Every foot has a story. 

 This is not your typical “in this person has internal tibial torsion, yada yada yada” post.  This post poses a question and the question is “Why does this gentleman have a forefoot adductus?”

The first two pictures show me fully internally rotating the patients left leg. You will note that he does not go past zero degrees and he has femoral retroversion. He also has bilateral internal tibial torsion, which is visible in most of the pictures. The next two pictures show me fully internally rotating his right leg, with limited motion, as well and internal tibial torsion, which is worse on this ® side

 The large middle picture shows him rest. Note the bilateral external rotation of the legs. This is most likely to create some internal rotation, because thatis a position of comfort for him (ie he is creating some “relief” and internal rotation, by externally rotating the lower extremity)

 The next three pictures show his anatomically short left leg. Yes there is a large tibial and small femoral component. 

 The final picture (from above) shows his forefoot adductus. Note that how, if you were to bisect the calcaneus and draw a line coming forward, the toes fall medial to a line that would normally be between the second and third metatarsal’s. This is more evident on the right side.  Note the separation of the big toe from the others, right side greater than left. 

Metatarsus adductus deformity is a forefoot which is adducted in the transverse plane with the apex of the deformity at LisFranc’s (tarso-metatarsal) joint. The fifth metatarsal base will be prominent and the lateral border of the foot convex in shape . The medial foot border is concave with a deep vertical skin crease located at the first metatarso cuneiform joint level. The hallux (great toe) may be widely separated from the second digit and the lesser digits will usually be adducted at their bases. ln some cases the abductor hallucis tendon may be palpably taut just proximal to its insertion into the inferomedial aspect of the proximal phalanx (1)

Gait abnormalities seen with this deformity include a decreased progression angle, in toed gait, excessive supination of the feet with low gear push off from the lesser metatarsals. 

 It is interesting to note that along with forefoot adductus, hip dysplasia and internal tibial torsion are common (2) and this patient has some degree of both. 

 His forefoot adductus is developmental and due to the lack of range of motion and lack of internal rotation of the lower extremities, due to the femoral retrotorsion and internal tibial torsion.  If he didn’t adduct the foot he would have to change weight-bearing over his stance phase extremity to propel himself forward. Try internally rotating your foot and standing on one leg and then externally rotating. See what I mean? With the internal rotation it moves your center of gravity over your hip without nearly as much lateral displacement as would be necessary as with external rotation. Try it again with external rotation of the foot; do you see how you are more likely displace the hip further to that side OR lean to that side rather than shift your hip? So, his adductus is out of necessity.

Interesting case! When you have a person with internal torsion and limited hip internal rotation, with an adducted foot, think of forefoot adductus!

1.  Bleck E: Metatarsus adductus: classification and relationship to outcomes of treatment. J Pediatric Orthop 3:2-9,1983.

2. Jacobs J: Metatarsus varus and hip dysplasia. C/inO rth o p 16:203-212, 1960

Subtle clues. Helping someone around their anatomy

This patient comes in with low back pain of years duration, helped temporarily with manipulation and activity. Her exam is relatively benign, save for increased lumbar discomfort with axial compression in extension and extension combined with lateral bending. Believe it or not, her abdominal and gluteal muscles (yes, all of them) test strong (no, we couldn’t believe it either; she is extremely regular with her exercises). She has bilateral internal tibial torsion (ITT) and bilateral femoral retro torsion (FRT). She has a decreased progression angle of the feet during walking and the knees do not progress past midlilne. There is a loss of active ankle rocker with gait, but not on the exam table; same with hip extension. 

We know she has a sweater on which obscures things a bit, but this is what you have to work with. Look carefully at her posture from the side. The gravitational line should pass from the earlobe, through the shoulder, greater trochanter and through or just anterior to the lateral malleolus.

In the top picture, can you see how her pelvis is anterior to this line? Do you see how it gets worse when she lifts her hands over her head (yes, they are directly over head)? This can signify many things, but often indicates a lack of flexibility in the lumbar lordosis; in this case, she cannot extend her lumbar spine further so she translates her pelvis forward. Most folks should have enough range of motion from a neutral pelvis and enough stability to allow the movement to occur without a significant change. Go ahead, we know you are curious, go watch yourself do this in a mirror and see if YOU change.

Looking at the bottom left picture, can you pick out that she has a genu valgus? Look at the hips and look at the tibial angle.

