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Male Speaker: â is going to be Dr. Jeff Cusack. He is going to Walk on the Wild Side, Significance of Myofascia as a Component of Human Gait. So please welcome Dr. Jeff Cusack.
Jeff Cusack: Okay, just make sure it's â all right, good morning, and thank you. I assure you, we will not run one second over. Lunch is waiting for us and ultimately the afternoon scanning session. All right, so, I was not here Friday but after yesterday, we had a lot on biofilms, wound care products, surgery up the Ying-Yang this morning.
So as a change of pace, hopefully, letâs have a look at something a little bit more dynamic, something you need to be aware of in your practice, as I will explain. There are literally hundreds, if not thousands, of practitioners out there that are begging for referrals of competent podiatric physicians to help them in their practice of what is now being called spatial medicine. And it is the actual and, finally, integration of all of the disciplines that are responsible for movement of our patients.
Meaning, physicians and, of course, the orthopedists and podiatric docs, along with physiatry, chiropractic, physical therapy, and the new generation of the fitness trainers, Pilates instructors, all of whom have had a considerable amount of instruction as to the critical aspect that function of the foot plays in the overall function of those patients. And the point Iâm trying to get at is that, as we know, many of these folks that we see in our office for the manifestations of abnormal foot function ultimately requiring surgical correction as you just heard.
For the bunion deformities yesterday and the insensate patient with the collapse of the foot after the wound has broken down, which of course is nothing more â the wound being nothing more than a callous under a specific abnormal portion of the foot. So the point is, understand that you will hear more and more of this, and if you can develop an expertise or an appearance of this to these folks that are looking desperately for patients to refer to you ostensibly for foot orthotic control of that abnormally functioning foot, it can add a considerable niche to your practice.
So I do want to review some of the theories of gait that have been shoved down our throats for way too long and Iâll show you why we are moving in a different direction. Weâre going to talk about â this is the hot area now, the so-called myofascial meridian lines.
Weâre going to talk about tensegrity, and I will tell you a bit about it. And when you get the call inevitably, that word is inserted. Thatâs kind of the code to see if youâre up to speed on it. And of course, being a podiatric conference here, we have to finally leave you with some information that will bring you to the point where you can help these individuals in the practice.
You watch someone walk and for once, weâre not going to discuss, at least, for myself, an abnormal gait, which we often do, certainly when Iâm up on the podium here. You look at a well-constructed, functional human walking, and the different aspects of it, the reciprocity between the shoulder and the pelvic rotations. Youâve talked about it as being different than ataxic, steppage, shifting gait, and so on. Itâs an elegant gait. It certainly should be relaxed, unique. We know that, even in a pathological description of a patient.
Dick Schuster used to revel in the fact he could blindfold himself and no matter who walked up behind him, if he had heard you walk once, he would identify you 100% of the time by your particular gait. So we do know thereâs a uniqueness to it, but graceful, and I might add efficient. And that has been one of the things that have differentiated Homo sapiens from say, our Neanderthal ancestral creatures who were bigger and bulkier than we were. But theyâre not around. We are. We are designed for efficiency.
And the traditional model of a muscular dominant gait is so antiquated and just flies in the face of what we now know, and Iâll explain why. And you look at â and Iâm apologizing. I donât know why Mr. Laurel West â back up and go forward. There he goes.
Contrast, other creatures of bipedal locomotion. Different specie of penguins love to group using weight shift, wobbling back and forth, two right-handed upper creature penguin and the gorilloid gait.
Notice one thing thatâs lacking in the two right-handed creatures. There is a total rotation of the entire trunk. There is no disassociation between the pelvic and shoulder girdle, which is key to understanding now how we know gait functions. And of course, as I say, these fellows over here is a group using primarily lateral weight-shifting back and forth.
With apologies to our francophone friends in the audience, existential author and philosopher Jean Claude Sartre, I think itâs pronounced â again, I apologize. But again, the more we think we understand about how we walk, the less we understand how we walk.
