External tibial torsion and lower back pain

How can external tibial torsion and lower back pain possibly be related? Let’s take a quick look at the anatomy and see how.

knees neutral, note external rotation of the right foot and decreased progression angle

knees neutral, note external rotation of the right foot and decreased progression angle

Remember the external tibial torsion is present if we drop a plumbline from the tibial tuberosity and it passes between the first and second metatarsals or more medially. This increases the progression angle of the foot. This occurs due to “over rotation" of the lower extremity during development, often exceeding the 1.5 degrees per year of external rotation per year up to age 15 or occurring for a longer period of time, up to skeletal maturity. It can be uni or bilateral.

note when the foot is neutral, the knee points inward

note when the foot is neutral, the knee points inward

Often, due to the increased progression angle, people will try to "straighten their feet" (ie, decrees their progression angle) to move forward in the sagittal plane. This places the knees to the inside of the sagittal plane which causes medial knee fall and sometimes increased mid and forefoot pronation. This results in increased medial spin of the thigh bilaterally which increases the lumbar lordosis. Combine this with a sway back or anterior pelvic tilt and you have increased pressure on the lumbar facet joints. The facets are designed to carry approximately 20% of the load put in these circumstances are often called upon to carry the much more. This often results in facet imbrication and lower back pain. You can strengthen the abdomen all you like but if you do not change the attitude of the foot, a will often develop lower back pain, especially when the abs fatigue. Now think about if the deformity is unilateral; this will often cause asymmetrical rotation of the pelvis in a clockwise or counter clockwise direction.

So, what can you do you?

Since external tibial torsion is a "hard deformity", we can influence how the bone grows before skeletal maturity but after that will not change significantly with stretching or exercise.

  • You can teach them to walk with an increase in progression angle (ie “duck footed”). This will often keep the knee in the sagittal plane and can be surprisingly well tolerated

  • You can use a foot leveling orthotic or arch support to bolster the arch and change the mechanics of the foot, causing external rotation of the tibia which will often result in a decrease in progression angle in compensation while still keeping the knee in the sagittal plane

  • You could place a full length varus wedge in the shoe which, by inverting the foot, externally rotates the tibia which the person will often compensates for by decreasing there progression angle to keep the knee and the sagittal plane



Dr Ivo Waerlop, one of The Gait Guys



#tibialtorsion #lowbackpain #LBP #progressionangle





Sometimes it’s OK for “toes in“ squats

We hear from folks and also read on a lot of blogs and articles about whether your toes should be in or out for squats or other types of activities. The real answer is “it depends”.

What it depends on is the patient’s specific anatomy. That means we need to pay attention to knees and hips and things like femoral and tibial torsion‘s. It’s paramount to keep the knees in the sagittal plane, no matter what the lower extremity orientation is.

When somebody has external tibial torsion (i.e. when you drop a plumbline from there to view tuberosity it passes medial to the line between the second and third or second metatarsal) then having your feet and externally rotated position places the knees in sagittal plane. Having the patient go “toes in” with this type of anatomy will cause both knees to for medially and create patellofemoral tracking issues.

Likewise, like the patient in the video, (Yes, I know I say “external tibial torsion“ at the beginning of the video but the patient has internal tibial torsion as you will see from the remainder of the video) when somebody has internal tibial torsion (I.e. when you drop a plumbline from the tibial tuberosity it passes lateral to the second metatarsal or a line between the second and third metatarsal) you would need to point the toes inward to keep the knees in the sagittal plane as demonstrated in the video. You can also see in the video when her feet are placed “toes out“ they fall outside sagittal plane laterally which creates patellofemoral tracking issues like it was in this particular patient.

So, knees in or knees out? It depends…

Dr. Ivo Waerlop, one of The Gait Guys

#internaltibialtorsion #externaltibialtorsion #kneepain #kneesin #kneesout #squats #thegaitguys

External tibial torsion or femoral retrotorsion?

