The amazing power of compensation. Coming to a patient in your office… Maybe today

This gal has had a right sided knee replacement. She has an anatomical right short leg, a forefoot supinatus, an increased Q angle and a forefoot adductus. So, what’s the backstory?

When we have an anatomical short leg, we will often have a tendency to try to “lengthen“ that extremity and “shorten” the longer extremity. This is often accomplished through pelvic rotation although sometimes can be with knee flexion/extension or change in the Q angle. When the condition is long-standing, the body will often compensate in other ways, such as what we are seeing here.

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The fore foot can supinate in an attempt to lenthen the extremity. Note how the right extremity forefoot is in varus with respect to the rearfoot, effectively lengthening the extremity. As you can see from the picture, this is becoming a “hard“ deformity resulting in a forefoot varus.

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Over time, the forefoot has actually “adducted “ as you can see, again in an attempt to lengthen the extremity. Remember that supination is plantar flexion, abduction and inversion, all three which are visible here.


You will also see that the Q angle is less on the right side (se above), effectively lengthening that extremity, but not quite enough as we can see from the picture :-)



Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #shortleg #kneereplacement #tkr #forefootvarus #gait #thegaitguys

There is more than one way around an LLD....

Leg length discrepancies. Love them, hate them, they happen. They can be either functional, anatomical or both.

No matter what the cause, there are numerous ways to compensate for a leg length discrepancy. Today we are going to look at one of the more common ones, "leaning" to the short leg side to create enough clearance for the opposite lower extremity. This patient has a left sided short leg. Note how he abducts his pelvis, utilizing both the stance limb gluteus medius and swing limb quadratus lumborum of the left leg to create enough space to swing the right leg through.

Want to know more about LLD’s and their compensations? Join us on onlinece.com, Wednesday, April 17th for Biomechanics 307. 6 PM Mountain time. See you there!

Dr Ivo Waerlop, one of The Gait Guys.

#LLD #leglengthdifference #leglengthdiscrepancy #leglengthinequality #compensation #gait #gait analysis #thegaitguys

Gait is "all encompassing"

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Last week we did a presentation on some very classic, yet challenging, gait video case presentations. This slide was a big piece of our presentation. 
We discussed that there are volitional and non-volitional movements that accompany the adequate and appropriate postural system control.
If you want to hurt your brain, read this paper. 
But in a nutshell what this paper says is that we have a constant switching between steady state cortical neuron discharge and and non-steady state discharge. For example, when we are on a flat road, no obstacles ahead of us, nothing but boring open road, the system sort of runs on an automated program, making limb movements calculated off of a normal unchallenged baseline. But, if there are roots, rocks, curbs, bikes to dodge, puddles to hurdle etc, the volitional and postural systems must change their operation, and alter limb movements based off of those postural systems as we pay attention, and negotiate the obstacles. There is this delicate symphony occurring between automated posture, calculated posture, rhythmic limb movements. In other words, there are volitional, reactionary and anticipatory plans and adjustments occurring in the background at all times.
But, make no mistake, bad, faulty, inefficient motor patterns can become automated if injuries are left, if they are left partially rehabed, if we teach our clients faulty patterns by overloading them and forcing adaptive patterns to inappropriate load or fatigue. These modifications occur deep in the CNS, much in the premotor cortices, and take into account body schema (their correct or distorted perception of where they are, or their limbs are, in space). Build strength or endurance on an altered schema, one that might be present from an old injury, and one will build strength and endurance where one does not want them to go. Properly training clients, offering corrective exercise and the like is far deeper that just asking your client to load and get stronger, unless you wish to assume that their limitations and compensations are unimportant. This takes us right back to the asymmetry debate, which we know so many love to dive into. Asymmetry is the norm of course, just don't be the person creating more of it for your client.

"Adaptive gait control requires constant recalibration of walking pattern to navigate different terrains and environments. For example, motor cortical neurons do not exhibit altered discharge during steady-state locomotion, but altered discharge occurs when the experimental animal has to overcome obstacles. Loops from the motor cortical areas to the basal ganglia and the cerebellum may contribute to this purpose (ie, contribute to accurate and adaptive movement control that requires volition, cognition, attention, and prediction). In contrast, cortical processing seems unnecessary during the automatic execution of locomotion. Rather, high-level processing may occur in the systems between the basal ganglia, cerebellum, and brainstem in the absence of conscious awareness. - TAKAKUSAKI , Neurophysiology of Gait: From the Spinal Cord to the Frontal Lobe. Movement Disorders, Vol. 28, No. 11, 2013

 

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Holy Leg Length discrepancy!