It's confusing. And here's in part how this started. I did, which you told me not to. Sorry, I hit the wrong button.
We were taught and it is still taught and it is still the only way to introduce students to gross anatomy. What's called particulate, the parts anatomy, origin insertion, innovation action, origin insertion, innovation action.
And of course, we need to know on the surface, what is it that the quadricep muscle does in isolation before you can appreciate what it does in gait. But understand that approach is completely inadequate to try and explain what we now want to discuss as coordinated movement. The idea is the movement that's going to occur. Oops, here we go.
A little bit further and I know every one of us in this room, no matter what the age, we all started with Saunders and it was back, I think, around '56 with the 6 determinants. The purported goal of utilizing those 6 determinants was to minimalize the vertical displacement of the center of mass. The problem with it was, it was â it's been long since, kind of debunked in that if you minimalize â if you look to minimalize the vertical displacement of your center of mass. The only way you can achieve it is primarily knee flexion, which involves â and the ordinary amount of metabolic energy.
A little bit further down, Cavagna, we still use elements of his inverted pendulum theory. The foot becomes the pivotal point of rotation over which the trunk rotates. Elements of Cavagna's theory are still in play today.
David's little walking man model if â if you go to the YouTube and you'll see David Magee's walking man, little model using â but look up here in inclined planes. So David looking at the interaction of kinetic energy and gravitational pull on the incline.
But probably the most eloquent model, mid 80's, '86, '87 is Serge Gracovetsky up in Canada. His spinal engine model, another code word if you are contacted and that comes into the conversation, you need to be versed in this. Serge looked that and utilized the concept of what's called coupled movement to actually explain how the heck do we, when we are taught, when you walk, you internally rotate one side, the stance limb pronates, the swing limb advances forward. The questions Serge answered eloquently was, âHow the heck do you internally and externally rotate the pelvic structure?â Because when you look at the muscles that are actually physically, mechanically capable of doing it, are too darn small to initiate that kind of movement.
Coupled movement is how Lovett actually discovered â not discovered but described a scoliotic curvature. It's a physical property that engineers use and it's simply that when you have a lateral band in the presence of a kink in the rod, in this case a lordosis in the lower spine, the third movement that always comes out is axial rotation. But, even Serge when you read his book and watch his videos, he still is lacking in trying to get the reciprocity between the shoulder and the pelvic girdles.
We all know Jacquelin Perry's work. Absolutely amazing work, prolific woman and her pivotal rockers, the inferior surface of the calcaneus being number one, ankle movement being the second pivotal rocker, followed by the most critical for us as podiatric physicians directly not to discard the other two, the MTPJ rotation.
But on the other hand, Jacquelin was also known for her description of the human creature as composed of â or comprised of a so-called passenger unit, which she often called that the HAT, head, arms, trunk, being passively carried by the lower extremity or what you call the locomotive system.
Two issues with it, it's a light dominant theory of gait, light dominant, and the implication is that the passenger unit supplied no direct input into the mechanics of the human gait. And they kind of set us off to decide for a bit.
Dr. Frykberg, when we had that MIS lecture yesterday and if you â they were added. It was kind of interesting. I forgot exactly what Bob had referred to but again, this concept of everything new being old once again, we're going to go way old on this. And we're actually going to go back and look at old Isaac here, sitting here getting his head bumped by an apple. But the relationship between gravity and motion, you cannot deny the fact that we function in a gravitational field. And it can destroy us or you can utilize it. And there is a way that you can use it in a positive manner.
Hooke is another scientist whose spring elastic discovery and the relationship again of tension, in gravity formed together, the basis of what is now being discussed in these terms. Gait is using â and I'll go over this in a second, but human gait is actually using gravity to stretch and release very critical aspects of the human body, specifically these myofascial meridian lines, which we're going to get to in a second.
