Brian LaRue, DPT, ATC, brings the benefits of gait training and analysis to a busy practice.

A skill learned before vivid memories are formed, walking is something most people do without giving much thought to the complicated biomechanics involved in the process—until something starts to hurt.

Among other factors, proper gait encompasses a person’s step length, foot placement, joint movements, and balance—and goes a long way to a healthy, pain-free life.

“The foot and ankle are contributors to a lot of problems of the lower extremities in general, so if a patient comes in with an ankle problem, you can’t just look at that joint; you have to look above and below it,” says Brian LaRue, DPT, ATC. “And when patients come in with other problems, I always take a look at what is happening at the foot and ankle to determine if there are any biomechanical aberrations, differences that may need to be addressed.”

LaRue’s interest in gait training was sparked while attending graduate school at Widener University, Chester, Pa, where he studied and learned under his professor, Chris Wise, PT, MSPT, OCS, ATC, MTC. He continues to focus on this niche as a full-time physical therapist (PT) at PRO Physical Therapy’s Pike Creek Center location in Wilmington, Del.

Employing seven full-time PTs, three athletic trainers, and two physical therapist assistants, the Pike Creek Center cares for between 400 and 500 patients each week. Established more than a decade ago, PRO Physical Therapy is owned and operated exclusively by PTs; and its 14 locations serve communities in Delaware, Maryland, and Pennsylvania.

During his 4 years with the practice—beginning as an aide, then a certified athletic trainer, and finally a PT—LaRue has clocked time in several of these locations. He has been at his current facility for more than a year, and he spends his time working with a wide variety of patients.

“This clinic sees primarily younger sports-medicine cases, treating a lot of high school kids, weekend warriors—just athletes in general,” LaRue says, adding that alongside their regular clientele, the therapists at the Pike Creek Center also care for a considerable number of nonsports-related injuries. “We do see our fair share of postoperative patients—total-knee replacements, total-hip replacements—and [anterior cruciate ligament (ACL) reconstructions], bunionectomies, and numerous other upper and lower extremity injuries.”

The full-service facility is also equipped to treat stroke patients and those with neurological conditions, including one recent patient who suffers from an extremely rare condition known as transverse myelitis.

A Perfect Fit

Treating such a broad spectrum of patients is possible because of PRO Physical Therapy’s commitment to tailoring treatment to the individual. This philosophy is a perfect complement to LaRue’s personal approach to gait analysis.

Though assessments are as unique as the patient being treated, LaRue starts with the basics, observing his patients in a static examination, which allows him to note their natural stances, and what is occurring in a weight-bearing status. He follows with a moving exam, which can be as simple as having clients walk down the hall and observing them to putting them on a treadmill and asking them to walk or run.

“I also have patients lie on a table for a full non-weight-bearing exam, which allows me to look at their foot and ankle biomechanics, as well as identify any sagittal, frontal, and transverse plane abnormalities, and feel with my hands to see what is really happening,” he says. “If anybody is having a gait problem, they will receive some form of gait training through individual, patient-oriented treatment.”

Treatment requires attention to detail along with consistent—and often hands-on—adjustments, reteaching people how to walk properly.

“Someone’s going to walk how they feel most comfortable, and you have to correct them by using proprioceptive feedback through your hands to show them the right way while they’re walking, breaking it down step-by-step, or by providing verbal feedback once they’ve completed the task,” LaRue says.

Because they work primarily with athletes, the therapists at the Pike Creek Center are committed to getting patients not only back on their feet but back in the game as well.

“Getting the younger athletes strong and improving their motion is not sufficient; you have to get them back to playing their sport,” LaRue says. Catering to their client base, the clinic’s therapists have designed an advanced training program to elevate the patient’s level of postinjury performance beyond what was established before he or she was injured. “We strive in making them better and faster than they were prior to the injury using plyometrics, speed, endurance, and agility training,” LaRue explains.

Taking a Team Approach

His interest and extensive experience with gait analysis and training makes LaRue a valuable resource to the PRO Physical Therapy clinics.

“It’s always been here, but it has evolved into my niche. More of my colleagues are becoming interested in focusing on how problems in the foot and ankle are often the cause of trouble in other joints,” he says. “There are times when they have a patient with a foot or ankle type of problem, and they will have me take a look at them to get my opinion and advice.”

The open atmosphere in the clinic helps foster this spirit of information sharing, encouraging therapists to play off each other’s strengths and collaborate on specific cases.

In addition to these impromptu consultations, committees were established that specialize on a specific aspect of therapy. For example, one has been formed for the upper extremities, another for the lower extremities, and one for aquatic therapy.

Composed of therapists and athletic trainers from throughout the organization, these teams meet monthly and provide an opportunity for these professionals to work in concert on challenging cases.

The teamwork extends to physicians who refer their patients to the team at the Pike Creek Center. When they see someone for the first time, the therapists perform a complete assessment and give the physician a written evaluation and detailed treatment plan.

