Knee braces and long legs?

Knee brace fixed at a zero to 5 degree flexion angle, creating a long leg? 

We know that the knee is supposed to flex during stance phase, usually around 20-25 degrees (depending on speed and weight, increases in bot increases the flexion requirement) to create dampening from vertical oscillation of the pelvis. What happens if they cannot flex? This creates a virtual "long leg" on that side this will usually result in:

  • Increased vertical translation of the pelvis upward on the braced side and

  • A compensation to make up for this "long leg; circumduction in this case,  but it could be any of the other compensations that we have talked about in posts here on the blog. 



work arounds? They are tough as each can create their own set of problems

  • allow more flexion in the knee on the braced side (not always possible)

  • place a full length sole lift on the opposite side to make up for the difference

  • use crutches

  • use a skateboard : )

we are sure you have some as well that you would LOVE to share with us

Dr Ivo Waerlop, one of The Gait Guys

#shortleg #LLD #compensations #legbrace #gaitproblem #thegaitguys

 

K ShamaeiGS SawickiAM Dollar Estimation of quasi-stiffness and propulsive work of the human ankle in the stance phase of walking - PloS one, 2013 - journals.plos.org

MORAIS FILHO, Mauro César; REIS, Renata Albertin dos  and  KAWAMURA, Cátia Myuki.Evaluation of ankle and knee movement pattern during maturation of normal gait. Acta ortop. bras. [online]. 2010, vol.18, n.1 [cited  2019-04-25], pp.23-25.

Balance..

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Did you know that the posterior spinocerebellar tract is essential for normal gait? It receives information from ALL muscle spindles, Golgi tendon organs and joint mechanoreceptors and coordinates them not only with the cerebellum but also with the vestibular system. Abnormalities within this system are present (but perhaps not apparent) all gait pathologies.

Whoa! Dangerous shoes ahead....

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Holy smokes ! Can you believe this?

Take a look at these BRAND NEW, just out of the box pair of Brooks Cadence shoes. We do not usually see many manufacturer defects from this brand. Looks like someone might have been asleep at the “upper goes on the midsole” machine

Check out the varus cant to the rearfoot of the right shoe. Now look at the forefoot valgus cant to the left shoe. This would not be a great shoe for someone who has too much rear foot eversion and midfoot pronation on the right and and uncompensated forefoot valgus on the left, but we do not think it was designed for that specific, small niche market.

Think of the biomechanical implications on a "neutral" foot. Placing the right rear foot in varus would effectively halt or slow pronation in the rear foot and midfoot of that foot. This could be a good thing for an over pronator but, in a neutral foot, this would cause them to toe off in supination on that side resulting in low gear push off and biomechanical insufficiency, not to mention the increased external rotation of the lower extremity and lack of shock absorption from 1 of the 4 mechanisms of shock absorption left (mid foot pronation, ankle dorsiflexion, knee flexion, thumb flexion, contralateral drop of the pelvis). Now, imagine if that same person had internal tibial torsion. Talk about placing the knee outside of the sagittal plane ! Can you say macerated meniscus?

And now the left shoe. Look at the valgus cant! If you had and uncompensated forefoot valgus, where the forefoot is everted with respect to the rear foot or a forefoot varus, where they had adequate range of motion to allow the first ray to descend, then this could be a good thing, otherwise they are toeing off in too much pronation. This could be a real problem for a midfoot pronator or someone with large amounts of external tibial torsion, because they commonly toe off in too much pronation and low gear to begin with, as this shoe would accelerate pronation from midfoot to the forefoot

The bottom line? Look at your patients/clients shoes, as well as your own before purchasing them and examined for manufacturer defects. The upper should sit squarely on the midsole and the shoe should not rock or tip from side to side.

TGG

Want to bring out gait pathology? Add something new into the mix...

image source: https://en.wikipedia.org/wiki/Walking

image source: https://en.wikipedia.org/wiki/Walking

We have talked about bringing out compensations and asymmetries in gait patterns by adding a novel stimulus to the exam, like having the client/patient put their hands over their heads, or close their eyes. Here is yet another tool for your toolbox: having the client walk backwards.