In a way that if you release them at the right time and place, you can actually create what is being described as, as close to free energy, a free ride as you can possibly get. Okay. Again, it's almost what will give us the spring to our gait so to speak.
Here's one of the problems up to now. The way fascia has been described anatomically, we were taught in cadaver lab and so on, in much the same way as the muscles were particularly parts, okay. It is a fabric that holds us together, but it's this traditional understanding it, had it as being this isolated structures, thoracolumbar fascia line and so on. And again, it's probably because of the way that the technique, the dissection techniques reveal these different pieces of very critical anatomy. Because when you open these specimens up you, you do destroy these connections between point A and point Z on the human body.
Any of you that have experienced the pleasure, ha ha, of a roughing session, as vows by old Ida herself here, know what I am speaking about. It is probably one of the most painful fascia releasing techniques that are out there and will remain so.
However, old Ida, in her brilliance, and if you look at her and if you want to get an essence of this woman, just Google Ida Rolf quotes and you'll see her approach to human creatures.
She recognized two things. One, the presence of these long fascial connections across the entire body. The impact of gravitational field on this human creature. And the critical fact that these facial lines must be preserved in order to affect normal muscle function.
One of her other philosophies is to treat the human specimen as an onion. You peel it back and you work from the outside in. It's another quote that she's famous for. Always work from the outside in. The ultimate goal being find and release these adhesions between these long meridian lines that are somehow inhibiting movement and/or causing such dysfunction that it results in pain.
Move it forward to the mid-90s and this is the fellow right now that is probably going to be most responsible for dragging us whether we want to or not. I suggest you jump on his anatomy train right now. As I said, there are people begging for us to see their patients.
Tom Myers taught anatomy at the Rolf Institute for many, many years. And he developed the Anatomy Trains. And I'll, at the end, explain where you can get at some of this information. It was a game he set up for the students as they performed their dissections to help them understand these 12 meridians. And I'll just list them in a second for you.
However, what Tom reiterated from what Dr. Rolf had come up with was that these long meridian lines not only linked these muscles together, but in such a manner, it connects the upper and lower extremity, number one. And number two, connects them in many of the lines contralaterally.
And in this particular example, notice the gluteal through the thoracolumbar fascia ultimately ties in with the latissimus muscle which, again, ties into the left humeral area. There's your connection between the lower right and the upper left extremity.
And before I lose you entirely and say, "What the hell does this matter to me? What do we care about?" here are the lines.
There are 12 of them and the one that's of most interest to us podiatrically is the so-called spiral line which I've indicated. There's a left and a right. But again, it's that contralateral cross that makes all the difference in the world for these patients.
I told you this is a code word. You can jot it down if you wish and be ready because you will get questioned. It's like the code. If you don't know what tensegrity is, they'll just hang up and go to the next individual.
You Google tensegrity, inevitably, this gentleman is going to pop up, old Buckminster Fuller. How you combine being a philosopher with an architect, I have no idea, but that's an interesting combination. He is both. And many of his sculptors have this sort of appearance. He combined the words "tension" and "integrity" or what he calls "floating compression" in his architectural designs. He looks differently at constructing buildings, if you will, or sculptors.
It's based on â he uses component struts in compression, but the key to understanding tensegrity is it's inside a network that is under constant tension. So if I just back up one, you look at some of his sculptors, on the surface, all of these bars are being suspended within a network, in this case of a steel cable. All right.
So Myers came along and said, "Here's â this is how you need to view the human body." The bones and the muscles are literally contained within this net of fascia which is then placed under constant tension. Everything floats.
So now, what I'm going to show you is the fact that when you work within a gravitational field, remember, gravity is always inducing flexion to the ground. And when you look at your lower extremity joints, they are referred to as folding joints.
When you jump off â if I were to jump off this platform and land with my knees extended, the shock wave would probably be felt on the tenth floor. The instinct is, as I land to flex, to knees. So gravity is tending to pound us down to the floor.