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This young lad presents to your office complaining of bilateral knee discomfort at the medial aspect, just below the patella, particularly when ascending and descending stairs and hills. You narrow it down to abnormal patellar tracking and 2 possibilities of who is driving the bus, but which is it?

Torsions of an extremity are said to exist when they measure two or more standard deviation‘s outside of normal. In external tibial torsion, the shaft of the tibia over rotates more than it’s 1.5° per year from zero at birth to greater than 19°. You are left with a foot that is has an increased progression angle and a center of gravity falls medial to the foot causing abnormal patellar tracking.

Femoral retro torsion is said to exist when the head of the femur over reduces from its 35° angle at birth to less than 8° resulting in severely limited internal rotation of the hips bilaterally. The lower extremity is often externally rotated to compensate.

An easy differential for the 2 is to drop a plumbline from the tibial tuberosity through the foot. This line normally passes through the second or between the second and third metatarsal‘s. If it falls medial to that it is eternal tibial torsion and lateral to that most likely internal tibial torsion or potentially a metatarsus varus or forefoot adductus.

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Another differential would be to perform “Craigs test” and measure how much internal and external rotation of the femur there is at the femoral acetabular articulation.

An easier way to put it is; those with femoral retrotorsion have less hip internal rotation and often increased amounts of external rotation; often they can’t even get past zero, never mind the requisite 4-6 degrees for normal gait. Those with increased internal rotation and diminished external rotation most likely have femoral antetorsion.

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So, Which is it? When his knees are Straightahead, his feet point out; when his feet are straightahead, his knees point inward. A plumbline from the tibial tuberosity passes medial to the second metatarsal. Looking at the pictures, you can see that he is external tibial torsion along with a sandal thong deformity that we talked about last week.

Dr Ivo Waerlop, one of The Gait Guys.

#externaltibialtorsion #outturnedfoot #increasedprogressionangle #kneepain #thegaitguys

Sixth toe disease...That growth on the outside of your foot… Or on somebody’s foot is coming to see you…

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You know what we’re talking about. That extra growth on the lateral aspect of the foot that happens way too often and many of your clients. A Taylor’s bunion or sometimes referred to as a “bunionette”. 

What is the usual fix?

Usually in a ski boot or hiking boot, they blow out the lateral side of the shoe. This is usually not a good fix because most of these folks have internal tibial torsion and somewhat of a forefoot supinatus/varus.

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The internal tibial torsion places the knee outside the saggital plane and an arch support without a forefoot valgus post will just push it further out, creating a conflict at the knee. The forefoot supinatus and/or varus places them on the outside of the foot as well. Remember, most of these folks are ALREADY on the outside of the foot and the foot wants to migrate laterally...so creating more space just means it migrates farther. Good thought, doesn’t work that way.

IMG_6710.JPG

So what did we do?

  • We created a valgus post for the forefoot (see picture above) tapering from lateral to medial and to help “push“ the distal aspect of the first ray down (because there was motion available that was not being used)

  • We gave him exercises to help descend the first ray like the extensor hallucis brevis exercise, toe waving as well as peroneus longus exercises

  • We gave him plenty of balance and coordination work

    Dr Ivo Waerlop, one of The Gait Guys




#6thtoe #internaltibialtorsion #forefootvarus # forefootsupinatus #gaitanalysis #thegaitguys







We’ve told you once and we will tell you again…

Folks with femoral retro torsion often experience lower back pain with twisting movements

This left handed hydrology engineer Presented to the office with an acute onset of lower back pain following “swinging a softball bat”. He comments that he always “hit it out of the park“ and hit “five home runs“ in the last game prior to his backs demise.