Both forward and backward walking share pattern generation control circuits in the brainstem, providing similar (though reversed) kinematic patterns. Backward walking requires different muscle activation sequences which can highlight subtle gait asymmetries, particularly in individuals that have cortical impairment (like the kids with cerebral palsy in this paper) or perhaps people with more subtle cortical impairments, like cerebellar dysafferentation from abnormal joint and muscle mechanoreceptor input and integration. Don’t believe us or what the study says, try it on yourself! It can be a humbling experience : )

In part, the study concludes: “The observed spatiotemporal asymmetry assessments may reflect both impaired supraspinal control and impaired state of the spinal circuitry.”

The next time you are having a difficult time seeing something in an evaluation, or are trying to bring out an asymmetry, in addition to your other tricks, have them walk backwards.

Cappellini G, Sylos-Labini F, MacLellan MJ, Sacco A, Morelli D, Lacquaniti F, Ivanenko Y. Backward walking highlights gait asymmetries in children with cerebral palsy. J Neurophysiol. 2018 Mar 1;119(3):1153-1165. doi: 10.1152/jn.00679.2017. Epub 2017 Dec 20.

Is there a need for "Gait Retraining'?...We think so

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

photo source: https://commons.wikimedia.org/wiki/File:Severe_(Tönnis_grade_3)_osteoarthritis_of_the_hip.jpg

There seems to be some controversy with regards to gait retraining. Some folks seem to believe that it should be “left to itself” and they are fully compensated already (1). Perhaps this is true…or not. We have not seen any studies that compare gait retraining vs non gait retraining as a whole, but there seems to be plenty for specific conditions (2). We all see folks AFTER THE FACT and seek to correct the problems and reverse, halt or slow the progression of further pathology. That seems to be what many of us do.

This recent study (3) looks ate altered loads and muscle recruitment patterns in patients with osteoarthritis. they conclude:

“This study documents alterations in hip kinematics and kinetics resulting in decreased hip loading in patients with hip OA. The results suggested that patients altered their gait to increase medio-lateral stability, thereby decreasing demand on the hip abductors. These findings support discharge of abductor muscles that may bear clinical relevance of tailored rehabilitation targeting hip abductor muscles strengthening and gait retraining.”

There is substantial evidence that hip pathomechanics lead to osteoarthritis (4, 5). Wouldn’t it make sense to assist in altering motor patterns and correct those biomechanical faults before it becomes a problem? Lets change our focus (if we haven’t already) and concentrate on skill, endurance and strength, in that order for the betterment of ourselves, our patients and humanity.

  1. Nigg BM, Baltich J, Hoerzer S, Enders H. Running shoes and running injuries: mythbusting and a proposal for two new paradigms: “preferred movement path” and “comfort filter” Br J Sports Med. 2015 Jul; doi: 10.1136/bjsports-2015-095054. bjsports - 2015-095054. 

  2. Davis IS, Futrell E. Gait Retraining: Altering the Fingerprint of Gait. Physical medicine and rehabilitation clinics of North America. 2016;27(1):339-355. doi:10.1016/j.pmr.2015.09.002. FREE FULL TEXT

  3. Meyer CAG, Wesseling M, Corten K, Nieuwenhuys A, Monari D5, Simon JP, Jonkers I, Desloovere K. Hip movement pathomechanics of patients with hip osteoarthritis aim at reducing hip joint loading on the osteoarthritic side. Gait Posture. 2018 Jan;59:11-17. doi: 10.1016/j.gaitpost.2017.09.020. Epub 2017 Sep 22.

  4. Christian Egloff, Thomas Hügle, Victor Valderrabano: Biomechanics and pathomechanisms of osteoarthritis Swiss Med Wkly. 2012;142:w13583 FREE FULL TEXT

  5. https://www.the-rheumatologist.org/article/get-out-of-your-oa-box/?singlepage=1&theme=print-friendly

How about that arm swing?

