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Recording started. Fantastic. Right. So I'm going to be talking about muscle today. I'm trying with, because I don't get on that. Well, with Medal, I've got two screens so I can see you on there, so I can pick on, on the, all your people to ask questions on. So that's why I keep looking up and down is because I've got 22 screens in front of me. Right. So I'm going to talk about muscle. I'm gonna be talking about the anatomy, muscle. I'm gonna be talking about some actions and then I'm going to talk about a couple of disorders which are relevant to pediatrics which affect muscle. Um So, and actually a muscle. So you were all very aware, we spent the last time cutting through them. So we've got a muscle tenderness junction and that's kind of the weak link between where the muscle is, um, is attaching onto, onto your tendon and that's, that's your sort of functional point. Um And that's much more prone to um, uh tears, especially when you're looking at sort of eccentric contractions. Um, and we'll talk about the different types of vacancy you get muscle. Um And So when we look at, um when we look at muscle, we look at this, there's a noncontractile um elements which we talked about and then there's a contractual elements. Um And so we've got a f my seminar f my SIM, it's surrounding the muscle bundles. So that's our sort of uh thick layer around there. And then you've got your fascicle which are within, within the muscle bundles. Um and those, um and there's uh my c um is surrounding it and then each of those vesicles you've got fibers within and the individual fibers are surrounded by endo Missy, okay. Um which also has a really basic sciences, but it's the sort of thing you do need to go for the exams. You can see you get vessels running down it and because your muscle is extremely well vascularized as you, as you discover when you're, when you're splitting a muscle and you find getting off the bleeding. Um So, um the picture at the bottom for those of you are getting close to the exam, there'll be lots of groaning, but you should have seen this picture and you're, you need to learn it and you, the simple fact is, is like many of these things, you just need to know the concept of the, the thick and thin and um filaments. So you've got your thick filaments, which is your um what, what component is that? And if you want to talk, um it's the girl. Um it's the MRI S in excellent, good guess. Yeah. Okay. So you got your Myson, which is your pick, which is your pick full of it. And then what's your, what's the next one? So what's your thin filament acting? Well done, Maria? Thank you. Very good. Right. Ok. So, um, so you're my Bible is this collection of the sort of sarcomere. So these um these little bands which you're looking at there. So, you know, there's microfit bills tiny and then you've got your little sacrum ears. Um And so you've got your thick um my assent, you've got your thin little um acting and then you've got the lines in between and I always have to sort of remind myself in this, but this deadline is the sort of link between your acting's. Um the H band is your myosin, your eye band is you're acting and then your a band is a combination of both your, your acting and your Myerson together. So when you have a contraction, the Eben stays the same length where the H and the I shorted. Okay. So you have some contractile elements of some long contract elements, okay? You want more detail than that then uh you know, you need to. So how does that happen? So what happens? Well, we've got the, the neuromuscular junction, they've got a motor input. So, um who's next? And can somebody tell me what happens at the, at the motor endplate? Um in order to get the, the signal from, from the nerve to the muscle, um you get a nerve Axion potential reaching the uh um uh reaching the nerve terminal which and the deep polarization causes release of acetylcholine from the vehicles from the nerve terminal, which then binds to uh nicotine except acetylcholine receptors on the muscarinic muscarinic side muscle side which causes calcium channel, voltage, voltage gated calcium channels to open. And then you get deep polarization of the sarcomere and contraction. Yeah, very good. And, and so I don't know, I never particularly I didn't listen to medical school, but I had to learn the stuff for the F R C S and then probably forgot it. But it does sort of come back when you, when you remember. So, you know, last alkaline is um uh is released. Um What's happening is your sodium channels of depolarizing, which is what's causing Astelin Kaling to go. And it crosses that cleft that you can see on there. It's as primary left. The troponin comes across the left. The A CH binds to the uh to the receptors causing that that release of calcium, calcium and binds the troponin went. And then that means the maya trope trope mycin then sort of exposes those Miocene receptors, the acting then attaches to the myosin and that then causes your ATP breakdown which causes your contraction, clear as mud, okay. And the relevance for for and those of you who again are close to the exam. We'll know that people have been asked this recently. An exam is how does botulinum antitoxin? I should say work. So we call, call it Botox. Botox is of course the, the sort of trade name there's Botox as dis port. But how does, how does botulinum toxin? So you've got some pictures there. But if somebody want to talk me through, go on a G. Mhm. Uh So where is that picture? So both uh a paper from round Metandren uh Eastwood, but essentially um snare protein is required um attached to the Astelin calling physicals. So that you then so on the picture on the left, the vehicles then attached to the snare protein um then it releases that your ass style calling. So Botox when you put it in the neuromuscular junction or botulinum A in clinical practice is that it then cleaves your snare protein. So your ass style calling is not released because the complex not form, that's excellent. So the theory previously was that the ass choline receptors were being blocked by the, by the botulinum antitoxin. But actually, that's not the case, the botulinum antitoxin is actually stopping the A CH being released at all. So it's stopping that fusion of the membrane so that the neurotransmitter can be released. Um And that's how it works. Um Does that make sense? Does anybody have any questions from that? Because actually, that's uh it's a concept you just have to know. Okay. Yeah, I can just, I'm feeling the enthusiasm. It's just like this is so awesome. Every is enjoying it. And um you know, about fast and slow fibers. Do you remember the slow red ox sort of thing? So, you've got your, you've got your type one fibers. So you're sort of kind of chunky fibers. Their, their endurance. Say there your aerobic um uh muscle fibers, they, they will take you on a long, a long journey. Whereas the type one and your fast, they fatigue really quickly there for your sprint. So for me, about 5 to 10 seconds um and then, and they're anaerobic. So um so it's going on different pathways. Okay. So what types of skeletal muscle movements do we know? Like concentric and eccentric? Yeah. Okay. So tell me, tell me about that. Uh construct concentrate is muscle contraction with shortening and eccentric, is contraction with muscle lengthen. And uh yeah, there's I, so I, so something as well. So you've got isotonic, same force, isometric, same length. So if you're pushing against the wall, um and I so kinetic. Same speed. Good, well done. Yeah. OK. So it's does your muscle shorten. So the muscle stays the same length and then that's ayso metrics, the meter, I suppose it's just distance, isn't it? So the muscle stays the same uh same, but your, but your exerting the same amount of energy, eyes are kinetic, which it means that you're going at the same muscular movement and then isotonic is to keep the same tension throughout your movement. Um So what you will see is quite frequently is this, so when you talk about, um uh if you're just, you're holding a weight and keeping it still, then that's your eyes a metric if you're then isotonic. So if you're, if you're moving it, so if you're maintain the same tension throughout, you can do concentric. So you're flexing your shortening the length, but you're keeping the power on the same e centric, you're lengthening the muscle whilst you're doing the same amount of force going through it and you're eccentric contractions, the ones where you're more likely to, to get the muscular tears in. So that's your, you know, you're paying squash and your uh and your fancy