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

Subtle clues to an LLD?

Leg length discrepancies, whether their functional anatomical, have biomechanical consequences north of the foot. This low back pain patient exhibited 2 signs. Can you tell what they are?

can you see the difference ?

can you see the difference ?

how about now?

how about now?

compare right to left

compare right to left

compare right to left

compare right to left

can you see the difference in the Q angles?

can you see the difference in the Q angles?

Look at the first picture and noticed how the left knee is hyper extended compared to the right. Sometimes we see flexion of this extremity. This is to "functionally shorten" that extremity.

Now look at the Q angles. Can you see how the left QL angle is greater than the right? This usually results from a long-term leg length discrepancy where the body is attempting to compensate by increasing the valgus angle of that knee, effectively shortening the extremity.

Dr Ivo Waerlop, one of The Gait Guys

#subtle #clues #LLD #leglengthdiscrepancy #leglengthinequality #thegaitguys #gaitabnormality

Low Back Pain? Check for Femoral Retrotorsion on the Same Side

note the right sided leg length discrepancy

note the right sided leg length discrepancy

right tibia is anatomically shorter

right tibia is anatomically shorter

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

more internal rotation available on the left side at the hip. Note the internal tibial torsion as well

very little internal rotation available at the right hip

very little internal rotation available at the right hip

This right handed concrete worker presented to our office with right-sided lower back pain. He was lifting a bag of concrete moving from left to right which she estimates weighing between 60 and 80 pounds. He did this repetitively throughout the day and subsequently developed right sided lower back pain. The pain is in the suprailiac region and is described as dull, achey. Is exacerbated by right rotation and right lateral bending.

His exam found him to have a right sided anatomical leg length discrepancy, tibial left (see above) and femoral retro torsion on the right with no internal rotation of the hip past 0 degrees (see picture of full internal rotation of the right hip and cmpare it with the left); left side had approximately 10 degrees internal rotation. He also has bilateral internal tibial torsion, R > L. Palpation findings revealed tightness in the lumbar multifidus and quadratus lumborum with a loss of lateral bending to the right at L2 through L4 and a loss of flexion about the right sacroiliac joint. Lower extremity reflexes were 2+ with bilateral symmetry; sensation to vibration was intact at the distal phalanges; motor strength was strong and graded as 5/5.

Think about the implications of his right-sided leg length discrepancy first. This places his foot and a relative supinated posture compared to the left. Remember that supination is plantar flexion, inversion and adduction.

His femoral retro torsion on the right limits his internal rotation at the hip. When his foot planted with a diminished progression angle secondary to the internal tibial torsion, and he has to rotate from left to right, very little, if any motion, can occur at the right hip and therefore must occur in the lumbar spine. Remember the lumbar spine has very limited range of motion begin with with most of that occurring at the L5-S1 junction, depending upon its anatomy. Now superimpose a long lever load and rotary force. Back pain!

We instructed him on proper lifting technique and also talked about keeping the shoulders and hips in the same plane when lifting or load. If he does need to lift a load and spin unilateral on his right lower extremity, we asked him to externally rotate the right lower extremity. He was treated with manipulation and neuromuscular acupuncture.

If you have somebody with unilateral lower back pain, think about the implications if they have any femoral torsion or version present

Dr. Ivo Waerlop, one of The Gait Guys.

#lowbackpain #LBP #femoralretrotorsion #femoral #torsion #gait #gaitanalysis #thegaituys

The Mighty Multifidus

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:

"Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity."

see also our post here: https://tmblr.co/ZrRYjx14tXWrD

Dr Ivo Waerlop, one of The Gait Guys

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print] The immediate effect of dry needling on multifidus muscles' function in healthy individuals. Dar G1,2, Hicks GE3.

#gait, #gaitanalysis, #multifidus, #lowbackpain, #proprioception,#thegaitguys

Asymmetry seems to matter with pathology.

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

When you have low back pain, your gait is apt to be asymmetrical

...And that is just what this study showed. It looked at 82 right leg dominant folks with slightly less than 1/2 of them havong low back pain. The folks with lower back pain spent more time on their non dominant leg at the beginning of a gait cycle and on their dominant leg at the end of it. Not surprising that they wanted to find a more stable base or center their COP over the weight bearing foot, especially in light to the fact that the back has such poor cortical representation.

Sung PS, Danial P. A Kinematic Symmetry Index of Gait Patterns Between Older Adults With and Without Low Back Pain. Spine (Phila Pa 1976). 2017 Dec 1;42(23):E1350-E1356. doi: 10.1097/BRS.0000000000002161.

