Knee hyperextension? Or does this photo suggest something more ?

You walk into the exam room and see a patient standing there just like this, What thoughts immediately flood your head ?
For me, I quickly start to juggle some things like, this:

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- anterior-meniscofemoral impingement ? Are his first words going to be knee pain ?
- tibial tuberosity/osgood type traction issue due to quad dominance? Are his first words going to be knee pain?
-loss of ankle rocker? Are his first words shin pain or plantar foot pain?
- tibialis posterior tendinitis ? Is he going to point to the medial ankle gutter or lower medial shin as his pain area?
-likely anterior pelvis tilt (hence weak lower abdominals), weak glutes, low back pain ?
-hamstring tightness, cramps, pain, posterior knee pain?

Just rambling real fast this morning after seeing this picture on an old hard drive.
Train your brain to think fast, think of possibilities top to bottom, don't wait for your patient to tell you where their problem is.
I play this game when i ask all my patients to walk to the back of the office to my exam room. I am watching, thinking, mental gymnastics.
Our jobs are to solve puzzles, put meaningful pieces together, to solve problems.
I use the analogy of building a puzzle. You open the box, search out the straight peripheral edges, then clump together colors, patterns. Your history and examination and gait observation should be about a process of putting together the most likely clinical picture and puzzle. And then you start to execute. Sometimes you have to walk things back, but you have to start somewhere.
But, if you wait until you get into the room, wait for the patient to say, "anterior knee pain" to start your thinking, it is easy to get tunnel vision and forget all of the other possible pieces of the puzzle that might be playing into that anterior knee pain.
REmember this, how your client moves , poorly or well, is not the problem, it is just how they are moving with the pieces and patterns available to them or how they are avoiding patterns that are painful. How they move is not the problem, it is their strategy. It is our job to find out why they are moving that way, and if it is relevant to their complaint.
Start big, funnel to small.

Shawn Allen, the other gait guy
#gait, #gaitanalysis, #gaitproblems, #clinicalthinking, #buildingpuzzles

The over extended knee, genu recurvatum. Watch your kids.

In 2011, in our infancy here at The Gait Guys, we were at the airport. And we saw this . . . .

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What do you see here in this young lady ? What you should see here matters. They are just visual things, and lead to visual hypotheses, but it is your job to prove or disprove them. If you like to play these kinds of mental gymnastic games, this is valuable work. This is the work that sets you up to move skillfully, quickly and confidently in the exam and treatment room.
Join us for a rewind, back to 2011.

A young lady with knee recurvatum. Even at the airport you are not safe from The Gait Guys !

Standing waiting for my parents luggage I had to do a double take when i saw this excessive genu recurvatum of the knees. Of course it was much worse in person because of the added dimension that a photo cannot give.  This poor gal probably doesn’t even know she needs us. 

What do we see here and what assumptions can we extrapolate (assumptions from mere standing of course)  ?:

We are going to keep it to things from pelvis down or we will be here all day.

  1. Anterior pelvis tilt. She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  Combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis.
  2. The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extennsion.
  3. The knees are likely locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis.
  4. She will be in relative ankle plantarflexion instead of balancing the tibia neutrally over the talus.  Relative constant plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. This gal will likely have problems controlling pronation we suspect because of such assumed imbalances.

These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. I was going to walk behind to take a pic so we could make some assumptions about the frontal plane, but people all around were already getting suspicious of me snap photos of so many of them. 

Remember, these are just assumptions from a single static photo. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us.

Oh, and we must not forget to once again thank Mr. UGG boot for helping add another dimension of challenge to this lovely lady ! Although this assumption would be better made off of a frontal plane photo.

Beware of geeks in the airport and shopping malls snapping photos and video. It is likely us, The Gait Guys.

Shawn and Ivo

rewind: https://thegaitguys.tumblr.com/post/14809328401/a-young-lady-with-knee-recurvatum-even-at-the

Singer Songwriter Jewel and her knee hyperextension. 
 One of our favorite television shows is “Alaska: The Last Frontier”.  What some of you might not know is that the show is about Singer Songwriter Jewel’s family, the Kilchers. Yes, Her name is Jewel Kilcher.  The theme to the show is written and sung by Jewel and her father Atz Kilcher.  The Kilcher’s are tough folk who live off the grid (mostly) and maintain a subsistence living off the land in Alaska.   
 Use the photo above to help you clearly understand what we are talking about in this video  here (link)   where we see Jewel and her dad getting ready to sing the show’s theme. In this video, Jewel is in some insanely high heeled shoes and being the gait geeks that we are we could not help but notice the degree of knee hyperextension she was displaying.   
 What can we extrapolate from this genu recurvatum / hyper extension knee posturing  ?: 
 We are going to keep it to things from pelvis down or we will be here all day. 
   Anterior pelvis tilt.  She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  In many cases combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis. 
 The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extension, the pelvis is often also translated forward into the sagittal plane pushing the head of the femur into anterior glide into the front of the acetabulum. 
 The knees are often locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis. 
 She will be in ankle plantarflexion because of the footwear instead of balancing the tibia neutrally over the talus.  The tibia will rest on the posterior talus. If constant, the plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve.  
  These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now.  
 Remember, these are just assumptions. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us. 
 The Gait Guys. 
 Shawn and Ivo

Singer Songwriter Jewel and her knee hyperextension.