I will show you how, as you move forward, this two â these two combinations, when things work well, in parts, almost this constant ability to store and release energy not from muscular tissue even isometrically or eccentrically loaded, but from the connecting fascial bands. This is how you need to look at how a human functions.
As you advance a leg through the swing phase, the stance limb is akin to pulling this arrow back on this bow and arrow here. You're pulling back tension. And literally, if the timing is right and you release it at the right time, this is all being done primarily through these bands of fascia, these meridian lines that I identified for you earlier. All 12 lines are in play when the individual is moving forward. You are storing elastic energy which is then released.
So the question then becomes, how do you stretch the fascia? Okay, very easy. First is the surface, which we take for granted, but if any of you have walked along the beach or â when I used to live in Northport, there was a high school that, in the fall, always brought the kids down for cross country to make them run on the sand with the thought being it would strengthen them up. And therefore, if you could run well on the sand, you'd run even better on a hard surface.
But when you try to walk distance on a soft beach, is it easy or hard?
It's actually quite hard and very, very fatiguing. Why? Because the sand is displacing from under your foot and not allowing you to take advantage of being able to store and release any effective energy, the reaction force of the ground.
Well, drop up or drop down, whatever your perspective, and let's think about a foot for a moment that is unstable past 50% of mid stance, which is when the heel is going to come up off the ground. That foot becomes sand. It is unable and incompetent to enable any significant passage of that centeredness. You cannot store and release energy, all right? So keep that in mind.
Terminal stance is where it's at. Down here, lower left, this little pole vaulter. I'll show you something in a second. But goes back to Cavagna's pivotal rotational point, the inverted pendulum, so to speak. The third rocker of peri, the MTPJs.
We just heard a lecture on forefoot surgery and of course, the underlying thought in all of our bunion corrections is hopefully, restoration of first MTPJ rotational movement. Why? Because not so much that it's going to reduce the pain the patient came to us with. Yes, we hope. But number two is this is what I'm trying for because drop down to the right-hand, lower right here, this gentleman as he's power walking and you watch very, very carefully how far out that left leg now and the right leg now swings, directly depends on how much movement he is able to achieve at the MTPJs. So any blockage of movement at the MTPJ is going to work its way up that entire lower extremity and shorten his step length. And I'll show you the consequence of that in a second.
All right. So terminal stance mobility is critical and we know in order to achieve that, you've got to work with a foot.
That's what makes the foot so interesting, at least as far as I'm concerned. It all hinges. It, meaning, distal function always hinges on all of the joints proximal to that MTPJ being in line. This Born to Walk book, I'll give you the source later, but it's a magnificent book you really should look at. And we know the consequence of a block of that first MTPJ, whether it's structural and/or more interesting to us is the functional block, the so-called functional hallux limitus.
Look at this poor slob as he tries to rotate and he falls laterally. But think for a minute. I mean, it is comical. The guy even missed the cushion there. But when you think about it, one of the most common ways to avoid MTPJ rotation, whether it's structural or the more interesting, the momentary lock, the so-called functional hallux limitus that Dananberg had us thinking about for many, many years now is what? You go lateral â Bojsen-Moller talked about high gear, low gear push-off.
High gear transfers, first MTPJ rotation is blocked. You have no choice. You go lateral through the lesser MTPJs. And of course, we've had a couple of lectures. There was one this morning on plantar plate and so on. The consequences of low gear push-off are well-known to every one of you in this audience.
All right. So we have a checklist that we need to consider. And that is, as I said, the beauty of the foot is that everything distal requires proximal consideration, let's put it that way. We always start with the subtalar joint because unless we're dealing with a minimalist runner, and thank God there are very few of them any longer where the forefoot is brought to the ground first, the foot was in fact designed to work proximal to distal. You've got to get the subtalar joints to act together, so to speak.
