Some more really subtle things...How sharp are YOUR eyes?

As I study this video more and more (yep, we just keep looking at things because we are that nerdy and that paranoid that we missed something) I saw at least 3 very subtle findings. 

Watch the video of this right handed physical therapist who had L knee reconstruction (MCL/ACL with hamstring allograft) a few (hundred) times and see what you come up with, then come back and read this. We lie to slow things down and even frame by frame it with the slow motion feature or space bar to stop it. As background to the clinical exam, he has limited hip and knee extension on the left, 4/5 weakness of the quadratus femoris. His popliteus tests strong and 5/5. He has right sided back pain with L sided knee pain at the joint line and just inferior and medial. the treadmill is at a 2% grade at 2 mph.

Notice how he has a pelvic drift to the right during stance phase on that side. Why do you think? Remember, he has had a left sided knee surgery that left him with limited knee extension on that side. This creates a functional short leg on that side (the left), so he needs to get the longer (right) leg around. We don’t always see lateral movement of the pelvis on the longer leg side, but our guess is he is trying to “shorten” the longer leg side; lateral translation in the coronal plane is one strategy to accomplish that.

Now look at the left side. Can you see the subtle hip hike to clear the right leg? How about the small amount of circumduction? Sometimes folks will employ more than one strategy to get around a long leg, but ususally one will predominate, but not in this case. 

Did you catch the abductory twist of the right heel? The longer leg side needs to go through a greater range of motion of ankle dorsiflexion which will store more potential energy in the tricep surae as well as long flexors of the toes, that energy needs to go somewhere!

Now think about step length. It will often be shortened on the shorter leg side. He still needs to move forward the same amount, so he uses the right arm to help propel his center of mass forward. Do you see the increased arm swing? 

And why does he abduct his right arm so much? Where is his center of mass at left foot strike? It is all the way to the right, because of the “short leg”, correct? How can you counterbalance that? Abducting the arm would certainly accomplish that. Why does it go across the body? It is no longer needed to be that lateral during stance phase on the right, but he still needs to use it to propel himself forward with the shortened step length we talked about before. 

Mental gymnastics, running through what runs through our minds and why things may appear the way that they do. A great lesson in knowing what is supposed to happen and when in the gait cycle



Dr Ivo Waerlop, one of The Gait Guys



#kneepain #lowbackpain #gaitanalysis #thegaitguys #visualgaitanalysis

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

Case Studies in Gait Analysis: Focus on the Short Leg (online video class)

Case Studies in Gait Analysis: Focus on the Short Leg
*link is below

*this is the online Continuing education class we did last week, for those of you who could not get to the Wednesday evening class.
*our entire catalogue of lectures and seminars are all here on this site for CE/CEU

Case Studies in Gait Analysis: Focus on the Short Leg
- Review anatomical vs functional short leg
-Review the kinematics and kinetics of the short leg during the gait cycle
-View and discuss case studies looking at functional and anatomical short legs
-Predict pathomechanics that will arise from a short leg
-Propose remedies for the gait abnormalities seen

Link: https://chirocredit.com/course/Chiropractic_Doctor/Biomechanics_211

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Increased unilateral foot pronation and its effects upward into the chain.

Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Nothing earth shaking here, we should all know this as fact. When a foot pronates more excessively, the arch can flatten more, and this can accentuate a leg length differential between the 2 legs. But it is important to note that when pronation is more excessive, it usually carries with it more splay of the medial tripod as the talus also excessively plantarflexes, adducts and medially rotates. This action carries with it a plantar-ward drive of the navicular, medial cuneiforms and medial metatarsals (translation, flattening of the longitudinal arch). These actions force the distal tibia to follow that medially spinning and adducting talus and thus forces the hip to accommodate to these movements. And, where the hip goes, the pelvis must follow . . . . and so much adaptive compensations.
So could a person say that sometimes a temporary therapeutic orthotic might only be warranted on just one foot ? Yes, of course, one could easily reason that out.
-Shawn Allen, one of The Gait Guys

#gait, #gaitanalysis, #gaitproblems, #thegaitguys, #LLD, #leglength, #pronation, #archcollapse, #orthotics, #gaitcompensations, #hippain, #hipbiomechanics

Gait Posture. 2015 Feb;41(2):395-401. doi: 10.1016/j.gaitpost.2014.10.025. Epub 2014 Nov 3.
Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking.
Resende RA1, Deluzio KJ2, Kirkwood RN3, Hassan EA4, Fonseca ST5.

A flexed leg is a shorter leg: When loss of knee extension really matters.

A flexed knee is a shorter leg, period.
A knee with any loss of terminal extension, is more bent knee, and thus a shorter leg, period.