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

note the internal tibial torsion. drop a plumbline from the tibial tuberosity. it should pass through the 2nd met or between the 2nd and 3rd met shafts

He presented antalgic with a pelvic shift to the left side, flexion of the lumbar spine with 0° extension and a complete loss of the lumbar lordosis. He could not extend his lumbar spine past 0° and was able to flex approximately 70. Lateral bending was approximately 20° on each side. Neurological exam negative. Physical exam revealed bilateral femoral retro torsion as seen above. Note above the loss of internal rotation at the hips of both legs, thus he has very limited internal rotation of the hips. Femoral retroversion means that the angle of the neck of the femur (also known as the femoral neck angle) is less than 8°, severely limiting internal rotation of the hip and often leading to CAM lesions.

Stand like you’re in a batters box and swing like you’re left handed. What do you notice? As you come through your swing your left hip externally rotates and your right hip must internally rotate. He has no internal rotation of the right hip and on a good day, the lumbar spine has about 5° of rotation with half of that occurring at the lumbosacral junction. Guess what? The facet joints are going to become compressed!

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

bisect the calcaneus. the line should fall though the 2nd metatarsal or between the 2nd and 3rd met shafts

Now combine that with bilateral 4 foot adductus (see photos above). His foot is already in supination so it is a poor shock observer.

Go back to your “batters box“. Come through your swing left handed. What do you notice? The left foot goes into a greater amount of pronation in the right foot goes into a greater amount of supination. Do you think this is going to help the amount of internal rotation available to the hip?

When folks present with lower back pain due to twisting injuries, make sure to check for femoral torsions. They’re often present with internal tibial torsion, which is also present in this individual.

Remember a while ago we said “things occur in threes”. That goes for congenital abnormalities as well: in this patient: femoral retro torsion, internal tibial torsion and forefoot adductus.

What do we do? Treat locally to reduce inflammation and take steps to try to improve internal rotation of the hips bilaterally as well as having him externally rotate his right foot when he is in the batteries box to allow him to "create" more internal rotation of the right hip.

Dr Ivo Waerlop, one of The Gait Guys

#internalrotation #hipproblem #femoraltorsion #femoralversion #retroversion #retrotorsion #thegaitguys

Holy twisted tibias Batman! What is going here in this R sided knee pain patient?

Screen Shot 2019-06-10 at 12.28.38 PM.png

In the 1st picture note this patient is in a neutral posture. Note how far externally rotated her right foot is compared to the left. Note that when you drop a plumbline down from the tibial tuberosity it does not pass-through or between the second and third metatarsals. Also note the incident left short leg

Screen Shot 2019-06-10 at 12.28.56 PM.png

In the next picture both of the patients legs are fully externally rotated. Note the large disparity from right to left. Because of the limited extra rotation of the right hip this patient most likely has femoral retro torsion. This means that the angle of her femoral head is at a greater than 12° angle. We would normally expect approximately 40° of external Rotation. 4 to 6° is requisite for normal gait and supination.

Screen Shot 2019-06-10 at 12.28.47 PM.png

In the next picture the patients knees are fully internally rotated you can see that she has an excessive amount of internal rotation on the right compare to left, confirming her femoral antetorsion.

Screen Shot 2019-06-10 at 12.28.38 PM.png

When this patient puts her feet straight (last picture), her knees point to the inside causing the patello femoral dysfunction right greater than left. No wonder she has right-sided knee pain!

Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).


a note on tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 15 degrees until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°).

Wow, cool stuff, eh? Dr Ivo Waerlop, one of The Gait Guys

#tibialtorsion #tibialversion #kneepain #thegaitguys #gaitanalysis

Ode to the Popliteus

Remember the popliteus? To recap, it contracts at the initial contact phase of the walking gait cycle, to act as an accessory PCL (look HERE

https://www.thegaitguys.com/search?q=popliteus&f_collectionId=57d4982c91b18610c6ee3e0f

to read about that), then contracts eccentrically to slow the rate of internal rotation of the femur on the tibia until midstance, so as not to macerate the meniscus; It then contracts concentrically to accelerate the external rotation of the femur on the tibial plateau so it rotates faster then the tibia, to protect the meniscus as well. So, internal rotation of the femorotibial complex from initial contact to midstance and external rotation of the complex from midstance to preswing. Got it?