And why does this guy have hip pain?

line up the center of the heel counters with the outsoles, and what do you see?

line up the center of the heel counters with the outsoles, and what do you see?

can you see how the heel counter is centered on the outsole, like it is supposed to be

can you see how the heel counter is centered on the outsole, like it is supposed to be

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

notice how the heel counter of the shoe is canted medially on the outsole of the shoe, creating a varus cant

Take a guy with lower back and left sided sub patellar pain that also has a left anatomically short leg (tibial) and bilateral internal tibial torsion and put him in these baby’s to play pickleball and you have a prescription for disaster.

Folks with an LLD generally (soft rule here) have a tendency to supinate more on the short leg side (in an attempt to make the limb longer) and pronate more on the longer leg side (to make the limb shorter). Supination causes external rotation of the lower limb (remember, we are trying to make the foot into a rigid lever in a “normal” gait cycle). this external rotation with rotate the knee externally (laterally). Folks with internal tibial torsion usually rotate their limb externally to give them a better progression angle (of the foot) so they don’t trip and fall from having their feet pointing inward. This ALSO moves the knee into external rotation (laterally), often moving it OUTSIDE the saggital plane. In this case, the knee, because of the difference in leg length AND internal tibial torsion AND the varus cant of the shoe, has his knee WAY OUTSIDE the saggital plane, causing faulty patellar tracking and LBP.

Moral of the story? When people present with a problem ALWAYS TAKE TIME TO LOOK AT THEIR SHOES!

Get your foot in High Gear!

image source: Foot Orthoses and Other Conservative Forms of Foot Care. Michaud 1997; Williams an Wilkins: with permission

image source: Foot Orthoses and Other Conservative Forms of Foot Care. Michaud 1997; Williams an Wilkins: with permission

When it comes to gait, getting the 1st ray to the ground is the name of the game. When weight travels through the medial forefoot and we are able to push off the 1st ray complex, that is called "high gear push off". This was 1st discussed F Bojsen-Møller in this excellent paper (1), that just happens to be a free full text! Craig Payne, The Running Research Junkie has offered and excellent commentary on the topic here as well.

High Gear Push Off can happen when 3 conditions are met: 

  1. we have a intact visual, vestibular and kinesthetic systems that ensure we can remain upright in the gravitational plane.
  2. we have an intact calcanocuboid locking mechanism
  3. we have adequate skill, endurance and strength of our extensor hallucis brevis

The 1st condition is more global and ensures that our cerebellum and vestibular apparatus are playing nice together to create balance, of the literal sort, We seek to keep our visual axes parallel and our center of gravity over our foot. Remember that the BODY will move itself AROUND the visual axes. If the axes are off, the brain will tilt the head and the body will move AROUND the head to accommodate. We have talked about that in these posts here on the blog. 

The 2nd condition, the calcaneo-cuboid locking mechanism, works in the coronal plane and relies on a functioning peroneal group, where the peroneus longus and brevis wrap around the lateral malleolus, cuboid and tail of the 5th metatarsal, crossing the foot diagonally to insert on the base of the 1st metatarsal. When working properly, its actions will be to plantar flex and everting the forefoot, lowering the 1st ray complex down and assisting the shift of the center of gravity more medial for the weight to pass through the medial foot and out through the hallux (ideally). 

The 3rd condition, the ability to descend the 1st ray, relies on the actions of the peroneus, appropriate supination of the forefoot and ability of the extensor hallucis brevis to do its job.  Because the tendon travels behind the axis of rotation of the 1st metatarsal phalangeal joint, in addition to providing extension of the proximal phalynx of the hallux, it can also provide a downward moment on the distal 1st metatarsal (when properly coupled to and temporally sequenced with the flexor hallicus brevis and longus). If the axis of motion for the 1st metatarsal phalangeal joint moves posteriorly, to behind (rather than under) the joint, the plantar pressures increase at MTP’s 4-5 and decrease at the medial mid foot, moving you into low gear push off.  If moved even further posteriorly, the plantar pressures, and contact time in the mid foot and hind foot (2). For more on the extensor hallucis brevis, see our post here.

As you can see, high gear is desirable over low gear push off, but sometimes circumstances or biomechanics do not permit. High gear push off ensures the forefoot is dorsiflexed and everted with respect to the rearfoot and the calcaneocuboid and talonavicular joint axes are perpendicular to one another, giving us a rigid lever to push off of as the center of gravity moves medially across the foot. In low gear push off, the foot is inverted and plantarflexed and the stress falls on the lesser metatarsals and lateral stabilizing complex of the ankle, moving the center of gravity laterally, in addition to the calcaneocuboid and subtalar joint axes being more parallel,  creating a less rigid lever for push off and decreased mechanical efficiency.

