Holy Leg Length discrepancy!

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

Short leg and mottling of the skin

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!) : )

1. http://reference.medscape.com/article/1084257-overview
2. Ceballos-Quintal JM, Pinto-Escalante D, Castillo-Zapata I. A new case of Klippel-Trenaunay-Weber (KTW) syndrome: evidence of autosomal dominant inheritance. Am J Med Genet. 1996 Jun 14. 63(3):426-7.
3. Sung HM, Chung HY, Lee SJ, Lee JM, Huh S, Lee JW, et al. Clinical Experience of the Klippel-Trenaunay Syndrome. Arch Plast Surg. 2015 Sep. 42 (5):552-8.
4. http://reference.medscape.com/article/1084257-clinical

“Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  Welcome to a global industry problem.”  -Dr. Allen

Which hip will have troubles extending ?

Remember this quiz question from 2 weeks ago ? I talked about how the body will compensate to level the pelvis (and eyes and vestibular apparatus).

Lets go further down the rabbit hole.  Here is your question of the week (you may have to go back and review the prior blog post if you are unsure of how the body will cope with the slope.  Here is that first blog post.

Question: Which hip will have troubles getting into hip extension and thus terminal glute-hip-pelvis stabilization ?

Answer:  scroll down (at least think about it for a second)

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Answer:

The leg on the up slope of the beach, the non-water side leg will have to be in a modest degree of knee flexion to shorten and accommodate to the slope. A Flexed knee is not an extended one and it will be far more difficult to extend the hip and get into the glutes. Propulsion will also be compromised.  For you indoor small track runners this will happen to you on the inside leg on the curves of the track. This is why we see so many hamstring injuries during indoor track.  Think about it ! It is not just bad luck.  Go ahead, tally up  your teams history of hamstring injuries, you should find more on the left leg for track runners. It is simple applied biomechanics.   Also, imagine the altered demand on the quadriceps on that flexed knee (the right knee in the picture above, and the left knee in circle track runners). Furthermore, what is the likelihood that the right pelvis will deviate into an anterior tilted posture ? You bet ya, a greater tendency, and thus a possibly shortened quadriceps/hip flexor mechanism.  Do you think this could inhibit hip extension and gluteal function ? You bet ya.  Oh, and one more thing, if you are true gait nerd, you should have asked yourself one more question, what about ankle rocker ?  Yes, you will need more ankle rocker on the beach side foot (flexed knee side). When the knee flexes, there must be more ankle rocker for this to occur, if not, you may implode into some unwelcome arch collapse, because arch collapse offers more false ankle rocker. What a mess huh !   Now, do not be shocked EVER again when your client’s come back from a sunny beach vacation from walking the beaches for hours every day, and find themselves a stark raving mad mess.  It is not the salty ocean air or the tequila, it is the slope. One could make a case that walking up and down the beach should balance things out, but that is only if we are balanced and symmetrical when we start out. Gravity always wins.

One final rant. If you are offering “corrective exercises” to your clients, you had better know at least the basics of movement and biomechanics. And further more, you had better know how to examine for them, and that means hands on assessment of the body, not just looking at how your client moves through a battery of tests. If the prior blog post (here) and today’s blog post principles are not remedial principles of knowledge for you, offering corrective exercises without this knowledge and a physical exam to confirm your assumptions is fraught with disaster, or at least helping your client to build deeper compensations on their prior compensations. Is your client feeling better because they are truly fixed, or have your prescribed corrective exercises merely raised the capacity and durability of their compensation ?  This is the kind of stuff that keeps my new patient scheduling booked at 4-8 weeks out … . .  frustrated clients.

This is why we do not offer online consultations like some do. Because, we have not figured out how to obtain the third dimension needed in our gait and movement observation (thank you Oculus Rift, the future is near) but more so, we cannot take that information and put it together with our own physical examination to determine whether if what we are seeing is the actual problem, or a compensation. Here in lies the pot of gold.

Another clinical pearl from Dr. Allen

A test question from Dr. Allen, see how you do with this photo critical thinking.

When you walk on the beach you are on a slope. The leg closer to the water naturally drops down to a lower surface. 

Here is the game …  to keep the pelvis level on the horizon, one would have to:

a. shorten the water side leg

b. lengthen the water side leg

c. pronate the water side leg

d. supinate the water side leg

e. lengthen the beach side leg

f. shorten the beach side leg

g. pronate the beach side leg

h. supinate the beach side leg

i. externally rotate the water side leg

j. internally rotate the water side leg

k. externally rotate the beach side leg

l. internally rotate the beach side leg

m. flex the water side hip

n. extend the water side hip

o. flex the beach side hip

p. extend the beach side hip

******Ok, Stop scrolling right now !!!!!  

List all the letters that apply first.