around on the gastric and your gas truck tears or the biceps stairs when we'd love doing uh lifting weight. Okay. So what muscular diseases do you guys know? Thank you, Duchenne. Duchenne Becker's very good. Okay. So what, what, what's the big global umbrella term for them? Mhm. Excellent. Thanks. Muscular dystrophy. Thank you. Okay. Right. So we're starting from there. Okay. So what, what is that, what is that sign being shown at the moment? Uh This is the back. Uh our son gower sound fantastic. And actually do you know what I had a kid? It was during COVID? It was it last year or the year before. Um, and it, he was two years old and mom said, you know, he walked normal time, he seemed fine. Um, but he just hasn't then been keeping up and I saw this little one in the clip in the classroom. He had some toys on the floor and then we, um, tried to get him up to go onto the couch and he literally did this. So what does this, what does go sign Chauth a proximal myopathy? They have to use their hands to help them get up, get up from. So they're literally walking up their body with their hands, aren't they? In order to make up for the fact they don't have the power in the proximal muscles in order to bring themselves up, right? And it's really, it's really marked. Okay. So, so what is not a good history? What's the problem with that? Uh They, I think they don't live beyond 30 year 30 because of they get progressive part of ask, well, respiratory uh failure. So, but what's the actual problem? Mask of history? Let's not go down to the uh what's this? Sorry. Um So they lacked dystrophin gene. Yeah, occurs, inspectors reduced dystrophin gene. So therefore, uh they lack the fact that they can um they have really poor muscle uh quality. Whereas in Becker's, if it's reduced, at least they have some muscle, let's just stay with muscular dystrophy as a global thing. Biggie rather than flipping between additions and uh it gets a bit confusing of you. So what just generally just tell me about. So you tell me there's a problem with the dystrophin gene. So, what does that mean? So they uh dystrophin helps with acting framework. So they stabilize the acting in terms of contraction. Um And if they have, they have poor muscle regeneration, so therefore, it's been replaced by fat uh rather than pure muscle every time they lose muscle. Okay. But there's nothing else in there as well. So, no distractions are protein, isn't it? So, they've got a problem with their, their dystrophin gene. And so as a consequence, they get a breakdown of muscle, don't they get a sort of necrosis of your muscle? And what, what might that show? So how might, you know that, that's see how that's happening. Uh So in patient's in muscular dystrophy, we can do uh muscle biopsy. Okay. But before then, uh what was that? Sorry, LDH CK CK. Sorry, I don't know. I don't know how the LDH thing. But yeah, so it's okay. And that's much more simple test. Yeah, some paper or something. So, yeah. So it's, your creatinine kinase isn't. And that's quite a simple test to do, isn't it? So, um you know, far more than trying to do a biopsy because you're absolutely right. Muscle biopsy will tell us, went it. But before then if you've got a C K and what might see a race CK show. So what sort of levels of, of race? Uh, some other people come in because I'm aware again, they can bed at the only ones answer at the moment. There's no wrong answers. Yep. Sorry, I'm Maria, my apologies and Penelope. Yes. Sorry, Maria. Uh, there are usually the CK is elevated due to, uh, muscle, uh, necrosis. Excellent. Do you know what sort of level the 60 thousands? Exactly. So you can sometimes get kids coming through where they've got a CK of sort of 300 or 2 50. Is that worry that's fairly within normal limits. Actually, they've just had a really, like, they've just done a lot. Um, we're talking about sort of, you know, 5000. That's a sort of suitcase. So massive. See, case they can come with, I think for this kid he had a cat. So make 3000. Um, so all the one that, uh, good. So, we've decided it's a problem with the gene. It's a dystrophin, uh, the district gene expressing distraction. We've said that it look, it causes muscle breakdown, muscle necrosis. And, um, and we've said that they get some proximal weakness, whatever signs might have you might be looking for, they have difficulty getting up and down stairs or getting out of chairs and that kind of thing, you know? Exactly. Just as that with that proximal weakness. But what else might. So, you know, and you're gonna have that fatigue ability, aren't, you said the child might not be as, as active, not meeting their developmental milestones as you would expect are actually losing those developments. What else? Different gate? Yeah. So they might have a foot drop and they might have a high stepping gate. Good. Yeah. So do they get a foot drop in it? What do they tend to present more commonly than foot drop? Uh, I don't know they have, what's the opposite of foot drop, tiptoeing. It's a common cause of sort of tiptoe gate. So they can't, is referred to you as a tiptoe as a tiptoe walker. You have to be thinking is this, is this a presentation of um of a muscular district and, and you know, you're doing your CK is one way of excluding that. What are you feeling clinically when you look at the child, they get this calf hypertrophy? That is pseudo hypertrophy. It's not muscle, very good. And that's what I was saying about because you're getting the pattern form attrition, isn't it? So, yeah, they get these, these really sort of plump and um and it's sort of inappropriately large casts for the size of the child. Excellent. Yeah, that's really good. Okay. Yeah. Um and do you guys know the uh so we talked about it being a genetic condition um as with everything because it got uh is there a particular um inheritance that you should know about for muscular dystrophy? Excellent. Process it. Yeah, Anish is his hand up. Well done. Really? Yeah. Excellent, excellent processes. Very good. Okay. So it's one of those ones that great when it comes up on the exam is because it's nice example. Excellent, good. Okay. Um, and so that's, that's what cough I purchased you might look like. So it does, it looks like uh, it just inappropriately large carbs. So it's a progressive disease is skeletal muscle. Their nerves are normal and it's remembering that. So they tend to be male patient's excellent recessive. So the male patient, excellent recessive um and their tiptoe walkers and why might they get any hyper extension if they've got an incline is deformity, then it just allows them to get their foot to the floor. Yeah, definitely, definitely. There's definitely some cheating and also you've got the proximal weakness as well. So they might, they might use that sort of hyper extension in order to keep them, their legs straight. Yeah. Good. Okay. Um And um exactly as you said, so they're CK is raised, they have a muscle biopsy which um which shows the low levels of district. Okay. Uh So X P 21 genius responsible for the frustration. Um and it's a protein which is present in uh smooth and skeletal muscle. Um It's a mutation in translation ending up people reduce your absolute driven and you get this progressive uh necrosis of muscle um and it's not inflammatory. So it's just really important to be aware. It's, it's a myopathy. Not a myocyte. Okay. So, um, Iggy, uh, Iggy definitely was talking about decisions and Becker's okay. What is the difference between Descends and Becker's somebody who's not a biggie. Uh, there is dystrophin but the level is reduced in Baker. Yes. Yeah. Yeah, I agree. Becca Becca's patient's live longer than Duchennes patient's additions. Yeah, they do. Absolutely. Yeah. Definitely. Definitely. Definitely. I agree. So, so, it's, it's absolutely right. So, these are patients who live longer. So it's less severe, isn't it? We say that because they've got, they've got some dystrophin. They're not as, it's very effective. When do they present later with Becca's? Yeah. So you're, you're Duchennes might present a sort of quite a young age. They're more sort of infantile young Children, whereas Rebecca's can be much older. Okay. What else do I put? Uh, so 3 to 6, um, excellent recessive. Um They get cuff and virtually scoliosis or we didn't talk about that. Um And um both of them get a cardiomyopathy, but it tends to be worse than the decisions and they get this progressive deterioration from the respiratory and their cardiac disease. Um And um it says it intellectually impaired, so you can get intellectual impairment. I've got to say I've got some Dashinski too, don't you actually