Exploring the Links Between Human Movement, Biomechanics & Gait
A visual example of the consequences of a leg length discrepancy.
This patient has an anatomical (femoral) discrepancy between three and 5 mm. She has occasional lower back discomfort and also describes being very “aware” of her second and third metatarsals on the left foot during running.
You can clearly see the difference in where patterns on her flip-flops. Note how much more in varus wear on the left side compared to the right. This is most likely in compensation for an increased supination moment on that side. She is constantly trying to lengthen her left side by anteriorly rotated pelvis on that side and supinating her foot and trying to “short” the right side by rotating the pelvis posteriorly and pronating the foot.
With the pelvic rotation present described above (which is what we found in the exam) you can see how she has intermittent low back pain. Combine this with the fact that she runs a daycare and is extremely right-handed and you can see part of the problem.
Leg length discrepancies become clinically important when they resulting in a compensation pattern that no longer works for the patient. Be on the lookout for differences and wear patterns from side to side.
These pix come to us from one of our brethren, Dr Scott Tesoro in Carbondale of a 73 yr old golfer with mild LBP and a L knee replacement three yrs ago. He has a VERY short R leg (close to an inch).
What you are seeing is he ultimate compensation for a short leg. Note how he takes the shorter side and supinates it (to the max!). You can see the external rotation of the lower leg and thigh to go along with it. If you look carefully and extrapolate how his left leg would look “neutral”, you can see he has internal tibial torsion on this (right) side as well. He has some increased midfoot pronation on the right compared to the left, but not an excessive amount.
A full length sole lift would probably be in order, as well as potentially addressing some of his compensations. Wow, what a great set of pictures !
Pain on the outside of the leg? Could it be your orthotic? What you wear on your feet amplifies the effect of the orthotic.
This woman presented with right-sided pain on the outside of her leg after hiking approximately an hour. She noticed a prominence of the arch in her right orthotic. She hikes in a rigid Asolo boot ( see below). Remember that footwear amplifies the effect of an orthotic!
In the pictures below you can see the prominent arch. The orthotic has her “over corrected” so that she toes off in varus on that side. The rigid footwear makes the problem worse. The peroneus group is working hard (Especially the peroneus longus) to try and get the first Ray down to the ground.
The “fix” was to soften the arch of the orthotic and grind some material out. Look at the pictures where the pen is pointing to see how some of the midsole material was taken out. Notice how I ground it somewhat medial to further soften the arch.
She felt better much better after this change and is now a “happy hiker” 🙂
Welcome to Monday, Folks, and News You Can Use! Sometimes, it’s the subtle things that make all the difference.
Take a look at this patients right leg versus left legs (knees in particular). What do you see? Can you notice the subtle bend in the right knee? Can you see how she hyperextends the left? Can you see that she has an anatomical deficiency (Tibial) of the left tibia? This is a common finding if you look for it.
Noticing subtle changes like these in your examination can make all the difference in your outcomes. This particular patient happens to have right-sided knee pain. On examination (difficult to see from the photos) she has increased amounts of mid foot pronation. She presented with right sided back pain running from the supra iliac region up along the right lumbar paraspinal’s. You can manipulate this patient forever and her problem is not going to improve until you address the cause.
Develop keen sense of observation. Become a “student of the obvious”. Keep your eyes and ears open. Expand your clinical skill set. Sometimes, when all we have is a hammer, everything starts to look like a nail.
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 : ).
How much “dip” in the coronal plane is in your single leg squat?
“In conclusion, the Single-Leg Squat is a reliable tool to identify patients that would need to improve their hip and trunk muscle weakness and dysfunction (by strengthening and neuromuscular coordination retraining). ”
Crossley et al., Am J Sports Med 39 (2011) 866 – 873.
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.