You're presenting at the AMT Conference,
00:00:17 --> 00:00:18 which is far from Colorado.
00:00:18 --> 00:00:19 It's at sea level.
00:00:19 --> 00:00:21 Are you going to be okay?
00:00:21 --> 00:00:22 Are you going to adjust to
00:00:22 --> 00:00:23 that coming from Colorado?
00:00:23 --> 00:00:24 I'm going to feel great.
00:00:24 --> 00:00:24 You're going to feel good.
00:00:25 --> 00:00:25 That's what you learned.
00:00:25 --> 00:00:26 Minus the humidity.
00:00:27 --> 00:00:28 Right, right.
00:00:29 --> 00:00:29 But it's October.
00:00:29 --> 00:00:32 That's October, November, December.
00:00:32 --> 00:00:33 That's when you want to be in Florida.
00:00:34 --> 00:00:35 That's the way to do it, Kelly.
00:00:35 --> 00:00:36 You're smart.
00:00:36 --> 00:00:38 You train, live in Colorado,
00:00:38 --> 00:00:38 come to sea level,
00:00:38 --> 00:00:39 and you can blow us away.
00:00:40 --> 00:00:41 So you're presenting at the
00:00:41 --> 00:00:42 AOMT conference,
00:00:42 --> 00:00:44 and we want to give a little teaser.
00:00:44 --> 00:00:45 So let's just start from the start.
00:00:45 --> 00:00:47 What do you get to share?
00:00:47 --> 00:00:48 What do you get to teach
00:00:48 --> 00:00:49 people this year at AOMT?
00:00:49 --> 00:00:50 And we'll learn a little bit.
00:00:50 --> 00:00:51 This is the tease before the tease.
00:00:53 --> 00:00:54 Yeah, good question.
00:00:54 --> 00:00:56 So I will be presenting with
00:00:56 --> 00:00:56 two of my colleagues.
00:00:57 --> 00:00:59 on an out-of-the-box
00:00:59 --> 00:01:00 approach to regional
00:01:00 --> 00:01:02 interdependence specific to
00:01:02 --> 00:01:03 the lower extremity.
00:01:03 --> 00:01:06 So the title of our presentation,
00:01:06 --> 00:01:07 it's going to be two parts.
00:01:08 --> 00:01:09 The first part is going to
00:01:09 --> 00:01:11 be talking about a top-down approach,
00:01:11 --> 00:01:12 and the second part will be
00:01:12 --> 00:01:14 talking about a bottom-up approach,
00:01:15 --> 00:01:15 and in both,
00:01:15 --> 00:01:17 we'll be giving case scenarios,
00:01:17 --> 00:01:19 showing videos of gaits
00:01:20 --> 00:01:21 from different patient presentations,
00:01:21 --> 00:01:23 and then, you know, giving some
00:01:23 --> 00:01:24 attendees some different
00:01:24 --> 00:01:26 ideas of techniques they
00:01:26 --> 00:01:28 can use to treat those deviations.
00:01:28 --> 00:01:29 You've got to mention your
00:01:29 --> 00:01:31 co-presenters or they would be,
00:01:31 --> 00:01:32 they would feel left out.
00:01:32 --> 00:01:32 They're not here right now,
00:01:32 --> 00:01:33 but who are they?
00:01:33 --> 00:01:34 Yeah, they would.
00:01:34 --> 00:01:36 So it's Dr. Laura Baum and
00:01:36 --> 00:01:37 also Dr. Mary Beth Geiser.
00:01:38 --> 00:01:38 Now you're good.
00:01:38 --> 00:01:39 You've got them in there.
00:01:39 --> 00:01:40 You've snuck them in.
00:01:40 --> 00:01:41 We got them in.
00:01:42 --> 00:01:43 So let's give a little tease.
00:01:43 --> 00:01:44 The presentation with your
00:01:44 --> 00:01:45 co-presenters is going to
00:01:45 --> 00:01:47 be a little more robust and
00:01:47 --> 00:01:48 that's how we get you, right?
00:01:48 --> 00:01:48 We're going to teach you
00:01:48 --> 00:01:49 right now while you listen
00:01:49 --> 00:01:50 on the podcast or watch
00:01:50 --> 00:01:51 them on the video.
00:01:52 --> 00:01:53 But you're going to learn
00:01:53 --> 00:01:54 more when you come in person.
00:01:55 --> 00:01:56 And I've been to the AM conference,
00:01:56 --> 00:01:57 pretty robust.
00:01:57 --> 00:01:59 So go to the website link in
00:01:59 --> 00:02:00 the show notes in the bio
00:02:00 --> 00:02:01 to to find out more.
00:02:02 --> 00:02:03 But let's start with this.
00:02:03 --> 00:02:04 Help us understand the
00:02:04 --> 00:02:06 importance of gait analysis
00:02:06 --> 00:02:07 and physical therapy.
00:02:07 --> 00:02:07 You know,
00:02:07 --> 00:02:08 how does it impact patient outcome?
00:02:08 --> 00:02:09 Like what's the outcome?
00:02:09 --> 00:02:10 Patient outcomes,
00:02:11 --> 00:02:12 particularly in your area,
00:02:12 --> 00:02:13 orthopedics and lower
00:02:13 --> 00:02:15 extremity amputee care.