Now look at the video of this gal with L sided medial knee pain and past history of a left tibial plateau fracture in her youth. Do you see it? Hmmmm; doesn’t look like internal rotation does it? Don’t see it? Remember that the whole complex SHOULD be internally rotating until the swing phase leg passes the stance pase leg. See it now? Considering that the popliteus tested weak on the clinical exam, does this surprise you?

Agreed that there are many factors initiating internal rotation (and thus pronation) of the stance phase leg from initial contact to midstance, like plantar flexion, adduction and eversion of the talus, contraction of the lower leg anterior compartment muscles, eccentric contraction of the quads and hamstrings, just to name a few, can you see how (a least theoretically) one bad player can ruin the team?

Yes, popliteus rehab, along with abdominal core and foot core endurance exercises are in her future.

Dr Ivo Waerlop, one of The Gait Guys

#popliteus #kneepain #kneeproblem #thegaitguys #gaitanalysis

Neuroma! Triple Threat....

Can you guess why this patient is developing a neuroma on the left foot, between the 3rd and 4th metatarsals?

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This gal presented to the office with pain in the left foot, in the area she points to as being between the 3rd and 4th metatarsals. It has been coming on over time and has become much worse this spring with hiking long distances, especially in narrower shoes. It is relieved by rest and made worse with activity.

Note the following:

  • She has an anatomical short leg on the left (tibial)

  • internal tibial torsion on the left

  • left forefoot adductus (see the post link below if you need a refresher)

Lets think about this.

The anatomical short leg on the left is causing this foot to remain in relative supination compared the right and causes her to bear weight laterally on the foot.

The internal tibial torsion has a similar effect, decreasing the progression angle and again causing her to bear weight laterally on the foot, compressing the metatarsals together.

We have discussed forefoot adductus before here on the blog. Again, because of the metararsal varus angle, it alters the forces traveling through the foot, pushing the metatarsals together and irritating the nerve root sheath, causing hypertrophy of the epineurium and the beginnings of a neuroma.

In this patients case, these things are additive, causing what I like to a call the “triple threat”.

So, what do we do?

  • give her shoes/sandals with a wider toe box

  • work on foot mobility, especially in descending the 1st ray on the left

  • work on foot intrinsic strength, particularly the long extensors

  • treat the area of inflammation with acupuncture

Dr Ivo Waerlop, one of The Gait Guys

#forefootadductus #metatarsusadductus #neuroma #gaitanalysis #thegaitguys #internaltibialtorsion

3 things

Its subtle, but hopefully you see these 3 things in this video.

I just LOVE the slow motion feature on my iPhone. It save me from having to drag the video into Quicktime, slow it down and rerecord it.

This gal has a healing left plantar plate lesion under the 2nd and 3rd mets. She has an anatomical leg length deficiency, short on the left, and bilateral internal tibial torsion, with no significant femoral version. Yes, there are plenty of other salient details, but this sketch will help.

  1. 1st if all, do you see how the pelvis on her left dips WAY more when she lands on the right? There is a small amount of coronal plane shift to the right as well. This often happens in gluteus medius insufficiency on the stance phase leg (right in this case), or quadratus lumborum (QL) deficiency on the swing phase leg (left in this case) or both. Yes, there are other things that can cause this and the list is numerous, but lets stick to these 2 for now. In this case it was her left QL driving the bus.