 

1. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J Anat. 1979 Aug; 129(Pt 1): 165–176.  link to free full text: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1233091/

2. van der Zwaard BC1, Vanwanseele B, Holtkamp F, van der Horst HE, Elders PJ, Menz HB Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait. J Foot Ankle Res. 2014 Mar 19;7(1):20.

 

A bit about the QL...

 

As we have said in previous posts,  though they can’t act independently we like to think to think of the QL as having two divisions. The lower division arises from the medial portion of the iliac crest and adjacent iliolumbar ligament and inserts onto the transverse processes of the lumbar vertebrae, in the coronal plane from lateral to medial and in the saggital plane from posterior to anterior. The upper division arises from the lumbar transverse processes of the upper 4 lumbar vertebrae and insert into the inferior border of the 12th rib, running in the coronal plane from medial to lateral and in the saggital plane from anterior to posterior; about half of the fascicles of this second division act on the twelfth rib and the rest act on the lumbar spine.

The QL is primarily a coronal plane stabilizer causing lateral bending to the ipsilateral side when the foot is planted as well as posterior rotation of the lumbar spine on the weight bearing side.   When acting unilaterally without the ipsilateral foot fixed on the ground, it can raise the ilia on the side of contraction. It is active during single limb support during stance phase of gait on the contralateral side (along with the external oblique) to elevate the ilium. This is coupled with the ipsilateral anterior fibers of the gluteus medius and minimus pulling the iliac crest toward the stable femur. Sahrmann states “the QL is optimally situated to provide control of lateral flexion to the opposite side via its eccentric contraction to provide control of the return from lateral flexion via its concentric contraction. The muscle is also positioned to play a role in the rotation that occurs between the pelvis and spine during walking”.

Acting bilaterally, it extends the lumbar spine, deepening the lordosis and acting to limit anterior shear of the vertebral bodies.

It is also able to stabilize the 12th rib during forced expiration, thus acting as an accessory muscle of respiration. This fixation is important when we need to superimpose pelvic movements upon it. Furthermore, it increased activation in response to increasing compression in static upright standing postures.

Here is a video of a low back screen we often use

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/

Those Multifidi   The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.    Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.    RESULTS and CONCLUSION: “Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.”    see also our post  here .    J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print] The immediate effect of dry needling on multifidus muscles’ function in healthy individuals. Dar G1,2, Hicks GE3.

Those Multifidi

The multifidi are important proprioceptive sentinels for the low back, as well as the rest of the body, for virtually every activity you do weight bearing, including gait. They are implicated in many instances of low back pain, especially folks with flexion or extension intolerance, since their fiber orientation and thus mechanical advantage (or disadvantage) is dependent upon whether or not you are maintaining a normal lumbar lordosis.

Modalities which boost their function are an excellent adjunct to the rehabilitation process. Since they are not under volitional control (go ahead, try and contract your L2/L3 multifidus), they are innervated by the vestibulospinal tract and we must use proprioceptive work to engage them. Dry Needling is one modality that can help them to become functional again.

RESULTS and CONCLUSION:
“Significant difference was found in the percentage of change of muscle activation post needling between groups on the right side at level L4-5. A slight increase in the percentage of muscle activity, post procedure was observed in the dry needling group compared with the control group, although not significant in other segments examined. An improvement of back muscle function following dry needling procedure in healthy individuals was found. This implies that dry needling might stimulate motor nerve fibers and as such increase muscle activity.”

see also our post here.

J Back Musculoskelet Rehabil. 2015 Sep 6. [Epub ahead of print]
The immediate effect of dry needling on multifidus muscles’ function in healthy individuals. Dar G1,2, Hicks GE3.

What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another  “The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.  The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”  From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.

What types of tests do YOU use to assess lumbopelvic control? We have talked about the multifidus lift test before; here is another

“The clinical test of thoracolumbar dissociation was devised into assess a patient’s ability to perform anterior/posterior pelvic tilt in sitting while attempting to maintain a constant position of the thoracolumbar junction.

The results demonstrate that the clinical test of thoracolumbar dissociation has acceptable inter-rater reliability when used by trained physiotherapists. This test described here is the first to assess the ability to dissociate movement of the lumbopelvic region from that of the thoracolumbar region.”

From: Elgueta-Cancino et al., Manual therapy (2015) 418-424(Epub ahead of print). All rights reserved to Elsevier Ltd.