Exploring the Links Between Human Movement, Biomechanics & Gait
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 !
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 : ).