  2. Watch the left and right forefeet. can you see how she strikes more inverted on the left? this is a common finding, as the body often (but not always) tries to supinate the shorter extremity (dorsiflexion, eversion and adduction, remember?) in an attempt to “lengthen” it. Yes, there is usually anterior pelvic tilt accompanying it on the side, because I knew you were going to ask : )

  3. Look how her knees are OUTSIDE the saggital plane and remain there in her running stride. This is commonly seen in folks with internal tibial torsion and is one of the reasons that in our opinion, these folks should not be put medially posted, torsionally rigid, motion control shoes as this usually drive the knees FURTHER outside the saggital plane and can macerate the meniscus.

Yep, lots more we could talk about on this video, but in my opinion, 3 is a good number.

Dr Ivo Waerlop, one of The Gait Guys

#thegaitguys #gaitanalysis #footpain #gaitproblem #internaltibialtorsion #quadratuslumborum #footstrike

https://vimeo.com/329212767

Things seem to come in 3's...

Things tend to occur in threes. This includes congenital abnormalities. Take a look this gentleman who came in to see us with lower back pain.

Highlights with pictures below:

  • bilateral femoral retrotorsion

  • bilateral internal tibial torsion

  • forefoot (metatarsus) adductus

So why LBP? Our theory is the lack of internal rotation of the lower extremities forces that motion to occur somewhere; the next mobile area just north is the lumbar spine, where there is limited rotation available, usually about 5 degrees.

Dr Ivo Waerlop, one of The Gait Guys.

#tibialtorsion #femoraltorsion #femoralretrotorsion #lowbackpain #thegaitguys #gaitproblem

this is his left hip in full internal rotation. note that he does go past zero.

this is his left hip in full internal rotation. note that he does go past zero.

full internal rotation of the right hip; note he does not go past zero

full internal rotation of the right hip; note he does not go past zero

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

note the internal tibial torsion. a line dropped from the tibial tuberosity should go through the 2nd metatarsal or between the 2nd and 3rd.

ditto for the keft

ditto for the keft

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

a line bisecting the calcaneus should pass between the 2nd and 3rd metatarsal shafts. If talar tosion was present, the rearfoot would appear more adducted

less adductus but still present

less adductus but still present

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

look at that long flexor response in compensation. What can you say about the quadratus plantae? NO bueno…

Ditto!

Ditto!

Motion control Shoes + Internal Tibial Torsion = Knee Pain

Thinking about putting a motion control shoe under that foot to control pronation? You had better make sure you make friends with the knee, as it will often (depending on the compensation) be placed OUTSIDE the SAGGITAL PLANE. Like Dr Allen has said many times before , the knee is basically a hinge joint placed between 2 ball and socket joints, and it is usually the one to start grumbling...

Learn more as Dr Ivo Waerlop of The Gait Guys explains in this brief video

#gait #Gaitanalysis #gaitguys #thegaitguys #kneepain #motioncontrolshoes #internaltibialtorsion

https://vimeo.com/154496722

A primer on tibal torsions and versions....

We get tired of reading posts on squats, lifting, lunges and the whole “have your toes in”, “Have your tires pointing out”, “keep your feet straight” sort of advice for best performance. The truth of the matter is, when the knee is in the saggital plane, you will have the best results and cause the least amount of damage to the knee and menisci. In our opinion, if you are not paying attention to femoral and tibial torsions and versions, you are missing the boat.

This is not a post for the faint of heart, but hopefully will help clear up some questions you may (or may not) have had. Grab a cup of your favorite beverage and enjoy...

The tibia and femur are more prone to torsional defects, as they are longer lamellar (layered) bones as opposed to the cancellous bone that makes up the talus. These often present as an “in toeing” or “out toeing” of the foot with respect to the leg; changing the progression angle of gait.

Tibial versions and torsions can be measured by the “thigh foot angle” (the angulation of the foot to the thigh with the leg bent 90 degrees: above right) or the “transmalleolar angle” (the angle that a line drawn between the medial and lateral malleoli of the ankle makes with the tibial plateau).