In the bottom left picture, did you note the progression angle (or lack of) in her feet? This is a common finding (but NOT pathognomonic) in patients with internal tibial torsion. Notice the forefoot adductus on the right foot?

So what do we think is going on?

  • ITT and FRT both limit the amount of internal rotation of the thigh and lower leg. Remember you NEED 4 degrees of each to walk normally. Most folks have significantly more
  • if you don’t have enough internal rotation of the lower extremity, you will need to “create” it. You can do this by extending the lumbar spine (bottom picture, right) or externally rotating the lower extremity
  • Since her ITT and FRT are bilateral, she flexes the pelvis and nutates the pelvis anteriorly.
  • the lumbar facet joints should only carry 20% of load
  • she is increasing the load and causing facet imbercation resulting in LBP.

What did we do?

  • taught her about neutral pelvic positioning, creating more ROM in the lumbar spine
  • had her consciously alter her progression angle of her foot on strike, to create more available ROM in internal rotation
  • encouraged her to wear neutral shoes
  • worked on helping her to create more ankle rocker and hip extension with active drills and exercise (ie gait rehabilitation); shuffle walks, Texas walk, toes up walking, etc

why didn’t we put her in an orthotic to externally rotate her lower extremity? Because with internal tibial torsion, this would move her knee outside the saggital plane and create a biomechanical conflict at the knee and possibly compromising her meniscus.

Cool case, eh? We thought so. Keep on learning so your brain keeps expanding. If you are not growing your brain, you are shrinking it!

The Gait Guys

Photo: Where is your knee joint hinge point ?  Say that 4 times fast.

Here is a photo of 4 elite runners. We suspect it is an 800m race  because #100 is Ahmed Bile who is the son of Olympian and world champion Abdi Bile.

In this photo you can see that Ahmed #100 has a significantly large foot progression angle (large foot turn out) and this likely represents external tibial torsion or femoral antetorsion while #454 has a neutral foot turn out as does #232.  #46 has a modest foot progression angle. Grossly, #46 also has the patella right over the foot and so tibial torsion is not likely. Now, move up to observe their knee progression. All of them have a forward (sagittally) oriented knee progression. How can that be? Well, it is simple if you know your torsional issues. After all, the knee is a hinge and if you are running forward your knee pretty much should hinge forward as well.  Now, there is much room for conversation here and debate but we are just trying to make and observation and a point. To a large extent the knee rules the roost in the lower limb in terms of sagittal progression because it is the joint with the least number of tolerances. The knee only hinges in flexion and extension where as the hip and ankle/foot have frontal and axial planes they can notably tap into when the sagittal is challenged.  Again, look at #100 and our point is made.

Look at the 2 fellas in the middle (454 and 232). they have a internally (medially) postured knee/thigh yet their foot progression angle is mostly neutral and the knees are hinging forward.  Does #454 have internal tibial torsion? It could be (hint, look at his right trailing leg, specifically the patella and foot postures) but the left limb looks cleaner although adducted suggesting he might like the cross-over gait or it is more external tibial torsioned. Where as the 2 outer fellas, 100 and 46, are more neutrally oriented knees/thighs (one could make the case that #100 has a more externally oriented femur) yet increased progression foot progression angle in an environment of a forward hinging knee.

So what gives ? Torsions. Yes, we are soapboxing on torsions again. Torsions in the tibia, torsions in the femur. Versions are normal expressed angles, tibial torsions are abnormal.

Now, as life would have it, look over the right shoulder of #100. See the fella in the red headband? Ya, that guy losing.  He has the cleanest lines of the bunch. How is that for cruel irony ?  Sometimes it ain’t what you got, it is what you do with what you got.  Unless of course he is actually wincing in pain and trailing behind because he got spiked by #100 and that hideously frontal plane splayed foot !

Lastly, this wouldn’t be an official Gait Guys post if we did not preach to remember that “what you see is not the problem, what you see in a gait analysis is the person’s compensatory strategy around their deficits”. And here we see deficits. Our observations today are merely just that, observations. Now someone has to get them on a table and examine them and confirm our observations, prove them wrong and/or discover the joint, muscular and motor pattern deficits that created these observations.  Or, someone has to confirm that all parts are working and that they were at the end of the line when the straight long bones were first handed out.  

Today’s Lesson:  Get in line, and get in line early. (just kidding of course)

The Gait Guys.  Calling it they way we see it, but reserving the right to plead the 5th or change our minds after an examination.  We would suggest to everyone, when it counts and when your reputation is on the line, plead the 5th, until you have completed your hands on clinical examination.  ”Seeing may be believing” but that still doesn’t always make it so.