“PRO Physical Therapy really focuses on having the same therapist work with the same patients to ensure continuity of care,” LaRue says. “You develop a rapport with them, and every day they walk into the clinic you talk with them and ask how they are doing—so every time you see this person, their condition and progress is being evaluated.”

Therapists also provide a full re-evaluation every eight to 10 visits, depending on the patient and what he or she needs, laying out the patient’s advancement and recommendations for continuing therapy. Between documented reports, therapists will contact physicians directly, if necessary, to discuss the patient’s care or progress.

Size Matters

The nature of gait training demands lots of room to move. Being able to work without the confines of a cramped environment helps ensure the best results from techniques such as plyometrics and speed and agility training, according to LaRue, who makes use of much of the 8,000 square feet of space in his current facility.

It is also important to have a variety of equipment options available during therapy. LaRue works with both common pieces found in any quality neighborhood gym—such as treadmills and elliptical trainers—and unique options like pools for aquatic training and a patented machine that provides benefits similar to those from a stair machine but allows the patient to sit.

This type of variety is important to keep patients challenged. The recent transverse myelitis case treated at Pike Creek Center is just one example. When she first came to the clinic, the patient had significant balance issues and was unable to walk without the assistance of a cane. She had previously been confined to a walker and was very skeptical about the possibility of walking without any device.

“I started her in the pool, where we could really work on her balance and core strength, meanwhile breaking down the gait cycle while unloading her legs. We got her walking correctly,” LaRue says. A month later, she was transitioned to dry-land training that challenged her balance by having her walk on various surfaces, such as foam mats and grass. “I would also take her outside and have her step up and over curbs, just finding ways to challenge her balance. At this point, she is functionally fully independent and doesn’t need any sort of walking assistance whatsoever,” he says.

Getting Better Means Getting Involved

LaRue’s focus extends beyond treating injured athletes. In addition to his full-time position, he volunteers regularly as part of a community-based program for healthy runners.

Created by a local podiatric surgeon, Ray Feehery, DPM, the clinics are free of charge and allow runners to obtain flexibility, strength, and biomechanical screening.

“Dr Feehery videotapes them and looks at them biomechanically in slow motion for the analysis,” LaRue says. Each participant receives a report card detailing their injury potential and a list of areas they need to work on relating to their flexibility or strength. The report card also includes advice on shoewear selection. “He gives recommendations for things that might help them, such as the need for over-the-counter orthotics or a stronger, tailored fit of a custom orthotics built for them,” LaRue notes.

These screening opportunities are scheduled on request, but usually take place once or twice per month. LaRue volunteers at all of them, lending a hand in the screening, evaluating the runners’ flexibility and strength. As much as these encounters help the athletes, the returns have been monumental for LaRue.

“The hands-on experience is invaluable, and I’m able to take a lot of what I’ve learned over there and apply it to my patients,” he says. “It has provided me with a better understanding, and it makes a difference when I conduct evaluations on my patients, making me much more comprehensive and thorough.”

Plugging Into Experience

LaRue’s professional relationship with Feehery extends beyond the time he volunteers to screen local sports enthusiasts. About 4 months ago, LaRue began making rounds with Feehery. This has provided additional real-world experience that has not only added to LaRue’s enjoyment of his field, but has greatly expanded his knowledge base.

“He has a strong biomechanical background, and he has been teaching me everything he knows as far as how to look at the foot and ankle and the biomechanics involved,” says LaRue, who connected with the physician simply by calling him and expressing an interest in learning more about the speciality. “A lot of our therapists often do rounds with a variety of doctors in the area including podiatrists, because in addition to really learning under them, it gives us a chance to get a better idea of what they want to see in the clinic and what we can do to serve them and our patients better.”

Finding and shadowing a professional well versed in gait analysis and training is something LaRue highly recommends for those interested in learning more about the specialty.

Aside from the work he does with Feehery, LaRue counts himself fortunate to be mentored by Paul Schweizer, PT and part owner of PRO Physical Therapy, who also works at the Pike Creek Center.

“Paul has been a therapist for the past 25 years and has run countless Boston marathons, and I was lucky enough to come into this clinic with him and have the opportunity to learn under him,” he says. “I think finding a mentor is a very important thing, because it gives you access to someone you can go to with any questions, as well as pull from them as much knowledge as they have.”

On the Horizon

As his own enthusiasm about gait training continues to grow, LaRue sees the field increasing and garnering more attention on a regular basis. He believes it will continue to grow as more people learn about the important role proper gait plays in treating patients.

“Before I started studying it extensively, I didn’t realize how much the foot and ankle affected things. I think a big part of it is getting the information out, because once people realize how important it is, they’ll be eager to learn more about it,” LaRue says. “This is patient-oriented care and in some cases, you can treat the knee forever, but if you don’t treat the foot and ankle, the patient is never going to get better—and our job is to get patients better.”

Dana Hinesly is a contributing writer for Physical Therapy Products.