Stand up, bend one knee 10 degrees, you have shortened the global top to bottom length of that leg.
So when walking, you will plunk down onto that shorter leg, and there will be a cost.

This is old hat for our long time readers, but it is a good reminder to look for loss of terminal knee extension.

I just saw a lady with a uni-knee replacement of 5 months. Failing some aspects of rehab, they are stuck. There is hip,knee and ankle pain on walking.
She had a loss of terminal knee extension, thus a short leg, true shortness.
I placed a 2mm full sole length rubber-cork lift in the shoe (*DO NOT USE JUST A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts and causing plantarflexion at the ankle. Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, or want to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
She put the shoe back on with the 2mm sole lift in the shoe and walked 20 steps and started to tear up. No pain.

Sometimes things are simple. We more closely restored the leg length by adding more vertical height. Yes, the problem still exists, but its global effects are somewhat muted. She stopped premature heel rise, could feel her glutes, stopped the abrupt plunk onto the leg, *stopped the sudden abrupt knee flexion loading that was crippling her.

I then took it out, "shoe'd" her up again, and she was dumbfounded, all the pain returned as did her awareness of what she was coping with.

Now, sent her away with the sole lift to accommodate for 2 weeks, and we will restart the rehab once things have time to get used to the "new norm". Now the rehab will work, we think. Time will tell

One thing is for sure, and now yesterdays post rings more clear and true, if you build strength on compensation, you earn and own that compensation.

The Gait Guys

#gait, #gaitproblems, #gaitcompensations, #strength, #heellift, #solelift, #TKA, #hippain, #shortleg

Photo courtesy of Pixabay, beautiful photo isn't it !?

Heel lift or sole lift ?

*DO NOT USE A HEEL LIFT, please, for the love of God and all that is beautiful on this earth stop using just heel lifts to correct a length length discrepancy, and thus causing plantarflexion at the ankle by raising just the heel. What about raising the forefoot, too ?! Heel lifts are specific unicorns you only use when you are trying to get more plantarflexion at the ankle, unload a barking unresponsive achilles tendonitis, or for some strange reason you wish to rush someone to the forefoot, or want a shorter posterior compartment (amongst other stupid things you probably do not want in your client mechanics)).
Besides, many people's problems arise from insufficient ankle rocker/dorsiflexion as it is , so why are you sentencing them to the depths of hell by predisposing them to pre-plantarflexed strategies ? You should love your clients ! Using a heel lift requires smarts, deep smarts, and intimate understanding of the pitfalls of pre-positioning the heel higher than the forefoot and what it may do to your clients mechanics over time. Did decades of high heel ramp, high heel-toe drop shoes or a century of high heeled women's shoes not teach us anything? (ok, we are going overboard here to make our point :)
When do we almost exclusively use a heel lift? Very temporarily in unresponsive achilles tendonopathies, and even that can be argued. But, sometimes you have to use unicorns and black magic.
Use your noggin, daily.

shawn and ivo, the gait guys

#gait, #gaitproblems, #gaitanalysis, #thegaitguys, #heellifts, #solelifts, #anklerocker, #ankleplantarflexion, #ankledorsiflexion, #heeltoedrop, #heelrise, #shortachilles

Where the knee hinges matters.

It is easy to see the big things, but, we sometimes forget that the small things matter.
Sometimes it take an obvious glaring asymmetry to make us appreciate that the small asymmetries can make the same or similar impact over a long period of time. Rivers can carve out canyons over time.

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Here we see the gross difference that polio can make in leg size and in leg length. We must remember that changing a leg length also changes the symmetrical relationship of where the 2 knees hinge. A foot that pronates more than the other leg can lower the knee hinge point just a little because the talus drops further from its vertical height. We know very well that it for certain alters the hinge direction, posturing it more medially, but we cannot forget that a cranky knee on a side where the foot is flatter or pronates more excessively than the other is not to be ignored.
In this photo, we have dotted the knee at the same point on the patella. It is clear the knees will not hinge at the same time, thus stride and step lengths will change, and step width will be impacted. The pelvis will also spin more to one side on a pelvis that is lower on one side. This will impact lumbar spine sagittal happiness and stability/mobility. Hip and pelvis drift are real things in this case, and need your attention. *Just like a client that has a painful foot, a more pronated foot, more tibial torsion on one side etc. these things matter, and they often matter years down the road when many thousands of miles have been clocked into the subtle asymmetry. Sometimes these little things matter in our athletes too, who put the pedal to the floor asking the body for more.

Come hear our lecture tonight on www.onlineCE.com. You have to sign up early to get in. We won't disappoint. See you then. 7pm central time.

