Lumbar link? Ankle, spinal pathologies coexist in cadavers | Lower Extremity Review Magazine

It makes sense…but which came 1st?

Just make sure you ask your foot patients about their back, and your back patients about their feet

The Gait Guys

Lumbar link? Ankle, spinal pathologies coexist in cadavers | Lower Extremity Review Magazine

Spine pain and arm swing. Do you truly get this ? You had better.

We have all seen that runner who swings the one  arm more than the other, they may even violently thrust the one arm across the front of the torso. If you have been a spectator half way through any race you have seen this person. And, if you are watching carefully in your gym, lab, office or gait lab  you have seen the accentuated arm swing on one side (or is it the loss of arm swing on the opposite, we discussed some of these games in last weeks blog post here). You have also see the person who is running with a water bottle in their hand and altering their neurological arm-leg swing opposite pairing and thus their anti-phasic shoulder-pelvic girdle pairing (see attached photo). (If you are lost when we discuss the terms phasic and anti-phasic you will want to go and read this previous blog post.

Knowing that which you are seeing in your client is their highest level of neurologic motor compensation, and not likely their problem, represents a higher thought process in a diagnostician. Unfortunately, it also opens a whole bunch of clinical thought process mental gymnastics. 

Our purpose of today’s blog post is to revisit an important aspect of the clinical examination, observation.  Listening and watching (and knowing what you are seeing, and not seeing) are two of the biggest pieces of a clinical exam other than the hands on assessments. One has to be good at all of the pieces.  But then their is the knowledge base that is needed to base the information and choices upon so that the proper path to remedy can be chosen.  Without the knowledge the actions and choices can be dramatically incorrect and devastating to an athlete or client/patient.  Make the wrong choice for a patient and they do not get better, perhaps even get worse. Make the wrong choice for an athlete and you deepen their compensation and increase their risk for injury.  This is one of our pet peeves because we recognize that we have a deep knowledge base and yet we find ourselves without the certainty and answers on a regular basis and yet we see people making similar choices for clients and athlete with only a small piece of the knowledge necessary on their table to make those choices.  If you don’t know what you don’t know, and yet your still swimming in the risky waters, you are already in deep trouble. 

Here are two articles that you should be familiar with. We talk about them in depth in our “arm swing” online course #317 here.  These articles talk about phasic and antiphasic motions of the arms and shoulder-pelvic blocks.  They talk about spine pain and how spine pain clients reduce the antiphasic rotational (axial) nature of the shouder girdle and pelvic girdle. They elude to the subcortial pattern of choice to rotate them as a solid unit to reduce spine rotation, axial loading and compression and that spine pain disables the normal arm-leg pendulums.  If you do not know and  understand these principles, and you are training, treating or coaching people, you are a problem waiting to happen for your client. You, are the problem and your choices could likely hurt your client.  IF you do not know how to address them or fix them safely, it is your job to send them to someone who does. 

So the next time you see an aberrant arm swing, during your exam, your observations and your history better delve into all things relevant. How about that 20 year “healed” ankle fracture that your client dismisses as “oh, but that was 20 years ago, its not part of this problem i am having now”.  How about that episode of frozen shoulder that was “fixed” 15 years ago or that episode of hip or knee pain from falling on ice or the random big toe pain or the headaches ?  If they dismiss all of this because they are just coming to see you for spine pain or because their running partner says their arm swing stinks on the right you had better sit down for a longer ride, because you  know better now.  Unless you prefer to see life through tunnel vision. Sure it is easier, but don’t you want more for your client ?

Sorry for the rant.

Shawn and Ivo, …… the gait guys.

1. Eur Spine J. 2011 Mar;20(3):491-9. doi: 10.1007/s00586-010-1639-8. Epub 2010 Dec 24.
Gait adaptations in low back pain patients with lumbar disc herniation: trunk coordination and arm swing.  Huang YP et al.
2. J Biomech. 2012 Jan 10;45(2):342-7. doi: 10.1016/j.jbiomech.2011.10.024. Epub 2011 Nov 10.

Mechanical coupling between transverse plane pelvis and thorax rotations during gait is higher in people with low back pain.

You can only “borrow” so much before you need to “pay it back”

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.

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

  • Top left: 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.
  • Top right: 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.
  • Top center:normal internal rotation of the left hip; internal tibial torsion
  • 3rd photo down: 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
  • 4th and 5th photos down: 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 (for more on progression angles, click here). 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 and  rotating 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 limiting  his 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/

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.