You should have many letters.  *** And here is the kicker for bonus points, the letters can be unscrambled to spell the name of one of the most popular of the Beatles. Name that Beatle.

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don’t look, figure it out before you scroll down further. It is important you try to work through the question and its foundational principles.

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Answer: B, D, F , G, I ,L , N, O

* now, more importantly, make sure you think of these issues in all your clients with leg length discrepancies, both anatomic and function and when the pelvis is not level. This is the most important take away from today’s test question. If you got the answers correct, you have the knowledge to implement. If you did not get the answer correct, you need to hammer down the HOW and WHY of the answer before you start playing with people’s bodies putting in heel lifts (boooo), sole lifts, orthotics, postings etc. If you do not have the foundation to play by the rules, you should not be playing.

ok, we were messing with ya on the Beatles thing. Sorry.

Dr. Shawn Allen

Using a boot to heal a bone, tendon, post-op ?  Think deeper please.

Please please, please ! If you are going to put your client in a CAM rocker boot/shoe for a fracture, or post-op can you please try to level out the leg length discrepancy caused by the thickness of the boot’s sole ? Please ? Pretty please with sugar on top?

Some boot brands have a huge midsole thickness. This leads to a functionally longer leg length. If they are barefoot much of the day, there will be a huge leg length discrepancy. If in shoes all day, you can offset this with a sole lift in the healthy foot’s shoe or you can add something like this to the outsole. Use common sense. IF someone is in a CAM boot for 6 weeks and thus a longer leg, this is going to promote a knee flexed posture on the boot side (ie. shortens the leg) and/or hyperextension of the healthy leg’s knee, supination of the foot, more forefoot habitus (sustained calf loads) and even frontal plane lurch pelvis gait mechanics (this is why many folks will get opposite hip pain). These embedded gait flaws must be addressed and remedied after they are out of the boot to reset normal gait. We have seen enough problems come to our offices that are suspect as a result of prolonged boot use and failure to reteach normal gait patterns, meaning, to reduce the learned gait behaviors of being in a boot for prolonged periods. Gait retraining is just as important as the rehab post-boot removal.  Of course, this is rarely done.  Using logic is never a bad thing.   

Dr. Shawn Allen, one of the gait guys

Here is a neat device we found to help.http://www.braceshop.com/procare-evenup-shoe-balancer-walker-system.htm?gdftrk=gdfV28018_a_7c2568_a_7c10961_a_7c32290&gclid=Cj0KEQiA37CnBRChp7e-pM2Mzp0BEiQAlSxQCCeL74AvCkYXbQX_jV1jEP27mfocB87f8pSfbo2PZMIaAsOV8P8HAQ

Difference between adult and infant gait compensation.

We highly doubt the infants compensated to the point of “recovering symmetrical gait”. It just isn’t possible seeing as there was frank asymmetry in leg length. However, it is quite possible they accomodated quicker with a more reasonable compensation, that MAY have appeared to have less limp. We did not do the study, but over a beer we might guess that the investigators might agree that our verbiage is closer to accurate. None the less, cool stuff to cogitate. We are very appreciative of this study, there is something to take from this study.

“The stability of a system affects how it will handle a perturbation: The system may compensate for the perturbation or not. This study examined how 14-month-old infants-notoriously unstable walkers-and adults cope with a perturbation to walking. We attached a platform to one of participants’ shoes, forcing them to walk with one elongated leg. At first, the platform shoe caused both age groups to slow down and limp, and caused infants to misstep and fall. But after a few trials, infants altered their gait to compensate for the platform shoe whereas adults did not; infants recovered symmetrical gait whereas adults continued to limp. Apparently, adult walking was stable enough to cope with the perturbation, but infants risked falling if they did not compensate. Compensation depends on the interplay of multiple factors: The availability of a compensatory response, the cost of compensation, and the stability of the system being perturbed.”- From the Cole et all study (reference below)

– thoughts by Shawn Allen

references:

Infant Behav Dev. 2014 Aug;37(3):305-14. doi: 10.1016/j.infbeh.2014.04.006. Epub 2014 May 20.Coping with asymmetry: how infants and adults walk with one elongated leg.Cole WG1, Gill SV2, Vereijken B3, Adolph KE4.

http://www.ncbi.nlm.nih.gov/pubmed/24857934