Short leg and Pronation

Dr Allen was ON FIRE on tonites onlinece.com lecture Biomechanics 322). Hope you will join us again (or next time if you missed us). We talked about many of the aspects of a static exam and how it effects weight bearing in the foot. The word "short leg" came up more than once, and yes, from Dr Allen : )

Remember, as the foot pronates more on one side, the center of gravity will move medially. You will often see more toe clenching (and resultant quadratus plantae weakness) on the more pronatory side and more toe elongation on the more supinatory side. You will often also see more splay and elongation on the pronatory side, and less elongation and less splay on the supinatory side. Remember, these are guidelines and not rules, and there are ALWAYS exceptions.

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Simulated knee flexion contracture to elucidate knee-spine syndrome

When we have on one side either a:
- fixed knee flexion deficit
- weak quadriceps mechanism
- short quadriceps-hip flexor complex with anterior pelvis predominance

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. . . these often present functionally as a short leg on that side. Perhaps better put, these will cause a premature forefoot loading response. This loading response will expedite ankle rocker during the stance phase of gait. This will often result in an overactive calf muscle complex and thus shortness over time, further blunting the ankle rocker during tibial progression over the ankle.
Furthermore, there will be a heavy lurching loading response on that same leg, it will surely look like a short leg, functionally. This is why it is imperative to check for full knee extension, ability to engage the quads with endurance and strength in full extension, and be able to connect that anterior chain with the lower abdominals and hip flexors without dumping into an anterior pelvis posture.
The loads move. They move up and down. There are many other causes of this descriptive mechanical chain problem above. Even a weak anterior shin compartment will cause many of these abrupt forefoot loading responses (that can also functionally resemble a knee flexion contracture) and promote early and excessive knee flexion during early limb loading response, when we rather should be posturing over a more stable and extended knee. They feed off of each other. It is why these syndromes of problems get intermixed and complicated to both diagnose and remedy.

PS: we chose this photo for a reason today, because high heels make us load the forefoot prematurely during the gait cycle, and we have to dampen the loads with the quadriceps.

Take what you will from this study, but it is really the global picture it suggests. That being, everything can affect everything.
PS: we hate the name they put on this study at the end. . . . "Knee-spine syndrome". For what its worth.

"However, the 30 degrees (simulated knee) contracture significantly changed the kinematics in each of the following planes. In the coronal plane, the trunk tilted to the contracture side in standing and walking. In the sagittal plane, posterior inclination of the pelvis in standing significantly increased. In addition, anterior inclination of the trunk and pelvis during walking significantly increased. In the axial plane, trunk rotation to the unaffected side significantly decreased during walking. The vertical knee force in the contracture limb decreased, being accompanied by the increase of the force in the unaffected limb during standing and walking. Results of our study suggest that knee flexion contracture significantly influences three-dimensional trunk kinematics during relaxed standing and level walking, and will lead to spinal imbalance. These facts may explain the onset of the "Knee-Spine Syndrome".

Gait Posture. 2008 Nov;28(4):687-92. doi: 10.1016/j.gaitpost.2008.05.008. Epub 2008 Jun 26.

A gait analysis of simulated knee flexion contracture to elucidate knee-spine syndrome.

Harato K1, Nagura T, Matsumoto H, Otani T, Toyama Y, Suda Y.

Podcast 128: Usain Bolt, Plantaris Tears, Arm Swing

Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_128final.mp3

http://thegaitguys.libsyn.com/podcast-128-usain-bolt-plantaris-tears-arm-swing

https://www.thegaitguys.com/podcasts/


Key Tagwords:

usain bolt, plantaris tear, plantaris, sole lifts, heel lift, leg length, short leg, heel drop, shoeque, symmetry, asymmetry, sprinters, scoliosis, tendinopathy, achilles, runners, marathons, running injuries, arm swing

Our Websites:
www.thegaitguys.com
summitchiroandrehab.com   doctorallen.co     shawnallen.net


Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Superficial plantar cutaneous sensation does not trigger barefoot running adaptations.

https://www.ncbi.nlm.nih.gov/pubmed/28728130

Arm swing
http://www.medicalnewstoday.com/articles/173680.php

Usain bolt
https://mobile.nytimes.com/2017/07/20/sports/olympics/usain-bolt-stride-speed.html?referer=

Plantaris tears
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978447/

Pod #124: Gluteal gripping, Runner's dystonia. Are leg length differences real ?

Key tag words:
running, gait, injuries, kidney, kidneydamage, marathoners, foot, feet, dehydration, heatstroke, elon musk, neural lace, hip pain, crossfit, squats, deadlifts,  LLD, short leg, dystonia, runner's dystonia, posture, 

Summary:  Today we hit some very important topics on how to examine a client and how asymmetries play into gait, running, posture and pathomechanics. We hope you enjoy today's show, it is our first one back in 6 weeks. We are back strong after a brief early summer sabbatical. Back to the "podcast every 2 weeks" again. Thanks for being patient while Ivo recharged for the second half of the year.   Plus, on today's show, we also dive into Runner's kidney, dehydration, gluteal gripping, runner's dystonia, functional leg length differences due to asymmetries, and more !