cognitively? Not, not bad at all. Um So, um equina stick to Walkers. They might walk on the preventative agenda. Albert Gate taught me through um that X ray. What what does that show? Quite pronounced scoliosis? Yeah. Good. I need more. I need more. There's a Kevin the spine. What else? What sort of curve is? It is a single, single, uh, what's the word for it? It was a single curve, single. Okay. I'm not going to give you points for that. So, you have a little bit but there's a name for it. Anybody else c shape. Right. Main. Very good. Okay. Yeah. So, so you're right. You're absolutely right. So, um, when you're looking at a, a scoliosis, you know, on the, and we're talking about on the Corona plane here, aren't we? You're looking at that s shaped curve generally, which means they're much more balance ahead is above the pelvis. Um, the, uh, muscular dystrophies because of muscular weakness, get, they get a C shaped curve. They have a C shaped curve on which is better t shaped or s shaped has shaped brilliant. Why, why is that Tom? Because the head stays over the pelvis and with a C shaped, it's of torn side. So it just gets progressively worse. Yeah, exactly. And they tip really, really quickly. So these kids go from having a relatively minor C shaped curve to a horrendous 19, 200 degrees within six months, they can go really, really quickly. So, actually the, the muscular dystrophies, they treat their scoliosis is much more aggressively. The reason being is that these are life limiting re scoliosis because of the amount of respiratory compromise that they cause. So, um, I think you're saying you've got your decisions where they have, um, fatality in their early twenties. Um, and they get this, uh, sort of, um, they reduced respiratory function due to the muscle weakness and, um, and if they have, uh, if the worse their lungs are the short of their life expectancy. Okay. What condition is this? Okay? I'm gonna start asking people now. Uh, coming. So what was happening? Okay. I might be wrong. It might, it looks like I tried right poses. Yeah. Okay. Why does it look like Africa purposes? Because there is um, um, the, the joints look stiff and there is a, uh, joint creases that I'm not sure I'd say stiff joints because of course, how do you know that they're stiff? But, yeah, absolutely. It's a lack of creases, isn't it? So, you're looking at the, the knees where, you know, where there is a joint creases? Where are the creases around the groin? You know, they're just, you don't normally have this sort of smooth tubular looking limbs and then what's happening on the, on the lower limbs? I mean, literally this is if you Google arthrogryposis, sorry. So they stole it from the internet. Severe, severe, obvious, um, uh, um, grab food deformities. Very good. Yeah. Okay. So it's club foot certainly on that right foot, isn't it now? Yeah, you can see marrow. So you got a little arrow to help you. They're having you on the patient. What is this? Nobody there? That's a Taylor's, I think. Yeah. So that's the head of the Taylors, isn't it? Why is the head of the Taylors there because of the severe addiction of the? Yeah. So, what deformity do you have in classic? All right. That's right. And somebody else, um, anyone, yeah. Production various and, uh, fantastic. Yeah. And I just, you know, I'm so pleased I just got given this model, I, I feel, I feel like all grown up now because I'm so pleased with my little uh my little of my own very own club foot model, but I can show you. Um So um what you're looking at when you look at a club foot. So this is like the bones of this child. Um You see the bit that's is um says it's a lovely bit just there. That's your tail ahead. And so the deformity that you have in comfort, you've got that uh Kaveh. So the drop first ray and that's where you get this media crease. So you've got the medial crease just there. That's where your, your crease. So you can see the, the higher raj that first ray has dropped down with, then you've got your, that curvature of your lateral border and that's from your metatarsal doctor. So that's that the curvature coming down the side there. And you can see the curvature of this patient So you've got abductus. So you've got your cavus, your doctors and then the heel, when you look at on the back, the heel is really, really curved into, into various. Um, and you can't tell the patient is embarrassed apart from the fact that if you can see the tailor head, it suggests the whole heel is going to be pointing this direction, um, as the tailor head is in pointing down that way. okay. And then you've got your a quietness, which again, it's hard to tell that you can imagine if you swung the foot into its normal position. Um, then just like that, that you could, that you would actually be in quite a tiptoe position. So that gives you the clear about the a quietness. Yeah. So I'm confident and that obviously happens with the after breath basis. Um And um, and yeah, that really smooth, smooth, lack of lack of priests around the ankles. Okay. What osteoporosis? Uh No, no, don't, don't all speak to the weather's, you're, you're over talking, please. So, uh Filipino, you have, you said that it's, you get stiffness of the joint, don't you? These are babies who don't move so they get a kind easier. So they're the ones who just don't move around because they're so stiff, okay. And they get these really fibrotic joints. So they, these are really difficult, um, kids to treat, you know, we talked about that sort of congenital dissipation. Um That Mitchell was saying, and I've not seen one where it's so bad that you have to actually open it up. So, um, but, you know, you can, those things can definitely happen out for our post is, but you're so you're, you've got really fibrotic joints, you've got your absolute places and you get these sort of thin, uh a trophic limits because you actually have absence of the muscles. Um And do you guys know what the actual problem is in our football post is? So what happens? There's something about the interior who are no uh cells. So there's neuropathy versus myelopathic. And I'm sort of focusing on the myopathic because that's the most common and, and that's sort of what we're doing at the moment, but essentially it's, it's amyloid tissue, isn't it? So, amyloidosis that, that replaces your normal um muscle musculature. So you end up with this sort of fatty infiltration with these, these um really atrophied. Um Basically just sort of rubbish muscles. Um that and um and that because there's no muscular pull, you end up with these sort of fibrosis joints. Um And so your Myer sites are being replaced by the adipose tissue. Um And um and you know, it can be, it can be life limiting. Um but these kids can okay. So it's very rare having someone in 3000 live births. Um As I say, they can't move around. So they get this joint stiffness, have these sort of thin a traffic limbs quite frequently. They are missing muscles. So, for example, um uh they might, they might actually not have a biceps at all. So they have this sort of very extended arm, um which they can't flex up actively or passively. Um The joints are actually pending on the bones are normal and that's the difference. So, and, and actually, as I say, um nerves can be normal, it's associated with some of the conditions. So, um you know, the muscular dystrophies, mitochondrial disorders, you can get um Larson's which was mentioned before, which is that multiple dislocations. And so as I said, you can get metaplasia or classical, you can get it where it just affects the hands and feet. So you might see a child who has um foot deformed, your hand deformity but nothing in the trunk or uh anywhere else. Um And it's uh not only condition what's happened here, Miss Chase just very quickly. Do they have not, they have uh abnormal or low, lower intelligence? No, they know they, they're uh intellectually normal. Okay, thanks. Which is actually rubbish when you think about it. It depending on the severity. Yeah. What's that? You come on, this isn't obscure muscle. Now, you guys should know that uh D D H left discussion of the left hip. Thank you, Ben, who is currently doing pediatrics with us and knowledge. Uh huh. Brilliant. So, yeah, they, so they get dissipated joints and the problem is these aren't easy desiccation because you can imagine that tissue. It's not, this isn't like this isn't, it is BPH. But it's a, it's a much more trata logic TDH. So these ones are much harder to get back in. So I, I, when this one was a little person I didn't, uh and after gram and that doesn't move. And in fact, when I, when I did the open reduction for this