Want to learn more about these kinds of things, foot beds, foot types, shoe anatomy and shoe function, proper shoe prescription etc ?  Our National Shoe Fit program will help you get smarter about this stuff. email us at : thegaitguys@gmail.com 

Gait Guys online /download store:http://store.payloadz.com/results/results.aspx?m=80204

*Photo courtesy of BIG EAST Conference

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

Hmmm. We are fully internally rotating this gentleman’s lower leg (and thus hip) on each side. What can you tell us?

Look at the upper picture. Does the knee go past midline? NO! So we have limnited internal rotation of the hip. What are the possible causes?

  • femoral retro torsion
  • tight posterior capsule of hip
  • OA of hip
  • tight gluteal group (max or posterior fibers of medius)
  • labral derangement

Now line up the tibial tuberosity and the foot. What do you see? The foot is externally rotated with respect to the leg. What are the possible causes?

  • external tibial torsion
  • subtalar valgus
  • fracture/derangement causing this position

Now look at the bottom picture. Awesome forearm and nice choice of watch. Good thing we didn’t wear Mickey Mouse!

Look at upper leg. Hmm. Same story as the right side.

Look at the lower leg and line up the tibial tuberosity and the foot. What do you see? The foot is internally rotated with respect to the leg. What are the possible causes?

  • internal tibial torsion
  • subtalar varum
  • fracture/derangement causing this position

So this individual will have very different lower leg mechanics on the right side compared to the left (external torsion right, internal left). We refere to this as “windswept” biomechanics, as it looks like the wind came in from the right and “swept” the feet together to the left.

What will this look like? Most likely increased pronation on the right and supination on the left. What may we see?

  • calcaneal (rearfoot) valgus on right
  • calcaneal (rearfoot) varum on the left
  • bilateral knee fall to midline
  • knee fall to midline on right occurring smoother than on left
     (the patient has an uncompensated forefoot varus bilaterally; he is already partially pronated on the right, so it may appear to be less abrupt)
  • toeing off in supination more pronounced on the left (due to the internal torsion and forefoot varus)

The Gait Guys. Increasing your foot and gait IQ with each and every post.

OK Folks

Take a look at these pics for a moment, then come back and read.

Ready? Lets see how much you remember about torsions and versions. Take a look at this child that was brought in by their parent (legs were too short to drive themselves : )  ) They were wondering if the child needed orthotics. What do we see?

top left photo: legs are in a neutral position. note the position of the knee (more specifically the tibial tuberosity and patellae can sometimes fake you out. ( OK, maybe not you, but they can sometimes fake SOME people out). The plane of the 2nd metatarsal is LATERAL to the tibial tuberosity, This is EXTERNAL TIBIAL TORSION; it appears greater on the (patients) right (look also at the left lower leg in the center picture as well, it has less torsion). Note also the lower longitudinal arches bilaterally (they are typically higher in non-weightbearing but in children this young they are typically lower in the early stages).

top right photo: I am fully internally rotating the right lower leg and hip. Note the position of the knee; it does not rotate as much as you would expect (normally 40 degrees) when compared to the distance the foot seems to have travelled. This hip is RETRO-TORSIONED (remember we are born anteverted about 40 degrees, which decreases approximately 1.5 degrees per year to puberty, resulting in an 8-12 degree angle in the adult. If you need a review, go back and read the February 27th post). Go back and read our 5 part series on Versions and Torsions (“Are you Twisted ?”).

Center photo: I am fully externally rotating the right leg. Note that range of motion is much greater than internal rotation and exceeds 40 degrees. This supports the previous paragraph, retro-torsion.

Bottom left: I am fully internally rotating the left lower leg. It appears normal  with about 40 degrees (or more) of internal rotation. This femur is NORMAL or has NORMAL FEMORAL VERSION.

Bottom right: I am externally rotating the left leg. Motion appears to mimic internal rotation and is approximately equal. This supports the previous paragraph as NORMAL FEMORAL VERSION.                               

In summary:

  • External tibial torsion, R > L
  • flattened longitudinal arches
  • Right femoral retrotorsion
  • Left femoral version, NORMAL

Well, what do you think? Are orthotics going to help this kiddo? No, probably not, they may even make the problem worse, by slowing derotation of the talar head, forcing them into more permanent varus of the forefoot.                                                                                                           

How did you do? Can you see now why torsions and versions (the degree of “twistedness” of a limb is so important? They help you understand skeletal development and help you to make clearer decisions.