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Do you ever notice that sometimes when people have a problem with one of their lower extremities, there are arm swing changes? Usually on the opposite side? This can be anything from a short leg to lack of ankle dorsiflexion, lack of hip extension or even over pronation.

Many times, gait changes, including arm swing, are an "above down" process. This means it begins in the cortex, affects the pattern generators which subsequently will affect extremities distal to that. Sometimes this is a metabolic problem, sometimes vestibular (which can also be mechanical, causing decreased joint and muscle mechanoreceptor input to the cerebellum and vestibular nucleii), sometimes a combination of both. Throw a figure-of-eight ankle wrap on and walk. Your ROM is decreased (mechanical); this reduces input to your cerebellum which reduces input to your vestibular system. Your ankle dorsiflexion and step length will be diminished on that side; this will often cause an increase in arm swing on the contralateral side, which increases the metabolic "cost".

Arm swing may be coached, but we believe this is not always the correct approach as if it is a vestibular problem with altered cerebellar input (Something with the actual semicircular canals or perhaps input from muscle spindle or Golgi tendon organs), coaching arm swing makes the patient "look better" but does not really "fix" the problem; Which may be something as simple as joint pathomechanics, ligamentous restriction or a lack of skilled/endurance/strength in appropriate musculature.  If it is a metabolic issue, sometimes coaching arm swing can improve mechanical efficiency but at the cost of decreasing cortical efficiency, because the brain is such an energy hog.

Arm swing is there for a reason. It tells you something about what is going on or what is not going on. Just because it looks bad does not mean that it is necessarily the problem. Look deeper and keep your eyes, ears and mind open.

We will be talking about the case with this gal. her crossover gait and armswing, alonng with 2 other cases, on our 3rd Wednesdays class on onlince.com: Biomechanics 320  on 8/15/2018

Meyns P, Bruijn SM, Duysens J. The how and why of arm swing during human walking. Gait Posture. 2013 Sep;38(4):555-62. doi: 10.1016/j.gaitpost.2013.02.006. Epub 2013 Mar 13.

Wu Y, Li Y, Liu AM, Xiao F, Wang YZ, Hu F, Chen JL, Dai KR, Gu DY. Effect of active arm swing to local dynamic stability during walking. Hum Mov Sci. 2016 Feb;45:102-9. doi: 10.1016/j.humov.2015.10.005. Epub 2015 Nov 23.

Footwear IS Medicine

We always have said that "Shoes ARE medicine" Here's an article that supports that.

"Footwear plays an integral role in force distribution on the lower extremities, and choosing appropriate footwear is one of many strategies people can use to manage knee pain caused by joint disorders. When footwear is properly fit, force and stress can be shifted away from weaker parts of the knee, and the leg stabilized. This may lead to a significantly better quality of life for patients with knee problems, such as osteoarthritis (OA) and patellofemoral pain syndrome."

 

http://lermagazine.com/article/the-effect-of-footwear-on-the-management-of-pain-caused-by-disorders-of-the-knee-joint

This is part 2 of a 2 part post; with the video from the case previously discussed

please note the following in the video:

  • body lean to left during left stance phase (to clear right longer leg)
  • circumduction of right lower extremity  (to clear right longer leg)
  • lack of arm swing bilaterally (cortical involvement)
  • patient looking down while walking (decomposition of gait)
  • shortened step length (decomposition of gait)
  • increased tibial varum bilaterally

ASSESSMENT:  This patient’s short leg and internal tibial torsion impediments to her full recovery. She has increased tibial varum noted which is complicating the picture. This is causing pathomechanics and an abductory moment not only at the knee but also in the lumbar, thoracic and cervical spines.