00:02:16 --> 00:02:17 Yeah,
00:02:17 --> 00:02:19 so gait analysis is an extremely
00:02:19 --> 00:02:20 important tool in our
00:02:20 --> 00:02:22 toolbox as physical therapists.
00:02:22 --> 00:02:25 And this is certainly true in orthopedic,
00:02:25 --> 00:02:28 but other areas of PT practice as well.
00:02:28 --> 00:02:29 You know,
00:02:29 --> 00:02:31 we use it as an assessment in
00:02:31 --> 00:02:32 terms of how does someone
00:02:33 --> 00:02:35 use their range of motion, their strength,
00:02:35 --> 00:02:36 their flexibility, right,
00:02:36 --> 00:02:37 all those good things,
00:02:38 --> 00:02:39 and execute a very
00:02:39 --> 00:02:41 necessary functional task.
00:02:41 --> 00:02:43 And I think sometimes we
00:02:43 --> 00:02:44 forget about movement
00:02:44 --> 00:02:45 observation as an
00:02:45 --> 00:02:47 assessment tool that
00:02:48 --> 00:02:48 actually provides more
00:02:49 --> 00:02:50 meaningful information for
00:02:50 --> 00:02:52 me than a single special
00:02:52 --> 00:02:54 test when it comes to assessment.
00:02:55 --> 00:02:56 As for the patient outcomes
00:02:56 --> 00:02:58 part of your question, you know,
00:02:58 --> 00:02:59 I can't tell you how many
00:02:59 --> 00:03:00 times a week patients tell
00:03:00 --> 00:03:02 me their goal for therapy
00:03:02 --> 00:03:03 is to walk again.
00:03:04 --> 00:03:06 Whether it's they want to walk pain-free,
00:03:06 --> 00:03:07 they want to walk further,
00:03:07 --> 00:03:08 they want to walk faster, right,
00:03:09 --> 00:03:10 or walk periods.
00:03:11 --> 00:03:12 And what better way to help
00:03:12 --> 00:03:14 them meet that goal than to
00:03:14 --> 00:03:15 provide specialized
00:03:15 --> 00:03:17 intervention based on the way they walk?
00:03:18 --> 00:03:19 And I think that's
00:03:19 --> 00:03:20 especially true when you're
00:03:20 --> 00:03:21 working with individuals
00:03:21 --> 00:03:22 following limb loss,
00:03:23 --> 00:03:24 but the added layer is
00:03:24 --> 00:03:26 figuring out whether their
00:03:26 --> 00:03:27 gait deviations are driven
00:03:28 --> 00:03:30 by musculoskeletal impairments,
00:03:30 --> 00:03:32 prosthetic alignment issues,
00:03:32 --> 00:03:33 or a combination of the two.
00:03:34 --> 00:03:35 All right, so we mentioned top-down,
00:03:35 --> 00:03:37 bottom-up, right?
00:03:37 --> 00:03:38 Burning the candle at both ends.
00:03:39 --> 00:03:40 Go a little deeper, elaborate.
00:03:41 --> 00:03:41 Top-down,
00:03:41 --> 00:03:43 bottom-up approaches you mentioned.
00:03:44 --> 00:03:45 How do those strategies
00:03:45 --> 00:03:47 differ besides the top and bottom,
00:03:47 --> 00:03:48 obviously?
00:03:48 --> 00:03:49 And in what situations would
00:03:49 --> 00:03:51 each be most effective?
00:03:52 --> 00:03:52 Yeah,
00:03:52 --> 00:03:54 so both strategies are based in
00:03:54 --> 00:03:56 concepts of regional interdependence,
00:03:57 --> 00:03:57 right?
00:03:57 --> 00:03:59 And so I think in school we've all learned,
00:03:59 --> 00:04:00 or in the clinic,
00:04:00 --> 00:04:01 we have all learned some element of
00:04:02 --> 00:04:02 You know,
00:04:02 --> 00:04:04 your knee pain may be related to
00:04:04 --> 00:04:07 impairments at the hip or, you know,
00:04:07 --> 00:04:09 foot and ankle pain might
00:04:09 --> 00:04:11 be related to impairments up at the hip.
00:04:12 --> 00:04:12 Our presentation is just
00:04:12 --> 00:04:13 going to be providing a
00:04:13 --> 00:04:15 more systematic way of
00:04:15 --> 00:04:17 looking at that and treating that.
00:04:17 --> 00:04:19 So, for a top-down approach, you know,
00:04:19 --> 00:04:20 that term is going to be
00:04:20 --> 00:04:21 referring to starting at
00:04:21 --> 00:04:22 the hip and then
00:04:22 --> 00:04:23 systematically going down
00:04:23 --> 00:04:25 to the knee and then this
00:04:25 --> 00:04:26 to the foot and ankle.
00:04:26 --> 00:04:28 And bottom up will just be vice versa.
00:04:28 --> 00:04:29 Start at the foot and ankle,
00:04:29 --> 00:04:30 then work your way more
00:04:30 --> 00:04:33 proximally up the kinetic chain.
00:04:33 --> 00:04:35 For simplicity purposes, right,
00:04:35 --> 00:04:36 this is a teaser.
00:04:37 --> 00:04:38 You might choose a top-down
00:04:38 --> 00:04:40 approach when you're
00:04:40 --> 00:04:41 treating an individual who
00:04:41 --> 00:04:44 has low back pain, hip pain, pelvic pain,
00:04:44 --> 00:04:45 right?