At a gestational age of 5 months, the fetus has approximately 20° of internal tibial torsion. As the fetus matures, The tibia then rotates externally, and most newborns have an average of 0- 4° of internal tibial torsion. At birth, there should be little to no torsion of the tibia; the proximal and distal portions of the bone have little angular difference (see above: top). Postnatally, the tibia should twist outward (externally) a total of 1.5 degrees per year until adult values are reached between ages 8 and 10 years of 23° of external tibial torsion (range, 0° to 40°).

Sometimes the rotation at birth is excessive. This is called a torsion. Five in 10,000 children born will have rotational deformities of the legs. The most common cause is position and pressure (on the lower legs) in the uterus (an unstretched uterus in a first pregnancy causes greater pressuremaking the first-born child more prone to rotational deformities. Growth of the unborn child accelerates during the last 10 weeks and the compression from the uterus thus increases. As you would guess, premature infants have less rotational deformities than full-term infants. This is probably due to decreased pressure in the uterus. Twins take up more space in the uterus and are more likely to have rotational deformities.

Of interesting note, there is a 2:1 preponderance of left sided deformities believed to be due to most babies being carried on their backs on the left side of the mother in utero, causing the left leg to overlie the right in an externally rotated and abducted position.

Normal ranges of versions and torsions are highly variable. Ranges less than 2 standard deviations are considered internal tibial torsion and greater external tibial torsion.

Internal tibial torsion (ITT) usually corrects 1 to 2 years after physiological bowing of the tibia (ie tibial varum) resolves. External tibial torsion (TT) is less common in infancy than ITT but is more likely to persist in later childhood and NOT resolve with growth because the natural progression of development is toward increasing external torsion.

Males and females seem to be affected equally, with about two thirds of patients are affected bilaterally and the differences in normal tibial version values are often expected to be cultural, lifestyle and posture related.

The ability to compensate for a tibial torsion depends on the amount of inversion and eversion present in the foot and on the amount of rotation possible at the hip. Internal torsion causes the foot to adduct, and the patient tries to compensate by everting the foot and/or by externally rotating at the hip. Similarly, persons with external tibial torsion invert at the foot and internally rotate at the hip. Both can decrease walking agility and speed if severe. With an external tibial torsion deformity of 30 degrees , the capacities of soleus, posterior gluteus medius, and gluteus maximus to extend both the hip and knee were all reduced by over 10%.

So, there you have it. Ina nutshell, the basics that will take you far and wide on your journey to better performance and biomechanics for yourself and your patients/clients.

 

So, you do weighted carries?

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

 

Nothing earthshaking here (1) , but a few takeaways:

  • Asymmetric loading of L5-S1 will most likely become more significant if the individual has a L5-S1 facet tropism, where one (or both) of the facets is (are) facing saggitally, as loading will be be even greater.  This has been associated with disc derangement (2) and degeneration (3).

 

  • The body does seem to adjust for the load, but it takes at least to the second step. We need to make sure the proprioceptive feedback loops (joint and muscle mechanoreceptors and their associated pathways) are functioning well. Manipulate, mobilize, facilitate, inhibit as appropriate.

 

  • The increased varus moment and hip abduction on the unweighted side are most likely to move the center of gravity more to the midline, which makes sense. This may become problematic with folks with increased internal tibial torsion, especially with femoral retroversion/torsion as they already have limited internal rotation available to them at the hip

 

 

 

 

 

 
1. Wang J, Gillette JC. Carrying asymmetric loads during stair negotiation: Loaded limb stance vs. unloaded limb stance. Gait Posture. 2018 Jun 19;64:213-219. doi: 10.1016/j.gaitpost.2018.06.113. [Epub ahead of print]
2. Chadha M, Sharma G, Arora SS, Kochar V. Association of facet tropism with lumbar disc herniation. European Spine Journal. 2013;22(5):1045-1052. doi:10.1007/s00586-012-2612-5.
3. Berlemann U, Jeszenszky DJ, Buhler DW, Harms J (1998) Facet joint remodeling in degenerative spondylolisthesis: an investigation of joint orientation and tropism. Eur Spine J 7: 376-380.

