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.

Hmmm..What’s going on here? Can you see it?

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 : ).

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.

Being a gait geek offers you a unique perspective in many situations.

Perhaps you have been with us for some time now and would like to check your gait acumen. If you are new, or these terms are foreign to you; search here on our blog through hundreds of posts to become more comfortable with some of the vocabulary.

Watch this video a few times (we slowed it down for you) and write down what you see.

Did you see all of these in this brief video?

  • bilateral loss of hip extension
  • bilateral loss of ankle rocker
  • less ankle rocker on right
  • bilateral increased progression angle  
  • dip in right pelvis at right heel strike
  • arm swing increased on R

The Gait Guys. Increasing your gait competency each and every day.

special thanks to NL for allowing us to use this video footage.

More on the Great Debate: Does decreased step height (resulting in less vertical oscillation) increase running economy

There continues to be a plethora of conflicting data out there on the web. Yes, shocking realization !

This study looks at 16 triathletes; 8 folks trained in the “pose method” of running for 12 weeks, versus the 8 folks who just kept running in their usual fashion (ie. the control group perhaps also known as the “beer and Doritos group”  : )  ). They measured changes in stride length (decreased in posers), vertical oscillation (decreased in posers) and oxygen cost (increased in posers).

According to the study’s conclusion

“The global change in running mechanics associated with 12 weeks of instruction in the pose method resulted in a decrease in stride length, a reduced vertical oscillation in comparison with the control group and a decrease of running economy in triathletes”

Why the changes? Perhaps it takes longer to train appropriately in this method and to become efficient at the method. Perhaps when you lose the “pendulum effect” we spoke about last Thursday on the blog, you become less efficient, or maybe there is another factor. MAYBE “pose running” just isn’t more efficient. Time and more studies will tell.

The Gait Guys. Telling it like it is and bringing you the meat….without the filler

all material copyright 2013 The Gait Guys/ The Homunculus Group. Please ask before lifting our stuff.

J Sports Sci. 2005 Jul;23(7):757-64.

Effect of a global alteration of running technique on kinematics and economy.

Source

Department of Exercise Science, Health Promotion and Recreation, Colorado State University – Pueblo, Pueblo, CO, USA. george.dallam@colostate-pueblo.edu

Abstract

In this study, we examined the consequences of a global alteration in running technique on running kinematics and running economy in triathletes. Sixteen sub-elite triathletes were pre and post tested for running economy and running kinematics at 215 and 250 m.min-1. The members of the treatment group (n=8) were exposed to 12 weeks of instruction in the “pose method” of running, while the members of the control group (n=8) maintained their usual running technique. After the treatment period, the experimental group demonstrated a significant decrease in mean stride length (from 137.25+/-7.63 cm to 129.19+/-7.43 cm; P<0.05), a post-treatment difference in vertical oscillation compared with the control group (6.92+/-1.00 vs. 8.44+/-1.00 cm; P<0.05) and a mean increase in submaximal absolute oxygen cost (from 3.28+/-0.36 l.min-1 to 3.53+/-0.43 l.min-1; P<0.01). The control group exhibited no significant changes in either running kinematics or oxygen cost. The global change in running mechanics associated with 12 weeks of instruction in the pose method resulted in a decrease in stride length, a reduced vertical oscillation in comparison with the control group and a decrease of running economy in triathletes.

PMID:16195026 [PubMed – indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/16195026

More on the Great Debate: Does decreased step height (resulting in less vertical oscillation) increase running economy

There continues to be a plethora of conflicting data out there on the web. Yes, shocking realization !

This study looks at 16 triathletes; 8 folks trained in the “pose method” of running for 12 weeks, versus the 8 folks who just kept running in their usual fashion (ie. the control group perhaps also known as the “beer and Doritos group”  : )  ). They measured changes in stride length (decreased in posers), vertical oscillation (decreased in posers) and oxygen cost (increased in posers).

According to the study’s conclusion

“The global change in running mechanics associated with 12 weeks of instruction in the pose method resulted in a decrease in stride length, a reduced vertical oscillation in comparison with the control group and a decrease of running economy in triathletes”

Why the changes? Perhaps it takes longer to train appropriately in this method and to become efficient at the method. Perhaps when you lose the “pendulum effect” we spoke about last Thursday on the blog, you become less efficient, or maybe there is another factor. MAYBE “pose running” just isn’t more efficient. Time and more studies will tell.

The Gait Guys. Telling it like it is and bringing you the meat….without the filler

all material copyright 2013 The Gait Guys/ The Homunculus Group. Please ask before lifting our stuff.

J Sports Sci. 2005 Jul;23(7):757-64.

Effect of a global alteration of running technique on kinematics and economy.

Source

Department of Exercise Science, Health Promotion and Recreation, Colorado State University – Pueblo, Pueblo, CO, USA. george.dallam@colostate-pueblo.edu

Abstract

In this study, we examined the consequences of a global alteration in running technique on running kinematics and running economy in triathletes. Sixteen sub-elite triathletes were pre and post tested for running economy and running kinematics at 215 and 250 m.min-1. The members of the treatment group (n=8) were exposed to 12 weeks of instruction in the “pose method” of running, while the members of the control group (n=8) maintained their usual running technique. After the treatment period, the experimental group demonstrated a significant decrease in mean stride length (from 137.25+/-7.63 cm to 129.19+/-7.43 cm; P<0.05), a post-treatment difference in vertical oscillation compared with the control group (6.92+/-1.00 vs. 8.44+/-1.00 cm; P<0.05) and a mean increase in submaximal absolute oxygen cost (from 3.28+/-0.36 l.min-1 to 3.53+/-0.43 l.min-1; P<0.01). The control group exhibited no significant changes in either running kinematics or oxygen cost. The global change in running mechanics associated with 12 weeks of instruction in the pose method resulted in a decrease in stride length, a reduced vertical oscillation in comparison with the control group and a decrease of running economy in triathletes.

PMID:16195026 [PubMed – indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/16195026