The Gait Guys. Twisted in a good way. Versioned but not torsioned.

all material copyright 2013 The Gait Guys/The Homunculus Group. all rights reserved. please don’t use our stuff without asking : )

Twisted, Part 4

 

Hopefully you have been keeping us with us. If you missed the 1st 3 of this series, go back 3 weeks and start reading again, or do a search on the blog page for “torsion”.

The final chapter of developmental versions involves the femur. The degree of version is the angle between an imaginary line drawn through the condyles of the femur and an imaginary line drawn through the head and neck of the femur. This is often referred to as the femoral neck angle or FNA.

Beginning about the 3rd month of embryological development (Lanz and Mayet 1953) and reaches about 40 degrees (with an average of 30-60 degrees) at birth. It then decreases 25-30 degrees by adulthood to 8-20 degrees with males being at the lower and females at the upper end of the range.

The FNA angle, therefore, diminishes about 1.5 degrees a year until about 15 years of age. Femoral neck anteversion angle is typically symmetrical from the left side to the right side.

What causes torsion in the first place? By the sixth month in utero, the lumbar spine and hips of the fetus are fully flexed, so perhaps it is positional. Other sources say it coincides with the degree of osteogenesis. There is a growing consensus that muscular forces are responsible, particularly the iliopsoas  or possibly the medial and lateral hip rotators.

Additional changes can occur after birth, particularly with sitting postures. “W” sitting or “cross legged” sitting have been associated with altering the available range of motion and thus the FNA, with the range increased in the direction the hip was held in; W sitting causing increased internal rotation and antetorsion and cross legged causing external rotation and retro torsion.

As discussed previously, there are at least 3 reasons we need to understand torsions and versions, They can alter the progression angle of gait, they usually affect the available ranges of motion of the limb and they can alter the coronal plane orientation of the limb.

1. fermoral torsions often alter the progression angle of gait.  In femoral antetorsion torsion, the knees often face inward, resulting in an intoed gait and a decreased progression angle of the foot. This can be differentiated from internal tibial torsion (ITT) by looking at the tibia and studying the position of the tibial tuberosity with respect to the foot, particularly the 2nd metatarsal. In ITT, the foot points inward while the tibial tuberosity points straight ahead. In an individual with no torsion, the tibial tuberosity lines up with the 2nd metatarsal. If the tibial tuerosity and 2nd met are lined up,  and the knees still point inward, the individual probably has femoral ante torsion. Remember that a decreased progression angle is often associated with a decreased step width whereas an increased angle is often associated with an increased step width. See the person with external tibial torsion in the above picture?

2. Femoral torsions affect available ranges of motion of the limb. We remember that the thigh leg needs to internally rotate the requisite 4-6 degrees from initial contact to midstance (most folks have 40 degrees) If it is already fully internally rotated (as it may be with femoral retro torsion), that range of motion must be created or compensated for elsewhere. This, much like internal tibial torsion, can result in external rotation of the affected lower limb to create the range of motion needed.

Femoral retro torsion results in less internal rotation of the limb, and increased external rotation.

Femoral ante torsion results in less external rotation of the limb, and increased internal rotation.

3. femoral torsions usually do not effect the coronal plane orientation of the lower limb, since the “spin” is in the transverse or horizontal plane.

The take home message here about femoral torsions is that no matter what the cause:

  •  FNA values that exist one to two standard deviations outside the range are considered “torsions”
  • Decreased values (ie, less than 8 degrees) are called “retro torsion” and increased values (greater than 20 degrees) are called “ante torsion”
  • Retro torsion causes a limitation of available internal rotation of the hip and an increase in external rotation
  • Ante torsion causes an increase in available internal rotation  of the hip and decrease in external rotation
  • Femoral ante torsion will be perpetuated by “W” sitting (sitting on knees with the feet outside the thighs, promoting internal rotation of the femur)
  • Femoral antetorsion will be perpetuated by sitting cross legged, which forces the thigh into external rotation.

 

Stay tuned for a case tomorrow to test your learning over the last few weeks.

 

We remain: Bald, good looking and intelligent…The Gait Guys

 

 

All material copyright 2013 The Gait Guys/ The Homunculus Group. All rights reserved.  Please ask to use our stuff!