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

Short leg and mottling of the skin

Have you ever heard of Klippel-Trenaunay Syndrome? I hadn’t either, until I had a patient come in with low back pain and a gait issue and said she had it.

Evidently, in 1900, noted French physicians Klippel and Trenaunay first described a syndrome in 2 patients presenting with a port-wine stain and varicosities of an extremity associated with hypertrophy of the affected limb’s bony and soft tissue. Klippel-Trenaunay-Weber syndrome (KTWS) is characterized by a triad of port-wine stain, varicose veins, and bony and soft tissue hypertrophy involving an extremity (1).

Most cases KTWS are sporadic, although a few cases in the literature report an autosomal dominant pattern of inheritance (2). There is no racial predilection, even distribution between males and females and presents at birth or during early childhood (3). It generally affects a single extremity, although cases of multiple affected limbs have been reported. The leg is the most common site followed by the arms, the trunk, and rarely the head and the neck(4).

This patient had a history of low back pain with a recent epidural steroid injection. Exam highlights included a R sided leg length discrepancy approximately 5mm (tibial and femoral). Pelvic tilt to the right (for LLD) with anterior rotation of that side of the pelvis, posterior on the opposite side (counter clockwise pelvic distortion pattern). Lumbar flexion off 60/90 with all motion occurring in the lumbar spine (ie: no hip hinge), extension 20/30, lateral bending 30/45 BL with pain ipsilateral. Decreased low back endurance of <50 seconds in extension.

Right lower extremity was smaller (appeared hypoplastic) than left and had multiple discolorations in the skin (see pictures). L sided Q angle > R (12 vs 8 degrees). Less internal rotation of the right lower extremity compared to left, but with normal limits. Gait revealed a shift and hike to the right during stance phase with an increased arm swing on the right. Foot intrinsics were weak (lumbricals, EDL, FDB, dorsal intrerossei)

She walked in a pair of Chaco sandals with allowed much greater calcaneal eversion bilaterally R > L.

MRI revealed paraspinal marbling at the lower part of the lumbar spine, improving as you move rostrally. Small disc herniations at L3/4, 4/5, 5/S1, which did not effect the exiting nerve roots. Degenerative changes in the lumbar facet joints. There was no radiographic evidence of instability.

Impression:
It seems that she did not have enough intrinsic for the strength to stop calcaneal eversion in her Chaco’s and therefore this was causing increased foot pronation. This, combined with her leg length discrepancy, was contributing to increasing the lordosis in her lumbar spine, causing facet joint irritation. This was compounded by weakness and lack of endurance of the lumbar paraspinal musculature. The effects of the Klippel-Trenaunay Syndrome are evident with the IPO plasticity of the right lower extremity and accompanying musculoskeletal abnormalities.

What did we do?

  • Gave her endurance exercises for the lumbar spine.
  • Gave her propriosensorv exercises for the lumbar spine
  • Recommended she continue with the 5 mm sole lift.
  • Advised getting rid of the Chaco sandals as they allow too much calcaneal eversion and sticking to a shoe that has a stronger/larger heel counter.
  • acupuncture to improve circulation and proprioception as well as muscular function
  • we will monitor weekly for the next 4 to 6 weeks.

All in all, and interesting use with a little twist (not a torsion, of course!) : )

1. http://reference.medscape.com/article/1084257-overview
2. Ceballos-Quintal JM, Pinto-Escalante D, Castillo-Zapata I. A new case of Klippel-Trenaunay-Weber (KTW) syndrome: evidence of autosomal dominant inheritance. Am J Med Genet. 1996 Jun 14. 63(3):426-7.
3. Sung HM, Chung HY, Lee SJ, Lee JM, Huh S, Lee JW, et al. Clinical Experience of the Klippel-Trenaunay Syndrome. Arch Plast Surg. 2015 Sep. 42 (5):552-8.
4. http://reference.medscape.com/article/1084257-clinical

Can you believe they missed this? Sometimes you just need to look.

This gal has knee pain on the R a “funny gait” and right sided low back pain in the sacro iliac joint fr the last 3 years. She felt like she needed to keep her right leg bent and her left straight all the time. She was unable to hike or walk distances longer than 1 mile or time longer than 30 minutes without slowing down and having pain. She has had reconstructive surgery on the right knee for an ACL/MCL, physical therapy, medication, counseling and even stroke rehabilitation/gait retraining.

