Why does this gal have so much limited external rotation of her legs? 

 We have discussed torsions and versions here on the blog many times before. We rarely see femoral antetorsion. She came in to see us with the pain following a total hip replacement on the right.

 Note that she has fairly good internal rotation of the hips bilaterally but limited external rotation. This is usually not the case, as most folks lose internal rotation. We need 4 to 6° internal and external rotation to walk normally. This poor gal has very little external rotation available to her.

Have you figured out what’s going on with hips yet? She has a condition called femoral ante torsion.   This means that the angle of the femoral neck is in excess of 12°. This will allow her to have a lot of internal rotation but very little external rotation.  She will need to either “create” or “borrow” her requisite external rotation from somewhere. In this case she decreases her progression of gait (intoed), and borrows the remainder from her lumbar spine.

 So what do we do? We attempt to create more external rotation. We are accomplishing this with exercises that emphasize external rotation, acupuncture/needling of the hip capsule and musculature which would promote external rotation (posterior fibers of gluteus medius,  gluteus maximus, vastus medialis, biceps femoris). A few degrees can go a very long way as they have in this patient. 

confused? Did you miss our awesome post on femoral torsions: click here to learn more.

Low back pain and quadriceps compensation. A study.

“Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.“- Hart et al.

Recently I discussed a paper (link below) about how soleus  motoneuron pool excitability increased following lumbar paraspinal fatigue and how it may indicate a postural response to preserve lower extremity function.
Today I bring you an article of a similar sort.  This paper discusses the plausibility that a relationship exists between lumbar paraspinal muscle fatigue and quadriceps muscle activation and the subsequent changes in hip and knee function when running fatigue ensued. 

"Reduced external knee flexion, knee adduction, knee internal rotation and hip external rotation moments and increased external knee extension moments resulted from repetitive lumbar paraspinal fatiguing exercise. Persons with a self-reported history of LBP had larger knee flexion moments than controls during jogging. Neuromuscular changes in the lower extremity occur while resisting knee and hip joint moments following isolated lumbar paraspinal exercise. Persons with a history of LBP seem to rely more heavily on quadriceps activity while jogging.”- Hart et al.

Whether this or any study was perfectly performed or has validity does not matter in my discussion here today. What does matter pertaining to my dialogue here today is understanding and respecting the value of the clinical examination (and not depending on a gait analysis to determine your corrective exercise prescription and treatment). When an area fatigues and cannot stabilize itself adequately, compensation must occur to adapt. Protective postural control strategies must be attempted and deployed to stay safely upright during locomotion. The system must adapt or pain or injury may ensue, sometimes this may take months or years and the cause is not clear until clinical examination is performed. Your exam must include mobility and stability assessments, motor pattern evaluation, and certainly skill, coordination, ENDURANCE and strength assessments if you are to get a clear picture of what is driving your clients compensation and pain. 

So, if your client comes in with knee, hip or ankle pain and a history of low back pain, you might want to pull out these articles and bash them and other similar ones into your brain. Remember what I mentioned when i reviewed the soleus article ? I mentioned that the reduced ankle dorsiflexion range may be from a soleus muscle postural compensation reaction to low back pain. In today’s discussion, impairment of the hip ranges of motion or control of the knee (from quadriceps adaptive compensation) may also be related to low back pain, in this case, paraspinal fatigue.  

Sometimes the problem is from the bottom up, sometimes it is from the top down. It is what makes this game so challenging and mind numbing at times. If only it were as simple as, “you need to work on abdominal breathing”, or “you need to strengthen your core”.  If only it were that simple. 

Dr. Shawn Allen, one of the gait guys

References:
J Electromyogr Kinesiol. 2011 Jun;21(3):466-70. doi: 10.1016/j.jelekin.2011.02.002. Epub 2011 Mar 8.
Effects of paraspinal fatigue on lower extremity motoneuron excitability in individuals with a history of low back pain. Bunn EA1, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.

J Electromyogr Kinesiol. 2009 Dec;19(6):e458-64. doi: 10.1016/j.jelekin.2008.09.003. Epub 2008 Dec 16. Jogging gait kinetics following fatiguing lumbar paraspinal exercise.
Hart JM1, Kerrigan DC, Fritz JM, Saliba EN, Gansneder B, Ingersoll CD

How relaxed, or shall we say “sloppy” is your gait ?

Look at this picture, the blurred left swing leg tells you this client has been photographed during gait motion. 