Show links:

http://traffic.libsyn.com/thegaitguys/pod_124final.mp3

http://thegaitguys.libsyn.com/pod-124

Our Websites:
www.thegaitguys.com

summitchiroandrehab.com   doctorallen.co     shawnallen.net
Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Kidney Damage in Runners. 82%  !?
http://www.newsweek.com/running-bad-you-marathons-damage-kidneys-runners-bodies-575829
 
Kidney nephropathy in mesoamericans.
http://www.ajkd.org/article/S0272-6386(15)01257-3/fulltext  
 
Elon Musk's Neural Lace.
https://www.scoopwhoop.com/elon-musk-launches-neuralink-which-hopes-to-combine-your-brain-with-artificial-intelligence/
 
Leg length discrepancies,do they really even exist ?
Dystonia ?
The Gluteal gripping phenomenon.

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Holy Leg Length discrepancy!

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

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

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

Pain on the outside of one leg, inside of the other. 

Whenever you see this pattern of discomfort, compensation is almost always at play and it is your job to sort it out. 

This patient presents with with right sided discomfort lateral aspect of the right fibula and in the left calf medially. Pain does not interfere with sleep.  He is a side sleeper 6 to 8 hours. His shoulders can become numb; left shoulder bothers him more than right.

PAST HISTORY: L shoulder surgery, rotator cuff with residual adhesive capsulitis. 

GAIT AND CLINICAL EVALUATION: see video. reveals an increased foot progression angle on the right side. Diminished arm swing from the right side. A definite body lean to the right upon weight bearing at midstance on that side.

He has external tibial torsion bi-lat., right greater than left with a right short leg which appears to be at least partially femoral. Bi-lat. femoral retrotorsion is present. Internal rotation approx. 4 to 6 degrees on each side. He has an uncompensated forefoot varus on the right hand side, partially compensated on the left. In standing, he pronates more on the left side through the midfoot. Ankle dorsiflexion is 5 degrees on each side. 

trigger points in the peroneus longus, gastroc (medial) and soles. 

Weak long toe extensors and short toe flexors; weak toe abductors. 

pathomechanics in the talk crural articulation b/l, superior tip/fib articulation on the right, SI joints b/l

WHAT WE THINK:  

1.    This patient has a leg length discrepancy right sided which is affecting his walking mechanics. He supinates this extremity as can be seen on video, especially at terminal stance/pre swing (ie toe off),  in an attempt to lengthen it; as a result, he has peroneal tendonitis on the right (peroneus is a plantar flexor supinator and dorsiflexor/supinator; see post here). The left medial gastroc is tender most likely due to trying to attenuate the midfoot pronation on the left (as it fires in an attempt to invert the calcaneus and create more supination). see here for gastroc info

2.    Left shoulder:  Frozen shoulder/injury may be playing into this as well as it is altering arm swing.

WHAT WE DID INITIALLY (key in mind, there is ALWAYS MORE we can do):    

  •  build intrinsic strength in his foot in attempt to work on getting the first ray down to the ground; EHB, the lift/spread/reach exercises to perform.
  • address the leg length discrepancy with a 3 mm sole lift
  • address pathomechanics with mobilization and manipulation. 
  • improve proprioception: one leg balancing work
  • needled the peroneus longus brevis as well as medial gastroc and soles. 
  • follow up in 1 week to 10 days.

Pretty straight forward, eh? Look for this pattern in your clients and patients

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Short leg and mottling of the skin

Have you ever heard of Klippel-Trenaunay Syndrome? I hadn’t either, until I had a patient come in with low back pain and a gait issue and said she had it.

Evidently, in 1900, noted French physicians Klippel and Trenaunay first described a syndrome in 2 patients presenting with a port-wine stain and varicosities of an extremity associated with hypertrophy of the affected limb’s bony and soft tissue. Klippel-Trenaunay-Weber syndrome (KTWS) is characterized by a triad of port-wine stain, varicose veins, and bony and soft tissue hypertrophy involving an extremity (1).

Most cases KTWS are sporadic, although a few cases in the literature report an autosomal dominant pattern of inheritance (2). There is no racial predilection, even distribution between males and females and presents at birth or during early childhood (3). It generally affects a single extremity, although cases of multiple affected limbs have been reported. The leg is the most common site followed by the arms, the trunk, and rarely the head and the neck(4).