 

Abstract

BACKGROUND:

Individuals often carry items in one hand instead of both hands during activities of daily living. Research Question The purpose of this study was to investigate low back and lower extremity frontal plane moments for loaded limb stance and unloaded limb stance when carrying symmetric and asymmetric loads during stair negotiation.

METHODS:

Participants were instructed to ascend and descend a three-step staircase at preferred pace using a right leg lead and a left leg lead for each load condition: no load, 20% body weight (BW) bilateral load, and 20% BW unilateral load. L5/S1 contralateral bending, hip abduction, external knee varus, and ankle inversion moments were calculated using inverse dynamics.

RESULTS:

Peak L5/S1 contralateral bending moments were significantly higher when carrying a 20% BW unilateral load as compared to a 20% BW bilateral load for both stair ascent and stair descent. In addition, peak L5/S1 contralateral bending moments were significantly higher during step one than for step two. Peak external knee varus and hip abduction moments were significantly higher in unloaded limb stance as compared to loaded limb stance when carrying a 20% BW unilateral load.

SIGNIFICANCE:

General load carriage recommendations include carrying less than 20% BW loads and splitting loads bilaterally when feasible. Assessment recommendations include analyzing the first stair step and analyzing both the loaded and unloaded limbs.

The Adductor Magnus; Not just for adduction anymore...

add mag.png
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Yet another paper (1) to support the notion that the adductors (particularly the adductor magnus, in this paper), act as external rotators (especially eccentrically), not internal rotators as is commonly purported in many anatomy texts (2) . Remember that the lower extremity is internally rotating (as a whole) from initial contact to midstance and externally rotating from midstance to pre swing. SOMETHING needs to help attenuate some of that internal rotation (and pronation) that occurs during the 1st part of stance phase and assist in external rotation (and supination); now you can add the adductor magnus to the popliteus, deep six external rotators, anterior and posterior compartments of the lower leg to the hamstrings and quads.

"This study suggests that adductor magnus has at least two functionally unique regions. Differences were most evident during rotation. The different direction-specific actions may imply that each segment performs separate roles in hip stability and movement. These findings may have implications on injury prevention and rehabilitation for adductor-related groin injuries, hamstring strain injury and hip pathology."

 

1. Benn ML, Pizzari T, Rath L, Tucker K, Semciw AI1 . Adductor magnus: An emg investigation into proximal and distal portions and direction specific action. Clin Anat. 2018 Mar 9. doi: 10.1002/ca.23068. [Epub ahead of print]

2. Leighton RD. A functional model to describe the action of the adductor muscles at the hip in the transverse plane.Physiother Theory Pract. 2006 Nov;22(5):251-62.



 

add mag.png

How can feet relate to golf swing?

This 52 year old right handed gentleman presented with pain at the thoracolumbar junction after playing golf. He noticed he had a limited amount of “back swing” and pain at the end of his “follow through”.

Take a look a these pix and think about why.

Full internal rotation

Full internal rotation

full external rotation

full external rotation

full internal rotation

full internal rotation

full external rotation

full external rotation

neutral

neutral

neutral

neutral

Hopefully, in addition to he having hairy and scarred legs (he is a contractor by trade), you noted the following

  • Top: note the normal internal rotation of the right hip; You need 4 degrees to walk normally and most folks have close to 40 degrees. He also has internal tibial torsion.
  • second picture: loss of external rotation of the right hip. Again, you need 4 degrees (from neutral) of external rotation of the hip to supinate and walk normally.
  • third picture: normal internal rotation of the left hip; internal tibial torsion
  • 4th picture: limited external rotation of the left hip, especially with respect ti the amount of internal rotation present; this is to a greater degree than the right
  • last 2 pictures: note the amount of tibial varum and tibial torsion. Yes, with this much varum, he has a forefoot varus.