00:04:45 --> 00:04:47 Because looking at the hip more proximally,
00:04:47 --> 00:04:49 that might be the most plausible,
00:04:49 --> 00:04:50 you know,
00:04:50 --> 00:04:52 explanation for their symptoms
00:04:52 --> 00:04:53 or their gait deviations.
00:04:54 --> 00:04:55 but maybe the patient isn't
00:04:55 --> 00:04:57 improving the way you thought they would,
00:04:58 --> 00:05:00 or their gait deviation isn't changing.
00:05:00 --> 00:05:01 And then you could start to consider,
00:05:01 --> 00:05:02 following our approach,
00:05:03 --> 00:05:04 looking at the knee and
00:05:04 --> 00:05:05 then the foot and the ankle.
00:05:05 --> 00:05:08 As for bottom-up, you know, same idea,
00:05:08 --> 00:05:09 it might be most relevant
00:05:09 --> 00:05:11 for a patient experiencing
00:05:11 --> 00:05:12 foot and ankle pain, right?
00:05:12 --> 00:05:13 That kind of makes sense to us.
00:05:14 --> 00:05:15 But kind of as I was mentioning,
00:05:15 --> 00:05:16 if they don't respond to
00:05:16 --> 00:05:17 the way you're expecting them to,
00:05:18 --> 00:05:18 you have to start
00:05:18 --> 00:05:20 considering contributors more proximally,
00:05:21 --> 00:05:21 because the foot and ankle
00:05:21 --> 00:05:23 is really just the first contact point
00:05:24 --> 00:05:26 on the ground in the gait cycle.
00:05:26 --> 00:05:27 And then a lot happened from there.
00:05:27 --> 00:05:28 All right.
00:05:28 --> 00:05:28 Well,
00:05:28 --> 00:05:30 we've got to bring in some sort of
00:05:30 --> 00:05:32 manual therapy technique, right?
00:05:32 --> 00:05:33 Because you're presenting it
00:05:33 --> 00:05:36 and that's sort of a common thread.
00:05:36 --> 00:05:39 So help us understand,
00:05:39 --> 00:05:40 maybe give us an example of
00:05:40 --> 00:05:41 a few techniques that you
00:05:41 --> 00:05:42 might use and explain how
00:05:42 --> 00:05:44 they address gait-related
00:05:44 --> 00:05:46 problems specifically.
00:05:47 --> 00:05:47 Sure.
00:05:47 --> 00:05:48 So let's start at the head.
00:05:49 --> 00:05:50 So let's say you see a
00:05:50 --> 00:05:52 patient who is having a
00:05:52 --> 00:05:54 really short stride length,
00:05:54 --> 00:05:56 meaning they're not getting
00:05:56 --> 00:05:57 into full hip extension at
00:05:58 --> 00:06:00 that terminal stance phase of gait.
00:06:01 --> 00:06:03 Maybe you try going to a
00:06:03 --> 00:06:05 prone P to A or posterior
00:06:05 --> 00:06:07 to anterior mobilization to
00:06:07 --> 00:06:09 the hip to improve extension.
00:06:10 --> 00:06:11 And I think we would maybe
00:06:11 --> 00:06:12 all logically start there.
00:06:13 --> 00:06:14 Also looking at, you know,
00:06:15 --> 00:06:15 I know you asked about
00:06:15 --> 00:06:16 manual therapy techniques,
00:06:16 --> 00:06:17 but also looking at hip
00:06:18 --> 00:06:19 flexor length and kind of
00:06:19 --> 00:06:20 other contributors to that
00:06:20 --> 00:06:21 limited mobility.
00:06:22 --> 00:06:23 But a more out-of-the-box
00:06:23 --> 00:06:25 approach to that specific
00:06:25 --> 00:06:27 gait deviation would be to
00:06:27 --> 00:06:28 maybe use the sideline
00:06:28 --> 00:06:30 lumbopelvic mobilization or
00:06:30 --> 00:06:32 even manipulation to build
00:06:32 --> 00:06:35 more anterior rotation of that innominate,
00:06:35 --> 00:06:36 which is a very necessary
00:06:37 --> 00:06:38 part of hip extension.
00:06:39 --> 00:06:40 So kind of thinking out of
00:06:40 --> 00:06:42 just that femoroacetabular joint.
00:06:44 --> 00:06:45 At the knee,
00:06:45 --> 00:06:47 a common deviation I see is
00:06:47 --> 00:06:49 patients remain in slight
00:06:49 --> 00:06:50 knee flexion throughout the
00:06:50 --> 00:06:52 entire gait cycle,
00:06:52 --> 00:06:53 which would be abnormal
00:06:53 --> 00:06:54 into stance phase.
00:06:54 --> 00:06:56 Very important that patients
00:06:56 --> 00:06:57 be able to access that
00:06:57 --> 00:06:59 terminal knee extension.
00:07:00 --> 00:07:01 And so I would start by
00:07:01 --> 00:07:03 assessing various accessory
00:07:03 --> 00:07:04 motion around the knee
00:07:05 --> 00:07:06 joint or the knee complex.