Certainly, congruency of those joints, whether it's bi or tri, to articulate has been shown to be a bit more favorable than leaving them non-congruent and, in particular, a pronated position. What it might take to do that, by and large, whether it's some modest varus posting of the hind foot, if you need to be more aggressive, we certainly have the methods now through the work that Kevin has done with his skive method. And/or a little more aggressive, be more aware of yourself when you go down the Blake inverted cast, they're very difficult to adjust if you over-correct.
Next is midtarsal joint. We're getting closer to the MTPJs. Subtalar, midtarsal joint because distal to the midtarsal joint lies that very critical first ray. It needs to be stabilized against that hind foot. And there are a couple of modifications as well that you can consider in your orthotic design if you sense that, in particular, the calcaneocuboid joint is not as stable as you would like, which in turn affects longus function. And one is that enhanced lateral pitch to the calcaneus. You can have your laboratory. Even a 2 millimeter enhancement of that inclination angle works wonders. If needed, if, again, it's an oblique dominant, correctible midtarsal dominant flatfoot.
LaPorta loves talking about the non-surgical evidence. He used that term probably four or five years ago, I assume, when he was at the Schuster seminar. You can extend the module of that orthosis long along the lateral column of the foot. A long low lateral flange provides significant transverse plane stability to the orthosis. And again, because of the axial rotations of the oblique axis off the sagittal and transverse planes, there's only a 5 degree difference. It's almost 1-to-1. So if you can block any portion of that abduction moment of the forefoot, it in turn will affect sagittal alignment.
And all of that in turn gives us what we're really looking for. Remember, how far out the swinging limb is able to â what's the word I'm looking for â to carry, which in turn is stretching those key meridian lines of fascia directly depends on arthrodial rotation at the first MTPJ. If this is blocked for whatever reason, that swinging limb is going to prematurely contact the ground. And I'll show you those consequences.
There are any number of these so-called motion enhancing platforms that Howard had started to develop and others had picked up on as well. Each laboratory seems to have a whole number of these, but all designed extensively to enable plantar flexion of the first ray along with a redirection toward the Bojsen-Moller high gear rotational movement, okay?
As I say here, there is a reality check, none the least of which is fascia unfortunately, like any other tissue in the human body, is responsive to the aging process. It does become more plastic as we age. Although, if you get into some of the work by Dr. Rolf, Ida, she felt very strongly that periodic, believe it or not, ballistic training is what she called it, ballistic training of fascia to regularly try to enhance the elastic ability of those tissues will prolong the function of its â of the fascia, all right.
In other words, you can sort of slow down the aging effect on the fascial planes. But again, reality is collagen changes in these tissues become more plastic than elastic. The problem is that you see old granny â grandpa here, the gait becomes more concentric in nature, more hip and knee flexion is required.
Pick it up, put it down, pick it up, put it down, pick it up, put it down.
Sarcopenia, age-related sarcopenia, the muscles begin to waste. There is not as much muscle power to walk this way, all of which causes these individuals to devolve into sedentary creatures. Autoimmune disease, of course. This one, Myers talks a lot about in his Trains book, and that is among all generations, because of the constant texting and whatever else they do on the phones, but the sedentary attitude that we have induced in all of our patient models now, has caused adaptive shortening of some of these key fascial planes, which are going to be a lot more difficult to mobilize for us, speaking podiatrically.
So just to summarize, as I say, we only had a half-hour but to give you a little taste, you be aware of this myofascia. It is a combination of forward movement using rotational forces of walking certainly within a gravitational field. I didn't know how else to phrase it, the Goldilocks effect. It's, as always, the right amount of everything.
I'll give you two reading assignments. This book here, Born to Walk, if you have any interest in this at all, this book will put you right where you need to be if you do get these phone calls from these individuals. Tom's books are phenomenal but they are high-end as far as your commitment to them. They are rather difficult to understand at first. James took his work and kind of digested it and integrated it. It is a phenomenal book. Both are, by the way.
And with that, I thank â
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