The brain is wired so that it will (generally) not allow you to walk with your toes pointing in (pigeon toed), so you rotate them out to somewhat of a normal progression angle. If you have internal tibial torsion, this places the knees outside the saggital plane. (For more on tibial torsion, click here.) If you rotate your extremity outward, and already have a limited amount of range of motion available, you will take up some of that range of motion, making less available for normal physiological function. If the motion cannot occur at the knee or hip, it will usually occur at the next available joint cephalad, in this case the spine.

The lumbar spine has a limited amount of rotation available, ranging from 1.2-1.7 degrees per segment in a normal spine (1). This is generally less in degenerative conditions (2).

Place your feet on the ground with your feet pointing straight ahead. Now simulate a right handed golf swing, bending slightly at the waist androtating your body backward to the right. Now slowly swing and follow through from right to left. Note what happens to your hips: as you wind back to the right, the left hip is externally rotating and the right hip is internally rotating. As you follow through to the left, your right, your hip must externally rotate and your left hip must externally rotate. Can you see how his left hip is inhibiting his back swing and his right hip is limitinghis follow through? Can you see that because of his internal tibial torsion, he has already “used up” some of his external rotation range of motion?

If he does not have enough range of motion in the hip, where will it come from?

he will “borrow it” from a joint more north of the hip, in this case, his spine. More motion will occur at the thoracolumbar junction, since most likely (because of degenerative change) the most is available there; but you can only “borrow” so much before you need to “Pay it back”. In this case, he over rotated and injured the joint.

What did we do?

  • we treated the injured joint locally, with manipulation of the pathomechanical segments
  • we reduced inflammation and muscle spasm with acupuncture
  • we gave him some lumbar and throacolumbar stabilization exercises: founders exercise, extension holds, non tripod, cross crawl, pull ups
  • we gave him foot exercises to reduce his forefoot varus: tripod standing, EHB, lift-spread-reach
  • we had him externally rotate both feet (duck) when playing golf

The Gait Guys. Helping you to store up lots “in your bank” of foot and gait literacy, so you can help people when they need to “pay it back”, one case at a time.

(1) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2223353/

(2) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705911/

Tibial Torsion and Genu Valgum

Join us in this brief video about tibial torsion and genu valgum in a 6-year-old

Mooney JF 3rd Lower extremity rotational and angular issues in children. Pediatr Clin North Am. 2014 Dec;61(6):1175-83. doi: 10.1016/j.pcl.2014.08.006. Epub 2014 Sep 18.

Killam PE. Orthopedic assessment of young children: developmental variations. Nurse Pract. 1989 Jul;14(7):27-30, 32-4, 36.

Kling TF Jr, Hensinger RN. Angular and torsional deformities of the lower limbs in children. Clin Orthop Relat Res. 1983 Jun;(176):136-47.

When the wrong shoe, meets the right foot

Is it any wonder that this gentleman has pain on the dorsum of this his feet?

1st of all, how about his internal tibial torsion? It is bilateral, L > R. This places the majority of his weight on the outside of his feet, keeping him somewhat supinated most of the time.

2nd: he has an anatomical leg length discrepancy on the right which is tibial (see pictures 2 and 3). This will place EVEN MORE weight on the outside of the right foot, as it will often remain in supination in an attempt to "lengthen" itself.

3rd, take a look at his shoes. Is this particular model supposed to be rear foot posted in varus? Talk about adding insult to injury! This will place this guys feet into EVEN MORE supination and EVEN MORE on the outside of his feet. maybe the right shoe is worn into more supination because of his right sided LLD?

And if that wasn't enough, this particular shoe has increased torsional rigidity through the midfoot, slowing or arresting any hope of shock absorption that he may have. 

Yikes! We sure wish more folks knew more about feet and shoes! Maybe they should think about taking the National Shoe Fit Program? Email us for more info.