child, I was literally peeling the femoral head off the I lack wing. It was so stuck, everything was stuck. It was, it was awful, it was really difficult. Um So your hip dislocations really recasting treatment, they have a high rate of failure, but you generally do try to get joints back into joints and you'll find that I'll keep banging that drama for all the various um complex Children that especially that under the tree, you want the joint that to be reduced to get any contractions. Um And you can actually end up having to do releases. So you might have to do anterior releases. Um Osteo releases are quite questionable because um if you, you imagine trying to release the property seal flosser, there's a bit of plot quick in there that you have to be quite careful about not releasing. And as I say, with the Talipes, you still treat a Africa orthotic child's foot with comfort as a, as a C T V. You don't, you don't change your management from that. Can you guys hear me over psychological? You mainly hearing Mr Psychological, you can perfectly, his voice carries a quick. Um, yeah. So, uh, so you're, you still use Concerta, you still do the train that you just got to be aware. It's a complex foot more likely to recur and you're going to need to have them splintered. You're not going to be able to just sort of do the pon settee, put them on boots and bars at nighttime and expect them to have their feet to maintain in a good position. There. Also, the kids where you see your congenital vertical tail life. So those are the ones where that rock bottom foot. So that curved roots that the tailor head sitting in the middle of the foot. And as I said up, Alan, so you get these sort of, they get these very long. So they're sort of, um, their, their arms can be really, really straight and just like those knees we saw and the baby, you can just see there. Do you see how it's very, very straight? And they often have this really flexed wrist. Um, and, um, and they can't bend their arm up to get to their mouth and that's the problem. So we, we do do releases. So we link them the triceps and there is, um, triceps transfer or lack dorset transfers to make up for the absent or dysfunctional biceps in order to the child some, some flexion um because you know, having your arms out straight means you can't get, you know, wash your hair, you can't get your food to your mouth. And I said dislike for grab posters. So if you've got a child who's got bilateral club, cert, you want to be talking about the fact that it could be a dip, a thick, you know, 50% of them are. But you also need to talk to me about teratological and our program post. This is definitely one that needs to be on your list of differential. So in some rate, we talked a little bit about the structure of muscle. We've talked about the action of botulinum toxin and we talked about the must be distribute. Uh I'm gonna end my screen share, I think. Okay. Right. Okay. Um Any questions from that guys just, just really enjoyed it. It's really loving, loving. Okay, cool. Today. Oh uh Do we need to know about any of the other dystrophies apart from decision and Becker's know because there is that whole one that happens in much older people, doesn't it? It's a, it's called C 30 or something done, but there's lots of different types of muscular dystrophies, but they're a bit of scare and they tend to be an older. So, no, you know, Duchennes and you know, Becca's, that's probably that's good. Going to be enough. Any other questions, any treatment for uh Duchennes currently? So they do steroids. Um, uh, but, um, no, it's still very life limiting. There's not yet. I mean, gene therapy is coming through. So, you know, but that's a home person. It is that gene therapy works. And, uh, but at the moment, no, however, when you look at sort of spinal muscular atrophy and neuro urine s in which is the gene therapy for that, that's a life changing. Now where suddenly got a whole bunch of kids who weren't living, you know, into double figures, suddenly they might actually have some decent survivorship and it's a complete game changer. So things are coming through, but at the moment and practicalities of genetic testing, so presumably all these patients will have some form of genetic testing. Uh It's an MD T approach A G. So I actually in this child, I'm going to uh an MD T approach because what I want to pediatrician to be involved in this patient and the video therapy and occupational therapy. And I'm going to ask a mess icis to review this patient. And then you'd also ask a pediatric neurologist if you're thinking along the the lines of a muscular dystrophy. Okay, good. Right. Should we slide gracefully onto gate? Which again is a really like people love this. Stop it. It's like um uh and should I screen tire screen share? Okay. Right. So gait the F R C S now, I have shown quite a lot of you guys this video before I'm and I'm just trying to put wine in my, I'm not drinking that I'm having cloaks. Um So all of you will have seen, hopefully have seen this video because you have seen talks to me before. Um So you can absolutely rock this. And I want by the end of this talk to you to be able to confidently tell me what you're seeing when you're seeing this child, child walking. And one thing I will say especially, and I do say to the for individuals who get stuck with me in clinic is you need to start talking. As soon as you see the patient walking makers for a child, you're going to get about two laps and then they're bored. So you see the child walking, you can get a little bit of an idea. But the first thing you say there's a child and what, what do you say? You'll be glad to know you forget all of that pain and misery over time. He's not talking about the gait, but it's relevant. So what's the first striking thing you see in the child? So I can see that this child's gate, he's walking purely on tiptoes and, and with his knees flexed. Yeah. Fantastic. So, you know, you, and it's just really saying something because you'd be surprised how many people when you see a child walking, we'll just stay silent and just watch it for a bit in the hope that it epiphany. Comes where they can suddenly blurt out. This is amazing. You do actually have to start somewhere. So it's, it's saying, you know, the most obvious things that you can see first. So you can tell me that child is walking on tiptoes with a flex knee and flexed hip gait. When you look at your throat, when you're looking at them from, from the side, when you're looking at them from the front, how are they? What can you do that? Can I see it again? Sorry. They say they got their knees in Valgus there. So I'm internally rotated at the Thank you. So that's apparent valgus, isn't it? So I wouldn't say Valgus, Tom when you're, when you're, when somebody standing up, you can talk about their, their alignment. So they're Valgus or Varus. But if you imagine yourself standing, I'm not going to do it because it never works out well when I try to do this online. But when you're standing, if you internally rotate your knees, so if you point your feet, in words, you give yourself loads of apparent valgus if you externally rotate your feet, so your, your only kept pointing outwards, you give yourself apparent virus. Okay. So you can make yourself when you're walking or standing look like you're not the needle bow leg, even though you might have normal mechanical alignment. Does that make sense? So a child, child might look like they're, they're valgus. But actually, and they may well be, but you can't say that from their walk. What you can say though is that their knees are pointing in? So they've got squinting of the patella which suggests they've got internal rotation of their thighs. And what is, what is his legs doing? His knees are knocking against under, they're crossing. So, what's that called? Stuttering? Excellent. Yeah, Maria. So this is a sizzling gates, isn't it? So, the legs are crossing in front of each other? Okay. And this is your, this is your sort of classical, you know, to say what you see, you see those legs leg crossing in front of the ever. So you've immediately told me huge amount about this child's walking, okay, just within a few, a few minutes of prompting. But if you see the chance just walking, you can really say, you know. Yeah, again, a tiptoe, the knees are flex, their hips are flex, the knees are squinting and, and, and their legs seem to be sizzling and if you look at their pelvis there, um swing in the pelvis forward max. So there seems to be some some rotation of the pelvis as they're walking. And that's a huge amount of information that you've given from