Hey Check it out! John Wayne has either a Left short leg or a weak left Gluteus medius and a compensatory increased arm swing on the Right ! Watch for the lean to the left on Left stance phase and the arm swing to pull him through. WE guess even the Duke needs a hand sometimes !

The “Dukes” of Gait Shawn and Ivo

So. How did you do?

As you can see, this individual lists to the R upon weight bearing on that side (midstance); did you pick up the increased progression angle of the foot on that side? How about the mild genu valgus?

Why would someone walk like this? There are a few plausible explanations.

1. he has a weak gluteus medius on the R side.

2. he has a R short leg and needs to lean to that side to get the long leg side (L) to clear.

3. impaired left ankle rocker (causing premature heel rise and left side early departure) could also cause him to accelerate onto the right as well.

His options to compensate are to either lean to the weak side (R) or to shift his pelvis to the weak side (R). He could also circumduct the leg or flex the thigh to get that side to clear the ground. He has a mild BL circumdcution, probably to clear the knee from the opposite one.

His increased arm swing on the L is to help propel him forward, most likely due to weakness of the external obliques to assist in initiation of flexion of the thigh, and weakness of the gluteus medius, which also helps to propel the leg forward. He also does not push off adequately with the R leg; This is probably due to loss of hip extension and inadequate ankle rocker on that side.

The increased progression angle on the R helps to stabilize his body weight because he is leaning the torso to the R and his center of gravity moves right as well (he makes a wider base for himself)

Yup, you’re a geek!   We remain The Geeks of Gait…Ivo and Shawn

Here is a big topic. Everyone seems to think that stretching makes a big difference, truth is it makes a difference, but it is not big. But is “some” enough ? The topic comes up in a range we really feel is important, ankle dorsiflexion range.  You hear us talk about it all the time as “ankle rocker”.  The facts are that you need 100+ degrees of ankle dorsiflexion range to achieve normal biomechanics across the ankle ankle  in walking, and near 115 degrees for running (put another way, 10degrees past 90degrees vertical for walking and 25degrees past vertical for running, ref. T. Michaud).  If you do not have these ranges then you must compromise normal biomechanics.  This is where functional pathology starts, ie. injuries. This study found the following: The meta-analyses showed that calf muscle stretching increases ankle dorsiflexion after stretching for < or = 15 minutes (WMD 2.07 degrees; 95% confidence interval 0.86 to 3.27), > 15-30 minutes (WMD 3.03 degrees; 95% confidence interval 0.31 to 5.75), and > 30 minutes (WMD 2.49 degrees; 95% confidence interval 0.16 to 4.82). So, what does this mean ? Well, upon initial impressions it seems that none of them gained more than 3 degrees of dorsiflexion range, even after 30 minutes of stretching.  The study suggested that these numbers according to research stats, were “statistically significant”. But in our mind, if you have 90 degrees range, a “statistically significant” loss in our opinion, then gaining another 3 degrees (ok, lets jump the moon and assume you stretched for 60 minutes and achieved 5degrees)…..well, you are still not at 100 degrees and have to compromise normal mechanics which could mean injury. Bottom line, you have to find another way to get this range back, stretching is not going to float your boat the whole way.  This is why we like the shuffle walks (as seen on our YouTube videos) to engage and strengthen the anterior compartment.  This strength will help to reflexively release the tight posterior compartment.   You cannot have a relatively normal lengthened posterior compartment if the anterior team is insufficiently strong.  The Gait Guys

Does calf stretching increase ankle dorsiflexion range of motion? A systematic review.

graphic above by Edward Muybridge

Leg length discrepancies and heel lifts. To lift or not to lift…

The Gait Guys

Leg length discrepancies (LLD’s) are encountered on a daily basis. They are the root of many ankle, knee, hip and spinal problems. The questions the clinician must ask are “How much is significant?”, “How much do I add?” What are some of the signs and symptoms?” “What is the etiology?” and “How do I detect it?” A literature search (2003) provided the following information and answers.

How much is significant?

Most authorities claim that deficiencies of greater than ¼ inch (6mm) are clinically significant (1, 2) though some sources state that differences as little as 4 mm are significant (5). Subotnick (3) states that because of the threefold increase in ground reactive forces with running, lifts should be used with inequalities of greater than 1/8” inch (3mm).

How much do I add?