Now, visualize a line up from that right foot through the spine. You will see that it is clearly under the center/middle of the pelvis. But of course, it is easier to stand on one leg (as gait is merely transferring from one single leg stance to the other repeatedly) when your body mass is directly over the foot.  To do this the pelvis has to drift laterally over the stance leg side.  Sadly though, you should be able to have enough gluteal and abdominal cylinder strength to stack the foot and knee over the hip. This would mean that the pelvis plumb line should always fall between the feet, which is clearly not the case here.  This is sloppy weak lazy gait. It is likely an engrained habit in most people, but that does not make it right. It is pathology, in time something will likely have to give. 

This is the cross over gait we have beaten to a pulp here at The Gait Guys over and over … . . and over.   This gait this gait, this single photo, means this client is engaging movement into the frontal plane too much, they have drifted to the right. We call it frontal plane drift. To prevent it, it means you have to have an extra bit more of lateral line strength in the gluteus medius and lateral abdominal sling to fend off pathology. You have to be able to find functional stability in the stacked posture, and this can take some training and time.  Make no mistake, this is a faulty movement pattern, even if there is not pain, this is not efficient motor patterning and something will have to give. Whether that is lateral foot pain from more supination strategizing, more tone in the ITB perhaps causing lateral knee or hip pain, a compensation in arms swing or thoracic spine rotation or head tilt  … … something has to give, something has to compensate. 

So, how sloppy is your gait ? 

Do you kick or scuff the inside of your opposite shoe ? Can you hear your pants rub together ? Just clues. You must test the patterns, make no assumptions, please.

Shawn Allen, one of the gait guys

When is a hamstring strain not a hamstring strain?

We have always have found the quadratus femoris is one of, if not the, 1st hip muscle to become dysfunctional in hip pain patients. Perhaps it is due to it being the southern most stabilizer of the deep 6. Long known as an adductor, but also external rotator, we find it is employed eccentrically when the foot the planted and people rotate to the same side as weight bearing, or people take a “sudden stumble” while running. It often mimics an insertional hamstring strain with regards to location. We were happy to see it is getting some of the attention it deserves : )

http://www.anatomy-physiotherapy.com/articles/musculoskeletal/lower-extremity/hip/1528-function-of-the-quadratus-femoris-and-obturator-externus

The gluteus medius and low back pain.

We see this one ALL the time. We are sure you do as well.
“Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP.”
It is often more on the side of pelvic frontal plane drift. The abdominals and spinal stabilizers also often test weak on this same side. We often see compromise of hip rotation stability as well because , since the hip is relatively adducting (because the pelvis is undergoing repeated frontal plane drift, hence no hip abduction) there is often a component of cross over gait phenomenon which can threaten rotation stability of the lower limb (type “cross over gait” into the search box of our tumblr blog for a landslide of work we have written on that phenomenon).

Eur Spine J. 2015 May 26. [Epub ahead of print]
Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls.
Cooper NA1, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA.

http://www.ncbi.nlm.nih.gov/pubmed/26006705

Podcast 91: Gait, Vision & some truths about leg length discrepancies

Show sponsors:
www.newbalancechicago.com

A. Link to our server:
http://traffic.libsyn.com/thegaitguys/pod_91f.mp3

Direct Download:
http://thegaitguys.libsyn.com/91

Other Gait Guys stuff

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:
Monthly lectures at : www.onlinece.com   type in Dr. Waerlop or Dr. Allen,  ”Biomechanics”

Our Book: Pedographs and Gait Analysis and Clinical Case Studies

electronic copies available here:

Amazon/Kindle:

http://www.amazon.com/Pedographs-Gait-Analysis-Clinical-Studies-ebook/dp/B00AC18M3E

Barnes and Noble / Nook Reader:

http://www.barnesandnoble.com/w/pedographs-and-gait-analysis-ivo-waerlop-and-shawn-allen/1112754833?ean=9781466953895

https://itunes.apple.com/us/book/pedographs-and-gait-analysis/id554516085?mt=11

Hardcopy available from our publisher:

http://bookstore.trafford.com/Products/SKU-000155825/Pedographs-and-Gait-Analysis.aspx

Show notes:

Gait and vision: Gaze Fixation
What’s Up With That: Birds Bob Their Heads When They Walk
http://www.wired.com/2015/01/whats-birds-bob-heads-walk/
 
Shod vs unshod
 
Short leg talk:
11 strategies to negotiate around a leg length discrepancy

From a Reader:

Dear Gait Guys, Dr. Shawn and Dr. Ivo,  I was referred to this post of yours on hip IR…http://thegaitguys.tumblr.com/post/14262793786/gait-problem-the-solitary-externally-rotated   I am impressed by the level of details of your understanding of the gait and biomechanics. Although I am still trying to understand all of your points in this post, I would like to ask you:  What if my IR is limited due to a structural issue? The acetabular retroversion of the right hip in my case. 