seeing that child walk. Okay. So what are the prerequisites of gait? What do you need to, what do you need to know? Energy, cons conservation, energy, good, excellent weather, Penelope. So, energy conservation, good. What else? Clearance on swing Well, don't tell anybody else. Can I help Penelope with this? Clearance and swing energy conservation or Penelope carry on? Nobody else is chipping in um, adequate. I think progressions or step length. Exactly. Exactly. So you need to be able to prepare yourself forward. Otherwise your gait is, is inefficient. So, if you just shuffle a few steps and it takes an enormous amount of energy, that's, uh, that's not a gate. Yeah. So good. What else is there? Stability? Uh Yeah, play stability when, when what's happening when you're in stands? Good. Excellent. But, and I think there's something else that I'm missing. There is anybody else help Penelope out. So what happens are you standing and you're stepping forward what you need to do to your foot in order to, so he'll strike, it's more prepositioning. You need to be able to position your foot, sorry, you need to be able to provision, position your foot nicely so you can swing it through and then you can, and then you can prove it. I said in swing, I don't mean that. So prepositioning foot in order to get yourself your, your foot striking the ground in a way that's going to keep you upright good. We're done. Okay. So this is the gate cycle and um you guys should be aware of this and certainly have seen it. It may be a sort of medical school thing, but it's definitely something you need to be aware of so your stamp space and the way that when you talk of the gate cycle, it's taking you from, when you started on your right leg to a new, returned to your right leg. Ok. So it's one whole gait cycle, which is essentially two steps. So one step from one leg and one step from the other. Okay. And we spend when we're walking about 60% of the time with our feet on the ground and about 40% of the time with our leg off the ground. And that's what's around when you're walking when you're running or jogging. So we start off, we start off with heel strike, okay. So we get initial contact, okay. So when we, when we get heel strike, Artibonite five, so that we're not slapping up, look down, we're getting a heal nicely down to the ground. Um, our glute max is helping with that knee extension moment. And um, and you've got, you've got some, some tightening of the posterior capsule of your knee. So this is the time that if you've got a lot of access city and some hyperextension, you may see the legs starting to hyperextend. So that's your heel strike, your initial contact. Then what you're doing is you're bringing propelling your body forward, okay. So you're starting, you're starting to fire your quads there and that's bringing your body over over your knee. Okay. And during this, I want you to just think about what each segment of the knee, hip and what we're doing as we then go into mid stance, that's where we're nice and straight. So here is over our knee, which is over our ankles were all in the extension. And that's when that sort of coupling. Um when we talk about your, um your gas struck complex gastrus layers, complex tightening from having that eccentric contracture of the, of the foot fully dorsiflexed, um, and the, and the, the knee and extension. Um and you can see that going on as you get for your terminal stance when you bring your heel up and this is when we, we start, need to get some clearance, isn't it? So you're, you're, you've propelled your body forward, you're now gonna toe off. So you're using, um you're using your blood flexes to do that. You're using direct them to help bring your propel your um fly forwards. Whilst at the same time, you're starting to, to use your hamstrings to flex your knee up, um uh and your hip objective, okay. And then your initial and mid swing, you're starting to think about bringing your leg forward and to see which then propels forward and you get more and more contraction from your earlier. So that's the directors in order to bring your knee forward before you can extend your knee and go back into that, into that terminal swing where your tip aunt is firing to bring your foot up. So that you can then plant your heal nicely down on the floor. Okay. So what does that mean? So tell me what you can see there guys can I can I have a volunteer to have a little look at that. Anyone, anyone else has spoken before? Anyone new? Well, there's 30 people in here. There must be, they must be. You don't want the same four faces, five faces constantly coming up. We'll have a game is chase. Yeah, please do have um, so, uh you can see that he's not achieving heel strike. Excellent. Yeah, so he's predominantly walking on the head of his metatarsals. Yeah. Very good. He looks unsteady. Yeah, he does. Do you know why I might look on city? Uh, it might be a muscle issue, might know, but why might you then see and when you're that high up, it's probably really hard to walk a lot of energy example, sometimes you see these tiptoe walkers and they can't stand still. So trying to stand if you try to do it yourself, if you're trying to stand on your tiptoes, it's surprisingly difficult to keep yourself. So you're fine propelling forward, but you're really bad at staying completely still because the balance is poor because you're doing it on a very narrow surface area. Good. So, yeah, so we're looking at him. So he's very high in his tiptoes. So he's basically walking for his metatarsal heads, isn't it? What else can you say, um, he, um, so as a result of that, it look, he's sort of the sort of mid portion of the gate cycle. She looks short maybe in comparison to anything else. So the midst dance fails and the toe off and that sort of thing is all shortened. I don't know. Yeah, let's face it. Well, the thing is you're not, you've not got no heart heel strike. You don't really have clearance because you're not getting your foot up. Are you when you're walking also? He's twisting, which isn't a bit easiest to than interpret, but you're not getting an enormous amount of deflection. So he's spending more time on the floor. So he's spending less time in swing and much more time in stance, isn't he? But what else? So you, you told me that about his feet being in a quietness. What else can you see for that? We talk about all the segments. So, what, what about hips in these? So his, his knees is thing probably extended. Mean there isn't anything on there. That's good. Okay. He's extended and then, yeah, he's still tilting at the level of the pelvis. So he is, yeah, exactly an invitation to help him. Why do you think he might be tilting forward to stabilize himself? So to, yeah, to sort of propel, isn't it? So he's got his knees and extension and he might be using that force to bring his center of gravity forward. A bit in order to try to propel himself. Yeah, absolutely. But it's relevant than the knees go nicely into extension, isn't it? Ok, good. So when we, when we look at gate NASA, we expected to logic gate chart and have you guys any experience of seeing gate chart. So if I show you a picture here, this is a gate chart and this world could well be this chart. Okay? And what this gate chart is showing us is what does the, what does the child get? What does happens to this child during the cycle? Okay. So what can you see? So they're so black dotted is the top one, this one is grab. So black dot is normal. Okay. This is what you should be that it should be doing with your ankle flexion. So when you're your stance, you've got just as you get to your, your heel strike, it may be just under two, a neutral sort of foot position, okay as you bring your, your foot forward. So you go flat to the ground and then you bring your whole body over the top of you, don't you? Which means you get a little bit more dorsiflexion of your foot. That's dorsiflexion of your ankle. And then as you're coming towing off, you're starting to go deeper into that tall reflection, aren't you? And um, so you go into quite deep flexion as you go as you toe off your foot is now in the air. So you're coming around and you're reposition your foot because we know that finances told us that prerequisite for gait was that we don't trip over our toes is to swing your leg through. So you have to be able to dorsiflex your foot in order to dorsiflexion that in order to clear your toes so that you can bring your leg over and start again. Okay. So this is a normal ankle Judd. So if you're showing the red line, well, what would be this patient's uh position of their, of their ankle throughout the