These pix come to us from one of our brethren, Dr Scott Tesoro in Carbondale of a 73 yr old golfer with mild LBP and a  L knee replacement three yrs ago. He has a VERY short R leg (close to an inch).

What you are seeing is he ultimate compensation for a short leg. Note how he takes the shorter side and supinates it (to the max!). You can see the external rotation of the lower leg and thigh to go along with it. If you look carefully and extrapolate how his left leg would look “neutral”, you can see he has internal tibial torsion on this (right) side as well. He has some increased midfoot pronation on the right compared to the left, but not an excessive amount.

A full length sole lift would probably be in order, as well as potentially addressing some of his compensations. Wow, what a great set of pictures !

One way compensations develop   
  We have all had injuries; some acute some chronic. Often times injuries result in damage to the joint or articulation;  when the ligament surrounding a joint becomes injured we call this a “sprain”.   
  Joints are blessed with four types of mechanoreceptors.  We have covered this in many other posts (see  here  and  here ).  These mechanoreceptors apprise the central nervous system of the position (proprioception or kinesthesis) of that body part or joint via the dorsal column system or spinocerebellar tracts. Damage to these receptors can result in a mismatch or inaccuracy of information to the central nervous system (CNS). This can often result in further injury or a new compensation pattern.   
  Joints have another protective mechanism called arthrogenic inhibition (see diagram above). This protective reflex turns off the muscles which cross the joint. This was described in a few great paper by Iles and Stokes in the late 80’s an early 90’s (vide infra). Not only are the muscles inhibited, but it can also lead to muscle wasting; there does not need to be pain and a small joint effusion can cause the reflex to occur.   
  If the muscles are inhibited and cannot provide appropriate afferent (sensory) and efferent (motor) information to the CNS, your brain makes other arrangements to have the movement occur, often recruiting muscles that may not be the best choice for the job. We call this a “compensation” or “compensation pattern”. An example would be that if the glute max is inhibited (a 2 joint muscle, with a larger attachment to the IT band and a smaller to the gluteal tuberosity; it is a hip extender, external rotator and adductor of the thigh), you may use your lumbar erectors (multi joint muscles; extensors and lateral rotators of the lumbar spine) or hamstrings (2 joint muscles; hip extenders, knee flexors, internal and external rotators of the thigh)  to extend the hip on that side, resulting in aberrant mechanics often observable in gait, which may manifest itself as a shortened step length, increased vertical displacement of the pelvis, lateral shift of the pelvis or increase in step height, just to name a few. Keep this up for a while and the new “pattern” becomes ingrained in the CNS and that becomes your  new default  for that motion.   
    Now to fix the problem, you not only need to reactivate the muscle, but you need to retrain the activity.   Alas, the importance of doing a thorough exam and thorough rehab to fix the problem.    
  Often times, the fix is much more involved than figuring out what the problem is (or was). Take your time and do a good job. Your clients and patients will appreciate it!  

Ivo and Shawn, the gait guys

   Young A ,  Stokes M ,  Iles JF  : Effects of joint pathology on muscle.  Clin Orthop Relat Res.  1987 Jun;(219):21-7  

   Iles JF ,  Stokes M ,  Young A .: Reflex actions of knee joint afferents during contraction of the human quadriceps.  Clin Physiol.  1990 Sep;10(5):489-500.  


  image from:  http://chiroeco.com/chiro-blog/results-to-referrals/2013/04/03/neurology-based-simplified-musculoskeletal-assessment/

One way compensations develop

We have all had injuries; some acute some chronic. Often times injuries result in damage to the joint or articulation;  when the ligament surrounding a joint becomes injured we call this a “sprain”. 

Joints are blessed with four types of mechanoreceptors.  We have covered this in many other posts (see here and here).  These mechanoreceptors apprise the central nervous system of the position (proprioception or kinesthesis) of that body part or joint via the dorsal column system or spinocerebellar tracts. Damage to these receptors can result in a mismatch or inaccuracy of information to the central nervous system (CNS). This can often result in further injury or a new compensation pattern. 