One of the easiest ways to determine the amount of lift needed is to examine the person in a weight bearing posture and add lifts under the short leg until the pelvis is even or until the lumbar spine is straight. If using off weight bearing measurements, you need to add 1/3 more height than measured because the talus is positioned 1/3 of the way between the calcaneus and metatarsal heads (4, 13). So, a heel lift placed under the calcaneus will only raise the talus 2/3 of that height. Lifts placed under the calcaneus can shorten the tricep surae muscles (4, 6) and apply increased pressure to the metatarsal heads (12); full length sole lifts are more physiological, though not always practical. Due to the supinatory moment of the short leg on heel strike, a lift may cause overcompensation and increased supination, with a tendency to overweight the lateral column and possibly injure the lateral ankle. Careful observation of gait post addition of a lift is in order and a valgus post running at least the length of the 5th metatarsal along with the lift should be considered (8, 9). Heel lifts also cause EMG changes of leg muscles, with decreased recruitment of gastrocnemius and tibialis anterior directly proportional to the height of the heel lift (18, 19). A lift or LLD changes the ground reactive forces associated with gait, increasing vertical force on the longer leg, along with increased joint stresses along the kinetic chain (14, 20).

Generally speaking, lifts greater than 3/8” (9mm) require extrinsic modifications to footwear (4, 6, 8). Find a competent individual to perform this work for you. Large discrepancies should be treated gradually, at a rate of ¼ inch every 4 weeks, less if symptoms do not permit.

What are signs and symptoms associated with LLD’s?

Compensation comes in many forms, depending whether it is acute (recent injury caused an LLD or compensation resulting in one, or long term. The deficiency can cause injury on the short or long legged side (or both).

The long leg moves through a greater arc during all portions of swing phase (7). The person may flex the knee to compensate and shorten the arc. The individual may also maximally pronate and evert the calcaneus an additional 3 degrees or greater on that side in an attempt to lower the navicular to the ground and shorten that leg. This causes an increased amount of internal rotation of the tibia and thigh causing muscular dysfunction (tightness of the hip flexors, strain of the intrinsic external rotators from eccentric deceleration of the thigh), along with medial knee strain (especially with concomitant genu valgus) (4, 6, 8, 9, 10, 11, 21, 22).

The short leg side will often supinate in an attempt to lengthen and cushion some of the shock of heel strike, since it has a greater vertical distance to travel (14); this often occurs with hyperextension of that knee. This lessens the dampening ability of the knee (since it flexes almost 20 degrees between heel strike and full forefoot load), and speeds the rate of subtalar pronation (since the rear foot is inverted and still must pronate the same amount (4). Many individuals will try and attenuate impact by contracting the contralateral hip abductor muscles and eccentrically lower the shorter extremity (4, 14). This can produce excessive strain of that musculature (trochanteric bursitis) as well as pathomechanical abnormalities of the L4 and L5 motion segments (due to increased body rotation toward the short side and attachments of the iliolumbar ligaments; this can cause degenerative changes if present long term (11, 12)).

What’s the etiology?

LLD’s can be structural (anatomical) or functional (pathomechanics, compensation). LLD’s can be due to foot problems (overpronation/supination, fractures), leg or thigh problems (congenital shortening, deformity, fracture), or pelvic compensation (rotation of ilia, fractures).

Text Box: Long leg adaptations "	Drooping of shoulder with elevation of iliac crest on long leg side "	Pirformis/external rotator tightness "	Tightness of hip flexors "	Increased lordosis "	Posterior rotation (flexion) of ilia (can shorten leg up to 6mm "	Medial knee degenerative changes/pain "	Increased pronationText Box: Short leg adaptations "	raised shoulder with depression of iliac crest on long leg side "	TFL tightness "	Decreased lordosis "	Anterior rotation (extension) of the ilia (can lengthen leg up to 6mm) "	Lateral knee degenerative changes "	Increased supination

 

So, what is the etiology? A lot can be gleaned from the history. Past trauma is the most obvious so pay close attention. This could result in flattening of the calcaneus or overpronation due to ligamentous laxity; tibial fractures can cause shortening as well as increased or decreased tibial torsion; similar findings can occur in the femur, along with anteversion or retroversion; pelvic trauma can be more subtle and x-ray can often provide the most information (1, 2, 4, 6).

How do you determine a leg length inequality?

There are a number of methods, each with their own merit. X –ray is most accurate, but exposes the patient to ionizing radiation. Weight bearing seems most appropriate, since symptomatology usually presents itself then. Supine measurements are said to be influenced by asymmetrical muscle tension, table pressure on the innominates and hip flexor length (15).

With the patient weight bearing and both feet placed below the trochanters, observe the level of the medial malleoli. Next, compare the heights of the tibial plateaus. Femoral length can be judged by the heights of the greater trochanters, and pelvic alignment judged by the heights of the iliac crests (4, 17).

Alternately, lay the person supine and observe the heels and medial malleoli. If there is noticeable discrepancy, they may have a short leg; if there isn’t, they still may have a discrepancy that they are compensating for. Check the range of motion of the foot and ankle in 6 general directions: plantar flexion (40-45 degrees), dorsiflexion (20-25 degrees, depending on whether the knee is flexed or extended), inversion of the forefoot (3-60 degrees, on average), and eversion of the forefoot (20-45 degrees on average), calcaneal inversion (4-20 degrees) and calcaneal eversion (4-10 degrees). Excessive calcaneal eversion usually means over pronation due to a longer leg on that side; excessive inversion can mean a long leg due to a cavus foot type (2, 4, 6, 8, 9, 12). Lack of flexibility in the posterior compartment of the calf usually causes a greater degree of pronation (16).