gate? What would, what would you, what would you say they would look like? Probably like this child. So they're not achieving any dorsiflexion whatsoever. Yeah, exactly. Exactly. So really, really hard tip. Does that make sense? Everyone? Because we're looking at the gate chart is really confusing and I used to hate looking at them because they didn't make any sense. What you have to do is break it down in your head thinking about the gait cycle and then suddenly they make a lot more sense, feel free to ask questions as we go along. Okay. So, uh mostly one of these, these videos from uh one of my C P talks before. Now, who's going to, who's gonna tell me about this? Can I have a volunteer, Nikki very bravely volunteered herself. Does anybody else want to volunteer? There's no wrong answers? I mean, obviously there's 100% is, but I won't, I won't, I won't, I wouldn't be mean, I promise. Wow. Um, it's quite a slow gait. It looks to be, um, uh, was lurching. His knees are flexed. Um, and, uh, he's spending more time in the, in stance than in swing, uh, than you'd expect. Yeah. What else is sick? So, what's the positioning of each of those segments? Are you going to take your turn to tell me about ankles, knees and hips? So hips, flexed, knees, flexed, ankles, flexed, dorsiflex because we should have blood flecks suspect. Good. Okay. Yeah, absolutely. And see that that is all that, that is explained to me because this is, I mean it is pants video. I'm sorry, but actually this is what you're getting clinic. This is what you're getting your exam. You get just shown a child who may or may not work for you. They don't walk for long and they certainly don't do beautiful gate lab videos for you. They do pottering around and you have to try to work out what is going on with the child. Okay. So what's, what's so if I tell you what might be these uh if you were going to describe this gate, what might you call it anyone crouch? Excellent. Yeah. So this is this, this is couch crouched gait, isn't it? This is your CPK it. And you guys do need to be aware of these because they are coming up in the exam. So even if you say like, I'm never going to see a C P get in my entire life, you may well find your face with them during your F R C S. So you need to be aware of what you're looking at and how you're gonna manage them. So, yeah. So this is a classic crouched gait, isn't it? And why, what's the problem with crouched gait? Why, why is it a problem? You know, he's walking. Why am I? What's the problem? Very energy intensive? Exactly. It really is. And if you try and do it to yourself, you get knackered really quickly. What else, what other problem might have happened? Yeah. What might they complain of? So, they might complain of getting tired? But what else might they complain? Uh, yeah, absolutely. So, knee pain is a major problem when you've got a knee, knee flexion, um, gate because you're putting an enormous amount of pressure on your telephone, more joint, aren't you? So, about 90% of people have, um, have very, with crouch care, have very hyper tellers and they're much more likely to get knee pain. Good. Excellent. So, yeah, knee pain. They might, uh, you know, we said they get tired but actually they might just come off lex because they're deep and deep in there. Crouch, they get new contractions and they just become very chair shaped and it's easier for these Children as they become heavier teenagers to move. Into a wheelchair than it is to put around when you look weird or different than, than your peers at school because, you know, kids aren't kind to each other, uh, necessarily good. Okay. And that's sort of the classic sort of couch gate position. And you can imagine the crouch get, when you think of your center of gravity, your center of gravity is falling. You imagine it's going down from the hips down to the floor. Your moment is coming just behind the knee, which is a knee flexion moment. So, how might you treat that? That's not my phone. Yeah. Right. Thank you. No, anyone, anyone, how are you going to treat it? Go on time release is contract your releases. So we'll go video therapy first, which is a great start. So, if we imagine that we are, we are, this is, this is uh giving exam answers. You're going to be giving me the sort of the c event you're going to be saying there's conservative and they're surgical. Okay. So, conservative options therapy. Absolutely. If you can get that chance, have stronger quadriceps muscles, then they might be able to get themselves more into extension and you can get them better position and upright and stronger and keep them on their feet. So, yeah, the physiotherapy hydrotherapy get them moving 100%. Yeah, that's brilliant. What, what might another conservative measure the injections? So, yeah, if they've got a lot of spasticity and they in the hamstrings which is causing them to be forced into the couch because they're, they're really tight then yet. But try them antitoxin. Um, you know, we've got some issues with Botox if, you know, we know from studies coming further that causes some fibrosis. So it's not, and it's not a permanent solution. So you could use Botox and then strengthen their cords. Yeah. What else? And then going to operative management? Which, no, no. Say in stone conservative, conservative you're not allowed to like stretching and splinting. Cafe, the knee ankle for. Yeah. Yeah, exactly. So they're not, I'm not going to give you cafe, you're allowed, you, you're allowed the ankle foot emphasis to it. What's the name for it where you're wanting to explain to me what the orthotic, it looks like an AFO but it's got a proximal extension which goes anteriorly excellent. It almost looks like a Sarmento. It does. It's doing the same sort of thing, isn't it? Yes. So it just provides anterior support so that you can fully extend your knee, I think. And then kind of, is that right? So your same innto your same into is putting weight through your Pemra condos onto the cast so that you're not putting so much weight for your tibia, your um your uh the AFO the orthotic that you are describing is a fixed device that's converting that reflection to that over dorsiflexion in. So when you're to be, is pointing forwards to create a knee extension moments. And that's why they're called ground reaction force AFO so graph owes. So your cafes, your knee A F O s are ones that go up above the, above the knee. Um and are supported if you got a unstable knee, for example. Thanks. Yeah. Good, excellent. Yeah. And then you're allowed a knife and, and you could try some hamstring length thing. However, the trouble is these Children are often in this position because we, what we've done is we've linked from their calf muscles because they were that child who was really, really tiptoe and you couldn't fit them in splints and they were doing really badly and falling over all the time. So we made the cars longer. So they're down to the floor and then they become bigger and heavier and they've tipped into grouch. So sometimes it's a problem that we're over lengthen them or that we, they must look at weaker because the natural history is one of going into a crouch gate. So you might think that hamstring but you might even have to do bony surgery in order to straighten their legs. So, just a thermal osteotomy, for example. Yeah. It's, it's a really, it's really difficult is that these older Children who have spastic diplegia who are just coming off legs as they, as they, as they get older. Good. Okay. So, what's this chart showing? This chart is showing pelvic tilt? Okay. And what we're looking at here is the black line being normal. Now, tell me what's happening on the red line. What's the problem? The chart has got. So, again, it's that same stance. So, so they're going from, um, heel strike all the way through the heel to the other wheel strikes and they're starting on stance and going through to swing. What does that red line share? So, it is showing that the thank you that the reflection that should be happening in their hips is happening in the pelvis. Well, it might be happening in both mightn't it, but what does it, what does it suggest? So you're absolutely right. The pelvis is tilting forward as they're sticking their, their leg out. So they're, they're flexing their hip, aren't they? But you're right. The whole pelvis is tipping forwards. Oh, sorry. Yes, I was going to say that it does it show that there tilting forwards in order to gain momentum to, yeah, it may be. So they're using their body weight. So they, they're putting the center of gravity forward in order to bring it to propel themselves for. So they probably got