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

 Gastroc Anyone?

 An interesting and innovative rehab tip for a torn branch of the tibial nerve innervating it, along with some requisite anatomy.

Ankle Plantarflexors as Gait compensators ?

We are always talking about compensations. We have worn out our statement “what you see in someone’s gait is not their problem, ti is their compensation stratetgy(s).”
Here is a study with an interesting thought.
Just remember, try to fix the underlying problems. But, realizing sometimes you cannot, especially in the elderly population, sometimes you have to give a strategy to help them even though it is not the solution you want. And remember also that driving the anterior compartment with appropriate exercises as our “shuffle walk” might stop any loss of ankle dorsiflexion that might be met with the extra calf work that this article seems to suggest.

From the study: “ Of particular importance were the compensatory mechanisms provided by the plantar flexors, which were shown to be able to compensate for many musculoskeletal deficits, including diminished muscle strength in the hip and knee flexors and extensors and increased hip joint stiffness. This importance was further highlighted when a normal walking pattern could not be achieved through compensatory action of other muscle groups when the uniarticular and biarticular plantar flexor strength was decreased as a group. Thus, rehabilitation or preventative exercise programs may consider focusing on increasing or maintaining plantar flexor strength, which appears critical to maintaining normal walking mechanics.”

Gait Posture. 2007 Mar;25(3):360-7. Epub 2006 May 23.
Compensatory strategies during normal walking in response to muscle weakness and increased hip joint stiffness.
Goldberg EJ1, Neptune RR.
http://www.ncbi.nlm.nih.gov/pubmed/16720095

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

So what do we see here?

a limp on the left?
a short leg on the right?
a weak gluteus medius on the left?
a shortened step length on the right?
increased arm swing on the left?

watch the push off (terminal stance/pre swing) on the right and then the left. Note how the left is weaker?
now watch the heel strike. Notice how it is shorter when the right strikes the ground than the left?
did you note the pelvic shift to the left on L stance phase? How about the subtle increased knee flexion on the left?

This gentleman has an atrophied gastroc/soleus on the left from an injury. He compensates by increasing thigh flexion on the left to clear the leg. Because he has lost gastroc/soleus strength on the left (the lateral gastrocis an important inverter of the heel after midstance and important component of rearfoot supination), the rearfoot everts more. allowing more midfoot pronation. This collapse of the midfoot brings his weight more medially, so he shifts his pelvis laterally (to the left) to keep his center of gravity over the foot.

Fix?

  • Make client aware of what is going on.
  • make sure gastroc/soleus complex strength and function is maximized through muscle work, acupuncture, muscle activation, functional gait exercise

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Kicking gait?

And now… A question from a reader….

 Dr Allen- There are a few questions troubling me. The first one concerns the loss of the ankle rocker phase of gait which can have implications further up the kinetic chain. It concerns the interplay of gastroc and soleus. Is it possible for gastrocnemius to work as a knee extensor when the foot is in the closed chain position – especially if the bodies centre of mass has advanced in front of the knee joint ? Thanks – RB

Hi RB_____,

yes it is possible…….it is a retrograde movement as you have described.
it is not commonly seen, but can be, and usually manifests itself, in one of 2 ways.

Typically the client is more ligamentously lax than others……..and they tend to have a “kicking” type gait, where they thrust the leg out in front, like kicking a ball, with each step forward. This causes a heavy heel strike and locks the knee in preparation for midstance, and then follows your thinking. By the way, this client also seems to like standing in a hyperextended knee position at rest.

We remember that the gastroc soleus group begins to fire in the first 10% of stance phase (it is acting as a knee extensor here); to promote eccentric deceleration of the forward moving tibia, and continues to fire until terminal swing. It is believed the soleus provides much of the deceleration force and the gastroc assists in inverting the ankle at midstance and primarily flexes the knee at pre swing, just prior to toe off (Nordin, Frankel 2001). If the gastroc /soleus group fires prematurely, or excessively, particularly in prior to midstance, then we see the action you describe, and it manifests itself as premature heel rise and loss of ankle rocker.

A sudden hyperextesion at midstance or later, in a neurologically competent individual, is unlikely, as he force is too abrupt at this point and there is too much of a mechanical disadvantage.

We hope this helps explain things a bit. Please email us back if it doesn’t!

Uber Geeks, Shawn and Ivo