Joints have another protective mechanism called arthrogenic inhibition (see diagram above). This protective reflex turns off the muscles which cross the joint. This was described in a few great paper by Iles and Stokes in the late 80’s an early 90’s (vide infra). Not only are the muscles inhibited, but it can also lead to muscle wasting; there does not need to be pain and a small joint effusion can cause the reflex to occur. 

If the muscles are inhibited and cannot provide appropriate afferent (sensory) and efferent (motor) information to the CNS, your brain makes other arrangements to have the movement occur, often recruiting muscles that may not be the best choice for the job. We call this a “compensation” or “compensation pattern”. An example would be that if the glute max is inhibited (a 2 joint muscle, with a larger attachment to the IT band and a smaller to the gluteal tuberosity; it is a hip extender, external rotator and adductor of the thigh), you may use your lumbar erectors (multi joint muscles; extensors and lateral rotators of the lumbar spine) or hamstrings (2 joint muscles; hip extenders, knee flexors, internal and external rotators of the thigh)  to extend the hip on that side, resulting in aberrant mechanics often observable in gait, which may manifest itself as a shortened step length, increased vertical displacement of the pelvis, lateral shift of the pelvis or increase in step height, just to name a few. Keep this up for a while and the new “pattern” becomes ingrained in the CNS and that becomes your new default for that motion.

Now to fix the problem, you not only need to reactivate the muscle, but you need to retrain the activity. Alas, the importance of doing a thorough exam and thorough rehab to fix the problem.

Often times, the fix is much more involved than figuring out what the problem is (or was). Take your time and do a good job. Your clients and patients will appreciate it!

Ivo and Shawn, the gait guys

Young A, Stokes M, Iles JF : Effects of joint pathology on muscle. Clin Orthop Relat Res. 1987 Jun;(219):21-7

Iles JF, Stokes M, Young A.: Reflex actions of knee joint afferents during contraction of the human quadriceps. Clin Physiol. 1990 Sep;10(5):489-500.

image from: http://chiroeco.com/chiro-blog/results-to-referrals/2013/04/03/neurology-based-simplified-musculoskeletal-assessment/

Podcast 69: Advanced Arm Swing Concepts, Compensation Patterns and more

Plus: Foot Arch Pathomechanics, Knee Pivot Shift and Sesamoiditis and more !

A. Link to our server: 

http://traffic.libsyn.com/thegaitguys/pod_70ff.mp3

Direct Download: http://thegaitguys.libsyn.com/podcast-70

Permalink: 

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

http://store.payloadz.com/results/results.aspx?m=80204

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

1. “Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”
What happens when we change the length of one leg? How do we compensate? Here is a look at the short term consequences of a newly acquired leg length difference.
http://www.ncbi.nlm.nih.gov/pubmed/24857934
2. Medial Longitudinal Arch Mechanics Before and After a 45 Minute Run
http://www.japmaonline.org/doi/abs/10.7547/12-106.1

3. Several months ago we talked about the pivot-shift phenomenon. It is frequently missed clinically because it can be a tricky hands on assessment of the knee joint. In this article “ACL-deficient patients adopted the … .* Remember: what you see in their gait is not their problem, it is their strategy around their problem.
http://www.clinbiomech.com/article/S0268-0033(10)00264-0/abstract

4.Do you know the difference between a forefoot supinatus and a forefoot varus?
"A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation. ”
http://www.ncbi.nlm.nih.gov/pubmed/24980930

5. Pubmed abstract link: http://www.ncbi.nlm.nih.gov/pubmed/24865637
Gait Posture. 2014 Jun;40(2):321-6. Epub 2014 May 6.
Arm swing in human walking: What is their drive?
Goudriaan M, Jonkers I, van Dieen JH, Bruijn SM