This patient had a history of low back pain with a recent epidural steroid injection. Exam highlights included a R sided leg length discrepancy approximately 5mm (tibial and femoral). Pelvic tilt to the right (for LLD) with anterior rotation of that side of the pelvis, posterior on the opposite side (counter clockwise pelvic distortion pattern). Lumbar flexion off 60/90 with all motion occurring in the lumbar spine (ie: no hip hinge), extension 20/30, lateral bending 30/45 BL with pain ipsilateral. Decreased low back endurance of <50 seconds in extension.

Right lower extremity was smaller (appeared hypoplastic) than left and had multiple discolorations in the skin (see pictures). L sided Q angle > R (12 vs 8 degrees). Less internal rotation of the right lower extremity compared to left, but with normal limits. Gait revealed a shift and hike to the right during stance phase with an increased arm swing on the right. Foot intrinsics were weak (lumbricals, EDL, FDB, dorsal intrerossei)

She walked in a pair of Chaco sandals with allowed much greater calcaneal eversion bilaterally R > L.

MRI revealed paraspinal marbling at the lower part of the lumbar spine, improving as you move rostrally. Small disc herniations at L3/4, 4/5, 5/S1, which did not effect the exiting nerve roots. Degenerative changes in the lumbar facet joints. There was no radiographic evidence of instability.

Impression:
It seems that she did not have enough intrinsic for the strength to stop calcaneal eversion in her Chaco’s and therefore this was causing increased foot pronation. This, combined with her leg length discrepancy, was contributing to increasing the lordosis in her lumbar spine, causing facet joint irritation. This was compounded by weakness and lack of endurance of the lumbar paraspinal musculature. The effects of the Klippel-Trenaunay Syndrome are evident with the IPO plasticity of the right lower extremity and accompanying musculoskeletal abnormalities.

What did we do?

  • Gave her endurance exercises for the lumbar spine.
  • Gave her propriosensorv exercises for the lumbar spine
  • Recommended she continue with the 5 mm sole lift.
  • Advised getting rid of the Chaco sandals as they allow too much calcaneal eversion and sticking to a shoe that has a stronger/larger heel counter.
  • acupuncture to improve circulation and proprioception as well as muscular function
  • we will monitor weekly for the next 4 to 6 weeks.

All in all, and interesting use with a little twist (not a torsion, of course!) : )


1. http://reference.medscape.com/article/1084257-overview
2. Ceballos-Quintal JM, Pinto-Escalante D, Castillo-Zapata I. A new case of Klippel-Trenaunay-Weber (KTW) syndrome: evidence of autosomal dominant inheritance. Am J Med Genet. 1996 Jun 14. 63(3):426-7.
3. Sung HM, Chung HY, Lee SJ, Lee JM, Huh S, Lee JW, et al. Clinical Experience of the Klippel-Trenaunay Syndrome. Arch Plast Surg. 2015 Sep. 42 (5):552-8.
4. http://reference.medscape.com/article/1084257-clinical

“Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  Welcome to a global industry problem.”  -Dr. Allen   Which hip will have troubles extending ?  Remember this quiz question from 2 weeks ago ? I talked about how the body will compensate to level the pelvis (and eyes and vestibular apparatus).  Lets go further down the rabbit hole.  Here is your question of the week (you may have to go back and review the prior blog post if you are unsure of how the body will cope with the slope.   Here is that first blog post.   Question: Which hip will have troubles getting into hip extension and thus terminal glute-hip-pelvis stabilization ?  Answer:  scroll down (at least think about it for a second)  .  .  .  .  .  .  Answer:  The leg on the up slope of the beach, the non-water side leg will have to be in a modest degree of knee flexion to shorten and accommodate to the slope. A Flexed knee is not an extended one and it will be far more difficult to extend the hip and get into the glutes. Propulsion will also be compromised.  For you indoor small track runners this will happen to you on the inside leg on the curves of the track. This is why we see so many hamstring injuries during indoor track.  Think about it ! It is not just bad luck.  Go ahead, tally up  your teams history of hamstring injuries, you should find more on the left leg for track runners. It is simple applied biomechanics.   Also, imagine the altered demand on the quadriceps on that flexed knee (the right knee in the picture above, and the left knee in circle track runners). Furthermore, what is the likelihood that the right pelvis will deviate into an anterior tilted posture ? You bet ya, a greater tendency, and thus a possibly shortened quadriceps/hip flexor mechanism.  Do you think this could inhibit hip extension and gluteal function ? You bet ya.  Oh, and one more thing, if you are true gait nerd, you should have asked yourself one more question, what about ankle rocker ?  Yes, you will need more ankle rocker on the beach side foot (flexed knee side). When the knee flexes, there must be more ankle rocker for this to occur, if not, you may implode into some unwelcome arch collapse, because arch collapse offers more false ankle rocker. What a mess huh !   Now, do not be shocked EVER again when your client’s come back from a sunny beach vacation from walking the beaches for hours every day, and find themselves a stark raving mad mess.  It is not the salty ocean air or the tequila, it is the slope. One could make a case that walking up and down the beach should balance things out, but that is only if we are balanced and symmetrical when we start out. Gravity always wins.  One final rant. If you are offering “corrective exercises” to your clients, you had better know at least the basics of movement and biomechanics. And further more, you had better know how to examine for them, and that means hands on assessment of the body, not just looking at how your client moves through a battery of tests. If the prior blog post  (here)  and today’s blog post principles are not remedial principles of knowledge for you, offering corrective exercises without this knowledge  and a physical exam  to confirm your assumptions is fraught with disaster, or at least helping your client to build deeper compensations on their prior compensations.   Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?    This is the kind of stuff that keeps my new patient scheduling booked at 4-8 weeks out &hellip; . .  frustrated clients.  This is why we do not offer online consultations like some do. Because, we have not figured out how to obtain the third dimension needed in our gait and movement observation (thank you Oculus Rift, the future is near) but more so, we cannot take that information and put it together with our own physical examination to determine whether if what we are seeing is the actual problem, or a compensation. Here in lies the pot of gold.  Another clinical pearl from Dr. Allen

“Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  Welcome to a global industry problem.”  -Dr. Allen

Which hip will have troubles extending ?

Remember this quiz question from 2 weeks ago ? I talked about how the body will compensate to level the pelvis (and eyes and vestibular apparatus).

Lets go further down the rabbit hole.  Here is your question of the week (you may have to go back and review the prior blog post if you are unsure of how the body will cope with the slope.  Here is that first blog post.

Question: Which hip will have troubles getting into hip extension and thus terminal glute-hip-pelvis stabilization ?

Answer:  scroll down (at least think about it for a second)

.

.

.

.

.

.

Answer:

The leg on the up slope of the beach, the non-water side leg will have to be in a modest degree of knee flexion to shorten and accommodate to the slope. A Flexed knee is not an extended one and it will be far more difficult to extend the hip and get into the glutes. Propulsion will also be compromised.  For you indoor small track runners this will happen to you on the inside leg on the curves of the track. This is why we see so many hamstring injuries during indoor track.  Think about it ! It is not just bad luck.  Go ahead, tally up  your teams history of hamstring injuries, you should find more on the left leg for track runners. It is simple applied biomechanics.   Also, imagine the altered demand on the quadriceps on that flexed knee (the right knee in the picture above, and the left knee in circle track runners). Furthermore, what is the likelihood that the right pelvis will deviate into an anterior tilted posture ? You bet ya, a greater tendency, and thus a possibly shortened quadriceps/hip flexor mechanism.  Do you think this could inhibit hip extension and gluteal function ? You bet ya.  Oh, and one more thing, if you are true gait nerd, you should have asked yourself one more question, what about ankle rocker ?  Yes, you will need more ankle rocker on the beach side foot (flexed knee side). When the knee flexes, there must be more ankle rocker for this to occur, if not, you may implode into some unwelcome arch collapse, because arch collapse offers more false ankle rocker. What a mess huh !   Now, do not be shocked EVER again when your client’s come back from a sunny beach vacation from walking the beaches for hours every day, and find themselves a stark raving mad mess.  It is not the salty ocean air or the tequila, it is the slope. One could make a case that walking up and down the beach should balance things out, but that is only if we are balanced and symmetrical when we start out. Gravity always wins.

One final rant. If you are offering “corrective exercises” to your clients, you had better know at least the basics of movement and biomechanics. And further more, you had better know how to examine for them, and that means hands on assessment of the body, not just looking at how your client moves through a battery of tests. If the prior blog post (here) and today’s blog post principles are not remedial principles of knowledge for you, offering corrective exercises without this knowledge and a physical exam to confirm your assumptions is fraught with disaster, or at least helping your client to build deeper compensations on their prior compensations. Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  This is the kind of stuff that keeps my new patient scheduling booked at 4-8 weeks out … . .  frustrated clients.

This is why we do not offer online consultations like some do. Because, we have not figured out how to obtain the third dimension needed in our gait and movement observation (thank you Oculus Rift, the future is near) but more so, we cannot take that information and put it together with our own physical examination to determine whether if what we are seeing is the actual problem, or a compensation. Here in lies the pot of gold.