00:07:07 --> 00:07:09 But we have to think about, you know,
00:07:09 --> 00:07:10 not only a posterior glide
00:07:10 --> 00:07:12 of the femur on the tibia
00:07:12 --> 00:07:14 or an anterior glide of the
00:07:14 --> 00:07:15 tibia on the femur,
00:07:15 --> 00:07:17 but think about the screw
00:07:17 --> 00:07:18 home mechanism of the knee
00:07:18 --> 00:07:20 and that combination of
00:07:20 --> 00:07:22 that glide and rotation that happens,
00:07:23 --> 00:07:24 as well as that proximal
00:07:24 --> 00:07:26 tibiofibular joint, right?
00:07:26 --> 00:07:28 Is that joint moving as well?
00:07:29 --> 00:07:30 We could also consider doing
00:07:30 --> 00:07:32 some interventions for
00:07:32 --> 00:07:33 superior patellar glide.
00:07:34 --> 00:07:34 But we have to kind of
00:07:34 --> 00:07:36 figure out why isn't that
00:07:36 --> 00:07:38 patient able to access knee extension?
00:07:38 --> 00:07:39 Well, do they have it?
00:07:39 --> 00:07:41 And then are they able to access it?
00:07:42 --> 00:07:43 And, you know,
00:07:43 --> 00:07:44 our presentation
00:07:44 --> 00:07:45 particularly is going to be
00:07:45 --> 00:07:46 really incorporating a lot
00:07:46 --> 00:07:48 of themes from that screw
00:07:48 --> 00:07:49 home mechanism and more of
00:07:49 --> 00:07:51 those combined movement patterns.
00:07:53 --> 00:07:53 Next,
00:07:53 --> 00:07:55 kind of going down to the foot and ankle,
00:07:55 --> 00:07:57 the most common thing I see,
00:07:57 --> 00:07:58 and I'm sure other
00:07:58 --> 00:07:59 therapists when they hear
00:07:59 --> 00:08:00 this are going to be like, yeah, me too.
00:08:01 --> 00:08:03 is limited ankle dorsiflexion.
00:08:03 --> 00:08:04 That's, you know, by and large,
00:08:04 --> 00:08:06 the most common deviation
00:08:06 --> 00:08:07 at the foot and ankle.
00:08:07 --> 00:08:09 And so that might look like
00:08:09 --> 00:08:11 an early heel rise in gait,
00:08:11 --> 00:08:13 or they may externally
00:08:13 --> 00:08:14 rotate their foot that
00:08:14 --> 00:08:15 they're avoiding
00:08:15 --> 00:08:17 dorsiflexion and great toe
00:08:17 --> 00:08:19 extension and midfoot
00:08:19 --> 00:08:20 pronation altogether.
00:08:22 --> 00:08:23 We've all learned that
00:08:23 --> 00:08:25 talocral distraction manipulation.
00:08:25 --> 00:08:26 I also like to treat the
00:08:27 --> 00:08:28 subtalar joint for that
00:08:28 --> 00:08:29 with a similar technique,
00:08:29 --> 00:08:31 but just changing the
00:08:31 --> 00:08:33 pre-positioning of the foot
00:08:33 --> 00:08:35 and the ankle to bias one over the other.
00:08:35 --> 00:08:37 And then I like to follow
00:08:37 --> 00:08:39 that with a talonavicular
00:08:39 --> 00:08:40 joint treatment.
00:08:40 --> 00:08:41 So whether that's a
00:08:41 --> 00:08:43 mobilization or a manipulation,
00:08:43 --> 00:08:45 I typically treat that in
00:08:45 --> 00:08:47 prone because we know that
00:08:47 --> 00:08:49 dorsiflexion and pronation
00:08:49 --> 00:08:50 are coupled movements.
00:08:51 --> 00:08:51 Right.
00:08:51 --> 00:08:52 Especially, you know,
00:08:52 --> 00:08:55 applicable to that stance phase of gait.
00:08:56 --> 00:08:58 And keep in mind that in mid stance,
00:08:58 --> 00:08:59 we also need controlled
00:08:59 --> 00:09:00 internal rotation at the hip.
00:09:00 --> 00:09:02 So going right back up the chain.
00:09:02 --> 00:09:02 Yeah.
00:09:03 --> 00:09:03 Bottom up, top down.
00:09:04 --> 00:09:06 Your presentation at the M
00:09:06 --> 00:09:07 Conference this year is
00:09:07 --> 00:09:08 going to emphasize the
00:09:08 --> 00:09:09 collaboration and
00:09:09 --> 00:09:10 synergistic movements
00:09:10 --> 00:09:12 within that lower extremity
00:09:12 --> 00:09:12 in the kinetic chain.
00:09:13 --> 00:09:14 How can physical therapists
00:09:14 --> 00:09:15 ensure that they're not
00:09:15 --> 00:09:16 missing critical links?
00:09:16 --> 00:09:17 PTs are always scared.
00:09:17 --> 00:09:18 What are we missing?
00:09:18 --> 00:09:20 Should we record it and have
00:09:20 --> 00:09:20 them do it again?
00:09:20 --> 00:09:21 So how can you make sure PTs
00:09:21 --> 00:09:22 ensure they're not missing
00:09:22 --> 00:09:23 critical links in the chain
00:09:23 --> 00:09:25 when assessing and treating
00:09:25 --> 00:09:25 their patients?
00:09:26 --> 00:09:27 Yeah, great question.