6. This is Your Brain On Guitar
http://www.the-open-mind.com/this-is-your-brain-on-guitar/

Go ahead and try this at home.   remember last mondays post? (if not, click  here ). Here is one way of telling whether your (or someone else’s) vestibular system is working. It will also give you an idea of how some people compensate.     Ready?     
  Stand up (barefoot or shoes does not matter). 
   place your hands resting on the top of your hips with your thumbs to the back (like your Mom used to, when you were in trouble). Your thumbs should be resting on your quadratus lumborum (QL) muscle.  
   tilt your HEAD to the LEFT 
   you should feel the muscle (ie the QL) under your RIGHT thumb contract 
   come back upright 
     repeat, but this time lean your BODY to the LEFT     
  same thing right? Now check the other side. 
    Everything OK? Everything fire as it should?   Now lets add another dimension. 
  slide your fingers down so they are just below the crest of the hip, resting above the greater trochanter (the bump on the side of your upper thigh). This should place your fingers on the middle fibers of the gluteus medius. 
   tilt your head (or body ) to the LEFT. 
   You should feel the LEFT gluteus medius and the RIGHT QL contract. These muscles should be paired neurologically. When walking, during stance phase on the LEFT: the LEFT gluteus medius helps to maintain the pelvis level, while the RIGHT QL, assists in hiking the RIGHT side. 
   If everything works OK, then your vestibulospinal spinal system is intact and your QL and gluteus medius seem to be firing and appropriately paired. If not? That is the subject for another post.     The Gait Guys. Helping you to understand the concepts of WHY compensations occur.

Go ahead and try this at home.

remember last mondays post? (if not, click here). Here is one way of telling whether your (or someone else’s) vestibular system is working. It will also give you an idea of how some people compensate.

Ready?

  • Stand up (barefoot or shoes does not matter).
  • place your hands resting on the top of your hips with your thumbs to the back (like your Mom used to, when you were in trouble). Your thumbs should be resting on your quadratus lumborum (QL) muscle.
  • tilt your HEAD to the LEFT
  • you should feel the muscle (ie the QL) under your RIGHT thumb contract
  • come back upright


repeat, but this time lean your BODY to the LEFT

  • same thing right? Now check the other side.


Everything OK? Everything fire as it should?

Now lets add another dimension.

  • slide your fingers down so they are just below the crest of the hip, resting above the greater trochanter (the bump on the side of your upper thigh). This should place your fingers on the middle fibers of the gluteus medius.
  • tilt your head (or body ) to the LEFT.
  • You should feel the LEFT gluteus medius and the RIGHT QL contract. These muscles should be paired neurologically. When walking, during stance phase on the LEFT: the LEFT gluteus medius helps to maintain the pelvis level, while the RIGHT QL, assists in hiking the RIGHT side.


If everything works OK, then your vestibulospinal spinal system is intact and your QL and gluteus medius seem to be firing and appropriately paired. If not? That is the subject for another post.

The Gait Guys. Helping you to understand the concepts of WHY compensations occur.

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Things may not always be how they appear.

What can you notice about all these kids that you may not have noticed before?

Look north for a moment. What do you notice about all the kids with a head tilt? We are talking about girl in pink on viewers left, gentleman in red 2nd from left, blue shirt all the way on viewers right. Notice how the posture of the 2 on the left are very similar and the one on the right is the mirror image?

What can be said about the rest of their body posture? Can you see how the body is trying to move so that the eyes can be parallel with the horizon? This is part of a vestibulo cerebellar reflex. The system is designed to try and keep the eyes parallel with the horizon. The semicircular canals (see above), located medial to your ears, sense linear and angular acceleration. These structures feed head position information to the cerebellum which then forwards it to the vestibular nucleii, which sends messages down the vestibulo spinal tract and up the medial longitudinal fasiculus to adjust the body position and eye position accordingly. 

Can you see how when we add another parameter to the postural position (in this case, running; yes, it may be staged, but the reflex persists despite that. Neurology does not lie), that there can be a compensation that you may not have expected?

What if one of these 3 (or all three) kids had neck pain. Can you see how it may not be coming from the neck. What do you think happens with cortical (re)mapping over many years of a compensation like this? Hmmm. Makes you think, eh?

Ivo and Shawn. The Gait Guys. Taking you a little further down the rabbit hole, each and every post.