Another clinical pearl from Dr. Allen

A test question from Dr. Allen, see how you do with this photo critical thinking.  When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface.   Here is the game &hellip;  to keep the pelvis level on the horizon, one would have to:  a. shorten the water side leg  b. lengthen the water side leg  c. pronate the water side leg  d. supinate the water side leg  e. lengthen the beach side leg  f. shorten the beach side leg  g. pronate the beach side leg  h. supinate the beach side leg  i. externally rotate the water side leg  j. internally rotate the water side leg  k. externally rotate the beach side leg  l. internally rotate the beach side leg  m. flex the water side hip  n. extend the water side hip  o. flex the beach side hip  p. extend the beach side hip   ******Ok, Stop scrolling right now !!!!!       List all the letters that apply first.    You should have many letters.  ***  And here is the kicker for bonus points , the letters can be unscrambled to spell the name of one of  the most popular of the Beatles . Name that Beatle.  .  .  .  don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.  .  .  .  .  .  .     Answer: B, D, F , G, I ,L , N, O  * now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.  ok, we were messing with ya on the Beatles thing. Sorry.  Dr. Shawn Allen

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

.

.

.

don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

.

.

.

.

.

.


Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

Using a boot to heal a bone, tendon, post-op ?  Think deeper please.  Please please, please ! If you are going to put your client in a CAM rocker boot/shoe for a fracture, or post-op can you please try to level out the leg length discrepancy caused by the thickness of the boot&rsquo;s sole ? Please ? Pretty please with sugar on top?  Some boot brands have a huge midsole thickness. This leads to a functionally longer leg length. If they are barefoot much of the day, there will be a huge leg length discrepancy. If in shoes all day, you can offset this with a sole lift in the healthy foot&rsquo;s shoe or you can add something like this to the outsole. Use common sense. IF someone is in a CAM boot for 6 weeks and thus a longer leg, this is going to promote a knee flexed posture on the boot side (ie. shortens the leg) and/or hyperextension of the healthy leg&rsquo;s knee, supination of the foot, more forefoot habitus (sustained calf loads) and even frontal plane lurch pelvis gait mechanics (this is why many folks will get opposite hip pain). These embedded gait flaws must be addressed and remedied after they are out of the boot to reset normal gait. We have seen enough problems come to our offices that are suspect as a result of prolonged boot use and failure to reteach normal gait patterns, meaning, to reduce the learned gait behaviors of being in a boot for prolonged periods. Gait retraining is just as important as the rehab post-boot removal.  Of course, this is rarely done.  Using logic is never a bad thing.      Dr. Shawn Allen, one of the gait guys   Here is a neat device we found to help.http://www.braceshop.com/procare-evenup-shoe-balancer-walker-system.htm?gdftrk=gdfV28018_a_7c2568_a_7c10961_a_7c32290&amp;gclid=Cj0KEQiA37CnBRChp7e-pM2Mzp0BEiQAlSxQCCeL74AvCkYXbQX_jV1jEP27mfocB87f8pSfbo2PZMIaAsOV8P8HAQ

Using a boot to heal a bone, tendon, post-op ?  Think deeper please.

Please please, please ! If you are going to put your client in a CAM rocker boot/shoe for a fracture, or post-op can you please try to level out the leg length discrepancy caused by the thickness of the boot’s sole ? Please ? Pretty please with sugar on top?

Some boot brands have a huge midsole thickness. This leads to a functionally longer leg length. If they are barefoot much of the day, there will be a huge leg length discrepancy. If in shoes all day, you can offset this with a sole lift in the healthy foot’s shoe or you can add something like this to the outsole. Use common sense. IF someone is in a CAM boot for 6 weeks and thus a longer leg, this is going to promote a knee flexed posture on the boot side (ie. shortens the leg) and/or hyperextension of the healthy leg’s knee, supination of the foot, more forefoot habitus (sustained calf loads) and even frontal plane lurch pelvis gait mechanics (this is why many folks will get opposite hip pain). These embedded gait flaws must be addressed and remedied after they are out of the boot to reset normal gait. We have seen enough problems come to our offices that are suspect as a result of prolonged boot use and failure to reteach normal gait patterns, meaning, to reduce the learned gait behaviors of being in a boot for prolonged periods. Gait retraining is just as important as the rehab post-boot removal.  Of course, this is rarely done.  Using logic is never a bad thing.   

Dr. Shawn Allen, one of the gait guys

Here is a neat device we found to help.http://www.braceshop.com/procare-evenup-shoe-balancer-walker-system.htm?gdftrk=gdfV28018_a_7c2568_a_7c10961_a_7c32290&gclid=Cj0KEQiA37CnBRChp7e-pM2Mzp0BEiQAlSxQCCeL74AvCkYXbQX_jV1jEP27mfocB87f8pSfbo2PZMIaAsOV8P8HAQ

Difference between adult and infant gait compensation.

