So a patient presents to your office with a recent history of a L total knee replacement 8 weeks ago AND a recent history of a resurgence of low back pain, supra iliac area on the L side. Hmmmm. Hope the flags went up for you too!

His global lumbar ROM’s were 70/90 flexion with low back discomfort at the lumbo sacral junction, 20/30 extension with lumbosacral discomfort, left lateral bending 10 degrees with increased pain (reproduction); right lateral bending 20 degrees with a pulling sensation on the right. Extension and axial compression of the lumbar spine in left lateral bending reproduced his pain.

Neurologically he had an absent patellar reflex on the left, with diminished sensation over the knee medially and laterally. Muscle strength 5/5 in LE; sl impaired balance in Left single leg standing. There was incomplete extension of the left knee, being at 5 degrees flexion (right side was zero).

He has a right sided leg length deficiency (or a left sided excess!) of 5 mm. Take a look at the tibial lengths in the 1st 3 pictures. See how the left is longer? In the next shot, do you see how the knee cannot completely extend? Can you imagine that the discrepancy would probably be larger if it did?

Now look at the x rays. We drew a line across from the non surgical leg to make things clearer.

Now, think about the mechanics of a longer leg. That leg will usually pronate more in an attempt to shorten the leg, and the opposite side will supinate to attempt to lengthen. Can you see how this would cause clockwise pelvic rotation (in addition to anterior pelvic rotation)? Can you see this patients in the view of the knees from the top? Do you understand that the lumbar spine has very limited rotation (about 5-10 degrees, with more movement superiorly (1)  ). Does it make sense that the increased range of motion could effect the disc and facet joints and increase the patients low back pain?

So, how do we fix it? Have you seen the movie “Gattica”? Hmmm….A bit extreme. How about a full length 3mm sole lift to start, along with specific joint manipulation to restore normal motion and some acupuncture to reduce inflammation? We say that is a good start.

The Gait Guys. Increasing your gait literacy with each and every post. If you liked this post, please send it to someone else for them to enjoy and learn. 

(1) Three-Dimensional In Vivo Measurement of Lumbar Spine Segmental Motion Ruth S. Ochia, PhD, Nozomu Inoue, MD, PhD, Susan M. Renner, MS, Eric P. Lorenz, MS, Tae-Hong Lim, PhD, Gunnar B. Andersson, J. MD, PhD, Howard S. An, MD Spine. 2006;31(15):2073-2078.

Finishing up the week on kids and gait, here is a rewind that talks about proprioceptive clues and gait. It all goes back to the beginning…

Have a great weekend

The Gait Guys

Podcast 67: Biotech of Running’s Future, Rothbart’s Foot, 100 Ups

A. Link to our server:

Direct Download:

http://traffic.libsyn.com/thegaitguys/pod_67finals.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-67

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

The cyborg era begins next week at the World Cup
 
The One Exercise That Just Might Change Your Running Forever
 

What Foot Strike Photos From 10K Olympic Trials Say About Barefoot Running by 

Podcast 67: Biotech of Running’s Future, Rothbart’s Foot, 100 Ups

A. Link to our server:

Direct Download:

http://traffic.libsyn.com/thegaitguys/pod_67finals.mp3

Permalink: http://thegaitguys.libsyn.com/podcast-67

B. iTunes link:

https://itunes.apple.com/us/podcast/the-gait-guys-podcast/id559864138

C. Gait Guys online /download store (National Shoe Fit Certification and more !) :

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

D. other web based Gait Guys lectures:

www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

______________

Today’s Show notes:

The cyborg era begins next week at the World Cup
 
The One Exercise That Just Might Change Your Running Forever
 

What Foot Strike Photos From 10K Olympic Trials Say About Barefoot Running by 

A Serious Gait Problem: Pancompartmental Compromise of the Lower Leg.

“Pan” is a prefix (combining form) meaning all, entire, everything, everywhere 

This was a case we discussed during a more recent podcast, perhaps pod 63 or 64? This doctor had fallen asleep with the left leg dangling over the side of his bed. The issue was that the leg not only dangled over the mattress, but also over a wooded side bed frame, so there was a firm upward compression into the posterior/popliteal compartment. He awoke the next day with complete loss of function of the foot and ankle.  This video is 8 weeks after the compressive event and there has been a significant improvement in function, but there are still some deficits here.  Can you see them ?  We will show you come other video clips in a future blog post discussing some other components of his gait but lets get you familiar with the case today.