 Master of your own physiology  
  You don’t need perfect mechanics to win. Look at these fine gents and take note.  
 On the left we have Kenensia “Canny” Bekele, world and Olympic 5,000m and 10,000m world record holder, who sat back as Mo Farah and Haile Gebrselassie set the pace for most of the race, and then sprinted at the end and won by 1 second. Note the crossover and lack of space between his thighs. Note also the internal tibial torsion of the left tibia and slight head tilt to the right. 
 In the middle is Mo Farah, the current 10,000 meter Olympic and World champion and 5000 meter Olympic, World and European champion. look at the pelvic dip on the right..and the valgus angle of the left knee…and external tibail torsion of the left tibia…and the differing arm swing (right side abducted). 
 Finally, on the right,  we have Haile Gebrselassie, an Ethiopian like Bekele, who won two Olympic gold medals over 10,000 meters and four Wld Championship titles in the event. He won the Berlin Marathon four times consecutively and also had three straight wins at the Dubai Marathon.  At 40, he is the eldest of the group, with his right lower extremity external tibial torsion and subtle dip of the left pelvis on right sided weight bearing. 
 So What? All these great athletes have mastered their own physiology and overcome any biomechanical faults they may appear to have. Could they be faster? Maybe. We think so. 
 Your body will find a way to compensate. That does not mean you will be slower. It means, like each of these men, that you will probably be injured at some point. 
 In the words of Big Z from Surf’s Up “Winners find a way”. You can too and so can your clients and athletes. Skill, endurance and strength. The big 3. Make sure you an the folks you care for have them. 
  We are The Gait Guys. Teaching you more with each post we write and helping you sort through the sea of information out there.

 Master of your own physiology

You don’t need perfect mechanics to win. Look at these fine gents and take note.

On the left we have Kenensia “Canny” Bekele, world and Olympic 5,000m and 10,000m world record holder, who sat back as Mo Farah and Haile Gebrselassie set the pace for most of the race, and then sprinted at the end and won by 1 second. Note the crossover and lack of space between his thighs. Note also the internal tibial torsion of the left tibia and slight head tilt to the right.

In the middle is Mo Farah, the current 10,000 meter Olympic and World champion and 5000 meter Olympic, World and European champion. look at the pelvic dip on the right..and the valgus angle of the left knee…and external tibail torsion of the left tibia…and the differing arm swing (right side abducted).

Finally, on the right,  we have Haile Gebrselassie, an Ethiopian like Bekele, who won two Olympic gold medals over 10,000 meters and four Wld Championship titles in the event. He won the Berlin Marathon four times consecutively and also had three straight wins at the Dubai Marathon.  At 40, he is the eldest of the group, with his right lower extremity external tibial torsion and subtle dip of the left pelvis on right sided weight bearing.

So What? All these great athletes have mastered their own physiology and overcome any biomechanical faults they may appear to have. Could they be faster? Maybe. We think so.

Your body will find a way to compensate. That does not mean you will be slower. It means, like each of these men, that you will probably be injured at some point.

In the words of Big Z from Surf’s Up “Winners find a way”. You can too and so can your clients and athletes. Skill, endurance and strength. The big 3. Make sure you an the folks you care for have them.

We are The Gait Guys. Teaching you more with each post we write and helping you sort through the sea of information out there.

"Action Expresses Priorities"- Gandhi

“Action expresses priorities.” -Mahatma Gandhi
So much truth to this statement.  It pertains to gait analysis perfectly.  
For years now you have heard us say, “What you see is NOT what is wrong with someones gait, rather you see their COMPENSATION STRATEGY around what IS wrong." 
The body is always strategizing to negotiate around pain, instability (functional or anatomic) or immobility.  What you see in gait are those strategies. You may not see their immobility for example, you see how they move when increasing mobility in one or multiple areas to cope with immobility in another. 
*Translation= The gait action strategy you see expresses the body’s compensation priority to make gait possible around the underlying problems that are preventing the clean, optimal and primary gait motor pattern from surfacing.
Thanks to Gray Cook for unearthing this Gandhi quote on his twitter.
So what do we see here?


a limp on the left?
a short leg on the right?
a weak gluteus medius on the left?
a shortened step length on the right?
increased arm swing on the left?

watch the push off (terminal stance/pre swing) on the right and then the left. Note how the left is weaker?
now watch the heel strike. Notice how it is shorter when the right strikes the ground than the left?
did you note the pelvic shift to the left on L stance phase? How about the subtle increased knee flexion on the left?

