Neuroma! Triple Threat....

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

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

Note the following:

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

  • internal tibial torsion on the left

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

Lets think about this.

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

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

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

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

So, what do we do?

  • give her shoes/sandals with a wider toe box

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

  • work on foot intrinsic strength, particularly the long extensors

  • treat the area of inflammation with acupuncture

Dr Ivo Waerlop, one of The Gait Guys

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

3 things

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

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

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

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

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

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

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

Dr Ivo Waerlop, one of The Gait Guys

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

https://vimeo.com/329212767

Things seem to come in 3's...

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

Highlights with pictures below:

  • bilateral femoral retrotorsion

  • bilateral internal tibial torsion

  • forefoot (metatarsus) adductus

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

Dr Ivo Waerlop, one of The Gait Guys.

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

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

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

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

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

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

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

ditto for the keft

ditto for the keft

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

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

less adductus but still present

less adductus but still present

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

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

Ditto!

Ditto!

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

Motion control Shoes + Internal Tibial Torsion = Knee Pain

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

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

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

https://vimeo.com/154496722

NO hip internal rotation? Forget the glutes, have you looked at the femur?

Screen Shot 2019-02-14 at 3.13.23 PM.png

Some developmental versions involve the femur. The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas  or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

There are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait.  In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up,  and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. See the person with external tibial torsion in the above picture?

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  •  FNA values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation  of the hip and decrease in external rotation

  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

Dr Ivo Waerlop, one of The Gait Guys

#gait, gait analysis, #thegaitguys, #femoraltorsion, #antetorsion, #retrotorsion

So your patents foot points in or out... Have you considered talar torsion in the differential?

Screen Shot 2019-02-14 at 3.12.59 PM.png

The talus is to the foot, as the lunate is to the hand. It is the only bone that has the entire weight of the body passing through it before being distributed to the foot. It’s motion during pronation should be flexion, adduction and eversion, and in supination: extension,  abduction and inversion.

At birth, the angle between the talar neck and talar dome is 30 degrees adduction. This reduces to 18-20 degrees in the adult (see above). During this reduction of angle, the talar head also everts or “twists” laterally (ie promotes pronation), which helps to correct the supination and adducted position of the forefoot in adults present in infants (Saffarian 2011).

Abnormal talar loading and “untwisting” in development  has been linked to formation of a Rothbart foot type, also known as metatarsus primus elavatus (Rothbart 2003, 2009,2010. 2012). The 1st metatarsal is elevated and inverted with respect to the rest of the foot, with it behaving much like a fore foot varus.

Talar torsion (sometimes called subtalar version) results when there is a 10 degree or greater change in the final position of the talar head. This can cause an adducted position of the forefoot, often mistakenly called “forefoot adductus’, which actually only applies to the metatarsals, and not at all to the talus.

An adducted forefoot provides challenges to gait with many possible compensations. As discussed previously, there are at least 3 reasons we need to understand torsions and versions:

1. They will often alter the progression angle. In talar adduction, there will often be a decreased progression angle of the foot. This causes the individual to toe off in supination.

2. They affect available ranges of motion of the limb. We remember that the lower leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance, If it is already fully internally rotated, that range of motion must be created elsewhere. This may result in external rotation of the affected lower limb, excessive pronation through the deformity (if possible), or rolling off the lateral aspect of the foot.

3. They often can effect the coronal plane orientation of the lower limb. In talar torsion, the head of the talus often does not “untwist” appropriately resulting in a functional forefoot varus, with excessive forefoot pronation occurring at terminal stance and pre swing.

There you have it in a nutshell. Talar tosion: Present in 8% of the population (Bleck 1982) and coming to your clinic (or maybe it has already been there!

We will be talking about talar torsion, as well as many other torsional deformities of the the lower limb this wednesday evening on online.com: Biomechanics 305. Hope to see you there

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #thegaitguys, #talartorsion,#talus, #progressionangle, #toein, #toeout



Got a kid that "toes in"?

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

image source: W Phillips https://somepomed.org/articulos/contents/mobipreview.htm?38/8/39046

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett,  M.D illustration for International Association for Dance Medicine and  Science 2011

Photo Credit: Illustration based off Jake Pett, B.F.A. and Stuart Pett, M.D illustration for International Association for Dance Medicine and Science 2011

image courtesy: T Michaud

image courtesy: T Michaud

Got a kid that "toes in" during gait? Are you seeing this?

  • smaller foot progression angle

  • greater knee adduction

  • more internally rotated and flexed hips

  • greater anterior pelvic tilt

Wondering what could be causing it?

We start life with the hips anteverted (ie, the angle of the neck of the femur with the shaft of the femur is > 12 degrees; in fact at birth it is around 35 degrees) and this angle should decrease as we age to about 8-12 degrees). When we stand, the heads of our femurs point anteriorly; it is just a matter of how much (ante version or ante torsion) or how little (retro version or retro torsion) that is.

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The angle of the femur neck to its shaft diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

There are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. 

