Looking for the subtle clues will help you. You should have hypotheses and work to prove or disprove them. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

We used to call this a “windswept” presentation. It is not that it is incorrect, but it is so vague.  

Look at these fippy floppers. Look closely at the dark areas, where foot oils and whatnot have played their changes in the leather upper of the flops. The right f.flop displays more lateral heel loading, rear foot inversion if you will. You can even see that there is less big toe pressure on this right side and even some increased lateral forefoot loading. This client appears to be more supinated clearly. You can even see there is more lightness to the arch leather on the right, again, more supination is suggested.

The left f.flop suggests the opposite. More medial heel pressures and more over the medial forefoot and arch. 

Now this clients f.flops tell a story.  So, this client is being windswept to the right we used to say, appearing to pronate more on the left and supinating more on the right.  Why are they doing this? Is the left leg functionally longer and by pronating they reduce the functional length of the leg (yet, increase internal spin of the limb and the host of naughty things that come with that). Is the right leg shorter, and by supinating they are raising the ankle mortise and arch which helps reduce the length differential ?  MAybe a bit of both, finding common ground for a more symmetrical pelvis ?  Who knows. This is where you need your physical exam, but, now you have some hypotheses to prove or disprove. 

“Remember, this client is displaying these weight bearing differences side to side for a reason, this is their adaptive strategy. It is your job to prove that this is the cause of their pain, their adaptive strategy to get out of pain, or this is now a failed adaptive strategy causing pain, yet still not the root of the problem.”

Is there some right hip pain from the right frontal pelvis drift creating some aberrant loading on the greater trochanter from ITB tension ? Perhaps a painful right hallux big toe, and they are unloading it to avoid pain? Maybe some knee pain or low back pain ? Who knows? Take your history and start putting the pieces together, it is your job. Just don’t screen them and throw corrective exercises at them, you owe it to them to examine them, take their history, watch them walk, teach them about what you see, and then sit down, spread the puzzle pieces out, look for the straight edges and corner pieces, and begin to build their puzzle. 

Clues, they are everywhere, if you look for them.

Dr. Shawn Allen, one of the gait guys

Got big toe pain? Think it’s gout? Think again!   Things are not always what they appear to be. 

This gent came in with first metatarsophalangeal pain which had begun a few months previous. His uric acid levels were borderline high (6) so he was diagnosed with gout.  It should be noted his other inflammatory markers (SED rate and CRP) were low. Medication did not make the symptoms better, rest was the only thing that helped. 

The backstory is a few months ago he was running in the snow and “punched through"the snow, hitting the bottom of his foot on the ground. Pain developed over the next few days and then subsided. The pain would come on whenever he try to run or walk along distances and he noticed a difficult time extending his big toe.

 Examination revealed some redness mild swelling over the 1st metatarsophalangeal joint (see pictures above) and hallux dorsiflexion of 10°.   If we raised the base of the first metatarsal and pushed down on the head of the 1st, he was able to dorsiflex the 1st MTP approximately 50°. He had point tenderness over the medial sesamoid. We shot the x-rays you see above. The films revealed a fracture of the medial sesamoid with some resorption of the bone.

The  sesamoid fracture caused the head of the 1st metatarsal to descend on one side, and remain higher on the other, altering the axis of rotation of the joint and restricting extension. We have talked about the importance of the axis of this joint in may other posts (see here and here).

 He was given exercises to assist in descending the first ray (EHB, toe waving, tripod standing).  He will be reevaluated in a week and if not significantly improved we will consider a wedge under the medial sesamoid. 

A pretty straight forward case of “you need to be looking in the right place to make the diagnosis”. Take the time to examine folks and get a good history.

It has been a year, but this video is still as important as it ever was. Now that we have many of new viewers, perhaps they missed this one. It is always good to review. Enjoy !