The power to bend bones.

What have we here? Hmmm. This little girl was brought in by her mother because of intermittent knee pain and “collapsing” of the knees while walking, for no apparent reason.

The ankle dorsi flexion (or ankle rocker; see last 2 pictures; we are fully dorsiflexing the ankles)  needs to occur somewhere, how about the knees? Or in this case, the tibia. Wow!

You are looking at a 4 year year with a condition called genu (and tibial) recurvatum. Genu recurvatum is operationally defined as knee hyperextension greater than 5 degrees. The knee is hyperextended, and in this case, the tibia is literally “bent backward”. Look at the 2 pictures of her tibia.

Generally speaking, the tibial plateau usually has a slight posterior inclination (as it does in this case; look carefully at the 1st picture) causing the knee to flex slightly when standing. Sometimes, if it is parallel with the ground and the center of gravity is forward of the knees, the knee will hyperextend (or in this case, the tibia will bend) to compensate.

In this particular case, the tibia has compensated more, rather than the knee itself. The knee joint is stable and there is no ligamentous laxity as of yet. She does not have a neurological disorder, neuromuscular disease or connective tissue disorder. She has congenitally tight calves.

As you can imagine, her step length is abbreviated and ankle rocker is impaired.

So what did we tell her Mom?

• keep her barefoot as much as possible (incidentally, she loves to be barefoot most of the time, gee, go figure!)
• have her walk on her heels (she’s a kid, make a game of it)
• showed her how to do calf stretches
• balance on 1 leg with her eyes open and closed
• keep her out of backless shoes (like the clogs she came in with)
• keep her out of flip flops and sandals where she would have to “scrunch” her toes to keep them on.
• follow back in 3 months to reassess

There you have it. Next time you don’t think Wolff’s (or Davis’s) law* is real, think about this case. Want to know more? Consider taking our National Shoe Fit Program, available by clicking here.

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*Wolff’s law: Bone will be deposited in areas of stress and removed in areas of strain. or put another way: bone in a healthy person or animal will adapt to the loads under which it is placed

Davis’s law: soft tissue will adapt to the loads that are placed on it

Another Gait variant: The Apropulsive gait style

Here is another important video for all you gait fanatics out there. You will see some of these components in your athletes, patients, family or even yourself if you are paying enough attention.

These animated videos are great because they exaggerate the pathology.  Here we see several things:

1. excessive forward arm swing: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
2. forward head “bobbing”: again, this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
3. a heavy forward lurching lean: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.
4. pronounced knee lift-hip flexion: this is attempting to create a forward propulsive action to help them move over the suspected primary biomechanical gait pathology.

So, what is driving all of these attempts to create more than normal forward propulsion ?

If you look down at the feet you see a lack of ankle rocker (dorsiflexion) as evidenced by early heel departure. This fella puts his foot on the ground and then tries to move across his ankle but he hits a restriction at the range limitation. He cannot move forward sufficiently to normalize a sound effective and efficient propulsive gait.  At the moment his ankles lock out from hinging further forward he must go into the above strategies to pull his body mass forward past his foot plant and literally pull the foot off the ground and move forward to the next dysfunctional step. Everything he is doing is to try to create forward propulsion sufficient to move across ankles that do not dorsiflex enough.

* IMPORTANT: Remember: premature heel rise typically leads to premature activation of the calf muscles, gastrocsoleus. And when this happens, the gait becomes vertical and bouncy in nature as the calf muscles are being used to lift the body more than to propulse it forward. This can lead to posterior compartment injury. Additionally, this causes a quick premature forefoot loading response which can create increased burden on the METatarsal head and fat pad but it will also create a grip response of the toes and possible hammering which can disable the lumbricals and other foot intrinsic muscles).

And if that isn’t bad enough, on the sagittal views, we see the knees hinging outside the normal forward progression line and if that isn’t bad enough, on the views from behind he clearly is dipping the contralateral hip-pelvis during stance phase (when standing on the right leg, the left pelvis drops) which is a key sign of suspect gluteus medius weakness. 

even the simple cases have nice topics for review.  Failure to have sufficient components for effortless forward motion in gait will result in compensations to get the job done.

TAKE HOME POINT: identifying and restoring ankle rocker is pretty darn important. And that does not mean simply via stretching the posterior compartment. Frequently the anterior compartment is the weakness driving the pathology, but not always.

Pixar should call us……… Shawn and Ivo

The Guys of all things Gait