I.e. if I am structurally unable to rotate the hip internally.
What will happen? 
What would be a solution to the problem in that case? 

Single-leg drop landing movement strategies 6 months following first-time acute lateral ankle sprain injury – Doherty – 2014 – Scandinavian Journal of Medicine & Science in Sports
http://onlinelibrary.wiley.com/doi/10.1111/sms.12390/abstract

Hey Gait Guys,

I understand that 1st MP Joint dorsiflexion, ankle rocker, and hip extension are 3 key factors for moving in the sagittal plane from your blog and podcasts so far. I really love how you guys drill in our heads to increase anterior strength to increase posterior length to further ankle rocker. I’ve seen the shuffle gait and was curious if you had a good hip extension exercise to really activate the posterior hip extensors and increase anterior length. 

Podcast 73: Cross Fit and Squatting. Knees out ?

Podcast 73: Femoral and Tibial Torsions and Squatting: Know your Squatting Truths and Myths

*Show sponsor: www.newbalancechicago.com

Lems Shoes.  www.lemsshoes.comMention GAIT15 at check out for a 15% discount through August 31st, 2014.

A. Link to our server: http://traffic.libsyn.com/thegaitguys/pod_74f.mp3

Direct Download: 

http://thegaitguys.libsyn.com/podcast-73-cross-fit-squatting-knees-b. out

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:

1. Bioengineers create functional 3D brain-like tissue   http://www.nih.gov/news/health/aug2014/nibib-11.htm

2.  A Novel Shear Reduction Insole Effect on the Thermal Response to Walking Stress, Balance, and Gait
 
3.  Hi Shawn and Ivo, There is a lively debate in the Crossfit community about “knees out” during squatting. I have attached a blog post. It might be a good blog post or podcast segment. 
 
4. Shoe Finder ?
 
5.  Michael wrote: “I know this is too broad a topic for facebook, but I was wondering what your general recommendation would be for someone with flat feet and exaggerated, constant over-pronation. I’ve tried strengthening my calves and ankles, but have seen no noticeable reduction in the automatic “rolling in” of my feet whenever walking or standing. I can consciously correct the over-pronation, of course, but as soon as I stop tensing my arch muscle, everything flops back down.”

House MD. :  Is he using his cane on the correct side ?

This is a great video clip (when you click on the youtube link it  might not work. Try clicking here ……go ahead and click that link to watch and then come back. Note to listeners…. there is controversy over the lyrics, there always has been and always will be …..but they are listed below at the end of the post.)

When can you ever go wrong with AC/DC ? Combine that with Hugh Laurie from HOUSE MD and you have a great mix.

So, watching this video, why is he using his cane incorrectly?  We all know that House’s has a problem with the right hip and leg.  “The Rules” state that with a hip problem the cane should always be used on the opposite side to change the D2 lever arm (Click here for a great lesson on this) with a nice follow up here (click). After watching these 2 Gait Guys videos you will clearly understand (perhaps to a better level than most of your therapists and doctors who gave you the cane) why it is used on the opposite side.

So, why in the world is the brilliant Dr. House using it on the same side ?  We have received this question more than once.  And the answer is quite simple.  His problem is extracapsular. In the pilot episode of House MD it was explained that he suffered a vascular infarct to the quadriceps muscle.  Like bone infarcts, muscular infarcts can be painful. If he contracts the quadriceps when loading the leg there will be pain.  Just like if the infarct were osseous,  the loading of the cortical bone and stress on the trabecular infrastructure in that case, axial loading of the limb (muscular or osseous) will drive pain. So, to lessen the issue he uses the cane on the same side to literally share his body mass load over the length of the cane.  He is essentially attempting to use the cane as his weight bearing limb.  The cane use on the opposite side is best used when you are attempting to unload the muscular compressive forces across the hip (acetabulofemoral) joint.  Contraction of the gluteus medius generates the greatest joint compressive loading of all of the hip muscles because of its orientation during gait. Thus, utilizing the cane on the opposite side acts as a hydraulic lift necessitating a shift in body mass closer to the joint and reducing the compressive demands on the gluteus medius muscle. 

* Rule breaker: sure, you can still use the cane on the same side to reduce the gluteus medius forces, it is just a bit more awkward.  But it can be done.  Think about and elderly folk who had a weaker opposite arm, they would feel more comfortable using House’s strategy. The rules are not hard pressed. 

So, House is using the cane correctly for his condition. 

