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 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
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!) : )
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 : ).
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?
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.