00:09:27 --> 00:09:29 I think the main message
00:09:29 --> 00:09:30 that we want to send with
00:09:30 --> 00:09:31 our presentation is
00:09:31 --> 00:09:32 consider impairments in
00:09:33 --> 00:09:34 other areas of the kinetic
00:09:34 --> 00:09:36 chain that might contribute
00:09:36 --> 00:09:37 to symptom development.
00:09:37 --> 00:09:40 I think in PT school or
00:09:40 --> 00:09:42 maybe in residencies or if
00:09:42 --> 00:09:43 you pursue fellowship,
00:09:43 --> 00:09:45 you really get hammered
00:09:45 --> 00:09:46 home with more of that look
00:09:46 --> 00:09:48 elsewhere approach.
00:09:48 --> 00:09:49 But it's easy to get into
00:09:49 --> 00:09:51 the clinic and start seeing
00:09:51 --> 00:09:52 patients and get into a
00:09:52 --> 00:09:53 rhythm and you kind of
00:09:53 --> 00:09:54 start to forget about
00:09:54 --> 00:09:56 things that are outside of that patient's
00:09:56 --> 00:09:58 pain zone, right,
00:09:58 --> 00:10:00 or their exact location of symptoms.
00:10:01 --> 00:10:03 But the human body is complex, right?
00:10:03 --> 00:10:04 Gait is a complex movement
00:10:04 --> 00:10:05 and something that we're
00:10:05 --> 00:10:07 all doing every single day.
00:10:07 --> 00:10:08 You know,
00:10:08 --> 00:10:10 I would also argue that looking
00:10:10 --> 00:10:12 at some of the impairments outside of,
00:10:13 --> 00:10:13 you know,
00:10:13 --> 00:10:14 that exact area of pain could
00:10:15 --> 00:10:16 also explain ongoing or
00:10:16 --> 00:10:17 persistent symptoms.
00:10:18 --> 00:10:18 You know,
00:10:18 --> 00:10:19 maybe that is that missing link
00:10:19 --> 00:10:21 to why someone keeps coming
00:10:21 --> 00:10:22 back to you with the same
00:10:23 --> 00:10:24 symptoms once a year.
00:10:25 --> 00:10:25 right?
00:10:25 --> 00:10:26 Or maybe it's every two
00:10:26 --> 00:10:27 years or something like that.
00:10:27 --> 00:10:28 And, you know,
00:10:28 --> 00:10:30 we do have evidence support
00:10:30 --> 00:10:31 that when someone has
00:10:31 --> 00:10:32 experienced low back pain,
00:10:32 --> 00:10:33 they're at an increased
00:10:33 --> 00:10:35 risk for recurrent back
00:10:35 --> 00:10:36 pain again in the future.
00:10:36 --> 00:10:38 And so I would offer that if
00:10:38 --> 00:10:39 we begin to consider those
00:10:39 --> 00:10:41 other areas and think about, you know,
00:10:41 --> 00:10:43 how someone moves more generally,
00:10:43 --> 00:10:45 I think we might be able to
00:10:45 --> 00:10:46 decrease that risk and
00:10:46 --> 00:10:48 fully return people to function.
00:10:48 --> 00:10:51 I think it's also helpful to
00:10:51 --> 00:10:52 I think I may have mentioned this already,
00:10:52 --> 00:10:54 but when you get stuck with
00:10:54 --> 00:10:55 a patient and you're just like,
00:10:55 --> 00:10:56 I do not know what else to
00:10:56 --> 00:10:57 do for this person.
00:10:57 --> 00:10:59 I assessed their foot and ankle.
00:10:59 --> 00:11:01 I treated what I found and I
00:11:01 --> 00:11:03 don't understand why it's
00:11:03 --> 00:11:03 not getting better, right?
00:11:03 --> 00:11:05 We've all been there where
00:11:05 --> 00:11:07 we get frustrated and you
00:11:07 --> 00:11:08 run out of treatment ideas.
00:11:08 --> 00:11:09 And so I would say turn
00:11:09 --> 00:11:11 towards function and start
00:11:11 --> 00:11:12 to assess their gaze.
00:11:12 --> 00:11:14 And one way you can really
00:11:14 --> 00:11:14 make sure you're not
00:11:14 --> 00:11:16 missing more subtle
00:11:16 --> 00:11:18 deviations or asymmetries
00:11:18 --> 00:11:20 is to use video analysis.
00:11:20 --> 00:11:20 You know,
00:11:20 --> 00:11:22 there's a lot of really great
00:11:22 --> 00:11:23 apps out there that are
00:11:23 --> 00:11:25 totally free or just the
00:11:25 --> 00:11:27 iPhone camera has that slow-mo feature.
00:11:27 --> 00:11:29 And sometimes that gives me
00:11:29 --> 00:11:31 enough of a brief look and
00:11:31 --> 00:11:33 I'll even record it on the
00:11:33 --> 00:11:34 patient's phone, right?
00:11:34 --> 00:11:35 So they can see it.
00:11:35 --> 00:11:37 And then you get that buy-in
00:11:37 --> 00:11:38 and you can record it again
00:11:38 --> 00:11:39 on their phone a few months
00:11:39 --> 00:11:41 from now and they can
00:11:41 --> 00:11:42 compare their progress.
00:11:42 --> 00:11:44 So I've had good success with that.
00:11:44 --> 00:11:45 And also,
00:11:45 --> 00:11:46 if you do record on your own phone,
00:11:46 --> 00:11:48 just remember with HIPAA to
00:11:48 --> 00:11:49 delete it because
00:11:49 --> 00:11:50 and not keep it on your phone.