Rules are meant to be broken.  Look at our leaders (all parties) in Washington, they do it everyday ! And when you are as smart as House you know when to break the rules. 

Thanks for the reminder AC/DC ……lyrics

“Living easy, living free

Season ticket on a one-way ride

Hey Momma, look at me

I’m on my way to the promised land.

Asking nothing, leave me be

Taking everything in my stride

Dont need reason, dont need rhyme

Aint nothing I’d rather do”

Shawn and Ivo……….. or maybe it is Beavis & Butthead ?

(uh, that’s cool dude !  huhhh huhhhhh …… Those Gait Guys Rule…… !!!! )

The Hip, Part 3: More on Hip Rim Syndromes and Labral Tears

Tomorrow, in Part 4 (the last part), we will talk about functional hip problems in runners and cyclists but today we will finish up this little topic on some of the internal hip derangements. For tomorrow, remember our key words from the other day, INTERNAL HIP ROTATION range……. it is important stuff when we discuss gait and the hip problems that result from pathologic gait patterns.

________________________________

Labral detachments and tears are the most common clinically significant abnormalities to be identified.  To date it still seems that evaluation of the patient with chronic mechanical hip pain remains somewhat of a diagnostic dilemma for physicians.  The differential diagnosis is diverse including common entities such as osteoarthritis, fracture, and avascular necrosis, as well as less common entities including pigmented villonodular synovitis, synovial osteochondromatosis, snapping hip syndrome, and hemorrhage into the ligamentum teres.  Childhood disorders such as Perthes disease and dysplasia also need to be considered with adolescents. Similar to findings in the knee and shoulder, radiographs appear normal in the vast majority of patients with internal derangement as a cause for hip symptoms. In one study, labral lesions were identified at arthroscopy in 55% of patients with intractable hip pain. 

Imaging: As with other joints in the body, magnetic resonance (MR) arthrography of the hip has emerged as a technique for diagnosis of internal derangement of the hip.  In addition to depicting labral lesions, MR arthrography may also depict intraarticular loose bodies, osteochondral abnormalities, and abnormalities of the supporting soft-tissue structures. Radiographs in patients with labral tears are typically unremarkable. If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.

Labral lesions have a strong correlation with symptoms such as:  anterior inguinal pain, painful clicking, transient locking. “giving way” of the hip. Pain may be reproduced with flexion and internal rotation of the hip. An audible click may also be present at times. The patient history usually does not reveal significant trauma. The onset of pain may be related to sports and may involve a mild twisting or slipping injury.  Major trauma such as dislocation may result in labral tear.


Patients with developmental dysplasia of the hip are at increased risk for labral tears and abnormalities of the labral rim. The Rim syndromes are categorized by two types of acetabular dysplasia;  one being the incongruent oval shaped acetabulum the other being the congruent, spherical acetabulum with poor lateral coverage of the femur head which leads to fatigue fractures of the acetabulum socket and articular and interosseous cyst formation. In patients with developmental dysplasia, the acetabular rim and the labrum are placed under increased stress. 
The possibility of a pathologic labral condition should be considered in individuals with developmental dysplasia of the hip in whom the pain is disproportionate to the radiographic changes, as well as in patients who have not experienced significant improvement after osteotomy. The fact that a detached labrum increases the risk of failure of treatment has been recognized.

Summary:
Mechanical hip pain can be a real enigma unless your doctor really knows their stuff. Not many studies talk about neuromuscular support, muscular function and movement patterns of the hip largely because the education in this area is poor, in our opinion.  Physician skill level with years of experience is also a real challenge when dealing with mechanical hip pain and the causes (as we have discussed here) of anatomic pathology that might occur when the normal hip mechanics are challenged.  Add an abnormal gait pattern to the mix and it is no wonder why some hip problems go undiagnosed in the early stages of problem.
A pathologic labral conditions, detachments or tears, are a common cause of chronic hip pain, and MR arthrography of the hip is the imaging procedure of choice for identifying an abnormal labrum.  Detachments are more common than tears and are identified on the basis of the presence of contrast material interposed at the acetabular-labral junction. 

_________________________________________________________
There is not a ton of literature out on the Rim syndromes, since some of you have been asking about it.  Here is an article we found. Link for article purchase is at the header of today’s blog.
J Bone Joint Surg Br. 1991 May;73(3):423-9.
The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.
Klaue K, Durnin CW, Ganz R.
Abstract
The acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or ‘os acetabuli’ as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.