One of our favorite television shows is “Alaska: The Last Frontier”.  What some of you might not know is that the show is about Singer Songwriter Jewel’s family, the Kilchers. Yes, Her name is Jewel Kilcher.  The theme to the show is written and sung by Jewel and her father Atz Kilcher.  The Kilcher’s are tough folk who live off the grid (mostly) and maintain a subsistence living off the land in Alaska.  

Use the photo above to help you clearly understand what we are talking about in this video here (link)  where we see Jewel and her dad getting ready to sing the show’s theme. In this video, Jewel is in some insanely high heeled shoes and being the gait geeks that we are we could not help but notice the degree of knee hyperextension she was displaying.  

What can we extrapolate from this genu recurvatum / hyper extension knee posturing  ?:

We are going to keep it to things from pelvis down or we will be here all day.

  1. Anterior pelvis tilt. She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  In many cases combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis.
  2. The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extension, the pelvis is often also translated forward into the sagittal plane pushing the head of the femur into anterior glide into the front of the acetabulum.
  3. The knees are often locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis.
  4. She will be in ankle plantarflexion because of the footwear instead of balancing the tibia neutrally over the talus.  The tibia will rest on the posterior talus. If constant, the plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. 

These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. 

Remember, these are just assumptions. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us.

The Gait Guys.

Shawn and Ivo

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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.

The Gait Guys. Making you gait IQ higher with each post.

*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

A young lady with knee recurvatum. Even at the airport you are not safe from The Gait Guys !  
 Standing waiting for my parents luggage I had to do a double take when i saw this excessive genu recurvatum of the knees. Of course it was much worse in person because of the added dimension that a photo cannot give.  This poor gal probably doesn’t even know she needs us.  
 What do we see here and what assumptions can we extrapolate (assumptions from mere standing of course)  ?: 
 We are going to keep it to things from pelvis down or we will be here all day. 
   Anterior pelvis tilt.  She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  Combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis. 
 The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extennsion. 
 The knees are likely locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis. 
 She will be in relative ankle plantarflexion instead of balancing the tibia neutrally over the talus.  Relative constant plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. This gal will likely have problems controlling pronation we suspect because of such assumed imbalances. 
  These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. I was going to walk behind to take a pic so we could make some assumptions about the frontal plane, but people all around were already getting suspicious of me snap photos of so many of them.  
 Remember, these are just assumptions from a single static photo. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us. 
 Oh, and we must not forget to once again thank Mr. UGG boot for helping add another dimension of challenge to this lovely lady ! Although this assumption would be better made off of a frontal plane photo. 
 Beware of geeks in the airport and shopping malls snapping photos and video. It is likely us, The Gait Guys. 
 Shawn and Ivo

A young lady with knee recurvatum. Even at the airport you are not safe from The Gait Guys !

Standing waiting for my parents luggage I had to do a double take when i saw this excessive genu recurvatum of the knees. Of course it was much worse in person because of the added dimension that a photo cannot give.  This poor gal probably doesn’t even know she needs us. 

What do we see here and what assumptions can we extrapolate (assumptions from mere standing of course)  ?:

We are going to keep it to things from pelvis down or we will be here all day.

  1. Anterior pelvis tilt. She appears to be sitting back into her pelvis so to speak, doing so we can see an increased lumbar lordosis pressing the pelvis anterior.  Combine this with suspect weak lower abdominals and the pelvis drops in the front. This position is often met with isometric contraction of the gluteals helping to maintain the forward/anterior shifted pelvis.
  2. The above, will create an abnormal (possibly increased) tensile load on the hamstrings since the ischeal tuberosities are being drawn cephalad (up). This can create a net posterior shift of the knee joint since she is in relative hip extennsion.
  3. The knees are likely locked into hyperextension. This will create meniscal tensions and certainly cause increased patellofemoral pressures.  This can also create the rarely diagnosed, but often present, anteriormeniscofemoral impingement syndrome. In this type of presentation the anterior compressive forces are so great compared to what should be balanced forces around the entire joint that the superior leading edge of the anterior mensicus (can affect medial or lateral menisci) begins to become impinged and irritated as the femur rolls and translates too far anterior. You have to know it exists to make the diagnosis.
  4. She will be in relative ankle plantarflexion instead of balancing the tibia neutrally over the talus.  Relative constant plantarflexion means shorter posterior compartment (gastroc-soleus) and usually weak anterior compartment (tibialis anterior and long extensors of toes).  If she is a runner we bet shin splints were on her holiday list of things to resolve. This gal will likely have problems controlling pronation we suspect because of such assumed imbalances.

These are just the sagittal plane flaws we can assume. There are more but this is plenty to think about right now. I was going to walk behind to take a pic so we could make some assumptions about the frontal plane, but people all around were already getting suspicious of me snap photos of so many of them. 

Remember, these are just assumptions from a single static photo. Like in video analysis, anything you pic up on film is just a compensation. It does not tell you what you have wrong until you can test them for neuromuscular integrity and motor pattern assessments.  Do not hang your hat on photos or video analysis. Do the extra work that is required.  After all, you know where ASSUMPTIONS get us.

Oh, and we must not forget to once again thank Mr. UGG boot for helping add another dimension of challenge to this lovely lady ! Although this assumption would be better made off of a frontal plane photo.

Beware of geeks in the airport and shopping malls snapping photos and video. It is likely us, The Gait Guys.

Shawn and Ivo