This gentleman has an atrophied gastroc/soleus on the left from an injury. He compensates by increasing thigh flexion on the left to clear the leg. Because he has lost gastroc/soleus strength on the left (the lateral gastrocis an important inverter of the heel after midstance and important component of rearfoot supination), the rearfoot everts more. allowing more midfoot pronation. This collapse of the midfoot brings his weight more medially, so he shifts his pelvis laterally (to the left) to keep his center of gravity over the foot.

Fix?

  • Make client aware of what is going on.
  • make sure gastroc/soleus complex strength and function is maximized through muscle work, acupuncture, muscle activation, functional gait exercise

The Gait Guys. Bringing you the meat, without the filler.

Copyright 2012: The Gait Guys/The Homunculus Group. All rights reserved. Don’t rip off our stuff!

Muscle coordination is habitual rather than optimal.

The nervous system often takes the path of least resistance. Gait compensations are similar. What you are sometimes are seeing is the “least common denominator” with regards to compensation and conservation of energy.  Here is an article that exemplifies this finding.






Abstract

When sharing load among multiple muscles, humans appear to select an optimal pattern of activation that minimizes costs such as the effort or variability of movement. How the nervous system achieves this behavior, however, is unknown. Here we show that contrary to predictions from optimal control theory, habitual muscle activation patterns are surprisingly robust to changes in limb biomechanics. We first developed a method to simulate joint forces in real time from electromyographic recordings of the wrist muscles. When the model was altered to simulate the effects of paralyzing a muscle, the subjects simply increased the recruitment of all muscles to accomplish the task, rather than recruiting only the useful muscles. When the model was altered to make the force output of one muscle unusually noisy, the subjects again persisted in recruiting all muscles rather than eliminating the noisy one. Such habitual coordination patterns were also unaffected by real modifications of biomechanics produced by selectively damaging a muscle without affecting sensory feedback. Subjects naturally use different patterns of muscle contraction to produce the same forces in different pronation-supination postures, but when the simulation was based on a posture different from the actual posture, the recruitment patterns tended to agree with the actual rather than the simulated posture. The results appear inconsistent with computation of motor programs by an optimal controller in the brain. Rather, the brain may learn and recall command programs that result in muscle coordination patterns generated by lower sensorimotor circuitry that are functionally “good-enough.”

J Neurosci. 2012 May 23;32(21):7384-91.

YET MORE compensations for short legs…

We remember from from the last few weeks, there at least SIX common compensations for a short leg. Last week we looked at hip hiking. Here is the list, in case you needed a reminder:

  • hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive knee bend on the long leg side
  •  pronation of the longer side, supination of the shorter
  • leaning to he shorter leg side
  • circumduction of the longer leg around the shorter
  • excessive ankle plantar flexion on short side

This time we will look at excessive knee bend on the long leg side. Normally the knee bends about 20 degrees at loading response/ midstance, and about 50 degrees during swing phase to create “clearance”.

Watch this gals R knee during swing. Yes, she has an abnormality of the R great toe extensor (torn extensor hallicus longus and brevis), but also a L short leg. It makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the longer leg.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Excessive knee flexion. Yet another compensation to look out for. 

Ivo and Shawn. …still bald…still good looking…still geeky…… The Gait Guys

Clearing that long leg….

Even MORE on short legs…

We remember from last week, and the week before, there at least SIX common compensations for a short leg.

We recounted them and spoke about leaning to the side of the short leg last time. Here are the others, in case you need a reminder:

  •  pronation of the longer side, supination of the shorter
  • circumduction of the longer leg around the shorter
  •  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive ankle plantar flexion on short side
  •  excessive knee bend on the long leg side

Lets look at “circumduction" of the longer extremity. Swinging the longer leg out and around helps to create clearance for the longer leg.  It makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the asymmetry. This can sometimes occur with one of the other compensations, but we usually see it by itself.

This compensation often occurs with a pelvic dip on the same side, due to weakness of the gluteus medius complex.

Watch the above video (which we slowed down for you) that we captured on “the Gait Cam” a few times to see what we are talking about. This person has a left short leg and has a pelvic drift during stance phase to that side . We slowed it down so it is easier to see.

Remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Circumduction….Tautological gait…Increasing your gait vocabulary on a daily basis..

Ivo and Shawn.

Lean on me…

More on short legs…

We remember from last week, there are several common compensations for a short leg.