The Hip, Part 3: More on Hip Rim Syndromes and Labral Tears

Tomorrow, in Part 4 (the last part), we will talk about functional hip problems in runners and cyclists but today we will finish up this little topic on some of the internal hip derangements. For tomorrow, remember our key words from the other day, INTERNAL HIP ROTATION range……. it is important stuff when we discuss gait and the hip problems that result from pathologic gait patterns. ________________________________ Labral detachments and tears are the most common clinically significant abnormalities to be identified.  To date it still seems that evaluation of the patient with chronic mechanical hip pain remains somewhat of a diagnostic dilemma for physicians.  The differential diagnosis is diverse including common entities such as osteoarthritis, fracture, and avascular necrosis, as well as less common entities including pigmented villonodular synovitis, synovial osteochondromatosis, snapping hip syndrome, and hemorrhage into the ligamentum teres.  Childhood disorders such as Perthes disease and dysplasia also need to be considered with adolescents. Similar to findings in the knee and shoulder, radiographs appear normal in the vast majority of patients with internal derangement as a cause for hip symptoms. In one study, labral lesions were identified at arthroscopy in 55% of patients with intractable hip pain. 
Imaging: As with other joints in the body, magnetic resonance (MR) arthrography of the hip has emerged as a technique for diagnosis of internal derangement of the hip.  In addition to depicting labral lesions, MR arthrography may also depict intraarticular loose bodies, osteochondral abnormalities, and abnormalities of the supporting soft-tissue structures. Radiographs in patients with labral tears are typically unremarkable. If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.Labral lesions have a strong correlation with symptoms such as:  anterior inguinal pain, painful clicking, transient locking. “giving way” of the hip. Pain may be reproduced with flexion and internal rotation of the hip. An audible click may also be present at times. The patient history usually does not reveal significant trauma. The onset of pain may be related to sports and may involve a mild twisting or slipping injury.  Major trauma such as dislocation may result in labral tear.

Patients with developmental dysplasia of the hip are at increased risk for labral tears and abnormalities of the labral rim. The Rim syndromes are categorized by two types of acetabular dysplasia;  one being the incongruent oval shaped acetabulum the other being the congruent, spherical acetabulum with poor lateral coverage of the femur head which leads to fatigue fractures of the acetabulum socket and articular and interosseous cyst formation. In patients with developmental dysplasia, the acetabular rim and the labrum are placed under increased stress. 
The possibility of a pathologic labral condition should be considered in individuals with developmental dysplasia of the hip in whom the pain is disproportionate to the radiographic changes, as well as in patients who have not experienced significant improvement after osteotomy. The fact that a detached labrum increases the risk of failure of treatment has been recognized.Summary:Mechanical hip pain can be a real enigma unless your doctor really knows their stuff. Not many studies talk about neuromuscular support, muscular function and movement patterns of the hip largely because the education in this area is poor, in our opinion.  Physician skill level with years of experience is also a real challenge when dealing with mechanical hip pain and the causes (as we have discussed here) of anatomic pathology that might occur when the normal hip mechanics are challenged.  Add an abnormal gait pattern to the mix and it is no wonder why some hip problems go undiagnosed in the early stages of problem.A pathologic labral conditions, detachments or tears, are a common cause of chronic hip pain, and MR arthrography of the hip is the imaging procedure of choice for identifying an abnormal labrum.  Detachments are more common than tears and are identified on the basis of the presence of contrast material interposed at the acetabular-labral junction. 
_________________________________________________________There is not a ton of literature out on the Rim syndromes, since some of you have been asking about it.  Here is an article we found. Link for article purchase is at the header of today’s blog. J Bone Joint Surg Br. 1991 May;73(3):423-9.The acetabular rim syndrome. A clinical presentation of dysplasia of the hip.Klaue K, Durnin CW, Ganz R.AbstractThe acetabular rim syndrome is a pathological entity which we illustrate by reference to 29 cases. The syndrome is a precursor of osteoarthritis of the hip secondary to acetabular dysplasia. The symptoms are pain and impaired function. All our cases were treated by operation which consisted in most instances of re-orientation of the acetabulum by peri-acetabular osteotomy and arthrotomy of the hip. In all cases, the limbus was found to be detached from the bony rim of the acetabulum. In several instances there was a separated bone fragment, or ‘os acetabuli’ as well. In acetabular dysplasia, the acetabular rim is subject to abnormal stress which may cause the limbus to rupture, and a fragment of bone to separate from the adjacent bone margin. Dysplastic acetabuli may be classified into two radiological types. In type I there is an incongruent shallow acetabulum. In type II the acetabulum is congruent but the coverage of the femoral head is deficient.

The Hip, Part 3: More on Hip Rim Syndromes and Labral Tears