Now, perform Allis’s test. Bend both knees to 90 degrees and observe the height of the tibial plateaus. The lower one is usually the side of the discrepancy (which can be in tibial length or due to excessive pronation). Now walk superior to the knees and observe the femurs from more cephalad (4). Is there a discrepancy? If so, the problem may be in the femur length, femoral head angle or pelvis. Extend the knees so that the legs are lying flat on the exam table. Palpate the greater trochanters on both sides. Is one lower than the other? If so, they probably have coxa vara on the short side or coxa valga on the long side. If they are even, you need to look at the pelvis. Does one ASIS palpate more anterior or posterior than the other? This could represent compensation. A posterior or “flexed” ilia, usually causes a short leg on that side; an anterior or extended ilia usually causes a long leg on that side. Now stand the patient up and perform a Gillet Test. Have them stand erect and hold onto something for balance. Palpate the PSIS on one side along with the 2nd sacral tubercle. Have them raise their thigh to 90 degrees on the side you are palpating. The PSIS should nutate backward (flex) and drop .5-1.5 cm on the side of the raised leg. Now have them raise the opposite leg. The sacrum should nutate backward and down. If either of these movements does not occur, consider pelvic pathomechanics and treat accordingly. Recheck for motion as well as leg length when done.

Standing observation often (but not always) reveals overpronation on the long leg side and relative supination on the short leg side. The shoulder is often higher on the short side and the waistline dips to the long side because of posterior rotation of the innominate. The shoulder will dip to the side of the short leg on heel strike during dynamic evaluation (4, 6, 8, 9, 10, 11). Gait observation usually reveals adduction of the pelvis toward the stance phase leg with a lateral sway in excess of 1” during stance phase. The person will seem like they are “stepping into a hole” on the short side.

Conclusion

Leg length inequalities occur due to a variety of anatomical and physiological conditions. Careful analysis and examination can often reveal its etiology. To lift or not to lift is a clinical decision that is left to the clinician and patient, with a careful balance between what is perceived as improved biomechanics and tolerance levels of the patient with regards to their presenting symptomatology.

References available by request

Clinical Video Case Study: Tibial Varum with added Post-op ACL complications.

This is a case of ours. This young man had a left total knee reconstruction (Left ACL and posterolateral compartment reconstruction; allograft ligaments for both areas). This video is roughly 3 months post surgery.

Q: What anatomical variants are seen in this individual?

A: Note the genu and tibial varum present. This results in an increased amount of pronation necessary (right greater than left, because of an apparent Left sided short leg length;

* NOTE: post-operatively at this point the client had still some loss of terminal left knee extension. thus the knee was in relative flexion and we know that a slightly flexed knee appears to be a shorter leg. Go ahead, stand and bend your left knee a few degrees, the body will present itself as a shorter leg on that left side with all the body compensations to follow such as right lateral hip shift and left upper torso shift to compensate to that pelvic compensation.)

Normally, in this type of scenario (although we have corrected much of it at this point by giving him more anterior compartment strength and strategy as evidenced by his accentuated toe extension and ankle dorsiflexion strategies, these are conscious strategies at this point for the patient), the functionally shorter left leg has a body mass acceleration down onto it off of the longer right leg stance phase of gait. This sagittal (forward) acceleration is met by a longer stride on the right with an abrupt heel strike (in other words, the client is moving faster than normal across the left stance phase so there is abrupt and delayed heel strike on the right because of a step length increase. (again, this is just commentary, had we videoed this client weeks before this, you would have seen these gait pathologies. This video shows him ~70% through a gait corrective phase with us.)

Again, this client has bilateral tibial varum. You can see this as evidence due to the increased calcaneal valgus (ie. rearfoot pronation; look at the achilles valgus presentation).
He increases his arm swing on the Left to help bring the longer Right lower extremity (relative) through.
if you look closely you can also see early right heel departure which is driven by the increased forward momentum of the body off of the short left limb. In other words, the body mass is moving forward faster than normal onto the right limb (because of the abbreviated time spend on the left “short” leg) and thus the forward propulsed body is pulling the right heel up early and the heel is spinning inwards creating a net external rotation on the right limb (look for the right foot to spin outwards/externally ever so slightly in the second half of the video).

Early heel departure means early mid and forefoot weight bearing challenges and thus reduced time to cope well with pronation challenges. As we see in this case where the right foot is pronating more heavily than the left. You can think of it this way as well, the brain will try to make a shorter leg longer by supinating the foot to raise the arch, and the longer leg will try to shorten by creating more arch collapse/pronation.