WHAT DID WE DO?:                    

  • We attempted to do the one leg standing exercise. She needed to hold on and did not feel stable on the left hip while performing this.  This is probably more of confidence rather than ability issue. 
  • We gave her the stand/sit exercise to try to improve gluteal recruitment.
  • We also gave her the lift/spread/reach exercise to attempt to strengthen her feet.
  • A full-length 5 mm lift was cut for the left shoe  She felt more stable when walking on this.
  • She was treated with IC, PIR and manipulative therapy and neuromuscular stim of the knee as well as left hip area above, below and at the joint line of the knee as well as gluteus medius and minimus.   
  • We may need to consider building a more aggressive orthotic with a forefoot varus post depending upon her progress and response to care  

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn

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Yes, we are all twisted: Part 1

Developmentally speaking, that is.  Version and Torsion are the words we need to know. There are 3 normal versional changes that take place in the lower extremity development from infant to adult: rotation of the talar head/neck, tibial rotation, and femoral rotation  (see above). 

So, what is the difference between a torsion and version?

A version is a normal variation in the “twistedness” of a limb (longitudinally speaking) between its proximal and distal portions, representing a normal range of development (see femur above) .  An example is the head and neck of the femur has an angle of 8-12 degrees with respect the femoral condyles.

A torsion is the same condition with the amount of twist 1 to 2 standard deviations greater. An example is when the angle of the femoral neck and greater than 15 degrees, the condition of femoral ante torsion exists (see photo above).

There are at least 3 reasons you need to understand about developmental torsions and versions that occur with growth:

  1. Since they occur in the transverse (horizontal) plane, they affect the progression angle of the foot and thus gait
  2. They affect available ranges of motion of a limb (ex the femur needs to internally rotate 4-6 degrees for normal gait) and can cause pain and/or gait alterations
  3. They can affect the coronal (frontal) plane orientation of the lower limb, which can affect gait and shoe choices. A Rothbart foot type with an elevated 1st metatarsal head will often result in a varus (or inverted) position of the forefoot with respect to the rear foot.

In this series, we will explore these 3 major versional changes, one at a time.

The Gait Guys. Bald? Yes! Good looking? You bet! Yes, we are a little more twisted than most folks : )

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.  Please ask before recycling our stuff!

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!

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Torsions 

This gentleman has 2 excellent examples of thing you will see commonly: femoral retrotorsion and internal tibial torsion.

The neck of the femur usually makes an 8-25 degree angle (average 18 degrees) with the shaft of the femur. If this is greater than 25 degrees it results in a condition called femoral antetorsion and if less than 8 degrees, it is called femoral retrotorsion.

Femoral retrotorsion results in one having LESS internal rotation of the hip (and increased external rotation) and femoral antetorsion results in having a GREATER amount of internal rotation (and less external rotation).

We normally need 4 degrees of internal rotation of the hip to walk normally. Most people have at least 40 degrees. Look at the shots above of this gentleman who has almost zero. This range of motion needs to come from somewhere, and in this individual, it is occurring at the foot (in the form of a “spin” with gait, and complimentary tight achilles tendons).

Now look at the alignment of the tibial tuberosity with the lower leg. See how it faces medially? It should be about 22 degrees in the adult. More than this is called external tibial torsion and less (like here) is internal tibial torsion. Note how the foot is “toed in” on both sides? This will keep the foot in supination longer and you will weight the outside of the foot more. Put a conventional orthotic on this person without forefoot valgus posting and you are asking for a meniscus problem!

Now look at the “bow” (or varum, as it is called) of the tibia. Normal here is 4-6 degrees and he is in excess of 10. You will often see this in clients with internal tibial torsion.

So, what’s the fix?

You could do a surgery, like they did to Ethan Hawke in “Gattica” or you could make sure the foot has an adequate tripod (which this client did not). Tripod exercises (coming soon on the blog), EHB exercises, Toe waving exercises are all important, as well as foot, knee and hip manipulation to assure normal mechanics are present. Make sure that hip internal rotation is adequate and that gluteus medius and minimus finction is appropriate, as well as vastus lateralis (yes, lateralis is an INTERNAL ROTATOR when the foot is on the ground).

Torsions. Hope you are seeing these as much as we are.

Your twisted Gait Geeks; Ivo and Shawn