We highly doubt the infants compensated to the point of “recovering symmetrical gait”. It just isn’t possible seeing as there was frank asymmetry in leg length. However, it is quite possible they accomodated quicker with a more reasonable compensation, that MAY have appeared to have less limp. We did not do the study, but over a beer we might guess that the investigators might agree that our verbiage is closer to accurate. None the less, cool stuff to cogitate. We are very appreciative of this study, there is something to take from this study.

“The stability of a system affects how it will handle a perturbation: The system may compensate for the perturbation or not. This study examined how 14-month-old infants-notoriously unstable walkers-and adults cope with a perturbation to walking. We attached a platform to one of participants’ shoes, forcing them to walk with one elongated leg. At first, the platform shoe caused both age groups to slow down and limp, and caused infants to misstep and fall. But after a few trials, infants altered their gait to compensate for the platform shoe whereas adults did not; infants recovered symmetrical gait whereas adults continued to limp. Apparently, adult walking was stable enough to cope with the perturbation, but infants risked falling if they did not compensate. Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”- From the Cole et all study (reference below)

- thoughts by Shawn Allen

references:

Infant Behav Dev. 2014 Aug;37(3):305-14. doi: 10.1016/j.infbeh.2014.04.006. Epub 2014 May 20.Coping with asymmetry: how infants and adults walk with one elongated leg.Cole WG1, Gill SV2, Vereijken B3, Adolph KE4.

http://www.ncbi.nlm.nih.gov/pubmed/24857934

Can you believe they missed this? Sometimes you just need to look. This gal has knee pain on the R a “funny gait” and right sided low back pain in the sacro iliac joint fr the last 3 years. She felt like she needed to keep her right leg bent and her left straight all the time. She was unable to hike or walk distances longer than 1 mile or time longer than 30 minutes without slowing down and having pain. She has had reconstructive surgery on the right knee for an ACL/MCL, physical therapy, medication, counseling and even stroke rehabilitation/gait retraining. On exam she has a marked genu varus bilaterally. Knee stability is good anterior/posterior drawer; valgus/varus stress. One leg standing with both eyes open is less than 15 seconds, eyes closed is negligible. She has an anatomically short L leg; at least 2 cm which is both tibial and femoral. She was unaware of this and noone had adressed it in any way. She was given a 10mm sole length lift for the L leg and propriosensory exercises. She was encouraged to walk with a heel to toe gait. She felt 50% better immediately and another 20% after 2 weeks of doing the exercises. She had gone on several 5 mile hikes for over 2 hours with minimal discomfort. Nothing earth shaking here. Just an exam which covered the basics and some common sense treatment. Too bad they are not all that easy, eh? The takeaway? Look and listen. The problem was on the side opposite her complaint, as it can be many times. Look at the area of chief complaint 1st, but then look everywhere else : ).

Podcast 91: Gait, Vision & some truths about leg length discrepancies

Show sponsors:
www.newbalancechicago.com

A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_91f.mp3

Direct Download:
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Other Gait Guys stuff

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

D. other web based Gait Guys lectures:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Our Book: Pedographs and Gait Analysis and Clinical Case Studies

electronic copies available here:

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http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

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Hardcopy available from our publisher:

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Show notes:

Gait and vision: Gaze Fixation
What’s Up With That: Birds Bob Their Heads When They Walk
http://www.wired.com/2015/01/whats-birds-bob-heads-walk/
 
Shod vs unshod
 
Short leg talk:
11 strategies to negotiate around a leg length discrepancy

From a Reader:

Dear Gait Guys, Dr. Shawn and Dr. Ivo,  I was referred to this post of yours on hip IR…http://thegaitguys.tumblr.com/post/14262793786/gait-problem-the-solitary-externally-rotated   I am impressed by the level of details of your understanding of the gait and biomechanics. Although I am still trying to understand all of your points in this post, I would like to ask you:  What if my IR is limited due to a structural issue? The acetabular retroversion of the right hip in my case. 

I.e. if I am structurally unable to rotate the hip internally.
What will happen? 
What would be a solution to the problem in that case? 

Single-leg drop landing movement strategies 6 months following first-time acute lateral ankle sprain injury - Doherty - 2014 - Scandinavian Journal of Medicine & Science in Sports
http://onlinelibrary.wiley.com/doi/10.1111/sms.12390/abstract

Hey Gait Guys,

I understand that 1st MP Joint dorsiflexion, ankle rocker, and hip extension are 3 key factors for moving in the sagittal plane from your blog and podcasts so far. I really love how you guys drill in our heads to increase anterior strength to increase posterior length to further ankle rocker. I’ve seen the shuffle gait and was curious if you had a good hip extension exercise to really activate the posterior hip extensors and increase anterior length.