some pelvic tilt in order to, to literally propel themselves forward. And it may well be that they're having to have normally use their early S O S in order to really pull themselves forward. So that may, that may be evoking more of a pelvic tilt. So, yeah, so you've got the whole Pelvis is tilting forward. Now, what does this share? Thank God. There's some things or is it just gonna be, uh, practical Ben and Tom, do you wanna do you know, uh, I think the bank is on an, um, meeting and then Tom answers and he's having to put his gun then you can, you can answer, keeps stealing from me. Um, uh, so the, uh, yeah, so it's essential to the hip is, uh in, in flexion more than normal throughout the whole of the, through the whole cycle. So, rather than them using that tilt or whatever, in order to bring themselves forward. So it being a positional thing, the this is hip flexion for out cycle which suggests that the hips are flexed throughout cycle. Now, the hips maybe flexed because they've got a lot of knee flexion and that's one way of keeping themselves forward or it may be that their anterior structures like they're earlier. So it's very, very tight and therefore they can't extend how clinically might you be able to work out if it's one or the other a assess whether they've got a fixed flexion deformity? Excellent, excellent, neutral. Exactly. Examination is like a Thomas test to see and that's been just describe Thomas's test for everybody just so we're all on the same page. Um So patient lying uh flat on the bed, uh making sure you've got a hand under the uh low arch of the lumbar spine to ensure they're not changing the position of the pelvis, uh flexing uh the hip you're not examining. So flex up the uh contralateral hip is into the chest. And then looking at ensuring that the pelvis is remaining stable. Looking at what reflection of the hip is, whether they can get the other lady looking at straight on the bed. Oh, there's no extraction. And Thomas's test is like we do loads and pediatrics and I think you probably should do more in adult land. But the reality is how many of you when you're doing, seeing your arthritic hips, you're really getting them to do a proper Thomas's death. You may be, you may be very good. But I think, I think it's something that sometimes it can be a slightly lost thing that we don't do is we should do and we're examining hip. So Thomas tests really, really important. Good. And then the last one. So what does, what does this chart say? Somebody else? Somebody new, there's no wrong answers. Anyone again, it just stays in flexion the whole way through the gate cycle. Probably tight hamstrings. But, well, the trouble is you don't know, do you? So you might have, you might have weakness, you might have, you know, you're likely to have tight hamstrings, aren't you? But all you can say is that this is a flex. Any gait can't use this patient walk entirely with deflection. Excellent. And you can see that your normal cycle is one of you, you put your leg out here and needs nice and straight as you bring yourself forward, just go into that sort of mid stance. You get a little hub just before you get to mid stance where you're flexing your knee and then you, and then you bring your foot up and you're having to bend your knee quite deeply in order to clear your foot from the, from the ground. Good. And then there's a whole bunch of other stuff which is relevant. Okay. So don't learn every single gate on us as chart. The ones you really need to know about are about your, your knee flexion, your hip flexion and your ankle flexion. And if you really be fancy, then know about your pelvic tilt, but starting to talk about pelvic rotation. So how much they're rotating their pelvis as they're walking? What's their foot progression and foot progression angle is relevant if you're looking at a child where you're trying to work out with, you know, exactly Mr Mitchell saying about that rotation. So what does the chart show on that top? Right? Anyone just out of that? So they're walking into did. Yeah. So they're the, the side that you're looking at is a red line. So that's in towed for our cycle, isn't it? And then what's the Thank you, Tom. Um uh um And then the blue line which is the bottom dotted line is the other leg. And what's that showing the opposite. So, exactly. So, yeah. So what does that show Nicky, uh, foot's externally rotated? So, yeah, this is a patient of walking. Really windswept, aren't they? So, 1 ft is pointing in 1 ft point. Yeah. Okay. Right. So I'm aware of time. So, and as I say, these aren't new. Can I have another volunteer to look at, look at another video. Can't the same people come on with people, you know, 29 of you, you've given up your afternoon to listen to this. You can't very passive. I can see your names. Talk to me. Somebody on mute. Mhm Somebody hasn't taken before anyone, anyone around I'm going to pick a random Oscar Oscar the U one. Are you listening? Hello? Yes. Yes, I am yesterday. Brilliant. Okay Oscar. I'm sorry, I was having trouble with my, my microphone with the iphone. Sure. No worries. Look at your little screen and tell me what you can see. Just say what you say. Just talk. Yeah. Okay. So this is uh it's an abnormal gait. Um It's like a lurching gate um Antalgic in a way and the fact that he's swinging, swinging through with the left leg. So there's an a tiptoe on the right, almost at the end. There's a high push off at the end and a flat such story on the left. Yeah. Okay, externally rotated. Also on the left muscle wasting on that side too. Yeah. It, he's not got a proper heel strike or push off on the left hand side at all? No, he doesn't. Does it that foot sort of flapping down, isn't it? So, it looks like that doesn't really have any power, foot, foot drop there as well. Yeah. Brilliant. Do you see how, when he's stepping? So, it's not, if I tell you he's not going on to tiptoe on that right hand side. So, what thing, why does it, why is he sort of seeming to talk about bolting, compensating with compensating with his abductors, I suppose, of the hip. So I think he, at that point, his right leg is straight and his left leg is off the ground. What does that tell you a leg length discrepancy is likely? Yeah, it is, isn't it? So if you look at, if you look at him there, he's got both knees are straight to the moment and the heel is off the floor by a few centimeters, isn't it? So this is a short leg gait. So this is what you can see sometimes it's as they're walking. Do you see how the whole pelvis? So you can see how he tips down the whole of it, stepping down in order to get down there. And so, so you can then, and he's having to flex his knee a little bit more on that left hand side, you see a deep reflection in order to compensate for the fact that he's having his whole purpose down. Okay. And then you can talk about, what about the size of the legs? Do? The legs look the same size, we know one shorter on the left compared to the does, doesn't it? Yeah, the left leg, the left leg looks really short, doesn't it? So, it looks short entirely way in the quads and the Cialis and the gas trucks as well. Exactly. And it just doesn't look like there's any musculature, does it and it doesn't really look like there's any power, no knee flexion, it doesn't look like he's controlling. So this is a neurologic limb. So this is a patient had, I think they have a sort of major injury which has caused him to have a nerve palsy. Um, and, um, and that's why they have sort of a complete muscle wasting. So it's great. They're walking, but that's quite a significant difference. A short leg gait. So you can see the head and shoulders tipping down as the patient's walking. So that sort of bobbing that he was doing. Pelvis was dropping on the effective side of heal stroke. So it's not Trendelenburg gate, but we talked about a vaulting gate. So, did you see that he was hopping up, wasn't he in order to clear his leg? And also you can have that sort of flexed knee? Yeah. Good. Okay. And, um, all right, we'll move to somebody else. So, uh, you asked if I got on my list. Uh Vicky, Vicky Stone. Uh So Vicky, what's the condition that you think this child might, might have, have had? What happened? Uh Looks like Perthes maybe. Yeah, effectively left it. So, why, why do you think it's perfect because they're looks like there's been some fragmentation of the femoral head there. Again, it looks quite wide. It does, it does. And, and Mr Mitchell talked about that sort of cocks magna that you can sometimes get with purples. And that is quite a big head, isn't it a little bit of lateral subluxation? Yeah. So how, so, you