00:11:51 --> 00:11:53 But video analysis can be super helpful.
00:11:53 --> 00:11:53 Yeah.
00:11:53 --> 00:11:54 All right.
00:11:54 --> 00:11:56 Well, physical therapists love examples.
00:11:56 --> 00:11:58 We love the case.
00:11:58 --> 00:11:59 I was working with this person.
00:11:59 --> 00:12:02 I'd like to share.
00:12:02 --> 00:12:03 Give us a real-world case
00:12:03 --> 00:12:04 study or example where the
00:12:04 --> 00:12:05 application of the
00:12:05 --> 00:12:06 techniques you just talked
00:12:06 --> 00:12:08 about are going to help
00:12:08 --> 00:12:09 improve a patient's gait.
00:12:09 --> 00:12:10 And what were the key
00:12:10 --> 00:12:11 takeaways from that
00:12:11 --> 00:12:12 particular experience?
00:12:13 --> 00:12:13 Yeah,
00:12:14 --> 00:12:15 so the case that kind of stands out
00:12:15 --> 00:12:16 the most to me where this
00:12:16 --> 00:12:18 has happened recently is I
00:12:18 --> 00:12:19 had a patient with a really
00:12:19 --> 00:12:21 complicated orthopedic history,
00:12:21 --> 00:12:22 relatively young guy.
00:12:23 --> 00:12:25 He fractured both of his
00:12:25 --> 00:12:27 tali with a relatively low
00:12:28 --> 00:12:29 impact incident.
00:12:29 --> 00:12:31 He brought his dirt bike to a stop,
00:12:31 --> 00:12:32 put his feet on the ground
00:12:33 --> 00:12:35 and broke both of his tali,
00:12:35 --> 00:12:37 which is kind of crazy.
00:12:37 --> 00:12:39 So he had a surgery.
00:12:39 --> 00:12:41 They did an open reduction
00:12:41 --> 00:12:42 internal fixation and
00:12:42 --> 00:12:43 For both of them,
00:12:44 --> 00:12:45 long journey in recovery.
00:12:45 --> 00:12:47 I did not treat him after
00:12:47 --> 00:12:48 that original surgery.
00:12:49 --> 00:12:49 But that surgery was
00:12:49 --> 00:12:51 successful for his left ankle.
00:12:51 --> 00:12:53 His right ankle, on the other hand,
00:12:53 --> 00:12:55 continued to have pain and
00:12:55 --> 00:12:56 just ongoing mobility
00:12:56 --> 00:12:58 limitations and felt super stiff.
00:12:59 --> 00:13:00 So he went back to the
00:13:00 --> 00:13:02 surgeon and they decided to
00:13:02 --> 00:13:03 take the hardware out and
00:13:03 --> 00:13:06 see if that could help with
00:13:06 --> 00:13:07 his pain and his symptoms.
00:13:08 --> 00:13:09 And so that's when he was
00:13:09 --> 00:13:09 then referred to me,
00:13:10 --> 00:13:11 was after the hardware was taken out.
00:13:12 --> 00:13:14 So when I looked at his gait
00:13:14 --> 00:13:15 during the evaluation,
00:13:15 --> 00:13:17 I noted a few different things.
00:13:17 --> 00:13:20 So I saw that he had a
00:13:20 --> 00:13:21 really early heel rise.
00:13:21 --> 00:13:22 So kind of showing some of
00:13:22 --> 00:13:24 those signs of that lack of
00:13:24 --> 00:13:25 ankle dorsiflexion.
00:13:25 --> 00:13:27 He had decreased midfoot
00:13:27 --> 00:13:29 pronation in that stance phase,
00:13:30 --> 00:13:31 a lack of terminal knee extension, right?
00:13:31 --> 00:13:33 All of those movements go together.
00:13:33 --> 00:13:34 So that does make sense.
00:13:35 --> 00:13:36 And then he also had that
00:13:36 --> 00:13:37 decreased stride length
00:13:37 --> 00:13:38 that I was talking about,
00:13:38 --> 00:13:40 a lack of hip extension.
00:13:41 --> 00:13:42 So in my examination,
00:13:43 --> 00:13:44 obviously I'm going to look
00:13:44 --> 00:13:46 at range of motion, strength, right,
00:13:46 --> 00:13:47 all those bread and butter
00:13:47 --> 00:13:50 things that we all know and love in PT.
00:13:51 --> 00:13:52 And in doing so, I cleared his hip.
00:13:53 --> 00:13:55 So I think most people, when they,
00:13:55 --> 00:13:55 you know,
00:13:55 --> 00:13:56 would get that referral for
00:13:56 --> 00:13:58 someone after hardware
00:13:58 --> 00:13:59 removal in the ankle,
00:13:59 --> 00:14:00 they may not go look at the
00:14:00 --> 00:14:01 hip on day one.
00:14:02 --> 00:14:03 Um, but I did right.
00:14:03 --> 00:14:04 Just to clear it.
00:14:04 --> 00:14:05 And so I didn't find any
00:14:05 --> 00:14:07 substantial impairments at the hip.