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

 

The take home message here about femoral torsions is that no matter what the cause:

  • the angle of the femur neck to shaft values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 

Great paper here

link to full text: http://onlinelibrary.wiley.com/doi/10.1002/jor.22746/abstract;jsessionid=AC848D963DCA526402D71260BDFC91F6.f04t04

Dr Ivo, one of the Gait Guys

#gait,#gaitanalysis,#femoralneckangle, #femoraltorsion, #antetorsion, #retrotorsion, #toein

 

Tibial torsion and the effect on progression angle

more tibial torsion = a change in progression angle.

How does tibial torsion impact the development of the foot progression angle?

Stratifying the data by Foot Progression Angle (FPA) revealed there were significant differences in tibial torsion among the groups and provided evidence that tibial torsion influences the direction and magnitude of the FPA. Offsetting torsions between the tibia and femur were more common in people with higher and lower FPA and had clearer patterns where the tibia tended to follow the direction of the FPA.

So, got that? The foot progression angle follows the tibial torsion...

Why do we care?

the greater the “kickstand” angle to the foot, the more we progress through the mid foot (rather than from the lateral aspect of the heel, up the lateral column, across the transverse metatarsal arch and through the 1st ray). This causes more mid foot pronation and more medial knee fall, resulting in gait inefficiency and often times in our experiences, increased knee pain.

Gait Posture. 2016 Sep;49:426-30. doi: 10.1016/j.gaitpost.2016.08.004. Epub 2016 Aug 3.
The rotational profile: A study of lower limb axial torsion, hip rotation, and the foot progression angle in healthy adults.
Hudson D1.

Do you know your Torsions? If so, then you here is what you need to know about twisted people...

Are you twisted? Are your patients/clients twisted? You know about tibial torsions from yesterday but do you know about femoral torsions?

To go along with yesterdays post, here is some more info on femoral torsions. If you missed it, click here

The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

IMAGE SOURCE: Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion,  Physical Therapy , Volume 84, Issue 6, 1 June 2004, Pages 550–558,  https://doi.org/10.1093/ptj/84.6.550

IMAGE SOURCE: Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion, Physical Therapy, Volume 84, Issue 6, 1 June 2004, Pages 550–558, https://doi.org/10.1093/ptj/84.6.550

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) the femoral neck angle reaches 60 degrees and decreases, with growth, to about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

image source: T Michaud, with permission

image source: T Michaud, with permission

As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

  1. fermoral torsions often alter the progression angle of gait. In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up, and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width.

  2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

  • Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

  • Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

          3. femoral torsions usually do not effect the coronal plane orientation of the lower limb,      since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  • FNA values that exist one to two standard deviations outside the range are considered “torsions”

  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”

  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation

  • Ante torsion causes an increase in available internal rotation of the hip and decrease in external rotation

  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)

  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

Michael T Cibulka; Determination and Significance of Femoral Neck Anteversion, Physical Therapy, Volume 84, Issue 6, 1 June 2004, Pages 550–558, https://doi.org/10.1093/ptj/84.6.550

http://www.clinicalgaitanalysis.com/faq/torsion.html

Souza AD, Ankolekar VH, Padmashali S, Das A, Souza A, Hosapatna M. Femoral Neck Anteversion and Neck Shaft Angles: Determination and their Clinical Implications in Fetuses of Different Gestational Ages. Malays Orthop J. 2015;9(2):33-36.

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!

So, you do weighted carries?

METHODS:

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

 

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

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

 

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

 

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

 

 

 

 

 

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

 

Abstract

BACKGROUND:

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

METHODS:

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

RESULTS:

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

SIGNIFICANCE:

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

image from: http://boneandspine.com/what-is-anteversion-and-retroversion/

image from: http://boneandspine.com/what-is-anteversion-and-retroversion/

Femoral versions and torsions?

While searching for something else, we ran across this post. A pretty good lay discussion and explanation about femoral torsions. Technically, versions are NORMAL variations or limb rotations that are within accepted limits and TORSIONS are pathological, when it measures 2 or greater standard deviations from the mean and is considered pathological. Femoral versions are the angular difference between the transcondylar and transcervical axes. The femur is normally anteverted (1). 

We liked the last section talking about how to compensate for them and "acceptable" work arounds and biomechanics. 

https://b-reddy.org/2013/05/09/talking-about-hip-retroversion/

1. Staehli L in: Fundamentals of Pediatric Orthopedics Lippincott Williams & Wilkins, Jun 15, 2015 p 144

How can feet relate to golf swing?

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

Take a look a these pix and think about why.

Full internal rotation

Full internal rotation

full external rotation

full external rotation

full internal rotation

full internal rotation

full external rotation

full external rotation

neutral

neutral

neutral

neutral

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

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

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

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

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

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

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

What did we do?

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

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

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

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

Tibial Torsion and Genu Valgum

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

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

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

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

When the wrong shoe, meets the right foot

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

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

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

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

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

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