This is part 2 of a 2 part post; with the video from the case previously discussed

please note the following in the video:

  • body lean to left during left stance phase (to clear right longer leg)
  • circumduction of right lower extremity  (to clear right longer leg)
  • lack of arm swing bilaterally (cortical involvement)
  • patient looking down while walking (decomposition of gait)
  • shortened step length (decomposition of gait)
  • increased tibial varum bilaterally

ASSESSMENT:  This patient’s short leg and internal tibial torsion impediments to her full recovery. She has increased tibial varum noted which is complicating the picture. This is causing pathomechanics and an abductory moment not only at the knee but also in the lumbar, thoracic and cervical spines.

WHAT DID WE DO?:                    

  • We attempted to do the one leg standing exercise. She needed to hold on and did not feel stable on the left hip while performing this.  This is probably more of confidence rather than ability issue. 
  • We gave her the stand/sit exercise to try to improve gluteal recruitment.
  • We also gave her the lift/spread/reach exercise to attempt to strengthen her feet.
  • A full-length 5 mm lift was cut for the left shoe  She felt more stable when walking on this.
  • She was treated with IC, PIR and manipulative therapy and neuromuscular stim of the knee as well as left hip area above, below and at the joint line of the knee as well as gluteus medius and minimus.   
  • We may need to consider building a more aggressive orthotic with a forefoot varus post depending upon her progress and response to care  

 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

The Power of Observation: Part 2

Let’s take a closer look at yesterdays post and the findings. If you are just picking up here, the post will be more meaningful if you go back and read it. 

The following are some explanations for what you were seeing:

torso lean to left during stance phase on L?

if he has a L short leg, he will need to clear right leg on swing phase. We have spoken of strategies around a short leg in another post. This gentleman employs 2 of the 5 strategies; torso lean is one of them

increased progression angle of both feet?

Remember he has femoral retroversion. You may have read about retrotorsion here. He has limited internal rotation o both thighs and must create the requisite 4-6 degrees necessary to walk. He does this by spinning his foot out (rotating externally).

decreased arm swing on L?

This is most likely cortical, as he seems to have decreased proprioception on both legs during 1 leg standing. Proprioception feeds to the cerebellum, which in turn fires axial extensors through connections with the vestibular system. Diminished input can lead to flexor dominance (and extensors not firing). Note the longer stride forward on the right leg compared to the left with less hip extension (yes, we know, a side view would be helpful here).

circumduction of right leg?

This is the 2nd strategy for getting around that L short leg.

clenched fist on L?(esp when standing on either leg)

see the decreased arm swing section. This is a subtle sign of flexor dominance, which appears to be greater on the right.

body lean to R during L leg standing?

This is again to compensate for the L short leg. He has very mild weakness of the left hip abductors as well, more when moving or using them in a synergistic fashion (ie functional weakness) than to manual testing.

Well, what do you think? Now you can see how important the subtle is and that gait analysis may complex than many think.

We are and we remain, the Geeky Guru’s of Gait: The Gait Guys