We recounted six common adaptations and spoke about pronation of the longer side, and supination of the shorter side last time. Here are the others, in case you need a reminder:

  •  lean of torso to the short leg side
  • circumduction of the longer leg around the shorter
  •  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive ankle plantar flexion on short side
  •  excessive knee bend on the long leg side

Lets look at “The lean”. Leaning to the short side helps to create clearance for the longer leg. The lean in essence helps to lift the pelvis on the swing side by using a shift body mass to the stance leg, similar to in a Trendelenburg gait. It makes no difference if the leg is functionally or structurally short, the body still needs a strategy to move around the asymmetry. The lean can often be mistaken for a weak gluteus medius on the side they are leaning to (which would look very similar). Sometimes, the two can occur concurrently as well. 

Often with “the lean” there will be an increased arm swing on the opposite side to “help” pull the long leg through , while creating a counter balance effect.

Watch the above video several times to see what we are talking about. This person has a left short leg and leans to that side. We slowed it down so it is easier to see.

Again, the thing to remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Short legs and compensations. There not just for breakfast anymore.

Ivo and Shawn. Two guys with two short legs… ; )



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There is more than one way around a long leg…..
or…There are many compensations for a short leg

The 1st in a series…

You have heard us speak on LLD’s (leg length deficiencies) in previous posts here, here and here; but how about the compensations? What will you see visually?

We count about six common adaptations:

  •  pronation of longer side, supination of shorter side
  •  lean of torso to the short leg side
  • circumduction of the longer leg around the shorter
  •  hip hike on long leg side (seen as contraction of hip abductors, obliques and quadratus  lumborum on short leg side)
  • excessive ankle plantar flexion on short side
  •  excessive knee bend on the long leg side


The thing to remember here is that what you are seeing is the compensation, not necessarily the problem. When one leg is shorter, something must be done to get the longer leg through swing phase.

Lets look at the pronation/ supination scenario:

We often (but not always) see increased pronation on the longer leg side, in the bodies attempt to shorten the extremity. This is often accompanied by posterior rotation of the ilia on that side, resulting in saggital plane imbalances. This, of course, puts the external and internal obliques, as well as quadratus lumborum on that side in a shortened position, decreasing their mechanical efficiency. This all contributes to a loss of hip extension and usually, a loss of ankle rocker.

How about transverse plane changes? The lower extremity spins internally which places the vastus lateralis in a position of mechanical advantage, and the gluteus maximus and middle and posterior fibers of the gluteus medius in lengthened position, decreasing their efficiency, while placing the anterior fibers of the medius and minimus in a position of increased mechanical advantage. These changes will often contribute to changes in the frontal plane, often causing a “shift” to one side during walking and running gait.

Frontal plane dysfunction will be determined by the degree of functional leg length discrepancy created, along with how the other compensations are playing out.

Wow! Really, six compensations for a short leg? There are many more, these are only the most common ones we see. You probably see others in your analysis we haven’t mentioned here.

Stay tuned for more on this subject in future posts!

We are THE Gait Guys. Not set on world domination, just foot and gait literacy…

So. How did you do?

As you can see, this individual lists to the R upon weight bearing on that side (midstance); did you pick up the increased progression angle of the foot on that side? How about the mild genu valgus?

Why would someone walk like this? There are a few plausible explanations.

1. he has a weak gluteus medius on the R side.

2. he has a R short leg and needs to lean to that side to get the long leg side (L) to clear.


3. impaired left ankle rocker (causing premature heel rise and left side early departure) could also cause him to accelerate onto the right as well.

His options to compensate are to either lean to the weak side ® or to shift his pelvis to the weak side ®. He could also circumduct the leg or flex the thigh to get that side to clear the ground. He has a mild BL circumdcution, probably to clear the knee from the opposite one.

His increased arm swing on the L is to help propel him forward, most likely due to weakness of the external obliques to assist in initiation of flexion of the thigh, and weakness of the gluteus medius, which also helps to propel the leg forward. He also does not push off adequately with the R leg; This is probably due to loss of hip extension and inadequate ankle rocker on that side.

The increased progression angle on the R helps to stabilize his body weight because he is leaning the torso to the R and his center of gravity moves right as well (he makes a wider base for himself)

Yup, you’re a geek!   We remain The Geeks of Gait…Ivo and Shawn