What you should see here:

1- Left heel shows a staggered drop. He cannot hold heel rise because of compromise to the posterior compartment strength (gastrocsoleus complex). This was a drastic improvement from his complete inability to heel rise at all at on his initial visit. You can easily see the fatiguability of the calf after just a few steps. 

2- There is a pathetic attempt at heel walking; gross function testing of the anterior compartment. What appears to be an attempt at just right heel walking is actually an attempt to do it on both sides, there is just still so much weakness in the left anterior compartment that you cannot even see his attempts to dorsiflex the foot/ankle or toes. But, what we do not show here is that he has non-weight bearing dorsiflexion now, which was completely absent for the first 6 weeks.  

Neuronal regeneration is possible. It takes time.  Depending on your referenced source the numbers vary. But in his case, in 8 weeks there is progressive improvements and he can say for certain that in the last 2 weeks they are exponential.  The time to restoration of neuronal function is said to be directly proportional to the measurable length of nerve damage.  

What is interesting in this case, is that there is anterior and posterior compartment neurologic compromise. This was a case of vascular and mechanical compression to the neurovascular bundle at the popliteal/knee level. 

Wallerian degeneration is a process that results when a nerve is severely damaged. The axon of the nerve which is separated from the neuron cell body degenerates distal to the injury. The part of the axon distal to the injury begins its degeneration within 24-36 hours of the lesioning event and is followed by myelin sheath degradation. Somewhere around 4 days from the time of the injury, the distal end of the portion of the nerve fiber proximal to the lesion begins sprouting in an attempt to regrow and fill the gap along the length of axonal damage. Sources vary, but many seem to indicate a 1mm per day reinnervation. 

More on this case next time, but the stage has been set.

Shawn and Ivo

Another IFGEC Certified Doc!

Here is what Dr Brad Hochstein has to say about the National Shoe Fit Certification Program.

“Taking the National Shoe Fit Certification course has introduced me to many things that I didn’t take into consideration when working with my patients. The depth of information introduced is very helpful and presented more clearly than other courses I have taken in the past. I have studied a lot of the concepts that are introduced through the program in the past but struggled to put everything together. This certification did just that for me. It has helped me to link things together and look “outside the box” more than I had in the past.

I am a chiropractor with an extensive functional/biomechanics background and this has added another level of depth to my practice assessment and treatment. I am excited to incorporate the knowledge I have gained through this certification into my practice to give my patients an even better experience!”

Is it time to up your knowledge base and separate yourself from other clinicians, coaches, trainers, therapists and retailers?

Want to know more? Email us at : thegaitguys@gmail.com

Can you see it?

Here we are again. We have looked at this picture before; once about head tilt, and another about flip flops and form.

Take a good look at this picture and what is different about the child in blue all the way to the right and all the others with the exception of the boy in pink, that we really cannot see?

Can you see it? No, we don’t mean the flip flops (but if you caught that all the boys were in sneakers and all the girls are in flip flops, you are good!)

How about looking at arm swing? Remember this post on arm swing and crossover gait, with the simple cue for correction? All of the children EXCEPT the boy in blue, are drawing their arms ACROSS their body (ie: flexion, internal rotation and adduction). Take a look at their legs. Yep, crossover gait (flexion, internal rotation and adduction). Little boy blues arms are going relatively straight and going in the saggital plane, where the others are going in the coronal plane.

We are not saying that blue does not have some gait challenges, like his torso shift to the left (or pelvic drift to the right), most likely do to gluteus medius weakness or inappropriate firing of the gluteus medius on the left stance phase leg; or his head tilt to the right, which most likely represents a compensation for the right pelvic drift and left body lean.

Arm swing. A very important clue to the puzzle we call gait and compensation. It is more prevalent than you think, and, in some cases, easily corrected with a simple cue.

The Gait Guys. Making it real and pertinent, in each and every post.