00:14:07 --> 00:14:09 And so that kind of led me towards,
00:14:10 --> 00:14:11 I think this is really more
00:14:11 --> 00:14:12 foot and ankle driven,
00:14:12 --> 00:14:13 which is more kind of
00:14:13 --> 00:14:14 traditional based on the
00:14:14 --> 00:14:15 referring diagnosis.
00:14:16 --> 00:14:16 Right.
00:14:16 --> 00:14:20 Um, so when I looked at his knee,
00:14:20 --> 00:14:22 I actually found he had a
00:14:22 --> 00:14:23 lot of hypo mobility or
00:14:24 --> 00:14:25 decreased movement at that
00:14:25 --> 00:14:27 proximal tibiofibular joint.
00:14:28 --> 00:14:28 which again,
00:14:29 --> 00:14:29 makes sense when you're
00:14:29 --> 00:14:31 talking about the ankle complex,
00:14:31 --> 00:14:32 but might not be something
00:14:32 --> 00:14:34 you would look at with every, you know,
00:14:34 --> 00:14:35 post-op foot and ankle patient.
00:14:36 --> 00:14:38 So I treated that joint with
00:14:38 --> 00:14:40 manipulation a few times,
00:14:40 --> 00:14:41 a couple sessions,
00:14:41 --> 00:14:42 and that actually cleared
00:14:42 --> 00:14:43 that up pretty quickly.
00:14:43 --> 00:14:45 And that restored his knee extension.
00:14:45 --> 00:14:46 So that was pretty cool.
00:14:47 --> 00:14:48 And then I focused most of
00:14:48 --> 00:14:50 my time and energy on those
00:14:50 --> 00:14:51 impairments in the foot and ankle.
00:14:51 --> 00:14:53 So I did a lot of treatment to his
00:14:53 --> 00:14:55 talocrural joint,
00:14:55 --> 00:14:57 the distal tibiofibular joint,
00:14:57 --> 00:14:58 subtalar joint,
00:14:58 --> 00:15:00 and then his talonavicular
00:15:00 --> 00:15:02 joint was just super locked up.
00:15:02 --> 00:15:03 Makes a lot of sense with
00:15:03 --> 00:15:05 the injury that he had,
00:15:05 --> 00:15:06 but I actually think
00:15:06 --> 00:15:07 treating his talonavicular
00:15:07 --> 00:15:09 joint restored more of a
00:15:09 --> 00:15:11 normal gait pattern than
00:15:11 --> 00:15:12 even treating talocrural,
00:15:13 --> 00:15:14 which may surprise some people,
00:15:14 --> 00:15:16 certainly surprised me in this case.
00:15:17 --> 00:15:20 He benefited from treatment of both areas,
00:15:20 --> 00:15:21 but ultimately,
00:15:22 --> 00:15:23 That approach was successful
00:15:24 --> 00:15:26 in minimizing his gait deviation.
00:15:26 --> 00:15:29 So the time to his heel rise was delayed.
00:15:29 --> 00:15:31 It's still not perfect if I'm being picky,
00:15:32 --> 00:15:33 but he got back full
00:15:33 --> 00:15:34 pronation in stance phase
00:15:34 --> 00:15:36 and his drive length is symmetrical.
00:15:36 --> 00:15:40 So to me, that's a huge win in terms of,
00:15:40 --> 00:15:41 you know,
00:15:41 --> 00:15:42 kind of where's his plan of care now.
00:15:43 --> 00:15:45 His dorsiflexion is still a bit limited,
00:15:45 --> 00:15:48 but in communication with his surgeon and
00:15:48 --> 00:15:49 She's kind of said she
00:15:49 --> 00:15:50 doesn't think further
00:15:50 --> 00:15:52 improvement is really possible.
00:15:52 --> 00:15:53 He's certainly developing
00:15:53 --> 00:15:54 some of that early
00:15:54 --> 00:15:56 post-traumatic arthritis.
00:15:56 --> 00:15:57 So we're really in a
00:15:57 --> 00:15:59 maintenance phase of care now,
00:15:59 --> 00:16:00 transitioning towards
00:16:00 --> 00:16:02 independent management with
00:16:02 --> 00:16:03 a gym program.
00:16:03 --> 00:16:03 He does a lot of
00:16:04 --> 00:16:06 self-mobilizations at home,
00:16:06 --> 00:16:07 which has helped us get a
00:16:07 --> 00:16:08 lot more carryover.
00:16:09 --> 00:16:11 And a lot of corrective exercises, right?
00:16:11 --> 00:16:12 This is certainly a manual
00:16:12 --> 00:16:13 therapy conference,
00:16:13 --> 00:16:15 but shameless plug for
00:16:15 --> 00:16:16 corrective exercise, right?
00:16:17 --> 00:16:18 You have to do that to get
00:16:18 --> 00:16:19 those corrections to stick.
00:16:20 --> 00:16:20 And for him,
00:16:20 --> 00:16:23 that's been a huge component as well.
00:16:24 --> 00:16:24 So we're really just trying
00:16:24 --> 00:16:26 to optimize things as much
00:16:26 --> 00:16:29 as we can and prolong time
00:16:29 --> 00:16:30 to another potential surgery.
00:16:31 --> 00:16:32 That's great.
00:16:32 --> 00:16:33 I like how you told that in the story.
00:16:33 --> 00:16:35 A lot of takeaways from that.
00:16:36 --> 00:16:38 Most importantly for me is I
00:16:38 --> 00:16:40 now know what the plural of talus is.