On exam she has a marked genu varus bilaterally. Knee stability is good anterior/posterior drawer; valgus/varus stress. One leg standing with both eyes open is less than 15 seconds, eyes closed is negligible. She has an anatomically short L leg; at least 2 cm which is both tibial and femoral. She was unaware of this and noone had adressed it in any way.

She was given a 10mm sole length lift for the L leg and propriosensory exercises. She was encouraged to walk with a heel to toe gait. She felt 50% better immediately and another 20% after 2 weeks of doing the exercises. She had gone on several 5 mile hikes for over 2 hours with minimal discomfort.

Nothing earth shaking here. Just an exam which covered the basics and some common sense treatment. Too bad they are not all that easy, eh? The takeaway? Look and listen. The problem was on the side opposite her complaint, as it can be many times. Look at the area of chief complaint 1st, but then look everywhere else : ).

Does this guy have a short leg or what? How good are your eyes?

One again, we had the gait cam, investigating gait on the east coast. What do we see in this gent?

  • heel strike on out side of left foot with increased progression angle

he appears to be stabilizing the left side during stance phase. notice the upper torso shift to the left during left stance phase

  • abbreviated arm swing on right

note that ankle rocker is adequate on the left

  • body lean to right on right stance phase

gluteus medius weakness on right? short leg on right?

Good.

  • Did you also notice the loss of ankle rocker on the right, compared to the left? This results in less hip extension on that side as well.
  • He flexes his right thigh less than his right during pre swing and swing

external obliques should be firing to initiate hip flexion, perpetuated by the psoas, iliacus and rectus femoris. This does not appear to be happening.

All of this is great BUT nothing like being able to actually examine your patients is there? You can see how gait analysis can tell us many things, but they need to be confirmed by a physical exam.

The Gait Guys. Educating (and hopefully enlightening) with each post. Keep your eyes open and your thinking from the ground up : )

Wow! What would you do?

This is part 1 of a 2 part post. Look for the other one a few minutes after this one with a video up top for the conclusion

PRESENTING PROBLEM: This 54 YO female patient presents with with left sided knee pain.  She had a total knee replacement (TKR) done in 2011.  She’s had a significant amount of discomfort on the medial aspect of the knee since then. She had an MRI of the hip done thinking the problem was there, and found nothing.   She is walking with a bad limp, left leg is half inch shorter than the right.  Pain is worse at night, changes with weather. 

She has knee pain on the lateral aspect (points to tibial plateau and joint line) with swelling that goes down to the ankle left side.  She has been wearing a “Good Feet” OTC orthotic on the left side which she states helps quite a bit.

Generally speaking, stretching and analgesics make the discomfort better.    Ibuprofen 400 mg. b.i.d. can take the edge off  Soft sided brace (neoprene sleeve) makes a difference as well. The hard sided brace gives her difficulty.

WORK HISTORY: She works for a preschool.  Her job involves standing and getting up and down a lot.  

FAMILY HISTORY:  She has left sided lid ptosis, this evidently is familial.  

PHYSICAL EXAM:  She stood 5’ 1” and weighed approx. 150 pounds.

Viewing the knees bi-lat., the left knee is markedly externally rotated.

She does have a left short leg; tibial and femoral.  She has bilateral tibial torsion (look at the tibial tuberosities and drop a line straight down; it should pass through the 2nd metatarsal head) and marked internal tibial torsion on the left side (>60 degrees) with femoral retrotorsion (less than 8 degree angle of femoral head with the shaft) on this side.  There is no rotation of the thigh or leg past zero degrees midline. .  She had 10 degrees of tibial varum on the left hand side.  Her Q-angle is 10 degrees on that side.  There is plantar flexion inversion of the foot.  Left lower extremity has less sensation secondary to the her TKR  surgery.

Gait evaluation reveals a fair amount of midfoot pronation noted on the left hand side in addition to an intoed gait.  She has to lean her body over to the left to get the right leg to clear.

Some mild weakness noted of hip abduction musculature left hand side gluteus medius, middle and anterior fibers. Knee stability tests were negative.

Neurologically, otherwise, she had full integrity with respect to sensation, motor strength and deep tendon reflexes in the upper and lower extremities.

Please see part 2 of this post for additional info including our assessment and what WE did.

 The Gait Guys. Making it real, each and every post here on the blog.

special thanks to SZ for allowing us to publish her case, so others can learn