know, he talked about the fact that that means the credit cancer a little bit higher. What might this child have when, when they're standing and walking? What might you say when you've got your GTs just a little bit higher, you know, got cocks the bread and they're shorter neck there. Um So they might have a bit of a leg length discrepancy. So that, yeah, they may do. Yeah. Why must your abductors if you, if you shorten, if you shorten them the liver? Um So you might hold your hip a bit flex? Really? I guess. Well, they might just generally in Perth face might they, but no, not, not so much that so if you imagine if you think of um if you're, when you're thinking of how your abductors work, so your abductors work to hold your pelvis and L shape don't they say they creating the ele your doctors are nice and tight and that means your pelvis stays nice and level as you try to do activity. If you shorten the lever arm on your, on your adductors, you can end up uh d functioning them. If you defunction. What then happens? Yeah, you get palpitation and what's that called? Like Trendelenburg? Excellent. Yeah. So this might be a child who ends up with a Trendelenburg Gate. Okay. So Trendelenburg, they can have normal hippo doctors, which means exactly that L shape. So imagine that left leg is if you look straight straight up and across the pelvis, that pulse is nice and nice and straight, even on the other side that they stand, I'm sorry if on the other side they stand and they've got sorry on that side and they've got weekend doctors, the whole pelvis tilts down, doesn't it? So it's you're standing, but the pelvis tilt to the side, which is, is not the affected side. And that can sometimes be a little bit confusing. So that's your week hip for doctor. So that's your Trendelenburg. And the Trendelenburg eight is quite marked and sometimes it can be mistaken because of a pain. So you can, so you can have sort of Trendelenburg, an antibiotic can actually look pretty similar, unfortunately. Um But yeah, so if you've got a shortened early from and definitely the birthdays, kids or anyone who's got quite a lot of cocks of error. Good. Okay. Uh, somebody else on my list. Did, did you take certain? Yeah. Lovely. Ok. What can you see that? Uh, normal? Very, that's just important. So, this is like a stiff knee gate. Yeah. Great. The left, uh, yes, it is left. Sorry. Yeah, I don't know my left or right. Yes, it is left side. Okay. So it's a stiff knee gate. Brilliant. Okay. So the knees, uh, state and so what's he doing to compensate that knee, not flexing? Um, he is trying to flex his hip on the other side. Yes. So it's sort of doing a little bit of bolting, isn't he? We talked about that sort of lifting himself up in order to clear your foot. Yeah. Um, and he's, and when you see his foot landing, he's not towing off and he'll strike quite as beautifully. It's more sort of foot flat, isn't it? Because he doesn't have that knee flexion to the preposition is like good, lovely. So, and there's Antalgic Gates and there's Stephanie Gate. So intelligent gates. Um, they didn't have a shortened stance, data. They spend less time putting weight through that side and they might lurch over to the uh the or painful side in order to reduce the joint reaction forces. I'm not good. You'll have a whole session on joint reaction forces. But if you just think of it as the center of the, the force is coming down, a body failed gravity um the counteracting forces are hip productive. Um And um, and then in between the two is the, the amount of force going through the hip, which is a combination of that force going down between us and the, the counter acting force of our abductors. If you bring your center of gravity, overall flow that way over your, um, your painful joint, you're narrowing that distance which reduces the joint reaction force. Um Is there a question? Yeah. Yeah. Okay. Right. And then finally, and any volunteers, did you, uh, Daniel wants you on there? Uh Joe Pang here. Brilliant. Good. Okay. J tell me what you can see. Okay. Just, uh, the right leg. Uh Okay. So there's no real good toe off, uh, outsides, the right leg seems to be a little bit more extended at the knee. Uh There's more infection going in on the left hand side. It looks to be a little bit broad base. So it is like a broad base gait. Yeah. Absolutely. And you'll see that one go to the front page. Yeah. Sort of broader base. But what's happening that mean? You said that it's going a bit over straight? What, what's that called? Uh Yeah, I think that's good. Yeah. So they're happy for them to me and there's a term for that. Does anybody know what that term is? So, back kneeing is a term for it. So it's where you flick your knee back into hyperextension. Why? Might, you do that? Why might you need to hyperextend his name? Um So you lock your knee out. So you're a little bit more stable when he's standing. Yes. Why? The same reason he's got the hands on there because his quads is uh hold on. Yeah, cause he is pledging you. Yeah. Yeah, you could take this. So it's a proximal weakness, isn't it? So it's a way of compensating for the fact that you don't have a strong extensive mechanism. You can put your hand there or you hyperextend, you need to stop your knee giving way and flexing up when you're trying to keep yourself up and you're absolutely right. That foot's really floppy, isn't it? There's no real power. So they hitting the ground and you can sort of see the, the force reverberating for the foot that's kind of floppy and um and uh wasted, isn't it? Um And yeah, you've got this sort of this lurching kind of wide based gait, haven't you? Um So what might be the condition? Anybody got an idea what condition might be affecting this patient? Could it be like muscular dystrophy or something? Um So probably not. And the reason I'm saying that is, that tends to be predominately just proximal weakness and you tend to, to have more of carb hypertrophy and you tend to have a bit more sort of power where this looks like they're completely floppy distantly, they don't have good if I tell you that they've got normal sensation, but a lot of motor weakness very good. Like, yeah, this is a polio, a paralysis. Exactly. That's the anterior helpful home sales. Uh He said, right. Ok. So weakness. So, um if it's in the hip, it might be in trend to Kellenberg need get weak quadriceps, you do that back, meaning that we saw um and in your ankle, you might have a high stepping gate where you might put, might slap as you go on the, on your initial contact and you'd use a sort of foot drop sprint. That's case, I don't think we'll spend too much time. So hopefully by the end of this, you're able to look at this kid and come up with something to say when you're seeing when walking around um in your, in your exam. And if you're shown a gait analysis, you should be able to on that chart, try and draw out what that child's um gait analysis is going to, is going to look like. Um And then just as it's a little bit of a reminder when you're, when you're looking at your C P kids, you're going to be um looking to see those different segments. So are they up on their tiptoe or are they foot, foot flat or dorsiflex is any flex route gave? And what are their hips doing as well? So hopefully you've got an idea about assessing assessing child when you see them walking. So thinking about looking at them from side on front on and then imagine them from the top about how much of that pelvic rotation that you see, you should be able to just bang out the immediate abnormalities because the trouble is there is that stunned pause when you first look at the gate and you can't just leave that for a significant period because you won't get any points. So you do need to say what you see, unpracticed to Lincoln Clinic, get your patient's to walk and just talk about what you can see. Um It is very apparent on people who just haven't really watched many people walk because it's being able to describe what abnormality you can see and then do just think about the different implications of what you can imagine you can see on, on their gait analysis. Okay. All right. Turn to seen, right. That's great. Does anybody have any questions for me? Thank you, Dan. They were stating of the hair. Okay. Do you have any questions? So I hope you guys are all coming. Well, those of you can kind of be coming to our session in Cambridge next week. Thank you for being a very engaged audience. Um If nobody has any other questions, thank you. Anyone has any other questions for me? Brilliant. All right. Take care everyone. Thank you. Thank you. Cheers. Thanks. Thanks. Thank you.