00:16:40 --> 00:16:41 Yeah, I don't know.
00:16:41 --> 00:16:42 I'm hoping I got that right.
00:16:44 --> 00:16:46 I didn't take Latin in high school.
00:16:46 --> 00:16:48 I think you said it on the podcast.
00:16:48 --> 00:16:49 And since it's recorded,
00:16:49 --> 00:16:51 no one can change it.
00:16:51 --> 00:16:52 Yeah, there we go.
00:16:52 --> 00:16:53 And if they're going to confront you,
00:16:53 --> 00:16:54 it's going to be when you
00:16:54 --> 00:16:55 walk off stage at the AM
00:16:55 --> 00:16:56 conference this year.
00:16:57 --> 00:16:58 And we had a really fruitful
00:16:58 --> 00:16:59 discussion about the plural
00:16:59 --> 00:17:00 form of talus.
00:17:01 --> 00:17:02 That's the thing to have
00:17:02 --> 00:17:04 over a drink in the networking hour.
00:17:04 --> 00:17:06 It's my suggestion for that.
00:17:07 --> 00:17:07 Kelly,
00:17:07 --> 00:17:08 last thing we do on the show is
00:17:09 --> 00:17:09 final thoughts.
00:17:09 --> 00:17:10 Is there anything you'd want
00:17:10 --> 00:17:12 to sort of leave with the audience?
00:17:12 --> 00:17:12 This is your chance for a
00:17:13 --> 00:17:15 plug to be there for your
00:17:15 --> 00:17:16 presentation in person.
00:17:16 --> 00:17:17 But what would you want to
00:17:17 --> 00:17:18 leave with the audience of
00:17:18 --> 00:17:19 your colleagues today?
00:17:20 --> 00:17:21 Yeah, sure.
00:17:21 --> 00:17:22 I would say just a message
00:17:22 --> 00:17:24 to continue to look above
00:17:24 --> 00:17:26 and below the area of the
00:17:26 --> 00:17:27 patient's pain involvement.
00:17:27 --> 00:17:29 Think about them as in their
00:17:29 --> 00:17:31 movement as more generally
00:17:31 --> 00:17:32 as a human being, right?
00:17:32 --> 00:17:34 What do they need to execute
00:17:34 --> 00:17:34 the task that they're
00:17:34 --> 00:17:35 having trouble with?
00:17:35 --> 00:17:37 And we could even go on and
00:17:37 --> 00:17:38 on and on about into the
00:17:38 --> 00:17:41 trunk and mobility limitations there.
00:17:41 --> 00:17:42 But I think that's really
00:17:42 --> 00:17:43 the take home message.
00:17:44 --> 00:17:45 And then obviously have to say,
00:17:45 --> 00:17:47 come to the presentation to
00:17:47 --> 00:17:48 learn more techniques.
00:17:49 --> 00:17:50 And we're going to be
00:17:50 --> 00:17:51 creating a video gallery
00:17:51 --> 00:17:52 and a private YouTube channel
00:17:53 --> 00:17:54 that people can take with them.
00:17:54 --> 00:17:55 Cause I don't know about you,
00:17:55 --> 00:17:56 but sometimes I go to these
00:17:56 --> 00:17:57 great courses or
00:17:57 --> 00:17:59 conferences and in the moment I'm like,
00:17:59 --> 00:18:01 I'm totally going to remember this.
00:18:01 --> 00:18:02 And I don't, right.
00:18:03 --> 00:18:03 You know,
00:18:03 --> 00:18:04 you get back to clinic and you're like,
00:18:04 --> 00:18:06 how, where were their hands again?
00:18:06 --> 00:18:06 And you know,
00:18:06 --> 00:18:07 everyone's trying to take
00:18:07 --> 00:18:08 videos on their cell phones,
00:18:08 --> 00:18:10 but you get someone else's
00:18:10 --> 00:18:11 cell phone and your view
00:18:11 --> 00:18:12 and it just doesn't work well.
00:18:12 --> 00:18:13 So we're going to actually
00:18:13 --> 00:18:14 create a video channel
00:18:14 --> 00:18:16 afterwards where people can
00:18:16 --> 00:18:17 go back and look at those
00:18:17 --> 00:18:18 techniques and hopefully
00:18:19 --> 00:18:20 use them more consistently
00:18:20 --> 00:18:22 and successfully in the clinics.
00:18:23 --> 00:18:23 That's what I like to hear.
00:18:24 --> 00:18:27 Kelly, I hope to see you in Orlando,
00:18:28 --> 00:18:29 maybe with Mickey Mouse or
00:18:29 --> 00:18:30 Minnie Mouse ears.
00:18:30 --> 00:18:31 You're so close in proximity.
00:18:31 --> 00:18:32 You've got to kind of touch
00:18:32 --> 00:18:33 on Disney for the day.
00:18:33 --> 00:18:34 But thanks so much for
00:18:34 --> 00:18:35 sharing what you'll be
00:18:35 --> 00:18:35 talking about with your
00:18:35 --> 00:18:38 colleagues this October with Amt.
00:18:38 --> 00:18:39 Yeah, thanks so much for having me.
00:18:41 --> 00:18:41 And that's it.
00:18:41 --> 00:18:42 Anything we didn't ask?
00:18:42 --> 00:18:43 Anything we, you know.
00:18:43 --> 00:18:46 No, that was easy peasy.